What are the indications for Achilles tendon repair?

Indications for Achilles Tendon Repair

Surgical repair of the Achilles tendon is indicated for complete ruptures in young, active patients and athletes, chronic tendinopathy unresponsive to 2-3 months of conservative care, and persistent partial ruptures not responding to conservative treatment. 1

Primary Indications for Surgical Repair

• Complete Achilles tendon rupture in:

  • Young, active patients
  • Athletes (to minimize re-rupture risk and optimize return to sport)
  • Patients desiring to return to high-level physical activities 1, 2

• Chronic tendinopathy that has failed conservative management:

  • Unresponsive to 2-3 months of proper conservative treatment
  • Conservative measures should include: relative rest, ice therapy, NSAIDs, heel lifts/orthoses, open-backed shoes, stretching, eccentric strengthening exercises, and weight loss if indicated 1

• Persistent partial ruptures not improving with conservative treatment 1

Diagnostic Confirmation Before Surgical Decision

Before proceeding with surgical repair, diagnosis should be confirmed using:

1. Physical examination - At least two of the following tests should be performed:

   • Thompson/Simonds squeeze test
   • Assessment of decreased ankle plantar flexion strength
   • Presence of a palpable gap
   • Increased passive ankle dorsiflexion with gentle manipulation 1

2. Imaging studies:

   • Ultrasound (92% accuracy for differentiating full vs. partial tears)
   • MRI (95% sensitivity/specificity for tendon pathology) 1

Surgical Approach Considerations

When surgical repair is indicated, options include:

• Open repair - Traditional approach with direct visualization
• Limited open repair - Smaller incision
• Percutaneous repair - Less invasive approach 1

The percutaneous approach shows higher physical and mental component scores on quality of life measures and may provide the best balance between preventing rerupture and avoiding complications 1, 3. Percutaneous repair is associated with shorter operation duration and lower risk of infection compared to open repair 4.

Patient-Specific Factors Influencing Surgical Decision

• Age and activity level:

  • Younger, active patients and athletes typically benefit more from surgical repair 1
  • Older, less active patients often do better with non-surgical management 1

• Comorbidities:

  • Significant comorbidities may favor non-surgical approach 1
  • Conditions affecting wound healing (diabetes, peripheral vascular disease) increase surgical risks

• Time since injury:

  • Acute ruptures (within 2 weeks) have better surgical outcomes
  • Chronic ruptures may require more complex reconstruction techniques

Post-Repair Rehabilitation Considerations

Rehabilitation after surgical repair is crucial for optimal outcomes:

• Early protected weight-bearing and mobilization are recommended to prevent muscle atrophy 1, 5
• Controlled ankle mobilization with free plantar flexion and limited dorsiflexion at 0° should begin after the second postoperative week 5
• Immediate full weight bearing leads to higher patient satisfaction and earlier return to pre-injury activity 5
• Functional bracing rather than rigid casting post-operatively results in shorter hospital stays, less time off work, and quicker return to sporting activities 4

Outcomes After Surgical Repair

• 89.6% of patients can resume sport activity with an average delay of 7.7 months 3
• 57.7% of patients return to a level equal or superior to their pre-injury level 3
• High-level athletes (Tegner score ≥7) show a strong correlation between regained ankle strength and successful return to previous level of play 2
• Early range of motion after Achilles repair is safe with no increased risk of rerupture in compliant patients 6

Common Pitfalls to Avoid

• Misdiagnosis or inadequate imaging before treatment decision
• Injecting corticosteroids directly into the tendon (increases rupture risk)
• Prolonged immobilization leading to muscle atrophy and deconditioning
• Overly aggressive early rehabilitation
• Failing to address bilateral tendon issues (common even when symptoms appear unilateral) 1