The Alfredson Protocol for Achilles Tendonitis

Using Eccentric Exercises to Treat Achilles Tendon Problems

Photo of a man running up the stairs.
The Alfredson Protocol can help treat your Achilles tendonitis. DaveLongMedia/ E+/ Getty Images

If you have Achilles' tendonitis, then you understand how this condition can limit your ability to walk and run.  It can prevent you from participating in your normal recreational and athletic activities, and it may interfere with your normal work routine.

There are many different physical therapy treatments available to manage Achilles' tendonitis.  A physical therapist can help by controlling the initial inflammatory process, and then by recommending gentle and progressive loading exercises for your Achilles' tendon as it is healing.

In more recent years, there has been evidence published indicating Achilles' tendonitis is not an actual inflammatory process.  Some histological studies indicate that the typical inflammatory cells found with tendonitis are not present.  Therefore, Achilles' tendonitis is often referred to as Achilles' tendonipathy, especially when it has lasted for more than a few weeks and has become a chronic condition.

Gentle stretching and progressive loading of the Achilles' tendon is necessary to successfully treat Achilles tendinopathy.  Some studies indicate that eccentric loading of the tendon is favorable to other types of exercise.  The Alfredson protocol is a method that is used to progressively load your injured Achilles' tendon to treat the tendonipathy.

What is Eccentric Exercise?

Eccentric loading of a tendon occurs when your muscle and tendon are contracting as you are lengthening the muscle.

 This is in direct opposition to concentric contractions, or muscles and tendons that shorten as you contract them.

A simple example of an eccentric contraction is to hold something in your hand with your elbow bent. Slowly allow your elbow to straighten out while holding the weight.  You can visualize your bicep muscle lengthening as you are holding the weight while you are slowly straightening your elbow.

 This is an eccentric contraction or eccentric loading of your bicep muscle.

Achilles' Tendonitis Basics

Achilles' tendonitis is a common running injury.  Signs and symptoms of Achilles' tendonitis or tendinopathy are:

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

If you suspect you have  Achilles' tendinopathy, it is a good idea to check in with your doctor to ensure the correct diagnosis.

The Alfredson Protocol Exercises

The Alfredson protocol for Achilles' tendinopathy is actually two separate exercises.  To perform the exercises, you must have a small step or curb on which to stand.  Be sure to check in with your doctor or physical therapist to ensure that it is safe for you to exercise and that you are performing the exercises correctly.   Here is how you perform the Alfredson protocol:

  • Stand on a step with the balls of your feet on the edge.  Your heels should be hanging over the edge of the step.
  • Hold onto something stable for balance.
  • Keep both knees straight.
  • Using both feet, lift your heels and rise up onto the balls of your feet.
  • Keep your foot with the painful Achilles' tendon on the step, and lift your non-injured foot off the step.
  • Slowly lower yourself down using your injured ankle.  Your heel should move towards the floor, and the ball of your foot should remain in contact with the edge of the step.
  • Return your non-injured foot to the step and repeat the exercise.

The Alfredson protocol calls for performing this exercise for 3 sets of 15 repetitions.  When performing the exercise with your knees straight, a specific muscle that makes up the Achilles' tendon called the gastrocnemius is loaded and challenged.

Once you perform 3 sets of 15 repetitions with your knees straight on the step, repeat the Alfredson protocol with your knees slightly bent.  This places stress upon a specific muscle called the soleus that joins the gastrocnemius to form your Achilles' tendon.  Again, perform 3 sets of 15 repetitions.

The two exercises of the Alfredson protocol should be performed twice daily.  That means that you should do 3 sets of 15 repetitions of the straight knee and bent knee heel lowering exercises in the morning and in the evening.  In total, you should be performing 180 repetitions of the exercise daily.

What Should I Expect to Feel After the Exercise?

After performing the two exercises of the Alfredson protocol, you may feel soreness or pain in the back of your ankle by your Achilles' tendon and soreness in your calf muscles.  This soreness will last for a day, and the soreness will become much less as you progress with the exercises over the course of weeks.  The Alfredson protocol indicates that you continue with the exercises unless the pain becomes disabling.  If this occurs, consult your doctor.

Although there is research concluding the effectiveness of the Alfredson protocol, some individuals find the completion of 180 repetitions of exercise daily to be difficult to achieve.  A study in the February 2014 issue of the Journal of Orthopaedic and Sports Physical Therapy indicated that a modified version of the Alfredson protocol with a "do as much as tolerated" approach achieved similar positive results as the full 180 repetition protocol.

How Long Should I Continue the Alfredson Protocol?

The Alfredson protocol should be continued for 12 weeks to see optimal results.  During that time, you may wish to consult with a physical therapist who can offer advice on when to return to normal activities, such as running.  Your physical therapist can prescribe balance exercises with a BAPS board and plyometric exercises to ensure that you will be able to run and jump without suffering a re-injury to your Achilles' tendon.

The Alfredson protocol is a method to provide eccentric loading to your Achilles' tendon to treat the painful condition of Achilles' tendinopathy.  It is a simple method to ensure that you can quickly and safely treat your condition and return to your previous level of function.

Sources: Stevens, M. and Tan, C. (2014) Effectiveness of the alfredson protocol compared with a lower repetition-volume protocol for midportion achilles tendinopathy: a randomized controlled trial. JOSPT 44(2) 59-67.
http://www.runnersworld.com/stretching/eccentric-calf-strengthening-achilles-tendinopathy-five-years-later

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