How quickly does an Achilles tendon rupture require surgical repair?

Timing of Surgical Repair for Achilles Tendon Rupture

Acute Achilles tendon ruptures should be referred to an orthopedic surgeon or podiatric foot and ankle surgeon within 1-2 weeks of injury, with surgical repair ideally performed within 2-14 days after injury for optimal outcomes. 1, 2

Diagnostic Confirmation

• Diagnosis should be confirmed using at least two of the following:

  • Thompson/Simonds squeeze test
  • Assessment of ankle plantar flexion strength
  • Palpation for gap or defect in tendon
  • Evaluation of passive ankle dorsiflexion 1

• Imaging approach:

  • Initial plain radiography to identify any associated bony abnormalities
  • MRI as preferred advanced imaging (95% sensitivity and specificity)
  • Ultrasound as alternative (94% specificity, 58% sensitivity) 1

Timing of Surgical Intervention

The timing of surgical repair is critical:

1. Acute ruptures (0-2 weeks): Optimal window for primary repair with best functional outcomes

   • Surgical referral should occur within 1-2 weeks of injury 1
   • Surgical intervention ideally within 2-14 days after injury 2

2. Subacute ruptures (2-4 weeks): More challenging but still amenable to primary repair

3. Chronic ruptures (>4-6 weeks): Require more complex surgical techniques

   • Typically need augmentation of the repair
   • May require gastrocnemius advancement, turndown, or tendon transfer 3

Surgical vs. Non-surgical Approach

The decision between surgical and non-surgical management should consider:

Surgical Treatment Recommended For:

• Young, active patients
• Athletes seeking return to sports
• Complete ruptures
• Persistent partial ruptures not responding to conservative treatment 1

Non-surgical Management Recommended For:

• Older, less active patients
• Patients with significant comorbidities
• Tendinopathy without complete rupture 1

Surgical Technique Considerations

• Minimally invasive approaches provide the best balance between preventing rerupture and avoiding complications 1, 4

• Surgical options include:

  1. Open repair
  2. Limited open repair
  3. Percutaneous repair 1

• Surgical repair significantly decreases rerupture rate (Risk Ratio of 0.36,95% CI 0.21-0.64) compared to non-surgical treatment 2

• However, surgical repair carries higher risk of wound complications 2

Post-Surgical Rehabilitation

• Early protected weight-bearing (within 2 weeks) after surgical repair 1
• Early ankle mobilization rather than prolonged immobilization 1
• Accelerated rehabilitation leads to:
  • Higher patient satisfaction
  • Less use of rehabilitation resources
  • Earlier return to pre-injury activities
  • Increased calf muscle strength
  • Reduced muscle atrophy and tendon elongation 1

Potential Pitfalls and Complications

• Surgical complications:

  • Wound infections
  • Nerve injury (particularly with percutaneous techniques)
  • Rerupture
  • Scar adhesions 1

• Common pitfalls to avoid:

  • Delayed diagnosis leading to chronic rupture
  • Inadequate imaging
  • Overly aggressive early rehabilitation
  • Injecting corticosteroids directly into the tendon
  • Prolonged immobilization causing muscle atrophy 1

• Recovery expectations:

  • 95% return to work rate at 12 months
  • However, 58% of patients still report some functional deficits at 12 months post-surgery 5

The decreasing trend in surgical Achilles tendon repairs observed in some registries may reflect evolving practice patterns, with accelerated functional rehabilitation protocols making non-surgical approaches more viable in selected patients 5. However, for optimal outcomes in appropriate candidates, timely surgical referral within 1-2 weeks remains essential.