Surgical repair vs. non-operative management of acute Achilles tendon ruptures: Current evidence and controversies

Abstract

The Achilles tendon is one of the most robust tendons of the human body, and unfortunately, the most ruptured. Historically, surgical management was the golden standard, aiming to restore baseline activity with low re-rupture rates. With the development of new functional rehabilitation protocols, the paradigm started shifting towards nonoperative approaches, to avoid surgical complications. Moreover, the introduction of adjunct therapies, such as low-level laser therapy, extracorporeal shockwave therapy, or plasma-rich-protein injections, widened the scope of treatment. While both surgical and nonoperative approaches have demonstrated comparable outcomes, an ideal treatment algorithm is still a subject of debate. This literature review meticulously studies major trends in surgical and nonoperative management of acute Achilles tendon ruptures, describing most prevalent techniques and protocols, comparative results, and complication rates. It also highlights the latest updates on the use of adjunct therapies and injections, aiming to guide clinical decision making in treating this common injury.

Introduction

Despite being a strong, large, and robust structure, the Achilles tendon is the most commonly ruptured tendon in the human body. ¹ In fact, the incidence of acute rupture, in different parts of the world, has increased, reaching up to 45% between 2002 and 2021. ² This musculoskeletal injury predominates in adults of the general population, who are between 30 and 40 years of age, with a male-to-female ratio of at least 2:1. ³ Risk factors include age, sex, use of steroids or fluoroquinolones, hyperuricemia, and metabolic syndromes. ⁴ This injury is also seen in younger athletes, specifically in high-impact sports athletes, basketball, football, tennis, and rugby players, as their ankles sustain sudden stops and rapid changes in direction during play. ¹

Acute ruptures usually lie within the segment that extends from 2 to 6 cm from the tendon’s calcaneal insertion, as it is the area that is the least vascularized, and hence, the most susceptible to injury secondary to trauma or repetitive biomechanical stresses. ⁵

Historically, surgical repair of acute Achilles tendon rupture was considered to be the golden standard to achieve satisfactory functional outcomes in the general population and return to play in high performance athletes. This is because nonoperative management was associated with a higher risk of re-rupture. ⁶ However, with the integration of functional rehabilitation protocols to nonoperative approaches in treating acute Achilles tendon ruptures, comparable outcomes and fewer re-rupture rates were recorded. ² From here, over the past 15 years, it was noticed that the incidence of surgical repair of acute Achilles tendon rupture has decreased, as the paradigm shifts towards the adaptation of non-surgical techniques. ⁷

Whether or not these new protocols are superior to surgical management is still a matter of debate. Therefore, this article aims to establish a review of the existing literature, describing all available treatment strategies to acute Achilles tendon rupture. It will expose the most recent evidence regarding the possible superiority of one treatment option over another, as well as it will tackle the controversies when it comes to the role of adjunct modalities and plasma-rich-proteins (PRP) in addressing this injury.

Treatment options

Surgical repair

Surgical repair has long been the go-to method for treating acute Achilles tendon ruptures. ⁴ The two existing primary surgical approaches are open repair and minimally invasive techniques. While the open surgical approach allows direct visualization and secure suturing of the torn tendon ends to enable early mobilization and weight-bearing, the minimally invasive or percutaneous techniques, which was introduced more recently, reduce wound complications associated with open surgery. ⁸

Open repair

Definition & patient position

Open repair of the Achilles tendon is the surgical approach that uses a direct longitudinal incision, medial or midline to the Achilles, to fully expose the ruptured tendon ends for a strong end-to-end suture repair. The patient is positioned prone (face-down) on the operating table, for optimal access to the posterior ankle. This ensures proper alignment and tension of the tendon during repair. ⁹ Alternative positions like supine or lateral exist, but prone remains the most common.

The suture thread usually chosen is a high-tensile, nonabsorbable suture (e.g., braided polyester or Ultra-High Molecular-Weight Polyethylene (UHMWPE)) to withstand the significant forces on the Achilles. This strong suture is placed in a configuration that securely grasps the tendon ends. ¹⁰ After suturing, the ankle is typically plantarflexed to relax the tendon as knots are tied, restoring the continuity of the Achilles. The paratenon (tendon sheath) is usually closed to augment healing and prevent infection. ¹¹

Suturing techniques

For open Achilles tendon repairs, different suture techniques exist. Each involves a specific pattern of suture threading through the tendon ends. The most common techniques are:

