Achilles Tendonitis Exercises: An Evidence-Informed Loading Guide for Midportion and Insertional Pain

The argument about Achilles rehab is almost never about which exercise. It’s about how far the heel is allowed to drop — and that depends entirely on where the tendon hurts.

Most people search for “Achilles tendonitis.” Clinicians and trials say tendinopathy, because the current consensus reserves that word for tendon pain linked to loading activity, and because what follows from it is graded loading rather than anti-inflammatory care.¹

Here’s the fork that decides everything below. Pain within about 2 cm of the heel bone is insertional. Pain 2–7 cm up the cord is midportion. The best-evidenced protocol for one can aggravate the other.¹²

Picture a rope running over the lip of a pulley. Pull it and you stress its whole length. Bend it hard over that lip and you crush the fibres at one point. The Achilles insertion wraps around the upper border of the heel bone, so pulling your toes toward your shin doesn’t just tension the tendon — it presses it into bone.²

This article screens and explains. It cannot diagnose. If your pain began with a sudden pop, if you can’t push off, or if both heels ache with long morning stiffness, use the screening section below and get assessed before you load anything.

Achilles Tendonitis or Tendinopathy? And Why It Isn’t Just a Runner’s Problem

“Tendonitis” implies inflammation. The condition trials actually study and treat is a load-capacity problem in the tendon — which is why the Dutch multidisciplinary guideline, one of the most thorough syntheses in the field, uses “tendinopathy” throughout and organises its recommendations around load rather than rest.¹ Tendon adapts to progressive mechanical load, and that response is the single lever every trial in this article pulls.³

Now the statistic almost nobody quotes. In a Dutch primary-care cohort of 57,725 people, midportion Achilles tendinopathy appeared at 1.85 per 1,000 registered patients per year — and a relationship with sport was recorded in only 35% of cases.⁴ For two in three people who walked into a GP’s office with this, no link to sport was recorded at all.

So who’s at risk? Honest answer: the evidence is thin. A systematic review of ten cohort studies — all judged at high risk of bias — found limited evidence for nine clinical risk factors, among them prior lower-limb tendinopathy or fracture, use of ofloxacin (a quinolone antibiotic), moderate alcohol use, training in cold weather, and reduced plantar flexor strength.⁵

What didn’t associate is just as useful. Twenty-six other candidates — including being overweight, static foot posture, and overall physical activity level — showed no association in that review.⁵

Insertional or Midportion? Find the Sore Spot Before You Pick an Exercise

Press along the tendon with one fingertip. Tender within about 2 cm of the heel bone points to insertional. Tender 2–7 cm above it, often in a slightly thickened section of the cord, points to midportion.¹² That one finding changes the exercise, the range of motion, the footwear, and whether you stretch at all.

This split is not academic hair-splitting. It’s the difference between a protocol working and a protocol failing.

In 2003, Umeå researchers ran the same eccentric calf-training programme for 12 weeks in two groups from the same clinic. In 90 of 101 midportion tendons (89%), the result was satisfactory and patients returned to their pre-injury activity level. In the insertional group, only 10 of 31 tendons (32%) reached the same outcome.⁶

Five years later the same group published the correction: a modified regimen in which the heel was not lowered into dorsiflexion, stopping the drop at neutral. Eighteen of 27 patients (67%) were satisfied and back to their previous tendon-loading activity.⁷ The variable that moved was range of motion, not effort.

What you’re checking	Insertional	Midportion
Where it’s tender	Within ~2 cm of the heel bone, right where the tendon attaches	2–7 cm above the attachment, in the cord itself
What aggravates it	Uphill walking, deep squats, sprint starts, shoe pressure on the back of the heel	Running, hopping, jumping, first steps after rest
The provocative position	Ankle pulled up toward the shin, which presses the tendon against the heel bone	End-range mid-tendon load; less position-specific
Which loading track	Floor-level heel raises, heels lifted, dorsiflexion limited, no calf stretching	Full-range heel drops off a step, below level
What the evidence looks like	One 12-week randomised trial, n=42, published 2025	Two decades of RCTs — the most-studied tendon protocol in sports medicine

This is a screening step, not a diagnosis. The two can coexist, insertional pain can sit alongside a bony prominence at the back of the heel or an inflamed bursa,¹ and only a clinician can palpate, take a history, and rule out the alternatives below.

