Achilles tendinopathy is treated with progressive loading, in five stages: isometric holds for pain, then heavy slow resistance or eccentric heel drops as the main programme, then progressive load increase, then energy-storage work, then return to running. The core programme runs for twelve weeks before it should be judged. The realistic timeline to comfortable running is three to six months, and a five-year follow-up of the standard eccentric protocol found average symptom scores improved from 49 to 84 out of 100.
Where a tendon has already had six months of good loading and is still painful, the next option is covered in PhysioHub’s review of shockwave therapy for Achilles tendinopathy.
These are stages rather than options. They run in order, and the timings overlap.
| Stage | When | What it is for | Typical dose |
|---|---|---|---|
| 1. Isometric holds | Weeks 0 to 2, and during flares | Reducing pain enough to start loading | 5 holds of 45 seconds, 1 to 2 times daily |
| 2. Heavy slow resistance or eccentric heel drops | Weeks 2 to 12 | The main treatment, building tendon capacity | 3 sets of 15, twice daily for eccentrics; 3 to 4 sets of 6 to 15, 3 times weekly for heavy slow resistance |
| 3. Progressive load increase | Weeks 6 to 16 | Adding external weight as capacity grows | Increase load rather than repetitions |
| 4. Energy storage and plyometrics | Weeks 12 onwards | Preparing the tendon for the speed of running | 2 to 3 sessions weekly, on alternate days |
| 5. Graded return to running | Month 3 to 6 | Rebuilding running volume without re-provoking it | Every other day, walk-run to start |
The most common reason this fails is stopping at stage two. Pain settles around weeks eight to twelve, running resumes at previous volume, and the tendon, which has capacity for slow heavy work and none for fast elastic work, flares within a fortnight.
This is a documentary review of published loading protocols rather than a programme prescribed for your tendon. The five stages reflect the sequence used in current tendon rehabilitation practice, ordered by when each is introduced.
The sources read were the five-year follow-up of Alfredson’s heel-drop programme in chronic mid-portion Achilles tendinopathy, which reported VISA-A scores rising from 49.2 at baseline to 83.6 at five years, and a randomised controlled trial in JOSPT comparing the full Alfredson protocol against a lower repetition-volume version. Evidence checked in August 2026.
Two things this review deliberately does not do. It does not claim the specific numbers are optimal: the original protocol prescribes 180 heel drops a day, and the JOSPT trial exists precisely because that volume is onerous and may not be necessary. And it does not distinguish in detail between mid-portion and insertional tendinopathy in every stage, though the distinction matters enormously and is covered in the cautions.
No treatment costs are quoted, because prices were not verified for this review.
Find the sore spot with one finger. Two to six centimetres above the heel bone is mid-portion tendinopathy, which is what most of this programme is written for. Right at the bone is insertional, which needs the range limiting.
Check the warm-up pattern. Tendinopathy classically hurts for the first ten minutes of activity, eases during, and is worst the following morning. That pattern is close to diagnostic.
Rule out the emergency first. A sudden sharp pain like being kicked in the back of the leg, with difficulty pushing off, needs same-day assessment for a rupture. This programme does not apply to that.
Look at the tendon. A visible thickening in the mid-portion supports the diagnosis. A tendon that has become thicker is not a tendon that is beyond help; thickening is part of how it adapts.
Note whether stretching helps or hurts. If calf stretching consistently makes it worse, that points to the insertion, where end-range dorsiflexion compresses the tendon against the bone.
What it is
Holding a static calf raise position under load without movement, typically a mid-range heel raise held for 45 seconds.
What it is for
Reducing pain enough to begin loading, and maintaining some tendon stimulus in a tendon too irritable for movement. It is the entry point rather than the treatment.
What to actually do
Five holds of around 45 seconds, resting a minute between, once or twice a day. Start on two legs and progress to one as tolerated. For an insertional problem, keep the heel level rather than dropping it.
What the evidence supports
Isometric loading produces short-term reductions in tendon pain, and the size and reliability of that effect has been questioned in later work. It is used because it is safe and because it lets people start, rather than because it is a proven treatment on its own.
Limits and cautions
Do not stay here. Isometrics do not build the capacity the tendon needs, and a programme that never progresses past this stage will not resolve the problem.
Why it ranks first
It is the only stage that works on a tendon too painful to move, which makes it the way in for the people who need the programme most.
