The Achilles tendon connects the calf muscles to the heel bone. This structure is fundamental for movements like walking, running, and jumping, as it transmits the powerful force generated by the calf muscles to the foot. When the Achilles tendon is severely damaged, either through a sudden, complete tear or long-term degeneration, surgery may be necessary to restore function and mobility. Surgical approaches are categorized based on the nature and severity of the injury, differentiating between acute tears and chronic tissue degradation.
Surgical Repair for Acute Ruptures
Acute Achilles tendon ruptures often occur during sports activities and present as a sudden “pop” in the back of the ankle. Prompt intervention is required to re-establish the connection between the torn ends. The goal of surgical repair is to bring the two separated tendon stumps together so they can heal with enough tension to allow for a strong push-off movement.
Open Repair
Open Repair involves making a single, larger incision along the back of the lower leg to expose the entire rupture site. This traditional approach allows the surgeon a clear view to directly stitch the torn ends of the tendon together using strong non-absorbable sutures. While providing the most mechanically secure repair, this technique carries a higher risk of wound healing complications and infection due to the longer incision length.
Minimally Invasive Repair (MIR)
Minimally Invasive Repair (MIR) aims to achieve the same result through several smaller incisions, often less than an inch each. Specialized instruments and needles are passed through these small openings to weave sutures across the rupture site and pull the tendon ends into contact. This technique is associated with a lower rate of surgical site infection and faster initial recovery due to reduced trauma to the surrounding soft tissues. Both open and minimally invasive techniques result in similar re-rupture rates, though MIR may carry a slightly increased risk of injury to the nearby sural nerve.
Debridement Procedures for Chronic Tendinopathy
Chronic Achilles tendinopathy (tendinosis) involves degradation and thickening of the tendon tissue over time. When non-surgical treatments fail, debridement is performed to remove the diseased tissue and eliminate the source of chronic irritation. The surgeon makes an incision to access the affected area, often near the heel bone. The damaged, non-viable tendon tissue is meticulously excised, leaving the healthy parts intact. This process may also involve removing calcifications or bone spurs (Haglund’s deformity) that irritate the tendon.
If the damaged tissue accounts for less than half of the tendon’s thickness, the remaining healthy tissue is strong enough for simple stitching repair. The goal is to reduce the thickness of the diseased area and restore the tendon’s normal shape and function without the need for additional tissue. The procedure aims to eliminate pain caused by chronic degradation that has resisted conservative care for three to six months.
Tendon Transfer and Reconstruction
When an Achilles injury is severe, involving significant tissue loss, a large gap after rupture, or failure of a previous repair, reconstructive surgery is necessary. In these complex cases, the remaining Achilles tendon is often too weak or short to function properly. This third category of surgery involves using a healthy tendon from another part of the foot to augment or bridge the defect.
The most common method is the Flexor Hallucis Longus (FHL) tendon transfer. The FHL tendon is responsible for flexing the big toe and runs along the inner side of the ankle. The surgeon harvests a portion of this tendon, reroutes it to the heel bone (calcaneus), and anchors it to act as a new or reinforcing Achilles tendon.
The FHL is chosen because its function complements the ankle’s movement, and its loss does not cause a significant deficit in foot function. This transfer is reserved for situations where more than 50% of the Achilles tendon is compromised and requires removal. This invasive procedure provides the necessary strength to restore push-off capability for chronic ruptures or severe tendinosis where primary repair is impossible.
Navigating Post-Surgical Recovery
Regardless of the specific surgical technique used, the recovery process is a structured and lengthy progression aimed at safely restoring strength and mobility. The initial phase focuses on protection and immobilization, with the patient typically placed in a cast or boot immediately after the operation. Weight-bearing is usually avoided for the first few weeks to allow the repaired tendon to begin healing without mechanical stress.
The transition to a removable walking boot with controlled weight-bearing typically begins around the two to six-week mark, depending on the surgeon’s protocol. Physical therapy (PT) is an integral component of recovery, starting with gentle range-of-motion exercises and gradually progressing to strengthening and balance training. The goal of PT is to combat muscle atrophy and regain the full functional capacity of the ankle.
Patients may begin walking and return to most daily activities within three to six months. However, a full return to demanding sports or high-impact activities generally takes between six and twelve months, as the healing tendon continues to mature and strengthen over a full year.