Acute Achilles Tendon Ruptures: A Comparative Analysis of Surgical and Non-Surgical Treatment Outcomes

Acute Achilles tendon rupture (AATR) is a common injury, particularly among physically active individuals¹. This injury has an incidence of 31 per 100,000 per year². Characterized by a sudden, sharp pain in the back of the ankle, often accompanied by a popping or snapping sensation, AATR can significantly impair mobility and quality of life³. The Achilles tendon, the largest and strongest tendon in the body, connects the calf muscles to the heel bone, enabling essential movements like walking, running, and jumping¹. When this tendon ruptures, it disrupts the connection between the muscles and the bone, leading to pain, weakness, and difficulty with plantar flexion (pointing the foot downwards)¹.

Historically, surgical intervention was the preferred treatment for AATR, primarily due to concerns about high re-rupture rates associated with non-surgical management⁴. However, advancements in non-surgical treatment protocols, particularly the introduction of early functional rehabilitation, have challenged this traditional approach². This article aims to provide a comprehensive comparison of surgical and non-surgical treatment outcomes for AATR, considering re-rupture rates, functional outcomes, and potential complications.

Re-rupture Rates

Re-rupture, a significant concern following AATR, refers to the tendon tearing again after initial treatment⁵. Several meta-analyses have investigated re-rupture rates associated with surgical and non-surgical treatment. A meta-analysis of 29 studies, including both randomized controlled trials and observational studies, revealed a significant reduction in re-ruptures after surgical treatment (2.3%) compared to non-surgical treatment (3.9%)⁶. This difference, while statistically significant, represents a relatively small absolute risk reduction of 1.6%⁶.

Importantly, re-rupture rates in non-surgical treatment have shown improvement with the adoption of accelerated functional rehabilitation protocols². These protocols emphasize early range of motion and weight-bearing exercises, promoting tendon healing and strength¹. Studies utilizing these protocols have reported no significant difference in re-rupture rates between surgical and non-surgical groups². This highlights a crucial point: while surgical treatment may have a lower re-rupture rate overall, this difference is minimized or eliminated with the use of accelerated functional rehabilitation protocols in non-surgical treatment. ¹

Functional Outcomes

Functional outcomes encompass various aspects of recovery, including ankle range of motion, calf muscle strength, and the ability to perform daily activities and return to sports¹. Historically, surgical treatment was believed to provide superior functional outcomes⁷. However, recent studies suggest that non-surgical treatment with early functional rehabilitation can achieve comparable results⁸.

A meta-analysis of 14 studies found no statistically significant difference between surgical and non-surgical groups in terms of returning to sports, Achilles tendon Total Rupture Score (ATRS), abnormal motion of the foot and ankle, the ability to perform a single heel-rise, and torque for plantar flexion¹. However, the surgical group demonstrated significantly better outcomes in terms of sick leave and calf muscle abnormalities¹.

Risks and Benefits of Surgical Treatment

Surgical treatment for AATR involves reconnecting the torn ends of the tendon through an incision in the back of the calf⁹. This procedure aims to restore the tendon's anatomical alignment and promote healing with minimal scarring¹⁰. In cases of severe damage, the surgeon might replace part or all of the Achilles tendon with a tendon taken from another place in your foot⁹. For tears very close to the insertion point at the heel bone, suture anchors may be used to repair and reconnect the Achilles directly into the calcaneus bone¹⁰. If the tendon was damaged before the rupture, the tendon may need to be reconstructed using a graft from another tendon in the body¹⁰. If a badly torn tendon needs to be partially removed, an Achilles tendon transfer may be necessary¹¹.

Benefits:

1. Reduced re-rupture rate: Surgical treatment generally demonstrates a lower re-rupture rate compared to non-surgical management, particularly in the absence of accelerated functional rehabilitation protocols².
2. Faster rehabilitation: Surgical intervention may allow for earlier weight-bearing and a more aggressive rehabilitation program, potentially leading to a faster return to pre-injury activity levels¹².
3. Improved functional outcomes: While recent studies suggest comparable functional outcomes with non-surgical treatment, some evidence suggests that surgery may result in better tendon strength and overall function¹³.

