Updated: Dec 5, 2022
Achilles tendinopathy exercise series:
Eccentric exercises for Achilles tendonitis - How they work and when to use them (this article)
There is no one-size-fits-all exercise regime when it comes to treating Achilles tendonitis or tendinopathy, and the exercises we prescribe for patients are very rarely the same. In this article, we discuss how eccentric calf raise exercises may benefit your Achilles tendon, when we might use them, and why they are not really our first choice of exercise when it comes to treating Achilles tendon pain. 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:
Alison also discusses eccentric exercises for Achilles tendonitis in this video:
What are eccentric calf raise exercises?
An eccentric contraction is where the muscle lengthens whilst under relatively constant tension. An example of an eccentric contraction for the calf muscle is the down phase of the classic calf raise exercise that’s so often associated with Achilles tendinopathy rehab – the calf muscles lengthen while lowering you down slowly.
Using eccentric exercises for Achilles tendinopathies gained popularity with the research conducted by Alfredson in the late 1990s, which pioneered the way in which we treat Achilles injuries and prescribe exercises for them today.
Alfredson used the method of slowly lifting yourself up on two feet and then lowering down on the painful foot only. This is an example of an eccentric dominant exercise, because the muscle works the hardest whilst it lengthens. You can also use eccentric contractions in combination with concentric contractions as part of isotonic exercises.
What are the benefits of doing eccentric exercises for an injured tendon?
Eccentric dominant exercise programmes have been shown to help improve pain, function, and strength in patients who have Achilles tendonitis or tendinopathy. The research suggests that it does this in several different ways:
When you look at an ultrasound scan of an Achilles tendon that has been painful for quite some time, it is usually thicker compared to an uninjured one, and it also has some extra blood vessels growing into it (neovascularization). A 12-week eccentric heel raise exercise programme has been shown to lead to a reduction in both tendon diameter and neovascularization. So, it may help restore the injured tendon.
It may also strengthen the rest of the tendon by laying down more healthy collagen fibres, making it more robust. So, even if the injured area does not fully heal, the rest of the tendon is now strong enough to cope with your activities.
Eccentric exercises may also improve the tendon’s response to the activity (strain) by increasing its stiffness.
Researchers are also considering the possibility that eccentric training helps through improving the Achilles’ springiness, allowing us to push off better when walking, running, or jumping.
Why we don't tend to use eccentric-only exercise programmes
We actually don't prescribe eccentric-only exercise programmes very often for our Achilles patients. You may think this strange, considering all the benefits I've just listed above. However, more research has been conducted since the original work done by Alfredson, and this shows that other types of exercise are also important in tendon rehabilitation and may actually be easier to tolerate.
More commonly now, isotonic exercises, which work on both the lengthening (eccentric) and the shortening (concentric) phases, are prescribed. And, if you take part in sports that require explosive calf muscle contractions, plyometric exercises are also recommended to ensure that your tendon is fully prepared for your sport.
Eccentric exercises also tend to be more aggravating (they easily cause more pain) and are often not the best choice for tendons that are quire irritable.
Therefore, as each individual is different and can tolerate different types of exercise and has varying fitness levels, goals, health issues, and genetics, there is no recipe; it's best to be assessed by a medical professional to help establish what exercises are best for your individual case. The main take-home message is that strength training is the most effective, evidence-based treatment for Achilles tendinopathy that we have, and that it needs to include the eccentric phase.
When may we consider using eccentric-biased exercises?
Achilles rehab can sometimes reach a plateau, where a patient seems stuck and unable to progress. In cases like these, it can often help to mix the exercises up and try a different approach. Depending on what you've been doing, you physio may decide to trial heavy eccentric calf raise exercises to see if it can bring about the changes required.
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. and Magnusson, S.P., 2015. "Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial." The American Journal of sports Medicine, 43(7), pp.1704-1711.