What is the recommended treatment for Achilles tendonitis?

Treatment for Achilles Tendinitis

The recommended first-line treatment for Achilles tendinitis includes eccentric strengthening exercises, activity modification, appropriate footwear changes, and NSAIDs for short-term pain relief, with most patients achieving full recovery through conservative management. 1

Initial Treatment Approach

Conservative Management (First 6-8 Weeks)

• Activity Modification:

  • Reduce activities that cause pain
  • Implement relative rest without complete immobilization
  • Avoid flat shoes and barefoot walking 2, 1

• Physical Interventions:

  • Regular calf muscle stretching exercises
  • Eccentric strengthening exercises (highest evidence-based effectiveness) 1
  • Cryotherapy for acute pain relief 2
  • Open-backed shoes for insertional tendinitis 2
  • Heel lifts or orthoses 2, 1

• Pharmacological Management:

  • NSAIDs (e.g., naproxen 500mg twice daily) for short-term pain relief 1, 3
  • Use the lowest effective dose for shortest duration 3
  • Avoid corticosteroid injections near the Achilles tendon due to risk of rupture 2, 1

Phased Rehabilitation Approach

Phase 1 (0-4 weeks)

• Pain control
• Protected range of motion exercises
• Gentle stretching

Phase 2 (4-8 weeks)

• Progressive strengthening exercises
• Eccentric training
• Gradual return to low-impact activities

Phase 3 (8-12 weeks)

• Occupation-specific training
• Functional exercises
• Gradual return to pre-injury activity levels 1

Management of Persistent Symptoms

If no improvement occurs after 6-8 weeks of conservative treatment:

1. Continue initial treatments
2. Consider referral to a podiatric foot and ankle surgeon 2
3. Add additional interventions:
   • Customized orthotic devices
   • Night splinting
   • Immobilization cast or fixed-ankle walker-type device 2, 1

If no improvement after 3-6 months of well-managed conservative treatment:

1. Consider extracorporeal shock wave therapy 2, 1
2. Evaluate for surgical intervention 1

Special Considerations

For Insertional Achilles Tendinitis

• Open-backed shoes to reduce pressure
• Heel lifts or orthoses
• Avoid corticosteroid injections 2
• Consider immobilization for acute or refractory cases 2

For Haglund's Deformity with Bursitis

• Open-backed shoes
• Orthoses and accommodative padding
• NSAIDs
• Physical therapy
• Corticosteroid injections (avoiding the Achilles tendon) 2

Prognosis and Follow-up

• Regular assessment at 2,6, and 12 weeks to evaluate progress 1
• Approximately 80% of patients fully recover with exercise-based treatment alone 4
• Return to full activity when patient demonstrates:
  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to uninjured side 1

Common Pitfalls to Avoid

• Overuse of imaging for initial diagnosis when clinical assessment is sufficient 1
• Corticosteroid injections near the Achilles tendon 2, 1
• Prolonged immobilization beyond 3 weeks 1
• Failure to address biomechanical factors (e.g., overpronation) 5, 6
• Delayed referral for surgical evaluation when conservative measures fail 1

Research shows that eccentric exercises have particularly strong evidence for effectiveness, with one 5-year follow-up study showing that 80% of patients fully recovered with exercise treatment alone 4. Surgical intervention, when necessary, has shown good to excellent results in 70-90% of cases 6, 7.