J Korean Foot Ankle Soc.  2019 Sep;23(3):83-90. 10.14193/jkfas.2019.23.3.83.

Current Updates in the Treatment of Achilles Tendon Rupture

  • 1Department of Orthopedic Surgery, Sun General Hospital, Daejeon, Korea. kjb9290@hanmail.net


Achilles tendon rupture is a common sports injury encountered in younger populations. Various treatment methods are used for acute and chronic rupture. Several treatments for each condition are available, each having their advantages and disadvantages. In an acute rupture, surgical treatment may be a priority for younger patients or those wishing a quick return to play, but the long-term functional outcome is similar to non-surgical treatment. In addition, the re-rupture rate shows a slight difference between the two treatments. The clinical outcomes are similar regardless of the surgical treatment, but an accelerated rehabilitation program should be accompanied by good results. In chronic and neglected rupture, surgical treatment is preferred over non-surgical treatment. Treatments are chosen based on the size of the tendon defect. This article reviews the current updates in the treatment of Achilles tendon rupture that will help clinicians choose the appropriate treatment.


Achilles tendon; Rupture; Operations; Therapeutics

MeSH Terms

Achilles Tendon*
Athletic Injuries
Return to Sport


  • Figure 1 The technique of casting for nonsurgical treatment of Achilles tendon rupture. With the patient sitting, the below-knee cast is placed with the foot in gravity equinus.

  • Figure 2 (A) Various suture techniques for repair of ruptured Achilles tendon. Double-suture Bunnell technique. (B) Single-suture Bunnell technique. (C) Double-suture Kessler technique. (D) Single-suture Kessler technique. (E) Double-suture Krackow technique. Data from Clanton et al. (In: Coughlin M, Saltzman C, Anderson RB, editors. Mann's surgery of the foot and ankle. 9th ed. Philadelphia: Saunders Elsevier; 2014. p.1625-40).19)

  • Figure 3 Schematic configurations of the repair. (A) Percutaneous repair of Achilles tendon. (B) Percutaneous repair of Achilles tendon. (C) Percutaneous repair of Achilles tendon. (D) Preparation of the patient for the repair. (E) Postoperative gross photo in the intraoperative field. Data from the article of Guillo et al. (Surgeon. 2013;11:14-9).21)

  • Figure 4 Direct end-to-end repair. (A) Debridement of chronic ruptured Achilles tendon. (B) Sutures are placed between proximal and distal stump of tendon.

  • Figure 5 V-Y tendon advancement or lengthening technique. (A) Debridement of the chronic ruptured Achilles tendon. (B) Obvious defect in Achilles tendon following resection of a nonviable area is measured. (C) Closure of Bunnell sutures, and the proximal segment was sutured by Y-shape.

  • Figure 6 Single turn-down flap technique. (A) Obvious defect in Achilles tendon following resection of a nonviable area. (B) Turn-down flap is marked in midportion of Achilles. (C) Sutures are placed in distal stump of tendon.

  • Figure 7 (A) Flexor hallucis longus (FHL) tendon transfer technique. FHL harvested in distal aspect of incision near fibro-osseous tunnel. (B) FHL tendon is secured with a pull-out suture and passed through a drill hole in calcaneus.


