Medically reviewed by Dr. Tom Biernacki, DPM — Board-certified foot & ankle surgeon, 3,000+ surgeries performed. Updated April 2026 with current clinical evidence. This article reflects real practice experience from Balance Foot & Ankle Specialists in Howell and Bloomfield Hills, Michigan.
Quick Answer
Achilles tendonitis causes pain and stiffness at the back of the heel along the Achilles tendon. Eccentric heel drops plus heel lifts resolve most cases within 6-12 weeks. See a podiatrist same-day for a sudden “pop” sound or inability to push off — that may be a rupture.
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Medically Reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist, Balance Foot & Ankle Specialists, Michigan. Last updated April 2026.
The Alfredson eccentric loading protocol — published by Håkan Alfredson in 1998 and now with over 25 years of supporting evidence — remains the foundational exercise intervention for mid-portion Achilles tendinopathy, producing clinically meaningful pain reduction and return to sport in 60–90% of patients when performed correctly and consistently. Understanding the biomechanical rationale, precise exercise technique, and progression criteria helps patients achieve optimal outcomes and avoid the common errors that limit protocol effectiveness.
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Biomechanical Rationale
Eccentric loading — muscle contraction while lengthening under load — produces greater tendon mechanical stimulus than concentric (shortening) or isometric loading. The Alfredson protocol specifically targets the gastrocnemius-soleus-Achilles complex in the eccentric phase, generating controlled tensile stress that stimulates tenocyte activity, collagen production, and structural reorganization of the disorganized tendon tissue that characterizes tendinopathy. The protocol also appears to reduce neovascularization (the pathological blood vessel ingrowth into degenerative tendon that is associated with pain generation) through mechanisms not yet fully understood.
Protocol Details and Common Errors
Exercise: standing on a step edge — rise up on both feet to the top position (concentric phase with both feet), then shift weight to the involved foot only, and slowly lower the heel below the step edge through the full range (eccentric phase, 3 seconds down). Perform 3 sets of 15 repetitions twice daily, 7 days per week — total 6 sets/day. Gastrocnemius-specific: knee straight. Soleus-specific: knee bent to 45 degrees. The protocol must cause mild-to-moderate pain during exercise — this is expected and indicates the correct loading threshold; the “no pain, no gain” instruction is one of the most counterintuitive but evidence-supported aspects. Common errors: performing the concentric rise on the involved leg (removes the eccentric stimulus); stopping at the first sign of discomfort (underloading); not performing daily (insufficient stimulus frequency). Progress to heavier loading (weighted backpack) when 3×15 without load is pain-free. Dr. Biernacki at Balance Foot & Ankle supervises Achilles tendinopathy rehabilitation with loading protocol instruction, diagnostic ultrasound monitoring, and adjunctive PRP or ESWT when indicated. Call (810) 206-1402 at our Bloomfield Hills or Howell office.
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Our board-certified podiatrists treat this condition at two convenient locations. Same-day appointments often available.
When to See a Podiatrist
Many foot conditions can be managed conservatively at home, but some require professional evaluation. See a podiatrist promptly if you experience:
- Pain that persists for more than 2 weeks despite rest
- Swelling, redness, or warmth that isn’t improving
- Numbness, tingling, or burning in the feet
- A wound or sore that is not healing within 2 weeks
- Any foot concern if you have diabetes or poor circulation
- Nail changes that suggest fungal infection or other problems
At Balance Foot & Ankle, our three board-certified podiatrists — Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin — provide comprehensive foot and ankle care at our Howell and Bloomfield Township offices. Most insurance plans are accepted.
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If home care isn’t resolving your Achilles tendon pain, a visit with a board-certified podiatrist is the fastest path to accurate diagnosis and a personalized plan. At Balance Foot & Ankle Specialists, Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin offer same-day and next-day appointments at both our Howell and Bloomfield Hills offices. We perform on-site diagnostic ultrasound, digital X-ray, conservative care, advanced regenerative treatments, and minimally invasive surgery when indicated.
Call (810) 206-1402 or request an appointment online. Most insurance plans accepted, including Medicare, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare.
Differential Diagnosis: What Else Could It Be?
Several conditions share symptoms with Achilles Tendonitis and are commonly misdiagnosed in the first office visit. Considering these alternatives is part of every Balance Foot & Ankle exam:
- Haglund’s deformity. Bony bump at the back of the heel rubbing against the shoe counter.
- Insertional vs. mid-substance Achilles. Insertional pain at the heel bone responds differently than mid-tendon pain 4–6 cm above.
- Retrocalcaneal bursitis. Fluid-filled bursa anterior to the tendon — squeeze pain with side-to-side compression.
If your symptoms don’t fit the textbook pattern, ask your podiatrist which differentials they ruled out — that conversation often shortcuts months of trial-and-error treatment.
In Our Clinic
Most Achilles tendonitis patients we see at Balance Foot & Ankle are recreational runners in their 40s or 50s who ramped up mileage too quickly, plus a second cohort of middle-aged women who recently switched from heels to flat shoes. The first question we ask is whether the pain is at the insertion on the heel bone versus 2–6 cm up the mid-substance — the treatment ladder is genuinely different. Eccentric heel-drops, heel lifts, and a soft-strike gait retraining pass resolve ~80 % of cases. The ones who aren’t improving by week 8 usually have an unrecognized Haglund’s deformity or insertional calcific tendinosis that needs imaging.
Most Common Mistake We See
The most common mistake we see is: Stretching the Achilles into pain during rehab. Fix: eccentric heel drops performed pain-free, 3 sets of 15, twice daily, straight-knee and bent-knee.
Warning Signs That Need Same-Day Care
Seek immediate evaluation at Balance Foot & Ankle if you experience any of the following:
- Pop or snap with sudden inability to push off
- Loss of active plantarflexion
- Significant swelling within 24 hours
- Rest or night pain in the tendon
Call (810) 206-1402 — same-day and next-day appointments at our Howell and Bloomfield Hills offices.
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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
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- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
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