Treatment of Achilles Tendinitis
The recommended first-line treatment for Achilles tendinitis includes conservative measures such as eccentric strength training, stretching, deep friction massage, and addressing biomechanical issues with appropriate footwear and orthotics. 1
Initial Treatment Approach
Conservative Management (First 6-8 weeks)
- Activity modification: Decrease activities that aggravate symptoms
- Eccentric strengthening exercises: Particularly effective for Achilles tendinopathy 1
- Stretching: Regular calf-muscle stretching exercises
- Physical modalities:
- Deep friction massage of the gastrocnemius-soleus complex
- Cryotherapy (ice) for pain relief
- Footwear modifications:
- Open-backed shoes to reduce pressure on the tendon
- Heel lifts or orthoses to unload the tendon
- Avoid flat shoes and barefoot walking
- NSAIDs: For pain management (though primarily for symptom relief rather than healing)
- Weight loss: If indicated
Addressing Biomechanical Factors
- Evaluate for anatomic deformities such as:
- Forefoot and heel varus
- Excessive pes planus (flat feet)
- Overpronation
- Provide appropriate orthotic devices to correct these issues 1
Treatment Based on Tendinopathy Type
Insertional Achilles Tendinitis
- Characterized by pain at the tendon insertion into the calcaneus
- Key treatments:
- Open-backed shoes
- Heel lifts or orthoses
- NSAIDs
- Stretching exercises
- Avoid corticosteroid injections (specifically contraindicated) 1
Non-insertional Achilles Tendinitis
- Pain typically located 2-6 cm proximal to the insertion
- Similar conservative approach with emphasis on eccentric loading exercises
If No Improvement After 6-8 Weeks
Second-line Interventions
- Referral to a podiatric foot and ankle surgeon
- Continue initial treatments
- Consider additional interventions:
- Immobilization with cast or fixed-ankle walker-type device
- Customized orthotic devices
- Night splinting
Refractory Cases (No Improvement After 2-3 Months)
Advanced Treatment Options
- Cast immobilization if not previously used
- Extracorporeal shock wave therapy (though evidence shows mixed results) 1
- Surgical options may be considered for cases failing conservative management 1
Important Considerations and Pitfalls
- Avoid corticosteroid injections near the Achilles tendon due to risk of tendon rupture 1
- Most patients (approximately 80%) recover fully within 3-6 months with appropriate conservative management 1
- The condition is often degenerative rather than inflammatory, making the term "tendinopathy" more accurate than "tendinitis" 1, 2
- Recognize that Achilles tendinopathy is multifactorial, often involving both intrinsic and extrinsic factors 2
- Pay special attention to training errors in athletes (overtraining was identified as a factor in 82% of cases in one study) 3
By following this stepwise approach to treatment, most patients with Achilles tendinopathy can achieve significant improvement without requiring surgical intervention.