Global Approaches to Surgical Treatment of Achilles Tendon Ruptures
A comprehensive analysis of international surgical trends for Achilles tendon rupture management, revealing significant variations in treatment preferences across countries.
Achilles Tendon Rupture Treatment by Country
Compare how different countries approach treatment of Achilles tendon ruptures. Countries are colored based on their current surgical rates.
Germany
Slight decline but still predominantly surgical
Source: bookinghealth.com/disease/achilles-tendon-rupture/germanyJapan
Increase in surgical treatment from 67% in 2010 to 72% in 2017
Source: pmc.ncbi.nlm.nih.gov/articles/PMC8543583/United States
Surgical repair rate remained stable at around 70%
Source: journals.sagepub.com/doi/10.1177/2325967114549948South Korea
Slight decrease but remained predominantly surgical
Source: pubmed.ncbi.nlm.nih.gov/34708136/New Zealand
Selective approach to treatment with 39
Source: pubmed.ncbi.nlm.nih.gov/21733434/Denmark
Sweden
Significant decline in surgical treatment
Source: bmjopensem.bmj.com/content/10/3/e001960Australia
68% decrease in surgical repairs between 2009 and 2014, continuing to decline to 12
Source: research.monash.edu/en/publications/twelve-month-outcomes-following-surgical-repair-of-the-achilles-tUnited Kingdom
Strong trend toward non-operative management
Source: www.bmj.com/content/364/bmj.k5120About This Data
Treatment approaches for Achilles tendon ruptures vary significantly across countries, influenced by healthcare systems, medical traditions, and evolving research. Countries like the UK favor conservative management with evidence showing equivalent outcomes, while the US shows a strong preference for surgical intervention, particularly among athletic populations.
Recovery rate with proper conservative treatment according to Willits et al. (2010)
Average re-rupture rate difference between surgical and non-surgical approaches (Ochen et al., JAMA 2019)
Proportion of centers using early weight-bearing protocols in non-surgical management (Kearney et al., 2021)
Note: In the UK and Australia they are called "anaesthetists" rather than "anesthesiologists" as in the US. Medical terminology varies between countries based on different healthcare systems and traditions.
Surgical Approach Groups
High Surgical Rate Countries
Countries with strong preference for surgical treatment (70-95% of cases)
Mixed Approach Countries
Countries using both surgical and non-surgical approaches (30-70% surgical)
Low Surgical Rate Countries
Countries primarily using non-surgical management (under 30% surgical)
Surgical Treatment Trends by Country
| Country | Current Surgical Rate | Historical Change | Trend Direction | Key Finding |
|---|---|---|---|---|
| France | 92% (2019) | 92% (2018) → 92% (2019) | Stable or insufficient data | Strong preference for surgical treatment despite similar re-rupture rates. Early weightbearing and mobilization within 30 days optimized outcomes without increasing re-rupture risk. |
| Germany | 88.7% (2018) | 92.3% (2005) → 88.7% (2018) | Decreasing surgical rate | Operation remains standard therapy, though trend toward conservative functional therapy exists |
| Italy | 80% (2015) | 85.3% (2001) → 80% (2015) | Decreasing surgical rate | Surgical management remains the standard of care across all regions of Italy, with the highest rate of procedures in the northern regions |
| Japan | 72% (2017) | 67% (2010) → 72% (2017) | Increasing surgical rate | Japan shows a counter-trend with increasing surgical treatment rates compared to Western countries |
| United States | 70% (2015) | 69.5% (2005) → 70% (2015) | Increasing surgical rate | The incidence of Achilles tendon ruptures is increasing with time, but the trend in operative and nonoperative treatment remained stable between 2005 and 2015. Treatment decisions appear to be influenced primarily by patient age. |
| South Korea | 61% (2017) | 65% (2009) → 61% (2017) | Decreasing surgical rate | Incidence of Achilles tendon ruptures has increased with continued preference for surgical management |
| New Zealand | 39.4% (2010) | Insufficient data | Stable or insufficient data | Results support surgery in patients under 40 years (particularly males) if no contraindications. Functional bracing with non-operative treatment yields low re-rupture rates in patients over 40, especially females. |
