What is the treatment for an Achilles tendon rupture?

Treatment of Achilles Tendon Rupture

Both surgical and non-surgical treatment are viable options for acute Achilles tendon rupture, with the choice depending on patient factors: non-surgical treatment with functional rehabilitation is preferred for lower-demand patients (including nursing home residents) due to lower complication rates, while minimally invasive or limited open surgical repair combined with early mobilization offers the best outcomes for active individuals who can comply with rehabilitation protocols. 1, 2, 3

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis using at least two of the following clinical tests 4, 1:

• Thompson/Simonds squeeze test (calf squeeze fails to produce ankle plantarflexion) 4
• Decreased ankle plantar flexion strength 4
• Palpable gap in the tendon 4
• Increased passive ankle dorsiflexion with gentle manipulation 4

Advanced imaging (ultrasound or MRI) is not routinely necessary when clinical diagnosis is clear, though ultrasound can confirm tendon apposition for non-surgical candidates 1, 5

Treatment Algorithm

Non-Surgical Treatment

Non-surgical management is the preferred approach for:

• Nursing home patients or low-demand individuals 1
• Patients with significant surgical risk factors 1
• Those who can comply with immobilization and rehabilitation protocols 5

The American Academy of Orthopaedic Surgeons supports non-surgical management when combined with proper functional rehabilitation, citing similar functional outcomes to surgery with lower complication rates, particularly fewer wound-related issues. 1

Protocol specifics:

• Initial immobilization with ankle in 20 degrees plantarflexion using a high-shaft boot with 3-cm hindfoot elevation 5
• Ultrasound confirmation that tendon ends are ≤10mm apart in neutral position and completely apposed in 20 degrees plantarflexion 5
• Progress to protected weight bearing within 2 weeks 1
• Begin mobilization by 2-4 weeks using a protective device that limits dorsiflexion 1, 2
• Extend hindfoot elevation for 6-8 weeks, then transition to 1-cm elevation for additional 3 months 5

Critical caveat: Non-surgical treatment historically carries a higher rerupture risk (approximately 6-10%) compared to surgical repair, making patient compliance absolutely essential 3, 5

Surgical Treatment

Surgical repair is preferred for:

• Active individuals and athletes seeking to return to pre-injury activity levels 3, 6
• Patients who can comply with post-operative protocols 2
• Those presenting with delayed diagnosis where tendon ends cannot be approximated 6

Surgical technique hierarchy based on outcomes:

1. Minimally invasive/percutaneous repair (first-line surgical option):

   • Significantly higher physical and mental component scores compared to open repair 2
   • Significantly less wound breakdown, delayed healing, and fewer scar adhesions 2
   • Trade-off: Higher risk of sural nerve injury compared to open techniques 2

2. Limited open repair (alternative surgical option):

   • Allows return to normal walking, stair climbing, and sports in significantly less time than standard open repair 2
   • Significantly fewer severe wound infections and superficial infections compared to open repair 2

3. Standard open repair (avoid when possible):

   • Higher rates of wound complications and infection 2
   • Should be reserved for complex cases or when minimally invasive techniques are not feasible 6

The combination of minimally invasive repair and accelerated functional rehabilitation offers the best results in treating Achilles tendon rupture. 3

Post-Treatment Rehabilitation (Both Surgical and Non-Surgical)

Early protected weight bearing (≤2 weeks) is recommended following both surgical repair and non-surgical management:

• Enables quicker return to activities during the first 6 months 2
• By 12 months, outcomes (pain and function) are similar regardless of early or delayed weight bearing protocols 2

Mobilization protocol:

• Begin mobilization by 2-4 weeks using a protective device 1, 2
• Walking boot must limit dorsiflexion to protect the tendon during healing 2
• Transition through progressive weight bearing as tolerated 1

Patient compliance with the prescribed protocol is crucial to prevent rerupture—this cannot be overemphasized. 2

Complications to Monitor

All patients require monitoring for:

• Deep vein thrombosis (occurs with both surgical and non-surgical management) 1, 2
• Rerupture (higher with non-surgical treatment and non-compliance) 3, 5
• Residual tendon lengthening affecting function 1
• Wound complications (surgical patients only, especially with open repair) 2
• Sural nerve injuries (surgical patients, particularly with percutaneous techniques) 2

Special Population Considerations

For nursing home patients specifically:

• Non-surgical treatment is strongly preferred due to lower complication rates and similar outcomes 1
• The nursing home setting may present challenges for rehabilitation adherence, requiring close supervision and modified protocols 1
• Regular assessment of healing progress and adjustment of rehabilitation protocols based on patient progress and tolerance is necessary 1