the achilles tendon is the thickest and strongest tendon in the human body . like any other tendon in the body
achilles tendon ruptures are increasing in frequency due to an overall increase in athletic activity , especially in men in their thirties and forties .
about 18 out of 100,000 humans rupture their achilles tendon each year , depending on the social environment .
acute ruptures of the achilles tendon occur most often in men in the third and fourth decades of life who intermittently participate in athletic activity . 

1(a ) and ( b)intra - operative view of ruptured achilles tendon ( a ) and ( b)intra - operative view of ruptured achilles tendon the spectrum of achilles tendon ruptures includes both acute and chronic injuries .
treatment options include operative repair with postoperative immobilization , operative repair with accelerated rehabilitation using early weight bearing , as well as non - operative treatment .
clinical evaluations of non - operative treatment have demonstrated a re - rupture rate of 1030% .
other drawbacks of non - operative treatment include decreased plantar flexion and decreased endurance when compared to surgically repaired tendons . some reports , however , suggest that the results of non - operative management are equivalent to operative repair [ 46 ] .
several current studies favor operative repair via open or percutaneous techniques in younger , active patients who wish to return to pre - injury activities [ 7 , 8 ] .
in addition , re - rupture is less in surgically repaired achilles tendons . complications of operative repair include infection and poor wound healing .
ultimately , decision - making regarding the treatment options relies on many factors including patient age , chronicity of the tear , functional demand , medical comorbidities , and patient expectations .
the achilles tendon is composed of tendinous fibers contributed by the gastrocnemius and soleus muscles .
the blood supply to the achilles tendon has three principle sources : the musculotendinous junction , the osseous insertion , and multiple vessels in the mesotenon .
injection studies using computer assisted imaging show a reduction in the number and the mean relative area of mesotenal vessels in the mid - section of the tendon .
similarly , the number of intratendinous vessels is fewest 4  cm from the calcaneal insertion .
diagnosis of an acute achilles tendon rupture can usually be made by history and physical examination alone .
mri or ultrasound can be helpful in cases of suspected rupture for pre - operative planning , but is usually unnecessary
. the patient will often describe abrupt severe pain over the tendon with an activity requiring forceful plantar flexion such as while playing tennis .
pop  or have the sensation of being hit in the back of the heel .
physical examination signs that suggest achilles tendon rupture include weakness of plantar flexion and a palpable defect over the posterior calf .
a thompson test is performed by squeezing the calf and observing motion at the foot . with an intact tendon
with a rupture , plantar flexion does not occur with squeezing the calf   ( fig . 
note lack of plantar flexion with squeezing of the calf demonstrating a ruptured achilles tendon normal thompson s test .
note lack of plantar flexion with squeezing of the calf demonstrating a ruptured achilles tendon controversy regarding operative versus non - operative treatment focuses on re - rupture rates and wound complications related to surgery .
khan et  al . compared the results of all randomized trials comparing surgical and conservative management in a meta - analysis .
results gave a pooled re - rupture rate of 3.5% in the operatively treated group and 12.6% in the non - operative group .
complications such as adhesions , altered sensation , and wound infection , however , were more common in operatively treated patients with 34.1% in the operative group versus 2.1% in the non - operative group [ 6 , 13 , 14 ] . in a large prospective study of 196 consecutive patients with acute achilles tendon
ruptures that were treated with 8  weeks of casting and immediate postoperative weightbearing , the re - rupture frequency was 7% .
this is only slightly higher than most results in operatively treated groups [ 24 , 6 , 15 ] . due to the similar percentage of re - rupture between most studies advocating surgery and their promising results with non - operative management , ingvar et  al .
question the necessity for surgical repair of achilles tendons , with all of its risks and high cost . in 1977 ,
this technique involves passing a suture through small stab wounds above and below the tendon tear . the original article reported on 18 patients with only two minor complications .
prospectively studied 134 percutaneous repairs and found a rerupture rate and return to pre injury activities comparable to open procedures .
percutaneous repair has the added benefit of being done under local anesthesia without a tourniquet .
. showed no significant difference between open compared to percutaneously repaired tendons , but a significantly higher rate of wound infection in the open group compared to the percutaneous group .
historically , patients were immobilized in a rigid cast for at least 46  weeks to allow for presumed tendon healing .
current trends , however , favor minimizing postoperative immobilization and focus on early weightbearing with excellent results . in a rat model of tendon
were able to show that physical activity speeds up tendon healing as compared to plaster immobilization .
this suggests that that there may be some stimulatory effect of mechanical loading on tendon healing . in a clinical prospective study with full postoperative weight bearing in a controlled ankle motion walker accompanied by active stretching ,
jacob and paterson showed few minor complications , high patient satisfaction , and no re - ruptures .
patients with both acute and chronic tears repaired with an open technique did equally well under this treatment protocol . in their meta - analysis of randomized trials comparing early postoperative weightbearing with cast immobilization , suchak et  al . found no difference in re - rupture rates and more excellent rated subjective patient responses .
patients preferred the early function protocol with a mobile cast for multiple reasons including a decrease in leg edema , the ability to bear weight , and easier and faster ability to obtain normal gait after removal of the cast .
