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Achilles tendon rupture

102 citationsUpdated Sep 2026
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Overview

Achilles tendon rupture incidence has increased, yet the use of operative treatment has decreased [37]. Controversy persists regarding the management of both acute and chronic ruptures despite a substantial body of evidence [2]. The American Academy of Orthopaedic Surgeons (AAOS) recommendations range from Inconclusive to Moderate, indicating that further studies are needed for stronger guidance [9]. For chronic Achilles tendon rupture, a 2024 guideline serves as a valuable resource for physicians making surgical treatment decisions [12]. In situations of clinical equipoise for acute rupture, shared decision-making provides a useful framework for discussing treatment options, supporting patient autonomy as they weigh risks and benefits [132].

Operative treatment decreases rerupture rates but increases the risk of minor complications compared to non-operative management [35, 36]. Conversely, results indicate no differences in reoperation rates between operative and nonoperative management [49]. Studies suggest equivalent functional outcomes with or without surgical treatment for acute rupture provided a functional rehabilitation program is followed [132]. While there appears to be a clinically important difference in complication risk between minimally invasive surgical treatment and nonoperative treatment, this difference was not statistically significant [128]. For chronic rupture, surgical intervention yields superior patient-reported outcomes compared with non-surgical treatment [1]. Both nonoperative and operative management of myotendinous ruptures demonstrate good outcomes, although literature on this specific topic is limited [27].

Long-term recovery remains incomplete for the majority of patients two years after injury, regardless of treatment modality, with only minor improvements occurring between one- and two-year evaluations [4]. Open end-to-end repair provides long-term functional outcomes with consistent good to excellent results [3]. Minimally invasive repair offers excellent long-term outcomes [8], and percutaneous techniques yield essentially identical clinical and functional outcomes with no reruptures or major complications at a minimum follow-up of 24 months [23]. Intraoperative ultrasonography assistance is an efficient, reliable, and safe method for minimally invasive repair [50]. Timing is critical: patients operated on within 48 hours after injury have better outcomes and fewer adverse events than those operated on after 72 hours [18]. However, patients presenting more than two weeks after rupture may be successfully treated with minimally invasive repair [5], and those treated by percutaneous repair 14 to 30 days after injury achieve similar results at one year as those treated within 14 days [21]. Seventeen years of experience with a nonoperative protocol for acute rupture confirmed good functional outcome and patient satisfaction [10].

Anatomy & Pathophysiology

Anatomy

The Achilles tendon is the thickest, strongest, and largest tendon in the human body, measuring approximately 12–15 cm in length [52]. It is formed by the confluence of the gastrocnemius and soleus tendons in the distal calf, inserting at the calcaneal tuberosity [54, 152]. The gastrocnemius muscle attaches above the knee to the posterior aspect of the medial and lateral femoral condyles, while the soleus originates from the upper part of the posterior tibia, fibula, and interosseous membrane [54]. Functionally, the gastrocnemius is most effective in plantarflexion with the knee extended, whereas the soleus is most effective with the knee flexed [54]. The fibers rotate 90 degrees toward the insertion, with gastrocnemius fibers lying lateral and soleus fibers lying medial to the insertion point [54]. As the only musculotendinous unit crossing two major joints (knee and ankle, as well as subtalar), the tendon acts as the major plantar flexor of the ankle and a weak knee flexor due to the gastrocnemius insertion on the posterior femoral condyles [72]. It also acts as an inverter of the heel because it runs just medial to the hindfoot axis of rotation [72].

The tendon is innervated by the tibial nerve and is surrounded by a paratenon consisting of loose areolar tissue rather than a true synovial sheath [72, 152]. This paratenon covers the tendon medially, posteriorly, and laterally, while the Kager fat pad marginates it anteriorly [152]. Lubrication is aided by two bursae: the retrocalcaneal bursa anterior to the tendon and the superficial bursa posterior to it [72]. The plantaris tendon is variably present as a thin slip coursing from superolateral to inferomedial along the ventral surface, inserting onto either the distal Achilles tendon or the calcaneal tuberosity [152]. The sural nerve runs in the midline of the gastrocnemius-soleus muscle to the musculotendinous junction, where it crosses to the lateral side of the tendon [72].

Morphometric data indicate an average insertion height of 19.8 mm, with an average proximal width of 23.8 mm and a distal width of 32.1 mm [135].

Vascularity and Pathophysiology

Vascularity is supplied through the paratenon on the deep surface, muscular arterial branches within the gastrosoleus complex proximally, and small interosseous vessels at the calcaneal insertion distally [54]. The major blood supply travels through the mesotendon, with the richest supply via the anterior mesentery [133]. A zone of relative avascularity exists 2 to 6 cm proximal to the insertion, correlating with a vascular watershed region resulting from the lack of a true synovial sheath [54, 72]. While this vascular arrangement suffices for normal low-demand conditions, increased demand can lead to inadequate vascularity, subsequent degeneration, and fibrosis [54]. With increasing age, the anterior mesenteric supply becomes reduced, and age-dependent changes in collagen crosslinking increase stiffness and loss of viscoelasticity, predisposing the tendon to injury [133].

