Achilles Tendinopathy in Austin: Heavy–Slow Resistance That Actually Works
When the Achilles keeps nagging, rest alone won’t solve it—and random calf raises won’t either. The fix is a criteria-based loading plan with heavy–slow resistance (HSR) as the backbone, plus smart progressions for gait, plyometrics, and return-to-run. This guide lays out exactly how to dose load, how to advance without flare-ups, and how to know you’re actually getting better.
We reference three credible overviews you can share with any clinician who asks: AAOS OrthoInfo on Achilles tendinopathy basics and red flags, BJSM for up-to-date tendinopathy loading principles and return-to-sport criteria, and APTA ChoosePT for patient-facing rehab guidance you can trust.
What Achilles Tendinopathy Is (And Isn’t)
Tendinopathy means the tendon is irritated and under-prepared for the loads you’re putting through it—not “torn to shreds.” With the Achilles, that irritation typically shows up in two patterns:
Mid-portion (2–6 cm above the heel) — classic morning stiffness, warms up with easy movement, hurts later with speed or hills.
Insertional (right where the tendon meets the calcaneus) — crankier with deep dorsiflexion, step-downs, or shoes that dig into the heel.
Pain is not the enemy; unplanned spikes in load are. Your job is to rebuild tissue capacity and mechanics so day-to-day and sport-level loads feel routine again.
(See AAOS OrthoInfo for plain-English basics, red flags, and imaging indications.)
Why Heavy–Slow Resistance Beats “Endless Eccentrics”
Eccentrics helped a generation of athletes, but HSR tends to win in the real world because it:
Builds true capacity (strength and stiffness) across eccentric + concentric + isometric actions.
Is easier to progress and track (sets × reps × load).
Fits busy lives—3 focused sessions per week usually beats 12 micro-sessions you won’t do.
In short: HSR gets you strong where it matters—so you can tolerate hills, speed, and deceleration without flaring the tendon.
(For the loading rationale and return-to-sport thinking, see BJSM’s tendinopathy discussions.)
The Loading Plan (12 Weeks You Can Defend)
Cadence rule: ~3 seconds down, ~2 seconds up, steady tempo unless noted.
Pain rule: 0–3/10 during and a predictable ≤24-hour after-response is acceptable. If you’re spiking to 5–6/10 or waking up much stiffer, pull the load or volume back and re-earn it.
Phase 1 (Weeks 1–4): Set The Base
Isometric Heel-Raise Holds (straight knee) — 5 × 30–45s, RPE 7–8/10, 3–5 times/week early, then 3 times/week.
Use a Smith machine, leg press, or heavy dumbbells if bodyweight is too easy.
HSR Heel Raises (Bilateral → Single-Leg) — 3 × 8–10, RPE 7/10, 3×/week.
Insertional nuance: start on flat ground; avoid deep dorsiflexion below neutral for now.
Accessory strength: seated calf raise (soleus bias) 3 × 10–12; hip abduction/ER and hinge pattern 2–3 sets each.
Advance when: morning stiffness is trending down, and loads hit RPE 7–8 without next-day backlash.
Phase 2 (Weeks 5–8): Single-Leg Strength Is King
Single-Leg HSR Heel Raises (knee straight) — 4 × 6–8, RPE 8/10, add external load.
Seated HSR (soleus bias) — 4 × 6–8, RPE 8/10.
Tempo overload: 4s down / 2s up on the last 2 sets.
Tendon conditioning: 2–3 ×/week; non-HSR days stay easy walk/cycle only.
Advance when: you can do 3×8 single-leg with added load and stable form (no ankle wobble, no bouncing).
Phase 3 (Weeks 9–12): Elastic Return (Without Reckless Plyos)
Heavy Top-Set: single-leg standing calf raise 1 × 5 (RPE 8.5–9), then 3 × 6 back-off sets.
Soleus Power: seated raise 3 × 6 heavy, then 2 × 10 lighter “flush” sets.
Elastic prep (every 3–4 days):
Submax pogo series (double-leg → alternating → gentle single-leg), 3 × 10–15 contacts.
Split-stance decel lowers (front foot elevated), 3 × 6–8 each side.
Green light: next-day tendon feels “used” but predictable; morning stiffness baseline stays stable or better.
(For patient-facing loading expectations and safety, see APTA ChoosePT.)
Form Cues That Protect The Tendon
Foot tripod: big toe, little toe, heel evenly grounded.
Quiet ankle: avoid rapid bounce at the bottom; pause before rising.
Straight knee vs bent knee: straight hits gastrocnemius more; bent targets soleus—you need both.
No lateral cheat: don’t roll to the outer foot to escape pain. Reduce load and keep the line.
Gait, Shoes, And Surfaces
Cadence nudges: a small step-rate increase can reduce peak tendon load during run re-entry.
Shoes: short-term heel lift or slightly higher-drop trainers can calm symptoms; wean as capacity rises.
