Abstract
Background:
Mental health disorders are increasingly acknowledged as significant factors influencing surgical outcomes. However, their effect on recovery after Achilles tendon repair (ATR) remains inadequately defined. Psychosocial elements may modify pain perception, opioid consumption, adherence to rehabilitation protocols, and overall utilization of health care services.
Purpose:
To evaluate the postoperative complications among patients with preexisting mental health diagnoses in the context of ATR.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
A retrospective analysis was performed using the TriNetX Research Network on August 14, 2025. Patients with a mental health disorder diagnosis within 1 year before ATR were identified using the International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes. These patients were compared with controls without a documented diagnosis of mental health disorders. Propensity score matching (1:1) was performed for age, sex, body mass index, and other important comorbidities. The initial search identified 11,787 patients who underwent ATR. Outcomes at 3, 6, 12, and 24 months included ankle pain, stiffness, complex regional pain syndrome (CRPS), wound complications, opioid use, and revision repair. Odds ratios (OR) with 95% CIs were calculated.
Results:
After matching, 1767 patients were included in each group. At 3 months, the mental health cohort had 1.59 times higher odds of wound complications (7.2% vs 4.6% [95% CI, 1.19-2.1]; P = .01), 1.39 of ankle stiffness (5.2 vs 3.8% [95% CI, 1.01-1.92]; P = .04), and 1.56 of ankle pain (22 vs 15% [95% CI, 1.32-1.86]; P < .001) compared with the control group. Additionally, the mental health group had higher incidence of emergency department visits (OR, 1.50 [95% CI, 1.19-1.9]; P = .001), reoperation for any reason (OR, 1.51 [95% CI, 1.15-1.99]; P = .003), readmission (OR, 1.76 [95% CI, 1.24-2.50]; P = .001), and opioid use (OR, 1.58 [95% CI, 1.37-1.81]; P < .001). At 6 months, all these differences persisted (all P < .05). At 1 year, ankle pain (12.4% vs 9.3%) and opioid use (22.8% vs 16.4%) remained significantly elevated in the mental health cohort. At 2 years, ankle pain, opioid use, and CRPS (1.4% vs 0.6%; OR, 2.52 [95% CI, 1.20-5.26]; P = .01) were significantly more common. Revision rates did not differ between groups at any time point.
Conclusion:
Our study showed that mental health disorders are associated with an increase in postoperative complications after ATR. The persistence of pain and opioid dependence over 2 years underscores the significant long-term impact of psychosocial factors on the recovery process. These findings support the incorporation of routine psychosocial screening and perioperative mental health support into comprehensive care strategies to reduce complications and enhance functional outcomes.
Achilles tendon rupture (ATR) is a common orthopaedic injury, comprising a high proportion of total tendon ruptures. 30 ATR most commonly occurs in patients who participate in high-intensity sports, often characterized by a loud “pop.”24,36 Although ATRs are associated with sports, up to 25% occur from minor trauma unrelated to sporting activity. 33 These ruptures are characterized by intense pain, leading to changes in gait pattern and recurrent swelling.23,28 Despite the emergence of nonoperative protocols for treating ATR, including functional rehabilitation, protected weightbearing, plantarflexion booting, or casting, multiple studies have shown that surgical treatment often leads to lower overall complication rates.6,18,46
In the United States, between 2012 and 2016, the incidence of ATRs increased from 1.8 per 100,000 persons to 2.5 per 100,000 persons. 30 Recent advances in technique minimize surgical risks, but postoperative complications, such as wound healing issues, infection, rerupture, venous thromboembolism, and sural nerve injury, remain clinically significant.5,19-21,40 Established risk factors for adverse outcomes include advancing age, tobacco use, diabetes, obesity, and surgical delay.5,13,19-21,40 However, the role of mental health disorders as a risk factor for postoperative complications is increasingly recognized.