Achilles tendon rupture is related to this relatively hypovascular area, which angiography confirms is located 2 to 6 cm above the insertion [133]. Seventy-five percent of ruptures occur between 5 and 6 cm proximal to the calcaneal tuberosity, directly correlating with this zone of relative hypovascularity [39]. The pathophysiology likely involves a combination of the hypovascular area and repetitive microtrauma, which causes an inflammatory reparative process unable to keep pace with stresses due to decreased vascularity, with mechanical overload completing the rupture [133]. Repetitive microtrauma may render the reparative process impossible to sustain, leading to degenerative attrition [133]. Additionally, a theory proposes that rupture results from the failure of inhibiting mechanisms at the musculotendinous unit due to fatigue, resulting in eccentric overload [133].

Tendinosis is most commonly due to hypoxia, which predisposes the critical zone to thickening because of its relative hypovascularity [152]. Myxoid degeneration is the second most frequent etiology, characterized by the accumulation of mucoid vacuoles among tendon fibers that may coalesce to form interstitial tears [152]. Less common causes include lipoid and ossific degeneration, describing the accumulation of fat and ossification within the tendon [152]. Degenerative ossification occurs proximal to the insertion, in contrast to enthesopathy, which occurs at the insertion [152]. Chronic inflammation is a feature of both mid-portion Achilles tendinopathy and rupture, with pro-inflammatory profiles in ruptured tendons differing slightly due to acute inflammation and increased vascularisation from recent trauma [43]. Although functionally distinct from rotator cuff tendons, they share common cellular and molecular inflammatory disease mechanisms [43].

The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known and warrant further studies [175]. Tendon injury is thought to be caused by a failed healing process resulting in altered tendon structure, neovascularization, and nerve ingrowth [67]. The risk for developing Achilles tendinopathy is likely multifactorial, related to an interaction of intrinsic and extrinsic factors that lead to tendon overloading [67]. Lower extremity impairments that lead to abnormal kinetics and/or kinematics specifically producing eccentric overload can result in injury [67]. Genes associated with the collagen-production pathway may functionally affect tendon strength and stiffness, leading to an abnormal tendon response during loading [67]. Those with a family history of tendinopathy have five times the risk of developing Achilles tendinopathy [67]. The Kager fat pad does not remain static during ankle range of motion but deforms and its pressure changes [171].

Injury Mechanisms

Most Achilles tendon ruptures share characteristic injury features, including Achilles tendon elongation, closed-chain movements, and sudden loading [19]. The most common mechanism is taking off from a stopped position just before toe-off in a dorsiflexed foot [123]. Other common mechanisms include pushing off with the weight-bearing forefoot while extending the knee, sudden unexpected dorsiflexion of the ankle, and violent dorsiflexion of the plantar flexed foot, as in a fall from a height [154]. Disruption can also occur from a direct blow to the contracted tendon or from a laceration [154]. Most ruptures occur as an indirect loading mechanism during eccentric muscle contracture [39]. A subgroup of patients with acute rupture have antecedent pain at the Achilles, and these tendons frequently show degenerative changes on histopathologic evaluation [39].

Basketball-specific movement patterns among NBA players who sustained ruptures include forefoot loading and rapid ankle dorsiflexion, along with proximal lower limb extension and musculotendinous complex elongation [169]. Three-dimensional reconstruction of a rupture in a professional football player revealed a multiplanar injury mechanism preceding the rupture [137].

Histopathology

Pathological features are significantly more pronounced in samples taken from the site of rupture than in samples taken proximally and distally in acute Achilles tendon ruptures [7]. However, there were no significant differences in the mean pathologic sum-scores in the samples taken proximally and distal to the site of rupture [7]. Unruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations, with the latter demonstrating histopathological evidence of failed healing response even in areas macroscopically intact [7]. Achilles tendinosis does not always precede Achilles tendon rupture [55].

Classification

Anatomical Location: Achilles tendon disorders are broadly classified into insertional and non-insertional conditions based on anatomical location [16]. Insertional Achilles tendinopathy is defined as symptoms localised within the first 2 cm of the attachment of the Achilles tendon to the calcaneus [38]. Midportion Achilles tendinopathy is defined as symptoms localised more than 2 cm above the distal attachment of the Achilles tendon [38], specifically located 2–7 cm from the insertion onto the calcaneus [161]. The distinction between insertional and midportion Achilles tendinopathy is justified by differences in prognosis during non-surgical treatment [38].

Imaging-Based Classifications: An MRI-based classification system offers a reliable method for identifying the anatomical location of Achilles tendon ruptures [46]. An Achilles tendon tear classification system demonstrated substantial to almost perfect reliability [127]. Ultrasound imaging criteria based on the continuum model of tendon pathology demonstrated 'substantial' to 'almost perfect' intra-rater and inter-rater reliability for staging Achilles tendinopathy [134]. The clinical diagnosis of Achilles tendinopathy does not require the presence of structural changes shown on ultrasound imaging [134].