| Denmark | 20.2% (2013) | 62.7% (1994) → 20.2% (2013) | Decreasing surgical rate | Decreasing trend in surgical management, with significant shift toward non-operative treatment |
| Finland | 15.2% (2019) | 78.6% (1997) → 15.2% (2019) | Decreasing surgical rate | ATR incidence increased while operative treatment decreased significantly. The plateau in incidence during the second half of the study period suggests stabilization. |
| Sweden | 14.4% (2021) | 46.5% (2002) → 14.4% (2021) | Decreasing surgical rate | Achilles tendon rupture incidence has increased by 45% while surgical interventions have decreased by 55% |
| Australia | 12.3% (2019) | 68% (2009) → 12.3% (2019) | Decreasing surgical rate | Australia shows a significant shift away from surgical management, with a 68% decrease in surgical repairs from 2009-2014, mirroring international trends. This shift is attributed to emerging high-quality evidence supporting non-surgical approaches with lower complication rates. |
| Canada | 9.2% (2013) | 20.1% (2003) → 9.2% (2013) | Decreasing surgical rate | Surgical repair rates have substantially decreased while Achilles rupture incidence has increased |
| United Kingdom | 5% (2020) | 40.2% (2010) → 5% (2020) | Decreasing surgical rate | Operative treatment reduces re-rupture risk but increases complications. Final decision should be based on patient-specific factors and shared decision-making. |
Regional Insights
Scandinavian Countries
Sweden, Denmark, and Finland show the most dramatic shift away from surgical management, with current surgical rates ranging from 14-20%. These countries were early adopters of evidence-based changes following high-quality studies showing comparable outcomes with well-managed non-operative protocols.
Continental Europe
France, Germany, and Italy maintain high surgical rates (80-92%) despite the same evidence being available. This suggests strong influence of medical tradition, training pathways, and healthcare system incentives in treatment decision-making.
English-Speaking Countries
The UK (5%) has shifted dramatically to non-operative management, while Canada (9%) shows a similar trend. Australia (35%) is transitioning but at a slower pace, and the US (70%) maintains a strong preference for surgical approaches despite similar healthcare systems and shared literature.
Asia-Pacific
Japan shows a counter-trend with increasing surgical treatment rates (67% to 72%), while South Korea maintains relatively high surgical rates (61%). This suggests cultural and regional factors may influence treatment beyond purely clinical considerations.
Healthcare Economics and Surgical Decision-Making
Analysis of global treatment patterns reveals a striking correlation between healthcare payment models and the prevalence of surgical intervention for Achilles tendon ruptures. This relationship persists despite growing research indicating comparable outcomes between well-managed non-operative protocols and surgical repair.
| Healthcare System Type | Representative Countries | Surgical Rate | Treatment Trend |
|---|---|---|---|
| Nationalized healthcare with salaried surgeons | Sweden, Finland, UK, Denmark | 5-20% | Strong shift toward non-operative management since 2008-2010 |
| Mixed systems with fee-for-service elements | Australia, Canada, New Zealand | 9-60% | Gradual shift toward non-operative management |
| Predominantly fee-for-service systems | US, France, Germany, Italy | 70-92% | Minimal change or stable high surgical rates despite evidence |
| Asian healthcare systems | Japan, South Korea | 61-72% | Japan showing increasing surgical rates (67% to 72%, 2010-2017) |
Economic Influences on Treatment Selection:
- Scandinavian Approach: Sweden, Finland, and Denmark—countries with nationalized healthcare systems where surgeons typically receive salaries rather than fee-for-service payments—have experienced the most dramatic shifts away from surgical management. Sweden's surgical incidence decreased from 13.4 to 6.0 per 100,000 person-years between 2002 and 2021, with current surgical rates around 14-15%16. Finland showed a similar decline from 13.6 to 4.9 per 100,000 person-years (1997-2019)30.
