Achilles Tendinitis with Plantar Fasciitis: Pain Management and Therapy

Understanding the Conditions

Achilles Tendinopathy

• Peritendinitis without tendinosis - inflammation of the paratenon only
• Peritendinitis with tendinosis - paratenon inflammation plus intratendinous degeneration
• Pure tendinosis - intratendinous thickening without paratenon involvement

Plantar Fasciitis

• Repeated microtears at the plantar fascia origin at the medial calcaneal tuberosity initiate a chronic injury-repair cycle
• Biggest single risk factor: BMI >30 kg/m²
• Strongly associated with gastrocnemius contracture (the same muscle group contributing to Achilles tendinopathy)
• ~90-95% of cases resolve within 12 months regardless of specific treatment used
• Surgery is required in fewer than 5% of patients

Shared Pathomechanism

Treatment Framework

Phase 1: Conservative (First-Line, 0-6 Months)

Activity Modification

• Reduce or eliminate aggravating activities (running, prolonged standing, hill climbing)
• Avoid barefoot walking, especially on hard floors in the morning
• Transition to cushioned, supportive footwear with a slight heel lift

Stretching - The Single Most Important Intervention

• Stand on a step with forefoot on the edge
• Raise up on both feet, then lower slowly on the affected leg only over 3 seconds (eccentric phase)
• Perform 3 sets × 15 repetitions, twice daily
• Do with knee straight (targets gastrocnemius) and knee bent (targets soleus)
• This protocol has the strongest evidence for noninsertional tendinopathy (SOR: B) - Textbook of Family Medicine 9e
• Note: For insertional Achilles tendinopathy, aggressive eccentric heel drops below step level may worsen symptoms - use modified flat-surface protocol

• Before getting out of bed, pull toes into dorsiflexion and hold for 10 seconds; repeat 10 times
• Self-massage of the plantar fascia (rolling foot on a frozen water bottle or tennis ball)
• Calf/Achilles stretch against a wall: both knee-straight and knee-bent versions
• These stretching protocols are the key to effective nonoperative management for plantar fasciitis - Miller's Review of Orthopaedics 9th Ed

Orthotics and Mechanical Support

• Heel cups/cushioned inserts - reduce impact at the calcaneus
• Medial arch support orthotics - unload the plantar fascia origin
• Night splints - maintain ankle at 0-5° dorsiflexion overnight, preventing the re-tightening of the Achilles-plantar fascia complex that causes morning pain; particularly helpful when both conditions coexist
• Heel lifts (5-10 mm) - reduce Achilles tension, especially useful for insertional type
• For insertional Achilles tendinopathy, an open-backed shoe removes direct pressure on the Haglund prominence - Roberts and Hedges' Clinical Procedures

Pharmacological

• NSAIDs (e.g., ibuprofen 400-600 mg TID with food, for 2-4 weeks) - reduce acute inflammation and pain; marginally increase pain relief compared to conservative measures alone in plantar fasciitis
• Topical NSAIDs (diclofenac gel) - useful in patients with GI contraindications
• Topical glyceryl trinitrate (GTN) patches 0.2 mg/24h - applied directly over the tendon; the Alfredson-Cook algorithm includes GTN patches for noninsertional Achilles tendinopathy; mechanism involves NO-mediated collagen synthesis stimulation - Rheumatology, 2-Volume Set (Elsevier, 2022)

Physical Therapy

• Structured program including calf strengthening, proprioception training, gait retraining
• Therapeutic ultrasound for plantar fasciitis - a 2024 systematic review in PeerJ (PMID: 38529309) found it reduces pain intensity and functional disability in plantar fasciitis RCTs
• Manual therapy (soft tissue mobilization, joint mobilization)
• Taping (low-Dye or calcaneal taping) - provides short-term pain relief by supporting the medial arch; requires referral to podiatry for proper fitting

Phase 2: Second-Line Interventions (After 6-12 Weeks of Failed Conservative Therapy)

Extracorporeal Shock Wave Therapy (ESWT)

