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Achilles tendon repair

118 citationsUpdated Sep 2026

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Overview

Achilles tendon rupture treatment remains a subject of clinical controversy, with the tendon’s healing capacity relying on a combination of intrinsic and extrinsic mechanisms [1, 2]. Surgical repair is not universally established as the gold standard for every patient, as non-surgical management is not inferior to surgery regarding 1-year patient-reported and functional outcomes [6, 14]. While percutaneous and minimally invasive techniques yield essentially identical clinical and functional outcomes to standard open repair with no reruptures or major complications at 24 months, long-term results after minimally invasive repair are considered excellent [7, 9].

Despite these advances, the majority of patients have not fully recovered two years post-injury regardless of the treatment modality chosen, with only minor improvements observed between 1- and 2-year evaluations [3]. Acute Achilles tendon repair carries a major complication rate of 3% requiring reoperation [13]. Although a clinically important difference in complication risk exists between minimally invasive surgical treatment and nonoperative treatment, this difference was not statistically significant [72]. Furthermore, the addition of platelet-rich plasma (PRP) to surgical treatment offers no superior clinical or functional results and provides no long-term patient benefit [75, 78].

Indications extend beyond the acute window; patients presenting more than 2 weeks after rupture may be successfully treated with minimally invasive repair, and those treated by percutaneous repair 14 to 30 days post-injury achieve similar results at one year as those treated within 14 days [5, 10]. All patients undergoing operative repair experience lengthening after surgery [16]. For chronic ruptures and reruptures, reconstruction with Achilles allograft restores function and strength comparable to acute repairs [11], while the use of a free gastrocnemius aponeurosis flap renders good overall subjective and objective outcomes in the majority of patients [8].

Anatomy & Pathophysiology

Tendon Healing and Histology

Repaired Achilles tendons exhibit lower material stiffness than the contralateral tendon [19], a deficit that may underpin greater ankle joint motion and long-term functional limitations [19]. Even after a long-term healing phase, healed tendons retain inferior elastic properties [45], and at one year post-surgery, biomechanical analysis reveals that the tendon has not achieved restitutio ad integrum [79]. Tendon structure within the first 12 weeks correlates with later walking gait and heel-rise symmetry, suggesting prognostic value in patient care [22]. In acute ruptures, pathological features are significantly more pronounced at the rupture site than in proximal or distal samples [21], although no significant differences exist in mean pathologic sum-scores between these proximal and distal regions [21]. Ruptured tendons demonstrate histopathological evidence of a failed healing response even in macroscopically intact areas [21], indicating that unruptured and ruptured tendons represent two distinct populations [21].

Experimental models further elucidate the healing trajectory. Complete mid-portion rupture in rat Achilles tendons leads to remote and time-mismatched changes in uninjured regions [142]. Foci of mineralization were found in 3/6 of rat tendons at 8 weeks postinjury [142], while at 17 weeks, 5/6 exhibited calcified tendon matrix [142]. The temporal healing response in rodents depends on both surgical treatment and the timing of immobilization or activity [155]. Pharmacological interventions show varied effects: daily oral doxycycline accelerated matrix remodeling and dynamic and equilibrium biomechanics, with enhancements most evident at 3 to 6 weeks [73]. Conversely, autologous platelets have no effect on the healing of human Achilles tendon ruptures [135], though variation in elasticity modulus provides biologically relevant information regarding healing, even if the connection to late clinical results remains unclear [135].

Molecular and cellular mechanisms drive the repair process. Microarray analysis identified central nervous system-like glutamate-based signaling machinery in tendon cells [138]. Inflammatory response and pro-proliferative genes were significantly upregulated from 24 hours through 21 days postinjury [138], with day 7 showing the largest increase in genetic activity, particularly in collagen and extracellular matrix gene expression [138]. Nucleostemin- and Oct 3/4-positive stem/progenitor cells exhibit disparate anatomical and temporal expression during healing [80]. Advanced glycation end products impair tendon repair in rats [134]. Rapamycin-mediated inhibition of the mTOR pathway promotes healing in a collagenase-induced model, though its impact on biomechanical strength is limited [132]. Promethazine downregulates Wnt/β-catenin signaling and increases biomechanical forces in the early healing stage [150], whereas IWR-1 compromised biomechanical properties [150].

