What is the treatment algorithm and timeline for Achilles tendinitis?

From the Guidelines

The treatment of Achilles tendonitis should start with a 1-2 week period of rest, ice, compression, and elevation (RICE), along with activity modification to reduce tendon loading, as this approach has been shown to reduce pain and promote tendon healing 1. The initial management of Achilles tendonitis involves a combination of conservative measures, including:

• Rest and activity modification to avoid exacerbating the condition
• Ice therapy, which has been found to be effective for short-term pain relief and may help reduce swelling and pain in cases of acute inflammatory tendinopathies 1
• Compression and elevation to reduce swelling
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen to manage pain and inflammation, with topical NSAIDs being a viable option to reduce gastrointestinal risks 1 The use of eccentric calf strengthening exercises is also recommended, as these have been shown to be beneficial in promoting tendon remodeling and reducing pain in Achilles tendinopathy 1. It is essential to note that the treatment algorithm for Achilles tendonitis is progressive, and the duration of each phase may vary depending on the individual's response to treatment. Some key points to consider in the treatment timeline include:
• The initial 1-2 week period of RICE and activity modification
• The implementation of eccentric calf strengthening exercises, which should be performed for at least 12 weeks
• The use of night splints to maintain ankle dorsiflexion during sleep
• The pursuit of physical therapy for 6-8 weeks, focusing on stretching, strengthening, and proper biomechanics
• The consideration of shockwave therapy or platelet-rich plasma injections if symptoms persist beyond 3 months despite conservative measures
• The evaluation and correction of contributing factors such as improper footwear, training errors, or biomechanical issues
• The gradual return to activity as pain allows, typically beginning around 4-6 weeks, with full return to high-impact activities usually possible by 3-4 months if healing progresses well.

From the Research

Treatment Algorithm for Achilles Tendinitis

• The treatment of Achilles tendinitis typically involves a combination of conservative management strategies, including eccentric exercise training, which is considered the gold standard 2.
• A systematic review of conservative treatment options for Achilles tendinopathy found that numerous therapeutic choices are available, but no single therapy is universally accepted, except for eccentric exercise training 2.
• Complex conservative treatment measures, including micro-current therapy, have been shown to be effective in treating achillodynia, with significant improvements in subjective symptoms and high patient satisfaction 3.

Timeline for Treatment

• The treatment timeline for Achilles tendinitis can vary depending on the severity of the condition and the individual's response to treatment.
• A study on the use of injectable celecoxib nanoparticle hydrogels for Achilles tendon regeneration found that long-term anti-inflammatory effects can be achieved through sustained release of the hydrogel, which can alleviate excessive inflammation and induce tissue regeneration 4.
• Nonsurgical management of midsubstance Achilles tendinopathy typically focuses on tendon loading exercises and symptom modulating treatments, with a small percentage of patients considering shockwave or sclerosing treatment and possibly surgery if unresponsive to initial management 5.

Treatment Options

• Platelet-rich plasma (PRP) injections have been investigated as a treatment option for Achilles tendonitis, but a systematic review of high-quality randomized controlled trials found no significant differences between treatment groups and control groups following PRP injections 6.
• Eccentric exercise training remains a commonly used protocol for the treatment of Achilles tendinopathy, and is considered the gold standard 2.
• Other treatment options, such as micro-current therapy, may be considered as part of a complex conservative treatment approach 3.