To evaluate and discuss controversies that have arisen as management of acute and chronic Achilles tendon ruptures continues to evolve. Areas of debate include operative versus nonoperative treatment, best repair or reconstruction techniques, timing of post-op weightbearing protocols, and newer functional rehabilitation interventions. With the incidence of Achilles tendon ruptures increasing, the goal of this review is to provide a resource in determining best treatment options. Evidence demonstrates that operative and nonoperative management yield comparable long-term functional outcomes. However, surgical repairs offer lower rerupture rates and earlier return to activity. There is a trend towards minimally invasive techniques for primary repairs, favored due to reduced wound complications and faster recovery. Earlier surgical intervention after injury shows improved functional outcomes. For chronic ruptures, flexor hallucis longus tendon transfer is the workhorse of secondary reconstruction. Early functional rehabilitation has been shown to be safe and effective across treatment strategies. The management of Achilles tendon injuries remains a complex clinical challenge that demands a comprehensive understanding of the tendon biomechanics, and distinct pathophysiological differences between acute and chronic presentations. Selection between operative and non-operative management requires individualized consideration, while adhering to evidence-based rehabilitation protocols is paramount to successful functional outcomes. Navigating these patient specific treatment options for various patient populations promotes optimal recovery in the short and long term.

Despite extensive research on Achilles tendon ruptures (ATR), the lived experience of patients remainsunder explored. This study aimed to investigate the experiences of individuals managed non-surgically within the National Health Service (NHS). Qualitative study using semi-structured, one-to-one interviews. NHS services in the United Kingdom providing non-surgical management for ATR. Fifteen patients (mean age 54.5 years) who had sustained an ATR and were managed non-surgically. Participants were recruited from a specialist ATR clinic. A stakeholder-informed topic guide was used to conduct semi-structured interviews. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis. Coding was undertaken independently by two researchers, with themes reviewed by the full research team. The study followed COREQ guidelines for qualitative reporting. Three themes were identified: (1) The experience of injury and entering the healthcare system: 'it felt as if my whole ankle had exploded' participants described sudden injury onset, sometimes painless, and varied understanding of treatment options; (2) The experience of non-surgical immobilisation: 'you're being told so much in that first session…I just couldn't remember' boot immobilisation was valued for mobility but challenged comfort and self-management; and (3) The rehabilitation journey: 'it happened so unexpectedly so it can happen again' fear and uncertainty about rehabilitation and returning to sport were common, shaping participant's rehabilitation experience. This study highlights how diverse ATR injury experiences, early management variability, and boot-related challenges impact recovery. Fear of re-rupture shapes rehabilitation and return to sport, emphasising the need for clearer guidance on boot use, weightbearing, and rehabilitation progression, alongside consistent healthcare professional support to optimise outcomes.

Mechanical integrity of a flexor hallucis longus tendon transfer using an all-inside endoscopic approach.

A systematic review of orthotic devices for conservative management of achilles tendon rupture in adults.

Biology Votes Repair?: Commentary on an article by Keyu Wei, MD, et al.: " Comparative Efficacy of Surgical Versus Nonsurgical Management for Acute Achilles Tendon Rupture in a Novel Mouse Model ".

Acute Achilles tendon rupture is a common and serious injury in sports medicine. Clinical studies demonstrate that both surgical and nonsurgical interventions can achieve satisfactory outcomes; however, considerable debate exists regarding the optimal treatment modality for this injury. Currently, most animal experimental studies on acute Achilles tendon rupture lack clinical relevance due to inadequate fixation of the ankle joint. This study involved 162 male C57BL/6 mice and 30 Scx-CreER T2 ; Rosa26-tdTomato transgenic mice. The injury+repair groups underwent Achilles tenotomy followed by Kessler suture repair, while the injury+no repair groups underwent tenotomy alone. Ankle joints were immobilized at 160° (plantar flexion) or 90° (neutral alignment). Samples were collected at 2 and 4 weeks post-injury for biomechanical, histological, and quantitative real-time PCR (qPCR) analyses, including tracing of Scx + tendon progenitor stem cells. Biomechanical analysis was performed 2 and 4 weeks post-injury. At 2 weeks, the injury+repair group immobilized at a maximum plantar flexion angle of 160° showed significantly higher failure force and stiffness compared with the injury+no repair+160° group. However, there was no significant difference between the groups at 4 weeks (p > 0.05). The failure force in each 160° group was significantly higher than in the corresponding 90° group (p < 0.0001). Histological analysis indicated better collagen fiber alignment and higher expression of collagen type I alpha 1 (COL1A1) in the injury+repair groups. qPCR revealed generally higher expression of tendon repair-related genes ( Scx, Tnmd, Tgfb1 ) in the injury+repair groups, while inflammatory factors ( Il1b, Il6 ) were higher in the injury+no repair+90° group. Scx + tendon progenitor stem cell tracing showed the greatest percentage in the injury+repair+160° group. Both surgical and nonsurgical treatments for acute Achilles tendon rupture achieved satisfactory tendon healing results when the ankle joint was maintained in maximum plantar flexion. However, surgical treatment yielded superior histological tendon repair. The results suggest that clinical trials may show immobilization in maximum plantar flexion following surgery to be optimal for tendon healing.

