Partial or complete rupture of the Achilles tendon, commonly presenting with sudden posterior-ankle pain and loss of plantar-flexion function.
THE MSK CLINICAL STORY
Who kicked my heel? The mystery with nobody behind you
A fictional teaching case. Follow the clues, enjoy the conversation, and make the decisions a thoughtful clinician would make—not an instant diagnosis from a single symptom.
Scene 01 · The patient walks in
A weekend badminton player pushes off to reach a shot. He looks behind him: 'Someone kicked me!' Nobody is there. He struggles to push off and cannot manage a single-leg heel rise.
A little clinic conversation
Patient: 'Maybe it's a calf cramp?' Therapist: 'A cramp is possible in some stories. This one needs an Achilles check first.'
Scene 02 · Follow the clues
A sudden kick-like sensation, weak plantar flexion and an abnormal calf-squeeze response raise concern for Achilles rupture.
Plot twist · What could fool us?
Some people with a ruptured Achilles can still point their toes using other muscles. Active plantar flexion alone does not rule out rupture.
Choose your learning lens
Same clinical case, two ways to understand it. The complete examination and treatment guide is still available below.
In everyday words
The strong tendon behind your ankle may have torn. This needs prompt medical assessment and a protected treatment pathway—not a vigorous massage or stretching session.
Scene 03 · The rehabilitation journey
First: protect and obtain a specialist plan. Later: staged loading, calf strength and eventually propulsion, within the selected operative or nonoperative protocol.
A patient felt kicked in the heel, cannot push off and shows no plantar flexion on calf squeeze. Best action?
Choose one answer to reveal the explanation. No score, no pressure—just better clinical reasoning.
These cases teach reasoning; they do not provide a diagnosis for an individual patient. Always consider red flags, contraindications, comorbidities and local referral pathways.
Each test includes patient setup, therapist position, hand placement, exact performance, positive finding and clinical interpretation.
Thompson (Calf-Squeeze) Test
Assess Achilles tendon continuity.
Patient position
Prone with feet beyond the edge of the plinth, or kneeling with feet unsupported.
Therapist position
At the foot of the tested side.
Hand placement
Both hands around the calf muscle belly.
How to perform
1Ensure the ankle is relaxed.
2Squeeze the calf firmly.
3Observe the foot for plantar flexion.
4Compare with the opposite side if uncertain.
Positive sign
Absent or markedly reduced plantar flexion during calf squeeze.
Interpretation
Strongly supports Achilles tendon rupture.
Clinical note: A positive Thompson test can establish strong clinical suspicion; imaging is not automatically required when the examination is clear.
Matles Test
Assess resting ankle position for tendon discontinuity.
Patient position
Prone with both knees flexed to about 90°.
Therapist position
At the foot of the table.
Hand placement
No special hand placement; observe ankle resting position.
How to perform
1Flex both knees to about 90°.
2Compare resting ankle position side to side.
Positive sign
Injured ankle falls toward more dorsiflexion / less resting plantar flexion.
Interpretation
Supports Achilles rupture when combined with other findings.
Differential Diagnosis
Severe calf strain
Achilles tendinopathy
Plantaris injury
Ankle sprain
DVT
Investigations / Imaging
Diagnosis is often clinical when Thompson and examination are clear.
Ultrasound or MRI may help when findings are equivocal, partial tear is suspected or surgical planning requires it.
Complete Rehabilitation Plan
From protection to full function
Phase 0 — Immediate Protection & Referral
Protect tendon length and enter an evidence-based operative or nonoperative pathway.
What to do
Prompt orthopaedic/medical assessment
Immobilize in plantar flexion/equinus according to local protocol
Avoid unprotected dorsiflexion stretching
Shared decision-making regarding operative vs nonoperative management
Exercise dosage
Maintain safe hip/knee/toe ROM and general conditioning as allowed by the treating protocol
Progress when
Formal rupture pathway established
Protection/boot protocol understood
Phase 1 — Protected Functional Rehabilitation
Restore safe weight bearing and controlled motion without tendon elongation.
What to do
Boot/wedges and weight-bearing progression per protocol
Early safe ROM within protocol
Calf isometrics when cleared
Gait training
Exercise dosage
Isometric plantar flexion: multiple low-to-moderate effort holds when cleared
Hip/knee strengthening: 2–4 sets of 8–15
Progress when
Walking in boot safely
No wound/skin concerns
No excessive pain/swelling
Protocol milestones met
Phase 2 — Calf Strength Restoration
Rebuild plantar-flexor strength and tendon load capacity.
What to do
Progress seated to standing calf loading
Double- to single-leg heel raise progression
Balance and gait normalization
Exercise dosage
Calf raises: 3–5 x 6–15 with progressive load
Soleus-biased seated raises: 3–4 x 8–15
Balance: 3 x 30–60 s
Progress when
Good heel-raise height/control
Walking without meaningful limp
No reactive swelling
Phase 3 — Energy Storage & Return
Restore hopping, running and sport/work demands.
What to do
Plyometric progression
Running
Acceleration/deceleration
Sport-specific work
Exercise dosage
Plyometrics 2–3 times/week after strength prerequisites
Running volume and speed progressed gradually
Progress when
Strong repeated single-leg heel raise
Hop/run tolerance
Near-symmetrical functional capacity
Manual Therapy — Role & Application
Do not aggressively mobilize into dorsiflexion early or stretch the healing tendon beyond protocol.
Later joint/soft-tissue techniques may address secondary stiffness once tendon protection allows.
Scar mobilization may be considered after surgical wound healing.
Modalities — Use / Avoid
Modalities are secondary to protection and progressive loading.
Compression may help swelling when medically appropriate.
Monitor for DVT signs during immobilization.
Return / Discharge Criteria
Protocol completed
Near-symmetrical calf strength/endurance
Repeated single-leg heel raises with good height
Running/hopping demands tolerated
Clinician/orthopaedic clearance for high-demand sport when required
Common Clinical Mistakes
Treating rupture like simple Achilles tendinopathy
Early aggressive dorsiflexion stretching
Ignoring tendon elongation risk
Progressing running before calf capacity is restored
Clinical Pearls
Calf squeeze with no plantar flexion = Achilles rupture until proven otherwise.
Operative and nonoperative pathways both require structured rehabilitation.
Continue learning
Connect assessment with management
Use the related PNA learning pathways to explore examination techniques and structured rehabilitation. A test result should always be interpreted alongside the history, full examination and clinical presentation.
Use these sources as a starting point for clinical learning. A reference being listed here does not, by itself, establish that every recommendation on this page is strongly supported. Check the original publication, study design, population and limitations before applying findings to an individual patient.
Educational resource only. Tests and treatment plans must be adapted to the individual patient, irritability, comorbidities, surgical restrictions and local scope-of-practice requirements.
