Torn Achilles: Recovery Time and Tips from Physiotherapist!

You have just experienced an Achilles tendon rupture and are wondering about the recovery time, the duration of the healing process, the time off work, with or without surgery in the case of a partial rupture or a complete tear.

As a physiotherapist, I will address the most frequently asked questions from patients after an Achilles torn tendon. I rely on my experience as physical therapist and in-depth research from international scientific publications (all references at the end of the article).

As always, I am available to address any comments or questions you may have at the end of the article, in the comments section!

Happy reading! 🙂

What does a torn Achilles tendon look like?

Every year, millions of people experience an Achilles tendon rupture, with 5 to 50 people out of 100,000 affected annually (Amendola 2022).

The Achilles tendon is the most commonly injured tendon in the human body (Tarantino 2020).

What are the causes of an Achilles tendon rupture?

Several studies are trying to identify who is more prone to Achilles tendon ruptures.

We have evidence of low to very low certainty that you are more likely to have an Achilles tendon rupture if:

• You are taking certain medications: steroids, quinolones, and oral bisphosphonates.
• You have certain medical conditions: chronic tendon inflammation and Achilles tendinopathy, diabetes, hyperparathyroidism, kidney failure.
• You have a history of musculoskeletal injuries.
• You regularly engage in sports activities.
• It is springtime.
• You have genetic predispositions.

Source: Xergia 2022

An Achilles tendon rupture generally occurs during activities or events that apply sudden or excessive pressure on the tendon:

• Sports: basketball, tennis, football, sprinting, and jumping.
• Intense physical activity such as trail running or a marathon in running.
• Trauma to the Achilles tendon.
• Accidents or falls that cause a sudden ankle flexion, putting tension on the Achilles tendon.

What are the symptoms of an Achilles tendon rupture?

The symptoms of a partial or complete Achilles tendon rupture often include:

• Sudden, intense, and sharp pain at the back of the leg or base of the heel. Some describe it as a whip-like or snapping sensation.
• Swelling: You may notice significant swelling at the back of the leg or around the ankle. This can occur shortly after the injury or within hours.
• Difficulty walking or standing on tiptoes.
• A popping or tearing sensation at the time of injury.
• Bruising (ecchymosis) around the affected area.

If you consult a healthcare professional with these symptoms:

• They will ask you questions.
• They will conduct a clinical examination.

Certain clinical tests are performed and are quite sensitive.

1️⃣ Thompson test:

• You lie on your stomach, with your feet slightly protruding from the surface.
• Your doctor/physiotherapist locates the calf and applies slight pressure on the calf muscle just below where the Achilles tendon should be present.
• At the same time, the practitioner’s other hand is placed on your foot.
• Your doctor/physiotherapist applies pressure with the hand on the calf to trigger a contraction of the gastrocnemius muscle, which is linked to the Achilles tendon.
• If the Achilles tendon is intact, the muscle contraction will result in foot movement, with normal plantar flexion. This means that the foot will move downward, toward the toes.
• In the case of an Achilles tendon rupture, the muscle contraction will not cause any foot movement. There will be no observable plantar flexion.

2️⃣ Decreased resting tension of the tendon in a lying position.

3️⃣ Palpation to assess the presence or absence of a tendon defect.

To confirm the diagnosis, an ultrasound of the Achilles tendon is typically performed. This examination is highly sensitive, which means that if there is no evidence of partial or complete rupture on the ultrasound, the likelihood of a rupture is very low.

Source: Amendola 2022

Partial rupture of the Achilles tendon

A partial rupture of the Achilles tendon occurs when the tendon is partially torn but not completely severed:

• One part of the tendon remains intact.
• The other part may show a partial tear or widening.
• The severity of a partial rupture can vary, ranging from a minor injury to a more significant tear.

A partial rupture is less common and slightly more challenging to diagnose (Gatz 2020).

Total rupture of the Achilles tendon

A total rupture of the Achilles tendon occurs when the tendon is completely severed, separating it into two distinct parts.

