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Acute complete Achilles tendon rupture — MSRA MCQ

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HardSoft Tissue InjuryAcute complete Achilles tendon ruptureMSRA

A 52-year-old woman presents to an urgent treatment centre 2 hours after forcefully pushing off during badminton. She heard a snap and felt as though she had been kicked in the back of the calf. Her BMI is 34 kg/m² and she uses oral oestrogen-containing hormone replacement therapy. She walks with a flat-footed gait and can plantarflex the ankle against resistance. Examination reveals a palpable gap 4 cm proximal to the calcaneal insertion, increased resting dorsiflexion compared with the unaffected side, and absent plantarflexion during calf compression. There is no bony tenderness over the malleoli, navicular or base of the fifth metatarsal. She can take four steps, and distal neurovascular examination is normal. Which is the most appropriate initial management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Immobilise in equinus, arrange acute fracture-clinic review, and assess VTE and bleeding risk

The forceful push-off, perceived kick and snap suggest Achilles rupture. The palpable gap, increased resting dorsiflexion and absent plantarflexion on calf compression constitute the Simmonds triad and provide strong clinical diagnostic evidence. Retained walking and resisted plantarflexion do not exclude rupture because the other plantarflexors remain functional. The tendon should be protected immediately in equinus using an appropriate cast or a boot with heel wedges, thereby approximating the torn ends. Acute fracture-clinic or equivalent orthopaedic-pathway review should follow; ultrasonography may be arranged by that service but should not postpone protective immobilisation or referral. Lower-limb immobilisation also requires assessment of VTE against bleeding risk. Her obesity and oral oestrogen exposure increase concern, but pharmacological prophylaxis depends on the individual risk balance. A and D use neutral positioning, which may allow tendon-end separation; the supplied fracture-screening findings also do not support routine radiography. B incorrectly delays immobilisation and makes management contingent on imaging despite a diagnostic examination. E uses appropriate positioning and risk assessment but assigns an acute complete rupture to a routine community pathway rather than timely fracture-clinic review.

Reference: Achilles tendon rupture: management and rehabilitation (October 2025) — https://www.royalberkshire.nhs.uk/media/vq0plc5n/achilles-tendon-rupture-conservative-management_oct25.pdf Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism — Recommendations (Published 21 March 2018; updated 13 August 2019; last reviewed 18 September 2024) — https://www.nice.org.uk/guidance/ng89/chapter/Recommendations Acute Achilles tendon rupture (22 October 2015) — https://www.bmj.com/content/351/bmj.h4722.abstract