29 studies were included in this meta-analysis comparing operative and non-operative treatment for acute Achilles tendon ruptures. The primary outcome of interest was the rate of re-rupture. Secondary outcomes included the rate of complications, functional outcomes, time to return to sports and time to return to work. The results revealed a significantly lower rate of re-rupture, but a higher rate of complications, in the operative group compared to the non-operative group. Similar findings to the primary analyses were observed in the sensitivity analyses based on early and late weight bearing status, high quality studies and studies conducted after the year 2000. There were no significant differences in re-rupture rate in studies utilizing accelerated functional rehabilitation. There was no significant difference between the operative and non-operative groups in the pooled result for time to return to work.