İhsan ErenDouble-leg heel raise
Hold on lightly to a worktop. Lift both heels together and rise up onto your toes, pause for a moment at the top, then lower slowly over 3 seconds.
15 reps, 3 sets, once a day12 weeksLength of loading exercise programmes with proven benefit
100%Satisfied with treatment at week 12 after heavy slow resistance training; 80% with eccentric exercise
92%Adherence to the heavy slow resistance programme; 78% with the eccentric programme
1 yearFollow-up period over which the gains lasted with both programmes
What is it?
The Achilles tendon connects the calf muscles to the heel bone and is the strongest tendon in the body. When running, jumping or walking loads are increased over a short time and exceed the tendon's capacity to adapt, the tendon becomes worn and painful. The pain is usually in the middle part of the tendon; sometimes it is where the tendon attaches to the heel.
Risk factors include increasing your running distance or speed too quickly, hill training, a change of shoes, older age, excess weight, diabetes and fluoroquinolone antibiotics.
Symptoms
- Pain and tenderness in the tendon, a few centimetres above the heel
- Pain and stiffness with your first steps in the morning or after sitting for a long time
- Pain that is worse at the start of activity, eases as you warm up, then gets worse again
- Thickening or swelling of the tendon
Why are loading exercises the main treatment?
Tendons get stronger by adapting to load that is increased gradually. The American Physical Therapy Association's 2018 guideline also recommends loading exercises as the mainstay of treatment. The classic method is the eccentric programme developed by the Swedish orthopaedic surgeon Alfredson: slowly lowering your heel off a step, twice a day, for 12 weeks.
A study of 58 patients in Denmark compared this eccentric programme with heavy slow resistance training done three days a week. Both programmes clearly improved pain and function, and the gains were still there after 1 year. At week 12, the heavy slow resistance group had higher satisfaction (100% vs 80%) and better adherence to the programme (92% vs 78%).
Mild, bearable pain during exercise is fine. What matters is that the pain is no worse the next morning; if it is, reduce the number of reps or the load in your next session.
Treatment
- Loading exercisesEccentric or heavy slow resistance training; the load is increased at a pace the tendon can adapt to.
- Adjusting the loadRunning distance, speed and hills are cut back for a while; rather than resting completely, you keep doing activities that do not make the pain worse.
- FootwearComfortable shoes with a slightly raised heel can reduce the load on the tendon while it is painful.
- Cortisone injectionA cortisone injection into the tendon is generally not recommended because of the risk of rupture.
- Gradual returnOnce the pain is under control, you return step by step to sports that involve running and jumping.
Exercises at home
Six exercises for the Achilles tendon
Start with the double-leg heel raise; as it gets easier, progress to one leg and to heel drops off a step. Do the movements slowly and with control.
Single-leg heel raise
When the double-leg version feels easy, do the same movement standing on the foot of your painful side. As it gets easier, you can increase the load by putting weights in a backpack.
10–15 reps, 3 sets, once a dayHeel drop off a step (straight knee)
Stand with the front of your feet on the edge of a step and hold on to a wall or banister. Rise onto your toes using both feet, then shift your weight onto the painful leg and slowly lower your heel below the level of the step over 3 seconds. Come back up using both feet.
15 reps, 3 sets, twice a day, 12 weeksHeel drop off a step (bent knee)
Do the same movement with your knee slightly bent. This works the deep calf muscle (soleus) more.
15 reps, 3 sets, twice a day, 12 weeksWall calf stretch
Place your hands on a wall and step your painful leg back. Keeping your back knee straight and your heel on the floor, move your hips towards the wall; you should feel a gentle stretch in your calf.
30 seconds, 3 repsSingle-leg balance
Stand on the foot of your painful side, holding on lightly to a worktop. As it gets easier, hold on less or close your eyes briefly.
30 seconds, 3 timesVideo
Videos for Achilles tendinopathy
From the YouTube channel of US physical therapists Bob Schrupp and Brad Heineck.
Two key self-treatments for the Achilles tendon
Two key evidence-based self-treatments.
Easing Achilles pain
Short self-help techniques for relief when it is painful.
Frequently asked questions
Can I keep running?
Often yes, but with a reduced load. If the pain while running stays mild and is no worse the next morning, you can carry on. Cut back on hills, tempo runs and speed sessions for a while.
How long does it take to heal?
It takes patience. In studies, the exercise programmes lasted 12 weeks and the gains were maintained after 1 year. For some people, full recovery can take a few more months.
Should I have a cortisone injection?
A cortisone injection into the Achilles tendon is generally not recommended, as it can weaken the tendon and increase the risk of rupture. Regular loading exercises should be tried first.
Are stretching exercises enough?
On their own, they are usually not enough. What the tendon really needs to heal is loading exercises that are increased gradually; stretches can be added to these.
When to seek help right away
See a doctor without delay if you have any of the following:
- A sudden “pop” or a feeling like being kicked in the heel, followed by being unable to rise onto your toes (the tendon may have ruptured)
- Redness or warmth around the heel, or a fever
- Swelling, pain and redness in the calf
- Tendon pain that starts while you are taking a fluoroquinolone antibiotic
- Achilles pain on both sides together with joint pain or stiffness in the lower back
Sources
- Martin RL, Chimenti R, Cuddeford T, et al. Achilles pain, stiffness, and muscle power deficits: midportion Achilles tendinopathy revision 2018. J Orthop Sports Phys Ther. 2018;48(5):A1-A38.
- Beyer R, Kongsgaard M, Hougs Kjær B, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43(7):1704-1711.
- Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26(3):360-366.