At a glance: Midsubstance Achilles tendinopathy is damage to the body of the Achilles tendon, typically 2–6 cm above where it attaches to the heel. It's caused by repetitive overloading — the tendon can't keep up with the demands placed on it. Eccentric loading exercises are the single most effective treatment, with success rates of 60–90% when performed consistently for 12 weeks.

⚠️ Important Safety Warning

If you suspect an Achilles tendon tear — a sudden pop, sharp pain, or inability to push off — do not begin any stretching or exercises. Even mild Achilles pain, combined with excess body weight, ankle instability, or balance problems, can be a sign of a more serious injury. Please call Dr. Patish at (760) 728-4800 before starting any Achilles rehabilitation program.

Understanding Achilles Tendinopathy (Midsubstance)

Your Achilles tendon is the strongest tendon in your body, connecting your calf muscles to your heel bone. When it's overloaded — from running, jumping, or even just a sudden increase in walking — the collagen fibers inside the tendon start to break down faster than your body can repair them. This creates a cycle of degeneration that causes pain, stiffness, and thickening. The good news: tendons respond remarkably well to controlled loading. The eccentric exercises in this program literally stimulate your tendon to remodel and rebuild itself.

Achilles Tendinopathy (Midsubstance) — Posterior view

Achilles Tendinopathy (Midsubstance) — Medial view

Common Symptoms

Pain and stiffness in the Achilles tendon, especially in the morning
Pain 2–6 cm above the heel that worsens with activity
Thickening or a bump in the tendon
Pain that may improve with gentle warm-up but returns with intense activity
Gradual onset over weeks or months (not a sudden injury)

The Walking Self-Test

Before you begin any exercises, this simple self-test shows you what your feet are actually doing when you walk. Most of us have no idea — we just walk. But your feet may have quietly developed blind spots: parts of the sole that don't engage anymore, toes that don't push off, or an arch that has checked out. This test takes 60 seconds and gives you a personal baseline you can revisit after each week of exercises to feel your progress.

How to do it: Take off your shoes and socks. Walk slowly across a room — about 10 steps. Pay close attention to each step and notice: Does your heel land first, or does your whole foot slap down at once? As your weight moves forward, do you feel it roll through your arch? Do all five toes engage and push off at the end of the step, or do some of them just ride along? Is one foot doing more work than the other? Don't try to "fix" anything — just notice. That awareness is the starting point. Repeat this test after one week of doing your exercises. Most patients are surprised by how much they can feel changing.

Do this before your very first exercise session, then repeat it once a week. It's your personal progress tracker — no equipment, no numbers, just awareness. Many patients tell us this simple test was the moment they realized their feet weren't working the way they thought.

How to Monitor Pain During Exercise

Use a 0–10 scale to rate your pain during exercise, where 0 is no pain and 10 is the worst imaginable.

🟢 0–3: You're in the clear. This level of mild discomfort is normal and safe.

🟡 4–5: Proceed with caution. Reduce the number of reps or don't push as far into the stretch.

🔴 Above 5: Stop the exercise. Go back to the easier tier and try again in a day or two.

Which Level Should I Start At?

Mild — "It bothers me, but I can get through my day"

Pain ≤3 out of 10 at rest. You're walking normally. Daily activities are manageable with minor discomfort.

Moderate — "It's changing how I move"

Pain 4–6 out of 10. You might be limping or avoiding certain activities. Some things you used to do easily are now uncomfortable.

Severe — "It's hard to put weight on it"

Pain 7+ out of 10. Walking is difficult. You may need to hold onto furniture or avoid standing altogether.

Start With These Exercises

Step Heel Raise (Eccentric)

This is the heavy hitter for Achilles tendon rehabilitation. The eccentric phase — the slow lowering of your heel below the step — is where the magic happens. When you lower under load, it stimulates the tendon to remodel and repair itself at the cellular level. This is based on the Alfredson protocol, which has the strongest evidence of any exercise for Achilles tendinopathy (tendon damage from overuse). It's not comfortable at first — mild to moderate pain during the exercise is actually expected and acceptable — but it works.

