Progressive treatment exercises for Achilles tendonitis/tendinopathy: What, when, and how much?
Updated: May 27
When it comes to exercises for Achilles tendonitis, there is no one-size-fits-all exercise programme. This article explains how every patient and every injury is different, and which variables we take into account at Treat My Achilles when we design a bespoke Achilles rehab programme. It also advises how such a programme should be adapted according to the patient’s progress. Remember, if you need more help with an Achilles injury, you're welcome to consult one of our team via video call.
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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 have also made a video about this:
A progressive exercise plan, as described in this article, is one of the two pillars of our approach to Achilles injury rehab. The other pillar is “relative rest”, i.e. finding that moving sweet spot of how much activity your injured tendon can tolerate without making its symptoms worse. You can read more about relative rest for Achilles rehab here.
Why do exercises for Achilles tendonitis?
When your Achilles tendon is injured, it usually feels stiff and painful. These symptoms will very likely get worse if you just ignore them and carry on with your sport and your normal daily activities.
Doing the correct exercises can:
Reduce pain – An injured tendon produces chemicals as part of the injury-and-repair process that irritate your pain receptors and make them react. When you keep your foot and ankle very still (e.g. when you’re sleeping), these chemicals accumulate, which increases your pain. This is why those first few steps in the morning can be so uncomfortable. The right types of exercise and movement improve your circulation, which gets rid of the chemicals, and so your pain is reduced.
Reduce stiffness – The stiffness in your injured tendon is caused by extra fluid that accumulates between the injured fibres. Again, if you keep your foot still, more fluid accumulates and the stiffness feels worse. But if you do the correct exercises, your circulation improves and the stiffness decreases. As the tendon heals, the stiffness eventually disappears altogether.
Strengthen the tendon – An injured tendon loses some of its strength and endurance (load bearing capacity); this is why it now hurts when you try to use it as normal. The only way to restore its strength so it can cope with the work it has to do during your normal daily activities and sport is through a graded strength training programme.
Exercise programmes have to be individualised
There is no one-size-fits-all exercise programme for treating Achilles tendonitis because:
Every Achilles injury is slightly different (sensitivity to pain, tendon strength, tendon endurance, which part of the tendon is affected).
People differ with regards to how fast they heal, their general fitness and strength, other health conditions they might have, and medication they might be using.
People have different goals.
For an exercise programme to be effective, it has to take all of these variables into account.
What exercises to do for Achilles tendonitis
Calf raise exercises
Your Achilles tendon attaches your calf muscles (gastrocnemius and soleus) to your heel bone. The calf muscles and Achilles tendon therefore work as a unit. So, if you want to strengthen the Achilles tendon, you have to do exercises that contract the calf muscles.
The most commonly used exercise for Achilles tendonitis is the calf raise (also referred to as heel raise), where you go up onto your toes and lower yourself back down again. There are plenty of variations on this exercise, and each type may benefit your Achilles injury at a different stage of your recovery.
Bent knee vs. straight knee
When you do a calf raise exercise with your knees straight, you work the gastrocnemius muscle harder. When you do it with your knees bent, the soleus has to work more.
In most cases of Achilles tendonitis, straight-knee calf raises get the job done, but there are instances where you have to add in bent-knee ones to achieve full recovery. Your physio can advise on what is right for you.
If you have insertional Achilles tendinopathy (right at the bottom of the tendon, where it is attached to the heel bone), bent-knee calf raises while standing can cause trouble, because they stretch and compress the injured part of the tendon at the heel bone. In these cases, and especially during the early stages of recovery, it is better to do the soleus calf raise exercises while sitting down and to place something under your heel to avoid stretching the tendon too much.
Bent-knee calf raises while standing can also irritate the kneecap, especially when they are done with added weight.
Type of muscle contraction
An isometric contraction is when you tense a muscle without moving your body. For calf raises, you go up on your toes and hold that position for several seconds. Isometric contractions can be useful during the early stages of rehab, when your Achilles tendon is still very irritated or perhaps not strong enough to do the other types of contraction. We discuss the benefits of isometric exercises and how to use them for Achilles tendonitis rehab in detail here.
An eccentric contraction is when a muscle lengthens while it is contracting. For calf raise exercises, this is the lowering down phase. An eccentric-only exercise is where you do the calf raises in such a way that the muscles and tendon you want to strengthen work harder on the way down, e.g. go up on your toes on both feet, and then slowly lower yourself down only on the injured side.
Eccentric exercises have been shown to aid recovery from Achilles tendonitis. However, we don’t recommend using only these exercises for Achilles rehab, as it won’t restore your tendon’s full function. We discuss the benefits and uses of eccentric-only calf raise exercises for Achilles tendonitis here.
Isotonic exercises involve both concentric muscle contractions (where the muscle shortens) and eccentric contractions (where it lengthens). An example of an isotonic exercise used for Achilles rehab is where you lift up on your toes (concentric contraction of the calf muscles) and lower yourself back down slowly (eccentric contraction of the calf muscles). As opposed to eccentric-only exercises, the muscles and tendon are under constant load during the up and the down movement.
Isotonic exercises are recommended for an Achilles rehab programme, because they strengthen the full movement pattern we use when we walk, run, and jump. You can find a more detailed discussion of isotonic exercises for Achilles tendon rehab here.
When we run and jump, our Achilles tendons act like springs and undergo rapid stretching-and-shortening cycles. Our calf muscles also have to produce quick, forceful contractions. An injured tendon’s stretching-and-shortening cycle is less effective.
While research has shown that some people’s stretching-and-shortening cycles are fully restored via heavy, slow isotonic exercises, it is not the case for everyone.
