Management and Outcomes of Achilles Tendon Re-rupture: A Retrospective Cohort Study

Abstract

Background:

Achilles tendon re-rupture is a challenging complication with limited data guiding optimal management. The purpose of this study was to evaluate treatment strategies, patient characteristics, and outcomes of Achilles tendon re-ruptures in an academic large single institution series.

Methods:

A retrospective review was done of acute Achilles tendon re-ruptures (2015-2025). Index ruptures and re-ruptures were confirmed by clinical examination and a positive Thompson test. Minimum clinical follow-up was 3 months. Clinical outcomes included reoperation rates and return to normal activity. Patient-reported outcomes were collected at a minimum of 1 year post–secondary repair and included visual analog scale (VAS; n = 32) and Foot and Ankle Ability Measure (FAAM-ADL; n = 15) scores.

Results:

Forty-one re-ruptures were identified with a mean follow-up of 22.4 months. Mean age at re-rupture was 43.6 years (82.9% male; body mass index 29.8). Index ruptures were primarily treated operatively (65.9%) at a median of 4 days post-injury. Re-ruptures occurred at a median of 96 days (IQR 53.5-136), most commonly because of falls (47.5%) and at the midsubstance area of the tendon (70.7%). Most re-ruptures were treated operatively (82.9%) with flexor hallucis longus transfer (52.9%). In surgically treated re-ruptures (n = 34), wound dehiscence occurred in 7 patients (20.6%). Six of 7 wound dehiscence cases had their index rupture treated surgically. Mean FAAM-ADL was 90.1 and VAS was 1.39. Operative treatment of the re-rupture was associated with a higher rate of return to normal activity “operative 73.5% vs nonoperative 14.3%” (P = .006).

Conclusion:

Achilles tendon re-ruptures most commonly occurred 3 months from initial treatment and were predominantly managed surgically. Operative treatment was associated with higher rates of return to normal activity, but carried a substantial risk of wound complications, with a higher unadjusted rate among patients with a history of prior operative repair that did not remain significant after adjustment.

Level of Evidence:

Level III, retrospective cohort study.

Introduction

The incidence of Achilles tendon rupture (ATR) is approximately 31 per 100 000 persons and most commonly occurs in men aged 37-44 years.^1,2 These injuries classically affect younger, active adults; however, with an aging population, ATR is increasingly observed in older individuals as well. ² The majority of patients sustain midsubstance ruptures and report no antecedent Achilles pain, with injury typically occurring during an abrupt push-off maneuver in recreational sporting activities.^3,4

Management of acute Achilles tendon ruptures remains controversial and is largely influenced by the functional demands of the patient.^1,5,6 Nonoperative treatment traditionally consists of cast immobilization followed by functional bracing. ⁷ Operative management encompasses a wide range of surgical techniques, and no definitive consensus exists regarding the optimal approach.^8,9 Regardless of treatment modality, achieving a biomechanically robust repair while minimizing complications is critical, particularly in high-demand patients. Surgical repair is associated with risks including infection, sural nerve injury, and thromboembolism. ¹⁰ However, surgical repair is thought to reduce the risk of one of the most devastating complications—Achilles tendon re-rupture.^11,12

Reported re-rupture rates vary widely in the literature, ranging from 0.6% to 12.6%,^1,6 with most re-ruptures occurring within the first 10 weeks following initial treatment. ⁶ Identified risk factors include increased body mass index, male sex, and younger age.^13,14 Patients who experience re-rupture demonstrate inferior long-term functional outcomes in the injured limb compared with those who undergo successful primary repair.^15,16 Existing studies evaluating Achilles tendon re-rupture are limited by small cohort sizes and heterogeneous treatment strategies.^15,16 Consequently, there remains a scarcity of data guiding the optimal management of Achilles tendon re-rupture. The purpose of this study was to evaluate management strategies, patient characteristics, and outcomes of Achilles tendon re-ruptures in a large academic single-institution series.

Methods

Study Design

This retrospective cohort study was conducted to evaluate management strategies and outcomes of Achilles tendon re-ruptures in a large single-institution series. Institutional review board approval was obtained prior to study initiation.

A Structured Query Language (SQL)-based query of our institutional electronic medical record database was performed to identify patients with potential Achilles tendon re-rupture. The query included encounters between January 1, 2015, and January 6, 2026. This search identified 1130 unique encounters corresponding to 859 unique patients. All records were manually screened by trained research personnel to confirm the presence of a true Achilles tendon re-rupture (Figure 1).

