What is the appropriate initial management for heel tendinitis (Achilles tendinopathy)?

Initial Management of Heel Tendinitis (Achilles Tendinopathy)

Start immediately with eccentric strength training combined with activity modification, NSAIDs, cryotherapy, heel lifts, and daily calf stretching—this conservative approach resolves symptoms in approximately 80% of patients within 3-6 months. 1

First-Line Conservative Treatment (0-6 Weeks)

Patient-Directed Measures

• Perform eccentric strength training exercises daily—this is the most effective treatment option and should be initiated immediately 1
• Stretch calf muscles and Achilles tendon 3-5 times daily to improve flexibility and reduce pain 2
• Apply ice through a wet towel for 10-minute periods to reduce inflammation 2
• Use heel lifts or orthotic devices to reduce tension on the Achilles tendon 2
• Modify activities that worsen pain, but complete rest is not necessary 2
• Lose weight if overweight to reduce stress on the tendon 2

Footwear Modifications

• Wear open-backed shoes to reduce pressure on the inflamed area 3, 2
• Use over-the-counter heel cushions and arch supports 3
• Avoid flat shoes and barefoot walking 3

Medical Interventions

• Prescribe NSAIDs (such as naproxen) for pain relief and inflammation reduction 3, 4
• Consider padding and strapping of the foot for additional support 3
• Use shoe orthotics to correct overpronation or pes planus, addressing underlying anatomic misalignment 1

Critical Caveat: Corticosteroid Injections

• Do NOT inject corticosteroids near the Achilles tendon due to risk of tendon rupture 3, 4
• Local corticosteroid injections are specifically not recommended for insertional Achilles tendinitis 3

If No Improvement After 6-8 Weeks

• Refer to a podiatric foot and ankle surgeon 3, 2
• Continue all initial conservative treatments 3
• Add customized orthotic devices (though these show only moderate benefit at 7-12 weeks with no clear advantage over prefabricated orthotics) 4
• Consider night splinting 4
• Use immobilization with a walking boot or cast for more stubborn cases 2
• Consider advanced imaging with MRI to assess the condition more thoroughly 2

If No Improvement After 6 Months

• Surgical intervention is indicated after 6 months of failed conservative management 5, 6
• Consider shock wave therapy or nitric oxide patches if symptoms do not improve with physical therapy 5, 6
• Peritendinous injections at the interface between the Achilles tendon and Kager's triangle could be considered if physical therapy fails 6
• Surgical options include debridement of damaged tendon tissue, removal of prominent bone spurs, and resection of inflamed bursa 2

Distinguishing Insertional vs. Non-Insertional Tendinopathy

Insertional Achilles Tendinitis

• Pain and swelling at the posterior heel where the tendon attaches to the calcaneus 3
• Increased activity and pressure from shoes aggravate pain; relief occurs when walking barefoot 3
• Prominence may be palpable medially and laterally to the Achilles tendon insertion 3
• Radiographs often show spurring or erosion at the insertion 3

Non-Insertional (Mid-Portion) Tendinopathy

• Pain proximal to the tendon insertion with thickening and tender, palpable nodules on examination 1
• Typical tendon thickness of around 6mm compared to the unaffected side 2

Expected Outcomes

Most patients respond to conservative treatment within 6-8 weeks, with approximately 80% achieving full recovery within 3-6 months 1, 2. However, patients should understand that symptoms may recur with either conservative or surgical approaches 6.