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Achilles tendon repair

114 citationsUpdated Sep 2026

Overview

Achilles tendon rupture treatment remains a subject of clinical controversy, with a large body of evidence addressing both acute and chronic presentations [1]. The tendon’s capacity to heal after division relies on a combination of intrinsic and extrinsic mechanisms [2]. Current data suggests that surgical repair should not be considered the gold standard for every patient, as non-surgical treatment is not inferior to surgery regarding 1-year patient-reported and functional outcomes [6, 14]. Furthermore, the majority of patients have not fully recovered two years after injury regardless of the treatment modality chosen, with only minor improvements observed between 1- and 2-year evaluations [3].

Surgical intervention is associated with specific risks and outcomes. Acute Achilles tendon repair carries a major complication rate of 3% requiring reoperation [13]. All patients undergoing operative repair experience lengthening after surgery [16]. While there appears to be a clinically important difference in the risk of complications between minimally invasive surgical treatment and nonoperative treatment, this difference was not statistically significant [72]. Platelet-rich plasma (PRP) offers no patient benefit in the longer term, and its addition to surgical treatment does not appear to offer superior clinical and functional results [75, 78].

Minimally invasive and percutaneous techniques are increasingly utilized for acute ruptures. These approaches yield essentially identical clinical and functional outcomes with no reruptures or major complications observed at a minimum follow-up of 24 months [7]. Long-term outcomes after minimally invasive repair are excellent [9], and this approach may be considered a more suitable option to achieve overall better outcomes [32]. Endoscopically-assisted percutaneous repair is safe and feasible for acute rupture [23], and percutaneous suturing with endoscopic control offers a reasonable treatment option with a low number of complications [52]. Patients presenting more than 2 weeks after rupture may be successfully treated with minimally invasive repair [5], and those treated by percutaneous repair 14 to 30 days after injury achieve similar results at 1 year as those treated within 14 days [10].

Anatomy & Pathophysiology

Tendon Healing and Histopathology

Ruptured Achilles tendons exhibit histopathological evidence of failed healing in macroscopically intact areas, a feature that distinguishes them from unruptured tendons [21]. These pathological features are significantly more pronounced at the rupture site than in samples taken 4 cm proximal or 1 cm distal to the insertion, although no significant differences exist in mean pathologic sum-scores between proximal and distal samples [21]. In animal models, complete mid-portion rupture leads to remote and time-mismatched changes in uninjured regions [142]. Specifically, foci of mineralization were found in 3/6 of rat Achilles tendons at 8 weeks postinjury, and 5/6 exhibited calcified tendon matrix at 17 weeks [142]. The healing process involves a temporal expression profile where inflammatory response and pro-proliferative genes are significantly upregulated from 24 hours postinjury through to 21 days [138]. Day 7 postinjury shows the largest increase in genetic activity, particularly regarding the expression of collagens and other extracellular matrix genes [138]. Additionally, central nervous system-like glutamate-based signaling machinery is present in tendon cells during healing [138], while nucleostemin- and Oct 3/4-positive stem/progenitor cells exhibit disparate anatomical and temporal expression during rat Achilles tendon healing [80].

Pharmacological interventions yield varied results on healing dynamics. Daily oral administration of doxycycline accelerated matrix remodeling and the dynamic and equilibrium biomechanics of surgically repaired Achilles tendons, with enhancements most evident at 3 to 6 weeks [73]. Rapamycin-mediated inhibition of the mTOR pathway promotes tendon healing in collagenase-induced Achilles tendinopathy, though its impact on biomechanical strength is limited [132]. Conversely, advanced glycation end products impair the repair of injured tendon in rats [134]. Promethazine downregulates Wnt/β-catenin signaling and increases the biomechanical forces of the injured Achilles tendon in the early stage of healing [150]. Autologous platelets have no effect on the healing of human Achilles tendon ruptures [135].

Augmentation techniques influence both speed and quality of repair. The healing process is faster in tendons augmented intratendinously compared to those augmented peritendinously [20]. Intratendinous graft reinforcement results in a healed tendon that is biomechanically more similar to normal tendon and has more graft-tendon orientation histologically than peritendinous augmentation [20].

Biomechanics and Mechanical Properties

Repaired Achilles tendons are characterized by lower material stiffness than the contralateral tendon [19]. This lower material stiffness may underpin greater ankle joint motion and long-term deficits [19]. Even after a long-term healing phase, healed Achilles tendon has inferior elastic properties [45]. At 1 year after surgery, Achilles tendons did not show a 'restitutio ad integrum' from a biomechanical point of view [79]. Tendon structure within the first 12 weeks relates to later walking gait and heel-rise symmetry [22].

Functional deficits persist even in patients who have returned to full activities. Reduced plantar flexor muscle-tendon unit work supports that an elongated tendon and shorter muscle fascicles constrain functional capacity [55]. Reduced and shifted functional ankle range of motion underlies performance deficits after Achilles tendon repair [55]. Disproportionate weakness in end-range plantar flexion is apparent in patients who have returned to full activities after Achilles tendon repair [154]. Decreased passive joint stiffness in dorsiflexion is also apparent in this population [154]. Furthermore, these patients demonstrate an inability to perform a heel rise when initiated from a plantarflexed position [154].