Background:Achilles tendon ruptures are among the most debilitating injuries in professional basketball, often leading to prolonged absence and long-term performance decline. While calf strains are common among National Basketball Association (NBA) athletes, their role as a precursor to Achilles rupture remains poorly understood.Hypothesis:A previous calf strain would be associated with increased odds of Achilles tendon rupture in NBA players and that affected players would experience significant post-injury performance declines.Study Design:Case-cohort study; Level of evidence, 3.Methods:Publicly available data on NBA players from 1958 to 2024 were analyzed, with the data search conducted in June 2025. Players with Achilles ruptures (n = 60) were compared with players with calf strains who did not sustain a rupture (n = 258). Logistic regression adjusted for age, body mass index, position, starter status, and workload. Pre- and postinjury performance was evaluated over 2 seasons using paired t tests. Descriptive analyses characterized injury laterality, game context, quarter, shoe type, and draft position. Video review assessed injury mechanisms.Results:Previous calf strain was associated with increased odds of Achilles rupture (odds ratio, 2.49; 95% CI, 1.16-5.22; P = .02). Among those with both injuries, 85.7% occurred on the same side, with a mean interval of 1.9 years. Of all players, a total of 75% returned to play. Postinjury declines were observed in player efficiency rating (−2.46), win shares (−3.23), games played (−260.3), and minutes per game (−5.19) (all P < .001). Return was more likely in younger players and those on multiyear contracts. Video analysis revealed a consistent “false step” mechanism in 95% of cases with footage. Most Achilles tendon ruptures occurred during in-game activity, while shoe type was evaluated descriptively and was not associated with player position or preinjury workload.Conclusion:Our study showed that previous calf strain is associated with an increased risk of Achilles tendon rupture in NBA players and may serve as a clinically identifiable risk marker. Rupture leads to substantial and sustained performance decline, even among those who return. Targeted rehabilitation and movement retraining may help mitigate progression to rupture in high-risk athletes.

ABSTRACT Purpose To evaluate the impact of Achilles tendon ruptures (ATRs) on return to play, longitudinal performance, and career longevity in National Football League (NFL) players using a matched cohort design. Methods A retrospective matched cohort study of 62 NFL players who sustained ATRs between 2008 and 2022, matched 1:1 to 62 non-injured controls by position, age (±1 year), height (±2 inches), weight (±10 lbs), and years in league (±1 year). Return-to-play (RTP) was assessed using multivariable logistic regression. Performance was measured using Approximate Value (AV) across three seasons before and after injury. Mixed-effects difference-in-differences modeling with placebo testing and survival analysis were the primary analytic methods. Results Mean age at injury was 27.24 ± 3.46 years. The RTP rate was 80.6% (50/62). Defensive position was the only independent predictor of RTP (OR 8.30, 95% CI 1.48–42.08; p = .015). ATR was associated with a 20.7% injury-attributable performance decline beyond natural career aging (DiD β = −1.24 AV; p = .043), with the largest decrement in the first post-injury season. Of 48 players with valid pre- and post-injury data, only 27.1% recovered to their pre-injury performance level. ATR independently increased the hazard of career termination by 68% (HR 1.68, 95% CI 1.18–2.39; p = .004), with injured players accruing 1.4 fewer active seasons over 10 years. Conclusions ATRs in NFL players are associated with significant and persistent performance decline beyond natural career aging, despite a high RTP rate. Return to play does not equate to restoration of pre-injury performance or preservation of career longevity. Level of evidence Level III, retrospective matched cohort study.

Accelerometry-derived physical activity following Achilles tendon rupture: A prospective cohort study.

