Eccentric Exercise Protocols for Achilles Tendinopathy
Achilles tendinopathy is a common overuse injury seen in runners, athletes, and active adults. Eccentric exercise protocols have become the gold standard for conservative management, offering effective pain relief and tendon remodeling.
Why Eccentric Exercises Work
Eccentric exercises involve lengthening the muscle while it contracts under load. For the Achilles tendon, this means controlled lowering of the heel below a neutral position. Research shows eccentric training promotes:
- Collagen fibre realignment.
- Increased tendon stiffness and load capacity.
- Reduced neovascularisation and tendon pain.
This makes it an evidence-based first-line intervention for both insertional and mid-portion Achilles tendinopathy.
Alfredson Protocol
The most well-known eccentric program is the Alfredson protocol, widely adopted in Australia and internationally. It includes:
- Exercise: Heel drops off a step, performed with knee straight and bent.
- Dosage: 3 sets of 15 reps, twice daily.
- Duration: 12 weeks.
- Load: Progressively increased using weights in a backpack when pain decreases.
Pain during exercise is acceptable and often expected, but it should remain tolerable.
Modified Protocols for Insertional Tendinopathy
For insertional Achilles tendinopathy, exercises are modified to reduce compression at the tendon insertion:
- Heel drops are performed from the ground instead of off a step.
- Range of motion is limited to avoid excessive dorsiflexion.
This reduces aggravation while still providing eccentric loading.
Progressions and Variations
As patients improve, eccentric programs can be progressed by:
- Adding resistance through weighted vests or machines.
- Incorporating single-leg calf raises with eccentric emphasis.
- Combining with isometric and concentric strengthening for complete rehabilitation.
Sports-specific drills, such as plyometrics or agility training, are added later to prepare for return to activity.
Clinical Considerations
- Consistency is critical—patients must adhere to the daily protocol for best results.
- Pain monitoring ensures that discomfort stays within safe, manageable levels.
- Adjunct treatments like orthotics, shockwave therapy, or manual therapy may support outcomes when combined with exercise.
Conclusion
Eccentric exercise protocols are highly effective, evidence-based interventions for managing Achilles tendinopathy. By reducing pain, improving tendon strength, and supporting long-term function, they remain the cornerstone of physiotherapy treatment in Australia and globally.