Surgical technique influences biomechanical outcomes. The Bunnell technique demonstrated a significantly higher maximum load than the Kessler technique in cadaver studies under cyclic loading conditions [152]. The typical failure mode of the Bunnell technique shows potential to optimize biomechanical behavior by using stronger suture material [152]. Both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair [33, 141]. The Achillon-like configuration and the modified percutaneous repair of ruptured Achilles tendon provided similar biomechanical performance [130]. The Panda Rope Bridge Technique biomechanically outperformed other minimally invasive Achilles tendon repair techniques in a bovine model [161]. Graft fixation at two different interference screw insertion angles for insertional Achilles tendon reconstruction exhibited equivalent biomechanical performance [162].

Pathophysiology of Rupture and Elongation

Differential elongation of the gastrocnemius tendon can abolish knee-ankle coupling and lead to unrecognized elongation despite apparent tendon approximation [123]. Nonoperative treatment of Achilles tendon ruptures requires immobilization in maximal ankle plantar flexion (60°) to achieve tendon-edge apposition [62]. Immobilization of the knee may not be necessary to achieve tendon-edge apposition in Achilles tendon ruptures [62]. Repair within the first 48 hours in the treatment of acute Achilles tendon ruptures achieves the best biomechanical and histological outcomes [61]. The temporal postinjury healing response of rodent Achilles tendons depends on both surgical treatment and the timing of immobilization or activity [155]. Functional weight-bearing mobilization after Achilles tendon rupture enhances early healing response [68]. Pain, rather than fear of movement, was associated with the high variability in loading parameters after Achilles tendon rupture repair with early functional mobilization [151]. Flexor hallucis longus (FHL) shows early muscle volume recovery after Achilles tendon repair, suggesting it compensates for decreased ankle plantarflexion strength [159].

Classification

Acute Rupture

Acute Achilles tendon rupture is defined as an injury occurring less than 14 days prior to presentation [38]. Clinical diagnosis is confirmed by the presence of two or more of the following signs: decreased strength of ankle plantarflexion, a palpable gap or defect, increased ankle dorsiflexion with gentle manipulation, and a positive Thompson test [29]. There is no difference in strength and clinical outcome between early and late repair after Achilles tendon rupture [5].

Chronic Rupture

Chronic Achilles tendon rupture (CATR) is defined as a complete rupture with a delay in diagnosis or treatment for more than 4–6 weeks [136]. More than 20% of acute Achilles tendon injuries are misdiagnosed, leading to a chronic Achilles tendon rupture [136]. In chronic Achilles tendon rupture, the tendon ends retract and the gap fills with scar [136]. Direct repair of chronic Achilles tendon ruptures using scar tissue located between the tendon stumps obviates the need to use normal autologous tissue [58]. Ipsilateral free semitendinosus tendon graft transfer can be used to reconstruct the Achilles tendon in the presence of a large gap greater than 6 centimetres [48].

Clinical Presentation

Diagnostic Findings

Achilles tendon ruptures commonly occur during sports activities, with most patients presenting between the third and fourth decades of life [29]. In a retrospective multicenter case series of 38 patients aged <25 years, 42% were male and the mean age was 18.9 years (range 10.4–22.8 years) [53].

Pathology and Imaging

Histopathological features in acute Achilles tendon ruptures are significantly more pronounced at the site of rupture than in samples taken 4 cm proximal or 1 cm distal to the insertion [21]. Unruptured Achilles tendons and ruptured Achilles tendons represent two distinct populations, with ruptured tendons demonstrating histopathological evidence of failed healing response even in areas macroscopically intact [21]. Repaired Achilles tendon is characterized by lower material stiffness than the contralateral tendon, which may underpin greater ankle joint motion and long-term deficits [19]. Tendon structure within the first 12 weeks after injury relates to later walking gait and heel-rise symmetry, indicating potential prognostic value for 6-month outcomes [22]. The roles of ultrasonography and magnetic resonance imaging during the healing process after Achilles tendon rupture are limited due to a weak correlation with clinical findings [59]. Ultrasonography is useful to observe the intratendinous morphology of repaired Achilles tendons and to provide information for patients who wish to return to sports [66].

Functional Deficits and Recovery

The majority of patients with an Achilles tendon rupture have not fully recovered 2 years after injury regardless of surgical or non-surgical treatment, with only minor improvements occurring between the 1- and 2-year evaluations [3]. Following Achilles tendon repair, less than 75% of National Football League players returned to the NFL [18]. Reduced plantar flexor muscle-tendon unit work after repair supports that an elongated tendon and shorter muscle fascicles constrain functional capacity, with reduced and shifted functional ankle range of motion underlying performance deficits [55]. In adults with acute Achilles tendon rupture, nonoperative treatment, open repair, and minimally invasive surgery did not differ for health status at 12 months [42].

Complications and Risk Factors

Medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment [36]. The incidence of emergency department visits within 90 days of Achilles tendon repair was 8.4%, with over half of visits occurring in the first 4 weeks postoperatively [60]. Disadvantages of conservative treatment include elongation of the musculotendinous unit and a higher rerupture rate [29]. Open repair has a lower rate of rerupture but has been associated with major wound complications and scar formation [29].

Investigations

MRI: Magnetic resonance imaging has a limited role during the healing process after Achilles tendon rupture due to a weak correlation with clinical findings [59]. Intra-tendon MRI abnormalities are frequent in chronic Achilles tendon rupture but likely represent non-pathologic cicatricial remodeling [127].

