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Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair



Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair.


A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included.


One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment.


Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician.

Level of evidence


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Fig. 1
Fig. 2



Achilles Rupture Performance Score


Achilles Tendon Total Rupture Score


Below knee cast


Combined functional treatment


Coleman Methodology Score






Deep vein thrombosis


Early mobilization


Full weight bearing








Non-weight bearing


Plantar flexion


Partial weight bearing


Return to sports


Return to work


Sural nerve damage


p < 0.01


  1. 1.

    Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P (2002) Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am 84-A:161–170

    Article  PubMed  Google Scholar 

  2. 2.

    Barfod KW, Nielsen F, Helander KN, Mattila VM, Tingby O, Boesen A, Troelsen A (2013) Treatment of acute Achilles tendon rupture in Scandinavia does not adhere to evidence-based guidelines: a cross-sectional questionnaire-based study of 138 departments. J Foot Ankle Surg 52:629–633

    Article  PubMed  Google Scholar 

  3. 3.

    Bhattacharyya M, Gerber B (2009) Mini-invasive surgical repair of the Achilles tendon—does it reduce post-operative morbidity? Int Orthop 33:151–156

    Article  PubMed  Google Scholar 

  4. 4.

    Brumann M, Baumbach SF, Mutschler W, Polzer H (2014) Accelerated rehabilitation following Achilles tendon repair after acute rupture—development of an evidence-based treatment protocol. Injury 45(11):1782–1790

    Article  PubMed  Google Scholar 

  5. 5.

    Calder JDF, Saxby TS (2005) Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Br J Sports Med 39:857–859

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Carmont MR, Maffulli N (2008) Modified percutaneous repair of ruptured Achilles tendon. Knee Surg Sports Traumatol Arthrosc 16:199–203

    Article  PubMed  Google Scholar 

  7. 7.

    Carmont MR, Rossi R, Scheffler S, Mei-Dan O, Beaufils P (2011) Percutaneous & mini invasive Achilles tendon repair. Sports Med Arthrosc Rehabil Ther Technol 3:28

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 10:2–11

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Costa ML, MacMillan K, Halliday D, Chester R, Shepstone L, Robinson AHN, Donell ST (2006) Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br 88:69–77

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    da Costa Santos CM, de Mattos Pimenta CA, Nobre MRC (2007) The PICO strategy for the research question construction and evidence search. Rev Lat Am Enferm 15:508–511

    Article  Google Scholar 

  11. 11.

    Del Buono A, Volpin A, Maffulli N (2014) Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review. Br Med Bull 109:45–54

    Article  PubMed  Google Scholar 

  12. 12.

    Demetracopoulos CA, Gilbert SL, Young E, Baxter JR, Deland JT (2014) Limited-open Achilles tendon repair using locking sutures versus nonlocking sutures: an in vitro model. Foot Ankle Int 35:612–618

    Article  PubMed  Google Scholar 

  13. 13.

    Doral MN (2013) What is the effect of the early weight-bearing mobilisation without using any support after endoscopy-assisted Achilles tendon repair? Knee Surg Sports Traumatol Arthrosc 21:1378–1384

    Article  PubMed  Google Scholar 

  14. 14.

    Groetelaers RPTGC, Janssen L, van der Velden J, Wieland AWJ, Amendt AGFM, Geelen PHJ, Janzing HMJ (2014) Functional treatment or cast immobilization after minimally invasive repair of an acute Achilles tendon rupture: prospective, randomized trial. Foot Ankle Int 35:771–778

    Article  PubMed  Google Scholar 

  15. 15.

    Guillo S, Del Buono A, Dias M, Denaro V, Maffulli N (2013) Percutaneous repair of acute ruptures of the tendo Achillis. Surgeon 11:14–19

    Article  PubMed  Google Scholar 

  16. 16.

    Hockenbury RT, Johns JC (1990) A biomechanical in vitro comparison of open versus percutaneous repair of tendon Achilles. Foot Ankle 11:67–72

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Jielile J, Sabirhazi G, Chen J, Aldyarhan K, Zheyiken J, Zhao Q, Bai J (2012) Novel surgical technique and early kinesiotherapy for acute Achilles tendon rupture. Foot Ankle Int 33:1119–1127

    Article  PubMed  Google Scholar 

  18. 18.

    Kearney RS, Costa ML (2012) Current concepts in the rehabilitation of an acute rupture of the tendo Achillis. J Bone Joint Surg Br 94:28–31

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Kearney RS, Parsons N, Underwood M, Costa ML (2015) Achilles tendon rupture rehabilitation: a mixed methods investigation of current practice among orthopaedic surgeons in the United Kingdom. Bone Joint Res 4:65–69

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Khan RJ, Carey Smith RL (2010) Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev 9(9):CD003674. doi:10.1002/14651858.CD003674.pub4

    Google Scholar 

  21. 21.

