Address safety, settle excessive irritability and maintain useful movement.
What to do
Adjust running/jumping load while maintaining tolerable activity
Begin calf isometrics or controlled raises
For insertional symptoms, initially limit deep dorsiflexion compression
Exercise dosage
Calf isometric: 4–5 x 30–45 seconds
Heel raises within tolerable range: 3 x 8–12
Progress when
Daily function is stable or improving.
No new red flags or progressive neurological deficit.
Exercise response returns to baseline by the following day.
Phase 2 — Mobility, Strength & Capacity
Restore the specific strength, mobility and control required by the condition.
What to do
Progress heavy slow calf strengthening with straight and bent knee
Build single-leg heel-rise endurance
Add low-level hopping when strength and pain response allow
Exercise dosage
Standing and seated calf raises: 3–4 x 6–12, 2–3 days/week
Progress external load as tolerated
Progress when
Target movement and resistance are tolerated with good quality.
Functional capacity is improving without sustained symptom flare.
Progression is based on objective performance and patient goals.
Phase 3 — Functional Restoration & Return to Activity
Rebuild real-world, occupational or sporting capacity.
What to do
Progress plyometrics, running speed, hills and sport demands
Increase one load variable at a time
Maintain calf strength after return
Exercise dosage
Pogos/hops: 2–4 sets of 10–20 contacts
Run-walk progression; increase duration before speed/hills
Progress when
Condition-specific return criteria are met.
Full task exposure is completed progressively.
No clinically meaningful deterioration during the following 24 hours.
Manual Therapy — Role & Application
Manual therapy may address ankle mobility restrictions but is not a tendon-healing treatment.
Avoid aggressive friction or stretching that increases insertional compression.
Modalities — Use / Avoid
Heel lift may temporarily reduce tendon load in selected cases.
Do not use passive modalities as a substitute for progressive calf loading.
Return / Discharge Criteria
Repeated single-leg heel raises with adequate height/endurance
Hopping tolerated
Running and sport exposure completed without significant next-day worsening
Common Clinical Mistakes
Complete rest until pain disappears
Deep heel drops for irritable insertional tendinopathy
Progressing running and plyometrics together
Missing acute rupture
Clinical Pearls
Progressive tendon loading is first-line care.
Insertional and midportion presentations may need different starting ranges.
Continue learning
Connect assessment with management
Use the related PNA learning pathways to explore examination techniques and structured rehabilitation. A test result should always be interpreted alongside the history, full examination and clinical presentation.
Use these sources as a starting point for clinical learning. A reference being listed here does not, by itself, establish that every recommendation on this page is strongly supported. Check the original publication, study design, population and limitations before applying findings to an individual patient.
Educational resource only. Tests and treatment plans must be adapted to the individual patient, irritability, comorbidities, surgical restrictions and local scope-of-practice requirements.
