Sunday, September 11, 2011

Injury Series: Flat eccentric heel drops for insertional Achilles tendonitis

Introduction

Back in August, we saw how a rehab program consisting of eccentric heel drops with a bent and straight knee reversed damage to the Achilles tendon by inducing collagen remodeling.  One thing I didn't make clear enough is that Alfredson's eccentric heel drop protocol, developed in 1998, was designed for midpoint Achilles tendonitis.  In most cases of Achilles injury, the tendon is damaged between 2 and 6 cm from the insertion point at the calcaneus (heel) bone.  But in a minority of cases, the tendon is damaged at the insertion point—right at the heel bone.  While it might seem like a trivial difference, these are actually parsed into two separate injuries.  While both are the result of damage to the collagen fibers, the surrounding tissue at the insertion of the Achilles tendon is very different from the tissue near the midpoint of the Achilles.

Insertional Achilles tendonitis is fairly easily differentiated from midpoint Achilles tendonitis based on where the pain is localized.  In the latter case, it is a point (as the name suggests) around the middle of the tendon, whereas in insertional Achilles tendonitis, the pain is, of course, at the insertion of the tendon.  But it can also radiate around the heel bone in general and even onto the sole of the foot.  In the early stages, it often feels like a throbbing bruise to the back of the heel.  The area where pain usually localizes after the initial inflammation dies down is highlighted above in red. There are a lot going on near the insertion of the Achilles—there's the retrocalcaneal bursa (a small sac of fluid that reduces friction on the Achilles), the plantar fascia, the Achilles itself, and the fat pad underneath the heel.  All of these can become irritated, and this contributes to the intractability common in chronic insertional Achilles tendonitis.

Treatment with eccentric exercise

Understandably, people first assumed that the eccentric heel drop protocol devised for the midpoint Achilles tendonitis would work just as well on insertional Achilles tendonitis; however, once researchers got around to investigating this, they found that, in contrast to the >80% return-to-activity rate seen in multiple studies for subjects with midpoint Achilles tendonitis, subjects with insertional Achilles tendonitis had a paltry 32% return-to-activity rate.  This problematic result probably stumped researchers for some time—the original study linking eccentric heel drops to good recovery prospects in midpoint Achilles tendonitis was published in 1998, but productive results for insertional Achilles tendonitis did not make it into the literature until 2008.  In the interim period, Alfredson and his coworkers discovered how very minute differences in exercise protocol can make a world of difference in injury rehab. As we covered last week, a 2004 pilot study showed that eccentric decline squats are a highly effective rehab exercise for patients with patellar tendonitis. The results, confirmed by a more thorough clinical trial a year later, showed that just a small change in protocol—doing an eccentric squat on a decline instead of on flat ground—had a significant effect on the patients' outcome.

These finding suggest that eccentric exercises to repair tendons should be highly targeted to put a large, controlled stress on the tendon which cannot be mitigated by other muscle groups.  One key difference that Alfredson et al. highlighted was that, in a regular eccentric squat, various other muscle groups could help stabilize the knee and take some load off the patellar tendon. In a decline squat, these muscles are inhibited, forcing the quadriceps (via the pateller tendon) to do the lion's share of the work.  So, in the case of insertional Achilles tendonitis, might it be possible to alter the exercise to specifically target the insertion point of the tendon instead of the midpoint?

         Modifying the eccentric heel drop
Image from sportsinjuryclinic.net
Alfredson et al. hypothesize that the forces on the insertion point of the Achilles tendon are different from the forces on the midpoint of the Achilles when the ankle is in dorsiflexion (with the toes "pulled" up towards the knee).  The retrocalcaneal bursa, which is highlighted in red in the image to the left, can pinch the last few centimeters of the Achilles tendon when the ankle is dorsiflexed, which can actually cause compression along the insertion of the Achilles tendon (vs. tension, which is what we would expect to see in the Achilles when the ankle is dorsiflexed).  If this is the case, it would explain the poor results of the traditional eccentric heel drop protocol for patients with insertional Achilles tendonitis: because the heel drop is done on a step (bringing the ankle into dorsiflexion), and the maximal force on the Achilles tendon as a whole occurs when the downward motion is stopped, the exercise does not effectively stress the insertion point of the Achilles—it is under compression, not tension, at the bottom of the heel drop.  However, if the eccentric exercise is stopped before the ankle goes into dorsiflexion, the insertion point will be properly stressed.  The best way to do is is simply by doing the exercise on a flat surface instead of off a step.  