BACKGROUND Mycobacterium mucogenicum is a rapidly growing nontuberculous mycobacterium that rarely causes cutaneous disease. Patients receiving tumor necrosis factor-alpha (TNF-alpha) inhibitors are at increased risk for opportunistic and granulomatous infections, including nontuberculous mycobacteria. To our knowledge, this is the first reported case of a cutaneous infection caused by M. mucogenicum in a patient receiving infliximab for inflammatory bowel disease (IBD). CASE REPORT We describe a 57-year-old man with Crohn's disease on infliximab who presented with dermal abscesses, ulcerations, and lymphangitis. The patient initially received empiric levofloxacin therapy and developed an early Achilles tendon rupture within 4 days, likely related to underlying enthesiopathy and fluoroquinolone exposure. Microbiologic evaluation confirmed M. mucogenicum. He was treated with trimethoprim-sulfamethoxazole and clarithromycin, while infliximab was continued due to active disease. The patient showed clinical improvement with resolution of systemic symptoms and progressive healing of skin lesions. Antimicrobial therapy was continued for 6 months with sustained response. CONCLUSIONS This case highlights the importance of early recognition of nontuberculous mycobacterial infections in patients receiving TNF-alpha inhibitors. Combined therapy with clarithromycin and trimethoprim-sulfamethoxazole was safe and effective despite continued infliximab use. Our case suggests that fluoroquinolones should be used with caution in patients with IBD and suspected enthesiopathy due to the potential risk of tendon rupture.

Background:Absorbable sutures (such as Vicryl sutures) support tendon rupture repair, but the immune response triggered by the sutures affects tendon healing. A rat Achilles tendon model was used in this study to explore the role of sutures in tendon healing.Purpose:To evaluate the physicochemical properties, biomechanical properties, cytotoxicity, heat-induced pain sensitivity, histological alterations, and the responses of regulatory T (Treg) cells and macrophages to polyamide (PA), polyglycolic acid (PGA), and poly(lactic-co-glycolic acid) (PLGA) sutures in Achilles tendon healing.Study Design:Controlled laboratory study.Methods:A rat Achilles tendon rupture model was established, followed by modified Kessler repair with size 5-0 PA, PGA, and PLGA sutures. The repaired tendons were tested at 2 weeks and 4 weeks after surgery. The ultimate load and failure stress of the repaired tendons were evaluated using a uniaxial loading device. The samples were stained with hematoxylin and eosin (H&E) as well as Sirius red for histological evaluation. Immunohistochemical analysis was conducted to investigate alterations in macrophages and Treg cells.Results:All 3 sutures (PA, PGA, and PLGA) maintained structural integrity after repair. However, compared with nonabsorbable PA, absorbable sutures (PGA and PLGA) demonstrated higher failure loads. At 4 weeks after suture, the postsutured tendons in the 3 groups were thicker, and the PGA (78.64 ± 4.69 N) and PLGA (71.19 ± 3.81 N) groups demonstrated significantly greater ultimate loads than the PA (54.76 ± 5.79 N) group; compared with the PLGA group, the PGA group exhibited more adhesion. Histologically, the Bonar scores for the PGA (9.60 ± 0.89) and PLGA (9.80 ± 0.83) groups were significantly lower than that for the PA group (11.20 ± 0.83) at 4 weeks postsuture. Collagen type III predominated in the PA and PLGA groups, whereas collagen type I was predominant in the PGA group at 2 weeks postsuture. Immunohistochemical analysis demonstrated that the proportions of CD86+ (M1, proinflammatory) macrophages, CD206+ (M2, anti-inflammatory) macrophages, and CD25 and Foxp3 (Treg cell markers) were significantly greater in the PGA group than in the PLGA and PA groups at 2 weeks after surgery.Conclusion:The PGA and PLGA groups demonstrated comparable biomechanical properties, whereas compared with the PGA group, the PLGA group exhibited superior healing outcomes (fewer adhesions and more balanced collagen remodeling) and milder Treg cell and macrophage responses.Clinical Relevance:These results can help clinicians choose suture materials.

