When I repair a torn Achilles tendon with keyhole assistance, I work through two small cuts, with a camera through one and the instruments through the other. An operation is not the only option [1]. The current position of the American Orthopaedic Foot & Ankle Society (AOFAS) is that both surgery and non-surgical treatment are reasonable, and that the decision should be made jointly with the patient [1]. I always take people through both options, with the pros and cons of each; what a rupture is, and how it is first managed, are described on my Achilles tendon rupture page.
What is keyhole-assisted Achilles tendon repair (arthroscopically assisted repair)?
In a keyhole (arthroscopic) repair, I make two small cuts, each less than a centimetre long, one on either side of the tendon. I find the torn ends of the tendon, freshen them, and free them above and below so that they can be brought together. Once the ends lie next to each other, I repair them with special sutures or anchors. Sutures are surgical stitches.
The camera lets me see the tendon itself, and also look further forward for problems with the other tendons, the joint, or a bony growth.
Looking inside with a camera gives us the option of checking all other structures, and this is done in every case we do with a camera (arthroscopy).
If small pieces of bone have pulled away with the tendon (avulsions), or there are small fractures, I can fix them in the same operation. The same repair can also be done through an open cut. If the tendon is infected and needs a full open clean-out, I operate open, because the saline that opens up the space for the camera is likely to spread the infection. Saline is a salt-water solution.
Do I need surgery for a torn Achilles? How I decide
I think families mostly ask whether surgery is essential, and how soon the person will be back on their own feet for their daily activities. Three things decide the treatment I recommend: the gap between the torn ends, the person’s age and demands, and other health conditions such as diabetes or long-term steroid use. In my practice, a gap of up to 1.5 or 2 cm in a fresh tear can be brought together by holding the ankle in certain positions.
The gap can be measured on an MRI and also on ultrasonography of the ankle and foot. This gap decides our management protocol.
Two randomised trials have compared surgery with treatment without an operation [2] [3]. In the 2022 trial, the tendon ruptured again more often without surgery [2]. In the 2010 trial, the numbers of re-ruptures were small and close in the two groups, and they do not show a confirmed difference [3]. This comparison is about re-rupture only; the figures, which differ a good deal between the two trials, are set out on my Achilles tendon rupture page [2] [3].
When is the operation done?
When I say that a torn Achilles is not urgent, I mean that the operation does not need to be done immediately: not on the same day you come to see me, or the next day. In my practice, the operation is planned within a few days, ideally from 4–5 days after the injury, and not beyond 3 weeks. In my experience, by then the inflammation from the injury has settled, and the tendon is in good condition for the repair.
…by delaying the surgery by more than three weeks, the tendon and the muscle undergo degeneration and can hamper the quality of repair and the rate of recovery.
In my experience, delay reduces the chance of the tendon healing well first time.
Keyhole or open repair: what the research shows
The research on this question compares minimally invasive repair in general with open repair, and it does not test keyhole-assisted (arthroscopic) repair specifically [4]. A 95% confidence interval (95% CI) is the range within which the true figure is likely to lie. A 2018 analysis that pooled eight randomised trials (Grassi and colleagues; 182 people with minimally invasive repair and 176 with open repair) found fewer complications overall after minimally invasive repair (risk ratio 0.21, 95% CI 0.10–0.40; a risk ratio below 1 means fewer complications in that group) [4]. That is a pooled reduction in complications, not proof that minimally invasive repair is better in general [4]. The same analysis found a lower pooled risk of wound infection after minimally invasive repair (risk ratio 0.15, 95% CI 0.05–0.46) [4].
People who had minimally invasive repair were more likely to report a good or excellent result (risk ratio 1.18, 95% CI 1.04–1.33, p = 0.009), which is not the same as showing better recovery of function [4].