• Both high-energy (radial/focused) and low-intensity ESWT have demonstrated success
• A 2023 systematic review and meta-analysis (Charles et al., Front Immunol, PMID: 37662911) confirmed effectiveness for both Achilles tendinopathy and plantar fasciitis, making it the ideal shared intervention when both are present
• A 2024 systematic review in Br J Sports Med (Rhim et al., PMID: 38228375) supports ESWT in athletes with both conditions
• Typically 3-5 sessions weekly or biweekly; patients may experience post-treatment soreness for 24-48 hours
• Cortisone injection should not be given in the 6 weeks preceding ESWT (reduces effectiveness)

Corticosteroid Injections

• Provide short-term pain relief (~1 month) for plantar fasciitis
• Risks: Fat pad atrophy, plantar fascia rupture (risk increases with >2-3 injections)
• NOT recommended for Achilles tendinopathy - repeated injections are associated with tendon rupture; even a single injection is controversial - Roberts and Hedges; Miller's Review of Orthopaedics
• A useful rule: maximum 2-3 plantar fascia injections lifetime; never inject directly into the Achilles tendon

Platelet-Rich Plasma (PRP) Injections

• Plantar fasciitis: A 2024 meta-analysis (Herber et al., Foot Ankle Surg, PMID: 38395675) found PRP superior to other injection modalities for plantar fasciitis
• Achilles tendinopathy: A 2023 meta-analysis (Desouza et al., Eur J Orthop Surg Traumatol, PMID: 37225947) showed benefit in chronic Achilles tendinopathy
• However, earlier studies (2016) showed conflicting results vs. placebo for Achilles - evidence is stronger for plantar fasciitis

High-Volume Injections (Achilles)

• Injection of large volumes (10 mL saline + local anesthetic ± steroid) around the Achilles paratenon
• A 2024 systematic review (Hassan et al., Br Med Bull, PMID: 39496560) supports use in recalcitrant noninsertional Achilles tendinopathy
• Thought to strip neovascular ingrowth and break perineural fibrosis

Laser Therapy

• A 2024 systematic review and meta-analysis (Saleh et al., Lasers Med Sci, PMID: 38990213) found both high-intensity and low-level laser therapy effective in musculoskeletal pain including plantar fasciitis

Walking Boot / CAM Boot

• Short-term immobilization (4-6 weeks) in a controlled ankle motion boot can provide relief in refractory cases of either condition by offloading the heel

Phase 3: Surgical (Failure After 6-12 Months of Conservative Therapy)

Plantar Fasciitis Surgery

• Limited plantar fasciotomy (medial half release only) - indicated in <5% of cases
• Complete release is discouraged - risks overloading the lateral column, metatarsal stress fractures, and arch collapse
• Gastrocnemius recession - increasingly favored as the primary or sole procedure when clear equinus deformity is the driver; addresses the shared mechanism for both conditions simultaneously - Miller's Review of Orthopaedics 9th Ed

Achilles Tendinopathy Surgery

• Noninsertional: Ventral paratenon stripping, open/endoscopic tendon debridement, gastrocnemius recession
• Insertional: Calcaneal exostectomy (with or without Haglund resection), tendon debridement ± tendon transfer (FHL transfer when >50% tendon volume involved)
• Return to sport: ~67-78% at 8-10 months post-exostectomy
• Surgical management indicated only after failure of at least 6 months of nonoperative treatment - Campbell's Operative Orthopaedics 15th Ed 2026

Practical Combined Treatment Protocol

Key Evidence Summary

Important Warnings

1. Fluoroquinolone antibiotics must be avoided or discontinued immediately in patients with active Achilles tendinopathy - associated with spontaneous rupture
2. Corticosteroid injection into or around the Achilles tendon carries significant rupture risk - strongly discouraged; do not exceed 2-3 plantar fascia injections lifetime
3. Complete plantar fascia release risks arch collapse and lateral column overload - only partial medial release is appropriate
4. Heel drops below step level for insertional Achilles tendinopathy may worsen symptoms - use modified protocol on flat surface

Sources: Campbell's Operative Orthopaedics 15th Ed 2026; Miller's Review of Orthopaedics 9th Ed; Harrison's Principles of Internal Medicine 22E; Roberts and Hedges' Clinical Procedures in Emergency Medicine; Rheumatology 2-Volume Set (Elsevier 2022); Textbook of Family Medicine 9e; PubMed PMIDs: 37662911, 38228375, 38395675, 37225947, 39496560, 38529309, 38990213

Topical Glyceryl Trinitrate (GTN) Patches for Achilles Tendinopathy and Plantar Fasciitis

What is Topical GTN?