Condition	Where it hurts	Signature clue	Why it changes the plan
Midportion tendinopathy	2–7 cm above the heel bone	Localised thickening in the cord; worst on first steps and on loading	Full-range heel drops and heavy slow resistance are both on the table
Insertional tendinopathy	Within ~2 cm of the attachment	Pain reproduced on palpation of the insertion and on a single-leg hop	Dorsiflexion becomes the thing to limit, not the thing to chase
Achilles rupture, partial or complete	Sudden, at any level	A pop or the sense of being kicked in the back of the leg; loss of push-off; sometimes a palpable gap	Not a loading question at all — urgent assessment
Plantar heel pain	Under the heel, toward the inside	Stabbing pain on the first steps in the morning, easing as you move	Different tissue, different protocol
Inflammatory enthesitis	Often the insertion, often both sides	Prolonged morning stiffness, younger adult, other joints involved	A medical question, not a progression

Pain under the heel rather than behind it is a different tissue with a different playbook — our plantar fasciitis guide covers that one. And a systemic cause is a real branch of the tree: the Dutch guideline explicitly includes identifying patients whose tendon pain comes from a rheumatic enthesitis or another systemic condition.¹

Red flags — stop and see a clinician

A sudden pop, or the sensation of being kicked in the back of the leg, sudden loss of push-off, or a palpable gap in the tendon. A clinician can squeeze the calf and watch the foot for a response, among other checks. This is an urgent assessment, not a rehab plan.
Both heels involved, prolonged morning stiffness, a younger adult, other joints painful. Clinicians consider inflammatory enthesitis here, which the Dutch guideline treats as a distinct group requiring a different work-up.¹
Achilles pain that began during or shortly after a course of fluoroquinolone antibiotics. In a Dutch primary-care cohort, ofloxacin carried an adjusted relative risk of 10.1 (95% CI 2.2–46.0) for Achilles tendinitis; for fluoroquinolones as a class the estimate was 3.7 but the confidence interval crossed 1 (0.9–15.1) and the authors flagged their small numbers.⁸ The guideline still advises considering avoiding these antibiotics when an alternative exists.¹ Speak to the prescriber before loading.
Night pain, pain at complete rest, redness, warmth or fever, or pain that climbs steadily through activity instead of easing.

Should You Rest an Achilles Tendon or Load It?

Load it. In a living network meta-analysis of 29 randomised trials, the conclusion for midportion tendinopathy was blunt: wait-and-see is not recommended, because every active treatment class looked superior to it at three months.⁹ The Dutch guideline says the same thing in patient-facing language — expect no more than limited short-term improvement from waiting it out.¹

One trial shows what waiting actually looks like. Among 75 people with chronic midportion tendinopathy randomised to eccentric loading, shockwave, or wait-and-see, 60% of the eccentric group reported being completely recovered or much improved at four months, against 24% of the wait-and-see group.¹⁰

Rest also costs you something: it lets the tendon shed exactly the capacity you’ll eventually have to rebuild. That’s why slow, heavy lengthening under tension is the mechanism rather than a gimmick — the same principle behind eccentric hamstring work for injury prevention. Robert-Jan de Vos and colleagues at the Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Centre in Rotterdam, sit behind both of those documents, and their position is consistent across a decade of work: start with a calf-muscle exercise programme, because it’s easy to prescribe, low-cost, and has few harms.⁹

Nor does loading mean stopping your sport. In a randomised study of 38 people, one group kept running and jumping throughout rehab under a pain-monitoring rule while the other stopped for six weeks. Both improved, and no difference in the rate of improvement was found between them.¹¹

That permission comes with a number, defined further down. Continuing to run is not the same as running through pain.