Surfaces: start flat and predictable; add camber, hills, and trails only after single-leg strength milestones hit.
Return-To-Run Ladder (Criteria, Not Dates)
Only start when: single-leg HSR ≥ bodyweight + external load, seated HSR progressing, and daily life is quiet.
Run-Walk Start (20–25 min): 1 min run / 2 min walk × 8–10.
Build Continuous Time: add 2–4 minutes of total run time per session if next-day is predictable.
Introduce Incline: light hills only after 2–3 pain-stable weeks of flat running.
Add Strides: 4–6 × 15–20s gentle accelerations on flat ground, 48 hours apart.
Advance Surfaces: track → road → mild camber → trails.
Rules:
If next-day pain or stiffness jumps, repeat the last successful step (or drop one).
Keep HSR in the program 2×/week while mileage climbs.
When Imaging Or Referral Makes Sense
Red flags: sudden “gunshot” pain with a palpable gap (possible rupture), significant calf swelling/calf pain (possible DVT), or night pain unrelated to activity.
Plateau: no improvement after 6–8 weeks of well-executed loading and gait changes.
Insertional pain that worsens with any dorsiflexion despite load control—get eyes on form, check bony factors, and consider imaging if progress stalls.
(See AAOS OrthoInfo for red-flag detail and care pathways.)
Why People Stall (And How We Unstick Them)
Under-dosed loading: bodyweight forever won’t change tendon capacity. We program loads you can measure and progress.
Too much plyo too soon: you must earn elastic work with strength first.
Messy foot mechanics: collapsing arch or toe-out cheaters overload the tendon. We coach tripod and alignment.
A noisy life pattern: adding hills, speed, or new shoes while ramping HSR hides your progress. We change one variable at a time.
Where Manual Therapy And NMR Fit
Manual therapy (joint/soft-tissue) reduces guarded tone and helps restore motion at the talocrural/subtalar joints.
Neuromuscular re-education teaches your system to use the new capacity: tripod stance, single-leg balance with perturbations, step-downs with clean alignment, controlled deceleration.
Neither replaces loading—they make loading work better.
Concierge Physical Therapy In Austin: Faster Carryover
Strength built in the gym must survive your real environment—your staircase, your neighborhood hills, your garage gym. Our Concierge Physical Therapy brings assessment tools and portable treatment gear to you in Austin, Westlake, and Rollingwood, so we can tune footwear, surfaces, and routines where you actually move.
For in-studio care or blended plans, see Orthopedic Physical Therapy, Sports Injury Rehabilitation, Neuromuscular Re-education, and Performance Recovery.
Benchmarks You Can Track
Single-leg HSR (standing): 3×8 with external load and perfect form.
Seated HSR (soleus): 3–4×6–8 heavy with smooth tempo.
Hop symmetry: double- to single-leg progressions without pain spike or wobble.
Run volume: two uninterrupted 30-minute runs, flat, symptom-predictable next day.
Morning stiffness: trending down and stable under load increases.
(Thresholds are individualized; we set yours at evaluation.)
If you’re done guessing—and ready for a plan with measurable progress—book an evaluation. We’ll load the tendon the right way, coach the details that protect it, and guide your return to hills, speed, or trails with numbers you can trust.
FAQs
Q: How Often Should I Do Heavy–Slow Resistance For Achilles Tendinopathy?
A: Most do best with 3 HSR sessions/week for 8–12 weeks, leaving a rest day between tendon-heavy sessions. Add light movement on off days, but avoid stacking hills or speed work onto early HSR weeks.
Q: What If Pain Rises To 5–6/10 During Or After A Session?
A: That’s a sign the dose exceeded tolerance. Reduce load or total reps by 20–30% next time and hold that level until the 24-hour response is predictable again. Pain 0–3/10 with a quiet next morning is the target.
Q: Do I Need Imaging Before Starting Rehab?
A: Often no. A good exam plus a trial of care is appropriate for typical presentations. We refer for imaging if red flags appear, if there’s suspicion of partial tear/rupture, or if you plateau despite well-dosed loading. (See AAOS OrthoInfo for red-flag scenarios.)
Q: Are Eccentrics Enough, Or Do I Need HSR?
A: Eccentrics can help, but HSR is easier to load, track, and progress, and it builds concentric and isometric strength you’ll need for hills and speed. Many plans blend a little of both; the spine of the program is HSR. (See BJSM discussions for rationale.)
Q: How Soon Can I Add Plyometrics Or Hills?
A: After you earn single-leg strength (clean 3×8 with load) and your morning stiffness stays predictable. Start with submax pogo series and introduce gentle hills only after 2–3 stable weeks of flat running.
Q: Can Manual Therapy Replace Strength Work?
A: No. Manual therapy reduces pain and improves motion; strength and NMR create lasting change. Use manual to open the door, then HSR + NMR to walk through and lock it behind you. (Patient-facing reinforcement at APTA ChoosePT.)
