What is the treatment for Achilles tendonitis with neovascularization (formation of new blood vessels) and mild fusiform (spindle-shaped) changes in the tendon?

From the Guidelines

Treatment for Achilles tendonitis with neovascular and mild fusiform changes should begin with a conservative approach combining rest, ice, and anti-inflammatory medications, with a strong focus on eccentric strengthening exercises and physical therapy, as recommended by the most recent and highest quality study 1. The conservative approach should include:

• Rest and reduced activity to prevent further damage and promote healing and pain relief, as supported by evidence rating C 1
• Cryotherapy, such as applying ice for 15-20 minutes several times daily, to provide acute relief of tendinopathy pain, with evidence rating B 1
• Eccentric strengthening exercises, particularly heel drops performed on a step, to reverse degenerative changes and promote healing, with evidence rating B 1
• NSAIDs, such as naproxen or ibuprofen, for short-term pain relief, but with no effect on long-term outcomes, and evidence rating B 1 The neovascular changes indicate chronic inflammation, making proper rehabilitation crucial. If conservative treatment fails after 3-6 months, consider shockwave therapy or platelet-rich plasma injections, with evidence rating B 1. Surgical options should only be considered after exhausting non-operative approaches, with evidence rating B 1. Throughout recovery, modify activities to avoid high-impact exercises, gradually returning to normal activities as symptoms improve. It is essential to note that the use of locally injected corticosteroids may be more effective than oral NSAIDs in acute-phase pain relief but does not alter long-term outcomes, with evidence rating B 1. Additionally, therapeutic ultrasonography, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit for tendinopathy, with evidence rating B 1. The American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommends treatment with physical therapy over no treatment with physical therapy, with a strong recommendation and moderate level of evidence 1.

From the Research

Treatment Options for Achilles Tendonitis with Neovascular Changes and Mild Fusiform Changes

• Conservative treatments have been researched for Achilles tendinopathy, including nonsteroidal anti-inflammatory medication, eccentric exercise, stretching, orthotics, bracing, glyceryl trinitrate patches, injection therapies, shock wave therapy, and low-level laser therapy 2
• Eccentric exercise and shock wave therapies are treatments with the highest evidence-based effectiveness for Achilles tendinopathy 2
• For insertional Achilles tendinopathy, conservative first-line therapy includes reduction of activity levels, administration of non-steroidal anti-inflammatory drugs, adaptation of footwear, heel wedges, and orthoses or immobilization 3
• Eccentric stretching exercises can achieve a 40% reduction in pain, and extracorporeal shock wave therapy can reduce pain by 60% with a patient satisfaction of 80% 3
• Operative therapy is indicated after 6 months of unsuccessful conservative therapy, and open debridement allows all pathologies to be addressed, including osseous abnormalities and intratendinous necrosis 3
• Activity modification and rehabilitation with a focus on progressive tendon-loading are recommended for Achilles tendinopathy, with adjuvant treatment with procedures (e.g., injections, shockwave therapy) and rarely surgical intervention for recalcitrant cases 4
• Nonsurgical management of Achilles tendon disorders includes nonsteroidal anti-inflammatory drugs, physical therapy, bracing, and footwear modification, while surgical treatment includes debridement of the diseased area of the tendon with direct repair 5
• An accurate diagnosis and early conservative management can improve patient quality of life and reduce unnecessary surgical consultations for Achilles tendon-related pain 6

Key Considerations

• Neovascularization and the ingrowth of new nerve fibers may contribute to Achilles tendinopathy pain 2
• Imaging modalities, such as ultrasound and magnetic resonance imaging, can be helpful in confirming the diagnosis and guiding treatment 2, 5
• Patient self-reports of morning stiffness and/or pain in the tendon area, pain on palpation of the tendon, and detection of Achilles tendon thickening are useful for diagnosis 2