Stretching is a component of Achilles tendinopathy management, but it is not the primary treatment. Understanding this distinction matters because many people with Achilles tendinopathy focus exclusively on stretching while under-emphasising the progressive loading exercises that have the strongest evidence for producing lasting structural improvement in the tendon.
This guide covers the role of stretching, the best stretches for Achilles tendinopathy, and critically, the important distinction between mid-portion and insertional Achilles tendinopathy that determines which stretches are appropriate and which should be avoided.
Important note: Achilles tendinopathy is a clinical condition with multiple potential contributing factors and varying presentations. This guide provides evidence-based information, but persistent or severe Achilles pain should be assessed by a physiotherapist who can confirm the specific presentation and guide the appropriate programme.
Understanding Achilles Tendinopathy
The Achilles tendon is the thickest and strongest tendon in the body, transmitting the forces of the gastrocnemius and soleus muscles to the calcaneus (heel bone) during every step. Achilles tendinopathy refers to a degenerative condition within the tendon tissue where the normal organised collagen structure is disrupted and replaced with disorganised scar-like tissue, producing pain, stiffness, and reduced load-bearing capacity.
The two anatomical locations:
Mid-portion Achilles tendinopathy:
Pain located 2 to 6 centimetres above the calcaneal insertion, in the body of the tendon. This is the most common presentation (approximately 55 to 65 percent of Achilles tendinopathy cases). The tendon may be visibly thickened at this location. The underlying pathology involves intratendinous degeneration without significant involvement of the tendon-bone attachment.
Insertional Achilles tendinopathy:
Pain located at or just above the point where the Achilles tendon inserts into the posterior calcaneus (the back of the heel bone). This presentation (approximately 20 to 25 percent of cases) often involves reactive bone changes at the calcaneal insertion, including calcaneal bone spurs, and frequently includes involvement of the retrocalcaneal bursa (the small fluid-filled sac between the tendon and the heel bone).
Why this distinction changes the management:
The distinction between mid-portion and insertional tendinopathy is not merely anatomical: it directly determines which stretches and exercises are appropriate and which can worsen symptoms. The heel-drop stretch from a step (the most evidence-based exercise for mid-portion tendinopathy) places the tendon in a stretched, compressed position at the calcaneal insertion and can significantly aggravate insertional tendinopathy. Using the mid-portion protocol for an insertional presentation is one of the most common management errors.
The Role of Stretching in Achilles Tendinopathy
Stretching for Achilles tendinopathy addresses the calf tightness that is both a contributing factor to tendinopathy development and a consequence of the pain-mediated movement restrictions that develop after onset. By reducing the resting tension in the gastrocnemius and soleus, stretching reduces the passive load on the Achilles tendon during standing and walking.
What stretching does:
- Reduces resting calf tension and passive Achilles tendon load
- Improves the available ankle dorsiflexion range
- Reduces the morning stiffness that is characteristic of Achilles tendinopathy
What stretching does not do:
- Directly remodel the pathological tendon tissue
- Restore the normal collagen organisation of the degenerated tendon
- Produce the structural improvement in the tendon that loading exercises achieve
The evidence on stretching alone:
Research comparing stretching alone versus stretching plus progressive loading (eccentric calf exercises) for Achilles tendinopathy consistently finds that the combined approach produces significantly better outcomes. The landmark Alfredson 1998 study, which established the evidence base for eccentric calf loading in Achilles tendinopathy, found that the eccentric loading protocol produced dramatic improvements while rest and stretching alone had failed to resolve symptoms in the study population.
This does not mean stretching is unimportant: it is a valuable adjunct to the primary loading programme. But it should be understood as a supporting intervention rather than the primary treatment.
Stretches for Mid-Portion Achilles Tendinopathy
The following stretches are appropriate for mid-portion Achilles tendinopathy (pain 2 to 6 centimetres above the heel).
Stretch 1: Standing Gastrocnemius Stretch (Wall)
As covered in the gastrocnemius and soleus stretches article on this site, the straight-knee wall stretch is the primary gastrocnemius stretch.
How to do it:
- Stand facing a wall with both hands on the wall
- Step one foot back 60 to 80 centimetres with the back knee straight
- Lean into the wall, pressing the back heel into the floor
- Feel the stretch in the upper-to-mid calf of the back leg
- Hold for 45 to 60 seconds
- Perform 2 to 3 repetitions per side
Modification for Achilles sensitivity: If the stretch produces pain directly in the painful tendon region (rather than the muscle belly), reduce the intensity by moving the back foot slightly closer to the wall.
Stretch 2: Standing Soleus Stretch (Bent-Knee Wall)
As covered in the gastrocnemius and soleus stretches article on this site, the bent-knee stretch specifically targets the soleus.
