Quick Answer Reviewed by Dr. Tom Biernacki, DPM, FACFAS · Updated May 2026

Midportion: Alfredson Eccentric Protocol

The Alfredson eccentric heel drop protocol (1998) remains the gold standard for midportion Achilles tendinopathy with level 1 evidence. The protocol: stand on the edge of a step on the affected foot, rise on both feet, lower on the affected foot alone — going below the level of the step (maximally dorsiflexing the ankle) during the lowering phase. 3 sets of 15 repetitions, twice daily, 7 days a week, for 12 weeks. Perform with both straight and slightly bent knee to load both gastrocnemius and soleus. It will be painful — the original Alfredson research required patients to work through pain. This provocation drives tendon remodeling through mechanobiological signaling. Patients who stop when it hurts get no benefit. Alfredson’s original paper showed 90% success in patients who completed the protocol — a result that has been replicated dozens of times.

Insertional: Modified Protocol + Heel Lift

Insertional tendinopathy uses heavy-slow resistance exercise (HSR) rather than the Alfredson eccentric protocol — heel drops to neutral only (not below step level), performed slowly with a 3-second lowering phase. A 5–8mm heel lift (orthotic heel raise or small wedge insole) reduces dorsiflexion at the insertion during walking and is an important adjunct. Avoid classic Achilles stretches (standing calf stretch against a wall) which maximally dorsiflex the ankle and compress the insertion. Shoe modification to soften or cut away the posterior counter reduces direct mechanical pressure on the Haglund prominence.

Surgical Options (Persistent Cases)

For midportion tendinopathy failing 12+ weeks of Alfredson protocol, options include high-volume injection (saline + anesthetic separating the peritenon neovessels), platelet-rich plasma injection (moderate evidence), ESWT (extracorporeal shockwave therapy — strong evidence, non-invasive), and surgical débridement/scraping. For insertional tendinopathy with Haglund’s deformity, calcaneal osteotomy (removing the bony prominence) combined with Achilles tendon débridement and reattachment is effective for recalcitrant cases. Results of Achilles surgery in carefully selected patients are generally excellent.

Topical Pain Relief During Rehabilitation: Doctor Hoy’s Natural Pain Gel

Doctor Hoy’s Natural Pain Relief Gel — Foundation Wellness Partner

30% commission | Arnica + camphor natural analgesic | Replaces Biofreeze

The Alfredson protocol is uncomfortable by design — working through pain is part of the mechanism. Doctor Hoy’s Natural Pain Relief Gel (arnica + camphor base) provides meaningful topical analgesia that allows patients to complete their rehabilitation protocol without systemic NSAIDs. Applied directly to the midportion or insertional region 15–30 minutes before exercise sessions, it reduces peritendinous pain enough to allow exercise compliance — which is the single most important predictor of outcome in eccentric training protocols.

Unlike Biofreeze (which we no longer recommend — it has been reformulated and lacks the same arnica component), Doctor Hoy’s combines camphor for counter-irritant analgesia with arnica for peritendinous anti-inflammatory action. We recommend it to all Achilles tendinopathy patients undertaking the rehabilitation protocol as a compliance tool — not as a substitute for mechanical loading.

Not Ideal For:

Acute tendon rupture — requires imaging and surgical evaluation, not topical analgesia
Open wounds or skin breakdown over the tendon
Replacing mechanical loading (eccentric exercise) — topical analgesia is a rehabilitation aid, not treatment
Use over active infection or cellulitis around the tendon

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Most Common Mistake: Treating Insertional Tendinopathy Like Midportion

The most damaging mistake we see — and it is extremely common — is patients (and providers) applying the standard Achilles stretch (stand facing a wall, back knee straight, lean forward to feel the calf stretch) to insertional tendinopathy. This stretch, which is appropriate for midportion tendinopathy, maximally dorsiflexes the ankle and creates exactly the compressive force at the insertional region that is causing the problem. Patients report weeks of worsening symptoms after beginning a standard calf stretching protocol for what turned out to be insertional rather than midportion tendinopathy. Equally harmful is the below-step-level Alfredson eccentric drop for insertional tendinopathy — the extended dorsiflexion position compresses the inflamed insertion. The key rule: if your pain is at the heel bone, not in the middle of the tendon, do not stretch to maximum dorsiflexion. Eccentric exercises stop at neutral. Add a small heel lift instead. See a podiatrist to confirm the distinction before starting any Achilles rehabilitation protocol.

