- Early functional rehabilitation yields ATRS 72–86 at 6–12 months and 5–12% re-rupture rates; outcomes comparable to surgery but reliant on patient compliance.
- Kinesiophobia, anxiety, depression, low motivation and variable social support are prevalent in non-operative ATR and plausibly affect adherence and recovery.
- Future trials should measure I-PRRS, TSK-11, validated motivation scales and guideline-based compliance; prioritise cohort studies linking baseline psychology with compliance and re-rupture.
Br Med Bull. 2026 Oct 5;160(1):ldag041. doi: 10.1093/bmb/ldag041.
ABSTRACT
INTRODUCTION: Non-operative management of acute Achilles tendon rupture (ATR) with early functional rehabilitation produces functional outcomes equivalent to surgery, but its effectiveness depends critically on patient compliance with bracing, weight-bearing and physiotherapy. Psychological factors, including motivation, self-efficacy, kinesiophobia, and social support, are plausible determinants of compliance and outcome, yet have received minimal systematic attention.
SOURCES OF DATA: Seven databases were searched from inception to June 2026 without language restriction. Studies of adults with ATR managed non-operatively, with any psychological assessment reporting compliance, re-rupture rate, Achilles Tendon Total Rupture Score (ATRS) or return to sport, were eligible. Six studies met the inclusion criteria (797 non-operative patients in total), and two further non-operative randomized controlled trials were used for functional benchmarking only. Data were synthesized narratively (SWiM framework).
AREAS OF AGREEMENT: Non-operative management with early functional rehabilitation yields ATRS scores of 72-86 at 6-12 months, comparable to operative cohorts, with re-rupture rates of 5%-12% under functional bracing. Treatment success depends on patient compliance, and functional deficits persist for years irrespective of the management modality.
AREAS OF CONTROVERSY: Surgery continues to carry a lower re-rupture incidence than conservative management, although the absolute difference has narrowed with early functional rehabilitation. Whether pre-treatment psychological profiling should inform the choice between operative and non-operative management remains unvalidated, and no included study reported compliance as a formal outcome or its association with any psychological factor.
GROWING POINTS: Kinesiophobia, anxiety, and depression are present throughout the first year of non-operative rehabilitation, and kinesiophobia scores above the clinical cut-off were observed in most participants of the only dedicated non-operative cohort. Kinesiophobia and readiness-to-return scores do not appear to differ between operatively and non-operatively managed patients, supporting a common psychological assessment framework. Qualitative evidence identifies motivation and social support as key facilitators of recovery.
AREAS TIMELY FOR DEVELOPING RESEARCH: Future non-operative ATR randomized trials should incorporate the I-PRRS, TSK-11, and a validated motivation measure as pre-specified secondary outcomes, together with guideline-based compliance definitions. A prospective cohort study of baseline psychological profile as a predictor of compliance and re-rupture should be prioritized, followed by evaluation of simple psychological screening within consent and treatment-selection pathways.
PMID:42949430 | DOI:10.1093/bmb/ldag041
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