Risks:

1. Surgical complications: As with any surgical procedure, Achilles tendon repair carries risks such as infection, nerve damage, wound healing problems, and complications from anesthesia⁹.
2. Scarring and adhesions: Surgical repair can lead to scar tissue formation and adhesions, potentially affecting ankle range of motion and long-term function¹⁵.
3. Calf weakness: Some patients may experience persistent calf weakness following surgery, although this is usually addressed through rehabilitation¹⁴.

Risks and Benefits of Non-Surgical Treatment

Non-surgical treatment for AATR typically involves immobilizing the ankle in a cast, splint, or walking boot with the foot pointed downwards¹⁶. This allows the tendon to heal naturally without the need for surgery¹³. Dynamic ultrasonography can be used to assess the gap between the tendon ends¹⁷.

Benefits:

1. Avoidance of surgical risks: Non-surgical treatment eliminates the risks associated with surgery, such as infection, nerve damage, and anesthesia complications⁸.
2. Less invasive: Non-surgical management is less invasive, avoiding the need for an incision and subsequent scar¹³.
3. Comparable outcomes: Recent studies indicate that non-surgical treatment with early functional rehabilitation can achieve similar functional outcomes to surgery, particularly for individuals with lower activity levels⁸.

Risks:

1. Higher re-rupture rate: Non-surgical treatment may have a slightly higher re-rupture rate compared to surgery, although this difference is minimized with accelerated functional rehabilitation¹⁶.
2. Longer immobilization period: Non-surgical management often requires a longer period of immobilization in a cast or boot, which can be inconvenient and potentially lead to stiffness⁸.
3. Weaker tendon strength: While functional outcomes are often comparable, non-surgical healing may result in a slightly weaker tendon compared to surgical repair⁸.
4. Tendon elongation: Non-surgical treatment may result in lengthening of the tendon, leading to poor strength¹⁸.
5. Skin necrosis: In cases with a bony lump or skin tension, non-surgical treatment with a plantarflexed cast carries a risk of skin necrosis¹⁹.

Rehabilitation Protocols

Rehabilitation plays a crucial role in recovery from AATR, regardless of the chosen treatment approach²⁰. Rehabilitation protocols aim to restore ankle range of motion, strengthen the calf muscles, and improve overall function²¹. Blood flow restriction techniques may be used to enhance strength without overloading the newly repaired tendon¹⁰.

Surgical Rehabilitation

Following surgical repair, rehabilitation typically involves a period of immobilization in a splint or cast, followed by a gradual transition to weight-bearing in a walking boot²². Early rehabilitation focuses on controlling swelling, protecting the repair, and gradually increasing ankle range of motion²¹. As healing progresses, exercises to strengthen the calf muscles and improve balance and coordination are introduced²³. The overall goal is to restore full function and facilitate a safe return to pre-injury activities²⁴. Return to sport may take 9 to 12 months depending on the severity of injury and nature of the sport the patient desires to play²⁵.

Here's an example of a surgical rehabilitation protocol: ²²

Weeks 1-2:

1. Goals: Protection of repair, reduction of swelling.
2. Brace: Splint in plantarflexion.
3. Weight-bearing: Non-weight-bearing (NWB) with crutches.
4. Exercises: Active dorsiflexion up to neutral, pain-free ankle isometrics (inversion, eversion, dorsiflexion, and sub-maximal plantarflexion), open-chain hip and core strengthening in boot.

Weeks 3-6:

1. Goals: Graduated weight-bearing, active dorsiflexion up to neutral.
2. Brace: CAM boot with heel wedges, gradually removing wedges every 5-7 days.
3. Weight-bearing: Begin graduated weight-bearing with crutches in the CAM boot.
4. Exercises: Active dorsiflexion to neutral, pain-free ankle isometrics, open-chain hip and core strengthening.

Weeks 7-12:

1. Goals: Regain ankle range of motion (ROM), may sleep out of boot if comfortable.
2. Brace: Boot at all times with 1-inch heel lift.
3. Weight-bearing: Weight-bearing as tolerated (WBAT) in boot.
4. Exercises: Active ankle eversion/inversion, passive dorsiflexion, standing calf stretch, continue eversion, inversion, and plantarflexion isometrics with resistance bands, initiate balance exercises, stationary bike with minimal resistance, pool exercise if the wound is fully healed, hip and core strengthening.