Krackow technique

This method is a locking-loop suture that runs longitudinally within the tendon, creating multiple locking loops on each side of the rupture. It uses two suture strands per tendon end, with usually three or more locking loops in each, providing a strong grasp on the tendon fibers. It distributes tension along a longer tendon length and typically yields excellent holding strength. ¹²

Kessler technique

This method is a grasping, box-type stitch, where the suture enters and exits each tendon stump once. Strands traverse the rupture in an “X” or box configuration, and knots are usually tied on the tendon surface. The Kessler stitch allows more gapping and lower failure loads, since it is considered simpler and less robust than the Bunnell and Krackow sutures. ¹³ Modified versions, like the double or triple Kessler, add additional strands or locking components, which have improved its strength to comparable levels as other suture methods. ¹⁴

Bunnell technique

A longitudinal weave technique, where the suture is passed in a crisscross manner in and out of the tendon length at alternating levels, creating a secure hold. In Achilles repairs, a double Bunnell, consisting of two strands, is sometimes used to increase strength. ¹⁵ When comparing multi-strand repairs, like the double Krackow, double Bunnell, and double Kessler, McCoy et al. reported no significant difference when it comes to the strength of the weaves. This suggests that with adequate suture strands, all three techniques can achieve robust repairs. ¹⁶

Comparison of suture techniques

During an open Achilles tendon repair, the choice of suture techniques has been widely debated. None of the techniques has been shown to be clinically superior to the others. Multi-strand locking-loop configurations, such as the Krackow or double Bunnell, offer stronger initial tensile strength than a basic two-strand Kessler, which is more prone to gapping and failure under stress. ¹⁶ Moreover, both techniques exhibit significantly higher load-to-failure compared to the Kessler suture. ¹³ However, when the Kessler is augmented to double or triple configurations, its biomechanical performance competes or even surpasses the other methods in gap resistance and cyclic loading durability. ¹⁴

As long as the repair construct is robust, there is limited clinical evidence as to which technique offers better functional outcomes or lower re-rupture rates. However, some evidence suggests that Krackow repairs may support slightly earlier weight-bearing due to the greater initial tensile strength. ¹² In contrast, modified Kessler repairs have been associated with less bulk at the repair site, reducing irritation during rehabilitation and ankle motion. ¹⁶

As such, the surgeon’s familiarity, case-specific anatomy, and intraoperative factors often guide technique choice. ¹⁷

Advantages of open repair

Open repair of acute Achilles tendon rupture provides direct visualization of the tendon, allowing the surgeon to precisely align and secure the tendon ends, minimize elongation, and ensure strong anatomical apposition. ¹⁸ This technique enables a more robust initial fixation, often permitting earlier mobilization and weight-bearing, without compromising tendon integrity. ¹⁹ Thus, when performed with care, open repair provides a reliable and effective option for ensuring tendon healing and functional recovery, and it is considered the gold standard for patients without contraindications.

Disadvantages of open repair

While effective, open repair of Achilles tendon ruptures has its own downsides. The longitudinal incision disrupts the superficial soft tissues and the paratenon. ¹⁷ This may compromise local blood supply and increase the risk of wound healing complications and infections, particularly in patients with comorbidities, like diabetes, or with patients with a smoking history. This risk is especially pronounced in the distal Achilles region, where subcutaneous tissue is thin and poorly vascularized. ⁸ Open repair has a higher rate of superficial wound infection, approximately 5.4% compared to less than 1.2% in minimally invasive repairs. ⁴ Open repair also may damage the sural nerve, particularly if the incision is placed too laterally. However, this risk is typically low, approximately 0–1%, since the nerve can be visualized and protected during open surgery. ⁴

Minimally invasive surgery (MIS)

Rationale for MIS

Minimally invasive surgery (MIS) for Achilles tendon repair was introduced to reduce the soft tissue complications that are associated with the long incisions and extensive dissections involved in open repair. ²⁰ The first percutaneous technique was described by Ma and Griffith in 1977, using multiple stab incisions, to preserve the paratenon and minimize scar formation, all while achieving adequate tendon re-approximation. Since then, percutaneous and mini-open methods have evolved to try and yield outcomes comparable to open repair, while significantly reducing incision length and surgical trauma. ²⁰

What is minimally invasive repair and how is it performed

MIS refers to surgical techniques that use small incisions, which are typically 1 to 2 cm or stab wounds, to reapproximate the ruptured Achilles tendon without full open exposure. ²¹ In percutaneous methods, such as the Ma-Griffith technique, sutures are passed blindly through skin punctures using a Bunnell-type pattern and secured subcutaneously, with tendon alignment verified by palpation or ultrasound.^21,22 Mini-open repairs provide limited direct visualization of the rupture via a short incision, which is approximately 2 to 3 cm, while still using percutaneous suture passage in the distal and proximal tendon segments. ²³ Tools like the Achillon jig and the PARS system (Percutaneous Achilles Repair System) allow standardized, multi-strand suture placement through small incisions, which enhances the biomechanical strength, and simultaneously preserves the soft tissue. ²³ MIS may be performed with the patient prone or supine and is best used for acute ruptures with minimal tendon gap, where augmentation is not required. ²⁴

