What is the initial treatment for Achilles tendinopathy or insertional tendinitis?

Initial Treatment for Achilles Tendinopathy and Insertional Tendinitis

Begin with eccentric strengthening exercises combined with activity modification, stretching, ice therapy, and footwear adjustments—this conservative approach achieves full recovery in approximately 80% of patients within 3-6 months and represents the gold standard treatment. 1, 2

First-Line Conservative Treatment Algorithm

Core Treatment Components (Start All Simultaneously)

• Eccentric strengthening exercises are the most effective conservative treatment, stimulating collagen production and guiding normal alignment of newly formed collagen fibers 3, 1, 2, 4
• Activity modification: Reduce or eliminate activities causing pain while continuing activities that don't worsen symptoms 1, 2
• Gastrocnemius-soleus stretching exercises improve flexibility and reduce tension on the tendon 3, 1, 2
• Cryotherapy (ice) provides short-term pain relief by reducing tissue metabolism and blunting inflammatory response 1, 2

Footwear and Mechanical Modifications

• Open-backed shoes reduce pressure on the insertion site, particularly important since patients typically experience relief when walking barefoot 3, 1
• Heel lifts or orthoses unload the tendon and can correct biomechanical abnormalities like overpronation or pes planus 3, 1, 2
• Address anatomic deformities such as forefoot and heel varus, excessive pes planus, or foot pronation, as these biomechanical factors contribute to persistent symptoms 3, 2

Pain Management

• NSAIDs (oral or topical) for short-term pain relief, with topical formulations having fewer systemic side effects 3, 1, 2
• NSAIDs should not be recommended over other analgesics for long-term management 1

Critical Pitfall to Avoid

Do NOT inject corticosteroids into or near the Achilles tendon—this may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture. 3, 2

Treatment Timeline and Progression

• Continue the initial conservative regimen for 6-8 weeks before considering more aggressive interventions 3, 1, 2
• If improvement occurs, continue treatments until symptoms completely resolve 3, 1
• If no improvement after 6-8 weeks, refer to a podiatric foot and ankle surgeon 3, 2

Second-Line Options (After 6-8 Weeks Without Improvement)

• Immobilization with a cast or fixed-ankle walker-type device for particularly acute or refractory cases 3
• Extracorporeal shock wave therapy has shown 60% pain reduction with 80% patient satisfaction and represents the next best option when exercise fails 5, 6
• Night splinting may be added to the treatment regimen 3

Evidence Nuances

The combination of eccentric exercise plus soft tissue therapy ranked highest for short-term pain control in network meta-analysis (SUCRA value 84.8), though overall confidence in the evidence remains very low 4. Research on platelet-rich plasma (PRP) shows mixed results—one study demonstrated effectiveness comparable to shock wave therapy 7, while another review noted insufficient evidence for routine recommendation 5. Given the strong guideline support for eccentric exercises and the uncertain benefit-to-risk ratio of injections, prioritize exercise-based rehabilitation over injection therapies 1, 2, 6.

Expected Outcomes

With appropriate conservative treatment initiated early and strict avoidance of pain-provoking activities, approximately 80% of patients achieve full recovery within 3-6 months 1, 2. Eccentric exercises can achieve a 40% reduction in pain when integrated as a core component of physiotherapy 5.