Surgical versus functional conservative treatment of acute Achilles tendon rupture

INTRODUCTION

Acute Achilles tendon rupture is the most frequent rupture of a lower limb tendon in adults, and the population-based evidence shows that its incidence has not stopped increasing. A nationwide Swedish register of 53,688 ruptures recorded between 2002 and 2021 documented sustained growth in incidence together with a steady decline in the proportion managed surgically and a prolonged delay to surgery, while United States emergency department data covering 2012 to 2016 estimated more than 350,000 injuries across the period.(1,2) Parallel increases have been reported in South Korea, Italy and Japan, and more recent United States figures confirm that the trend continued between 2019 and 2024, which marks the injury as a growing burden on active and aging populations.(3-6) The incidence rises most steeply in middle-aged recreational athletes, and re-rupture itself is concentrated in men, in younger patients and in those managed with traditional immobilizing rehabilitation, three features that matter for how the treatment decision is framed.(7) National registers in Scandinavia and Italy show the same demographic gradient, with surgery increasingly reserved for younger patients while older adults are managed conservatively, a shift that reflects both the epidemiology and the evolving preference for less invasive care.(1,4)

The rupture classically occurs during sudden forced dorsiflexion of a plantar-flexed ankle, often in racket or ball sports, and it compromises plantarflexion strength, walking tolerance and the capacity to return to previous activity for many months after the injury.(2) Although the diagnosis is usually clinical, ultrasound is increasingly used to measure the tendon gap and to guide whether a rupture qualifies for nonoperative care, a practice that the individualized treatment algorithm of the Copenhagen trial has formalized.(8) Because the tendon heals with elongation and thickening regardless of treatment, patients frequently retain a measurable deficit in strength and high-impact function even when their symptoms improve, and the morphology of the healed tendon diverges from the uninjured side.(9,10) Prospective imaging shows that the ruptured tendon lengthens and thickens in both operated and conservatively managed patients, while the gastrocnemius atrophies and angle-specific plantarflexor torque remains reduced, which explains why patient-reported scores and performance measures do not always move together.(9,11) The injury therefore carries consequences that extend well beyond the acute episode, and the treatment choice has to account for both the early risk of failure and this longer horizon of incomplete recovery. The economic burden runs in parallel: operative care costs more in the months after the injury and this difference only dissipates years later, while the functional and reoperation outcomes that would justify the higher initial cost do not materialize.( 12) Against this background the persistence of wide variation in practice, with surgical rates declining in Scandinavia but remaining stable in the United States, reflects genuine uncertainty rather than the absence of evidence.( 1,13)

For decades the management debate opposed open surgical suture against cast immobilization. Surgical repair was favored because it restored tendon apposition and appeared to reduce the re-rupture rate, whereas conservative care avoided wound and nerve problems at the cost of a higher failure rate.( 14) The trials that established this trade-off largely treated the conservative arm with several weeks of rigid cast, and it is precisely in that comparison that surgery earned its re-rupture advantage. That balance began to shift when early functional rehabilitation, defined as immediate or early weight bearing with controlled ankle motion inside a brace or orthosis, was introduced for both strategies.(15) A blinded randomized comparison showed that early weight bearing within nonoperative treatment did not alter the midterm outcome, which supported the safety of functional loading after the rupture.(16) When both groups receive the same functional aftercare, the gap in re-rupture between surgery and conservative treatment narrows, and several modern randomized trials have reported equivalent functional scores at one year.(17,18) Rehabilitation after operative treatment has itself been systematized, which removes part of the historical advantage attributed to surgery and makes the aftercare protocol at least as important as the index decision.(19) The older randomized trials that established the re-rupture benefit of surgery, from Canada, Sweden and the United Kingdom, all compared repair against prolonged cast immobilization, and their conservative arms would now be considered outdated; this single difference in the comparator explains much of the apparent drift in the evidence across decades.(14)

Existing syntheses still disagree on the net effect of surgery, and the disagreement extends beyond statistics. Some meta-analyses concluded that operative treatment lowers re-rupture while preserving comparable function, whereas others, restricted to trials that applied early functional rehabilitation, found no meaningful difference and drew attention to the added surgical complications.(20-22) A further meta-analysis of randomized trials and a long-term synthesis of muscular performance reached the same guarded conclusion, that surgery offers a modest re-rupture advantage without a functional gain.(23-25) Fragility analyses add another caveat: many of the statistically significant differences in favor of surgery can be overturned by very few additional events, which weakens the confidence that should be placed in those pooled estimates.(26) Return to sport, the outcome that matters most to active patients, is reported inconsistently and appears incomplete in both strategies, which leaves clinicians without a clear benchmark.(27) The disagreement persists because the reviews pooled different conservative protocols, mixed immobilization with functional treatment, and included few of the recent randomized and registry-based comparisons published between 2018 and 2026.(28)

The objective of this systematic review is to synthesize the evidence on re-rupture, functional recovery and complications after surgical repair versus functional conservative treatment of acute Achilles tendon rupture in adults, and to organize that evidence into a treatment decision framework. The review is deliberately narrow in scope: it does not adjudicate between surgical techniques, nor does it assess biological augmentation, but it offers a current answer to the single question that a patient with a fresh rupture actually asks. The review question follows the PICO format: in adults with acute Achilles tendon rupture, does surgical repair reduce re-rupture and improve function compared with functional conservative treatment?

