Treatment of Achilles Tendinopathy
Eccentric strengthening exercises are the gold standard treatment for Achilles tendinopathy and should be initiated immediately along with relative rest, ice application, and activity modification, with approximately 80% of patients achieving full recovery within 3-6 months. 1
First-Line Conservative Treatment Protocol
The cornerstone of management consists of the following components, all initiated simultaneously 1:
- Eccentric strengthening exercises are the most effective conservative treatment, stimulating collagen production and guiding normal alignment of newly formed collagen fibers 1, 2
- Relative rest by reducing activity to decrease repetitive loading of the damaged tendon, while continuing activities that don't worsen symptoms 3, 1
- Cryotherapy with melting ice water through a wet towel for 10-minute periods provides short-term pain relief by reducing tissue metabolism and blunting inflammatory response 3, 1
- Gastrocnemius-soleus stretching exercises improve flexibility and reduce tension on the tendon 3, 1
- Deep friction massage of the gastrocnemius-soleus complex is helpful for symptom relief 3, 4
Biomechanical Correction
Address underlying anatomic abnormalities that perpetuate the condition 3:
- Shoe orthotics to correct overpronation or pes planus problems 3, 1
- Heel lift orthotics to unload the tendon for pain relief 3, 1
- Open-backed shoes to reduce pressure on the insertion site in insertional tendinopathy 1
Pain Management
For acute pain relief only, not long-term management 3, 1:
- NSAIDs (oral or topical) provide short-term pain relief but have no effect on long-term outcomes 3, 1
- Topical NSAIDs have fewer systemic side effects than oral formulations 3, 1
- NSAIDs should not be recommended over other analgesics for long-term use 1
Treatment Duration and Progression
Follow this algorithmic approach 1, 4:
- Continue the initial treatment regimen for 6-8 weeks before considering more aggressive interventions 1
- If improvement occurs, continue treatments until symptoms completely resolve 1
- If no improvement after 6-8 weeks, refer to a podiatric foot and ankle surgeon while continuing initial treatments, and consider immobilization with a cast or fixed-ankle walker device 4
- Surgery is reserved for carefully selected patients who have failed 3-6 months of conservative therapy 3
Critical Pitfalls to Avoid
Do not inject corticosteroids into or around the Achilles tendon - this is specifically contraindicated due to increased risk of tendon rupture 4. While corticosteroid injections may be more effective than oral NSAIDs for acute pain relief in other tendinopathies, they should be avoided in Achilles tendinopathy 3, 4.
Recognize that this is a degenerative condition (tendinosis), not an inflammatory one (tendonitis) - the pathology involves chronic degenerative changes rather than acute inflammation, so anti-inflammatory treatments alone are insufficient 3, 4.
Important Clinical Context
The natural history involves gradually increasing load-related localized pain coinciding with increased activity 3. Physical examination typically reveals thickening and tender, palpable nodules, with pain localized proximal to the tendon insertion 3. The etiology is multifactorial, including improper technique, anatomic misalignment, weakness, uneven training surfaces, and improperly fitted footwear 3.
Early initiation of eccentric exercises and strict avoidance of pain-provoking activities are key to achieving the 80% recovery rate within 3-6 months 1.