Alfredson Protocol for Achilles Tendonitis

The surgeon who tried to rupture his own Achilles

In 1993, Swedish orthopaedic surgeon Håkan Alfredson developed persistent pain in the middle of his Achilles tendon. Treatment at the time usually meant rest, anti-inflammatories and, if the pain refused to settle, surgery. Alfredson asked his boss to operate. His boss said no, because the clinic couldn't afford to lose a surgeon for months of recovery.

Frustrated, Alfredson decided to load the tendon heavily enough to rupture it. A rupture, he reasoned, would finally force his boss's hand.

Instead, the opposite happened. The more heavily he loaded the tendon, the better it felt. Alfredson later said he was pain-free and running again after around three weeks. That result led to a study of 15 recreational athletes and, in 1998, the publication of the programme now known as the Alfredson Protocol.^[1]

A terrible plan had accidentally produced a useful discovery.

What is the Alfredson Protocol?

"Eccentric" refers to the lowering part of a movement, when the calf muscles and Achilles tendon work while lengthening. During a heel drop, you rise using both legs, transfer your weight onto the affected side, then lower slowly on that leg alone.

The original programme included:

• Three sets of 15 straight-knee heel drops
• Three sets of 15 bent-knee heel drops
• Both exercises performed twice daily
• Training every day for 12 weeks
• Extra weight added once bodyweight became too easy

That comes to 180 heel drops a day. The straight-knee version leans on the gastrocnemius, the larger calf muscle, while bending the knee shifts more of the work to the soleus, the deeper calf muscle underneath it.

The original study reported substantial improvement after 12 weeks, though it was a small trial, and later research has shown the Alfredson Protocol isn't the only effective way to load an Achilles tendon.^[1][4]

First, locate the pain

People commonly search for "Achilles tendonitis", but a persistent Achilles problem is more accurately described as Achilles tendinopathy.

Midportion Achilles tendinopathy

Pain is usually felt around 2 to 6 centimetres above the heel bone. This is the condition the original Alfredson Protocol was built for, and the heel is traditionally lowered below the level of the step, provided that range suits the individual.

Insertional Achilles tendinopathy

Pain is felt where the tendon attaches directly to the back of the heel. Lowering the heel below a step can increase compression at that attachment and aggravate symptoms. A modified programme may start on a flat surface instead, without dropping the heel below neutral. Research into insertional Achilles rehab increasingly supports limiting excessive compression in the early stages of loading.^[6]

More depth doesn't automatically mean a better exercise. Use the range your tendon can tolerate and your clinician recommends.

Sudden pain, bruising, major swelling, weakness pushing off, or a snapping sensation can indicate a tear or rupture. Get that assessed promptly.

How to perform the heel drops

Use a solid step or stable exercise platform, and keep a wall or handrail within reach.

Straight-knee heel drop

1. Stand with the front of both feet supported and the heels free to move.
2. Use both legs to rise onto your toes.
3. Transfer your weight to the affected side.
4. Keep the working knee straight.
5. Slowly lower the heel under control.
6. Put the other foot down and use both legs to rise again.
7. Complete three sets of 15 repetitions.

Bent-knee heel drop

Repeat the movement with the working knee slightly bent. The affected leg does the lowering work, and the other leg helps you back to the top. Move slowly and avoid bouncing.

Once bodyweight becomes comfortable, the original programme adds load with a weighted backpack. Build resistance gradually, rather than introducing your tendon to every hardback book in the house at once.

Is it supposed to hurt?

The original protocol allowed participants to work through non-disabling tendon pain, which doesn't mean sharp, severe or rapidly worsening pain should be ignored. Modern clinical guidance supports progressive tendon loading as a first-line treatment for midportion Achilles tendinopathy, but the exercise should suit the person's pain tolerance and current capacity.^[2]

Watch how the tendon responds:

• During the exercise
• Later that day
• The following morning
• Across the following week

Some discomfort can be acceptable. A clear worsening trend suggests the total load is too high. Pain rules aren't universal, and a physiotherapist can help you choose an appropriate range, resistance and repetition count, particularly if the diagnosis is uncertain or symptoms have dragged on for months.

Can you keep running?