How to do it:
- Stand facing a wall with both hands on the wall
- Step one foot back with the back knee bent (30 to 45 degrees)
- Drive the bent knee forward and downward while keeping the back heel flat
- Feel the stretch lower in the calf, closer to the ankle
- Hold for 45 to 60 seconds
- Perform 2 to 3 repetitions per side
Stretch 3: Step Gastrocnemius Stretch (Heel Drop — Mid-Portion Only)
This is the stretched position of the Alfredson eccentric heel drop protocol and provides the greatest gastrocnemius stretch achievable.
How to do it:
- Stand on the edge of a step with the forefoot on the step
- Knee is straight (gastrocnemius version)
- Lower the heel below the step level under gravity
- Hold the stretched position for 30 to 45 seconds
- Perform 2 to 3 repetitions per side
CRITICAL: This stretch is ONLY appropriate for mid-portion Achilles tendinopathy. The hanging heel position places significant compression on the Achilles tendon at its calcaneal insertion, which can severely aggravate insertional Achilles tendinopathy. If there is any uncertainty about whether the presentation is mid-portion or insertional, seek physiotherapy assessment before performing this stretch.
Stretch 4: Step Soleus Stretch (Bent-Knee Heel Drop — Mid-Portion Only)
The bent-knee version of the step stretch, targeting the soleus specifically.
How to do it:
- Stand on the edge of a step with the forefoot on the step
- Bend the knee to approximately 30 to 45 degrees
- Lower the heel below the step level
- Hold for 30 to 45 seconds
- Perform 2 to 3 repetitions per side
Same restriction applies: This stretch is appropriate for mid-portion Achilles tendinopathy only.
Stretch 5: Plantar Fascia and Achilles Morning Stretch
The morning first steps are typically the most painful for both plantar fasciitis and Achilles tendinopathy because the tendon and fascia shorten during sleep and are subjected to sudden tensile load with the first weight-bearing.
Before getting out of bed:
- While still in bed, loop a towel or band around the forefoot of the affected foot
- Pull the foot toward the shin (dorsiflexion) and simultaneously pull the toes back
- Hold for 30 seconds
- Repeat 10 times before standing
- This gentle stretch before the first steps significantly reduces the severity of morning pain
Modified Approach for Insertional Achilles Tendinopathy
Insertional Achilles tendinopathy requires a significantly modified stretching approach because:
The compression problem: The Achilles tendon is compressed against the calcaneal insertion during maximum ankle dorsiflexion (as occurs in the step stretches). In mid-portion tendinopathy, this compression is distant from the pathology. In insertional tendinopathy, this compression is directly at the site of pathology and can worsen the inflammatory and degenerative process.
What to avoid in insertional tendinopathy:
- Heel-drop stretches from steps (the hanging heel position maximally compresses the insertion)
- Aggressive end-range ankle dorsiflexion stretching
- Running uphill (which places the tendon in a compressed dorsiflexed position repeatedly)
What is appropriate for insertional tendinopathy:
Gentle wall stretches within a comfortable range, stopping before the stretch reaches end-range dorsiflexion. The goal is to maintain reasonable calf flexibility without the aggressive end-range stretch that compresses the insertion.
The modified insertion stretch protocol:
- Standard standing wall stretch (gastrocnemius): Hold at a comfortable mid-range rather than driving to end-range ankle dorsiflexion. If any pain is felt at the heel insertion, reduce the stretch intensity.
- Standard bent-knee wall stretch (soleus): Performed at mid-range dorsiflexion, stopping before pain at the insertion.
- Avoid all step-based heel-drop stretches.
The Progressive Loading Programme: The Primary Treatment
As stated at the outset, stretching is an adjunct to the primary treatment for Achilles tendinopathy: progressive loading exercises that drive structural remodelling of the degenerated tendon tissue.
The Alfredson Eccentric Protocol (Mid-Portion)
The Alfredson protocol, developed by orthopaedic surgeon Hakan Alfredson in the 1990s, remains the most evidence-supported loading intervention for mid-portion Achilles tendinopathy:
Straight-knee eccentric heel drops (gastrocnemius):
- Stand on the edge of a step on the forefoot of the affected leg
- Rise onto the toes using the unaffected leg (or both legs)
- Transfer weight to the affected leg only
- Slowly lower the heel below the step level on the affected leg (3 to 5 seconds)
- The eccentric lowering is the training stimulus
- Repeat: 3 sets of 15 reps, twice daily
- Perform through mild to moderate pain (this was the original protocol specification; current adaptations allow modification for those with very high pain levels)
Bent-knee eccentric heel drops (soleus):
Identical procedure with the knee of the working leg bent (approximately 30 degrees) throughout the lowering phase.
