Achilles Tendonitis Treatment & Management

Paratenonitis

Relative rest from activities that involve forceful and repetitive ankle plantarflexion are recommended. In athletes wishing to maintain conditioning while waiting for the injury to heal, cross training with activities that don’t involve forceful plantarflexion can be employed. Examples of these exercises are swimming, biking (with the pedal on the heel), and aqua jogging. In mild cases, a runner may continue to run and still allow their injury to heal by simply reducing their mileage and eliminating hills for a while. In severe cases, complete rest with crutches or a walking cast or boot may be needed for a short time.

Icing to reduce inflammation and pain is often helpful.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can also reduce inflammation and pain.

Heel lifts of 10-15 mm for short-term use my reduce symptoms by reducing the stress and excursion of the tendon.

Fluoroquinolones should be stopped, as these agents have been associated with Achilles tendinitis and rupture.

Tendinosis

The initial treatment for tendinosis is similar to paratenonitis (above), although tendinosis tends to less responsive to NSAIDs and ice, unless there is concomitant paratenonitis.

Some clinicians feel patients with Achilles tendinosis are predisposed to rupture and should be protected, but this is controversial.

Physical therapy

Correcting strength and flexibility deficits of the muscle-tendon unit in Achilles tendinitis can commence when the acute pain subsides. This can be done under the supervision of a physical therapist or from instructions or handouts from the physician. Calf stretches should be done with the knee in both extension (to stretch the gastrocnemius muscle) and flexion (to stretch the soleus muscle).

Strengthening usually starts with isometric exercises, and progresses to isotonic and, finally, isometric exercises. As with stretching, strengthening should be done with the knee in extension and flexion. A heavy-load, eccentric, calf strengthening program has been show to be highly beneficial for treating resistant tendinosis in runners and for getting them back to full activity.^{[19, 20]}

Cross training with low-impact exercises can begin during this phase. If pain develops, the athlete should decrease the amount of activity one level to alleviate the pain.

If the individual is pain free with low-impact activity, the athlete can begin sport-specific training. If pain develops as activity is escalated, the patient should decrease the level of activity to one that doesn’t cause pain.

Care must be taken to not commit another training error if that is what initially caused the tendinitis.

The patient should warm up the muscle-tendon unit well before engaging in vigorous activity, such as sprinting and jumping.

In chronic, refractory cases of paratenonitis and tendinosis with a tight heel cord despite stretching, a “night splint” can be used.^[21] This orthosis is similar to an orthopedic boot and is worn at night keeping the ankle at 5º dorsiflexion.

In refractory cases with hyperpronation, a custom orthotic with a medial heel posting may be tried.

In chronic cases of paratenonitis, some authors have advocated bupivacaine injection into the sheath to disrupt adhesions. Others have suggested that 2 cm of saline injection to the sheath may lift the paratenon off the tendon and lead to improvement.

Medical issues/complications

Steroid injections into and around the tendon are not advised because they have been shown to weaken the tendon.

Achilles tendinitis may progress to rupture. Steroid injections, especially multiple injections, may weaken the tendon, leading to tendon rupture.

Surgical intervention

Operative treatment may be indicated if there are disabling or unacceptable symptoms despite 6-12 months of nonoperative treatment.^{[22, 23]} .

MRI is obtained before surgery to better define the pathology.

Although there are no absolute indications to surgery, relative contraindications include noncompliant patients, an active infection site, and patients with potential wound-healing problems (eg, diabetes mellitus, peripheral vascular disease, smokers).

In paratenonitis, fibrotic adhesions and nodules are excised, freeing up the tendon. Longitudinal tenotomies may be performed to decompress the tendon. Satisfactory results have been obtained in 75-100% of cases.

In tendinosis, in addition to the above procedures, the degenerated portions of the tendon and any osteophytes are excised. Haglund’s deformity, if present, is removed. If the remaining tendon is too thin and weak, the plantaris or flexor hallucis longus tendons can be weaved through the Achilles tendon to provide more strength. The outcome is generally less favorable than surgery for paratenonitis. Twenty-five percent of patients were unable to return to preinjury level of activity

Surgery is followed immediately with passive ROM and progressive weight bearing and strengthening for 2-3 weeks. When the patient is able to ambulate without pain, he or she may begin closed chain activities, such as biking or stair climbing. Running may begin at 6-10 weeks after surgery. Participation in competitive sports can start after 3-6 months.

Other treatment

Operative brisement (ie, injection of dilute anesthetic into the paratenon sheath under ultrasound guidance to break up adhesions) may be useful in patients with peritenonitis or tendinosis with peritenonitis.

Platelet-rich plasma (PRP) injections have become popular recently for refractory tendinosis, particularly chronic lateral epicondylitis. Results of studies on the effectiveness of PRP injections have been mixed. With regard to Achilles tendinosis, recent study results indicated no difference in outcome between intratendinous PRP injections and saline injections at 1 year.^[24]

The athlete must be sure that the underlying cause of the tendinitis has been corrected.

If it was a training error, the athlete must be educated on importance of starting a new activity slowly and to increase activity gradually, including allowing rest days.

If hyperpronation was hypothesized as the cause, orthotics could be considered.

The athlete should remain on a maintenance program of daily stretching after activity and every-other-day strengthening.

If the activity of choice is a high impact one such as running or jumping, it is advised that the athlete start with low-impact activity.

If symptoms don’t return, gradual progression to higher impact and sport-specific activity can be carried out. Sport-specific activity can subsequently be introduced.

Physical therapy

Achilles tendinitis is best prevented, treated, and maintained by preserving good ROM in the heel cord complex. Such motion can be gained with the use of an incline board, wall leans, or the "foot on chair" stretching exercises. Application of moist heat or compresses before workouts and at night are beneficial. Cold modalities should be used following strenuous activities to provide pain relief and anti-inflammatory effects.