From Jonsson et al.
In a 2008 study published in the British Journal of Sports Medicine, Jonsson et al. investigated this modified version of the eccentric heel drop exercise.  The flat eccentric heel drops are done as follows: starting on the uninjured side and standing on level ground, the patient raises the heel of the uninjured leg off the ground.  All body weight is then transferred to the injured leg with the ankle in a plantar-flexed (foot pointed down) position and the knee straight.  The patient then slowly lowers the heel to the ground, then uses the uninjured leg to return to the starting position.  Unlike the exercises for midpoint Achilles tendonitis, there is no bent-leg variant for this exercise.  The flat eccentric heel drop protocol consists of three sets of fifteen repetitions done twice a day for twelve weeks.  If there is pain on both sides, the subjects in Jonsson's study used a box to get into the "up" position, avoiding any concentric contraction of the calf.  Just like all of the previous eccentric exercises we've seen, patients are encouraged to exercise into moderate pain (though instructed to stop if it becomes debilitating).  Once the exercise can be performed without pain, weight is added progressively using a backpack (illustrated at right) so the exercise is always done with mild or moderate pain. 

Results and limitations

The results from the 2008 paper, which was a small pilot study with 27 patients (34 injured tendons), were promising.  After the 12 week program, 67% were able to return to their pre-injury activity levels.  Their VAS scores (visual analogue scale, 0-100 scale of tendon pain) decreased significantly.  Unfortunately, there were some major flaws and shortcomings in the study's design.  Perhaps because this was a pilot study, there was no control group—a rather egregious scientific error, especially considering that Alfredson's research group has been fairly good about adhering to good scientific practices in the past.  Without a control group doing some sort of other rehab protocol, it's impossible to compare whether the flat eccentric heel drop program is any better than another recovery plan.  Comparing results of one study to another is crude and evokes apple-to-orange comparisons.  But because this is only a small pilot study, perhaps we can forgive this sin.

However, in a baffling move, Jonsson et al. parse the study subjects into two groups: those who said they were "satisfied" with their outcome and those who said they were "not satisfied."  They then attempted to show statistically significant differences between the groups.  This move is puzzling, as it is more an investigation of injury psychology than anything else.  This might have been interesting if they could have shown that the dissatified subjects were more likely to have Haglund's deformity on the back of their heel or were older in age, for example, but they found no such associations.  In fact, the only difference between satisfied and dissatisfied subjects was their follow-up VAS score.  Patients who were satisfied with their outcome experienced (surprise!) less tendon pain than those who were not.  Finally, there were some shortcomings that limit this study's applicability to runners.  First, the subjects were recreational walkers, joggers, and casual athletes.  Second, most were over fifty years old.  Like the studies on patellar tendonitis, which usually used volleyball or basketball players due to the higher incidence of that particular injury in those sports, Jonsson's study consists mostly of subjects from the demographic which makes up most insertional Achilles tendonitis cases—moderately active middle-aged men and women.  The use of such casual subjects might hint that compliance with the assigned protocol was not spectacular.  One reason doctors and physical therapists usually love working with serious athletes is that they are much more likely to actually do the exercises they are prescribed, and hence achieve a better outcome.

Conclusion: the flat eccentric heel drop

Given these shortcomings, it's obvious that a larger, better-designed study should be done, I can only hope that Alfredson's research group is currently conducting one.  Despite the flaws, modifying the eccentric heel drop program in this way for insertional Achilles tendonitis is still probably a good idea.  Though I usually don't believe in jumping on the bandwagon for a new therapy or treatment after just one paper, in this case, the theoretical underpinnings are fairly sound, and the proposed change is not a radical departure from the well-established eccentric heel drop program for midpoint Achilles tendonitis.  Further, it's fairly clear that a) small changes in the way an exercise is done can have a big impact on recovery and b) the traditional eccentric heel drop off a step is not particularly effective for insertional Achilles tendonitis. 

In short, the modified protocol is as follows:
  • 3 sets of 15 straight-legged eccentric heel drops on flat ground, twice a day for twelve weeks
  • Starting with the heels raised and your weight on the injured leg, use the calf muscles to slowly lower your heel to the ground, keeping your knee straight.
  • Use your good leg to return to the starting position.
  • Exercise into mild or moderate pain, but stop if pain becomes excruciating
  • Once you can complete all three sets without pain, add weight using a backpack.
  • Once you have recovered, it is not a bad idea to keep doing these exercises for maintenance/prevention.
Well, unless I'm forgetting something, it looks like I've done it! I've finally put out a fairly concise post on an injury! Of course, this really is more of an addendum to the Achilles tendonitis article from a few weeks ago.  In any case, look forward to some longer, more detailed posts on new subjects.  We've reached the current limits of research on progressive eccentric exercise as a rehab program for tendon injuries.  Hopefully we'll see some new articles in the next few years on creative eccentric exercises for some of the other recalcitrant tendon issues common in runners: the hamstring tendons, the smaller tendons in the foot, and some of the deep tendons in the hips.  Until then, you can look forward to more posts in the injury series from me about proven treatments for common injuries like IT band syndrome, groin pain, and many more.  There's also plenty of non-injury related issues to read and write about too.  Look for posts in the next few weeks about some of the "scientific sins" common in exercise physiology, a quick reference guide for anatomic terms of location (distal, medial, etc.), and perhaps some thoughts on training and racing as the cross country season gets rolling for high school and college athletes across the country.