Ultrasonography: Ultrasonography is useful for observing the intratendinous morphology of repaired Achilles tendons and providing information for patients wishing to return to sports [66]. High-resolution ultrasound guidance can be used intraoperatively during minimally invasive repair of the Achilles tendon [39].

Other Considerations: Tendon structure within the first 12 weeks relates to later walking gait and heel-rise symmetry, indicating that tendon structure could have prognostic value in patient care [22]. From 19 weeks onwards, radiodensity appears to reflect mechanical properties of the tendon and might to some extent predict the final outcome [144].

Repaired Achilles tendons are characterized by lower material stiffness than the contralateral tendon, which may underpin greater ankle joint motion and long-term deficits [19]. The healed Achilles tendon after rupture has inferior elastic properties even after a long-term healing phase [45]. In the repaired Achilles tendon, there is a decrease in elasticity compared to the non-injured side [70].

Histopathological features are significantly more pronounced in samples taken from the site of rupture than in samples taken proximally and distal to it [21]. There are no significant differences in mean pathologic sum-scores in tendon samples taken proximally and distal to the site of rupture [21]. Unruptured Achilles tendons and ruptured Achilles tendons are part of two distinct populations, with the latter demonstrating histopathological evidence of a failed healing response even in areas that are macroscopically intact [21].

A clinical test exists that is accurate and repeatable for mapping the sural nerve in conjunction with percutaneous Achilles tendon repairs [25].

Treatment

Non-Operative

Non-surgical treatment of Achilles tendon ruptures is not inferior to surgery regarding 1-year patient-reported and functional outcomes [14]. The results of nonoperative orthotic treatment were better overall than published results of operative repair of acute Achilles tendon rupture [115]. Early weight-bearing did not influence outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture [64].

Operative

Indications: Open surgical repair of acute Achilles tendon ruptures significantly reduces the risk of reruptures when compared with nonoperative management [65]. The statistical nonsignificance of studies reporting equivalent rerupture rates in the management of acute Achilles tendon ruptures with open repair versus nonoperative management with early functional rehabilitation can be reversed by changing the outcome status of only a few patients [116].

Surgical Approach / Technique: Percutaneous and minimally invasive techniques of repair of the Achilles tendon yielded essentially identical clinical and functional outcomes with no reruptures or major complications observed at a minimum follow-up of 24 months [7]. These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision-making process [57]. The results of the study support the choice of (modified) percutaneous suturing under local anesthesia as the method that brings comparable functional results to open repair, with a significantly lower rate of complications [148]. This technique allows a strong percutaneous repair of the Achilles tendon with visualisation of the apposed tendon ends, allows early weight bearing, and minimises risk of sural nerve damage [27]. This technique is safe and feasible for treatment patients with acute rupture of Achilles tendon [23]. The proposed method offers a reasonable treatment option for acute total Achilles tendon rupture with a low number of complications [52]. The procedure is simple and promotes natural repair of the ruptured Achilles tendon by bridging the intact proximal tendon and calcaneus with high-strength sutures and knotless anchors, reducing complications [49]. This new and minimally invasive technique could be an alternative in the management of acute Achilles tendon rupture [51]. It might be a reliable option for Achilles tendon repair [15]. The results of surgical treatment for ruptured Achilles tendon are good overall [35]. It is hoped that our technique will improve the functional outcome of those patients with acute Achilles tendon rupture [12]. Minimally invasive Achilles repair provides an opportunity for early rehabilitation [17].

Implant Selection: Increasing the number of suture strands from 4 to 6 does not alter the Achilles tendon resting angle (ATRA) or heel-rise height after minimally invasive Achilles tendon repair [83]. The results of this study, using a porcine model to simulate a minimally invasive technique for Achilles tendon repairs, suggest that the use of a double locked tape suture configuration leads to a stronger overall construct [158]. It provides 3 levels of fixation to repair the tendon [143].

Adjuncts: The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon [39]. The study demonstrates an accurate and repeatable clinical technique for mapping the sural nerve in conjunction with percutaneous Achilles tendon repairs [25]. A pre-existing Achilles tendon lesion is not an absolute contraindication for an endoscopic procedure [111].

Revision: The goal of the technique is to mitigate difficulties associated with revision Achilles tendon surgery while enabling patients to avoid long-term functional sequela of re-rupture [4]. Patients with severe local complications after repair of the Achilles tendon can be treated effectively using chimeric flaps with tendon grafts or flaps combined with a tendon transfer [43]. This minimally invasive technique allows reconstruction of the Achilles tendon using the tendon of semitendinosus preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of large gap (greater than 6 centimetres) [48]. Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft provides a significant improvement of symptoms and function, although calf circumference and ankle plantarflexion strength do not recover fully [76]. This technique allows reconstruction of the Achilles tendon using peroneus brevis preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of previous surgery [107]. The LSR technique is a viable surgical intervention strategy for a chronic Achilles tendon rupture in a rodent model, and it performs similarly, if not better, when directly compared with a more clinically accepted surgery, the GFT [104]. This method may provide a less traumatic and low-risk option for the treatment of delayed wound healing after Achilles tendon surgery [31]. The author recommends tissue expansion as an excellent way to avoid skin healing problems in complicated Achilles tendon ruptures, particularly for missed total ruptures where skin closure is difficult [120].

Rehabilitation and Postoperative Care: After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied [30].