MIS versus open repair

The primary advantage of MIS is the significant reduction in wound complications. A meta-analysis of randomized controlled trials reported a superficial infection rate of only 0.4% for MIS compared to approximately 6% for open repair, a difference with important clinical implications given the potentially severe consequences of infection. ²⁰ MIS also offers cosmetic benefits, smaller scars, reduced pain, and earlier return of mobility due to less disruption of the paratenon and surrounding soft tissues. ⁴ These benefits make MIS particularly suitable for patients with compromised wound healing capacity. ¹⁷

Multiple randomized trials and meta-analyses have consistently demonstrated that both minimally invasive surgery and open repair yield similar outcomes in terms of re-rupture rates, functional recovery, and long-term tendon integrity. ²⁵ Re-rupture rates in both techniques are consistently low about 2.5% for open repair and 1.5% for MIS, with no statistically significant difference between the two techniques. ²⁰

Moreover, that same study reported that while open repair was associated with a longer operative time and more superficial infections, MIS had a higher risk of temporary sural nerve palsy, with no overall difference in re-rupture or functional recovery. ²⁰ Patient-reported outcome measures, such as PROMIS and Achilles Tendon Total Rupture Score (ATRS), also tend to be similar between MIS and open repair at the 1 year follow up visit. ²⁶

While MIS often enables faster early recovery due to easier wound care and shorter hospital stays, by 1 year, outcomes tend to converge with those of open repair. In a prospective cohort study, MIS patients demonstrated significantly shorter operative times and incision lengths, with lower pain in the first 2 weeks and faster functional recovery, yet both groups achieved similar scores by 48 weeks ⁸

However, MIS is not without limitations. Other than the higher rates of sural nerve injuries, percutaneous techniques can risk incomplete tendon capture or alignment, possibly resulting in a lengthened tendon or re-rupture. Although tools like ultrasound and modern devices decrease these risks, the limited exposure in MIS can still pose technical challenges, especially in complex or chronic ruptures.^18,27

In summary, MIS offers a safe, effective alternative to open surgery, with its main advantages being fewer wound complications and faster initial recovery. However, the choice of technique should be individualized based on patient anatomy, rupture complexity, and surgeon expertise.

Postoperative care

Rehabilitation protocols

Postoperative management after Achilles tendon repair is crucial for optimizing healing and function. Historically, nonoperative protocols favored immobilization in a cast in equinus position for 6 to 8 weeks and kept non-weight bearing to protect the repair. While this minimized stress on the tendon, it often led to joint stiffness, muscle atrophy, and prolonged functional recovery. ²⁸ Modern postoperative protocols emphasize early functional rehabilitation, incorporating early range of motion (ROM) and partial weight-bearing. Recent studies have shown that this approach does not increase the risk of re-rupture compared to prolonged immobilization.^29,30 Controlled early loading supports tendon healing by enhancing collagen organization and reducing complications such as adhesions and muscle wasting. ³¹

Extended casting (beyond 2 weeks) is now uncommon except in select high-risk or noncompliant patients, as it is associated with poorer functional outcomes. Early weight-bearing has been shown to reduce the risk of deep vein thrombosis (DVT), a known complication of prolonged immobilization. ³²

Short-term immobilization, using a cast or splint, for 10 to 14 days, helps protect the incision during early healing, after which a functional boot is employed. The boot is initially set in approximately 20° to 30° plantarflexion and adjusted gradually toward neutral over the next 6 to 8 weeks ³³

Formal physical therapy is usually initiated between weeks 2 and 6, with increasing intensity after full weight-bearing is achieved. Rehabilitation focuses on progressive strengthening, proprioceptive training, and gait normalization in accordance with tendon-loading principles. ³⁴ ROM exercises such as active plantarflexion and dorsiflexion to neutral and partial weight-bearing with crutches are generally initiated within 2 to 3 weeks post-op, depending on wound status and patient tolerance. This strategy aims to balance tendon protection with mechanical stimulation for healing. ¹⁹

Current protocols allow protected partial weight-bearing in a boot with crutches by week 2 and progress to full weight-bearing by weeks 6 to 8, depending on patient tolerance and wound healing. A randomized controlled trial demonstrated that full weight bearing at 2 weeks post-op did not increase re-rupture rates in surgical patients. ³⁵ Concerns about tendon elongation due to early loading have been refuted by recent trials, which show no adverse effect on tendon length or strength, provided that excessive dorsiflexion is avoided early on.^36,37

At 8 to 12 weeks, patients are transitioned to regular footwear with heel lifts to reduce tendon strain during gait retraining. ³⁸ By 12 to 16 weeks, light jogging may be initiated if strength and range of motion have progressed without complications. Return to sports is permitted around 6 months, assuming adherence to loading milestones and tendon integrity.

