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Ankle & tendon

Achilles Tendon Rupture

Q: Can I take the boot off at night?

From about week 8 , yes. If you get up in the night, for example to go to the toilet, put the boot back on first.

Most Achilles tendon ruptures can be treated without surgery, in a boot with a structured, early-walking rehabilitation programme. A large trial (Myhrvold, NEJM 2022) found similar function with or without an operation, although re-rupture was more common without surgery. Whether to operate is a shared decision, made together after examination.

The Achilles tendon joins the calf muscle to the heel bone. A rupture usually happens during a sudden push-off, such as sprinting in football, lunging for a tennis shot or tripping on a kerb, and is most common between the ages of 30 and 50.

Symptoms

A sudden snap or a feeling of being kicked or hit in the back of the heel
Pain and swelling just above the heel
Weakness pushing off, difficulty standing on tiptoe, and a limp
Sometimes a gap you can feel in the tendon

If you think you have ruptured your Achilles, keep weight off the leg and get assessed promptly. Early treatment in the correct position matters.

How it is diagnosed

The diagnosis is usually made by clinical examination. An ultrasound scan is not needed in most cases, though some pathways request a scan to examine the extent of the injury.

Non-surgical treatment

Most ruptures can be treated without surgery. The foot is held pointing down in a cast or a VACOped boot, and the boot is gradually brought to neutral over the following weeks while you start walking in it.

The evidence for this approach is strong. The UK STAR trial (Costa et al., Lancet 2020) treated 540 patients across 39 UK hospitals without surgery. Early walking in a functional brace showed no difference in Achilles function scores (ATRS) at 9 months compared with a plaster cast, with similar re-rupture rates (5% in the brace group and 6% in the cast group).

When surgery helps

Surgical repair is a day-case procedure. There is no single gap measurement that decides whether you need an operation. Mr Hester will talk it through with you so that you can decide together.

In the Myhrvold trial (NEJM 2022), 554 patients were randomised to non-surgical treatment, open repair or minimally invasive repair. Function at 12 months was similar. Re-rupture was more common without surgery (6.2% compared with 0.6% in each surgical group), but nerve injuries were more common after minimally invasive surgery (5.2%) than after open repair (2.8%). Complications after Achilles rupture surgery are uncommon but recognised (including wound problems and nerve injury).

The choice depends on your goals, your health, your lifestyle and how you feel about the risks of each option. Surgery may lower the risk of the tendon tearing again, but it has its own risks, such as wound problems, infection, nerve irritation and the risks of an anaesthetic.

Recovery timeline

The rehabilitation is very similar with or without surgery. A typical boot plan:

Weeks 1–2: cast or VACOped boot locked at Level 3, non-weight-bearing.
Weeks 3–4: Level 3, weight-bearing in the boot.
Weeks 5–6: Level 2.
Weeks 7–8: Level 1, flat sole; the boot can come off at night from week 8.
Weeks 9–12: Level 0.
Week 13: into shoes with 6–8 mm gel heel cups, continued until 3 to 5 months.

The risk of re-rupture is highest between weeks 8 and 16, as you come out of the boot, so progress steadily rather than quickly. Running usually starts at about 6 months, once you can do 10 single-leg heel raises; sport at 6 to 9 months, once your hop test is at least 75% of the other side; and the pre-injury level is typically reached at 12 to 18 months. Progress is tracked with the Achilles Tendon Total Rupture Score (ATRS).

All patients are offered blood-thinning injections (low molecular weight heparin) for 6 weeks unless they already take an anticoagulant. This is in line with NICE guidance NG89, which advises considering such injections for people whose leg is immobilised.

As a guide, people return to seated work at 2–3 weeks, standing work at 8–10 weeks and heavy work at 3–5 months. For driving, check with your insurer; otherwise wait until you are out of the boot.

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth) at King's College Hospital, one of only four Major Trauma Centres in London. He is also Site Principal Investigator at King's for the NIHR TiLLI trial, which is studying blood-clot prevention in people whose lower leg is immobilised.

Appointments are available privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard, and in the NHS at King's College Hospital. To book, call 020 7046 8004 or email th@os.clinic. Insured patients need a GP referral and an authorisation code; self-pay patients are welcome.

Frequently Asked Questions

Do I need surgery for a ruptured Achilles?

Usually not. Most ruptures heal well in a boot with early walking. Surgery lowers the re-rupture risk but adds wound and nerve risks, so the decision is made together.

Do I need an ultrasound scan?

Not in most cases. The diagnosis is usually made by examination.

When can I walk on it?

You are non-weight-bearing for the first 2 weeks, then walk in the boot from week 3.

When can I run again?

Usually at about 6 months, once you can do 10 single-leg heel raises on the injured side.

Is a rupture the same as Achilles tendinopathy?

No. Tendinopathy is a painful, degenerate tendon that has not torn. For mid-substance tendinopathy that has not settled with rehabilitation, Mr Hester uses high-volume paratenon injections.

