What is the initial treatment for a patient diagnosed with right Achilles tendinitis?

Initial Treatment for Right Achilles Tendinitis

Begin with activity modification, heel lifts or orthoses, NSAIDs, stretching exercises, and cryotherapy as first-line treatment, while avoiding corticosteroid injections directly into or near the Achilles tendon. 1

First-Line Conservative Management

The American College of Foot and Ankle Surgeons provides clear initial treatment recommendations for Achilles tendinitis:

Activity Modification and Mechanical Interventions

• Decrease activity levels to prevent ongoing tendon damage while avoiding complete immobilization that leads to muscle atrophy 1
• Use open-backed shoes to reduce direct pressure on the posterior heel where the Achilles inserts 1
• Apply heel lifts or orthoses to reduce tensile stress on the tendon during weight-bearing 1
• Consider weight loss if indicated as an adjunctive measure 1

Exercise Therapy

• Initiate regular calf-muscle stretching exercises immediately as part of the treatment regimen 1
• Progress to eccentric exercise programs once acute symptoms improve, as this has proven beneficial specifically for Achilles tendinosis 1
• Tensile loading stimulates collagen production and guides proper alignment of newly formed collagen fibers 1

Pharmacologic Management

• NSAIDs are effective for pain relief and may provide anti-inflammatory benefit in acute cases 1, 2
• For acute tendonitis and bursitis, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (not exceeding 1250 mg on day one, then 1000 mg daily thereafter) 2
• Topical NSAIDs eliminate gastrointestinal hemorrhage risk while maintaining pain relief efficacy 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods for short-term pain relief 1
• Ice reduces tissue metabolism and may blunt the inflammatory response in acute cases 1

Critical Pitfall: Corticosteroid Injections

Local corticosteroid injections are NOT recommended for Achilles tendinitis. 1 This is a crucial distinction from other tendinopathies:

• Corticosteroids may inhibit healing and reduce tensile strength of the tendon 1
• They predispose to spontaneous rupture when injected into or near the tendon substance 1
• The role of inflammation in tendinopathies is unclear, making anti-inflammatory corticosteroids potentially counterproductive 1

Timeline and Escalation

6-8 Week Assessment Point

• If improvement occurs within 6-8 weeks, continue initial treatments until symptoms fully resolve 1
• If no improvement after 6-8 weeks, refer to a podiatric foot and ankle surgeon 1

Advanced Conservative Options (After Specialist Referral)

• Continue initial treatment measures 1
• Add immobilization cast or fixed-ankle walker-type device 1
• Consider customized orthotic devices for biomechanical correction 3

Distinguishing True Achilles Tendinopathy

Ensure the diagnosis is accurate before initiating treatment:

• True Achilles tendinopathy presents with posterior heel pain proximal to the insertion with palpable thickening and tender nodules 3
• Pain medial to the Achilles may represent flexor hallucis longus tendinopathy or tibialis posterior dysfunction, requiring different management 3
• Obtain plain radiographs as first-line imaging to identify calcific changes, spurring, or erosion at the Achilles insertion 1, 3

Prognosis

Approximately 80% of patients fully recover within 3-6 months with conservative outpatient treatment 3. The key is early initiation of the complete conservative regimen while strictly avoiding corticosteroid injections that could compromise tendon integrity.