Achilles treatment

Achilles tendonitis exercises and stretches: the right programme for where it hurts

The exercise that heals a sore Achilles cord can aggravate a sore Achilles insertion. Work out which one you have, then follow the programme for it: about twelve weeks, most days of the week.

Written and reviewed by Dr. Tom Biernacki, DPM, FACFAS · board-certified foot and ankle surgeon

Loading exercise is the Achilles tendonitis treatment with the strongest evidence behind it. It is also the one most often done wrong, because most exercise sheets give a single programme for two different problems. This page gives you both programmes, how much discomfort is acceptable, when to stretch and when not to, and a printable sheet to keep by the stairs.

On this page

Which type do you have?

Press along the tendon from the heel bone upwards and find the sorest spot. Where it sits decides the programme.

Midportion Insertional
Where it hurts In the cord itself, roughly 2–6 cm above the heel bone Right on the back of the heel bone, where the tendon attaches
What you feel A thickened, tender segment you can pinch between finger and thumb Tenderness on the bone, often with a bump that shoes rub
Heel drops below the step Usually fine, and part of the treatment Often makes it worse, because it squeezes the tendon against the bone
Programme Heel drops off a step Floor-level heel drops, no drop below level

If you are not sure, start with the insertional version. It is the gentler of the two and it does not harm a midportion tendon. The full explanation of why the two behave differently is on the Achilles tendonitis page.

Do not start exercises if the pain began with a pop or snap, a feeling of being kicked in the back of the leg, or sudden weakness pushing off, or if you cannot rise onto tiptoe on that leg. That is a possible Achilles rupture and needs same-day assessment. See sudden heel pain for the other causes that should not be exercised through.

How much pain is OK during the exercises

Tendons respond to load, and a little discomfort during the exercises is expected. What matters is how the tendon behaves afterwards. A Swedish randomised trial let people with Achilles tendinopathy keep running and jumping during rehabilitation, as long as pain stayed within set limits, and they did as well at twelve months as a group who stopped those activities for six weeks.

Use these three checks after every session:

  • During: discomfort is acceptable if it stays mild to moderate. Many clinicians use about 5 out of 10 as the ceiling.
  • By the next morning: it has settled back to where it was. Morning stiffness is the most honest gauge of how the tendon coped with yesterday.
  • Week to week: the baseline is steady or improving, not climbing.

If any of the three fails, drop the load for a few days (fewer repetitions, less weight, or both legs instead of one) rather than stopping altogether.

Midportion Achilles exercises: heel drops off a step

This is the classic Alfredson programme. In the 1998 study that introduced it, fifteen recreational athletes with long-standing midportion Achilles pain did these heel drops for twelve weeks, and all fifteen were back to running at their previous level. It is the programme most later research has been measured against.

  1. Set up. Stand on the edge of a step on the balls of both feet, holding a rail or wall for balance. Heels hang free.
  2. Rise on both feet, then take the good foot off the step so the sore leg is holding you at the top.
  3. Lower slowly on the sore leg, about three seconds, until the heel is below the level of the step.
  4. Come back up using both legs. The lowering is the exercise; the lift is just the way back up.
  5. Straight knee: 3 sets of 15. Then repeat with the knee slightly bent for another 3 sets of 15. The bent-knee version works the soleus, the deeper calf muscle that also pulls on the Achilles.
  6. Twice a day, every day, for twelve weeks. When a session feels easy, add weight: a backpack with a few books in it, increased gradually.

Prefer three sessions a week? A 2015 Danish trial compared the daily heel-drop programme with heavy, slow calf raises (lifting and lowering over about three seconds each way, getting heavier across the twelve weeks) done three times a week. Both worked equally well at twelve weeks and at one year. More people stuck with the heavier, less frequent programme. The best programme is the one you will still be doing in week ten.

Insertional Achilles exercises: no drop below level

Same principle, different range. When the pain is at the bone, letting the heel sink below the step presses the tendon into the back of the heel bone at exactly the sore spot. The fix, tested in a 2008 pilot study from the same Swedish group, is to do the lowering from the floor so the heel never drops below level. Two thirds of the patients in that study were satisfied and back to their usual activity after about four months.

  1. Start with holds if it is very irritable. Rise onto both toes, stop halfway, and hold for 30 to 45 seconds. Rest a minute. Repeat about five times, once or twice a day. Holds like this are often the least painful way to begin loading an angry insertion.
  2. Progress to floor-level heel drops. Stand on a flat floor, rise on both feet, shift onto the sore leg and lower slowly, about three seconds, until the heel touches the floor. Do not let it go lower.
  3. 3 sets of 15, twice a day. Knee straight, then repeat with the knee slightly bent.
  4. Add weight slowly once the sets are comfortable, the same way as the midportion programme.
  5. Put a small heel lift in both shoes while it settles. Raising the heel a little reduces both the pull and the compression at the insertion. Both shoes, so you do not create a leg-length difference.

