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Acute Achilles tendon rupture — MSRA MCQ

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ModerateSoft Tissue InjuryAcute Achilles tendon ruptureMSRA

A 44-year-old recreational tennis player attends a GP-led urgent treatment centre 3 hours after pushing off to reach a short ball. He felt a sudden painful pop in his left calf and initially thought someone had kicked him. He can walk with a limp but cannot push off normally or rise onto the toes of the affected side. There is swelling and bruising around the distal calf and ankle. A palpable gap is present approximately 4 cm proximal to the calcaneal insertion. With the patient prone and feet hanging over the edge of the couch, squeezing the left calf produces no plantarflexion, whereas the right foot plantarflexes normally. Active plantarflexion is present but weak. Ankle radiographs show no fracture. Distal pulses and sensation are normal. What is the most appropriate management now?

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Correct answer: E — Fit a plantarflexed walking boot with heel wedges, undertake venous thromboembolism risk assessment, and arrange urgent fracture-clinic or orthopaedic review

This is an acute Achilles tendon rupture: the mechanism is forceful push-off, he describes a pop and being kicked in the calf, there is a palpable tendon gap, and the calf-squeeze (Thompson) test is positive. Preserved active plantarflexion does not exclude rupture, because accessory plantarflexors can still generate some movement. Normal radiographs do not alter the clinical diagnosis. Initial UK urgent-care management is protection in plantarflexion using a walking boot with heel wedges, assessment of venous thromboembolism risk, and urgent fracture-clinic/orthopaedic pathway referral. Definitive treatment may be functional bracing or operative repair, but that decision follows specialist assessment. Ultrasound may be requested by the fracture clinic, but should not delay protective immobilisation and referral. A gastrocnemius strain would not usually produce a palpable Achilles gap with an absent plantarflexion response on calf squeeze. MRI is not the appropriate first-line investigation in an uncomplicated clinically apparent rupture. Immobilising the ankle in neutral risks tendon elongation and is therefore inappropriate.

Reference: Achilles tendon rupture: management and rehabilitation (2026) — https://www.cuh.nhs.uk/patient-information/achilles-tendon-rupture-management-and-rehabilitation/ Non-insertional Achilles tendinopathy (31 July 2025) — https://www.rightdecisions.scot.nhs.uk/borders-ref-help-toolkit/orthopaedic/foot-and-ankle/non-insertional-achilles-tendinopathy/