How should insertional Achilles tendinopathy be treated?

Treatment of Insertional Achilles Tendinopathy

Begin with eccentric strengthening exercises combined with activity modification, ice, and footwear adjustments—this conservative approach achieves full recovery in approximately 80% of patients within 3-6 months. 1

First-Line Conservative Treatment Algorithm

Core Treatment Components

Eccentric strengthening exercises are the gold standard and most effective treatment, stimulating collagen production and guiding normal alignment of newly formed collagen fibers. 1, 2 This mechanical loading addresses the underlying degenerative pathology, unlike anti-inflammatory medications which only provide temporary symptom relief. 2, 3

• Activity modification: Reduce or eliminate activities causing pain at the heel insertion site (such as Bulgarian split squats or other eccentric loading exercises), while continuing activities that don't worsen symptoms. 1, 2
• Gastrocnemius-soleus stretching: Perform stretching exercises to improve flexibility and reduce tension on the tendon insertion. 1, 2
• Cryotherapy: Apply ice for short-term pain relief by reducing tissue metabolism and blunting inflammatory response. 1, 2

Footwear and Biomechanical Modifications

Open-backed shoes, heel lifts, or orthoses reduce pressure on the insertion site and unload the tendon. 1, 2 Pay special attention to correcting anatomic deformities such as forefoot and heel varus, excessive pes planus, or foot pronation, as these biomechanical factors contribute to persistent symptoms. 4, 2

Pain Management

NSAIDs (oral or topical) provide short-term pain relief but should not be recommended for long-term management. 1 Topical NSAIDs have fewer systemic side effects than oral formulations. 1

Critical Pitfall to Avoid

Never inject corticosteroids into or near the Achilles tendon insertion—this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture. 2, 3 Any short-term pain relief does not compensate for these significant risks. 2

Treatment Timeline and Progression

• Continue the conservative regimen for 6-8 weeks before considering more aggressive interventions. 1, 2
• If improvement occurs, continue treatments until symptoms completely resolve. 1, 2
• Early initiation of eccentric exercises and strict avoidance of pain-provoking activities are key to achieving the 80% success rate. 1

Second-Line Options (After 6-8 Weeks Without Improvement)

If conservative treatment fails after 6-8 weeks, extracorporeal shock wave therapy (ESWT) is the next best nonoperative option to reduce pain at the insertion site. 5 ESWT appears safe, noninvasive, and effective, though expensive. 4 Evidence shows ESWT produces significant improvement in VISA-A and VAS scores comparable to platelet-rich plasma injections. 6

Surgical Consideration

Surgery is reserved for patients who fail 3-6 months of exhaustive conservative treatment and includes débridement of insertional calcifications, intratendinous degenerative tissue, and any Haglund deformity. 7, 8 Approximately 20% of patients who don't respond to conservative measures may require surgical intervention. 1

Terminology Note

Label this condition as "tendinosis" or "tendinopathy" rather than "tendonitis", reflecting its chronic degenerative nature rather than acute inflammation. 2, 3 This distinction reinforces why anti-inflammatory medications offer only temporary relief without addressing the underlying pathology. 2, 3