What is the treatment for an Achilles tendon tear?

Treatment of Achilles Tendon Tear

Both surgical and nonsurgical treatment achieve similar functional outcomes at 12 months for acute Achilles tendon ruptures, but surgery (particularly minimally invasive or limited open techniques) significantly reduces rerupture risk from 6.2% to 0.6%, making it the preferred approach for most active patients despite slightly higher nerve injury risk. 1

Initial Diagnosis

Confirm the diagnosis using at least two of the following clinical tests 2, 3:

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

Advanced imaging (ultrasound or MRI) is not routinely necessary when clinical diagnosis is clear, though it can confirm uncertain cases 3. The American Academy of Orthopaedic Surgeons found insufficient evidence to recommend for or against routine imaging 2.

Treatment Selection Algorithm

For Active, Healthy Patients:

Surgical repair is preferred due to the substantially lower rerupture rate (0.6% vs 6.2% with conservative management), despite similar functional scores at 12 months 1.

Surgical technique hierarchy based on outcomes 4:

1. Limited open or minimally invasive repair (first-line surgical option):

   • Significantly faster return to normal walking, stair climbing, and sports 4
   • Fewer severe wound infections and superficial infections compared to open repair 4
   • Higher physical and mental component scores 4
   • Less wound breakdown and fewer scar adhesions 4
   • Caution: Sural nerve injury occurs in 5.2% with minimally invasive vs 2.8% with open repair 1

2. Standard open repair (alternative if minimally invasive not available):

   • Higher wound complication rates 4
   • More scar adhesions 4
   • Still achieves 0.6% rerupture rate 1

For Nursing Home or Low-Demand Patients:

Nonsurgical management is preferred due to lower complication risk and similar functional outcomes in this population 3. The higher rerupture rate (6.2%) is acceptable given reduced activity demands and surgical risks 1.

Post-Treatment Protocol (Surgical or Nonsurgical)

Immediate Post-Operative/Injury Phase:

• Short leg cast for 12-20 days (average 16.5 days) 5
• Begin protected weight bearing within 2 weeks - this accelerates return to activities in the first 6 months compared to traditional non-weight bearing 4, 3

Weeks 2-8:

• Transition to walking boot limiting dorsiflexion at 2-4 weeks 4, 3
• Average bracing duration: 6.9 weeks 5
• Begin mobilization by 2-4 weeks using protective device 6, 4

Rehabilitation Phase:

• Eccentric strengthening exercises are essential and may reverse degenerative changes 6
• Cryotherapy (10-minute periods through wet towel) for acute pain relief 6
• NSAIDs (topical preferred for fewer systemic effects) for short-term pain management 6

Expected Timeline:

• Single heel raise possible by 12 months in all patients 5
• Full recovery within 3-6 months for most patients 6
• Return to pre-injury athletic activity achieved in 85.7% of surgical patients 5
• By 12 months, pain and function outcomes are similar regardless of early vs delayed weight bearing 6, 4

Critical Pitfalls to Avoid

Partial Tears Require Special Consideration:

The traditional "50% rule" (conservative management for tears <50% width) may be inadequate. Recent finite element modeling demonstrates that partial ruptures affecting less than 50% can progress to complete ruptures during functional rehabilitation, regardless of tendon twist configuration 7. Persistent partial tears respond poorly to conservative measures and may require surgical excision of degenerated tissue 8.

Compliance is Non-Negotiable:

Patient non-compliance with protective devices significantly increases rerupture risk 6, 3. This is particularly challenging in nursing home settings requiring close supervision 3.

Monitor for Complications:

• Deep vein thrombosis requires monitoring in all patients regardless of treatment approach 6, 4, 3
• Nerve injuries occur more frequently with minimally invasive techniques (5.2%) 1
• Wound puckering occurs more with percutaneous repair 4

Avoid Misinterpreting Post-Operative MRI:

In the early healing phase, acute scar tissue appears T2W hyperintense similar to rerupture, and tendon gaps may appear larger due to remodeling 9. Understanding normal healing prevents misdiagnosis of re-tear 9.