Complications and Outcomes: Repaired Achilles tendon was characterised by lower material stiffness than the contralateral tendon, which may underpin greater ankle joint motion and long-term deficits [19]. In the repaired Achilles tendon, there is a decrease in the elasticity compared to the non-injured side [70]. Achilles tendon suture in anaesthetised rats causes a markedly reduced capillary perfusion and increased postcapillary venous filling pressures indicating venous stasis within ten minutes after tendon suture [147].

Augmentation and Biological Factors: In reinforcing Achilles tendon repair, the site of the tendon graft affected the result, with intratendinous grafts resulting in healed tendons more similar biomechanically to normal tendon than peritendinous augmentation [20]. The augmentation of Achilles tendon repair with bovine extracellular matrix xenograft decreases gapping and increases the repair construct stiffness and ultimate failure load in a cadaveric model [156]. Treatment with ACS has the potential to improve Achilles tendon healing and should be considered as a treatment modality in man [24]. This mid-term evaluation of the ability of the Achilles tendon to repair after division suggests a combination of intrinsic and extrinsic mechanisms [2].

Complications

Wound Complications: Open Achilles tendon repair carries a reported wound complication rate of 7 to 13% and a deep infection rate of 2 to 4% [108]. A meta-analysis of prospective, randomized studies identified a 4.7% risk of infection following repair [108]. Tobacco use, diabetes mellitus, steroid use, and obesity are associated with increased wound complication rates [108]. Medical comorbidities can complicate the postoperative course, increasing the cost of care and duration of treatment [36]. Minimally invasive techniques may result in a lower wound complication incidence compared to conventional open procedures for chronic ruptures [41], and proponents of percutaneous repairs cite a decreased incidence of wound complications and infections compared to open repairs [67].

Nerve Injury: The incidence of sural nerve injury is much lower with the use of an Achillon jig than in published series of percutaneous Achilles tendon repair without a jig [169]. Initial reports of percutaneous Achilles tendon repair showed possible sural nerve damage, while more recent reports seem to have minimized this complication [67].

Rerupture: Nonoperative treatment of Achilles tendon ruptures has historically been associated with a high risk of rerupture, ranging from 13 to 30% [108]. In one group of 30 patients treated conservatively, three reruptures occurred within one year [86]. Distal suture placement during minimally-invasive repair for higher-risk patients leads to results equivalent to lower-risk patients treated with a standard technique, except for a higher re-rupture rate [167]. The greatest potential downside to percutaneous repairs is the strength of the repairs, which has been shown by some authors to be as much as 50% weaker than open repairs [67].

Thromboembolic Events: Achilles tendon repair and ankle fracture surgery show higher risks and protracted time courses for acute venous thromboembolism compared to other lower extremity orthopaedic surgeries [90]. Early functional mobilization does not prevent the high incidence of deep venous thrombosis during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual [133]. The incidence of deep venous thrombosis and pulmonary embolism after Achilles tendon rupture is highly variable in the literature [126].

Functional Deficits and Adhesions: The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6% [165]. One patient in a conservative treatment group developed adhesions that resulted in loss of function [86].

Other Considerations: The timing of surgical intervention after an Achilles tendon rupture did not significantly affect the overall postoperative complication rate [122]. The complication rate was low in all groups of patients treated for acute Achilles tendon rupture [168]. The trend for the number of reported complications in Achilles tendon rupture publications is decreasing [163].

Recovery

Light activity (weeks): Evidence supports early mobilization and controlled ankle movement beginning after the second postoperative week [30]. Accelerated rehabilitation protocols permit immediate full weight bearing starting within the first 2 weeks after the operation [38]. Early mobilization is beneficial for patients with acute Achilles tendon rupture whether they are treated surgically or nonsurgically [119].

Full activity (months): Repair of acute Achilles tendon ruptures through a minimal lateral incision permits a return to sports as early as 4 months [40]. A new Achilles tendon repair approach enables early mobilization exercise without costly specialized orthosis or immobilization and allows an early return to normal life and sports activities [114]. Open minimally invasive Achilles tendon repair and an early rehabilitation programme provides satisfactory results with early return to previous functional status with low complication rates [113]. Minimally invasive Achilles tendon repair in combination with a functional rehabilitation program is a safe and quick procedure with a low rate of re-rupture and a high level of patient satisfaction [118]. The results of Achilles tendon repair with an early weightbearing and an early range of motion rehabilitation program are good [110]. Minimally invasive technique may result in a lower wound complication incidence and provide better early functional recovery and return to moderate-intensity exercise time than the conventional open procedure in treating chronic Achilles tendon ruptures [41].

Rehabilitation protocol: After the second postoperative week, controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied following acute rupture repair [30]. Rehabilitation protocols are considered accelerated if they allow immediate full weight bearing starting within the first 2 weeks after the operation, early ankle mobilization initiated after the second week post-operatively at the latest, or the combination of both [38].

Functional milestones: The Ankle-GO is a valid tool to evaluate and discriminate patients during the return to sports continuum after Achilles tendon repair and to predict return to sports at the same level at 9 months after surgery [74].

Other Considerations: The goal of revision Achilles tendon surgery using posterior tibial tendon allograft and flexor hallux longus transfer is to mitigate difficulties associated with revision surgery while enabling patients to avoid long-term functional sequela of re-rupture [4]. The mean concentration of pyruvate during early Achilles tendon rupture healing may predict patient outcome at 6 and 12 months post-operatively and possibly be used as a biomarker of healing [164].

