Posted by: chocolata | 12 March, 2010

Hinging boot vs. Non-hinging boot

Norm has given me lots of useful information about both hinging (e.g. the MC Walker) and non-hinging boots (e.g. Aircast) for ATR treatment. (You can see the post at http://AchillesBlog.com/chocolata/2010/03/02/3-weeks-after-my-atr/#comments.) Especially after reading the following part, I came to think that the hinged one was more suitable for me.

Norm> The hinging just makes your gait a little more natural and realistic,
Norm> especially as your calf strength builds up. (I’m still working on that,
Norm> though in shoes this time. 8 yrs ago, I did it all in the hinged boot,
Norm> ’til I could “push off” normally again.)

However, I’ve found out a boot I will be given from my NHS clinic is Aircast and have been wondering how unnatural/unrealistic/uncomfortable it can be to walk in the non-hinged boot as my calf strength builds up.

It is unfortunate the clinic uses only the non-hinging boot and it was too much to ask to extend their tight budget to get me a hinged one. Once I get the Aircast boot in 2 weeks time, I will be PWB. I’m not sure how long it will take until my calf builds up enough muscles to “push off normally”, but I guess 1-2 moths may be necessary in my case because my bad foot will be immobilized in the cast a little over 6 weeks.

I will be teaching a few classes a day Mondays through Fridays at a university and can sit down from time to time while teaching. My working environment is relatively safe, but commuting requires me 30-minutes walk in total at each end and 1-hour train ride with one change in the rush hour. If walking in the hinged boot is MUCH easier as my calf strength builds up, I wouldn’t mind to invest in one even if I won’t use it for a long time. I want to make my transition from the boot to 2 shoes safer and less scary.

Could you share your boot experience with me? Comments from both those who have used both types and those have used only one are appreciated. ;-)

Responses

Chocolata, there’s absolutely no functional difference for several weeks, because you wouldn’t let a hinged boot “hinge” until maybe 7 or 8 weeks after you were first immobilized. So you’ve got some time to think about it.

The AirCast is a popular boot. It’s very large, so it’s hard to get pants over it, and it has hard bumps on its surface that can be uncomfortable for your other leg when you sleep. The inflatable bladders inside — the “Air” part — usually make it pretty comfortable.

It only has 3 (huge!) Velcro straps, fewer than most boots. That makes it quicker to put on and off than most. But some people find that the straps don’t hold their ankle and heel down into the boot as well as the 5 or 6 straps on some other boots. If your foot slides up and down a lot, it could reduce the protection your tendon gets, and some people get skin abrasions from it.

I didn’t have any of those problems myself, but others have mentioned them here and elsewhere online. (I think one of the rave online reviews for the VacoPed = VacoCast complained about the AirCast.)

The AirCast is all semi-rigid plastic, and has an extra plastic “tongue” — like an L-shaped splint — that sits in front, just inside the straps. I don’t think any of the other boots has that piece. And even with it, it flexes a bit, especially if the straps aren’t very tight.

There’s no built-in adjustment for ankle angle — the boot’s always at 90 degrees — so those adjustments are made with heel wedges under the insole, which is a flat slab of foam rubber.

Anyway, all the boots are very similar at first — like a cast that you can adjust for comfort and remove at appropriate times. I just like the ones that hinge because they can bridge the chasm between a totally immobilized ankle and one that’s “free as a bird” in a normal shoe. But the vast majority of booted ATR patients, post-op and non-surgical, get put into fixed boots like the AirCast and end up doing OK. (The UWO study I’m following was co-sponsored by the AirCast company, and every patient was put in an AirCast, and went straight from it to 2-shoes. And the results were excellent.)

Even with a hinged boot, I found myself going back and forth between the boot and the shoe. After I started wearing 2 shoes in the house, I’d still put on the boot for several weeks, when I was going out, or doing scary things like bicycling. With an AirCast and your schedule, you’ll probably do the same thing — maybe wearing the boot for your long commute, then teaching in shoes. At least for a week or two.