divided their treatment groups into three sections based on the number of days between achilles tendon rupture and surgery : acute tears ( < 7  days ) , sub chronic tears ( > 7  days but < 4  weeks ) , and chronic tears ( > 4  weeks ) .
all patients resumed their normal activities within 100  days of operative repair , regardless of time until surgery .
thus , according to this study , there does not appear to be an advantage of early operative repair over delayed surgical treatment .
the main concern to prolonged treatment delay after achilles tendon rupture is weakness of plantar flexion .
controversy regarding operative versus non - operative treatment focuses on re - rupture rates and wound complications related to surgery .
khan et  al . compared the results of all randomized trials comparing surgical and conservative management in a meta - analysis .
results gave a pooled re - rupture rate of 3.5% in the operatively treated group and 12.6% in the non - operative group .
complications such as adhesions , altered sensation , and wound infection , however , were more common in operatively treated patients with 34.1% in the operative group versus 2.1% in the non - operative group [ 6 , 13 , 14 ] . in a large prospective study of 196 consecutive patients with acute achilles tendon
ruptures that were treated with 8  weeks of casting and immediate postoperative weightbearing , the re - rupture frequency was 7% .
this is only slightly higher than most results in operatively treated groups [ 24 , 6 , 15 ] . due to the similar percentage of re - rupture between most studies advocating surgery and their promising results with non - operative management , ingvar et  al .
question the necessity for surgical repair of achilles tendons , with all of its risks and high cost .
this technique involves passing a suture through small stab wounds above and below the tendon tear . the original article reported on 18 patients with only two minor complications .
prospectively studied 134 percutaneous repairs and found a rerupture rate and return to pre injury activities comparable to open procedures . complications included complete and partial reruptures , sural neuritis , and superficial wound infection .
percutaneous repair has the added benefit of being done under local anesthesia without a tourniquet .
. showed no significant difference between open compared to percutaneously repaired tendons , but a significantly higher rate of wound infection in the open group compared to the percutaneous group .
historically , patients were immobilized in a rigid cast for at least 46  weeks to allow for presumed tendon healing .
current trends , however , favor minimizing postoperative immobilization and focus on early weightbearing with excellent results . in a rat model of tendon
rupture using wheel running for early tendon motion , bring et  al . were able to show that physical activity speeds up tendon healing as compared to plaster immobilization .
this suggests that that there may be some stimulatory effect of mechanical loading on tendon healing . in a clinical prospective study with full postoperative weight bearing in a controlled ankle motion walker accompanied by active stretching ,
jacob and paterson showed few minor complications , high patient satisfaction , and no re - ruptures .
patients with both acute and chronic tears repaired with an open technique did equally well under this treatment protocol . in their meta - analysis of randomized trials comparing early postoperative weightbearing with cast immobilization , suchak et  al . found no difference in re - rupture rates and more excellent rated subjective patient responses .
patients preferred the early function protocol with a mobile cast for multiple reasons including a decrease in leg edema , the ability to bear weight , and easier and faster ability to obtain normal gait after removal of the cast .
sorrenti et  al . divided their treatment groups into three sections based on the number of days between achilles tendon rupture and surgery : acute tears ( < 7  days ) , sub chronic tears ( > 7  days but < 4  weeks ) , and chronic tears ( > 4  weeks ) .
all patients resumed their normal activities within 100  days of operative repair , regardless of time until surgery .
thus , according to this study , there does not appear to be an advantage of early operative repair over delayed surgical treatment .
the main concern to prolonged treatment delay after achilles tendon rupture is weakness of plantar flexion .
many authors advocate surgical repair , mostly citing decreased re - rupture rates and improved functional outcome .
no studies show a clear advantage to early surgical intervention over delayed repair . waiting for surgical repair for longer than 1  month may show worse functional results postoperatively .
non - operative treatment has shown similar re - rupture rates as compared to surgically repaired tendons .
any patient undergoing achilles tendon repair should understand the inherent risks of an invasive procedure including bleeding , infection , and pain at the surgical site . in our practice , we offer surgical repair of the ruptured achilles tendon for those patients who wish to return to an active lifestyle . while for many years
, patients were rigidly immobilized for 68  weeks postoperatively , new studies have shown excellent results with early weightbearing , and this is quickly becoming the standard of care amongst many physicians .
 the achilles tendon is the strongest and thickest tendon in the human body . like any other tendon in the body , however , it is susceptible to rupture . 
 many surgeons advocate early operative repair of the ruptured achilles tendon , citing decreased re - rupture rates and improved functional outcome . waiting for surgical repair for longer than one month may lead to inferior functional results postoperatively . 
 non - operative treatment has higher re - rupture rates as compared to surgically repaired tendons , but may be the treatment of choice in some patients . while for many years , patients were rigidly immobilized in a non - weightbearing cast for 68  weeks postoperatively , newer studies have shown excellent results with early weightbearing , and this is quickly becoming the standard of care amongst many physicians . 
Introduction
Anatomy
Physical examination
Operative versus non-operative management
Open versus percutaneous repair
Postoperative management
Impact of time until surgery
Conclusion