What is the treatment for Achilles Tendinosis/Tendinitis or Achilles Bursitis?

Treatment of Achilles Tendinosis/Tendinitis and Achilles Bursitis

The treatment of Achilles tendinosis/tendinitis and Achilles bursitis should begin with conservative measures including activity modification, NSAIDs, stretching exercises, and appropriate footwear changes, with eccentric exercise being the gold standard for Achilles tendinopathy. 1

Initial Treatment Approach

For Achilles Tendinosis/Tendinitis:

1. Activity Modification

   • Decrease activities that aggravate symptoms
   • Avoid complete immobilization to prevent muscle atrophy 1
   • Continue activities that don't worsen pain

2. Pain Management

   • NSAIDs (oral or topical) for pain relief 1, 2
   • Ice application through a wet towel for 10-minute periods 1
   • Avoid corticosteroid injections directly into the Achilles tendon due to risk of rupture 1

3. Exercise Therapy

   • Eccentric strengthening exercises - the most effective and gold standard treatment 1, 3
   • Regular calf muscle stretching 1
   • Tensile loading to stimulate collagen production and guide normal alignment 1

4. Footwear Modifications

   • Open-backed shoes to reduce pressure on the area 1
   • Heel lifts or orthoses to unload the tendon 1
   • Correction of overpronation or pes planus with shoe orthotics 1

For Achilles Bursitis (especially with Haglund's Deformity):

1. Footwear Modifications

   • Open-backed shoes to reduce pressure 1
   • Orthoses and accommodative padding 1

2. Pain Management

   • NSAIDs for inflammation and pain relief 1, 2
   • Corticosteroid injections (avoiding the Achilles tendon) may be considered 1

3. Physical Therapy

   • Stretching exercises 1
   • Weight loss if indicated 1

Treatment Progression

If No Improvement After 6-8 Weeks:

1. For Achilles Tendinosis/Tendinitis:

   • Referral to a podiatric foot and ankle surgeon 1
   • Consider immobilization cast or fixed-ankle walker-type device 1
   • Continue initial treatments

2. For Achilles Bursitis:

   • Referral to a podiatric foot and ankle surgeon 1
   • Consider immobilization cast or fixed-ankle walker-type device 1
   • Consider bursa injection (avoiding the Achilles tendon) 1

If No Improvement After 2-3 Months:

1. For Achilles Tendinosis/Tendinitis:

   • Consider cast immobilization if not previously used 1
   • Consider extracorporeal shock wave therapy 4, 5
   • Evaluate for surgical intervention in refractory cases 5, 6

2. For Achilles Bursitis:

   • Consider surgical intervention - resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 1
   • Some patients may require calcaneal osteotomy to correct alignment 1

Important Considerations and Pitfalls

1. Corticosteroid Injections:

   • Avoid injecting directly into the Achilles tendon due to risk of rupture 1
   • May be more effective than NSAIDs for acute pain but do not alter long-term outcomes 1
   • May inhibit healing and reduce tensile strength of tissue 1

2. Diagnostic Imaging:

   • Plain radiography may show calcific tendinosis, calcaneal avulsion fracture, or soft-tissue swelling 1
   • Ultrasonography can demonstrate tendon thickening and heterogeneous echogenicity 1
   • MRI is useful for showing partial tendon tears, tendon thickening, bursitis, and chronic degenerative changes 1

3. Surgical Considerations:

   • Surgery should be considered only after failed conservative management 6
   • Surgical options include debridement, partial excision of the paratenon, release of adhesions, or excision of Haglund's deformity 6

4. Special Populations:

   • Lower doses of NSAIDs should be considered in elderly patients and those with renal or hepatic impairment 2

Remember that Achilles tendinopathy is not primarily an inflammatory condition but rather a failed healing response 5. This understanding should guide treatment approaches, focusing on promoting proper tendon healing rather than simply addressing inflammation.