Norm - I see why you’ve got the AirCast boot!
I have 6 days to try out the AirCast boot before leaving the UK. If I want the MC Walker, I should get one while I’m in the UK because it’s not sold in Japan.
Thanks you so much for the input and useful comments!

The MC Walker is a good boot, in my experience. If I were choosing today, I’d likely go with the good-looking VacoPed (called VacoCast in North America).

It’s no more expensive than the MC Walker, and it seems very spiffy — e.g. the shell is completely waterproof, so it can be used in a swimming pool(!). One of their videos shows a guy swimming in the boot, then sitting at the side of the pool, taking the boot off, wringing out the liner, reassembling the boot and (off-camera, but presumably) toweling off his leg and putting the boot back on, and walking away! The MC Walker might survive that, but it’s not recommended in the manual, for sure!

I’ve never seen a Vacoped up close, but it sounds well-designed and very high-tech, like a cross between a ski boot and The Terminator! The vacuum fit system would probably produce a good fit to your leg — and if it isn’t great, you probably don’t have to use the vacuum pump. The MC Walker just has a thick wrap-around-and-Velcro liner, then a bunch of Velcro straps, to adjust the fit. I found it comfy, but I think I’m “easy”!

Actually, I ALMOST escaped from the AirCast! When I presented to my fancy Ortho surgeon, and he talked me out of the surgery, we walked into their own equipment shop along with a technical assistant type. I had actually brought along my Donjoy MC Walker boot!

The surgeon thought it would be better to start with a new boot, and the same one that was used in the study. They were selling the AirCast for $150, which didn’t seem like a big deal if it was going to cure my AT, so I bought it.

Even in hindsight, it might not have been worth alienating my Doc over the $150, or the differences between the two boots (=~0 in the early weeks). When the time came that I wanted to be in a hinged boot, I just switched boots (over his mild objections).

Dear Chocolata

I’m 7 weeks post-op, was in fiberglass cast for 4.5 weeks, PWB at 12 days, FWB at 4 weeks, by putting the cast in a Bledsoe Boot.

When put into the Aircast Boot at 4.5 weeks, found walking very difficult and could not keep heel locked down, which caused a lot of irritation at the incision site. Also the shape of the bottom did not allow me to rock forward in the normal walking stride. I did not want to injure another body part - knees or hips - trying to walk in the Aircast.

It was either go back to the Bledsoe Boot, or go 2 shoes. I chose 2 shoes and found the transition easy. PT says my range of motion is close to normal, and being 2 shoes will complete the ROM work. (Knee now touches wall with toes 1 inch out).

If they put you into the Aircast, they will probably give you some heel wedges. Try to wean yourself off those wedges ASAP, but don’t work through any pain. The objective is to increase ROM safely.

I try to walk about 3-4 miles a day. I believe that loosens up my tendon, and builds strength faster than the conservative PT protocols. I am very careful not to stretch the AT. In fact, most of the accidental stretches happened when I was in the boot, when off-balance or in a slip. Many re-ruptures occur in a boot at 6 or so weeks, when the leg is weakest, ROM the smallest, and folks lose their balance.

Norm - I checked out VacoCast’s web site again and watched the videos you mentioned this time. I’m not interested in dancing in it, but swimming in the boot in a pool sounds so nice! I’ve emailed an inquiry to the representative in the USA, since the UK one hasn’t replied to my inquiry yet. The UK one doesn’t show the products on their home page and a chance to get information/product from them seems not high. :(
The price isn’t shown on the home page, but someone who bought it wrote that the latest model costs about 370 dollars ! Phew!!

Hi Lou,
Thanks a lot for your comments! I didn’t know re-ruptures could occur in a boot so often. I thought the boot could provide fairy good protection like the cast.

