Achilles Tendon Rupture: 48 Questions Patients Ask

The Achilles tendon connects the calf muscles to the heel bone and lets you push off when you walk, run and jump. A rupture is a complete tear of the tendon. It usually happens during an explosive movement, when the calf muscle contracts while it is being stretched, such as pushing off to sprint or landing from a jump.¹

Most ruptures happen in people who play recreational sports into their thirties and forties, and they are more common in men between 30 and 40 years of age. Ruptures have become more common as more adults stay active in sports.¹

Ruptures usually occur during a sudden, forceful push-off or landing. Pre-existing changes in the tendon can make it more likely to tear.¹

Many people describe feeling as if they were kicked or hit in the back of the ankle, sometimes with a pop. Walking is often still possible, but pushing off and rising onto the toes are weak. See Achilles tendon rupture for more on symptoms.

Dr. Dold examines the leg, including the Thompson test, in which squeezing the calf normally points the foot downward; with a complete rupture, the foot does not move. He usually orders an MRI to confirm the tear and see the size and location of the gap, which helps guide treatment.

Yes. Up to 25% of acute Achilles ruptures are not treated within the first 4 weeks because of a missed diagnosis or a delay in seeking care.² Because you can often still walk, a rupture can be mistaken for a sprain. If you felt a pop and have weakness pushing off, get checked promptly.

Non-surgical treatment is very different from no treatment. A rupture left untreated for 4 weeks or more is considered chronic. In a study of patients whose chronic ruptures were eventually repaired, function scores were 62 out of 100 a year after surgery, and the calf remained smaller than the other side.^1,2

Not always. Dr. Dold’s review of the research found that both surgery and non-surgical treatment with an accelerated rehabilitation protocol are excellent options, and that patients should understand the benefits and risks of each to choose what fits them best.¹ Dr. Dold makes this decision with you. Surgery is often recommended for athletes, for ruptures diagnosed late or for a large gap between the tendon ends; non-surgical treatment is an excellent choice for many other patients.

For many years, non-surgical treatment was linked to much higher re-rupture rates, as high as 9.8% to 10.9% in some analyses.^3,4 Many of those studies, however, kept patients immobilized for long periods. In one trial with 8 weeks of immobilization followed by 8 weeks of partial weight bearing, 20.8% of non-surgical patients re-ruptured.⁵

Accelerated functional rehabilitation. When non-surgical patients start protected movement early instead of staying immobilized, several meta-analyses found no significant difference in re-rupture rates between surgery and non-surgical care.^6,7,4 A randomized trial using an identical functional bracing protocol for both groups found the same.⁸ In a multicenter randomized trial of 144 patients in which both groups followed the same accelerated rehabilitation protocol, re-rupture occurred in 2 surgical and 3 non-surgical patients, with no clinically important differences in strength, motion or calf size.⁹

No. Some studies still report higher re-rupture rates without surgery, including the 2022 trial above,¹⁰ and a 17-year experience with an early weight-bearing, non-surgical protocol reported a re-rupture rate of 9.65%.¹¹ Dr. Dold can review these numbers with you.

Most studies found no significant difference in Achilles Tendon Total Rupture Scores between surgical and non-surgical patients at 12 months.^10,4,3,8

The most common questionnaire used to measure recovery after an Achilles rupture. Patients rate limitations such as strength, fatigue, stiffness, pain and difficulty with daily activities and sport, giving a score out of 100.¹

Yes. In a meta-analysis of randomized trials, at least one complication (other than re-rupture) occurred in 20.4% of surgical patients vs 6.9% of non-surgical patients. Scar adhesion, sural nerve injury and superficial infection were significantly more common after surgery.⁴ Other meta-analyses also found fewer overall complications with non-surgical treatment.^6,7

Possibly. In a randomized trial, non-surgically treated tendons healed longer (about 88 mm vs 69 mm at 18 months), and calf (soleus) muscle loss increased over time in the non-surgical group. Greater calf atrophy was linked to weaker push-off strength.¹² A meta-analysis found no significant difference in calf circumference.⁷

Dr. Dold usually recommends discussing surgery if you are a competitive or high-demand athlete, if the rupture was diagnosed late or if the gap between the tendon ends is large. Surgery also reduces the risk of the tendon healing too long, which can weaken push-off.¹²

Ideally within about 2 weeks of the injury. Ruptures that are treated later may need a more involved repair.

A rehabilitation approach that begins controlled ankle movement and protected weight bearing early, rather than keeping the leg immobilized for many weeks. Researchers define it as allowing free ankle motion exercises within the first 3 weeks.⁶ In one trial, patients removed their brace for 5 minutes each hour from day 10 to practice moving the ankle, without bending the foot upward past neutral.¹³

Yes. Dr. Dold uses the same accelerated functional rehabilitation protocol for both, as in a large multicenter randomized trial of accelerated rehabilitation.⁹

In a systematic review of non-surgical treatment, re-rupture occurred in 6.0% of patients who began early functional movement vs 12.8% of those who did not.¹⁴ Functional rehabilitation has also been associated with fewer complications overall (5% vs 9.8%).¹⁵

In a review of non-surgically treated patients, those who came out of their boot within the first 8 weeks had a 9.6% re-rupture rate vs 2.7% for those who stayed in it longer.¹⁴ Earlier boot removal was linked to better function scores, so the decision is a balance, which is why Dr. Dold weans patients out of the boot between 8 and 12 weeks.^14,1

Early weight bearing alone did not change the re-rupture risk, but it was associated with fewer blood clots (3.4% vs 13.1%).¹⁴ That review also found somewhat lower function scores when weight bearing started in the first 4 weeks.¹⁴ Dr. Dold’s protocol balances these findings by starting with 2 weeks of no weight bearing, then building up gradually.

