What is the initial treatment for non-intentional Achilles tendinopathy?

Initial Treatment for Non-Intentional Achilles Tendinopathy

Begin with eccentric strengthening exercises as the gold standard treatment, combined with activity modification, stretching, and cryotherapy, while strictly avoiding corticosteroid injections into the tendon. 1, 2

First-Line Conservative Management

Activity Modification

• Reduce activities that cause pain to prevent ongoing damage, while continuing activities that don't worsen pain. 1
• Limit high-impact activities and repetitive loading of the tendon until symptoms improve. 3

Eccentric Exercise Program (Gold Standard)

• Eccentric strengthening exercises are the most effective conservative option and universally accepted treatment. 1, 2
• These exercises stimulate collagen production and guide normal alignment of newly formed collagen fibers, addressing the underlying degenerative pathology. 1
• This is the only therapy with universal acceptance across all evidence sources. 2

Stretching and Manual Therapy

• Perform regular stretching exercises of the gastrocnemius-soleus complex to improve flexibility and reduce tension on the tendon. 3, 1
• Deep friction massage of the gastrocnemius-soleus complex is generally considered helpful. 3

Pain Management

• Apply cryotherapy (ice therapy) for short-term pain relief, which reduces tissue metabolism and may blunt inflammatory response. 1
• Use NSAIDs (oral or topical) for short-term pain relief, with topical formulations having fewer systemic side effects. 1
• Decreased activity during acute phases helps manage symptoms. 3

Biomechanical Corrections

Footwear and Orthotic Interventions

• Use open-backed shoes to reduce pressure on the posterior heel area. 3, 1
• Apply heel lifts or orthoses to unload the tendon for pain relief. 3, 1
• Correct anatomic misalignments such as forefoot and heel varus, excessive pes planus, or foot pronation with shoe orthotics. 3, 1
• Avoid flat shoes and barefoot walking during the acute phase. 3

Weight Management

• Recommend weight loss if indicated, as excess weight increases tendon loading. 3

Critical Pitfall to Avoid

Never inject corticosteroids into or near the Achilles tendon—this may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture. 3, 1

Treatment Timeline and Escalation

Initial Phase (0-6 to 8 Weeks)

• Continue all initial conservative treatments for 6-8 weeks before considering more aggressive interventions. 3, 1
• If improvement occurs, continue treatments until symptoms completely resolve. 3, 1

Refractory Cases (After 6-8 Weeks Without Improvement)

• Refer to a podiatric foot and ankle surgeon or sports medicine specialist. 3, 1
• Consider immobilization with a cast or fixed-ankle walker-type device in particularly acute or refractory cases. 3
• Additional options may include customized orthotic devices if not already tried. 3

Physical Examination Findings to Expect

On examination, you will typically find thickening of the tendon with tender, palpable nodules located proximal to the tendon insertion at the posterior heel. 3 Pay special attention to anatomic deformities during your assessment, as these biomechanical factors often contribute to development and persistence of the condition. 3, 1