Sage Journals: Discover world-class research

Abstract

Background:

Achilles tendon rupture (ATR) is among the most common foot and ankle injuries, with a rising incidence of up to 50 per 100 000 persons. We sought to investigate the medicolegal characteristics associated with ATR.

Methods:

Westlaw Precision, an online, legal database from across the United States, was queried for all jury verdicts and settlements pertaining to “malpractice” and “Achilles” tendon rupture from 1980 to 2024. Data extracted included date and state of claim filing, patient and defendant demographics, jury verdict, monetary payments, basis of litigation, and listed patient complications.

Results:

A total of 50 of 236 claims were included in this analysis. A defendant verdict was reached in 82% of claims. The average indemnity payment was $431 405. Orthopaedic surgeons were named in 44% of claims. Nearly one-half of claims were levied due to a delayed or missed diagnosis (24%) or insufficient informed consent (18%). Subsequent surgery was the most frequent complication of the alleged negligence (18%); however, patient death occurred in 14% of claims as well. Patient disagreement with the treatment strategy was seen in 18% of claims.

Conclusion:

Achilles tendon rupture is an infrequent source of medicolegal burden within foot and ankle treatment. Such legal action most commonly arises from diagnostic delays, insufficient informed consent, and patient disagreement with the treatment strategy. Early recognition, comprehensive counseling on management options and risks, and shared decision making are essential strategies to reduce litigation risk and improve patient outcomes.

Level of Evidence:

Level IV, case series / retrospective database review without comparison group.

Visual Abstract

This is a visual representation of the abstract.

Keywords

Achilles litigation tendon foot malpractice

Introduction

Achilles tendon ruptures (ATRs) are among the most common foot and ankle injuries, with a rising incidence of up to 50 per 100 000 persons.^1,2 Such injuries occur in both the elderly and the young, active adult populations and are associated with a substantial degree of long-term morbidity.^2,3 The optimal management strategy is still controversial, with both operative and nonoperative treatment carrying a risk profile including rerupture, infection, sural nerve injury, and deep vein thrombosis (DVT).^1,4,5 Furthermore, despite their prevalence, ATRs are often misdiagnosed as ankle sprains in as much as one-quarter of cases, introducing additional difficulty in ATR management.⁶

Previous medicolegal research pertaining to foot and ankle pathology has identified forefoot surgery and postoperative infection to be the most common drivers of foot and ankle litigation.^7,8 Given the frequency of misdiagnosis and controversy surrounding ATR management, it may be plausible that patients may seek out legal action when faced with unanticipated complications during their recovery process.^1,2,9,10 The present study sought to describe the medicolegal characteristics associated with Achilles tendon rupture.

Methods

Data Source

The Westlaw Precision (Thomson Reuters, Eagan, MN) database was used for the retrospective analysis of malpractice claims. This database is a subscription-based platform that compiles state and federal court documents including court proceedings, jury verdicts, and settlements. Individual courts, law firms, and attorneys across all US states and territories report claim details to the Westlaw database. Institutional review board approval was obtained for this study.

Inclusion and Exclusion Criteria

Inclusion criteria were defined as all jury verdicts and settlements filed because of a complaint of medical malpractice surrounding a rupture of the Achilles tendon. Exclusion criteria were defined as follows: (1) claims without a final verdict or that had gone to appeals court; (2) claims not resting on the basis of medical malpractice.

Data Collection

A search of the Westlaw Precision database was conducted on June 17, 2025. All malpractice claims filed between 1980 and 2024 were identified through the keyword search function of Westlaw. The search query was “Achilles” AND (“tear” OR “rupture” OR “orthopedic”). Each claim was then screened against the inclusion criteria for relevance. Data to be extracted included date and location of filing, plaintiff demographics (sex, age, occupation), defendant specialty, mechanism of injury, method of treatment, alleged basis of litigation, damages as a result of the alleged negligence, and any monetary awards. Geographic distribution was evaluated based on state population per 1 million persons. State population figures were obtained from the United States Census Bureau (https://data.census.gov/profile).¹¹

Statistical Analysis

Descriptive statistics were calculated and reported as a mean ± SD. Univariate analysis was conducted using χ² tests for categorical variables and independent t test for continuous variables. Statistical significance was defined as P < .05 a priori.