Other Considerations: Reactive tendinopathy was initially defined as symptom duration shorter than 6 weeks, but this subclassification was not used in the Dutch multidisciplinary guideline due to inconsistent definitions [38]. Chronic Achilles tendinopathy is defined as a condition lasting 3 months or longer [38]. Histological degenerative changes in Achilles tendinopathy can be classified as hypoxic degeneration, hyaline degeneration, mucoid or myxoid degeneration, fibrinoid degeneration, fatty degeneration, calcification, or fibrocartilaginous or osseous metaplasia [26]. Hypoxic degenerative tendinopathy was associated with subcutaneous tendon rupture in more than 75% of 891 ruptured tendons [26]. The insertion of the Achilles tendon exhibits a gradual transition from fibrous to fibrocartilaginous tissue due to compressive and shear stresses [161].

Clinical Presentation

Epidemiology and Risk Factors

Achilles tendon ruptures occur most frequently in recreational male athletes in the third to fifth decades [39]. Complete rupture is usually a sequel to a sedentary lifestyle and participation in sports activities [31]. In a Finnish nationwide study, the incidence of Achilles tendon ruptures increased while the use of operative treatment decreased [37]. Age serves as a risk factor for contralateral tendon rupture in patients with acute Achilles tendon rupture [32]. Specifically, patients who sustain Achilles tendon rupture in their 30s have a significantly increased risk for contralateral tendon rupture [32]. Age was found to be the strongest predictor of outcome after Achilles tendon rupture [63]. Females present a larger deficit in heel-rise height at 3 months following an Achilles tendon rupture compared with males [29].

Mechanism of Injury

Most ruptures occur as an indirect loading mechanism during eccentric muscle contracture [39]. Seventy-five percent of ruptures occur between 5 and 6 cm proximal to the insertion on the calcaneal tuberosity [39]. The location of 75% of ruptures correlates to a zone of relative hypovascularity [39].

History and Symptoms

Patients typically report a sensation of being kicked or shot in the leg despite no contact occurring to the tendon [39]. A subgroup of patients with an acute rupture have antecedent pain at the Achilles [39]. In a cohort of 66 patients with clinically diagnosed complete rupture, eight patients (12.1%) reported prodromal symptoms of tendinosis before their injury [25].

Physical Examination

Physical examination reveals a decreased resting tension compared with the contralateral side [39]. Plantar flexion weakness is evident, with recruitment of toe flexors to substitute for the power of the gastrocnemius-soleus complex [39]. A palpable gap is present at the site of the rupture [39]. Thompson testing is positive, indicating the absence of passive ankle plantar flexion upon calf squeeze with the patient positioned prone [39]. Thompson testing is highly sensitive (96%) and specific (93%) for a complete acute Achilles rupture [39].

Diagnostic Imaging

The diagnosis of a suspected Achilles rupture is based largely on history and physical examination [39]. Diagnostic imaging is not needed in most cases, but can be useful to rule out alternative or additional injuries, confirm the diagnosis, or better define the injury for preoperative planning purposes [39]. MRI and ultrasonography can both be used to confirm an Achilles tendon rupture in the case of ambiguous physical examination findings but are not routinely necessary [39]. MRI and ultrasonography may be helpful to localize the level of an acute rupture, identify any underlying tendinosis at the site of the rupture, and quantify gapping of tendon ends [39]. MRI is unnecessary for diagnosing acute Achilles tendon ruptures when clinical diagnostic criteria are used [25].

Pathology and Histology

A subgroup of patients with an acute rupture have antecedent pain at the Achilles, and these tendons frequently show degenerative changes on histopathologic evaluation [39]. Nonruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations [17]. Pathological features were significantly more pronounced in the samples taken from the site of rupture than in the samples taken proximally and distal to it [7]. There were no significant differences in the mean pathologic sum-scores in the samples taken proximally and distal to the site of rupture [7]. Ruptured Achilles tendons demonstrate histopathological evidence of failed healing response even in areas macroscopically intact [7]. Hypoxic degenerative tendinopathy, alone or in combination with other forms of tendon degeneration, was shown to be associated with subcutaneous tendon rupture in >75% of 891 ruptured tendons [26]. Histologically, degenerative changes are found in 90% of the biopsy specimens taken from symptomatic parts of the tendon [26].

Acute vs. Chronic Classification

Achilles ruptures must be divided into acute versus chronic; the distinction is most commonly described as 4 to 6 weeks [39]. Chronic ruptures are often the result of missed initial diagnosis, which can occur in up to 25% of cases [39]. Early diagnosis of Achilles tendon rupture is extremely important for successful treatment [44].

Functional Deficits and Recovery

The majority of patients with an Achilles tendon rupture have not fully recovered 2 years after injury regardless of surgical or non-surgical treatment [4]. Only minor improvements occur between the 1- and 2-year evaluations after Achilles tendon rupture [4]. Attenuated muscle strength and function were present during walking as long as 2 to 5 years after rupture, as determined by 3-dimensional gait analysis [6]. The time to recover full function after an Achilles tendon rupture is at least 12 months [30]. Tendon elongation in the free tendon is evident in patients with and without persistent muscle weakness following an Achilles tendon rupture [33]. Findings suggest altered tendon mechanics with compensatory shifts toward biarticular muscle activation, reduced activation variability, and redistribution of joint power along the limb one year after acute unilateral Achilles tendon rupture [13].

