What is the best management approach for an elderly patient with achilles tendinosis?

Management of Achilles Tendinosis in the Elderly

The cornerstone of treatment for elderly patients with Achilles tendinosis is eccentric strengthening exercises combined with relative rest, ice, and activity modification, which achieves full recovery in approximately 80% of patients within 3-6 months. 1, 2, 3

Initial Conservative Management (First-Line Treatment)

Activity Modification

• Immediately reduce or eliminate activities that provoke pain (such as running, jumping, or prolonged walking) while continuing activities that don't worsen symptoms 2, 3
• This prevents ongoing tendon damage while maintaining general fitness 3

Eccentric Strengthening Exercises (Gold Standard)

• Eccentric exercises are the most effective conservative treatment, stimulating collagen production and guiding normal alignment of newly formed collagen fibers 2, 3
• These exercises should be initiated early and performed consistently 2
• For elderly patients, start with low-intensity exercises and progressively increase duration, as recommended for older adults 1

Stretching Program

• Perform gastrocnemius-soleus stretching exercises to improve flexibility and reduce tension on the tendon 2, 3
• Stretch for 5 minutes each morning and 10 minutes each evening, seven days per week, as outlined in exercise prescriptions for older adults 1
• Include hamstrings and Achilles tendon stretches using illustrated handouts 1

Cryotherapy

• Apply ice for short-term pain relief, which reduces tissue metabolism and blunts inflammatory response 2, 3

Footwear Modifications

• Use open-backed shoes to reduce pressure on the insertion site 2, 3
• Consider heel lifts or orthoses to unload the tendon 2, 3
• Address any anatomic deformities such as forefoot varus, heel varus, excessive pes planus, or foot pronation, as these biomechanical factors contribute to persistent symptoms 3

Pain Management

NSAIDs

• Use oral or topical NSAIDs for short-term pain relief only 2, 3
• Topical NSAIDs have fewer systemic side effects than oral formulations, which is particularly important in elderly patients with comorbidities 2
• NSAIDs should not be recommended over other analgesics for long-term management 3

Critical Pitfall to Avoid

• Never inject corticosteroids into the Achilles tendon, as they inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 3

Treatment Duration and Progression

• Continue the conservative treatment regimen for 6-8 weeks before considering more aggressive interventions 2, 3
• If improvement occurs, continue treatments until symptoms completely resolve 2
• Early initiation of eccentric exercises and strict avoidance of pain-provoking activities are key to achieving the 80% success rate 2

When to Consider Specialist Referral

• Refer to orthopedic surgery if no improvement occurs after 6-8 weeks of conservative treatment 3
• Surgical management (including tendon debridement, calcaneal exostosis ostectomy, and retrocalcaneal bursa excision) is reserved for patients who fail 3-6 months of conservative therapy 4, 5

Special Considerations for Elderly Patients

Exercise Prescription Modifications

• Consider chair-based exercises as a starting point for frail elderly patients 1
• Use the Borg Rate of Perceived Exertion (RPE) scale at 12-15 for resistance training and 13-14 for aerobic activities 1
• Start with repeated short bouts of low-intensity exercise every day, progressively increasing duration 1

Comorbidity Management

• Medical clearance and appropriate follow-up are important for older adults starting exercise programs 1
• Evaluate patients' physical activity levels during health maintenance examinations and adjust prescriptions periodically 1

Joint Mobility Assessment

• Assess for mobility deficits in the ankle and foot, as movement restrictions can contribute to persistent tendinopathy 6
• Joint-directed manual therapy or self-mobilization exercises may be beneficial when mobility deficits are identified 6