- Fee-for-Service Impact: Countries where surgeons are primarily reimbursed per procedure (US, France, Germany) maintain significantly higher surgical rates (70-92%) despite access to the same research evidence21,22,49. In France, 92% of acute Achilles tendon ruptures were treated surgically in 2018-201921, while Germany reported rates above 88% as of 2018.
- Evidence Implementation Timing: The rapid adoption of non-operative management in the UK, Sweden, and Finland closely followed publication of key randomized controlled trials showing equivalent outcomes. These systems could implement evidence-based changes more rapidly due to centralized guidelines and absence of financial incentives favoring surgery16,39.
- Counter-Trend in Japan: Japan demonstrated an increase in surgical treatment rates from 67% in 2010 to 72% in 201742, despite having universal healthcare coverage. This suggests that while payment models are influential, other factors such as surgical training, cultural preferences, and practice traditions also play significant roles.
Economic Analysis:
The persistent high surgical rates in fee-for-service systems suggest financial incentives may influence treatment selection. A surgeon performing Achilles repair typically receives significantly higher compensation than for managing the same condition non-operatively, creating an inherent economic incentive that may consciously or unconsciously affect clinical decision-making.
Additionally, hospital systems and ambulatory surgery centers generate substantially more revenue from surgical cases than non-operative care, potentially influencing institutional protocols and practice patterns. This economic reality helps explain why countries with predominantly fee-for-service systems have been slower to adopt non-operative management despite mounting evidence supporting its efficacy.
In contrast, systems where physician compensation is not directly tied to procedure volume (such as in Sweden, Finland, and the UK) have more readily embraced non-operative management following evidence demonstrating comparable outcomes with lower complication rates16,30. These healthcare systems also typically implement standardized treatment guidelines more uniformly than decentralized fee-for-service systems.
Case Study: Australia's Transition
Australia represents an interesting intermediate case with a mixed healthcare system. Following the publication of key research in 2010, Australia experienced a 68% decrease in surgical repairs between 2009 and 201419. The surgical rate declined from 68% to 35%, suggesting that while economic incentives matter, evidence can drive significant practice changes even in systems with fee-for-service elements when supported by strong research and professional guidelines.
Surgical Rates vs Incidence
Surgical Treatment Trends with 2025 Projections
Latest Surgical Rates by Region
Global Trends in Achilles Tendon Rupture Incidence and Surgical Versus Non-Surgical Treatment Rates
Introduction
The Achilles tendon, the strongest and largest tendon in the human body, plays a critical role in locomotion by connecting the calf muscles to the heel bone. This robust structure is essential for activities such as walking, running, and jumping, bearing loads up to 12 times body weight during running.
Despite its strength, the Achilles tendon is susceptible to rupture, a common musculoskeletal injury that can result in significant morbidity. Achilles tendon rupture typically occurs due to sudden, forceful plantarflexion or dorsiflexion of the foot, often during sports participation involving rapid acceleration, deceleration, or changes in direction.
The management of Achilles tendon rupture has evolved over time, with primary treatment options including surgical repair and non-surgical management. This report analyzes the global trends in the incidence of Achilles tendon ruptures and the corresponding shifts in treatment approaches across various countries.