So, what would you like to hear about in the future? Training? Racing? Speed? Injuries? I'd love to know.

71 comments:

  1. Great article, thanks for writing it. I'm a little confused about the flat heel drops though. Could you just keep the uninjured foot in the air and do both drops and raises on the injured foot to accomplish the same thing. Seems awkward to me to use the uninjured foot to return to the plantar-flexed position.

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  2. Hi Jeff,

    The reason you are supposed to go back "up" on the uninjured foot is because the program is designed to AVOID any concentric strengthening of the calf muscles. It seems that concentric strength (like going "up" for a calf raise) aggravates an injured tendon but doesn't stimulate any tissue healing. It's unclear exactly why this is. I think that doing concentric strength is like pulling on both ends of a knotted rope: it just tightens the knot.

    There has been at least one study that tried using ONLY concentric calf strength (as opposed to this method, which uses ONLY a eccentric calf strength exercise), but that concentric-only study got very poor results when compared to an eccentric-only program.

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  3. I have pain to both AT, but was confused on how to use a "box" - If there is pain on both sides, the subjects in Jonsson's study used a box to get into the "up" position, avoiding any concentric contraction. Exactly how would I use a box? Thanks

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  4. Ah, good question. The idea is to get a small box—maybe 6" high, and use it as a step to get to the "up" position. So when you are doing your flat eccentric heel drops on your left side, put the box to your right and step up using your right leg, but keeping your foot FLAT on the box so you are using your quads to get "up" (much like a squat or leg press) instead of your calves.

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  5. Hi John - you pointed me here from the "Eccentric exercise and tendon remodeling, part I: Achilles tendonitis" article which you also wrote. I should have dug a bit deeper before asking the question. Thanks not only for pointing me here, but also for putting this wonderful info together!

    Another quick quesiton - if I have not been doing eccentrics recently for my Achilles, should I just right into doing 3 sets of 15 twice per day? Or is it better to ease into the program, say 2 sets once per day, moving up to 3 sets, and eventually doing this twice per day? Or is the stimulus achieved by this exercise important enough to just jump right in?

    Thanks once again! This exercise may end of a lot of heartache.

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  6. Well, in the studies, the subjects were instructed to jump right in, unless they experienced severe pain (mild to moderate pain is okay!). So if you can only do 2 sets of 15 before you get severe pain, that's fine—just slowly work your way up to 3 sets. But if you can do 3 sets of 15 twice a day with only mild/moderate pain or discomfort, jump right in! Good luck!

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  7. Thanks John - your answers are much appreciated!

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  8. Is there any adaptation if BOTH ankles are involved? Thanks for any help!

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  9. Hi Tony,

    If you have insertional Achilles tendonitis on BOTH sides, do the exercise on both sides obviously, but use a small box to get into the "up" phase. See my comment above on Dec 29th for a bit more on why. Best of luck!

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  10. Thank you for a great article. I have read the abstract online, but your post adds much much more.

    I am a 56-year-old male who has been wearing minimalist footwear for almost 3 years (I read your post on that too). About 5 weeks ago (wintertime in my hemisphere) I played tennis intensely for hours, although I had not played much since the end of the summer. I was playing on an unforgiving concrete surface.

    I did not take the injury seriously and I have continued to be a "weekend warrior" playing an hour or so on weekends. A couple of days ago when I started Googling, I discovered that I should be taking this more seriously than I have been.

    My injury is surely insertional Achilles tendinopathy and I have started the 12-week regimen today. Thanks again.

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    1. i have had so called "insertional achilles tendonits/busitis "for 22 months. i have had a good crack at the drop ecc ex's twice (4-6 wks), and the "flat " eccentric ex's once ( about 6 weeks), unfortunately the pain gets worse and worse, I start at 2 reps of 10 once a day and try to build from there, but the pain gets worse that i can't progress.. so that i really struggle to walk the next few days. Is this technique really any6 good for the bursitis??

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    2. Hi Nic,

      Sorry to hear about your problems. It's often hard to distinguish bursitis and insertional Achilles tendonitis, and they sometimes present TOGETHER, further muddling the issue. If the eccentric drops have only been making the problem worse, you probably have to look elsewhere for answers. You might be in that unlucky ~30% or so of people for whom eccentric heel drops don't solve your problems. Keep looking! Finding a good doctor who will work with you is a huge help.

