Achilles Repair and Rehabilitation

The goal of treatment is to have an Achilles and calf that functions as best as possible, allowing full activity and sport.

The Achilles tendon is exceptionally strong and, as yet, we don’t know why it ruptures. It often happens during the simplest activities and you and any spectators may have heard it snap. Patients often say it feels as though they were hit from behind.

When the tendon ruptures, It is very much like a rope snapping with two frayed ends. The tendon heals with scar tissue and it’s very important that they are as close together as possible. They should then heal with the optimum tension giving the muscle maximum power once recovered. If the tendon ends gap then this leaves the muscle lax and weaker.

Naturally, because the Achilles is so strong, it takes a long to time to heal fully. It will take several months to be functioning well and over a year to heal fully. Research has shown that a tendon heals best if it is carefully moved in a protected environment – therefore Physiotherapy is an essential part of this and you will get to know your physio well!

Preparation for Surgery

You should have received a letter detailing the codes and costs for the surgery and giving instructions on where to go and at what time. Please check these details carefully as you will be liable for any costs not covered by your insurers.

You will need to be nil-by-mouth – No food for 6 hours before surgery. Clear fluids can be taken for up to 2 hours before the operation.

MRSA status

Before or on admission to hospital a nasal swab will be taken to screen for MRSA. There is a small chance this is positive. If so your operation will be moved to the end of the list or rarely to another day to prevent cross infection.


The surgery is normally a daycase procedure, performed under a general anaesthetic with local anaesthetic after for additional pain relief. It is not normally a particularly painful operation and most patients report minimal pain.


The Achilles is repaired using a minimally invasive (MI) or keyhole technique. This is performed through a 1-2cm transverse incision over the rupture site. The keyhole surgery causes minimal trauma to the Achilles sheath and skin and so has the lowest risks. It also allows rapid healing with benefits in early rehabilitation. The surgery is performed with strong permanent sutures passed using MI methods. Even though the incision is small, the tendon repair can be assessed and visualised to ensure that the best tension and repair has been achieved.


At the end of the surgery, the leg is immobilised in a plastercast with a soft bandage at the front or “backslab”, to allow for any swelling. You will be discharged in this, on crutches non-weight bearing (NWB). The cast will be changed at 10-14 days to a protective boot for 8-10 weeks.

Risks of Surgery

It is important to be aware of the risks of surgery. The vast majority of patients have no problems, but complications can happen and we do our best to minimise these risks.


Approx 1% risk. Usually this is a small infection of the skin that can be treated with oral antibiotics. Very rarely, a deep infection occurs requiring further surgery and this will compromise the final outcome.

Nerve Injury

Risk 1%. The sural nerve is a sensory that supplies sensation to the skin of the side of the foot and heel. It can be temporarily or permanently damaged. Usually no further treatment is needed. Rarely the nerve will be painful requiring further surgery.


Risk 2-3%. This is usually due to a slip or fall.

Blood Clots

Risk 2-5%. You will be given an oral anticoagulant to protect against this. If it does occur, this is treated with oral anticoagulants for 3 months.

Immediately after surgery

You will be referred to a physiotherapist who will advise on walking while keeping weight off the ankle using crutches. You will be sent home only when you are comfortable.

Pain relief and take home medications

You will be given high doses of prescription painkillers to take home. Use these for the first 2-3 days and reassess.

There is a small risk of blood clots “DVT’s” with Achilles surgery and you will be prescribed a blood thinner for 2 weeks.


Initially you will be Non WB for 2 weeks then partially WB in a protective boot, with Full WB at the 4 week stage.

Using crutches can be difficult even for the able-bodied. There are some useful aids that can be bought or hired.

  • The knee rover is a scooter with brakes that takes the weight of the leg.
  • The iWalk is a ‘peg-leg’ – it requires good balance.


View Rehabilitation Videos

Vacoped Rehab Achilles Rupture

0-2 weeks Non-Weight Bearing (NWB) in POP
2-4 weeks Partial Weight Bearing (PWB) in boot up to 50%
4+ weeks Full weight bearing (FWB) in boot
10+ Weeks FWB in Shoes
Phase 1  Protection (0-8 weeks)
Phase 2  Early Mobilisation (6-12 weeks)
Phase 3  Strengthening (12-20 weeks)
Phase 4  Return to Activity (5-7 months)
Phase 5  Return to play (8-12 months)
Patient guide

  • Plaster cast (POP) Non weight bearing (NWB)
  • Rest and elevate the limb 45MINS/HOUR ABOVE HIPS
  • Use crutches / knee scooter / iWalk and “Even up” shoe or thick heels on the other side to balance height
  • Shower using waterproof cover & sitting on a stool
Physiotherapy guide

  • Patient in Equinus POP NWB
  • Train on use of crutches
  • Rehab other limbs
  • Activate toes without Achilles activation
Patient guide

  • WEAR Vacoped 24 hours a day (remove sole overnight)
  • Remove for physio and for washing
  • Partial weight bear (PWB) on crutches, up to 50% body weight in Vacoped boot.
  • Avoid any upward (Dorsiflexion DF) stretches
  • Maintain strength of unaffected joints
  • Increase VACOPED motion by 1 Notch / Week (only move the bottom lock not the top lock – see video)
    E.g. Week 3: 30-25° Week 4: 30-20°
Physiotherapy guide

