What is the recommended treatment for a patient with calcified Achilles tendinitis?

Treatment of Calcified Achilles Tendinitis

Begin with a 6-8 week trial of conservative management including eccentric strengthening exercises (the gold standard), activity modification, NSAIDs, heel lifts, and stretching, while strictly avoiding corticosteroid injections near the Achilles tendon due to rupture risk. 1, 2

Initial Conservative Treatment (First 6-8 Weeks)

Mechanical Interventions

• Wear open-backed shoes to reduce direct pressure on the calcified area 1, 2
• Use heel lifts or orthotic devices to reduce tension on the Achilles tendon 1
• Apply over-the-counter heel cushions and arch supports to unload the tendon 2
• Avoid flat shoes and barefoot walking 2

Exercise-Based Therapy (Most Important)

• Perform eccentric strengthening exercises - this is the gold standard and most effective conservative treatment for Achilles tendinopathy, as it stimulates collagen production and guides normal alignment of newly formed fibers 2
• Implement regular calf-muscle stretching exercises to improve flexibility and reduce tendon tension 1, 2
• Modify activities that cause pain while continuing pain-free activities to prevent ongoing damage 1, 2

Pharmacologic Management

• Use NSAIDs (oral or topical) for pain management and potential anti-inflammatory effects, with topical formulations having fewer systemic side effects 1, 2
• Apply cryotherapy (ice) for short-term pain relief to reduce tissue metabolism and blunt inflammatory response 1, 2

Lifestyle Modifications

• Recommend weight loss if the patient is overweight 1, 2

Critical Safety Warning

Never inject corticosteroids into or around the Achilles tendon - this may inhibit healing, reduce tensile strength of the tissue, and predispose to spontaneous tendon rupture 1, 2. This is particularly important in calcified tendinitis where the tendon is already compromised.

Secondary Interventions (After 6-8 Weeks Without Improvement)

• Refer to a podiatric foot and ankle surgeon or specialist 1, 2
• Consider immobilization with a cast or fixed-ankle walker-type device for particularly acute or refractory cases 1, 2
• Add customized orthotic devices to correct biomechanical issues such as forefoot and heel varus, excessive pes planus, or foot pronation 2
• Implement night splinting to maintain tendon length 2
• Continue all initial conservative measures while adding these interventions 2

Advanced Treatment (After 3-6 Months Without Improvement)

• Consider extracorporeal shock wave therapy for recalcitrant cases 2
• Evaluate for surgical intervention including debridement of diseased tendon with direct repair, or tendon transfer if necessary to augment Achilles tendon strength 2, 3

Common Pitfalls to Avoid

• Do not use corticosteroid injections - this cannot be emphasized enough given the high rupture risk 1, 2
• Do not discontinue treatment prematurely - allow the full 6-8 weeks before escalating care 1
• Do not overlook biomechanical abnormalities - address underlying anatomic deformities that contribute to ongoing tendinopathy 2
• Do not rely solely on passive modalities - eccentric exercises are essential and superior to passive treatments like massage or ultrasound 2