      Best of luck,

      John

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  11. I just found this link, which seems to be Per Jonsson's thesis, which is free and gives details of all five studies from the Alfredson group.

    https://docs.google.com/viewer?a=v&q=cache:Vxy799xaOiIJ:umu.diva-portal.org/smash/get/diva2:234360/FULLTEXT01+&hl=en&gl=us&pid=bl&srcid=ADGEESg-Hyyhf_84VNjQOpRKi9rgI18N7r2nIvSTTwJr3-N22eW8adrvH4t5QG-jML16ym485_7TYyTSbgRbSiEr8sZcH9QuRxxEhLg2YkVgR09tWVRjJW2UIwIaTIh8_PrZAFGOl5Ld&sig=AHIEtbRZGluAIKRCfZ0aTpv9A1hH2K3V3A

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  12. I've been doing the flat eccentric heel drops for insertional achilles pain for the past 8 weeks. I have not been running in order to allow the achilles to heal. My doctor and PT both suggested that I can begin running again every other day. I ran for 15 minutes yesterday, with a number of walking breaks mixed in. The heel was a bit sore by the end of the day. Is this to be expected or does this mean that I should take further time off? Also, I'm assuming that that I continue with the heal drops once I return to running. Is that correct? Thanks for sharing your thoughts on this. Your site is very informative.
    -Ken

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  13. Hi Ken,

    Some soreness when you start back running is probably normal. I've gotten messages from a few other people who describe similar issues. Work with your doctor and PT and see what they think, but as long as the soreness at the end of the day doesn't worsen over time, you can probably proceed with caution. And yes, I recommend you continue with the heel drops once you've started up running again, as they probably confer a protective benefit too.

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  14. Thanks for the great read, including the original Achilles tendonitis one. This is what I'm currently dealing with. I have a pretty bleak outlook on my life as a runner. But still crossing my fingers.

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  15. Thanks for the great article. I am suffering from insertional tendonitis and hopefully this will provide me some relief. I have ruptured one achilles already and now the other is hurting at the insertion point (just like the ruptured one did before it finally let go). Docs keep telling me to stretch but it seems the stretching makes it WORSE. So your article makes sense. My heel gets sore only during high load like sprinting or jumping, I can walk around fine and it's not super painful in the morning etc.

    So my questions is should I just try these heel drops now my heel is sore from the previous stretching but it's not what I would call painful. Also is there any benefit to combining these exercises with some massage techniques like Active Release Therapy (ART) to help break down scar tissue or should I only try the heel drops?

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  16. Thanks for the great information on Achilles tendonitis, which I've been struggling with since November 2011. I recently began the exercise protocol for midpoint tendonitis, but I've found that afterward I feel soreness at the insertion point. I wonder if that means I should ease off and do fewer exercises or try the flat technique instead of the step. Would the flat heel drops still have a beneficial effect on my midpoint tendinitis?

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  17. Would it hurt to use ice, foam roller, and stretching in addition?

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  18. It certainly can't hurt to ice and foam roll. I'm not a big fan of stretching injured tendons, since you are essentially tugging on an already-strained connection. That being said, gentle stretching is probably okay. One trick I have used in the past to loosen up my calves is to apply heat packs to the muscle (and not the tendon). This can loosen up your calves without having to actually tug on the tendon by stretching it. Foam rolling is also great for that same reason.

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  19. Is it possible to have insertional AND non-insertional achilles tendonitis?

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  20. From my reading it is fairly common to have both insertional tendinitis and insertional tendinopathy at the same time (and also retrocalcaneal bursitis thrown in.) I have both and they are responding well to the Jonsson modified programme of heel drops on the flat. I know another couple of runners with both. Initially, I used ice and topical NSAID (voltarol) to get rid of the inflammation at the insertion. The space between the tendon and calcaneous is small, and when there is inflammation in this region (possibly including the retrocalcaneal bursa) I think a self perpetuating cycle of swelling, impingement and further irritation can occur. Also footwear needs to be addressed - many modern shoes have a stiff heel-cup that presses on the Achilles insertion and this needs to be avoided at all costs.

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  21. I meant to say, non-insertional tendinopathy above.

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  22. Chronic tendonitis (mid way). 2 years now - every time the swelling goes down (from icing), eccentric stretches are recommended - they just seem to be re-injuring me, as it progressively becomes worse with these! Has anyone just not done the stretches and found it's come good? 4th prp injection coming up. I'm so sick of all of this - put on 13 kgs and can't do basic exercise even - too young to be put out to pasture. Ultrasound shows lots of micro tears, but I'm starting to think there's more to play here. Would an mri scan assist in diagnosis? What do I do when every single health professional has told me to do these stretches and it just makes it worse?? Have tried everything except Active Release Therapy (which scars me as some people have said not to have it done).

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    1. er, that would be ART 'scares' me!! Open to any suggestions!

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    2. I am Tom W from below. I have found that I just switched to biking (which I can do pretty hard) and elipitical without too much pain so that is what I am doing to work out the problem. I too have had poor results with stretching. One doc seemed to shed light on my issue by stating that I have tendonosis - which does not involve swelling and inflammation so much as - pointing out that the tendon is thickened period with scar tissue and you have to work through that scarring, so the tissue has to regenerate in some way. Someone else on the web, the SOCKDOC, says don't stretch damaged tendon so that is what I am doing now. Just finding exercises that don't stretch the tendon too much. What do you think?

