How would you approach chronic Achilles tendonitis that persists despite rest and physical therapy?

When situations like this arise, the first step is to re-evaluate the duration of symptoms and ensure the full trial of conservative management (rest, ice/heat, NSAID/Tylenol, PT) has been done. Oftentimes, it takes months to fully recover, even with these measures. If the symptoms persist despite adherence to conservative management, I would refer the patient to podiatry. In an effort not to get an imaging study that may not be helpful for guiding management decisions, I would not get an MRI prior to referring to podiatry. I know that shock wave is offered by some physical therapists, but I do not personally have much experience with them.