eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Achilles Tendon Injuries and Tendonitis: Treatment & Medication

Author: Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School
Coauthor(s): Christian J Fulmer, DO, Private Practice in Sports and Family Medicine; Team Physician, Valley Christian High School
Contributor Information and Disclosures

Updated: Oct 14, 2009

Treatment

Rehabilitation Program

Physical Therapy

• Achilles tendon rupture
  • Physical therapy for a patient with an Achilles tendon rupture focuses primarily on postoperative care.
  • Therapy usually is initiated at 6-8 weeks following surgery with simple active range of motion (ROM) exercises, 20 minutes twice daily. The patient then progresses to isometric ankle exercises with knee and hip strengthening. Eventually toe raises and progressive resistance exercises are added, culminating with proprioceptive training. At 12 weeks, devices may be utilized to enhance ROM passively with a realistic goal for full range of motion at 6 months.
• Achilles tendonitis
  • Physical therapy for patients with Achilles tendonitis consists of several stages. The initial goal of physical therapy is to control the inflammation.
  • In the first and part of the second phase, pain is used to guide the intensity of exercise. Active ankle dorsiflexion with gentle calf stretching is performed.
  • In the intermediate phase, strengthening replaces active ROM, and neuromuscular control programs are initiated.
  • In the third phase of rehabilitation, progressive stress is applied under good control to allow the collagen to form appropriately. As pain resolves, perform aggressive stretching and active resisted motion.
  • One therapeutic modality that has gained interest is the performance of eccentric loading exercises. A review article demonstrated that this modality improves pain in patients with chronic Achilles tendinopathy. Further research is ongoing in an effort to clarify the exact role of eccentric training in tendinopathies.
  • Cryotherapy is useful in all of these stages. Physical modalities, such as ultrasound and electrical stimulation, also are useful to decrease pain and inflammation.

Medical Issues/Complications

• Medical therapy for a patient with an Achilles tendon rupture consists of rest, pain control, serial casting, and rehabilitation to maximize function. Ongoing debate surrounds the issue of whether medical or surgical therapy is more appropriate for this injury.
  • Activity modification for a ruptured Achilles tendon requires crutch ambulation without weight bearing. Once initiated, serial casting dictates the activity level.
  • Orthotic therapy is useful after serial casting. Serial casting usually results in some Achilles contracture, and heel lifts are used after casting. Depending on the degree of shortening and rate and aggressiveness of physical therapy, initiate use of 1-2 inch heel lifts with gradual weekly or biweekly adjustment directed toward weaning the patient off of the heel lifts.
  • Casting is one way to treat Achilles tendon rupture. Overall healing rates are similar to those of surgical reanastomosis, yet the return-to-activity benefits of surgery are debated. Nonetheless, this is viable therapy, especially for more sedentary patients and older persons. The initial cast applied is a long-leg cast with some knee flexion and ankle plantar flexion to allow free edges of the Achilles to approximate. The cast is changed in series, decreasing the plantar flexion and eventually moving toward short-leg casts in a neutral ankle position. This treatment lasts 6-12 weeks.
  • High-energy extracorporeal shock wave therapy has shown promise as a treatment for insertional Achilles tendinopathy. One study demonstrated that a single treatment was more effective than traditional conservative treatment in improving pain and enabling patients to return to their activities.
  • Medical therapy for Achilles tendon rupture is concerned primarily with pain control; some of the remedies are outlined below (see Medication).
• Medical therapy for Achilles tendonitis includes activity modification, orthotic therapy, physical therapy, and analgesic anti-inflammatory medication.^1,2,3
  • Activity modification for Achilles tendonitis requires that the patient abstain from aggravating activities with a minimum of rest to preserve overall fitness. This may include modification of the offending activity, such as avoiding running uphill or on uneven surfaces. If the athlete is a cyclist, proper saddle adjustment can help to reduce symptoms.
  • Orthotic therapy in Achilles tendonitis also consists of the use of heel lifts; however, lifts usually are not used to the extent utilized after serial casting for rupture. The goal is eventually to use conventional shoes. Orthotic devices usually are used bilaterally to prevent a gait imbalance. Since overpronation and cavus foot deformities can cause tendonitis, custom orthotics to correct overpronation or shock absorbing shoes for cavus deformities can alleviate pain as well.
  • Casting is an option for resistant Achilles tendonitis. This is the ultimate form of rest for the Achilles tendon and is usually a last resort for this condition. A cast boot can be used.
  • Medical therapy for Achilles tendonitis includes pain control and use of anti-inflammatory medications, some of which are detailed below (see Medication).

Surgical Intervention

• Surgical techniques are varied and usually involve reapproximation of the torn ends of the Achilles tendon, sometimes reinforced by the gastrocnemius-soleus aponeurosis or plantaris tendon. Controversy exists as to whether surgical or conservative treatment is preferable.⁴
• Advocates of conservative treatment cite the similar results between conservative and surgical treatment when looking at ROM, strength, power, and functional levels as a reason for avoiding surgery. Surgical advocates argue that full function is achieved more quickly with surgical therapy than with conservative therapy, especially for athletic individuals. The surgical approach is supported by a lower rate of rerupture, greater postoperative power, and low infection rate. Finally, conservative clinicians state that, with early application and prolonged duration of casting, the rerupture rate is decreased significantly.
• Surgery has often been applied in cases of recalcitrant Achilles tendonitis. Techniques include peritenon stripping and debridement of pathologic tissue to create an acute and better healing wound. Aftercare involves prolonged casting, and there is concern that the immobilization caused by casting is as curative as the surgical technique. Nonetheless, surgery is usually a last resort in treatment of tendonitis.
• While the reasons are not precisely known, surgery tends not to be as successful in nonathletic individuals with chronic Achilles tendinopathy. Nonathletic patients tend to have a more prolonged recovery, a greater risk of complications, and they are more likely to need further surgery than athletic individuals.

Consultations

Consultation is helpful when a DVT is diagnosed.

Medication

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or have sustained injuries.

Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Opioid analgesics

Control of moderate to severe pain.

Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab)

Drug combination indicated for moderate to severe pain.

Nonsteroidal anti-inflammatory drugs

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Naproxen (Naprosyn, Aleve, Naprelan, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.

Cyclo-oxygenase II inhibitors

Control of pain and inflammation, especially in cases of contraindication to conventional anti-inflammatories. Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-II inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-II inhibitors the most beneficial.

Celecoxib (Celebrex)

Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.

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