Scar Tissue

Well, after the re-rupture scare, I find myself full of questions and unsure how to proceed. It was such a relief that I completely forgot to drill my ortho with questions. When I go to physio tomorrow I will be asking plenty but was hoping some people here might have some good insight.

1. I do have some pain still around the sides of the AT, should that be of concern?

2. Should I try walking in 2 shoes again, or is there a level of healing that needs to happen first?

3. Am I theoretically at a higher risk to rerupture because I did tear scar tissue.

4. Is tearing scar tissue typically a major setback or a couple days/weeks?

Thanks in advance for any insight! I feel like I am flying blind right now and I’m not really sure if I am putting too much stress on it or not enough.


#1 andrew1971 on 07.25.12 at 3:02 PM

Those look like solid questions to ask - I’d love to read about the answers.

I am sure that your PT review will reveal a lot.

#2 kimjax on 07.25.12 at 3:24 PM

I thought tearing scar tissue was a good thing! Scar tissue is holding up my DF right now.

#3 andrew1971 on 07.25.12 at 3:44 PM

I am only assuming that Eva’s “scar tissue” tearing was brought on by some unexpected trauma, so the result is that the impact produced a tearing of scar tissue that was not broken down and/or ready to be discarded just yet.

The result is that this particular tear of scar tissues has left eva in pain and with more questions than answers - certainly takes the wind out of my sails reading it.

#4 eva10 on 07.25.12 at 4:00 PM

It definitely caused some trauma. When I saw the ortho yesterday I had noted that I couldn’t even think about trying to stand without the boot.

I felt a little better today and opted to take a few steps in my runners. It was definitely uncomfortable and resembled nothing like the act of walking. Before Saturday it really was just the scar tissue holding me back, now there is definitely some pain and discomfort moving by foot around.

I’m hoping this too shall pass, and the sooner the better!

#5 andrew1971 on 07.25.12 at 4:15 PM

Eva - can u describe how it happened (was it a trip, as fall etc??)?

#6 eva10 on 07.25.12 at 4:20 PM

I think I may have walked over a small gopher hole, but I’m not entirely sure. I lost footing and could feel a tear and immediately assumed I had reruptured it, but I recall the sensation being on the sides of my ankle and not directly behind.

#7 andrew1971 on 07.25.12 at 4:33 PM

Yep, it was an unexpected trip and like you say u felt the ripping on the sides.

I am sure the result of the discussions tomorrow regarding the AT itself will be positive.

Thinking out loud - it could be that, as well as scar tissue you’ve managed a light sprain of the ankle too - make sure they have a good look for all types of injury beyond the ATR and/or scar tissue.

Regardless though, if it were me I would be using the boot when not inside the house at least until the ankle stopped hurting - but I have a hinged boot (rather than a fixed aircast boot) and they’re designed for the purpose of allowing ankle movement in a controlled and protected manor :)

#8 eva10 on 07.25.12 at 4:45 PM

I hear you Andrew! Rest assured I have no plans on walking on grass anymore. I will definitely be using the boot more, but I really struggled with not having the wedge in there. It seemed easier on 2 shoes than to have it in the boot, but moving forward I will have to suck it up and just wear the boot when I am around any sort of hazard!
Are you still enjoying driving Andrew :)

#9 andrew1971 on 07.25.12 at 5:15 PM

Hey Eva, I think you are in an aircast boot right? Grab a $90 hinged rom walker (aka adjustable cam walker) for easier walking (u need a high sole shoe for the other foot though), learn how to adjust it and find a ‘range setting’ that suits you (or ask your doctor to assist) should make it easier for you to walk around protected in the wild outdoors than the aircast model :)

Me, I think I overdid it a bit on the weekend and I knew I needed to rest it a day or three so I’ve just been going about my business for 3 days.

Today though I took the missus to work today (5mile roundtrip) and it felt 100x better than Sundays driving….then I decided to keep my trainers on as I walked to the house (I should be putting the boot on) and that felt good too, so I also did the house stairs without the boot and that also felt good.

But it’s the near misses like this that re-enforce the delicate times the next 4 weeks are and I forced myself back into the boot.

