What is the treatment for Achilles tendinitis?

From the Guidelines

Achilles tendinitis is best treated through a combination of rest, physical therapy, and pain management, with a focus on eccentric strengthening exercises and supportive footwear, as recommended by the most recent and highest quality study 1. The initial treatment involves reducing activities that cause pain, particularly high-impact exercises like running and jumping, while applying ice to the affected area for 15-20 minutes several times daily to reduce inflammation.

• Over-the-counter pain medications such as ibuprofen (400-800mg three times daily) or naproxen (220-440mg twice daily) can help manage pain and inflammation, but should be used for no more than 10-14 days without medical supervision, as noted in 1 and 1.
• Physical therapy is crucial for recovery, focusing on eccentric strengthening exercises where the tendon is loaded while lengthening, such as heel drops performed 3 sets of 15 repetitions twice daily for 12 weeks, as supported by 1 and 1.
• Stretching the calf muscles and Achilles tendon should be done gently, holding each stretch for 30 seconds and repeating 3-5 times daily.
• Supportive footwear with proper cushioning and possibly heel lifts can reduce strain on the tendon, as suggested by 1 and 1. For persistent cases, a healthcare provider might recommend night splints, custom orthotics, or in severe cases, corticosteroid injections, platelet-rich plasma therapy, or even surgery, with Achilles tendon lengthening being considered in combination with an offloading device to promote and sustain healing of the ulcer, as recommended in 1. Recovery typically takes weeks to months, and gradually returning to activities only when pain-free helps prevent recurrence by allowing the tendon to heal properly and regain strength.

From the FDA Drug Label

Management of Pain, Primary Dysmenorrhea, and Acute Tendonitis and Bursitis Because the sodium salt of naproxen is more rapidly absorbed, naproxen sodium is recommended for the management of acute painful conditions when prompt onset of pain relief is desired. Naproxen may also be used The recommended starting dose of naproxen is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required.

Treatment of Achilles Tendinitis:

• The recommended starting dose of naproxen is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required.
• Naproxen sodium is recommended for the management of acute painful conditions when prompt onset of pain relief is desired.
• The initial total daily dose should not exceed 1250 mg of naproxen, and thereafter, the total daily dose should not exceed 1000 mg of naproxen 2.

From the Research

Treatment Options for Achilles Tendinitis

• Conservative treatments that have been researched include:
  • Nonsteroidal anti-inflammatory medication
  • Eccentric exercise
  • Stretching
  • Orthotics
  • Bracing
  • Glyceryl trinitrate patches
  • Injection therapies (corticosteroids, hyaluronic acid, platelet-rich plasma injections)
  • Shock wave therapy
  • Low-level laser therapy 3
• Nonsteroidal anti-inflammatory medication and corticosteroid injections may provide short-term relief but do not appear effective in the longer term 3
• Eccentric exercise and shock wave therapies are treatments with the highest evidence-based effectiveness 3

Pharmacological Approaches

• Many pharmacological treatments have been proposed for the management of tendinopathy, with no agreement regarding the overall best option available both for Achilles and patellar tendinopathy 4
• No univocal evidence exists regarding the best non-operative management, which includes non-steroidal anti-inflammatory drugs, platelet-rich plasma, high volume image-guided injections, hyaluronic acid, and prolotherapy, for tendinopathy 4

Effectiveness of Anti-Inflammatory Treatment

• Clinical symptoms in early tendinopathy improved with physical rehabilitation, but this improvement was not augmented with the addition of NSAID treatment 5
• Short-term ibuprofen treatment has no effect on gene expression in human chronic tendinopathic tendon or leads to any clear changes in tendon pain or function 6

Rehabilitation and Prevention

• Achilles tendinopathy has a good clinical prognosis with most patients improving with activity modification and rehabilitation, with a focus on progressive tendon-loading 7
• Recalcitrant cases may require adjuvant treatment with procedures (e.g., injections, shockwave therapy) and rarely surgical intervention 7