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Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Quick Answer:
Quick Answer: Eccentric heel drop exercises — specifically the Alfredson protocol — are the gold standard conservative treatment for mid-portion Achilles tendinopathy. The protocol involves standing on the ball of the foot at the edge of a step, rising to tiptoe bilaterally, then slowly lowering the heel below step level on the affected foot over 3 seconds. Three sets of 15 repetitions twice daily for 12 weeks. The eccentric (lengthening) contraction stimulates collagen synthesis and tendon remodeling that addresses the underlying pathological changes of tendinopathy — not just symptoms. Clinical trials show 60–90% good-to-excellent outcomes at 12 weeks. Critical caveat: insertional Achilles tendinopathy requires modified protocol — full eccentric heel drops worsen insertional symptoms.
Why Eccentric Heel Drops Work for Achilles Tendinopathy
Achilles tendinopathy — the most common tendon injury in runners — results from a failure of tendon homeostasis: the rate of tendon collagen breakdown exceeds the rate of repair, leading to disorganized fibril architecture, neovascularization, and painful tendon thickening. Traditional rest and anti-inflammatory approaches address symptoms without stimulating the biological remodeling needed to restore normal tendon structure. Eccentric loading addresses this directly.
Eccentric exercise — where a muscle contracts while lengthening — has been shown in multiple randomized controlled trials to stimulate tenocyte activity, increase collagen synthesis, and improve tendon mechanical properties. The Achilles tendon is uniquely responsive to eccentric loading because the muscle-tendon unit experiences its highest mechanical forces during the lengthening phase of the gait cycle. By applying controlled eccentric load, the Alfredson heel drop protocol stimulates the remodeling process that restores normal tendon architecture.
The Alfredson Protocol: Complete Instructions
The original Alfredson protocol for mid-portion Achilles tendinopathy, from Håkan Alfredson’s landmark 1998 Scandinavian study, is performed as follows:
Straight-knee heel drops (targeting the gastrocnemius): Stand on the ball of both feet at the edge of a step, heels hanging off the edge. Rise to tiptoe using both feet. Transfer all weight to the affected leg. Slowly lower the heel below the step level over 3 seconds. Return to tiptoe using both feet. Perform 3 sets of 15 repetitions. Rest 2 minutes between sets.
Bent-knee heel drops (targeting the soleus): Perform the same exercise but with the knee bent to approximately 30 degrees throughout. This shifts the eccentric load from the gastrocnemius to the soleus component of the Achilles. Perform 3 sets of 15 repetitions with bent knee.
Both exercises should be performed twice daily, 7 days per week, for 12 weeks minimum. The Alfredson protocol specifically instructs patients to continue the exercises through the pain that typically occurs in the first weeks — Alfredson’s original patients were instructed to stop only if the pain became disabling. This counterintuitive instruction reflects the reality that initial eccentric loading discomfort is part of the remodeling stimulus, not a sign of injury.
Progression: From Bilateral to Loaded
For patients whose pain initially prevents the standard single-leg protocol, a bilateral-to-unilateral progression is used: begin with both feet lowering simultaneously. Progress to unilateral lowering (affected leg only) as pain allows. Advanced progression adds external load via a backpack or held dumbbells — adding 5–10 kg as tolerance increases for athletes who have conquered bodyweight eccentric loading. The Alfredson protocol specifically requires patients to progress until they reach a pain level of 3–4/10 and no higher during the exercise.
Who Should NOT Perform Full Eccentric Heel Drops
Insertional Achilles tendinopathy — affecting the tendon at the calcaneal attachment rather than the mid-tendon — is the critical contraindication to full eccentric heel drops. When the heel drops below the step edge, compressive forces are generated at the tendon-bone insertion that aggravate insertional pathology. Patients with insertional tendinopathy are managed with isometric loading, partial-range heel drops (not below neutral), and avoidance of end-range dorsiflexion positions. Dr. Biernacki differentiates mid-portion from insertional tendinopathy with ultrasound imaging and prescribes the appropriate protocol for each patient’s specific diagnosis.
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Yes4All Heavy-Duty Balance Board Step Platform
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Stable step platform for Alfredson eccentric heel drop protocol — provides the necessary step edge for full range heel drops without the instability of stairs or improvised surfaces.
Dr. Tom says: “Using this platform made my Alfredson heel drop protocol consistent and safe — no slipping or wobbling on the stair edge.”
