What is the recommended initial management for calcaneal (Achilles) tendinitis?

Initial Management of Achilles (Heel) Tendinitis

For insertional Achilles tendinitis, begin with conservative management including open-backed shoes, heel lifts or orthoses, NSAIDs, activity reduction, stretching exercises, and weight loss if indicated, while strictly avoiding corticosteroid injections near the tendon. 1

First-Line Conservative Treatment (0-6 weeks)

The American College of Foot and Ankle Surgeons recommends a multimodal approach for initial management:

Mechanical Modifications

• Open-backed shoes to reduce direct pressure on the posterior heel 1
• Heel lifts or orthoses to decrease tension on the Achilles tendon insertion 1
• Avoid flat shoes and barefoot walking 1

Activity and Rehabilitation

• Decreased activity levels to allow tissue healing 1
• Regular calf-muscle stretching exercises as a cornerstone of treatment 1
• Eccentric strength training should be started immediately, as it is the most effective treatment option for tendinopathy 2
• Cryotherapy for pain and inflammation control 1

Pharmacologic Management

• NSAIDs for pain relief and anti-inflammatory effects 1

Weight Management

• Weight loss if indicated to reduce mechanical load 1

Critical Safety Warning

Local corticosteroid injections are NOT recommended for insertional Achilles tendinitis due to the risk of tendon rupture. 1 This is a crucial distinction from other heel pain conditions where steroid injections may be appropriate. Multiple sources emphasize avoiding the Achilles tendon when considering any injection therapy. 3

Immobilization for Refractory Cases

In particularly acute or refractory cases during the initial 6-8 week period, immobilization may be considered using a cast or fixed-ankle walker-type device. 1

Expected Timeline and Escalation

• Continue initial treatments if improvement occurs within 6-8 weeks until symptoms fully resolve 1
• Approximately 80% of patients fully recover within 3-6 months with conservative outpatient treatment 2
• If no improvement after 6-8 weeks, referral to a podiatric foot and ankle surgeon is appropriate 1

Advanced Conservative Options (After 6-8 Weeks Without Improvement)

When referred to a specialist, additional treatments may include:

• Immobilization cast or fixed-ankle walker-type device if not previously used 1
• Continued initial conservative measures 1

Common Pitfalls to Avoid

• Never inject corticosteroids into or near the Achilles tendon - this significantly increases rupture risk 1, 3
• Don't allow patients to continue high-impact activities or training errors that precipitated the condition 4
• Address underlying biomechanical abnormalities (foot hyperpronation, gastrocnemius-soleus inflexibility) early, as these perpetuate the problem 4
• Ensure proper footwear - poorly designed shoes are a frequent causative factor 4

Diagnostic Confirmation

• Radiographs should be obtained to identify spurring or erosion at the Achilles tendon insertion, which is commonly seen in insertional tendinitis 1
• Physical examination typically reveals prominence medially and laterally to the Achilles insertion with central or global tenderness 1