I’m glad to hear you did well in your transition into 2 shoes. The rush hour commuting in Tokyo is tough even for healthy people and it’s important for me to protect my AT in a boot. I also need to walk a lot in a boot from 10 weeks post ATR (I’m on non-surgical route), and I have been curious about what sorts of difference different types of boots can bring about to my walking. So it’s great I can get information from others about their boot experiences here. ;-)

I am also thinking about purchasing a boot when I finally get out of the plaster cast.

I am on conservative protocol (UK) and when the cast comes off in 3 weeks have been told to extend the heel on my shoes 5-8mm and will be in 2 shoes from then on.

This worries me, one slip or false move and I could re-rupture. If I could go from cast to a boot it would hopefully provide some protection, but also allow me to start pwb with a bit of confidence. (total of 8 weeks in plaster)

What is considered the average length of time in a boot?
Do you wear it all the time or just when you go outdoors?

I think I will have a chat with the Ortho at my next appointment.

Sydw

Dear Chocolata

You absolutely need to be in a boot when walking/commuting. I suggest you try walking in it to make sure you are comfortable before you leave the office. My Aircast Boot’s plastic shell rubbed me above its liner, and cut my leg. I took a hair dryer and softened the shell and flared it out to keep it away from my skin.

And make sure the heel stays in place and does not lift. That irritation of the incision was the most pain I experienced since the actual rupture. Since you will be walking a lot, you need to be comfortable.

In the excitement of finally losing the cast, I did not pay attention to these things. But you may be in the boot for 6 or more weeks.

To Sydw

I only used the boot outside and at work.

I think your doc feels your tendon is strong enough to work on ROM, which is what shoes will provide.

Yes, boots do provide some protection, but are not as good as a cast.

Hi Sydw,
I’m also under the NHS treatment in the UK and your treatment protocol sounds very similar to mine. As you said, it’s so scary to go into 2 shoes right after a cast. Some may make good recovery under such protocol without re-rupture, but I thought I wanted to do anything I could reduce re-rupture risk in my transition into 2 shoes.

If I had not been able to persuade a consultant to give me a boot last week (4 weeks 2 days after ATR), I would have tried to get consent from him to use a boot which I would purchase on my own expense. The cast technician knew its advantages over the cast and so did the consultant, but it took some time for the consultant to make his decision because of their tight budget.

It’s your important foot and don’t feel bad about asking your ortho to make a change to your treatment protocol. Some people may not worry about re-rupture when they switch into 2 shoes, some other do worry about it. If you are the latter type like me, it’s better to get a boot. By doing so, our worries can decrease and it has a positive effect on our mind as well as our AT healing!

I was told it’d take 1 week to order a boot. If you don’t want to be put in another cast at the next appointment (6 weeks after ATR?), you can bring a boot with you in the original package. If I were you, I would call the clinic to check what kind of boot they usually use. Bringing one familiar to them might increase a chance to persuade your ortho to use the boot.

Good luck with your next appointment, and keep us informed!

Lou - I’m sorry you cut your leg while using the AirCast boot. It has only 3 Velcros and I have heard they don’t hold an ankle tightly enough, which seems a cause of the problem you mentioned. I have to be careful with this problem, since I will be walking a lot in the AirCast boot, if I don’t get a hinged boot by myself. I will also remember that boots are not as good as casts in terms of protection. Thanks a lot for sharing your experiences with me!

I think a properly fitted boot should be just as protective as a cast — but only when you’re in it, of course. Losing your balance in a “walking cast” while FWB is also risky for an AT. Not because it isn’t supportive, but because our natural reaction when falling is to react strongly to catch ourselves — and that often includes telling our calf muscle to pull hard on our AT.

The liner on my Aircast extended up past the top of the boot, and way past the top of the L-shaped “tongue”, which bears most of the big force when you walk. They make different size boots and (removable) liners, and it’s conceivable that yours was messed up, Lou. I also didn’t notice much difference in the rounded shape of the bottom of the sole — though the MC Walker’s is smooth rubber, and the AirCast’s has big non-skid ridges.

