What degrees to to fix or hinge for ROM vaco? …And at how many weeks?

My hospital and PT shrug at the vacocast. They are not familiar with it. To me, it’s my best friend.

They know wedges. They know you go from 4 wedges to 0 (25 deg to 0 fixed in Vaco).

I have been fixed at 0 degrees in vaco since week 5 post surgery. I am almost at week 7. The doc plan is to stay in cast till week 12.

It seems logical to me that if vaco allows for some controlled plantar/dorsi ROM then that would be ideal transition to 2 shoes. That is before trying to have brain and sleepy propioreceptors fight between fear and rehab in two shoes.

My docs don’t know vaco so I stay fixed at 0 till the end. I want to know what Kobe’s docs did? If you don’t know that, please let me know any thoughts. I don’t want to be experimenting in the dark.

11 Responses to “Best use of Vaco ROM (Range of Motion)?”

  1. normofthenorth Says:

    First, there have been hinged/ROM orthotic boots available for a long time, long before the Vaco came along. No excuses for your Docs not being familiar with the concept.

    I THINK that 2 standard (1-cm) heel wedges takes you to around 20 degrees, roughly 10 degrees per wedge. I haven’t done the math (trig) for a long time, but for sure lots of OSs and clinics use that equivalency. Mind you, the bigger (longer) your feet, the smaller angle you get from the same wedges, and vice versa, so there is no real equivalency except for constant-size (like average-sized) feet.

    I’ve been recommending bit.ly/UWOProtocol for a long time, AND recommending an amendment that slips in a hinged boot (hinged from 0=neutral to “infinity”, unlimited plantarflex) around 7 weeks in. But we were discussing a study and protocol on Suddsy’s site that got great results (including near-zero rerupture rate) with earlier FWB and earlier ROM/hinge-ing. Check ‘em out.

  2. andrewc Says:

    Hi Bionic
    I went into my vaco at a fixed 15 degrees at 2 weeks with fwb. At 4 weeks We set the boot at a fixed position of 0 degrees and my doc told me to set it between 0 and 10 degrees when I got home adding 5 degrees a week. By week 7 I was at 0 and 30 degrees which I stayed at until week 9. The only change was that I moved to the flatter sole at week 8.

  3. blue1993 Says:

    Hi Bionic. I switched to the Vaco from a fixed boot when I hit 6 weeks post op.
    I am now approaching 8 and have set mine at 5^ dorsa flex and 10 plantar. I aim to add 5^ after another week. When I’m sat for a period of time I lock it at neutral.
    I find that the small amount of pivot I get helps my natural stride - small steps at the moment
    I agree in your thoughts on transition into 2-shoes. My advice would be don’t over do it. You’ll know if you set too much range, believe me!

  4. blue1993 Says:

    See Hillie’s comment on my post - http://achillesblog.com/blue1993/2013/07/19/a-generic-rehab-protocol-using-a-vaco-cast-ped/

  5. hillie Says:

    I don’t get this! In your July archive, your posts and the ensuing replies gave you some great info on the way ahead.

    You and your doctors can also speak to others - try talking to good physio’s too as they are usually the ones who will really get you back to fitness.

  6. bionic Says:

    Thanks Hillie,

    I don’t get what you don’t get. And I suspect you don’t get that. ; )

    You’re right there is great info on the way ahead in July posts. However, unless I’m missing it, there isn’t any substantial address to my specific query here about taking advantage of ROM ranges with hinged boots.

    My doctor access has been almost non-existent apart from one receptive telephone interaction to get me into PT. I was pretty excited about PT. I have worked with mostly excellent PTs over the years, and for the trickiest recovery I end up with a disinterested PT.

    To walk or run would be nice, but that’s not my goal. Pre-ATR I had much fun blazing past and through those half my age, like so many others on this blog. I don’t feel quite finished with that yet.

  7. normofthenorth Says:

    Bionic, I think Hillie is talking about the detailed Vaco protocols — including the specific timing of particular hinged/ROM angles — that she and others have recently posted, on your pages and also on Suddsy’s. One of those protocols is accompanied by compiled results, which seem significantly better than UWO’s, which (along with the 2007 NZ study) formed the Gold Standard for modern rehab protocols with excellent results.

    Don’t those protocols (and especially the one with the compiled excellent results) answer your questions?

    Whenever I have a choice of following the best results in a large published study, or imitating one or two pals or bloggers — or following one overworked Doctor’s default protocol — I always go with the evidence, and that’s what I advise you to do too.

    Lots of people still go with the Doctor, regardless of indications that he or she isn’t keeping up with the literature, and even regardless of evidence that the Doc is bored or distracted or uncaring. But imitating/following one or two pals or bloggers, even if they did well, seems scary.

  8. hillie Says:

    Thanks for answering this, Norm, while I was tucked up in bed and fast asleep!

    Bionic, you have what may be the most expensive Achilles boot out there but this is pointless with the protocol that you are following, where a $50 dollar version would be adequate. Of course you are frustrated.

    Unless you’ve had some complications necessitating wearing your boot up to week 12, you’re also going to be way behind the new standard. How patient are you?

    Do you have the key to adjust your Vaco boot? I know that some doctors and physio’s keep hold of them, not trusting their patients who may be a little more adventurous. Of course I wouldn’t suggest that you create a little ROM of your own…

    The information that I referred to, I had originally posted on Suddsy’s excellent blog. Suddsy was a surgical case, me a non-op. Almost identical protocols though, and both with ‘that’ boot.

    Take a copy of the Exeter and UWO data to the hospital and pin it up on the notice board in the ortho or fracture clinic. Crazy idea eh?

  9. bionic Says:

    Thx all

    hillie I see your info on sudsys blog… and now on blue’s. Very detailed and helpful guidance and totally agree with you re ‘posting protovol up on ortho notice board’. I may navigate with docs re my care. . but after I’m done I’m going to do what i can to help then overhaul hospital achilles care.

    I see the abstract of the vaco study says excellent results. I also see only 7% or so are open atr surgeries in that study. I would be very interested to know how they measure results. I couldn’t find the full study in databases I can access.

    Many of these things are based on the economics of work comp, insurance and productivity. In other words measurement is how soon one is able to walk and function. That may or may not correlate to how fast and hard some one can play a sport and pivot a year down the road. And is there an inverse correlation?

    Also remain interested in what a wider range of people are doing(presumably with doc direction) so I have some idea of how much to push my doc without scaring them off. Based on the helpful input re earlier rehab here, I talked to doc to get my rehab going at 6 weeks instead of 12.

  10. hillie Says:


    I (and Suddsy) posted the info on your achillesblog on 4th July.

    Not sure why you call it the vaco study after reading the abstract. Why not the Exeter study, or even the Royal Devon & Exeter study? The information in there is from the hospital’s own results - you wanted to know how the report results were measured. Simples - real people (patients, including me), real data recorded, results published.

    Get your doctors to talk to (or email) Exeter’s (that’s in the UK). Great orthopaedic centre.


  11. superjewgrl Says:

    Bionic I know you’ve tried the aircast and hate it as much as I do. Tell me what makes the Vaco boot superior? I am in a cast for 4 weeks but I go back in 2 for follow up. Maybe I can come up with a formidable case to switch before it’s time for me to transition to the boot.

    Glad to see your doing well.

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