Achilles Tendinopathy: Exercises and Treatment Guide

Achilles tendinopathy is a common and frustrating condition—that painful, stiff tendon that makes every step feel like a challenge. Whether you're a runner, a weekend warrior, or just someone dealing with persistent heel cord pain, the right exercises can make a significant difference.

Important: Sudden, severe Achilles pain—especially with a "pop" or inability to push off—may indicate a rupture and requires immediate medical attention. This guide covers tendinopathy (chronic tendon degeneration), not acute rupture.

Understanding Achilles Tendinopathy

What Is It?

Tendinopathy (previously called tendinitis) is degeneration and disorganization of tendon tissue, usually from repetitive overload. Unlike acute inflammation, it involves structural changes in the tendon itself.

Two Types

Midportion tendinopathy: Pain 2-6 cm above the heel bone. Most common type.

Insertional tendinopathy: Pain where tendon attaches to heel bone. Often associated with bone spurs.

Why It Happens

The Achilles is the strongest tendon in the body, but it has relatively poor blood supply in its mid-section. Contributing factors:

• Sudden increase in training load
• Running (especially hills and speed work)
• Tight or weak calf muscles
• Poor footwear
• Biomechanical factors
• Age (tendon changes over time)
• Previous Achilles injury

Symptoms

• Pain and stiffness, especially in morning
• Pain at start of activity that warms up
• Pain after activity
• Tenderness to touch
• Thickening of the tendon
• Decreased push-off strength

Why Exercise Works

Tendons respond to load. The right amount of stress stimulates the tendon to remodel and heal. Too little load = continued degeneration. Too much = further damage.

The key is progressive loading:

1. Reduce pain with isometrics
2. Build tendon capacity with eccentrics
3. Progress to full loading

Isometric Exercises (Pain Relief)

Isometrics (muscle contraction without movement) can provide immediate pain relief and are safe even in irritable tendons.

Standing Isometric Calf Raise

1. Stand on one or both feet
2. Rise onto toes
3. Hold at top position 30-45 seconds
4. Perform 4-5 repetitions
5. Can do multiple times daily

For insertional tendinopathy: Perform on flat ground (not off a step) to avoid aggravating the insertion.

Wall Isometric

1. Face wall, hands on wall
2. Push onto toes against wall
3. Hold 30-45 seconds
4. 4-5 repetitions

Seated Heel Raise Isometric

If standing is too painful:

1. Sit with feet flat
2. Push down through toes, lifting heels
3. Hold 30-45 seconds
4. Add weight across knees to increase load

Eccentric Exercises (Primary Treatment)

Eccentric loading (lowering phase of the exercise) is the gold standard for Achilles tendinopathy treatment.

Alfredson Protocol (Midportion)

The original research protocol:

Straight-knee eccentric:

1. Stand on step, balls of feet on edge
2. Rise up on both feet
3. Shift weight to affected leg
4. Slowly lower heel below step level (eccentric phase)
5. Use other leg to help rise back up
6. 3 sets of 15 repetitions, twice daily

Bent-knee eccentric: Same protocol with knee slightly bent (targets soleus muscle).

Progression:

• Start with body weight
• Add weight via backpack or weighted vest as tolerated
• Some discomfort during exercise is acceptable (up to 5/10)
• Progress when exercises become too easy

Duration: 12 weeks of consistent daily exercise.

Modifications for Insertional Tendinopathy

Traditional heel-drops below step level may aggravate insertional problems.

Modified eccentric:

1. Perform on flat ground (not off step)
2. Rise on both feet
3. Lower slowly on affected leg
4. Don't go below neutral (floor level)
5. 3 sets of 15, twice daily

Silbernagel Protocol (Alternative)

A more graduated approach:

Phase 1 (Weeks 1-2):

• Isometrics for pain
• Bilateral heel raises
• Easy eccentric loading

Phase 2 (Weeks 3-6):

• Single-leg heel raises (concentric + eccentric)
• Increase load progressively
• Add resistance as tolerated

Phase 3 (Weeks 6-12):

• Heavy slow resistance training
• Explosive movements as tolerated
• Return to running protocol

Heavy Slow Resistance Training

Emerging research supports heavy slow resistance as equivalent or superior to eccentrics.

Protocol

1. Seated calf raise machine or leg press calf raise
2. 3 sets of 15 reps (week 1)
3. Progress to 4×12, then 4×10, then 4×8, then 4×6 over weeks
4. Increase weight as you decrease reps
5. 3-second lift, 3-second lower
6. 3 times per week

This approach builds load capacity through the full range with controlled tempo.

Calf Strengthening

Beyond specific tendon rehab, overall calf strength matters.

Standing Calf Raises

1. Stand on step, heels off edge
2. Rise onto toes
3. Lower slowly
4. 3 sets of 15

Progression: Single leg, add weight.

Seated Calf Raises

Targets soleus (deeper calf muscle).