Achilles tendon ruptures (ATRs) are rare but severe injuries for players in the National Football League (NFL). Systematic video analysis of these injuries, combined with player tracking data and epidemiological analysis, can provide critical insight into the circumstances surrounding ATRs in the NFL and inform potential injury mitigation strategies. To characterize the injury scenarios and situational patterns associated with ATRs in the NFL through a retrospective review of all in-game ruptures over 7 seasons. Descriptive epidemiology study. All ATRs from 7 seasons (2018-2024) of NFL games were identified through the NFL's league-wide electronic medical records and reviewed to identify the time of injury, player-to-player contact, and injury scenario. These data were integrated with player and game information to evaluate injury rates across player characteristics and game variables. Time-aligned player tracking metrics, including speed and direction of motion, were also calculated to evaluate player movements at the time of injury. A total of 77 ATRs occurred during NFL games from 2018 to 2024. These were primarily noncontact (64%) or indirect contact (35%) injuries that occurred at relatively low translational player speeds. Overall, 3 primary injury scenarios accounted for 97% of ATRs: change of direction (40%), overload (30%), and rock back (27%). Players typically had a similar body position at the time of injury. In most cases, the injured leg was extended behind the body, with the ankle dorsiflexed and the hip and knee extended. Defensive players and those with >3 years of NFL experience had a higher injury rate. This study presents a comprehensive analysis of how ATRs occur in NFL games. The relatively low player speeds and predominantly noncontact nature of these injuries indicate that the high tendon loads that contribute to rupture are likely driven by player body positioning and propulsive push-off mechanics. Interventions that target high-risk player movement patterns could be effective injury prevention strategies, especially for rock back injury scenarios in which player motion appears to be more of a planned movement strategy rather than a reaction.

Psychological and functional assessment of Achilles tendon ruptures and their return to sports.

Achilles tendon rupture impairs the functional performance of the triceps surae muscle-tendon unit. However, long-term effects of different rehabilitation programs on these impairments remain unclear. This study evaluated the long-term effects of early rehabilitation versus cast immobilization after Achilles tendon repair. We also examined whether the uninjured side could serve as a reference for the "healthy" side. Males with previous Achilles tendon rupture (n = 20) and a group of healthy male controls (CTR; n = 10) participated. Participants with Achilles tendon rupture included a short-term physical therapy group (STPT; n = 10) and a plaster cast group (PC; n = 10). Triceps surae morphology and ankle functionality were compared among groups. No between-group differences were found in the patient-reported outcomes. The injured side presented lower heel rise height, plantar flexors strength, gastrocnemius medialis thickness, calf volume, and shorter fascicle length than CTR. On the injured side, the STPT preserved ankle range of motion and showed greater plantar flexion and total range of motion than the PC. We used a computational model that demonstrated that tendon elongation was the main determinant of heel rise height deficit. The uninjured side presented lower heel rise height than the CTR group. Despite favorable patient-reported outcomes, long-term structural and functional deficits persist after Achilles tendon rupture, regardless of rehabilitation approach. Findings suggest that the rehabilitation programs used did not fully restore muscle-tendon function and highlight limitations of using the uninjured side as a control.NEW & NOTEWORTHY This study compares early mobilization and plaster cast rehabilitation after Achilles tendon rupture, with surgeries performed by a single surgeon. We demonstrate that long-term structural and functional deficits persist 2 yr after Achilles tendon rupture, regardless of rehabilitation type. With a computational model, we investigated the mechanisms underlying heel-rise deficits, quantifying structural contributions. Including a healthy control group revealed that the uninjured side also shows impairments, calling into question its use as a reference in clinical and research settings.

Surface EMG analysis of tibialis anterior and gastrocnemius activity under different loading positions.

Artistic gymnastics is a complex and challenging sport. The specific demands of gymnastics place athletes at unique risk of injuries to the spine, as well as upper and lower extremities. Changes to the rules and scoring system since the 2004 Olympics have encouraged athletes to perform more challenging skills, adding to the risk of injury. Single-sport specialization occurs at a young age among competitive gymnasts, introducing an increased risk of overuse injuries. Common injuries include spondylolysis, medial-sided elbow injuries, gymnast's wrist, ligamentous injuries of the knee, and Achilles tendon ruptures. It is important to understand these injury patterns to properly prevent, treat, and safely return these athletes to play.

