Achilles tendon repair stitches a torn tendon back together and cuts the risk of a second rupture, while a boot with early movement gives the same function at one year in trials. This guide covers the signs of a tear, surgery or a boot, open and minimally invasive repair, rehabilitation week by week and the stay.
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Orthopedics
Achilles tendon repair lowers the risk of a second rupture. A boot with early movement heals the tendon too.
In a Norwegian trial of 554 adults, the tendon tore again in 6.2 percent of those treated in a boot and 0.6 percent of those who had surgery, yet function at one year came out the same in both. The right choice depends on your sport, your work, the gap between the tendon ends and how soon you were seen. Send your ultrasound or MRI and the date of the injury, and our orthopedic team will tell you which route fits.
554
Adults in the largest trial of surgery against a boot
6.2% vs 0.6%
Second ruptures after a boot and after surgery
Same
Function at one year after a boot, open repair or keyhole repair
The Achilles tendon joins the calf muscles to the heel bone and carries several times the body's weight with every push off the ground. It tears in men between 30 and 50 more than anyone else, in a sudden sprint, a jump or a lunge in football, basketball, tennis or padel.
In patients with Achilles' tendon rupture, surgery (open repair or minimally invasive surgery) was not associated with better outcomes than nonoperative treatment at 12 months.
Randomized trial of 554 patients, New England Journal of Medicine, 2022
The first hours matter for both routes.
1
Stop
Do not try to walk it off.
2
Point the foot down
A splint or boot that holds the toes pointed down brings the torn ends together, whichever treatment follows.
3
Get a scan
An ultrasound within days shows the gap between the tendon ends with the foot pointed down, and that gap feeds the decision.
4
Decide within a week
Surgery works best in the first one to two weeks, and a boot program has to start straight away to give the tendon its best chance of healing at the right length.
Why the tendon gives way
Most ruptures happen four to six centimeters above the heel, where the blood supply is poorest. Years of small wear, steroid injections near the tendon and some antibiotics of the fluoroquinolone family weaken it, and then a single forceful push finishes the job.
Signs of a torn Achilles
The squeeze test
Lying face down, the doctor squeezes the calf. With an intact tendon the foot flexes downward, and with a ruptured one it does not move. The test takes seconds and picks up nearly every complete tear, even when you can still walk with a limp.
Partial tears and chronic tendon pain
Gradual pain and swelling in the tendon, worse in the morning, points to tendinopathy rather than a rupture, and it gets its own treatment program of loading exercises. Partial tears show on ultrasound and heal in a boot.
A complete rupture announces itself.
A pop or the feeling of being kicked in the back of the heel.
No standing on tiptoe on the injured side.
A gap you can feel in the tendon.
Weak push-off, a flat-footed walk and swelling around the ankle within hours.
Surgery or a boot
Both routes work, and both use the same early movement program afterward. Surgery buys a lower chance of a second rupture and a slightly faster return to work, at the price of a wound, a small risk of infection and a nerve at risk of bruising. A boot avoids the operation. It asks for strict discipline with the rehabilitation schedule in return, because a single careless step out of the boot in the first weeks stretches the healing tendon. We discuss both with every patient.
Who leans toward surgery
Athletes in jumping and sprinting sports who want the lowest risk of a second rupture. People seen more than two weeks after the injury, when the ends have pulled apart. Anyone whose ultrasound shows a wide gap with the foot pointed down, a tear right at the heel bone, or a tendon that has already torn once. People with diabetes, smokers and those on steroids carry a higher wound risk, and for them the boot gains ground.
What the trials show
Ten randomized trials and dozens of large observational studies have compared the two routes. Their answer changed when rehabilitation changed.
Before and after early movement
Older trials kept the leg in a cast for six to eight weeks, and in those trials the tendon tore again far more after nonoperative care. Modern programs let patients bear weight in a boot within days and move the ankle within weeks, and the gap in second ruptures narrowed sharply.
The Norwegian trial of 554 patients
The number of tendon reruptures was higher in the nonoperative group (6.2%) than in the open-repair or minimally invasive surgery group (0.6% in each).
Myhrvold and colleagues, New England Journal of Medicine, 2022
What it means for you
Function, strength and daily activity came out the same at one year. Surgery prevented one second rupture for every 18 patients operated, and nerve injuries ran higher after surgery.
Why early movement changes the answer
If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45).
Meta-analysis of randomized trials, Journal of Bone and Joint Surgery, 2012
Back to work
The same analysis found surgical patients returned to work 19 days sooner, with no difference in calf size, strength or function.
The Canadian trial of 144 patients
Willits and colleagues gave every patient the same accelerated program, early weight bearing and early ankle movement, and randomized half to surgery. Two tendons tore again after surgery and three after the boot. Strength, motion and calf size matched at two years, while complications ran at 13 after surgery and 6 without, most of them wound problems.
1
Weeks 0 to 2
A boot with heel wedges holding the foot pointed down, crutches, weight as comfort allows.
2
Weeks 2 to 8
Full weight in the boot, with a wedge removed every one to two weeks and gentle ankle movement out of the boot several times a day, never stretching the tendon.
3
Weeks 8 to 12
Shoes with a heel lift.