Insertional problems are slower than midportion ones. Six months is not unusual, and it helps to know that before week eight. A shoe whose stiff heel counter rubs the sore spot will keep it going however well you do the exercises; see Haglund’s deformity if there is a bump there.

Dr. Tom Biernacki on the stages of Achilles tendinosis, from a healthy tendon to a rupture, and the exercises and pain-relief options that fit each stage. Michigan Foot Doctors.

Achilles stretches: when they help and when they do not

Stretching feels like the obvious treatment, and for a midportion problem gentle calf stretching is reasonable alongside the loading work. It is not a substitute for it: stretching changes how the calf feels, while loading changes what the tendon can tolerate.

  • Wall calf stretch (straight knee). Hands on a wall, sore leg behind, heel down, knee straight, lean forward until you feel the calf. Hold 30 seconds, three times.
  • Bent-knee calf stretch. Same position, but bend the back knee while keeping the heel down. You will feel it lower, towards the tendon. Hold 30 seconds, three times.
  • For insertional pain, skip the deep stretches. Hanging the heel off a step, or leaning hard into a wall stretch, compresses the tendon against the bone. Keep any stretch gentle and short of the sore spot being pinched.

If stretching reproduces the exact pain at the back of the heel bone, that is the tendon being compressed, not a tight muscle being lengthened. Stop that stretch.

Progressing, and getting back to running

Complete rest is rarely the answer. The trial above found no harm in continued running when pain stayed within limits, and a tendon rested into weakness tends to flare again on the first run back. A sensible order:

  1. Walking without a limp, and the morning stiffness settling.
  2. Single-leg heel raises on the sore side getting close to the good side in number.
  3. Gentle hops on both feet, then on the sore foot, without pain climbing the next morning.
  4. Easy running on the flat, short and slow, every other day at first.
  5. Hills, speed work and jumping last. These load the Achilles hardest and are the usual cause of a relapse.

Keep doing the loading programme through the return to running, and for a while after. Stopping the exercises the week the pain goes is the most common reason it comes back. More on running with heel pain is on the heel pain after running page.

Printable Achilles exercise sheet

A one-page summary of both programmes, the pain rules and the progression, sized to print on a single sheet of letter paper.

Download the Achilles exercise sheet (PDF)

Common questions

How often should I do Achilles tendonitis exercises?

The heel-drop programme is done twice a day, every day, for about twelve weeks. The heavy slow alternative is done three times a week for the same twelve weeks. Both are on this page. Doing either one only now and then is the most common reason a programme “does not work”.

Should Achilles exercises hurt?

Some discomfort during the exercises is normal and expected. The limits are: it stays mild to moderate while you do them, it has settled by the next morning, and it is not creeping up from week to week. Sharp pain, pain that lingers into the next day, or a steady rise means the load is too high. Reduce it rather than stopping.

How long do Achilles exercises take to work?

Plan on twelve weeks for a midportion problem and longer, often three to six months, for an insertional one. Improvement tends to be gradual rather than sudden, so judge it by the trend in your morning stiffness over weeks, not by how one session felt.

Can I stretch my Achilles if the pain is at the heel bone?

Gently, and never into the pinch. Deep stretching, and heel drops below a step, compress the tendon against the heel bone at the insertion, which is usually the exact spot that hurts. Floor-level loading and a small heel lift in both shoes are the better tools for insertional pain.

Is walking good for Achilles tendonitis?

Usually, yes. Walking is a mild, steady load and most people can keep doing it within the same pain limits as the exercises. Flat ground, a supportive shoe with a slightly raised heel, and shorter walks while it is irritable are sensible. Steep hills and long barefoot stretches on hard floors are the harder versions.

Should I keep doing the exercises once it stops hurting?

Yes, for a while. Taper to two or three sessions a week rather than stopping outright, and keep them going through any return to running. The tendon lags behind the pain in regaining its strength, and stopping early is the usual reason it comes back.

Back-of-heel pain in Michigan?

If you are a month into a programme and the tendon is getting angrier, the type or the dose is usually wrong. Dr. Biernacki can confirm which Achilles problem you have and set the programme to match, in Howell or Bloomfield Township.

See how to be seen

This page is education, not a diagnosis. Stop and get assessed if the pain started with a pop, if you cannot rise onto tiptoe on that leg, or if the back of the ankle is hot, red and swollen. Read our editorial policy for how it was written and what it will not claim.