Mental health disorders, particularly depression and anxiety, are highly prevalent among patients undergoing musculoskeletal procedures. Prospective studies have shown that more than half of patients experience at least mild depressive symptoms in the year after ATR, with a history of mental health disorder independently associated with greater severity and persistence of these symptoms. 12 The inability to work during postoperative rehabilitation can further exacerbate depressive symptoms, which may impair rehabilitation adherence and functional recovery. 12 Extensive database analyses demonstrate that preoperative mental illness is associated with higher odds of surgical complications, extended length of stay, and increased 30-day readmission rates.26,29,37 Notably, patients with anxiety or depression have a 44% to 77% higher risk of perioperative complications after surgery. The risk is even greater for those with severe mental illness.
In orthopaedic trauma populations, depression is an independent predictor of increased postoperative complications. 44 Despite this relationship, few studies examine the association between ATRs and mental health. While systematic reviews of Achilles tendinopathy have found that psychological variables, such as anxiety, depression, and catastrophizing, are associated with pain and disability outcomes, few studies investigate correlations between surgical repair of ATRs and mental health on postoperative outcomes.34,41 Defining this relationship may help identify patients at increased risk for prolonged pain, wound complications, and opioid dependence after ATR, thereby informing perioperative risk stratification and targeted interventions. This study aimed to determine the associations between preoperative mental health disorders and postoperative outcomes after ATR, with a focus on ankle pain, wound complications, postoperative opioid use, and reoperation or revision over a 2-year postoperative period. We hypothesized that preoperative mental health disorders would be associated with increased rates of postoperative complications after ATR repair.
Methods
Study Design
This retrospective cohort study was conducted using TriNetX, LLC. This global health research network provides access to electronic medical records from approximately 100 million patients across large health care organizations (HCOs). On August 14, 2025, the database was queried on the Research network, which included 107 HCOs, to identify patients with and without mental health disorders undergoing ATR. TriNetX is a Health Insurance Portability and Accountability Act (HIPAA)-compliant database that provides real-time clinical data for deidentified patients; thus, the study was exempt from institutional review board approval.
Cohort Selection and Propensity Match
Patients who have mental health disorders were identified using the International Classification of Diseases, 10th edition (ICD-10)—including those with major depressive disorder, bipolar disorder, dysthymic disorder, depressive episodes, adjustment disorder, generalized anxiety disorder, and anxiety disorder. Patients were included if they carried at least 1 of these diagnoses within the 1 year preceding their ATR. Procedure codes using Current Procedural Terminology (CPT) defined the ATR (27650, 27652). To refine the study's scope, patients were included only if they had a visit to a TriNetX-affiliated facility within 2 years of their ATR. Patients <12 years were excluded.
Propensity score (1:1) matching was performed using the TriNetX algorithm to account for age, sex, body mass index, tobacco use, alcohol-related disorders, generalized atherosclerosis, diabetes mellitus, chronic kidney disease, essential primary hypertension, old myocardial infarction, chronic obstructive pulmonary disease, hepatic fibrosis, dementia, and cerebrovascular diseases. The platform integrates the nearest-neighbor matching with a tolerance level of 0.01 and ensures that the difference between propensity scores does not exceed P = .01
Outcome Measures
Primary outcomes were ankle pain and opioid use, which were analyzed using nonoverlapping interval-based windows (1 to 90 days, 3 to 6 months, 6 months to 1 year, and 1 to 2 years) to capture new events occurring within each period. Additional primary outcomes—including complex regional pain syndrome (CRPS), stiffness, wound complications (wound dehiscence, superficial or deep surgical site infections, organ and space infection, seroma/hematoma), reoperation for any reason, and revision surgery—were evaluated as cumulative incidence from the ATR procedure to each follow-up time point (3-, 6-, 12-month, and 2-year).
Secondary outcomes included medical complications, assessed cumulatively at 3 and 6 months after ATR. These outcomes included postoperative infection (including superficial and deep surgical site infections), deep vein thrombosis, lower limb mononeuropathy, rehabilitation utilization, hospital readmissions, and emergency room (ER) visits.
Specific codes used to define inclusion criteria and outcome variables are provided in the Appendix (Appendix A).
