Part of Achilles tendinopathy
Heel drops for Achilles tendonitis: how to do them properly
Warning signs, and when to get help
What are heel drops, and are they the same thing as shoe heel drop?
No. They are two different things, and they sit side by side in search results. A heel drop is an exercise. Shoe heel drop, sometimes called heel to toe offset, is the height difference between the heel and the forefoot of a shoe, which manufacturers quote in millimeters. If you came here wanting to know what heel height suits a sore Achilles, shoes and heel lifts for Achilles tendonitis is the page you want.
The exercise is a calf raise with the lifting half removed from the sore leg. You go up on both feet, take the good foot away at the top, then lower on the sore leg alone, slowly. Clinicians call that an eccentric contraction, which just means the muscle is working while it lengthens. Our eccentric calf raise page has the video and the cues, and calf raise on a step is the version where the balls of the feet sit on the step edge.
How do you do a heel drop properly?
Up on two, down on one. The sore leg should never do the rising, and this is the first of the two places almost everybody loses the technique: the moment the other foot starts to feel like it is in the way, people begin rising on the working leg, and the exercise quietly becomes something else.
Lower slowly enough that you could stop halfway down and hold there. The descent is the exercise, and it is the other place the technique goes. It is the first thing to shorten when you get tired, so count it out loud to yourself if you have to. Speed is a safety point: AAOS OrthoInfo warns that rapid movement can create a risk of damage to the tendon, and that these exercises can damage the Achilles if they are done wrongly, which is why it advises learning them with a physical therapist watching before you do them alone at home.
Alfredson and colleagues (1998) used a straight knee and a bent knee, and the two are not interchangeable, so keep the working knee straight for one set and bent for another. The bent knee version shifts more of the work to the deeper calf muscle (soleus). Our bent-knee calf raise page covers that position on the way up.
Decide where the bottom of the movement is before you start, not while you are tired. Whole foot on a step means the heel comes down to step level. Ball of the foot on the step edge means the heel can sink below it. Those are two different exercises and the second one is not simply the harder version of the first, because it asks the ankle to bend further up.
Plenty of good programs never go below the step at all: the Guy's and St Thomas' NHS leaflet has its readers stand with the heels over the edge of a step and then says, for its own strengthening exercise, not to drop the heels lower than the step. If that is what you were given, you have not been short-changed.
If you are pulling yourself up on the wall or the counter, the calf is doing less than you think, so the hand is there for balance and not for support. That is the general version, and two groups need the stricter one: if you have osteoporosis, numbness in your feet, or have fallen in the past year, keep a hand on the support for the whole of every raise and ask your physio before you do them without it. Standing on one leg on the edge of a step is the highest balance demand on this page, and OrthoInfo's own instruction for the exercise is to hold a railing.
Alfredson's group added their weight in a backpack, and that is the order to copy once the exercise stops being hard: more weight before more repetitions. The weighted calf raise page sets out how that is usually done, and if you have a heart condition or blood pressure that is not under control, check with your doctor before the heavy work and breathe steadily rather than holding your breath.
How many heel drops, how often, and for how long?
The study protocol was 3 sets of 15 with the knee straight and 3 sets of 15 with the knee bent, twice a day, every day, for 12 weeks, with weight added in a backpack once the exercise no longer hurt (Alfredson and colleagues, 1998). That is 180 lowerings a day. It is what 15 people in one small study did, and it is not a target you have failed to hit.
The guidelines are broader than any single protocol, and deliberately so. The Dutch multidisciplinary guideline recommends progressive calf muscle strengthening exercises for at least 12 weeks, says the form of exercise therapy should suit the individual patient, and asks clinicians to weigh motivation, time and what equipment someone actually has (de Vos and colleagues, 2021). It puts no sets, repetitions or sessions per week on it.
The 2024 US clinical practice guideline does put a frequency on it: tendon loading at least 3 times a week, at an intensity as high as the tendon tolerates (Chimenti and colleagues, 2024). Read that as a floor rather than a target, and a soft one. It carries the guideline's weakest grade, and the guideline's own review of the trials found that frequency, anywhere from once a day to three sessions a week, did not seem to change how people ended up. Silbernagel and colleagues (2020) summarize the evidence the same way, any mechanical loading being effective, eccentric or slow concentric and eccentric, and put their floor lower still at twice a week.
The trials behind the two best known ones sat a long way apart on frequency, twice a day in one and a few heavier sessions a week in the other, and ended in the same place (Alfredson and colleagues, 1998; Beyer and colleagues, 2015). The flavor matters less than doing it for long enough.