Investigations

Clinical Examination

The physical examination for acute Achilles tendon rupture should include two or more of the following tests: the clinical Thompson test (Simmonds squeeze test), decreased ankle plantar flexion strength, presence of a palpable gap, or increased passive ankle dorsiflexion with gentle manipulation [126]. The Thompson test is highly sensitive (96%) and specific (93%) for a complete acute Achilles rupture [39]. Physical examination reveals a decreased resting tension compared with the contralateral side, plantar flexion weakness with recruitment of toe flexors, and a palpable gap at the site of the rupture [39]. The absence of ankle plantar flexion is not a reliable sign for Achilles tendon rupture [184]. The diagnostic triad of gap, posture, and calf squeeze is more sensitive than magnetic resonance imaging [184]. Clinical diagnosis of Achilles tendon tear is certain when the knee flexion and calf squeeze tests are positive, making imaging superfluous in such instances [186].

Imaging

Routine use of magnetic resonance imaging, ultrasound, and radiography to confirm the diagnosis of acute Achilles tendon rupture has an Inconclusive strength of recommendation [126]. Diagnostic imaging is not needed in most cases but can be useful to rule out alternative or additional injuries, confirm the diagnosis, or better define the injury for preoperative planning purposes, especially in cases of delayed or unclear diagnosis [39]. MRI and ultrasonography may be helpful to localize the level of an acute rupture, identify any underlying tendinosis at the site of the rupture, and quantify gapping of tendon ends, which may influence treatment [39]. The roles of ultrasonography and magnetic resonance imaging during the healing process after Achilles tendon rupture are limited due to a weak correlation with clinical findings [114]. MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy, though there was no statistically significant difference in favor of one imaging modality over the others [148].

Ultrasound and Biomarkers

Greater Achilles tendon cross-sectional area seen on ultrasound 6 weeks after surgical repair had good clinical prediction for long-term functional outcome [65]. Tendon structure assessed by ultrasound imaging changes over the first 24 weeks of healing after Achilles tendon rupture, suggesting it could be used as a biomarker to track tendon healing early in recovery [180]. Magnetic resonance imaging techniques can be used as an adjunct to clinical evaluation by monitoring morphologic effects in clinical treatment studies of Achilles tendinopathy [109]. In symptomatic, tendinopathic Achilles tendons, the ultrasonographic tendon structure improved during nonoperative treatment and normalized after 24 weeks to values of matched asymptomatic controls [174].

Histopathology and Pathology

Ruptured Achilles tendons demonstrate histopathological evidence of failed healing response even in areas macroscopically intact, distinguishing them from unruptured tendons [7]. Pathological features were significantly more pronounced in samples taken from the site of rupture than in samples taken proximally and distal to it [7].

Other Considerations

A study systematically mapped the location and morphology of Achilles tendon stumps via magnetic resonance imaging [172]. Interposed tissue between the tendon stumps is suitable for repair of chronic Achilles tendon rupture if preoperative MRI shows a thickened fusiform-shaped Achilles tendon with diffuse intratendinous high-signal alterations throughout [173]. Intra-tendon MRI abnormalities are frequent in chronic Achilles tendon rupture but likely represent non-pathologic cicatricial remodeling [181]. MRI-derived measures of Achilles tendon fat content may be able to distinguish xanthomas from control and tendinopathic tissue [182].

Treatment

Non-Operative

Non-operative management remains a viable strategy for acute Achilles tendon ruptures, with overall rerupture rates in recent studies being low enough to support its continued use as an initial treatment option [86]. Utilizing an accelerated rehabilitation programme may yield results comparable to operative treatment while reducing the incidence of adverse events [89]. Immediate weight-bearing is a recommended option within non-operative protocols [117], and early weight-bearing does not negatively influence outcomes at 4.5 years post-treatment [69]. However, adjunctive platelet-rich plasma (PRP) injections have not demonstrated benefit; four PRP injections did not improve function or healing compared with placebo over 12 months [95], nor did PRP improve patient-reported function or quality of life two years after injury compared with placebo [105].

Operative

Indications: Open surgical repair of acute Achilles tendon ruptures significantly reduces the risk of reruptures compared with nonoperative management [100]. While operative treatment is generally preferable, nonoperative treatment is an acceptable alternative [60]. In adolescent patients, operative management is associated with significantly higher rates of failed management (5.2% vs 0.19%) and overall complications compared to nonoperative treatment [110].

Surgical Approach / Technique: Percutaneous and minimally invasive repair techniques yield essentially identical clinical and functional outcomes to other methods, with no reruptures or major complications observed at a minimum follow-up of 24 months [23]. The jigless knotless internal brace technique is a reliable option for Achilles tendon repair [120]. For complicated ruptures, particularly missed total ruptures where skin closure is difficult, tissue expansion is recommended to avoid skin healing problems [122].

Other Considerations: Surgical treatment achieves excellent or good outcomes in 91% of patients [28], with overall results being good [101]. At 12 months, nonoperative treatment, open repair, and minimally invasive surgery do not differ regarding health status in adults with acute rupture [102]. No clinically relevant difference exists between operative and non-operative treatment regarding tendon elongation measured by the Achilles tendon resting angle (ATRA) one year after acute rupture [107]. Both nonoperative and operative management of myotendinous Achilles tendon ruptures demonstrate good outcomes [27].

