How to diagnose and treat Achilles tendon inflammation?

Diagnosis and Treatment of Achilles Tendon Inflammation

The most effective approach to diagnosing and treating Achilles tendon inflammation involves recognizing that most cases are not truly inflammatory but rather degenerative tendinopathies requiring eccentric strengthening exercises as first-line treatment. 1

Diagnosis

Clinical Assessment

• Pain characteristics: Morning stiffness and/or pain in the tendon area
• Physical examination:
  • Thorough inspection for swelling, asymmetry, and erythema
  • Palpation for tenderness along the Achilles tendon
  • Range-of-motion testing
  • Examination maneuvers that simulate tendon loading to reproduce pain 2
  • Thompson/Simonds squeeze test (for suspected ruptures) 1

Imaging

• Ultrasound: 92% accuracy for differentiating full vs. partial tears; 58% sensitivity and 94% specificity for tendinopathy 1
• MRI: 95% sensitivity and 95% specificity; particularly useful when diagnosis remains unclear 2, 1
• Plain radiography can help rule out other conditions 2

Treatment Algorithm

1. Conservative Management (First 6-8 weeks)

• Relative rest: Reduce activities that exacerbate symptoms
• Eccentric strengthening exercises: The most evidence-based effective conservative treatment 1, 3
• Ice therapy: For pain management
• NSAIDs: Effective for acute pain relief but not recommended over other analgesics for long-term use 2, 1
• Biomechanical corrections:
  • Heel lifts or orthoses
  • Open-backed shoes
  • Address foot pronation, pes planus, or heel varus if present 1
• Stretching exercises: Particularly for posterior thigh muscles 1
• Weight loss: If indicated 1

2. For Persistent Symptoms (After 6-8 weeks)

• Shock wave therapy: One of the treatments with highest evidence-based effectiveness 3
• Consider additional modalities:
  • Low-level laser therapy
  • Ultrasound therapy
  • Technique modification 2, 3

3. For Refractory Cases (After 2-3 months)

• Surgical treatment: Reserved for patients who have failed conservative therapy 2, 1
  • Options include open repair, limited open repair, or percutaneous repair
  • Percutaneous repair shows higher physical and mental component scores on quality of life measures 1

Important Considerations

Pathophysiology Understanding

• Most cases labeled as "tendonitis" are actually degenerative conditions (tendinosis/tendinopathy) rather than inflammatory processes 2
• The condition progresses from reactive tendinopathy (tenocyte proliferation) to tendon disrepair (focal collagen disruption) to degenerative tendinopathy (cell death, collagen disorganization) 3

Treatment Pitfalls to Avoid

1. Misdiagnosis: Incorrectly labeling as inflammatory "tendonitis" rather than degenerative "tendinopathy" 2
2. Corticosteroid injections: Avoid injecting directly into the tendon as this increases rupture risk 1
3. Prolonged immobilization: Leads to muscle atrophy and deconditioning 1
4. Inadequate rehabilitation: Most patients (80%) fully recover within 3-6 months with proper conservative care 2

Special Populations

• Athletes: May require more aggressive treatment and rehabilitation protocols to return to sport 1
• Bilateral assessment: Important even when symptoms appear unilateral, as bilateral tendon damage is common 1
• Older, less active patients: Often prefer non-surgical management 1

By following this structured approach to diagnosis and treatment, most patients with Achilles tendon inflammation can achieve significant improvement in pain, function, and quality of life without requiring surgical intervention.