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Acute complete Achilles tendon rupture — MSRA MCQ

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HardSoft Tissue InjuryAcute complete Achilles tendon ruptureMSRA

A 43-year-old recreational tennis player attends a GP-led urgent treatment centre 3 hours after pushing off to reach a ball. He felt a sudden painful snap in his left calf and initially thought he had been struck from behind. He stopped playing immediately. There is mild posterior ankle swelling but no wound, deformity or bony tenderness. He can actively plantarflex the ankle, although this is weak and painful, but cannot perform a single-leg heel raise. The resting position of the affected foot is more dorsiflexed than the other side. There is a palpable gap approximately 4 cm proximal to the calcaneal insertion. Simmonds-Thompson testing produces no plantarflexion on the affected side. Distal neurovascular examination is normal. What is the most appropriate management today?

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Correct answer: E — Immobilise in an equinus walking boot with three heel wedges, perform VTE risk assessment, and refer today to the local fracture clinic or orthopaedic pathway

This is an acute complete Achilles tendon rupture: the mechanism is a forceful push-off, there is a palpable tendon gap and the Simmonds-Thompson test is positive. Preserved active plantarflexion does not exclude rupture because other flexors can contribute to ankle plantarflexion; the inability to perform a single-leg heel raise and abnormal resting ankle position further support complete functional disruption. Initial management should protect apposition of the tendon ends by holding the ankle in equinus, typically using a walking boot with three wedges. VTE risk assessment is required because reduced mobility and lower-limb immobilisation increase thrombotic risk; anticoagulation is prescribed when indicated by that assessment, rather than automatically. Referral through the local fracture clinic or orthopaedic pathway should be made today so that definitive functional bracing versus operative management can be considered. A is inappropriate because this presentation is clinically diagnostic; ultrasound may be arranged by the specialist pathway if needed, but should not delay protective immobilisation. B mistakes a clinically evident Achilles rupture for a calf muscle injury. D and E hold the ankle in neutral, which risks separating the torn tendon ends; routine follow-up also delays definitive care.

Reference: Achilles tendon rupture: management and rehabilitation (accessed 16 August 2026) — https://www.cuh.nhs.uk/patient-information/achilles-tendon-rupture-management-and-rehabilitation/ MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria (2012) — https://pubmed.ncbi.nlm.nih.gov/22538958/