Figure 1.

Cohort selection flow diagram.

During screening, 95 cases were identified as potential re-ruptures. Fifty-four cases were excluded because of incomplete clinical data, absence of an acute rupture (ie, cases involving chronic rupture or tendinopathy), or less than 3 months of clinical follow-up. The final study cohort consisted of 41 patients with confirmed complete Achilles tendon re-ruptures. Re-rupture was confirmed by clinical examination and a positive Thompson test. Magnetic resonance imaging (MRI) was the primary imaging modality used as needed by the primary provider to confirm a complete re-rupture. A subset of patients (17%) had their index rupture treated at an outside institution; however, these patients were included because sufficient documentation regarding the index injury was available.

Data Collection

For each patient, baseline demographic characteristics and clinical variables were collected. When available, rupture location was recorded using predefined anatomic categories: distal/insertional (0-2 cm from the calcaneal insertion), midsubstance (2-6 cm), and proximal (>6 cm). Location classification was based on operative documentation or the treating surgeon’s description in the medical record. Including management of both the index and re-rupture, this cohort was treated by a total of 11 fellowship-trained orthopaedic foot and ankle surgeons and 4 podiatrists (excluding outside providers). Weightbearing protocols vary slightly between providers and management strategy, so this information was recorded and evaluated to minimize potential confounding in outcomes assessment. In general, patients were initially immobilized in a short-leg, nonweightbearing cast with the ankle maintained in slight plantarflexion. Patients were then transitioned to a removable Achilles boot with heel wedges. Progressive weightbearing was initiated in a controlled fashion with gradual removal of heel wedges over time. Patients subsequently began a structured physical therapy program.

All relevant complications were recorded. Patient-reported outcomes were obtained through telephone follow-up at a minimum of 1 year following the re-rupture. Patients were asked to complete the Foot and Ankle Ability Measure–Activities of Daily Living (FAAM-ADL) and a visual analog scale (VAS) for pain. The overall patient-reported outcome measure response rate yielded 15 valid FAAM-ADL responses (37% of the cohort) and 32 valid VAS scores (78% of the cohort). Return to normal activity was assessed as a binary outcome (yes/no) at latest clinical follow-up. “Yes” was defined as documentation of discharge from formal physical therapy and return to baseline or unrestricted activities of daily living, as determined by the treating surgeon’s clinical note. Although outcome measures such as return to work, normal activity, or sport do not represent validated patient-reported outcome instruments, they have been regularly used as functional outcomes in the orthopaedic literature.^17,18 Given the limited availability of patient-reported outcome measure data in this retrospective cohort, return to normal activity was included to provide an additional assessment of functional recovery.

Data Analysis and Statistics

Descriptive statistics were used to summarize the data. Continuous variables are reported as means with SDs, whereas categorical variables are reported as frequencies and percentages. Comparative analyses were performed using the Mann-Whitney U test for continuous variables and Fisher exact test for categorical variables. Because of limited sample size, comparative analyses between variables were hypothesis generating and should therefore be interpreted with caution; correction for multiplicity testing was not performed. Firth penalized regression was performed to evaluate independent associations between treatment modality and key outcome variables. Covariates were limited to clinically relevant variables to avoid model overfitting due to rare events. Statistical significance was defined as a 2-sided P value <.05. All analyses were performed by a trained biostatistician using R statistical software (version 4.5.1; R Foundation for Statistical Computing).

Results

Demographics and Baseline Characteristics

A total of 41 patients with confirmed Achilles tendon re-rupture met inclusion criteria (Figure 1). The mean age at the time of re-rupture was 43.6 ± 12.5 years (Table 1). The cohort was predominantly male (n = 34, 82.9%). The mean body mass index (BMI) was 29.8. Tobacco use was documented in 8 patients (19.5%).

Table 1.

Patient Demographics and Baseline Characteristics (N = 41). ^a

Characteristic	Value
Age at re-rupture, y	43.6 ± 12.5
Male sex	34 (82.9)
BMI	29.8 ± 4.5
Weight, lb	204 ± 34.8
Height, inches	69.0 ± 3.4
Tobacco use	8 (19.5)

Abbreviation: BMI, body mass index.

^aValues are presented as mean ± SD for continuous variables and n (%) for categorical variables.