    Khan RJK, Fick D, Keogh A, Crawford J, Brammar T, Parker M (2005) Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 87:2202–2210

    Article  PubMed  Google Scholar 

  22. 22.

    Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M (1994) Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15:349–353

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Lansdaal JR, Goslings JC, Reichart M, Govaert GAM, van Scherpenzeel KM, Haverlag R, Ponsen KJ (2007) The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment. Injury 38:839–844

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Leppilahti J, Forsman K, Puranen J, Orava S (1998) Outcome and prognostic factors of achilles rupture repair using a new scoring method. Clin Orthop Relat Res 346:152–161

    Article  Google Scholar 

  25. 25.

    Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R (2003) Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med 31:692–700

    Article  PubMed  Google Scholar 

  26. 26.

    Maffulli N, Tallon C, Wong J, Peng Lim K, Bleakney R (2003) No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon. J Sports Med Phys Fitness 43:367–379

    CAS  PubMed  Google Scholar 

  27. 27.

    Majewski M, Schaeren S, Kohlhaas U, Ochsner PE (2008) Postoperative rehabilitation after percutaneous Achilles tendon repair: early functional therapy versus cast immobilization. Disabil Rehabil 30:1726–1732

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Mark-Christensen T, Troelsen A, Kallemose T, Barfod KW (2014) Functional rehabilitation of patients with acute Achilles tendon rupture: a meta-analysis of current evidence. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-3180-5

    PubMed  Google Scholar 

  29. 29.

    McCullough KA, Shaw CM, Anderson RB (2014) Mini-open repair of achilles rupture in the national football league. J Surg Orthop Adv 23:179–183

    Article  PubMed  Google Scholar 

  30. 30.

    McMahon SE, Smith TO, Hing CB (2011) A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot Ankle Surg 17:211–217

    Article  PubMed  Google Scholar 

  31. 31.

    Metz R, van der Heijden GJMG, Verleisdonk E-JMM, Kolfschoten N, Verhofstad MHJ, van der Werken C (2011) Effect of complications after minimally invasive surgical repair of acute achilles tendon ruptures: report on 211 cases. Am J Sports Med 39:820–824

    Article  PubMed  Google Scholar 

  32. 32.

    Nilsson-Helander K, Thomée R, Silbernagel KG, Grävare-Silbernagel K, Thomeé P, Faxén E, Eriksson BI, Karlsson J (2007) The Achilles tendon Total Rupture Score (ATRS): development and validation. Am J Sports Med 35:421–426

    Article  PubMed  Google Scholar 

  33. 33.

    Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Thomée R, Faxén E, Silbernagel KG (2011) Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 19:1385–1393

    Article  PubMed  Google Scholar 

  34. 34.

    Olsson N, Silbernagel KG, Eriksson BI, Sansone M, Brorsson A, Nilsson-Helander K, Karlsson J (2013) Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med 41:2867–2876

    Article  PubMed  Google Scholar 

  35. 35.

    Ortiz C, Wagner E, Mocoçain P, Labarca G, Keller A, Del Buono A, Maffulli N (2012) Biomechanical comparison of four methods of repair of the Achilles tendon: a laboratory study with bovine tendons. J Bone Joint Surg Br 94:663–667

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M (2012) Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am 94:2136–2143

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Suchak AA, Bostick GP, Beaupré LA, Durand DC, Jomha NM (2008) The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am 90:1876–1883

    Article  PubMed  Google Scholar 

  38. 38.

    Thermann H, Zwipp H, Tscherne H (1995) Functional treatment concept of acute rupture of the Achilles tendon. 2 years results of a prospective randomized study. Unfallchirurg 98:21–32

    CAS  PubMed  Google Scholar 

  39. 39.

    Ware J, Kosinski M, Keller SD (1996) A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34:220–233

    Article  PubMed  Google Scholar 

  40. 40.

    Wright JG, Swiontkowski MF, Heckman JD (2003) Introducing levels of evidence to the journal. J Bone Joint Surg Am 85-A:1–3

    Article  PubMed  Google Scholar 

  41. 41.

    Yotsumoto T, Miyamoto W, Uchio Y (2010) Novel approach to repair of acute achilles tendon rupture: early recovery without postoperative fixation or orthosis. Am J Sports Med 38:287–292

    Article  PubMed  Google Scholar 

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We thank Mrs. Maren Hella Thun for the preparation of the figures.

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Correspondence to Hans Polzer.

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Braunstein, M., Baumbach, S.F., Boecker, W. et al. Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc 26, 846–853 (2018).

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  • Achilles tendon rupture
  • Minimal invasive repair
  • Accelerated rehabilitation