All statistical calculations were performed on SPSS, version 30.0 (IBM Corp).

Results

A total of 236 claims were screened against the predetermined inclusion and exclusion criteria. A total of 186 claims were excluded, with 5 duplicate claims, 166 claims unrelated to medical malpractice (personal injury and premises liability litigation), and 15 non-ATR malpractice claims. After filtering for inclusion, 50 claims were put forth for further, in-depth analysis (Figure 1). A defendant verdict was reached in 41 (82.0%) claims. Plaintiff-favorable outcomes included 8 (16.0%) plaintiff verdicts and 1 (2.0%) settlement. The average indemnity payment was $431 405 ± 321 592 (range: $5000-$1 533 288).

Figure 1.

Screening flow diagram.

Plaintiff Demographics

Plaintiffs had a mean age of 52.5 years ± 15.1 (range: 23-85 years) at the time of injury with a slight male predominance (n = 27; 54.0%). Plaintiff and defendant demographics can be found in Table 1. Geographic analysis revealed that although most claims originated from the Northeast (n = 18; 36.0%), California and Pennsylvania both had the greatest number of claims by state (n = 7; 14.0%) (Figure 2A). After adjusting for state population, however, Pennsylvania and Washington (n = 4; 8.0%) accounted for the greatest number of claims per 1 million persons (Figure 2B). California accounted for 22% of the 9 claims resulting in an indemnity payment with an average payout of $62 530. The 3 states with the highest payouts were Maryland ($1 533 288), Pennsylvania ($1 049 697), and New York ($420 000). The frequency of ATR claims filed annually did not change significantly across the study period, with an average of 1.2 claims filed per year from 1984 to 2024 (r = 0.1140, P = .4305).

Table 1.

Plaintiff and Defendant Demographics.

	Defendant Verdict, n (%)	Plaintiff Verdict, n (%)	P Value
Plaintiff age	n = 41	n = 9
Adult (n = 47)	38 (92.7)	9 (100.0)	.4026
Elderly (n = 3)	3 (7.3)	0 (0.0)
Plaintiff sex	n = 41	n = 9
Male (n = 27)	20 (48.8)	7 (77.8)	.1140
Female (n = 23)	21 (51.2)	2 (22.2)
Defendant specialty	n = 41	n = 9
Orthopaedic surgery (n = 22)	18 (43.9)	4 (44.4)	.9763
Podiatry (n = 9)	8 (19.5)	1 (11.1)	.5525
Family medicine (n = 8)	6 (14.6)	2 (22.2)	.5739
Miscellaneous^a (n = 6)	5 (12.2)	1 (11.1)	.9278
Emergency medicine (n = 5)	4 (9.8)	1 (11.1)	.9023
Region	n = 41	n = 9
Northeast (n = 18)	16 (39.0)	2 (22.2)	.3416
Midwest (n = 13)	10 (24.4)	3 (33.3)	.5797
West (n = 12)	9 (22.0)	3 (33.3)	.4691
South (n = 7)	6 (14.6)	1 (11.1)	.7827

Miscellaneous specialties: hospital/medical group (2); internist (2); midlevel provider (2).

Figure 2.

(A) State distribution of malpractice claims. (B) State distribution of malpractice claims per 1 million people.

Causes and Treatment of ATR

Details regarding the cause of ATR and the subsequent treatment can be found in Table 2. Out of 19 (38.0%) claims including specific information regarding the mechanism of injury leading to ATR, 10 (52.6%) listed ATR as a complication of a separate, unrelated treatment. Eight of these 10 claims cited an alleged medication-induced ATR (levofloxacin [5], corticosteroid injection [1], and concurrent treatment with a fluoroquinolone and corticosteroid [2]) and 2 cited ATR as a result of an alleged surgical complication. Sporting injuries made up 5 (26.3%) of the 19 claims, all of which included jumping sports (volleyball [n = 3] and basketball [n = 2]). Operative intervention was documented in 24 claims (48.0%), whereas nonoperative management, such as casting or bracing, was used in 9 claims (18.0%). Seventeen (34.0%) claims did not specify operative or nonoperative management. A preexisting Achilles tendinopathy was documented in only 2 (4.0%) claims.