Achilles Tendon Index Rupture Characteristics

The majority of index ruptures were treated by orthopaedic surgeons (36, 87.8%) (Table 2). Cases were evenly distributed between providers, with the highest-volume surgeon managing 10 index ruptures. Sports-related injuries represented the most common mechanism of rupture, accounting for 26 cases (63.4%). Falls were the second most common mechanism (n = 9, 22.0%), whereas 1 rupture (2.4%) occurred with recreational activity. Twenty-seven patients (65.9%) underwent operative treatment for the index rupture, whereas 14 patients (34.1%) were treated nonoperatively. Seven index ruptures (25.9%) treated surgically were done with a percutaneous approach (PARS), whereas the rest were treated with the open approach. The median time from index rupture to intervention was 4 days.

Table 2.

Characteristics of Index Achilles Tendon Rupture (N = 41). ^a

Characteristic	Value
Primary provider for index rupture
Orthopaedic surgery	36 (87.8)
Podiatry	3 (7.3)
Unknown	2 (4.9)
Mechanism of index rupture
Fall	9 (22.0)
Recreational activity	1 (2.4)
Sports-related	26 (63.4)
Unknown	5 (12.2)
Worker’s compensation related	3 (7.3)
Primary treatment
Nonoperative	14 (34.1)
Operative	27 (65.9)
Days from index rupture to intervention b	4.00 [1.00, 9.75]

^aUnless otherwise noted, values are presented as n (%) for categorical variables.

^bContinuous non-normally distributed variables presented as median values with first and third quartiles.

Achilles Tendon Re-rupture Characteristics

The most common mechanism of re-rupture was a fall, accounting for 19 cases (47.5%) (Table 3). Only 1 (2.4%) Achilles tendon re-rupture was managed by a podiatrist. Similar to the index rupture, case volume was evenly distributed, with the highest-volume surgeon accounting for 13 cases. Sports-related injuries were responsible for 11 cases (27.5%), whereas 8 re-ruptures (20.0%) occurred during other recreational activities. The mechanism of injury was unknown in 3 cases (7.3%). The median time from index repair to re-rupture was 96 days, with only 3 re-ruptures occurring outside the first year postoperatively (Figure 2). All 3 outliers were insertional tears, occurred during sporting activities, and had index ruptures treated surgically.

Table 3.

Characteristics and Management of Achilles Tendon Re-rupture. ^a

Characteristic	Value
Mechanism of re-rupture
Fall	19 (47.5)
Recreation (non-sport activity)	8 (20.0)
Sports-related	11 (27.5)
Unknown	3 (7.3)
Days from index repair to re-rupture b	96.0 [53.5, 136]
Re-rupture location
Insertional (0-2 cm)	8 (19.5)
Midsubstance (2-6 cm)	29 (70.7)
Proximal (>6 cm)	4 (9.8)
Occurred at same site as index rupture	37 (90.2)
Secondary treatment
Nonoperative	7 (17.1)
Operative	34 (82.9)
Weeks to full weightbearing, mean ± SD	3.88 ± 1.58
Surgical techniques used in revision repair
FHL tendon transfer	18 (52.9)
V-Y advancement	7 (20.6)
Turn-down flap	3 (8.8)
Other	6 (17.6)
Provider managing re-rupture
Orthopaedic surgery	40 (97.6)
Podiatry	1 (2.4)

Abbreviation: FHL, flexor hallucis longus.

^aValues are presented as mean ± SD for continuous variables and n (%) for categorical variables.

^bContinuous non-normally distributed variables presented as median values with first and third quartiles.

Figure 2.

Histogram plot of time to re-rupture (weeks) from the index intervention, excluding 3 patients who had re-ruptures after 1-year. The black dashed bar represents the median.

The majority of re-ruptures occurred in the midsubstance region of the tendon (29, 70.7%). Most patients underwent operative management of the re-rupture (34, 82.9%), whereas 7 patients (17.1%) were treated nonoperatively. Among patients undergoing operative revision, flexor hallucis longus (FHL) tendon transfer was the most commonly used technique performed in 18 cases (52.9%). V-Y advancement was used in 7 cases (20.6%), and a turn-down flap was used in 3 cases (8.8%). Patients were allowed to return to full weightbearing at a mean of 3.88 ± 1.58 weeks following treatment.

Outcomes Following Achilles Tendon Re-rupture

Seven patients with re-rupture were managed nonoperatively (17.1%). The primary reason for nonoperative treatment was patient preference, as 3 patients were advised to undergo revision surgery but declined. In the remaining cases, nonoperative management was selected based on factors such as minimal tendon gapping, musculotendinous junction location of the re-rupture, or perceived adequate tendon continuity. Postoperatively, these patients were managed with a period of immobilization and protected weightbearing.