1. Möller A, Astron M, Westlin N. Increasing incidence of Achilles tendon rupture. Acta Orthop Scand. 1996; 67:479–481. DOI: 10.3109/17453679608996672.
2. Maffulli N, Waterston SW, Squair J, Reaper J, Douglas AS. Changing incidence of Achilles tendon rupture in Scotland: a 15-year study. Clin J Sport Med. 1999; 9:157–160. DOI: 10.1097/00042752-199907000-00007.
3. Vosseller JT, Ellis SJ, Levine DS, Kennedy JG, Elliott AJ, Deland JT, et al. Achilles tendon rupture in women. Foot Ankle Int. 2013; 34:49–53. DOI: 10.1177/1071100712460223.
4. Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand. 1996; 67:277–279. DOI: 10.3109/17453679608994688.
5. Guss D, Smith JT, Chiodo CP. Acute Achilles tendon rupture: a critical analysis review. JBJS Rev. 2015; 3:01874474-201504000-00003. DOI: 10.2106/JBJS.RVW.N.00015.
6. Uquillas CA, Guss MS, Ryan DJ, Jazrawi LM, Strauss EJ. Everything Achilles: knowledge update and current concepts in management: AAOS exhibit selection. J Bone Joint Surg Am. 2015; 97:1187–1195. DOI: 10.2106/JBJS.O.00002.
7. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012; 94:2136–2143. DOI: 10.2106/JBJS.K.00917.
8. Bergkvist D, Åström I, Josefsson PO, Dahlberg LE. Acute Achilles tendon rupture: a questionnaire follow-up of 487 patients. J Bone Joint Surg Am. 2012; 94:1229–1233. DOI: 10.2106/JBJS.J.01601.
9. Steginsky BD, Van Dyke B, Berlet GC. The missed Achilles tear: now what? Foot Ankle Clin. 2017; 22:715–734. DOI: 10.1016/j.fcl.2017.07.004.
10. Fruensgaard S, Helmig P, Riis J, Stovring JO. Conservative treatment for acute rupture of the Achilles tendon. Int Orthop. 1992; 16:33–35. DOI: 10.1007/BF00182981.
11. Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture. A review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop Relat Res. 1986; (207):156–163. DOI: 10.1097/00003086-198606000-00029.
12. Blake RL, Ferguson HJ. Achilles tendon rupture. A protocol for conservative management. J Am Podiatr Med Assoc. 1991; 81:486–489. DOI: 10.7547/87507315-81-9-486.
13. Nistor L. Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study. J Bone Joint Surg Am. 1981; 63:394–399. DOI: 10.2106/00004623-198163030-00012.
14. Wang D, Sandlin MI, Cohen JR, Lord EL, Petrigliano FA, SooHoo NF. Operative versus nonoperative treatment of acute Achilles tendon rupture: an analysis of 12,570 patients in a large healthcare database. Foot Ankle Surg. 2015; 21:250–253. DOI: 10.1016/j.fas.2015.01.009.
15. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010; 92:2767–2775. DOI: 10.2106/JBJS.I.01401.
16. Young SW, Patel A, Zhu M, van Dijck S, McNair P, Bevan WP, et al. Weight-bearing in the nonoperative treatment of acute achilles tendon ruptures: a randomized controlled trial. J Bone Joint Surg Am. 2014; 96:1073–1079. DOI: 10.2106/JBJS.M.00248.
17. Kastoft R, Bencke J, Speedtsberg MB, Penny JØ, Barfod K. Early weight-bearing in nonoperative treatment of acute Achilles tendon rupture did not influence mid-term outcome: a blinded, randomised controlled trial. Knee Surg Sports Traumatol Arthrosc. 2019; 27:2781–2788. DOI: 10.1007/s00167-018-5058-4.
18. Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019; 364:k5120. DOI: 10.1136/bmj.k5120.
19. Clanton TO, Waldrop NE 3rd. Athletic injuries to the soft tissues of the foot and ankle. In : Coughlin M, Saltzman C, Anderson RB, editors. Mann's surgery of the foot and ankle. 9th ed. Philadelphia: Saunders Elsevier;2014. p. 1625–1634.
20. Schipper O, Cohen B. The acute injury of the Achilles: surgical options (open treatment, and, minimally invasive surgery). Foot Ankle Clin. 2017; 22:689–714. DOI: 10.1016/j.fcl.2017.07.003.
21. Guillo S, Del Buono A, Dias M, Denaro V, Maffulli N. Percutaneous repair of acute ruptures of the tendo Achillis. Surgeon. 2013; 11:14–19. DOI: 10.1016/j.surge.2011.12.002.