METHODS

Study design and eligibility criteria

A systematic review was undertaken following the PRISMA 2020 reporting framework.(29) The review focused on comparative evidence concerning the management of acute Achilles tendon rupture in adults. Eligible investigations included randomized controlled trials and prospective or retrospective comparative cohort studies evaluating operative treatment, including open, minimally invasive and percutaneous repair, against nonoperative approaches involving cast immobilization or functional rehabilitation. The assessment covered tendon re-rupture, functional recovery measured through patient-reported or performance-based outcomes, treatment-related complications and return to activity.

Studies addressing chronic or neglected injuries, insertional tendinopathy, recurrent ruptures or biological augmentation were not eligible. Animal and cadaveric investigations, review articles, study protocols and clinical series without a comparison group were also excluded. The review was limited to English-language publications issued between 2018 and 2026, consistent with the bibliographic period established by the target journal.

Information sources and search strategy

The literature search incorporated Scopus, PubMed, OpenAlex and Crossref, with Scopus serving as the principal database for the structured retrieval process. Its field-specific search functionality allowed the use of predefined combinations of terms, while the other three sources provided supplementary bibliographic coverage.

Five primary searches were performed in Scopus, applying the publication-year restriction PUBYEAR > 2017 AND PUBYEAR < 2027. The main search expression was TITLE-ABS-KEY("Achilles tendon rupture" AND (surgical OR surgery OR operative OR repair) AND (conservative OR nonoperative OR non-surgical OR functional)). Additional searches examined functional treatment, re-rupture in relation to treatment, randomized study designs, and minimally invasive or percutaneous procedures. Four complementary searches addressed epidemiological characteristics, return to sport, rehabilitation protocols and complications.

In accordance with PRISMA-S recommendations, the complete syntax, execution date and retrieval count were documented for each primary Scopus search. Across the four sources, 973 records were identified, comprising 590 from Scopus, 183 from PubMed, 100 from OpenAlex and 100 from Crossref. Removal of duplicate entries reduced the dataset to 572 unique records for screening. All databases were accessible and returned results without search failures. A common final search date was established across the sources to define a consistent temporal reference for the review. The sequential search process prioritized Scopus-indexed literature while extending retrieval to potentially relevant records available through the supplementary sources.

Data extraction and outcome measures

Study-level information was collected directly from the original reports, preserving the values provided by the investigators. Extracted variables included re-rupture rates, functional assessment scores and complication counts. Each entry was linked to the corresponding section of its source document, and information not explicitly reported was left uncompleted rather than inferred.

Functional recovery was assessed using the instruments available in the included studies. These principally comprised the Achilles tendon Total Rupture Score (ATRS), a ten-item patient-reported measure specifically developed for Achilles tendon injuries and supported by evidence of responsiveness in validated translations, together with the PROMIS measures of physical function and pain interference.(30-32) When reported, objective functional assessments were also collected, including heel-rise performance, dynamometric strength measurements and hop or jump testing.

RESULTS

Consistency across designs

The seventh component examines whether the randomized and observational evidence point in the same direction, since agreement across study designs is itself a meaningful form of corroboration. The randomized trials and the propensity-matched registry agree that surgery does not improve function and that its benefit is confined to a lower failure rate, and they agree that surgery adds a measurable complication excess.(8,13,17) The smaller comparative cohorts diverge in magnitude, reporting larger surgical advantages in function and return to activity, but those estimates are the ones most exposed to confounding by indication, in which younger and higher-demand patients are selected for surgery.(36,38) The consistency across the strongest designs therefore reinforces the framework, while the divergence of the weakest designs illustrates why their estimates should not drive the decision.