Table 2.

Claim Characteristics.

	Defendant Verdict, n (%)	Plaintiff Verdict, n (%)	P Value
Cause of ATR	n = 41	n = 9
Complication of treatment (n = 10)	10 (24.4)	0 (0.0)	.0976
Medication induced (n = 8)	8 (19.5)	0 (0.0)	.1482
Surgical complication (n = 2)	2 (4.9)	0 (0.0)	.4989
Sporting injury (n = 5)	4 (9.8)	1 (11.1)	.9023
Trauma (n = 4)	4 (9.8)	0 (0.0)	.3286
Not specified (n = 31)	23 (56.1)	8 (88.9)	.0665
Type of treatment	n = 41	n = 9
Operative repair (n = 24)	19 (46.3)	5 (55.6)	.6164
Conservative (n = 9)	7 (17.1)	2 (22.2)	.7158
No treatment (n = 9)	7 (17.1)	2 (22.2)	.7158
Not specified (n = 8)	8 (19.5)	0 (0.0)	.1482
Agreement with treatment strategy	n = 27	n = 6
Agreed with treatment strategy (n = 24)	20 (74.1)	4 (66.4)	.5127
Disagreed with treatment strategy (n = 9)	7 (25.9)	2 (33.3)	.5127

Abbreviation: ATR, Achilles tendon rupture.

In total, 9 patients attributed their adverse outcomes to the treatment strategy they received: 6 patients reported that operative intervention was performed when conservative management should have been attempted, whereas 3 patients attributed adverse outcomes to having received conservative rather than operative management. However, this disagreement between the treatment rendered and the patient’s perceived appropriate management was not significantly associated with the final verdict (P = .5127).

Alleged Negligence and Complications

Table 3 describes the alleged negligence and resulting complications for all 50 claims. No variables were found to be predictive of a plaintiff or defendant verdict. Nearly one-quarter of claims (n = 12) alleged a delayed or missed diagnosis of ATR as the basis of litigation. The average alleged delay in diagnosis of ATR was 3.38 months ± 2.18 months (range: 1-7 months). Insufficient informed consent regarding alternative treatment modalities or risks of treatment was cited in 18% (n = 9) of claims.

Table 3.

Alleged Negligence and Subsequent Complications.

	Defendant Verdict, n (%)	Plaintiff Verdict, n (%)	P Value
Alleged negligence	n = 41	n = 9
Delayed/missed diagnosis (n = 12)	9 (22.0)	3 (33.3)	.4691
Insufficient informed consent (n = 9)	8 (19.5)	1 (11.1)	.5525
Treatment error (n = 7)	5 (12.2)	2 (22.2)	.4324
Inadequate management of postoperative complications (n = 7)	5 (12.2)	2 (22.2)	.4324
Failure to refer (n = 6)	6 (14.6)	0 (0.0)	.2212
Negligent surgery (n = 6)	4 (9.8)	2 (22.2)	.2973
Inadequate postoperative prophylaxis (n = 3)	2 (4.9)	1 (11.1)	.4758
Complications as a result of alleged negligence	n = 41	n = 9
Need for surgery/reoperation (n = 9)	9 (22.0)	0 (0.0)	.1206
Achilles tendon rupture (n = 8)	8 (19.5)	0 (0.0)	.1482
Death following VTE (n = 7)	5 (12.2)	2 (22.2)	.4324
Infection (n = 6)	5 (12.2)	1 (11.1)	.9278
Pain and suffering (n = 6)	6 (14.6)	0 (0.0)	.2212
Gait disturbance (n = 5)	3 (7.3)	2 (22.2)	.1771
Loss of/decreased function (n = 4)	2 (4.9)	2 (22.2)	.0824
Deformity/disfigurement (n = 3)	2 (4.9)	1 (11.1)	.4758
Nerve injury (n = 2)	2 (4.9)	0 (0.0)	.4989

Abbreviation: VTE, venous thromboembolism.

