What is the recommended initial assessment and management for a patient with a suspected Achilles tendon rupture, including indications for operative versus non‑operative treatment?

Management of Acute Achilles Tendon Rupture

For suspected Achilles tendon rupture, confirm diagnosis using at least two clinical tests (Thompson squeeze test, decreased plantar flexion strength, palpable gap, or increased passive dorsiflexion), then select treatment based on patient activity level: surgical repair for young, active patients and non-operative management for elderly or low-demand patients, both followed by early protected weight-bearing within 2 weeks. 1, 2, 3

Initial Clinical Assessment

The diagnosis should be confirmed using at least two of the following clinical tests 1, 2, 3:

• Thompson/Simonds squeeze test (squeezing the calf fails to produce plantar flexion)
• Decreased ankle plantar flexion strength when compared to the contralateral side
• Palpable gap in the tendon substance
• Increased passive ankle dorsiflexion (Matles test)

Imaging is not routinely necessary when clinical diagnosis is clear 1, 2. However, ultrasound can confirm diagnosis in uncertain cases and can differentiate full-thickness from partial-thickness tears with 92% accuracy 4. MRI achieves sensitivities >90% in diagnosing ankle tendon tears but adds little value when clinical diagnosis is straightforward 4.

Treatment Selection Algorithm

Surgical Treatment Indications 1, 3:

• Young, active patients desiring return to sports
• Patients with high functional demands
• Patients who cannot tolerate higher rerupture risk (6.2% non-operative vs 0.6% surgical)
• Younger, healthier patients seeking optimal functional recovery
• Patients who can comply with postoperative protocols

Non-Operative Treatment Indications 1, 2, 3:

• Elderly or low-demand patients
• Nursing home residents
• Patients with significant comorbidities or surgical risk factors
• Patients unable to comply with surgical rehabilitation
• Patients who prioritize avoiding wound complications

The evidence shows that surgery is not mandatory—the American Academy of Orthopaedic Surgeons grades surgical treatment as only a "weak" recommendation, as non-surgical treatment produces similar long-term functional outcomes when combined with proper rehabilitation. 1, 3, 5

Surgical Approach Selection

When surgery is chosen, limited open repair or minimally invasive techniques should be the default surgical approach rather than traditional open repair 3. The evidence demonstrates:

• Limited open repair shows significantly fewer severe wound infections, superficial infections, and minor surgical site infections compared to standard open repair, with faster return to walking, stair climbing, and sports 1, 3
• Percutaneous repair results in less wound breakdown, fewer scar adhesions, and higher patient satisfaction scores 1, 3

Critical caveat: Percutaneous techniques carry a higher risk of sural nerve injury (5.2%) compared to open repair (2.8%) or non-operative treatment (0.6%) 5. Limited open repair balances these concerns effectively 3.

Rehabilitation Protocol (Both Surgical and Non-Operative)

Early mobilization is critical for optimal outcomes 1, 2, 3:

• Within 2 weeks: Progress to protected weight-bearing in a walking boot that limits dorsiflexion to 0 degrees 1, 3
• By 2-4 weeks: Begin controlled ankle mobilization with free plantar flexion while maintaining the protective device 1, 2
• Throughout rehabilitation: Use a protective device that prevents dorsiflexion beyond neutral to prevent repair compromise 1

Early protected weight-bearing within 2 weeks and early mobilization by 2-4 weeks produce the fastest functional recovery without increasing rerupture risk 1. Delaying weight-bearing beyond 2 weeks unnecessarily prolongs recovery 3.

Return to Activity Timeline

For surgical patients 1:

• 10-12 weeks: Low-impact activities typically begin
• 3-6 months: Plan return to sports, with timing dependent on sport demands and functional testing
• 4-6 months: Full sports participation generally safe for most activities

Complications to Monitor

All Patients 1, 2, 3:

• Deep vein thrombosis (occurs with both surgical and non-operative management)
• Rerupture risk: 6.2% non-operative vs 0.6% surgical 3, 5
• Residual tendon lengthening affecting function

Surgical-Specific Complications 3, 5:

• Sural nerve injury: Higher with percutaneous (5.2%) than open repair (2.8%)
• Wound complications: Significantly reduced with limited open or minimally invasive approaches

Critical Pitfalls to Avoid

• Choosing traditional open repair when minimally invasive options are available increases wound complications unnecessarily 3
• Inadequate patient counseling about compliance requirements can increase rerupture risk, particularly in non-operative management 3
• Delaying mobilization beyond 2-4 weeks prolongs recovery without benefit 1, 3
• Assuming surgery is mandatory: The most recent high-quality evidence shows non-operative treatment produces similar functional outcomes at 12 months, with the primary difference being rerupture rates 5