22. Hsu AR, Anderson RB. Mini-open Achilles tendon rupture repair. Tech Foot Ankle Surg. 2017; 16:55–61. DOI: 10.1097/BTF.0000000000000135.
23. Metz R, van der Heijden GJ, Verleisdonk EJ, Kolfschoten N, Verhofstad MH, van der Werken C. Effect of complications after minimally invasive surgical repair of acute achilles tendon ruptures: report on 211 cases. Am J Sports Med. 2011; 39:820–824. DOI: 10.1177/0363546510392012.
24. Hsu AR, Jones CP, Cohen BE, Davis WH, Ellington JK, Anderson RB. Clinical outcomes and complications of percutaneous achilles repair system versus open technique for acute Achilles tendon ruptures. Foot Ankle Int. 2015; 36:1279–1286. DOI: 10.1177/1071100715589632.
25. Clanton TO, Haytmanek CT, Williams BT, Civitarese DM, Turnbull TL, Massey MB, et al. A biomechanical comparison of an open repair and 3 minimally invasive percutaneous Achilles tendon repair techniques during a simulated, progressive rehabilitation protocol. Am J Sports Med. 2015; 43:1957–1964. DOI: 10.1177/0363546515587082.
26. Taşatan E, Emre TY, Demircioğlu DT, Demiralp B, Kırdemir V. Long-term results of mini-open repair technique in the treatment of acute Achilles tendon rupture: a prospective study. J Foot Ankle Surg. 2016; 55:971–975. DOI: 10.1053/j.jfas.2016.04.016.
27. Ververidis AN, Kalifis KG, Touzopoulos P, Drosos GI, Tilkeridis KE, Kazakos KI. Percutaneous repair of the Achilles tendon rupture in athletic population. J Orthop. 2015; 13:57–61. DOI: 10.1016/j.jor.2015.09.004.
28. Ma GW, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop Relat Res. 1977; (128):247–255. DOI: 10.1097/00003086-197710000-00036.
29. Rouvillain JL, Navarre T, Labrada-Blanco O, Garron E, Daoud W. Percutaneous suture of acute Achilles tendon rupture. A study of 60 cases. Acta Orthop Belg. 2010; 76:237–242.
30. Maffulli N, Longo UG, Ronga M, Khanna A, Denaro V. Favorable outcome of percutaneous repair of Achilles tendon ruptures in the elderly. Clin Orthop Relat Res. 2010; 468:1039–1046. DOI: 10.1007/s11999-009-0944-1.
31. Kocaoglu B, Ulku TK, Gereli A, Karahan M, Turkmen M. Evaluation of absorbable and nonabsorbable sutures for repair of achilles tendon rupture with a suture-guiding device. Foot Ankle Int. 2015; 36:691–695. DOI: 10.1177/1071100714568868.
32. Baig MN, Yousaf I, Galbraith JG, Din R. Absorbable Polydioxanone (PDS) suture provides fewer wound complications than polyester (ethibond) suture in acute Tendo-Achilles rupture repair. Ir Med J. 2017; 110:566.
33. Ahmad J, Jones K, Raikin SM. Treatment of chronic Achilles tendon ruptures with large defects. Foot Ankle Spec. 2016; 9:400–408. DOI: 10.1177/1938640016640895.
34. Mao H, Shi Z, Xu D, Liu Z. Neglected Achilles Tendon Rupture Treated with Flexor Hallucis Longus transfer with two turndown gastrocnemius fascia flap and reinforced with plantaris tendon. Acta Orthop Belg. 2015; 81:553–560.
35. Takao M, Ochi M, Naito K, Uchio Y, Matsusaki M, Oae K. Repair of neglected Achilles tendon rupture using gastrocnemius fascial flaps. Arch Orthop Trauma Surg. 2003; 123:471–474. DOI: 10.1007/s00402-002-0443-2.
36. Lin JL. Tendon transfers for Achilles reconstruction. Foot Ankle Clin. 2009; 14:729–744. DOI: 10.1016/j.fcl.2009.08.007.
37. Azar FM. Traumatic disorders. In : Azar FM, Canale ST, Beaty JH, editors. Campbell's operative orthopaedics. 13th ed. Philadelphia: Elsevier;2013. p. 2405–2456.
38. Turco VJ, Spinella AJ. Achilles tendon ruptures--peroneus brevis transfer. Foot Ankle. 1987; 7:253–259. DOI: 10.1177/107110078700700407.
39. Gallant GG, Massie C, Turco VJ. Assessment of eversion and plantar flexion strength after repair of Achilles tendon rupture using peroneus brevis tendon transfer. Am J Orthop (Belle Mead NJ). 1995; 24:257–261.
40. Mann RA, Holmes GB Jr, Seale KS, Collins DN. Chronic rupture of the Achilles tendon: a new technique of repair. J Bone Joint Surg Am. 1991; 73:214–219. DOI: 10.2106/00004623-199173020-00009.