This is just one example, and specific protocols may vary depending on the surgeon and the individual's needs.

Non-Surgical Rehabilitation

Non-surgical rehabilitation protocols also involve a period of immobilization, typically in a cast or walking boot with heel lifts²⁶. Early functional rehabilitation emphasizes early weight-bearing and controlled ankle motion to promote tendon healing and prevent stiffness²⁴. As the tendon heals, exercises to strengthen the calf muscles and improve balance and proprioception are gradually introduced²⁷. The rehabilitation program is tailored to the individual's needs and goals, with the aim of restoring full function and facilitating a safe return to activities²⁸.

Here's an example of a non-surgical rehabilitation protocol: ²⁷

0-2 Weeks:

1. Goals: Protect the injured tendon, control pain and swelling.
2. Immobilization: Plaster cast or rigid boot with the foot pointing downwards.
3. Physiotherapy: Elevate the limb, wear the boot 24 hours a day, pain control, maintain hip/knee/toe movement.

2-4 Weeks:

1. Goals: Confidently weight-bearing as pain allows, begin gentle ankle plantarflexion exercises.
2. Immobilization: Rigid walking boot with the foot pointing downwards.
3. Physiotherapy: Weight-bear with crutches as discomfort allows, maintain spinal/hip/knee/toe range of motion, gently actively plantarflex foot, dorsiflex back to the position in the boot, massage, swelling control.

4-8 Weeks:

1. Goals: Progress to fully weight-bearing, regain full inversion and eversion, aim for ankle plantigrade/foot flat.
2. Immobilization: Rigid walking boot with wedges being removed weekly to plantigrade position.
3. Physiotherapy: Remove one wedge per week, active resisted plantarflexion, eversion and inversion with theraband, seated heel raises, maintain hip/knee/toe movement, exercise bike with boot on, gait re-education.

8-12 Weeks:

1. Goals: Normal walking, increase ankle and lower limb muscle strength.
2. Immobilization: Boot with ankle plantigrade/foot flat on the ground.
3. Physiotherapy: Continue active resisted theraband exercises, allow dorsiflexion to return naturally, exercise bike with boot on, seated heel raises, double leg stance out of boot, single leg stand in boot progressing to out of boot.

12-24 Weeks:

1. Goals: Mastering proprioceptive control, aim for normal dorsiflexion range, jogging, increase exercise intensity, sports-specific drills.
2. Physiotherapy: Theraband exercises, progress muscle strengthening, proprioceptive rehabilitation, gastroc/soleus conditioning, single heel raises, introduce running and sports-specific drills.

This is just one example, and specific protocols may vary depending on the individual's needs and the healthcare provider's recommendations.

Guidelines and Recommendations

Professional medical organizations provide guidelines and recommendations for the treatment of AATR. These guidelines often emphasize shared decision-making between the patient and the healthcare provider, considering individual factors such as age, activity level, and overall health⁶.

The American Academy of Orthopaedic Surgeons (AAOS) suggests that the diagnosis of AATR can be established through physical examination findings, including a positive Thompson test, decreased plantar flexion strength, and a palpable defect in the tendon⁴. Imaging studies, such as ultrasound or MRI, may be used to confirm the diagnosis and assess the extent of the injury⁴.

Treatment recommendations often consider the individual's needs and preferences. Younger and more active individuals, particularly athletes, may be more likely to choose surgical repair to minimize the risk of re-rupture and facilitate a faster return to sports²⁹. Older or less active individuals may opt for non-surgical management, especially if they have medical conditions that increase surgical risks³. Ultimately, the choice between surgical and non-surgical treatment should be individualized based on patient factors, preferences, and access to resources like functional rehabilitation programs. ³

Patient Testimonials

Patient testimonials provide valuable insights into the experiences and outcomes of individuals who have undergone treatment for AATR. While individual experiences can vary, these testimonials offer a glimpse into the recovery process and potential challenges.