Mechanism of Action

1. Nitric oxide synthase (NOS) is upregulated after tendon injury - all three isoforms (eNOS, bNOS, iNOS) are found in healing fibroblasts of injured rat and human tendons in a time-dependent pattern. In normal uninjured tendons, NOS activity is negligible.
2. NO stimulates collagen synthesis - in cultured human tenocytes, adding NO via chemical donors or adenoviral transfection resulted in measurably enhanced collagen synthesis. This is the proposed pro-healing mechanism.
3. Blocking NOS impairs healing - competitive NOS inhibition in animal tendon injury models reduced tendon healing, confirming NO's role is causative, not incidental.
4. GTN as a localized NO donor - the patch placed directly over the tendon releases NO transdermally at the target site, avoiding systemic cardiovascular doses. - Bokhari & Murrell, J Shoulder Elbow Surg, 2012 (PMID: 22244067)

• Analgesic effect (possibly through peripheral nociceptor modulation)
• Tendon repair effect (via fibroblast collagen synthesis stimulation)

Evidence for Achilles Tendinopathy

Positive RCTs (Paoloni/Murrell Group)

• 65 patients (84 Achilles tendons), noninsertional Achilles tendinopathy
• GTN group (1.25 mg/24h) vs. placebo patch + identical rehabilitation
• Results at 6 months: 78% of GTN tendons were asymptomatic vs. 49% in the placebo group (p=0.001)
• Reduced pain with activity at 12 and 24 weeks, reduced night pain at 12 weeks, improved ankle plantar flexor strength at 24 weeks

Negative/Null Studies

• 40 patients, GTN vs. standard physical therapy alone
• No significant clinical benefit in pain (3.0 vs. 3.1, p=0.42) or disability scores at 6 months
• Histology of surgically treated tendons: no difference in neovascularization, collagen synthesis, or NOS expression between GTN-treated and control tendons

• 76 patients (30 women, 46 men, mean age 45.6 years)
• Daily GTN ointment vs. placebo over 24 weeks, both groups did 12-week eccentric exercise program
• Primary outcome: VISA-A score (pain, function, activity) at 24 weeks
• Result: No significant difference between GTN and placebo at 6, 12, or 24 weeks
• Adjusted mean difference at 24 weeks: -3.8 (95% CI -10.6 to 3.0) - negative values favour GTN but the CI crosses zero
• This was a well-designed, adequately powered trial published in Br J Sports Med (2024)

Systematic Review and Meta-Analysis

• Pooled SMD for all tendinopathies: -1.57 (95% CI -2.47 to -0.67) - technically significant but with high heterogeneity
• When grouped by tendinopathy type: effects were insignificant or borderline insignificant for Achilles, rotator cuff, patellar, and lateral epicondylitis
• NNT = 3.53 (95% upper CI 12.4) - wide confidence interval
• Conclusion: No convincing evidence that topical GTN is more effective than placebo for tendinopathy pain

• GTN for patellar tendinopathy showed some signal in network meta-analysis but was based on low/very low strength of evidence
• Conclusion: No adjunct (including GTN) added benefit over exercise therapy alone
• Recommends exercise monotherapy for at least 3 months before any adjunct is considered

Evidence for Plantar Fasciitis

• The plantar fascia is not a tendon - it is an aponeurosis with different cellular composition
• The depth of the plantar fascia from the skin surface means percutaneous NO delivery may be less effective
• No published clinical trial has tested this application

• ESWT induces local NO release as part of its anti-inflammatory mechanism (Mariotto et al. 2009, PMID: 19601786) - this is one reason ESWT works in both Achilles tendinopathy and plantar fasciitis
• Botulinum toxin type A injection has also been studied (50 units), which may share some NO-pathway overlap