Key Evidence

• [L5] There is a large body of evidence addressing treatment of acute and chronic Achilles tendon ruptures; however, controversy remains. [1] (10.2106/jbjs.o.00002)
• [L3] This mid-term evaluation of the ability of the Achilles tendon to repair after division suggests a combination of intrinsic and extrinsic mechanisms. [2] (10.1302/0301-620x.99b1.bjj-2016-0131.r1)
• [L1] The majority of patients with an Achilles tendon rupture have not fully recovered 2 years after injury regardless of surgical or non-surgical treatment, with only minor improvements occurring between the 1- and 2-year evaluations. [3] (10.1007/s00167-011-1511-3)
• [L5] The goal of the technique is to mitigate difficulties associated with revision Achilles tendon surgery while enabling patients to avoid long-term functional sequela of re-rupture. [4] (10.1016/j.eats.2021.11.001)
• [L3] Patients presenting more than 2 weeks after Achilles tendon rupture may be successfully treated with minimally invasive repair. [5] (10.1007/s00167-018-5340-5)
• [L2] The results suggest that more may not be better when it comes to Achilles tendon repair, and there is enough evidence to question whether surgical repair should be the gold standard for every patient. [6] (10.2106/jbjs.15.01165)
• [L3] The percutaneous and minimally invasive techniques of repair of the Achilles tendon yielded essentially identical clinical and functional outcomes with no reruptures or major complications observed at a minimum follow-up of 24 months. [7] (10.1097/blo.0b013e3180396f07)
• [L4] The use of a free gastrocnemius aponeurosis flap to treat chronic ruptures and reruptures of the Achilles tendon rendered a good overall subjective and objective outcome in the majority of patients. [8] (10.1007/s00167-008-0492-3)
• [L4] Long-term outcome after minimally invasive Achilles tendon rupture repair is excellent. [9] (10.1177/0363546510392012)
• [L3] Patients with Achilles tendon rupture treated by percutaneous repair 14 to 30 days after injury achieved similar results at 1 year as patients treated within 14 days after injury. [10] (10.1177/0363546520908592)
• [L2] Reconstruction of chronic ruptures with Achilles allograft appears to restore function and strength comparable to acute repairs. [11] (10.1177/0363546507312167)
• [L4] It is hoped that our technique will improve the functional outcome of those patients with acute Achilles tendon rupture. [12] (10.1016/j.arthro.2006.07.053)
• [L4] Acute Achilles tendon repair is associated with a major complication rate of 3% requiring reoperation. [13] (10.1177/03635465251365520)
• [L1] The non-surgical treatment of Achilles tendon ruptures is not inferior compared with that of surgery in terms of 1-year patient-reported and functional outcomes. [14] (10.1186/s12891-020-03320-3)
• [L3] It might be a reliable option for Achilles tendon repair. [15] (10.1186/s13018-019-1471-8)
• [L1] All patients undergoing operative repair of Achilles tendon ruptures had lengthening after surgery. [16] (10.1177/0363546520909389)
• [L4] Minimally invasive Achilles repair provides an opportunity for early rehabilitation. [17] (10.1186/s12891-024-07489-9)
• [L3] Following Achilles tendon repair, less than 75% of players returned to the NFL. [18] (10.1177/1071100717718131)
• [L2] Repaired Achilles tendon was characterised by lower material stiffness than the contralateral tendon, which may underpin greater ankle joint motion and long-term deficits. [19] (10.1007/s00167-017-4624-5)
• [L5] [20] (10.1007/s00402-003-0626-5)
• [L4] [21] (10.1007/s00167-010-1193-2)
• [L2] Additionally, tendon structure within the first 12 weeks relates to later walking gait and heel-rise symmetry, which may indicate that tendon structure could have prognostic value in the care of these patients. [22] (10.1007/s00167-018-5277-8)
• [L4] This technique is safe and feasible for treatment patients with acute rupture of Achilles tendon. [23] (10.1016/j.arthro.2016.03.078)
• [L5] Treatment with ACS has the potential to improve Achilles tendon healing and should be considered as a treatment modality in man. [24] (10.1177/0363546509348047)
• [Paper] The study demonstrates an accurate and repeatable clinical technique for mapping the sural nerve in conjunction with percutaneous Achilles tendon repairs. [25] (10.1016/j.injury.2006.10.016)
• [L4] This technique allows a strong percutaneous repair of the Achilles tendon with visualisation of the apposed tendon ends, allows early weight bearing, and minimises risk of sural nerve damage. [27] (10.1007/s00167-007-0411-z)
• [L4] [29] (10.1016/j.arthro.2017.09.027)
• [L1] After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied. [30] (10.1016/j.injury.2014.06.022)
• [L4] This method may provide a less traumatic and low-risk option for the treatment of delayed wound healing after Achilles tendon surgery. [31] (10.1016/j.eats.2021.11.007)
• [L3] Therefore, minimally invasive surgery may be considered a more suitable option for acute Achilles tendon repair to achieve overall better outcomes. [32] (10.1002/ksa.12163)
• [L1] Both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance Achilles tendon repair. [33] (10.1016/j.jisako.2023.03.027)
• [L4] The results of surgical treatment for ruptured Achilles tendon are good overall. [35] (10.1016/j.otsr.2013.03.024)
• [L3] Medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment. [36] (10.1007/s00167-018-5295-6)
• [L2] [38] (10.1007/s00167-015-3795-1)
• [Paper] The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. [39] (10.1016/j.eats.2022.10.006)
• [L4] The repair of acute Achilles tendon ruptures through a minimal lateral incision provides excellent functional outcomes, avoided complications including sural nerve injury, and permits a return to sports as early as 4 months. [40] (10.1016/j.arthro.2010.04.062)
• [L3] Minimally invasive technique may result in a lower wound complication incidence and provide better early functional recovery and return to moderate-intensity exercise time than the conventional open procedure in treating chronic Achilles tendon ruptures. [41] (10.1007/s00167-022-07167-0)
• [L1] In adults with acute Achilles tendon rupture, nonoperative treatment, open repair, and minimally invasive surgery did not differ for health status at 12 months. [42] (10.2106/jbjs.22.00965)
• [L4] Patients with severe local complications after repair of the Achilles tendon can be treated effectively using chimeric flaps with tendon grafts or flaps combined with a tendon transfer. [43] (10.1302/0301-620x.97b2.34521)
• [L3] This study shows that the healed Achilles tendon after rupture has inferior elastic properties even after a longterm healing phase. [45] (10.1007/s00167-017-4791-4)