Comparative Outcomes and Rehabilitation

Controversy remains regarding the optimal treatment for acute and chronic Achilles tendon ruptures despite a large body of evidence [2]. The dissemination of results from a landmark trial comparing surgical and non-operative management led to a statistically significant decrease in the rate of surgical repair for acute Achilles tendon ruptures in Ontario within one year of the trial's presentation [90]. Standardised treatment protocols can be implemented to guide decision-making and treatment of acute Achilles tendon rupture in large standard trauma hospitals [92].

Guideline Recommendations: None of the 16 recommendations made by the AAOS work group on the diagnosis and treatment of acute Achilles tendon rupture was graded as strong; most are graded inconclusive, four are graded weak, two are graded as moderate strength, and two are consensus statements [48]. The two moderate-strength AAOS recommendations include suggestions for early postoperative protective weight bearing and for the use of protective devices that allow for postoperative mobilization [48]. A specific guideline serves as a valuable resource for physicians making decisions regarding the surgical treatment of patients with chronic Achilles tendon rupture [12]. There is an emphasis on the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history [11].

Complications

Surgical Complications

Wound complications: Operative treatment of Achilles tendon ruptures increases the risk for minor complications when compared to non-operative treatment [35] [36]. The overall functional outcome of open repair is associated with a high complication rate, mainly due to wound problems and infection [62]. Classic tenorrhaphies have a high incidence of soft tissue damage, which occurs in 20% of cases [149].

Nerve palsy: Modern minimally invasive repairs offer a reduced risk of iatrogenic sural nerve problems compared to open techniques [162].

Timing and Technique: Patients with acute Achilles tendon rupture undergoing operation within 48 hours after injury had a lower number of adverse events compared with patients undergoing operation after 72 hours [18]. Percutaneous and minimally invasive techniques of repair of the Achilles tendon yielded no reruptures or major complications observed at a minimum follow-up of 24 months [23].

Rerupture

Operative treatment of Achilles tendon ruptures decreases rerupture rates when compared to non-operative treatment [35] [36]. The most important postoperative complication in Achilles tenorrhaphy is re-rupture, which is quite uncommon using the open technique [149].

Long-Term Functional Deficits

Continued deficits in calf muscle endurance and strength remained 7 years after Achilles tendon rupture [58]. The healed Achilles tendon after rupture has inferior elastic properties even after a longterm healing phase [66].

Histopathological Findings

Patients with a history of Achilles tendon rupture appear to have elevated levels of MMP-2, MMP-7 and TIMP-2 in serum [76].

Recovery

General Prognosis: Most elite soccer players take 1 year to reach peak match participation after an Achilles tendon rupture [190].

Surgical Recovery and Outcomes: Percutaneous repair of neglected Achilles rupture using the index technique proved a satisfactory patient-reported and objective measurement at a one-year follow-up [24]. Primary end-to-end repair augmented with the peroneus brevis tendon provides reliable mid- to long-term functional outcomes for closed traumatic Achilles tendon ruptures with unfavorable intraoperative characteristics [68]. The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection [62]. After the 11-year follow-up, early mobilization and immobilization in tension after Achilles rupture repair resulted in similar clinical outcomes and isokinetic strengths [125]. DVT during immobilization affects patients' long-term functional outcomes 3 years after Achilles tendon rupture repair [121]. The results suggest a previously unknown mechanism where increased metabolic response associated with longer duration of operative time may improve patient outcome after Achilles tendon rupture surgery [185].

Rehabilitation and Mobilization: Early ankle range of motion was improved without the risk of Achilles tendon elongation and without altering long-term functional outcome following functional weight-bearing mobilization [41]. There appears to be no difference between surgical and non-surgical groups regarding early motion, suggesting that controlled early motion is the important part of treatment of ruptured Achilles tendon [79]. The ruptured Achilles tendon elongates for 6 months after surgical repair regardless of early or late weightbearing in combination with ankle mobilization [30].