The UK Foot and Ankle Thromboembolism (UK-FATE) Collaborative evaluated incidence of venous thromboembolism (VTE) in foot and ankle surgery and Achilles tendon (AT) rupture. As part of the data collection, infection within 90 days was a secondary outcome. This study aimed to evaluate overall rate of superficial and deep infection following foot and ankle surgery in trauma, elective, and acute diabetic surgery. Data were collected prospectively across 68 centres in the UK for all patients who underwent foot and ankle surgery between 1 June and 30 November 2022. Over 500,000 data points were collected, including development of superficial and deep infection within 90 days of procedure and presence of comorbidities. UK-FATE captured 90-day infection data for a total of 9,723 cases. When nonoperatively managed AT ruptures were excluded, infection data were available for 9,591 trauma, elective, and acute diabetic procedures. Overall superficial and deep infection rates in all procedures were 4.1% (n = 397/9,591) and 1.4% (n = 133/9,591), respectively. Both superficial (7.4% (n = 29); p < 0.001) and deep infection (8.7% (n = 34); p < 0.001) rates were highest in acute diabetic procedures. Deep infection differed between trauma (1.4% (n = 65/4,351)) and elective (0.7% (n = 34/4,785)) procedures (p < 0.001), but superficial infection rates were similar (3.9% (n = 171/4,245) and 4.1% (n = 197/4,588), respectively (p = 0.638)). On multivariate regression analysis, peripheral vascular disease (OR (odds ratio) 2.86 (95% CI 1.74 to 4.56); p < 0.001), smoking (OR 1.54 (95% CI 1.18 to 2.00); p = 0.001), diabetes (OR 1.83 (95% CI 1.35 to 2.44); p < 0.001), American Society of Anesthesiologists grade III to IV (OR 1.94 (95% CI 1.37 to 2.73); p < 0.001), and chemical VTE prophylaxis (OR 1.38 (95% CI 1.03 to 1.85); p = 0.031) were independent predictors for developing infection. Rates of superficial and deep infection were significantly higher in patients with acute diabetic surgery. Deep infection rates were higher in trauma than in elective surgery, but superficial infection rates were similar. Comorbidities and smoking affected infection rate in foot and ankle surgery, and should be optimized preoperatively and considered in postoperative monitoring.

Endoscopic versus open flexor hallucis longus tendon transfer for reconstruction of chronic achilles tendon rupture: A prospective randomized pilot trial.

BackgroundOutcome after an acute Achilles tendon rupture often leaves individual variations in recovery and lingering impairment. Simple and accurate methods to assess healing during early rehabilitation are lacking. In this pilot study, we developed and evaluated a graded assessment procedure based on Thompson´s test. The aim was to examine if foot movement of the injured foot can be reliably assessed with the Four-point Scale of Thompson’s test (FST).MethodsThe observed foot movement on the injured side, was graded in four categories, zero to three, in relation to the foot movement on the non-injured side. Assessments of foot movement for 24, non-surgically treated, individuals were performed at 2, 4, 8, 10 and 12 weeks after the injury. The movement was visually measured by two examiners, physiotherapists, and simultaneously measured using a marker based three-dimensional motion analysis system (3D-MA). Visual FST measurements were compared with the 3D-MA–based measurements.For each method, intra- and inter-observer agreement as well as between method agreement was evaluated using AC2 agreement measure and difference plots.ResultsThe intra- and inter observer agreement for the FST showed that that the agreement for examiner 1 was 0.94 and for examiner 2, 0.84 while the agreement between 1 and 2 was 0.83. Intra-observer agreement for the 3D-MA measurements for examiner 1 was 0.84 and for examiner 2 were 0.85 while the agreement between examiner 1 and 2 was 0.70. Agreement between methods for examiner 1 was 0.67 and for examiner 2, 0.57. Both measurement methods showed a similar increase of the average foot movement over the follow-up period. ConclusionsOur findings suggests that the inter- and intra-examiner agreements were high indicating that the scale is reliable within and between raters. The agreements between FST and 3D-MA was moderate indicating that criterion validity needs further studies against a modified marker-based 3D motion analysis.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12891-026-10011-y.

Achilles tendon ruptures (ATRs) are uncommon but career-threatening injuries in elite athletes. Limited evidence exists regarding return-to-sport (RTS) and performance outcomes among National Hockey League (NHL) players following ATR. This study aimed to evaluate RTS rates and post-injury performance metrics in NHL players after ATR, using matched controls for comparison. NHL players who sustained an ATR between the 2000-2001 and 2024-2025 seasons were identified using publicly available databases and confirmed through independent sports news sources. Each player was matched 1:1 to a control based on position, age and pre-injury performance using a validated similarity algorithm. Demographic data and performance metrics, including points per game (PPG), games played (GP), average time on ice (ATOI) and a validated hockey-specific performance score (PS), were collected for two seasons before and after the injury or index date. RTS rates and pre- versus post-injury changes were assessed using paired t tests, with significance set at p < 0.05. A total of 20 NHL players met the inclusion criteria and were successfully matched to controls. The overall RTS rate was 87.0%, rising to 100% when accounting for players who retired from the NHL but continued playing professionally in other leagues. Although players with ATR (cases) demonstrated performance declines post-injury, no significant differences were observed in PS, PPG, ATOI or GP at any position, except for PS when all positions were analysed collectively. Similarly, control players experienced non-significant performance declines across all metrics post-index. ATR in NHL players is associated with high RTS rates and largely preserved performance metrics. While a modest decline in PS was observed, other key metrics remained stable compared to matched controls. These findings support favourable functional recovery and can inform post-injury expectations and management. Level III.