Treatment of Achilles Tendinopathy
The cornerstone of Achilles tendinopathy treatment is eccentric exercise combined with relative rest, with NSAIDs for short-term pain relief and extracorporeal shockwave therapy reserved for refractory cases. 1
Initial Conservative Management
Eccentric Exercise Program
- Eccentric strengthening is the most effective treatment and may reverse degenerative changes in both Achilles and patellar tendinopathy 1
- Eccentric exercises have proven beneficial specifically for Achilles tendinosis in multiple studies 1
- For insertional Achilles tendinopathy specifically, eccentric exercise combined with soft tissue therapy ranks as the most effective treatment combination for short-term pain control (SUCRA value 84.8) 2
- Tensile loading through eccentric exercise stimulates collagen production and guides normal alignment of newly formed collagen fibers 1
Activity Modification
- Reduce activity to decrease repetitive loading of the damaged tendon 1
- Allow patients to continue activities that do not worsen pain 1
- Avoid complete immobilization to prevent muscular atrophy and deconditioning 1
- Stretching exercises are widely accepted as helpful 1
Pain Management
- NSAIDs are recommended for short-term pain relief but have no effect on long-term outcomes 1
- Topical NSAIDs are effective and may have fewer systemic side effects than oral formulations 1
- Cryotherapy provides effective short-term pain relief; apply ice through a wet towel for 10-minute periods 1
Second-Line Treatments for Refractory Cases
Extracorporeal Shockwave Therapy (ESWT)
- ESWT appears to be a safe, noninvasive, effective but expensive means of pain relief for chronic tendinopathies 1
- When exercise is unsuccessful, ESWT is the next best nonoperative treatment option to reduce pain 3
- Recent protocols use radial ESWT (0.48 mJ/mm², 2,000 shockwaves, 10 Hz, 1.6 bars, 2 sessions once weekly) 4
Corticosteroid Injections (Use with Caution)
- Locally injected corticosteroids may be more effective than oral NSAIDs for acute-phase pain relief but do not alter long-term outcomes 1
- Use cautiously as they may inhibit healing and reduce tensile strength, predisposing to spontaneous rupture 1
- Avoid injection directly into the tendon substance due to deleterious effects 1
- Consider peritendinous injections only after physical therapy proves ineffective 5
Adjunctive Therapies
- Orthotics and braces are safe and may help correct biomechanical problems like excessive foot pronation 1
- No conclusive recommendations exist for their effectiveness, but clinical experience and patient preference should guide use 1
- Therapeutic ultrasound, iontophoresis, and phonophoresis have uncertain benefit 1
Surgical Intervention
- Surgery is an effective option in carefully selected patients who have failed three to six months of conservative therapy 1
- Surgical options include tendon-preserving débridement, tendon detachment with reattachment, calcaneal osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer 6
Important Clinical Pearls
Diagnostic Considerations
- Most patients present with chronic tendinosis rather than acute inflammation by the time they see a physician 1
- Palpation elicits well-localized tenderness similar to activity-related pain 1
- Reserve imaging (ultrasound or MRI) for unclear diagnosis, recalcitrant pain despite adequate conservative management, or preoperative evaluation 1
Risk Factors to Address
- Greater running distance increases odds of developing Achilles tendinopathy (OR 1.67) 7
- Lower peak ankle inversion moment and lower peak ankle external rotation angle are biomechanical risk factors 7
Common Pitfalls
- Do not use wait-and-see approach—all active treatments are superior at 3-month follow-up for midportion tendinopathy 8
- Avoid complete immobilization which causes muscular atrophy 1
- Be cautious with corticosteroid injections as they may predispose to rupture 1
- Most evidence is of very low to low certainty, with 76% of trials at high risk of bias 8