Biomechanics and Functional Deficits

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]. These deficits are underpinned by reduced and shifted functional ankle range of motion [55]. Specific impairments include disproportionate weakness in end-range plantar flexion [154], decreased passive joint stiffness in dorsiflexion [154], and an inability to perform a heel rise when initiated from a plantarflexed position [154]. Differential elongation of the gastrocnemius tendon can abolish knee-ankle coupling [123] and lead to unrecognized elongation despite apparent tendon approximation [123].

Biomechanical comparisons of repair techniques reveal distinct performance profiles. Both open and percutaneous techniques are biomechanically viable approaches for primary mid-substance repair [33, 141]. The Achillon-like configuration and modified percutaneous repair provided similar biomechanical performance [130]. In a cadaver study, the Bunnell technique demonstrated significantly higher maximum load compared to the Kessler technique [152], with the typical failure mode of the Bunnell technique suggesting potential optimization through stronger suture material [152]. In a bovine model, the Panda Rope Bridge Technique biomechanically outperformed other minimally invasive techniques tested [161]. For insertional reconstruction, graft fixation at two different interference screw insertion angles exhibited equivalent biomechanical performance [162]. However, biomechanical findings regarding open versus percutaneous techniques must be interpreted in the context of clinical outcomes data and differing complication profiles [57].

Anatomical and Surgical Considerations

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus [84, 85], articulating with the dome of the talar body [84, 85]. The mortise widens and the ankle becomes more stable in dorsiflexion owing to the shape of the talar dome [84, 85], widening 1 to 1.5 mm during motion from plantar flexion to dorsiflexion [84, 85]. The ankle is responsible for most sagittal plane motion of the foot and ankle [84, 85], with a range of motion including 23 to 48 degrees of plantar flexion [84, 85] and 10 to 23 degrees of dorsiflexion [84, 85]. The distal fibula has a convex medial surface, while the incisura fibularis is a concave surface of the distal lateral tibia [84, 85]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [84, 85], and ankle dorsiflexion results in external rotation and proximal translation of the fibula [84, 85].

Ligamentous structures provide critical stability. The anterior talofibular ligament originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [84, 85]. The calcaneofibular ligament extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [84, 85], and the posterior talofibular ligament extends from the posterior lateral malleolus to the posterolateral talus [84, 85]. The anterior talofibular ligament is the weakest ankle ligament [84, 85], whereas the posterior talofibular ligament is the strongest [84, 85]. Medially, the deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body, functioning primarily to resist lateral talar translation and external rotation [84, 85]. The posterior deep deltoid is the most important component of the deltoid ligament complex [84, 85]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [84, 85], functioning primarily to resist valgus/eversion ankle forces [84, 85].

The deltoid ligament on the medial side of the ankle is composed of superficial and deep layers [92]. The deep portion is the primary medial stabilizer of the ankle joint [92], with the deep posterior tibiotalar ligament comprising the largest band of the complex [92]. The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [92]. The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion [92], while failure of the superficial deltoid ligament is most commonly at its insertion on the anterior malleolus [92]. The deltoid ligament has a rich vascular supply from the medial tarsal artery, posterior tibial artery, and tibialis anterior artery [92].

Neural anatomy is critical for surgical planning. The superficial peroneal nerve penetrates the deep fascia and lies subcutaneously 8 to 10 cm proximal to the tip of the lateral malleolus [89]. The deep peroneal nerve lies between the tendons of the anterior tibial and extensor digitorum longus, just lateral to the extensor hallucis longus [89], and usually lies just lateral to the anterior tibial artery [89]. The saphenous nerve is located just medial or posterior to the saphenous vein and in a slightly deeper plane 3 to 5 cm proximal to the tip of the medial malleolus [89]. A clinical technique exists for mapping the sural nerve in conjunction with percutaneous Achilles tendon repairs [25].

Surgical and nonoperative considerations influence healing outcomes. Nonoperative treatment of Achilles tendon ruptures requires immobilization in maximal ankle plantar flexion of 60° to achieve tendon-edge apposition [62]. Immobilization of the knee may not be necessary to achieve tendon-edge apposition in nonoperative treatment [62]. Preservation of the blood supply to the ruptured tendon is important for optimal healing and reduction of the rate of rerupture [146].

