Why surgery isn't (usually) required after an Achilles tendon tear (backed by science)
Treatment Outcomes per 100 Patients
Surgical Treatment
Non-Surgical Treatment
When it comes to treating an Achilles tendon rupture, there are several options available, including rest, physical therapy, and surgery. However, when it comes to determining whether surgery is necessary for an Achilles rupture, there are a few key factors that must be considered.
One of the most important factors in the healing of a tendon is the proximity of the torn ends. Tendons, like bones, heal well in the right conditions, and for the Achilles tendon, it is believed that healing is optimal when the two torn ends are close together. This can usually be achieved by putting the foot into a tip-toe position and keeping it there with a plaster cast or boot.
However, if the ends of the tendon do not come together well, leaving a gap, surgery may be an option. In these cases, an ultrasound scan is typically used to determine the presence of a gap between the torn ends of the tendon. If a gap is present, the operation is performed to bring the ends together and ensure optimal healing.
It is important to note that surgery does not make the tendon strong. Regardless of whether surgery is performed or not, the same long recovery period is required to regain strength and flexibility in the affected area. During this time, individuals may need to wear a cast or boot and participate in physical therapy to help the tendon heal properly.
The Risks of Surgery
While surgery has traditionally been considered a standard treatment for Achilles tendon ruptures, it comes with several significant risks that patients should be aware of:
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Infection: Any surgical procedure carries a risk of infection. In the case of Achilles tendon surgery, infection rates are reported to be between 2-4% of cases.
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Wound healing problems: The skin over the Achilles tendon has relatively poor blood supply, which can lead to complications in wound healing. Some patients experience delayed healing or wound breakdown.
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Nerve damage: The sural nerve runs close to the surgical site and can be injured during the procedure, potentially leading to numbness or tingling in parts of the foot.
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Deep vein thrombosis: Despite blood thinners, surgery increases the risk of blood clots forming in the leg.
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Scar tissue: Surgery inevitably results in scar tissue formation, which can cause long-term stiffness or discomfort.
The Alternatives to Surgery
Modern research has shown that non-surgical treatment can be just as effective as surgery for many patients. The key alternatives include:
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Conservative management: Using a boot or cast to immobilize the ankle in a plantarflexed (toes-down) position.
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Early functional rehabilitation: Starting controlled movement exercises earlier in the recovery process.
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Progressive loading: Gradually increasing weight-bearing activities under professional supervision.
Recent studies have shown that these non-surgical approaches can achieve similar outcomes to surgery in terms of:
- Tendon healing
- Return to normal activities
- Risk of re-rupture
- Long-term strength and function
How to Treat a Rupture Without Surgery
The non-surgical treatment protocol typically follows these steps:
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Immediate care: The ankle is positioned in plantarflexion (toes pointing downward) as soon as possible after injury.
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Immobilization: A cast or boot is applied with the foot in the optimal healing position.
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Protection phase: The first 2-3 weeks focus on protecting the tendon while allowing initial healing.
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Early movement: Controlled exercises begin around week 4, while maintaining the protective boot.
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Progressive loading: Gradually increasing weight-bearing activities starting around week 6-8.
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Rehabilitation: Structured physical therapy program beginning around week 8-10.
Success with non-surgical treatment depends on:
- Early intervention
- Strict adherence to the treatment protocol
- Regular monitoring by healthcare professionals
- Patient commitment to the rehabilitation process
Rule #1 is toes down 24/7
It is important for patients to understand that every step in the recovery journey is crucial to avoid any setbacks, and one of the most important steps is keeping your toes down at all times.
Keeping your toes down, also known as plantarflexion, helps to maintain the optimal healing position for the torn ends of the tendon to come together. This is because the downward position of the foot places tension on the tendon and helps to promote healing. By avoiding dorsiflexion, or upward movement of the foot, you reduce the risk of re-rupture and ensure that the tendon has the best chance to heal properly.
Have you got enough blood thinners?
An Achilles rupture is a serious injury that requires a proper recovery plan to ensure optimal outcomes. One of the key components of the recovery process is blood-thinning treatment, which helps to prevent the development of blockages in the leg veins. This is a relatively high-risk injury, and the use of blood-thinners is often recommended to reduce this risk.
There are two main options for blood-thinning treatment – injections or tablets. Different hospitals have different policies regarding which option is best, so it is important to discuss your options with your specialist. Additionally, there is no clear consensus on the best duration for taking blood-thinners. Some Foot and Ankle Surgeons recommend taking them for 6 weeks after an Achilles rupture, similar to the duration recommended for hip or knee operations.
If you have not been given any blood-thinners, taking 150mg of Aspirin a day is a good interim measure until you can discuss the issue with your specialist. However, it is important to keep in mind that even with blood-thinners, it is still possible (though very rare) to develop a thrombosis or blocked vein. If you experience swelling of your whole leg up to the knee, even if it is painless, it is important to seek medical attention promptly.
When to stop using crutches
Using crutches after an Achilles rupture is a common form of support during the initial stages of recovery. However, after about 4 weeks, it’s important to start weaning off crutches and transition to weight-bearing exercises. This is because relying on crutches for too long can lead to muscle imbalances, decreased mobility, and even further injury. Additionally, using crutches can also put excessive strain on your upper body, causing discomfort and pain in your arms, hands, and shoulders.
