What is the recommended treatment for Achilles tendonitis?

Treatment of Achilles Tendonitis

The recommended first-line treatment for Achilles tendonitis 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 adjustments. 1

Initial Conservative Management

Non-Pharmacological Interventions

• Eccentric strengthening exercises: Most effective for non-insertional tendinopathy
  • Perform twice daily, 3 sets of 15 repetitions
  • Continue for at least 12 weeks 1
• Activity modification and relative rest:
  • Avoid activities that exacerbate symptoms
  • Address contributing factors (improper technique, uneven training surfaces) 1
• Footwear modifications:
  • Open-backed shoes for insertional tendinopathy
  • Heel lifts or orthoses to reduce tendon strain 1
  • Custom orthotics for biomechanical issues or over-the-counter arch supports for flat feet 1
• Deep friction massage of the gastrocnemius-soleus complex 1
• Stretching of the calf muscles 1
• Cryotherapy: Ice application for 10-minute periods through a wet towel for acute pain relief 1

Pharmacological Management

• NSAIDs (e.g., naproxen):
  • Use the lowest effective dose for the shortest duration
  • For short-term pain relief only; no effect on long-term outcomes 1, 2
  • Starting dose of naproxen for tendonitis: 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required
  • Initial total daily dose should not exceed 1250 mg, thereafter not exceeding 1000 mg daily 2
  • Consider topical NSAIDs for similar efficacy with fewer systemic side effects 1
• Avoid corticosteroid injections for insertional tendinopathy as they increase the risk of tendon rupture 1

Monitoring and Progression

• Evaluate pain and function every 2-4 weeks 1
• Continue treatments until symptoms resolve 1
• Imaging (MRI or ultrasound) should only be considered if symptoms persist despite appropriate conservative management 1

Advanced Interventions for Persistent Cases

• Night splinting and immobilization options:
  • Cast immobilization or fixed-ankle walker-type devices during activity 1
• Extracorporeal shock wave therapy (ESWT):
  • Consider for refractory cases after 6-8 weeks of conservative management 1

When to Consider Referral

• If no improvement occurs after 2-3 months of comprehensive conservative treatment, consider referral to a podiatric foot and ankle surgeon 1
• Surgical options may be considered for symptoms persisting despite 3-6 months of conservative therapy 1, 3
• Surgical interventions may include:
  • Debridement of the diseased tendon
  • Removal of calcifications or enthesophytes
  • Achilles tendon lengthening for recalcitrant cases 1

Prevention Strategies

• Correct anatomic deformities (forefoot and heel varus, excessive pes planus, foot pronation) 1
• Weight management for patients with elevated BMI 1
• Limit barefoot walking 1
• Regular calf-muscle stretching exercises 1
• Metatarsal padding, stiff-soled shoes or rocker-bottom shoes to reduce forefoot motion 1

Common Pitfalls to Avoid

1. Using corticosteroid injections for insertional tendinopathy (increases rupture risk) 1
2. Relying solely on NSAIDs without implementing eccentric exercises 1
3. Discontinuing conservative treatment too early (should continue for at least 12 weeks) 1
4. Failing to address underlying biomechanical issues or improper footwear 1
5. Returning to full activity before adequate healing and rehabilitation 1