Data Analyses
All statistical analyses were performed using the TriNetX platform. Independent t tests and chi-square tests were employed to assess differences between unmatched and matched cohorts for continuous and categorical variables, respectively. The incidence of complications was analyzed in relation to the presence of mental health disorders, yielding odds ratios (ORs) with 95% CIs for each comparison. Continuous variables are presented as means and standard deviations, while categorical variables are reported as counts and percentages. Statistical significance was established at a threshold of P < .05.
Results
The initial search identified 1816 patients with a documented mental health disorder and 9971 without. After propensity score matching, 1767 patients were retained in each cohort for the final comparative analysis (Figure 1). Baseline characteristics were well balanced after matching (Table 1).
CONSORT flow of participants through the study. ATR, Achilles tendon repair; CONSORT, Consolidated Standards of Reporting Trials; PSM, propensity score-matching.
Demographic Characteristics Before and After Propensity Score Matching Between Mental Health and Control Cohorts Who Underwent ATR a
Data are presented as mean ± SD or n (%). Bold P values indicate statistical significance. ATR, Achilles tendon repair; BMI, body mass index.
Short- and Mid-term Outcomes
At 3 months, patients with mental health disorders exhibited significantly higher rates of wound complications (7.2% vs 4.7%; OR, 1.59 [95% CI, 1.19-2.11]; P = .001), ankle stiffness (5.2% vs 3.8%; OR, 1.39 [95% CI,1.01-1.92]; P = .04), and ankle pain (22% vs 15%; OR, 1.56 [95% CI, 1.32-1.86]; P < .001) compared with controls. This group also demonstrated significant increase in health care utilization, including ER visits (10.6% vs 7.4%; OR, 1.50 [95% CI, 1.19-1.9]; P = .001), reoperations (7.8% vs 5.3%; OR, 1.51 [95% CI, 1.15-1.99]; P = .003), hospital readmissions (5% vs 2.9%; OR, 1.76 [95% CI, 1.24-2.50]; P = .001), rehabilitation (36.6% vs 33.1%; OR, 1.16 [95% CI, 1.01-1.33]; P = .03), and opioid use (43.9% vs 32.3%; OR, 1.58 [95% CI, 1.37-1.81]; P < .001) (Table 2).
ATR Postoperative Outcomes in Mental Health Versus Control Patients at 3- and 6-Month Follow-up Period a
Data are presented as n (%), unless otherwise indicated. Bold P values indicate statistical significance. ATR, Achilles tendon repair; ER, emergency room; DVT, deep vein thrombosis; OR, odds ratio; Postop, postoperative.
At 6 months, these disparities persisted. The mental health cohort continued to show statistically significantly greater risk of wound complications (7.9% vs 5.7%; OR, 1.42 [95% CI, 1.09-1.85]; P = .01), ankle stiffness (5.9% vs 4.4%; OR, 1.38 [95% CI, 1.02-1.87]; P = .03), and ankle pain (15.9% vs 10.9%; OR, 1.53 [95% CI, 1.28-1.85]; P < .001). Similarly, ER visits (14.8% vs 9.9%; OR, 1.58 [95% CI, 1.29-1.94]; P < .001), reoperations (8.7% vs 6.5%; OR, 1.37 [95% CI, 1.07-1.76]; P = .01), rehabilitation utilization (40% vs 32.3%; OR, 1.16 [95% CI, 1.02-1.3]3; P = .03), hospital readmissions (6.3% vs 3.9%; OR, 1.64 [95% CI, 1.21-2.24]; P = .001), and opioid use (17.5% vs 12.5%; OR, 1.48 [95% CI, 1.24-1.78]; P < .001) all remained significantly higher in the mental health cohort compared with the nonmental health cohort (Table 2).
Long-term Outcomes
At 1 year, ankle pain was reported in nearly one-third of patients with mental health disorders (12.4% vs 9.3%; OR, 1.38 [95% CI, 1.12-1.69]; P < .001). Opioid use also remained significantly higher at this time point compared with the control cohort (22.8% vs 16.4%; OR, 1.51 [95% CI, 1.28-1.77]; P < .001), whereas other complications showed no significant differences (Table 3).
ATR Postoperative Outcomes in Mental Health Versus Control Patients at 1- and 2-Year Follow-up a
Data are presented as n (%), unless otherwise indicated. Bold P values indicate statistical significance. ATR, Achilles tendon repair; OR, odds ratio.
