Expert’s Desk · Tendon
Achilles rupture: surgery or not, and when can you play again?
Short answer
An Achilles tendon rupture is a tear of the thick tendon that connects the calf muscles to the heel bone, usually during a sudden jump, explosive start or lunge. People typically feel a "kick" or a pop at the back of the ankle; push-off is then lost when walking and they cannot rise onto the toes on one leg. This should not be waited out as a simple sprain; see a doctor the same day. A careful examination is usually enough for the diagnosis.
Not every Achilles rupture needs surgery. Large randomized trials show that non-surgical treatment with early weight-bearing and controlled movement gives function similar to surgery at one year. Surgery may reduce the risk of re-rupture by a small amount, but adds risks such as infection, wound problems and nerve injury. Whichever route is chosen, long and gradual rehabilitation is at the center of treatment. About four in five people return to sport, but return usually takes more than 6 months, and getting back to the previous level can take over a year. Return is planned on tests, not on the calendar.
Contents
Why does the Achilles tear, and who gets it?
The Achilles is the body's thickest and strongest tendon; it transmits the force of the calf muscles to the heel when you walk, run and jump. Ruptures usually occur a few centimeters above where the tendon attaches to the heel, in a zone with relatively poor blood supply. The typical mechanism is a sudden, forceful calf contraction while the foot pushes off: an explosive first step or jump in basketball, a sprint start in football, a lunge in racket sports, or even a stumble on a stair.
This is not only an injury of professional athletes. In a Danish national registry covering 1994–2013 and 33,160 ruptures, the annual incidence was about 27 to 31 per 100,000 people, with the rise driven mainly by people over 50. Men were affected about three times as often as women, and the average age was around 45. In other words, middle-aged weekend athletes are a key risk group.
Main risk factors:
- Middle age and male sex: the two clearest factors in registry data.
- Sudden, unaccustomed load: returning to intense matches or training after a long break, or a sudden rise in jumping and sprinting.
- Certain medicines: fluoroquinolone antibiotics (such as ciprofloxacin or levofloxacin) have been associated with Achilles tendon disorders in case-control research.
- Pre-existing Achilles pain: chronic tendinopathy may set the stage in some people, but many people report no symptoms before the rupture.
Symptoms: how do you know?
- A sudden "pop" or the feeling of being kicked or hit at the back of the ankle
- Pain and swelling above the heel (pain can be surprisingly mild)
- Weak push-off and a limp when walking
- Inability to rise onto the toes on one leg
- Sometimes a palpable gap along the tendon
A common mistake: many people can still walk and can still point the foot down a little, because other muscles partly help. That is why an Achilles rupture is sometimes mistaken for an ankle sprain or a calf strain and missed.
The most widely used examination is the calf squeeze test (Thompson or Simmonds test): with the patient lying face down, the calf is squeezed; if the tendon is intact the foot moves down, if it is ruptured it does not. In Maffulli's prospective study of 174 patients, this test detected the rupture in 96% (sensitivity); in a comparison group of 28 people without a rupture, it correctly identified the intact tendon in 93% (specificity). Feeling for a gap was less sensitive (73%). In the same study, at least two clinical tests were positive in every patient, which supports using several tests together.
When is imaging needed?
A careful examination is usually enough for the diagnosis. Ultrasound or MRI can help when the examination is unclear, when a partial tear or another problem is suspected, and in planning treatment. Imaging is added to the examination, not used instead of it.
Blood clot risk during treatment
While the leg is immobilized in a boot or cast, the risk of a blood clot in the deep veins (deep vein thrombosis) rises. In a meta-analysis of foot and ankle surgery (Calder et al., 2016), symptomatic clots were found in about 7% of patients with Achilles rupture, and about 35% when screened with imaging, including clots without symptoms; the risk was high with both surgical and non-surgical treatment. Whether clot-preventing medicine is used is decided by the doctor, weighing each person's own clot and bleeding risk factors.
Surgery or not? What does the evidence say?
