Achilles Rupture & Tendinosis: A Complete Guide

The Achilles Tendon

The Achilles tendon is the largest and strongest tendon in the body, connecting the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). It transmits force during walking, running, and jumping. Despite its strength, it is susceptible to both acute rupture and chronic degeneration (tendinosis).

Achilles Tendon Rupture

An Achilles tendon rupture typically occurs in patients aged 30–50, often during recreational sport. It is commonly described as a sudden, sharp pain in the back of the leg — "like being kicked or shot." The patient may hear a pop and will be unable to push off through the foot or stand on tiptoe. The Thompson test (squeezing the calf with no plantarflexion) confirms the rupture.

Surgical vs. Non-Surgical Treatment of Rupture

Surgical repair involves suturing the torn tendon ends together through a small incision. It offers a lower re-rupture rate compared to conservative treatment (approximately 3–5% vs. 10–12%) and is generally recommended for active patients under 65.

Conservative management in a functional rehabilitation boot is a valid option for older or less active patients, or those with medical conditions that increase surgical risk. Modern functional bracing protocols have substantially reduced the gap in outcomes between surgical and non-surgical approaches.

Achilles Tendinosis

Achilles tendinosis is a chronic degenerative condition of the tendon, distinct from tendinitis (acute inflammation). It presents as pain and stiffness in the mid-tendon or at the heel bone insertion, typically in runners and other active individuals. Characteristic features include morning stiffness that warms up with activity, and a tender thickening of the tendon.

Treatment of Tendinosis

The cornerstone of treatment is a progressive eccentric loading exercise program (Alfredson protocol), a specific form of physiotherapy with strong evidence. Approximately 80% of patients achieve satisfactory results with 12–16 weeks of eccentric training. Other options include shockwave therapy, orthotics, and activity modification.

Surgery is reserved for refractory cases (usually >6 months of failed conservative treatment). Options include open or minimally invasive tendon debridement.

Further Reading

Dr Smith has written in more detail about this topic on his own site: Achilles tendon problems and Achilles surgery.