Managing Achilles Tendinopathy
Achilles tendinopathy is one of the most frustrating injuries for runners. It hurts, so you run less, maybe do some calf raises, start training again and it comes right back. It can feel like a never ending - and extremely dispiriting - cycle.
I experienced this myself almost 10 years ago for a miserable 18 months. The pain would increase so I would stop running, do calf raises, then when the pain eased off I’d return to training only for it to flare again. It finally ended when I learnt that tendons require load - progressive, targeted load - to heal completely.
Why your Achilles flares up again and again
Tendons adapt slowly, over weeks and months. When you load a muscle, you can see meaningful adaptation within days and weeks. Tendon tissue works on a much more pedestrian timeline. Collagen remodelling, which underpins tendon strength, takes weeks to months. Research suggests it can take up to 12 weeks to see measurable structural changes on imaging like MRI.
This creates a common problem. Pain settles before the tendon is truly ready. Training resumes too quickly, load spikes again, and symptoms return. It feels like a cycle of progress and setback, but in reality the tendon has never fully healed. Inside is cellular chaos, nor order.
So how should you rehab your Achilles?
Pain is useful here, to a point. A tolerable level of discomfort during and after exercise is acceptable. Many athletes work within a 0 to 2 out of 10 pain range. Symptoms should settle within 24 hours and should not progressively worsen week to week.
Consistently escalating pain or increasing morning stiffness suggests the load is too high.
A simple rehab protocol - continue for at least 12 weeks
Rehab should progress from controlled isometric loading to energy storage and return to performance.
Phase 0: Protect
If walking is painful then you may need to offload for 1-3 days. Light, low-impact crossing training may be acceptable.
Phase 1: Isometric loading (pain control and beginning healing)
Focus on reducing pain and reintroducing load.
Double leg calf raise holds
30 to 45 seconds per hold
4 to 5 repetitions
1 to 2 times per day
Progress to single leg holds as pain allows.
Continue to use isometrics as a warm up before running for 4-16 weeks.
You may be able to do some easy running during this period depending on the condition of your achilles. If the pain exceeds 2/10 or increases after running you need to hold off from running. You can maintain fitness through cross training (more info in my online course).
Phase 2: Heavy slow resistance (strength development)
Build tendon and calf strength once isometrics feel easy and largely pain free. You can use isometrics as a warm up.
Standing calf raises (straight knee)
Seated calf raises (bent knee)
3 to 4 sets of 6 to 10 reps
Slow tempo, around 3 seconds up and 3 seconds down
3 times per week
Load should feel challenging by the final reps. Use added weight where possible (for seated calf raises you can put weights on top of a firm cushion on your thigh, don’t put weights on your knee).
By this phase you may be able to do a bit more running - again within your pain levels. Avoid anything that aggravates it, which might include hills, speed sessions or certain shoes or surfaces. Keep up the cross training to maintain fitness.
Phase 2b: Eccentric loading
Once you are pain free in your rehab exercises you can incorporate eccentric loading. This is the most demanding step so far and beginning it too early (or skipping it) can prevent you from fully recovering.
Eccentric loading puts tension on the tendon in a stretched/elongated state so it must be introduced and progressed slowly.
Bodyweight eccentric calf raises
1-2 sets of 8-12 reps
2-3 times a week
Then once the above is easy and pain free:
Weighted eccentric calf raises
3 to 4 sets of 6 to 10 reps
2-3 times a week
Phase 3: Energy storage and release - Plyometrics
Prepare the tendon for the demands of running.
Single leg calf raises with quicker tempo
Hopping in place
Skipping
Progress to bounds and light plyometrics
1-3 times per week (tiny doses go a long way)
Start with low volume and build gradually. Monitor next day stiffness closely.
As you progress you can maintain the exercises from a previous step, isometrics work particularly well as a warm up.
By now most running should be comfortable. If symptoms build up ease off temporarily to allow your body time to catch up.
What next?
I developed my online course A Runner’s Guide to Injury Prevention and Rehab to help runner’s like you reduce - and rehab - muscular skeletal injuries.
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