At 4 weeks post-injury, most patients have made significant progress in their healing journey and are ready to start gradually putting more weight on their foot. This can be achieved through physical therapy and progressive weight-bearing exercises, which help to strengthen the muscles in your ankle and improve stability. It’s important to follow the guidelines provided by your doctor and physical therapist, as everyone’s recovery timeline is different.
As you progress, you should notice a gradual improvement in your mobility and an increased ability to perform everyday activities without relying on crutches. The ultimate goal is to regain full weight-bearing and normal walking patterns, allowing you to return to your pre-injury activities without restriction. In conclusion, while crutches are a useful tool in the early stages of Achilles rupture recovery, they should not be relied upon indefinitely. Stopping crutch use after 4 weeks is a crucial step in your journey towards a full recovery.
Lowering the boot angle
Recovering from an Achilles rupture can be a long and challenging process, but one small milestone that can bring a great sense of satisfaction is the gradual lowering of the ankle angle in your recovery boot. This adjustment is a sign that your Achilles tendon is healing and regaining its strength, allowing you to gradually bear more weight and put more pressure on your foot. It’s a gradual process that often happens in stages, but each step forward is a step closer to a full recovery. As you make these adjustments, you’ll start to feel more confident in your ability to walk, run, and enjoy your favourite activities again. Whether it’s the first time you’re able to walk without crutches or the moment you’re finally able to wear shoes instead of a cast, each small adjustment is a victory worth celebrating. The journey to a full recovery from an Achilles rupture may be long, but each small success along the way is a reminder of how far you’ve come and how much further you can go.
As your heel comes down there may be tightness – all to be expected
As you begin to regain strength and mobility in your heel and calf, it is common to experience tightness in the affected area. This is a sign that your muscles and tendons are adjusting to the new normal, and it is all to be expected as part of the healing process.
One of the key things you can do to manage this tightness is to keep up with your physical therapy exercises. Stretching, strengthening, and mobility exercises are essential for helping your heel and calf return to their full range of motion. Additionally, you may want to consider massaging the area or using a foam roller to help increase blood flow and reduce tightness.
It’s also important to keep in mind that healing from an Achilles rupture takes time, so be patient and give your body the time it needs to fully recover. If you experience any unusual pain or swelling, don’t hesitate to contact your healthcare provider. With the right care and attention, you can regain full function in your heel and calf and get back to your regular activities as soon as possible.
In conclusion, it’s normal to experience tightness in your heel and calf after an Achilles rupture, but don’t let that discourage you. With consistent physical therapy, patience, and persistence, you will be able to overcome this setback and return to the activities you love.
Get your physio booked
After suffering from an Achilles rupture, it is important to start your rehabilitation process in order to regain full strength and mobility in your leg. The physiotherapy team generally starts working with patients 9-10 weeks after the injury. This timeline allows for the initial healing process to take place, and for the patient to start building up strength in their calf muscles.
To achieve the goal of building calf muscle strength, a specific rehabilitation protocol is used by the physiotherapy team. This protocol involves lots of exercises to be done in between visits to the physiotherapist. However, it is crucial to not do vigorous stretches, even if the tendon feels tight, as it can result in long term loss of power in the leg. With time and normal activity, any tightness should gradually resolve.
Therefore, we encourage all Achilles rupture patients to book their physiotherapy appointments after week 10. This will ensure that they are able to start the rehabilitation process and work towards regaining full strength and mobility in their leg.
Sitting Tip-Toe Exercises
As an Achilles tendon tear patient, it is important to perform specific exercises to help with your recovery. One such exercise is the sitting tip-toe exercise. This exercise is designed to help improve calf strength and promote healing of the torn tendon. To perform the exercise, simply sit with your affected leg extended in front of you and your heel on the ground. Then, lift your heel up towards your toes and hold for a count of 10 seconds. Repeat this exercise several times a day, gradually increasing the number of repetitions as you get stronger. It is important to listen to your body and not push too hard, as overdoing it can set back your progress. However, with consistency and dedication, the sitting tip-toe exercise can be a valuable tool in your recovery journey.
Choosing your shoes after completing your time in an orthopaedic boot
After successfully recovering from an Achilles tendon tear, it is important to choose the right shoe to ensure proper healing and prevent future injuries. The first and most crucial factor to consider is the height of the heel. A shoe with a high and stable heel can help alleviate any discomfort and provide proper support to the affected area. This will also aid in the proper alignment of your foot and prevent any further stress to the tendon.
The stability of the heel is also a critical factor to consider when selecting a shoe after an Achilles rupture recovery. The shoe should provide adequate support to the heel and ankle, so you can maintain proper balance and stability. This will help reduce the risk of re-injury and ensure that your foot is protected at all times. It is recommended to seek the advice of a podiatrist or physical therapist to help you select the best shoe for your specific needs. They will be able to assess your foot and provide you with guidance on the best shoe for your unique circumstances.
If you made it to this stage – the hard work is mainly done. However, please take it easy – there are still snakes on the board.
A last reminder before you go please keep your TOES DOWN AT ALL TIMES – DAY AND NIGHT – 24/7