Here are some patient experiences with surgical treatment:

1. One patient who underwent surgical repair emphasized the importance of diligent physical therapy, including daily exercises and the use of an exercise bike at home. They were able to participate in a one-mile run race 9 months after surgery and a sprint triathlon one year after surgery³⁰.
2. Another patient described their surgical experience in detail, including the use of a PARs device and a relatively quick recovery with minimal pain. They were able to start physical therapy and weight-bearing 2 weeks after surgery³¹.
3. A patient who had surgery 10 years prior reported having no problems with their Achilles tendon since the operation³⁰.

Here are some patient experiences with non-surgical treatment:

1. One patient who opted for non-surgical treatment highlighted the importance of a gradual build-up of activity and the willingness to adjust the rehabilitation plan as needed. They were racing again 4 months after the rupture and completed an Ironman 12 months after the injury³⁰.
2. Another patient who had both surgical and non-surgical treatment for Achilles tendon ruptures reported a better outcome with the conservatively treated tendon³⁰.

These testimonials illustrate the variability in recovery experiences and highlight the importance of individualized treatment plans and rehabilitation protocols.

Conclusion

The optimal treatment for AATR remains a topic of ongoing discussion and research. While surgical treatment has traditionally been favored for its lower re-rupture rates, advancements in non-surgical management, particularly early functional rehabilitation protocols, have led to comparable outcomes in many cases. The decision between surgical and non-surgical treatment should be made on an individual basis, considering factors such as age, activity level, overall health, and personal preferences. Regardless of the chosen approach, diligent rehabilitation is crucial for restoring ankle function and facilitating a safe return to activities.

To summarize the key findings:

Factor	Surgical Treatment	Non-Surgical Treatment
Re-rupture rate	Lower overall, but comparable with accelerated functional rehabilitation in non-surgical treatment	Higher overall, but minimized with accelerated functional rehabilitation
Functional outcomes	May provide slightly better tendon strength and calf muscle recovery	Comparable to surgical treatment with early functional rehabilitation
Complications	Risk of infection, nerve damage, wound healing problems	Risk of re-rupture, tendon elongation, stiffness
Rehabilitation	May allow for earlier weight-bearing and a more aggressive program	Emphasizes early weight-bearing and controlled ankle motion
Patient factors	Often preferred by younger, more active individuals	May be suitable for older or less active individuals

This table provides a concise overview of the key differences between surgical and non-surgical treatment for AATR, aiding in informed decision-making.

Works cited

1. Surgical vs. nonoperative treatment for acute Achilles ... - Frontiers, accessed February 17, 2025, https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2024.1483584/full

2. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis | The BMJ, accessed February 17, 2025, https://www.bmj.com/content/364/bmj.k5120

3. Achilles Tendon Rupture: What Is It, Symptoms & Treatment - Cleveland Clinic, accessed February 17, 2025, https://my.clevelandclinic.org/health/diseases/21703-achilles-tendon-rupture

4. Treatment of Acute Achilles Tendon Rupture - PMC, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC7031433/

5. Achilles Tendon Rupture | Surgical Non-surgical options - Dr Hamish Curry, accessed February 17, 2025, https://hamishcurry.com.au/achilles-tendon-rupture/

6. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis - PubMed, accessed February 17, 2025, https://pubmed.ncbi.nlm.nih.gov/30617123/

7. Operative Versus Nonoperative Treatment of Acute Achilles Tendon Rupture: A Propensity Score–Matched Analysis of a Large National Dataset, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC9974620/

8. Achilles Tendon Rupture: Should You Choose Surgery or Try Non-Surgical Treatments?, accessed February 17, 2025, https://www.urgentcareforfeet.com/achilles-tendon-rupture-should-you-choose-surgery-or-try-non-surgical-treatments/

9. Achilles Tendon Repair Surgery | Johns Hopkins Medicine, accessed February 17, 2025, https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/achilles-tendon-repair-surgery

10. Achilles Tendon Rupture: Symptoms, Treatment, Recovery - HSS, accessed February 17, 2025, https://www.hss.edu/conditions_achilles-tendon-rupture-injuries.asp

11. Achilles Injuries Treatment - Penn Medicine, accessed February 17, 2025, https://www.pennmedicine.org/for-patients-and-visitors/find-a-program-or-service/orthopaedics/foot-and-ankle-pain/achilles-injuries-treatment

