Key Exercises in the Treatment of Achilles Tendonitis: A Protocol

Can incorporating an exercise program like the Alfredson Protocol help athletes and individuals who have hurt their Achilles tendon find pain relief and healing so they can return to regular physical activities?

Exercise Protocol Achilles Tendonitis

Achilles tendonitis occurs when the tendon at the back of the ankle gets injured. It is common in runners. For individuals who have Achilles tendonitis, walking and running can be painful. You might have to stop engaging in exercise and physical activities like sports. Depending on your job, having the condition may make working harder. Here are a few of the signs and symptoms of the condition:

• Pain in the back of the lower leg, just above the heel.
• Pain with running, jumping, or pointing the toes.
• A small lump on the Achilles tendon just above the heel.

The first line of treatment is to rest and ice the tendon. Anti-inflammatory medications can help reduce pain. (American Academy of Orthopaedic Surgeons, 2022) Physical therapy can include strengthening exercises, ultrasound heat therapy, and deep massage. Exercises stretching the nearby muscles will help gradually increase the stress the tendon can handle, eventually reducing inflammation and swelling. Stretching and flexibility exercises will help an Achilles tendon heal. (University of Michigan, 2023)

The only way to determine if an individual has injured their Achilles tendon is to see a doctor. If the injury is Achilles tendonitis, a physical therapist may be recommended. A physical therapist can train individuals on the Alfredson protocol, an exercise protocol program for those with Achilles tendonitis (tendinopathy) that research has shown is helpful for those with the condition. The therapist will train on how to exercise to strengthen the tendon. The exercises stretch the Achilles tendon to help it handle forces and stress, known as eccentric loading. (Stevens M., & Tan C. W. 2014)

Inflammation

Tendonitis is inflammation of a tendon. However, studies have shown that the tendon might not be inflamed in those with the condition. When an area of the body is inflamed, inflammatory cells are present. Individuals usually feel pain in the inflamed area. For those with Achilles tendonitis, the tendon will present with pain, but not necessarily because the tendon is inflamed. Under a microscope, researchers examined tissue from the tendons of those with Achilles tendonitis. They did not find inflammatory cells in the tissue. (Stevens M., & Tan C. W. 2014) This means that although individuals felt pain, they were not inflamed. If there are no inflammatory cells in the tendon, this could explain why those with Achilles tendonitis often do not find relief from the anti-inflammatory treatment of non-steroidal anti-inflammatory drugs (NSAIDs). Studies have shown that gentle exercise protocols for the tendon are more helpful. However, researchers are not sure why these exercises are so beneficial. (O’Neill S., Watson P. J., & Barry S. 2015)

Eccentric Exercise

A chiropractic physical therapy team can help individuals heal the injury with eccentric loading exercises. Eccentric loading exercises work the muscles and tendons to help them get stronger. Once healing has begun, they can help strengthen the tendon. Individuals start slowly with easy exercises and then work up to harder ones. They will have the patient lengthen or stretch out the muscle. As the patient moves, the muscles and tendons contract or shorten. The Alfredson protocol consists of eccentric loading exercises for the Achilles and the muscles that support it.

Alfredson Protocol

Before exercising, talk to a doctor or physical therapist to know if it’s safe. How to do the Alfredson protocol:

1. First, stand on a small step or curb.
2. Stand with the balls of your feet on the edge.
3. Your heels should hang over the edge.
4. Hold onto something for balance.
5. Keep the knees straight.
6. This will load a muscle part of the Achilles tendon called the gastrocnemius.
7. Using both feet, lift the heels and rise onto the balls of the feet.
8. Keep the foot with the painful Achilles tendon on the step.
9. Lift the non-injured foot off the step.
10. Slowly lower down using the injured ankle.
11. The heel should move towards the floor.
12. The ball of the foot should remain in contact with the edge of the step.
13. Return the non-injured foot to the step.
14. Repeat the exercise.

Do three sets of 15 reps with the knees straight. Then, do the Alfredson protocol again with the knees slightly bent. This will work a muscle called the soleus, which connects to the gastrocnemius. Perform three sets of 15 repetitions. Perform both exercises twice a day. This could be in the morning and the evening. The Alfredson protocol is most beneficial when done for about 12 weeks. (Stevens M., & Tan C. W. 2014)

Injury Medical Chiropractic and Functional Medicine Clinic

The Alfredson exercise protocol can be done at home with a step or raised platform to put the feet on safely. Individuals should consider working with a personal trainer to ensure safety and get the most out of the workouts. Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to build optimal health and wellness solutions. We focus on what works for you to relieve pain, restore function, prevent injury, and help mitigate issues through adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal problems.

Functional Foot Orthotics Achieve Optimal Performance

References

American Academy of Orthopaedic Surgeons. OrthoInfo. (2022). Achilles Tendinitis. https://orthoinfo.aaos.org/en/diseases–conditions/achilles-tendinitis/

University of Michigan. (2023). Achilles Tendon Injury: Physical Therapy and Rehab. https://www.uofmhealth.org/health-library/tr2261

Stevens, M., & Tan, C. W. (2014). Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. The Journal of orthopaedic and sports physical therapy, 44(2), 59–67. https://doi.org/10.2519/jospt.2014.4720

O’Neill, S., Watson, P. J., & Barry, S. (2015). WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY?. International journal of sports physical therapy, 10(4), 552–562.