What is the treatment for an Achilles tendon rupture?

Treatment of Achilles Tendon Rupture

For most patients with acute Achilles tendon rupture, minimally invasive or percutaneous repair combined with early functional rehabilitation offers the optimal balance of low rerupture rates, fewer wound complications, and faster return to activity compared to traditional open repair or non-operative management. 1, 2

Initial Diagnosis Confirmation

Confirm the diagnosis using at least two of these clinical findings: 3

• Thompson/Simonds squeeze test (absence of plantar flexion when calf squeezed)
• Decreased ankle plantar flexion strength
• Palpable gap in the tendon
• Increased passive ankle dorsiflexion compared to uninjured side

Advanced imaging (ultrasound or MRI) is unnecessary when clinical diagnosis is clear but can confirm uncertain cases. 3

Treatment Selection Algorithm

For Active Patients and Athletes

Surgical repair is preferred because it significantly reduces rerupture risk and allows faster return to sport with better peak torque/explosiveness. 4, 5

Surgical technique hierarchy based on outcomes:

1. Percutaneous or minimally invasive repair (FIRST CHOICE): 1, 2, 6

   • Significantly higher physical and mental component scores than open repair
   • Significantly less wound breakdown and fewer scar adhesions
   • Minimal sural nerve injury risk compared to traditional percutaneous techniques
   • Comparable functional outcomes to open repair with fewer complications

2. Limited open repair (SECOND CHOICE): 1

   • Faster return to normal walking, stair climbing, and sports than standard open repair
   • Significantly fewer severe wound infections and superficial infections than open repair
   • Better visualization than percutaneous techniques

3. Traditional open repair (LAST CHOICE): 1, 5

   • Higher rates of wound complications and infection (10.60 times higher risk than non-operative)
   • Reserve for delayed presentations or complex cases where tissue quality requires direct visualization

For Nursing Home Patients or Low-Demand Individuals

Non-surgical treatment with functional rehabilitation is preferred due to similar functional outcomes to surgery but significantly lower complication rates, particularly wound-related issues. 3 The rerupture risk (3.9% vs 2.3% surgical) is acceptable given the 4.9% surgical complication rate versus 1.6% non-operative complication rate. 4

Post-Treatment Immobilization and Rehabilitation Protocol

Weeks 0-2: 3, 1

• Immobilize in maximum plantar flexion initially (surgical) or protective boot (non-operative)
• Progress to protected weight bearing within 2 weeks - this is critical for optimal outcomes
• Early weight bearing (≤2 weeks) results in quicker return to activities during the first 6 months

Weeks 2-4: 3, 1

• Transition to protective device (walking boot) that limits dorsiflexion to protect healing tendon
• Begin mobilization by 2-4 weeks using the protective device
• Gradual increase in weight bearing as tolerated

Weeks 4-12: 1

• Continue functional rehabilitation with progressive loading
• By 12 months, outcomes (pain and function) are similar regardless of early versus delayed weight bearing protocols

Return to Activity: 4

• 88% of surgical patients return to baseline activity by 5 months
• Average return to normal activities is 3.3 months with early mobilization protocols 7

Critical Complications to Monitor

Deep vein thrombosis: Monitor all patients regardless of treatment approach. 3, 1

Rerupture risk factors: 3

• Non-compliance with protective devices significantly increases rerupture risk
• Patient adherence to prescribed protocols is crucial

Surgical-specific complications: 1, 5

• Wound infections (significantly higher with open repair)
• Sural nerve injuries (can occur with both percutaneous and open techniques)
• Wound puckering (more common with percutaneous repair but cosmetically acceptable)

Non-operative complications: 3

• Residual tendon lengthening affecting function
• Slightly higher rerupture rate (acceptable trade-off in appropriate patients)

Common Pitfalls to Avoid

• Do not delay weight bearing beyond 2 weeks - traditional prolonged immobilization increases muscle atrophy and delays recovery without improving outcomes 1, 7
• Do not choose open repair as first-line surgical option - percutaneous/minimally invasive techniques have superior complication profiles 1, 2
• Do not fail to close the paratenon during open repair - this causes scarring and wound complications 4
• Do not undertension or overtension the repair - check resting tension intraoperatively by comparing to the contralateral leg 4