What to expect: This is a 12-week commitment, and that's important to understand upfront. Most patients start feeling improvement around weeks 4–6, with significant gains by 12 weeks. At 5-year follow-up, this protocol shows lasting results. The goal is to get back to your normal activities without that nagging tendon pain.

How to do it: Stand on the edge of a step or stair with the balls of your feet on the step and your heels hanging off the edge. Hold a railing for balance. Rise up on BOTH feet (this is the easy part), then shift your weight to the affected leg and SLOWLY lower your heel below the step level — count to three on the way down. Use your good leg to push yourself back up. Don't use the affected leg to push up, only to lower down.

Level	Hold	Reps	Sets	How Often	Tips
Mild	slow 3-sec lower	15	3	2×/day	Do this TWICE — once with a straight knee (targets gastroc) and once with a bent knee (targets soleus). Pain up to 5/10 during the exercise is acceptable and expected
Moderate	slow 3-sec lower	10	2	1×/day	Start with both legs lowering together. Progress to single-leg when pain drops to 3/10 or less
Severe	slow 3-sec lower	8	1	every other day	Both legs only. If this is too painful, stick with seated heel raises (the exercise above) until your pain drops enough to try these

How to progress: Bodyweight → add a weighted backpack (5 lbs at a time). Both legs → single leg. Work up to the full Alfredson protocol (3×15, twice daily). Once that's manageable, the Silbernagel protocol adds concentric (pushing up) and eventually plyometric (jumping) phases.

⚠ When to skip this: Do NOT do this with a suspected Achilles rupture. IMPORTANT: If your pain is at the insertion point (where the tendon attaches to the heel bone — insertional tendinopathy), do NOT let your heel drop below the level of the step. Modify to flat-ground heel raises only. Also avoid with an acute Jones fracture.

Seated Heel Raise

This is a gentle way to start strengthening your calf and Achilles tendon without putting your full body weight through them. Because you're sitting, the load on the tendon is much lower — which makes this a great starting point if standing exercises are still too painful. It mainly targets the soleus muscle and begins the process of tendon loading, which is how tendons heal and get stronger (they actually need controlled stress to remodel and repair).

What to expect: This is your stepping stone to the more challenging standing exercises. Within 2–3 weeks you should notice you can do more reps with less discomfort. When you can comfortably do 3 sets of 15 with hand pressure on your knees, you're ready to progress to standing heel raises.

How to do it: Sit in a sturdy chair with your feet flat on the floor, about hip-width apart. Place your hands on top of your knees — they'll add a little resistance. Raise both heels off the floor as high as you can, hold briefly at the top, then lower slowly. Think "slow elevator going up, even slower coming down."

Level	Hold	Reps	Sets	How Often	Tips
Mild	2 sec at top	15	3	1×/day	Press your hands into your knees for added resistance. 2 seconds up, 2-second hold, 3 seconds down
Moderate	2 sec at top	10	2	1×/day	Hands resting lightly — no pressing. Slow and controlled
Severe	1 sec at top	8	1	every other day	Both feet together. Stop if heel pain gets worse during or after

How to progress: Both feet → single leg. Add weight by placing a heavy book or dumbbell on your knee. When 3×15 single-leg with added weight is comfortable, you're ready for standing heel raises and eventually step eccentrics.

⚠ When to skip this: Skip during acute calcaneal (heel bone) fracture, active gout flare, or the first 2 weeks after Achilles surgery.

Wall Calf Stretch — Gastrocnemius (Straight Knee)

This stretch targets the gastrocnemius — the big, powerful calf muscle that gives your leg its shape. It crosses both the knee and the ankle, which is why you stretch it with a straight knee. When this muscle is tight (a condition called equinus), it forces the front of your foot to work overtime with every step, contributing to heel pain, bunions, metatarsalgia, Achilles problems, and more. Loosening it up is one of the single most impactful things you can do for your feet.

What to expect: You should feel a noticeable difference in ankle flexibility within 2–4 weeks of daily stretching. Many patients report that heel pain and forefoot pressure begin to ease as the calf loosens. The clinical goal is at least 10 degrees of ankle dorsiflexion (the ability to pull your foot up toward your shin) — your podiatrist can measure this at your visit.

