What is the treatment for Achilles tendon pain?

Treatment for Achilles Tendon Pain

The most effective first-line treatment for Achilles tendon pain is eccentric strengthening exercises performed twice daily (3 sets of 15 repetitions) for at least 12 weeks, combined with relative rest, activity modification, and appropriate footwear changes. 1

Initial Management

• Eccentric strengthening exercises: The cornerstone of treatment

  • Perform twice daily, 3 sets of 15 repetitions
  • Continue for at least 12 weeks
  • Gradually increase intensity as symptoms improve

• Activity modification:

  • Reduce activities that aggravate symptoms
  • Avoid barefoot walking
  • Limit repetitive loading of the damaged tendon

• Footwear modifications:

  • Use open-backed shoes to reduce pressure on insertional tendinopathy
  • Consider heel lifts or orthoses to reduce tension on the Achilles tendon
  • Avoid flat shoes

• Pain management:

  • NSAIDs for short-term pain relief only (no effect on long-term outcomes) 1, 2
  • Cryotherapy (ice application) for 10-minute periods through a wet towel

Anatomic Considerations

Different types of Achilles tendinopathy require slightly different approaches:

1. Insertional tendinopathy (pain at heel attachment):

   • Open-backed shoes to reduce pressure on the area
   • Heel lifts or orthoses
   • Avoid corticosteroid injections (not recommended) 3

2. Non-insertional tendinopathy (mid-portion):

   • Responds better to eccentric exercises
   • May present with thickening and palpable nodules 3

Additional Conservative Measures

If no improvement occurs after 6 weeks of initial treatment:

• Orthotic devices:

  • Custom orthotics for biomechanical issues (overpronation, pes planus)
  • Over-the-counter arch supports for flat feet

• Night splinting to maintain tendon length

• Immobilization options:

  • Cast immobilization
  • Fixed-ankle walker-type device during activity 3

• Deep friction massage of the gastrocnemius-soleus complex 3

• Stretching of the calf muscles 3, 1

Treatment Progression and Monitoring

• Evaluate pain and function every 2-4 weeks
• Continue treatments until symptoms resolve
• If no improvement after 2-3 months of comprehensive conservative treatment:
  • Consider extracorporeal shock wave therapy 1
  • Consider referral to a podiatric foot and ankle surgeon 3

Risk Factors to Address

• Weight management for overweight patients (elevated BMI increases risk) 1
• Correct anatomic deformities:
  • Forefoot and heel varus
  • Excessive pes planus
  • Foot pronation 3

Common Pitfalls and Caveats

1. Avoid corticosteroid injections for Achilles tendinopathy as they increase the risk of tendon rupture 1

2. Don't rely solely on NSAIDs - they provide only short-term pain relief without affecting long-term outcomes 1, 2

3. Don't expect quick results - Achilles tendinopathy typically requires at least 12 weeks of consistent eccentric exercise therapy

4. Don't ignore biomechanical factors - addressing foot alignment issues with appropriate orthotics is crucial for long-term success

5. Don't progress activities too quickly - gradual return to sport-specific activities is essential to prevent recurrence

Achilles tendon pain is often multifactorial in etiology (improper technique, anatomic misalignment, weakness, uneven training surfaces, improperly fitted footwear) 3, requiring a comprehensive approach that addresses all contributing factors for optimal outcomes.