Chronic and Neglected Achilles Rupture Reconstruction
in Los Angeles
Medically Reviewed by Dr. Pegah Panirian, DPM, foot and ankle surgeon
Overview
Dr. Pegah Panirian reconstructs chronic, missed and neglected Achilles ruptures at The Feet Institute in Los Angeles. If your Achilles tore months or years ago and your calf is still weak, she can rebuild it by moving a nearby big-toe tendon (FHL tendon transfer), lengthening the tendon above the gap (V-Y advancement) or bridging the gap with donor tendon (allograft).
Key points
- A chronic Achilles rupture is a complete tear left untreated for more than four to six weeks, so the torn ends have pulled apart and filled with scar tissue.
- Ruptures missed for months or years can still be reconstructed. The delay mainly affects which technique Dr. Panirian uses and how long your recovery takes.
- An old rupture does not need emergency surgery, but your calf muscle keeps shrinking while the tendon ends stay apart.
- Dr. Panirian sees patients at the Los Angeles/Beverly Hills and Westchester/Marina Del Rey offices, with next-day appointments available.
What is a chronic or neglected Achilles rupture?
A chronic or neglected Achilles rupture is a complete tear of the Achilles tendon that was not treated in the first four to six weeks. During those weeks your calf muscle pulls the upper end of the tendon away from the lower end, and scar tissue fills the space. The two ends can then no longer be stitched back together directly.
Most chronic ruptures start in one of three ways:
- A missed rupture. About one in five Achilles ruptures is missed at first, usually diagnosed as an ankle sprain, because you can still walk on a torn Achilles.
- A boot-treated tear that healed with a gap. Boot treatment works when the ends are held together. If they separate, the tendon heals in a stretched position or does not rejoin at all.
- A re-rupture after surgery. A repaired tendon can tear again, and the second tear usually leaves less healthy tendon for the next repair.
Why is my old Achilles injury still weak?
An Achilles that is still weak months or years after an injury usually has one of three problems. The tendon never joined back together, it healed but ended up too long, or it healed well and your calf muscle never regained its strength.
These signs point to a rupture that never healed:
- No single-leg heel raise. Standing on your injured leg alone, you cannot rise onto the ball of your foot.
- A flat-footed walk. Your step has little push-off, and the limp gets worse when you walk faster.
- Weakness on stairs and slopes. Climbing stairs, walking uphill and jogging feel weak on that side.
- A thinner calf. The calf on your injured leg is visibly smaller than the other one.
- A dip or lump above your heel. You can feel a soft gap, or a thick lump of scar, in the tendon about 2 to 6 centimeters above your heel bone.
| What you notice | Likely cause | Usual treatment |
|---|---|---|
| A dip or scar lump above your heel, and no single-leg heel raise | The tendon never rejoined, and scar is bridging the gap | Reconstruction surgery |
| No gap, but a low, weak heel raise, and your ankle bends up further than the other one | The tendon healed long | A calf-strengthening program first; surgery only if that fails |
| An even, intact tendon and a smaller calf | Your calf muscle lost bulk while you were in the boot and never regained it | A structured calf-strengthening program |
A tendon that heals long is common after an Achilles rupture. Researchers reviewing recovery after rupture found that the tendon keeps lengthening for about six months, and that the longer it ends up, the lower and weaker the heel raise.
Pain and thickening that built up over months, with no pop and no sudden loss of push-off, is more likely Achilles tendinopathy (long-term tendon pain, often called tendonitis), which Dr. Panirian also treats.
How big is the gap, and why does it matter?
The gap is the distance between the healthy ends of your tendon once the scar between them is cleared. Surgeons choose the reconstruction mainly by that distance and by how healthy the remaining tendon is.
Dr. Panirian examines both legs side by side. She feels for a gap in the tendon, compares how each foot rests when you lie face down and squeezes each calf to see whether the foot moves (the Thompson test). An MRI then shows how far apart the tendon ends are, how much scar lies between them and how healthy the remaining tendon and your calf muscle look.
| Gap between healthy tendon ends | Usual technique |
|---|---|
| 2 to 3 cm or less | The ends are sewn together directly, sometimes after the upper tendon is slid down to gain length |
| About 2 to 6 cm | V-Y advancement, often combined with an FHL tendon transfer |
| More than 5 to 6 cm | FHL tendon transfer, with an allograft when too little tendon is left |
The ranges overlap because two surgical grading systems, the Myerson and Kuwada classifications, set slightly different cut-offs. If the tendon that is left is thin or frayed, Dr. Panirian may add a transfer or graft even when the gap is short. She measures the gap again in surgery, after the scar is removed, and tells you beforehand whether she will add an FHL tendon transfer or a graft if it turns out longer than the MRI showed.