Alfredson eccentric protocol, step edge for heel drops, stable platform for calf exercises
Patients who prefer to use stairs — a standard step works fine if stable and appropriately elevated
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Gaiam Adjustable Ankle Weights (5-10 lb)
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Adjustable ankle weights for progressive eccentric loading beyond bodyweight — used in the advanced Alfredson protocol once bodyweight heel drops are pain-free and 3 sets of 15 can be completed without significant pain.
Dr. Tom says: “Added ankle weights to my heel drops when bodyweight became easy — the progression felt exactly right for recovery.”
Advanced Alfredson protocol loading, experienced tendinopathy rehabilitation, progressive eccentric loading
Early-stage tendinopathy where bodyweight eccentric loading already produces significant discomfort
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OPTP Slant Board (30-Degree Incline)
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Inclined stretching board used alongside the eccentric protocol — provides the complementary static calf stretching that improves Achilles tendon extensibility during rehabilitation from tendinopathy.
Dr. Tom says: “My podiatrist prescribed both the heel drops and the slant board together — the combination was more effective than either alone.”
Complementary calf stretching with Alfredson protocol, plantar fasciitis and Achilles combined protocol
Insertional Achilles tendinopathy where forced dorsiflexion under load worsens insertion symptoms
Disclosure: We earn a commission at no extra cost to you.
✅ Pros / Benefits
- Alfredson eccentric protocol achieves 60–90% good-to-excellent outcomes for mid-portion Achilles tendinopathy
- Eccentric loading addresses underlying tendon structural pathology — not just symptom suppression
- Protocol can be performed at home with minimal equipment — a step or step platform is sufficient
- 12 weeks of consistent execution produces durable outcomes that are maintained at 1-year follow-up
❌ Cons / Risks
- CONTRAINDICATED for insertional Achilles tendinopathy — must be distinguished from mid-portion pathology
- Initial weeks involve expected exercise-related discomfort — patients who stop due to early pain do not complete the protocol
- 12-week commitment with twice-daily sessions is demanding — compliance is the primary predictor of outcome
- Complete or significant partial Achilles rupture is a contraindication — requires surgical or immobilization management
Dr. Tom Biernacki’s Recommendation
The Alfredson protocol is one of the most validated treatments in all of podiatric sports medicine — 12 weeks, twice a day, and the evidence is genuinely compelling. But two mistakes kill the results: first, applying it to insertional tendinopathy instead of mid-portion, which makes it worse. Second, stopping in week three when it hurts. The pain in the first few weeks is part of the process. I tell patients: keep going through the discomfort, not through the sharp pain. There’s a difference.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
How do you do eccentric heel drops for Achilles tendinopathy?
Stand on the ball of both feet at a step edge. Rise to tiptoe on both feet. Transfer all weight to the affected leg. Slowly lower the heel below the step level over 3 seconds. Return to tiptoe using both feet. Perform 3 sets of 15 repetitions with straight knee (targets gastrocnemius) and 3 sets of 15 with bent knee (targets soleus). Repeat twice daily for 12 weeks.
Do eccentric heel drops hurt?
Mild to moderate discomfort during the heel-lowering phase is expected and acceptable in the Alfredson protocol — particularly in the first 2–4 weeks. Alfredson’s original instructions told patients to continue through pain that was moderate but not disabling. Pain typically decreases significantly by weeks 6–8 as tendon remodeling progresses. Sharp, severe pain, especially with audible popping or significant swelling, is a reason to stop and consult Dr. Biernacki.
How long before eccentric heel drops help Achilles pain?
Most patients notice meaningful improvement in Achilles pain between weeks 6–8 of the Alfredson protocol. Morning stiffness often decreases first. Full resolution of symptoms typically occurs at 10–12 weeks. Some patients with severe tendinopathy or structural changes visible on ultrasound may require longer — or additional treatments such as shockwave therapy or PRP — before complete resolution.
Can I run during the Alfredson eccentric protocol?
The original Alfredson study allowed continued running during the protocol — patients were not asked to rest. Many runners find they can maintain modified training (reduced mileage, slower pace, avoiding hills) during the 12-week program. Dr. Biernacki provides individualized guidance on running volume modification based on the severity of tendinopathy and patient response to the protocol.
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For more on related conditions and treatments:
- Achilles tendonitis complete guide
- Insertional Achilles tendonitis treatment
- Eccentric heel drops for Achilles
- Plantar fasciitis stretches
- Pain above the heel (back of foot)
- Howell podiatrist office
- Bloomfield Hills podiatrist office
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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.
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If home treatment isn’t providing relief for your heel pain, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.
Same-day appointments available. (810) 206-1402
Frequently Asked Questions
How long does plantar fasciitis take to heal?