In practice most home programs start at 2 to 3 sets of 10 to 15 and build from there, which is roughly where our exercise pages start, though each one carries its own numbers: the single leg heel raise starts at 8 to 15 a side, and the weighted raise at 3 sets of 8 to 12 twice or three times a week. Where an exercise page and a study disagree, follow the exercise page and your physio, who will adjust the numbers, the speed and the weight to your tendon.
Should heel drops hurt?
The pain monitoring model from the Swedish trial allowed pain up to 5 out of 10 during activity. It allowed pain afterward to reach 5 as long as it was back to its usual level by the next morning, and it did not allow pain or morning stiffness to build from one week to the next (Silbernagel and colleagues, 2007). A degree of tendon discomfort during the exercise is therefore expected, which surprises people who have been told to stop at the first twinge. Silbernagel's later clinical guide puts the priority on avoiding moderate or severe pain and symptoms that worsen over time (Silbernagel and colleagues, 2020).
A tendon that is a bit achy afterward and back to its baseline when you get out of bed coped with the session. A tendon that is stiffer or sorer for longer the next morning was asked for too much, and the answer is one step back, not a week off. So the test is tomorrow morning, not tonight. Sharp pain, or pain that climbs with each repetition, stops the set.
Heel drops or heavy calf raises: does it matter which?
Beyer and colleagues (2015) randomized 58 people whose midportion pain had lasted more than 3 months to daily heel drops or to heavy slow resistance, which is heavy calf raises done slowly with weight added. Both groups improved by 12 weeks and held that improvement at 1 year, with no difference between them in symptoms, function, tendon thickness or tendon blood vessels. The difference was in sessions done: the heavy slow group completed 92 percent of its planned sessions and the heel drop group 78 percent. A systematic review of 16 randomized trials in midportion tendinopathy found that eccentric exercise had the most evidence of effectiveness among the nonsurgical options, which is the reason heel drops are still the default instruction (Magnussen and colleagues, 2009).
That gives you a genuine choice, and the useful question is which one you will actually do. Six sets twice a day fits some lives and not others. Three sessions a week of heavier work fits others, which is close to the alternative Silbernagel and colleagues (2020) describe: heavier heel rises at a gym 3 times a week, with lighter ones at home on the days in between. A program done three times a week beats a program done twice a day for nine days and then abandoned, and the trial evidence says you are not giving anything up by picking the one you can keep. The staged Achilles tendinopathy program runs from holds through to single leg heel raises and the weighted work, so both routes are in there.
When heel drops are the wrong exercise
Insertional pain, meaning pain on the bone at the very back of the heel, is the one that sends most people to this page. Bending the ankle up a long way presses the tendon against the heel bone, and that is exactly what the bottom of a below-step heel drop does. If your pain is at the back of the heel (insertional), keep heel raises on a flat floor or at step level, and skip any exercise that lets the heel drop below a step until your physio says otherwise.
The sources point the same way: AAOS OrthoInfo says heel drops should be performed only for noninsertional Achilles tendinitis and not if you have the insertional kind. The Dutch multidisciplinary guideline advises, for insertional Achilles tendinopathy, initially doing the exercises on a flat surface (de Vos and colleagues, 2021).
The reason for the change is in the study before it: when Fahlstrom and colleagues (2003) ran the standard eccentric program, which loads the tendon into full ankle-up range, 89 percent of the midportion tendons came out satisfactory against only 32 percent of the insertional ones, 10 of 31. That is why Jonsson and colleagues (2008) built a version without the bottom of the range. Silbernagel and colleagues (2020) describe limiting how far the ankle bends up by putting a lift under the heel while you do the heel raises, and give the thickness as 0.5 to 1 inch, which they convert to 1.3 to 2.5 cm.
Rehab after an Achilles rupture or Achilles surgery is its own program. A healed tendon can end up longer than it was, so that program leaves out calf stretching and keeps the heel at step level or on the floor. Follow the plan your surgeon and physio gave you rather than this page, and read Achilles tendon rupture for what that rehab looks like.
A tendon that started hurting on a fluoroquinolone antibiotic is a different conversation. The warning list below tells you to contact your doctor straight away and to hold off the calf exercises until you have been checked. The UK medicines regulator tells patients to stop the antibiotic at the first sign of tendon pain or swelling and to rest the painful area until they can see their doctor, and says tendon damage can start within 48 hours of the first dose or appear months after the course has finished (MHRA, 2024). Everything else on this page assumes a tendon that nobody suspects has been weakened by a medicine.