Is it too late to fix an Achilles tear from months or years ago?
No. The longer the ends stay apart, the wider the gap tends to become and the thinner your calf gets, so you are more likely to need an FHL tendon transfer or a graft and a longer course of physical therapy.
A custom ankle-foot brace (AFO) with physical therapy is the alternative to surgery for people who walk mostly on level ground or whose health makes surgery risky.
| Compared on | Brace and physical therapy | Reconstruction surgery |
|---|---|---|
| Push-off strength | Not restored, because the tendon ends stay apart | Returns over months of physical therapy |
| Who it is for | Walking on level ground; higher surgical risk | Climbing stairs, walking uphill, running or sport |
| How long it takes | The brace is worn for walking, long term | About a year of recovery |
How does Dr. Panirian reconstruct a chronic Achilles rupture?
Dr. Panirian, a leading Achilles surgeon in Los Angeles, uses three reconstructions, alone or combined. She measures the gap, checks how thick the remaining tendon is and asks whether you need to run, climb or play sport before choosing.
- FHL tendon transfer. A nearby tendon that bends the big toe is moved to strengthen and bridge the Achilles. The flexor hallucis longus (FHL) runs just in front of the Achilles, pulls in the same direction and stays attached to its own muscle and blood vessels, so it adds pulling power to your calf as well as filling the gap. She anchors it into your heel bone.
- V-Y advancement. The tendon above the tear is lengthened in a V-to-Y pattern to close the gap. She cuts an upside-down V into the tendon sheet at the bottom of your calf muscle and slides the tendon down, using only your own tissue.
- Allograft reconstruction. Donor tendon tissue is used to bridge a large gap. She uses it when too little of your own tendon is left, usually together with an FHL tendon transfer.
What happens during Achilles reconstruction surgery?
Chronic Achilles reconstruction is a single operation through an incision along the back of your ankle. The incision is usually longer than for a fresh repair, because Dr. Panirian needs room to clear the scar and, for a transfer, to reach the FHL tendon.
- Clearing the scar. She removes the scar tissue between the tendon ends, back to healthy tendon.
- Measuring the gap. With your foot held pointed down, she measures the gap that is left.
- Transfer, advancement or graft. Depending on the gap, she releases the FHL tendon from your big toe, makes the V-Y cut above the tear or prepares the donor graft.
- Anchoring to the heel bone. She fixes the FHL tendon or graft into a small tunnel drilled in your heel bone, then sews the Achilles over it.
- Splint. Your leg goes into a splint with your foot pointed down, which keeps tension off the new tendon while it heals.
What are the side effects of FHL tendon transfer?
After an FHL tendon transfer, your big toe presses down with less force. Most patients in published studies had this weakness, and few noticed it when walking. Less common but more serious are slow wound healing, infection and irritation of the sural nerve.
- Big toe weakness. Sprinters and others who need a strong grip from the big toe notice it most.
- Slow wound healing. The skin over the back of your ankle is thin and has a limited blood supply, so the incision can heal slowly or reopen. Smoking, diabetes and poor circulation raise the risk.
- Infection. Most are surface infections treated with antibiotics and dressings. A deep infection can need another operation.
- Sural nerve irritation. The sural nerve runs along the outer side of the Achilles. If it is stretched or caught in scar, you may feel numbness or tingling along the outer edge of your foot.
- Transfer detaching from the heel bone. This is uncommon and most likely in the first weeks, which is one reason you keep weight off your heel early in recovery.
- Ankle stiffness. Your ankle may bend upward a little less than the other one.
- Blood clots. As with other leg surgery and time in a boot, a clot in your calf veins (deep vein thrombosis) is a risk.
V-Y advancement and allograft reconstruction carry the same wound, infection and nerve risks, without the change in big toe strength.
How long is recovery after chronic Achilles reconstruction?
Full recovery takes about a year, and calf strength often keeps improving into the second year. Most people walk in a regular shoe at around 10 to 16 weeks, start jogging at 5 to 6 months and return to demanding sport at 8 to 12 months once their calf passes strength testing. Recovery takes longer than after a fresh Achilles repair because the transferred tendon or graft has to heal into bone, and your calf has to regain the strength it lost over months.
| Stage | Typical timing | What you wear and do |
|---|---|---|
| Splint or cast | Weeks 0 to 4 | Your foot is held pointed down. You keep little or no weight on your heel and raise your leg to control swelling. |
| Walking boot | Weeks 4 to 10 | Heel wedges come out in stages. You put more weight on your foot each week and start bending your ankle gently. |
| Shoe with heel lift | Weeks 10 to 16 | A supportive shoe, often with a small heel lift, and physical therapy for calf strength and balance. |
| Strengthening | Months 4 to 6 | Heel raises, cycling and gym work. You start jogging once you can manage repeated single-leg heel raises. |
| Return to sport | Months 8 to 12, or later | Running, jumping and court sports, once your physical therapist’s strength tests show you are ready. |
Surgeons who have published their reconstruction protocols report these timings; in one long-term study, surgeons kept patients in a cast for four weeks and a brace for six more. Your own timeline depends on the technique, the size of the gap, how long your calf has been weak, smoking, diabetes and how regularly you do your therapy exercises.