The heel lifts keep the ankle pointed slightly downward so the tendon ends stay close together while they heal. Dr. Dold starts with a 4 cm lift, reduces it to 2 cm at 4 weeks and removes it at 6 weeks.

Not for the first 2 weeks. From 2 weeks you can remove it for bathing and dressing, and from about 6 weeks you can sleep without it, as directed.

The torn tendon ends are sewn back together. Dr. Dold performs the surgery as an outpatient procedure under general anesthesia with a nerve block for pain control, so you go home the same day.

The traditional approach uses an incision of about 8 to 12 cm on the back of the ankle.¹ Open repair has a low re-rupture rate, and some studies found it gives a strong initial repair that limits stretching of the tendon.¹ In one meta-analysis, return to sport after open repair was about 20 days faster than after minimally invasive repair.¹⁶

The tendon is repaired through an incision of usually 3 cm or less, using special instruments to pass the sutures. Examples include the Achillon device, the Percutaneous Achilles Repair System (PARS) and the Dresden instrument.¹

Dr. Dold performs both minimally invasive and open repairs and chooses based on your tear, your tissue quality and your goals. When the tendon is degenerated or the tear is chronic, he may augment the repair.

A small nerve near the Achilles that provides feeling to the outside of the foot. Irritation or injury can cause numbness or tingling there. Sural nerve injury is more common after surgery than with non-surgical treatment,⁴ and was less common with open repair than minimally invasive repair in one meta-analysis.¹⁶

Complications reported after Achilles surgery include superficial infection, scar adhesion, sural nerve injury and blood clots.⁴ Minimally invasive techniques reduce incision-related complications.^17,16

Ruptures left untreated for 4 weeks or more often need a more involved reconstruction. In one study, function scores and calf size remained limited a year after these ruptures were repaired.² Research on the best management of chronic ruptures is limited.¹

The research is mixed. One meta-analysis found PRP improved upward ankle motion (dorsiflexion), the strength of that motion and calf circumference, but not push-off (plantar flexion) strength or pain.¹⁹ However, a large placebo-controlled trial of a single PRP injection in non-surgical patients found no difference in function at 2 years,²⁰ and another meta-analysis found no improvement in function, re-rupture, calf size or return to sport.²¹ Differences in how PRP is prepared and given may explain the mixed results.¹

Dr. Dold offers biologics as an option to Achilles patients: PRP or bone marrow concentrate (BMAC) applied to the repair during surgery, or a PRP injection for patients treated without surgery. Using PRP or BMAC to treat an Achilles rupture is not FDA-approved and is considered off-label, research on BMAC for Achilles ruptures is limited, and these treatments are usually not covered by insurance.

Dr. Dold asks patients to avoid anti-inflammatory medicines (NSAIDs) such as ibuprofen and naproxen for 6 weeks after a PRP or BMAC treatment.

At 2 weeks, three times a week, for both surgical and non-surgical treatment.

Usually within 1 to 2 weeks, with the leg elevated when possible.

If your left Achilles was injured and you drive an automatic, often at about 1 to 2 weeks, once you are off narcotic pain medicine. If it was your right Achilles, usually not until you are out of the boot, at about 8 to 12 weeks.

Most patients wean out of the boot between 8 and 12 weeks and transition to a regular athletic shoe, using crutches or a cane as needed during the transition.

Usually at about 4 to 5 months, depending on your strength and how the tendon has healed. Walking and running on a treadmill or anti-gravity treadmill may begin earlier in therapy.

Usually at 6 to 9 months. After open repair, about 75% to 85% of patients return to sport at their pre-injury level, although definitions vary between studies.¹ In one meta-analysis, the average return to sport after open repair was about 163 days in that study.¹⁶

Most do. In a study of NFL players, 72% returned to play, at an average of about 11 months after surgery.²² Return timelines for recreational athletes differ from those for professional players.¹

Some calf muscle loss is common, especially with non-surgical treatment.¹² The later phases of rehabilitation focus on calf strengthening to regain muscle size, power and endurance.

Achilles ruptures carry a risk of blood clots. Most of Dr. Dold’s patients take aspirin for about 4 weeks. Go to an emergency department if you develop calf pain or swelling that does not improve with elevation, chest pain or shortness of breath.

A new pop, sudden weakness pushing off or a return of the gap you could feel at the time of injury. Call the office right away if this happens.

It is uncommon, but a rupture of the opposite tendon has been reported after Achilles injuries.¹⁵ Dr. Dold recommends following your rehabilitation program and building strength gradually.