What is the treatment for a total Achilles tendon rupture?

Treatment of Total Achilles Tendon Rupture

Both surgical and nonsurgical treatment are viable options for acute total Achilles tendon rupture, with the choice depending primarily on patient activity level, comorbidities, and rerupture risk tolerance—though surgery (particularly minimally invasive techniques) reduces rerupture rates from 6.2% to 0.6% while nonsurgical treatment avoids wound complications. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis using at least two of the following clinical tests: 1, 3

• Thompson/Simonds squeeze test (calf squeeze fails to produce plantar flexion) 1, 3
• Decreased ankle plantar flexion strength 1, 3
• Palpable gap in the tendon 1, 3
• Increased passive ankle dorsiflexion with gentle manipulation 1, 3

Advanced imaging (ultrasound or MRI) is not routinely necessary when clinical diagnosis is clear, though it can confirm uncertain cases. 3, 4

Treatment Decision Algorithm

Nonsurgical Treatment

Nonsurgical management is appropriate for: 1, 3

• Low-demand patients (elderly, sedentary, nursing home residents) 3
• Patients with significant surgical risk factors (multiple comorbidities, poor wound healing potential) 1
• Patients who prioritize avoiding wound complications 1

Key evidence: The 2022 NEJM multicenter RCT showed no difference in functional outcomes at 12 months between surgical and nonsurgical groups (mean Achilles tendon Total Rupture Score changes: -17.0 vs -16.0 vs -14.7 points, P=0.57), though rerupture rates were higher with nonsurgical treatment (6.2% vs 0.6%). 2 The AAOS guidelines confirm nonsurgical treatment produces similar functional outcomes, time to return to work, and pain levels compared to surgery, with fewer minor complications related to surgical intervention. 1

Nonsurgical protocol: 3, 5

• Initial immobilization in equinus position 3
• Progress to protected weight bearing within 2 weeks 3, 5
• Transition to protective device limiting dorsiflexion 3, 5
• Begin mobilization by 2-4 weeks using protective boot 3, 5, 4
• Continue protection for approximately 6-8 weeks total 3

Surgical Treatment

Surgery is preferred for: 1, 6

• High-demand patients (athletes, active individuals desiring return to sports) 1
• Patients who cannot tolerate higher rerupture risk 6, 2
• Younger, healthier patients seeking optimal functional recovery 6

Critical surgical technique selection: 1, 5, 7

Minimally invasive or limited open repair is superior to traditional open repair and should be the default surgical approach. 5, 6, 7, 8

• Percutaneous repair: Significantly less wound breakdown/delayed healing, fewer scar adhesions, and higher physical/mental component scores compared to open repair. 1, 5 However, wound puckering occurs more frequently, and there is risk of sural nerve injury (5.2% in recent trials). 5, 2

• Limited open (mini-open) repair: Allows faster return to walking, stair climbing, and sports compared to standard open repair, with significantly fewer severe and superficial wound infections. 1, 5 A 2021 study showed superior AOFAS scores (95.0±3.8 vs 92.3±5.3) and ATRS scores (93.8±3.8 vs 90.9±4.5) compared to percutaneous repair, with zero sural nerve injuries versus 5 cases in the percutaneous group. 7

• Traditional open repair: Higher rates of wound complications and infection; should generally be avoided unless direct visualization is required for complex cases. 1, 5

Post-operative protocol: 5, 4

• Early protected weight bearing within 2 weeks following repair 5, 4
• Use walking boot that limits dorsiflexion 5, 4
• Begin mobilization by 2-4 weeks using protective device 5, 4
• Early weight bearing enables quicker return to activities during first 6 months, though by 12 months outcomes are similar regardless of protocol 5

Critical Complications to Monitor

For all patients (surgical and nonsurgical): 1, 3, 5, 4

• Deep vein thrombosis (occurs with both treatment approaches) 1, 3, 5
• Rerupture risk (6.2% nonsurgical vs 0.6% surgical; patient compliance with protective protocols is crucial) 3, 5, 2
• Residual tendon lengthening affecting function 1, 3

Surgical-specific complications: 1, 5, 2

• Sural nerve injury (5.2% minimally invasive, 2.8% open repair, 0.6% nonsurgical) 2
• Wound complications (higher with open repair) 1, 5
• Wound puckering (more common with percutaneous repair) 5

Common Pitfalls

• Delaying weight bearing beyond 2 weeks unnecessarily prolongs recovery without improving outcomes 5, 4
• Choosing traditional open repair when minimally invasive options provide superior complication profiles 5, 6, 7
• Inadequate patient counseling about compliance requirements—non-compliance significantly increases rerupture risk regardless of treatment choice 3, 4
• Failing to individualize based on activity demands—the 2022 NEJM trial showed equivalent 12-month outcomes, but this doesn't account for the critical difference in rerupture rates for active patients 2