Heel Drops, Heavy Slow Resistance or Isometrics: Is There a Best Achilles Exercise?

What the Evidence Actually Shows

Heel drops (eccentric training). The Alfredson-style eccentric heel-drop programme became one of the most widely used exercise approaches for midportion Achilles tendinopathy. It can be effective, particularly for midportion tendinopathy, but it is one option rather than the only one.

Heavy slow resistance. A randomised controlled trial in chronic midportion Achilles tendinopathy compared heavy slow resistance training, performed three times a week, with a twice-daily eccentric heel drop programme. Both groups improved similarly in symptoms and function. The heavy slow resistance programme also involved fewer exercise sessions and had higher reported adherence in the trial.

Comparing protocols more broadly. A 2023 systematic review and meta-analysis of 12 randomised trials in midportion Achilles tendinopathy did not identify one loading protocol as clearly superior to another. The certainty of this evidence is limited, as most of the included trials had some concerns about risk of bias. An earlier systematic review found limited evidence that eccentric loading produces better outcomes than other loading approaches for Achilles tendinopathy, supporting the use of progressive concentric-eccentric and heavy slow resistance approaches alongside eccentric training.

Isometrics. Isometric loading can be useful when dynamic exercise is poorly tolerated, particularly as an early way of introducing or maintaining calf loading. Isometrics are not necessarily low-load for the tendon, and a reliable pain-relieving effect has not been clearly demonstrated specifically in Achilles tendinopathy. A clinical trial of 91 people with chronic midportion Achilles tendinopathy found that isometric calf exercises did not provide immediate pain relief compared with isotonic exercise or rest. So we treat isometrics as a useful tool rather than a mandatory first step.

The More Useful Question

The goal isn't to find the one "correct" Achilles exercise. It's to progressively expose the tendon to the loads it needs to tolerate. The best exercise is therefore often the one that provides an appropriate training stimulus, can be progressed, and fits the person's symptoms, goals and circumstances.

That means thinking about:

• Type of load: slow strengthening, then faster and more elastic loading such as skipping, hopping and bounding
• Magnitude: bodyweight, then added load through a backpack, dumbbells or a machine
• Speed: slow and controlled, then progressively quicker
• Volume and endurance: the ability to tolerate repeated single-leg loading, not simply produce one high-force contraction
• Position and range: standing and seated calf raises load the calf muscles differently, and range may need limiting for insertional tendinopathy

Progressive isotonic strengthening is a central component of rehabilitation and should be progressed as strength and symptom tolerance improve.

Strength Is Not the Same as Energy-Storage Capacity

A runner may have good maximal calf strength but still lack the capacity to tolerate repeated, fast stretch-shortening loads. This is why rehabilitation needs to progress from strength towards hopping, running and other energy-storage demands when those activities are part of the person's goal.

A Note on Insertional Tendinopathy

Exercise choice matters more for insertional tendinopathy, because the tendon can be sensitive to compression at the insertion in deep dorsiflexion. For an irritable insertional tendon, calf raises may initially be performed from flat ground or with dorsiflexion range limited, rather than dropping the heel below the level of a step. As symptoms and capacity improve, range can be progressively increased where appropriate.

A 2025 trial in insertional tendinopathy illustrates this well: both programmes used progressive loading, and the difference lay in how much compression and dorsiflexion was allowed. Read more in Insertional vs Midportion Achilles Tendinopathy: Why Location Changes Rehab.

How We Choose Exercises at IP Physio

We choose exercises based on the location of your symptoms, how your tendon responds, what you enjoy and can realistically keep doing, and what you are returning to. Objective calf strength and capacity testing can help identify meaningful limitations in force production, side-to-side differences and, depending on the assessment used, the ability to tolerate repeated or faster loading. Retesting then shows whether the programme is working.

For the full picture, including pain-guided loading and imaging, read Achilles Tendinopathy: Midportion vs Insertional, Symptoms & Rehab.