What are the treatment options for Achilles tendinopathy and bilateral plantar fasciitis?

Treatment Options for Achilles Tendinopathy and Bilateral Plantar Fasciitis

The most effective first-line treatment for both Achilles tendinopathy and plantar fasciitis is a conservative approach consisting of relative rest, eccentric strengthening exercises, and activity modification, which leads to recovery in approximately 90% of patients within 3-6 months. 1

Initial Treatment Approach

For Achilles Tendinopathy:

1. Relative rest and activity modification

   • Reduce activities that cause pain but maintain some activity to prevent deconditioning 1
   • Avoid complete immobilization to prevent muscle atrophy

2. Eccentric strengthening exercises

   • Gold standard treatment with strong evidence of effectiveness 2
   • Should be performed daily despite mild discomfort
   • Typically involves heel drops from a step with controlled lowering

3. Footwear modifications

   • Open-backed shoes to reduce pressure on the tendon 1
   • Heel lifts or orthoses to unload the tendon

4. Pain management

   • Ice application (10-minute periods through wet towel) 1
   • NSAIDs for short-term pain relief only (not for long-term outcomes) 1
   • Avoid corticosteroid injections into the Achilles tendon due to risk of tendon rupture 1

For Plantar Fasciitis:

1. Stretching exercises

   • Regular calf muscle and plantar fascia stretching 1
   • First-morning and after-prolonged-sitting stretches

2. Footwear and support

   • Avoid flat shoes and barefoot walking 1
   • Over-the-counter heel cushions and arch supports initially
   • Custom orthotic devices if no improvement after 6 weeks 1

3. Pain management

   • Ice massage (rolling foot over frozen water bottle) 3
   • NSAIDs for short-term pain relief 1
   • Corticosteroid injections may be considered for recalcitrant cases 1

4. Night splinting

   • Maintains dorsiflexion during sleep to prevent morning pain 1

Treatment Algorithm

Phase 1 (First 6 weeks):

• Patient-directed measures:
  • Regular stretching
  • Ice application
  • Activity modification
  • Appropriate footwear
  • Over-the-counter supports
  • NSAIDs as needed for pain

Phase 2 (If no improvement after 6 weeks):

• Physician-prescribed treatments:
  • Custom orthotic devices
  • Night splinting
  • Eccentric strengthening program
  • Physical therapy
  • Limited corticosteroid injections (for plantar fasciitis only)

Phase 3 (If no improvement after 2-3 months):

• Consider:
  • Cast immobilization or walking boot 1
  • Extracorporeal shock wave therapy (ESWT)
    • High-quality evidence supports ESWT for plantar fasciitis 4
    • Limited evidence for Achilles tendinopathy 4

Phase 4 (If no improvement after 6 months):

• Consider surgical options:
  • Plantar fasciotomy for recalcitrant plantar fasciitis 3
  • Surgical intervention for Achilles tendinopathy 1

Special Considerations

For Achilles Tendinopathy:

• Pay attention to anatomic deformities such as forefoot/heel varus and excessive pronation 1
• Distinguish between insertional and non-insertional tendinopathy, as treatment approaches differ slightly 1
• Physical examination often reveals thickening and tender, palpable nodules 1

For Plantar Fasciitis:

• Most patients present with heel pain with first steps in the morning or after prolonged sitting 3
• Sharp pain with palpation of the medial plantar calcaneal region is diagnostic 3
• Pain can be elicited by passive ankle/first toe dorsiflexion 3

Treatment Efficacy and Pitfalls

• Success rate: Conservative treatment is effective in approximately 90% of patients within 3-6 months 1, 5

• Common pitfalls:

  1. Misdiagnosing tendinopathy as inflammatory "tendonitis" when it's usually degenerative "tendinosis" 1
  2. Overreliance on corticosteroid injections, which may weaken tendon structure 1
  3. Complete immobilization, which can lead to muscle atrophy 1
  4. Failing to address biomechanical factors like foot pronation or tight Achilles tendon 5
  5. Expecting immediate results when most treatments require weeks to months for effectiveness

• Emerging treatments: Platelet-rich plasma (PRP) injections may be considered for cases refractory to conventional treatment for over 12 months 6, though more research is needed before widespread recommendation

Remember that both conditions are typically self-limiting with appropriate conservative care, and patience with the treatment protocol is essential for successful outcomes.