I can go two shoes I know it, but I dont have the strength or the reflexes to prevent an injury if I trip or fall.

I intend to continue ‘out of boot’ moments around the house, but these will be controlled, and time limited and outside the house remains a boot only zone.

For now though - I am fingers crossed that results and discussions you have tomorrow make Thursday a good day for you :)

#10 normofthenorth on 07.25.12 at 8:26 PM

Like Andrew, I also favor a hinged boot for a smoother safer transition from boot to shoes. There’s ~0 evidence of benefit, but it seems & feels so logical… Protection against mishaps while you transcer more and more weight and force to the AT and calf. I could walk faster in the hinged boot than the fixed one, too, which I enjoyed.

OTOH, the UWO study produced excellent results (post-op and non-op) with the fixed AirCast…

#11 eva10 on 07.26.12 at 12:34 AM

Great to see you doing so well Andrew!!

It’s weird, I asked my ortho about a hinged boot before and he dismissed fairly quickly. I know this round I will be extremely cautious, but I’ll see how physio goes tomorrow. Andrew/Norm - are either of you using the vacocast?

#12 andrew1971 on 07.26.12 at 4:27 AM

In the UK, our national healthcare becomes more complicated by which county you live in and the selection of boot varies by county - I don’t know of any that offer the vacocast - it’s reserved for people with private medical cover I suspect.

Regarding the vacacast - I think at this stage of your healing, the ‘vacuum’ part of the model is surpurfluous to requirement - it’s the adjustable support hinge/brace part (which the achilles vaco boot has of course) thats most important…… again though, they offer the ‘even-up boot leveller’ on their site to allow more uniform walking…..the hinge boot for me ticks all the boxes at this stage (set-up correctly it protects the ankle from over extending whilst enabling free movement within your own limits) at a fraction of the cost.

#13 jimminyc on 07.26.12 at 7:43 AM

Andrew, interesting point there on the UK policy regarding boots. My local hospital (Poole) gives the Aircast boot (which I had) plus wedges, worked okay for me. However, my physio mentioned that they did trial the Vacocast boot for a while (Poole seem quite advanced on ATR protocols and trials) but stopped it at a late stage giving supply problems as the reason!

And you are right, it’s all part of the great British postcode NHS lottery! Some places don’t even offer to operate and make you take the non op approach, this may not be a bad thing, but then the protocol becomes very important, agressive seems better? I have even heard of hospitals not even having a protocol and it just being down to the surgeon you see or perhaps even the wind direction!!

#14 rogerg on 07.26.12 at 9:26 AM

Andrew, so right on UK policy, but I do know that Leicester and Edinburgh supply VACOboots. I have had further discussions with the people at Vacoped today, after initiallly thinking that it must be an easy sell for them, NOT SO ! Despite the obvious cost savings on regular plaster changing etc etc, many Orthopods will not even discuss the boot alternative apparently. My correct sized boot has been delivered today and I will be taking it in to my appointment on Monday, with the
Orthopods agreement; hopefully he will have a good look at it and change his views: too late to save my money however ! Still worried about an op after 4 weeks in plaster ? Orthopod still thinks the ‘big gap’ is too much to heal, without surgery ? Think that I might have to change to an auto car: any experiences post ATR in length of time to drive, either Auto or manual ?

Roger G.

#15 jimminyc on 07.26.12 at 10:02 AM

Roger, I went the operation route, right foot ATR, manual car, right hand drive, driving at 11 weeks post op. J

#16 eva10 on 07.26.12 at 12:23 PM

Definitely has to be scar tissue. I’m walking around in my boot without the wedged heel with absolutely no discomfort. Now onto physio to get me back on track!!

And now a giant sigh of relief!!!!!

#17 andrew1971 on 07.26.12 at 12:36 PM

Fantastic news Eva - I am soo pleased for you, onwards and upwards!!