And some tendons are simply too sore for the exercise at all. If calf raises on two feet already hurt, heel drops on one leg are several steps ahead of where you are. The program's early stage uses holds and seated work instead, including the seated calf raise, which loads the calf without your body weight on the leg. Stretching is at most an extra here, not the treatment, and the soleus stretch on a step is one your physio may or may not want in your program depending on where the pain sits.
When to see a physio or doctor
See a physio (physical therapist) or doctor if the pain is severe, stops you walking normally, keeps getting worse, or has not improved after a few weeks of looking after it yourself. The single most useful thing an assessment gives you here is which part of the tendon is sore, because that decides whether the heel goes below the step or not, and getting it wrong is the commonest reason heel drops make someone worse.
Go back if 3 months of consistent loading has changed nothing. That is a different conversation from slow progress, and why Achilles pain is not getting better works through what usually turns out to be missing. The warning signs below each carry their own timing, and those come ahead of any exercise question.
Related exercise programs
Warning signs
Get emergency help now
- You felt a sudden pop or snap at the back of your ankle, it felt as if someone hit or kicked you in the calf, or walking or rising onto your toes on that leg suddenly became weak or difficult. Stop exercising and go to an urgent care center or emergency department the same day, even if you can still walk, as this can be a torn (ruptured) Achilles tendon. This page does not cover a rupture.
Get help now, day or night
- Your tendon pain or swelling started while you were taking a fluoroquinolone antibiotic, such as ciprofloxacin or levofloxacin, or in the months after a course. Contact your doctor straight away. The UK medicines regulator (MHRA) advises stopping the antibiotic at the first sign of tendon pain or swelling and talking to your doctor. Hold off the calf exercises until you have been checked.
Get help today
- A calf or thigh that is newly swollen or getting more swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.
- The tendon or heel is hot, red and swollen, or you have a fever or feel unwell. Get medical help the same day, and go to an emergency department if you feel very unwell. If you have a very high or very low temperature, shivering you cannot control, you are breathing very fast or finding it hard to breathe, you are confused or your speech is slurred, your skin, lips or tongue look blue, gray, pale or blotchy (on brown or black skin this can be easier to see on the palms of the hands or soles of the feet), or you have a rash that does not fade when you press it, call emergency services, as this can be sepsis.
- The pain started with a fall or a blow to the back of the ankle, and there is bruising or you cannot put weight on the foot. Get it checked the same day.
- The pain is there at night or at rest as well as with activity and keeps getting worse. If you are being treated for cancer now, contact your cancer team the same day.
Book an appointment
- Your heel or Achilles pain comes with back pain and stiffness that is worse in the morning and at night, or with painful, swollen joints elsewhere, or both heels became painful without an obvious reason. The same applies if you also have psoriasis, Crohn's disease or ulcerative colitis, or have had a red, painful, inflamed eye (iritis). This is not an emergency, but see your doctor in the next week or two, as it can be a sign of an inflammatory arthritis such as ankylosing spondylitis.
- You have numbness, tingling, burning or loss of feeling in the foot, often along the outer edge. Book an assessment with a doctor or physio in the next week or two. If it came on over hours or days, started after an injury, is spreading, or comes with weakness in the foot, get medical advice the same day.
- The pain is there at night or at rest as well as with activity and keeps getting worse. If you have had cancer, now or in the past, or are losing weight without trying, see your doctor sooner, within a day or two, and mention it. This applies even if the pain is not getting worse.
- The pain is there at night or at rest as well as with activity and keeps getting worse. See your doctor within a few days.
Common questions
How many heel drops should I do a day?
The study protocol and a sensible starting point are two different numbers. Alfredson and colleagues (1998) used 3 sets of 15 with the knee straight and 3 sets of 15 with the knee bent, twice a day, every day. Our eccentric calf raise page starts lower, at 2 to 3 sets of 10 to 15 slow lowerings once or twice a day, because most people cannot walk into 180 repetitions a day from a standing start. Build toward whatever your physio sets, not toward a number off a study. The Dutch multidisciplinary guideline asks for progressive calf strengthening for at least 12 weeks and says the form of exercise should suit the individual patient (de Vos and colleagues, 2021), which puts the weight on months of consistency rather than on twice-daily sets.
What is the Alfredson protocol?
It is the exercise program from a 1998 study of 15 recreational athletes who had long-standing Achilles tendon pain in the cord of the tendon despite other nonsurgical treatment. They did heavy slow lowering with the knee straight and with the knee bent, 3 sets of 15 each, twice daily for 12 weeks, adding weight in a backpack once the exercise stopped being painful. All 15 were back to running at 12 weeks (Alfredson and colleagues, 1998). It was small, and the 15 people treated conventionally that the paper compares them with were not randomized: they were a separate group with the same diagnosis who all ended up having surgery. That study is the reason heel drops became the standard advice, and it is not the only program that works.
