From the Guidelines
The treatment of Achilles tendinitis should follow a progressive algorithm starting with conservative measures for 3-6 months before considering more invasive options. Initially, activity modification is essential—reducing activities that aggravate symptoms while maintaining fitness through low-impact exercises like swimming or cycling. Pain management includes NSAIDs such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks to reduce inflammation, as supported by 1. Physical therapy forms the cornerstone of treatment, focusing on eccentric strengthening exercises (3 sets of 15 repetitions, twice daily for 12 weeks) and gastrocnemius-soleus stretching (holding for 30 seconds, 5 repetitions, 3 times daily), which has been shown to be effective in treating Achilles tendinopathy 1.
Some key points to consider in the treatment algorithm include:
- Rest and reduced activity to prevent further damage and promote healing, as recommended by 1 and 1
- Cryotherapy for acute relief of tendinopathy pain, with repeated applications of melting ice water through a wet towel for 10-minute periods being most effective, as stated in 1
- Eccentric strengthening as an effective treatment of tendinopathy, which may reverse degenerative changes, as noted in 1
- The use of orthotics and braces, which may be beneficial in treating Achilles tendinopathy, especially in cases with anatomic misalignment, as suggested by 1
Supportive measures include heel lifts (0.5-1cm) in both shoes to reduce tendon strain and night splints to maintain ankle dorsiflexion during sleep. If symptoms persist beyond 3 months, second-line treatments include extracorporeal shock wave therapy (3-5 sessions, one week apart) or platelet-rich plasma injections. Corticosteroid injections are generally avoided due to the risk of tendon rupture, as warned against in 1 and 1. For cases resistant to 6+ months of conservative treatment, surgical options like tendon debridement or gastrocnemius recession may be considered. Throughout treatment, addressing biomechanical factors with proper footwear and possibly custom orthotics is important, as Achilles tendinitis often results from repetitive microtrauma and overuse rather than acute inflammation, as discussed in 1 and 1.
From the Research
Treatment Algorithm for Achilles Tendinitis
- The treatment algorithm for Achilles tendinitis typically involves a combination of activity modification, rehabilitation, and progressive tendon-loading exercises 2.
- The treatment approach may vary depending on the location and severity of the tendinitis, with midportion (noninsertional) and insertional tendinopathy having distinct features and differences in therapeutic paradigms 2.
- Conservative management, including eccentric training programs, can be effective in improving functional outcomes and reducing pain in patients with Achilles tendinitis 3.
Timeline for Treatment
- Acute Achilles tendon-related pain (lasting less than 6 weeks) can be managed with early conservative treatment, including activity modification and rehabilitation 4.
- Chronic Achilles tendinitis (lasting more than 6 weeks) may require a more prolonged treatment period, with some studies suggesting a treatment duration of 3-6 months 5, 6.
- Return to play or full activity is typically reported to occur within 4-6 weeks following injection of platelet-rich plasma (PRP) 6.
Role of Platelet-Rich Plasma (PRP) Injections
- PRP injections have been proposed as an additional therapy in the treatment of chronic midsubstance Achilles tendinopathy, but their efficacy remains highly debated 5, 3.
- Some studies suggest that PRP injections may improve functional outcomes and reduce pain in patients with Achilles tendinitis, but the evidence is limited and inconclusive 5, 3.
- A systematic review with meta-analysis found no difference in clinical outcome between PRP and placebo groups at different points in time using the VISA-A score as outcome parameter 3.