What is the initial treatment for Achilles tendinopathy?

Initial Treatment for Achilles Tendinopathy

The initial treatment for Achilles tendinopathy should focus on conservative measures including relative rest, eccentric strengthening exercises, stretching, ice therapy, NSAIDs, and appropriate footwear modifications. 1

Understanding Achilles Tendinopathy

Achilles tendinopathy is a common overuse condition characterized by:

• Insidious onset of posterior heel pain and swelling 1
• Pain that worsens with increased activity and pressure from shoes 1
• Relief when walking barefoot 1
• Tenderness and often palpable thickening of the tendon 1

Initial Treatment Algorithm

Step 1: Activity Modification and Relative Rest

• Reduce activities that cause pain to prevent ongoing damage 1
• Complete immobilization should be avoided to prevent muscle atrophy 1
• Continue activities that don't worsen pain 1

Step 2: Physical Interventions

• Eccentric strengthening exercises - the gold standard treatment and most effective conservative option 2, 1

  • Stimulates collagen production and guides normal alignment of newly formed collagen fibers 1
  • Has proven beneficial in multiple studies 1

• Stretching exercises for the gastrocnemius-soleus complex 1

  • Generally considered helpful and widely accepted 1
  • Improves flexibility and reduces tension on the tendon 1

• Cryotherapy (ice therapy)

  • Effective for short-term pain relief 1
  • Applications of ice through a wet towel for 10-minute periods are most effective 1
  • Reduces tissue metabolism and may blunt inflammatory response 1

Step 3: Footwear and Orthotic Modifications

• Open-backed shoes to reduce pressure on the area 1
• Heel lifts or orthoses to unload the tendon 1
• Shoe orthotics to correct overpronation or pes planus problems if present 1

Step 4: Pain Management

• NSAIDs (oral or topical)
  • Effective for short-term pain relief 1
  • Topical NSAIDs may have fewer systemic side effects 1
  • Note that most chronic tendinopathies have minimal inflammation 1

Important Considerations and Pitfalls

• Avoid corticosteroid injections into the Achilles tendon

  • Local injections of corticosteroids are not recommended for Achilles tendinopathy 1
  • May inhibit healing and reduce tensile strength, predisposing to spontaneous rupture 1

• Duration of initial treatment

  • Continue initial treatment for 6-8 weeks before considering more aggressive interventions 1
  • If improvement occurs, treatments should be continued until symptoms resolve 1

• When to refer to specialist

  • If no improvement occurs after 6-8 weeks of conservative treatment 1
  • Consider referral to a podiatric foot and ankle surgeon 1

Second-Line Treatment Options (if initial treatment fails)

• Immobilization cast or fixed-ankle walker-type device 1
• Extracorporeal shock wave therapy 3, 4
• Surgical intervention (only after failed conservative management for 3-6 months) 4

Anatomical Considerations

• Pay special attention to anatomic deformities such as forefoot and heel varus, excessive pes planus, or foot pronation 1
• These biomechanical factors often contribute to the development and persistence of Achilles tendinopathy 1

Remember that Achilles tendinopathy has a good clinical prognosis with most patients improving with activity modification and rehabilitation focused on progressive tendon-loading 5.