Nine (18.0%) claims cited the need for a subsequent surgery as the main complication of the alleged negligence. A total of 8 (16.0%) claims listed ATR as the complication of the alleged negligence. Of these, 7 were medication induced, whereas 1 was due to a procedural error, resulting in an alleged ATR during surgery. Although loss or decreased motion was associated with a greater proportion of plaintiff verdicts (22.2% vs 4.9%), this did not reach statistical significance (P = .0824).

Notably, 7 (14.0%) claims resulted in patient death, specifically due to a venous thromboembolism (VTE) in the immediate postoperative period. Four of the 7 (57.1%) claims were levied on the basis of alleged insufficient informed consent through a failure to disclose the risk of VTE as a possible complication of ATR treatment whereas the remaining 3 (42.9%) cited inadequate postoperative prophylaxis and discharge instructions as the alleged negligence. In the 5 claims that provide information regarding VTE prophylaxis, 3 alleged no prophylaxis was ever initiated, 1 alleged insufficient dosing of Heparin, and 1 alleged that the defendant failed to instruct the patient to use aspirin as a prophylaxis rather than analgesic, causing the patient to prematurely discontinue taking the medication. Zero claims mentioned the use of a preoperative ultrasonographic scan to diagnose preexisting DVT.

Defendant Specialty Comparison

A total of 22 claims (44%) listed an orthopaedic surgeon as the defendant, with the remaining 28 (56%) claims filed against a nonorthopaedic practitioner. The 3 most frequently named nonorthopaedic specialties were podiatry (n = 9; 18%), family medicine (n = 8; 16%), and emergency medicine (n = 5; 10%). Table 4 offers a comparison of alleged negligence and subsequent complication by defendant specialty. Of note, orthopaedic surgeons faced significantly greater risk of malpractice claims alleging inadequate postoperative prophylaxis (P = .0439) and claims resulting in death following VTE (P = .0165). In contrast, nonorthopaedic practitioners faced significantly greater risk of malpractice claims alleging failure to refer to an orthopaedic surgeon (P = .0206) and treatment complication resulting in an ATR (P = .0062).

Table 4.

Claim Comparison by Defendant Specialty.

	Orthopaedic Defendant, n (%)	Nonorthopaedic Defendant, n (%)	P Value
Alleged Negligence	n = 22	n = 28
Delayed/missed diagnosis (n = 12)	4 (18.2)	8 (28.6)	.3932
Insufficient informed consent (n = 9)	4 (18.2)	5 (17.9)	.9763
Treatment error (n = 7)	3 (13.6)	4 (14.3)	.9476
Inadequate management of postoperative complications (n = 7)	4 (18.2)	3 (10.7)	.4500
Failure to refer^a (n = 6)	0 (0.0)	6 (21.4)	.0206
Negligent surgery (n = 6)	4 (18.2)	2 (7.1)	.2331
Inadequate postoperative prophylaxis^a (n = 3)	3 (13.6)	0 (0.0)	.0439
Complications as a result of alleged negligence	n = 22	n = 28
Need for surgery/reoperation (n = 9)	5 (22.7)	4 (14.3)	.4406
Achilles tendon rupture^a (n = 8)	0 (0.0)	8 (28.6)	.0062
Death following VTE^a (n = 7)	6 (27.3)	1 (3.6)	.0165
Infection (n = 6)	4 (18.2)	2 (7.1)	.2331
Pain and suffering (n = 6)	2 (9.1)	4 (14.3)	.5747
Gait disturbance (n = 5)	1 (4.5)	4 (14.3)	.2545
Loss of/decreased function (n = 4)	0 (0.0)	4 (14.3)	.0646
Deformity/disfigurement (n = 3)	2 (9.1)	1 (3.6)	.4146
Nerve injury (n = 2)	2 (9.1)	0 (0.0)	.1035

Abbreviation: VTE, venous thromboembolism.

denotes significance at p < 0.05.