3 sets of 15, twice daily.
The 12-week timeline:
The Alfredson protocol is performed twice daily for 12 weeks before outcomes are assessed. Most people with mid-portion Achilles tendinopathy experience significant improvement within 6 to 8 weeks, with continuing improvement through week 12.
Modified Loading for Insertional Tendinopathy
For insertional Achilles tendinopathy, the eccentric heel-drop protocol from a step is contraindicated (as discussed above). The modified loading approach:
Flat surface heel raises (no heel drop below neutral):
- Stand with both feet flat on the floor (not on a step)
- Rise onto the toes
- Lower slowly to the flat starting position
- The lowering stops at neutral — the heels do not hang below the step
- 3 sets of 15, twice daily
The flat surface position maintains the therapeutic eccentric loading stimulus while avoiding the calcaneal insertion compression of the step version.
Adjunct Interventions That Complement Stretching and Loading
Heel raise inserts:
A small heel raise inside the shoe slightly shortens the Achilles tendon, reducing the tensile load at rest. This provides symptom relief while the loading programme is developing the tendon’s capacity. Not appropriate as a long-term solution but useful during the initial pain management phase.
Load management:
Reducing activities that aggravate the tendon (particularly uphill running, which compresses the insertion, and high-volume sprint training) while maintaining the loading programme allows the structural adaptation to progress without repeated re-irritation.
Ice and anti-inflammatory approaches:
Ice applied for 15 to 20 minutes after loading sessions can reduce local soreness. Anti-inflammatory medications may provide short-term symptom relief but do not address the underlying degenerative process and may impair the tendon remodelling that progressive loading stimulates.
A Complete Achilles Tendinopathy Programme
Daily:
- Morning pre-standing stretch: 10 repetitions of the towel dorsiflexion pull before first steps
- Gastrocnemius wall stretch: 3 x 45 seconds per side
- Soleus wall stretch: 3 x 45 seconds per side
Twice daily (loading — mid-portion protocol):
- Straight-knee eccentric heel drops: 3 x 15 per side
- Bent-knee eccentric heel drops: 3 x 15 per side
Twice daily (loading — insertional protocol, substituted for above):
- Flat surface straight-knee calf raises with slow eccentric: 3 x 15 per side
- Flat surface bent-knee calf raises with slow eccentric: 3 x 15 per side
Continue for 12 weeks before assessing outcomes.
When to Seek Assessment
Seek physiotherapy or medical assessment if:
- The pain is severe and limiting walking
- Symptoms are not improving after 6 to 8 weeks of consistent management
- There is significant swelling, warmth, or redness around the tendon
- The pain follows a fall or a sudden increase in training load
- There is any uncertainty about whether the presentation is mid-portion or insertional
- Complete tendon rupture is suspected (sudden severe pain with loss of plantarflexion power)
Frequently Asked Questions
How long does Achilles tendinopathy take to heal?
Mid-portion Achilles tendinopathy managed with the eccentric loading programme typically shows significant improvement within 6 to 12 weeks. Complete resolution and return to full training often takes 3 to 6 months. Insertional Achilles tendinopathy generally takes longer to respond and may require 6 to 12 months of consistent management. Chronic Achilles tendinopathy (symptoms present for more than 3 months) typically takes longer to respond than acute presentations.
Should I stretch my Achilles tendon if it is painful?
Gentle stretching within a comfortable range is generally appropriate. Aggressive stretching that reproduces the tendon pain or that persists through significant discomfort is not. For insertional Achilles tendinopathy, avoid end-range dorsiflexion stretching entirely. The morning pre-standing stretch described in this guide is appropriate for both presentations and specifically addresses the morning pain that is most debilitating.
Can I run with Achilles tendinopathy?
Running during Achilles tendinopathy is possible but should be managed carefully. Pain during running that exceeds 3 to 4 out of 10 or that does not settle within 24 hours after running suggests the running load is too high for the current tendon capacity. Running volume and intensity should be reduced to a level where the pain stays within this range while the loading programme is performed. Complete rest from running is not routinely recommended as it does not produce the structural tendon adaptations that progressive loading drives.
Is the Alfredson protocol painful?
The original Alfredson protocol specifically instructs continuation of the exercise through pain, with the rationale that the pain diminishes as the structural remodelling progresses. Current adapted protocols allow more pain-guided management, where the exercise is performed within a 3 to 5 out of 10 pain tolerance during the session, with the expectation that the pain will not worsen after the session. If the exercise consistently produces more than this level of pain, the load should be reduced (bilateral rather than single-leg, fewer reps, or a higher starting position on the step).