Should I have surgery for a ruptured Achilles tendon?

Introduction

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This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

An Achilles tendon rupture may be treated with surgery and rehabilitation or by using a cast, splint, brace, walking boot, or other device that will keep your lower leg from moving (immobilization) and rehabilitation. Consider the following when making your decision:

• Both surgery and immobilization are usually successful. Your decision will probably depend on you how feel about possibly having another rupture and surgical complications. Another rupture is less likely after surgery than after immobilization, but immobilization has fewer complications.
• If you are younger and/or active, surgery is often recommended.
• If you are older and/or inactive, immobilization is often recommended.

Medical Information

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What is the Achilles tendon and what is an Achilles tendon rupture?

The Achilles tendon connects the calf muscles to the heel bone. It is the biggest tendon in the human body and allows you to rise up on your toes while walking. It withstands a large amount of force with each foot movement.

An Achilles tendon rupture occurs when the tendon is completely torn in two. When this happens, your leg may be weak and walking may be difficult. You may not be able to rise up on your toes. You must treat an Achilles tendon rupture.

How effective is treatment for an Achilles tendon rupture?

Both immobilization and surgery are generally successful—they both result in the tendon healing. Your decision will probably depend on you how feel about possibly having another rupture and surgical complications. Another rupture is less likely after surgery than after immobilization, but immobilization has fewer complications.

What are the risks of treatment?

Complications, such as wound infection, are rare in nonsurgical treatment. However, there is a greater likelihood of the tendon rupturing again. Surgery using several small incisions (percutaneous) provides less likelihood of another rupture, but wound infection is more likely with surgery than with nonsurgical treatment. This type of surgery may also result in nerve damage; however, newer techniques for percutaneous surgery may make nerve damage less likely than when older techniques are used. Surgery using one large incision (open) has the least chance of another rupture, but it has the highest chance of wound infection.

If you need more information, see the topic Achilles Tendon Problems.

Your Information

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Your choices are:

• Treat the rupture nonsurgically with a cast or brace (immobilization).
• Have percutaneous surgery, where the tendon is stitched together through several small cuts.
• Have open surgery, where the tendon is stitched together through one large cut.

How you treat the rupture takes into account your personal feelings and the medical facts.

Deciding about surgery or a cast or brace

General reasons to have surgery

General reasons to not have surgery and to use a cast or brace (immobilization)

There is less risk of another rupture in the future than with nonsurgical treatment. You are an active person. You are a younger person. You have a job that requires leg strength. Avoiding another rupture is more important to you than the risk of complications. Improved surgical techniques are lowering the complications rate. You can generally return to normal activity more quickly. Are there other reasons you might want to have surgery?

There is less risk of general and wound complications than found in surgery. You are not an active person. Avoiding complications is more important to you than the risk of another rupture. You have a disease, such as diabetes, that may increase the risks of surgery. You are an older person. Are there other reasons you might not want to have surgery?

The following table compares immobilization and types of surgery.¹ New techniques may reduce the complication rates for percutaneous surgery.

It is sometimes difficult to determine how surgeries compare, because of differences in the age and activity level of those having surgery. The success of your surgery can depend on your surgeon's experience, the type of surgery you have, how badly your tendon is damaged, how soon after rupture the surgery is done, and how soon your rehabilitation program starts after surgery and how well you follow it.

In the table, early mobilization refers to beginning movement and weight bearing sooner after the surgery rather than later.

The percentages given can also be read as "out of 100." For example, the rerupture rate of open surgery is 2.2%, which means that about 2 people out of 100 having open surgery will have another rupture.

Problems with treatment choices

Result	Nonsurgical treatment with a cast or brace	Percutaneous surgery	Open surgery
Having another rupture (rerupture rate)	9.8%	3.6% 6.6% with early mobilization	2.2% 1.4% with early mobilization
Minor wound complication (such as superficial infection or delayed healing)	0.5% skin complication rate	4.9% 6.6% with early mobilization	12.3% 4.9% with early mobilization
Major wound complication (such as deep infection)	--	-- 3.3% with early mobilization	2.3% 0.4% with early mobilization
Minor general complication (such as pain or temporary nerve damage)	8.5%	8.5% 14.8% with early mobilization	8.1% 5.3% with early mobilization
Major general complication (such as deep vein thrombosis or permanent nerve damage)	0.6%	0.8% 0.8% with early mobilization	0.8% 0.4% with early mobilization

These personal stories may help you make your decision.

Wise Health Decision

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Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about surgery for an Achilles tendon rupture. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I worry about complications, especially wound infections and skin problems.	Yes	No	Unsure
I worry about having another rupture.	Yes	No	Unsure
My surgeon is experienced with percutaneous procedures.	Yes	No	Unsure
I'm not very active.	Yes	No	Unsure
My job requires that I have strong legs.	Yes	No	Unsure
I'm an active person and want to remain active.	Yes	No	Unsure
I have a condition, such as diabetes, that may make surgery riskier.	Yes	No	Unsure
I want to return to my normal activity level as quickly as possible.	Yes	No	Unsure

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use surgical or nonsurgical treatment.

Check the box below that represents your overall impression about your decision.

Leaning toward having surgery

Leaning toward NOT having surgery

Return to the topic Achilles Tendon Problems.

References

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Citations

1. Wong J, et al. (2002). Quantitative review of operative and nonoperative management of Achilles tendon ruptures. American Journal of Sports Medicine, 30(4): 565–575.

Credits

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Author	Kathe Gallagher, MSW
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman
Primary Medical Reviewer	Martin Gabica, MD - Family Medicine
Specialist Medical Reviewer	Nicola Maffulli, MD, PhD - Orthopedics
Last Updated	January 30, 2007