Discussion

This study is the first to provide a focused, multidecade review of malpractice litigation related to Achilles tendon rupture. As seen in broader foot and ankle malpractice trends, most ATR-related lawsuits stemmed from diagnostic delays, inadequate informed consent, and treatment complications.^7,12-14 Importantly, more than 14% of claims involved patient death in the setting of postoperative VTE, underscoring the critical role of preoperative counseling and thorough risk disclosure.

Achilles tendon ruptures are a commonly misdiagnosed injury, possibly because of the diagnostic challenges for the unfamiliar practitioner, leading to patients frequently presenting to the orthopaedic clinic with a chronic rupture, or one that has gone untreated for greater than 6 weeks.^6,15 Patients with chronic ruptures require more technically challenging procedures than those with acute ruptures, with many surgeons opting for graft augmentation.^15-17 In the present study, delayed diagnosis of ATR was the most common basis of litigation with an average delay in diagnosis of >2 months after injury and prior to presentation at a specialty clinic. First-line treatment providers must maintain a high degree of clinical suspicion for ATR in patients. The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPGs) recommend the use of at least 2 of the following physical examination tests/findings to aid in the diagnosis of ATR: Clinical Thompson test, decreased ankle plantarflexion strength, the presence of a palpable gap or defect at the posterior ankle, or increased passive ankle dorsiflexion.¹⁸ Primarily a clinical diagnosis, ultrasonography, and magnetic resonance imaging may also be used to confirm physical examination findings suggestive of ATR.¹⁹ However, heightened awareness and clinical suspicion is paramount in decreasing the rates of misdiagnosis and delays in definitive treatment, subsequently mitigating a considerable source of ATR-related litigation.

Despite strong evidence supporting comparable outcomes regardless of treatment strategy,^20,21 18% of claims evaluated in this study involved patient disagreement with the treatment strategy they underwent and cited concerns over allegedly inappropriate treatment decisions. The prevalence of claims citing treatment disagreement suggests that the presence of multiple initial management options may create a context in which patients attribute poor outcomes to physician judgment and error, underscoring the need for improved patient education and expectation management.¹³ This emphasis on patient education is especially pertinent given the poor readability of many current patient education materials within foot and ankle surgery and overall low health literacy rates among US adults.^22-25 Standard discharge paperwork or postoperative instructions may not be as comprehensible as anticipated and, as such, physicians must take care to ensure key information is conveyed clearly and effectively. Thorough documentation of patient instructions may also prove useful in defending against claims of negligence during ATR-related malpractice suits.

A considerable portion of claims in this study were related to VTE (14.0%). Although the overall incidence of VTE in foot and ankle surgery ranges from 0.22% to 0.42%,^26,27 this risk increases substantially in patients undergoing treatment for ATR, with reported DVT rates ranging from 3% to 9%.^28-30 Studies have reported conflicting findings regarding VTE risk factors in patients undergoing ATR treatment. Although current CPGs acknowledge the prevalence of VTE in patients with ATR, the lack of high-quality data precludes official recommendations for the use of routine chemoprophylaxis in ATR management.^18,27,31 Nonetheless, the limited use of prophylaxis observed in this study suggests that its implementation may aid in mitigating medicolegal exposure. In cases where a delay in definitive management is expected, initial care providers might consider starting VTE prophylaxis before referral to orthopaedic surgery. Similarly, given the high rate of VTE in this subset of patients, orthopaedic surgeons should consider obtaining preoperative ultrasonography in high-risk patients to rule out DVT before surgical intervention. When a DVT diagnosis is confirmed, prophylaxis should be initiated without delay.

