What is the best treatment approach for a patient presenting with swelling and tendonitis of the Achilles tendon?

Treatment of Achilles Tendon Swelling and Tendonitis

Begin with eccentric strengthening exercises combined with calf-muscle stretching, heel lifts or orthotics, activity modification, and NSAIDs for acute pain relief as your first-line treatment approach for 6-8 weeks. 1

Critical Terminology Clarification

The condition should be labeled as "tendinosis" or "tendinopathy" rather than "tendonitis" because approximately 80% of cases involve chronic degenerative changes rather than acute inflammation. 1 This distinction is crucial because it explains why anti-inflammatory treatments alone provide only temporary relief without addressing the underlying pathology. 1

Initial Conservative Treatment (First 6-8 Weeks)

Core interventions include:

• Eccentric strength training - This is the most effective and popular treatment option with strong evidence supporting its use. 1
• Regular calf-muscle stretching of the gastrocnemius-soleus complex. 1
• Shoe orthotics to correct overpronation or pes planus problems, addressing underlying anatomic misalignment. 1
• Heel lift orthotics to unload the tendon for pain relief. 1
• Relative rest of the affected area combined with cryotherapy (icing). 1
• NSAIDs for acute pain management - Naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required, with initial total daily dose not exceeding 1250 mg. 2
• Deep friction massage of the gastrocnemius-soleus complex. 1
• Activity limitation and avoidance of flat shoes and barefoot walking. 3
• Weight loss if indicated. 3

Specific Considerations for Insertional Achilles Tendonitis

If the patient has insertional tendonitis (pain and swelling at the tendon insertion with posterior heel prominence):

• Open-backed shoes to reduce pressure on the area. 3, 4
• Heel lifts or orthoses are particularly important. 3, 4
• Pain typically worsens with shoe pressure and improves when walking barefoot. 3
• Radiographs often show spurring or erosion at the Achilles tendon insertion. 3

Critical Pitfall: Corticosteroid Injections

Local corticosteroid injections into or around the Achilles tendon are specifically NOT recommended due to significant risk of tendon weakening and potential rupture. 3, 1, 4 This is one of the most important clinical pitfalls to avoid, as corticosteroids may inhibit healing and reduce tensile strength of the tissue. 4

If No Improvement After 6-8 Weeks

Refer to a podiatric foot and ankle surgeon while continuing initial treatments. 3, 1 Additional interventions at this stage include:

• Immobilization cast or fixed-ankle walker-type device during activity. 3, 1
• Customized orthotic device if not already implemented. 3
• Night splinting may be considered. 3

Expected Recovery Timeline

Approximately 80% of patients fully recover within 3-6 months with conservative outpatient treatment. 1 The morning and evening doses of treatment exercises do not have to be equal in intensity, and more frequent interventions than twice daily are generally not necessary. 2

Diagnostic Imaging When Needed

• Plain radiographs may show calcific tendinosis, spurring, or soft tissue swelling. 4
• Ultrasound can demonstrate tendon thickening and heterogeneous echogenicity. 4
• MRI is useful for showing partial tendon tears, tendon thickening, bursitis, and chronic degenerative changes. 4

Common Clinical Pitfalls to Avoid

• Do not rely on anti-inflammatory treatments alone - the underlying pathology is degenerative, not inflammatory. 1
• Avoid therapeutic ultrasound as primary treatment when evidence-based options (eccentric exercises, stretching, orthotics) have proven efficacy. 1
• Do not pursue long-term systemic corticosteroids due to rupture risk. 1
• Address causative factors such as improper training techniques, biomechanical abnormalities (particularly overpronation), and gastrocnemius/soleus insufficiency to prevent recurrence. 5