Sydw, many protocols call for FWB in a boot from fairly early on (mine said from 4 weeks, FWB “as tolerated”) and getting out of the boot around 4 weeks thereafter (mine said at 8 weeks). I think all 3 of you are following slower protocols than “mine”, which was taken from the large U.W.O. study I linked and discussed on my blog.

For my first ATR, 8 yrs ago, I waited around 9 weeks before getting into a (hinged) boot, and I spent about 8 weeks in it (to 17 weeks), until I could walk normally in bare feet (including the “push off” at the end of each stride). Unfortunately, my physio told me THAT DAY to do as many 1-legged heel raises as I could, and that hurt my AT (at the heel attachment point) enough that I couldn’t walk properly for another month. I spent that month back in the hinged boot.

Adjusting a slow start to a faster protocol is not simple, because some progress depends primarily on the calendar, and some is based on earlier motion and exercise, building on prior steps.

Lou recommends being aggressive at removing the heel lifts. I’d be even more aggressive at (a) getting into physio and gentle exercises and (b) getting toward FWB, as fast as your foot can tolerate the pressure, without pain.

All other things equal, it probably makes sense to linger longer in a boot if it can hinge (toe down) than if it’s fixed. In either case, there’s an obvious tradeoff between the safety of the boot (vs. the risks of shoes), vs. the extra exercise and ROM and “training” (balance/proprioception, etc.) that comes in shoes.

Surgeons and protocols present fixed deadlines for the key transitions, but I think it’s perfectly reasonable to inject some patient judgment into the mix during the transition from boot to shoes. Like wearing the boot outside the house but not inside, etc., etc.

The good news is that neither of you two (chocolata and Sydw) have a surgical incision, so there’s no chance of a boot irritating that! :-P

I agree with Norm about the need for PT, if you don’t go into shoes/barefoot ASAP. The Aircast boot limits ROM and makes you walk funny. I wound up throwing the bad foot forward okay, but the good foot could only go forward to the point of heel of good foot to toe of bad foot. So it took me a lot longer to get anywhere in the boot.

You lose much of the stride in the good foot, unless you point the bad foot toe out, which a lot of people do, but this creates other issues for the PT to resolve..

I wound up pivoting on the heel, and then pivoting on the front/toe area to keep both feet parallel. It is during that pivoting that I was vulnerable to spinouts and unexpected stretches, especially if your attention is not totally on that foot and ground on which you are walking..

Regarding walking/commuting: I found people much more courteous if I was using my crutch. You’ll be using it while PWB. I suggest a crutch or cane even during FWB to get people to give you more room, alert others to your ankle situation, and to use to catch yourself during those unexpected losses of balance. People don’t seem to notice when you have just the boot on, but the crutch/cane invokes courtesy. On the other hand, it also signals vulnerability, if you are walking/commuting. But a cane can be an effective self-defense weapon if necessary.

One last suggestion: If you are concerned about others behind you hitting your tendon when you get to 2 shoes, such as with a shopping cart, on the train, etc. consider getting/making a tendon shield (strap on a shin guard), or at least wrapping with a bandage.

Hi Chocolata, Lou & Norm

Thanks for your replies.

My other thought when contemplating the boot, was to buy some new shoes, but of the ankle boot/shoe variety. I am keen to get the next stage in the healing process on the move. (PWB, FWB, ROM & PT)

Obviously they would have to be easy to put on & comfortable, as I would be wearing them most of the day.

Chocolata, did you look into buying new shoes of the ankle variety?

Sydw

If you want shoes that are easy to put on and comfortable, get Crocs. I did as soon as I was FWB and they have been truly great. I can wear all my shoes now but still wear the Crocs at home a lot. They are also really handy for wearing at a pool when you swim again.

