Achilles tendonitis heel drop exercises have proven to be very successful for chronic Achilles tendon pain. The Hakan Alfredson’s heel drop protocol involves twice daily exercises for 12 weeks.
What is Hakan Alfredson’s heel drop protocol?
Alfredson created an Achilles rehabilitation program based on eccentric exercises but made three innovations:
- If your Achilles pain gets worse this is not necessarily a bad thing. It could just be part of the normal healing process.
- Heel drop exercises should be performed both with the leg straight and bent.
- A total of 180 repetitions should be done every day for 12 weeks. This is a lot more than most Achilles rehab programs would advocate.
Studies have been shown the Hakan Alfredson’s heel drop protocol to be the most effective treatment method for long-term chronic Achilles tendon pain in up to 90% of patients.
Heel drop exercises
- Eccentric exercises involve the patient dropping the heel to horizontal in a slow and controlled manner.
- An eccentric muscle contraction is one where the muscle gets longer as it contracts rather than shortening.
- With heel drop exercises it is the calf muscles at the back of the lower leg which are contracting at the same time as they lengthen.
- Stretching exercises for the muscles at the back of the lower leg should also be done regularly.
However, the routine is tough and must be done daily for 12 weeks without fail. The patient is likely to suffer some discomfort and may feel their injury is getting worse before they see improvement.
Why does Hakan Alfredson’s protocol work?
If the two exercises are done strictly this should total 180 repetitions every day for 12 weeks. In the short term, exercise:
- Increases tendon volume
- Stimulates collagen production
The tensile strength of the tendon will increase over time, making it able to cope better with the loads expected of it in day-to-day activities and sports training.
Keep a record of your exercises
It is important to keep a record of the exercises you do. A 12-week record sheet detailing which exercises should be done and when can be downloaded here.
Heel drop eccentric strengthening exercises
For Achilles tendonitis heel drop exercises keep the knee straight and bent to isolate the gastrocnemius and soleus muscles.
- The gastrocnemius is the larger muscle that originates from the femur (thigh bone) so needs to be stretched and strengthened with the knee straight.
- Bending the knee relaxes the gastrocnemius, leaving the soleus muscle to take more of the load.
Gastrocnemius heel drop
- Begin by standing with one foot on a step and the heel raised up
- Slowly lower the heel down keeping the leg straight until the foot is parallel to the ground but no further
- Then push up to the starting position using your uninjured leg to assist and repeat
- Perform 3 x 15 repetitions twice a day
- Maintain this every day for 12 weeks
- The exercise may be moderately painful
- Over time the pain in the Achilles may get worse before it gets better
- When 2 x 15 repetitions, twice a day are pain-free, you should increase the load
- You can do this by wearing a weighted vest or rucksack to increase the weight or load through the Achilles tendon
Soleus heel drop
- You can do this in exactly the same way as the gastrocnemius heel drop exercises. Keep your knee bent at about 45 degrees (half squat position)
Stretching exercises for Achilles tendonitis
Achilles stretches don’t actually stretch the tendon much. It is the calf muscles that need stretching. Stretching is an important part of the treatment and rehabilitation of Achilles tendinitis. Tight or shortened calf muscles may increase the strain on the Achilles tendon making it work harder.
- Place the leg to be stretched behind and lean forward, ensuring the heel is kept in contact with the floor at all times.
- Hold the stretch for 20 to 30 seconds and repeat it 3 times. This can be repeated several times a day and should not be painful.
- A stretch should be felt at the back of the lower leg. If not then move the back leg further back.
- A more advanced version of a calf stretch is to use a step and drop the heel down off it.
- Keep the back leg bent to stretch the soleus muscle
- Place the leg to be stretched behind and lean against a wall keeping the heel down
- A stretch should be felt lower down nearer the ankle at the back of the leg
- If this stretch is not felt then a more advanced version is to place the forefoot of the front leg against the wall with the heel on the floor and push the knee towards the wall
Stretching on a step
- This stretch can be performed to further the stretch on the calf muscles and Achilles. Stand on a step with the toes on the step and the heels off the back.
- Carefully lower the heels down below the level of the step until you feel a stretch – make sure you have something to hold on to!
- Hold for 15-20 seconds. This should be performed with the knee straight and then repeated with the knee bent to make sure you are stretching both muscles.
- Alfredson H, Lorentzon R. Chronic Achilles Tendinosis – recommendations for treatment and prevention. Sports Med 2000;29(2):135-46
- Alfredson H, Piettila T., Jonsson P et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine 1998;26(3):360-6