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.
This is a visual representation of the abstract.
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 χ 2 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).
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).
Plaintiff and Defendant Demographics.
Miscellaneous specialties: hospital/medical group (2); internist (2); midlevel provider (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.
Claim Characteristics.
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.
Alleged Negligence and Subsequent Complications.
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).
Claim Comparison by Defendant Specialty.
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 al 32 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 treatment6,36-38; (2) disclosure of the risk of VTE following ATR treatment, particularly following operative repair4,5,18; 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
Possible Expanded Topics of Discussion When Obtaining Informed Consent.
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
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
Supplementary Material
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