Achilles ruptures are a common pathology that present for care to foot and ankle surgeons. There is debate, however, in terms of what is the best course of action and in what patient population one should use select therapies. Should the rupture be treated with a traditional open incision, mini-open or a non-operative approach? In my practice, I will use all three approaches when treating these injuries and will highlight when and for whom I will choose each treatment option.
I’ll start with discussing non-operative management. I should note that I treat the majority of my patients with acute Achilles ruptures without surgery. Indeed, the literature is filled with studies, including more than 10 randomized control trials on the topic, which show similar outcomes between operative and non-operative management.1 It is important to note is many of these studies show greater complication rates in the operative groups with a slightly higher rate of re-rupture in non-operatively treated patients.1 I feel the risks outweigh any potential benefit in perusing operative management for any patient who I would consider to have high surgical risk based on medical co-morbidities or social history (i.e. diabetes, smoking, etc.). Furthermore, while I try not to generalize, I will seldom recommend operative intervention in patients above 45 to 50 years of age due to lower activity level and functional demands compared to a younger group.
My treatment protocol for non-operative management consists of four weeks in a gravity equinus cast followed by two weeks in a CAM boot with a heel lift, gradually reducing this lift to neutral position. Recent studies suggest that early mobilization may result in a decreased re-rupture rate.2 It is important to emphasize that early mobilization is not the same as no treatment at all and a neglected Achilles rupture in a high-risk patient can even lead to ulceration and ultimate amputation secondary to a calcaneal gait.
Next, I will discuss the mini-open approach for acute Achilles ruptures. This is my second most common treatment for acute ruptures. A question my residents often ask is, “why fix this at all if you advocate for non-operative management so often?” Having an open discussion with the patient in terms of their options is always important. I try to summarize findings in the literature to help them make an informed decision. While I am a proponent of non-operative management, in the younger, more athletic patient with a higher functional demand I will offer them an operative solution. I base this on rates of re-rupture which tend to be higher with non-operative management and the potential for possible weakness in the tendon if treated conservatively. In these patients who elect surgery, I will use a three cm, longitudinal incision just medial to the Achilles, placed between the proximal stump and the delve. I then perform the repair with suture in the proximal stump, anchored into the posterior calcaneus utilizing two anchoring screws. I typically use the PARS Achilles Jig System (Arthrex®) for these cases, but there are several techniques available to achieve the same goal via a mini-open approach. The image shown demonstrates a patient with the mini-open incision versus the traditional open approach.
Lastly, I will use a traditional open approach in patients who are undergoing revisions, have a re-rupture of a previously conservatively-treated rupture, present for surgery greater than two weeks from the date of injury or have a gap greater than four cm. I also have a low threshold for adjunctive procedures for these patients such as flexor hallucis longus (FHL) tendon transfer. In both surgical groups I institute four weeks of non-weightbearing, with passive range of motion exercises starting at two weeks and formal physical therapy and weight bearing starting at four weeks. Return to normal shoe gear takes place at eight weeks postop and I typically advise the patient to avoid dorsiflexion at the ankle past 90 degrees until the 12-week mark if possible.
There is no one-size-fits-all approach in any pathology, and this is particularly true in Achilles injuries. There are scenarios where every option is appropriate and the surgeon needs to discuss options with the patient to arrive at the appropriate decision based on the goals and expectations of both patient and doctor.
Dr. Ali Rahnama is a fellowship-trained foot and ankle surgeon and an Assistant Professor at the Georgetown University School of Medicine in Washington, D.C. You can follow him on Instagram @DrAliRahnama for interesting cases and educational material. Dr. Rahnama discloses that he was previously a consultant for Arthrex.
1. She G, Teng Q, Li J, Zheng X, Chen L, Hou H. Comparing surgical and conservative treatment on achilles tendon rupture: a comprehensive meta-analysis of RCTs. Front Surg. 2021;8:607743.
2. Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon: a prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br. 1992;74(2):206–209.
3. Inglis AE, Scott WN, Sculco TP, Patterson AH. Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment. J Bone Joint Surg Am. 1976;58(7):990-993.