What is the treatment for bilateral Achilles tendinopathy with chronic pain and stiffness?

Treatment for Bilateral Achilles Tendinopathy

Initial treatment for bilateral Achilles tendinopathy should focus on conservative measures including regular calf-muscle stretching, activity modification, NSAIDs, and open-backed shoes, with progression to immobilization if symptoms persist beyond 6-8 weeks. 1

Initial Conservative Management

For your bilateral Achilles tendinopathy with morning stiffness and pain, start with these first-line treatments:

• Activity Modification:

  • Reduce running and jumping activities
  • Avoid barefoot walking and flat shoes
  • Use open-backed shoes to reduce pressure on the tendon 1

• Pain Management:

  • NSAIDs (such as ibuprofen or naproxen) to reduce pain and inflammation 1, 2
  • Ice application (cryotherapy) for 15-20 minutes several times daily 1
  • Note: Corticosteroid injections are NOT recommended for Achilles tendinopathy as they may weaken the tendon 1, 3

• Supportive Measures:

  • Heel lifts or orthoses to reduce tension on the Achilles tendon 1
  • Consider over-the-counter arch supports 1
  • Weight loss if applicable 1

Rehabilitation Exercises

The most evidence-supported exercise protocol is progressive eccentric loading:

• Eccentric Calf Exercises (Alfredson's protocol):

  • Stand on edge of step with heels hanging off
  • Rise up on both feet, then slowly lower down on the affected foot(s)
  • Perform 3 sets of 15 repetitions twice daily with straight and bent knees 4, 5
  • This has the strongest evidence for effectiveness 2, 4

• Stretching:

  • Regular, gentle calf muscle stretching several times daily 1
  • Hold each stretch for 30 seconds, repeat 3-5 times

Treatment Timeline and Progression

1. First 6-8 weeks: Follow the above conservative measures

   • If improvement occurs, continue until symptoms resolve 1

2. If no improvement after 6-8 weeks:

   • Consider referral to a podiatric foot and ankle surgeon 1
   • Continue initial treatments
   • Add immobilization with cast or fixed-ankle walker-type device 1

3. For persistent symptoms beyond 3 months:

   • Consider additional interventions such as extracorporeal shock wave therapy 1, 2
   • Surgical options may be considered for cases not responding to 3-6 months of conservative treatment 3

Important Considerations

• Morning stiffness: Your symptom of 30+ minutes of morning stiffness is classic for Achilles tendinopathy 2
• Bilateral symptoms: While less common than unilateral cases, bilateral Achilles tendinopathy requires the same treatment approach
• Recovery timeline: Expect a prolonged recovery period of 3-6 months even with optimal management 3
• Avoid: Corticosteroid injections directly into the Achilles tendon as they increase risk of tendon rupture 1, 3

When to Seek Immediate Care

• If pain suddenly worsens or you experience a "popping" sensation, seek immediate medical attention as this could indicate tendon rupture
• If symptoms persist despite 6-8 weeks of consistent conservative treatment, professional evaluation is warranted 1

Based on your description of bilateral pain, morning stiffness, and functional limitations, you should begin treatment immediately and consider professional evaluation if symptoms don't improve within 6-8 weeks of consistent conservative care.