Informed consent is yet another underlying theme found across a considerable proportion of claims evaluated in this study. Indeed, Flaherty et al³² found that informed consent was determined to be a “critical” component of Achilles tendon repair procedures from a patient perspective. In such instances where a patient may be eligible for both operative and nonoperative management, discussions should prioritize risks that patients may find meaningful, rather than strictly adhering to what physicians deem clinically important such as expected postoperative mobility, risk of wound complications requiring additional surgery, or VTE and death. This approach aligns with the legal precedent set in the 2015 case Montgomery vs Lanarkshire Health Board, which emphasized a patient-centered discussion when obtaining informed consent.^33-35 In the case of ATR-related litigation, possible considerations for topics to include during an informed consent discussion can be found in Table 5. Namely, (1) a discussion regarding the risk of tendinopathy and ATR following fluoroquinolone or corticosteroid treatment^6,36-38; (2) disclosure of the risk of VTE following ATR treatment, particularly following operative repair^4,5,18; and (3) repeated patient education regarding signs and symptoms of VTE and home rehabilitation/medication instructions. A medication reconciliation for fluoroquinolone with concurrent corticosteroid treatment and patient education before initiating a fluoroquinolone may also be beneficial to decrease the incidence of medication-induced ATR.³⁹ Documentation of specific details discussed when obtaining informed consent may also provide a stronger legal defense than templated consent documents. Although not always possible in an emergent setting, obtaining informed consent over a longitudinal discussion held across several office visits has also demonstrated efficacy in minimizing the risk of facing medical malpractice.⁴⁰

Table 5.

Possible Expanded Topics of Discussion When Obtaining Informed Consent.

Possible Topics of Discussion for Informed Consent Surrounding Achilles Tendon Rupture (ATR)	Timing of Discussion
Disclosure of the heightened risk of ATR in patients taking fluoroquinolones or receiving corticosteroid injection treatments	Prior to prescribing fluoroquinolones or corticosteroid injections
The risk of VTE in patients undergoing treatment for ATR	Should ideally occur over several days, with the risk of VTE reiterated at several, separate encounters
The complications associated with operative vs nonoperative treatment of ATR	Prior to the day of surgery, during shared-decision making process
Signs and symptoms of VTE as well as proper education regarding postoperative mobility, weightbearing status, and medication regimen	Should ideally occur over several days, with home instructions reiterated at numerous visits before treatment and during initial routine follow-up

Abbreviation: VTE, venous thromboembolism.

Limitations

Although Westlaw Precision is among the largest repositories of legal proceedings in the United States, it is not comprehensive. It does not capture claims that were (1) settled out of court, (2) dismissed before trial, or (3) handled by nonparticipating courts that do not submit to Westlaw. As such, selection bias is inherent, and our findings should be interpreted as representative rather than exhaustive. Furthermore, there is a considerable degree of medical heterogeneity in the claims analyzed, as court documentation is typically transcribed by legal personnel with limited medical training. This lack of uniformity in medical information presented results in inconsistent reporting of clinical details such as surgical technique, occupation, or comorbidities, thereby limiting the granularity of our analysis. Future studies integrating multiple legal data sources or linking claims data with clinical registries could enhance the depth and reliability of findings. Finally, Westlaw is a US database and does not capture litigation filed outside the 50 states. As such, the results described herein may not be generalizable to malpractice trends in other countries with differing medicolegal pressures and systems.

Conclusion

Malpractice claims related to Achilles tendon rupture most often arise from delayed diagnosis and inadequate informed consent. Despite similar long-term outcomes between operative and nonoperative treatments, treatment discordance and miscommunication between physician and patient remain key drivers of litigation. Prioritizing patient-centered consent and shared decision making, maintaining a high index of suspicion to facilitate early diagnosis, and emphasizing patient education regarding postoperative instructions and signs/symptoms warranting a return to the hospital may help reduce medicolegal risk in ATR management.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251397974 – Supplemental material for Retrospective Analysis of Malpractice Claims Following Achilles Tendon Rupture

Supplemental material, sj-pdf-1-fao-10.1177_24730114251397974 for Retrospective Analysis of Malpractice Claims Following Achilles Tendon Rupture by Haad A. Arif, Devan Devkumar, Abbad Sultan, Kevin A. Williams and Michael D. Johnson in Foot & Ankle Orthopaedics

Footnotes

ORCID iDs

Haad A. Arif, MD,

Kevin A. Williams, MD,

Michael D. Johnson, MD,

Ethical Considerations

Ethical approval for this study was obtained from the University of Alabama at Birmingham Institutional Review Board (IRB-300015116).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

References

Myhrvold

Brouwer

Andresen

TKM

, et al. Nonoperative or surgical treatment of acute Achilles’ tendon rupture. N Engl J Med. 2022;386(15):1409-1420.

