Surgical Achilles Repair vs. Conservative Approach: Why the Research Will Shock You

Is surgery always required for Achilles ruptures?

I was back on the court, playing 3-on-3 at the local YMCA, finally feeling like myself again. After months of getting stronger, putting in the work, and rebuilding confidence in my explosiveness and shot-making, my body was responding. Every cut felt sharper. Every jumper, smoother.

Then came the moment.

I was at the top of the key, isolated. I gave my defender a simple tween move—just a quick left-to-right between the legs. I planted hard and drove off my right foot to blow past him. And then… bam.

A loud pop, like a champagne bottle exploding behind me.

I stumbled forward, confused. I looked back, half-expecting to see someone had kicked me. But no one was there. In an instant, my body dropped. My mind raced. I knew. I didn’t want to admit it, but deep down, I knew—I had just ruptured my Achilles tendon.

That moment marked the beginning of my journey through one of the most dreaded injuries in sports. Even as a physical therapist, what followed was a flood of questions, fears, and decisions I never thought I’d have to make.

Should I have surgery?

What would recovery look like?

Would I ever get back to the level I’d just fought to reach?

If you're reading this, there’s a good chance you're in the same position—or know someone who is. Ready for the good news?

You'll be okay.

I've read the latest research on conservative versus surgical approaches to help make an informed decision that's best for you.

Understanding the Achilles Tendon

The Achilles tendon, the largest and strongest in the human body, is also one of the most commonly injured. A recent study estimates that the number of people suffering acute ruptures in the United States is 7 to 40 per 100,000 annually.

Six weeks post-op of my Achilles rupture in Ketchikan, Alaska.

Anatomy

The Achilles tendon is a thick fibrous band of tissue connecting the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). It facilitates plantarflexion of the foot (imagine pushing down on a gas pedal), allowing us to generate and distribute large amounts of force in running, jumping, and various other sports and plyometric activities.

Mechanisms of Injury

Achilles tendon injuries can be categorized into two primary types: acute ruptures and degenerative overuse conditions. Acute ruptures often result from forceful movements, such as sudden pushing off or jumping, leading to a partial or complete tendon tear—or, in my case, playing basketball!

Conversely, overuse injuries occur due to repetitive tendon stress that exceeds the body's capacity to meet those demands. These injuries are commonly seen in marathon runners and the elderly.

Conservative vs. Surgical Repair:

Medical professionals have long debated the management of Achilles tendon injuries. While some advocate for conventional treatment involving non-surgical approaches, others favor surgical repair to ensure better outcomes. Understanding the evidence behind each approach is crucial for making informed treatment decisions.

Conservative Approach

Conservative management typically involves eight to ten weeks of immobilization in a walking boot with heel lifts. This is followed by gradual loading of the tendon through resistive and weight-bearing exercises.

Several high-quality, evidence-based studies have shown favorable outcomes with conservative treatment in select cases, particularly for partial tears and less active individuals.

Most notably, a 2022 randomized controlled trial from the New England Journal of Medicine found that surgery (open repair or minimally invasive surgery) was not associated with better outcomes than nonoperative treatment at 12 months.

The Case for Surgical Intervention

Despite the promising results of conservative treatment, surgical intervention remains an important consideration for specific patient populations. Surgery is often recommended for complete ruptures, high-demand athletes, or when conservative treatment fails to yield satisfactory results. Surgical techniques may involve open repair, percutaneous procedures, or the SpeedBridge technique.

The evidence supporting surgical intervention comes from multiple studies examining rerupture rates. A systematic review and meta-analysis by Gao et al. (2019) compared the outcomes of surgical repair versus conservative treatment for acute Achilles tendon ruptures. The study concluded that surgical repair was associated with a ~6% lower risk of re-rupture and a higher rate of return to pre-injury activity levels.

Specifically, the study found that re-rupture occurred in 14 of 381 surgically treated patients (3.7%) compared to 37 of 377 nonsurgically treated patients (9.8%).

Another 2019 study by Ochen, Y et al compared 10 randomized controlled trials and reported a smaller 1.6% difference in re-rupture across the populations.

While numerous studies have compared conservative versus surgical approaches, the evidence consistently shows that surgical repair typically reduces rerupture rates by approximately 1.6%-5% on average across different patient populations.

Surgical Risks and Complications

Surgical intervention is not without its risks. Like any surgical procedure, Achilles tendon repair carries potential complications that must be weighed against the benefits. The most common complications include:

1. Infection: Surgical site infections occur in approximately 2-8% of open Achilles tendon repairs, with minimally invasive techniques showing lower infection rates of around 1%-3%. Deep infections, though rare, can be particularly problematic and may require additional surgical intervention, antibiotics, and other forms of treatment.

   
   

2. Nerve Damage: The sural nerve, which provides sensation to the lateral foot, is at risk during Achilles tendon surgery. Studies report sural nerve injury rates ranging from 2%-8% depending on the surgical technique used, with percutaneous repairs showing higher rates of nerve complications compared to open procedures.

