What is the best treatment approach for a patient with an Achilles strain?

Achilles Strain Treatment

For an acute Achilles strain, begin immediate functional treatment with a lace-up or semi-rigid ankle brace combined with supervised eccentric exercise therapy starting within 48-72 hours, while avoiding immobilization beyond initial pain control. 1, 2

Initial Management (First 48 Hours)

• Apply ice for 10-minute periods through a wet towel to reduce pain and swelling in the acute phase, though recognize that cryotherapy alone has limited evidence for effectiveness 1, 3
• Use NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) for short-term pain and swelling reduction, which accelerates return to activity 1, 2
• Avoid complete immobilization as it leads to muscular atrophy, deconditioning, and delayed recovery without improving outcomes 1, 2
• Do not use corticosteroid injections into or around the Achilles tendon, as they may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 1

Functional Support (Critical Component)

• Apply a lace-up or semi-rigid ankle brace within 48 hours and continue for 4-6 weeks, as this approach is superior to immobilization and leads to faster return to sports (4.6 days sooner) and work (7.1 days sooner) 2
• Avoid elastic bandages or tape alone, as semi-rigid supports are more effective 2, 4
• Allow weight-bearing as tolerated immediately, avoiding only activities that cause pain 2

Exercise Therapy Protocol (Start Within 48-72 Hours)

Supervised eccentric exercise therapy has Level 1 evidence for effectiveness and should be the cornerstone of treatment 1, 2, 5

• Begin with range of motion exercises to prevent stiffness and maintain joint mobility 2, 4
• Progress to heavy-load eccentric calf muscle training, which shows very promising results for Achilles tendinosis and may reduce the need for surgical treatment 5
• Include proprioception training focusing on balance and coordination to prevent re-injury 2, 6
• Add progressive strengthening exercises as pain allows, emphasizing eccentric loading 1, 2
• Supervised exercises are superior to home-based programs alone—patients should work with a physical therapist rather than performing exercises independently 2

Specific Considerations for Insertional vs. Mid-Portion Achilles Pathology

• For insertional Achilles tendonitis (pain at the heel insertion with prominence medially/laterally): use open-backed shoes, heel lifts or orthoses, and avoid corticosteroid injections 1
• For mid-portion Achilles tendinosis: eccentric exercise therapy is particularly effective and should be emphasized 5
• Stretching exercises are widely accepted and generally thought to be helpful, though specific evidence is limited 1

Follow-Up and Monitoring

• Re-examine at 3-5 days post-injury when swelling has decreased to accurately assess ligament damage and severity 2, 4
• Continue functional support and exercises for 4-6 weeks minimum, with ongoing proprioception training incorporated into regular activities to prevent recurrence 2
• Monitor for signs of incomplete rehabilitation: persistent pain, workload limitations, or difficulty with sports-specific movements, as 5-46% of patients report long-term pain at 1-4 years despite initial treatment 2

Critical Pitfalls to Avoid

• Never immobilize beyond 3-5 days for initial pain control, as prolonged immobilization causes decreased range of motion, chronic pain, and joint instability without demonstrated benefits 1, 2
• Do not use the RICE protocol alone, as there is no evidence supporting its effectiveness as a standalone treatment 2, 6
• Avoid heat application in the acute phase, as it is not recommended for acute Achilles injuries 2, 4
• Do not skip delayed physical examination at 3-5 days, as initial examination cannot distinguish partial tears from complete ruptures 2

When to Consider Surgical Referral

• Reserve surgery for patients requiring quick recovery (professional athletes) or those whose complaints are not resolved by 2-3 months of conservative treatment 1
• Recognize that approximately 25% of patients may require surgical treatment when conservative measures fail, though eccentric exercise therapy may reduce this need 5
• Be aware that short-term surgical results are frequently good, but long-term follow-up shows possible deterioration, with prolonged calcaneal bone loss up to 1 year post-operatively 5