Ruptures of the anterior tibial tendon are quite rare but unfortunately still often missed. Most cases are caused by a degenerative process and only a small number of cases is caused by direct trauma or laceration. The main symptoms of an anterior tibial tendon rupture are swelling, mild pain, a weakened dorsiflexion, equinovalgus foot deformity and as an end-stage even a complete drop foot. However, in most cases the specific history in combination with the physical examination will lead to the diagnosis of anterior tibial tendon rupture. The treatment is dependent on several factors as aetiology, period of time to the onset of symptoms, age and level of activity. Surgical treatment is performed in selected cases, as described in the article, and a direct reinsertion or end-to-end suture of the tendon should be performed when possible. In difficult cases with delayed diagnosis, or initially misdiagnosed cases, a gracilis autologous tendon graft with tunnel-fixation to the medial cuneiform might be necessary to restore physiological biomechanics and gait patterns.