What is the treatment for Achilles tendinitis?

Treatment for Achilles Tendinitis

The first-line treatment for Achilles tendinitis includes eccentric exercises performed twice daily for at least 12 weeks, combined with activity modification, appropriate footwear, and NSAIDs for pain relief. 1

Initial Conservative Management

Exercise Therapy

• Eccentric exercises: Most effective intervention, especially for non-insertional tendinopathy
  • Perform twice daily, 3 sets of 15 repetitions, for at least 12 weeks 1
  • Regular calf-muscle stretching exercises 2, 1
  • Deep friction massage of the gastrocnemius-soleus complex 1

Activity Modification

• Limit barefoot walking 1
• Avoid flat shoes 2, 1
• Use supportive footwear with good arch support 1
• Relative rest to prevent ongoing damage while maintaining some tensile loading 1
• Continue activities that do not worsen pain 1

Pain Management

• NSAIDs (oral or topical) for symptom relief 2, 1, 3
  • Naproxen 500mg twice daily is an appropriate option for acute tendinitis 3
  • Topical NSAIDs provide similar efficacy with fewer systemic side effects 1
• Cryotherapy: Apply ice through a wet towel for 10-minute periods 2, 1

Supportive Devices

• Over-the-counter heel cushions and arch supports 2, 1
• Heel lifts to reduce tension on the Achilles tendon 2
• Night splinting if morning pain persists 2, 1

Treatment Based on Type of Achilles Tendinitis

Non-insertional Achilles Tendinitis

• Eccentric exercises are particularly effective 1
• NSAIDs and activity modification as described above 2, 1
• Consider corticosteroid injections only with extreme caution due to rupture risk 1

Insertional Achilles Tendinitis

• Open-backed shoes to reduce pressure on the area 2
• Heel lifts or orthoses 2
• NSAIDs, decreased activity, stretching exercises 2
• Avoid corticosteroid injections - not recommended due to increased risk of tendon rupture 2, 1
• Consider immobilization in particularly acute or refractory cases 2

Bursitis Associated with Haglund's Deformity

• Open-backed shoes, orthoses, accommodative padding 2
• NSAIDs, weight loss if indicated, physical therapy 2
• Corticosteroid injections (avoiding the Achilles tendon) may be considered 2

Treatment Timeline and Progression

First 6 Weeks

• Implement all initial conservative measures
• If improvement occurs, continue treatments until symptoms resolve 2

If No Improvement After 6-8 Weeks

• Referral to a podiatric foot and ankle surgeon 2
• Continue initial treatments
• Consider additional interventions:
  • Customized orthotic device
  • Night splinting
  • Limited corticosteroid injections (except for insertional tendinitis)
  • Casting or use of a fixed-ankle walker-type device during activity 2
  • Extracorporeal shock wave therapy for refractory cases 1

If No Improvement After 2-3 Months

• Continue initial treatment measures
• Consider cast immobilization if not previously used 2
• Further options include:
  • Surgery (for persistent cases)
  • Extracorporeal shock wave therapy 2, 1

Surgical Considerations

• Surgery should only be considered after 2-3 months of failed comprehensive conservative management 2, 1
• Surgical options may include:
  • Debridement of diseased tendon
  • Removal of calcifications or enthesophytes
  • Achilles tendon lengthening for recalcitrant cases 1

Important Cautions and Pitfalls

• Complete immobilization should be avoided as it leads to muscle atrophy 1
• Corticosteroid injections increase rupture risk and should be avoided especially for insertional tendinopathy 1
• Long-term NSAID use should be avoided, especially in patients with active inflammatory bowel disease 1
• Recognize that recovery can be prolonged - symptoms may take 3-6 months to resolve even with appropriate treatment 4
• Achilles tendinitis is often misdiagnosed - ensure proper differential diagnosis including partial tears, retrocalcaneal bursitis, and systemic inflammatory conditions 5