An eccentric heel drop training protocol is one of the most commonly prescribed rehab programmes for Achilles tendonitis. It works for many people, but for some it brings no relief from their tendon pain. This article explains why eccentric exercises for Achilles injuries might not have the desired effect and what you can do to fix this. 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.
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What are eccentric exercises for Achilles tendonitis?
An eccentric movement is when a muscle lengthens against resistance, as opposed to a concentric movement, where the muscle shortens against resistance.
For example, your calf muscles shorten when you go up on your toes (concentric contraction). When you lower yourself down again, your calf muscles are lengthening, but they are still contracting and using force against the gravity that wants to plonk you down fast (eccentric contraction).
The value of eccentric calf muscle exercises in the rehabilitation of Achilles tendonitis was demonstrated in a 1998 study by a team of researchers led by the Swedish tendon injury specialist Håkan Alfredson.
Since then, the Alfredson Protocol – or some version thereof – has often been prescribed for Achilles tendon rehab. It involves standing with your heels over the side of a step, lifting yourself up on your toes using both legs, and then slowly lowering yourself back down as far as you can go only on the injured side while carrying heavy weights.
However, this eccentric heel drop exercise regime doesn’t work for everyone. Below are some reasons why.
It may be too soon for eccentric heel drops for your Achilles tendonitis
If you have only just injured your tendon, and it's only been painful for say, a few days to a week, you might have what is called an acute reactive tendon, which means that the pain is the tendon’s way of telling you that you’ve been overloading it and expecting too much of it.
This is not the time to do eccentric heel drops, and especially not with weights. The last thing you want is to overload the tendon even more.
You, or ideally your physiotherapist, should apply the principle of relative rest to figure out what your Achilles tendon is capable of at this stage.
How deep you do your heel drops matter
The further you lower your heel down in a heel drop, the more the tendon gets stretched and compressed against your heel bone.
If you have a mid-portion Achilles tendinopathy, your tendon will be more likely to tolerate heel drops that go all the way down over the side of a step.
However, if your injury is right where your Achilles tendon inserts into your heel bone (insertional Achilles tendinopathy), the tendon might not like being compressed against the heel bone when you drop down that far.
We tend to start off our patients with insertional Achilles tendinopathy with heel drops on the floor and not over the side of a step, so that the tendon doesn’t get stretched over the heel bone so much while it is still quite irritated.
If you're a runner with insertional Achilles tendinopathy who likes to run up and down hills a lot, you will, however, have to add in this bigger range of movement over the side of a step in the later stages of your rehab.
Too many or too few eccentric heel drops
Many eccentric training protocols will follow a program of 3 x 15 heel drops twice a day, because that's what Alfredson and his team made their subjects do in their study.
However, when you think about it, it really depends on what each individual can tolerate.
A marathon runner who has a long training history and a lot of muscle endurance might not benefit from only three sets of 15 heel drops, whereas somebody who is sedentary might find that three lots of 15 are too much and end up flaring up their Achilles injury.
So, we do need to bear in mind people's unique circumstances, and your physiotherapist is ideally placed to guide you on how many sets and repetitions to start with and how to make these gradually more challenging.
The wrong weight for eccentric heel drops
As your heel drop exercises get progressively more difficult, you might have to start adding weight at some stage, either by holding dumbbells or carrying the weight in a backpack.
Like with the sets and reps above, it may not be useful to follow a protocol blindly where the amount of weight you add is concerned. It may be easy for a man weighing in at 100 kg to progress his heel drop rehab by adding 10 kg to his bodyweight. Not so for a 50 kg guy, because 10 kg as a percentage of his body weight is much more.
However, when we run, forces of up to six times our bodyweight go through our Achilles tendons. The same goes for sports that involve jumping. So if you want to be able to do these kinds of things again, eventually you will have to progress the weight you add to your heel drops. Again, your physiotherapist should be able to help you figure out how to gradually increase the weight without overcooking it.
You may need more than just eccentric exercises
If you've had your tendon pain for months or even years, and you can easily do weighted heel drops but it still hurts when you run, then maybe eccentric exercises are not enough.
Pushing off when we run and doing sports where jumping is involved also require strong concentric muscle movements, so you may benefit from adding some concentric exercises like heel raises and/or plyometrics (jumping and hopping) to your rehab programme.
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
Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. Am J Sports Med. 2015 Jul; 43(7):1704-11. doi: 10.1177/0363546515584760