What is the treatment for an Achilles tendon injury?

Treatment of Achilles Tendon Injury

Acute Complete Rupture

For acute Achilles tendon rupture, both surgical and non-surgical treatment are acceptable options with similar long-term functional outcomes, though surgical repair reduces rerupture risk and is preferred for younger, physically active patients. 1, 2

Diagnosis Confirmation

• Confirm diagnosis using at least two clinical tests: Thompson/Simonds squeeze test (calf squeeze with absent plantar flexion), palpable gap in the tendon, decreased plantar flexion strength, or increased passive ankle dorsiflexion (Matles test) 1, 2
• Advanced imaging (ultrasound or MRI) is not routinely necessary when clinical diagnosis is clear 1, 2

Treatment Selection Algorithm

Surgical Treatment is preferred for:

• Young, physically active patients who require return to high-level sports 3
• Patients where diagnosis or treatment has been delayed 3
• Athletes seeking to minimize rerupture risk (3-5% surgical vs higher non-surgical) 1, 4

Non-surgical Treatment is preferred for:

• Older patients with sedentary lifestyles 3
• Nursing home patients or those with limited mobility 2
• Patients with high surgical risk or wound healing concerns 1, 2

Surgical Technique Options (if surgery chosen)

Percutaneous or limited open repair techniques are superior to traditional open repair due to significantly fewer wound complications while maintaining equivalent functional outcomes 5:

• Percutaneous repair: Higher physical/mental component scores, significantly less wound breakdown, fewer scar adhesions, but increased risk of sural nerve injury and wound puckering 5
• Limited open repair: Faster return to walking, stair climbing, and sports; significantly fewer severe and superficial wound infections compared to open repair 5
• Open repair: Higher rates of wound complications and infection; reserve for complex cases 5

Post-Treatment Immobilization Protocol (Both Surgical and Non-Surgical)

Early protected weight bearing within 2 weeks is strongly recommended as it allows quicker return to activities during the first 6 months without compromising final outcomes 1, 2, 5:

1. Initial phase (0-2 weeks): Posterior splint or cast in equinus position; begin protected weight bearing by 2 weeks 1, 2
2. Weeks 2-4: Transition to protective device (walking boot) that limits dorsiflexion to prevent excessive stretch; begin mobilization 1, 2, 5
3. Weeks 4-6: Continue protected weight bearing with gradual increase in dorsiflexion 1
4. After 6 weeks: Progress to full weight bearing as tolerated 1

Critical Compliance Warning

Patient adherence to the protective device protocol is crucial—non-compliance significantly increases rerupture risk, as demonstrated by two reruptures in one study occurring exclusively in non-compliant patients who fell during the first 4 weeks 1, 2, 5

Return to Activity Timeline

• Return to work/daily activities: 3-6 months for most patients 1
• Return to sports: 3-6 months post-surgical treatment; athletes typically achieve 70-90% successful return 1, 4
• Peak recovery: By 12 months, pain and function outcomes are similar between early and delayed weight bearing protocols, though significant functional deficits may persist compared to the uninjured side 1, 6

Achilles Tendinopathy (Overuse Injuries)

Insertional Achilles Tendinitis

Conservative treatment is the first-line approach for insertional Achilles tendinitis 1:

• Open-backed shoes to reduce pressure on the insertion site 1
• Heel lifts or orthoses to decrease tension 1
• NSAIDs (topical preferred to avoid GI side effects) for pain relief 1, 7
• Eccentric strengthening exercises—proven effective for reversing degenerative changes 1, 7
• Weight loss if indicated 1
• Avoid corticosteroid injections at the Achilles insertion—risk of tendon weakening and spontaneous rupture 1

If no improvement after 6-8 weeks: Consider immobilization with cast or walking boot; refer to foot and ankle surgeon 1

Non-Insertional Achilles Tendinopathy

Eccentric exercise is the cornerstone of treatment for mid-substance Achilles tendinopathy 1, 7:

• Relative rest (avoid activities that worsen pain, but avoid complete immobilization to prevent atrophy) 1
• Cryotherapy: 10-minute applications through wet towel for acute pain relief 1, 7
• NSAIDs (topical or systemic) for short-term pain relief 1, 7
• Eccentric strengthening exercises—proven beneficial in multiple studies 1, 7
• Stretching exercises 1
• Orthotics/braces to unload and protect the tendon 1

Surgery is required in approximately 25% of cases when conservative treatment fails after 3-6 months, with frequency increasing with patient age and symptom duration 4

Complications to Monitor (All Achilles Injuries)

• Deep vein thrombosis—occurs with both surgical and non-surgical treatment 1, 2, 7, 5
• Rerupture (higher with non-surgical treatment and non-compliance) 1
• Residual tendon lengthening affecting function 1, 2
• Sural nerve injury (with surgical treatment, especially percutaneous) 5