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Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Quick Answer:
Quick Answer: Eccentric heel drops are the defining exercise of the Alfredson protocol for Achilles tendinopathy. The exercise involves a three-phase movement: concentric rise (up on both feet), isometric hold at peak, eccentric lowering (down on the affected foot alone) over a 3-second controlled descent until the heel falls below the step edge. The slow eccentric phase — the muscle lengthening under load — is the active ingredient: it creates the collagen synthesis stimulus that remodels pathological tendon tissue. Three sets of 15 repetitions with straight knee, three sets of 15 with bent knee, twice daily for 12 weeks. Both variations are required because the gastrocnemius and soleus contribute differently to Achilles tendon load and must each be eccentrically loaded.
The Science Behind Eccentric Heel Drops
The Alfredson eccentric heel drop protocol emerged from a 1998 clinical observation that patients with severe mid-portion Achilles tendinopathy who were denied surgical treatment and instead prescribed intensive eccentric loading recovered fully over 12 weeks. This counterintuitive finding — that loading a painful, degenerating tendon could restore it to health — spawned decades of research confirming and refining the approach.
The mechanism of eccentric loading in tendon rehabilitation involves three key biological processes. First, mechanical loading of tenocytes (tendon cells) in the lengthening direction stimulates collagen synthesis and fiber alignment — improving the mechanical quality of the tendon tissue. Second, eccentric loading reduces pathological neovascularization (blood vessel ingrowth) in the tendon, which is associated with pain generation in chronic tendinopathy. Third, progressive eccentric loading increases tendon stiffness and cross-sectional area, improving the tendon’s capacity to absorb future mechanical loads without breakdown.
Step-by-Step Technique: Straight-Knee Eccentric Heel Drop
Setup: Stand at the edge of a step or step platform with the ball of both feet on the edge and the heels hanging in space. Have a wall or railing within reach for balance support if needed.
Phase 1 — Concentric rise: Using both feet, rise to tiptoe (full plantarflexion). Keep both knees straight throughout. This concentric phase should not be rushed — a 1-second rise is appropriate.
Phase 2 — Weight transfer: Carefully transfer all body weight to the affected (symptomatic) foot. The non-affected foot may lightly touch the step for balance but should bear no weight.
Phase 3 — Eccentric lowering: Slowly lower the heel of the affected foot below the step level over exactly 3 seconds. This controlled, 3-second descent is the critical therapeutic element. Do not allow the heel to drop rapidly — the slow eccentric phase is what stimulates tendon remodeling.
Reset: Use both feet to return to the starting tiptoe position. Repeat. Perform 3 sets of 15 repetitions. Rest 2 minutes between sets.
Step-by-Step Technique: Bent-Knee Eccentric Heel Drop
Perform identically to the straight-knee variation but with the knee bent to approximately 30 degrees throughout all phases. The bent knee position reduces gastrocnemius contribution and places the eccentric load specifically on the soleus — the deep calf muscle that is a major contributor to mid-portion Achilles tendinopathy, particularly in running athletes. Perform 3 sets of 15 repetitions with the knee bent immediately after completing the straight-knee sets.
Pain Guidance During the Protocol
The Alfredson protocol’s unusual instruction is to exercise through pain — with a specific ceiling. Pain of 0–4/10 during the exercise is acceptable and expected, particularly in weeks 1–4. Pain above 5–6/10 suggests the load is too high — modify by using both feet for the lowering phase until tolerance improves. Sharp, sudden, or escalating pain, or any audible snapping, requires immediate cessation and clinical evaluation. Dr. Biernacki uses this pain-guided approach when prescribing the protocol — the goal is to load the tendon near but not beyond its current tolerance.
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Adjustable step platform for Alfredson eccentric heel drop protocol — provides the stable, appropriate-height step edge needed for full-range heel drops without the instability of improvised surfaces.
Dr. Tom says: “Having a dedicated platform for my heel drops made the protocol much more consistent than using the stairs.”
Alfredson eccentric heel drops, step edge for calf rehabilitation, stable platform
Patients comfortable performing the protocol on a standard stair step with appropriate caution
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Nordic Lifting Wrist Wraps (Grip for Weighted Protocol)
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Comfortable wrist wraps used when holding dumbbells during advanced loaded eccentric heel drops — allows easy grip of hand weights as the protocol progresses to loaded variations.
Dr. Tom says: “Used these when I added dumbbell loading to my heel drops — the wraps kept the grip comfortable through full sets.”
