Painful Achilles Tendon? Learn the Right Exercises

Painful Achilles tendon disorders are common in people who perform repetitive running and jumping activities.  It is also common in less active people.  Sedentary individuals with chronic disease such as high blood pressure, obesity, and diabetes are at an increased risk.  Even though it is commonly injured, the Achilles tendon is one of the largest and strongest tendons in the human body.  It spans from the calf muscle in the lower leg down to its attachment on the heel.  It is important to transfer forces during routine walking and explosive movements in sport.

Irritation of the tendon is commonly referred to as “Achilles tendinitis” which implies the presence of inflammation.  However, studies show there is an absence of inflammation in most people who are suffering from a painful Achilles tendon.  It is now widely believed the problem is related to degeneration and weakening of the tendon, not inflammation.  This explains why many treatments aimed at reducing inflammation, such as rest and anti-inflammatory medications, are ineffective.

The Role of Exercise in Managing a Painful Achilles Tendon

Research suggests 3 out of 4 athletes with a painful Achilles tendon will fully recover with conservative treatment including exercise.  The prognosis for sedentary individuals is less favorable.   Regardless of age or activity level, 4 to 6 months of conservative treatment is recommended.  Research suggests exercise is the most successful conservative treatment for painful Achilles tendon disorders.   The focus of the exercise program is to progressively load and strengthen the painful tendon.

Some pain, usually 5/10 or less is acceptable during exercise.  However, increased pain experienced during exercise should not persist into the next day.  If this occurs, you would be best served to see your physical therapist.   Traditionally recommended exercise includes eccentrics characterized by slow lowering of the heel from a tip-toe position.  More recently, other forms of strengthening exercise have been shown to be equally effective.  The 4 exercises described here have been supported by research.

2-Leg Heel Raise

This is the first exercise to be performed as part of a progression.  Stand with equal weight distributed between both legs.  Hold on to a wall or other object for support.  Slowly rise up on both tip-toes.  Pause 2 seconds then slowly lower to the starting position.  Typically 3 sets of 15 repetitions are performed daily.  As pain diminishes and strength improves over a few weeks, begin performing this exercise with the heels hanging from a step.  This will increase the range of motion of the exercise and provide a stretch stimulus to the tendon.   The exercise can be further progressed by adding a backpack with 10 pounds of weight.

1-Leg Heel Raise

This exercise should be performed during the first few weeks along with the 2-leg exercise.  If pain greater than 5/10 persists after the exercise and into the next day, the 1-leg version may need to be delayed.  Discuss this with your physical therapist.  Start by standing on the involved leg only.  Slowly rise up on to the tip-toe.  Pause 2 seconds then slowly lower to the starting position.  Typically 3 sets of 15 repetitions are performed daily.  As pain diminishes and strength improves over a few weeks, begin performing this exercise with the heels hanging from a step.  This will increase the range of motion of the exercise and provide a stretch stimulus to the tendon.   The exercise can be further progressed by adding a backpack with weight.

Eccentric Heel Drop

This exercise can also be performed during the first few weeks along with the 2-leg and 1-leg exercises.  If pain greater than 5/10 persists after the exercise and into the next day, it may need to be delayed.  Discuss this with your physical therapist.  Start by standing on the uninvolved leg only.  Slowly rise up on to the tip-toe of the uninvolved leg.  Then shift the weight onto the involved leg.  Slowly lower to the starting position using the involved leg only.  Repeat this sequence of “up with the good” and “down with the bad” leg.  Typically 3 sets of 10 to 15 repetitions are performed.  As pain diminishes and strength improves over a few weeks, begin performing this exercise with the heels hanging from a step.  The exercise can be further progressed by adding a backpack with weight.

Heavy Slow Resistance Heel Raise

For many people with a painful Achilles tendon, performing the previous 3 exercises regularly will achieve outstanding results within 3 months.  However, many athletes involved in running and jumping sports will require higher loads to strengthen the injured tendon.  Heavy slow resistance exercise is performed with progressively higher loads performed very slowly.  The exercises are initially performed with loads which allow 3 sets of 15 repetitions.  Every 2 to 3 weeks, the load is increased and the repetitions are decreased.  The goal is to slowly perform 3 to 4 sets of 6 to 8 repetitions with high loads to fully stimulate tendon remodeling.  These exercises can be performed with a barbell on the back or with exercise machines such as a leg press or calf raise machine.

Speed Recovery by Combing Exercise with Manual Therapy

Achilles tendon

Many people will fully recover within 12 weeks to 1 year of performing the Achilles tendon loading exercises.  This length of recovery may not be acceptable for some people.  Thankfully, research shows greater improvements can be made when exercise is combined with manual therapy performed by a physical therapist.  One recent study showed the addition of soft tissue techniques resulted in 100% of patients achieving a successful outcome at 12 weeks compared to 50% who performed only exercise.   During each session 15 minutes of soft tissue mobilization is applied to the lower leg, ankle, and foot musculature.  The purpose is to improve mobility and further stimulate tendon healing and remodeling.

Closing Thoughts

Painful Achilles tendon disorders can be debilitating.  Thankfully, exercise and other conservative treatments delivered by a physical therapist have been proven to be effective.  Recovery is usually not quick or easy.  Success is dependent on your commitment to perform the exercises regularly.  Expect some pain during the exercise but don’t progress things too quickly if pain persists into the next day.  Often a little guidance from your physical therapist can keep you on the right track.  Contact your physical therapist if you would like some help.


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