From the Guidelines
Achilles tendinopathy is best managed through a combination of clinical examination, imaging, and conservative approaches, including relative rest, activity modification, and eccentric calf strengthening exercises, with surgery reserved for cases resistant to conservative treatment after 3-6 months. Diagnosis typically involves patient history of posterior heel pain that worsens with activity, tenderness on palpation of the Achilles tendon, and possible thickening of the tendon. Ultrasound or MRI can confirm the diagnosis by showing tendon thickening, hypoechoic areas, or neovascularization 1. Management should begin with conservative approaches including relative rest, activity modification, and eccentric calf strengthening exercises performed twice daily with 3 sets of 15 repetitions for at least 12 weeks. These exercises involve standing on a step and slowly lowering the heel below the step level while the affected leg bears weight.
Some key points to consider in the management of Achilles tendinopathy include:
- Pain medication such as NSAIDs (ibuprofen 400-600mg three times daily or naproxen 500mg twice daily for 1-2 weeks) can help manage symptoms but doesn't accelerate healing 1
- Supportive footwear with a slight heel lift (0.5-1cm) can reduce tendon strain 1
- Physical therapy modalities like extracorporeal shock wave therapy may benefit some patients
- For cases resistant to conservative treatment after 3-6 months, more invasive options include platelet-rich plasma injections, high-volume injections, or surgery 1
- Corticosteroid injections directly into the tendon should be avoided due to increased risk of tendon rupture
- Recovery typically takes 3-6 months, and gradual return to activity is essential to prevent recurrence
- The condition results from repetitive microtrauma exceeding the tendon's repair capacity, leading to degenerative changes rather than inflammation in chronic cases 1.
It's essential to note that surgery is an effective treatment option in carefully selected patients, and referral to an orthopedic surgeon for surgical evaluation may be warranted if pain persists despite a well-managed conservative treatment trial 1.
From the Research
Diagnostic Approaches for Achilles Tendinopathy
- The diagnosis of Achilles tendinopathy is primarily clinical, with patient self-reports of morning stiffness and/or pain in the tendon area, pain on palpation of the tendon, and detection of Achilles tendon thickening being the most useful indicators 2.
- Imaging modalities such as ultrasound and magnetic resonance imaging (MRI) can aid in diagnosis, with MRI providing slightly better sensitivity and specificity 2.
- At least 10 simple clinical tests are available for the diagnosis of Achilles tendinopathy, but the most accurate and reproducible methods are based on patient symptoms and physical examination 2.
Management Options for Achilles Tendinopathy
- Conservative management options include eccentric (lengthening) exercises, extracorporeal shockwave therapy (ESWT), topical nitroglycerin, low-level laser therapy, orthoses, splints, or injections (e.g., corticosteroids, hyperosmolar dextrose, polidocanol, platelet-rich plasma) 3.
- Eccentric exercise and shock wave therapies are treatments with the highest evidence-based effectiveness 2.
- Nonsteroidal anti-inflammatory medication and corticosteroid injections may provide short-term relief but do not appear effective in the longer term 2.
- Surgical intervention is required after six months of conservative treatment, with options including open, percutaneous, or endoscopic methods 3, and procedures aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation 4.
Prevention Strategies
- Preventive strategies focusing on proper training techniques, load management, and addressing modifiable risk factors play a critical role in reducing the incidence of Achilles tendinopathy 5.
- Balance training (e.g., for soccer players) and shock-absorbing insoles (e.g., for military recruits) may be effective in specific populations 2.
- Ultrasound scans might be useful in predicting future Achilles tendinopathy occurrences 2.