Achilles Tendon Rupture

The Achilles tendon is the strongest tendon in the body. It connects the two calf muscles — the gastrocnemius and soleus — to the heel bone (calcaneus), transmitting the enormous forces needed for walking, running, jumping and climbing stairs.

A rupture occurs when the tendon tears, either partially or completely (fully). Complete ruptures are far more disabling and typically occur at the so-called “watershed zone” — an area 2–6 cm above the heel where the blood supply is least robust.

Most patients describe a sudden snap or “pop” sensation at the back of the ankle, often assuming they have been kicked or struck from behind — yet there is no one else there. This is a hallmark description of an Achilles tendon rupture.

Achilles tendon ruptures are increasingly common. UK studies suggest an incidence of 18–37 per 100,000 people per year, and this figure has been rising steadily over the past two decades alongside growth in recreational sport.

The typical patient is a man aged 30–50 who plays sport intermittently — the so-called “weekend warrior”. The male-to-female ratio is approximately 6:1. High-risk sports include squash, badminton, football, basketball, tennis, and running events involving explosive push-off.

Elite athletes are not immune: ruptures are well-documented in professional football, rugby and tennis players, where they represent career-threatening injuries requiring expert surgical management and structured rehabilitation.

Most ruptures occur during sport, typically with a sudden eccentric load — when the calf contracts forcefully as the foot is pushing off or the ankle is rapidly dorsiflexed (bent upwards). Common mechanisms include:

• Sudden acceleration or change of direction in racket sports
• Jumping and landing in basketball or volleyball
• Explosive sprint starts in football or athletics
• Tripping or stumbling on an uneven surface

Underlying tendon degeneration (tendinopathy) significantly increases rupture risk. Many patients report no prior tendon pain — the degenerative process is often silent until the tendon finally fails. Other risk factors include increasing age, male sex, prior corticosteroid injections into the tendon, use of fluoroquinolone antibiotics, and poor conditioning.

An acute Achilles tendon rupture typically presents with:

• Sudden severe pain at the back of the heel or lower calf — often described as a blow or a gunshot
• An audible snap or pop heard (and felt) at the moment of injury
• Inability to push off — the patient cannot rise on tiptoe on the affected side
• A palpable gap in the tendon, typically 2–6 cm above the heel
• Swelling and bruising around the back of the ankle, appearing within hours

Despite the dramatic injury, some patients are still able to walk (with a limp) because the toe flexors and peroneals remain intact. This can occasionally lead to delayed diagnosis if the Simmonds–Thompson test is not performed. Importantly, ability to walk does not exclude a complete rupture.

Diagnosis is primarily clinical. The Simmonds–Thompson test (squeezing the calf with the patient prone, knee flexed) is the gold-standard clinical test — absence of plantarflexion indicates a complete rupture.

Weight-bearing X-rays are sometimes taken to exclude a calcaneal avulsion fracture or calcification within the tendon, but they are not required in most acute ruptures.

For many patients, particularly those who are older or less active, non-surgical management with a functional rehabilitation protocol is an excellent option that achieves outcomes comparable to surgery.

Surgery is often preferred for younger, active patients and elite athletes, particularly when early return to high-demand sport is the goal. The options include:

Following surgery, patients are placed in a walker boot and begin the same structured rehabilitation protocol as non-surgical patients.

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore and an Honorary Associate Clinical Professor at UCL. He has a specific sub-specialty interest in Achilles tendon disorders, sports injuries of the foot and ankle, and complex hindfoot reconstruction.

• Volume and expertise: Mr Welck performs a high volume of Achilles tendon repairs and reconstructions, including FHL transfers for chronic ruptures.
• Modern protocols: He uses evidence-based functional rehabilitation protocols (including the VACOPED boot) that match surgical outcomes for appropriate patients.
• Access: Consultations are available at multiple sites across North and Central London, with rapid assessment for acute injuries.
• Shared decision-making: Mr Welck discusses the evidence for both surgical and non-surgical options with each patient, tailoring the treatment plan to individual goals, activity level and preferences.

If you have suffered an Achilles tendon rupture or are concerned about pain at the back of your heel, early specialist assessment is important. Mr Welck offers rapid access appointments across North and Central London.

Consultations are available at the Royal National Orthopaedic Hospital (RNOH) Stanmore and at private clinics across London.

Book a Consultation
Call 020 3475 7455