Ochen

Beks

van Heijl

, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019;364:k5120.

Noback

Jang

Cuellar

, et al. Risk factors for Achilles tendon rupture: a matched case control study. Injury. 2017;48(10):2342-2347.

Seow

Islam

Randall

, et al. Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute Achilles tendon ruptures: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc. 2023;31(8):3528-3540.

Deng

Sun

Zhang

Chen

Surgical treatment versus conservative management for acute Achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2017;56(6):1236-1243.

Shamrock

Dreyer

Varacallo

MA.

Achilles tendon rupture. In: StatPearls. StatPearls Publishing; 2025.

Kadakia

Orland

Sharma

Akoh

Chen

Parekh

SG.

Medical malpractice trends in foot and ankle surgery. J Foot Ankle Surg. 2022;61(1):104-108.

Favier

Beldame

Malpractice claims in forefoot surgery. Orthop Traumatol Surg Res. 2022;108(1, suppl):103152.

Attia

Mahmoud

d’Hooghe

Bariteau

Labib

Myerson

MS.

Outcomes and complications of open versus minimally invasive repair of acute Achilles tendon ruptures: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2023;51(3):825-836.

10.

Rynecki

Coban

Gantz

, et al. Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis. Orthopedics. 2018;41(5):e615-e620.

11.

Census Bureau Profiles Results. Accessed June 13, 2025. https://data.census.gov/profile

12.

Ring

Talbot

Clough

TM.

Clinical negligence in foot and ankle surgery: a 17-year review of claims to the NHS Litigation Authority. Bone Joint J. 2014;96-B(11):1510-1514.

13.

Sanders

FRK

Wimmer-Boelhouwers

Dijt

Kerkhoffs

GMMJ

Schepers

. Claims in orthopedic foot/ankle surgery, how can they help to improve quality of care? A retrospective claim analysis. Eur J Orthop Surg Traumatol. 2021;31(1):85-93.

14.

Carreras-Castañer

Martin-Fumadó

Serrano-Sanz

Arimany-Manso

Medical malpractice trends in foot and ankle surgery in Catalonia (Spain). J Foot Ankle Surg. 2022 ;61(5):1138.

15.

Mzeihem

El Bachour

Hemdanieh

El Baba

Tamim

Nassereddine

Achilles tendon rupture primary repair technique: a comparative retrospective study between graft versus no-graft. J Clin Orthop Trauma. 2024;51:102417.

16.

Okewunmi

Guzman

Vulcano

Achilles tendinosis injuries-tendinosis to rupture (getting the athlete back to play). Clin Sports Med. 2020;39(4):877-891.

17.

Feng

Maffulli

Oliva

, et al. Surgical management of chronic Achilles tendon rupture: evidence-based guidelines. J Orthop Surg Res. 2024;19:132.

18.

Chiodo

Glazebrook

Bluman

, et al. Diagnosis and treatment of acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010;18(8):503-510.

19.

Egger

Berkowitz

MJ.

Achilles tendon injuries. Curr Rev Musculoskelet Med. 2017;10(1):72-80.

20.

Maempel

Clement

Wickramasinghe

Duckworth

Keating

JF.

Operative repair of acute Achilles tendon rupture does not give superior patient-reported outcomes to nonoperative management. Bone Joint J. 2020;102-B(7):933-940.

21.

Lantto

Heikkinen

Flinkkila

, et al. A prospective randomized trial comparing surgical and nonsurgical treatments of acute Achilles tendon ruptures. Am J Sports Med. 2016;44(9):2406-2414.

22.

