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The Achilles tendon is the largest tendon in the human body and can be subject to enormous forces. The management of ruptures has been subject to much debate. To operate or not to operate is the question!
Surgical Repair
This is when the ends of the ruptured tendon are simply sutured together at surgery. It is a reasonably simple process. A small cut is made on the back of your heel and the rupture ends identified and repaired with strong sutures.
This can be done through a formal open approach or via smaller incisions or a minimally invasive approach. Less invasive methods have less risk of wound complications.
What are the risks of a tendon repair?
The general risks of any foot and ankle surgery also apply here and be sure to review that information.
This is the most feared problem with Achilles surgery. Fortunately, the rates are low and in the region of 1 in 100 or less in very severe cases. The blood supply to the skin around the back of the heal where Achilles surgery is performed is poor. If there is an infection or a wound healing problem, then this can lead to breakdown of the wound and loss of overlying skin. Management of this problem in the early and mild cases may merely be with antibiotics but severe cases may require several visits to the operating theatre with tissue reconstruction and plastic surgery.
The rates of wound healing issues are much higher if you smoke, have diabetes, or are immunosuppressed for any reason.
The sural nerve is a small nerve that runs at the back of the ankle and provides sensation to the outer side of your foot. This nerve is at risk during Achilles surgery. Injury may lead to numbness on the side of the foot. This is usually temporary but may rarely be permanent.
Very occasionally the surgical scar can be thickened and bulky or my adhere to the underlying tendon.
Achilles ruptures have a high rate of deep vein thrombosis formation in the calf veins. You will be given blood thinning medications for this. Please read the VTE document here for more information.
This is rarely encountered in patients who have had surgical repair and the rates are higher in those who have not had surgery. Essentially the repair ends either rupture before full healing or heal but in stretched out and elongated position which means that your calf feels weak at push off or unstable during landing.
What about non-surgical repair?
Non-surgical management of Achilles ruptures has gained significant popularity especially in the United Kingdom after good results were reported from a research group from Swansea in Wales. You can read their original scientific paper here.
They popularised a functional treatment strategy whereby the Achilles injury is treated without surgery but in a special boot called the Vacoped (see below) with early weight bearing and functional treatment.
This so called SMART (Swansea Morrison Achilles Rupture Treatment) regime is what I use when treating your Achilles injury whether it is with or without surgery and my version of the treatment is detailed below.
What are the risks of non-surgical repair?
Achilles ruptures have a high rate of deep vein thrombosis formation in the calf veins. You will be given blood thinning medications for this. Please read the VTE document here for more information.
This complication is the main drawback of non-surgical repair. Essentially the repair ends either rupture before full healing or heal but in stretched out and elongated position which means that your calf feels weak at push off or unstable during landing. If this were to occur and you were symptomatic from the dysfunction then surgical management will need to be considered. Occasionally the surgical options may be more complex than a simple primary repair.
Should I have surgery?
This is a question that will be answered according to an individual discussion with you. The information on this website may help you in your decision making.
There are factors regarding the injury itself that may mean surgery will give a better outcome. A rupture in the middle of the tendon or a rupture where the tendon ends have retracted apart either at the outset or because there has been a delay in presentation may be better treated with surgery.
Those tears that are near the muscle end of the calf or those which have a very well apposed ends can be treated non-surgically. Imaging with MRI and/ultrasound is an essential part of the decision making. It is important that these are done in a timely fashion so that any potential surgery result is not compromised.
There are patient factors to consider also. If you are lower demand or have medical problems such as diabetes or immunosuppression or if you are a smoker then the risks of wound problems may outweigh the benefits of surgery. On the other hand, if you are involved in a lot of explosive type activity such as required in sports then surgery may give you a stronger calf.
Be sure to discuss your individual circumstances with me so that a tailored treatment plan can be made for your individual injury.
What is the Achilles rehabilitation programme?
Whether repaired in surgery or being treated without surgery the principles of rehabilitation and the timescale of recovery is similar.
Essentially the aim is to bring the rupture ends of the tendon close together and reduce the tension in the rupture interval by placing the foot in a position where the foot is pointing downwards (equinus position) initially. This position is then gradually reduced towards a foot flat to a right angle (neutral position or zero degrees of plantarflexion). Ability to put your foot down and weight bear on it is gradually increased over the period as well as allowing some calf exercises. In my practice this is done initially in a plaster cast and then converted to the Vacoped boot.
Below is a general guidance. Please note that not all patients will fit exactly into this and variations may be necessary. The boot has a position number which appear in windows on either side of the moving plastic shell, and two locking blocks that are positioned above and below it. These blocks can be unlocked and moved with a special key. During the rehab, the upper lock remains static at its highest position, but the lower lock is sequentially moved down as per the table below so that the windows move to a lower number from 3 to 0. Each step is an additional 10˚ of movement.
| Week | Position of foot in boot/cast | Notes |
| 0-2 | In a cast or back slab with maximum Equinus | Non-weight bearing with crutches |
| 2-5 | Vacoped fitted pos. 3 – locked at 30˚ | Can weight bear with crutches– Wedged sole fitted |
| 5-7 | Vacoped pos. 2 (20˚) allow movement between 30˚-20˚ | Full weight bear – Wedged sole |
| 7-8 | Vacoped pos. 1 (10˚) allow movement between 30˚-10˚ | Full weight bear – flat sole – can start Theraband work |
| 8-9 | Vacoped pos. 0 (0˚) –allow movement between 30˚- 0˚ | Full weight bear – Flat sole – continue Theraband work |
| 9-10 | Vacoped Unlocked fully – full movement beyond neutral | Theraband exercises and full weight bearing in flat sole |
| 10 | Boot off | Outpatient visit |
I will review you in clinic at 2, 5 and 10-week points following the surgery or injury.
Week 2- The Vacoped boot is fitted, and the rehab plan is explained.
Week 5- I will also assess you again at week 5. This is an important point when the sequential unlocking process is beginning, and some ankle motion is then allowed. The condition of the tendon is assessed clinically and with an ultrasound machine if necessary. Physiotherapy referral and supervision my also be planned at this point.
Week 10- This is the final follow up if all is going according to plan then you can progress further with physiotherapy and start low impact exercise (swimming, gentle running etc) from the 12-week mark.
High impact exercises such as football, rugby and any explosive sprinting should be delayed for 6 months and introduced under the supervision of your physiotherapist. If there are any concerns, then I may need to see you at this juncture for a clinical assessment and/or imaging before you start sports.
You can watch several videos from the manufacturer here to help you become familiar with the boot.
