Cut or Cast? A Big RCT About Achilles Tendon Surgery in NEJM

A large RCT gives us new ways to clearly present surgical vs. non-surgical options to patients with ruptured Achilles

What’s the Claim?

Researchers in Norway performed a multicenter, randomized controlled trial (526 patients) and found that surgery for patients with Achilles tendon ruptures (whether traditional or minimally invasive repair) doesn’t result in better patient-reported outcomes at 12 months, but about 6% of the patients treated nonsurgically with serial casting had reruptures (compared with <1% of those in the surgical groups), while about 5% of those treated with open surgery had nerve injuries (compared with 2.8% in the MIS group and 0.6% in the nonsurgical group). There were no differences between MIS and traditional repair in any endpoints.

How’s It Stack Up?

This was a very well done, large (526 patients in three groups), multicenter RCT, and the interventions in all groups seemed both thoughtfully and well applied. For example, after casting in the nonsurgical group, an ankle-foot orthosis with heel wedges was used for 6 weeks, with gradual reduction in the number of heel wedges (from 3 to 1) over that span. The result was that all groups in this trial did better than we’re used to seeing both in terms of patient-reported outcomes and complications.

The researchers also performed physical measurements in a large majority of participants; those didn't find any important differences among the three study groups, either. In particular, all groups were comparable in terms of strength measurements.

What’s Our Take?

The idea that nonsurgical management is an option for this injury is not a new one; what caught our eye about this study is how well that approach served a large percentage of patients treated that way. It seems replicable, provided that we’re attentive to detail in terms of how we perform nonsurgical management.

On the flip side, the 6% versus <1% risk of rerupture is certainly a meaningful difference in favor of surgery, particularly for patients who really can’t or don’t want to risk having a rerupture, though surgery came with a roughly 1-in-20 chance of nerve injury in this trial in those treated with open surgery, and about 3% of those treated with MIS surgery.

This study is good enough to inform — and influence — our decision-making for this injury, because its findings paint a clear picture to patients about real-world-important tradeoffs. Summarizing it would make for a nice patient handout!


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.