Should heel drops hurt?
Some tendon discomfort while you do them is expected and acceptable. In the pain monitoring model used in the Swedish trial, pain during the exercise was allowed up to 5 out of 10. Pain afterward could also reach 5, provided it had settled by the next morning. Pain and morning stiffness were not allowed to build from week to week (Silbernagel and colleagues, 2007). Sharp pain, pain that climbs with every repetition, or a tendon that is clearly worse the next morning all mean the load was too much for now. Drop back a step rather than stopping.
How long until heel drops work?
Judge it month to month, not week to week. The trials behind both loading programs ran for 12 weeks and showed clear change inside them, and the first thing that usually shifts is the length of the stiff spell in the morning, not the level of pain. How long Achilles tendonitis lasts goes through the timeframes and the longer follow-up studies properly.
Do heel drops help insertional Achilles pain at the back of the heel?
A modified version, yes, and the full-range version is one to leave out: AAOS OrthoInfo says heel drops should be done only for noninsertional Achilles tendinitis and not for the insertional kind. The problem is not the exercise, it is the bottom of the movement. Jonsson and colleagues (2008) took the ankle-up part out of the program for people with insertional pain and had them lower only to floor level, never below it. Of 27 people with 34 painful tendons, at about 4 months 18 of them (67 percent, 23 of the 34 tendons) were satisfied and back to their previous tendon-loading activity. There was no comparison group, so treat it as promising and not proven. Our insertional or midportion Achilles tendinopathy page explains why the bottom of the range is the part that matters.
Are heel drops the same as calf raises?
They are two halves of the same movement. A calf raise works on the way up and the way down. A heel drop deliberately removes the way up from the sore leg, so that leg only does the lowering: you rise on two feet and come down on one. Heavy slow calf raises load both halves with weight added, and in a randomized trial of 58 people they did as well as daily heel drops at 12 weeks and at 1 year (Beyer and colleagues, 2015). Both are in the staged Achilles tendinopathy program.
References
- Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine. 1998;26(3):360-366. https://doi.org/10.1177/03635465980260030301
- Beyer R, Kongsgaard M, Hougs Kjaer B, Ohlenschlaeger T, Kjaer M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. American Journal of Sports Medicine. 2015;43(7):1704-1711. https://doi.org/10.1177/0363546515584760
- de Vos RJ, van der Vlist AC, Zwerver J, Meuffels DE, Smithuis F, van Ingen R, van der Giesen F, Visser E, Balemans A, Pols M, Veen N, den Ouden M, Weir A. Dutch multidisciplinary guideline on Achilles tendinopathy. British Journal of Sports Medicine. 2021;55(20):1125-1134. https://doi.org/10.1136/bjsports-2020-103867
- Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024. Journal of Orthopaedic and Sports Physical Therapy. 2024;54(12):CPG1-CPG32. https://doi.org/10.2519/jospt.2024.0302
- American Academy of Orthopaedic Surgeons. Achilles tendinitis. OrthoInfo. https://www.orthoinfo.org/en/diseases--conditions/achilles-tendinitis/
- Guy's and St Thomas' NHS Foundation Trust. Achilles tendinopathy. Patient information, resource number 4609/VER3. Last reviewed October 2024. https://www.guysandstthomas.nhs.uk/health-information/achilles-tendinopathy
- Jonsson P, Alfredson H, Sunding K, Fahlstrom M, Cook J. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. British Journal of Sports Medicine. 2008;42(9):746-749. https://doi.org/10.1136/bjsm.2007.039545
- Fahlstrom M, Jonsson P, Lorentzon R, Alfredson H. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surgery, Sports Traumatology, Arthroscopy. 2003;11(5):327-333. https://doi.org/10.1007/s00167-003-0418-z
- Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. American Journal of Sports Medicine. 2007;35(6):897-906. https://doi.org/10.1177/0363546506298279
- Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. Journal of Athletic Training. 2020;55(5):438-447. https://doi.org/10.4085/1062-6050-356-19
- Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clinical Journal of Sport Medicine. 2009;19(1):54-64. https://doi.org/10.1097/JSM.0b013e31818ef090
- Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate. Drug Safety Update. 22 January 2024. https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-must-now-only-be-prescribed-when-other-commonly-recommended-antibiotics-are-inappropriate
- NHS. Deep vein thrombosis (DVT). Page last reviewed 30 April 2026. https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/
- NHS. Symptoms: Ankylosing spondylitis. Page last reviewed 5 January 2023. https://www.nhs.uk/conditions/ankylosing-spondylitis/symptoms/
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-16.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.