Practical Prescribing Guide

Formulation and Dosing

Practical Application Steps

• Identify the point of maximum tenderness (usually 2-6 cm above the calcaneal insertion for noninsertional disease)
• Cut a standard 5 mg/24h patch into quarters
• Apply one quarter patch over the point of maximum tenderness
• Rotate slightly each day (left/right of the tendon) to prevent contact dermatitis
• Replace every 24 hours

• Apply over the tendon insertion at the posterior calcaneus
• Less evidence exists for insertional disease compared to noninsertional

• Apply over the medial calcaneal tuberosity (insertion of plantar fascia)
• Some clinicians use GTN ointment rather than a patch at this site for better conformity to the plantar surface

Side Effects

• Phosphodiesterase-5 inhibitors (sildenafil, tadalafil) - severe hypotension risk; absolute contraindication
• Other nitrate preparations - additive hypotension
• Antihypertensives - enhanced hypotension

Summary of Evidence Strength

Current Clinical Position

Sources: Rosen's Emergency Medicine; Rheumatology 2-Volume Set (Elsevier 2022); Paoloni et al. 2004 (PMID: 15118032); Kane et al. 2008 (PMID: 18359821); Kirwan et al. 2024 NEAT Trial (PMID: 39013615); Saltychev et al. 2022 meta-analysis (PMID: 34330192); Challoumas et al. 2023 (PMID: 37553459); Bokhari & Murrell 2012 (PMID: 22244067)

Does Topical GTN "Cure" Pain in Achilles Tendinopathy?

What "cure" would mean here

What the Evidence Actually Shows

Studies that found pain reduction (GTN helped):

• At 6 months: 78% of GTN-treated tendons were asymptomatic with daily activities vs. 49% in the placebo + exercise group
• Reduced pain during activity at 12 and 24 weeks
• Reduced night pain at 12 weeks
• This looks impressive - but critically, both groups did eccentric exercise, so the question is whether GTN added anything meaningful beyond what the exercise itself would achieve over time

• Significant long-term benefit maintained - but this was not a pure "cure"; patients continued activity modification

Studies that found NO pain benefit (GTN did not help):

• Pain scores at 6 months: GTN group 3.0 vs. control 3.1 — no difference (p = 0.42)
• Histology confirmed no increase in collagen synthesis in GTN-treated tendons

• Both groups improved significantly (eccentric exercise works)
• GTN added zero additional benefit over placebo at 6, 12, and 24 weeks
• VISA-A difference at 24 weeks: -3.8 points (95% CI -10.6 to 3.0) — clinically and statistically insignificant

• Effects were insignificant or borderline insignificant for Achilles tendinopathy, rotator cuff, patellar tendinopathy, and lateral epicondylitis
• Conclusion: "No evidence that NTG is more effective to reduce pain in tendinopathy than placebo"

The Honest Bottom Line

What Actually Does Reduce Tendon and Fascia Pain

1. Eccentric loading exercise (Alfredson heel-drop protocol) - the single most evidence-supported intervention; both GTN and placebo groups improved because of this
2. Time - 90-95% of plantar fasciitis and most Achilles tendinopathy cases resolve within 12 months regardless of specific treatment
3. Load management - reducing aggravating activities while maintaining graduated loading
4. ESWT - strong and consistent evidence for both conditions
5. Night splinting + stretching - effective for morning pain specifically

Topical Analgesic Patches for Achilles Tendinopathy and Plantar Fasciitis

The Key Classes Available as Patches/Topical Preparations

1. Topical NSAIDs - The Best-Evidenced Option

• For acute musculoskeletal pain (strains/sprains) at ~7 days:
  • Diclofenac Emulgel: NNT 1.8 (95% CI 1.5-2.1) - excellent
  • Ketoprofen gel: NNT 2.5 (2.0-3.4) - very good
  • Diclofenac Flector plaster: NNT 4.7 (3.7-6.5)
  • Diclofenac other plaster: NNT 3.2 (2.6-4.2)
• For chronic musculoskeletal pain (osteoarthritis):
  • Topical diclofenac (<6 weeks): NNT 5.0 (3.7-7.4)
  • Ketoprofen 6-12 weeks: NNT 6.9 (5.4-9.3)

