What is the recommended treatment for Achilles tendinitis?

Treatment for Achilles Tendinitis

Eccentric strengthening exercises are the gold standard treatment for Achilles tendinitis and should be performed twice daily (3 sets of 15 repetitions) for at least 12 weeks. 1

First-Line Treatment Approach

Rest and Activity Modification

• Relative rest to prevent ongoing damage while maintaining some tensile loading
• Avoid complete immobilization to prevent muscular atrophy 2
• Continue activities that do not worsen pain 2
• Limit barefoot walking 1

Physical Interventions

• Eccentric exercises: Most effective intervention, especially for non-insertional tendinopathy 1, 3
  • Perform twice daily, 3 sets of 15 repetitions
  • Continue for at least 12 weeks
• Cryotherapy: Apply ice through a wet towel for 10-minute periods for short-term pain relief 2, 1
• Stretching: Regular calf-muscle stretching exercises 1
• Deep friction massage of the gastrocnemius-soleus complex 1

Footwear and Orthotic Devices

• Use open-backed shoes to reduce pressure on insertional tendinopathy 1
• Consider heel lifts or orthoses 1
• Custom orthotics for biomechanical issues or over-the-counter arch supports for flat feet 1
• Stiff-soled shoes or rocker-bottom shoes to reduce forefoot motion 1

Medications

• NSAIDs: Effective for short-term pain relief only, no effect on long-term outcomes 2, 1
• Topical NSAIDs: Similar efficacy with fewer systemic side effects 2, 1
• Avoid corticosteroid injections: Strongly contraindicated, especially for insertional tendinopathy due to increased risk of tendon rupture 1, 2

Treatment Based on Type of Tendinopathy

Non-insertional Tendinopathy

• Responds better to eccentric exercises 1
• May present with thickening and palpable nodules 1

Insertional Tendinopathy

• Open-backed shoes to reduce pressure 1
• Heel lifts or orthoses 1
• Absolutely avoid corticosteroid injections 1, 2

Second-Line Interventions (for persistent symptoms)

• Night splinting and immobilization options (cast or fixed-ankle walker) 1
• Extracorporeal shock wave therapy after 6-8 weeks of failed conservative management 1

Monitoring and Progression

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

When to Refer

• Consider referral to a podiatric foot and ankle surgeon if no improvement after 2-3 months of comprehensive conservative treatment 1
• Surgical options may be considered for symptoms persisting despite 3-6 months of conservative therapy 1

Prevention Strategies

• Correct anatomic deformities (forefoot and heel varus, excessive pes planus, foot pronation) 1
• Address contributing factors: improper technique, weakness, uneven training surfaces, improperly fitted footwear 1
• Weight management for overweight patients, as metabolic syndrome components increase risk 1

Common Pitfalls to Avoid

• Using corticosteroid injections, which can increase rupture risk 2, 1
• Neglecting eccentric exercises, which are the most effective intervention 1, 3
• Complete immobilization, which leads to muscle atrophy 2
• Focusing only on pain relief without addressing biomechanical factors 1
• Continuing with ineffective treatments beyond 2-3 months without specialist referral 1