The Alfredson Protocol for Achilles Tendonitis

The Alfredson Protocol is an exercise program for people with Achilles tendonitis (tendinopathy). The exercises stretch your Achilles tendon in ways that help it handle forces and stress better. This is called "eccentric loading."

If you have Achilles tendonitis, walking and running can be painful. You might have to stop doing fun activities like playing sports. Depending on your job, having the condition may even make it harder for you to work.

This article will teach you about the Alfredson protocol for Achilles tendonitis. You will learn about the condition and how doing the exercises can help.

Achilles Tendonitis Basics

Achilles tendonitis occurs when the Achilles tendon at the back of the ankle gets hurt. It's common in people who are runners. Here are a few of the signs and symptoms of the condition:

  • 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 think you've hurt your Achilles tendon, the only way to find out for sure is to see your doctor.

Tendonitis or Tendinopathy?

In medical language, the word "tendonitis" means "inflammation of a tendon." However, studies have shown that there might not be inflammation in the tendon in people with the condition.

When a part of the body is inflamed, it will have inflammatory cells in it. People usually feel pain in the part of the body that is inflamed. If you have Achilles tendonitis, your Achilles tendon will hurt. However, it might not be because the tendon is inflamed.

In 2014, researchers looked at tissue from the tendons of people with Achilles tendonitis under a microscope. They did not see any inflammatory cells in the tissue. That means that even though the people felt pain in their tendons, it was not inflamed.

The term "pathy" is at the end of a medical word, it means "disease." Therefore, Achilles tendinopathy is a more accurate name for the condition, especially when someone has had it longer than a few weeks (chronic). However, your doctor or physical therapist may still call it Achilles tendonitis.

If there are no inflammatory cells in the tendon, that could explain why people with Achilles tendinopathy often do not get relief from the anti-inflammatory treatment. This includes medications like ibuprofen, which are non-steroidal anti-inflammatory drugs (NSAIDs).

There are ways to ease the pain from Achilles tendonitis, though. Studies have shown that gentle exercises and "eccentric loading" of the tendon are more helpful than other kinds of exercise if you have the condition. However, researchers are not sure why these exercises are so helpful. 

how to perform the alfredson protocol

Verywell / Laura Porter

What Is Eccentric Exercise?

If you hurt your Achilles tendon, a physical therapist can help you deal with the injury. Once you've started to heal, they can help you make your tendon stronger. You'll start out slowly with easy exercises, then work your way up to harder ones.

To get started, your physical therapist will teach you about "eccentric loading" exercises. They will have you stretch a muscle out (lengthen). As you do the move, the muscle and tendon get shorter (contract).

Here is an example: Hold something in your hand with your elbow slightly bent. Slowly let your elbow go straight while you are still holding the item. Your bicep will get longer as you are holding and slowly straightening your elbow. 

What you are seeing is an eccentric contraction or eccentric loading of your bicep muscle.

Recap

"Eccentric loading" exercises work your muscles and tendons to help them get stronger. The moves you do in the Alfredson protocol are eccentric loading exercises for your Achilles tendon and the muscles that support it.

The Alfredson Protocol Exercises

Before you do any exercises for your tendon, you'll need to talk to your doctor or physical therapist. They can let you know if it's safe to try them. If they say that it's OK, here's how to do the Alfredson protocol:

  1. First, you need a small step or curb that you can stand on.
  2. Stand on a step with the balls of your feet on the edge. Your heels should be hanging over the edge of the step.
  3. Hold onto something stable for balance.
  4. Keep both of your knees straight. This will load a muscle that's part of the Achilles tendon called the gastrocnemius.
  5. Using both feet, lift your heels and rise up onto the balls of your feet.
  6. Keep your foot with the painful Achilles tendon on the step. Lift your non-injured foot off the step.
  7. Slowly lower yourself down using your injured ankle. Your heel should move towards the floor. The ball of your foot should remain in contact with the edge of the step.
  8. Return your non-injured foot to the step and repeat the exercise.

You'll do three sets of 15 repetitions with your knees straight. Then, you can do the Alfredson protocol again with your knees slightly bent. This will work a muscle called the soleus, which connects to the gastrocnemius and makes your Achilles' tendon. Again, perform three sets of 15 repetitions.

You should do both exercises in the Alfredson protocol twice a day. You might want to do it in the morning and in the evening. Whenever you choose to do it, you'll be doing three sets of 15 repetitions with your knee straight knee and three sets of 15 repetitions with your knee bent. In total, you'll do 180 repetitions of the exercise a day.

What You'll Feel

You may feel soreness or pain in the back of your ankle by your Achilles tendon after you start the exercises. Your calf muscles might hurt, too. This soreness will last for about a day. As you make progress over the next few weeks, you'll feel less sore.

You should keep doing the exercises unless the pain becomes too much to continue. If this happens, call your doctor or physical therapist.

While research has shown that the Alfredson protocol works for many people, that doesn't mean it's easy to stick to. Some people find that doing 180 repetitions is too much.

That said, you don't have to give up on the exercises altogether. Research has shown that taking a "do as much as tolerated" approach was still helpful for people. It may even help as much as doing the full 180 repetitions a day version.

How Long to Do the Alfredson Protocol

The Alfredson protocol will be most beneficial if you stick with it for about 12 weeks. However, when you reach that point, don't jump back into your old routine just yet.

Ask your physical therapist about when you'll be ready to start doing things like going for a run. They can make sure that you're prepared and won't hurt your Achilles tendon again when you get back to your old routine.

For example, they might have you work on your balance with a BAPS board and do plyometric exercises.

Recap

The Alfredson protocol includes two exercises that you will do daily for 12 weeks. You will do a total of 180 repetitions of the moves that work your Achilles tendon each day.

At first, you might feel sore. This discomfort will get better with time. However, if it hurts too much to do the exercises at all, stop doing them and tell your doctor or physical therapist right away.

If you are not able to do 180 repetitions every day, you might be able to do an easier version of the exercises instead.

Summary

The Alfredson protocol includes exercises that provide eccentric loading to your Achilles tendon. It's used to treat a painful condition called Achilles tendinopathy.

The exercises work your Achilles tendon and the muscles that support it. You don't need any special equipment and you don't need to go to a gym. You can do the exercises at home as long as you have a step or raised platform you can safely put your foot on.

You'll need to do the exercises (which include 180 repetitions) every day for about 12 weeks to see the full benefits. If that's too much, ask your physical therapist if you can do a modified version.

A Word From Verywell

If you've hurt your Achilles tendon, make an appointment with your doctor. If they think you have Achilles tendonitis, working with a physical therapist might be the next step.

A physical therapist can show you how to do the Alfredson protocol, which research has shown is helpful for people with the condition. They can also show you how to do other kinds of exercise that will strengthen the tendon and get you back to your favorite activities.

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2 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. J Orthop Sports Phys Ther. 2014;44(2):59-67. doi:10.2519/jospt.2014.4720

  2. O'neill S, Watson PJ, Barry S. Why are eccentric exercises effective for Achilles tendinopathy? Int J Sports Phys Ther. 2015;10(4):552-62.