Non-operative management

Non-operative treatment of acute Achilles tendon ruptures has regained popularity as modern rehabilitation protocols are yielding outcomes comparable to surgery while avoiding the surgical risks. Historically, nonoperative care with prolonged casting showed higher re-rupture rates (∼10%–12% vs ∼3%–5% with surgery), ³⁹ driving preference for operative repair despite infection risk. In 2010, Willits et al. challenged this superiority of surgical repairs in outcomes by implementing an accelerated functional rehabilitation protocol to patients immediately after their injury. They were among the firsts to allow protected weight-bearing at the 2-weeks post-injury mark, accompanied with a series of range of motion exercises that increased in range and intensity over the following weeks. ⁴⁰ Their randomized control trial, which followed patients at three, six, twelve-, and twenty-four-months post-injury, illustrated that non-operative re-rupture rates, as well as other reported outcomes, are statistically similar to those obtained after surgery. As such, they shifted the paradigm towards considering non-operative management as an efficient established modality to treating acute Achilles tendon ruptures. ⁴⁰ A 2019 meta-analysis reported re-rupture rates of 2.3% for surgical versus 3.9% for non-operative approaches—a non-significant 1.6% difference when early motion protocols were used. Additionally, surgery carried more complications (∼5% vs ∼1%–2%), mainly wound infections. ³⁵ Consequently, non-operative management is increasingly favored, provided early functional rehabilitation is implemented.

Immobilization

According to Yang et al., nonoperative management typically begins with the ankle immobilized in plantarflexion to approximate tendon ends and to reduce tension for optimal healing. The leg is placed in a cast or rigid boot with ∼20°–30° of plantarflexion, maintained for about 4–6 weeks, then gradually adjusted towards neutral position through serial or dynamic casting. ²³ The ankle is then kept for another 2–4 weeks in neutral position. ³⁹ This approach preserves tendon apposition early and progressively lengthens the tendon to prevent stiffness. During this period of immobilization, which lasts from 6 to 8 weeks, patients are generally non-weight-bearing. ⁴¹

Strict casting offers simplicity and reliable tendon healing rates comparable to surgical repair, but prolonged immobilization increases risks of atrophy, stiffness, and delayed recovery. ⁴² Historically, re-rupture rates reached 12%–15% with extended casting, ³⁹ whereas modern shorter or functional bracing protocols markedly reduce this risk. ²³

Functional rehabilitation protocols

Functional rehabilitation refers to early controlled motion and weight-bearing in a protected range, rather than strict immobilization for the full healing period. In practice, this involves using a removable walking boot (often with heel wedges) and initiating gentle, limited ankle ROM exercises and partial weight-bearing, usually within the first 2 weeks after injury. ⁴⁰ The goal is to encourage tendon remodeling and muscle activation without compromising the healing. ²⁸ Strengthening and balance exercises are introduced gradually in this “functional” phase rather than after 6–8 weeks ⁴⁰

Early mobilization has been shown to stimulate tendon healing and may improve tendon elasticity and vascularity, without increasing the risk of rupture when done appropriately.^28,40,43 A 2022 systematic review of 6 RCTs by Coopmans et al., found no significant difference in re-rupture rates between accelerated functional rehabilitation and more delayed (cast) rehabilitation (pooled re-rupture odds ratio ∼0.97, p > 0.5). Functional outcomes such as return-to-sport times and patient-reported scores were also equivalent in early-motion versus cast groups. ⁴³ Notably, the meta-analysis by Ochen et al. indicated that when early range-of-motion rehabilitation is employed in non-operative care, the re-rupture rate becomes statistically indistinguishable from that of surgical repair. ³⁵

The advantages of early mobilization are reflected in patient experience: studies report higher patient satisfaction and quicker return to activities with functional rehab as compared to prolonged casting. ⁴⁴ There are also less joint stiffness and earlier restoration of ankle dorsiflexion range. Crucially, no increase in complications has been observed with early motion; if anything, avoiding prolonged immobilization may reduce risks such as deep vein thrombosis. ⁴⁴

