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Alfredson Protocol — Eccentric Heel Drops

Draftstrength95%intermediate⬤ strong evidence
View FHIR resourceFHIR R4 ActivityDefinition — the interoperable form of this exercise

Positions & Range of Motion

Start
standing on a step edge with the forefoot on the edge and the affected ankle raised into plantarflexion (heel up), knee locked straight for gastrocnemius bias or bent for soleus bias, free hand resting on a rail
End
heel lowered slowly over ~3 s to well below the level of the step into full ankle dorsiflexion
Range of Motion
eccentric ankle excursion from top-of-plantarflexion through past-neutral dorsiflexion below the step edge (~full available dorsiflexion)

How to Perform

Standing on a step edge, performing slow eccentric heel lowering on the affected leg. Both straight-knee (gastrocnemius bias) and bent-knee (soleus bias) versions. The gold standard for midportion Achilles tendinopathy. VISA-A improves from 49.2 to 83.6 at 5 years. 'Do-as-tolerated' protocol (avg 112 reps/day) produces similar outcomes to full 180 reps/day.

Watch on YouTube↗

Opens a YouTube search for “Alfredson Protocol — Eccentric Heel Drops”

Equipment:step
Starting position: standing

Coaching Cues

  1. 1

    Tall trunk, locked knee — calf lengthens against gravity

    (verbal)
  2. 2

    Lower the heel slowly toward the floor below the step

    (verbal)
  3. 3

    Take three full seconds to drop — count it out

    (verbal)
  4. 4

    Free hand on rail steadies but takes no weight

    (tactile)

Evidence-Based Dosing & EMG Data

Recommended Dosing

3×15 reps both straight-knee and bent-knee, 2x daily (180 total reps/day), 7 days/week, 12 weeks. Progress load when pain-free. 'Do-as-tolerated' alternative: avg 112 reps/day [Alfredson, Stevens 2014]

EMG Activation Data

Improved neuromuscular performance (torque, work, endurance) is the only mechanism consistently associated with clinical improvement [Malliaras 2013]

Muscles Involved (3)

Primary Movers

Gastrocnemius— Eccentric loading straight-knee version — gastrocnemius bias
Soleus— Eccentric loading bent-knee version — soleus bias

Stabilizers

Tibialis Posterior— Ankle stabilization during eccentric lowering

Easier Variations ↓

1

Bilateral Eccentric Heel Drops

Lower on both legs instead of single-leg. Reduces load by 50%.

2

Flat Ground Heel Raises

Standing heel raises on flat ground before progressing to step edge.

3

Regress to heel-raise

AUDIT: If single-leg step-edge eccentrics are painful, perform flat-ground bilateral heel raises first (Alfredson's stated regression).

Harder Variations ↑

1

Weighted Eccentric Heel Drops

Add a backpack with progressively increasing weight. Load increases when pain-free at bodyweight.

2

Heavy Slow Resistance Protocol

Progress to HSR: seated + standing + leg press calf raises at 6RM progressing to 4×6 [Beyer 2015].

3

Progress to heavy-slow-resistance-achilles

AUDIT: Pain-free through full bodyweight eccentric range; progress to heavily loaded HSR at 6RM building to 4x6. Alfredson's own progression list names HSR.

Target Movements (2)

Ankle PlantarflexionTalocrural Joint
Ankle DorsiflexionTalocrural Joint

Why This Exercise Matters

Everyday activities this exercise helps you do — essential means it directly trains the capacity the task needs:

WalkingStair ClimbingRunning and Jogging

Goals This Helps With

Rehab, performance, prevention, and mobility goals this exercise supports — essential means it's a cornerstone:

Achilles Tendinopathyrehab⚠Running Injury Preventionprevention

Evidence Sources (7)