Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial

J Orthop Sports Phys Ther. 2014 Feb;44(2):59-67. doi: 10.2519/jospt.2014.4720. Epub 2013 Nov 21.


Study design: Randomized clinical trial.

Objectives: To compare the effectiveness of the Alfredson eccentric heel-drop protocol with a "do-as-tolerated" protocol for nonathletic individuals with midportion Achilles tendinopathy.

Background: The Alfredson protocol recommends the completion of 180 eccentric heel drops a day. However, completing this large number of repetitions is time consuming and potentially uncomfortable. There is a need to investigate varying exercise dosages that minimize the discomfort yet retain the clinical benefits.

Methods: Twenty-eight individuals from outpatient physiotherapy departments were randomized to either the standard (n = 15) or the do-as-tolerated (n = 13) 6-week intervention protocol. Apart from repetition volume, all other aspects of management were standardized between groups. Tendinopathy clinical severity was assessed with the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire. Pain intensity was assessed using a visual analog scale (VAS). Both were assessed at baseline, 3 weeks, and 6 weeks. Treatment satisfaction was assessed at week 6. Adverse effects were also monitored.

Results: There was a statistically significant within-group improvement in VISA-A score for both groups (standard, P = .03; do as tolerated, P<.001) and VAS pain for the do-as-tolerated group (P = .001) at week 6, based on the intention-to-treat analysis. There was a statistically significant between-group difference in VISA-A scores at week 3, based on both the intention-to-treat (P = .004) and per-protocol analyses (P = .007), partly due to a within-group deterioration at week 3 in the standard group. There were no statistically significant between-group differences for VISA-A and VAS pain scores at week 6, the completion of the intervention. There was no significant association between satisfaction and treatment groups at week 6. No adverse effects were reported.

Conclusion: Performing a 6-week do-as-tolerated program of eccentric heel-drop exercises, compared to the recommended 180 repetitions per day, did not lead to lesser improvement for individuals with midportion Achilles tendinopathy, based on VISA-A and VAS scores.

Publication types

  • Comparative Study
  • Randomized Controlled Trial

MeSH terms

  • Achilles Tendon / injuries*
  • Adult
  • Exercise Therapy / methods*
  • Exercise Tolerance
  • Female
  • Heel
  • Humans
  • Male
  • Middle Aged
  • Pain Measurement
  • Pain Threshold
  • Patient Satisfaction
  • Sedentary Behavior
  • Tendinopathy / physiopathology
  • Tendinopathy / therapy*
  • Treatment Outcome