Initial Treatment for Achilles Tendinitis
Begin with conservative management including activity modification, NSAIDs, heel lifts, stretching exercises, and physical therapy, continuing this approach for 6-8 weeks before considering advanced interventions. 1
Immediate First-Line Interventions
Activity Modification and Mechanical Support
- Reduce or eliminate aggravating activities while maintaining some level of movement to prevent complete immobilization 1, 2
- Apply heel lifts or orthotic devices to reduce tension on the Achilles tendon during daily activities 1, 2
- For insertional Achilles tendinitis specifically, use open-backed shoes to eliminate direct pressure on the posterior heel 1
Pain and Inflammation Control
- NSAIDs (topical or oral) for short-term pain relief, with topical formulations having fewer systemic side effects 3, 4
- For naproxen specifically: start with 500 mg followed by 500 mg every 12 hours or 250 mg every 6-8 hours, not exceeding 1250 mg on day one and 1000 mg daily thereafter 4
- Cryotherapy applied through wet towel for 10-minute periods provides acute pain relief 3
Rehabilitation Program
- Gastrocnemius-soleus stretching exercises to address muscle inflexibility, a common predisposing factor 2, 5
- Eccentric strengthening exercises should be implemented as they may reverse degenerative changes in the tendon 3
- Physical therapy to correct biomechanical abnormalities such as foot hyperpronation or muscle weakness 2, 6
Critical Pitfalls to Avoid
Never inject corticosteroids into or near the Achilles tendon - this is explicitly contraindicated for insertional Achilles tendinitis and carries significant risk of tendon rupture 1. The guideline specifically states "local injections of corticosteroids are not recommended" for insertional disease 1.
Treatment Timeline and Escalation
6-8 Week Checkpoint
- If improvement occurs, continue initial treatments until symptoms fully resolve 1
- If no improvement after 6-8 weeks, refer to a podiatric foot and ankle surgeon for advanced management 1
Advanced Conservative Options (After Specialist Referral)
- Customized orthotic devices 1
- Night splinting to maintain tendon length 1
- Cast immobilization or fixed-ankle walker-type device for refractory cases 1
When to Consider Surgery
- Surgery is recommended only for chronic symptoms unresponsive to conservative therapy in patients who wish to continue athletic activities 2
- Surgical options include debridement of diseased tendon with direct repair, and possibly tendon transfer for augmentation 6
Important Considerations
The pathology of Achilles tendinopathy is not inflammatory but rather a failed healing response, which explains why treatment focuses on rehabilitation and mechanical unloading rather than aggressive anti-inflammatory measures 7. Training errors (excessive mileage, hill running, hard surfaces, poor footwear) and biomechanical abnormalities must be identified and corrected to prevent recurrence 2.
Expected recovery timeline: most patients with tendon injuries fully recover within 3-6 months with appropriate treatment 3, though this requires patient compliance with activity modification and rehabilitation protocols.