What is the treatment for Achilles tendonitis?

Treatment for Achilles Tendonitis

The most effective treatment for Achilles tendonitis is a progressive rehabilitation program centered on eccentric strengthening exercises, combined with relative rest and pain management strategies, with most patients fully recovering within 3-6 months with appropriate conservative treatment. 1

Initial Treatment Approach

First-Line Interventions

• Relative rest: Reduce activities that aggravate symptoms while maintaining some level of activity to promote healing 1
• Pain management:
  • NSAIDs (oral or topical): Effective for short-term pain relief 1
  • Acetaminophen (up to 4g/day): Alternative if NSAIDs are inadequate 1
  • Cryotherapy: Ice application through a wet towel for 10-minute periods 1
• Biomechanical support:
  • Heel lifts or orthoses to reduce tension on the Achilles tendon 2
  • Open-backed shoes for insertional Achilles tendonitis to reduce pressure 2, 1

Exercise Therapy

• Eccentric strengthening exercises: The cornerstone of Achilles tendonitis treatment 1
  • Begin with seated calf raises (isolates soleus)
  • Progress to bilateral standing heel raises
  • Advance to single-leg heel raises and add resistance as tolerated
  • Incorporate eccentric training (lowering phase of heel raises)

Treatment Based on Tendonitis Type

Non-insertional Achilles Tendonitis

• Stretching exercises for gastrocnemius and soleus muscles
• Progressive loading program starting with pain-free activities 1
• NSAIDs for inflammation control 2

Insertional Achilles Tendonitis

• Open-backed shoes to reduce pressure on insertion point 2
• Heel lifts or orthoses 2
• Avoid corticosteroid injections near the Achilles tendon insertion 2
• Weight loss if indicated 2

Progressive Rehabilitation Protocol

1. Early phase (0-2 weeks):

   • Pain-free walking with proper biomechanics
   • Low-load strengthening exercises
   • Pool-based exercises for reduced weight-bearing 1

2. Intermediate phase (2-6 weeks):

   • Progress to mid-intensity exercise
   • Add resistance with weights or bands
   • Balance and proprioceptive training 1

3. Advanced phase (6+ weeks):

   • Stationary cycling, elliptical training
   • Progress to plyometric exercises (when pain-free)
   • Sport-specific movement patterns 1

4. Return to activity phase:

   • Running progression on level surfaces
   • Begin at 30-50% of usual pace
   • Increase distance before increasing speed
   • Progress running volume by no more than 10% per week 1

When to Consider Additional Interventions

For Persistent Symptoms (6-8 weeks without improvement)

• Imaging: Plain radiographs to rule out other pathologies 1
• Additional therapies to consider:
  • Extracorporeal shock wave therapy (ESWT) - moderately effective but expensive 1, 3
  • Low-level laser therapy combined with exercise 1
  • Immobilization with cast or walker boot in refractory cases 2

For Chronic Cases (3-6 months without improvement)

• MRI without contrast to evaluate for tendon tears or other soft tissue injuries 1
• Referral to podiatric foot and ankle surgeon 2
• Surgical options may be considered for patients who have failed well-managed conservative therapy 1, 4

Cautions and Contraindications

• Corticosteroid injections:

  • Limit to 2-3 injections with 4-6 weeks between each 1
  • Avoid injections near the Achilles tendon insertion due to risk of rupture 2, 1
  • Prolonged use can inhibit tissue healing and increase long-term cartilage degeneration 1

• 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 1

Treatment Outcomes

With appropriate conservative management, approximately 80% of patients fully recover within 3-6 months 1. Early intervention with a structured rehabilitation program focusing on eccentric exercises yields the best outcomes and reduces the likelihood of requiring surgical intervention 5.