• [L4] This minimally invasive technique allows reconstruction of the Achilles tendon using the tendon of semitendinosus preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of large gap (greater than 6 centimetres). [48] (10.1186/1471-2474-9-100)
• [L4] The procedure is simple and promotes natural repair of the ruptured Achilles tendon by bridging the intact proximal tendon and calcaneus with high-strength sutures and knotless anchors, reducing complications. [49] (10.1186/s13018-025-05550-4)
• [L4] This new and minimally invasive technique could be an alternative in the management of acute Achilles tendon rupture. [51] (10.1186/s13018-018-0895-x)
• [L3] The proposed method offers a reasonable treatment option for acute total Achilles tendon rupture with a low number of complications. [52] (10.1007/s00402-009-0880-2)
• [L4] [53] (10.1177/23259671251413268)
• [L4] Reduced plantar flexor muscle-tendon unit work supports that an elongated tendon and shorter muscle fascicles constrain functional capacity, with reduced and shifted functional ankle range of motion underlying performance deficits. [55] (10.1177/03635465211019436)
• [L1] These biomechanical findings must be interpreted in the context of clinical outcomes data as well as the differing complication profiles of the two techniques to best inform the surgical decision‐making process. [57] (10.1177/2325967123s00319)
• [L4] [58] (10.2106/jbjs.15.00865)
• [L1] The roles of ultrasonography and magnetic resonance imaging during the healing process after Achilles tendon rupture are limited, due to a weak correlation with clinical findings. [59] (10.1007/s001670100245)
• [L3] The incidence of emergency department (ED) visits within 90 days of Achilles tendon repair (ATR) was 8.4%, with over half of visits occurring in the first 4 weeks postoperatively. [60] (10.1177/23259671251394377)
• [L5] [61] (10.1007/s00167-019-05536-w)
• [L5] The study suggests that nonoperative treatment of Achilles tendon ruptures requires immobilization in maximal ankle plantar flexion (60°), and that immobilization of the knee may not be necessary to achieve tendon-edge apposition. [62] (10.1177/03635465990270051501)
• [L2] Early weight-bearing did not influence outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. [64] (10.1007/s00167-018-5058-4)
• [L1] Open surgical repair of acute Achilles tendon ruptures significantly reduces the risk of reruptures when compared with nonoperative management. [65] (10.1177/0363546512453293)
• [L4] Ultrasonography is useful to observe the intratendinous morphology of repaired Achilles tendons and to provide useful information for patients who wish to return to sports. [66] (10.1177/2325967118789883)
• [L5] [67] (10.1177/0363546508328595)
• [L1] [68] (10.1007/s00167-016-4270-3)
• [L3] In the repaired Achilles tendon, there is a decrease in the elasticity compared to the non-injured side. [70] (10.1186/s13018-018-0751-z)
• [L2] There appears to be a clinically important difference in the risk of complications between minimally invasive surgical treatment and nonoperative treatment for acute Achilles tendon ruptures, but this was not statistically significant. [72] (10.1177/0363546508319312)
• [L5] Daily oral administration of doxycycline accelerated matrix remodeling and the dynamic and equilibrium biomechanics of surgically repaired Achilles tendons, although such enhancements were most evident at the 3- to 6-week time points. [73] (10.1177/0363546517716637)
• [L3] The Ankle-GO is a valid tool to evaluate and discriminate patients during the return to sports continuum after Achilles tendon repair and to predict return to sports at the same level at 9 months after surgery. [74] (10.1177/03635465251333142)
• [L1] The evidence from this study indicates that PRP offers no patient benefit in the longer term for patients with acute Achilles tendon rupture. [75] (10.1302/0301-620x.104b11.bjj-2022-0653.r1)
• [L4] Mini-invasive reconstruction of the Achilles tendon, with a gap lesion larger than 6 cm, using the ipsilateral free semitendinosus tendon graft provides a significant improvement of symptoms and function, although calf circumference and ankle plantarflexion strength do not recover fully. [76] (10.1177/0363546513479017)
• [L4] The addition of PRP to the surgical treatment of Achilles tendon rupture does not appear to offer superior clinical and functional results. [78] (10.1007/s00167-015-3580-1)
• [L3] From a biomechanical point of view, at 1 year after surgery Achilles tendons did not show a 'restitutio ad integrum'. [79] (10.1007/s00167-014-3484-5)
• [L5] [80] (10.1186/s12891-015-0658-3)
• [L3] Increasing the number of suture strands from 4 to 6 does not alter the Achilles tendon resting angle (ATRA) or heel-rise height after minimally invasive Achilles tendon repair. [83] (10.1177/2325967117723347)
• [L3] [86] (10.1016/j.injury.2015.10.070)
• [L3] The incidence and time course of acute VTE after lower extremity orthopaedic surgeries varies significantly depending on the surgical procedure, with Achilles tendon repair and ankle fracture surgery showing higher risks and protracted time courses. [90] (10.5435/jaaos-d-23-00495)
• [Paper] The LSR technique is a viable surgical intervention strategy for a chronic Achilles tendon rupture in a rodent model, and it performs similarly, if not better, when directly compared with a more clinically accepted surgery, the GFT. [104] (10.1177/03635465211023096)
• [L4] This technique allows reconstruction of the Achilles tendon using peroneus brevis preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of previous surgery. [107] (10.1186/1471-2474-8-100)
• [L3] [108] (10.1097/01.blo.0000144475.05543.e7)
• [L4] The results of Achilles tendon repair with an early weightbearing and an early range of motion rehabilitation program are good. [110] (10.1177/0363546504268720)
• [L4] A pre-existing Achilles tendon lesion is not an absolute contraindication for an endoscopic procedure. [111] (10.1007/s00167-008-0602-2)
• [Paper] Open minimally invasive Achilles tendon repair and an early rehabilitation programme provides satisfactory results with early return to previous functional status with low complication rates. [113] (10.1016/j.injury.2008.10.033)
• [L4] This new Achilles tendon repair approach enables early mobilization exercise without costly specialized orthosis or immobilization and allows an early return to normal life and sports activities, reducing the physical and economic burden on patients. [114] (10.1177/0363546509351557)
• [L4] The results of our nonoperative orthotic treatment were better overall than published results of operative repair of acute Achilles tendon rupture. [115] (10.2106/00004623-200406000-00011)
