You’ve completely torn your Achilles tendon. What now? Here's our guide to the pros and cons of surgery to stitch the tendon back together vs. immobilising your foot in an orthopaedic boot so the tendon can grow back together by itself. Also, what you should do afterwards to get your tendon back to its former strength. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.
In this article:
We've also made a video about this:
👉 And we have an article with advice about the treatment of partial Achilles tendon tears.
Do you need surgery for a complete Achilles tear?
Not necessarily. The research is showing that patients who are treated conservatively by:
placing their foot in an orthopaedic boot that keeps their foot in plantar flexion (toes pointed down),
allowing early mobilisation,
and doing rehab to strengthen up again
achieve similar long-term results to the ones who undergo surgery.
👉 Here's our article on what the non-surgical treatment of complete Achilles tears involve.
However, there is also some evidence that surgical repair of a torn Achilles tendon might lead to better performance in jumping and hopping activities than conservative management for high-performance athletes. But there's currently a lack of research specifically comparing conservative rehab plans that follow the principals mentioned above with surgery in high-performance athletes. So, it might be that the rehab protocol is the deciding factor.
Surgeons will sometimes also assess the gap between the tendon ends with the foot in full plantar flexion to decide whether surgery is needed. But there’s currently no consensus among researchers about this. Some studies found that having a gap of more than 10 mm when the foot is in full plantar flexion resulted in poorer outcomes when treated conservatively, while other studies found that the gap size didn’t impact the recovery process or outcome.
Am I more likely to re-tear my Achilles if I don’t have surgery?
Both types of treatment involve a re-rupture risk, but it does seem that surgery carries a lower risk. A recent review study found that the re-rupture rate after surgery was 2.3-5% versus 3.9-13% for conservative treatment.
However, conservative treatment meant lower rates of other types of complication. Typical complications of surgery include infection, sural nerve injuries, and chronic pain.
Research indicates that one key part of treatment that clearly helps reduce the risk of re-rupture – whether someone has surgery or not – is functional rehabilitation. It’s a crucial step that should always be part of the post-op rehab plan.
So, should I rather have surgery then?
Your surgeon is best placed to help you decide whether surgery is the best option for your torn Achilles. They will take all the factors into account: the specific features of your rupture, your medical history, general health, complication risk, and activity goals.
Factors that affect treatment success
The main factor that can cause poor healing when following a conservative approach is when someone does not have their foot immobilised in a plantar flexed position as soon as possible.
If they are placed in a boot but the foot is in a neutral position or they're just left to walk on it without a boot, the two ends of the torn tendon will pull away from one another.
This can cause the tendon to heal in a lengthened position, which means that it will likely not regain its full strength.
It might also mean that you will likely need to have surgery to get the two ends back together and that the surgery will be more complex, as it will be more difficult for the surgeon to bring the ends together.
With surgical repairs, being too aggressive with rehab and starting dorsiflexion stretches (toes pointed up, towards your shin) too soon can also cause the tendon to heal in a lengthened position.
Rehab for Achilles tendon ruptures
While clinicians might disagree about whether surgery or conservative treatment is the best solution for a complete Achilles tear, they do agree that following an extensive rehab programme is key to making a good recovery.
The type of rehab and when to start with it will depend on your specific case, e.g. whether you had surgery or opted for conservative treatment with a boot. There are also a few protocols that can be followed depending on the type of boot you’ve been wearing and what your doctor thinks is best.
What they all have in common is that they become progressively more challenging with the aim to strengthen your calf muscles and Achilles tendon back up to their previous level. The plans must also be adapted to match the individual's speed of healing and ultimate activity goals.
👉 Here's an example of what Achilles rehab after surgery might look like if you apply the latest research. And this article discusses what types of shoe might be most useful for Achilles ruptures.
It can take nine months or longer to regain proper strength and control in your calf muscles and Achilles tendon.
Despite doing everything right, you might still end up with a slight reduction in strength on the injured side compared to the uninjured side. But I often find that this happens when patients are prematurely discharged from rehab or not actually prescribed the correct level of rehab to allow them to regain their full strength.
Injections for Achilles rupture healing
PRP injections
A PRP injection involves injecting platelet rich plasma (prepared from your own blood) into the gap between the ends of the torn Achilles tendon. The rationale for doing this is that it might improve the speed of healing and the final quality of your recovery.
However, so far, the research suggests that it might not be useful. In a recent randomized controlled trial involving 230 patients where they injected either PRP or a placebo within 12 days of rupture, researchers found no difference in the speed of healing or quality of healing between the groups at 24 weeks and 2 years after the injection. These participants were all managed conservatively, without surgery. There's currently a lack of high-quality research looking at the efficacy of PRP and surgical repair.
Stem cell injections
Despite stem cell injections gaining popularity, there is very little research available to support its use. However, that research does seem to suggest that stem cell injections might improve Achilles rupture healing.
High risk of DVT
It appears that, regardless of the treatment choice, having a complete Achilles tendon tear might lead to deep vein thrombosis (blood clots in the calf), a condition that needs to be identified and treated immediately when it occurs.
🚨 If you experience any of the following symptoms, I suggest that you contact your doctor immediately or go to A&E to have it checked:
Significant swelling in the calf
The calf or ankle might feel hot/warm to touch
The calf might have red areas
You will likely experience quite a bit of pain (more than what you've had in the days leading up to this) in the calf or around the ankle and it is often described as a throbbing pain that is worse when your feet are down (e.g. sitting or standing) compared to when you’re lying down, but it may feel different for you.
How we can help
If you suspect that you’ve torn your Achilles tendon, the first step should always be to see a doctor or physio in person who can diagnose it for you and can immobilise your foot in plantar flexion (foot pointing downwards, away from your shin) in a boot and/or refer you for surgery if appropriate.
For the first 12 weeks after you’ve torn your tendon, it is usually best to consult a physiotherapist in person.
Our role starts once you’ve been cleared to start removing your boot (around 12 weeks post-rupture). It is only at this point that we can safely take over your rehab via video call.
Who we are
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master's Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.