Classification

Acute vs. Chronic: More than 20% of acute Achilles tendon injuries are misdiagnosed, leading to a chronic Achilles tendon rupture defined as a complete rupture with a delay in diagnosis or treatment for more than 4–6 weeks [136]. Chronic Achilles tendon rupture is characterized by retraction of the tendon ends and a gap filled with scar tissue [136].

Anatomical Basis: The Achilles tendon is formed by the distal extensions of the gastrocnemius and soleus muscles and attaches to the calcaneal tuberosity [136].

Other Considerations: The annual incidence of Achilles tendon rupture is 5 to 50 events per 100,000 persons [136]. Achilles tendon ruptures commonly occur during sports activities, and most patients are between the third and fourth decades of life [29]. A diagnosis of Achilles tendon rupture can be confirmed by the presence of 2 or more of the following signs: decreased strength of ankle plantarflexion, presence of palpable gap or defect, increased ankle dorsiflexion with gentle manipulation, and a positive Thompson test [29].

Long-term Outcomes: 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]. Repaired Achilles tendon is characterised 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]. 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].

Return to Sport: 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]. Following Achilles tendon repair, less than 75% of players returned to the NFL [18]. Treatment type did not significantly predict the results of the Achilles tendon total rupture score [117].

Clinical Presentation

Diagnosis and Physical Examination

Clinical assessment of the Achilles tendon includes mapping the sural nerve to guide surgical planning. An accurate and repeatable clinical technique exists for mapping the sural nerve in conjunction with percutaneous Achilles tendon repairs [25].

Epidemiology and Demographics

In a cohort of 38 patients aged <25 years treated for Achilles tendon tears or lacerations, 24 (63%) were analyzable. This group had a mean age of 18.9 years (range 10.4-22.8 years) and 42% were male [53].

Pathology and Histology

Histopathological analysis of acute Achilles tendon ruptures reveals that pathological features are significantly more pronounced in samples taken from the site of rupture than in samples taken proximally and distal to it [21]. There were no significant differences in the mean pathologic sum-scores in tendon samples taken proximally and distal to the site of rupture [21]. Ruptured Achilles tendons demonstrate histopathological evidence of failed healing response even in areas macroscopically intact, distinguishing them from unruptured tendons [21].

Imaging

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]. However, 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]. Tendon structure within the first 12 weeks after Achilles tendon rupture relates to later walking gait and heel-rise symmetry, indicating potential prognostic value for 6-month outcomes [22].

Functional Deficits and Outcomes

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 Achilles tendon 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].

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].

Investigations

Ultrasonography: Ultrasonography and magnetic resonance imaging have limited roles during the healing process after Achilles tendon rupture due to a weak correlation with clinical findings [59]. However, 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].

MRI: Intra-tendon MRI abnormalities are frequent in chronic Achilles tendon rupture but likely represent non-pathologic cicatricial remodeling [127].

Other Considerations: An accurate and repeatable clinical technique exists for mapping the sural nerve in conjunction with percutaneous Achilles tendon repairs [25]. 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]. In the repaired Achilles tendon, there is a decrease in elasticity compared to the non-injured side [70]. From 19 weeks onwards, radiodensity appears to reflect mechanical properties of the tendon and might to some extent predict the final outcome [144]. 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]. Pathological 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 the mean pathologic sum-scores in samples taken proximally and distal to the site of rupture [21].

Treatment

Controversy persists regarding the optimal management of acute and chronic Achilles tendon ruptures, with significant variation in perioperative and rehabilitation protocols [1, 26]. Current evidence supports both conservative and operative pathways, challenging the assumption that surgical repair is the universal gold standard [6, 29].

Non-Operative

Nonoperative treatment, open repair, and minimally invasive surgery yield comparable health status outcomes at 12 months in adults with acute rupture [42]. Results from nonoperative orthotic treatment have been reported as superior overall to published operative repair outcomes [115]. Early weight-bearing does not influence outcomes at 4.5 years following nonoperative management [64]. However, conservative treatment carries disadvantages including elongation of the musculotendinous unit and a higher rerupture rate [29].