Sources

Costa ML, Achten J, Marian IR, et al. Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR). Lancet. 2020;395:441–448. PMID: 32035553. https://pubmed.ncbi.nlm.nih.gov/32035553/
Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386:1409–1420. PMID: 35417636. https://pubmed.ncbi.nlm.nih.gov/35417636/
Achilles tendon rupture. Cambridge University Hospitals NHS Foundation Trust. https://www.cuh.nhs.uk/patient-information/achilles-tendon-rupture/
Venous thromboembolism in over 16s (NG89). NICE, 2018 (updated 2019). https://www.nice.org.uk/guidance/ng89/chapter/Recommendations

First two weeks after surgeryالأسبوعان الأولان بعد الجراحة

Items patients often find useful in the first two weeks. Always follow your surgical team's instructions; these are general suggestions, not medical advice. As an Amazon Associate I earn from qualifying purchases.عناصر يجدها المرضى مفيدة غالباً في الأسبوعين الأولين. اتبع دائماً تعليمات فريقك الجراحي؛ هذه اقتراحات عامة وليست بديلاً عن المشورة الطبية. بصفتي شريكًا في برنامج Amazon Associates، أحصل على عمولة من عمليات الشراء المؤهلة.

VACOped bootWalking boot often used after Achilles surgery, if advised (choose your size)View on Amazon →عرض على أمازون CrutchesFor the period when you need to keep weight off the footView on Amazon →عرض على أمازون Knee scooterAn alternative to crutches while non-weight-bearingView on Amazon →عرض على أمازون Leg elevation pillowHelps keep the foot raised while restingView on Amazon →عرض على أمازون Waterproof cast cover (lower leg)Keeps a cast, boot or dressing dry in the showerView on Amazon →عرض على أمازون Shower stoolA padded seat so you can sit to showerView on Amazon →عرض على أمازون

Recovery and after your operation: helpful productsالتعافي وما بعد العملية: منتجات مفيدة

As an Amazon Associate I earn from qualifying purchases. These are general suggestions, not a substitute for advice from your surgical team.بصفتي شريكًا في برنامج Amazon Associates، أحصل على عمولة من عمليات الشراء المؤهلة. هذه اقتراحات عامة، ولا تغني عن نصيحة فريقك الجراحي.

See all recommended equipment on Equipment & Devices.

Warning signs: when to get help

Emergency: call 999

if you have sudden breathlessness, chest pain (especially when breathing in) or you cough up blood. These can be signs of a blood clot on the lung.

Urgent problems: call 999 in an emergency, or NHS 111 for urgent advice, if you have:

Calf or thigh pain (sometimes throbbing), swelling, a tight calf, warmth or redness in either leg, especially if it is new or getting worse. These can be signs of a blood clot (DVT).
A sudden pop, snap or feeling of being kicked at the back of the heel, or you suddenly cannot push off. The tendon may have torn again. Put the boot back on with the toes pointing down, keep weight off the leg, and get urgent advice.
Wound problems after surgery: more redness or swelling, leaking fluid or pus, a wound that opens, or a temperature above 38°C.
Numbness, pins and needles, or toes that turn blue, white or cold, or a cast or boot that feels too tight and does not ease when you raise your leg.

For less urgent problems, contact Mr Hester's office if you have:

Pain that is not controlled by your painkillers.
Rubbing or pressure sores from the boot or cast. Cover the area with a dressing and ask for advice.

Mr Hester's office
Phone: 020 7046 8004 (the quickest way to reach the team)
Email: th@os.clinic

There is no out-of-hours line. If you feel very unwell or think it is an emergency, call 999. For urgent advice, call NHS 111.

Everyday questions

Can I shower or bathe?

Keep your cast or boot, and any wound, dry for about the first 2 weeks until the wound has healed. A waterproof cover helps. After that you can shower and wash as normal. When the boot is off, sit down to wash your foot, do not stand on it, and do not pull your foot up towards you. Swimming pools and hydrotherapy are fine once the wound has fully healed, if hydrotherapy is available to you. The boot liner can be washed; follow the maker's instructions.

Do I need crutches?

Only for the first 2 weeks, when you must keep weight off the leg. Once you are weight-bearing in the boot (from week 3), wean off them. They are only there for balance and most people do not need them. An Evenup on your other shoe makes walking much easier.

Can I take the boot off at night?

From about week 8, yes. If you get up in the night, for example to go to the toilet, put the boot back on first.

What about my other leg?

The boot's thick sole makes one leg longer than the other, which can cause back or hip ache. Wear an Evenup shoe balancer on your other shoe (see equipment).

When can I drive?

Driving depends on your insurance, so contact your insurer directly. Otherwise, wait until you are out of the boot.

When can I go back to work?

This depends on your job and your journey. As a guide: a seated job, 2–3 weeks; a job where you stand, 8–10 weeks; a heavy lifting job, 3–5 months. Mr Hester can provide a fit note.

Will I need surgery?

