Managing Achilles Tendinopathy in Primary Care: When to Treat and When to Refer

Clinical Asst Prof Eric Cher Wei Liang
Consultant, Department of Orthopaedic Surgery,
Service Director, Foot and Ankle Surgery,
Fellowship Lead, Foot and Ankle Surgery Fellowship Programme, Sengkang General Hospital;
Clinical Assistant Professor, NUS Yong Loo Lin School of Medicine, SingHealth Duke-NUS Musculoskeletal Academic Clinical Programme

A common cause of heel pain, Achilles tendinopathy is often managed effectively in primary care, with referral to a specialist for chronic cases that remain symptomatic and significantly affects daily living and may potentially require surgery.

We also answer frequently asked questions about corticosteroids and extracorporeal shockwave therapy in treatment and share outcomes of minimally invasive Zadek osteotomies performed for recalcitrant cases.

INTRODUCTION

Achilles tendinopathy (AT) is a common heel pain condition that can affect individuals of various ages, activity levels and lifestyle demands. It often causes
significant discomfort, leading to pain, swelling and reduced functionality.

Learn more about the role of primary care physicians in managing AT and how to help patients recover and maintain an active lifestyle.

AETIOLOGY

AT encompasses both tendinitis (inflammation) and tendinosis (degeneration) of the Achilles tendon. 

Classified broadly into two types, insertional Achilles tendinopathy (IAT) occurs where the tendon attaches to the heel bone, while non-insertional tendinopathy (non-IAT) affects the midportion of the tendon.

Overuse is one of the most common causes of AT, and very often, pain is exacerbated by inappropriate shoe wear, a sudden increase in physical demands and acute injuries to the foot. Chronic repetitive strain on the Achilles tendon can result in microscopic tears, degeneration and inflammation of the
tendon leading to pain and discomfort.

Structural abnormalities of the foot, such as malalignment, previous ankle injuries and poor biomechanics, are all contributing risk factors that predispose individuals to AT.

CLINICAL PRESENTATION

Individuals with AT commonly present with some of the following symptoms:

• Localised pain over the insertion or along the tendon
• Swelling along the tendon
• Worsening discomfort after periods of inactivity, including in the morning or after sitting for long periods
• Stiffness of the ankle
• Reduced ankle range of motion
• Progressive pain with physical activity

In chronic cases, a palpable bump may be present along the tendon, suggestive of degeneration, or a bony prominence at the tendon-bone insertion caused by calcification.

EVALUATING ACHILLES TENDINOPATHY

Diagnosis of AT is primarily clinical. A detailed medical history and physical examination are crucial in differentiating the different causes of heel pain,
such as Achilles rupture, calcaneum stress injuries, plantar fasciitis and os trigonum syndrome, to name a few.

Plain X-rays may be used to assess the presence of calcification along the Achilles tendon and structural deformities of the ankle.

Advanced imaging, including ultrasound and MRI, may sometimes be used to evaluate the extent of degenerative change, including the thickness of the tendon, the presence of tears and fluid accumulation within the bone-tendon interface.

Managing and Treating Symptomatic AT in the Primary Care Setting

In the primary care setting, management of symptomatic AT will mainly be focused on improving pain and restoring function. Treatment should be individualised and tailored based on the patient’s severity of condition, activity level, functional demands and expectations.

The prognosis for most cases of AT is generally reasonable. While it may sometimes take three to six months, or even longer, for symptoms to improve, the majority respond well to non operative management.

Patients can expect gradual improvement over several months and should be advised to continue a regular exercise routine for long-term recovery.

Conservative treatment includes:

1. Pain relief medication: Non-steroidal anti inflammatory drugs (NSAIDs) can help manage pain and inflammation, especially during the acute phase.
   
   
2. Rest: Symptoms typically improve after a period of rest.
   
   
3. Activity modification: Avoiding activities such as impact sports, running and jumping may help relieve acute painful symptoms. Sports such as swimming, cycling and cross-training are generally lower in impact. They can help maintain fitness while at the same time prevent excessive strain across the tendon-one interface.
   
