Achilles Tendinitis Exercises: A UK Physiotherapy Guide for 2026

A 12-week graded loading programme is the single most effective treatment for Achilles tendinitis. UK NHS physios prescribe heel drops or heavy slow resistance, not rest.

If you’re searching for Achilles tendinitis exercises, you’re likely dealing with a stiff, sore tendon that nags you on the stairs in the morning or after a weekend run. The single most effective treatment is not rest, ice, or anti-inflammatories alone, but a structured loading programme done consistently for at least 12 weeks. This is the core of modern UK NHS physiotherapy for this condition. It might seem counterintuitive, but controlled, mild pain during the exercises is considered acceptable and even part of the healing process.

First, what Achilles tendinitis really is, in modern UK terms

Most UK physios and NHS resources now use the term Achilles tendinopathy rather than tendinitis. This is because the underlying issue is rarely pure inflammation. It’s more commonly a degenerative process where the tendon’s collagen fibres become disorganised and develop micro-tears. There are two main patterns based on where it hurts. Midportion tendinopathy is pain located 2 to 6 centimetres above the heel bone; this is the most common type and responds very well to specific exercises. Insertional tendinopathy is pain felt right where the tendon attaches to the heel bone (calcaneus). This type is often linked with a bony bump called a Haglund deformity and can be provoked by different movements. Common UK risk factors include a sudden increase in running mileage, adding hill sessions, a change in footwear, tight calf muscles, weak glutes, being over 35, taking fluoroquinolone antibiotics like ciprofloxacin, or having diabetes or high cholesterol. Recognising your pattern is the first step to choosing the right exercise plan.

The principles every UK NHS physio applies

The UK NHS approach to managing tendinopathy is built on three key rules. First, load the tendon; do not rest it completely. Total rest weakens the tendon further. You can modify your activity—like swapping running for cycling or swimming for a few weeks—but you must keep doing your specific loading exercises. Second, mild pain during the exercise is allowed. Pain up to about 4 out of 10 on a personal scale that settles within 24 hours after the session is considered therapeutic. If pain goes above 5 out of 10 or gets worse overnight, that’s a sign to scale back the intensity. Third, this is about time, not intensity. Tendons remodel slowly. You might notice small improvements at 4 weeks, real change at 8 to 12 weeks, and full remodelling can take 3 to 6 months. The most common reason for recurrence is stopping the exercises as soon as it starts to feel a bit better.

The Alfredson eccentric heel drop programme

The Alfredson protocol, established in 1998, is a well-researched programme for midportion Achilles pain. It involves 3 sets of 15 repetitions of eccentric heel drops, performed twice a day for 12 weeks. You do the first three sets with your knee straight to target the gastrocnemius muscle, and then another three sets with your knee bent to target the deeper soleus muscle. That’s 180 repetitions a day. To do them, stand on a step with the ball of your foot on the edge and your heel hanging off. Use your good leg to push up onto your tiptoes. Lift the good foot off and slowly lower down on the painful leg over about 3 seconds. Use the good leg to push back up to the start. Mild, tolerable pain is okay. If pain is sharp or above 5/10, reduce the reps or do them on flat ground. As it gets easier in later weeks, you can add weight in a backpack.

Heavy Slow Resistance: the easier-to-stick-with UK alternative

A 2015 research trial by Beyer and colleagues compared the Alfredson programme to Heavy Slow Resistance (HSR) for chronic midportion tendinopathy. The results showed both were equally effective at 12 and 52 weeks, but patients found HSR easier to stick with and were more satisfied. Because of this, many UK NHS physiotherapy departments now favour HSR. A practical home version involves bilateral calf raises on a step, using a backpack filled with books for added weight. The tempo is key: 3 seconds up, 3 seconds down. Perform 6 to 15 repetitions (fewer reps with heavier weight), for 3 sets, three days a week. Gradually increase the weight as it becomes manageable. This slower, lower-frequency approach often fits better with the schedule of working adults and parents.

Insertional Achilles tendinopathy: a different programme

If your pain is located right on the heel bone, the standard Alfredson heel drop can sometimes make things worse. This is because lowering the heel below the step level stretches the tendon where it attaches, which can be provocative. NHS physiotherapy leaflets from hospitals like RUH Bath, OUH, and ESHT recommend a modified approach. In Phase 1 (first 4-6 weeks), do heel raises on the floor, not off a step. This avoids that deep stretch. Also, use a small heel raise insert (about 6-12 mm) in your shoes to offload the area during the day. In Phase 2, after pain settles, you can progress to heel raises on a step, but only lower your heel down to level with the step, not below. Continue using the inserts. In Phase 3, around 8-12 weeks, you can gradually introduce the full eccentric drop below neutral and slowly return to normal footwear. Always let pain guide your progress, not just the calendar.

A realistic 12 week UK home plan you can actually follow

The reality is that most UK adults won’t complete 180 reps every day for three months. This practical plan blends the best of both approaches. Weeks 1-2: Start with bilateral heel drops (using both feet) on a step, 3 sets of 10, once daily, using just your body weight. Walk but avoid running. Weeks 3-4: Progress to single-leg heel drops on the painful side, 3 sets of 12, twice daily. Introduce one or two sessions of HSR-style heavy slow calf raises with a loaded rucksack. Weeks 5-8: Build to the full Alfredson volume of 3 sets of 15 single-leg drops twice daily. Continue HSR sessions twice a week. You can begin gentle, short jogs of 5-10 minutes if pain after exercise settles within 24 hours. Weeks 9-12: Increase running distance by no more than 10 percent per week, maintain HSR twice a week, and continue daily heel drops. From Week 13 onwards, a maintenance dose of HSR twice a week is a good idea if you wish to keep running regularly.