For many years the default was "a torn Achilles needs surgery". Randomized trials since 2010 have changed that view. Modern non-surgical treatment does not mean weeks of immobilization in a cast: it starts in a boot or cast with the foot pointed down, but the program is built on early weight-bearing and early controlled movement.
| Study | What was compared | Key finding |
|---|---|---|
| Norway, 554 patients (NEJM 2022) | Non-surgical, open repair, minimally invasive surgery | No difference in the function score at 12 months. Re-rupture 6.2% non-surgical vs 0.6% in each surgical group. Nerve injury 5.2% minimally invasive, 2.8% open, 0.6% non-surgical. |
| Canada, 144 patients (2010) | Surgery vs non-surgical, both with accelerated rehabilitation | Re-rupture in 2 vs 3 patients; no clinically important difference in strength or range of motion; more complications with surgery (13 vs 6). |
| Sweden, 97 patients (2010) | Surgery vs non-surgical, both with early mobilization | Re-rupture 4% vs 12%, not statistically significant; similar function scores at 12 months. |
| Meta-analysis, 29 studies (BMJ 2019) | Surgery vs non-surgical | Re-rupture 2.3% vs 3.9% (difference 1.6 percentage points); other complications 4.9% vs 1.6% (difference 3.3 percentage points), mainly infection. No significant re-rupture difference in studies using accelerated rehabilitation. |
The bottom line: surgery may reduce the risk of re-rupture by a small amount, while adding risks such as infection, wound problems and nerve injury. One-year function is similar with both approaches. In the Danish registry, the rate of surgical treatment fell markedly from 1994 to 2013, with the decline accelerating between 2009 and 2013; the authors suggest this possibly reflects the first large randomized trials changing clinical practice.
There is also an answer to "cast or boot?": in the UK UKSTAR trial of 540 patients at 39 hospitals, 8 weeks in a traditional plaster cast was compared with a functional boot (brace) that allowed early weight-bearing; there was no difference in the function score at 9 months or in re-rupture (6% vs 5%). The authors considered early weight-bearing in a boot a safe and cost-effective option.
The decision is individual. Age, goals, sport, other conditions (diabetes, smoking, anything that impairs wound healing), the time since injury and the person's own preference are discussed together. Ruptures found late, weeks after the injury, are a separate topic and the options can differ.
Recovery: criteria, not the calendar
Recovery is long; walking normally again in the first months does not mean full recovery. In the Swedish trial, function of the injured leg was still significantly lower than the healthy leg at 12 months, regardless of treatment. The backbone of rehabilitation is gradual loading of the tendon and calf muscles: protected walking first, then heel-raise exercises, later jumping and running preparation.
Key criteria for returning to sport:
- Normal, pain-free walking and light jogging
- An acceptable side-to-side difference in repeated single-leg heel raises
- Confidence and balance in hopping and change-of-direction tests
- No symptoms during a graded trial of sport-specific movements
- Feeling psychologically ready
Will I return to sport, and when?
This is the first question almost everyone with an Achilles rupture asks. The short answer: most people do return, but it usually takes more than 6 months, and getting back to the previous level takes longer still.
| Who? | Returned to sport | Average time to return |
|---|---|---|
| All patients (108 studies, 6,506 patients) | 80% | — |
| Surgically treated patients (9 studies, 748 patients, mean age 41) | 77% | About 8 months |
| Professional football (soccer) players (surgically treated, 118 players) | 96% | About 7 months to full team training, about 9 months to matches |
| Professional athletes (NBA, NFL, baseball, football; 15 studies) | 76% | About 11 months |
Returning is not the same as returning to your previous level. In the 108-study review (Zellers et al., 2016), studies that described how return was determined reported lower rates. In a small French study that followed 65 surgically treated adults (mean age 41) for two years, 77% returned to sport, but only 45% reported being back to their pre-injury level; this share was still rising in the second year. In professional football, about one in five players did not play at their previous level in the two seasons after returning; being over 30 and having a re-rupture raised this risk.
The sport matters. In sports that demand explosive jumping and push-off, such as basketball, the loss of performance after return can be more marked despite surgery. In a review of professional athletes (Johns et al., 2021), performance measures of players who returned were lower than those of uninjured players in the NFL, NBA and football; in baseball no clear difference was seen (LaPrade et al., 2022).
Returning early may come at a price. In the professional football study, 4 of the 6 re-ruptures in the two seasons after return occurred in players who were back in matches within the first 6 months after injury. The numbers are small, but this supports returning on tests rather than on the calendar.
