Treatment of Achilles Tendinopathy
Eccentric strengthening exercises combined with relative rest, ice, and activity modification are the cornerstone of treatment, achieving full recovery in approximately 80% of patients within 3-6 months. 1, 2
First-Line Conservative Treatment Algorithm
Immediate Interventions (Start All Simultaneously)
- Eccentric strengthening exercises are the gold standard and most effective conservative treatment, working by stimulating collagen production and guiding normal alignment of newly formed collagen fibers 1, 2, 3
- Activity modification: Reduce or eliminate activities causing pain while continuing activities that don't worsen symptoms 1, 2
- Gastrocnemius-soleus stretching exercises improve flexibility and reduce tension on the tendon 1, 2
- Cryotherapy (ice) provides short-term pain relief by reducing tissue metabolism and blunting inflammatory response 1, 2
Adjunctive Mechanical Interventions
- Footwear modifications including open-backed shoes reduce pressure on the insertion site 1, 2
- Heel lifts or orthoses unload the tendon and should be considered, particularly if anatomic deformities such as forefoot/heel varus, excessive pes planus, or foot pronation are present 1, 2
Pain Management Strategy
- NSAIDs (oral or topical) can be used for short-term pain relief but should not be recommended over other analgesics for long-term management 4, 1
- Topical NSAIDs have fewer systemic side effects than oral formulations and are preferred when NSAIDs are indicated 1
Critical Pitfall to Avoid
Avoid corticosteroid injections into the Achilles tendon as they may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 2
Treatment Duration and Progression
- Continue initial conservative treatment for 6-8 weeks before considering more aggressive interventions 1, 2
- If improvement occurs, continue treatments until symptoms completely resolve 1
- Consider referral to a specialist if no improvement occurs after 6-8 weeks of conservative treatment 2
When Conservative Treatment Fails
- Surgery is effective and should be reserved for patients who have failed conservative therapy, typically after 6 months of non-operative management 4, 5
- Additional options before surgery include shock wave therapy or nitric oxide patches if standard conservative measures fail 5
- Peritendinous injections or injections at the interface between the Achilles tendon and Kager's triangle could be considered if physical therapy fails 5
Key Clinical Considerations
The natural history involves gradually increasing load-related localized pain coinciding with increased activity 4. Early initiation of eccentric exercises and strict avoidance of pain-provoking activities are key to achieving the 80% success rate with conservative treatment 1. Pay special attention to biomechanical factors, as anatomic deformities often contribute to development and persistence of symptoms 2.