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Achilles Tendon Ruptures: Return to Play

Zellers JA, Carmont MR, Silbernagel KG (2016) Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Br J Sports Med. 2016;50:1325-1332

Achilles tendon ruptures are relatively common in the middle-age male “weekend warrior” population, and present a significant obstacle to maintenance of health and prevention of morbidities related to inactivity. Muscle weakness, decreased endurance, and fear of re-rupture may cause an individual to avoid the sports activity during which injury occurred, and resulting altered biomechanics may induce other MSK problems like knee injuries and contralateral Achilles tendinopathy.


Achilles tendon ruptures are caused by rapid and forceful contraction, often in the eccentric loading phase (forced dorsiflexion). Risk factors include preceding tendinopathy, intermittent activity, recent changes in athletic training schedule, poor warm-up, and fluoroquinolone or corticosteroid use. Patients present with acute onset of localized pain associated with hearing or feeling a pop. There may be a prodrome of muscle pain prior to event. On physical exam, the injured leg may be more dorsiflexed when prone, have a palpable gap and be weak in plantar flexion. Lack of plantar flexion when the calf is squeezed is considered a positive Thompson test. Ultrasound may be used to determine complete vs. partial ruptures. Urgent referral to orthopedics should be considered as operative treatment should occur within 6 weeks to avoid tendon retraction, especially in young sprinting athletes. However, non-operative management involving functional rehabilitation and casting in resting plantar flexion is becoming more common in most patients as new evidence emerges. Re-rupture rates and plantar flexion strength have been shown to be not significantly different when comparing non-operative to operative management. Also, studies have consistently shown increased complications rates with operative management.

Traditional recommendations are that jogging can be started after 12-16 weeks, return to non-contact sport after 16- 20 weeks. and to contact sports after 20- 24 weeks. In this article, return to play (RTP) rates were close to 80% and average time to RTP was 6 months, ranging from 3 to 10.4 months. However, it did not differentiate between surgical and non-surgical management. Functional criteria to consider prior to RTP, as always, include range of motion, strength (using single-leg heel raises), and sport-specific movements.

Ryan Shields, MD, MSc, CCFP

PGY-3 Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (CAC SEM), Dip SPort & Exercise Medicine

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