Treatment for Pain Medial to the Achilles Tendon
Pain medial to the Achilles tendon most likely represents flexor hallucis longus (FHL) tendinopathy, tibialis posterior tendinopathy, or tarsal tunnel syndrome rather than Achilles tendinopathy itself, and requires targeted diagnosis before initiating treatment with eccentric exercises, orthotics for overpronation correction, and activity modification.
Diagnostic Clarification
The anatomic location is critical here. True Achilles tendinopathy presents with posterior heel pain proximal to the tendon insertion with thickening and tender, palpable nodules on examination 1. Pain that is specifically medial to the Achilles suggests alternative diagnoses:
- Tenderness at the medial calcaneal tubercle indicates plantar fasciitis 2
- Pain medial and deep to the Achilles may represent FHL tendinopathy or tibialis posterior dysfunction
- EMG and nerve conduction studies are required for confirmation of nerve entrapment, such as tarsal tunnel syndrome 2
Initial Diagnostic Workup
Radiographs are the first-line imaging modality for all heel pain to identify fractures, spurs, and Haglund deformity 2. If the diagnosis remains unclear after clinical examination and plain films, MRI or ultrasound may be used to evaluate soft tissue pathology 2.
Pay special attention to anatomic deformities such as forefoot and heel varus and excessive pes planus or foot pronation, which are often associated with medial ankle pain 1.
Treatment Algorithm (Assuming Medial Ankle Tendinopathy)
Initial 6-8 Weeks: Conservative Management
Start conservative treatment immediately with the following components 2:
- Eccentric strength training is the most effective treatment option for tendinopathy 3
- Stretching and deep friction massage of the gastrocnemius-soleus complex 3
- Shoe orthotics to correct overpronation or pes planus problems, addressing underlying anatomic misalignment 3
- Heel lift orthotics to unload the tendon for pain relief 3
- Relative rest of the affected area and icing 3
- NSAIDs for acute pain relief 3
- Activity modification, weight loss, and padding and strapping 2
6-8 Weeks: Reassessment
If no improvement after 6-8 weeks, refer to a podiatric foot and ankle surgeon while continuing initial treatments 3, 2. Consider immobilization cast or fixed-ankle walker device 3.
2-3 Months: Advanced Interventions
If still no improvement, consider customized orthotic devices, night splinting, limited corticosteroid injections (away from tendon insertion sites), and casting or fixed-ankle walker devices 2.
Critical Pitfalls to Avoid
Avoid local corticosteroid injections near the Achilles tendon insertion, as they are specifically not recommended and can increase rupture risk 3, 2. The condition involves chronic degenerative changes rather than acute inflammation and should be labeled as "tendinosis" or "tendinopathy" rather than "tendonitis" 3.
Do not rely on anti-inflammatory treatments alone, as the underlying pathology is degenerative rather than inflammatory 3. Approximately 80% of patients fully recover within three to six months with conservative outpatient treatment 3.
Pain-Monitored Activity Continuation
For athletic patients, continued tendon-loading activity such as running and jumping using a pain-monitoring model during treatment shows no negative effects and may be valuable 4. This approach gradually increases load on the tendon and calf muscle while monitoring pain levels 4.