Eccentric exercises (calf raises) for Achilles tendonitis – How they work and when to use them

Achilles tendinopathy exercise series:

• Progressive treatment exercises for Achilles tendonitis/tendinopathy: What, when, and how much?

• Is stretching a good idea with an Achilles tendinopathy/tendonitis?

• Isometric exercises for Achilles tendinopathy - How they work and when to use them

• Isotonic exercises - What they are and how to use them for treating Achilles tendonitis

• Eccentric exercises for Achilles tendonitis - How they work and when to use them (this article)

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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. 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. 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:

1. What are eccentric calf raise exercises?

2. What are the benefits of doing eccentric exercises for an injured tendon?

3. Why we don't tend to use eccentric-only exercise programmes

4. When may we consider using eccentric-biased exercises?

5. How we can help

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.

When you do eccentric calf raises, you typically lift up on two feet (so the calf doesn't work so hard) and then lower yourself down using only one leg (now that calf has to work much harder).

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:

1. 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.

2. 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.

3. Eccentric exercises may also improve the tendon’s response to the activity (strain) by increasing its stiffness.

4. 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.

A well-rounded Achilles exercise plan should retrain concentric, eccentric, and (if needed) explosive contractions.

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 everyone 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

Alison Gould is a chartered physiotherapist and holds an MSc in Sports and Exercise Medicine. You can follow her on LinkedIn, Facebook, Instagram, and Twitter.

References

1. Alfredson, Håkan, et al. "Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis." The American Journal of Sports Medicine, 26.3 (1998): 360-366.

2. 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.

3. O’Neill, Seth, Paul J. Watson, and Simon Barry. "Why are eccentric exercises effective for Achilles tendinopathy?" International Journal of Sports Physical Therapy, 10.4 (2015): 552.