Most Achilles ruptures can be treated without surgery, and both approaches give good results when the rehabilitation is well structured. There is no single measurement, such as the size of the gap between the tendon ends, that decides it. The choice comes down to you: your goals, your health, your lifestyle and how you feel about the risks of each option. Mr Hester will talk it through with you so that you can decide together. Surgery may lower the risk of the tendon tearing again, but it has its own risks, such as wound problems, infection, nerve irritation and the risks of an anaesthetic. The rehabilitation afterwards is very similar.

How is an Achilles rupture diagnosed?

The diagnosis is usually made by clinical examination. An ultrasound scan is not needed in most cases.

Is Achilles tendon repair a day case?

Yes. Surgical repair is a day-case operation in which the tendon ends are stitched together. The rehabilitation afterwards is very similar to treatment without surgery.

When can I run or play sport again after an Achilles rupture?

Running is usually possible from about 6 months and sport from 6–9 months. Getting back to your pre-injury level takes 12–18 months. As a guide, you should be able to do 10 single-leg heel raises on the injured side before you start jogging.

Where can I see Mr Hester about an Achilles rupture in London?

Mr Hester consults at four of London's premier private hospitals: The London Clinic, 20 Devonshire Place, London, W1G 6BW, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at the world renowned King's College Hospital London. To arrange a consultation, please contact us by phone, email or using the form on the contact page. Telephone 020 7046 8004.

Summary for your physiotherapist

Week 1 = first week after injury (non-operative) or surgery (operative). VACOped levels set plantarflexion: Level 3 = maximum equinus, Level 0 = plantigrade. Progress by milestone as well as by date.

Weeks	Boot / weight-bearing	ROM and restrictions	Strength / rehab	Milestone
1–2	Cast or VACOped locked Level 3; NWB, crutches	No DF, no stretching	Toes; prone knee flexion; standing hip flex/ext/abd	2-week review; wound check
3–4	VACOped Level 3; WB in boot; wean crutches (balance only); Evenup	No DF past boot	Gait re-education; proximal strength and conditioning; intrinsics	Comfortable WB in boot
5–6	VACOped Level 2; WB	Active ROM within boot	As above	Wound healed; pain controlled
7–8	VACOped Level 1, flat sole; WB; boot off at night from ~wk 8 (on if up at night)	No passive DF; inversion/eversion out of boot	Light resistance; bike in boot; hydro once wound healed	Pain-free calf activation
9–12	VACOped Level 0; WB; nights off	Active ROM out of boot	Progressive PF loading; balance	Plantigrade; no limp in boot
13 – 3–5 mo	Shoes + 6–8 mm gel heel cups both sides	Avoid extreme DF with forceful PF	Double-leg heel raises; PF load ≤ ½ BW; no eccentrics, running or jumping	Normal gait; good single-leg balance
~5–6 mo	Wean heel cups	–	Single-leg heel raise; gentle plyometrics	SLHR achieved
~6 mo	–	–	Phased jogging, guided by physio progress; eccentrics	~10 SLHR
6–9 mo	–	–	Hills, hops, cutting; return to sport	Hop tests ≥ 75% of other side; SLHR; normal toe-off sprint
12–18 mo	–	–	Pre-injury level	ATRS may be used to track progress

Blood clot prevention: daily low-molecular-weight heparin for 6 weeks for all patients, operative and non-operative, unless already anticoagulated.

Evidence behind this guide

UKSTAR (Costa et al., The Lancet, 2020): 540 patients treated without surgery. Early walking in a functional boot gave the same results at 9 months as a plaster cast, with similar re-rupture rates.
Willits et al. (Journal of Bone and Joint Surgery, 2010): with accelerated functional rehabilitation, re-rupture rates and function were similar with and without surgery, and there were fewer complications without surgery.
Leicester Achilles Management Protocol, LAMP (Aujla et al., Injury, 2019): 442 patients treated without surgery, walking in a boot from the start. The re-rupture rate was 2%.
SMART programme (Hutchison et al., Bone & Joint Journal, 2015): a structured rehabilitation programme with a re-rupture rate of 1.1%.
Myhrvold et al. (New England Journal of Medicine, 2022): function at 1 year was similar with and without surgery. Re-rupture was more common without surgery (about 6% compared with under 1%).
Achilles Tendon Total Rupture Score (Nilsson-Helander et al., American Journal of Sports Medicine, 2007): the patient questionnaire used to measure recovery.
NICE guideline NG89 (venous thromboembolism): recommendations on preventing blood clots when the leg is immobilised.

To discuss your injury with Mr Hester, please get in touch to arrange a consultation. Appointments are available privately in central London and in the NHS at King's College Hospital.

Book a Consultation

This guide is general information to help you understand a typical recovery. It is not personal medical advice and does not replace advice from Mr Hester or your physiotherapist, whose instructions should always come first. Recovery varies from person to person. For urgent problems such as a suspected blood clot, re-rupture or wound infection, call 999 in an emergency or NHS 111 for urgent advice. For less urgent concerns, contact Mr Hester's office on 020 7046 8004 or th@os.clinic.