How to do it: Stand facing a wall with your hands flat at shoulder height. Step one foot back about 2 feet. Keep the back knee STRAIGHT and the heel firmly on the ground — this is the key. Lean gently into the wall until you feel a good stretch in the upper calf of the back leg. Keep your toes pointed forward, not turned out.

Level	Hold	Reps	Sets	How Often	Tips
Mild	30 sec	3	1	3×/day	That's 90 seconds per leg, per session. It should feel like a firm, satisfying stretch — not pain
Moderate	30 sec	2	1	2×/day	Don't lean as far into the wall if the stretch is uncomfortable. Heel stays down no matter what
Severe	20 sec	2	1	1×/day	If standing is too much, try the seated version: sit with your leg out, loop a towel around the ball of your foot, and gently pull your foot toward you

How to progress: Increase hold time to 45–60 seconds. Try slight toe-in and toe-out angles to stretch different parts of the muscle. Eventually, you can do this on a slant board for a deeper stretch.

⚠ When to skip this: Do not do this if you suspect an Achilles rupture (a sudden pop or snap in the calf). If you have insertional Achilles tendinopathy (pain right where the tendon meets the heel bone), do NOT stretch past neutral — stop before you feel the heel stretch. DVT (blood clot) suspicion: if your calf is swollen, red, and warm, see a doctor immediately instead of stretching.

Wall Calf Stretch — Soleus (Bent Knee)

This is the partner stretch to the one above. The soleus is the deeper, flatter calf muscle that sits underneath the gastrocnemius. Because it only crosses the ankle (not the knee), you have to bend the knee to isolate it. It's a workhorse muscle — responsible for much of your standing endurance and push-off power when walking. Tightness here directly limits how far your ankle can bend, which cascades into problems throughout the foot.

What to expect: When the soleus loosens up, patients typically notice easier walking on inclines, less ankle stiffness after sitting, and improved squat depth. Combined with the gastroc stretch above, you're addressing the #1 biomechanical problem we see in the office: tight calves.

How to do it: Same wall position as above, but this time BEND the back knee while keeping the heel glued to the ground. The stretch will feel different — lower and deeper, closer to the ankle rather than high in the calf. That's exactly what you want.

Level	Hold	Reps	Sets	How Often	Tips
Mild	30 sec	3	1	3×/day	Always do this AFTER the straight-knee stretch — gastroc first, then soleus
Moderate	30 sec	2	1	2×/day	Bend the knee more to deepen the stretch, less to lighten it — you're in control
Severe	20 sec	2	1	1×/day	Seated option: sit with your knee bent, foot flat on the floor, and gently push your knee forward over your toes while keeping the heel down

How to progress: Work up to 45–60 second holds. Try single-leg soleus stretches on a step: stand on the edge with the heel hanging off, bend the knee, and let the heel drop gently below the step.

⚠ When to skip this: Same as the straight-knee stretch: avoid with suspected Achilles rupture, and limit the range for insertional Achilles tendinopathy (don't push the heel below neutral).

Add These When Ready

Single-Leg Balance

This is proprioception training — teaching your ankle to "know where it is" in space. After a sprain or injury, the tiny nerve sensors in your ligaments and tendons get damaged, which means your brain doesn't get accurate information about your ankle position. That's why the ankle feels "wobbly" or "unreliable." Balance training rewires those nerve connections and retrains the fast-twitch muscle reflexes that catch you before you roll your ankle. It's like physical therapy for your nervous system.

What to expect: You'll probably wobble a lot at first — that IS the exercise working. By 2–3 weeks you should be able to stand for 30 seconds without touching the wall. By 6 weeks, research shows significantly improved ankle stability and a 35–50% reduction in re-sprain risk. That's the kind of protection that lasts.

How to do it: Stand barefoot on one leg near a wall or kitchen counter — close enough to catch yourself if you need to. Keep the standing knee slightly soft (not locked), look straight ahead, and try to hold your balance without touching anything. It's okay to wobble. It's okay to touch the wall. That's the process.

