(updated 2026.01.11)

The outcome of treating midsubstance Achilles tendon tears depends mainly on correct rehabilitation, and not the choice of surgical vs. non-surgical treatment.

The problem with all the results found with a Google search is that most historical research has the following main flaws:

• no standardisation of patient selection

• no standardisation of treatment regimens

• no standardisation of rehabilitation type or duration

• invalid outcome measures used to draw conclusions

The above represents bad science, and leads to incorrect guidelines.

Modern, high-quality research studies using the only validated outcome measure (the ATRS = Achilles Tendon Rupture Score) have been carried out, comparing surgical vs non-surgical outcomes (* listed at the bottom). These studies have provided solid information with which which proper decisions can be made.

These studies have all shown that the magic in treating midsubstance Achilles ruptures depends on the correct implementation of a standardised protocol of Accelerated Functional Rehabilitation. This protocol combines:

• early progressive weightbearing, and

• early controlled range of motion in a hinged walker boot - not a cast, not a flat boot with wedges! A flat boot with wedges causes the hidfoot to remain in inadequate equinus while the midfoot bends more, causing the Achilles to heal stretched out.

The treatment protocol is as follows:

• 2 weeks non-weightbearing on crutches in an equinus front-slab, with blood thinners, then

• 2 weeks in a hinged walker boot locked at 30 degrees equinus, partial weightbearing 50% body weight, with blood thinners, then

• 2 weeks in the hinged walker boot, partially dynamised with 15-30 degrees plantar flexion range, full weight bearing (crutches still used for balance), +/- blood thinners, then

• 2 weeks in the hinged walker boot, dynamised with 0-30 degrees plantar flexion range, full weight bearing, no crutches.

The boot is only removed for 1 hour per day for washing and cleaning, with care taken not to move the ankle beyond the range provided by the boot. It is important to sleep with the boot on!

After 8 weeks, the boot is removed completely, and the patient starts to walk in normal shoes, using silicone heel cups inside the shoes. Physiotherapy begins at this stage. It is important not to be too aggressive with stretching at any point until 10 weeks after the initial injury.

The physiotherapy guidelines are as follows after the boot is removed: 

• Weeks 9-12: focus on achieving daily normal walking, range of motion, double heel raise, and proprioception. Running and jumping are strictly avoided! Starting aqua jogging is ok if other goals achieved.

• Months 3-5: Goal is single-heel raise, with progression to two-feet jumping. Start sports conditioning.

• Months 6-8: Introduce plyometrics, hill-running and sprinting. Return to competitive sports if the horizontal/vertical hop is ≥75% of the uninjured leg.

For the treatment to be successful, patient compliance is essential! A sobering consideration is that if someone is not compliant with non-operative rehabilitation, then the stakes of complications can be much higher in the same patient if surgery is offered. This makes non-compliance a particularly difficult problem to manage.

Results

If patients with surgical and non-surgical treatment use the same rehabilitation protocol, then the following are the results:

• No difference in the validated outcome score ATRS at 1 year and 2 years after injury , with average ATRS >85/100 (good to excellent result), regardless of surgeical vs. non-surgical management. While surgery provides faster initial strength recovery, long-term functional satisfaction at one to two years is comparable between surgical and conservative groups when modern rehabilitation protocols are strictly followed.

• No statistically significant difference in re-rupture rates – note that the risk of re-rupture is never zero, however the risk of re-rupture is less than the risk of wound complications from surgery in this area of the body with fragile and tight skin

• No difference in patients age <40 years old compared to >40 years old

• Some gender differences exist in recovery; female patients have a greater degree of deficit in heel-rise height compared to males, and they tend to report more symptoms post-surgery 

• While most athletes (70–90%) return to sport, many do not reach their pre-injury performance level - importantly, research proves that Achilles tendons are already show significant degeneration through their entire length by the time there is a rupture, and therefore patients sometimes describe the feeling of “running on a flat tyre” after healing, irrespective of surgical or non-surgical treatment.

Complications

• Venous Thromboembolism (clots): overall incidence of clots and pulmonary embolism is approximately 7.5%. 

• Re-rupture: previously reported at 13% for conservative vs 5% for surgical patients. However, with accelerated functional rehabilitation, these rates have dropped significantly to as low as 1.1% to 2% for all, regardless of whether surgery was performed.

• Without surgery, a difference in muscle girth and heel raise height can be noted compared with opposite side, but do not correlate with ATRS

• Tendon Elongation: a healed but lengthened tendon (≥10 mm) significantly reduces plantar flexion power and torque, impacting functional recovery. This occurs more often in non-operatively treated patients.

• Wound Healing Problems and Infection: occurs in 2.8% to 7.3% of surgical cases. Management involves antibiotics or negative pressure wound therapy for deep infections. Sometimes wound complications can be devastating, requiring plastic surgery tissue flaps to be transferred from other parts of the body, in order to cover the skin defect. These flaps can be unsightly but would be essential to heal the open wound.

• Sural Nerve Injury:  surgical risk in percutaneous (7.8%) and open repairs, resulting in sensory disturbances.

Therefore, overall, non-surgical treatment is overall generally considered superior to surgical treatment for acute midsubstance Achilles tendon ruptures in many patients, because non-surgical treatment has no wound healing problems and no nerve problems.

However, treatment decisions should be individualised and formulated in agreement with the patient. 

Please note that the following cases are exceptions to the above discussion:

• cuts to the leg with open wound over a cut Achilles – always need surgery

• insertional Achilles tears or avulsions – almost always need surgery

• musculotendinous Achilles tears – almost never need surgery

• “tennis leg” (gastrocnemius tear) – almost never need surgery, and different rehabilitation protocol

• delayed diagnosis or incorrect early management in a 90-degree cast or 90-degree boot – more likely to need surgery

• re-rupture – will likely need surgery

• professional athletes, based on superior fitness and biologic healing reserves, as well as access to their own rehabilitation services.

References:

• 2015 - Hutchison et al - The treatment of a rupture of the Achilles tendon using a dedicated management programme

• 2015 - Silbernagel et al - Sex Differences in Outcome After an Acute Achilles Tendon Rupture

• 2017 - Bhatia et al - Leicester Achilles Management Programme (LAMP)

• 2017 - Ellison et al. - Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon - Do Commonly Used Orthoses Produce the Required Equinus

• 2021 - She et al - Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture - A Comprehensive Meta-Analysis of RCTs

• 2024 - Fan et al - Surgical vs. nonoperative treatment for acute Achilles tendon rupture - a meta-analysis of randomized controlled trials

• 2025 - Cho et al - Comparison of open percutaneous or mini-open repair in the treatment of Achilles tendon ruptures - a systematic review and meta-analysis based on comparison studies

• 2025 - Dold - Acute Achilles Tendon Ruptures - An Update on Current Management Strategies

• 2025 - Fada et al - Return to Play After Achilles Tendon Rupture - Comparing Operative and Nonoperative Approaches in Athletes

• 2025 - Santana et al - Conservative treatment of achilles tendon rupture - a systematic review comparative with surgical treatment