What is the treatment for Achilles tendonitis?

Treatment of Achilles Tendinopathy

The treatment of Achilles tendinopathy should begin with conservative measures including open-backed shoes, heel lifts or orthoses, NSAIDs, decreased activity, stretching exercises, and weight loss if indicated. 1

Initial Assessment and Diagnosis

When evaluating a patient with suspected Achilles tendinopathy, perform a detailed physical examination including:

• Check for a palpable gap or loss of contour in the Achilles tendon
• Assess for decreased ankle plantar flexion strength
• Perform the Thompson test (calf squeeze test)
• Evaluate for increased passive ankle dorsiflexion with gentle manipulation 1

Patients typically present with:

• Insidious onset of posterior heel pain and swelling
• Pain aggravated by increased activity and pressure from shoes
• Relief of pain when walking barefoot 1

First-Line Treatment Algorithm

Immediate Conservative Measures (0-6 weeks)

1. Activity Modification:

   • Decrease activities that aggravate symptoms
   • Avoid complete immobilization to prevent muscular atrophy
   • Tensile loading of the tendon should be controlled but not eliminated 1

2. Footwear and Orthotic Devices:

   • Use open-backed shoes to reduce pressure on the area
   • Implement heel lifts or orthoses 1
   • Consider accommodative padding for comfort 1

3. Physical Therapy:

   • Regular calf-muscle stretching exercises
   • Eccentric strengthening exercises (proven beneficial for Achilles tendinopathy) 1

4. Pain Management:

   • NSAIDs for pain relief (naproxen 500mg twice daily) 2
   • Cryotherapy (ice through wet towel for 10-minute periods) 1

5. Weight Management:

   • Weight loss if indicated 1

Second-Line Treatment (if no improvement after 6-8 weeks)

If symptoms don't improve after 6-8 weeks:

1. Referral to a podiatric foot and ankle surgeon 1
2. Continue initial treatments
3. Additional interventions:
   • Immobilization cast or fixed-ankle walker-type device 1
   • Customized orthotic device
   • Night splinting (weak evidence shows it's as effective as eccentric exercise program) 3

Important Considerations and Cautions

• Corticosteroid Injections: Local injections of corticosteroids are NOT recommended for Achilles tendinopathy 1
• NSAIDs: While effective for pain relief, there's evidence suggesting that short-term NSAID treatment (naproxen 500mg twice daily for 7 days) does not provide additional clinical benefit when added to physical rehabilitation in early Achilles tendinopathy 4
• Imaging: Routine use of MRI, ultrasonography, and radiography to confirm diagnosis cannot be strongly recommended due to insufficient evidence 1
• Topical Treatments: Topical glyceryl trinitrate patches may be beneficial for reducing pain in chronic non-insertional Achilles tendinopathy 5

Treatment Progression Timeline

• 0-6 weeks: First-line conservative treatment
• 6-8 weeks: If no improvement, consider referral and second-line treatments
• 2-3 months: If still no improvement, consider cast immobilization if not previously used 1

Common Pitfalls to Avoid

1. Corticosteroid injections: These are contraindicated for Achilles tendinopathy due to risk of tendon rupture 1
2. Complete immobilization: This can lead to muscle atrophy and deconditioning 1
3. Delayed treatment: Patients with very short symptom duration (<1 month) show greater improvement with rehabilitation compared to those with longer symptom duration (>2 months) 4
4. Ignoring footwear: Proper footwear is a critical component of treatment 1
5. Overlooking eccentric exercises: These have proven beneficial specifically for Achilles tendinopathy 1

By following this structured approach to treatment, most patients with Achilles tendinopathy will experience significant improvement in symptoms and function.