Study	Country	Design	Sample	Surgical arm	Conservative arm	Follow-up
Myhrvold 2022(17)	Norway	RCT, 3 arms	554	Open repair; MIS	Functional, early weight bearing	12 months
Fischer 2021(35)	Germany	RCT, 3 arms	90	Open suture; MIS	Conservative, same aftercare	24 months
Toft (CARTA) 2026(8)	Denmark	RCT, 3 arms	300	Operative; individualized CARTA	Nonoperative	12 months
Channareddy 2021(18)	India	RCT	30	Surgical, functional rehab	Non-surgical, functional rehab	12 months
Crook 2023(13)	United States	Propensity matched registry	17,996	Operative	Nonoperative	up to 5 years
Burger 2025(36)	United States	Prospective comparative	216	Surgical repair	Functional nonoperative	final follow-up
Ge 2023(37)	United States	Retrospective cohort	103	Operative	Nonoperative	midterm
Ilyas 2023(38)	Pakistan	Prospective comparative	86	Surgical repair	Immobilization + functional rehab	6 months
Agrawal 2024(39)	India	Comparative	20	Open repair	Conservative	12 months
Kosiol 2022(10)	Austria	Retrospective pilot	18	Operative	Conservative, functional	26 months
Zhu 2024(9)	Canada	Retrospective cohort	24	Operative	Nonoperative	minimum 20 months
Braccagni 2021(11)	France	Prospective series	30	Surgical	Nonoperative	24 months

Note: RCT = randomized controlled trial; ATRS = Achilles tendon Total Rupture Score; PROMIS = Patient-Reported Outcomes Measurement Information System; AOFAS = American Orthopaedic Foot and Ankle Society score; MIS = minimally invasive surgery.

Component	Surgical repair	Functional conservative treatment	Supporting studies
Re-rupture	0.6% to 3%	up to 11% to 13%	Myhrvold 2022; Toft 2026; Ilyas 2023
Function (ATRS, PROMIS)	comparable scores	comparable scores	Myhrvold 2022; Channareddy 2021; Ge 2023
Complications	wound and sural nerve	re-rupture and thromboembolism	Myhrvold 2022; Crook 2023; Ilyas 2023
Return to activity	faster in one series	slower in one series	Ilyas 2023; Zhu 2024
Decision	individualized by demand and gap	valid default	Crook 2023; Myhrvold 2022

Note: Estimates are representative values extracted from the included studies and are not pooled. ATRS = Achilles tendon Total Rupture Score; PROMIS = Patient-Reported Outcomes Measurement Information System.

DISCUSSION

The objective of this review was to establish whether surgical repair reduces re-rupture and improves function relative to functional conservative treatment, and the evidence answers the two parts of that question separately. Re-rupture is consistently lower after surgery, with rates of 0.6% to 3% against 9.5% to 13% in the conservative arms that did not use early functional rehabilitation, but the randomized trials that applied functional aftercare to both groups found no difference in function and a substantially narrower re-rupture gap. The principal finding is therefore that surgery buys a lower re-rupture risk without a measurable gain in function, and it pays for that reduction with wound and nerve complications. Expressed in the terms a clinician needs at the bedside, the functional aftercare protocols reduced the surgical re-rupture advantage to a difference of just over five percentage points in the largest trial, which means that roughly one re-rupture is prevented for every eighteen or so patients operated on, a modest yield against the complication excess that the same trial documented.(17) The two halves of the PICO question therefore receive different answers, and treating the question as if it had a single answer is the main error that the decision framework is designed to prevent.

This conclusion agrees with the direction of the older literature while qualifying its magnitude. The landmark meta-analysis by Ochen and colleagues found a lower re-rupture rate after operative treatment and comparable functional scores, but the advantage was driven largely by trials that immobilized conservative patients in casts rather than treating them functionally.(14) More recent syntheses restricted to early functional rehabilitation reach the same endpoint, reporting no meaningful difference in function and a residual re-rupture advantage for surgery that fragility analysis shows can be overturned by very few events.(20-22,26) The discrepancy with reviews that still favor surgery is explained by the conservative comparator: studies using immobilization inflate the conservative re-rupture rate, whereas functional protocols close most of the gap, as the rehabilitation cohorts from Scandinavia also suggest.(15,16,19) A network meta-analysis of the randomized evidence reached the same reading, finding that the benefit attributed to surgery depends on which comparator sits in the conservative arm.(28) The included randomized trials reproduce exactly this contrast, since the Norwegian and Copenhagen trials, which used functional conservative care, reported re-rupture gaps far narrower than the immobilized cohorts reported in the Pakistani and Indian series.(8,17,38,39)

