162 Curr Rev Musculoskelet Med (2008) 1:161–164 Fig. 1 (a) and (b)—Intra-operative view of ruptured Achilles tendon studies using computer assisted imaging show a reduction in the number and the mean relative area of mesotenal vessels in the mid-section of the tendon. Similarly, the number of intratendinous vessels is fewest 4 cm from the calcaneal insertion [11]. Physical examination Diagnosis of an acute Achilles tendon rupture can usually be made by history and physical examination alone. MRI or ultrasound can be helpful in cases of suspected rupture for pre-operative planning, but is usually unnecessary. The patient will often describe abrupt severe pain over the tendon with an activity requiring forceful plantar ﬂexion such as while playing tennis. Often the patient will feel a ‘‘pop’’ or have the sensation of being hit in the back of the heel. Physical examination signs that suggest Achilles tendon rupture include weakness of plantar ﬂexion and a palpable defect over the posterior calf. A Thompson test is performed by squeezing the calf and observing motion at Fig. 2 Normal Thompson’s test. Note plantar ﬂexion of foot with squeezing of the calf. Indicative of intact Achilles tendon Fig. 3 Thompson’s test in patient with Achilles tendon rupture. Note lack of plantar ﬂexion with squeezing of the calf demonstrating a ruptured Achilles tendon the foot. With an intact tendon, the foot planterﬂexes with squeezing the calf (Fig. 2). With a rupture, plantar ﬂexion does not occur with squeezing the calf [12] (Fig. 3). Operative versus non-operative management Controversy regarding operative versus non-operative treatment focuses on re-rupture rates and wound compli- cations related to surgery. Khan et al. compared the results of all randomized trials comparing surgical and conserva- tive management in a meta-analysis. Results gave a pooled