(Golden Oldie) Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study

Key points

1. 01No statistically significant difference between surgical and nonsurgical groups in primary outcome (ATRS) at 3, 6, or 12 months
2. 02Surgical group had zero reruptures versus 5 (10%) in the nonsurgical group, though this difference did not reach statistical significance (P = .06)
3. 03Surgical group performed significantly better on drop countermovement jump (P = .003) and hopping (P = .040) at 12 months
4. 04Both groups still had functional deficits and reduced quality of life at 12 months compared to pre-injury levels
5. 05Six superficial wound infections (12%) occurred in the surgical group, all resolving with antibiotics and wound care

How it was conducted

Design

Single-centre randomized controlled trial; Level of evidence 1

Participants

100 patients (86 men, 14 women; mean age 40 years) with acute total Achilles tendon rupture

Groups

Surgical repair (n = 49) with immediate weightbearing and accelerated rehabilitation from day 1; nonsurgical brace treatment (n = 51) with immediate weightbearing

Primary outcome

Achilles tendon Total Rupture Score (ATRS; 0-100) at 3, 6, and 12 months

Secondary outcomes

Rerupture rate, functional jump and strength tests, FAOS subscales, physical activity level (PAS), EQ-5D quality of life

Follow-up

12 months

What they found

• ATRS at 12 months: surgical median 89 (mean 82 +/- 20) vs nonsurgical median 90 (mean 80 +/- 23); no significant difference (P = .68)
• ATRS at 3 months: surgical median 44 vs nonsurgical median 33; no significant difference
• Drop countermovement jump LSI at 12 months: surgical mean 91 +/- 15 vs nonsurgical mean 82 +/- 13; 95% CI 0.03-0.15, P = .003
• Hopping LSI at 12 months: surgical mean 103 +/- 36 vs nonsurgical mean 86 +/- 36; 95% CI 0.01-0.33, P = .040
• Reruptures: 0 in surgical group vs 5 (10%) in nonsurgical group; P = .06 (not statistically significant)
• Superficial wound infections: 6 (12%) in surgical group, 0 in nonsurgical group
• Deep vein thrombosis: 1 (2%) in surgical group, 2 (4%) in nonsurgical group
• EQ-5D at 12 months: surgical median 1.00 (mean 0.91 +/- 0.17) vs nonsurgical median 1.00 (mean 0.90 +/- 0.13); P = .30
• Both groups showed significantly lower EQ-5D at 12 months compared to pre-injury (surgical P = .03; nonsurgical P = .03)
• Physical activity (PAS) at 12 months: no significant difference between groups (P = .85); neither group differed significantly from pre-injury level

Limitations

• Not blinded; the single physical therapist available could not be kept unaware of treatment allocation
• Surgery and accelerated rehabilitation were combined, making it impossible to isolate which factor drove differences in functional outcomes
• Actual weightbearing load was not measured, only encouraged, so protocol adherence cannot be confirmed
• Sample size may have been insufficient to detect clinically meaningful differences (possible type II error), particularly for rerupture rates and functional outcomes

Why it matters

For patients

Patients who choose surgery can expect a safe procedure with a very low rerupture risk, but should not expect dramatically better pain relief or return to sport than with high-quality nonsurgical care at one year.

For clinicians

Both treatments are reasonable options; surgery may offer a functional edge on explosive tasks and reduces rerupture risk numerically, but the primary patient-reported score did not differ, and surgical wound complications occurred in 12% of the surgical group.

For readers

This RCT supports shared decision-making, with treatment choice guided by individual patient preference, activity demands, and tolerance for surgical risk rather than a clear superiority of either approach.