What is the treatment for Achilles tendonitis?

Treatment for Achilles Tendonitis

Begin with 6-8 weeks of conservative treatment including eccentric strengthening exercises, calf stretching, NSAIDs, heel lifts/orthotics, activity modification, and open-backed shoes; if no improvement, refer to a specialist and consider immobilization. 1, 2

Initial Conservative Management (First 6-8 Weeks)

Core Treatment Components

• Eccentric strengthening exercises are the most effective treatment with the strongest evidence and should be the foundation of therapy 2
• Calf muscle stretching of the gastrocnemius-soleus complex is essential and should be performed regularly 1, 2
• NSAIDs (such as naproxen 500 mg twice daily) provide pain relief and potential anti-inflammatory effects, though the condition is primarily degenerative rather than inflammatory 1, 3
• Heel lifts or orthotic devices reduce tension on the Achilles tendon and can correct underlying biomechanical issues like overpronation or pes planus 1, 2
• Open-backed shoes reduce pressure on the affected area 1
• Activity modification and relative rest prevent ongoing damage while allowing healing 1, 2
• Cryotherapy (ice) provides short-term pain relief 1

Important Terminology Note

• The condition should be labeled as "tendinosis" or "tendinopathy" rather than "tendonitis" because approximately 80% of cases involve chronic degenerative changes with disorganized collagen and abnormal neovascularization rather than acute inflammation 2, 4

Critical Safety Warning

• Never inject corticosteroids into or around the Achilles tendon due to significant risk of tendon weakening and potential rupture 1, 2
• Corticosteroids inhibit healing and reduce tensile strength of the tissue 1

Treatment Algorithm for Non-Responsive Cases

After 6-8 Weeks Without Improvement

• Refer to a podiatric foot and ankle surgeon or orthopedic specialist 2
• Continue initial conservative treatments (eccentric exercises, stretching, orthotics) 2
• Consider immobilization with a cast or fixed-ankle walker device 2

After 3-6 Months Without Improvement

• Surgical management becomes indicated for insertional Achilles tendinosis after conservative therapy has failed 4, 5
• Surgical options include Achilles tendon debridement, calcaneal exostectomy, retrocalcaneal bursa excision, and potential tendon reattachment using suture bridge techniques 4, 5

Diagnostic Imaging Considerations

• Plain radiography may show calcific tendinosis, calcaneal avulsion fracture, or soft tissue swelling 1
• Ultrasound demonstrates tendon thickening and heterogeneous echogenicity 1
• MRI is useful for showing partial tendon tears, tendon thickening, bursitis, and chronic degenerative changes 1

Expected Outcomes

• Approximately 80% of patients fully recover within 3-6 months with conservative outpatient treatment 2
• Pain relief from NSAIDs can begin within 1 hour for naproxen tablets 3

Common Pitfalls to Avoid

• Do not rely on anti-inflammatory treatments alone since the underlying pathology is degenerative, not inflammatory 2
• Do not pursue therapeutic ultrasound as primary treatment when evidence-based options (eccentric exercises, stretching, orthotics) have proven superior efficacy 2
• Do not overlook biomechanical abnormalities such as gastrocnemius-soleus weakness, inflexibility, or hindfoot malalignment with hyperpronation that must be corrected to prevent recurrence 6
• Do not ignore training errors including excessive mileage, training intensity, hill running, hard/uneven surfaces, or poorly designed shoes 6

Weight Management

• Weight loss is recommended if the patient is overweight to reduce mechanical stress on the tendon 1