Possibly, but that doesn't necessarily mean your usual mileage and intensity. One randomised study found no negative effect from continuing activities like running and jumping when they were managed using a pain-monitoring model alongside progressive rehab.^[3]

Your running may still need adjusting. Distance, pace, hills, speed sessions, surface and frequency all change the demand placed on the tendon. Morning stiffness is useful feedback here: if symptoms are repeatedly worse the day after running, your combined running and rehab load is probably exceeding what the tendon currently tolerates. The goal is to keep the tendon active without repeatedly triggering a major flare-up.

How long does it take to work?

The original programme lasts 12 weeks, but recovery rarely follows a neat schedule. Some people notice early improvement, while others need several months before running and everyday activity feel reliably better.

Track several measures rather than judging the tendon from one run:

• Morning pain and stiffness
• Pain during walking
• Quality of single-leg heel raises
• Calf strength and endurance
• Response to running
• The overall trend across several weeks

One good or bad day tells you little. Look for gradual improvement in strength, function and the amount of activity your tendon can tolerate.

Does it have to be exactly 180 heel drops?

No. A small trial found that a lower-volume, "do as tolerated" version produced similar improvements to the traditional 180-repetition programme.^[5] Other approaches work too: heavy slow resistance training and programmes combining the raising and lowering phases have produced comparable results in people with midportion Achilles tendinopathy.^[4]

The broader principle matters more than worshipping one repetition count: load the tendon consistently, progressively, and at a level it can tolerate. The best programme is the one that suits your condition and survives contact with your actual life.

Common Alfredson Protocol mistakes

Starting without knowing what the pain is. Heel pain has several possible causes. Get it assessed when the diagnosis is unclear.

Using a deep drop for insertional pain. The extra range can increase compression where the tendon meets the heel.

Lowering too quickly. The movement should be deliberate and controlled. Dropping through the movement isn't the same as loading through it.

Using the affected leg to rise. Rise with both legs, then transfer your weight and lower using the affected side.

Adding weight too aggressively. The tendon needs progressive demand, not an ambush.

Stopping as soon as symptoms improve. Pain can settle before strength and capacity have fully returned. Build back towards the demands of your running gradually.

Treating the protocol as a cure for everyone. The Alfredson Protocol is influential, not magic. Some people need a modified loading programme, a different form of resistance training, or further treatment.

Where Yoback fits

You can do heel drops on an ordinary step. It's free, it's everywhere, and it's perfectly adequate for a lot of people. The real problem is usually doing the work, repeatedly, for weeks.

Yoback gives you a dedicated, grippy surface for calf raises, calf stretching and lower-leg mobility work. It can sit out and stay ready to use, rather than relying on you remembering the routine every time you walk past a suitable staircase.

That matters because habits are shaped by friction. Every extra step required to start makes it easier to put off, and visible equipment doubles as a cue that makes the routine harder to forget.

Yoback doesn't diagnose Achilles pain, replace physiotherapy, or make the original protocol suitable for insertional symptoms. What it gives you is a purpose-built tool for regular calf work, along with a long list of other mobility and strengthening exercises. For a 12-week programme, making the routine convenient and obvious can matter more than finding another burst of motivation.

What Alfredson's accident really taught us

Alfredson's real lesson has little to do with hitting exactly 180 heel drops a day. Complete rest is rarely the full answer to a persistent tendon problem, and tendons need an appropriate level of load to regain their strength and capacity. He worked that out while trying to make his own injury worse, which isn't the part anyone should copy.

Identify where the pain is, load progressively, monitor the response, and get professional guidance when the situation is unclear. Understanding the exercise takes five minutes. Doing it consistently for long enough to make a difference is the part that counts.

If you want to try Yoback as part of that routine, it comes with free UK delivery, a 30-day money-back guarantee and a lifetime warranty, so there's no real risk in giving it a go.

References

1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine. 1998.
2. Chimenti RL et al. Achilles Pain, Stiffness, and Muscle Power Deficits, Midportion Achilles Tendinopathy Revision. Journal of Orthopaedic & Sports Physical Therapy. 2024.
3. Silbernagel KG et al. Continued sports activity using a pain-monitoring model during rehabilitation in patients with Achilles tendinopathy. American Journal of Sports Medicine. 2007.
4. Beyer R et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy. American Journal of Sports Medicine. 2015.
5. Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy. Journal of Orthopaedic & Sports Physical Therapy. 2014.
6. Jonsson P et al. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy. British Journal of Sports Medicine. 2008.