Practical Tips for Early Management of Achilles Tendon Rupture

Achilles tendon rupture is one of those injuries patients rarely forget, and understandably, it often comes with a significant fear of reinjury.

For clinicians, the early stage really matters. Getting both the diagnosis and initial management right can have a big impact on how the tendon recovers.

In her Practical, Dr Karin Gravare Silbernagel covers exactly how she assesses and manages Achilles tendon ruptures in the acute phase. This blog highlights a few great tips you can take into the clinic.

If you want to know exactly how an expert assesses and manages Achilles ruptures in the acute phase, watch Karin’s full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

Identifying a rupture

First thing’s first, you’ve got to figure out whether you’re actually dealing with an Achilles rupture.

This starts with listening to the patient’s account. That classic description of being hit from behind is a strong clue. Pain is usually present, although not always severe, and swelling may become more apparent after the first 24 hours.

Clinical testing is next. The Thompson test and Matles test can help confirm suspicion, alongside palpation of the tendon. It’s important to remember that plantarflexion may still be possible even with a rupture, so this should not rule it out.

Imaging can support your assessment, but it has limitations. MRI can sometimes give false negatives where the tendon ends appear to be in contact, so Karin often finds ultrasound more useful in practice.

See Karin demonstrate her assessment in this clip from her Practical:

Surgery or no surgery?

Once a rupture is identified, one of the first major decisions is surgical versus non-surgical management. Current thinking suggests outcomes are broadly equivalent, meaning the decision often comes down to patient factors and preferences.

Non-surgical management avoids an incision and reduces infection risk. Surgery, on the other hand, introduces risks such as scarring and wound complications. There is sometimes more concern about ensuring the tendon ends approximate well without surgery, but in reality both approaches can lead to good outcomes when managed appropriately. This is an important message to communicate early, as many patients assume surgery is necessary.

The role of education early on

Education is central from day one. Patients need reassurance that although recovery takes time (typically 6 to 12 months), the prognosis is generally good. The tendon continues to remodel well beyond the early stages, and early setbacks do not necessarily predict poor outcomes.

At the same time, patients should be made aware of the risk of Deep Vein Thrombosis (DVT), particularly in the early immobilisation phase. Clear guidance on recognising calf pain or unusual symptoms is important, as DVT is one factor that can lead to poorer outcomes.

In terms of rehab, it’s important to explain that some level of loading is beneficial for healing, rather than something to be avoided entirely. It’s also helpful to remind patients that it’s only the Achilles that requires protection, encouraging activity elsewhere can support physical fitness, confidence, and psychological wellbeing.

Initial management priorities

Early management focuses on protecting the tendon while allowing safe, progressive loading. The priority is to position the ankle in plantarflexion to bring the tendon ends together and avoid elongation. This is commonly achieved with a boot.

Karin is in favour of early weight bearing as tolerated in the boot, as this appears to support strength and recovery. In the first week, however, patients are often limited by pain and apprehension, so crutches are commonly used. Most patients begin to wean off crutches around 4 to 5 weeks while remaining in the boot.

Boot configuration is also important. Heel lifts are typically used to maintain plantarflexion. Some boots allow adjustable plantarflexion, which can simplify this process. Patients should be advised to wear the boot consistently, including at night, or substituting it for some sort of splint at least in the early stages.

Early exercises & monitoring progress

Within this protected phase, early movement and loading can begin in a controlled way.

Simple exercises such as seated isometric plantarflexion in the boot can be introduced 4–5 times per day, alongside toe curling to maintain foot muscle activity. Circulation exercises within the boot are also valuable. Importantly, these movements should not take the ankle beyond neutral (90 degrees).

Beyond the ankle, it is worth encouraging activity in other muscle groups. Exercises such as resisted knee extension can help maintain overall lower limb strength. For patients who are hesitant, simply practising weight bearing in a safe environment can be an important early step.

As the weeks progress, strengthening can be expanded to include resisted inversion and eversion in plantarflexion, and eventually plantarflexion with resistance bands.

In the early phase, there’s very little performance testing, it’s more about monitoring. Measures such as Achilles tendon resting angle (compared to the uninjured side) and calf circumference can provide useful insight into healing and muscle changes over time. If the patient has had surgery, regular monitoring of the scar is also important.

See Karin demonstrate this early-stage management in the clinic in this video from her Practical:

Wrapping up

Achilles tendon rupture can be a traumatic experience for the patient.

Initial management is about balancing protection with early, appropriate loading. Accurate diagnosis, clear communication around surgical versus non-surgical options, and strong patient education set the foundation.

From there, thoughtful use of immobilisation, gradual weight bearing, and simple early exercises can guide patients safely through the first few weeks. While recovery is not quick, getting these early decisions right can make a significant difference to long-term outcomes.

If you want to see exactly how an expert manages this stage in the clinic, watch Dr Karin Gravare Silbernagel’s full Practical here.