Achilles Tendinopathy Exercises: A Loading Programme That Works

Quick answer: the four loading stages

• Stage 1 - isometrics for pain modulation: mid-range calf holds, 5 x 30-45 seconds, once or twice daily. Useful when the tendon is highly irritable and every step hurts.
• Stage 2 - heavy slow resistance or eccentrics: bilateral then single-leg heel raises, 3-4 sets of 6-15 reps, 3-4 times per week, loaded progressively over weeks.
• Stage 3 - energy storage: hopping, skipping, and bilateral to single-leg pogos, introduced only when strength work is well tolerated and morning stiffness is settling.
• Stage 4 - energy storage and release: sport-specific plyometrics, sprint drills, change of direction, and graded return to running.
• Never skip stages because the pain feels manageable on the day. Tendon symptoms lag load by 24 hours, which is why the morning-after response is the real test.

First: midportion or insertional?

Palpate for the point of maximal tenderness. Midportion tendinopathy is tender roughly 2-6 cm above the calcaneal insertion, with pain that classically warms up during activity and stiffens after rest. Insertional tendinopathy is tender at the bone-tendon junction, is frequently aggravated by dorsiflexion, and often coexists with retrocalcaneal bursitis or a Haglund deformity.

The distinction matters because it changes the exercise setup. Insertional pain is usually irritated by loading into full dorsiflexion, so the classic protocol of heel drops off a step is often the wrong prescription. Keep insertional loading from a flat surface or a small block, restricting range to plantargrade rather than dropping below neutral.

The strength phase: dose is the intervention

The original Alfredson protocol (3 x 15 eccentric heel drops, twice daily, 7 days per week, for 12 weeks) has good evidence but poor adherence, and later work shows heavy slow resistance produces comparable or better outcomes at a fraction of the session volume. Either is defensible. What matters is that load increases over the programme rather than the same body-weight raises for three months.

A practical progression: bilateral heel raises, then bilateral loaded (backpack, dumbbells, or a Smith machine), then single-leg body weight, then single-leg loaded, then seated calf raise added to bias the soleus. Move slowly - roughly 3 seconds up, 3 seconds down - and train to genuine fatigue in the 6-15 rep range.

Progress load when the patient completes their prescribed sets with 2 reps in reserve and their 24-hour response is acceptable. Expect improvements over 8-12 weeks, and tell patients this from day one: an expectation of a 2-week fix guarantees they abandon the programme.

Pain rules patients can apply themselves

• Pain during loading up to about 5/10 is acceptable for tendinopathy - this is not a tissue-damage signal.
• The 24-hour rule: symptoms and morning stiffness the next day should be no worse than before the session. If they are, hold or reduce the load rather than stopping altogether.
• Track morning stiffness duration as the primary outcome. It is a more reliable progress marker than pain during activity, which fluctuates with the warm-up effect.
• Avoid complete rest. Detraining reduces tendon and muscle capacity and makes the eventual return to load harder.

Common reasons a programme stalls

• Load never actually increased - three months of body-weight calf raises is maintenance, not rehabilitation.
• Soleus was ignored. Running demands are largely soleus-driven, so seated calf raise progression is not optional for runners.
• Insertional pain loaded into full dorsiflexion, keeping the tendon compressed and irritable.
• Energy storage skipped entirely, so the patient is strong but returns to running without stiffness or elastic capacity, and flares within a week.
• Running volume returned in one step rather than a graded progression.
• Kinetic chain contributors unaddressed: reduced ankle dorsiflexion range, hip extensor weakness, or a sudden change in footwear, surface, or training volume.

Adjuncts, and what the evidence supports

A temporary heel raise can reduce dorsiflexion load and often helps insertional presentations in the short term; it is a symptom-management tool, not a treatment. Extracorporeal shockwave therapy has modest supporting evidence as an addition to exercise in recalcitrant cases, not as a replacement. Corticosteroid injection into the tendon is generally avoided given concerns about tendon integrity and poor longer-term outcomes.

Refer on when there is a palpable gap, a positive Thompson test, or a sudden onset with an audible snap - these suggest rupture. A hot, swollen, systemically unwell presentation, bilateral spontaneous tendinopathy in a young patient (consider familial hypercholesterolaemia), or recent fluoroquinolone use also warrant medical review.

Return to running criteria

• Pain-free or low, stable symptoms during daily activity, with morning stiffness under about 10 minutes.
• Single-leg heel raise capacity within roughly 10% of the uninvolved side for repetitions and load.
• Tolerates 10 x single-leg hops and 30 seconds of pogo hopping without a 24-hour flare.
• Then use a walk-run progression, starting with short intervals every other day, adding roughly 10% weekly volume, and keeping speed work and hills for last.

Key takeaways

• Distinguish midportion from insertional tendinopathy first - it changes the loading range you prescribe.
• Progressive load, not a specific exercise, is the active ingredient; heavy slow resistance and eccentrics both work.
• Use the 24-hour response and morning stiffness as the decision rule for progressing or holding.
• Add energy storage and release work before returning to running, or the flare is predictable.
• Expect 8-12 weeks minimum, and set that expectation on day one to protect adherence.

Frequently asked questions

What are the best exercises for Achilles tendinopathy?

Progressive calf loading is the core: isometric holds when irritable, then heavy slow resistance or eccentric heel raises, then hopping and running drills. The specific exercise matters less than steadily increasing load over 8-12 weeks.

How long does Achilles tendinopathy take to heal?

Most people improve meaningfully within 8-12 weeks of consistent loading, though full return to sport commonly takes 3-6 months. Long-standing cases take longer.

Should Achilles tendinopathy exercises hurt?

Some discomfort during loading, up to around 5/10, is acceptable. The key check is the next morning: if stiffness and pain are worse than usual 24 hours later, the dose was too high.

Are eccentric heel drops off a step suitable for insertional pain?

Usually not. Dropping below neutral compresses the insertion and often flares symptoms. Load from a flat surface within a comfortable range instead.

Should I stop running with Achilles tendinopathy?

Complete rest is rarely helpful. Reduce volume and intensity to a level with an acceptable 24-hour response, keep loading the tendon with strength work, and rebuild running gradually.