The complication profile provides the strongest argument for individualization rather than a default operation. Registry and database comparisons show that operative treatment adds complications within the first month and higher early cost that dissipates by five years, and the wound and sural nerve problems reported across the included series are absent from functional conservative care.(13,40,41) The conservative arm carries its own risks, however, principally re-rupture and the venous thromboembolism associated with lower-leg immobilization, so the trade-off is between different adverse events rather than between risk and safety.(7,42) Return to sport, the outcome most valued by active patients, is incomplete in both strategies and appears to depend more on the quality of rehabilitation than on the initial treatment decision, which further weakens the case for a routine operation.(27) The plausible mechanism behind the functional convergence is that tendon elongation and muscle atrophy develop in both arms and drive the residual strength deficit, while the surgical advantage operates only on the rare event of re-rupture, an explanation consistent with the imaging cohorts that documented elongation in operated and conservatively managed tendons alike.(9,10,25)

The findings also explain the observed drift in practice across health systems. Scandinavian registers show a sustained decline in the proportion of patients managed surgically over two decades, whereas United States administrative data show surgical rates that barely changed, a divergence that mirrors the difference between a system that adopted functional nonoperative protocols early and one in which surgical repair remained the default.(1,13) For podiatric practice, which sees the injury at first presentation and supervises much of the subsequent rehabilitation, the practical consequence is that the initial consultation should frame the decision around the patient's risk tolerance rather than around a presumed superiority of repair, and the podiatrist is well placed to deliver the functional bracing and loading schedule that the evidence shows to be the operative part of either pathway.(15,19) That division of labor, with the decision individualized and the rehabilitation standardized, is the clearest practical translation of the framework into daily care. It also means that the podiatrist need not choose between being an advocate for surgery or for conservative care, but can instead present both arms honestly with their respective risks, which is exactly what the component structure of this review is intended to make possible.

The synthesis has concrete limits that temper its conclusions. The evidence base is dominated by small comparative cohorts at serious risk of bias, and only four randomized trials could be included, two of them small and two large; the non-randomized studies assign treatment by preference, which confounds age, activity demand and rupture characteristics.(34) Paywalled full texts forced abstract-based extraction for several studies, and the two open-access landmark reports could not be downloaded by automated tools, so some outcome details rest on structured abstracts. The search was restricted to English and to four databases, and grey literature and trial registries were not screened beyond the registration cited in one report. The heterogeneity of conservative protocols, from cast immobilization to immediate weight bearing, prevented a meta-analysis, and the functional outcome instruments differed across studies. The surgical arm was itself heterogeneous, spanning open, minimally invasive and percutaneous techniques whose complication profiles are not identical, and the review treated them as a single category because too few studies separated them. Each of these limits can be overcome: future reviews should pool individual participant data, stratify by the conservative protocol actually delivered and by the surgical technique, and retrieve full texts through institutional access before concluding that the residual re-rupture difference is real.

The review also has strengths that deserve mention. It restricts the comparison to the modern era, in which functional rehabilitation is standard, it includes a large propensity-matched registry alongside the randomized trials, and it reports the searches verbatim so that the synthesis can be reproduced and updated.( 29) The evidence was extracted from primary studies rather than from previous reviews, and each estimate was traced to its source, which limits the risk of propagating pooled figures whose provenance is no longer clear. The decision framework is deliberately modest: rather than recommending one strategy, it maps each component of the trade-off to the evidence that supports it, which is the appropriate response to a question whose answer depends on patient preference.

For clinical practice, the framework supports a shared decision. Surgery remains reasonable for the young high-demand athlete and for ruptures with a large gap or delayed presentation, where apposition and tendon length matter, whereas functional conservative treatment is a defensible default for the typical recreational patient who accepts a slightly higher re-rupture risk to avoid wound and nerve complications.(8,13,17) When surgery is chosen, the technique is not neutral: minimally invasive repair carried the highest nerve injury rate in the Norwegian trial, so the choice of approach should be weighed alongside the decision to operate at all.(17) The economic evidence points in the same direction, since operative care costs more early without a lasting functional or reoperation advantage.(12) Research should now measure long-term tendon elongation and muscle performance in both strategies, because morphology and high-impact function appear to diverge even when patient-reported scores converge.(9,25) Trials should also standardize return-to-sport reporting, since that outcome remains the least documented of the framework and the one most likely to sway active patients. Until such data exist, the clinician can rely on the two components that are well supported, the re-rupture and function estimates from the large randomized trials, and treat the rest of the framework as context for a conversation rather than as measured fact.( 8,17)

CONCLUSIONS

Surgical repair of acute Achilles tendon rupture reduces the risk of re-rupture relative to conservative treatment, with rates from 0.6% to 3% against up to 13% in studies that immobilized the conservative arm, but the randomized trials that applied early functional rehabilitation to both groups found no difference in function and a substantially narrower re-rupture gap.

Functional recovery, measured with the Achilles tendon Total Rupture Score and PROMIS instruments, is comparable between strategies, whereas surgery adds wound, sural nerve and early complication risk. The decision should therefore be individualized within the proposed framework rather than governed by a universal preference for surgery.

References

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