Treatment for Achilles Tendonitis
The treatment of Achilles tendonitis should begin with conservative management including regular calf-muscle stretching, activity modification, NSAIDs, open-backed shoes, heel lifts or orthoses, and eccentric strengthening exercises for 6-8 weeks before considering more invasive interventions. 1
Initial Conservative Management (First 6 Weeks)
Pain Management and Activity Modification
- Relative rest and activity limitation: Reduce activities that cause pain and overload of the affected tendon
- NSAIDs: Naproxen 500mg twice daily for acute pain and inflammation (maximum 1000mg daily for maintenance) 2
- Cryotherapy: Ice application to reduce acute inflammation
- Footwear modifications:
- Open-backed shoes to reduce pressure on the tendon
- Avoid flat shoes and barefoot walking
- Heel lifts to unload the tendon
Physical Therapy Interventions
- Eccentric strengthening exercises: Most effective exercise intervention for Achilles tendinopathy 1
- Stretching exercises: Regular calf-muscle stretching of the gastrocnemius-soleus complex
- Deep friction massage: To reduce pain and promote healing
- Avoid: Corticosteroid injections are NOT recommended for Achilles tendonitis as they may increase risk of tendon rupture 1
Orthotic Devices
- Over-the-counter heel cushions and arch supports: For initial symptom relief
- Custom orthoses: To correct biomechanical issues such as overpronation or pes planus
Secondary Management (If No Improvement After 6 Weeks)
Additional Interventions
- Referral to podiatric foot and ankle surgeon for specialized evaluation
- Immobilization options:
- Cast immobilization
- Fixed-ankle walker-type device during activity
- Custom orthotic devices: More specialized than over-the-counter options
Tertiary Management (If No Improvement After 2-3 Months)
Advanced Interventions
- Continued initial treatments with possible addition of:
- Cast immobilization (if not previously used)
- Extracorporeal shock wave therapy (ESWT)
- Surgical consideration: For refractory cases not responding to conservative management 1, 3
Special Considerations
Insertional vs. Non-insertional Achilles Tendonitis
Insertional tendonitis (at heel attachment):
- More likely to benefit from heel lifts and open-backed shoes
- Radiographs may show spurring or erosion at insertion point 1
Non-insertional tendonitis (mid-portion):
- Typically responds better to eccentric exercises
- May present with thickening and palpable nodules 1
Common Pitfalls to Avoid
- Corticosteroid injections: Can increase risk of tendon rupture and are not recommended for Achilles tendonitis 1
- Prolonged immobilization: May lead to muscle atrophy and stiffness
- Premature return to full activity: Can cause recurrence or progression to chronic tendinopathy
- Ignoring biomechanical factors: Failure to address issues like improper footwear or anatomic misalignment can lead to persistent symptoms 1
Monitoring and Follow-up
- Evaluate pain and function every 2-4 weeks
- Continue treatments until symptoms resolve
- Gradually increase exercise intensity as symptoms improve
- Progress to sport-specific or activity-specific exercises as healing occurs
The evidence strongly supports a conservative approach initially, with eccentric strengthening exercises showing particular effectiveness for Achilles tendinopathy 1, 3. Surgical intervention should only be considered after failure of a comprehensive conservative management program of at least 2-3 months 1, 4.