By 2 years, ankle pain and opioid use remained more prevalent in the mental health cohort (12.2% vs 7.9%; OR, 1.62 [95% CI, 1.31-2] and 33% vs 22.3%; OR, 1.72; [95% CI, 1.49-1.98, respectively; both P < .001). Notably, CRPS was also significantly more common in this population (1.4% vs 0.6%; OR, 2.52 [95% CI, 1.20-5.26]; P = 01). Rates of revision repair and other significant complications were comparable between groups at all time points (Table 3).
Discussion
This study highlights the critical importance of screening and managing mental health conditions in patients undergoing ATR. The major findings of this study indicate that patients with preexisting mental health issues such as depression, anxiety, bipolar disorder, adjustment disorder, and obsessive-compulsive disorder, are associated with poorer postoperative outcomes compared with those without these conditions. Clinically, this is reflected by a higher incidence of wound complications (at 3 months: 7.2% vs 4.7%; OR, 1.59 [95% CI, 1.19-2.11]; P = .001), ankle stiffness (at 3 months: 5.2% vs 3.8%; OR, 1.39 [95% CI, 1.01-1.92]; P = .04), and ankle pain (at 3 months: 22% vs 15%; OR, 1.56 [95% CI, 1.32-1.86]; P < .001) compared with controls across all follow-up periods. Moreover, the findings suggest that these patients utilize more opioids (at 3 months: 43.9% vs 32.3%; OR, 1.58 [95% CI, 1.37-1.81]; P < .001), have increased ER visits (at 3 months: 10.6% vs 7.4%; OR, 1.50 [95% CI, 1.19-1.9]; P = .001), hospital readmissions (at 3 months: 5% vs 2.9%; OR, 1.76 [95% CI, 1.24-2.50]; P = .001), and complex regional pain syndrome (at 2 years: 1.4% vs 0.6%; OR, 2.52 [95% CI, 1.20-5.26]; P = .01) compared with those without these diagnoses.
Our findings are consistent with previous literature in both joint arthroplasty and sports medicine, where studies have similarly shown that patients with mental health disorders experience worse postoperative outcomes. For example, Aalders et al 1 reported that patients with anxiety or depression undergoing total hip arthroplasty had worse function (Oxford Hip Score; Hip Disability and Osteoarthritis Outcome Score-Physical Function), greater pain, and lower quality of life both preoperatively and up to 2 years postoperatively. Similarly, Sun et al 42 found that patients undergoing shoulder arthroplasty with diagnoses of anxiety, depression, bipolar disorder, or schizophrenia had higher rates of short-term complications and were more likely to require revision surgery within 2 years. Other studies in shoulder arthroplasty, rotator cuff repair, and anterior cruciate ligament reconstruction (ACLR) have shown that poor mental health disorders are associated with worse functional outcomes, suboptimal pain control, less favorable patient-reported results, and higher complication and revision rates.10,14,25,31,32
The present study also found that patients with mental health disorders were more likely to use rehabilitation services within 3 and 6 months postoperatively (OR, 1.16 for both; P < .03) compared with those without such conditions. Therefore, these patients demonstrated greater reliance on physical therapy during the early recovery period, possibly indicating greater functional challenges and a need for closer follow-up. In an extensive retrospective study of 226,402 patients, Baron et al 2 found that athletes with preoperative psychiatric comorbidities undergoing standard sports medicine procedures had more complicated postoperative courses and significantly higher health care costs ($9678.81 vs $6436.20; P < .0001) compared with those without such conditions. Systematic reviews further support a bidirectional relationship: musculoskeletal injury increases depressive symptoms, while preexisting depression predicts greater disability and slower recovery in athletes. 35 García et al 15 reported that patients with depression had significantly higher pain interference scores (59.1-65.7 vs 56.8-59.2 preoperatively; 46.3-52.3 vs 46.3-47.4 postoperatively) and lower physical function scores (Patient-Reported Outcomes Measurement Information System, 39.7-41.5 vs 33-38.1 preoperatively; 56.7-57.6 vs 51.6-56.7 postoperatively) compared with those without depression in ACLR. These suggest that the impact of mental health disorders on postoperative outcomes is broad and robust, extending to ATR.