   
4. Physical therapy: Referral to physiotherapy plays a vital role in recovery. Some of the treatments initiated include:
   - Eccentric strengthening exercises
   - Calf stretching exercises for the gastrocnemius and/or soleus muscles
   
   
5. Orthotic devices and shoe wear modification: The use of a heel lift or cushion may help improve symptoms by decreasing the tension on the tendon and reducing frictional pain between the heel and shoes.

For chronic AT that remains symptomatic and affects the patient’s daily living, a referral to an orthopaedic specialist may be warranted for consideration of
surgical intervention.

Surgical treatment may be recommended for individuals who are unresponsive to conservative therapies and have exhausted all other options in managing their chronic heel pain. Surgery may include arthroscopic or open procedures:

1. Gastrocnemius recession, a procedure to relax the tight calf muscles
2. Debridement of the diseased tendon
3. Calcaneoplasty to remove offending causes of pain, such as Haglund deformity
4. Calcaneum osteotomy
5. Corrective bony procedures to correct malalignment and foot deformities

WHAT IS NEW IN THE TREATMENT OF ACHILLES TENDINOPATHY?

Sengkang General Hospital (SKH) offers minimally invasive Zadek osteotomy (MIS ZO) as a treatment for recalcitrant chronic AT.

In the MIS ZO method, a sub-centimetre percutaneous incision is made over the calcaneum, and a dorsal closing wedge osteotomy is created using a cutting burr. The osteotomy is then closed and held together with two screws. This procedure reduces (1) mechanical impingement between the tendon and calcaneum tuberosity and (2) Achilles tendon tension by changing the orientation of the insertion.

Globally, there is growing evidence showing excellent results and improvement in pain after MIS ZO in the treatment of chronic AT. Besides smaller surgical wounds, patients’ postoperative recovery is much faster compared to traditional open surgery.

Clinical Outcomes

At SKH, patients are allowed to walk shortly after surgery, and most of them resume everyday daily living and independent ambulation at six weeks.

Our clinical results in SKH showed that, when compared to the traditional open surgery for Haglund excision and tendon reattachment, MIS ZO has comparable improvements in functional outcomes and pain, with (1) lower wound complications and (2) faster recovery and time to ambulation.¹

In addition, postoperative MRI scans performed inpatients who underwent MIS ZO showed (Figure 2):

1. Improvement in Achilles tendon thickness and inflammation
2. Regression of retrocalcaneal bursal effusion and
3. Improvement in paratenon thickening

These findings provide further evidence of the efficacy of ZO in the treatment of chronic AT.

WHAT ARE THE BENEFITS OF MIS ZADEK OSTEOTOMY IN THE TREATMENT OF CHRONIC AT?

Many studies have shown the benefits of MIS ZO in treating chronic AT.

Benefits include:

1. Minimally invasive
2. Faster recovery
3. Earlier weight-bearing and ambulation
4. Less postoperative pain and swelling
5. Lower risk of postoperative complications

NOTES TO GPs

1. Most AT may be treated conservatively and managed in the primary care setting.
   
   
2. Comprehensive conservative management should be adopted first, including pain relief, shoe wear modification, activity modification and physiotherapy exercise.
   
   
3. Surgery for symptomatic AT is a viable option for patients with persistent or worsening symptoms.
   
   
4. Early referral to an orthopaedic specialist is recommended if the patient has symptoms suggestive of a non-tendinopathic cause, such as tendon rupture, fractures or stress injuries.
   
   
5. Other causes of heel pain may need to be investigated for patients with recalcitrant discomfort after exhausting all conservative treatment.

REFERENCES

1. Gengatharan D, Huang D, Png WX, Rikhraj IS, Cher EWL. Outcomes of open versus minimally invasive Zadek osteotomy in treatment of insertional Achilles tendinopathy. Foot Ankle Surg. 2026 Jan 16

Dr Eric Cher is a fellowship-trained foot and ankle surgeon with the Department of Orthopedic Surgery at Sengkang General Hospital (SKH). He completed his subspeciality fellowship training in minimally invasive (MIS) and arthroscopy surgeries in Australia, Chile, and Japan. Dr Eric Cher is also the Service Director and Fellowship Lead for Foot and Ankle Surgery at SKH.

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