Key Evidence

  • [L4] Surgical intervention gave superior patient reported outcome compared with non-surgical treatment for patients affected by a chronic Achilles tendon rupture. [1] (10.1186/s12891-026-09890-y)
  • [L5] There is a large body of evidence addressing treatment of acute and chronic Achilles tendon ruptures; however, controversy remains. [2] (10.2106/jbjs.o.00002)
  • [L4] Open end-to-end repair of acute Achilles tendon ruptures provides long-term functional outcomes with consistent good to excellent results. [3] (10.1016/j.injury.2006.06.005)
  • [L1] The majority of patients with an Achilles tendon rupture have not fully recovered 2 years after injury regardless of surgical or non-surgical treatment, with only minor improvements occurring between the 1- and 2-year evaluations. [4] (10.1007/s00167-011-1511-3)
  • [L3] Patients presenting more than 2 weeks after Achilles tendon rupture may be successfully treated with minimally invasive repair. [5] (10.1007/s00167-018-5340-5)
  • [L3] Attenuated muscle strength and function were present during walking as long as 2 to 5 years after rupture, as determined by 3-dimensional gait analysis. [6] (10.1177/2325967113504734)
  • [L4] [7] (10.1007/s00167-010-1193-2)
  • [L4] Long-term outcome after minimally invasive Achilles tendon rupture repair is excellent. [8] (10.1177/0363546510392012)
  • [L5] AAOS recommendations on the management of Achilles tendon rupture range from Inconclusive to Moderate, with further studies needed for stronger recommendations. [9] (10.5435/00124635-201008000-00008)
  • [L4] Seventeen years of experience with a nonoperative treatment protocol for acute rupture of the Achilles tendon confirmed good functional outcome and patient satisfaction. [10] (10.1177/0363546515623501)
  • [L4] We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history. [11] (10.1186/s13018-022-03103-7)
  • [L1] The guideline serves as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with chronic Achilles tendon rupture. [12] (10.1186/s13018-024-04559-5)
  • [L3] Findings suggest altered tendon mechanics with compensatory shifts toward biarticular muscle activation, reduced activation variability, and redistribution of joint power along the limb. [13] (10.1016/j.jisako.2026.101198)
  • [L5] [16] (10.1302/0301-620x.95b10.31881)
  • [L4] Nonruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations. [17] (10.1177/03635465000280061401)
  • [L3] Patients with acute Achilles tendon rupture undergoing operation within 48 hours after injury had better outcomes and a lower number of adverse events compared with patients undergoing operation after 72 hours. [18] (10.1177/0363546518793655)
  • [L4] Most Achilles tendon ruptures share characteristic injury features, that is, Achilles tendon elongation, closed-chain movements, and sudden loading. [19] (10.1177/2325967123s00320)
  • [L3] Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patients treated within 14 days after injury. [21] (10.1177/0363546520908592)
  • [L3] The percutaneous and minimally invasive techniques of repair of the Achilles tendon yielded essentially identical clinical and functional outcomes with no reruptures or major complications observed at a minimum follow-up of 24 months. [23] (10.1097/blo.0b013e3180396f07)
  • [L4] Percutaneous repair of neglected Achilles rupture using the index technique proved a satisfactory patient-reported and objective measurement at a one-year follow-up. [24] (10.1186/s12891-023-06561-0)
  • [L2] [25] (10.1007/s11999-012-2355-y)
  • [L5] [26] (10.2106/00004623-200211000-00024)
  • [L1] Both nonoperative and operative management of myotendinous Achilles tendon ruptures demonstrated good outcomes after injury, although there is a limited amount of literature on this topic. [27] (10.1186/s12891-025-08286-8)
  • [L4] Surgical treatment of Achilles tendon ruptures achieved excellent or good outcomes in 91% of patients. [28] (10.1007/s004020050410)
  • [L2] Through this knowledge, we highlighted the importance of an individualised treatment for acute Achilles tendon ruptures with better outcome for both males and females. [29] (10.1002/ksa.12208)
  • [L1] The time to recover full function after an Achilles tendon rupture is at least 12 months. [30] (10.1177/0363546518781826)
  • [L4] Complete rupture of the Achilles tendon is usually a sequel to a sedentary life-style and participation in sports activities. [31] (10.1177/036354658901700305)
  • [L3] Patients who sustain Achilles tendon rupture in their 30s have significantly increased risk for contralateral tendon rupture. [32] (10.1007/s00167-019-05380-y)
  • [L4] Tendon elongation in the free tendon is evident in patients with and without persistent muscle weakness following an Achilles tendon rupture. [33] (10.1002/ksa.70445)
  • [L1] Operative treatment of Achilles tendon ruptures decreases rerupture rates but increases the risk for minor complications when compared to non-operative treatment. [35] (10.1177/2325967115s00146)
  • [L3] Operative treatment of Achilles tendon ruptures decreases rerupture rates but increases the risk for minor complications when compared with nonoperative treatment. [36] (10.1177/2325967115579188)
  • [L4] The incidence of Achilles tendon ruptures increased and the use of operative treatment decreased. [37] (10.1177/23259671221131536)
  • [Paper] [38] (10.1136/bjsports-2020-103867)
  • [L1] In addition, early ankle range of motion was improved without the risk of Achilles tendon elongation and without altering long-term functional outcome. [41] (10.1007/s00167-016-4270-3)
  • [L4] [43] (10.1136/bjsports-2017-098161)
  • [L4] Early diagnosis of Achilles tendon rupture is extremely important for successful treatment. [44] (10.1007/s00402-004-0784-0)
  • [L3] The MRI-based classification system offers a reliable method for identifying the anatomical location of Achilles tendon ruptures. [46] (10.1177/2325967126s00272)
  • [L1] [48] (10.5435/00124635-201008000-00007)
  • [L3] Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. [49] (10.1177/23259671231152904)
  • [L4] It is an efficient, reliable, and safe method for acute Achilles tendon rupture. [50] (10.1186/s13018-020-01776-6)
  • [L5] [52] (10.3390/jfmk5040095)
  • [L3] [55] (10.1007/s00167-018-5172-3)
  • [L2] Continued deficits in calf muscle endurance and strength remained 7 years after Achilles tendon rupture. [58] (10.1177/0363546517737055)
  • [L1] Operative treatment of ruptured Achilles tendons is preferable, but nonoperative treatment is an acceptable alternative. [60] (10.1177/036354659302100606)
  • [L3] The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. [62] (10.1016/j.injury.2018.08.012)
  • [L3] Age was found to be the strongest predictor of outcome after Achilles tendon rupture. [63] (10.1177/2325967120909556)
  • [L2] Greater Achilles tendon cross-sectional area seen on ultrasound 6 weeks after surgical repair had good clinical prediction for long-term functional outcome. [65] (10.1177/23259671231205326)
  • [L3] This study shows that the healed Achilles tendon after rupture has inferior elastic properties even after a longterm healing phase. [66] (10.1007/s00167-017-4791-4)
  • [L3] Primary end-to-end repair augmented with the peroneus brevis tendon provides reliable mid- to long-term functional outcomes for closed traumatic Achilles tendon ruptures with unfavorable intraoperative characteristics. [68] (10.1186/s12891-026-09668-2)
  • [L2] Early weight-bearing did not influence outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. [69] (10.1007/s00167-018-5058-4)
  • [L4] Patients with a history of Achilles tendon rupture appear to have elevated levels of MMP-2, MMP-7 and TIMP-2 in serum. [76] (10.1136/bjsm.2008.049411)
  • [L1] There appears to be no difference between the 2 groups, suggesting that controlled early motion is the important part of treatment of ruptured Achilles tendon. [79] (10.1177/0363546507307503)