Footwear, adjuncts and what UK runners often miss

Practical, everyday changes can support your recovery. Heel raise inserts from brands like Sorbothane or Heel Lift, placed in both shoes, are genuinely helpful, especially for insertional pain. Choose supportive trainers from brands like Brooks, Asics, or Hoka that have a noticeable heel-to-toe drop (8-12 mm); this reduces the stretch on the tendon. Avoid zero-drop minimalist shoes during your recovery. Calf foam rolling and self-massage can help with muscle stiffness around your loading sessions. Perform gentle calf stretches after your loading work, not before, as aggressive pre-stretching can aggravate the tendon. In the first few weeks, use cross-training like cycling or swimming to maintain fitness. What is often less helpful long-term includes ice (it numbs pain temporarily but doesn’t aid remodelling), ultrasound or laser therapy (where evidence is weak), and prolonged use of over-the-counter anti-inflammatory tablets beyond a week or so for pain control.

When to see a GP or self refer for NHS physiotherapy

Most cases can be managed at home with a consistent 12-week plan. However, you should seek medical advice if: your pain is not improving after 6-8 weeks of dedicated loading; you feel a sudden snap, pop, or sensation of being kicked in the calf (suggesting a possible rupture, which requires urgent attention via A&E or 111); you cannot push off, weight bear, or stand on tiptoes on the affected leg; there is significant swelling, bruising, or a visible gap in the tendon; or if your pain started after a recent course of fluoroquinolone antibiotics like ciprofloxacin. Most NHS areas allow self-referral to musculoskeletal physiotherapy—ask your GP surgery or check the NHS App. While wait times can vary, you can and should begin your loading programme at home straight away.

Frequently Asked Questions

Should I rest or load my Achilles when it hurts?

UK NHS guidance is clear: load, do not rest. Total rest weakens the tendon further. You should modify high-impact activities like running for a few weeks if pain is high, but you must continue with your daily heel drop or HSR exercises. Mild pain during the exercise is acceptable. Pain that worsens overnight or stays above 5 out of 10 is the signal to reduce the intensity, not to stop loading altogether.

How long until my Achilles tendinitis stops hurting?

With a consistent loading programme, you can expect noticeable improvement at 6 to 8 weeks. A return to gentle running is often possible at 8 to 12 weeks, provided pain settles quickly after sessions. Full tendon remodelling takes 3 to 6 months. The most common reason for the pain returning is stopping the exercises at the first sign of improvement. Most NHS physio plans are built around a solid 12-week block of loading.

My pain is right at the heel, not above it. Are heel drops still right for me?

That location suggests insertional Achilles tendinopathy, which needs a modified approach. Standard heel drops off a step can overstretch the tendon at the heel and increase pain. Start with heel raises on the floor, not off a step. Use a 6-12 mm heel raise insert in your shoes daily. Progress to step-based exercises after 4-6 weeks, but only lower to the step level initially. This distinction is explicitly covered in most UK NHS physiotherapy leaflets.

Can I keep running with Achilles tendinitis?

Usually, yes, but at a reduced volume. Drop your running mileage by 30-50 percent for the first 2-4 weeks. Swap some sessions for low-impact cross-training. Avoid hills and speed work while you continue daily loading. You can build mileage back up from week 4, by no more than 10 percent per week, if pain after running settles within 24 hours. If running consistently worsens your pain for a day or two afterwards, reduce further or pause and focus on loading only.

Are there any over the counter products that help?

Heel raise inserts (6-12 mm) are effective, particularly for insertional pain. Supportive trainers with a higher heel-to-toe drop also help. Topical ibuprofen gel can be used for short-term pain relief. A short course (7-10 days) of oral NSAIDs during a flare is reasonable if you tolerate them. Compression sleeves are popular but have limited evidence. It’s best to avoid spending money on TENS machines or home ultrasound devices, as the evidence for their benefit is poor.

Will I ever be able to run a marathon again?

For most runners, yes. A properly managed Achilles tendon can become stronger than it was before. A dedicated 12-week loading programme followed by ongoing maintenance work is the key. Many UK club runners and marathon finishers have successfully managed episodes of Achilles tendinopathy. The runners who struggle long-term are typically those who never completed a full, structured loading programme.

Could a fluoroquinolone antibiotic have caused this?

It’s possible. Medicines like ciprofloxacin carry an MHRA warning regarding the risk of Achilles tendon damage and rupture, especially in people over 60, those on steroid tablets, or with kidney problems. Symptoms can appear weeks after finishing the antibiotic course. If you have new Achilles pain after taking these medicines, see your GP promptly. The treatment approach is similar, but the risk of rupture may be higher, so high-impact activity should be avoided until you’ve been assessed.

This article is informational only and does not replace personalised advice from your GP, pharmacist, or another qualified healthcare professional.