It found no statistically significant difference between the two approaches in re-rupture, injury to the nerve on the outer side of the heel (the sural nerve), return to the previous level of activity, time to return to work, or ankle movement, and that does not mean the two approaches are equivalent [4]. The authors judged the evidence to be generally of low quality, because of risk of bias, differences between the trials, indirect reporting of outcomes and small numbers of patients [4].
A 2022 randomised trial of 526 people (Myhrvold and colleagues) reported sensory-nerve injury (numbness or altered feeling) in 9 of 172 people after minimally invasive repair (5.2%), 5 of 176 after open repair (2.8%) and 1 of 178 treated without surgery (0.6%) [2]. These are the trial’s descriptive figures, and no statistical test of the difference was reported [2]. A pooled result that found no significant difference and one trial’s descriptive figures are different kinds of statement [2] [4].
In my view, the main advantage of the keyhole approach is that it is done through small cuts. The sural nerve runs in the midline at some points and on the outer side at others; I know the anatomy of the nerve, and because I have the camera in my hand, I make sure that I do not touch it. Nerve injury after minimally invasive repair is still reported in the research above [4] [2].
Risks and what can go wrong
I think that after these operations the commonest cause of disappointment is stiffness, together with persistent swelling, though I would not call it a complication. Swelling is also one of the warning signs after the operation, set out below. I always explain to patients that swelling is the last thing to go, and that they need to focus on their rehabilitation, which concentrates on stretching the calf muscles to get their flexibility back; that helps them reduce the swelling themselves. Follow the recovery plan you are given for walking, wound care and exercise. I think the commonest problem afterwards is stiffness, with a mild limp that persists, and in my experience it usually recovers with good physiotherapy aimed at joint movement and strengthening.
The risks reported in the research described above include complications overall, wound infection and nerve injury (injury to the sural nerve in the pooled analysis, and sensory-nerve injury in the 2022 trial); the details are in the section on keyhole and open repair [4] [2]. The tendon can also tear again after a repair; how often that happened in two randomised trials, and the complications after surgery in one of them, which were mainly soft-tissue problems, are set out on my Achilles tendon rupture page [2] [3].
In a review of 1,172 people with an Achilles tendon rupture, a clot in the leg that caused symptoms (deep vein thrombosis, DVT) occurred in 5 people (0.43%) within three months [5]. A clot in the lung that caused symptoms (pulmonary embolism, PE) occurred in 4 people (0.34%) in the same period [5]. These figures count only clots that caused symptoms, because people were not routinely scanned [5]. In this cohort, the study did not identify age over 40, obesity or surgery as predictors of symptomatic DVT or PE [5]. That is not the same as saying these factors have no effect [5].
Recovery after the repair
Normally, after the repair you will be in a boot or a cast, and you should be comfortable. Swelling is the last thing to go, as described under Risks and what can go wrong.
When to contact me urgently after surgery
After the operation, the warning signs are the same as after any surgery, such as pain, swelling, or discolouration of the toes. These mean that you are having a complication, such as an infection, and I need to see you urgently. If the pain in your boot or cast is disturbing your sleep, come and see me as soon as possible. If you have sudden difficulty breathing, go to the nearest hospital emergency department straight away. To contact us: Dr. Kini, +91 99208 61187, or the clinic, +91 98207 89797.
Getting back to walking, work and sport
The commonest fear I hear is whether people will get back to the level they were at before the injury, and for athletes, whether they will return to competitive sport. Because an athlete’s demands are greater and different, I adjust both the treatment and how strongly the rehabilitation is emphasised.
A 2026 expert-consensus study (Gaspar and colleagues) proposed seven criteria that may inform decisions about returning to running after a repair: pain-free daily life, no pain during and after rehabilitation, walking without a limp, walking on tiptoe, ten single-leg heel rises, good single-leg balance, and psychological readiness [6]. These criteria are not validated, and the authors say they need to be tested in prospective studies before they can be used as rules for decisions [6].