  • [L1] The overall rerupture rate in this study was low, supporting the continued use of initial nonoperative management for the treatment of acute Achilles tendon ruptures. [86] (10.2106/jbjs.m.00248)
  • [L1] This study suggests that non-operative management of Achilles tendon ruptures utilizing an accelerated rehabilitation programme may produce comparable results with fewer adverse events. [89] (10.1016/j.arthro.2009.04.065)
  • [L3] The dissemination of results from a landmark trial comparing surgical and non-operative management led to a statistically significant decrease in the rate of surgical repair for acute Achilles tendon ruptures in Ontario within one year of the trial's presentation. [90] (10.1302/0301-620x.99b12.bjj-2017-0465.r1)
  • [L3] The study showed that it is possible to implement a standardised treatment protocol to guide the decision-making and treatment of an acute Achilles tendon rupture as part of daily care in a large standard trauma hospital. [92] (10.1007/s00402-018-2940-y)
  • [L1] In nonsurgically managed acute Achilles tendon rupture, 4 PRP injections did not improve function and healing compared with placebo over 12 months. [95] (10.2106/jbjs.21.00242)
  • [L1] Open surgical repair of acute Achilles tendon ruptures significantly reduces the risk of reruptures when compared with nonoperative management. [100] (10.1177/0363546512453293)
  • [L4] The results of surgical treatment for ruptured Achilles tendon are good overall. [101] (10.1016/j.otsr.2013.03.024)
  • [L1] In adults with acute Achilles tendon rupture, nonoperative treatment, open repair, and minimally invasive surgery did not differ for health status at 12 months. [102] (10.2106/jbjs.22.00965)
  • [L1] PRP injection did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo. [105] (10.1302/0301-620x.104b11.bjj-2022-0653.r1)
  • [L3] [107] (10.1007/s00167-020-06391-w)
  • [L4] Magnetic resonance imaging techniques can be used as an adjunct to clinical evaluation by monitoring morphologic effects in clinical treatment studies of Achilles tendinopathy. [109] (10.1177/0363546504263148)
  • [L3] Operative management of adolescent Achilles tendon ruptures is associated with significantly higher rates of failed management (5.2% vs 0.19%) and overall complications compared to nonoperative treatment, despite a lower incidence of nerve injury in the operative group. [110] (10.1177/2325967125s00282)
  • [L1] The roles of ultrasonography and magnetic resonance imaging during the healing process after Achilles tendon rupture are limited, due to a weak correlation with clinical findings. [114] (10.1007/s001670100245)
  • [L1] Immediate weight-bearing can be recommended as an option in the nonoperative treatment of Achilles tendon rupture. [117] (10.2106/jbjs.m.01273)
  • [L3] It might be a reliable option for Achilles tendon repair. [120] (10.1186/s13018-019-1471-8)
  • [L3] DVT during immobilization affects patients' long-term functional outcomes 3 years after Achilles tendon rupture repair. [121] (10.1002/ksa.12240)
  • [L4] The author recommends tissue expansion as an excellent way to avoid skin healing problems in complicated Achilles tendon ruptures, particularly for missed total ruptures where skin closure is difficult. [122] (10.1007/s001670100221)
  • [L4] The most common mechanism of injury is taking off from a stopped position just before toe-off in a dorsiflexed foot. [123] (10.1177/0363546519858609)
  • [L1] After the 11-year follow-up, early mobilization and immobilization in tension after Achilles rupture repair resulted in similar clinical outcomes and isokinetic strengths. [125] (10.1177/0363546515591267)
  • [L3] This study introduces an AT tear classification system that demonstrated substantial to almost perfect reliability. [127] (10.1177/23259671261428092)
  • [L2] There appears to be a clinically important difference in the risk of complications between minimally invasive surgical treatment and nonoperative treatment for acute Achilles tendon ruptures, but this was not statistically significant. [128] (10.1177/0363546508319312)
  • [L5] For acute Achilles tendon rupture, studies suggest equivalent functional outcomes with or without surgical treatment provided a functional rehabilitation program is followed; in such situations of clinical equipoise, shared decision-making provides a useful framework for the discussion of treatment options, supporting the autonomy of the patient as they weigh the risks and benefits of their treatment options. [132] (10.2106/jbjs.19.00144)
  • [L4] [134] (10.1136/bmjsem-2019-000699)
  • [L5] Results highlighted with an unprecedented level of detail the traditionally overlooked multiplanar nature of the injury biomechanics preceding an ATR, which might play a substantial role in triggering the tendon failure. [137] (10.1007/s00167-022-07078-0)
  • [L2] There was no statistically significant difference in favor of one imaging modality over the others, but MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy. [148] (10.1177/23259671211006826)
  • [L3] [149] (10.1016/j.injury.2016.09.009)
  • [L3] [161] (10.1007/s00167-012-2203-3)
  • [L5] [162] (10.1186/s13018-026-06685-8)
  • [L4] The study described basketball-specific movement patterns among NBA players who sustained Achilles tendon ruptures, supporting observations of forefoot loading and rapid ankle dorsiflexion while introducing new concepts regarding proximal lower limb extension and musculotendinous complex elongation. [169] (10.1002/ksa.70249)
  • [L5] The Kager fat pad does not remain static during ankle range of motion, but deforms and its pressure also changes. [171] (10.1007/s00167-019-05585-1)
  • [L4] This study is the first to systematically map the location and morphology of Achilles tendon stumps via magnetic resonance imaging. [172] (10.1186/s12891-026-09795-w)
  • [L4] Interposed tissue between the tendon stumps is suitable for repair of chronic Achilles tendon rupture if preoperative MRI shows a thickened fusiform-shaped Achilles tendon with diffuse intratendinous high-signal alterations throughout. [173] (10.1177/0363546506295939)
  • [L2] In symptomatic, tendinopathic Achilles tendons, the ultrasonographic tendon structure improved during nonoperative treatment and normalized after 24 weeks to values of matched asymptomatic controls. [174] (10.1177/0363546515605077)
  • [L5] The exact aetiology and pathophysiology of non-insertional Achilles tendinopathy are not fully known and warrant further studies. [175] (10.1136/jisakos-2017-000164)
  • [L2] Tendon structure assessed by ultrasound imaging changes over the first 24 weeks of healing after Achilles tendon rupture, suggesting it could be used as a biomarker to track tendon healing early in recovery. [180] (10.1007/s00167-018-5277-8)
  • [L4] Complications correlate with age, and intra-tendon MRI abnormalities are frequent but likely represent non-pathologic cicatricial remodeling. [181] (10.1016/j.otsr.2013.03.021)
  • [L4] MRI-derived measures of Achilles tendon fat content may be able to distinguish xanthomas from control and tendinopathic tissue. [182] (10.1186/s12891-021-04494-0)
  • [Letter] The absence of ankle plantar flexion is not a reliable sign for Achilles tendon rupture, and the diagnostic triad of gap, posture, and calf squeeze is more sensitive than magnetic resonance imaging. [184] (10.1016/j.arthro.2025.07.007)
  • [L2] The results suggest a previously unknown mechanism where increased metabolic response associated with longer duration of operative time may improve patient outcome after Achilles tendon rupture surgery. [185] (10.1007/s00167-017-4606-7)
  • [Letter] Clinical diagnosis of Achilles tendon tear is certain when the knee flexion and calf squeeze tests are positive, making imaging superfluous in such instances. [186] (10.1016/j.arthro.2025.07.010)
  • [L4] Most players take 1 year to reach peak match participation after an Achilles tendon rupture. [190] (10.1007/s00167-022-07082-4)