Early weight-bearing mobilization

Early weight-bearing mobilization is a key component of functional rehab, but it can be considered on its own as a modality. This approach emphasizes allowing the patient to begin bearing weight (in a boot or functional brace) relatively soon – often around 2 weeks after rupture – even if formal range-of-motion exercises are limited.^40,45,46 In contrast to the comprehensive therapy of functional rehab protocols, early weight-bearing mobilization might not include active ankle exercises or intensive supervised therapy in the initial weeks; rather, the focus is on mobilizing the patient with protected loading. ⁴⁶ Typically, the patient is transitioned from non-weight-bearing crutches to partial and then full weight-bearing in a walking boot by about 2 weeks post-injury. The boot often has heel wedges to maintain slight plantarflexion, and it restricts extreme ankle motion while allowing the patient to ambulate. ⁴⁵

Clinical evidence supports early weight-bearing in nonoperative treatment. A meta-analysis by El-Akkawi et al. compared early versus late weight-bearing in non-operative patients and found no significant difference in re-rupture rates between the groups. In that analysis of RCTs, early weight-bearing did not increase re-ruptures (p = 0.80) and was associated with some benefits, such as improved quality-of-life scores during treatment and a trend toward greater ankle range of motion recovery. No adverse events (e.g. tendon lengthening or delayed healing) were attributable to early loading. The main advantage of early mobilization with weight-bearing is quicker return to basic mobility – patients can perform daily activities sooner, with less muscle deconditioning. Even so, early weight-bearing serves as a bridge to formal physiotherapy: by the time the boot is removed (∼6–8 weeks), the patient has maintained some functional use of the limb, facilitating a faster rehabilitation thereafter. ⁴⁷

Physiotherapy and rehabilitation exercises

Early-phase rehabilitation (0–6 Weeks)

Early rehabilitation following an acute Achilles tendon rupture (managed non-operatively) focuses on protecting the healing tendon while gradually restoring motion and weight-bearing capacity. During the first 2 weeks, patients are typically non-weight-bearing, but gentle, controlled ankle range-of-motion (ROM) exercises (active plantarflexion and dorsiflexion to neutral) are initiated once tolerated to prevent stiffness and facilitate healing. ⁴⁸ By 2–6 weeks, an Achilles boot with heel lifts is used to allow partial weight-bearing, usually progressing from ∼25% to full weight-bearing as weeks advance. Throughout this phase, the ankle ROM is restricted to avoid excessive dorsiflexion (which could stretch the repairing tendon), and any exercises stay within a pain-free range. Isometric contractions or neuromuscular electrical stimulation of the calf may be introduced early to minimize atrophy, as long as they do not stress the tendon repair. ⁴⁸ Notably, when an accelerated rehab program is implemented correctly, clinical outcomes of non-operative management can be equivalent to surgical repair in terms of strength and return-to-activity, while avoiding surgical complications. Patient education and close supervision are vital to ensure compliance with precautions (such as using the boot correctly) because tendon elongation due to premature overstretching can lead to persistent weakness. ⁴⁸

Late-phase rehabilitation (6 weeks–12+ months)

Once initial healing has progressed (∼6–8 weeks post-injury), rehabilitation focuses on restoring ankle function, strength, and gait mechanics. Weight-bearing is advanced to full tolerance (typically by 6–8 weeks), and the boot is weaned off around 8 weeks, transitioning to regular footwear with optional bracing. ⁴⁸ Ankle ROM is progressed toward full range, gradually increasing dorsiflexion as healing allows. Structured strengthening begins with light open- and closed-chain exercises (e.g., resistance bands), progressing to calf strengthening. By ∼8–12 weeks, patients perform double-leg heel raises, then single-leg raises once pain-free and without compensation. ⁴⁸ Eccentric loading becomes the key focus in later stages to enhance tendon strength and elasticity. The Alfredson protocol—high-repetition, pain-tolerated eccentric heel drops (3 × 15 reps, twice daily for 12 weeks)—is often used to improve tendon force output and function. ⁴⁹