Thirty-four (82.9%) of re-ruptures were managed operatively. Twenty-six patients (63.4%) had a clinical follow-up at 1 year. Within this cohort, further surgical intervention was required in 5 patients (14.7%) at a median follow-up of 14.5 months post re-rupture surgery. Further surgeries were all irrigation and debridement procedures due to wound dehiscence. There were 2 additional cases of wound dehiscence successfully managed non-operatively, resulting in a surgical wound dehiscence rate of 20.6% following Achilles tendon re-rupture repair. There were no other complications documented in this cohort, including deep vein thrombosis, additional re-ruptures, or sural nerve injury.

In the overall cohort, 26 patients (63.4%) returned to their normal level of activity at the most recent follow-up (Table 4). With the numbers available, there were no significant differences in age (P = .212), sex (P = .627), BMI (P = .125), or follow-up duration (643 vs 690 days, P = .830) between patients who returned to normal activity and those who did not. At a minimum 1 year postoperatively, the mean FAAM-ADL score was 90.1 ± 12.6, and the mean VAS pain score was 1.39 ± 1.71.

Table 4.

Postoperative Outcomes Following Achilles Tendon Re-rupture. ^a

Outcome	Value
Further surgical intervention	5 (14.7)
Wound dehiscence b	7 (20.6)
Return to normal activity	26 (63.4)
Patient-reported outcomes
FAAM-ADL score (n = 15)	90.1 ± 12.6
VAS pain score (n = 32)	1.39 ± 1.71
Follow-up duration, d c	434 [215.5, 784.2]

Abbreviations: FAAM-ADL, Foot and Ankle Ability Measure–activities of daily living; VAS, visual analog scale.

^aValues are presented as mean ± SD for continuous variables and n (%) for categorical variables.

^bNote wound dehiscence and reoperation are expressed as percentages of surgically treated Achilles tendon re-ruptures (n = 34).

^cContinuous non-normally distributed variables presented as median values with first and third quartiles.

Secondary Comparative Analyses

When comparing treatment of the index Achilles tendon rupture, no difference was detected with the numbers available in regard to functional outcomes, pain, or return to activity in patients treated nonoperatively (n = 14, 34.1%) vs those managed surgically (n = 27, 65.9%, all P > .05). For management of the Achilles tendon re-rupture, operative treatment of the re-rupture was associated with a higher rate of return to normal activity (73.5%, 25/34 patients) than nonoperative treatment (14.3%, (1/7 patients, P = .006) with an odds ratio of 0.07 (95% CI 0.00, 0.51).

Within the surgically treated re-ruptures, patients who received V-Y advancement or FHL transfers were significantly heavier (193 vs 217 lbs, P = .021) and had lower FAAM-ADL scores (98.9 vs 83.0, P = .017). Patients experiencing wound dehiscence had a significantly longer median time from index rupture to re-rupture (170 vs 85 days, P = .026). In patients with re-ruptures treated surgically (n = 34), Firth regression adjusting for BMI and age showed that surgically managed index ruptures were associated with a 2.66-fold greater odds of experiencing wound dehiscence following secondary repair; however, this was not statistically significant (95% CI 0.45, 28.64).

Discussion

This study represents one of the largest single-institution series evaluating the management and outcomes of Achilles tendon re-rupture. The principal findings show that re-ruptures most commonly occur approximately 3 months after the index injury and are predominantly managed surgically. Although surgical treatment of re-rupture was associated with favorable patient-reported outcomes and higher rates of return to normal activity, it was also accompanied by a notable risk of wound complications, with a higher unadjusted rate among patients with a history of prior operative treatment.

The median time to re-rupture of 96 days in our cohort aligns closely with existing literature. Maempel et al ¹⁹ reported a median time to re-rupture of 98.5 days in a large epidemiologic study, with most re-ruptures occurring within the first 10 weeks following primary treatment. Similarly, the landmark trial by Myhrvold et al ⁶ found that half of all Achilles tendon re-ruptures occurred within the first 10 weeks after injury. This shows a critical window that likely represents the period of tendon remodeling and relative weakness prior to complete healing. The finding that 93% of re-ruptures occurred within the first year further emphasizes the importance of patient education regarding activity modification, postoperative weightbearing limitations, and immobilization compliance during this vulnerable period.

