Achilles tendon rupture rehabilitation: boot, surgery and return to running

The Achilles tendon joins the calf muscles to the heel bone. When it ruptures, the aim of treatment is for the torn ends to heal together so that the leg can push off again without lasting weakness. Cambridge University Hospitals says the diagnosis is usually made from the history, a feel for a gap in the tendon and a calf-squeeze test, with ultrasound used when needed to confirm the site.

Both routes lead into the same rehabilitation. Cambridge treats most patients with functional bracing, because the evidence suggests similar results to surgery without the wound complications. Milton Keynes says an operation is considered for delayed presentation, atypical or large ruptures and competitive athletes, as a decision between surgeon and patient. Cambridge gives its own list of reasons: delay of more than two to three weeks, a re-rupture or avulsion injury, fat within the gap, and elite athletes.

UKSTAR was a pragmatic trial across 39 NHS hospitals. Adults treated without surgery were randomly allocated to a below-knee plaster cast or a removable rigid walking boot, each worn for 8 weeks. Both started with the foot pointing down, using heel wedges in the boot, and the position was brought gradually to flat. The boot allowed full weight on the foot immediately because its base was flat on the floor.

At nine months there was no difference in the patient-reported Achilles tendon rupture score, and re-ruptures occurred in 17 of 266 people in the cast group and 13 of 274 in the boot group. The boot group did score slightly better at 8 weeks, but the difference did not persist at three, six and nine months. The authors conclude that early weight-bearing in a boot is a safe and cost-effective alternative to plaster.

Cambridge University Hospitals publishes its protocol. From week 0 to 4 the Aircast boot holds three wedges; week 5 has two, week 6 one and week 7 none, still in the boot. Week 8 brings supportive footwear with a single gel heel pad for two weeks. Full weight-bearing is encouraged in the boot, with crutches as needed. The boot is worn at all times, including in bed, and the foot stays pointing down when the boot is off.

Skin is inspected every day. If you are felt to be at risk of blood clots, the hospital prescribes blood-thinning injections for six weeks from the date of injury. Physiotherapy referral is made at the start, with treatment from about week 7, when active ankle movements within the boot, light resistance-band work, balance exercises and hip and knee strengthening begin.

• Keep the hips, knees and toes moving to prevent stiffness while the ankle is protected.

• Do not put weight on the bare foot out of the boot during the boot stage.

• Do not pull the foot upwards past 90 degrees or use anything to force it, Cambridge says.

Milton Keynes describes a cut of 3 to 5 cm at the back of the ankle, with the tendon ends cleaned and stitched together, and a temporary plaster with the foot pointing down. Most people go home the same day. No weight goes through the leg for the first two weeks, after which the stitches are removed and a surgical boot with three wedges is fitted so that weight can start to go through the leg, because that encourages healing.

The boot stays on for a further eight weeks, one wedge being removed every two weeks, and the tendon is checked at ten weeks. If progress is as expected, you move into supportive footwear and specialist physiotherapists guide rehabilitation. Some patients need serial plaster casts instead. Cambridge adds that after stitch removal at two weeks, surgical patients follow the same bracing pathway as those treated without surgery. Reported surgical risks include re-rupture, delayed wound healing, nerve irritation and infection, with smokers at much higher risk of wound problems.

Most of the recovery happens after the boot comes off. Cambridge describes a strength-and-control phase from about weeks 9 to 11, with the boot removed by the physiotherapist and a flat shoe with a heel cushion worn for 2 to 4 weeks. Milton Keynes says to build up walking distances in your own footwear and to drive when you can walk comfortably and make an emergency stop safely, starting with short distances.

A literature review of rehabilitation after rupture says protocols vary widely and that "early" has no agreed definition, with weight-bearing within four weeks commonly used in research as a working threshold. It concludes that early functional rehabilitation appears safe and effective across treatment strategies, which matches the direction taken by UK hospitals.

Milton Keynes gives a rough guide of running at six months and aiming for full sporting activity at nine months, and notes that it takes time to restore strength and balance. Cambridge reports that rehabilitation after rupture can take several months for symptoms to settle completely. Progress should be gated by calf strength and control, not by dates alone, so follow your physiotherapist's tests rather than a calendar.

Fear of re-rupture shapes this phase. A UK interview study of people managed without surgery found fear and uncertainty about rehabilitation and returning to sport were common, and that boot use, weight-bearing and progression were not always clearly explained. A separate interview study of NHS clinicians found limited training in managing ruptures, varied practice and service constraints, and recommended clearer, more standard pathways.

Cambridge advises seeking medical advice for sudden cramp-like pain in the calf, thigh or groin, a sudden increase in swelling, numbness or pins and needles, or wound concerns after surgery, and going to A&E for chest pain or shortness of breath, which can signal a clot reaching the lung. Skin problems under the boot, such as a pressure sore, or a boot that no longer fits properly, are worth reporting to your fracture clinic or physiotherapist.