Does surgery improve the chance of returning? The evidence is conflicting. One meta-analysis (Bak et al., 2024) found no difference in return rate between surgery and non-surgical treatment, while a larger meta-analysis of 35,896 patients that also included observational studies (Yang et al., 2025) reported a difference in favor of surgery. In the first meta-analysis, starting rehabilitation early after open repair shortened the time to return by about 4 weeks on average. For competitive athletes, this should be discussed openly as part of the treatment decision.
For the general principles, see return to sport: not the calendar, but the tests.
Who does less well?
- Late diagnosis: when a rupture is mistaken for a sprain and found weeks later, the gap between the tendon ends may widen and the options can change.
- Re-rupture: treatment can become more complex, so it is important not to rush the stages of rehabilitation.
- People who develop a clot: a clot during immobilization needs its own treatment and may prolong recovery.
- Impaired wound healing: smoking, diabetes and conditions that impair healing can raise the risk of complications after surgery; treatment choice takes this into account.
- Incomplete rehabilitation: increasing load before calf strength has returned can lead to lasting weakness and a limp.
Chronic Achilles pain is a different condition; see Achilles tendinopathy.
For clinicians
Diagnosis of acute Achilles rupture is clinical: in Maffulli's (1998) prospective series (n=174), sensitivity was 0.96 for the calf squeeze (Simmonds/Thompson) test, 0.88 for the Matles test and 0.73 for the palpable gap; specificities (0.93 / 0.85 / 0.89) were derived from a control group of 28 patients without rupture, and at least two tests were positive in every rupture. Ultrasound/MRI are not routine; they help in equivocal cases, in suspected partial rupture and in treatment planning. Level I evidence on treatment: in the Norwegian multicenter RCT (NEJM 2022, n=554) there was no difference in 12-month change in ATRS between non-operative treatment, open repair and minimally invasive surgery (P=0.57); re-rupture 6.2% / 0.6% / 0.6%, nerve injury 0.6% / 2.8% / 5.2%. Ochen et al. (BMJ 2019; 10 RCTs plus 19 observational studies) found lower re-rupture with surgery (RR 0.43; 95% CI 0.31 to 0.60; RD 1.6 percentage points) and more other complications (RR 2.76; 1.84 to 4.13; RD 3.3 percentage points); in studies with accelerated functional rehabilitation and early ROM the re-rupture difference was not significant (RR 0.60; 0.26 to 1.37). UKSTAR (Lancet 2020, n=540) compared 8 weeks of plaster cast with a functional brace allowing early weight-bearing in non-operative care; adjusted mean difference in 9-month ATRS −1.38 (−4.9 to 2.1), re-rupture 6% vs 5%. VTE: in the Calder et al. (2016) meta-analysis, clinical VTE in Achilles rupture was 7% (5.5 to 8.5) and radiological VTE 35.3% (26.4 to 44.3); the authors did not consider routine chemical prophylaxis justified after isolated foot and ankle surgery but explicitly excluded Achilles rupture from that statement. Prophylaxis should be decided by weighing individual VTE and bleeding risk. Fluoroquinolone use should be asked about (van der Linden, BMJ 2002). Return to sport: the overall rate is 80% (Zellers, BJSM 2016), but lower in studies that define how return was determined. In professional athletes, RTP is 76% with a mean time of about 11 months (Johns, Foot Ankle Int 2021); in surgically treated professional football players, return to unrestricted training was 199±53 days and to competition 274±114 days, 18% did not return to the previous level within two seasons, age over 30 and re-rupture were negative predictors, and 4 of 6 re-ruptures occurred in players returning before 180 days (Grassi, BJSM 2020). The effect of surgery on RTS rate is inconsistent (Bak 2024: no difference; Yang 2025: RR 1.32, weighted by observational data). Performance loss after return is more marked in sports with high explosive plantarflexion demand such as basketball (LaPrade, BJSM 2022). Self-reported return to pre-injury level can be as low as 45% at two years (Guerot 2026, n=65, level IV); preoperative counseling should avoid overly optimistic expectations. Single-leg heel-rise endurance and hop tests are useful in follow-up. The decision should be shared and based on patient-specific factors.
Frequently asked questions
How do I know if I tore my Achilles?