Advanced loaded Alfredson protocol, progressive eccentric loading with added weight
Bodyweight Alfredson protocol where no external loading is needed
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Diclofenac topical NSAID gel applied to the Achilles tendon region after eccentric training sessions — reduces local inflammatory response without systemic NSAID side effects during rehabilitation.
Dr. Tom says: “Applying this after my eccentric sessions helped manage the soreness during the first weeks of the Alfredson protocol.”
Post-eccentric exercise Achilles soreness management, adjunct anti-inflammatory during protocol
Primary treatment for Achilles tendinopathy — eccentric loading is the treatment; this is only adjunctive
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✅ Pros / Benefits
- Eccentric heel drops achieve 60–90% good-to-excellent outcomes in randomized trials for mid-portion Achilles tendinopathy
- Addresses the underlying structural tendon pathology through collagen stimulation — not just symptom suppression
- Protocol can be performed at home with a step — minimal equipment required for standard bodyweight version
- Outcomes are durable at 1-year follow-up — the tendon remodeling persists beyond the 12-week active protocol
❌ Cons / Risks
- Full eccentric heel drops are contraindicated for INSERTIONAL Achilles tendinopathy — clinical differentiation is essential
- Initial weeks involve moderate exercise-related discomfort — patients who stop early do not benefit from the protocol
- Requires twice-daily dedication for 12 weeks — compliance is the strongest predictor of outcome
- Severe or symptomatic partial Achilles tears require clinical assessment before beginning eccentric loading
Dr. Tom Biernacki’s Recommendation
Eccentric heel drops are one of my most-prescribed exercises — they’re simple, evidence-based, and genuinely effective for mid-portion Achilles tendinopathy. The protocol isn’t complicated, but patients need to understand the pain guidance. Some discomfort in the first few weeks is not a reason to stop — it’s expected. What would make me stop them is sharp, escalating pain or any feeling of tearing. Moderate, aching exercise discomfort? Keep going. That’s the stimulus working.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
How many heel drops should I do for Achilles tendinopathy?
The Alfredson protocol specifies 3 sets of 15 repetitions with the knee straight (gastrocnemius-focused) and 3 sets of 15 with the knee bent (soleus-focused), performed twice daily. This totals 180 repetitions per day per affected leg — maintained for 12 weeks. This exact load has the strongest clinical evidence; modified lower-volume protocols have weaker supporting evidence.
Should I feel pain during eccentric heel drops?
Mild to moderate pain (3–4/10) during the eccentric phase is acceptable and expected in the first 4 weeks, per the Alfredson protocol. Pain typically decreases progressively as tendon remodeling occurs. If pain is severe (6+/10), reduce load by using both feet to lower the heel until tolerance improves. Sharp, sudden pain or pain that escalates from session to session is a reason to stop and consult Dr. Biernacki.
Can I do eccentric heel drops for insertional Achilles pain?
No — full eccentric heel drops with the heel below step level are contraindicated for insertional Achilles tendinopathy. The deep dorsiflexion position compresses the tendon against the calcaneal bone and worsens insertional symptoms. Insertional tendinopathy requires a modified eccentric protocol where the heel does not drop below neutral, combined with isometric loading and avoidance of end-range dorsiflexion.
How long until eccentric heel drops relieve Achilles pain?
Most patients experience meaningful pain reduction between weeks 6–8 of the consistent Alfredson protocol. Morning tendon stiffness typically improves first. Full resolution of symptoms occurs at 10–12 weeks in most cases. Patients with severe structural changes or long-standing tendinopathy may require additional treatments (shockwave therapy, PRP) if the eccentric protocol alone is insufficient at 12 weeks.
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Frequently Asked Questions
When should I see a podiatrist?
If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).
What does treatment cost?
Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.
How quickly can I get an appointment?
Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.
Frequently Asked Questions
What’s the difference between Achilles tendinitis and tendinosis?
Tendinitis is acute inflammation (early-stage, under 6 weeks). Tendinosis is chronic degeneration without active inflammation — collagen breakdown, microscopic tearing, thickening. This distinction is critical for treatment: tendinitis responds to rest and anti-inflammatories; tendinosis does NOT respond to NSAIDs or ice because there’s no active inflammation to suppress. Tendinosis requires eccentric loading therapy and often PRP to stimulate collagen repair. Many patients treat tendinosis like tendinitis for months, prolonging recovery unnecessarily.
Will Achilles tendinitis lead to a rupture?
Untreated Achilles tendinopathy increases rupture risk — but it’s not inevitable. Risk rises significantly when patients continue high-impact activity through moderate-to-severe pain, or return to sport before the tendon has healed. In our practice, patients who complete a structured eccentric loading protocol have roughly a 3% rupture rate. Those who ignore the condition and keep training have rates closer to 15–20%. Early treatment isn’t optional — it’s rupture prevention.
