What is the recommended management for an Achilles tendon rupture?

Management of Acute Achilles Tendon Rupture

Both surgical and non-surgical treatment are viable options for acute Achilles tendon rupture, with the choice depending primarily on patient activity level, compliance capability, and comorbidities—but regardless of treatment chosen, early protected weight bearing within 2 weeks combined with early mobilization by 2-4 weeks produces the fastest functional recovery without increasing rerupture risk. 1, 2, 3

Initial Diagnosis

Confirm the diagnosis using at least two of the following clinical tests: 1, 2

• Thompson/Simonds squeeze test (calf squeeze with absent plantarflexion)
• Decreased ankle plantar flexion strength
• Palpable gap in the tendon
• Increased passive ankle dorsiflexion (Matles test)

Imaging is not routinely necessary when clinical diagnosis is clear, though ultrasound can confirm diagnosis in uncertain cases. 1, 2 MRI and radiography lack sufficient evidence to recommend for routine confirmatory use. 1

Treatment Selection Algorithm

Surgical Treatment is preferred for: 1

• Young, active patients desiring return to sports
• Patients with high functional demands
• Those who can comply with postoperative protocols

Surgical options include: 1

• Open repair (extended incision with direct visualization)
• Limited open repair (small incision, fewer wound complications than open) 1
• Percutaneous repair (no direct exposure, less wound breakdown but more wound puckering) 1

Critical caveat: Limited open repair demonstrates significantly fewer severe wound infections, superficial infections, and minor surgical site infections compared to standard open repair, with faster return to normal walking, stair climbing, and sports. 1

Non-surgical Treatment is preferred for: 1, 2

• Elderly or low-demand patients
• Nursing home residents
• Patients with significant comorbidities
• Those unable to comply with surgical rehabilitation

Important consideration: Non-surgical treatment shows similar long-term functional outcomes to surgery when combined with proper rehabilitation, with lower complication rates (particularly wound-related issues). 1, 2 However, the study by Moller et al found significantly fewer reruptures with surgical treatment. 1

Postoperative/Post-Injury Rehabilitation Protocol

Weeks 0-2: Initial Immobilization Phase

• Apply below-knee splint with foot in 10-20 degrees plantar flexion for first week 4
• Begin early protected weight bearing within 2 weeks (can start immediately post-surgery with proper boot) 1, 2, 5
• Use protective device that limits dorsiflexion to 0 degrees to prevent repair compromise 1, 5

Evidence supporting early weight bearing: Three studies found statistically significant improvement in time to return to activities including work, sports, and normal walking with early weight bearing. 1 Patients report better physical functioning scores and fewer limitations in daily living at 6 weeks. 1, 5 By 12 months, outcomes equalize regardless of early versus delayed weight bearing. 1, 6

Critical warning: One study found higher rerupture rate (2 of 23 patients) in early weight-bearing group, but both patients had documented noncompliance with protective splint use and fell during first 4 weeks. 1 This underscores that patient compliance is absolutely crucial to prevent rerupture. 1, 2, 5

Weeks 2-4: Early Mobilization Phase

• Transition to protective device allowing mobilization by 2-4 weeks 1, 2
• Continue limiting dorsiflexion to 0 degrees 3
• Begin controlled ankle mobilization with free plantar flexion 3
• Progress to full weight bearing in protective boot 3, 4

Evidence: Four trials comparing early mobilization to immobilization found mobilization significantly shortens time to return to work and sports. 3 The combination of full weight bearing and early mobilization showed significantly higher patient satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities, increased calf muscle strength, reduced atrophy, and reduced tendon elongation. 3

Weeks 4-6: Progressive Loading Phase

• Continue full weight bearing in protective device 1
• Gradually increase dorsiflexion range while monitoring for pain or excessive strain 3
• Begin gentle strengthening exercises 6

Weeks 6-8: Transition to Normal Footwear

• Discontinue protective boot by 6-8 weeks 6
• Transition to regular shoes 6
• Establish normal gait pattern without limp 6

Weeks 9-12: Advanced Rehabilitation

At 9 weeks post-repair, patients should be: 6

• Fully weight-bearing without protective boot
• Actively working on progressive ankle range of motion
• Engaging in structured strengthening exercises
• Beginning light sport-specific activities 6

Months 3-6: Return to Sport

• Plan return to sports between 3-6 months post-surgery 1, 6
• Low-impact activities typically begin around 10-12 weeks 6
• Full sports participation generally safe at 4-6 months depending on sport demands and functional testing 6

Physical Therapy Recommendations

Evidence is weak for specific supervised physical therapy protocols—no studies met inclusion criteria for evidence-based recommendations. 1 However, structured rehabilitation is strongly supported for ensuring proper exercise progression and monitoring complications. 6

Complications to Monitor

• Rerupture risk (lower with surgery per Moller et al, but patient compliance critical) 1, 2
• Deep vein thrombosis (can occur with both surgical and non-surgical management; one study found 2 DVTs in immobilization group despite prophylaxis) 1, 2, 4
• Wound complications (significantly more with open versus limited open repair) 1
• Residual tendon lengthening affecting function 2
• Sural nerve injury (no significant difference between surgical techniques) 1

Common Pitfalls to Avoid

• Allowing unrestricted dorsiflexion too early compromises tendon healing 5
• Removing protective boot before 6-8 weeks increases rerupture risk 5
• Failing to emphasize compliance with protective devices—documented noncompliance directly correlates with rerupture 1, 5
• Prolonged immobilization beyond 2 weeks delays functional recovery without improving outcomes 1, 3
• Using traditional 6-week non-weight bearing protocols—outdated approach that delays return to activities 1, 3