I don’t things these past days wil of stunted your recovery either, that scar tissue was bound to let go at some point ;)

But, lets agree we will both keep the boot on hand for those ‘out of the house’ adventures that are frought with opportunities to trip,slip, fall etc……. again we’re all in this together and I have it in my mind that the cycle from 12-16weeks seems to be less dangerous (out the boot) in that respect but watch out if you’re doing a lot of ‘off-road’ walking in fields and alike :)

Again fantastic news, so happy for you :)

#18 eva10 on 07.26.12 at 2:30 PM

Agreed Andrew!!! Learned my lesson and learned it well!! :)

I think we’re all pretty pumped to kick off week 17 and see where we are all at. I can’t wait! :)

#19 ryanb on 07.26.12 at 3:31 PM

Sounds more and more like this was very similar to my incident. Hurt when it happened- caused some pain and swelling in the short term. But, after a few days, I realized that I actually had better flexibility and function: I think it *had* to happen to enable future progress. Great news!

As for the hinged boot- my personal opinion is that we need exactly the opposite. Something which allowed freedom in all axes (rolling the foot, “yaw”ing the foot, plantar flexion), side-to-side and fore-aft motion at the ankle joint… but restricted dorsi-flexion to protect the Achilles. A hinged boot restricts all the motions that we haven’t hurt; but doesn’t provide protection in the one direction that we ARE compromised. Seems like the worst of all worlds- promoting atrophy for all the non-injured ankle muscles, while not protecting the Achilles. I even kicked around designs for a boot which would do the opposite for a while ;-)

#20 hillie on 07.26.12 at 4:14 PM

RogerG is obviously right about the cost savings of a boot compared to fortnightly cast changes - but there is potentially another cost saving too.

At least with the more technical boots, Vaco etc., the hospitals are able to take them back, insert new linings, add new velcro straps, even soles if necessary.

Having had the benefit of one of these boots during my rehab, I know that this whole refurb would take under 5 minutes, so a minimal labour and parts cost, and peanuts compared to serial casting or paying full price every time.

An example of recycling and saving the taxpayer’s money, and giving us a better rehab solution.

#21 hillie on 07.26.12 at 4:33 PM


What make of boots are you talking about? After 2 weeks in a cast I was in a boot which started off fixed at -30º. It was adjusted fortnightly: -30º to -15º ROM; -30º to 0º ROM; -30º to +15º ROM (for 1 week). Then I was into 2 shoes. Dorsi flexion was very much protected and by the time we got +15º the tendon was becoming stronger in any case. The progressive increase in ROM gave controlled, safe increase in the AT’s flexibility.

From week 4 I took the boot off to do Theraband exercises, and after a week or two longer encouraged to walk barefoot on safe indoor surfaces, and even try careful heel lifts. I could self-massage the calf muscles, and minimal atrophy occurred anywhere in the leg .

Sorry Ryan, I must have misread your post, it seems so wrong, from my experience at least.

#22 ryanb on 07.26.12 at 5:47 PM

The engineer in me looks at the ankle joint as having 6 degrees of freedom. The Achilles tendon articulates the joint through 1 (well 1/2) of one of these; it plantar flexes the foot or resists dorsi-flexion. The other 5.5 degrees of freedom are not affected by this injury, except for collateral damage (an ankle sprain) which many suffer concurrently.
A freely hinged boot in general (all of them) constrains 5 of the 6 degrees of freedom. It restricts motion in all 3 linear axes:
1) It prevents your foot from moving fore and aft relative to your ankle bones
2) It prevents your foot from moving (sliding) side to side relative to your ankle
3) This one… not so much, but it holds your foot steady; keeping it from pulling away (up and down) from your ankle.

(your ankle is designed to be pretty stable in all 3 of those; but it does have *some* play, requiring strength and limited flexibility in each for proper function).

A hinged boot also restrains motion in 2 of the 3 rotational axes:
1) It prevents your foot from rolling sideways (inside edge to outside edge)
2) It prevents your foot from twisting side to side (toes in/out) relative to your shin bone.

An open hinged boot has one degree of freedom- the rotational axis upon which it is hinged. I’ll call it “pitch”. This is the same axis that the achilles uses to articulate the foot.

As we go through long periods of immobilization (to heal the Achilles) we suffer a lot of atrophy. The calf muscle - by necessity - needs to be immobilized and protected during the healing process. But, the other 5 degrees of freedom suffer severe atrophy as well.