Several mechanisms may underlie these findings. Psychosocial stress, every day in depression and adjustment disorder, has been shown to impair wound healing by disrupting immune and endocrine function. In a landmark study, Kiecolt-Glaser et al 27 demonstrated that stressed individuals required significantly longer to heal minor skin wounds compared with controls, which may help explain the higher wound complication rates observed in our cohort. Pain outcomes are also strongly influenced by psychological state. Depression, anxiety, and obsessive-compulsive disorder often amplify pain perception and reduce pain tolerance, creating a cycle in which persistent pain exacerbates mental health symptoms and intensifies pain. 39 Furthermore, the emergence of complex regional pain syndrome in this group underscores the role of psychological vulnerability in the development of chronic pain syndromes. 4
Another key finding was the markedly higher opioid use among patients with depression, anxiety, or bipolar disorder. This association has been well-documented in orthopaedic populations, where mood disorders increase the risk of prolonged or chronic opioid use after surgery and often reinforce one another. 45 Patients with obsessive-compulsive disorder or adjustment disorder may likewise experience heightened health anxiety and maladaptive stress responses, contributing to increased medication use and more frequent ER visits. 7 From a patient-centered perspective, individuals face a dual challenge: recovering from major orthopaedic surgery while managing psychological burdens that heighten their risk of complications. These factors contribute to prolonged pain, higher health care use, and extended opioid reliance, ultimately delaying return to activity and undermining quality of life.8,22,43
A practical implication is the need for routine preoperative mental health screening in patients undergoing ATR. Tools such as the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 are simple to administer and can identify patients at risk for poor recovery. Early recognition allows for interventions such as counseling, stress-reduction strategies, or referral to mental health professionals, which may improve outcomes.3,9,16,38 As Daher et al 11 suggest for rotator cuff repair, optimizing mental health before elective procedures may reduce complications and improve long-term outcomes.
Integrating mental health into surgical care should extend beyond screening. A biopsychosocial model in which surgeons, therapists, pain specialists, and mental health providers collaborate may offer the most significant benefit. Shaw and Carreira 39 showed that foot and ankle patients with depression or anxiety achieve less pain relief and functional improvement after surgery, recommending greater attention to mental health in orthopaedic practice. Similarly, Weinerman et al 45 emphasized multidisciplinary care in orthopaedic trauma, noting that addressing psychological needs both before and after surgery improves outcomes and quality of life. Applied to ATR, this approach could include nonopioid pain strategies, cognitive-behavioral therapy, or mindfulness-based interventions. 45 Addressing mental health also helps patients feel supported, increasing motivation and engagement in rehabilitation. Psychological rehabilitation, such as cognitive behavioral therapy, has been shown to reduce anxiety and depression, improve pain control, shorten hospital stay, and enhance adherence to postoperative instructions, all of which may contribute to improved recovery after ATR.16,17
This study has several limitations that should be considered when interpreting the findings. First, as a retrospective analysis using an extensive, deidentified multicenter database, the study is inherently constrained by the quality and accuracy of administrative coding, which may lead to misclassification and incomplete capture of clinical details. Mental health conditions were identified using diagnostic codes; therefore, undiagnosed or unreported conditions may not be captured in the database. Essential variables—such as surgeon experience, surgical techniques, intraoperative events, and patient-reported outcomes—were unavailable, which may limit the depth of clinical interpretation. Additionally, all outcomes were identified using CPT and ICD codes, which are subject to documentation variability and may not fully reflect the complexity of postoperative events. Because the database identifies procedures using CPT codes without laterality, the exact number of ATRs could not be determined, and bilateral procedures could not be distinguished. Importantly, mental health disorders were treated as a broad exposure category in this analysis, and the study was not designed to determine whether specific psychiatric diagnoses confer differential risk of postoperative complications after Achilles tendon rupture. Finally, although the presence of preoperative mental health diagnoses provided valuable insight into their association with outcomes after ATR, psychological function assessed through validated patient-reported measures would likely offer a more accurate assessment of mental health-related risk than diagnostic coding alone.