How long does Achilles tendinitis take to heal?
Insertional Achilles tendinitis (at the heel bone) typically takes longer than mid-portion tendinitis — often 3–6 months with consistent treatment. Mid-portion responds faster, usually 6–12 weeks. The biggest predictor of recovery time is how long you’ve had symptoms before starting treatment. Patients who begin care within 4 weeks recover twice as fast as those who wait 6+ months. Chronic tendinosis can require 12–18 months even with optimal care.
What is eccentric heel drop exercise and does it work?
Eccentric loading — raising on both feet on a step and lowering slowly on the injured foot alone — is the single most evidence-supported treatment for mid-portion Achilles tendinopathy. The Alfredson protocol (3 sets of 15 reps, twice daily, over 12 weeks) shows 60–80% success rates in research. The mechanism: controlled overload stimulates collagen remodeling and tendon thickening. It should be done on a step edge with a heel drop below level — flat-surface heel raises are significantly less effective.
Can I exercise with Achilles tendinitis?
Yes, with modification. Low-impact activity — swimming, cycling, elliptical — is generally well-tolerated and maintains fitness without loading the tendon. Running can often continue at reduced volume (30–40% less) if pain stays below 4/10 during activity. Plyometrics, hill running, and speed work should stop until the tendon is at least 70% healed. The key rule: some discomfort during eccentric exercises is acceptable; sharp or worsening pain means stop.
Should I use heat or ice for Achilles tendinitis?
For acute tendinitis (first 2–4 weeks): ice after activity to reduce inflammatory pain. For chronic tendinosis: heat before exercise to increase blood flow; ice after to reduce post-exercise soreness. Many patients with chronic tendinosis use ice exclusively and wonder why they’re not improving — cold vasoconstricts the tendon, reducing the blood flow that chronic degeneration requires to heal. If symptoms have been present more than 6 weeks, switch your protocol.
What shoes help Achilles tendinitis?
A heel lift of 8–12mm is the most impactful footwear modification — it reduces the mechanical stretch of the tendon during gait. Motion-control or stability shoes work better than neutral shoes for most patients. Avoid minimalist and zero-drop shoes entirely during treatment. Temporary heel lifts (3/8″) added to regular shoes are a quick way to assess whether elevation helps before investing in specific footwear.
What is PRP therapy and does it work for Achilles tendinopathy?
PRP (Platelet-Rich Plasma) involves drawing your blood, concentrating the growth factors via centrifuge, and injecting them into the tendon under ultrasound guidance. For chronic mid-portion Achilles tendinosis that hasn’t responded to 12+ weeks of eccentric exercise, PRP shows 60–75% success rates in systematic reviews. Results take 6–12 weeks to manifest. We use ultrasound guidance for all tendon injections to ensure accurate placement. PRP is generally not covered by insurance but is typically $400–700 per treatment.
Does Achilles tendinitis affect both feet?
Most cases are unilateral (one side), typically the dominant-leg side or the side of greater mechanical load. Bilateral Achilles tendinopathy can occur in runners who dramatically increase training volume, but also warrants evaluation for systemic conditions — particularly fluoroquinolone antibiotic use (ciprofloxacin, levofloxacin are known to weaken tendons), seronegative arthropathies, and hypothyroidism. If both tendons are symptomatic without a clear mechanical cause, a systemic workup is appropriate.
When does Achilles tendinopathy require surgery?
Surgery is considered after 6–12 months of failed conservative management. Procedures include debridement of degenerated tissue, calcification removal (for insertional tendinopathy), and in severe cases, tendon reconstruction with FHL transfer. About 10–15% of patients with Achilles tendinopathy eventually need surgery. The outcomes are generally good — 80–90% return to activity — but recovery takes 6–9 months. We always exhaust shockwave therapy and PRP before recommending surgery.
Is Achilles tendinitis related to plantar fasciitis?
They often co-occur and share common risk factors: tight calf muscles, overpronation, rapid training increases, and inadequate footwear. Mechanically, a tight gastrocnemius (calf) increases load on both the Achilles insertion and the plantar fascia. Treating one effectively often improves the other. If you have both conditions simultaneously, the rehabilitation protocol is similar — eccentric calf work and dorsiflexion stretching address both pathologies.
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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.
Frequently Asked Questions
Can I see a podiatrist for heel pain without a referral?
How long does plantar fasciitis take to heal?
Should I walk on my heel if it hurts?
What does a podiatrist do for heel pain?
- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
- Plantar Fasciitis (APMA)
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
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