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  23. Lisa,

    If the eccentric heel drops are just hurting you and making your injury worse, perhaps you are in the 20% that isn't helped by this exercise. ART is certainly worth a shot, and I think you'll find it's not as intimidating as it seems. There's also something called Graston Technique which is worth a shot too. These types of manual therapies may sound scary, but probably not as scary as an injection! Best of luck.

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    1. Thanks John, go for an ultrasound next week to check if there's been any improvement since I've been doing them (one can always hope, in spite of the pain and swelling!!), nothing to lose at this stage, so well may try them too!, cheers, Lisa

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  24. thanks for the post. I have been exercising it, but I'm worried whether it will cause muscle imbalance as I don't do much thigh exercise except a little of Pilates. I can feel that my calves are getting stronger. My other concern is backpack on my back, it's heavy and I'm scared of getting my back hurt. thank you in advance

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  26. Tom W. Has anyone ever gotten over chronic insertional Achilles tendonitis? I think I need to hear that it is possible. I am going over a year in physical therapy with slow and backward sliding results recently. I would so love to be able to walk without pain again let alone run. I have been thru a whole gamit of techniques from exercises to boots to surgery. Current status is Calcaneal spur surgery on Oct. 17 (non orthoscopic) which got infected and now that is clearing up (4 weeks of antibiotics around the beginning of the year). I am currently doing PT with less stressful exercises than those talked about here - slight lungs, slight squats, standing on one leg with toe touches to side and front and back, etc. If someone else was in this situation and found a way to recovery I would so love to hear about how you accomplished this. I am on my fourth orthopeditic surgeon, second PT therapist, second chiroprator, second psychologist, and still seaeking answers. Thanks.

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  27. Is there any particular reason as to why there is not bent-leg variant for the flat eccentric drop? I would think it would work the same way as with the eccentric drops off a step.

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  28. I've wondered the same thing too and I don't have a good answer. My guess is that it is for the same reason that the eccentric heel drop is done on a flat surface: the insertion of the Achilles tendon might be best stressed when the ankle is perpendicular to the shin. When you bend your knee, your ankle is effectively more dorsiflexed, so perhaps it starts to "compress" the insertion of the Achilles tendon, as noted above.

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  29. Thanks John. This post, and the previous one, are the only two that I have read from your blog. However, I find them to be amazingly well-written. Extremely informative and you have a very strong ability of explaining very complex topics.
    You should be a physical therapist! You would be great.
    Looking forward to reading more from you.
    Thanks,
    Steve P.

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  30. I've had inspectional achilles tendonitis for almost a year now. Have had cortisone injections into peroneal tendon (when my Doc thought that was the problem as I had a lot of pain along the side of my foot) and have had PRP injection into the achilles tendon at back of heal bone once we gon an MRI and discovered I had severe distal achilles tendonitis with a small bursa to boot! All to no major progress (although a little after the PRP Injection, that was almost 4 weeks ago, 2 weeks in a walker boot). My doctor confirmed that I should begin these eccentric heel drops (alfredson protocol). I started this week, literally 2 days ago and really really hope it works. As someone in the thread mentioned above, previously I wanted to be able to run again, now I genuinely just want to be able to walk to the shop 50 meters away without limping like a descreveled 80 year old!
    If it works, I promise to return and let others know (Id imagine may make this promise, but I assume if it does work they forget and dance happily into the sun set, forgetting all about their fallen comrades). I stick rigidly to the afredson protocol and I’ll be back in the end of June to report if it worked.

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  31. Great article/post! I have a question: Is it OK to get up on the bad foot to also exercise the not bad one? I first did heel drops when I injured my achilles tendon abt. a year ago but as you propose on the bad foot. This acually led to me developing an arch under my previously flat foot, which was good but the good foot never got the exercise and thus remained flat. I stopped doing drops (all to early) once my achilles got better, now I relapsed. To avoid having an creating more inbalance, can I exercise both feet, even though that require getting up on the bad foot?

    Thanks again for a grat blog!

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  32. This looks quite useful. I´ve tried the other type of heel drops but recently found they made me worse. Still confused about how you´re supposed to do these ones though. Do the two feet stay on the ground the whole time with just the heels being raised and then the injured heel lowered? Or does the uninjured foot come right off the ground when the other is being dropped? Sorry, seems its just me that doesn´t find this clearly written. Is there a video available? Thanks.

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  33. This really helps! I just tried it yesterday and the pain subside, there is a little but really tolerable. Thanks for sharing this GOD BLESS!!! - Ariel (Philippines)

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  35. Hi John,
    I am really pleased I found your blog as my podiatrist had given me incorrect instructions for the eccentric exercises for insertional Achilles tendonitis.

    I have started doing the exercises and while it doesn't hurt while I am doing them, my heels are more painful the next day when I get out of bed. Should I keep doing them despite the soreness, or is there another sort of exercise that would be better?