Every time I received responses here, I felt I was so lucky to have found the site Dennis had created for us, to which lots of people have added so much useful information to share with others. I want to thank you all. :-)

When I started thinking about asking for a boot (ankle/foot brace), which required me to persuade the clinic to spend more money on my treatment, I also thought about having private PT as soon as possible. Under the NHS treatment here, it can take a long time to be allocated with physio sessions and I am going to arrange a private session for a date just after I’m put in a boot. A consultant might tell me that it’s too early to have PT, but I don’t think so. Just gentle massage around my ankle won’t do any harm to my AT.
Lou - thanks for your nudge with this. ;-)

Norm- What you wrote about difficulty in adjusting a slow start to a faster treatment protocol is what I should keep in my mind. Before I will be put in a boot, I will be spending 6 weeks being immobilized in a series of casts (no weight bearing) and I will be required to go slowly in my physio sessions. I should listen to my body and heart!

Sydw - I see! I thought you were talking about the ankle/foot brace.
On my next visit to the clinic (in the 7 weeks of my treatment), they will fit me in moon boot (AirCast) which they have ordered for me. It will be just fine, but I may buy a hinged boot by myself for my later stage of transition from the boot to 2 shoes. The MC Walker and VacoCast are on my list! Girls love shoes, don’t they?

To answer your another question, yes, I bought a pair Ecco shoes 1 week ago! I didn’t have any good walking shoes with me in the UK and had to buy a pair before my last visit to the clinic because I was told to bring one for my bad foot so that they could put some wedges onto the heal. I’m supposed to put it on when I reach the “2 shoes” stage. You can see my new shoes in my past post here. ;-)

Hi GerryR,
I haven’t put on Crocs before, but they look comfortable! I may want to buy a pair for my 12-hour flight. In my country (Japan) they take off shoes at the entrance of the house/flats and there is a definite line between outside and inside. At home I usually put on comfy slippers, but I don’t think I want to put on slippers until I can walk normally. Crocs looks easy to take on/off and its back strap looks good to hold my ankle. More shoes shopping! ;-)

Lou, I agree with everything you posted, except that our experiences in the AirCast boot were quite different. I do prefer the feel of clomping around in a hinge-ing boot (not the AirCast), but I had no trouble “rolling” over the rounded sole of the AirCast and getting a good long stride with my other leg. We must be built differently, or we walk differently, or something.

On the other hand, I have knees that have always been a bit too flexible in the hyper-extension direction — as a kid I’d sometimes stand with my knees locked a bit behind my hips and ankles! And every once in a while, I’d find my knee going backwards while I was clomping around aggressively in the boot. (Or maybe ieven n the hinged boot? I didn’t really pay attention to which boot I was wearing when that happened, and I haven’t worn any boot for several weeks now.)

But I never experienced any “spinning out” etc., and I was sometimes clomping on slippery surfaces (like snow or ice), too — and with a slippery plastic bag over my boot to keep it clean!!

Crocs (and even cheaper imitation crocs) are amazingly cushy and comfy. When I was first gimp-walking around the house out of the boots, my biggest problem wasn’t the fear of re-injury, it was the tenderness of my foot, especially at the heel. Walking barefoot on a wooden or vinyl-covered floor was Very Uncomfortable. But with Crocs, it felt as if the whole house had been covered in about an inch of cushy foam rubber!!

Chocolata, I assume that your Physio will be almost as nervous as you are, when you start PT, so you should be able to proceed at an appropriate pace. Don’t be shy about saying NO to any PT suggestions that don’t seem safe enough. 8 years ago, after many Physio sessions, I was pushed into one aggressive exercise too soon by my Physio, even though I actually DID know better, and it set me back a whole month.

On one of the external Achilles blogs that Dennis links to (I think it’s Simon Barratt’s ATR blog), the host queried all the bloggers who had re-ruptured their AT, and posted the summary results on how they did it. Around three or four (out of maybe a dozen) reported “physio”!! (Yikes!!)

I still remember how nervous I was the first time my present Physio told me to follow him — walking barefoot — across the clinic to another station, where the Laser was set up! It was almost the first time my foot had been outside my boot! I ended up putting my arm over his shoulder, just to make sure I didn’t fall! I’d rather be thought a wimp (or even BE one!) than re-tear this thing. . .

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