What it is
The main programme, in one of two forms. Eccentric heel drops mean rising on both feet and lowering slowly on the affected one, off the edge of a step. Heavy slow resistance means slow calf raises through the full movement, up and down, against substantial weight.
What it is for
Building the tendon’s load tolerance. This is the stage that changes the tendon, and everything else on this list supports it.
What to actually do
The original eccentric protocol is 3 sets of 15 with the knee straight and 3 sets of 15 with the knee bent, twice a day, for twelve weeks, which comes to 180 repetitions daily. Heavy slow resistance is 3 to 4 sets of 6 to 15 repetitions, three times a week, with enough weight that the last repetitions are genuinely hard, taking about 3 seconds up and 3 seconds down.
What the evidence supports
The five-year follow-up of the eccentric protocol found VISA-A scores improved from 49.2 to 83.6, with around 40% of participants completely pain free. A randomised trial in JOSPT compared the full protocol against a lower repetition-volume version and found the reduced volume was not inferior, which matters because adherence to 180 daily repetitions is poor.
Limits and cautions
Some pain during these exercises is expected and acceptable. The usual rule is that pain up to about 5 out of 10 during the exercise is fine, provided it has settled to baseline by the next morning. For insertional tendinopathy, do the exercises on flat ground rather than dropping the heel below the step.
Why it ranks second
It is the treatment. Stages one, three, four and five exist to get you into it, progress it and then convert its results into running.
What it is
Systematically adding external weight, through a rucksack, dumbbells, a weight vest or a calf raise machine, as the tendon tolerates more.
What it is for
Continuing to challenge the tendon once bodyweight stops being difficult. A tendon adapts to the load it meets, and a programme that stays at bodyweight for twelve weeks stops producing change around week five.
What to actually do
When you can complete the prescribed sets with the last few repetitions feeling comfortable, add weight rather than repetitions. Small increments, roughly weekly, judged on how the tendon feels the following morning.
What the evidence supports
Progressive overload is the mechanism underlying every effective tendon loading programme, and it is the variable most often left out when a programme is handed over as a sheet of exercises with fixed numbers.
Limits and cautions
Increase one variable at a time. Adding weight, repetitions and frequency in the same week makes it impossible to tell which change caused a flare.
Why it ranks third
It is not a separate set of exercises so much as the thing that makes stage two keep working, and it is the most commonly omitted part of the whole programme.
What it is
Fast, elastic loading: hopping, skipping, bounding and pogo work, where the tendon stretches and recoils rapidly rather than contracting slowly.
What it is for
Running loads the Achilles at speeds heavy slow work never reaches, and the tendon stores and returns energy with each stride. A tendon strong in slow work and untrained in fast work is exactly the tendon that flares in week two of a return to running.
What to actually do
Two to three sessions a week on alternate days, never consecutive days, because this is the highest-stress stage. Start with double-leg hopping on the spot, progress to single leg, then to directional hopping and skipping. Keep volumes low and quality high.
What the evidence supports
Staged tendon rehabilitation models place energy-storage loading between strength work and return to sport, on the reasoning that tendon capacity is speed-specific. This stage is the most clinically reasoned and the least directly trial-tested of the five.
Limits and cautions
Do not start this while the tendon is still painful on the morning after a strength session. Alternate days is not a suggestion: fast elastic loading needs a full recovery day between exposures.
Why it ranks fourth
It is the bridge nobody builds, and it is the reason a well-executed strength programme still ends in a flare when running resumes.
What it is
Rebuilding running volume from a low base, in a structured progression rather than by feel.
What it is for
Getting back to running without repeating the loading error that caused the problem in the first place, which in most cases was a rapid increase in volume, hills or pace.
What to actually do
Run every other day, not consecutive days. Start with walk-run intervals on flat, even ground. Increase one variable per week: distance, or frequency, or intensity. Hills and speed work come last, because both dramatically increase Achilles load. Keep the strength work going throughout, and expect to continue it at reduced frequency indefinitely.
What the evidence supports
The morning-after test is the most practical monitoring tool available. Stiffness and pain on the first steps out of bed that exceed your baseline mean the previous day was too much, and that signal is more reliable than how the tendon felt during the run.
Limits and cautions
Three to six months to comfortable running is normal for a tendinopathy that has been present for months. Anyone promising faster than that is describing a different problem.