Operative

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

Surgical Approach / Technique: Surgical treatment for ruptured Achilles tendon yields good overall results [35]. Biomechanical findings must be interpreted alongside clinical outcomes and differing complication profiles to inform decision-making [57]. Modified percutaneous suturing under local anesthesia provides functional results comparable to open repair with a significantly lower complication rate [148]. Percutaneous and minimally invasive techniques yield identical clinical and functional outcomes with no reruptures or major complications at a minimum 24-month follow-up [7]. These techniques are safe and feasible for acute rupture [23, 51] and offer reasonable treatment options with low complication numbers [52]. Specific percutaneous techniques allow strong repair with visualisation of apposed tendon ends, early weight bearing, and minimised sural nerve damage risk [27]. Other methods bridge the intact proximal tendon and calcaneus with high-strength sutures and knotless anchors to promote natural repair and reduce complications [49]. Minimally invasive repair facilitates early rehabilitation [17] and is hoped to improve functional outcomes [12]. Increasing suture strands from 4 to 6 does not alter the Achilles tendon resting angle or heel-rise height after minimally invasive repair [83]. In a porcine model, a double locked tape suture configuration leads to a stronger overall construct [158]. One technique provides three levels of fixation [143]. A pre-existing Achilles tendon lesion is not an absolute contraindication for an endoscopic procedure [111].

Revision: The goal of revision techniques is to mitigate difficulties associated with revision surgery while enabling patients to avoid long-term functional sequela of re-rupture [4]. Patients with severe local complications after repair can be treated effectively using chimeric flaps with tendon grafts or flaps combined with a tendon transfer [43]. Minimally invasive reconstruction using the tendon of semitendinosus preserves skin integrity over the site most prone to wound breakdown and is suitable for gaps greater than 6 centimetres [48]. Mini-invasive reconstruction with an ipsilateral free semitendinosus tendon graft for gaps larger than 6 cm provides significant improvement in symptoms and function, although calf circumference and ankle plantarflexion strength do not recover fully [76]. Reconstruction using peroneus brevis preserves skin integrity and is especially useful in the presence of previous surgery [107]. The LSR technique is a viable strategy for chronic rupture in a rodent model, performing similarly or better than the more clinically accepted GFT [104].

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 Wound Management: Specific methods may provide a less traumatic and low-risk option for delayed wound healing after Achilles tendon surgery [31]. Tissue expansion is recommended as an excellent way to avoid skin healing problems in complicated ruptures, particularly for missed total ruptures where skin closure is difficult [120]. The possibility of sural nerve injury due to blinded surgical techniques is a cause for concern [29].

Biological Augmentation and Experimental Findings: Treatment with ACS has the potential to improve Achilles tendon healing and should be considered as a treatment modality in humans [24]. Augmentation with bovine extracellular matrix xenograft decreases gapping and increases repair construct stiffness and ultimate failure load in a cadaveric model [156]. In reinforcing Achilles tendon repair, the site of the tendon graft affected the result [20]. When the graft was intratendinously, the healed tendon was more similar biomechanically to normal tendon and had more graft-tendon orientation histologically than the tendon augmented peritendinously [20]. Achilles tendon suture in anaesthetised rats causes markedly reduced capillary perfusion and increased postcapillary venous filling pressures, indicating venous stasis within ten minutes after tendon suture [147]. Repaired Achilles tendon is characterised by lower material stiffness than the contralateral tendon, which may underpin greater ankle joint motion and long-term deficits [19]. There is a decrease in elasticity in the repaired Achilles tendon compared to the non-injured side [70]. 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 and Infection: 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 the procedure [108]. Tobacco use, diabetes mellitus, steroid use, and obesity are associated with an increased rate of wound complications [108]. Medical comorbidities can complicate the postoperative course, increasing the cost of care and duration of treatment [36]. Minimally invasive techniques for chronic Achilles tendon ruptures may result in a lower wound complication incidence than conventional open procedures [41].

Nerve Injury: The incidence of sural nerve injury is much lower when using the Achillon jig for percutaneous Achilles tendon repair compared to published series without the use of a jig [169]. Sural nerve injuries are a primary outcome measure in systematic reviews comparing open versus minimally invasive repair of acute Achilles tendon ruptures [56].