• [L1] The statistical nonsignificance of studies reporting equivalent rerupture rates in the management of acute Achilles tendon ruptures with open repair versus nonoperative management with early functional rehabilitation can be reversed by changing the outcome status of only a few patients. [116] (10.1177/03635465231178831)
• [L3] Minimally invasive Achilles tendon repair in combination with a functional rehabilitation program is a safe and quick procedure with a low rate of re-rupture and a high level of patient satisfaction. [118] (10.1016/j.injury.2006.12.010)
• [L1] Furthermore, the study suggests that early mobilization is beneficial for patients with acute Achilles tendon rupture whether they are treated surgically or nonsurgically. [119] (10.1177/0363546510376052)
• [L4] The author recommends tissue expansion as an excellent way to avoid skin healing problems in complicated Achilles tendon ruptures, particularly for missed total ruptures where skin closure is difficult. [120] (10.1007/s001670100221)
• [L3] The timing of surgical intervention after an Achilles tendon rupture did not significantly affect the overall postoperative complication rate. [122] (10.1177/23259671251365622)
• [L5] This differential elongation can abolish knee-ankle coupling and lead to unrecognized elongation despite apparent tendon approximation. [123] (10.1007/s00167-021-06580-1)
• [L5] The incidence of deep venous thrombosis (DVT) and PE after Achilles tendon rupture are highly variable in the literature. [126] (10.1177/2325967114s00223)
• [L4] Complications correlate with age, and intra-tendon MRI abnormalities are frequent but likely represent non-pathologic cicatricial remodeling. [127] (10.1016/j.otsr.2013.03.021)
• [L5] The Achillon-like configuration and the modified percutaneous repair of ruptured AT provided similar biomechanical performance. [130] (10.1007/s00167-011-1868-3)
• [L5] Although its impact on biomechanical strength is limited, it may serve as a promising new strategy for treating tendinopathy. [132] (10.1186/s13018-025-06524-2)
• [L1] Early functional mobilization does not prevent the high incidence of DVT during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual. [133] (10.1007/s00167-019-05767-x)
• [L5] [134] (10.1186/s12891-024-07760-z)
• [L2] The variation in elasticity modulus provides biologically relevant information, although it is unclear how early biomechanics is connected to late clinical results. [135] (10.1177/0363546510383515)
• [Paper] [136] (10.1186/s13018-026-06780-w)
• [L5] [138] (10.1002/jor.20093)
• [L1] The results of this study suggest that both open and percutaneous techniques are biomechanically viable approaches for primary midsubstance Achilles tendon repair. [141] (10.1016/j.asmr.2024.100924)
• [L5] [142] (10.1007/s00167-020-06239-3)
• [L5] It provides 3 levels of fixation to repair the tendon. [143] (10.1016/j.eats.2024.103370)
• [L2] From 19 weeks onwards, radiodensity appears to reflect mechanical properties of the tendon and might to some extent predict the final outcome. [144] (10.1007/s00167-013-2720-8)
• [L5] Achilles tendon suture in anaesthetised rats causes a markedly reduced capillary perfusion and increased postcapillary venous filling pressures indicating venous stasis within ten minutes after tendon suture. [147] (10.1186/1749-799x-4-32)
• [L2] The results of the study support the choice of (modified) percutaneous suturing under local anesthesia as the method that brings comparable functional results to open repair, with a significantly lower rate of complications. [148] (10.1177/0363546504271501)
• [L5] IWR-1, however, compromised the biomechanical properties of healing tendons, whereas PH improved them. [150] (10.1177/03635465221077116)
• [L4] Pain, rather than fear of movement, was associated with the high variability in loading parameters. [151] (10.1177/0363546518824326)
• [L5] The Bunnell technique demonstrated a significantly higher maximum load, but the typical failure mode of the Bunnell technique shows potential to optimise biomechanical behavior by using stronger suture material. [152] (10.1007/s00402-008-0602-1)
• [L4] Disproportionate weakness in end-range plantar flexion, decreased passive joint stiffness in dorsiflexion, and the inability to perform a heel rise when initiated from a plantarflexed position were apparent in patients who had returned to full activities after Achilles tendon repair. [154] (10.1177/0363546505284186)
• [L5] This study demonstrates how the temporal postinjury healing response of rodent Achilles tendons depends on both surgical treatment and the timing of immobilization/activity timing. [155] (10.5435/jaaos-d-16-00620)
• [L5] The augmentation of Achilles tendon repair with bovine extracellular matrix xenograft decreases gapping and increases the repair construct stiffness and ultimate failure load in a cadaveric model. [156] (10.1177/0363546510397815)
• [L5] The results of this study, using a porcine model to simulate a minimally invasive technique for Achilles tendon repairs, suggest that the use of a double locked tape suture configuration leads to a stronger overall construct. [158] (10.1177/2325967126s00413)
• [L3] On the other hand, FHL showed early muscle volume recovery, and it suggested that FHL compensates for decreased ankle plantarflexion strength. [159] (10.1016/j.jisako.2023.03.013)
• [L5] In this bovine model, PRBT biomechanically outperformed the other minimally invasive Achilles tendon repair techniques that were tested and could therefore meet the requirements of accelerated rehabilitation. [161] (10.1177/23259671211008436)
• [L5] Graft fixation at two different interference screw insertion angles for IAT reconstruction exhibited equivalent biomechanical performance. [162] (10.1007/s00167-018-4864-z)
• [L4] The number of publications reporting Achilles tendon ruptures is increasing, the quality of articles is increasing, and the trend for the number of reported complications is decreasing. [163] (10.1177/03635465020300041701)
• [L3] The mean concentration of pyruvate during early Achilles tendon rupture healing may predict patient outcome at 6 and 12 months post-operatively and possibly be used as a biomarker of healing. [164] (10.1007/s00167-020-06037-x)
• [L3] The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6%. [165] (10.1007/s00167-021-06767-6)
• [L3] Distal suture placement during minimally-invasive Achilles tendon repair for higher-risk patients can lead to results equivalent to those in lower-risk patients treated with a standard TT MIR technique, except for the re-rupture rate which remained higher. [167] (10.1186/s12891-024-07630-8)
• [L3] The complication rate was low in all groups. [168] (10.1016/j.injury.2017.01.020)
• [L4] The incidence of sural nerve injury is much lower than published series of percutaneous Achilles tendon repair without the use of a jig. [169] (10.1016/j.injury.2017.01.018)