Achilles Tendonitis Exercises: The Two Protocols Side by Side

Achilles tendonitis exercises come in two tracks, and the sore spot picks the track: full-range heel drops off a step or heavy slow resistance for midportion pain, floor-level heel raises with the dorsiflexion taken out for insertional pain. Once you know where the tendon is tender, the exercise selection largely writes itself. The table below is the whole article compressed, drawn from the four anchor trials.²¹²¹³¹⁴

Variable	Midportion track	Insertional track
Where the pain is	2–7 cm above the heel bone	Within ~2 cm of the insertion
Main exercise	Single-leg heel raise and drop off a step, or heavy slow resistance across three loaded calf-raise variations	Heel raises without lowering below neutral
Range of motion	Full, including below the level of the step	Dorsiflexion deliberately limited
Footwear	Normal shoes	12 mm heel lifts in daily footwear through the programme
Calf stretching	Not the mechanism, but not the problem either	Eliminated for the duration
Frequency and duration	Alfredson: 2×/day, 7 days/week, 12 weeks. Heavy slow resistance: 3×/week, 12 weeks	Daily progressive loading over up to 12 weeks, outcomes reassessed at 24
Evidence behind it	Multiple RCTs over 20+ years; still no established gold standard	One 12-week RCT, n=42, published 2025
Change in the anchor trial (VISA-A, 0–100)	Eccentric 58→84; heavy slow resistance 54→89 at 52 weeks	+24.4 low-compression vs +12.2 high-compression at 12 weeks

Both tracks share three things: roughly 12 weeks, symptom-guided progression, and load added deliberately rather than on a schedule. They never share range of motion or stretching.

That constraint is the part most likely to get lost. Someone who has established they’re insertional needs “no deficit heel drops” to survive every future version of their plan, not just this week’s — which is where an AI coach with memory earns its place. SensAI’s coach retains a user-stated constraint like “insertional Achilles — keep me off deficit heel drops” and applies it the next time it builds a week, instead of the user re-explaining it session after session. It does not identify the subtype or choose the rehab track; that’s a clinical judgement, and the screening above is only a prompt to seek one.

The Midportion Protocol: Heel Drops Off a Step

For midportion pain there are two defensible 12-week programmes: the original eccentric heel-drop protocol, and heavy slow resistance. They reach similar outcomes. They cost very different amounts of your life.¹⁴

Before either: eccentric loading is the best-evidenced entry point, not a superior method. A 2026 meta-analysis of 21 randomised trials (n=994) found eccentric exercise beat passive physical modalities for pain but performed comparably to other forms of exercise, with heterogeneity in functional outcomes so extreme (I² = 86.1%) that the authors said it precluded definitive conclusions — and stated plainly that it “is not an independent gold standard superior to other forms of exercise.”¹⁵ An earlier review had already found as many as 45% of patients may not respond to isolated eccentric training.³

Option A: The Alfredson protocol — the original dose, in full

Here is the complete dose, which most pages describing this protocol never print: two exercises — one straight-knee, one bent-knee — 3 sets of 15 slow eccentric repetitions each, twice a day, seven days a week, for 12 consecutive weeks. That’s 180 repetitions a day, standing on a step, lowering the heel below step level, with load progressed by adding weight in a backpack as pain diminishes.¹²¹³¹⁴

That below-level version is the midportion protocol. If your pain is within 2 cm of the heel bone, skip to the next section.

The 1998 trial that launched it was small: 15 recreational athletes with chronic Achilles tendinosis and long-standing symptoms. After 12 weeks all 15 were back at their pre-injury level with full running activity, and calf strength on the injured side no longer differed from the healthy side. A comparison group of 15 treated conventionally — rest, anti-inflammatories, shoe changes, physiotherapy — succeeded in no case; all were ultimately operated on.¹²

Håkan Alfredson, then at the Department of Orthopaedic Surgery, University Hospital of Northern Sweden in Umeå, originated the protocol. He is also a co-author on the paper documenting its failure in insertional cases, and on the modified version built to fix it.⁶⁷ That self-correction is worth more than the original result.

A systematic review of eccentric protocols found strong evidence for the Alfredson programme as specified, and for easing into it during week one — but concluded that no uniform protocol exists and the most effective training parameters could not be determined from the literature.¹³

Option B: Heavy slow resistance — same outcome, one-third of the time

Heavy slow resistance is three gym sessions a week instead of fourteen home sessions, and in a head-to-head randomised trial it matched eccentric training on every clinical outcome while patients were far more likely to actually do it.¹⁴