Proprioceptive and balance training begins after boot removal, progressing from supported single leg stands to balance board exercises to retrain neuromuscular control and ankle stability. ⁴⁸ Gentle calf stretching may be added, avoiding excessive tension on the tendon during the first 3 months. As strength and ROM improve, patients resume light aerobic activity (jogging, cycling, elliptical) around 3–4 months, advancing to running, jumping, and agility drills closer to 6+ months. Aerobic conditioning shifts to weight-bearing modes to rebuild endurance. Progression to higher-impact activity is based on achieving ∼70%–80% of contralateral calf strength and endurance. ⁵⁰ Despite comprehensive rehab, many patients demonstrate calf strength and endurance deficits for up to a year, often linked to tendon lengthening. ⁵⁰ Continued eccentric strengthening and progressive loading beyond formal therapy are therefore recommended. With diligent rehabilitation, most return to non-contact sports by ∼6–9 months (if ∼80% strength regained) and full sports participation by ∼12 months once near-normal calf strength is achieved. ⁴⁸

Adjunct modalities for Achilles tendon rupture

Several adjunct therapies have been explored to enhance tendon healing and recovery, though clinical benefits remain limited.

Low-level laser therapy (LLLT)

Animal studies suggest LLLT may stimulate type I collagen synthesis and improve tendon strength. ⁵¹ However, clinical evidence is inconsistent. A double-blind RCT found no significant improvement in Achilles Tendon Total Rupture Score (ATRS) at 24 weeks between LLLT and sham therapy (66.5 ± 18.9 vs 69.6 ± 17.0, p = 0.67), with only minor pain reduction at week 12. ⁵² Routine use is therefore not recommended.

Electrical stimulation (NMES)

Experimental data show NMES enhances tendon strength in animal models, ⁵³ but human trials have not demonstrated clear benefit. A double-blind RCT found no significant differences in calf atrophy, MRI muscle volume, or functional outcomes between NMES and sham groups after Achilles repair. ⁵⁴

Transcutaneous electrical nerve stimulation (TENS)

TENS may reduce pain in the acute or rehab phase, improving exercise tolerance, but it does not influence tendon healing biology.^55,56

Extracorporeal shockwave therapy (ESWT)

ESWT is well established for chronic Achilles tendinopathy, improving pain and function when paired with eccentric exercise. Its role in acute ruptures or partial tears remains unproven, though limited case reports describe symptomatic and imaging improvement after ESWT in chronic partial tears. ⁵⁷

Comparative outcomes between surgical versus non-surgical modalities

Re-rupture rates

Traditionally, operative repair has been reported to yield lower re-rupture rates than nonoperative non-operative management. Early studies showed that surgery halved the risk of tendon re-tear compared to casting alone. ⁵⁸ However, the gap has narrowed significantly with modern functional rehabilitation protocols. In fact, during their RCT comparing surgical to non-surgical protocols, Willits et al. recorded only 3 re-ruptures in the accelerated functional rehabilitation group, over their 2-years follow up, versus only 2 re-ruptures in the surgical entity, rendering the difference in re-rupture rates statistically nonsignificant. ⁴⁰ Later on, a 2012 meta-analysis of RCTs supported the idea that when patients followed an early mobilization regimen, such as functional bracing with early ROM, re-rupture rates were statistically equivalent between surgical and nonsurgical modalities. ⁵⁹

Recent large-scale reviews confirm that re-ruptures are uncommon in both approaches. A 2019 systematic review of 29 studies done over 15,862 patients reported re-rupture rates of ∼2.3% with operative repair versus ∼3.9% with non-operative treatment. ³⁵ This relative advantage of surgery (risk ratio ∼0.43) was statistically significant, but the clinical difference was comparable. ³⁵ Notably, in studies that employed accelerated functional rehabilitation and early ROM, there was no significant difference in re-rupture rates between operative and nonoperative groups. ³⁵

Wound and infection complications

Unlike tendon re-rupture, wound complications are a risk unique to surgical treatment. Open Achilles repair requires an incision and carries risk of surgical site infection, wound dehiscence, adhesions, or scar problems that can reach ∼4.9%. ³⁵

Return to work and sports

Return to prior activity level—whether full-duty work or sports—is a critical outcome, especially for athletes and active individuals. The effect of treatment modality on return-to-play (RTP) rates and timing has been widely studied, with mixed findings. Traditionally, surgical repair was thought to promote earlier, more confident mobilization, potentially enabling faster return to sports or work. Evidence supports a modest time advantage with surgery: Soroceanu et al. reported that surgical patients returned to work about 19 days sooner than those treated nonoperatively, ⁵⁹ attributed to lower fear of re-rupture and earlier rehabilitation after stable repair. A recent review (>35,000 patients) found surgery increased the likelihood of return to sport by 1.32 times, with an absolute rate about 14% higher than non-operative care. ⁶⁰