A 2016 review of 108 studies (6,506 patients, with 85 studies measuring return to play) put the pooled rate of return to play after an Achilles rupture at 80% (95% CI 75–85%) [7]. Returning to play is not the same as returning to your previous level of sport; this is a 2016 estimate, not necessarily the latest one; and it is a pooled figure for Achilles rupture in general, not for keyhole-assisted repair [7].
Before your first visit
Bring any previous X-rays, ultrasound, MRI or CT scans, blood tests and earlier consultation notes, so that I can see what has already been done.
Common questions
Do I need surgery for a torn Achilles?
Not always: both surgery and non-surgical treatment are reasonable options, and the decision is made together [1]. In my practice, three things decide the treatment: the gap between the torn ends, your age and demands, and your other health conditions.
Is keyhole-assisted repair better than open repair?
Pooled trials found fewer complications and fewer wound infections after minimally invasive repair, on evidence of generally low quality, and no significant difference in several other outcomes [4]. That research is about minimally invasive repair in general, not keyhole-assisted repair specifically [4].
How soon should the operation be done?
I plan it within days rather than on the same day, and I do not let it wait too long, because in my experience the tendon and muscle begin to degenerate. The timing I aim for is set out under When is the operation done?.
Can the tendon tear again after repair?
Yes, it can, and how often it happened in two randomised trials is set out on my Achilles tendon rupture page [2] [3].
When can I play sport again?
It depends on what you need the tendon for: an athlete’s demands are greater, and I adjust the rehabilitation to them. The criteria experts have proposed for returning to running are set out under Getting back to walking, work and sport [6].
Before you decide
Bring your scans, reports and questions, and we will go through your own situation and the options together.
Disclaimer: This article is for general information. It does not replace advice about your own condition from a qualified foot and ankle specialist.
About the author
Read Dr. Kini’s profileReferences
- American Orthopaedic Foot & Ankle Society (AOFAS). Management of Acute Achilles Tendon Ruptures: Position Statement. Approved November 2024. www.aofas.org/docs/default-source/research-and-policy/position-statements/positionstatement_acuteachillesruptures_nov2024.pdf
- Myhrvold SB, Brouwer EF, Andresen TKM, Rydevik K, Amundsen M, Grün W, Butt F, Valberg M, Ulstein S, Hoelsbrekken SE. Nonoperative or Surgical Treatment of Acute Achilles’ Tendon Rupture. N Engl J Med 2022;386(15):1409–1420. doi:10.1056/NEJMoa2108447 · PMID 35417636 doi.org/10.1056/NEJMoa2108447
- Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. 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. doi:10.2106/JBJS.I.01401 · PMID 21037028 doi.org/10.2106/JBJS.I.01401
- Grassi A, Amendola A, Samuelsson K, Svantesson E, Romagnoli M, Bondi A, Mosca M, Zaffagnini S. Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery. J Bone Joint Surg Am 2018;100(22):1969–1981. doi:10.2106/JBJS.17.01364 · PMID 30480601 doi.org/10.2106/JBJS.17.01364
- Patel A, Ogawa B, Charlton T, Thordarson D. Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture. Clin Orthop Relat Res 2012;470(1):270–274. doi:10.1007/s11999-011-2166-6 · PMID 22045072 · PMCID PMC3237970 doi.org/10.1007/s11999-011-2166-6
- Gaspar M, Maffulli N, Memain G, Carmont MR, Hardy A, et al. Criteria for Return to Running After Surgical Repair of Acute Achilles Tendon Rupture: A Modified Delphi Consensus Study. Sports Med. Published online 26 July 2026; online ahead of print. doi:10.1007/s40279-026-02506-4 · PMID 42503592 doi.org/10.1007/s40279-026-02506-4
- Zellers JA, Carmont MR, Grävare Silbernagel K. 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. doi:10.1136/bjsports-2016-096106 · PMID 27259751 · PMCID PMC5136353 doi.org/10.1136/bjsports-2016-096106