What is the appropriate treatment for a patient with Achilles tendonitis?

Treatment of Achilles Tendonitis

Eccentric strengthening exercises are the first-line treatment for Achilles tendinopathy, combined with relative rest, ice application, and NSAIDs for acute pain relief. 1

Terminology and Pathophysiology

• 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 critical because anti-inflammatory treatments alone provide only temporary pain relief without addressing the underlying degenerative pathology. 1

Initial Treatment Protocol (First 6-8 Weeks)

Start with the following combination:

• Eccentric strengthening exercises are the most effective treatment with the strongest evidence supporting their use. 1 Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers. 2

• Stretching and deep friction massage of the gastrocnemius-soleus complex should be performed regularly. 1

• Relative rest that allows patients to continue activities that do not worsen pain, while avoiding complete immobilization to prevent muscular atrophy. 2, 1

• Cryotherapy through a wet towel for 10-minute periods provides short-term pain relief and reduces swelling. 2

• NSAIDs for acute pain relief: Naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (not exceeding 1250 mg on day one, then 1000 mg daily thereafter). 3 Topical NSAIDs eliminate gastrointestinal hemorrhage risk while providing pain relief. 2

• 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

If No Improvement After 6-8 Weeks

• Refer to a podiatric foot and ankle surgeon while continuing initial treatments. 1
• Consider immobilization with a cast or fixed-ankle walker device. 1

Critical Pitfalls to Avoid

Never inject corticosteroids into or around the Achilles tendon. 1, 4 This is specifically contraindicated because:

• Local corticosteroid injections inhibit healing and reduce tensile strength of the tissue. 2
• They significantly increase the risk of spontaneous tendon rupture. 2, 1, 4
• Long-term systemic corticosteroids and peritendinous injections are advised against by multiple guidelines. 1

Expected Outcomes

• Approximately 80% of patients fully recover within 3-6 months with conservative outpatient treatment. 1, 4
• Onset of pain relief from NSAIDs can begin within 1 hour. 3

Imaging Considerations

• Plain radiography may show calcific tendinosus, calcaneal avulsion fracture, and soft-tissue swelling. 2
• Ultrasonography demonstrates tendon thickening and heterogeneous echogenicity. 2
• MRI is useful for showing partial tendon tears, tendon thickening, bursitis, and chronic degenerative changes. 2