Why choose Dr. Panirian for Achilles reconstruction in Los Angeles?
- Cedars-Sinai trained. Surgical residency and chief resident at Cedars-Sinai Medical Center, where she is now a teaching attending.
- Board certification. Board certified by the American Board of Podiatric Medicine and board qualified by the American Board of Foot and Ankle Surgery.
- Hospital affiliations. Cedars-Sinai Medical Center, Cedars-Sinai Marina del Rey Hospital and Providence Saint John’s Health Center.
- New and old ruptures. Percutaneous (small-incision), mini-open (short-incision) and open repair of fresh tears, and reconstruction of chronic ones.
- Languages. Speaks English, Spanish and Farsi.
A chronic Achilles rupture requires more than a standard repair. Dr. Pegah Panirian is one of the few Los Angeles foot and ankle surgeons who regularly reconstructs chronic, neglected and previously repaired Achilles ruptures. She selects the surgical approach according to the size of the tendon gap, the quality of the remaining tissue and your functional goals, rebuilding the connection between the calf and heel so strength and push-off power can be restored through rehabilitation.
If an old rupture was mistaken for a sprain, failed to improve in a boot or has torn again after surgery, that does not necessarily mean you are out of options. Schedule a second-opinion consultation at The Feet Institute in Los Angeles near Beverly Hills or in Westchester near Marina del Rey to find out what reconstruction could make possible for you.
Common questions about chronic Achilles reconstruction
Does a ruptured Achilles ever fully heal?
A ruptured Achilles heals well when the torn ends are held together, by surgery or in a boot with your foot pointed down. Even then, your injured calf often stays a little weaker than the other, which is why physical therapists test your calf strength before clearing you for sport.
Can you still walk with an old Achilles rupture?
Usually, yes. The muscles behind your ankle and under your foot can point your foot down enough for a flat-footed walk, but they cannot lift your body weight onto your toes. A single-leg heel raise, running and climbing remain difficult.
Can an Achilles that re-ruptured after surgery be repaired again?
Yes. A re-rupture after an earlier repair is treated much like a chronic rupture: Dr. Panirian clears the scar and old stitches, measures the gap and usually rebuilds the tendon with an FHL tendon transfer, sometimes with an allograft. She reviews your earlier operative report and imaging when she plans the operation.
Is V-Y advancement for the Achilles the same as a V-Y flap?
No. A V-Y advancement flap in plastic surgery moves a triangle of skin to cover a wound. A V-Y advancement for the Achilles is cut into the tendon sheet at the bottom of the calf muscle and slides the tendon down to close a gap. The two share a name because both incisions start as a V and are closed as a Y.
Can I have Achilles reconstruction if I have diabetes?
Often, yes. Diabetes raises the risk of slow wound healing and infection at the back of your ankle, so Dr. Panirian checks your recent blood sugar results and the pulses in your foot before recommending surgery. If either is poor, a brace with physical therapy may be the safer choice.
Sources
- Schweitzer KM, Dekker TJ, Adams SB. Chronic Achilles ruptures: reconstructive options. Journal of the American Academy of Orthopaedic Surgeons, 2018;26(21):753-763. Accessed September 24, 2026.
- Maffulli N, Via AG, Oliva F. Chronic Achilles tendon rupture. Open Orthopaedics Journal, 2017;11:660-669. Accessed September 24, 2026.
- Cottom JM, Sisovsky CA. Neglected Achilles tendon ruptures. Clinics in Podiatric Medicine and Surgery, 2021;38(2):261-277. Accessed September 24, 2026.
- Bevilacqua NJ. Treatment of the neglected Achilles tendon rupture. Clinics in Podiatric Medicine and Surgery, 2012;29(2):291-299. Accessed September 24, 2026.
- Xu Y, Li C, Liu T, et al. Long-term outcome of flexor hallucis longus tendon transfer for chronic Achilles tendon rupture with large defect. Medicine, 2023;102(40):e35302. Accessed September 24, 2026.
- Wapner KL, Pavlock GS, Hecht PJ, et al. Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot & Ankle, 1993;14(8):443-449. Accessed September 24, 2026.
- Hoeffner R, Svensson RB, Bjerregaard N, et al. Persistent deficits after an Achilles tendon rupture: a narrative review. Translational Sports Medicine, 2022:7445398. Accessed September 24, 2026.