The Copenhagen trial randomised 58 people with chronic midportion tendinopathy — insertional and bilateral cases excluded — to eccentric training or heavy slow resistance for 12 weeks. Each session used three bilateral exercises: heel rises with a bent knee in a seated calf-raise machine, heel rises with a straight knee in a leg-press machine, and heel rises with a straight knee standing on a disc weight with a barbell on the shoulders. The tempo is the defining feature: 3 seconds up, 3 seconds down — 6 seconds per repetition, through full ankle range.¹⁴

Week	Sets × reps	Load target	Tempo
1	3 × 15	15-rep maximum	3 s up + 3 s down
2–3	3 × 12	12-rep maximum	3 s up + 3 s down
4–5	4 × 10	10-rep maximum	3 s up + 3 s down
6–8	4 × 8	8-rep maximum	3 s up + 3 s down
9–12	4 × 6	6-rep maximum	3 s up + 3 s down

Three sessions a week, all three exercises each session, 2–3 minutes rest between sets, with load reassessed as strength improves.¹⁴

Now the numbers that are the whole argument. Counting rest, the eccentric group faced 308 minutes a week — two 22-minute sessions a day, every day — against 107 minutes for heavy slow resistance across three sessions of roughly 36 minutes. Session compliance was 78% versus 92% (p<0.005), and satisfaction at 12 weeks 80% versus 100% (p=0.052). VISA-A ran from 58 at baseline to 84 at 52 weeks for eccentric training and 54 to 89 for heavy slow resistance, passing through the mid-70s for both at 12 weeks, with no statistical difference at any point.¹⁴ The trial was run by the group of S. Peter Magnusson at Bispebjerg Hospital and the University of Copenhagen, and what it reports is a compliance and time-expenditure gap, not an efficacy one — two regimens that worked equally well, one of which asked for three times the weekly minutes.¹⁴

Which makes it a scheduling problem, not a physiology problem. Home-based rehab fails on adherence far more often than on exercise selection, so a 12-week block belongs in the same place as the rest of your training rather than on a fridge note. SensAI can carry those rehab sessions inside the weekly plan it regenerates and keep them visible alongside everything else. It does not set the rehab progression; your symptoms and your clinician do.

The Insertional Protocol: Same Idea, Floor Only, Heels Lifted

If the pain is within 2 cm of the heel bone, the fix is not a different exercise. It’s the same loading with the compression removed: dorsiflexion limited during exercise, heel lifts in your shoes, and calf stretching taken out entirely.²

Back to the rope over the pulley lip: during end-range dorsiflexion the insertion wraps around the upper border of the heel bone and gets pressed into it, so the deficit heel drop that helps a mid-tendon is precisely the position that grinds an insertion.²

In 2025, Lieven Pringels, Luc Vanden Bossche and colleagues at Ghent University and Ghent University Hospital published the first randomised trial to test that logic directly. Forty-two sport-active adults with chronic insertional Achilles tendinopathy were randomised to low- or high-compression rehabilitation. Both arms ran the same four-stage progressive loading structure — isometric, isotonic, energy-storage and release, then sport-specific — three exercises daily, up to 12 weeks. Only the compression differed.²

VISA-A improvement was 24.4 points with low compression against 12.2 with high compression at 12 weeks (between-group difference 12.9, 95% CI 6.2 to 19.6), and 29.0 against 19.3 at 24 weeks (difference 10.4, 95% CI 3.7 to 17.1). Both groups improved; the low-compression group improved about twice as much by week 12.²

Element	What the 2025 trial did	Why it matters
Heel lifts	Two pairs of 12 mm adjustable lifts, sized to the shoe, for daily activities and running; height reduced stepwise only in the final return-to-sport stage	Reduces ankle dorsiflexion, and with it compression at the insertion
Range of motion	Exercises performed with ankle dorsiflexion limited; the comparison group worked in end-range dorsiflexion	End-range dorsiflexion presses the insertion against the heel bone
Calf stretching	Eliminated; daily calf massage with a therapy ball used instead to address muscle stiffness	Stretching addresses stiffness but loads the insertion in compression to do it
Progression rule	Advance only when pain stays below 5/10 during exercise, one hour after, and the following morning; no week-to-week increase in pain or stiffness; minimum 2 weeks per stage	Symptoms drive the calendar, not the reverse
Duration	Up to 12 weeks of loading; minimum 8 weeks before return to sport; outcomes reassessed at 24 weeks	Tendon adaptation runs in months

What this trial does not give you is a set-and-rep ladder. If you want a published numeric dose for insertional loading, the closest verified one is not from this trial at all — it’s the earlier Umeå pilot: 3 sets of 15 repetitions, twice a day, seven days a week, for 12 weeks, performed without loading into dorsiflexion, which produced satisfaction in 67% of patients.⁷ Treat that as a starting point to discuss with a clinician, not as the 2025 protocol.