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    1. Janet, I have read the Alfredson studies and the protocol they used for eccentric training. They said to expect soreness in the first 3-4 weeks, but it should start going away after that. Keep doing the exercises and if the soreness doesn't go away after 3-4 weeks, then the load needs to be decreased.

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  36. I'm in training for my first triathlon, and what looks to be insertional tendinopathy has flared up in my left Achilles. The doctor has assured me (and I concur) that it's still a fairly minor case, and I've caught it early and have started the flat heel-drops.

    My question is, will I do any damage if I keep running on it, despite being only a few days into the course of treatment? I rested initially, but with the Tri only weeks away, I'm very conscious of falling behind on my training and I know that doing the tri on insufficient training will be just as dangerous.

    Thanks for the concise article; I hope you can help me out further by answering this question.

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  37. Hello John. I want to thank you. I read both of your articles for the two kinds of achilles tendonitis. I am following the method for insertional and it is proving to be slow work but i can feel the results.Someone up above asked for a video. http://www.youtube.com/watch?v=hjNWF7QelNY I found that on youtube and was wondering if this is the exercise? Thank you for all of your help.

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  38. I'm a little confused as to how the flat eccentric heel drops are done. For example, my right leg has the achilles tendonitis. Do I raise up on my toes using both feet, raise my left leg (good leg) then lower down on my right leg, then put the left leg back down? Or do I raise up on my toes just on my right leg and lower down just on my right leg, then put my left leg down? Thanks.

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  39. Hi Anonymous,

    You should raise yourself up onto your toes using only your good leg (LEFT), then put your bad leg (RIGHT) down to do the "drop" portion. The reason for this is so that the eccentric portion of the exercise—the "down" part"—should be done on the injured side, but the concentric portion—the "up" part"—should NOT involve the injured side. Hope this helps!

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    1. thanks, makes more sense now.

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    2. me again, just tried it and it really makes you think about your movements.

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  40. Once you start doing these stretches, should you ice or use heat?

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  41. Hi, john. As a fellow long term Achilles tendon sufferer i'm full of questions (but I'll jump to the obvious, though). I've started this program of flat eccentric exercises for both my Achilles tendons. The pain in my Achilles is hard to pinpoint, but it includes the lower part close to the insertion as well. I've been doing it for about two weeks and since doing it with both legs gave me no pain, i proceeded to one legged ones. After 3 days I started to feel soreness in the morning that would go away as I started moving but returns as soon as I cool off. I'm afraid of aggravating this injuries which have kept me from running for 2 years now. Is this soreness to be expected? Is it advisable to continue until it goes away or should the exercise be terminated? I appreciate any advise since nothing I have done til now have been effective.

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  42. I've heard of several people doing eccentric rehab programs having some stiffness in the morning, and Alfredson et al.'s papers do mention that feeling some soreness is to be expected during and after the exercises, so my intuition would tell me that it isn't something you should be too worried about. Keep in mind that I'm not a doctor, though, so if you have concerns you should talk to a good doctor or physical therapist.

    As for heating vs. icing, I haven't seen evidence that either are particularly helpful in conjunction with the eccentric exercises, so I'd be inclined to avoid both while doing the rehab program. When you return to running, you can probably follow the conventional wisdom of heating before, then icing after.

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  43. Hi John,

    I'm glad I came across your blog. I think I may be coming down with a case of IAT. It is mild, but I want to keep it from getting any worse...and obviously get rid of it. I just have a few questions. Is it possible to have IAT or just AT in general and the tendon not get irritated from being squeezed between the fingers? Aside from the little bit of stiffness I initially feel in the beginning of only some runs that goes away after a little while into the workout, it really only exhibits a little bit of tenderness when I plantar flex my foot and press on the soft area on the back of my ankle just above my heel bone. And sometimes, I feel nothing while doing that. Basically what I'm wondering if you can tell me is, does pain in the tendon have to be felt by squeezing it from the sides and not from pressing on it from the back for it to be IAT/AT in general? Or does that not matter?

    My second question is, because I do not have any severe symptoms (i.e. no sharp pain), is it safe to keep running while using this protocol? All I have felt is tenderness, some stiffness and very mild dull aching. Oddly enough, I ran 12 miles this past Saturday and didn't have any issues...but today I ran 3 miles and felt a little stiffness in the beginning of the run that eventually subsided, as well as a little tugging/discomfort in the area while doing one-legged squats during my post-run strength routine. It seems as though I may have a mild case of IAT, but I'm not completely sure. Is it possible that doing the flat ground eccentric protocol will combat it and keep it from worsening while I continue to run without any severe flare-ups? Sorry for the little novel. I'm just not familiar with this, as I have never experienced any issues with my Achilles' tendons. Thanks in advance!

