Overview
The Achilles is the tendon that powers push-off: every stride, jump and rise onto the toes runs through it. When it ruptures, the calf can no longer push the foot down. Achilles tendon repair brings the torn ends back together and holds them with strong sutures so the tendon heals at its original length, which is what preserves calf strength. The goal is a tendon that is neither too long, which leaves permanent weakness, nor re-ruptured.
Dr. O'Donnell performs the repair as an outpatient at Bayside Surgery Center, ideally within the first one to two weeks after injury, and most patients return to running and sport at 6 to 9 months.
Who It's For
Repair is offered for a complete Achilles rupture, confirmed by a palpable gap and a positive Thompson test (squeezing the calf fails to move the foot), in patients who want the best chance of full push-off strength: athletes, active adults, and anyone whose work demands a strong calf. Surgery lowers the re-rupture rate compared with non-operative treatment and gives a more reliable return of strength, at the cost of a wound. Delayed presentations, where the ends have retracted and do not come together on ultrasound, are usually treated surgically, because a gap of that kind does not close on its own.
Non-operative treatment in a boot with heel wedges, following essentially the same early-motion protocol, is a reasonable choice for patients who are less active or have diabetes, smoke, or have skin problems that raise wound risk, provided the tendon ends come together on ultrasound with the foot pointed down. Dr. O'Donnell reviews both options at the first visit.
An ultrasound or MRI report of an Achilles tear is not by itself the reason to operate. Dr. O'Donnell recommends repair when the Thompson test, the palpable gap and the imaging all describe the same complete rupture, and the patient's activity and health favor surgery over the boot. The Achilles injury page covers how the diagnosis is confirmed and which findings on the scan are background.
What the Procedure Involves
The operation is done under a nerve block with sedation or a general anesthetic, with the patient lying face down. The open repair uses an incision of several centimeters along the inner side of the tendon, through which the frayed ends are trimmed and sewn together with a locking suture in heavy braided material, reinforced with finer sutures around the edge. The minimally invasive repair uses a much smaller incision at the rupture site and a guide that passes the sutures through the tendon under the skin, reducing wound complications; it is used when the tendon ends are healthy and the tear is in the mid-portion. In both, the tendon is repaired with the foot pointed down so that its resting length matches the other side. The operation takes about 45 minutes to an hour, the leg goes into a splint with the foot pointed down, and the patient goes home the same day on crutches.
Risks & How They Are Minimized
Re-rupture is the outcome the protocol is built to prevent: the tendon is held in plantarflexion with heel wedges that are removed gradually, no stretching past neutral is allowed for 6 weeks, and explosive loading is avoided until strength has returned. Elongation, a tendon that heals long and leaves the calf weak, is prevented by repairing at the correct tension and by the same restriction on early stretching. Wound healing problems are the risk specific to the Achilles, because the skin over it has a thin blood supply; they are minimized by careful incision placement, a minimally invasive approach when appropriate, and elevation in the first two weeks. Sural nerve irritation, numbness on the outer side of the foot, is a risk of the minimally invasive technique and is guarded against by the instrument path. Deep-vein thrombosis is a real concern with a splinted leg and is prevented with a blood thinner and early knee and hip motion. Infection is uncommon and is addressed with a pre-incision antibiotic.
Recovery & Rehabilitation
Early care protects the repair by holding the ankle in plantarflexion with heel wedges and returning it gradually to neutral, while weight bearing progresses in a boot.
| Phase | Timing | What happens |
|---|---|---|
| Protection | Weeks 0–2 | Splint or boot in plantarflexion; non-weight-bearing or protected weight bearing on crutches. Toe, knee and hip motion, straight-leg raises, elevation. Advance with wound healing and controlled swelling. |
| Protected motion & weight bearing | Weeks 2–6 | Progressive weight bearing in the boot with heel lifts, wedges removed gradually. Active plantarflexion and dorsiflexion to neutral only, gentle inversion and eversion, sub-maximal isometric plantarflexion, scar management. Advance with full weight bearing in the boot and dorsiflexion to neutral. |
| Motion & strength | Weeks 6–12 | Boot weaned to a shoe with a heel lift that is phased out. Dorsiflexion progressed gradually, calf strengthening from isometric to concentric and seated to standing, balance work, stationary bike. Advance with normal gait out of the boot, full motion, and heel raises progressing toward single-leg. |
| Advanced strengthening | Months 3–6 | Progressive resistive calf strengthening, single-leg heel raises, low-impact conditioning. Jogging progression late in the phase if criteria are met. Advance when single-leg heel-raise strength and endurance approach symmetry with no pain under load. |
| Return to sport | Months 6–9 | Running and plyometric progression, agility and sport-specific drills. Cleared on symmetric strength and hop and heel-raise testing, typically at 6 to 9 months. |
Desk work is possible within about a week with the leg elevated. Driving waits until out of the boot with a normal gait, about 6 to 8 weeks for a right leg. Cycling and swimming from about 3 months, jogging from 5 to 6 months once criteria are met, and running sport at 6 to 9 months.
Protocol summary
Precautions: splint or boot in plantarflexion with heel wedges, removed gradually; no passive dorsiflexion past neutral for the first 6 weeks; weight bearing progressed in the boot per protocol with no barefoot walking early; no sudden or explosive loading and no passive stretching into dorsiflexion early.
Criteria: the boot is weaned once weight bearing in it is full and dorsiflexion reaches neutral; strengthening advances with a normal gait out of the boot and full motion; jogging begins when single-leg heel-raise strength and endurance approach symmetry; return to sport requires symmetric strength and hop and heel-raise testing, typically at 6 to 9 months with surgeon clearance.
Physical Therapy Protocol
Achilles Tendon Repair PDF ↗Frequently Asked Questions
Is surgery necessary for a ruptured Achilles?
Not always. Non-operative treatment in a boot with heel wedges heals the tendon in most patients when the ends come together with the foot pointed down. Surgery still gives the lowest re-rupture rate and the most reliable return of push-off strength, which is why Dr. O'Donnell recommends it for athletes and active adults.
How long are you in a boot after Achilles surgery?
About 6 weeks in a splint and then a boot with heel wedges, with weight bearing in the boot from around week 2 and the wedges removed one at a time as the ankle returns to neutral. The boot is weaned to a shoe with a heel lift over weeks 6 to 12, and the lift is phased out as calf strength returns.
When can I walk normally after Achilles repair?
Full weight bearing in the boot is usually reached by 6 weeks, and a normal gait in a shoe by about 8 to 12 weeks. Walking without a limp depends on calf strength, which is rebuilt with heel raises over months 3 to 6.
When can I run after Achilles tendon repair?
A jogging progression starts late in the advanced strengthening phase, around 5 to 6 months, once single-leg heel-raise strength and endurance are close to the other side and there is no pain under load. Running sport and plyometrics follow over months 6 to 9, with clearance based on symmetric strength and hop testing.
What is the re-rupture rate after Achilles repair?
Low, in the low single digits in the published literature, and lower than non-operative treatment. Most re-ruptures happen in the first 3 months from a slip, a stumble or a stretch past neutral before the tendon has matured, which is why the boot, the wedges and the no-stretching rule are followed strictly through week 6.
This page is for general education and is not a substitute for a medical evaluation. The right procedure depends on your individual diagnosis, anatomy, and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.