  • Gentle ST massage (around scar, FHL, FDL Tib post tendons)
  • START gentle Planter flexion (PF) and forefoot Intrinsic strengthening
  • No Active or Passive DF above position held in the boot
  • Starts Quads, Hams and core strengthening in NWB in Vacoped boot
Physiotherapy guide

  • Start Compex Muscle Stimulator or alternative EMS (muscle stimulation) on calf start with low activation
  • Avoid any DF or stretches until out of the boot
  • Increase active forefoot exercises in PF position use a block / book to lift heel to keep in PF (Seated heel raises, peroneals, toe intrinsics, invertors of the ankle)
  • Can start Double Leg press with Vacoped boot & light weight
Patient guide

  • Continue increasing range: 1 NOTCH PER WEEK
    Week 5-30-15° Week 6 – 30-10°
  • Change to Flat sole at 10° (Position 1 on boot)
  • Discard even up / heels
  • Week 6 take-off boot at night / at rest in safe environment
WEEK 5 & 6
Physiotherapy guide

  • Continue NWB exercises and soft tissue work
  • Increase Muscle stim intensity
  • Introduce gentle Passive and Active PF ROM with light resistance band
  • Use a light weight on knee in seated heel raises - use heel raise to match PF of Vacoped boot
  • Aim for plantigrade by 6 weeks
  • Maintain core / activity of non-affected joints
Patient guide

  • Increase range: 1 notch per week
    Week 7 – 30-5° Week 8 – 30-0°
  • Avoid any DF stretches
WEEK 7 & 8
Physiotherapy guide

  • Continue soft tissue work as above
  • Continue Muscle stim increasing intensity
  • Continue Lower limb, ankle and forefoot exercises increasing weight or resistance band -use heel raise to match PF of Vacoped boot
  • Start gentle double Calf raises on leg press in Vacoped boot
  • By Week 8 Start in Vacoped boot Proprioception/Balance work
  • Functional movements (squats, sit to stand, steps sideways, one leg balance)
  • Start NWB aerobic- e.g. bike (push with heel not toes)
Patient guide

  • Increase range: 1 notch per week
  • Avoid any DF stretches
Physiotherapy guide

  • Continue with soft tissue work as above
  • Continue to use Muscle stim increasing intensity
  • Continue Lower limb, ankle and forefoot exercises increasing weight or resistance band
  • Start Gait re-education
  • Start Ecc/Con loading heel raises(bilateral to single emphasis on Ecc phase) using wedge under heel to start with
WEEK 10-13: FWB in shoe
Patient guide

  • Flat shoe with 1cm heel lift for 4 weeks.
  • Take care stretching tendon walking up and down stairs
WEEK 10-13: FWB in shoe
Physiotherapy guide

  • Continue with above exercises and Gait re education, progressing balance and proprioception
  • Continue with building up strength with the Leg press, leg extension hamstring curl.
  • Allow DF to return gradually by itself with walking – imperative not to stretch and push dorsiflexion eg. Lunge
  • Continue with above exercises progressing heel raises to single leg heel raise as able
WEEKS 13-20: Progress to Full Sports
Patient guide

  • FWB in flat shoe with 1cm heel lift for last week
  • THEN WB in shoes without heel lift
WEEKS 13-20: Progress to Full Sports
Physiotherapy guide

  • Continue with above exercises progressing weight, to add in lunges, side lunges single leg squat, single leg sit to stand, deadlifts as patient is able
  • Gentle return to Plyometrics to start forwards, backwards, directional, change of direction walking and progress as see fit
  • Can start swimming from week 16


Milestones – Rehab goals

WEEK 16 onwards to RTS
  • Normal gait pattern
  • Improving KTW 80% of other leg
  • Improving walking exercise tolerance
  • Single leg stance with good control for >10 seconds
  • Ankle ROM between 10° DF to 35° PF
  • Able to complete single leg heel raise
  • Able to return to running on flat surfaces at 5 months when have 70% strength of unaffected leg
  • Girth of calf 1/2cm of unaffected leg
WEEK 20 onwards
  • Able to single leg calf raise
  • Able to horizontal single leg hop x 3 with 75% of unaffected leg
  • Able to vertical single leg hop 75% of unaffected leg
  • Sprint with toe off phase of running gait
  • Education that it can take up to 1 year to return to normal preinjury level


When can I drive?

Manual - When you can do an emergency stop safely no earlier than 8 weeks

Automatic with left leg week 2

When can I return to work?

Sedentary – 2 weeks WFH and week 4 return to office

Manual labour – 12-16 weeks return to work

When can I cycle outdoors?

16 weeks post op can safely bike outdoors

When can I jog?

20 weeks post op with supervision of this milestone with Physio

When can I swim?

With a Vacoped boot start hydro with supervision of Physio at week 4 onwards

Swim only weeks 16

When can I play tennis?

4-6 months post to discuss milestone with physio

When can I wear normal shoe?

Week 15 onwards

When can I get back on the pitch?

Elite athlete – 6-9 months

Recreational athlete – 9 months

When can I wear high heels?

20 weeks onwards

When can I ski?

6 months post discuss with physio and consultant


View Rehabilitation Videos


Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis

BMJ 2019

This meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.