The honest ceiling: n=42, single centre, sport-active adults with symptoms lasting more than 12 weeks. The authors cautioned against generalising to non-sporting people or acute symptoms, noted they cannot separate out which component of the package did the work, and pointed out that the lower bound of both confidence intervals fell below the 10-point threshold usually treated as clinically meaningful.² Best available insertional evidence — and still one small trial.

For context on how thin the ground was before it: an earlier randomised trial of 50 people with chronic recalcitrant insertional tendinopathy found eccentric loading inferior to low-energy shockwave at four months, with 28% versus 64% reporting they were completely recovered or much improved.¹⁶ That eccentric arm loaded into dorsiflexion.

The insertional constraint has to hold for 12 weeks across every session and every plan regeneration — no lowering below neutral, no calf stretching, heel lifts staying in. That’s a memory problem more than a motivation one. SensAI’s coach keeps a stated constraint in place when it rebuilds the following week, so the limit doesn’t quietly disappear in week five. It does not determine rehabilitation readiness or decide when a constraint can be lifted.

Should You Stretch an Achilles Tendon?

Two answers, keyed to where it hurts. If the pain is insertional, calf stretching is the thing to stop. If the pain is midportion, stretching isn’t the mechanism that helps, but it isn’t the problem either.

The insertional half of that has direct trial support. Calf stretching was deliberately eliminated in the arm of the 2025 trial that produced the better outcome — replaced by daily calf massage with a therapy ball — for the same compression reason the heel doesn’t drop below neutral.² The earlier pilot points the same way: taking dorsiflexion out of the loading was the change that lifted satisfaction from 32% to 67%.⁶⁷

One caveat matters. The trial tested a package — heel lifts plus limited dorsiflexion plus no stretching — and its authors were explicit that they cannot attribute the result to any single component.² So this is a statement about a compressed tendon insertion during a 12-week loading programme, not a verdict on stretching in general; our full-body stretching guide covers the broader case.

How Much Pain Is Too Much During Achilles Exercises?

Pain up to 5 on a 0–10 scale during the exercise is acceptable.¹¹ Some discomfort under load is expected. But the number that decides anything isn’t the one you feel during the exercise — it’s how the tendon feels the following morning.

The pain-monitoring model refined by Karin Grävare Silbernagel, then at Göteborg University and Sahlgrenska University Hospital and now in the Department of Physical Therapy at the University of Delaware, sets three rules. Pain may reach 5 on a 0–10 scale during the exercise. Pain afterwards may also reach 5, but should have subsided by the following morning. And pain and stiffness must not increase from week to week.¹¹ Her five-year follow-up work concluded that a pain-monitoring model should be used whenever these patients are treated with exercise.¹⁷

Trials operationalise this in different currencies. The Copenhagen resistance trial allowed 40 to 50 mm on a 100 mm visual analogue scale during the exercises, capped discomfort during sport at 30 mm, and required tendon pain to have subsided by the next training session — otherwise, reduce the load.¹⁴ The 2025 insertional trial required pain below 5/10 during exercise, one hour after, and the next morning before advancing a stage.²

Zone	During the exercise (0–10)	Afterwards and the next morning	What to do
Green	Up to 5	Settles quickly; no worse the next morning; no week-to-week creep	Continue, and progress load on schedule
Amber	Up to 5	Back toward baseline by the next session but slower than before; the session feels harder than last week	Hold the current load. Don’t add weight or range
Red	Above 5, or climbing during the session	Still elevated the following morning, or worse week on week	Reduce load or range. The following-morning check is the one that decides
Stop	Sharp pain, night pain, pain at rest, or any red flag above	—	Stop and get assessed

That is autoregulation applied to a tendon: load moves with symptom response, not with the calendar — the same logic as training by effort rather than by fixed percentages.