Why it ranks fifth
It is where the previous four stages either pay off or are wasted, and it is the stage people rush.
| Stage | Builds tendon capacity | Reduces pain quickly | Needs equipment | Weekly frequency | Skip it? |
|---|---|---|---|---|---|
| Isometric holds | Minimally | Yes, short-term | No | Daily | Yes, if not very painful |
| Heavy slow resistance or eccentrics | Yes, this is the treatment | No, slower | Step, then weight | 3 to 14 sessions | No |
| Progressive load increase | Yes | No | Yes | Built into stage 2 | No |
| Energy storage and plyometrics | Yes, at speed | No | No | 2 to 3 | Only if not returning to running or sport |
| Graded return to running | Maintains it | No | No | 3 to 4 | Only if you do not run |
The last column is the practical one. Only stage one is genuinely optional, and only for a tendon that is not too painful to load. Stages two and three are the programme, and stages four and five are non-negotiable for anyone intending to run again.
If the tendon hurts to touch and you cannot face loading it, start at stage one this week and expect to move into stage two within a fortnight.
If you can already do a single-leg heel raise without much pain, skip stage one and start heavy slow resistance three times a week.
If the sore spot is right at the heel bone rather than above it, this is insertional. Do everything on flat ground, avoid dropping the heel below a step, and stop stretching the calf.
If you have done twelve weeks of loading and improved but plateaued, the missing piece is almost always stage three. Add weight rather than repetitions.
If you got back to running and it flared within two weeks, stage four was skipped. Go back and build the elastic capacity before rebuilding volume.
If six months of genuinely progressive loading has not helped, that is the point at which shockwave becomes a reasonable next conversation rather than the first thing to try.
Around Uckfield the Achilles cases cluster in a predictable way. Uckfield parkrun runs every Saturday at 9am on the trail course at Hempstead Playing Fields, and its surface and undulation ask more of a calf than a flat road route does. Add Uckfield Runners returning to hill sessions in the autumn, and the tendons that present in October and November are mostly attached to people who added hills, added pace, or added both in the same three weeks.
The pattern in the history is almost always the same, and it is a change in the type of loading rather than the amount. Someone whose weekly mileage has been stable for a year develops Achilles pain six weeks after starting a Tuesday hill session, and reports their mileage as unchanged, which it is. The Achilles does not respond to mileage alone; it responds to how fast and how forcefully it is being stretched and recoiled, and a hill session changes that more than an extra five kilometres of steady running ever would.
Where a tendon is not responding to loading and you want the broader picture of how these behave, the tendinopathy page covers it.
How long does Achilles tendinopathy take to heal?
The loading programme runs twelve weeks before it should be judged, and three to six months is the realistic timeline to comfortable running for a tendon that has been painful for months. A five-year follow-up of the standard eccentric programme found average symptom scores improved from 49 to 84 out of 100, with around 40% completely pain free.
What is the Alfredson protocol?
It is the original eccentric heel-drop programme for mid-portion Achilles tendinopathy: 3 sets of 15 repetitions with the knee straight and 3 sets of 15 with the knee bent, performed twice daily for twelve weeks. That comes to 180 repetitions a day, and a later randomised trial found a lower repetition volume was not inferior, which matters because adherence to the full version is poor.
Should Achilles exercises hurt?
Some pain during loading is expected and acceptable. The usual guide is that pain up to around 5 out of 10 during the exercise is fine, provided it has returned to your normal baseline by the next morning. Pain that is still raised 24 hours later means the load was too high for now.
Can I keep running with Achilles tendinopathy?
Often yes, at reduced volume, on alternate days, on flat even ground and without hills or speed work. Complete rest is rarely the right answer because tendons lose capacity quickly and the same load is waiting when you return. The morning-after response is the guide to how much is acceptable.
What is the difference between insertional and mid-portion Achilles tendinopathy?
Mid-portion pain sits two to six centimetres above the heel bone; insertional pain sits right at the bone. The distinction changes the exercises, because pulling the ankle up into full dorsiflexion compresses the insertion against the heel bone. Insertional problems are loaded on flat ground without dropping the heel, and calf stretching usually makes them worse.
Should I stretch my Achilles tendon?
For mid-portion problems, stretching is neither necessary nor particularly harmful, and loading is what changes the tendon. For insertional problems, hard calf stretching compresses the painful tissue and commonly makes symptoms worse, so it is best avoided.
When should I consider shockwave therapy for an Achilles problem?
After a genuinely progressive loading programme has been followed for at least three to six months without adequate improvement. Shockwave is an adjunct to loading rather than an alternative, and the tendons that respond best to it are the ones that have already had good rehabilitation.
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