Updated: May 27
It is understandable that active people might want to do their Achilles tendinopathy exercise progression quite quickly because they want to get out there and start running or playing their sport again. In this article, I explain why it is better to take your time with your Achilles rehab programme so you can get the most out of it and avoid injuring your tendon once again. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.
The terms tendinitis, tendonitis, tendinosis, and tendinopathy mean the same thing for all practical purposes, and we use these interchangeably in our articles.
In this article:
We also made a video about this:
What is a realistic Achilles rehab timeline?
A proper Achilles tendinopathy rehab programme takes at least 12 weeks and often much longer. This is because tendons take a longer time to react positively to exercise than muscles. The longer you’ve had your tendon pain for, the longer it usually takes to recover.
In such a rehab programme, there are certain targets that we want our patients to reach before they can safely progress to the next stage.
Most of our patients are active people who are keen to get back to their normal daily activities and sport. So it is not surprising that, when we explain these targets to them, some of them start racing ahead in their minds, thinking, “The quicker I can hit those targets, the quicker I can progress my Achilles rehab programme, the sooner my tendon will get better.”
This is why we try to ensure that they understand that it may well be counter-productive to progress their Achilles rehab programme too quickly. Read on to see why this is and how to go about progressing your Achilles exercises at the right pace.
How the Achilles tendon responds to rehab exercises
Whenever you do exercise, you get microdamage in your tissue, whether it’s in your muscles, tendons, or bones. This is absolutely normal, and it’s part of the strengthening process in which your body then repairs this microdamage so that the various types of tissue become stronger than before.
Your Achilles tendon is mainly made up of collagen fibres. Compared to other types of tissue, collagen fibres need quite a bit of time to rebuild and restore after exercise. Sports scientists estimate that this takes anything from 48 to 72 hours, with the tendons of people who are well-trained recovering somewhat quicker than those of people who are untrained or injured.
Achilles tendinopathy is an overuse injury that develops because your tendon didn’t get enough time to recover and repair after your exercise sessions. If you now rush your Achilles exercise progressions and don’t allow your tendon time to rebuild after your rehab sessions, you will likely just end up making it worse.
Example of how to progress an Achilles rehab programme
**This is just an example - every patient's programme and progression will look different.
When we treat, say, a runner with an Achilles tendinopathy, we first establish the baseline capacity (the current strength and endurance) of their injured tendon. Let’s say they can do 12 double-leg heel raises before the injured tendon starts hurting.
We would typically ask them to start off with three sets of ten double-leg heel raises. So, it's fewer than what they can do in one go, because they're going to do more sets.
Once they've done that three times on three non-consecutive days (see below about rest days) and it did not cause their tendon pain to increase, they will then start increasing those reps until they can hit the target of three double-leg sets of 20 without an issue.
Then we tell them, “Okay, let's test a small set of single-leg raises.” If the tendon accepts it, we start building those single-leg ones up over several sessions, never adding more than two or three, depending on how easy or difficult they were. And only adding if the previous session was easy and symptom free. If not, then they repeat the same session until it ticks both those boxes.
And all the time, we ask our patients to check that their tendon is happy with what they did the previous day. I say previous day, because tendons often don’t let you know immediately when you’re asking too much of them – they only complain after about 24 hours.
Also, when training for fitness (not rehab), some people really push those last two reps to get the most gains. I find it's best not to do that with a sensitive tendon or tendons in general during rehab. We usually get our patients to work to where they're tired but not super fatigued.
Once the patient can do three sets of 15 single-leg heel raises, they’re usually ready to progress to adding weights.
How to add and progress weights in Achilles rehab
Why weights? When we run, our feet and legs, including the Achilles tendon, are subjected to forces of up to six times our body weight. So, even single-leg heel raises with only your body weight will not make your injured tendon strong enough to cope with running.
As above, adding and increasing weights have to be progressed carefully, using the same principles.
For heel raises, you can hold the weights in your hands or put them in a backpack. This video by my colleague Ali has some practical tips for weight exercises for your Achilles tendon.
With patients who are runners, we look at working towards eventually having them do single-leg heel raises with between 20% and 50% of their body weight added before they can add running to their rehab.
For example, I weigh 72 kg. So, 20% of my body weight would therefore be between 14 kg and 15 kg, which I need to build up to before I can progress to the next stage of my rehab.
Now, if I start off with, say, 8 kg, there's a very big chance that my tendon will go, “Whoa mate! You've just strengthened us up to be able to cope with three sets of 15 with body weight, and now you're giving me 8 kilos extra!” So, I would flare my injury up because the difference between the strength I've trained to and the strength and the volume of exercise I'm asking it to do is just too big.
So again, if you want to get to that 20% of body weight, you have to do it really slowly in increments. If you can manage three sets of 15 heel raises with 3 kg, do at least the next session also with 3 kg, just to make sure all is fine and to strengthen the tendon up some more at that level before you move on. Only increase a weight if a session felt relatively easy and you did not experience an increase in symptoms over the next 24 hours.
Rest days are important in an Achilles rehab programme
Typically, when I start runners off with their heavy strength training and they're not doing anything like running or jumping yet – just strength training – I don't get them to do the heavy stuff more than three times a week.
For instance, if they do it on Monday, Wednesday, and Friday, they then have the Tuesday and Thursday between those sessions to recover. And then they have two days over the weekend to make sure that, if their body didn't quite repair all those collagen fibres during the week, they can be repaired properly before Monday comes again.
When you think about recovery, you have to look at all the activities in your week that load your tendon. For example, as soon as our patients start Achilles-loading sports (like running, basketball, etc.) again, we usually reduce the high-load strength sessions to just twice or sometimes even once a week, depending on the volume or intensity of the other activities.
So, your priorities with regards to the number of sessions and the frequency of strength training will change depending on what the focus of that specific rehab period is.
How we can help
Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Cook, J. and S. Docking (2015). "“Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians." British Journal of Sports Medicine 49(23): 1484-1485.