Which makes the daily note the actual engine of the protocol. A 0–10 rating and a next-morning check are what a 12-week block runs on, and SensAI’s coach can hold that reported symptom trend alongside your HRV and sleep data as general training context when it regenerates the week. To be exact about the boundary: heel and tendon symptoms plus clinical guidance govern rehab progression — not HRV — and SensAI does not provide a dedicated rehabilitation log or determine rehab readiness.

How Long Does Achilles Tendonitis Take to Heal?

Months, not weeks. A longitudinal meta-analysis pooling 31 cohorts across 24 studies found improvement beginning as early as two weeks and peaking at around 12 weeks, with a mean change of 21.11 points on the VISA-A.¹⁸ After that the curve flattens, and a real minority stay symptomatic for years.

The literature genuinely disagrees about how large that minority is. Two five-year follow-ups reached very different conclusions because they followed different populations and defined “recovered” differently, so both belong here rather than an average of them.

Time point	What the data shows	Population
~2 weeks	Symptoms can begin improving	Pooled loading-protocol cohorts, midportion
12 weeks	Peak pooled improvement: +21.11 VISA-A points	Pooled loading-protocol cohorts, midportion
12 weeks	+24.4 VISA-A with low-compression loading vs +12.2 with high-compression	Sport-active adults, insertional, n=42
1 year	32% still had symptoms (20 of 62)	Runners with new-onset tendinopathy
5 years	39.7% completely pain-free; 48.3% had sought one or more other treatments	Alfredson-protocol cohort, midportion
5 years	80% fully recovered (27 of 34); 20% had continued symptoms	Exercise-only cohort with pain monitoring
~10 years	19% still had symptoms; a third could do sport pain-free at pre-injury level	Conservatively treated midportion cohort

Those rows come, in order, from the pooled loading meta-analysis, the 2025 insertional trial, a one-year runner cohort, a five-year follow-up of Alfredson’s programme, a five-year exercise-only follow-up, and a ten-year prospective cohort.²¹⁷¹⁸¹⁹²⁰²¹

Robert-Jan de Vos and colleagues, who ran that ten-year study, framed the takeaway as a counselling problem: patients should be given realistic expectations up front.²¹ Most people do improve, and improvement typically starts inside a few weeks — but “most” is not “all,” and a protocol abandoned at week four was never given a chance to work.

Tracking it: VISA-A and what counts as real improvement

Every trial in this article measures the same thing: the VISA-A, an eight-question 0–100 questionnaire covering pain, daily function and sport, where 100 is a perfect score. Its developers were explicit that it is not designed to be diagnostic.²²

How much change counts? Trials here conventionally treat about 10 points as the minimal clinically important difference — the 2025 insertional trial and the heel-lift trial both use that threshold.²²³ A yardstick, not a validated pass mark for your individual tendon.

Getting back to running

Return is graded and symptom-led, not date-led, because recurrence risk concentrates precisely in the return-to-sport phase. A clinical commentary on return-to-sport programming for midportion tendinopathy recommends at least three months of exercise therapy before considering other treatments and notes recovery can take up to a year.²⁴ In the trial where people kept running throughout, they did so under an explicit pain-monitoring rule, not on feel.¹¹

Our couch-to-5K progression is one reasonable ramp, with the obvious caveat: tendon symptoms outrank the plan every time.

What This Evidence Still Can’t Tell You

The direction of the evidence is consistent. Its quality is not.

In the living network meta-analysis of 29 randomised trials, 22 (76%) were at high risk of bias, the remaining 7 had “some concerns,” and none was at low risk — which is why the authors reported large uncertainty in every comparative estimate.⁹

For insertional tendinopathy specifically, a 2023 network meta-analysis of nine trials (n=464) ranked eccentric exercise plus soft-tissue therapy highest for short-term pain, then concluded that no recommendation of a best treatment option could be made because confidence in all the included evidence was very low.²⁵ That’s the honest state of the field — why the 2025 trial matters, and why one n=42 trial can’t be treated as settled.

Heterogeneity in the eccentric literature is extreme (I² = 86.1% across 21 RCTs, n=994), and up to 45% of patients may not respond to isolated eccentric loading at all.³¹⁵ Defensible entry point. Not a gold standard.

