Achilles Tendon Rupture: Conservative vs. Surgical Management – What does the evidence say?

Achilles tendon rupture (ATR) is a prevalent injury, particularly among active individuals. The optimal treatment approach—conservative (nonoperative) versus surgical repair—has been extensively debated.

This blog reviews current evidence to elucidate the benefits and drawbacks of each modality, aiding clinicians and patients in making informed decisions.

🔍 Re-Rupture Rates

Surgical intervention consistently demonstrates a lower re-rupture rate compared to conservative treatment. A meta-analysis encompassing 14 randomized controlled trials (RCTs) with 1,399 patients revealed a re-rupture rate of 3.0% in the surgical group versus 9.6% in the nonoperative group (Odds Ratio [OR]: 0.30; 95% Confidence Interval [CI]: 0.18–0.54; P < 0.00001) . Similarly, another meta-analysis reported re-rupture rates of 4.31% for surgical treatment and 9.71% for conservative management (Relative Risk [RR]: 0.44; 95% CI: 0.26–0.74; P = 0.002) .

⚠️ Complication Profiles

While surgery reduces re-rupture risk, it is associated with a higher incidence of complications. The aforementioned meta-analysis noted a complication rate of 26.6% in the surgical group compared to 7.2% in the nonoperative group (RR: 4.07; 95% CI: 1.56–10.67; P = 0.004) . Specific complications more prevalent in surgical patients include:

• Wound/skin infections: 2.8% in surgical vs. 0.02% in nonoperative patients

• Sural nerve injuries: 0.42% vs. 0.08%

• Scar adhesions: 0.38% vs. 0.24% .

Conversely, the rates of deep vein thrombosis and pulmonary embolism were comparable between groups.

🏃‍♂️ Functional Outcomes and Return to Activity

Functional recovery metrics, including the Achilles Tendon Total Rupture Score (ATRS) and return-to-sport rates, show minimal differences between treatment modalities. In one meta-analysis, no significant difference was observed in patients returning to pre-injury activity levels (OR: 1.07; 95% CI: 0.58–1.96; P = 0.82) . ATRS scores were also similar across groups, with some studies reporting marginally higher scores in the nonoperative cohort .

However, surgical patients often experience a shorter duration of sick leave, suggesting a quicker initial recovery phase.

💰 Economic Considerations

An analysis of a large national dataset indicated that surgical management incurs higher initial costs compared to conservative treatment. At nine months post-treatment, surgical care was more expensive; however, by five years, the cumulative costs between the two approaches converged, showing no significant difference.

🧠 Clinical Implications

• Surgical Repair: Recommended for patients at higher risk of re-rupture or those requiring expedited rehabilitation, such as athletes. However, the increased risk of complications must be weighed.

• Conservative Management: Suitable for patients with lower activity demands or those at higher risk for surgical complications. The slightly elevated re-rupture rate is counterbalanced by a lower complication profile.

Advancements in functional rehabilitation protocols have enhanced outcomes in conservatively managed patients, potentially narrowing the gap between the two treatment modalities.

📌 Conclusion

Both conservative and surgical treatments for Achilles tendon rupture have distinct advantages and limitations. Surgical repair offers a reduced re-rupture rate but carries a higher risk of complications.

Conservative management presents a safer profile concerning complications but with a slightly increased risk of re-rupture. Treatment decisions should be individualized, considering patient-specific factors such as activity level, comorbidities, and personal preferences.