A tendon is a strong, fibrous connective tissue connecting muscle to bone throughout the body. Primarily composed of collagen, these structures transmit the mechanical force generated by muscle contraction into skeletal movement. Tendons are susceptible to injury, which falls into two categories: acute tears (sudden ruptures) and chronic tears (long-term degeneration due to repetitive strain). The necessity and method of repair are dictated by the tear’s severity and the quality of the remaining tissue.
Non-Surgical Management of Tendon Tears
Non-surgical management is often the first line of treatment for partial tears or for patients with lower functional demands. This approach protects the injured tendon while encouraging natural healing. Treatment begins with managing pain and swelling, often utilizing the RICE protocol: Rest, Ice, Compression, and Elevation.
Immobilization uses a cast, splint, or specialized boot to hold the affected joint in a position that brings the torn tendon ends closer together. For example, an Achilles tendon tear is often immobilized with the foot pointing downward (plantar flexion) to minimize tension on the repair site. Non-steroidal anti-inflammatory drugs (NSAIDs) may be used to manage pain and reduce inflammation in the acute phase of the injury.
A structured physical therapy program is the cornerstone of non-operative repair. Rehabilitation focuses on strengthening the surrounding muscles and tendons to provide mechanical support. For an Achilles tear, a functional rehabilitation protocol allows for early, controlled weight-bearing within the protective boot. This controlled loading stimulates the tendon to heal effectively, ensuring the newly formed tissue aligns correctly and gains strength.
Surgical Methods for Tendon Reconstruction
Surgical reconstruction is required when a tendon is completely ruptured or when a chronic tear results in significant tissue loss. General steps involve making an incision, identifying the torn tendon ends, and removing damaged or scarred tissue in a process called debridement. The specific technique for re-attachment is chosen based on the injury’s location and extent.
A direct repair is performed for fresh, acute tears where the tendon ends are relatively close together. This technique involves sewing the two torn ends back together using strong, non-absorbable sutures. The Modified Kessler suture technique is a widely used method, creating locking or grasping loops that pass through the core of the tendon for a strong, multi-strand repair. This core suture is often supplemented with a running peripheral suture to improve alignment and minimize gapping, which is important for preventing adhesions.
If there is a large gap between the torn ends, or the tendon quality is poor, a graft procedure or tendon transfer becomes necessary. In a grafting procedure, the surgeon bridges the defect using a piece of tendon harvested from another part of the patient’s body (autograft). Alternatively, tissue from a donor (allograft) may be used. The graft is anchored at both ends to restore the tendon’s full length and function.
A tenodesis procedure involves re-routing a nearby, less critical tendon or securing the tendon directly to the bone. When re-attaching a tendon to the bone, such as in a rotator cuff repair, suture anchors are commonly used. These small implants, which can be metallic or bioabsorbable, are drilled into the bone and contain strong sutures. The surgeon then uses these sutures to firmly secure the tendon against the bone surface, establishing a stable connection until biological healing can occur.
Structured Rehabilitation After Repair
The success of any tendon repair depends on a highly structured and phased rehabilitation program. The recovery process is divided into distinct stages that balance protecting the fragile repair with controlled movement to prevent scar tissue formation. The initial protection phase typically lasts for the first few weeks, focusing on pain management and strict immobilization to allow the tendon’s biological healing response to begin.
Following the initial period, the controlled motion phase begins, often between two and six weeks post-repair, and is guided by a physical therapist. During this time, the goal is to gently initiate movement to encourage tendon gliding and prevent the formation of dense adhesions that can restrict motion. Specific protocols, such as the early active motion approach for hand tendons, use specialized splints and exercises to ensure the repaired tendon moves through a small, controlled range of motion.
As the tendon gains strength, the strengthening phase is introduced, usually starting around six to twelve weeks. This involves progressive resistance exercises to rebuild muscle strength and tendon load capacity. Load progression must be carefully managed, as the repaired tendon is biomechanically weakest between five and twenty-one days post-repair. The final functional phase focuses on returning the patient to full activity, including sport-specific or work-related movements, with a complete return to strenuous activity often taking four to six months.