Conversely, several studies report no significant difference in ultimate return-to-activity between treatments. A 2024 meta-analysis found no difference in overall return-to-play rates between surgical and nonoperative management. ⁶¹ Both groups achieved high return rates when paired with modern rehabilitation protocols, aligning with earlier RCTs that show similar long-term outcomes regardless of repair method. Notably, the 2024 analysis showed that accelerated rehabilitation—early range of motion and weight-bearing—shortened the time to return by ∼4 weeks, regardless of treatment type. Combining surgery with early rehab led to faster RTP (∼4.2 weeks earlier) compared to surgery with prolonged immobilization, while early versus late rehab showed no significant difference in the non-operative group, likely because most modern nonoperative protocols already emphasize early motion. ⁶¹

Overall, return-to-work and sports outcomes are favorable with either approach. Most patients resume pre-injury activity within ∼6–12 months, surgical or not. ⁶¹ Rehabilitation strategy and patient factors (age, sport, tendon gap, etc.) likely influence RTP more than treatment choice alone. Thus, care should be individualized: elite athletes may benefit from surgery and aggressive rehab, while non-elite patients often achieve comparable recovery through functional rehab emphasizing early mobilization and strengthening.

Functional outcomes

Long-term outcomes—including patient-reported function, ankle ROM, strength, and activity performance—are key for comparing treatments. Functional recovery metrics such as ATRS, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, heel-rise tests, and isokinetic strength testing consistently show similar results between operative and non-operative care when modern rehabilitation is applied.^59,60 Moreover, the Leppilahti score, which evaluates patient reported pain, stiffness, muscle weakness, and footwear restriction, as well as active range of motion and isokinetic calf muscle strength, was found to be statistically non-significant between the two groups at one and 2 year follow ups (p = 0.53 and p = 0.89, respectively). ⁴⁰ A 2025 systematic review found no significant difference in 12-months ATRS (mean difference ∼7 points, not statistically significant), ⁶⁰ and Soroceanu et al. likewise reported no difference in calf circumference, strength, or functional scores between groups. ⁵⁹

Nonetheless, subtle performance advantages have been observed with surgery. Surgical repair tends to preserve plantarflexion power due to reduced tendon elongation. In a high-quality RCT using identical rehab, surgical patients demonstrated 16%–24% greater plantarflexion torque at 6 months and 10%–18% higher strength at 18 months (peak strength ∼110 Nm vs ∼96 Nm non-operative).^62,63 These strength gains did not markedly alter ATRS or AOFAS scores but were evident in endurance tasks such as repetitive heel rises. ⁶³ Lantto et al. also reported higher physical functioning and less bodily pain on SF-36 for the surgery group, despite similar activity scores. ⁶²

Tendon elongation

Tendon elongation is a key factor, as increased length can weaken push-off power and alter gait. Non-operative care has traditionally shown greater elongation because healing relies on scar tissue rather than direct tendon apposition. In a randomized MRI-based trial, nonoperatively treated tendons were ∼19 mm longer at 18 months, whereas surgically repaired tendons maintained near-normal length. ⁶³ This elongation correlated with reduced strength in the non-operative group. Surgical repair minimizes this by suturing the tendon ends, though some elongation still occurs; a long-term study reported an average 12 mm increase even after repair at 13-years follow-up. ⁶⁴ A small 2023 imaging study found no significant difference between groups, with both showing ∼40%–50% elongation versus the healthy side, ⁶⁵ though most literature confirms greater elongation after non-operative care.

Clinically, this presents as diminished push-off and heel-rise endurance. ⁶⁶ To limit elongation non-operatively, early immobilization in plantarflexion and gradual reduction of heel wedges are essential to maintain tendon coaptation. ⁴³ Some centers also use ultrasound monitoring to ensure the tendon ends remain approximated and adjust bracing if gapping is detected. ⁶⁷

Calf atrophy and strength

After Achilles rupture, the gastrocnemius-soleus complex undergoes atrophy from disuse and tendon dysfunction. Prolonged immobilization (as in traditional casting) causes greater atrophy, while early motion helps preserve muscle bulk. Studies assessing calf muscle volume show atrophy in both surgical and non-operative groups, but it is typically more pronounced after nonoperative care. ⁶⁴ Heikkinen et al. reported a ∼25% reduction in soleus muscle volume with nonsurgical treatment versus ∼18% with surgery under identical rehab protocols—a statistically significant 7% difference. ⁶³ This atrophy was mainly localized to the soleus, the primary plantarflexor linked to the Achilles. Strength deficits closely correlate with the degree of soleus atrophy, suggesting that tendon elongation and delayed reloading exacerbate muscle shrinkage and limit force generation.^63,64