Just seems to me, like there ought to be a better solution: one that immobilzes the “pitch” axis on your foot, but allows freedom in the other 5 directions/axes… to prevent needless wasting. I came up with some ideas. One used an air sprung, adjustable, mountain bike shock between your toes and shin which could provide variable levels of assistance to the Achilles/calf, while leaving the ankle free in all other directions (at least rotational ones); through the use of a few Heim joints.

That probably still makes no sense, but I’m tryin’ :-)

#23 andrew1971 on 07.26.12 at 6:22 PM

I think what you are looking for is a flexible coupling with an adjustable 6 degrees of movement etc etc etc… I’ve seen what you mean, it’s not available in an othosis yet though :) It’s got to be hydraulic or electric though - as air compresses and probably has too high a tolerance to be accurately counter active in supporting….. oh and it’s gotta cost less than $90 to be competitive to heath services ;)

Thinking about it deeper, I am not sure you can exercise so locally around an existing condition the calf is too complex a muscle group to achieve such a level of isolation.

But honestly they reality is if the achilles is suddenly and unexpectedly asked to do an impact contraction and produce an explosive force to counteract a trip/fall during the 0-12 week period there’s a higher statistical chance a re-rupture will occur.

What a hinged boot (or any other current design boot with adjustable RoM) allows you to WALK without the risk of sudden and unexpected yaw/roll/pitch etc… the boot protects you from accidents, and a hinged one in my untrained opinion allows more flexing of the achilles while you walk.

In terms of exercise - thats what physiotherapy is for, you regain muscle and strength in a controlled environment, without the boot exercising all those actions and reactions…. you don’t need a boot for that.

Sorry eva - the engineers have hijacked your blog :(

#24 kimjax on 07.26.12 at 6:30 PM

There is a better “engineered” solution, ryanb - scar tissue. :) Mine keeps me from fully flexing my AT right now in DF - almost like supports that slowly fall away as the AT/calf mechanism strengthens. All the other flexibility is maxed out now - but the scar tissue is still holding back full DF. You’d almost think it was designed to work that way…;)

I agree with you on the boot. It’s helpful during the early immobilization to get walking faster- but I think you do better “at some point” without it. And that’s individual to each injury. I agree that it would be good to have some motion in the other directions. I kept my boot loose enough that I could do isometrics against the sides with eversion and inversion.

#25 eva10 on 07.26.12 at 10:59 PM

Okay you engineers…..don’t worry about designing a boot! Build me something to prevent this from happening again :) thank you kindly!

#26 hillie on 07.27.12 at 9:08 AM

Ryan and Andrew

Perhaps we should meet up at the Annual Biomechanics Symposium in September at Bath Uni. I’m hoping to catch up with guys I worked with from the Bristol Robotics Laboratory and Bristol Uni. Interestingly, this year’s theme is “Early Intervention: Reducing costs of healthcare in the long term”.

Ryan, you’ve put up a good case for the better boots that exist currently, misunderstood (it appears) the need for complete calf immobilisation after 3 or 4 weeks, and ignored the self-help that you can provide with some simple exercises.

However, I love the irony that runs through your post, and the “thinking outside the box” (I hate that phrase…) that you show with your innovatory ideas. Great stuff!

#27 hillie on 07.27.12 at 9:21 AM

I could have worded that post a little better - I did not mean that you needed ‘complete calf immobilisation’ after 4 weeks. You certainly do not need it then. My apologies for the incorrect emphasis of my words.

#28 andrew1971 on 07.27.12 at 9:52 AM

Sorry Hillie, it’s interesting but not my field of expertise I work in factory automation, closest I get to robotics is a palletiser or a welding machine :)

Poor Eva, lets take our discussions elsewhere shall we :)

Happy healing Eva :)

#29 starshep on 07.27.12 at 6:23 PM

Ryanb, Andrew, Hillie

While you are working on those boots I’m gonna invent one of those tricorders you see on Star Trek that will heal an AT in just a few passes. I should have it ready by the 24th century.

#30 eva10 on 07.28.12 at 12:17 AM

Starshep, if you could expedite that process, a lot of us would appreciate it!! :)

#31 jenniferanderson on 07.28.12 at 12:25 AM

Yep! What Eva said.

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