Podiatry (Foot & Ankle Surgery)Foot & AnkleSurgery Center

Achilles Tendon Repair (Acute Rupture)

Dr. Gary Feldman, DPM, performs acute Achilles tendon repair using primary end-to-end suture techniques with robust locking-stitch constructs, allowing early protected weight-bearing protocols that speed rehabilitation.

Duration: 45–75 minutesAnesthesia: Regional or general

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What is achilles tendon repair (acute rupture)?

Acute Achilles tendon repair is surgery to stitch the two ends of a completely ruptured Achilles tendon back together. It is performed within six weeks of injury, before the tendon ends retract and scar. Surgery reduces re-rupture risk and restores the strength needed for running and sport.

Why this approach — at MOS

The Achilles tendon is unforgiving — both under-tension (too loose) and over-tension (too tight) at the time of repair leads to suboptimal functional outcomes. My primary intraoperative goal is restoring the correct resting tension, which I assess by comparing the operative ankle's resting plantarflexion posture to the contralateral side with the patient prone.

I use a Krackow locking suture with No. 5 FiberWire or equivalent high-strength suture as the primary construct. The Krackow stitch provides excellent pull-out strength because each loop interlocks with the previous one — it does not rely on compression alone. A second strand through each end is tied separately, creating a four-strand core repair with additional circumferential reinforcement. The paratenon is always closed as a distinct layer; I do not skip this step because paratenon coverage is critical to wound healing and tendon vascularization.

Our post-operative protocol follows early weight-bearing principles supported by published functional bracing research. Patients are placed in a boot with heel wedges and begin controlled ankle motion earlier than traditional cast protocols, which reduces calf muscle atrophy and improves patient satisfaction. Physical therapy begins at 2 weeks, focusing on edema control and gentle range of motion before progressive resistance training is introduced.

Patients in the Bethesda and surrounding Montgomery County area often come to me having been told they must choose between surgery and casting. I spend time in that first conversation explaining what the evidence shows — so the decision is genuinely theirs.

Who is a candidate?

Indications

Complete Achilles tendon rupture confirmed clinically (positive Thompson test, palpable gap) and/or on MRI
Rupture less than 6 weeks old (acute), with the tendon ends accessible and approximable
Active patients, athletes, or anyone wishing to minimize re-rupture risk and maximize push-off strength
Open or laceration-type Achilles injuries requiring surgical debridement and repair
Patients with excessive tendon gap on MRI (>10 mm) making conservative treatment biomechanically inadequate

Contraindications

Active skin infection, cellulitis, or wound at the posterior ankle (surgery must be delayed until cleared)
Peripheral vascular disease with compromised wound healing capacity
Non-ambulatory patients or those with profound medical comorbidities — non-operative casting may be preferred
Partial ruptures (<50% of tendon cross-section) — typically managed non-operatively
Patient preference for non-operative management after informed discussion of risks and re-rupture rates

Conservative Treatment First

Non-operative management is a legitimate option for acute Achilles rupture, particularly in sedentary patients or those with significant medical comorbidities. Modern non-operative protocols using functional bracing and early mobilization have shown re-rupture rates of approximately 10–12%, compared to 2–5% after surgical repair. However, non-operative treatment is associated with slower return to pre-injury activity levels and modestly inferior push-off strength at long-term follow-up in active patients.

The shared decision-making conversation between Dr. Feldman and each patient focuses on the patient's activity goals, risk tolerance for re-rupture, occupation (can they be safely non-weight-bearing?), and overall medical status. Athletes and physically active adults who want to return to running and sport generally have better outcomes with surgical repair. Older, less active patients seeking to return to normal walking may do equally well with non-operative management under close supervision.

The procedure

What Is Achilles Tendon Repair (Acute Rupture)?

Important distinction: This page covers acute Achilles tendon rupture — injury that has occurred within the past six weeks and is treated with primary repair. Patients whose rupture was missed, delayed in diagnosis, or inadequately treated and is now more than 6–8 weeks old require a different, more complex operation called Achilles tendon reconstruction. That procedure typically involves tendon transfers and/or augmentation because the ends can no longer be directly sutured together. See the Achilles Tendon Reconstruction page for chronic rupture information.

