What is the treatment for Achilles tendinitis?

Treatment of Achilles Tendinitis

Start with eccentric strengthening exercises combined with activity modification, stretching, NSAIDs, and cryotherapy—this is the gold standard conservative treatment that should be implemented immediately. 1, 2

Initial Conservative Management (First 6-8 Weeks)

Core Treatment Components

• Eccentric strengthening exercises are the most effective conservative treatment and should be the foundation of your management plan, as they stimulate collagen production and guide normal alignment of newly formed collagen fibers 1, 2, 3

• Reduce activities that cause pain while continuing activities that don't worsen symptoms to prevent ongoing tendon damage 1, 2

• Implement regular calf-muscle stretching exercises for the gastrocnemius-soleus complex to improve flexibility and reduce tension on the tendon 1, 2

• Apply ice (cryotherapy) for short-term pain relief, which reduces tissue metabolism and blunts inflammatory response 1, 2

Adjunctive Measures

• Use NSAIDs (oral or topical) for pain relief, with topical formulations having fewer systemic side effects 1, 2

• Provide over-the-counter heel cushions and arch supports to unload the tendon 1

• Recommend open-backed shoes to reduce pressure on the affected area, particularly for insertional tendinitis 4, 1

• Advise weight loss if indicated 4, 1

• Avoid flat shoes and barefoot walking 4

Critical Pitfall to Avoid

Never inject corticosteroids into or around the Achilles tendon—this is explicitly contraindicated as corticosteroids may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 1, 2. For insertional Achilles tendinitis specifically, local corticosteroid injections are not recommended 4, 1.

Secondary Interventions (After 6-8 Weeks Without Improvement)

If the patient shows no improvement after 6-8 weeks of conservative treatment:

• Refer to a podiatric foot and ankle surgeon 4, 1, 2

• Continue initial treatment measures while adding:

  • Customized orthotic devices to correct biomechanical issues 1
  • Night splinting to maintain tendon length 1
  • Immobilization with cast or fixed-ankle walker-type device for particularly acute or refractory cases 4, 1
  • Physical therapy interventions (land-based preferred over aquatic) 1

Biomechanical Assessment

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 and must be corrected 1, 2, 5

Advanced Treatment Options (After 2-3 Months of Failed Conservative Treatment)

If conservative treatment fails after 2-3 months:

• Consider cast immobilization if not previously used 4, 1

• Extracorporeal shock wave therapy for recalcitrant cases 4, 1

• Surgical intervention as a last resort, including debridement of diseased tendon with direct repair, and possibly tendon transfer to augment strength 1, 6

Special Considerations for Insertional Achilles Tendinitis

For insertional tendinitis specifically, the treatment approach differs slightly:

• Use open-backed shoes, heel lifts or orthoses, and decreased activity 4
• Avoid corticosteroid injections (this bears repeating for this specific location) 4, 1
• Consider immobilization earlier in particularly acute or refractory cases 4

Monitoring

Continue treatments until symptoms resolve if improvement occurs 1. Regularly assess pain levels, range of motion, and functional capacity 1.