What is the appropriate first-line treatment for an adult with acute Achilles tendonitis?

Treatment for Acute Achilles Tendonitis

Important Clarification

The provided evidence primarily addresses Achilles tendon rupture rather than Achilles tendonitis (tendinopathy). These are distinct conditions requiring different management approaches. I will address both based on the available evidence.

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First-Line Treatment for Acute Achilles Tendonitis (Tendinopathy)

For acute Achilles tendonitis, initiate conservative management with activity modification, eccentric strengthening exercises (Alfredson protocol), and avoid corticosteroid injections near the tendon. 1, 2

Conservative Management Protocol

• Activity modification is the cornerstone: reduce or eliminate aggravating activities, particularly running and jumping, while maintaining non-impact cardiovascular fitness 1, 2

• Eccentric exercise program (Alfredson protocol) should be started early, consisting of:

  • Two exercises daily: one with knee straight (targets gastrocnemius), one with knee bent (targets soleus) 3
  • Three sets of 15 repetitions, twice daily, seven days per week for 12 weeks 3
  • Progressive loading as tolerated 3

• Heel lifts or orthoses can reduce strain on the Achilles insertion by decreasing the dorsiflexion angle 1

• Open-backed shoes reduce direct pressure on the inflamed area, particularly for insertional tendonitis 1

• NSAIDs may provide symptomatic relief but do not enhance recovery when added to physical rehabilitation—a 2021 randomized controlled trial found no additive clinical benefit of 7-day naproxen treatment compared to placebo when combined with rehabilitation 4

• Physical therapy with supervised rehabilitation improves outcomes and ensures proper exercise progression 2

Critical Contraindications

• Avoid corticosteroid injections into or near the Achilles tendon—the only rigorous randomized controlled trial showed no benefit over placebo, and animal studies demonstrate temporary tendon weakening for several weeks post-injection with potential rupture risk 5

• Local corticosteroid injections are not recommended for insertional Achilles tendonitis 1

Treatment Timeline and Escalation

• Initial conservative treatment period: 6-8 weeks 1

• If improvement occurs: continue treatments until symptoms resolve 1

• If no improvement after 6-8 weeks: refer to a podiatric foot and ankle surgeon or orthopedic specialist for consideration of:

  • Customized orthotic devices 1
  • Night splinting 1
  • Cast immobilization or fixed-ankle walker-type device 1
  • Surgical intervention (rare, reserved for refractory cases) 2

Evidence on Early Intervention

• **Patients with very short symptom duration (<1 month) respond better** to physical rehabilitation compared to those with longer symptom duration (>2 months), with significantly greater improvements in VISA-A scores 4

• This emphasizes the importance of early recognition and treatment initiation 4

Common Pitfalls to Avoid

• Do not inject corticosteroids into the Achilles tendon substance—this temporarily weakens the tendon and may precipitate rupture 5

• NSAIDs alone are insufficient—they provide symptomatic relief but do not accelerate structural healing 4

• Avoid complete rest—eccentric loading is therapeutic and superior to rest alone 2, 3

• Address biomechanical abnormalities (improper training techniques, footwear issues) to prevent recurrence 2

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If This Is Actually Achilles Tendon Rupture (Not Tendonitis)

The majority of the provided evidence addresses acute Achilles tendon rupture, which is a complete tear requiring different management. If clinical examination reveals a palpable gap, positive Thompson test, or inability to plantarflex against resistance, this represents rupture rather than tendonitis.

For Acute Achilles Tendon Rupture:

• Surgical repair is preferred for young, active patients desiring return to sports, those with high functional demands, and patients who can comply with postoperative protocols 6

• Non-surgical treatment is appropriate for elderly or low-demand patients, nursing home residents, patients with significant comorbidities, and those unable to comply with surgical rehabilitation 6

• Early protected weight bearing (within 2 weeks) in a boot limiting dorsiflexion to 0 degrees produces fastest functional recovery without increasing rerupture risk 6, 7

• Early mobilization by 2-4 weeks postoperatively is recommended 6, 8