Psychological factors as predictors of compliance and outcome in non-operative management of Achilles tendon rupture: a systematic review
Nicola Maffulli, Filippo SpieziaAbstract
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.