12. Achilles Tendon Rupture - Massachusetts General Hospital, accessed February 17, 2025, https://www.massgeneral.org/orthopaedics/foot-ankle/conditions-and-treatments/achilles-tendon-rupture

13. Does a Ruptured Achilles Tendon Require Surgery? | New York, NY, accessed February 17, 2025, https://www.shouldersandknees.com/blog/does-a-ruptured-achilles-tendon-require-surgery/

14. Surgery for an Achilles Tendon Rupture - Kaiser Permanente, accessed February 17, 2025, https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.surgery-for-an-achilles-tendon-rupture.tr2154

15. Efficacy and complications of open and minimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study—preliminary report, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC3609980/

16. Treating Your Achilles Tendon Tear Part I: Non-surgical Treatments - Eugene Stautberg, MD, accessed February 17, 2025, https://www.estautbergmd.com/blog/treating-your-achilles-tendon-tear-part-i-non-surgical-treatments

17. Management of acute Achilles tendon ruptures: A review - PMC - PubMed Central, accessed February 17, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6215245/

18. Achilles Tendon Rupture, Surgical & Non Surgical Treatment - Orthosports, accessed February 17, 2025, https://orthosports.com.au/foot/achilles-tendon-rupture/

19. The Achilles tendon: Management of acute and chronic conditions - RACGP, accessed February 17, 2025, https://www1.racgp.org.au/ajgp/2020/november/the-achilles-tendon

20. Rehabilitation Guidelines for Achilles Tendon Repair, accessed February 17, 2025, https://www.tigerortho.com/pdfs/uw-health/achilles-tendon-rehab-final.pdf

21. Achilles Tendon Repair Rehabilitation Protocol | Stony Brook Medicine, accessed February 17, 2025, https://www.stonybrookmedicine.edu/northforkorthopedics/achilles-tendon

22. Post-Operative Achilles Tendon Repair Rehab Protcol | Physical Therapy (PT), accessed February 17, 2025, https://manhattansportsdoc.com/post-operative-achilles-tendon-repair-rehab-protocol-physical-therapy-pt/

23. Rehabilitation Protocol for Achilles Rupture Repair - Massachusetts General Hospital, accessed February 17, 2025, https://www.massgeneral.org/assets/mgh/pdf/orthopaedics/sports-medicine/physical-therapy/rehabilitation-protocol-for-achilles-tendon-repair.pdf

24. Physical Therapy Guideline for Achilles Rupture Repair - Massachusetts General Hospital, accessed February 17, 2025, https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/foot-ankle/PT-guidelines-achilles-rupture-repair.pdf

25. ACHILLES TENDON REPAIR CLINICAL PRACTICE GUIDELINE - Ohio State College of Medicine, accessed February 17, 2025, https://medicine.osu.edu/-/media/files/medicine/departments/sports-medicine/medical-professionals/knee-ankle-and-foot/achilles-repair-protocol-2020final-002.pdf

26. Nonsurgical Treatment for Achilles Injury - NYU Langone Health, accessed February 17, 2025, https://nyulangone.org/conditions/achilles-injury/treatments/nonsurgical-treatment-for-achilles-injury

27. Achilles Tendon Rupture – Non-operative treatment rehabilitation guidelines | London Foot and Ankle, accessed February 17, 2025, https://www.londonorthopaedicsurgery.co.uk/therapies-exercise-regimes/achilles-tendon-rupture-non-operative-treatment-rehabilitation-guidelines/

28. Non-Operative Achilles Rupture Rehabilitation Guideline - Sanford Health, accessed February 17, 2025, https://www.sanfordhealth.org/-/media/org/files/medical-professionals/resources-and-education/non-operative-achilles-rupture-guidelines.pdf

29. Achilles tendon rupture - Diagnosis and treatment - Mayo Clinic, accessed February 17, 2025, https://www.mayoclinic.org/diseases-conditions/achilles-tendon-rupture/diagnosis-treatment/drc-20353239

30. Complete Achilles rupture - Triathlon Forum, accessed February 17, 2025, https://forum.slowtwitch.com/t/complete-achilles-rupture/796421

31. Achilles Rupture and Surgical Experience (In-depth 10-day Post Surgery) - Reddit, accessed February 17, 2025,