Rerupture: Nonoperative treatment of Achilles tendon ruptures has historically been associated with a high risk of rerupture ranging from 13 to 30% [108]. In a group of 30 patients treated conservatively, three reruptures of the Achilles tendon occurred within one year [86]. Distal suture placement during minimally-invasive Achilles tendon repair for higher-risk patients does not prevent re-rupture, with the re-rupture rate remaining higher than in lower-risk patients treated with a standard technique [167]. Reruptures are a primary outcome measure in systematic reviews comparing open versus minimally invasive repair of acute Achilles tendon ruptures [56].

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 [133]. The incidence of deep venous thrombosis and pulmonary embolism after Achilles tendon rupture is highly variable in the literature [126].

Adhesions and Functional Deficits: The incidence of patient-reported adhesions following minimally invasive repair of Achilles tendon rupture was estimated to be 5.6% [165].

General Complication Rates: The timing of surgical intervention after an Achilles tendon rupture did not significantly affect the overall postoperative complication rate [122]. In a retrospective cohort study of percutaneous Achilles repair, the complication rate was 6.4% in the knotless technique group and 0% in the knotted technique group [100]. The complication rate was low in all groups of patients treated for acute Achilles tendon rupture regardless of timing [168].

Recovery

Light activity (weeks): The evidence does not specify a distinct week range for light activities such as desk work, driving, or light ADLs. However, accelerated rehabilitation protocols following minimally invasive or percutaneous repair allow immediate full weight bearing starting within the first 2 weeks after the operation [38].

Full activity (months): Return to sports is possible as early as 4 months following repair of acute Achilles tendon ruptures through a minimal lateral incision [40]. A new Achilles tendon repair approach enables early mobilization without costly specialized orthosis, allowing an early return to normal life and sports activities [114]. Open minimally invasive repair combined with an early rehabilitation programme provides satisfactory results with early return to previous functional status [113]. Minimally invasive repair with a functional rehabilitation program is a safe and quick procedure with a low rate of re-rupture and high patient satisfaction [118]. Results of repair with an early weightbearing and early range of motion rehabilitation program are good [110]. In chronic Achilles tendon ruptures, the minimally invasive technique may provide better early functional recovery and return to moderate-intensity exercise time than the conventional open procedure [41].

Complete recovery / outcome plateau (months): The provided evidence does not define a specific month range for the complete recovery or outcome plateau phase.

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]. Early mobilization is beneficial for patients with acute Achilles tendon rupture whether treated surgically or nonsurgically [119]. Functional weight-bearing mobilization after Achilles tendon rupture enhances early healing response [68]. Accelerated rehabilitation protocols are defined as allowing 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 evidence does not provide specific validated PROM trajectories or outcome-measure benchmarks.

Other Considerations: The ability of the Achilles tendon to repair after division suggests a combination of intrinsic and extrinsic mechanisms [2]. 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]. In experimental rabbit models, intratendinous plantaris graft reinforcement resulted in a healed tendon that was more similar biomechanically to normal tendon and had more graft-tendon orientation histologically than peritendinous augmentation [20]. In these models, the healing process was faster in tendons augmented intratendinously compared to those augmented peritendinously [20]. There is a lack of consensus and wide variation in management of Achilles tendon ruptures, particularly in perioperative and rehabilitation phases [26].

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)
• [L5] The study shows a lack of consensus and wide variation in management of Achilles tendon ruptures in the Netherlands, particularly in perioperative and rehabilitation phases. [26] (10.1007/s00167-018-5049-5)
• [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)
• [L1] The purpose of this meta-analysis was to compare clinical outcomes and complication-rates between the minimally invasive and the standard open repair of acute Achilles tendon ruptures. [44] (10.1007/s00402-020-03437-z)
• [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] [56] (10.1177/03635465211053619)
• [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)
• [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] 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)
• [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)
• [L3] [100] (10.1186/s13018-025-06320-y)
• [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] Treatment type did not significantly predict the results of the Achilles tendon total rupture score. [117] (10.1186/s12891-022-05875-9)
• [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)
• [Paper] [146] (10.1016/j.injury.2007.11.422)
• [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)
• [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)
• [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)
• [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
• Ankle fracture

References

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