What are the recommended initial evaluation and treatment approaches for heel and Achilles tendonitis?

Initial Evaluation and Treatment of Heel and Achilles Tendinitis

For heel and Achilles tendinitis, a detailed history and physical examination with specific diagnostic tests should be performed, followed by conservative treatment including activity modification, appropriate footwear, NSAIDs, and eccentric exercises as first-line therapy. 1

Diagnostic Evaluation

Clinical Assessment

• History findings to identify:

  • Onset (insidious vs. traumatic)
  • Pain characteristics (worse with activity, morning stiffness)
  • Aggravating factors (increased activity, shoe pressure)
  • Relieving factors (walking barefoot, rest)

• Physical examination should include at least two of these tests: 1

  • Thompson test (calf squeeze test)
  • Assessment of ankle plantar flexion strength
  • Palpation for gap or tenderness
  • Evaluation of passive ankle dorsiflexion

• Location-specific examination:

  • For insertional tendinitis: Check for prominence medially/laterally to tendon insertion
  • For Haglund's deformity: Assess for posterolateral prominence and tenderness lateral to Achilles tendon

Imaging

• Routine imaging is not required for initial diagnosis 1
• Consider radiographs if:
  • Insertional tendinitis (may show spurring/erosion at insertion)
  • Haglund's deformity (posterior prominence visible)
  • Trauma history (to rule out fracture)
• MRI or ultrasound may be considered for persistent symptoms but are not routinely recommended 1, 2

Treatment Approach

First-Line Treatment (0-6 weeks)

1. Activity modification:

   • Reduce activities that cause pain
   • Implement relative rest to prevent further damage 3

2. Footwear modifications:

   • Open-backed shoes for insertional tendinitis and Haglund's deformity
   • Heel lifts or orthoses 1

3. Pain management:

   • NSAIDs (naproxen 500mg twice daily) for short-term pain relief 4, 5
   • Cold application (20-30 minutes, 3-4 times daily) 3
   • Avoid corticosteroid injections in Achilles tendon (risk of rupture) 1, 5

4. Exercise therapy:

   • Eccentric strengthening exercises (highest evidence-based effectiveness) 5, 6
   • Daily stretching exercises 3
   • Gentle submaximal and aerobic exercise 3

Second-Line Treatment (if no improvement after 6 weeks)

1. Continue first-line treatments

2. Additional interventions:

   • Customized orthotic device
   • Night splinting
   • Immobilization cast or fixed-ankle walker-type device 1

3. Consider referral to podiatric foot and ankle surgeon 1

Third-Line Treatment (if no improvement after 2-3 months)

1. Continue appropriate first and second-line treatments

2. Consider advanced therapies:

   • Extracorporeal shock wave therapy (effective for calcific tendinopathy) 3, 5
   • Immobilization if not previously used 1

3. Surgical evaluation if pain persists despite 3-6 months of well-managed conservative treatment 3, 7

Special Considerations

For Insertional Achilles Tendinitis

• Avoid corticosteroid injections (not recommended near Achilles tendon) 1
• Immobilization may be considered in particularly acute or refractory cases 1

For Haglund's Deformity with Bursitis

• Accommodative padding and orthoses
• Corticosteroid injections may be considered (avoiding the Achilles tendon) 1
• Surgical intervention may include resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 1

For Acute Achilles Tendon Rupture

• Requires different management approach
• Diagnosis confirmed by two or more specific tests (Thompson test, palpable gap, etc.) 1
• Treatment options include surgical or non-surgical approaches 1

Treatment Monitoring

• Regular assessment at 2,6, and 12 weeks to evaluate:

  • Pain levels (especially pain on loading)
  • Range of motion
  • Functional improvement 3, 2

• Return to full activity when patient demonstrates:

  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to uninjured side 3

Common Pitfalls to Avoid

1. Overuse of imaging for initial diagnosis when clinical assessment is sufficient 1
2. Corticosteroid injections near the Achilles tendon (risk of rupture) 1, 5
3. Prolonged immobilization beyond 3 weeks (can lead to contractures) 3
4. Failure to address biomechanical factors contributing to tendinopathy 8
5. Delayed referral for surgical evaluation when conservative measures fail 1, 7