Achilles Tendinitis Exercises and Treatment Guide

What is Achilles tendinopathy and why does loading help?

The Achilles tendon connects the calf muscles (gastrocnemius and soleus) to the heel bone. When the tendon is overloaded repeatedly without adequate recovery, the internal structure degenerates — a process better described as tendinopathy than tendinitis, because the tissue change is not primarily inflammatory.

Loading the tendon through controlled, progressive exercise stimulates the collagen remodeling that restores tendon structure. The goal is to stress the tissue enough to provoke adaptation without re-injuring it. This is why rest alone rarely resolves the problem long-term.

The American Physical Therapy Association's clinical practice guideline for midportion Achilles tendinopathy recommends a structured loading program as the cornerstone of treatment 1Ref 1Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR (2018).Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.Structured loading program as the cornerstone of midportion Achilles tendinopathy treatment; return-to-sport staging; premature return as cause of prolonged symptoms.

What is the eccentric heel-drop exercise and how is it done?

The eccentric heel drop (also called the Alfredson protocol) is the most studied loading exercise for midportion Achilles tendinopathy. The movement involves:

1. Stand with the balls of your feet on the edge of a step, heel hanging off. 2. Use both feet or a railing to rise onto your toes (concentric phase). 3. Shift weight to the affected foot. 4. Slowly lower the heel below the step edge over 2–3 seconds (eccentric phase). 5. Return to the starting position and repeat.

The standard starting point is 3 sets of 15 repetitions, performed twice daily. One set is done with the knee straight (targeting the gastrocnemius) and one with the knee slightly bent (targeting the soleus). The protocol runs 12 weeks.

Some discomfort during the exercise is expected and acceptable — a monitored pain approach, where a mild level of pain during loading is tolerated. Sharp, escalating pain is a signal to reduce load 1Ref 1Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR (2018).Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.Structured loading program as the cornerstone of midportion Achilles tendinopathy treatment; return-to-sport staging; premature return as cause of prolonged symptoms.

What other exercises and treatments are used?

Heavy slow resistance (HSR) training is an alternative that some people tolerate better than eccentric-only work. Exercises like seated and standing calf raises with added weight, performed slowly (3 seconds up, 3 seconds down), apply similar tendon stimulus. Research on patellar tendinopathy found heavy slow resistance training produced comparable results to eccentric decline squat training, and patient satisfaction was higher with HSR 2Ref 2Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP (2009).Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy.Heavy slow resistance training produces comparable outcomes to eccentric training in tendinopathy with higher patient satisfaction.

Isometric holds — pressing the ball of the foot into a wall or step with the ankle at 90 degrees, holding for 30–45 seconds — are used in acute flare-ups because they provide load with less tendon movement, which reduces pain in the short term. A randomized trial found isometric contractions produced immediate analgesic effects superior to isotonic loading for patellar tendinopathy, supporting their use in pain management during flares 3Ref 3Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J (2015).Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.Isometric contractions produce immediate analgesic effects superior to isotonic loading during tendinopathy flares, supporting their use in acute pain management.

Manual therapy and stretching of the calf complex are adjuncts that improve ankle range of motion, which reduces tendon strain during walking and running.

Shockwave therapy (extracorporeal shockwave) is a non-invasive treatment delivered by a physical therapist or sports medicine clinician using a device that applies acoustic waves to the tendon. Evidence supports its use when loading programs alone have not worked.

Activity modification: continuing to walk and perform low-impact activity is encouraged; high-impact running or jumping should be reduced, then reintroduced gradually.

How is the return-to-running or return-to-sport progression structured?

A physical therapist typically guides a staged return-to-sport program after the tendon tolerates strength training without pain:

• Stage 1: Isometric loading, walking without pain
• Stage 2: Eccentric and isotonic calf loading
• Stage 3: Energy storage exercises — single-leg calf raise to failure, low-level hopping
• Stage 4: Running reintroduction (walk-run intervals)
• Stage 5: Full running, sport-specific drills

Return to full sport typically occurs between 3 and 6 months depending on symptom severity at presentation. The APTA guideline emphasizes that prematurely returning to high-impact loading before adequate strength and pain resolution is the most common cause of prolonged symptoms 1Ref 1Martin RL, Chimenti R, Cuddeford T, Houck J, Matheson JW, McDonough CM, Paulseth S, Wukich DK, Carcia CR (2018).Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.Structured loading program as the cornerstone of midportion Achilles tendinopathy treatment; return-to-sport staging; premature return as cause of prolonged symptoms.

What is the role of a physical therapist in Achilles tendinopathy?

A physical therapist (PT) or sports medicine clinician is the right first stop for Achilles tendon pain. They will:

• Confirm the diagnosis and distinguish midportion tendinopathy from insertional tendinopathy (which has a different protocol) and from a partial or full rupture
• Assess contributing factors: ankle stiffness, calf weakness, training load errors, footwear
• Tailor the loading program to your baseline strength and pain level
• Monitor progress and adjust the protocol

Gale can help you connect with a primary care or sports medicine clinician who can provide a referral or initial evaluation, and work alongside your physical therapist.