What is the gold standard for managing Achilles tendinopathy?

Gold Standard for Managing Achilles Tendinopathy

Eccentric exercise training is the gold standard for managing Achilles tendinopathy, with most patients (approximately 80%) fully recovering within 3-6 months with appropriate conservative treatment. 1, 2

Diagnosis and Assessment

• Pain is typically located proximal to the Achilles tendon insertion
• Physical examination often reveals:
  • Thickening and tender, palpable nodules
  • Pain exacerbated by activity and relieved with rest
  • Anatomic deformities (forefoot/heel varus, excessive pes planus, foot pronation)

Treatment Algorithm

First-Line Treatment (0-6 weeks)

1. Eccentric Strength Training Protocol

   • Begin with seated calf raises (isolates soleus)
   • Progress to bilateral standing heel raises
   • Advance to single-leg heel raises
   • Add resistance with weights or resistance bands
   • Incorporate eccentric training (lowering phase of heel raises)

2. Adjunctive Therapies

   • Stretching and deep friction massage of the gastrocnemius-soleus complex 3
   • Shoe orthotics to correct overpronation or pes planus 3
   • Heel lift orthotics to unload the tendon for pain relief 3
   • NSAIDs (oral or topical) for pain management 2
   • Open-backed shoes to reduce pressure on the area 3

Second-Line Treatment (6-12 weeks)

If no improvement occurs after 6-8 weeks:

1. Continue initial treatments
2. Consider immobilization with cast or fixed-ankle walker-type device 3
3. Progress to functional activities:
   • Pool-based exercises (reduced weight-bearing)
   • Stationary cycling
   • Elliptical training
   • Pain-free aqua jogging 2

Third-Line Treatment (3-6 months)

If symptoms persist despite 3 months of conservative management:

1. Consider imaging:
   • Plain radiographs if symptoms persist beyond 4-6 weeks
   • MRI without contrast if symptoms persist despite 6-8 weeks of management 2
2. Consider referral to a specialist if:
   • Pain persists despite 3-6 months of well-managed conservative treatment
   • Significant functional limitations impact quality of life 2
3. Consider surgical intervention after 6 months of failed conservative treatment 4, 5

Return to Activity Criteria

• Complete resolution of pain during and after activity
• Full range of motion compared to uninjured side
• Strength symmetry >90% compared to uninjured side
• Successful completion of sport-specific functional tests
• Ability to perform repeated single-leg hopping without pain 2

Important Considerations and Pitfalls

Cautions

• Corticosteroid injections are not recommended for Achilles tendinopathy as they may inhibit healing and reduce tendon strength 3, 2
• Avoid sudden increases in exercise intensity; progress load gradually to minimize reinjury risk 2
• Diabetic patients may respond less favorably to conservative measures and may require a modified approach 2

Special Populations

• Athletes may need more comprehensive rehabilitation before returning to full activity 2
• For insertional Achilles tendinitis, open-backed shoes are particularly important to reduce pressure on the area 3

Prognosis

• Over 90% of cases have good outcomes with appropriate conservative management
• Even with optimum management, resolution typically requires 3-6 months 2
• Surgical intervention should only be considered after 6 months of failed conservative treatment 4, 5

The evidence consistently supports eccentric exercise as the cornerstone of Achilles tendinopathy management 1, 6, with a progressive loading approach that gradually increases intensity based on patient response. This approach, combined with appropriate adjunctive therapies, provides the best chance for successful resolution of symptoms and return to full activity.