Red Flags: Possible Achilles Tendon Rupture

⚠️ Seek Emergency Evaluation If You Have:

Sudden severe pain in the calf or heel with an audible pop during activity — classic Achilles tendon rupture presentation; requires same-day emergency evaluation
Unable to push up on toes on the affected leg — positive Thompson test; strongly suggests complete rupture
Palpable gap or dip in the tendon above the heel — confirms significant tendon disruption
Rapid onset of severe swelling and bruising along the calf after an acute event — indicates significant tissue disruption
Currently taking or recently completed fluoroquinolone antibiotics — ciprofloxacin, levofloxacin significantly increase tendon rupture risk; report any new Achilles symptoms to your prescribing physician immediately
Chronic corticosteroid use — increases tendon fragility; any new Achilles symptoms warrant evaluation before continuing high-impact activity

Achilles Tendinopathy Evaluation at Balance Foot & Ankle

At Balance Foot & Ankle, Dr. Tom Biernacki evaluates Achilles tendinopathy with clinical examination (Royal London Hospital test, Thompson test, foot type and flexibility assessment), weight-bearing X-ray (to assess Haglund’s deformity and insertional calcification), and ultrasound imaging when soft tissue differentiation is needed. We prescribe individualized eccentric loading protocols, ESWT for recalcitrant cases, and surgical management for failed conservative care — at our Howell and Bloomfield Hills locations. Same-day appointments available for acute presentations. Request an appointment or call (810) 206-1402.

Frequently Asked Questions

How long does Achilles tendinopathy take to heal?

Mild Achilles tendinopathy caught early — within the first 4-6 weeks of symptoms — often responds within 6–8 weeks of the appropriate eccentric protocol. Moderate to severe tendinopathy, especially chronic cases present for 3+ months, typically requires 12 weeks of consistent Alfredson protocol and may take 6 months to reach full activity. Insertional tendinopathy with bone spur or Haglund’s deformity generally takes longer (3–6+ months) due to the structural bony component. The non-negotiable: consistency with the eccentric loading protocol. Patients who stop and start see consistently worse outcomes than those who complete 12 continuous weeks.

Can I run with Achilles tendinopathy?

For mild tendinopathy, continued running at reduced volume and intensity is compatible with recovery — and may even be beneficial compared to complete rest, which allows further deconditioning. The practical rule is the “pain monitoring model”: if pain during running is ≤5/10 and returns to baseline within 24 hours, the session was appropriate. If pain exceeds 7/10 during running or takes more than 24 hours to settle, that session was too much. Always run on flat surfaces (not hills) and in appropriate footwear. Significant tendinopathy with pain >5/10 throughout running warrants a brief 1–2 week rest while the eccentric protocol begins, followed by gradual return.

Should I stretch my Achilles if it hurts?

It depends on the type. For midportion tendinopathy (pain in the middle of the tendon, 2-6cm above the heel): gentle calf stretching is appropriate and helpful as an adjunct to eccentric loading. For insertional tendinopathy (pain at the heel bone): standard stretching that brings the ankle into maximum dorsiflexion is harmful and should be avoided. The distinction is critical — if you’re unsure which type you have, do not start a stretching program until you’ve been evaluated. A podiatrist can tell you with a 2-minute clinical examination. Treating the wrong type with the wrong protocol is the leading reason Achilles tendinopathy becomes chronic and difficult to manage.

When should I see a podiatrist for Achilles pain?

See a podiatrist for Achilles pain if the pain has been present more than 2–3 weeks, is limiting your activity or gait, has not improved with rest and footwear changes, or if you heard a pop or feel a gap in the tendon (emergency — possible rupture). Professional evaluation determines the type (midportion vs. insertional), severity, and appropriate rehabilitation protocol — all of which determine outcome. Starting the wrong protocol for the wrong type costs months of recovery time. Dr. Tom Biernacki at Balance Foot & Ankle in Howell and Bloomfield Hills MI offers same-day appointments for Achilles evaluation. Call (810) 206-1402.

Sources

Alfredson H, Pietilä T, Jonsson P, Lorentzon R. “Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis.” American Journal of Sports Medicine. 1998;26(3):360-366.
Maffulli N, Khan KM, Puddu G. “Overuse tendon conditions: time to change a confusing terminology.” Arthroscopy. 1998;14(8):840-843.
Rowe V, Hemmings S, Barton C, et al. “Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning.” Sports Medicine. 2012;42(11):941-967.
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.
Wiegerinck JI, et al. “Treatment for insertional Achilles tendinopathy: a systematic review.” Knee Surgery, Sports Traumatology, Arthroscopy. 2012;20(10):1681-1687.

Achilles Pain Limiting Your Running or Daily Activity?

Dr. Tom Biernacki identifies your type (midportion vs. insertional) and prescribes the exact protocol for it — not a generic Achilles treatment. Same-day appointments available.

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📞 (810) 206-1402 | Howell & Bloomfield Hills, MI

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Dr. Tom Biernacki, DPM

Affiliate Disclosure: This page contains affiliate links to products we recommend. If you purchase through these links, Balance Foot & Ankle may earn a small commission at no additional cost to you. We only recommend products we use with our patients.

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.

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