This relates to the noteworthy shift in injury mechanism from predominantly sports-related for index rupture (63.4%) to falls as the primary cause of re-rupture (47.5%). Importantly, the 3 re-ruptures that occurred beyond 1 year all involved distal ruptures during sporting activities. Insertional Achilles ruptures represent a distinct pathology that are often associated with chronic tendinopathy or enthesopathic calcification. ²⁰ Tendon-to-bone healing presents distinct challenges from tendon-to-tendon healing and therefore necessitates different surgical approaches and management strategies. Xiong et al ²⁰ found that 80% of patients with insertional reattachment for acute sleeve avulsion fracture of the Achilles tendon sustained during sporting activity at a minimum 5 years from surgery. Further, they found that preinjury insertional pain may be associated with poorer outcomes. In the present study, nearly 20% of Achilles tendon re-ruptures occurred within 0 to 2 cm of the calcaneal insertion, which exceeds the reported prevalence of distal tears among primary Achilles ruptures (~12%). ²¹ Whether this apparent overrepresentation of distal re-ruptures reflects an underlying relationship to index rupture location is a question the current data set cannot address, as index rupture location was not captured in this analysis. Therefore, the relationship between primary rupture location and subsequent re-rupture location, as well as the influence of time from the initial repair on re-rupture patterns, is an area of potential further investigation.

Re-ruptures in this series were predominantly managed operatively (82.9%). FHL transfer was the most commonly employed technique (52.9%), followed by V-Y advancement (20.6%). FHL tendon transfer was more commonly selected in heavier patients (mean 217 lb vs 193 lb, P = .021), which may reflect surgeon preference for a more robust reconstruction in patients with possible mechanical demands on the repair because of elevated BMI. The postoperative outcomes for the patients who underwent FHL transfer in this cohort are consistent with published literature. Xu et al ²² reported excellent long-term outcomes following FHL transfer for chronic Achilles tendon ruptures with large defects, with mean AOFAS scores of 90.4 and no re-ruptures at a mean follow-up of 62.6 months. V-Y advancement has demonstrated favorable long-term outcomes in the literature, which aligns with our cohort’s results. Guclu et al ²³ reported mean AOFAS scores of 95 at 16-year follow-up following V-Y plasty with fascia turndown for chronic ruptures, with no re-ruptures and only 11% superficial infection rate. The technique provides adequate length restoration without requiring tendon transfer, making it an appealing option for defects of moderate size or cases when the tendon is more tenuous such as re-rupture. It is important to note that the aforementioned literature predominantly reflects outcomes in the setting of chronic Achilles tendon ruptures rather than acute re-ruptures following prior repair, which represent distinct clinical entities. As such, comparisons regarding V-Y advancement and FHL transfer outcomes should be interpreted within this context, and the application of these techniques in the acute re-rupture setting warrants further dedicated investigation.

The reoperation rate of 14.7% in this series for surgical cases, exclusively due to wound dehiscence, is higher than typically reported for primary Achilles repairs but consistent with the increased complexity of revision surgery. Recent literature suggests that wound complications following Achilles surgery are multifactorial. Hendriks et al ¹³ identified BMI as a significant predictor of re-rupture and surgical delay of primary repair as a risk factor for wound dehiscence. In a meta-analysis of >15 000 primary Achilles tendon ruptures, Ochen et al ² found that operative treatment resulted in a significantly higher rate of complication, mostly attributed to surgical site infection (2.8%). Although not uncommon in the general orthopaedic population, the mean BMI of 29.8 in this cohort places patients in the overweight category, which may have contributed to the elevated wound complication rate. Zhou et al ²⁴ identified smoking, diabetes, and open wounds as significant risk factors for surgical site infections following Achilles surgery, whereas Bruggeman et al ²⁵ found that patients with diabetes, tobacco use, or steroid use had a 42.1% complication rate compared with 6.2% in those without these risk factors.

