Why Heel Raises Are the Foundation of Achilles Rehab

Achilles tendinopathy treatment Michigan.– /wp:heading –>

Heel raises—also called calf raises—are the single most evidence-supported exercise for Achilles tendinopathy rehabilitation. The Achilles tendon connects the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus), transmitting the enormous forces required for walking, running, and jumping. When the tendon develops tendinopathy (degeneration, microtearing, and failed healing), progressive loading through heel raise exercises stimulates tendon remodeling and restores load tolerance better than any other conservative intervention.

The evidence base is particularly strong for eccentric heel raises—the lowering phase of the movement—which create a specific type of mechanical stimulus that promotes collagen synthesis in the tendon. The Alfredson protocol, developed by Swedish orthopedic surgeon Håkan Alfredson in the late 1990s after he deliberately ruptured his own Achilles tendon to get surgery, demonstrated that heavy eccentric loading 3 times daily for 12 weeks produced remarkable outcomes in chronic midportion Achilles tendinopathy. Since then, heavy slow resistance (HSR) protocols combining both concentric and eccentric phases have shown equivalent or superior results with better patient compliance.

Types of Heel Raise Exercises

Eccentric Heel Drops (Alfredson Protocol)

The classic eccentric heel drop is performed on the edge of a step with the heel hanging off. Rise up on both feet, then shift to the affected foot and slowly lower the heel below the step edge over 3 seconds. Use the unaffected foot to return to the starting position. Perform 3 sets of 15 repetitions, twice daily (morning and evening), 7 days per week. Progress by adding weight (a backpack loaded with books) once bodyweight becomes easy. The protocol is designed to be performed through mild pain—if no soreness is felt, the exercise is not being done correctly or with sufficient load.

Heavy Slow Resistance (HSR) Protocol

The HSR protocol uses a slow 3-second up/3-second down tempo through full range of motion. Both legs are used for both the concentric (raising) and eccentric (lowering) phases. Start with bodyweight and progress to a loaded calf raise machine or leg press within 2–3 weeks. Training is performed every other day (3x per week) rather than daily, allowing tendon recovery between sessions. HSR achieves similar tendon structural improvements to eccentric-only protocols with fewer patient dropouts due to pain and better compliance over 12 weeks.

Straight-Leg vs. Bent-Knee Variants

Straight-leg heel raises (knee extended) primarily load the gastrocnemius, the larger, more superficial calf muscle. Bent-knee heel raises (knee flexed approximately 30 degrees) shift load to the soleus, the deeper calf muscle. The soleus attaches directly into the Achilles and is often the primary source of tendinopathy in insertional disease (where the Achilles meets the heel bone) and in middle-aged recreational athletes. A comprehensive Achilles rehab program should include both variants, particularly for insertional tendinopathy and soleus-dominant presentations.

Technique and Common Errors

Proper heel raise technique requires a full range of motion: rise through maximum plantar flexion (fully on the ball of the foot) and lower through dorsiflexion (heel below neutral on a step). Partial range of motion reduces the tendon load stimulus and limits the remodeling response. The most common error is rushing the eccentric phase—the lowering must be controlled over 3 seconds minimum. A second common error is allowing knee flexion to compensate when fatigue sets in, shifting load away from the intended muscle and tendon.

Pain during heel raises is expected and not a sign of injury progression—the tendon must be loaded to stimulate remodeling. The acceptable range is mild-to-moderate discomfort (3–5 on a 10-point scale) during exercise that resolves within 24 hours. If pain exceeds 5/10 or is significantly worse the following morning, reduce load or repetitions. Persistent pain lasting more than 24 hours after exercise indicates the load was excessive.

Who Should Use This Protocol

Heel raise protocols are appropriate for midportion Achilles tendinopathy (pain 2–6 cm above the heel insertion). Insertional Achilles tendinopathy (pain at the heel bone attachment) requires modification—standard eccentric heel drops with the heel hanging below the step compress the tendon against the heel bone and may worsen insertional symptoms. For insertional tendinopathy, heel raises are performed on flat ground (not with the heel below step level) using the HSR protocol.

Acute Achilles tendon rupture is a contraindication—do not attempt heel raises if you heard a pop and cannot push off or rise on your toes. This is a surgical emergency. Active inflammatory arthritis affecting the ankle tendon requires medical management before loading exercises. Patients with diabetes or peripheral neuropathy should complete heel raise rehabilitation under direct podiatric or physical therapy supervision.

Frequently Asked Questions

Medical References & Sources

• Alfredson H et al. — Heavy-load eccentric calf muscle training for chronic Achilles tendinosis (AJSM 1998)
• Beyer R et al. — Heavy Slow Resistance vs. Eccentric Training for Achilles Tendinopathy (AJSM 2015)
• American Orthopaedic Foot & Ankle Society — Achilles Tendinitis

Dr. Tom Biernacki, DPM is a board-certified podiatric surgeon at Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan. He manages Achilles tendinopathy with progressive loading programs, shockwave therapy, platelet-rich plasma injection, and surgical intervention for refractory cases.

Dr. Tom Biernacki, DPM

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.