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Objective This trial evaluated whether individualized treatment using the Copenhagen Achilles Rupture Treatment Algorithm (CARTA) is superior to default operative or non-operative strategies.Methods We conducted a multicentre, three-arm, parallel-group, randomised controlled trial. Adults with acute Achilles tendon rupture were randomised (1:1:1) to individualized CARTA, non-operative, or operative treatment. In the CARTA arm, surgery was indicated if ultrasound showed <25% tendon overlap or ≥7% elongation. The primary outcome was the Heel-Rise Work Test (HRWT) at 12 months. Secondary outcomes included HRWT at 6 months, and at both 6- and 12-months maximal heel-rise height, Achilles tendon Total Rupture Score (ATRS), Tegner activity scale, Copenhagen Achilles tendon Length Measure, Achilles Tendon Resting Angle (ATRA), and complication recordings.Results Between May 2018 and June 2023, 970 patients were screened; 300 were randomised (male/female 77/44, mean age 42 (SD 0.9)). At 12 months, data were available for 98 CARTA (64% operated), 100 non-operative, and 97 operative patients. There were no significant between-group differences in HRWT at 12 months. CARTA statistically significantly reduced re-rupture rates by 72% compared with non-operative treatment (3% [95% CI] [1,8] vs. 11% [6,19], p=0.03), improved ATRS by 8 points ([1,15], p=0.02), and improved ATRA by -2.4° ([-4.2,-0.6], p=0.01). No difference between CARTA and operative was found except 36% less were operated.Conclusion Individualized CARTA did not improve functional outcome at 12 months but showed statistically significantly reduced re-rupture rates and improved patient-reported outcomes compared with non-operative treatment, with fewer surgeries than routine operative care.