• The Achilles tendon and plantar fascia are relatively superficial structures
• Drug concentrations in subcutaneous tissue, tendon sheath, and peritendinous structures have been measured to be therapeutically meaningful
• Plasma levels remain well below those from oral dosing - minimal GI, renal, or cardiovascular risk

Topical Diclofenac for Achilles Tendinopathy - Direct Evidence

• Both groups improved on VISA-A scores, but no statistically or clinically significant difference between groups
• The improvements were below the minimum clinically important difference (MCID) for VISA-A
• Conclusion: Topical diclofenac alone over 4 weeks was not superior to placebo for chronic Achilles tendinopathy

2. Topical Lidocaine Patches

• Works by blocking sodium channels in peripheral nociceptors - pure analgesia, no anti-inflammatory effect
• SORT Level A evidence for postherpetic neuropathic pain
• Limited evidence for musculoskeletal tendon/fascia pain specifically
• May be useful for neuropathic component of chronic heel pain (particularly if lateral plantar nerve entrapment coexists with plantar fasciitis - the "first branch of lateral plantar nerve" syndrome)
• Limitation for plantar surface: The plantar skin is thick and keratinized, which reduces absorption - noted in textbooks that topical anesthetics have "no significant effectiveness for plantar surfaces" - Dermatology 2-Volume Set (Elsevier)
• More useful applied to the posterior heel (Achilles region) where skin is thinner

3. Capsaicin Patches

• Mechanism: initially activates TRPV1 receptors causing burning, then depletes substance P from nociceptive nerve terminals - leads to prolonged desensitization
• Evidence for musculoskeletal pain is weaker than for neuropathic pain
• Plantar fasciitis: Capsaicin has been studied for plantar warts and some plantar pain conditions - Fitzpatrick's Dermatology
• Useful where there is a significant neuropathic or central sensitization component to chronic heel pain
• Practical problem: The burning sensation is poorly tolerated on the foot, particularly the plantar surface
• The 8% high-dose patch (Qutenza) requires clinic application and provides ~3 months of relief per application - used for peripheral neuropathic pain

4. Salicylate Rubefacients

• Create local warmth and counterirritant effect via TRPV1 activation
• The Cochrane review found low-quality evidence for moderate efficacy in acute musculoskeletal pain
• Not well studied for tendinopathy specifically
• Useful as OTC accessible option for symptomatic relief
• Avoid near open wounds or broken skin

5. Compound/Combination Topical Patches

• Diclofenac + lidocaine
• Ketoprofen + gabapentin + cyclobenzaprine
• Menthol + methyl salicylate combinations

Comparison Table: Topical Analgesic Patches for Heel Pain

Practical Recommendations

• Diclofenac gel 1-2% (e.g., Voltaren Emulgel) applied 2-4 times daily directly over the tendon - good evidence for MSK pain, minimal systemic absorption, well tolerated
• Apply before exercise sessions to reduce pain enough to perform loading exercises
• A ketoprofen gel patch (worn for 12-24 hours) can provide sustained drug delivery overnight

• Diclofenac gel applied over the plantar heel - limited by skin thickness but still used widely
• Ibuprofen gel as an OTC alternative
• Apply after stretching in the morning and at night
• Some clinicians use a diclofenac plaster (Flector patch) cut to fit the heel and worn inside the shoe

• Lidocaine 5% patch applied to the posterior heel/medial ankle (not the plantar surface)
• Low-dose capsaicin if tolerated

The Important Caveat

Analgesic patches reduce pain. They do not heal tendons or fascia. They are most valuable as a tool to enable the primary treatment - graduated loading exercise - to be performed with less pain.

Sources: Derry et al. Cochrane Overview 2017 (PMID: 28497473); Bussin et al. 2021 (PMID: 33661967); Smith et al. Sports Health 2025 (PMID: 39460722); Campbell's Operative Orthopaedics 15th Ed 2026; Dermatology 2-Volume Set (Elsevier); Fitzpatrick's Dermatology; Katzung's Basic and Clinical Pharmacology 16th Ed