The Center for Podiatric Care and Sports Medicine

Is It an Achilles Rupture or a Sprained Ankle? Why 1 in 4 Achilles Tendon Ruptures Are Misdiagnosed

Posted by on Monday, February 29th, 2016


A quarter of all impending Achilles tendon ruptures are missed during initial examinations, according to a new study from researchers at the University School of Osteopathic Medicine and the Rothman Institute of Jefferson Medical College. Proper diagnosis is the linchpin of successful treatment outcomes, no matter what foot or ankle injury is being treated, so this is a topic that very much concerns podiatrists across the country, including us here at The Center for Podiatric Care and Sports Medicine where Achilles injury management is one of our specialties.

Achilles rupture
Did you know Achilles tendon ruptures do not always cause pain? Image Source:

Who Ruptures Their Achilles Tendons?

The Achilles tendon is the largest tendon in the body and is largely responsible for the explosive power we need to walk, run and jump. The review found that about 8% of all athletes will experience an acute rupture during their lifetime. In those instances, a snapping sound is heard and severe pain makes the injury unmistakable. Another 24% will experience chronic tendinopathy at some point in their careers. This type of discomfort usually flares during periods of activity and can be more difficult to diagnose, as it wouldn’t necessarily show up in all imaging tests.

Non-athletes are less likely to suffer a rupture, but we do see some cases, particularly with elderly, sedentary, overweight, and infrequent exercisers known as “weekend warriors.” People with autoimmune disease and plantar fasciitis have an increased risk of rupture, as do patients who smoke, receive localized steroid injections, or take certain antibiotics.

Why Are Achilles Ruptures So Difficult to Identify?

There are several reasons for missed or incorrect diagnosis:

The wide distribution of people who rupture their Achilles tendons: As clinicians, we need to broaden our idea of which type of patient sustains this injury. It’s not just athletes! According to Lower Extremity Review“Missed or delayed diagnosis occurred more commonly in patients aged 55 years or older and the injury was more likely to result from an event not related to sports participation (34% vs 19% that occurred during sports).”

The lack of pain: A third of patients with ruptured tendons did not experience pain, which runs contrary to popular belief. This is especially true when the rupture is preceded by a series of partial tears that occurred gradually over time. Podiatry Today explains, “The patient may not bother to seek care due to the fact that the pain is often tolerable and the limb still functions well enough for ambulation.”

The limitations of physical exams: A routine physical exam will not show an impending Achilles rupture nor will x-rays. Magnetic Resonance Imaging is helpful in determining the extent of Achilles tendon damage, but it’s not always routinely ordered. Most commonly, Achilles ruptures are misdiagnosed as ankle sprains. Since the 1980s, researchers have pointed to several widespread fallacies leading to a missed or incorrect Achilles tendon diagnosis. It was previously, wrongly believed that patients could not have a ruptured Achilles if:

  • The patient can walk.
  • The patient can flex the plantar muscle.
  • No gap is felt on palpation.
  • The patient does not have increased dorsiflexion with passive range of motion.

The type of help sought: More often than not, patients seek treatment from emergency room doctors or primary care physicians who do not have specialized training in conditions of the foot and ankle. Achilles tendinopathy and ruptures are among the chief conditions we diagnose and treat in our NYC practice, so we know a thing or two about detection.

The Good News about Achilles Injury Treatment

On a positive note, researchers found that most patients actually healed better with non-invasive, conservative treatment, rather than surgery. Rest, over-the-counter medication, physical therapy, and a few weeks in a walking boot is all that most patients require to manage their Achilles tendon injury.

That said, surgery is still the preferred mode of treatment when patients are young, active athletes with acute tears. As Dr. Joseph N. Daniel from Jefferson Medical College in Philadelphia explains, surgical intervention in younger athletes is “associated with lower rates of re-rupture and a quicker return to activity.”

Contact our NYC foot and ankle specialists to set up an exam and discuss your full range of options.


If you have any foot problems or pain, contact The Center for Podiatric Care and Sports MedicineDr. Josef J. GeldwertDr. Katherine Lai, Dr. Ryan Minara and Dr. Mariola Rivera have helped thousands of people get back on their feet. Unfortunately, we cannot give diagnoses or treatment advice online. Please make an appointment to see us if you live in the NY metropolitan area or seek out a podiatrist in your area.