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Ankle Tendon Tear? Most Don’t Need Surgery

| | Ankle
x-ray-like image of a skeleton with red resonating from a ankle tendon tear, indicating pain

Have you been told you have an ankle tendon tear and need surgery? Do you really need this procedure or will less invasive injections do the trick? Let’s review ankle tendon surgery and who needs it and who doesn’t.

What Is an Ankle Tendon Tear?

The ankle has many tendons that come from leg muscles. They help stabilize the ankle and move the foot up, down, left, and right. The ankle tendons include:

  • Peroneal
  • FHL (Flexor Hallicus Longus)
  • Tibialis Posterior
  • FDL (Flexor Digitorum Longus)
  • Tibialis Anterior
  • Achilles

These can be torn in trauma or due to wear and tear. The types of ankle tendon tears are (2):

  • Partial – only part of the tendon is damaged
  • Split – the tear is lengthwise through the tendon
  • Complete non-retracted – The tear is through and through the tendon, but enough fibers remain to hold the tendon together
  • Complete retracted – The tear is through and through, but there are no undamaged fibers and the tendon is snapped back like a rubber band.

Do X-rays Show Tendon Damage? Can an Ultrasound Show Tendon Damage?

No, x-rays can’t show tendon damage as they only show bones well. An ultrasound can show the tendon in high detail as can an MRI (3). Between the two technologies, for ankle tendon tears, ultrasound imaging is higher resolution. However, while many physicians have added ultrasound to their practice, most orthopedic surgeons and podiatrists have yet to learn how to effectively use the technology for diagnosis.

Do Tendon Tears Heal on Their Own?

Many smaller tears will heal on their own on the fly. However, larger tears may need rest or a boot to allow the tendon to heal (4). This can take 4-6 weeks. If that fails, then options include orthobiologic injections or surgery.

How Do You Treat a Torn Tendon in the Ankle?

If rest fails, then the two major options are:

  • Orthobiologic injections
  • Surgery

Orthobiologic injections include platelet-rich plasma or bone marrow stem cells. For example, research has shown that PRP injections can heal tendon tears based on pre and post-biopsy samples taken of the tendon (5). These procedures are performed using ultrasound guidance and are called Percutaneous Orthobiologic Tenotomy (Perc-OT).

The Perc-OT procedure starts with the doctor mapping out the location of the tendon tear with ultrasound imaging. A needle is then guided using ultrasound to the exact site of the tear where platelet-rich plasma (or bone marrow stem cells) are injected. These healing cells then enhance the body’s natural repair mechanisms.

As far as surgery is concerned, ankle tendon reconstruction uses either suturing or tendon grafts (6). Both of these techniques are associated with extensive downtime. Let’s review the recovery process below.

Ankle Tendon Repair or Reconstruction Recovery

You will be immobilized in a boot for 6-12 weeks (7). Range of motion exercises (gentle movement) will begin around 4 weeks. Also, expect to be off your foot for about a month. Putting partial weight on that foot can begin at about 4-8 weeks after surgery. Strengthening exercises can start with a physical therapist at around 6 weeks and running isn’t recommended until 3-6 months after surgery. Return to full sports won’t be until well after 6 months.

Perc-OT Candidacy and Recovery

First, only patients with partial, split, or complete non-retracted tears are candidates for the Perc-OT procedure. That’s about 7-8 in 10 patients who have an ankle tendon tear on MRI and have been told they need surgery. Hence, there’s a good chance you’re a candidate.

Second, recovery times can be everything from minimal for partial tears to about half or less of that for surgery. For example, if you have a partial ankle tendon tear, then you’ll likely be in pain and limping from post-injection soreness for the first 3-7 days. After that, expect to slowly return to normal activities over several weeks, but you are encouraged to walk and be as active as you feel able during this time.

For larger tendon tears, most patients aren’t immobilized, but a few with the largest tears may need to be. In the worst-case scenario, recovery would be about twice to three times as fast as what’s listed for surgery. Why? Less tissue damage from the procedure means a quicker recovery.

The upshot? Most ankle tendon tear patients don’t need surgery. If you do, this is a good guide for recovery and what to expect.


(1) Golanó P, Vega J, de Leeuw PA, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):557–569. doi: 10.1007/s00167-010-1100-x

(2) Davda K, Malhotra K, O’Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Rev. 2017;2(6):281–292. Published 2017 Jun 22. doi:10.1302/2058-5241.2.160047

(3) Park JW, Lee SJ, Choo HJ, Kim SK, Gwak HC, Lee SM. Ultrasonography of the ankle joint. Ultrasonography. 2017;36(4):321–335. doi:10.14366/usg.17008

(4) Ochen Y, Beks RB, van Heijl M, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019;364:k5120. Published 2019 Jan 7. doi: 10.1136/bmj.k5120

(5) Alsousou J, Thompson M, Harrison P, Willett K, Franklin S. Effect of platelet-rich plasma on healing tissues in acute ruptured Achilles tendon: a human immunohistochemistry study. Lancet. 2015 Feb 26;385 Suppl 1:S19. doi: 10.1016/S0140-6736(15)60334-8.

(6) Dombek, Michael F et al. Peroneal tendon tears: a retrospective review. The Journal of Foot and Ankle Surgery, Volume 42, Issue 5, 250 – 258

(7) van Dijk PA, Lubberts B, Verheul C, DiGiovanni CW, Kerkhoffs GM. Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1165–1174. doi: 10.1007/s00167-015-3944-6

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