The object of this study was to compare treatment of ruptured Achilles tendon by operative "end to end" surgery, percutaneous repair, or conservative therapy clinically; a subject of considerable controversy in the literature. These three methods were compared in 73 patients in a randomized trial between 1994 and 1996. After 2.5 years (11-41 months), the actual activities were assigned to the Hannover Achilles tendon score and the ability of doing work or sport activities was assessed. After this period, 59.3% of the patients showed good and excellent results on the Achilles tendon score, with over 79 points (open surgery 59.1%, percutaneous 60%, conservative treatment 58.3%). None of the patients reached the maximum score of 100 points. During the isometric strength tests, the patients with percutaneous repair had a lower weakening of the treated leg (8.9%) compared to the open-operated (12.7%) and non-operated patients (17.8%). Of the patients who had percutaneous surgery, 88% rated their treatment as good or excellent; those who had open surgery 77.3%, and those with conservative treatment 75%. The percutaneous group were able to resume work and sport much sooner than the other two groups. Bearing in mind the literature and these results, we have developed an algorithm for treating Achilles tendon rupture to assist decision making in daily routine. In this way, the use of percutaneous Achilles tendon repair can be carried out in most of cases.