The Achilles tendon is the largest and strongest tendon in the body, connecting the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). It transmits force during every step, providing the push-off power needed for walking, running, jumping, and climbing stairs. A complete rupture eliminates that force transmission, leaving the patient unable to rise on their toes and with a characteristic weakness in push-off.

Most ruptures occur 2–6 cm above the calcaneal insertion — the "watershed zone" of relatively poor blood supply. The injury is often described as feeling like a kick to the back of the leg or hearing a pop, followed by a sudden inability to push off. Thompson squeeze test (squeezing the calf and looking for ankle plantarflexion) confirms the diagnosis clinically; MRI confirms tear completeness and gap length when the examination is uncertain.

What Happens During Achilles Tendon Repair?

Surgery is performed at an ambulatory surgery center as an outpatient procedure. You are home the same day.

Anesthesia: Most patients receive a popliteal nerve block (numbing the sciatic nerve behind the knee) combined with light sedation or general anesthesia. The block provides excellent intraoperative and post-operative analgesia, reducing narcotic requirements significantly.

Positioning: You lie face-down (prone) with the operative foot hanging over the end of the table. A tourniquet is applied to the upper calf. The posterior ankle from mid-calf to heel is prepped and draped.

Incision: A longitudinal incision is made over the posterior medial aspect of the Achilles, typically 6–10 cm in length. The incision is positioned just medial to the tendon midline to protect the sural nerve (lateral) and minimize wound healing problems. The paratenon (the sheath surrounding the Achilles) is incised and preserved for closure.

Tendon identification and debridement: The two tendon ends are identified. The proximal end is typically bulbous; the distal end is ragged. Frayed and non-viable tendon tissue is debrided from both ends to expose healthy tendon for suture purchase.

Suture repair — Krackow technique: The most commonly used repair technique passes a locking, helical suture through each tendon end. The sutures are thick, braided, non-absorbable sutures (e.g., FiberWire, No. 5). The ankle is held in 20° of plantarflexion while the sutures are tied, approximating the two ends under appropriate tension. Additional interrupted sutures reinforce the repair circumferentially, improving the strength and appearance of the repair.

Augmentation (when indicated): For gap length greater than 2 cm or tendon tissue quality that appears compromised, augmentation with the plantaris tendon (a thin nearby tendon) or a suture tape reinforcement may be added.

Closure: The paratenon is closed over the repair as a separate layer — this is critical for blood supply and tendon gliding. Subcutaneous tissue and skin are closed, and a posterior splint holds the ankle in mild plantarflexion.

Recovery Room: The leg is elevated. Most patients are comfortable for 12–18 hours with the nerve block. Discharge with crutches or knee scooter, typically within 2 hours of surgery.

Recovery timeline

Days 1–14 (Splint, non-weight-bearing)

The posterior splint immobilizes the ankle in mild plantarflexion. Crutches or knee scooter for all ambulation. Leg elevation is critical — swelling is the enemy of wound healing. Sutures remain in place. Pain is typically moderate and well-managed with the nerve block and oral medication.

Weeks 2–6 (Boot with heel wedges, protected weight-bearing)

Sutures removed at the 2-week visit. Transition to a walking boot with heel lift wedges. Gradual progression from toe-touch to full weight-bearing in the boot over 4–6 weeks depending on repair quality and patient compliance. Physical therapy initiated for edema control and early range of motion.

Weeks 6–12 (Transition to shoe, progressive strengthening)

The boot is discontinued. Transition to a supportive shoe with a 1–1.5 cm heel lift. Physical therapy focuses on progressive calf strengthening — single-leg calf raises are the key milestone. Swelling and stiffness are still present and normal.

Months 3–6 (Progressive loading, sport-specific training)

Walking is normal and pain-free. Jogging and sport-specific movement patterns are introduced. Calf strength relative to the contralateral side is measured — most patients reach 75–80% at 4–5 months.

