Treatment of a Large Lump on the Achilles Tendon
Start with conservative management including open-backed shoes, heel lifts, NSAIDs, activity modification, and physical therapy for 6-8 weeks before considering surgical referral. 1
Initial Diagnostic Considerations
The most likely diagnoses for a large lump on the Achilles tendon include:
- Insertional Achilles tendonitis with prominence medially and laterally to the tendon insertion 1
- Haglund's deformity with associated bursitis presenting as a posterolateral prominence 1
- Chronic Achilles tendinosis with thickening of the tendon substance 2, 3
Physical examination should identify whether tenderness is central to the tendon (insertional tendinitis), lateral to the tendon (Haglund's/bursitis), or diffuse along the tendon (tendinosis). 1 Radiographs often reveal spurring or erosion at the Achilles insertion in insertional problems and a prominent posterior superior calcaneus in Haglund's deformity. 1
First-Line Conservative Treatment (0-8 Weeks)
For insertional Achilles tendinitis:
- Open-backed shoes to eliminate pressure on the posterior heel 1
- Heel lifts or orthotic devices 1
- NSAIDs for pain control 1
- Decreased activity and stretching exercises 1
- Weight loss if indicated 1
- Avoid corticosteroid injections near the Achilles tendon insertion 1
- Consider immobilization in acute or refractory cases 1
For Haglund's deformity with bursitis:
- Open-backed shoes and accommodative padding 1
- Orthotic devices 1
- NSAIDs 1
- Corticosteroid injections into the bursa (carefully avoiding the Achilles tendon itself) 1
- Physical therapy 1
For chronic tendinosis:
- Heavy load eccentric calf muscle training shows very promising results and may reduce the need for surgery 3
- Rest combined with progressive strengthening exercises 3
- NSAIDs, though scientific evidence supporting their use is sparse 3
Second-Line Treatment (After 6-8 Weeks Without Improvement)
Refer to a podiatric foot and ankle surgeon when initial conservative measures fail. 1
Additional interventions at this stage include:
- Immobilization cast or fixed-ankle walker-type device 1
- Continued conservative measures 1
- Bursa injection for Haglund's deformity (avoiding the tendon) 1
- Extracorporeal shock wave therapy for tendinosis 4
Surgical Options (After 2-3 Months of Failed Conservative Treatment)
For Haglund's deformity:
- Resection of the prominent posterior superior calcaneus and inflamed bursa 1
- Calcaneal osteotomy may be required to correct alignment 1
For chronic tendinosis:
- Debridement of diseased tendon with direct repair 2
- Tendon transfer may be necessary to augment strength 2
- Surgical treatment is required in approximately 25% of patients who fail conservative management 3
Critical Pitfalls to Avoid
- Never inject corticosteroids directly into or near the Achilles tendon insertion as this significantly increases rupture risk 1
- Do not dismiss the possibility of rheumatological causes, particularly in insertional tendinopathies 4
- Recognize that symptoms relieved by walking barefoot and aggravated by shoe pressure strongly suggest insertional problems or Haglund's deformity 1
- Doppler ultrasound is the most important diagnostic tool and should be utilized when diagnosis is uncertain 4