Level	Hold	Reps	Sets	How Often	Tips
Mild	30 sec	3	1	1×/day	Once 30 seconds is easy with eyes open, try closing your eyes. Then try standing on a pillow. Add arm movements or turn your head side to side for an extra challenge
Moderate	20 sec	3	1	1×/day	Eyes open only. Touch the wall when you need to — there's no shame in it. The wobbling IS the training
Severe	10 sec	5	1	1×/day	Keep two fingertips on the wall if needed. Wear shoes if barefoot is too painful. Progress to no touch when you're ready

How to progress: Hard floor → foam pad → folded pillow → BOSU ball. Eyes open → eyes closed (much harder!). Standing still → catching and throwing a ball → having someone gently push your shoulder.

⚠ When to skip this: Don't do single-leg balance if you're non-weight-bearing (fracture recovery). Skip during active vertigo or dizziness. Wait at least 1 week after an acute ankle sprain before trying this.

Half-Kneeling Dorsiflexion Mobilization

This mobilization targets the ankle joint itself — specifically the talocrural joint, where your shin bone meets your foot. Sometimes ankle stiffness isn't just tight muscles; the joint capsule itself gets stiff, especially after injury or immobilization. This exercise gently pushes the talus bone (your ankle bone) backward in its socket while improving dorsiflexion (the ability to bend your ankle upward). Think of it as "oiling" the hinge of a stiff door.

What to expect: You should notice improved ankle "bend" within 1–2 weeks. A simple home test: kneel in front of a wall, put your toes 4 inches from the wall, and try to touch your knee to the wall without lifting your heel. Track your progress by increasing the distance — 5 inches is good, 6+ inches is great.

How to do it: Kneel on one knee (a folded towel under the knee helps). Place the other foot flat on the floor in front of you. Keep that front heel firmly on the ground and gently drive the front knee forward over your toes — your knee should track over your 2nd or 3rd toe. You'll feel a deep stretch in the front of the ankle.

Level	Hold	Reps	Sets	How Often	Tips
Mild	5-sec oscillations or 30 sec sustained	15	3	1×/day	Oscillate: gentle rhythmic push-and-release at end range. Like rocking a stiff door open a little further each time
Moderate	5-sec oscillations	10	2	1×/day	Smaller range of motion — don't force it to end range. Stop immediately if you feel pinching in the front of the ankle
Severe	gentle oscillations only	8	1	every other day	Try the seated version: sit with your foot flat on the floor and gently lean your knee forward over your toes. Skip this if the ankle is still swollen

How to progress: Increase the depth of the lunge. Add a resistance band looped around the ankle (pulling backward) for a posterior glide mobilization — this gives the joint a mechanical advantage. Measure progress with the knee-to-wall test.

⚠ When to skip this: Skip with an acute ankle fracture. If you have a bone spur at the front of the ankle (anterior impingement), this may cause pinching — stop if you feel a sharp catch in the front of the joint. Wait for post-surgical clearance.

When to See Dr. Patish

See Dr. Patish if your Achilles pain has persisted beyond 2 weeks, if you notice significant swelling or a visible lump, or if you experienced a sudden pop (which could indicate a partial or complete tear). He can use ultrasound imaging to assess the tendon's condition and guide your treatment plan.

Frequently Asked Questions

Can I still exercise with Achilles tendinopathy?

Yes — in fact, controlled exercise is the treatment. Avoid activities that cause pain above 5/10, but don't stop moving entirely. The eccentric exercises in this program are specifically designed to load the tendon in a way that promotes healing. You may need to temporarily reduce running or jumping.

How long before I see improvement?

Most patients notice improvement around weeks 4–6 of consistent eccentric exercises. Full recovery typically takes 12 weeks. This is a commitment — don't give up at week 3.

📚 Learn more: Alfredson Protocol — Original Research (AJSM, 1998)

Need personalized guidance? Dr. Patish can evaluate your specific condition and adjust this program to your needs.

📅 Book Online 📞 Call (760) 728-4800