Parekh

McCahon

JAS

Nghe

Pedowitz

Daniel

Parekh

SG.

Foot and ankle patient education materials and artificial intelligence chatbots: a comparative analysis. Foot Ankle Spec. Published online March 19, 2024. doi:10.1177/19386400241235834

23.

Thomas

Khan

Saldanha

Ballester

Stott

Morgan

Foot school: preoperative education before day case elective foot and ankle surgery reduces the length of stay after surgery. Foot (Edinb). 2022;50:101893.

24.

Noback

Trupia

Dziesinski

Sarpong

Trofa

Vosseller

JT.

Ankle fractures: the current state of online patient information. Foot Ankle Spec. 2021;14(4):324-333.

25.

Arif

LeBrun

Moore

Friscia

DA.

Analysis of the most popular online ankle fracture–related patient education materials. Foot Ankle Orthop. 2024;9(2).

26.

Mizel

Temple

Michelson

, et al. Thromboembolism after foot and ankle surgery. A multicenter study. Clin Orthop Relat Res. 1998;348:180-185.

27.

Shibuya

Frost

Campbell

Davis

Jupiter

DC.

Incidence of acute deep vein thrombosis and pulmonary embolism in foot and ankle trauma: analysis of the National Trauma Data Bank. J Foot Ankle Surg. 2012;51(1):63-68.

28.

Yin

Wang

Liu

Wan

Complications in the management of acute Achilles tendon rupture: a systematic review and network meta-analysis of 2060 patients. Am J Sports Med. 2019;47(9):2251-2260.

29.

Caolo

Eble

Rider

, et al. Clinical outcomes and complications with open vs minimally invasive Achilles tendon repair. Foot Ankle Orthop. 2021;6(4):24730114211060063.

30.

Jamjoom

BA.

The influence of early weightbearing, controlled motion, and timing of orthosis removal on the nonoperative management of Achilles tendon rupture: a systematic review. J Foot Ankle Surg. 2021;60(4):777-786.

31.

Griffiths

Matthews

Pearce

Calder

JDF

. Incidence of venous thromboembolism in elective foot and ankle surgery with and without aspirin prophylaxis. J Bone Joint Surg Br. 2012;94(2):210-214.

32.

Flaherty

Mathur

Heyrani

, et al. Critical portions of a foot or ankle surgical procedure from patient and surgeon perspectives. J Am Acad Orthop Surg. 2024;32(16):754-761.

33.

Felstead

Solan

MC.

Consent in foot and ankle surgery. Orthop Traumatol. 2019;33(6):378-385.

34.

Chan

Tulloch

Cooper

Smith

Wojcik

Norman

JE.

Montgomery and informed consent: where are we now?

BMJ. 2017;357:j2224.

35.

Samanta

Legal standard of care: a shift from the traditional Bolam test. Clin Med (Lond). 2003;3(5):443-446.

36.

McCullagh

Coen

O’Keeffe

Fluoroquinolones and tendon injury: a 5-year review of Irish national incident and claims data. Ir J Med Sci. 2025;194(2):757-760.

37.

Fleming

Chen

Hall

Southwood

RL.

Risk of tendon injury in patients treated with fluoroquinolone (FQ) versus non-fluoroquinolone antibiotics for community-acquired pneumonia (CAP). Ann Pharmacother. 2024;58(8):771-780.

38.

Arabyat

Raisch

McKoy

Bennett

CL.

Fluoroquinolone-associated tendon-rupture: a summary of reports in the Food and Drug Administration’s adverse event reporting system. Expert Opin Drug Saf. 2015;14(11):1653-1660.

39.

Pantalone

Abate

D’Ovidio

Carnevale

Salini

Diagnostic failure of ciprofloxacin-induced spontaneous bilateral Achilles tendon rupture: case-report and medical-legal considerations. Int J Immunopathol Pharmacol. 2011;24(2):519-522.

40.

Bhattacharyya

Yeon

Harris

MB.

The medical-legal aspects of informed consent in orthopaedic surgery. J Bone Joint Surg Am. 2005;87(11):2395-2400.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.75 MB