Achilles tendinitis is treated primarily through targeted loading exercises that gradually strengthen the tendon over 12 weeks, combined with short-term pain management strategies. Most cases resolve without surgery, but recovery requires patience: even mild cases can take three months, and chronic or degenerative cases often take longer. The specific exercises you should do depend on where your pain is located along the tendon.
Where Your Pain Is Matters
Achilles tendinitis falls into two categories based on location, and each responds best to a different approach. Midportion tendinitis, the more common type, causes pain and swelling in the middle of the tendon, a few centimeters above the heel. Insertional tendinitis causes pain right where the tendon attaches to the heel bone, sometimes accompanied by a bony bump at the back of the heel.
This distinction matters because the go-to exercises for midportion tendinitis can actually irritate insertional tendinitis if done without modification. If your pain is at the heel bone itself, you’ll need a modified version of the standard protocol (more on that below). If you’re unsure which type you have, a physical therapist or sports medicine provider can tell you quickly with a physical exam.
What to Do in the First Few Days
When pain first flares, your instinct might be to ice it and rest completely. The current thinking in sports medicine has shifted away from that approach. A framework published in the British Journal of Sports Medicine recommends protecting the tendon from aggravating activities and letting your body’s early inflammatory response do its job. There’s no high-quality evidence that icing helps soft tissue injuries heal, and it may actually slow the process by disrupting the inflammation your body needs to begin tissue repair.
What does help early on: reducing the load on the tendon. That means temporarily cutting back on running, jumping, or hill work. It doesn’t mean total rest, which can weaken the tendon further. Light movement that doesn’t provoke sharp pain is fine and even encouraged. A heel lift of 7.5 to 15 millimeters placed inside your shoe can reduce strain on the tendon during this initial phase by slightly shortening the distance it has to stretch with each step.
Eccentric Loading: The Standard Exercise Protocol
The most studied treatment for midportion Achilles tendinitis is eccentric heel drops, often called the Alfredson protocol. “Eccentric” means you’re loading the tendon while it lengthens, which stimulates the tendon to remodel and strengthen. The protocol calls for 3 sets of 15 repetitions, performed twice a day.
There are two versions of the exercise, and you do both in each session. The first is a straight-knee heel drop: stand on the edge of a step on the balls of your feet, rise up on both feet, then slowly lower your affected heel below the step level using only that leg. The second is the same movement with a bent knee, which shifts more load to the lower portion of the calf. You use the unaffected leg to push back up each time, so the work is all in the lowering phase.
Some discomfort during the exercises is expected and acceptable. Sharp or worsening pain is not. Progression means adding weight (a loaded backpack works) once the bodyweight version becomes easy.
Modification for Insertional Tendinitis
If your pain is at the heel bone, performing heel drops off the edge of a step compresses the tendon against the bone at the bottom of the movement. This tends to make things worse. The modification is simple: do the same heel drops on flat ground instead, lowering only to floor level rather than dropping below it. This still loads the tendon eccentrically without that aggravating compression at the insertion point.
Heavy Slow Resistance: An Alternative Approach
A newer protocol that performs comparably to eccentric-only training is heavy slow resistance (HSR). This approach uses heavier weights at a slower tempo and includes both the lifting and lowering phases of each repetition. Each rep takes about 6 seconds: 3 seconds up, 3 seconds down.
The program runs for 12 weeks, 3 days per week, with a structured progression in weight:
- Week 1: 3 sets of 15 reps at a weight you can just barely complete 15 times
- Weeks 2 to 3: 3 sets of 12 reps at a heavier weight
- Weeks 3 to 5: 4 sets of 10 reps
- Weeks 6 to 8: 4 sets of 8 reps
- Weeks 9 to 12: 4 sets of 6 reps
The exercises are typically calf raises on a leg press or Smith machine, though seated calf raises also work for targeting the deeper calf muscle. Some people prefer HSR over daily eccentric drops because it requires only three sessions per week and feels more like a normal gym workout. Both approaches are well supported for midportion tendinitis.
How Long Recovery Actually Takes
Most people notice meaningful pain reduction within 6 to 8 weeks of consistent loading exercises, but full recovery often takes 3 months or longer. If the tendon has undergone degenerative changes from months or years of symptoms, the structural damage may not fully reverse. The good news is that symptoms can still resolve completely, allowing a full return to activity, even if imaging still shows some tendon thickening.
Recurrence is common, particularly if you ramp up activity too quickly after pain subsides. A conservative approach to returning to running or sport significantly reduces that risk. If your pain is caused partly by a bone spur at the heel, recovery may initially take only 4 to 6 weeks, but the spur itself can continue to mechanically irritate the tendon and cause symptoms to return.
When Exercises Alone Aren’t Enough
If 3 to 6 months of consistent loading exercises, footwear changes, and activity modification haven’t resolved your symptoms, shockwave therapy is a reasonable next step. The treatment involves placing a probe against the skin over the tendon and delivering pulses of energy for 5 to 10 minutes. It’s noninvasive and typically done in one session, with an occasional second treatment depending on how you respond. Shockwave therapy is used specifically for cases that haven’t improved with rehabilitation alone.
Steroid injections around the Achilles tendon are generally avoided. Corticosteroid use is associated with tendon damage and rupture, particularly in the Achilles tendon. The risk is even higher if you’re also taking a type of antibiotic called a fluoroquinolone. While injections can temporarily reduce pain, they weaken the tendon structure, which is the opposite of what you need.
Surgery Is a Last Resort
Surgery is reserved for cases where all conservative measures, including rehab, shockwave therapy, orthotics, and activity modification, have failed. It’s more commonly needed for insertional tendinitis, especially when a prominent bony bump (called a Haglund’s deformity) is mechanically irritating the tendon.
The procedure involves removing the bony prominence and any damaged sections of tendon. If the calf muscle is tight, the surgeon may lengthen it during the same operation. In cases where a significant portion of the tendon needs to be removed, a nearby tendon can be transferred to reinforce the repair. Recovery from Achilles surgery is lengthy, with running typically not starting until at least 12 to 16 weeks post-surgery.
Benchmarks for Returning to Running and Sport
One of the most frustrating aspects of Achilles tendinitis is knowing when it’s safe to return to high-impact activity. Pain alone isn’t a reliable guide, because the tendon can feel fine during a short jog but fail under the demands of sprinting or jumping. Sports physical therapists use specific benchmarks to gauge readiness.
Before you start running again, you should be able to perform at least 10 single-leg heel raises through your full range of motion with good control. Calf strength on the affected side should reach at least 90% of the unaffected side, measured by how many heel raises you can do and the height you achieve on each one. For athletes returning to cutting, jumping, or sprinting sports, single-leg hop distance and jump height should be within 10% of the other leg. These aren’t arbitrary numbers. Returning before hitting these thresholds is a reliable predictor of re-injury.
Building back to these benchmarks takes time, and the loading programs described above are how you get there. Consistency with the exercises matters far more than any brace, supplement, or passive treatment.