This is where plyometric exercises (hops and jumps) come in; they can restore the explosive function of your calf muscles and the stretching-and-shortening cycle of your Achilles tendon. Find more information about how to safely use plyometric exercises for Achilles rehab here.
Plyometric exercises are usually only added towards the end of a rehab programme, and it can be left out if you don’t do activities or sports that use these types of movement.
Slow vs. fast
The speed at which you perform your Achilles exercises also matters and will depend on your goals for that training session.
Goal: Optimise tendon strength
Very slow resistance training with heavy weights, where you take about 3 seconds to lift up into the calf raise and 3 seconds to lower back down, has been shown to provide better strength gains for the tendon than when the movement is done quickly.
Goal: Restore motor control
Motor control is how well your brain and nerves control your muscle contractions and movements. Research suggests that Achilles tendinopathy affects your motor control. Deliberately slowing your exercise down and really concentrating on where and how your foot is moving has been shown to restore motor control. See our article about motor control and Achilles rehab.
Goal: Optimise fast muscle contraction and stretch-shortening function of tendon
Once you’ve restored your tendon’s strength through heavy, slow resistance training, you can move on to regaining its ability to withstand the quick, forceful movements used in running and jumping. The best way to do this is with fast, bounding exercises using weights and plyometrics.
Step vs. floor
When you do your calf raise exercises over the edge of a step so that your heel goes lower than the ball of your foot on the downward movement, the tendon stretches and compresses more over the heel bone. This can really irritate your tendon if it is still very sensitive or if you have insertional Achilles tendonitis.
However, if you have mid-portion Achilles tendonitis, eventually doing your exercises over the edge of a step usually produces better results than doing them just to floor level.
Adding weight to your Achilles exercises
To regain full strength, you have to do your calf raise exercises with added weight, and the weight has to get heavier as your tendon grows stronger. This is especially important for people who want to do sports that involve running and/or jumping, because these actions can send forces equal to six times your body weight through your Achilles tendons.
However, you can aggravate the pain if you start with too much weight or increase the weight too quickly. Then again, you will likely not see good results if you keep on doing the same exercises with the same amount of weight. (Get some hand weights on Amazon.)
Where to start
One way to assess this is to look at how many calf raises you can do with good technique and without increasing your tendon pain during and in the 24 hours after the exercise.
We always start with the easiest calf raises, i.e. on two legs and with bodyweight only. If the patient finds these easy to do, we gradually increase the weight (the first step is usually to use only the injured leg with bodyweight) until we find their current upper limit.
If, however, double-leg calf raises with only bodyweight are already hard, or the patient is worried about aggravating their injury, we will likely start them off at this initial level or even with seated calf raises. Doing exercises that scare you, even if you are strong enough to do them, is not useful, as research has shown that it can hamper recovery.
How to progress
To regain full strength, you have to increase the weight over time. You should only increase it once you can do the full recommended number of reps and sets (your physio will set these goals) with good form and minimal discomfort.
Tendons can be fickle and often don’t hurt while you’re doing an exercise, only to flare up several hours later, so it is best to increase the weight in small increments (2 kg or 3 kg at a time).
Don’t rush it!
Tendons take a very long time to change their structure in response to exercise. So, whilst it is important to increase the weight when you no longer find the exercises challenging, it doesn’t mean that your tendon will be fully healed just because you’ve reached a certain weight. It also depends on the number of weeks that you’ve been doing the strength training.
I’ve had several patients flare up their tendon pain because they were too keen to increase the weight. Tendon rehab takes at least 12 weeks, but in most cases significantly longer, especially if you’ve had your injury for more than a year.
I usually advise my patients to increase the weight only when they’ve completed the max number of reps and sets I prescribed, using a specific weight, in at least two sessions without their symptoms increasing.
How often should you do your Achilles exercises?
This depends on the intensity of the exercise. When we exercise, our bodies sustain micro-damage. This is normal, and our bodies then repair the micro-damage and make us stronger than before. However, these repairs can only take place if you allow enough recovery time between exercise sessions.
Low-load exercises, like isometrics or double-leg calf raises with bodyweight only, don’t cause much micro-damage. So, you don’t need much recovery time and they can be done daily.
High-load exercises, like calf raises on a single leg, using extra weights, or plyometric exercises produce more micro-damage and usually require at least 48 hours recovery time – sometimes longer. These should therefore be done only two or three times a week and never on consecutive days.
The menopause, being older, and using certain medications (like statins) may delay your micro-damage recovery, and these factors have to be taken into consideration when you plan your rehab programme.
When are you done?
Some people may think that their Achilles rehab is complete once the pain and stiffness have gone, but this would be a mistake. Your rehab is only done once you have achieved the full strength and endurance your tendon requires to do the activities you want to be doing. The pain and stiffness usually subside long before the tendon’s full function is restored.
For example, if you are a:
Walker, you should be able to do your calf raises on a single leg, with some extra weight, and have built up your walking endurance back to your pre-injury level.
Runner, you should be able to do your calf raises with added weight (about 20% of bodyweight), have completed a plyometric programme, and have gradually built your running back up to your pre-injury level.
Each sport has its benchmarks.
There is research that shows that continuing a maintenance dose of calf raise exercises can help to prevent recurring Achilles tendon pain.
These maintenance exercises are usually less strenuous than the rehab ones, and they should fit in with the rest of your training programme.
For instance, if you’re in the final stages of marathon training or you’re in the middle of the football season, doing lots of high-intensity running and match play, your calves and Achilles tendons will be worked hard anyway, so your maintenance exercises should be reduced or even left out. If not, you may end up overtraining and not recovering properly.
Once you enter a less intense training period with your sport, you can increase your maintenance exercises again.
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
Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master's Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.
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