This can happen at any level of the tendon.

What is the treatment for an Achilles tendon rupture?

An Italian research team (Amendola et al. 2022) recently sought to synthesize all knowledge about the diagnosis and treatment of an acute Achilles tendon rupture.

They found the following number of studies based on the type of treatment evaluated:

This graph shows that, as often seen, there are more studies evaluating the outcomes and follow-ups of surgical treatments (operative treatment, minimally invasive surgery, and open repair) than non-operative treatments.

I will, therefore, partially rely on their results to present the different treatments for a total or partial Achilles tendon rupture.

Surgery after torn Achilles tendon?

In some cases, surgery is proposed as a treatment option for an Achilles tendon rupture. There are two main types of surgical techniques for an Achilles tendon rupture:

1. Open repair: An incision is made along the area of rupture, and the two ends of the tendon are realigned. The tendon is then sutured using absorbable or non-absorbable stitches. In some cases, grafts may be necessary.
2. Percutaneous or minimally invasive technique: The surgical team accesses the area without making a large incision, using endoscopy. They then perform similar types of sutures.

Here are the conclusions of a research team that compiled 12 trials involving more than 800 people after an Achilles tendon rupture, comparing the effectiveness of surgery versus conservative treatment (without surgery):

Surgical treatment for acute Achilles tendon rupture results in a significant reduction in the risk of a new rupture compared to non-surgical treatment, but it also leads to a significant increase in the risk of other complications, including wound infection. This complication can be reduced by performing percutaneous surgery.

Cochrane 2015

Another research team conducted a more recent study on the same subject, involving a sample of just over 1000 people affected by an Achilles tendon rupture:

In patients suffering from an Achilles tendon rupture, surgery (open repair or minimally invasive surgery) did not show better results than non-surgical treatment at 12 months.

The number of tendon ruptures was higher in the non-surgical group (6.2%) than in the open repair or minimally invasive surgery group (0.6% in each case). There were 9 nerve injuries in the minimally invasive surgery group (5.2% of patients) compared to 5 in the open repair group (2.8%) and 1 in the non-operative group (0.6%).

Myhrvold 2022

If the surgical team seeks your input to decide whether or not to proceed with the operation, these conclusions should help in your decision-making process.

And notably, this conclusion from the recently synthesized research team on Achilles tendon ruptures:

Surgical treatment clearly reduced the number of re-ruptures, albeit at the expense of a higher rate of complications. However, minimally invasive surgery still resulted in fewer complications and infections, making it the overall best treatment strategy for patients with functional demands.

Amendola 2022. Important to consider: these conclusions are from a team of surgeons.

Conservative / orthopedic treatment: immobilization, cast, brace?

If there is no surgery, a conservative treatment for the Achilles tendon will be implemented, which I will describe here.

Even if you undergo surgery, you may also have immobilization as part of the treatment.

Immobilization involves wearing a cast, brace, or walking boot.

Your foot may sometimes be positioned in slight equinus (toes pointing downward) to put the least possible tension on the Achilles tendon and promote healing. This can be achieved through:

• An equinus brace.
• Wearing 2 cm heel lifts for a few weeks, either placed in your shoe or secured with bandages. Afterward, you can decrease to 1 cm heel lifts to gradually reduce the tendon’s shortened position.

Our bodies are capable of allowing the Achilles tendon to heal even if it has been completely ruptured without any specific intervention. The key is not to impede the healing process by exerting too much stress on the tendon (e.g., through walking, jumping, or excessive ankle flexion).

Can you walk with an Achilles tendon rupture?

There are two main approaches in the rehabilitation of an Achilles tendon rupture, whether it’s operated or non-operated:

1. Early weight-bearing: You are allowed to start walking and putting weight on your foot in the first four weeks following the rupture.
2. Delayed weight-bearing: You are allowed to start walking gradually and putting weight on your foot only after at least four weeks or even longer.