41. Hansen S. Trauma to the heel cord. In : Jahss MH, editor. Disorders of the foot and ankle. Philadelphia: WB Saunders;1991. p. 2355–2360.
42. Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle. 1993; 14:443–449. DOI: 10.1177/107110079301400803.
43. Richardson DR, Willers J, Cohen BE, Davis WH, Jones CP, Anderson RB. Evaluation of the hallux morbidity of single-incision flexor hallucis longus tendon transfer. Foot Ankle Int. 2009; 30:627–630. DOI: 10.3113/FAI.2009.0627.
44. Coull R, Flavin R, Stephens MM. Flexor hallucis longus tendon transfer: evaluation of postoperative morbidity. Foot Ankle Int. 2003; 24:931–934. DOI: 10.1177/107110070302401211.
45. Duhamel P, Mathieu L, Brachet M, Compere S, Rigal S, Bey E. Reconstruction of the Achilles tendon with a composite anterolateral thigh free flap with vascularized fascia lata: a case report. J Bone Joint Surg Am. 2010; 92:2598–2603. DOI: 10.2106/JBJS.I.01578.
46. Lee JW, Yu JC, Shieh SJ, Liu C, Pai JJ. Reconstruction of the Achilles tendon and overlying soft tissue using antero-lateral thigh free flap. Br J Plast Surg. 2000; 53:574–577. DOI: 10.1054/bjps.2000.3407.
47. Maffulli N, Spiezia F, Testa V, Capasso G, Longo UG, Denaro V. Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon. J Bone Joint Surg Am. 2012; 94:906–910. DOI: 10.2106/JBJS.K.00869.
48. Dumbre Patil SS, Dumbre Patil VS, Basa VR, Dombale AB. Semitendinosus tendon autograft for reconstruction of large defects in chronic Achilles tendon ruptures. Foot Ankle Int. 2014; 35:699–705. DOI: 10.1177/1071100714531228.
49. Cienfuegos A, Holgado MI, Díaz del Río JM, González Herranz J, Lara Bullón J. Chronic Achilles rupture reconstructed with Achilles tendon allograft: a case report. J Foot Ankle Surg. 2013; 52:95–98. DOI: 10.1053/j.jfas.2012.06.006.
50. Hanna T, Dripchak P, Childress T. Chronic Achilles rupture repair by allograft with bone block fixation: technique tip. Foot Ankle Int. 2014; 35:168–174. DOI: 10.1177/1071100713514037.
51. Lepow GM, Green JB. Reconstruction of a neglected achilles tendon rupture with an achilles tendon allograft: a case report. J Foot Ankle Surg. 2006; 45:351–355. DOI: 10.1053/j.jfas.2006.06.004.
52. Parsons JR, Weiss AB, Schenk RS, Alexander H, Pavlisko F. Long-term follow-up of achilles tendon repair with an absorbable polymer carbon fiber composite. Foot Ankle. 1989; 9:179–184. DOI: 10.1177/107110078900900406.
53. Ozaki J, Fujiki J, Sugimoto K, Tamai S, Masuhara K. Reconstruction of neglected Achilles tendon rupture with Marlex mesh. Clin Orthop Relat Res. 1989; (238):204–208. DOI: 10.1097/00003086-198901000-00029.
54. Jennings AG, Sefton GK. Chronic rupture of tendo Achillis. Long-term results of operative management using polyester tape. J Bone Joint Surg Br. 2002; 84:361–363. DOI: 10.1302/0301-620X.84B3.0840361.
55. DeVries JG, Scharer BM, Summerhays BJ. Acute Achilles rupture percutaneous repair: approach, materials, techniques. Clin Podiatr Med Surg. 2017; 34:251–262. DOI: 10.1016/j.cpm.2016.10.011.
56. Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weight-bearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med. 2003; 31:692–700. DOI: 10.1177/03635465030310051001.
57. Costa ML, MacMillan K, Halliday D, Chester R, Shepstone L, Robinson AH, et al. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br. 2006; 88:69–77. DOI: 10.1302/0301-620X.88B1.16549.
58. Calder JD, Saxby TS. Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Br J Sports Med. 2005; 39:857–859. DOI: 10.1136/bjsm.2004.017509.
59. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med. 1995; 23:392–395. DOI: 10.1177/036354659502300403.
60. Suchak AA, Bostick GP, Beaupré LA, Durand DC, Jomha NM. The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am. 2008; 90:1876–1883. DOI: 10.2106/JBJS.G.01242.
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