Achilles Tendon Ruptures - To Repair or Not To Repair? That is the Question

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.

This blog post explores the anatomy, physiology, and mechanisms of injury of Achilles ruptures. Read along to compare the latest research on conservative versus surgical repair approaches and make an informed decision that's best for you.

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.

Tendonitis vs Tendinopathy

The previous consensus was that Achilles pain was a hallmark sign of tendonitis, regardless of the underlying causes. As a result, the recommendation was to stop physical activity and rest, thus allowing the "inflammation" to subside.

However, in many cases, the inflammatory response is either limited or absent altogether. Instead, modern research is shifting the paradigm towards tendinopathy.

The current understanding is that tendinopathy is primarily a degenerative condition resulting from repetitive overloading of the tendon rather than an inflammatory disorder.

This condition progresses through several stages, from initial reactive changes to chronic degeneration. Understanding the underlying degenerative processes and the various stages of tendinopathy is essential for effective management strategies and exercise programs.

A degenerative condition can deteriorate with inactivity, so we shouldn't immediately conclude that experiencing pain means you should stop your prior level of activity. Instead, you should monitor load and strengthen the tendon to meet the external demands that your body is placing on it.

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.

Conservative management typically involves a period of immobilization in a walking boot 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. A systematic review by Kearney et al. (2019) found that traditional treatment was successful in about 75% of patients with acute Achilles tendon ruptures, emphasizing the importance of patient selection and personalized treatment plans.

Surgical intervention is often considered for complete ruptures, high-demand athletes, or when conservative treatment fails to yield satisfactory results. Surgical techniques may involve open repair, minimally invasive, or percutaneous procedures.

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 lower risk of re-rupture and a higher rate of return to pre-injury activity levels.

However, surgical intervention also carried a higher risk of complications and reoperation, making patient preferences and the severity of the injury crucial considerations in decision-making.

The study concluded that re-rupture occurred in 14 of 381 surgically treated patients (3.7%) and 37 of 377 nonsurgically treated patients (9.8%).

Conclusion:

Having suffered a complete rupture of my Achilles tendon, I heavily weighed and considered the pros and cons. While conservative treatment can still be effective for successful for some patients, surgical repair remains viable, especially for active individuals and complete ruptures.

This is why I ultimately decided to undergo surgery, so I would feel more confident playing recreational basketball again.

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

• Individual's age

• Body Mass Index

• Psycho-social factors

• Activity levels

• The extent of the tear

• 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. Khan KM, Cook JL, Kannus P, et al. Time to abandon the "tendinitis" myth. BMJ. 2002;324(7338):626-627. doi:10.1136/bmj.324.7338.626

3. Kearney RS, Achten J, Lamb SE, et al. In-shoe plantar pressures within ankle-foot orthoses: implications for managing achilles tendon rupture. J Orthop Sports Phys Ther. 2019;49(1):34-42. doi:10.2519/jospt.2019.8613

4. 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

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.