When research teams compare the effectiveness of these two approaches, they find no significant difference in terms of recurrence of rupture, return to pre-injury sports activity, time to return to work, or frequency of adverse effects.

In any case, you can walk after an Achilles tendon rupture, using crutches. However, depending on the medical team you encounter, they may recommend partial weight-bearing or avoiding putting weight on the foot for a few weeks (or advising you to do touch-down weight-bearing, which means not putting much weight on the foot).

Source: Zhang 2021, Ghaddaf 2022

Personally, considering this data, I discuss with my patients the potential benefits of early weight-bearing: faster resumption of walking and easier mobility. Afterward, it’s up to each individual to make their decision based on their own assessment of the balance between benefits and risks.

Rehabilitation Protocol, Physical Therapy?

In the vast majority of cases, you will be prescribed physical therapy sessions with a Physical Therapist (PT). This means that a doctor or surgeon will recommend that you schedule an appointment with a PT to supervise your rehabilitation.

It is advisable to schedule an appointment promptly (within 2 weeks after the rupture), especially if you are unsure about what activities are allowed or not during this tendon healing phase, whether you have had surgery or not.Your physical therapist will:

• Answer your questions
• Provide reassurance
• Guide you on what you can or cannot do at home on a daily basis to:
  • Maintain your overall physical fitness, including muscle and cardiovascular conditioning
  • Maintain ankle (and other joint) flexibility based on post-operative instructions provided to you
  • Sustain and recover strength in the muscle groups that will be less active for a few weeks
  • Teach you how to move with crutches, including appropriate gait and weight-bearing based on instructions and your own assessment of risk
  • Alleviate your pain, improve sleep, and reduce ankle swelling

At the beginning, if you are unable to visit the clinic, home-based physical therapy sessions are possible (provided you can find a home-based PT, which is becoming more common).

Starting rehabilitation early (within 2 weeks after the injury) reduces the risk of re-rupture compared to starting later.

Source: Seow 2022

Pain after Achilles tendon surgery: Normal? How long?

Whether you have undergone Achilles tendon surgery or not, it is entirely normal to experience pain in the days (and sometimes weeks) following the tear.

The pain is mainly due to inflammation: when we have an injury in a certain area of our body, our body automatically triggers reactions to repair the damaged zone.

Thanks to inflammation, substances necessary for the healing of the tendon are brought to the damaged area. In exchange, fluids accumulate at this level, often causing swelling and pain.

If you have undergone surgery, inflammation may be slightly more significant initially because the surgical procedure may have also affected some tissues.

Another possible source of pain is that nerves passing near the injury may be stimulated by it, triggering pain.

Medication or non-medication treatments can help relieve pain while things return to normal, typically within a few days to a few weeks after the Achilles tendon rupture.

What is the healing time for a partial or complete rupture of the Achilles tendon?

Many people (and you probably are one of them) wonder how long it takes to heal from a partial or complete rupture of the Achilles tendon.

To answer this question, we need to agree on what we mean by “healing time” or “recovery time”. Often, different things are considered as part of the healing process.

Here is a table summarizing the various stages and healing times after this type of tendon injury.

Stage	How long does it take?
Less pain	Few days to few weeks
Tissue begins to heal	Immediately; significant metabolite concentrations at 2 weeks indicate healing process is on track (Valkering 2017)
Walking with crutches without bearing weight	Immediately
Walking with crutches and bearing weight on the affected foot	Immediately to few weeks
Walking without crutches	Few weeks to few months
Driving a car	Few weeks to few months
Returning to work	Immediately to few months

And a slightly more theoretical presentation of the stages of tendon healing and remodeling:

Stages of Healing	Duration
Inflammatory phase (Days 1-7)	Gradual reduction of pain and swelling; starts to bear weight with crutches or walking boot.
Proliferative phase (Weeks 2-6)	Improved mobility and reduced swelling; may transition from a cast to a walking boot.
Remodeling phase (Weeks 6-12)	Progressive weight-bearing; continued physical therapy; increased strength and flexibility.
Return to activity (Months 3-6)	Gradual return to regular activities and exercise; monitoring for any lingering symptoms.
Full recovery (Months 6-12)	Able to resume normal activities without restrictions; strength and flexibility almost fully restored.