See Also

References

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[169] Achilles tendon ruptures in National Basketball Association players: A sequential video analysis of injury mechanisms and biomechanical patterns. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70249

[171] Pressure changes in the Kager fat pad at the extremes of ankle motion suggest a potential role in Achilles tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05585-1

[172] Morphology-based classification program of Achilles tendon ruptures using magnetic resonance imaging: a mapping study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09795-w

[173] Reconstruction of Chronic Achilles Tendon Rupture with the use of Interposed Tissue between the Stumps. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506295939

[174] The Tendon Structure Returns to Asymptomatic Values in Nonoperatively Treated Achilles Tendinopathy but Is Not Associated With Symptoms. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515605077

[175] Achilles tendinopathy – pathophysiology: state of the art. Journal of ISAKOS. 2018. DOI: 10.1136/jisakos-2017-000164

[180] Tendon morphology and mechanical properties assessed by ultrasound show change early in recovery and potential prognostic ability for 6-month outcomes. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5277-8

[181] Treatment of chronic Achilles tendon rupture by shortening suture and free sural triceps aponeurosis graft. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.03.021

[182] Can Achilles tendon xanthoma be distinguished from Achilles tendinopathy using Dixon method MRI? A cross-sectional exploratory study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04494-0

[184] Regarding “ Infographic : Achilles Tendon Ruptures: Nonsurgical Versus Surgical Treatment”. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.07.007

[185] Longer duration of operative time enhances healing metabolites and improves patient outcome after Achilles tendon rupture surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4606-7

[186] Regarding “ Infographic: Achilles Tendon Ruptures: Nonsurgical Versus Surgical Treatment”. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.07.010

[190] Pre‐injury performance is most important for predicting the level of match participation after Achilles tendon ruptures in elite soccer players: a study using a machine learning classifier. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07082-4

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Using Creative Commons Public Licenses

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Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.