Purpose The best treatment for Achilles tendon (AT) ruptures remains controversial. Long-term follow-up with radiological and clinical measurements is needed. Methods In this retrospective multicentre cohort study, patients (n = 52) were assessed at a mean of 91 months follow-up after unilateral AT rupture treated by open, percutaneous or conservative (non-surgical) treatment. Demographic parameters, time off work, maximum calf circumference and clinical scores (ATRS, Hannover, AOFAS) were evaluated. Muscle volume and cross-sectional area of the calf and AT length were measured on MR images and were compared between groups and to each patient's healthy contralateral leg. Results Reduced muscle volume was found across all groups with a higher muscle volume in the conservative (729.9 ± 130.3 cm 3 ) compared to the percutaneous group (675.9 ± 207.4 cm 3 , p = 0.04). AT length was longer in the affected leg (198.4 ± 24.1 vs. 180.6 ± 25.0 mm, p \ 0.0001) without difference in subgroup analysis. Clinically measured ankle dorsiflexion showed poor correlation with AT length (R 2 = 0.07, p = 0.008). Muscle volume strongly correlated with the cross-sectional area (R 2 = 0.6, p \ 0.0001) but showed a weak correlation with the Hannover score (R 2 = 0.08, p = 0.048). Maximum calf circumference correlated with muscle volume (R 2 = 0.42, p \ 0.0001). Conclusions No significant difference between the treatment groups was found in muscle volume, AT length, clinical measures or days off work. Cross-sectional area and maximum calf circumference are cost-effective measurements and a good approximation of muscle volume and can thus be used in a clinical setting while clinical dorsiflexion should not be used. Level of evidence III.

Clinical scores do not predict biomechanical outcomes. Clinically measured MCC is a good predictor of PPFT and POFF and can easily be used in clinical practice. Relative POFF in side comparison as well as per body weight favours surgical treatment.