What is the treatment for Achilles tendonitis, particularly in patients with underlying medical conditions such as diabetes or rheumatoid arthritis?

Treatment of Achilles Tendonitis

Eccentric strengthening exercises are the gold standard first-line treatment for Achilles tendinopathy, combined with activity modification, calf stretching, orthotics/heel lifts, and NSAIDs for acute pain relief—while avoiding corticosteroid injections near the Achilles tendon due to rupture risk. 1, 2

Critical Terminology and Pathophysiology

The condition should be labeled as "tendinosis" or "tendinopathy" rather than "tendonitis" because most cases involve chronic degenerative changes rather than acute inflammation. 1 This distinction is crucial because it explains why anti-inflammatory treatments provide only temporary relief without addressing the underlying pathology. 1 Approximately 80% of patients fully recover within 3-6 months with conservative outpatient treatment. 1

Initial Treatment Protocol (First 6-8 Weeks)

Core Interventions

• Eccentric strengthening exercises: Most effective conservative treatment that stimulates collagen production and guides normal alignment of newly formed fibers. 1, 2, 3

• Calf-muscle stretching: Regular stretching of the gastrocnemius-soleus complex improves flexibility and reduces tendon tension. 1, 2

• Activity modification: Reduce activities causing pain while continuing pain-free activities to prevent ongoing damage. 2

• Orthotics: Use shoe orthotics to correct overpronation or pes planus problems, and heel lift orthotics to unload the tendon for pain relief. 1, 2

• Ice application: Apply cryotherapy for short-term pain relief to reduce tissue metabolism and blunt inflammatory response. 1, 2

• NSAIDs: Use oral or topical NSAIDs for pain relief (topical formulations have fewer systemic side effects), though these provide only symptomatic relief without addressing degenerative pathology. 1, 2

Additional Supportive Measures

• Avoid flat shoes and barefoot walking; use open-backed shoes to reduce pressure on the affected area. 2
• Consider weight loss if indicated. 2
• Use over-the-counter heel cushions and arch supports. 2

Critical Contraindications

Absolutely avoid corticosteroid injections into or around the Achilles tendon—they inhibit healing, reduce tensile strength, and predispose to spontaneous rupture. 2 This warning is particularly important for insertional Achilles tendinitis where local corticosteroid injections are specifically contraindicated. 1, 2 The American College of Rheumatology explicitly recommends against peri-tendon injections of the Achilles tendon due to rupture risk. 4

Secondary Interventions (After 6-8 Weeks Without Improvement)

If no improvement occurs after the initial 6-8 week treatment period, escalate care as follows: 1, 2

• Refer to podiatric foot and ankle surgeon while continuing initial treatment measures. 1, 2

• Add customized orthotic devices to correct biomechanical issues, particularly addressing forefoot and heel varus, excessive pes planus, or foot pronation. 2

• Night splinting to maintain tendon length. 2

• Immobilization with cast or fixed-ankle walker-type device for particularly acute or refractory cases. 2

• Physical therapy: Land-based interventions are preferred over aquatic therapy, with active supervised exercise preferred over passive modalities (massage, ultrasound, heat). 4, 1

Advanced Treatment for Refractory Cases (After 2-3 Months)

For cases failing conservative treatment after 2-3 months: 2

• Extracorporeal shock wave therapy: Has the highest evidence-based effectiveness for refractory cases after eccentric exercise. 3, 5

• Cast immobilization if not previously used. 2

• Surgical intervention as a last resort. 2

Special Considerations for Patients with Underlying Conditions

Diabetes and Rheumatoid Arthritis Patients

While the evidence does not specifically address modified protocols for diabetes or rheumatoid arthritis, these patients require heightened caution: 4

• Avoid systemic glucocorticoids for long-term treatment, though short-term use with rapid tapering may be considered in limited circumstances (polyarticular flares, pregnancy, inflammatory bowel disease flares). 4

• Monitor for tendon integrity more closely, as these conditions may compromise healing capacity. 4

• Emphasize biomechanical correction through orthotics, as anatomic deformities often contribute to persistent tendinopathy. 2

Common Pitfalls to Avoid

• Do not rely on anti-inflammatory treatments alone, as the underlying pathology is degenerative rather than inflammatory. 1

• Do not pursue therapeutic ultrasound as primary treatment when evidence-based options (eccentric exercises, stretching, orthotics) have proven efficacy. 1

• Do not use local corticosteroid injections for insertional Achilles tendinopathy, as they increase rupture risk. 1, 2

• Do not ignore biomechanical factors such as forefoot and heel varus, excessive pes planus, or foot pronation, as these contribute to development and persistence of symptoms. 2

Monitoring and Follow-up

• Regularly assess pain levels, range of motion, and functional capacity. 2
• Continue treatments until symptoms resolve if improvement occurs. 2
• Reassess at 6-8 weeks to determine need for escalation of care. 1, 2