See Also

• Achilles tendon rupture
• Achilles tendinopathy
• Ankle fracture

References

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[119] Acute Achilles Tendon Rupture. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510376052

[120] Achilles tendon surgery and wound healing. Knee Surgery, Sports Traumatology, Arthroscopy. 2001. DOI: 10.1007/s001670100221

[122] Association of Surgical Timing With Complications and Patient-Reported Outcomes After Achilles Tendon Repair. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251365622

[123] Loss of the knee–ankle coupling and unrecognized elongation in Achilles tendon rupture: effects of differential elongation of the gastrocnemius tendon. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06580-1

[126] Delayed Pulmonary Embolism Following Achilles Tendon Repair. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00223

[127] Treatment of chronic Achilles tendon rupture by shortening suture and free sural triceps aponeurosis graft. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.03.021

[130] A biomechanical comparison of the primary stability of two minimally invasive techniques for repair of ruptured Achilles tendon. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-011-1868-3

[132] Rapamycin-mediated inhibition of the mTOR pathway promotes tendon healing in a collagenase-induced achilles tendinopathy. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06524-2

[133] Early mobilization does not reduce the risk of deep venous thrombosis after Achilles tendon rupture: a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05767-x

[134] Advanced glycation end products impair the repair of injured tendon: a study in rats. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07760-z

[135] Autologous Platelets Have No Effect on the Healing of Human Achilles Tendon Ruptures. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510383515

[136] Polydeoxyribonucleotide improves scar healing following limited scar resection for chronic Achilles tendon rupture in a rat model. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06780-w

[138] Microarray analysis of healing rat Achilles tendon: Evidence for glutamate signaling mechanisms and embryonic gene expression in healing tendon tissue. Journal of Orthopaedic Research. 2006. DOI: 10.1002/jor.20093

[141] Open and Percutaneous Approaches Have Similar Biomechanical Results for Primary Midsubstance Achilles Tendon Repair: A Meta‐analysis. Arthroscopy, Sports Medicine, and Rehabilitation. 2024. DOI: 10.1016/j.asmr.2024.100924

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