Achilles Tendinopathy Exercises & Treatment 2026 | DPM

Type	Location	Imaging	Key Clinical Feature	Exercise Protocol
Non-insertional (mid-portion)	2–6cm above calcaneal insertion	MRI: fusiform thickening; intrasubstance degeneration	Pinch test positive; worse with running; improves with warm-up	Alfredson heavy-load eccentric protocol (3×15 twice daily)
Insertional	At calcaneal tuberosity insertion	MRI: enthesopathy; calcification; Haglund deformity	Posterior heel prominence; pain with heel cord stretch; shoe counter aggravates	Silbernagel combined eccentric-concentric; NO painful end-range stretch
Paratenonitis	Paratenon sheath (peritendinous)	MRI: peritendinous edema; sheath fluid	Crepitus on palpation; diffuse Achilles tenderness; acute onset	Rest → progressive loading; avoid eccentric overload in acute phase
Partial Tear	Variable; often mid-portion	MRI: focal high T2 signal; partial fiber disruption	Acute-on-chronic; sudden pain increase; Thompson + partial	NWB boot → progressive loading; surgical debridement if failed 6 months

Treatment	Evidence Level	Indication	Protocol	Outcome
Alfredson Eccentric Protocol	Level I (non-insertional)	Non-insertional mid-portion tendinopathy	3 sets × 15 reps, twice daily × 12 weeks; straight + bent knee	60–80% symptom improvement at 12 weeks
Silbernagel Combined Loading	Level I	Both insertional and non-insertional	Progressive eccentric-concentric × 12 weeks; pain monitored	Non-inferior to Alfredson; better adherence
Heavy Slow Resistance (HSR)	Level I	All types; poor tolerance to high-rep protocols	4 sets × 6 reps, 3× per week × 12 weeks; loaded at 6–8 RPE	Non-inferior to Alfredson; superior MRI tendon changes
ESWT (Shockwave)	Level I (non-insertional); Level II (insertional)	Failed 12 weeks exercise; calcific insertional	3–5 radial sessions; 2,000 pulses	60–75% improvement; best combined with exercise
PRP Injection	Level II (conflicting RCT data)	Partial tear; failed exercise + ESWT	Single or double injection under ultrasound	Some RCTs show benefit; others negative; adjunct not first-line
Surgical Debridement	Level III	Failed 6 months conservative; >50% tendon degeneration on MRI	Open or endoscopic; remove degenerative tissue; Haglund resection if insertional	75–85% good/excellent; 4–6 month recovery

Quick answer: Treatment for achilles tendinopathy exercises treatment recovery follows a stepwise approach: 1) conservative care first (rest, ice, supportive footwear, OTC anti-inflammatories), 2) physical therapy and targeted exercises, 3) in-office treatments (injections, custom orthotics) if conservative fails at 4-6 weeks, 4) surgery for refractory cases. Most patients resolve at step 1 or 2. Call (810) 206-1402.

https://www.youtube.com/watch?v=8opvH3qxkW4

Achilles tendinopathy is one of the most common running and sport injuries — and one of the most mismanaged. The treatment depends critically on where in the tendon the problem is located. Mid-portion and insertional Achilles tendinopathy require distinctly different approaches.

Mid-Portion vs. Insertional: Why It Matters

Mid-portion tendinopathy occurs 2-6 cm above the calcaneal insertion. The classic treatment is eccentric loading (heel drops). Insertional tendinopathy occurs at the bone-tendon junction. Eccentric exercises that take the heel below level are contraindicated for insertional disease — they increase compression at the insertion. Confusing the two leads to prolonged suffering.

Eccentric Heel Drop Protocol (Mid-Portion)

Alfredson’s protocol: stand on a step, rise on both feet, lower slowly on the affected foot only, going below step level. 3 sets of 15 repetitions, twice daily, 7 days per week for 12 weeks — even when it hurts (within reason). This protocol has the strongest evidence base of any tendinopathy treatment, producing clinically significant improvement in 60-80% of patients.

Insertional Achilles Treatment

Avoid eccentric loading below neutral. Heel lifts (7-10mm) reduce Achilles insertion loading. ESWT is particularly effective for insertional tendinopathy, targeting the degenerative tissue and calcification often present at the insertion. Load management (reduce high-impact activity by 30-50%) is critical. PRP for insertional disease refractory to 3-6 months of conservative care.

Additional Supportive Treatments

Night splints maintain the ankle in slight dorsiflexion overnight, reducing morning Achilles stiffness. Anti-inflammatory measures (ice, NSAIDs for acute flares). Gait retraining for runners with overstriding or excessive heel striking. Custom orthotics addressing underlying pronation or supination contributing to Achilles stress.

When Conservative Treatment Fails

After 3-6 months of appropriate eccentric exercise and conservative care, PRP and ESWT are the next steps before considering surgery. Achilles tendon debridement surgery for refractory tendinopathy has good outcomes but carries a prolonged recovery (3-6 months).

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In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your Achilles or tendon pain, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.