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  44. Hi, my name is Marilyn and, under anonymous, I had asked the 9/2/13 question as to how to perform this exercise. I don't run and I drive a school bus. I started getting pain in my right ankle/foot area about 2 yrs ago, Sept/Oct. By Dec when I saw my regular doctor she said it was achilles tendonitis. Went to an orthopedic for this and ITB issue, and he sent me to PT and the basic stretching was all that was done, along with other exercises, for the achilles issue. It never really worked so I suffered through the minor pain. Well the ITB issue sent me to get a 2nd opinion and I asked about the achilles tendonitis too. They took an xray and I had a heel bone spur. That doctor also said to do the basic stretches along with "friction massage" which should hurt while you're massaging/rubbing the back of the heel. It hurts but it actually makes it feel better. So I've been suffering through minor, but manageable pain for 1-1/2 yrs. In July I had arthroscopic left knee surgery for a torn meniscus and didn't do much of anything. In August my right ankle hurt really bad with every step I took. While doing my own research, and being my own doctor, I found your website and realized I had the insertional tendonitis and had been doing the wrong stretches all this time (thanks bozo doctors). I started these when my kids started school, Tuesday 9/3/13, have been doing them 2-3 times a day, iced a bit here and there and I want to say "THEY WORK"! I can walk with minimal pain and not limp and it's only been 5 weeks. The next 7 weeks look promising. So Thank you.
    Marilyn in Connecticut

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  45. Hi, dear John, Thanks for the article. It is very informative. I am 25 years old and have flat feet. I have been using arches in my shoes since 4 years as I got pain in my toes with walking. I donot run but I have been suffering from similar pain as in insertional achilles tendonitis since a month in left ankle. The pain is only felt while moving downstairs. I have no issue while walking. But if I use stairs many times I get a constant pain but no swelling. Dr. suggested my NSAIDs and a gel with 0.5% piroxicam and told me to take rest. It has been 15 days and I feel no improvement. I will perform the heel down exercise as described above but i feel no pain while doing it so should i directly use a back pack? Plus can I start with brisk walk which I have left after visiting my doctor who suggested rest? Is my condition tendonitis or am I confusing it with other conditions? I am in a great depression due to this. Cannot go down steps with putting stress on my left foot. Will I be able to step downstairs normal again?

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    1. Is there any other exercise that I should do? like stretching with a towel? Despirately waiting for your reply. Thanks

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  46. Hi, Great article, thanks for writing it.
    I am desperate for help and some good advice. I had terrible pain in my posterior ankle when on plantar flexsion; the pain is right at the top of the calcaneous when I plantar flex. It did not pain me when I ran so I was sure that I had impingement syndrome (os trigonum). I went for an MRI and there was no indication of os trigonum. The doctor who did the MRI said I had two tears in the Achilles tendon and Achilles tendonitis, as far as I am aware my problems are at the insertion.
    So based on that diagnosis I began 3 weeks ago the Alfredson program. I feel no pain (other than normal muscle and tendon soreness and tiredness due to work) in the tendon when I am doing the calf raises (straight leg and bent leg) and I am doing about 400-500 raises each day, per leg, with weight! And I have no pain in the next day when I walk or get up in the morning. I also have no morning stiffness.
    But I have two problems:
    1. I still have very bad pain when I plantar flex (it seems that the alfredson exercises is making the pain worse when I plantar flex)
    2. It now begins to feel like my tendon is a bit swollen and I have a bit of pain on the outside of the leg just below the soleus.
    I just read your article and it seems that maybe I should be doing your version of the calf raises since my problem appears to be at the insertion. Do you agree?
    I think what might be happening is that my tendon is becoming swollen and is being pinched by the calcanesous when I plantar flex. What do you think? Would you agree with this?
    Please help I have being suffering from this issue for 1.5 years now and it is really affecting me physically and mentally.
    Thank you.
    Ronan

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  47. This article was extremely helpful. I've been recovering from a double whammy. 6 months ago I twisted my ankle and was not able to properly rehab (I was living in a country that all hills and no or uneven pavement). 8 weeks go I had a bad epically awkward fall and tore my meniscus. I'm in rehab for the meniscus now and doing well, while also trying to work on the AT injury from my sprain. The eccentric heel lifts seem to be helping my AT quite a bit, but I'm afraid they may also be causing inflammation in my knee as I try to rehab that. Do you know of any studies or work on how these heel lifts/drops effect knee/meniscus ? Thank you!

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  48. I scanned through all the posts here, but I'm either missing it, or it's just not been fully explained.

    Question: Should both legs be exercised even if only one is injured? If so, must one use a box to get in the upward position on the injured side?

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  49. Hi Mark,

    In all the research that has been done to date, ONLY the injured side is subjected to the eccentric exercise, so that's the way to do it. Some people (not researchers) have wondered whether this might induce a muscle imbalance, but I think the fact that you're going back "up" on the healthy side by concentrically using your calf muscles should offset this.

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  50. Perhaps the reason why Eccentric loading has proven effective, and not concentric loading is time under tension, instead of contraction type. Concentric exercises tend to be done quickly, lasting 1-2 seconds at most. While Eccentric loading is to be done very slowly , 3 seconds or more.