One tightly scoped note on guidelines: the JOSPT clinical practice guideline was revised in December 2024 and is scoped specifically to midportion Achilles tendinopathy, superseding the 2018 edition.²⁶²⁷ The scope itself tells you something — the subtype with the least evidence is the one the guideline does not cover.

Frequently Asked Questions

Can I keep running with Achilles tendonitis?

Possibly, under a pain-monitoring rule. In a randomised study of 38 people, those who continued running and jumping under symptom monitoring improved at the same rate as those who stopped for six weeks.¹¹ The rule is the point, not the running.²⁸

Do heel lifts fix Achilles tendonitis?

It depends entirely on subtype. In insertional pain, 12 mm lifts were part of the package that roughly doubled 12-week improvement.² In midportion pain, a separate randomised trial of 100 people found heel lifts improved VISA-A by 9.6 points more than eccentric exercise at 12 weeks — statistically significant, but just short of the 10-point threshold the authors had pre-set as clinically important.²³

Is shockwave therapy worth trying?

Trials have tested it in both subtypes with results that point different ways: comparable to eccentric loading in midportion pain, better than dorsiflexion-loaded eccentric work in one insertional trial.¹⁰¹⁶ The 2023 insertional review still concluded no best treatment could be recommended.²⁵ It requires clinician assessment, and this article makes no recommendation about it.

It’s been over a year. Is it too late to start loading?

No. Persistence at 1 and 10 years is well documented, and the loading trials enrolled people with long-standing symptoms — the 1998 eccentric trial specifically recruited patients who had failed conventional treatment.¹²¹⁹²¹

Fluoroquinolones have a recognised association with Achilles tendon disorders, strongest for ofloxacin.⁸ Current guidance suggests considering an alternative antibiotic where one is available.¹ Speak to the prescriber before starting a loading programme.

The Bottom Line

Press the tendon. Within about 2 cm of the heel bone means floor-level loading with heels lifted, dorsiflexion limited and no calf stretching. Two to seven centimetres up means full-range heel drops off a step or heavy slow resistance three times a week.

Twelve weeks either way, with progress judged by how the tendon feels the following morning rather than by the calendar — improvement usually starting inside a few weeks, and a real minority taking far longer than anyone promised them.

SensAI can remember a user-reported tendon constraint and use aggregated recovery trends as general context when regenerating the next week’s training. It is not a diagnostic or rehabilitation service, and raw HealthKit data stays on-device. Persistent or worsening symptoms — or uncertainty about the cause — warrant assessment by a licensed clinician.

References

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Pringels L, Capelleman R, Van den Abeele A, Burssens A, Planckaert G, Wezenbeek E, Vanden Bossche L. “Effectiveness of reducing tendon compression in the rehabilitation of insertional Achilles tendinopathy: a randomised clinical trial.” British Journal of Sports Medicine, 2025;59(9):640-650. https://pubmed.ncbi.nlm.nih.gov/40011018/ ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹ ↩¹² ↩¹³ ↩¹⁴ ↩¹⁵
Malliaras P, Barton CJ, Reeves ND, Langberg H. “Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness.” Sports Medicine, 2013;43(4):267-286. https://pubmed.ncbi.nlm.nih.gov/23494258/ ↩ ↩² ↩³
de Jonge S, van den Berg C, de Vos RJ, van der Heide HJ, Weir A, Verhaar JA, Bierma-Zeinstra SM, Tol JL. “Incidence of midportion Achilles tendinopathy in the general population.” British Journal of Sports Medicine, 2011;45(13):1026-1028. https://pubmed.ncbi.nlm.nih.gov/21926076/ ↩
van der Vlist AC, Breda SJ, Oei EHG, Verhaar JAN, de Vos RJ. “Clinical risk factors for Achilles tendinopathy: a systematic review.” British Journal of Sports Medicine, 2019;53(21):1352-1361. https://pubmed.ncbi.nlm.nih.gov/30718234/ ↩ ↩²
Fahlström M, Jonsson P, Lorentzon R, Alfredson H. “Chronic Achilles tendon pain treated with eccentric calf-muscle training.” Knee Surgery, Sports Traumatology, Arthroscopy, 2003;11(5):327-333. https://pubmed.ncbi.nlm.nih.gov/12942235/ ↩ ↩² ↩³
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