Conclusion
Our study showed that mental health disorders are associated with an increase in postoperative complications after ATR. The persistence of pain and opioid dependence over 2 years underscores the significant long-term impact of psychosocial factors on the recovery process. These findings support the incorporation of routine psychosocial screening and perioperative mental health support into comprehensive care strategies to reduce complications and enhance functional outcomes.
Footnotes
Appendix A
Representation of the Outcomes Definition: Medical Codes for Included Diagnoses and Procedures a
| Variable | Code |
|---|---|
| Ankle pain | UMLS:ICD10CM:M25.571 |
| UMLS:ICD10CM:M25.572 | |
| UMLS:ICD10CM:M25.579 | |
| UMLS:ICD10CM:G89.18 | |
| Ankle stiffness | UMLS:ICD10CM:M25.67 |
| Lower limb mononeuropathy | UMLS:ICD10CM:G57 |
| Revision repair | UMLS:CPT:27654 |
| Hospital readmissions | CPT:99232, CPT:99233, CPT:99231, CPT:99235, CPT:99234, CPT:99236, HCPCS:G0316, HCPCS:G0379, SNOMED:32485007, CPT:1013675 |
| ER visits | CPT:99281, CPT:99282, CPT:99283, CPT:99284, CPT:99285, CPT:1013723, CPT:1013711, HCPCS:G0380, HCPCS:G0381, HCPCS:G0382, HCPCS:G0383, HCPCS:G0384 |
| Reoperation for any reason | UMLS:CPT:27654 |
| UMLS:ICD10CM:T81.41 | |
| UMLS:ICD10CM:T81.41XA | |
| UMLS:ICD10CM:T81.42 | |
| UMLS:ICD10CM:T81.42XA | |
| UMLS:ICD10CM:T81.31 | |
| UMLS:ICD10CM:T81.31XA | |
| UMLS:ICD10CM:T81.32 | |
| UMLS:ICD10CM:T81.32XA | |
| UMLS:ICD10CM:T81.89XA | |
| UMLS:ICD10CM:T81.89 | |
| Postoperative infection | UMLS:ICD10CM:T81.41 |
| UMLS:ICD10CM:T81.41XA | |
| UMLS:ICD10CM:T81.42 | |
| UMLS:ICD10CM:T81.42XA | |
| Complex regional pain | UMLS:ICD10CM:G90.529 |
| UMLS:ICD10CM:G90.52 | |
| UMLS:ICD10CM:G90.522 | |
| UMLS:ICD10CM:G90.521 | |
| Opioid use | UMLS:ICD10CM:F11.9 |
| UMLS:ICD10CM:F11.90 | |
| NLM:RXNORM:5489 | |
| NLM:RXNORM:3423 | |
| NLM:RXNORM:7052 | |
| NLM:ATC:N02AF | |
| NLM:RXNORM:2670 | |
| NLM:RXNORM:4337 | |
| NLM:RXNORM:10689 | |
| NLM:RXNORM:7804 | |
| Surgical wound complications | ICD10CM:T81.41 |
| ICD10CM:T81.41XA | |
| ICD10CM:T81.42 | |
| ICD10CM:T81.42XA | |
| ICD10CM:T81.31 | |
| ICD10CM:T81.31XA | |
| ICD10CM:T81.32 | |
| ICD10CM:T81.32XA | |
| ICD10CM:M96.84 | |
| ICD10CM: M96.840 | |
| ICD10CM: M96.842 | |
| DVT | UMLS:ICD10CM:I82.4 |
| Rehabilitation utilization | CPT:97161 |
| CPT:97164 | |
| CPT:97110 | |
| CPT:97112 | |
| CPT:97116 | |
| CPT:97140 | |
| CPT:97530 | |
| CPT:97750 |
CPT, Current Procedural Terminology; DVT, deep vein thrombosis; ER, emergency room; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; UMLS, Unified Medical Language System.
Final revision submitted March 9, 2026; accepted March 14, 2026.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval was not sought for the present study.