Deep vein thrombosis (DVT)

Achilles rupture treatment carries a recognized risk of venous thromboembolism due to reduced limb mobility. Both surgical and non-operative patients are susceptible—through cast immobilization or postoperative inactivity.^60,68 Historically, nonoperative casting was linked to higher DVT rates, ⁴⁴ but recent evidence indicates comparable risks with modern early-motion protocols. The 2025 meta-analysis by Yang et al. found no significant difference in DVT incidence between surgical and nonoperative groups (RR ∼ 0.93, p = 0.43). ⁶⁰ Absolute rates of DVT and PE were low (typically 1%–2%) and similar in both cohorts, reflecting the protective effect of early mobilization. ⁶⁰

Cost effectiveness

An important consideration in today’s healthcare environment is cost-effectiveness. Surgical management entails higher direct costs (surgeon fees, operating room, anesthesia) and potential hospitalization, whereas nonoperative care primarily involves casting or bracing with outpatient follow-up. Indirect costs vary, as longer recovery or re-rupture risk can increase lost workdays, while surgical complications also add expense.

Most studies find non-operative management more cost-effective when outcomes are similar. A 2020 cost-utility analysis (Markov model, 2 years) showed non-operative care “dominated” surgery—being less costly and slightly more effective in quality-adjusted life years (QALYs). ⁶⁹ A European analysis estimated surgery’s incremental cost-effectiveness ratio at ∼€45,000 per QALY, near the acceptability threshold, again favoring nonoperative care. ⁷⁰ A 2017 decision model comparing four strategies identified percutaneous repair as the most cost-effective overall, with functional rehab being the least expensive but marginally less effective (0.70 vs 0.78 QALY). ⁷¹ Minimally invasive repair may thus offer an optimal balance between cost and outcome by limiting re-rupture and hospital costs. ⁷¹

Overall, non-operative care remains the more cost-effective option, though surgery may be appropriate for athletes or high-income patients seeking faster return, as re-rupture—though rare—can be costly. ⁷⁰ The “best” treatment should ultimately be individualized through shared decision-making that considers clinical outcomes, patient values, risk tolerance, and socioeconomic factors. ³⁵

Is there a role for PRP in the management of acute Achilles tendon rupture?

Currently, the literature lacks strong evidence supporting the use of platelet-rich-plasma in the management of acute Achilles tendon ruptures, whether as a primary treatment modality or as a surgical adjunct. A double-blinded RCT (PATH-2) showed that patients treated with PRP did not show significant improvement in muscle-tendon function, ATRS, quality of life, pain, or goal attainment at 24 weeks follow-up, as compared to the placebo group. ⁷² However, a comprehensive literature review done by Wang et al. concluded that PRP injections did significantly improve patients’ dorsiflexion angle, dorsal extension ankle strength, and calf circumference, but failed to do so regarding plantarflexion angle, plantarflexion strength, and pain. ⁷³ These diverse results in literature can be explained by the lack of standardized protocols used in preparing the PRP, hindering the ability to test for its true efficacy in treating acute Achilles ruptures.

Noticeably, in a level 3 evidence case-control study, Sanchez et al. showed that combining open repair of acute Achilles tendon rupture with post-operative PRP injections aids in earlier ROM recovery in athletes (p = 0.025), earlier return to gentle running by around 5 weeks (p = 0.42), and earlier return to training activities (p = 0.004). Moreover, post-operative PRP injections were associated with a lesser increase of tendon cross-sectional area at site of rupture (p = 0.009). ⁷⁴ Nevertheless, these findings need to be further studied in larger RCTs.

What are the criteria for choosing one technique over the other?

Briefly, while current evidence shows comparable outcomes between surgical repair and new non-operative modalities, ⁶¹ a slight preference is preserved towards operative treatment in terms of earlier functionality, return to sports, and mildly lower re-rupture rates. ⁶⁰ This primarily concerns athletes, as they are eager to return to play the soonest without high risk of re-injury. Therefore, tendencies to surgical repair are mainly reserved to athletes and patients with high activity levels, whereas the choice can be a topic of debate for the rest of the population. With the current literature evidence, it is possible to reassure patients, who want to avoid surgery, that solid functional results are a huge possibility. It is just a matter of their compliance to established protocols.

Conclusion

Operative versus non-operative management of acute Achilles tendon ruptures has been a noticeable topic over years, yet advancement in research has been successful in closing the gap between the modalities. To do the right choice, surgeons must always take into account patient demographics, goals, compliance to protocols, and availability of rehabilitation centers in order to reach optimal results regardless of the treatment modality.