Among patients with Achilles tendon re-ruptures treated surgically (n = 34), the overall wound dehiscence rate was 20.6% (n = 7). Of the 7 patients who experienced wound dehiscence, 5 were treated with surgical debridement and 2 were managed successfully with nonoperative means. Importantly, 6 of 7 patients (85.7%) who experienced wound dehiscence had their initial rupture treated operatively. Foot and ankle literature has shown that prior surgery at the same incision site is associated with increased risk of infection. ²⁶ Further, if you consider patients who had both their index and re-ruptures managed surgically (n = 23), the resulting wound dehiscence prevalence in this cohort is 26.1% (n = 6). These findings have important implications for both the initial management of Achilles tendon ruptures and the treatment of subsequent re-rupture but should be interpreted with caution and in the context of the aforementioned work, particularly Bruggeman et al ²⁵ and Zhou et al. ²⁴ Although index rupture management demonstrated a significantly greater odds of wound dehiscence following operative re-rupture repair in univariate analysis, multivariable adjustment incorporating BMI and age did not yield statistical significance. This may reflect a genuine attenuation of the association when accounting for patient-level risk factors, though it is equally attributable to the inherent limitations of the statistical approach in the setting of a rare outcome and small sample size. Taken together, patients who underwent operative management of their index rupture may represent a subgroup at heightened risk for wound complications should re-rupture occur and require revision surgery through previously operated soft tissues. Surgeons should maintain appropriate vigilance in this setting, although confirmation in larger prospective series is necessary before definitive conclusions can be drawn.

Interestingly, patients who developed wound dehiscence following re-rupture repair also tended to have a longer interval between index repair and re-rupture, with only 1 of 7 patients experiencing re-rupture within the cohort mean of 3 months. The reason for this association remains unclear. One possible explanation is that later re-ruptures may be associated with higher-energy injury mechanisms, resulting in greater soft tissue disruption at the time of revision surgery.

In our study, the overall mean FAAM-ADL score was 90.1 and VAS pain score was 1.39, demonstrating excellent patient-reported outcomes comparable to those achieved following primary Achilles repair. However, only 65% of patients returned to their prior level of activity, which is lower than the typical 75% to 91% return-to-activity rates reported for primary repairs.^27,28 This result is not surprising as the discrepancy may reflect the pathophysiologic cumulative impact of 2 injuries to an isolated area as well as potential psychological changes and hesitancy that a patient may experience after re-rupture. Studies have even demonstrated that prior traumatic events can potentially hinder recovery because of anxiety and depression symptomatology leading to less favorable patient-reported outcome measures. ²⁹ Beyond return to sports, it is important to note that in our cohort, operative management of re-rupture was associated with significantly higher rates of return to normal activity (73.5% vs 14.3%, P = .006). This provides important guidance for specified patient counseling regarding treatment options. Surgical intervention may warrant consideration in active patients sustaining Achilles re-rupture; however, further validation with larger cohorts is needed before definitive treatment recommendations can be made. Importantly, because treating surgeons were not blinded to treatment allocation, the decision to clear a patient for unrestricted activity may have been influenced by clinical judgment and expectations regarding operative vs nonoperative management. Consequently, differences in the threshold for documenting return to activity could have introduced assessment bias and may have influenced the observed between-group differences.

This study has several limitations. First, the relatively low response rate for patient-reported outcomes (37%) may introduce response bias, although the large number of VAS responses (n = 32) provides reasonable confidence in the pain outcome data. Additionally, because of the inclusion of referred re-ruptures not managed at our institution, we were unable to reliably determine index rupture location for all cases. The cohort was treated by multiple surgeons with varying techniques and rehabilitation protocols, which may have introduced heterogeneity in outcomes. Pooling the heterogeneity of revision surgical techniques, including FHL transfer, V-Y advancement, and turn-down may have obscured procedure-specific differences in outcomes. However, this also enhances the generalizability of the findings to a real-world treatment of Achilles tendon ruptures. The absence of a standardized rehabilitation protocol limits the ability to determine optimal postoperative management, although the mean time to full weight-bearing of 3.88 weeks is consistent with current evidence supporting early functional rehabilitation.^30-32 The small number of patients whose re-ruptures were managed nonoperatively (n = 7) limits meaningful interpretation of return-to-activity comparisons between treatment groups, as findings in this subgroup are highly sensitive to individual patient outcomes. Finally, the study lacks objective strength testing and functional performance measures, which would provide a more comprehensive assessment of outcomes.

Conclusion

Achilles tendon re-ruptures most commonly occurred approximately 3 months after primary treatment. Surgical management was the predominant treatment strategy for re-rupture and was associated with favorable return to normal activity compared with nonoperative management in this selected cohort. However, these functional benefits must be weighed against a substantial risk of wound complications. Although operative treatment of Achilles tendon re-rupture was associated with functional recovery in appropriately selected patients, surgeons should carefully counsel patients regarding the elevated risk of wound complications and remain attentive to a possible, though not statistically confirmed, association with prior surgical history when planning revision procedures.