Treatment for Achilles Tendon Rupture
Both surgical and nonsurgical treatment options are viable for Achilles tendon rupture, with the choice depending primarily on patient factors, with surgical treatment recommended for young, active patients and athletes due to lower rerupture rates, while nonsurgical treatment is appropriate for older, less active patients or those with significant comorbidities. 1
Initial Management
- Apply a posterior splint or walking boot with the ankle in slight plantar flexion (10-20°) to reduce tension on the tendon 1
- Initially maintain non-weight bearing status with crutches
- Refer to an orthopedic surgeon or podiatric foot and ankle surgeon within 1-2 weeks 1
- Confirm diagnosis using at least two of the following tests:
- Thompson/Simonds squeeze test
- Assessment of ankle plantar flexion strength
- Palpation for gap or defect in tendon
- Evaluation of passive ankle dorsiflexion 1
- Obtain plain radiography to identify any associated bony abnormalities, followed by MRI (95% sensitivity and specificity) or ultrasound (94% specificity) 1
Treatment Decision Algorithm
Surgical Treatment
Indications:
- Young, active patients
- Athletes seeking to return to sports
- Complete ruptures
- Persistent partial ruptures not responding to conservative treatment 1
Surgical Options:
- Open repair: Extended incision for full visualization of rupture site
- Limited open repair: Small incision allowing direct visualization of ruptured ends
- Percutaneous repair: No direct exposure of rupture site 2
Benefits of surgical treatment:
Potential complications:
- Wound infections
- Nerve injury (particularly with open techniques)
- Scar adhesions 1
- Wound breakdown/delayed healing (more common with open repair) 2
Note: Limited open and percutaneous techniques reduce wound complications compared to open repair 1, with percutaneous repair showing higher physical and mental component scores on quality of life measures 1.
Nonsurgical Treatment
Indications:
- Older, less active patients
- Patients with significant comorbidities
- Partial tears 1
Protocol:
- Immobilization with posterior splint or walking boot with ankle in plantar flexion
- Progressive rehabilitation program
- Relative rest
- Ice therapy (10-minute applications through wet towel)
- NSAIDs for pain control 1
Benefits:
- Fewer complications related to surgery 1
- No wound healing issues
Drawbacks:
Rehabilitation Protocol
For both surgical and nonsurgical treatment:
- Early protected weight-bearing (within 2 weeks) after surgical repair 1
- Early ankle mobilization rather than prolonged immobilization 3
- Immediate full weight bearing with controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° after the second postoperative week 3
Benefits of accelerated rehabilitation:
- Higher patient satisfaction
- Less use of rehabilitation resources
- Earlier return to pre-injury activities
- Increased calf muscle strength
- Reduced muscle atrophy and tendon elongation 3
- No increased rerupture rate with progressive treatment 3
Important Considerations and Pitfalls
- Avoid misdiagnosis: Ensure proper clinical testing and appropriate imaging
- Avoid overly aggressive early rehabilitation: Follow a structured protocol
- Avoid injecting corticosteroids directly into the tendon
- Avoid prolonged immobilization: This leads to muscle atrophy and deconditioning 1
- Consider minimally invasive approaches: The combination of minimally invasive repair and accelerated functional rehabilitation appears to offer optimal results with superior functional outcomes and minimal complications 4, 5
The most recent evidence suggests that while open operative treatment significantly reduces rerupture risk compared to non-operative treatment, it carries a higher risk of complications such as wound infection 6. Percutaneous or minimally invasive techniques may provide the best balance between rerupture prevention and complication avoidance 5.