    I read an interesting study that showed longer duration (20 second) isometric contractions resulted in significant increases of tendon stiffness, while short duration (1 second) isometric contractions, did not. Both protocols induced muscle hypertrophy.

    This also might explain why the new "heavy slow resistance (HSR)" was more effective for treating patellar tendinopathy than eccentric only.

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  51. This comment has been removed by the author.

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  52. Hi John, I just came across this article in researching my case of insertional AT. I have taken 4 weeks off of running at this point and have been doing the flat eccentric exercises a couple times a day. I have little to no pain when doing every day tasks like walking, climbing stairs, etc. even cycling, but the tendon remains quite stiff if I make any attempt to flex into a dorsifleixion, to the point where it creaks (not audibly), and will make a popping sensation while flexing/stretching. While pain has decreased and almost completely gone away, there has been no improvement to those other symptoms. It creaks/pops the most when doing the eccentric exercises actually. I don't know how concerned to be with that since pain does not usually accompany those sensations. Is it a sign of swelling, damage, etc or could it just be due to the decreased movement/activity over the last 4 weeks? I'm dying to get back on the road, but am being very cautious as not to ruin the entire upcoming running season.

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    1. The stiffness you have when you dorsiflex is probably due to the scar tissue, which hasn't matured fully yet. Keep doing the eccentric exercises and over the next month or two, the scar tissue will mature into a much stronger tissue and won't give that stiff feeling anymore.

      Creeking, popping feelings are nothing to be worried about as long as there is no pain accompanied with it, they might have even been there before you had insertional AT, but you never payed any attention to it.

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  53. How do you know when it is safe to do these? I have just come down with insertional tendonopathy post-quinolone medication. how do I know if this risks rupture, which is quite common in Cipro victims, and when I can start? Thank you

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    1. Rachel are u based in uk or elsewhere?
      John - is there any advice u can offer for tendon disruption caused by quinine antibiotics. I've tried resting, acupuncture, stretching,sports massaged release massage. Nothing seems to be working. Mir is clean, no spurs, degeneration, inflammation.. Physio gave me eccentric drops but looking at this article seems she has prescribed the wrong exercises. I just . Want to get back running asap!

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  54. The read was very interesting.My challenge is Haglund's Deformaty and a Ironman in 6 weeks.I plane to run slow and finish.Any chance of a bad injury after the race?

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  55. @rachel
    How are you getting on now Rachel? I too have suffered with international retinopathy since taking ciprofloxacin. It's put me out of running for 7 months now. I was 5 months into training for uk iron man. The only thing I can do now is swimming. I'm 31 years old and a member of my local tri club so frustrating doesn't come close. Had an mri scan two months ago and nothing shows despite pain in both achilles at insertion onto heel bone.

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  56. I was diagnosed with insertional achilles tendinopathy a few months ago by a physiotherapist and was given eccentric exercises - standing on a step and dropping the heel below the level of the toes . No positive effect at all after 12 weeks .
    Since then I have noticed a permanent hard lump on the back of my heel which from my reading on the subject I assume is Haglund's deformity .
    Will the exercises detailed in this article work in this case or would surgery be required

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  57. Great article, thanks for putting in the effort.

    Question: is there any reason why you shouldn't do all three (flat, straight knee dorso, bent knee dorso)? I'm assuming the difference between straight vs bent knee is the part of the Achilles being targeted, so wouldn't adding flat foot just be targeting another part of the Achilles?

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  58. In the Alfredson pilot study, the authors hypothesize that the traditional eccentric drops off a step (the bent knee and the straight knee ones) cause the heel bone to "pinch" or "compress" the insertional part of the Achilles, which they think might be counterproductive. There's really no evidence for this though, it's just their guess. Even if that IS true, one thing I wonder about is workload: the traditional midpoint protocol calls for 3x15 twice a day of EACH exercise, so you're essentially doing 2*2*3*15 = 180 eccentric drops per day. But with this protocol, even doing 3x15 twice a day, you're only doing half that—90 drops—because there's only one exercise. There's definitely a need for more research on what an appropriate workload is.

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  59. Dear John, Thanks for your write-up!
    I developed heel pain both at the sole as well as at the back of the heel at Achilles insertion. I was diagnosed with Planter Fasciitis 9 months ago. That got seem to have got better with planter flexion and dorsiflexion excercises and ultrasound prescribed by the doctor/physio. I also used a heel insert as well as splint and gradually increased my walking over this period even though it use to get uncomfortable at the end of it. I also started feeling discomfort during/after the planter flexion and dorsiflexion excercises. However, 2 weeks back I again developed acute heel pain at the back of both heels with bumps at the back of the heels at Achilles insertion increasing. Now I have been diagnosed with insertion Achilles tendonitis/bursitis to be treated with physio therapy. My physio therapist has again started me on planter flexing and dorsiflexion excercises. Reading your excellent blog I am afraid it may cause further damage. Please advise.

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