What is the initial treatment for a patient with 1 week of Achilles tendonitis, without evidence of a tear, fusiform disorder, or vascular neogenesis on ultrasound?

Initial Treatment for Achilles Tendinitis

The most effective initial treatment for Achilles tendinitis of one week duration without tear, fusiform disorder, or vascular neogenesis includes eccentric strengthening exercises, activity modification, stretching, and NSAIDs for pain relief. 1

First-Line Treatment Approach

• Reduce activities that cause pain while continuing activities that don't worsen symptoms to prevent ongoing damage and promote tendon healing 2, 1
• Implement regular calf-muscle stretching exercises to improve flexibility and reduce tension on the tendon 1, 2
• Perform eccentric strengthening exercises as they stimulate collagen production and guide normal alignment of newly formed collagen fibers 2, 1, 3
• Apply ice (cryotherapy) for short-term pain relief through wet towel for 10-minute periods to reduce tissue metabolism and blunt inflammatory response 2
• Use NSAIDs (oral or topical) for pain relief, with topical options having fewer systemic side effects 2, 1
• Use heel lifts or orthoses to reduce pressure on the affected area 2, 1
• Consider open-backed shoes to reduce pressure on the area 2, 1
• Decrease activity levels during the acute phase 2, 1
• Consider weight loss if indicated 2, 1

Important Cautions

• Avoid corticosteroid injections into or around the Achilles tendon as they may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 2, 1, 4
• For insertional Achilles tendinitis specifically, local injections of corticosteroids are not recommended 2, 1
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning unless dealing with particularly acute or refractory cases 2

Follow-up and Progression

• If improvement occurs within six to eight weeks, continue treatments until symptoms completely resolve 2
• If no improvement occurs after six to eight weeks, referral to a podiatric foot and ankle surgeon is appropriate 2
• Additional treatments for persistent cases may include:
  • Customized orthotic devices to correct biomechanical issues 2
  • Night splinting to maintain tendon length 2
  • Immobilization with cast or fixed-ankle walker-type device for particularly acute or refractory cases 2
  • Physical therapy interventions 1

Biomechanical Considerations

• Pay special attention to anatomic deformities such as forefoot and heel varus, excessive pes planus, or foot pronation, as these biomechanical factors often contribute to the development and persistence of Achilles tendinopathy 1
• Address any footwear issues that may be contributing to the condition 2, 1

Advanced Treatment Options (for refractory cases)

• If conservative treatment fails after 2-3 months, consider:
  • Cast immobilization if not previously used 2
  • Extracorporeal shock wave therapy for recalcitrant cases 2
  • Surgical intervention as a last resort 2, 5
  • High-volume image-guided injection for cases with neovascularization (though not present in this case per ultrasound) 6

Treatment Algorithm

1. Start with activity modification, eccentric exercises, stretching, and NSAIDs 1, 3
2. Continue for 6-8 weeks, monitoring progress 2
3. If improving, continue until symptoms resolve 2
4. If not improving after 6-8 weeks, refer to specialist and consider additional interventions 2, 7

Remember that Achilles tendinopathy is not primarily an inflammatory condition but rather a failed healing response, which explains why eccentric exercises are considered the gold standard treatment 3, 7.