Global Trends in Achilles Tendon Rupture Incidence
Epidemiological studies from various parts of the world have consistently reported an increasing trend in the incidence of Achilles tendon ruptures over the past few decades:
• Sweden: 45% increase from 2002 to 2021 (28.8 to 41.7 cases per 100,000 person-years)
• Denmark: Significant increase between 1994 and 2013 (26.95 to 31.17 per 100,000 people annually)
• Finland: Increase from 17.3 to 32.3 per 100,000 person-years between 1997 and 2019
• United Kingdom: Increasing trend from 1995 to 2019, with rates around 8 cases per 100,000 people per year
• South Korea: Upward trend between 2009 and 2017, reaching 26.53 cases per 100,000 person-years
• New Zealand: Substantial increase from 4.7 to 10.3 per 100,000 between 1998 and 2003
Several factors contribute to this rising incidence, including an aging but active population, increased sports participation, rising obesity rates, certain medications (fluoroquinolones, corticosteroids), and improved diagnostic methods.
Evolution of Treatment Approaches: Surgical vs. Non-Surgical Rates
Recent years have witnessed significant changes in clinical practice regarding Achilles tendon rupture treatment:
• Canada: Substantial decline in surgical repair rates after 2009
• United Kingdom: Strong trend toward non-operative management
• Sweden: Decrease in surgical incidence from 13.4 to 6.0 per 100,000 person-years (2002-2021)
• Denmark: Decrease in surgically treated patients from 16.9 to 6.3 per 100,000 (1994-2013)
• Finland: Decrease in operative treatment from 13.6 to 4.9 per 100,000 person-years (1997-2019)
• Australia: 68% decrease in surgical repairs between 2009 and 2014
However, this trend is not universal:
• Japan: Increase in surgical treatment from 67% in 2010 to 72% in 2017
• France: 92% of acute Achilles tendon ruptures treated surgically (2018-2019)
• United States: Surgical repair rate remained stable at around 70% (2007-2015)
• Italy: Increasing hospitalizations for Achilles tendon repair (2001-2015)
The shift toward non-operative management in many regions is largely attributed to high-quality studies showing comparable outcomes with well-managed non-operative protocols that include early functional rehabilitation.
Demographic Characteristics of Achilles Tendon Rupture Patients
• Age: Typically 30-50 years, with Sweden showing an increase in median age from 44 (2002) to 50 (2021)
• Gender: Consistently higher incidence in males (2-12 times more likely than females)
• High-risk groups: Middle-aged men (40-49 years), 'weekend warriors', and increasingly older adults (>50 years)
• Activity association: Commonly linked to sports (basketball in US, soccer and badminton in Europe)
Outcomes Associated with Surgical and Non-Surgical Treatment
• Re-rupture risk: Surgical treatment shows a small reduction (1-2%) compared to non-operative management, but this gap narrows with functional rehabilitation protocols
• Complications: Surgery has significantly higher risks (infections ~2.8%, wound problems, nerve injury, DVT)
• Functional outcomes: Recent studies show comparable results between surgical and non-surgical approaches when non-operative management includes early functional rehabilitation
Conclusion
The incidence of Achilles tendon rupture has increased globally, while treatment approaches have evolved toward non-operative management in many regions. This shift is supported by evidence showing comparable functional outcomes and lower complication risks with non-operative treatment that includes early functional rehabilitation.
The optimal management strategy should be individualized, considering each patient's unique circumstances through shared decision-making between patient and clinician.
References
- Surgical vs. nonoperative treatment for acute Achilles' tendon rupture: a meta-analysis of randomized controlled trials - Frontiers
- Global trends in research of achilles tendon injury/rupture: A bibliometric analysis, 2000–2021 - Frontiers
- Achilles Rupture - Physiopedia
- Acute Achilles tendon ruptures between 2002–2021: sustained increased incidence, surgical decline and prolonged delay to surgery—a nationwide study of 53,688 ruptures in Sweden | BMJ Open Sport & Exercise Medicine
- Clinical and functional outcomes of 405 Achilles tendon ruptures - PubMed
- Operative Versus Nonoperative Treatment of Acute Achilles Tendon Rupture: A Propensity Score–Matched Analysis of a Large National Dataset - Sage Journals
- Increase in Achilles Tendon Rupture Surgery in Japan: Results From a Nationwide Health Care Database - PMC