4
Months 3 to 9
Strength work for the calf, then jogging around four months and sport from six to nine months, once you can do repeated single-leg heel raises.
Low numbers on both sides
Ochen and colleagues pooled 29 studies covering 15,862 patients. Second ruptures ran at 2.3 percent after surgery and 3.9 percent without it, and other complications at 4.9 percent against 1.6 percent, mostly infection after surgery. With early movement, the difference in second ruptures was no longer significant.
However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%).
Meta-analysis of 29 studies, BMJ, 2019
How the repair is done
The operation takes thirty to sixty minutes under a spinal or general anesthetic, lying face down. The surgeon stitches the frayed tendon ends together with strong sutures, sets the tension against the healthy side so the ankle rests at the same angle, and closes the thin skin over the back of the heel with care, since wound healing there decides much of the outcome.
Call the team the same day
A wound that leaks, opens or reddens, a temperature of 38 degrees or more, a calf that becomes hot, swollen and painful, sudden breathlessness, or a new pop with loss of push-off.
Ruptures found late
When a tear goes unnoticed for more than four to six weeks, the calf muscle pulls the upper end away and scar fills the gap. Stitching the ends no longer works. The surgeon lengthens the tendon from above or moves the tendon that bends the big toe onto the heel bone to power push-off, and recovery takes longer, close to a year to full strength.
Open or minimally invasive repair
Open repair uses an incision of eight to ten centimeters. Minimally invasive repair passes the sutures through incisions of two to three centimeters, with guides that hold the needle inside the tendon sheath.
The sural nerve
A small nerve runs beside the tendon. It carries feeling to the outer edge of the foot, keyhole techniques pass close to it, and a bruised nerve leaves numbness there that fades over months in nearly every case. We find and protect the nerve through the small incision.
Ten trials, open against keyhole
Attia and colleagues pooled ten randomized trials with 522 patients.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
Open against minimally invasive Achilles repair
Outcome
Open repair
Minimally invasive
Function score, out of 100
94.8
95.7
Second rupture
2.5 percent
1.5 percent
Superficial infection
6.0 percent
0.4 percent
Sural nerve injury
None reported
3.4 percent
Operating time
51 minutes
30 minutes
Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy.
Meta-analysis of 10 randomized trials, American Journal of Sports Medicine, 2023
Three treatments side by side
The Norwegian trial put all three routes in one study.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
Boot, open repair and minimally invasive repair at one year
Outcome
Boot
Open repair
Minimally invasive
Change in tendon score
Minus 17.0
Minus 16.0
Minus 14.7
Second rupture
6.2 percent
0.6 percent
0.6 percent
Nerve injury
0.6 percent
2.8 percent
5.2 percent
Reading the table
The score differences fell too small to matter. Each route carried its own trade, and we lay them out the same way in your consultation.
Recovery and the stay in Istanbul
Surgery runs as a day case or a one-night stay. We suggest five to seven days in Istanbul for the wound check and the first physiotherapy sessions, with the boot fitted and the wedge schedule written down before you fly. The cost depends on the technique, the night in hospital and the physiotherapy, and the estimate after the free review lists each.
Before the flight home, four things.
Clot prevention injections or tablets for the weeks in the boot, and an aisle seat.
The boot, spare wedges and a written schedule.
A letter for your local physiotherapist with the week-by-week program.
Follow-up after you return home through your coordinator, with a video of a heel raise at three months that the surgeon reviews.
A friend or relative can share your room on a companion bed. Coordinators speaking English, Arabic, French, Russian, Serbian, Romanian or Spanish meet you at the airport and arrange a wheelchair at both ends of the flight.
Achilles tendon repair FAQ
Do I need surgery for a torn Achilles?
No. A boot with early movement gives the same function at one year in trials. Surgery lowers the risk of the tendon tearing again, from around 6 percent to under 1 percent in the largest trial.
How soon after the injury should the repair happen?
Within one to two weeks. After four to six weeks the ends have pulled apart and a reconstruction replaces the simple repair.
When can I walk and play sport again?
You bear weight in a boot within days and walk in shoes with a heel lift from week eight. Jogging starts around four months and sport between six and nine.
When can I fly home?
Five to seven days after surgery, after the wound check, wearing the boot and taking clot prevention.
Can someone stay with me?
Yes. One companion sleeps in your hospital room on a companion bed, and the coordinator books a hotel room nearby for the physiotherapy days that follow the discharge.
References
Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or surgical treatment of acute Achilles' tendon rupture. New England Journal of Medicine. 2022;386(15):1409-1420.
Ochen Y, Beks RB, van Heijl M, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019;364:k5120.
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. Journal of Bone and Joint Surgery (American Volume). 2010;92(17):2767-2775.
Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. Journal of Bone and Joint Surgery (American Volume). 2012;94(23):2136-2143.
Attia AK, Mahmoud K, d'Hooghe P, et al. Outcomes and complications of open versus minimally invasive repair of acute Achilles tendon ruptures: a systematic review and meta-analysis of randomized controlled trials. American Journal of Sports Medicine. 2023;51(3):825-836.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assoc. Prof. Dr. Suat BATAR, Orthopedics and Traumatology.