The total healing time (including scar formation and return to all pre-injury activities) for an Achilles tendon rupture, with or without surgery, is approximately 3 to 9 months.

What is the duration of work leave after an Achilles tendon rupture?

In France, the Social Security system creates guidelines for doctors regarding recommended work leave durations after certain injuries or surgeries. However, there are no specific guidelines for Achilles tendon ruptures.

Of course, the duration of work leave will vary significantly depending on the type of job you have (office job vs. physically demanding work).

Here are some data from the United States 🇺🇸 on return to work after an Achilles tendon rupture:

• The duration of work leave was 59 days (2 months) after surgical treatment and 108 days (almost 4 months) after non-surgical treatment (Metz 2008).
• Patients whose Achilles tendon rupture was surgically repaired returned to work 19 days earlier than patients who underwent non-surgical treatment (Soreceanu 2012).

Are there any long-term consequences after an Achilles tendon rupture?

Most people recover without long-term consequences after an Achilles tendon rupture. Let’s be optimistic: you will likely be part of this group 🙂!

However, a tendon that has already been ruptured has a higher risk of re-rupturing, whether it was surgically repaired or not. This is referred to as “iterative rupture” of the Achilles tendon in such cases.

Nevertheless, this still applies to a minority of people.Here are the statements and findings of a Norwegian 🇳🇴 research team that followed over 500 people with Achilles tendon rupture for 1 year after the injury:

• Ruptures occurred in 6.2% of patients in the non-surgical group, 0.6% in the open repair group, and 0.6% in the group with minimally invasive surgery; no patient had more than one rupture.
• Half of the ruptures occurred within the first 10 weeks (range, 2 to 28) after the injury.
• There were 9 nerve injuries in the minimally invasive surgery group (in 5.2% of patients), 5 in the open repair group (in 2.8%), and 1 in the non-surgical group (in 0.6%).
• The incidence of other adverse events was similar in both groups.

Myhrvold 2022

In the year following the Achilles tendon rupture, approximately 1 to 6% of people experience a new rupture of the Achilles tendon.

Running and Sports After a Torn Achilles: When?

Most people who experience an Achilles tendon rupture (total or partial) and were active in sports before the injury resume sports activities in the months following the injury. This includes competitive or high-level sports.

For example, here are the rates of return to sports in sports that are among the most demanding for the Achilles tendon:

The rate of return to sports is 70-80% after a partial or total Achilles tendon rupture, whether treated surgically or non-surgically (Tarantino 2020).

Running is less demanding on the Achilles tendon than some of the sports mentioned here. Therefore, it is reasonable to assume that the rate of return to running is 80% or even higher.

Before considering running again, it is best to first resume walking without crutches on various terrains, including unstable surfaces, uphill, and downhill. Generally, this is possible (if all goes well) about 2 to 3 months after the rupture.

Running can then be gradually resumed:

• Start with 5 minutes,
• Observe how the body reacts during and after the run,
• Gradually increase the duration or intensity if everything feels okay.

Physical therapists are among the professionals who can supervise your sports resumption if you feel the need for assistance.

How to prevent an Achilles tendon rupture?

Addressing the question of how to prevent an (additional) Achilles tendon rupture involves considering the modifiable risk factors for such an injury.

There are some studies on this subject, which I mentioned in the section on the causes of an Achilles tendon rupture. However, the evidence in this regard is weak.

Moreover, acting on modifiable factors might require, for example, refraining from engaging in sports activities that put significant strain on the Achilles tendon, such as jumping! This is not necessarily what people want.

The most reasonable approach, in my opinion, is to introduce any new activity very gradually: the type of activity, intensity, frequency of practice, and duration of sessions. This is particularly important for activities involving jumping (team sports, athletics, racquet sports, trampoline, etc.).