Achilles Tendon Ruptures: Nonsurgical Versus Surgical Treatment

Achilles tendon ruptures are increasingly prevalent among active adults, requiring careful treatment selection between surgical repair (open or minimally invasive) and nonsurgical management. Surgical treatment reduces rerupture rates (2.3% vs 3.9% with nonsurgical management) and enables a faster return to work (19 days earlier on average) but carries risks such as wound infections (open 6% vs minimally invasive 0.4%), nerve injuries (open 2.8% vs minimally invasive 5.2%), and deep vein thrombosis (1%). Minimally invasive approaches match open repair outcomes with fewer superficial infections (0.4% vs 6%) but higher sural nerve injury risk (3.4% vs 0%). Meta-analyses confirm that surgery significantly reduces rerupture risk (relative risk, 0.43; 95% confidence interval, 0.31-0.60) but increases complication rates (relative risk, 2.76; 95% confidence interval, 1.84-4.13). Nonsurgical management and early weightbearing protocols have demonstrated comparable functional outcomes compared to surgery in selected patients. The UKSTAR trial (n = 527) validated functional bracing as an effective alternative to plaster casting, with no significant differences in Achilles Tendon Rupture Scores or rerupture rates. Although not significant, cost-effectiveness analysis shows surgical management is costlier overall but lowers indirect costs, likely attributable to faster recovery and return to work. Rehabilitation, particularly early mobilization, is critical for optimizing outcomes in both surgical and nonsurgical groups, with surgical patients demonstrating faster strength recovery (18% greater at 18 months). Modern strategies emphasize patient-centered care, recommending surgery for younger, high-demand patients and nonsurgical options for those with lower functional requirements or comorbidities. Shared decision-making remains essential to aligning treatment with individual patient goals and improving satisfaction.