The most typical sign is a sudden "kick" or pop at the back of the ankle during a jump or push-off, followed by heel pain, loss of push-off and inability to rise onto the toes on one leg. A doctor will squeeze the calf to see whether the foot moves. If you suspect it, get checked the same day.
Can you walk with a torn Achilles?
Often yes, with a limp. Because other muscles can still move the foot a little, people may think "if it were torn I couldn't walk" and delay seeing a doctor. Being able to walk does not mean the tendon is intact; being unable to rise on tiptoe on that leg is a more important sign.
Does a torn Achilles need surgery?
Not always. In large randomized trials, non-surgical treatment with early weight-bearing and controlled movement gave function similar to surgery at one year. Surgery may slightly lower the risk of re-rupture but adds risks such as infection and nerve injury. The decision is made together, based on age, sport, health and preference.
When can I return to sport after an Achilles rupture?
For most people, after more than 6 months. In a review of surgically treated patients, the average time to return was about 8 months; professional football players returned to matches after about 9 months on average, and athletes in leagues such as the NBA and NFL after about 11 months. The boot or cast phase lasts several weeks, but calf strength takes much longer to return. Strength and hop tests decide the actual date; in professional football, most re-ruptures occurred in players who returned within the first 6 months.
Will I get back to my previous level?
Many people do, but not everyone. About 82% of professional football players were playing at their previous level within two seasons. In a small study of 65 surgically treated adults, only about 45% felt back to their pre-injury level at two years, although this share was still rising in the second year. In other words, getting back to your previous level takes patience; not feeling fully ready at the end of the first year is common.
Can the Achilles tear again after treatment?
It can, but in most studies the rate is low. In a large meta-analysis, re-rupture was about 2.3% after surgery and about 3.9% after non-surgical treatment. That is why it matters not to rush the stages of rehabilitation and to increase load gradually.
Scientific references
- Other references
- Myhrvold SB, et al. Nonoperative or surgical treatment of acute Achilles' tendon rupture. N Engl J Med 2022;386(15):1409-1420.
- Ochen Y, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ 2019;364:k5120.
- Costa ML, et al. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation. Lancet 2020;395(10222):441-448.
- Willits K, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 2010;92(17):2767-2775.
- Nilsson-Helander K, et al. Acute Achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med 2010;38(11):2186-2193.
- Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med 1998;26(2):266-270.
- Ganestam A, et al. Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients. Knee Surg Sports Traumatol Arthrosc 2016;24(12):3730-3737.
- Zellers JA, et al. Return to play post-Achilles tendon rupture: a systematic review and meta-analysis of rate and measures of return to play. Br J Sports Med 2016;50(21):1325-1332.
- Cofano E, et al. Successful functional outcomes and return to sport rate can be achieved after surgery for acute Achilles tendon rupture: a systematic review. J Exp Orthop 2025;12(4):e70469.
- Grassi A, et al. Eighty-two per cent of male professional football (soccer) players return to play at the previous level two seasons after Achilles tendon rupture treated with surgical repair. Br J Sports Med 2020;54(8):480-486.
- Johns W, et al. Career outlook and performance of professional athletes after Achilles tendon rupture: a systematic review. Foot Ankle Int 2021;42(4):495-509.
- LaPrade CM, et al. Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review. Br J Sports Med 2022;56(9):515-520.
- Guerot M, et al. Return to sport and return to self-reported preinjury level after surgical repair of acute Achilles tendon rupture: a 2-year prospective cohort analysis. J Clin Med 2026;15(17):6512.
- Bak BM, et al. Return to play and functional outcomes following treatment of acute Achilles tendon ruptures: a systematic review and meta-analysis. J Foot Ankle Surg 2024;63(3):420-429.
- Yang Z, et al. Surgical treatment versus conservative management for acute Achilles tendon rupture: a systematic review and meta-analysis. J Orthop Surg Res 2025;20(1):626.
- Calder JD, et al. Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery. Knee Surg Sports Traumatol Arthrosc 2016;24(4):1409-1420.
- van der Linden PD, et al. Fluoroquinolones and risk of Achilles tendon disorders: case-control study. BMJ 2002;324(7349):1306-1307.
This information is for general guidance only; it does not replace an examination, a diagnosis, or your physician's individual advice. Please consult a physician for your symptoms. About the author: Doç. Dr. Oğuz Yüksel — Academic Profile.