   
   

Making the Right Choice for You

Again, opting for surgery isn't black and white.

Several factors come into play during the decision-making process. As a physical therapist, it's my responsibility to inform and educate you on the most up-to-date and accurate information. Ultimately, the best decision can be made by the patient.

In my experience, many patients rupture their Achilles while participating in a special hobby, whether that be basketball, tennis, soccer, or other explosive activities. If you're in your 20s-30s and still highly active, participating in sports regularly, I'd say you're generally better off electing for surgery. The slightly lower rerupture rate becomes more significant when considered over decades of continued athletic activity.

On the flip side, if you're in your mid-40s or are just looking to return to an active lifestyle—one that doesn't require consistent explosive movements or high-demand loading—you're generally golden with the non-operative route.

In my professional opinion, while there is no clinically meaningful difference in performance outcomes between the two approaches, the minor difference in rerupture rates may justify surgical intervention for younger, more active individuals.

Ultimately, the choice should be made collaboratively between patient and surgeon, considering individual risk factors, activity goals, and personal preferences while weighing the benefits against the potential surgical risks. While there is no clinically meaningful difference in performance outcomes, there is a minor difference in rerupture rates.

This is why I typically still advocate for athletes to go the surgical route.

Rehabilitation and Recovery Timeline

Recovery varies based on treatment choice and individual factors. Here's a general timeline:

• Weeks 0-2: Immobilization in a cast or boot; non-weight bearing.

• Weeks 2-8: Gradual weight-bearing begins in protective boot; start of physical therapy while the tendon heals.

• Weeks 8-12: Increased mobility exercises; focus on strength and balance. Gait retraining.

• Months 3-6: Return to low-impact activities like jogging. Introduction to plyometrics.

• Months 6-12: Progression to high-impact sports, depending on recovery.

Conclusion

Having suffered a complete rupture of my Achilles tendon, I heavily weighed and considered the pros and cons. While conservative treatment is effective for the majority of patients, surgical repair has a lower re-rupture rate, especially for high-level athletes.

This is why I ultimately decided to undergo surgery, so I would feel more confident playing recreational basketball again. That extra peace of mind can have a big psychological impact on the recovery process that often goes overlooked. It took me a while, in fact, 12+ months, but I eventually got back to exploding, loading, and trusting my leg again.

I'm thankful for my experience and knowledge regarding these types of injuries because I knew what to expect. The only thing I wish I had done differently is to have hired a basketball coach to help with my sloppy shooting form. Seriously, if ya'll have any tips, let me know in the comments below!

Mid-range jumper at 10-month post-op

Finally, there are many factors to consider when choosing, such as:

• Individual's age

• Job and financial impact

• Body Mass Index

• Psycho-social factors

• Activity levels

• Return to sport goals

• Prior injury history

• Anticipated compliance with the rehabilitation program.

If you're looking for personalized guidance on your Achilles tendon injury, I’m here to help. Contact me to schedule a consultation call or email, and I'll create a plan tailored to your unique needs and goals.

I'm currently accepting new clients, so reach out today to get started on your path to healing.

Resources:

1. Lemme NJ, Li NY, DeFroda SF, Kleiner J, Owens BD. Epidemiology of Achilles Tendon Ruptures in the United States: Athletic and Nonathletic Injuries From 2012 to 2016. Orthop J Sports Med. 2018 Nov 26;6(11):2325967118808238. doi: 10.1177/2325967118808238. PMID: 30505872; PMCID: PMC6259075.

2. Myhrvold, S. B., Brouwer, E. F., Andresen, T. K. M., Rydevik, K., Amundsen, M., Grün, W., Butt, F., Valberg, M., Ulstein, S., & Hoelsbrekken, S. E. (2022). Nonoperative or surgical treatment of acute Achilles' tendon rupture. New England Journal of Medicine, 386(15), 1409-1420. https://doi.org/10.1056/NEJMoa2108447

3. Gao K, Chen S, Guo Q, et al. Conservative versus surgical treatment for acute Achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2019;58(6):1194-1203. doi:10.1053/j.jfas.2019.05.005

4. Ochen, Y., Beks, R., Van Heijl, M., Hietbrink, F., Leenen, L., Van Der Velde, D., Heng, M., Van Der Meijden, O., Groenwold, R., & Houwert, M. (2019). Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. The BMJ, 364. https://doi.org/10.1136/bmj.k5120.

5. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-2775. doi:10.2106/jbjs.i.01437

Disclaimer

The information provided in this blog is strictly for educational and informational purposes. As a doctor of physical therapy, I aim to share the latest knowledge and insights about injuries, conditions, and rehabilitation. It is essential to understand that every individual's health condition is unique, and the content presented here should not replace professional medical advice or personalized care.

A qualified healthcare provider or licensed clinician can perform a thorough physical evaluation and conduct examinations while taking an extensive history to guide you through making an informed decision. The author of this blog post and its published platform shall not be held liable for any consequences, injuries, or damages resulting from using the information provided.