Months 6–12 (Return to sport)

Full return to unrestricted running and sport is typically cleared at 6–9 months when calf strength reaches 90% of the contralateral side and functional movement tests are passed. Return-to-sport criteria are objective, not based solely on time.

Recovery from Achilles repair is a long process — most patients significantly underestimate this at the outset. Calf muscle atrophy during the initial immobilization period is inevitable, and rebuilding strength is the primary limiting factor in returning to sport. The single-leg heel raise is the most important functional milestone, and many patients cannot perform it until 3–4 months post-operatively.

Wound healing deserves special attention. The posterior ankle skin is thin and subject to mechanical stress. Smoking is a major risk factor for wound complications and must be stopped before elective surgery. Diabetes must be well-controlled. Any sign of wound breakdown — redness, drainage, skin separation — should prompt immediate contact with Dr. Feldman's office at (301) 515-0900.

Physical therapy is not optional for a good outcome. Structured progressive calf strengthening, proprioception training, and return-to-sport progression at Maryland Orthopedic Specialists are coordinated with the surgical team to ensure appropriate timing of each phase.

Frequently Asked Questions

Should I have surgery or non-surgical treatment for my Achilles rupture?

Both are legitimate options. Surgery reduces re-rupture risk (approximately 2–5% vs. 10–12% non-operatively) and tends to produce slightly better push-off strength in active patients. Non-operative management with functional bracing avoids surgical wound risks. Your activity goals, age, overall health, and risk tolerance all factor into the decision. Dr. Feldman will discuss both options in detail so you can make an informed choice.

How long is the recovery from Achilles tendon repair?

Return to normal walking without a boot typically occurs at 6–10 weeks. Return to jogging is around 3–4 months. Full return to running and sport is typically cleared at 6–9 months when calf strength criteria are met. Most patients feel they have reached their final functional result by 12–18 months. This is one of the longer recoveries in orthopedics — patience and compliance with physical therapy are essential.

Will my Achilles be as strong as it was before the rupture?

The repaired tendon heals with scar tissue that integrates into the tendon structure. Long-term, most patients regain full functional strength — many elite athletes return to competitive sport after surgery. Calf strength testing at 12 months typically shows 90–100% of the contralateral side in compliant patients. The tendon itself may be slightly thicker at the repair site and may remain mildly enlarged, which is normal.

What are the main risks of Achilles tendon repair surgery?

The most significant risks are wound healing problems (especially in smokers or diabetics), sural nerve injury causing numbness along the lateral foot, and re-rupture (2–5% after surgical repair). Deep infection, deep vein thrombosis, and anesthesia complications are less common but real risks discussed during pre-operative consent. Wound complication risk is the primary reason surgery requires careful patient selection.

What is the difference between acute Achilles repair and Achilles reconstruction?

Acute repair (this procedure) is for fresh ruptures less than ~6 weeks old, where the tendon ends can be found, debrided, and sutured directly together. Reconstruction is for older, neglected ruptures where the ends have retracted, scarred, and shortened — they can no longer be joined end-to-end. Reconstruction requires a tendon transfer (flexor hallucis longus) and/or graft augmentation. It is a longer, more complex procedure with a longer recovery.

Can I prevent re-rupture after surgery?

Compliance with protected weight-bearing restrictions in the early post-operative period is the most important modifiable factor. Loading the repair before adequate healing (typically the first 6 weeks) is the highest-risk period. Beyond that, following the physical therapy protocol and not returning to sport until objective strength criteria are met reduces re-rupture risk. Re-rupture after a well-performed, well-healed repair is uncommon.

Will I need physical therapy after Achilles repair?

Yes — physical therapy is essential and not optional. Progressive calf strengthening, proprioception training, and return-to-sport functional testing are all components of a structured rehabilitation program. Maryland Orthopedic Specialists has in-house physical therapy that coordinates with Dr. Feldman's milestones for a seamless transition from surgery through return to activity.

Related conditions

Achilles Tendon Rupture Achilles Tendinopathy

Medically reviewed by Gary Feldman, DPM, FACFAS, DPM, FACFAS

Last reviewed May 20, 2026