Achilles tendon repair: options, recovery and risks

When surgery is considered

For background on the conditions, see Achilles tendon injuries.

• Acute rupture. Surgery is generally recommended for active people who want the lowest chance of re-rupture and the strongest push-off; non-surgical treatment is an alternative that avoids the risks of surgery.^[1] The decision is individualized, and it takes into account your age, activity, health, the timing of the injury and your preferences.
• Chronic or neglected rupture. When a rupture isn’t treated promptly, the tendon ends pull apart and the gap fills with scar; repair may require a tendon transfer or graft. There are evidence-based guidelines on the surgical management of chronic ruptures.^[6]
• Tendinopathy. Surgery is considered after about six months of unsuccessful non-surgical treatment. Options include debridement (removing damaged tendon tissue and, in insertional problems, the heel bone prominence that irritates the tendon; see Haglund deformity surgery) and lengthening of the calf muscle (gastrocnemius recession).^[2]

Repairing a ruptured tendon

• Open repair. An incision over the back of the lower leg lets the surgeon see the torn ends and stitch them together with strong sutures.
• Minimally invasive repair. Through smaller incisions, stitches are passed through the tendon and tied. A meta-analysis of 10 randomized trials (522 patients) found similar functional scores (AOFAS 94.8 with open repair and 95.7 with minimally invasive repair). There was no significant difference in total complication rates or in re-rupture (2.5% and 1.5%). The types of complication differed. Superficial infection was more common after open repair (6.0% compared with 0.4%). Injury to the sural nerve, which supplies sensation to the outer foot, was reported only after minimally invasive repair (3.4%).^[4]
• Augmentation, transfer or graft. For chronic ruptures or tendon with poor quality, the repair can be reinforced or the gap bridged with another tendon.^[6]

An evidence-based guideline on the surgical management of acute ruptures reports that a well-designed operative strategy supports early recovery, while surgical indications, timing, open versus minimally invasive technique and postoperative protocols remain areas of debate.^[7]

What the day of surgery involves

Achilles repair is usually done as an outpatient procedure with a nerve block or general anesthesia, and you go home the same day. After the operation, the leg is protected in a splint, boot or brace, often with the foot pointed slightly downward at first. Your surgeon will explain when you can put weight on the foot.^[1]

Recovery

Rehabilitation is a central part of recovery. Historically, patients were immobilized in a non-weight-bearing cast. A meta-analysis of 10 randomized trials (570 patients) found that early functional rehabilitation, which starts motion and weight-bearing in a brace, was as safe as casting. It brought higher patient satisfaction, a faster return to prior sports level in most trials, and no difference in major complications. By six months, strength differences were negligible.^[5] Physical therapy with strengthening and range-of-motion exercises is essential whether or not you have surgery.^[1] A full return to sport takes many months, and after surgery for tendinopathy, recovery can take up to a year.^[2] See recovery after foot and ankle surgery.

Risks

• Infection and wound problems. The skin over the back of the ankle has a limited blood supply, and healing problems can occur. In a large meta-analysis, complications were more frequent after surgery than after non-surgical treatment (4.9% compared with 1.6%), mainly because of infection.^[3]
• Nerve injury, especially of the sural nerve near the incision.^[4,1]
• Re-rupture, which is uncommon (about 2% to 3% after surgery in that meta-analysis).^[3]
• Blood clots. After an Achilles operation the leg is immobilized, and blood clots in the leg veins are a recognized risk; your surgeon will discuss your individual risk and whether preventive measures are appropriate.^[8,9]
• Ongoing pain or stiffness, including after surgery for tendinopathy: 20% to 30% of people continue to have some pain.^[2]

Questions to ask before deciding

• Am I a candidate for non-surgical treatment, and how would the risks compare for me?
• Which technique do you recommend, and why?
• How soon can I put weight on the foot, and what will physical therapy involve?
• How will my other health conditions (such as diabetes or smoking) change the risks?

When to seek care