1. Sit with weight across knees
2. Rise onto toes
3. Lower slowly
4. 3 sets of 15

Jump Rope (Later Stages)

Once pain is minimal:

• Start with 30-second intervals
• Progress duration gradually
• Builds reactive strength

Stretching

Controversial: Some argue against stretching for Achilles tendinopathy (may compress the tendon). Others find it helpful.

If Stretching Feels Good

Gastrocnemius stretch:

1. Wall stretch, back knee straight
2. Hold 30-60 seconds
3. Don't stretch into pain

Soleus stretch:

1. Wall stretch, back knee bent
2. Hold 30-60 seconds

Gentle only: Don't force deep stretches, especially with insertional issues.

Alternative: Active Mobility

Instead of static stretching:

• Ankle circles
• Slow controlled heel raises through full range
• Walking

Sample Treatment Programs

Week 1-2 (Acute Management)

Daily:

• Isometric holds: 5×45 seconds, 2-3 times daily
• Ice after activity if needed
• Reduce aggravating activities (running, jumping)

Every other day:

• Bilateral calf raises: 3×15
• Light eccentric loading (flat ground)

Weeks 3-6 (Loading Phase)

Daily:

• Eccentric heel drops: 3×15, twice daily
• Progress to weighted as tolerated

3× per week:

• Single-leg calf raises: 3×12
• Heavy slow resistance if available

Activity: Walking, cycling, swimming okay. No running yet.

Weeks 7-12 (Progressive Loading)

Continue:

• Eccentrics (weighted): 3×15 daily
• Calf strengthening: 3× per week

Begin:

• Jump rope or small hops: progress gradually
• Return to running protocol (see below)

Maintenance (Ongoing)

• Calf strengthening 2-3× per week
• Monitor for warning signs
• Maintain training load principles

Return to Running

Prerequisites

Before returning to running:

• Pain is minimal (2/10 or less with activities)
• Can do 25+ single-leg calf raises without significant pain
• Completed minimum 8-12 weeks of loading program
• Can hop without pain

Protocol

Week 1: Walk 5 min, jog 1 min × 3, walk 5 min (3 sessions)

Week 2: Walk 3 min, jog 2 min × 4 (3 sessions)

Week 3: Walk 2 min, jog 3 min × 4 (3 sessions)

Week 4: Jog 5 min, walk 1 min × 3 (3 sessions)

Progress by: Increasing jog intervals, decreasing walk intervals.

Rules

• Pain during running should be <3/10
• No worse the next morning
• No progressive increase in symptoms
• If symptoms flare, back up 1-2 weeks

Other Treatment Considerations

Footwear

• Adequate heel cushioning
• Heel lift insert (temporarily reduces tendon load)
• Avoid flat shoes and barefoot walking during acute phase

Activity Modification

Reduce:

• Running volume and intensity
• Hill training
• Speed work
• Jumping

Maintain fitness with:

• Cycling
• Swimming
• Elliptical
• Walking

Night Splint

May help reduce morning stiffness by keeping foot in neutral overnight.

Shockwave Therapy

For cases not responding to exercise. Typically 3-5 sessions.

Injections

PRP (Platelet-Rich Plasma): Some evidence for benefit, usually reserved for recalcitrant cases.

Cortisone: Generally avoided for Achilles (may weaken tendon).

Common Mistakes

Too Much Rest

Complete rest leads to further tendon weakening. Load is necessary for healing.

Returning to Running Too Soon

Tendons take longer to adapt than muscles. Even if you feel better, the tendon needs time to remodel (12+ weeks).

Not Enough Load

Light exercise won't create the stimulus needed for tendon adaptation. Progressive overload is key.

Inconsistent Effort

Skipping days undermines progress. Daily loading (or near-daily) is important.

Ignoring Pain Patterns

Pain that warms up is typical for tendinopathy. Pain that gets worse during activity or doesn't settle within 24 hours = too much load.

When to See a Professional

Immediately

• Sudden "pop" with severe pain (possible rupture)
• Unable to push off on affected leg
• Significant swelling with bruising

Soon

• No improvement after 6-8 weeks of consistent exercise
• Pain severe enough to limit daily activities
• Unsure of diagnosis

For Optimization

• Biomechanical assessment
• Gait analysis
• Manual therapy
• Supervised progression

The Bottom Line

Achilles tendinopathy requires patience and consistent loading. The tendon needs progressive stress to remodel—eccentrics and heavy slow resistance are the cornerstones of treatment.

Keys to success:

1. Load the tendon—isometrics for pain, eccentrics for remodeling
2. Be consistent—daily loading for 12+ weeks
3. Progress gradually—add weight as exercises become easier
4. Don't rush return to running—tendons adapt slower than you feel
5. Maintain calf strength—strong calves protect the Achilles

The Achilles is resilient, but it requires respect. Give it the progressive load it needs, and it will heal.

Load is medicine for tendons.