What is the next step in managing a patient with suspected Achilles tendinitis in a primary care office?

From the Guidelines

The next step in managing a patient with suspected Achilles tendinitis in primary care is to implement conservative treatment while confirming the diagnosis, focusing on activity modification, pain management, and physical therapy to improve outcomes and reduce the risk of complications. When managing Achilles tendinitis, it's crucial to understand that most cases are due to degenerative changes rather than acute inflammation, as noted in studies such as 1. The management plan should include:

• Activity modification: Reduce high-impact activities that exacerbate pain, while maintaining gentle range of motion exercises, as suggested by 1.
• Pain management: Prescribe NSAIDs such as ibuprofen 400-600mg three times daily with food for 1-2 weeks to reduce inflammation and pain, considering the guidance from 1.
• Physical therapy: Initiate a referral for eccentric strengthening exercises, which have shown superior outcomes compared to concentric exercises, as highlighted in 1.
• Supportive measures: Provide a heel lift (approximately 1-1.5cm) for both shoes to reduce tension on the Achilles tendon, and consider nighttime splinting to prevent morning stiffness, in line with recommendations from 1.
• Imaging: If symptoms persist beyond 4-6 weeks despite these measures, consider imaging (ultrasound or MRI) to confirm diagnosis and rule out partial tears, as discussed in 1. It's also important to avoid corticosteroid injections directly into the tendon, as they increase the risk of tendon rupture, a consideration emphasized by the need for cautious management to prevent morbidity and mortality, and improve quality of life.

From the Research

Next Steps in Managing Suspected Achilles Tendinitis

• The initial assessment of a patient with suspected Achilles tendinitis in a primary care office involves a thorough clinical examination and evaluation 2.
• Imaging modalities such as ultrasound and MRI can be used to confirm the diagnosis and assess the extent of the injury 3, 4, 5, 6, 2.
• Ultrasound is recommended over MRI for diagnosis and monitoring due to its high sensitivity and specificity in detecting Achilles tendon ruptures 6, 2.
• The use of ultrasound can help to rule out other injuries and provide additional clinical information, such as the measurement of the tendon gap in cases of rupture 5, 6.
• MRI can be useful in detecting partial tears and for postoperative assessment, as well as in evaluating the tendon morphology and tension 3, 4.
• The clinical examination and evaluation should be the primary basis for diagnosis and management, with imaging used as an adjunct to provide additional information 2.

Imaging Modalities

• Ultrasound:
  • High sensitivity (94.8%) and specificity (98.7%) in detecting complete Achilles tendon ruptures 6.
  • Can be used to measure the tendon gap in cases of rupture 5.
  • Recommended over MRI for diagnosis and monitoring 2.
• MRI:
  • Useful in detecting partial tears and for postoperative assessment 3, 4.
  • Can evaluate the tendon morphology and tension 3, 4.
  • Generally performed with 1.5Tesla (T) MRI, with a trend towards higher T strength in more recent studies 2.