What is the treatment for an Achilles injury?

Treatment of Achilles Tendon Injuries

For Achilles tendon injuries, treatment should be based on the specific diagnosis, with initial conservative management for most tendinopathies and surgical intervention recommended for complete ruptures in young, active patients and athletes. 1

Diagnosis and Classification

Before determining treatment, proper diagnosis is essential:

• Types of Achilles injuries:

  • Tendinopathy/Tendinitis (including insertional and non-insertional)
  • Paratenonitis (inflammation of surrounding tissue)
  • Bursitis (often associated with Haglund's deformity)
  • Partial tears
  • Complete ruptures

• Diagnostic tests:

  • Physical examination: Thompson/Simonds squeeze test, assessment of plantar flexion strength, palpable gap, increased passive ankle dorsiflexion 1
  • Imaging: Ultrasound (92% accuracy for differentiating full vs. partial tears) or MRI (95% sensitivity/specificity for tendon pathology) 1

Treatment Algorithm

1. Conservative Management (First-line for most tendinopathies)

For Tendinopathy/Tendinitis:

• Initial treatment (6-8 weeks):

  • Relative rest (reduce pain-causing activities without complete immobilization) 1
  • Ice therapy (10-minute applications through wet towel) 1
  • NSAIDs (oral or topical) for pain control 1
  • Heel lifts or orthoses 2
  • Open-backed shoes to reduce pressure (especially for insertional tendinitis) 2
  • Stretching and eccentric strengthening exercises 1
  • Weight loss if indicated 2

• If improvement occurs: Continue treatment until symptoms resolve 2

• If no improvement after 6-8 weeks:

  • Referral to podiatric foot and ankle surgeon or orthopedic specialist 2
  • Consider immobilization with cast or walker boot 2, 1
  • Custom orthotic devices 2
  • Night splinting 2

For Bursitis with Haglund's Deformity:

• Open-backed shoes, orthoses, accommodative padding
• NSAIDs
• Corticosteroid injections (avoiding the Achilles tendon itself) 2
• Physical therapy

2. Surgical Management

Indications for surgical treatment:

• Complete Achilles tendon ruptures in young, active patients and athletes 1, 3
• Persistent partial ruptures not responding to conservative treatment 1
• Chronic tendinopathy unresponsive to 2-3 months of conservative care 2
• Haglund's deformity with persistent symptoms (resection of prominent posterior calcaneus) 2

Surgical options:

• Open repair
• Limited open repair
• Percutaneous repair (higher quality of life scores) 1

Rehabilitation Protocol

Early rehabilitation phase:

• Initial immobilization with ankle in slight plantar flexion (10-20°) 1
• Early protected weight-bearing based on treatment plan 1
• Ice for pain control

Progressive rehabilitation:

• Tensile loading exercises to stimulate collagen production 1
• Eccentric strengthening exercises 1, 4
• Stretching exercises for posterior thigh muscles 1
• Gradual return to activities based on functional improvement 1

Important Considerations and Pitfalls

• Avoid corticosteroid injections directly into the tendon as this can increase rupture risk 1
• Avoid prolonged immobilization which leads to muscle atrophy and deconditioning 1
• Early protected weight-bearing and mobilization are recommended for both surgical and non-surgical treatments 1
• Surgical treatment in athletes improves strength outcomes and shortens return to play time compared to non-operative management 3
• About 70-90% of athletes successfully return to sport after Achilles tendon injury with appropriate treatment 5

Special Populations

• Athletes: Surgical repair typically recommended for complete ruptures to minimize re-rupture risk and optimize return to sport 1, 3
• Older, less active patients: Non-surgical management often preferred 1
• Patients with significant comorbidities: Non-surgical management typically recommended 1

Remember that Achilles tendon injuries often show bilateral tendon damage even when symptoms appear unilateral 6, suggesting the importance of addressing biomechanical factors and rehabilitation of both limbs to prevent future injury.