The debate over surgical versus conservative management for complete Achilles tendon rupture has been resolved by two major RCTs: the UKSTAR trial (2020, BMJ) and the AVLEG trial. Both demonstrated that early functional conservative management — a vacuum-assisted closure (VAC) boot with sequential heel wedge reduction, combined with early supervised physiotherapy — produces equivalent outcomes to surgical repair at 2 years, including re-rupture rates, strength, and return to sport.

Surgical repair is still preferred for elite athletes, young and highly active patients, and cases with tendon gap >10mm on ultrasound. Conservative management is preferred for older patients (>60), those with medical conditions increasing surgical risk, or those with delayed presentation (>2 weeks post-rupture). At Curis 360's Banashankari and Jayanagar clinics, our physiotherapists work closely with orthopaedic surgeons at Manipal, Apollo, and Fortis Hospitals in Bengaluru to ensure seamless rehabilitation coordination from day one — whether or not surgery is performed.

Both conservative and post-operative rehabilitation begin in a functional ankle brace (VAC boot) with 3–4 heel wedges raising the heel by 3–4 cm. This positioning holds the tendon ends approximated while early loading begins. Weight-bearing in the boot is commenced almost immediately in the conservative pathway (Day 1–2 if tolerated) and typically by Day 5–7 post-operatively.

During the first 8 weeks, our physiotherapists at Curis 360 Vasanthapura and Banashankari supervise the graduated heel wedge weaning protocol: one wedge removed every 2 weeks in most protocols, transitioning to a 1-wedge (1 cm) boot by week 6, and a flat boot by week 8. Simultaneously, in-boot exercises are initiated: ankle pumping and dorsiflexion range of motion within the boot (to prevent DVT and maintain blood supply), stationary cycling with the boot on, and upper body conditioning. For post-operative patients, wound inspection and scar mobilisation begin as soon as the wound is closed and sutures removed (typically day 14).

Transitioning out of the boot at week 8 is both a physical and psychological milestone. Patients typically walk flat-footed initially; their first goal is to restore heel-to-toe gait without a compensatory Trendelenburg lean. Our physiotherapists at Curis 360 Jayanagar and Vasanthapura focus intensively on calf strengthening during this phase using a staged protocol: seated calf raises (least load) → double-leg standing heel raises → single-leg heel raises (commenced when the patient can perform 20 pain-free double-leg heel raises).

Single-leg heel raise capacity is the primary functional benchmark throughout recovery. At 6 months post-injury, most patients cannot yet complete a full single-leg heel raise — a clinical sign that the tendon is still remodelling. Full single-leg heel raise height, endurance (20+ repetitions), and rate of force development (speed) matching the uninjured side must be achieved before return to sport is considered. The Limb Symmetry Index (LSI) of heel raise performance must reach >90% before sport return. Our Banashankari clinic uses a calf raise quantification protocol to objectively track this metric at each visit.

Plyometric training reintroduces the tendon to the rapid energy storage and release demands of sport. Our phase 3 protocol is progressive: double-leg jumping and landing → double-leg hopping in place → single-leg hopping in place → single-leg lateral hops → bounding and sprint accelerations. Each sub-phase requires achieving 10 consecutive pain-free repetitions before progression.

Return to full sport (e.g., football, badminton, squash) is typically cleared at 9–12 months — not earlier, regardless of how good the patient feels. The most dangerous period for Achilles re-rupture is 6–9 months post-injury, when the patient feels recovered but the tendon has not yet reached its peak mechanical strength (which requires 12–18 months for full collagen maturation). Our physiotherapists at Curis 360 provide a formal return-to-sport certificate based on objective testing — single-leg heel raise LSI >90%, hop testing LSI >90%, and sport-specific agility testing — not on time alone.