Most plantar fasciitis cases resolve within 6–12 months with consistent treatment. In our clinic, patients who begin care within the first 8 weeks see 80% improvement by month 3. Chronic cases — pain lasting over a year — typically require PRP injections or surgical intervention, but fewer than 5% of our patients reach that point. Starting treatment early is the single biggest factor in shortening recovery.
Why is plantar fasciitis pain worst in the morning?
Overnight, the plantar fascia contracts in a shortened position. Your first steps stretch it abruptly, causing micro-tears at the heel attachment and sharp pain. This ‘first-step pain’ that eases after 10–15 minutes is the hallmark diagnostic sign. If your pain worsens throughout the day rather than improving, a different diagnosis — stress fracture, fat pad atrophy, or nerve entrapment — should be explored.
Can I walk or run with plantar fasciitis?
You can often continue with modifications, especially in early-stage cases. Reduce mileage by 30–50%, avoid hills and speed work, and run on softer surfaces. Add aggressive calf stretching before and after. If pain exceeds 4/10 during activity, stop — pushing through moderate-to-severe pain causes scar tissue formation that can double your recovery time. We reassess runners every 3 weeks to adjust the plan.
Does plantar fasciitis require surgery?
Surgery is required in fewer than 5% of cases. We exhaust conservative options first: custom orthotics, physical therapy, night splints, corticosteroid injections, and shockwave therapy. If those fail after 6–12 months of consistent treatment, plantar fascia release or PRP is considered. In our practice, patients who follow a structured protocol almost never reach surgery.
What shoes help plantar fasciitis the most?
The three features that matter most: firm arch support (not soft cushioning — soft foam collapses under load), a slight heel elevation of 8–12mm to reduce fascia tension, and a wide, deep toe box. Motion-control and stability shoes outperform neutral cushioned shoes for most plantar fasciitis patients. Avoid flat shoes, flip-flops, and going barefoot on hard floors entirely.
Do I need custom orthotics, or will store-bought insoles work?
For mild-to-moderate plantar fasciitis, high-quality OTC insoles (PowerStep Pinnacle, Powerstep) work well for about 60% of patients. Custom orthotics are worth it when: your arch collapse is severe, OTC insoles haven’t helped after 8 weeks, or you have a secondary issue like leg-length discrepancy or overpronation driving the problem. We cast custom orthotics in-office when clinically indicated — typically covered by most PPO plans.
Is plantar fasciitis the same as a heel spur?
No — they’re related but different. A heel spur is a bony calcium deposit that forms on the bottom of the heel bone; plantar fasciitis is inflammation of the fascia ligament. About 70% of patients with plantar fasciitis have a heel spur on X-ray, but the spur is rarely the source of pain. Treating the fascia inflammation resolves symptoms in most cases without removing the spur.
What stretches actually work for plantar fasciitis?
The two most evidence-supported stretches: (1) Seated towel stretch — loop a towel around your foot, pull toes toward you, hold 30 seconds, repeat 3x before getting out of bed. (2) Calf-wall stretch with a straight knee and a bent knee — targets both the gastrocnemius and soleus. Research shows stretching 3x daily reduces symptoms significantly within 8 weeks. The Strassburg sock worn overnight is the highest-impact passive stretch available.
Can plantar fasciitis come back after it heals?
Yes — recurrence rate is 15–25% in the first year without maintenance. The three biggest recurrence triggers: returning to the shoes that caused the problem, stopping stretching when pain disappears, and sudden increases in activity. Patients who continue daily stretching, wear supportive footwear consistently, and use orthotics long-term have recurrence rates under 5% in our practice.
When should I see a podiatrist for heel pain?
See a podiatrist if: pain is severe and limits daily walking, pain hasn’t improved after 4 weeks of rest and stretching, pain is getting progressively worse, you’re having pain at night or at rest, or the pain is on the back or side of your heel rather than the bottom. Night and resting pain can indicate stress fractures, nerve compression, or Achilles pathology — conditions that need imaging to rule out.
What’s the difference between plantar fasciitis and tarsal tunnel syndrome?
Both cause heel pain but feel different. Plantar fasciitis pain is sharp, focal, and worst with first steps. Tarsal tunnel pain is burning, tingling, or electric — often radiating into the arch and toes — and worsens with prolonged standing. Tarsal tunnel is nerve compression (like carpal tunnel in the wrist); plantar fasciitis is ligament degeneration. A nerve conduction study and Tinel’s sign test differentiate them. Misdiagnosis is common — about 20% of chronic plantar fasciitis cases are actually tarsal tunnel.
Related Conditions
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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