Curr Rev Musculoskelet Med (2008) 1:161–164 DOI 10.1007/s12178-008-9025-4 The ruptured Achilles tendon: operative and non-operative treatment options Joshua A. Metzl Æ Christopher S. Ahmad Æ William N. Levine Published online: 20 March 2008 The Author(s) 2008 Abstract 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 6–8 weeks postoperatively, newer studies have shown excellent results with early weight- bearing, and this is quickly becoming the standard of care amongst many physicians. Keyword Achilles tendon Introduction The Achilles tendon is the thickest and strongest tendon in the human body. Like any other tendon in the body, however, it is susceptible to overuse and rupture (Fig. 1a and b). Achilles tendon ruptures are increasing in fre- quency 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, J. A. Metzl C. S. Ahmad W. N. Levine (&) Department of Orthopedic Surgery, Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, 622 West 168th Street, PH1117, New York, NY 10032, USA e-mail: WNL1@columbia.edu depending on the social environment [1]. 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. The spectrum of Achilles tendon ruptures includes both acute and chronic injuries. Treatment options include operative repair with postoperative immobilization, oper- ative 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 10–30% [2]. Other drawbacks of non- operative treatment include decreased plantar ﬂexion and decreased endurance when compared to surgically repaired tendons [3]. Some reports, however, suggest that the results of non-operative management are equivalent to operative repair [4–6]. 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 [9]. Complications of operative repair include infection and poor wound healing. Ultimately, decision-making regard- ing the treatment options relies on many factors including patient age, chronicity of the tear, functional demand, medical comorbidities, and patient expectations. Anatomy The Achilles tendon is composed of tendinous ﬁbers con- tributed by the gastrocnemius and soleus muscles. These ﬁbers then coalesce and insert on the calcaneal tuberosity. The blood supply to the Achilles tendon has three principle sources: the musculotendinous junction, the osseous inser- tion, and multiple vessels in the mesotenon [10]. Injection