Achillies Tendinopathy Part 2 : Rehabilitation

Click here to read our previous post on diagnosis and etiology

Many treatments are offered to patients with painful tendons, but the scientific evidence for most of the conservative and surgical treatments remains sparse. Activity modification and counselling of patient is must. In acute condition patient may need rest but in chronic case patient may not need rest and activities, which are not giving pain may be continued.

  • Manual therapy

Joint mobilisation may be done if joint restriction is found.

  • Taping :

Rigid Taping to correct the subtalar pronation may be done. Kinesio taping may also be done

Exercise programs ( mid portion tendinopathy)

  • Gradual tendon loading program

As per = Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity using a pain monitoring model during rehabilitation in patients with Achilles tendinopathy. Am J Sports Med. 2007

Phase 1: Weeks 1-2

Patient status: Pain and difficulty with all activities, difficulty performing ten 1-legged toe raises

Goal: Start to exercise, gain an understanding of their injury and of pain-monitoring model

Treatment program: Perform exercises every day

  • Pain-monitoring model information and advice on exercise activity
  • Circulation exercises (moving foot up/down)
  • 2-legged toe raises standing on the floor (3 sets × 10-15 repetitions/set)
  • 1-legged toe raises standing on the floor (3 × 10) • Sitting toe raises (3 × 10)
  • Eccentric toe raises standing on the floor (3 × 10)

 Phase 2: Weeks 2-5

Patient status: Pain with exercise, morning stiffness, pain when performing toe raises

Goal: Start strengthening

Treatment program: Perform exercises every day

  • 2-legged toe raises standing on edge of stair (3 × 15)
  • 1-legged toe raises standing on edge of stair (3 × 15)
  • Sitting toe raises (3 × 15)
  • Eccentric toe raises standing on edge of stair (3 × 15)
  • Quick-rebounding toe raises (3 × 20)

Phase 3: Weeks 3–12 (longer if needed)

Patient status: Handled the phase 2 exercise program, no pain distally in tendon insertion, possibly decreased or increased morning stiffness

Goal: Heavier strength training, increase or start running and/or jumping activity

Treatment program:

[restrict]Perform exercises every day and with heavier load 2-3 times/week

  • 1-legged toe raises standing on edge of stair with added weight (3 × 15)
  • Sitting toe raises (3 × 15)
  • Eccentric toe raises standing on edge of stair with added weight (3 × 15)
  • Quick-rebounding toe raises (3 × 20)
  • Plyometric training

Phase 4: Week 12–6 months (longer if needed)

Patient status: Minimal symptoms, morning stiffness not every day, can participate in sports without difficulty

Goal: Maintenance exercise, no symptoms

Treatment program: Perform exercises 2-3 times/week

  • 1-legged toe raises standing on edge of a stair with added weight (3 × 15)
  • Eccentric toe raises standing on edge of a stair with added weight (3 × 15)
  • Quick-rebounding toe raises (3 × 20)
  • Eccentric loading program 

Alfredson’s protocol

3 x 15 repetitions twice per day with extended knee, and another 3 x 15 repetitions twice per day with a flexed knee.
All exercises were 7 days per week. Patients were told to continue to exercise with pain unless it became disabling.
Patients were allowed to jog during their 12week rehabilitation so long as it caused only mild discomfort.

Why does eccentric exercise reduce pain in tendinopathy?

Although there are several possible explanations for the effectiveness of eccentric exercise, none have been fully investigated. Eccentric exercise alters tendon pathology in both the short term and the long term. In the short term, a single bout of exercise increases tendon volume and signal intensity on MRI.

A programme of eccentric exercise affects type I collagen production and, in the absence of ongoing insult, may increase the tendon volume over the longer term. As such, an eccentric exercise programme may increase tensile strength in the tendon over time. The effect of repetitive stretching, with a “lengthening” of the muscle-tendon unit, may also have an impact on the capacity of the musculotendinous unit to effectively absorb the load.

Another possible mechanism of action relates to the mechanical insult of the pain‐producing nerves. A unique feature of Alfredson’s eccentric training programme is that the patient is encouraged to undertake painful heel‐drop exercises. As the nerve structures found in painful human tendons lie in close proximity to the tendon vessels, and as these vessels disappear with muscle contraction and stretch, the good clinical effects demonstrated with eccentric training could be due to alteration of the neovascularization and accompanying nerves.

The number of repetitions (180 repetitions/day) may damage the vessels and accompanying nerves as they traverse the soft tissue outside the tendon into the dense tendinosis tissue.  However, that observation could also be the result of other upstream stimuli that influence both pain and neovascular obliteration, so we are not in a position to draw causal conclusions from an evidance related study.

How to approach Insertional tendinopathy :

Normal tendon attaches to bone through the enthesis organ. This complex attachment allows compression of the tendon against the upper aspect of the calcaneus to reduce load on the insertion and provide a mechanical advantage to the muscle-tendon unit.

This area of compression proximal to the tendon insertion is where pathology most commonly occurs and compression is maximal in dorsiflexion. Applying the concept clinically, Insertional Achilles tendinopathy presents with pain occurring in dorsiflexion based activities but less so in plantarflexion. Thus, stretching the Achilles over a step or completing the original Alfredson program may provoke pain as will running up hills or on soft surfaces such as the beach (the heel digs into the sand which increases dorsiflexion)

Insertional Achilles tendinopathy should be treated by keeping the tendon out of compression, i.e. progressive loading in more plantar flexion. Pain relief can be achieved with a substantial heel raise (preferably added to the outside of the shoe, in-shoe raises are often poorly tolerated) for everyday activity. As pain reduces and tendon capacity improves, compressive loads can be gradually re-introduced if required.


  1. Achilles tendinopathy: understanding the key concepts to improve clinical management Charlotte Ganderton , Jill Cook , Sean Docking , Ebonie Rio , Mathijs van Ark, Jamie Gaida
  2. Karel lewit manual therapy: musculoskeletal elsevier 2007
  3. Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med 2004388–11.
  4. Cythia norkin, Joint structure and function


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