How Should an Achilles Tendon Rupture Be Treated? A Recent Systematic Review Comparing Surgery and Conservative Care

The Achilles tendon is one of the strongest tendons in the body, bearing the load of daily activity and weight-bearing. Yet acute Achilles tendon rupture (AATR) is becoming more common, especially among active people and middle-aged to older men. Treatment falls mainly into surgical and conservative approaches, but which one works better has been debated in the academic literature for a long time.

A 2025 systematic review and meta-analysis by Yang and colleagues, published in the Journal of Orthopaedic Surgery and Research, included 33 studies covering 35,896 patients, providing the most recent and statistically meaningful evidence for this treatment decision.

Study analysis

Yang and colleagues searched large databases including PubMed, Embase, and the Cochrane Library for literature up to April 2025, selecting studies that involved acute Achilles tendon rupture, compared surgical and conservative treatment, and reported clear clinical outcomes. They organized the literature following PRISMA guidelines and assessed the level of evidence with the GRADE system. Statistically, they used risk ratio (RR) and mean difference (MD), choosing fixed- or random-effects models based on heterogeneity.

Comparison of the main findings

1. Re-rupture rate: lower in the surgical group

The re-rupture rate was 3.6% in the surgical group, significantly lower than 7% with conservative care (RR 0.44, 95% CI: 0.34–0.57, p less than 0.00001). In this study, surgery was associated with a 3.52% reduction in re-rupture risk.

2. Return-to-sport rate: higher likelihood in the surgical group

People who had surgery had a higher likelihood of returning to sport (RR 1.32, 95% CI: 1.03–1.69, p = 0.03), an overall increase of 14.44% in the return rate. This may reflect an inherent advantage of surgery in strength recovery and functional restoration.

3. Complication risk: conservative care carried lower risk

The infection rate in the surgical group was 2.54 times that of conservative care (total infection RR 2.54, p less than 0.0001), including superficial infection (RR 4.89) and deep infection (RR 1.91). Surgery was also associated with a higher risk of nerve injury (RR 3.67, p = 0.01).

4. Functional recovery measure (ATRS): no significant difference

Whether or not surgery was performed, the difference in Achilles Tendon Total Rupture Score (ATRS) was not significant (MD 7.02, 95% CI: -1.35–15.38, p = 0.10), indicating that the two treatments had a similar effect on everyday functional recovery.

PRP treatment showed no expected added benefit

In recent years, platelet-rich plasma (PRP), because it contains various growth factors, has been thought to potentially speed tendon healing. However, this study found:

• PRP showed no statistically significant difference on re-rupture rate, ATRS, ankle range of motion, or return to sport.

• PRP injection is costly and its effect is short-lived; with only a single injection, its effect may be insufficient to support long-term tendon healing.

For these reasons, there is currently not enough evidence to support including PRP in standard AATR treatment.

Considerations for treatment choice

Clinically, the decision should be individualized based on the patient’s age, activity demands, coexisting conditions, and access to care. For example, for people with high activity demands such as professional athletes, surgery may be more appropriate; for older patients or those with chronic conditions, conservative care may be considered first. What is suitable depends on your condition and a physician’s assessment.

For surgery, the main advantage is that it can markedly lower the risk of re-rupture while giving patients a higher likelihood of returning to their original level of sport or activity sooner. However, this approach also comes with a higher rate of complications, particularly a relatively higher risk of infection and nerve injury, and the overall cost is usually higher.

Conservative care, by contrast, is known for lower risk. Patients do not undergo surgery and can therefore avoid surgery-related complications such as wound infection and intraoperative nerve injury, and overall medical costs are lower. That said, this approach has a higher re-rupture rate, and functional recovery, especially of athletic ability and strength, may be slower and less complete than with surgery.

Summary

This systematic review and meta-analysis provides strong evidence that surgery was associated with advantages in lowering re-rupture and promoting return to sport, but at the cost of a higher risk of complications. PRP did not show a significant effect, and more research is still needed to confirm its mechanism and best conditions for use. For clinicians and patients, choosing a treatment should balance the medical evidence against individual needs to support the best possible recovery and quality of life. These are trial results and do not predict any individual’s outcome, and the right choice depends on your condition and a physician’s assessment.

References

J Orthop Surg Res. 2025 Jul 8;20(1):626.

Further reading

• Sports injury overview
• PRP prolotherapy
• Rehabilitation exercise prescription
• Pain management