Achilles Tendon Repair

Indication. An acute Achilles tendon rupture in an active patient who, after shared decision-making and counselling, elects surgical repair to minimise re-rupture risk and maximise strength and speed of return. The diagnosis is clinical — a positive Thompson test with a palpable gap 4–6cm proximal to the calcaneal insertion — and imaging is reserved for equivocal cases or chronic rupture (ultrasound is dynamic and cheap; MRI is the gold standard for gap size, tendon-end quality, and chronic change). Operative vs non-operative — the one decision. With modern accelerated functional rehabilitation, the re-rupture difference between surgery and non-operative care is small and the trade-off is the complication profile. The high-level evidence consistently shows:

Consent specifically for re-rupture (5–10 percent), wound breakdown or infection (5–10 percent), sural nerve injury with lateral foot numbness or a painful neuroma (10–15 percent), DVT/PE (1–5 percent), possible over-lengthening with a weak push-off, and the small residual strength deficit that often persists. Setup. Prone with the feet hanging free over the end of the table (allows intraoperative ankle motion and tension testing); chest rolls and padding of all pressure points. Thigh tourniquet at 350mmHg. Exsanguinate by elevation rather than Esmarch, which displaces the tendon ends and haematoma and makes identification harder. General or regional anaesthesia.

The goal: expose the rupture through a posteromedial longitudinal incision that protects the sural nerve, raise full-thickness flaps down to paratenon, freshen the tendon ends minimally, reapproximate them with a strong Krackow core suture reinforced by an epitendinous running suture, and close paratenon over the repair — then protect it with an accelerated functional rehabilitation protocol. The exposure is laid out in full as the first steps below.

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Accelerated functional rehabilitation | Phase | Timing | Protection | Activity | |-------|--------|------------|----------| | 1 | 0–2 weeks | CAM boot with 3 heel wedges (about 20 degrees plantarflexion); sutures out at 2–3 weeks | Weight-bearing as tolerated; ankle pumps | | 2 | 2–4 weeks | Remove 1 wedge (about 10 degrees plantarflexion) | Gentle ROM, no resistance; continue weight-bearing | | 3 | 4–6 weeks | Remove final wedge to neutral | Progressive ROM; begin isometric strengthening | | 4 | 6–12 weeks | Wean boot to a shoe with a heel lift | Progressive strengthening and proprioception | | 5 | 3–6 months | — | Running progression and sport-specific training | | 6 | 6–9 months | — | Return to sport, gated by functional testing | Return to sport is decided by function, not the calendar: a single-leg calf raise of 20 or more repetitions equal to the contralateral side, hop testing at 80 percent or more of the contralateral distance, and isokinetic strength at 90 percent or more. Add thromboprophylaxis (LMWH or aspirin) for 6 weeks. Expect a 6–12 month plateau and a residual calf-strength deficit of 5–15 percent at a year, improving to less than 5 percent by two years; about 80–90 percent return to their pre-injury sport. Lifetime re-rupture risk is about 2–5 percent, with most re-ruptures occurring at 6–12 weeks from premature loading. Complications

Epidemiology. The incidence of Achilles tendon rupture is rising worldwide, commonly reported at about 18–40 per 100,000 population annually in high-income settings, driven by greater recreational sport participation and an ageing active population. Peak age is 30–50 years (the classic weekend warrior), with a male predominance of about 4–5:1. Typical mechanisms are sudden eccentric loading — push-off, jumping, sprinting — in basketball, racquet sports, football, and recreational running. Recognised risk factors are fluoroquinolone antibiotics (boxed warnings from both US FDA and European EMA), corticosteroid use (systemic or local peritendinous), inflammatory arthropathy and metabolic disease (diabetes, obesity), pre-existing Achilles tendinopathy, and poor training progression. Anatomy and blood supply. The Achilles is the largest and strongest tendon in the body — about 15cm long from the gastrocnemius–soleus junction to the calcaneus, 5–6cm wide proximally narrowing to 2–3cm, and 5–7mm thick. Gastrocnemius fibres spiral 90 degrees to insert posterolaterally on the calcaneus. Blood supply comes from the musculotendinous junction proximally, periosteal vessels from the calcaneus distally, and the paratenon throughout (which provides about 25–30 percent of the supply — preserve it). The watershed zone, 2–6cm proximal to the insertion, has the poorest blood supply and is where about 90 percent of ruptures occur. Classification. Ruptures are classified by timing, by the anatomic gap (measured with the ankle at 90 degrees and the knee extended), and by tissue quality — each guiding whether primary repair alone suffices or augmentation is required.

Guidelines and global practice. Modern guidance has converged on accelerated functional rehabilitation for both pathways, with re-rupture differences that are statistically small and a complication burden weighted toward surgery.