Eccentric heel drop: how to do it and when it helps

Why lower slowly instead of doing ordinary calf raises?

Lowering slowly puts the emphasis on the lengthening, or eccentric, phase, which loads the tendon in a controlled way that tendons tend to respond to over weeks. A heel-drop program described by the Swedish surgeon Håkan Alfredson in the late 1990s made this exercise a standard part of Achilles rehab.

Programs have broadened since then. Many therapists now combine slow lowering with slow, heavy lifting on both phases, and progress to faster hopping and running drills before discharge. The principle that unites them is gradual, measured tendon loading rather than rest alone.

Straight knee or bent knee: which heel drop works which muscle?

The straight-knee drop works mainly the gastrocnemius, the larger calf muscle that crosses the knee, and the bent-knee drop shifts more work to the soleus, the deeper muscle below it. Both feed into the Achilles tendon, so many programs include both.

The soleus matters for runners because it carries a large share of the load in each stride. If your pain is low in the calf or you are coming back from a calf strain, a therapist may weight the program toward the bent-knee version. The page on calf pain when running covers other causes to rule out.

Should the heel drop below the step if the pain is at the back of the heel?

Often not. When the pain is where the tendon attaches to the heel bone, called insertional Achilles pain, dropping below the step can press the tendon against the bone, so therapists commonly keep that version level with the floor.

Pain a few inches above the heel, in the middle of the tendon, usually tolerates the full drop below the step. The Achilles tendinitis page and the page on pain in the back of the heel explain the difference in more detail.

How much discomfort is acceptable during a heel-drop program?

Many tendon programs allow some discomfort during the exercise, as long as it settles soon afterward and morning stiffness is no worse the next day. Your therapist will agree a ceiling with you, often on a 0 to 10 scale.

The next-morning check is the most useful guide. If the first steps out of bed are stiffer or more painful than usual, the previous day’s load was too much, and the dose comes down for a few days. For help setting that ceiling, complete the foot and ankle questionnaire.

Heel drop mistakes, plus easier and harder versions

The mistakes usually come from rushing the lowering or bouncing at the bottom. The variations change the depth, the load or the speed.

• Mistake: dropping fast or bouncing at the bottom.
• Mistake: rolling onto the outside of the foot as the heel lowers.
• Mistake: rising on the sore leg alone before it is ready.
• Easier: both feet lowering together, or lowering only to level.
• Harder: a backpack with a little weight, or holding a dumbbell.
• Harder still: slow single-leg raises and lowers, then hopping drills chosen by your therapist.

Eccentric heel drop, step by step

Use a stair with a rail at home, or the edge of a sturdy step. Hold on for balance so the calf, not your balance, is the limit.

1. Stand on the edge of the step

   Stand with the balls of both feet on the edge of the step and the heels hanging off. Hold the rail lightly.

2. Rise on both feet

   Push up onto your toes with both feet so the lift is shared and the sore side does not have to do the hard part.

3. Shift onto the working leg

   At the top, move your weight onto the leg you are training and lift the other foot slightly.

4. Lower slowly

   Take about three seconds to lower the heel, keeping the knee straight, until it sits just below the level of the step or as far as your therapist advises. Breathe out as you lower.

5. Come back up on both feet and repeat

   Put the other foot back down and rise on both feet again. For the bent-knee version, repeat the same sequence with the knee slightly bent throughout. Your therapist sets repetitions and frequency.