Tatyana’s AchillesBlog

No Duck Tape out there in California? Stay strong!

Do you own any heel wedges you can insert in the new boot? That change of ankle angle is one of MANY parts of ATR rehab that should be IMCREMENTAL! Your leg shouldn’t have to “care” whether or not you change brand of boot, it has to be guided through a program of re-education to be a good leg!!

My question is slightly off topic. There is lots of talk about incremental changes which I tend to agree with but I am using the Vacocast boot and at Week 4 the protocol I am following suggests moving from 30′ fixed to 15-30′ hinged. To me that seems like a fairly significant change at once. Can anyone share their experience or thoughts with this boot at this stage of recovery? Would you follow this protocol or make smaller, more frequent incremental changes?? I am following the VACOPED Accelerated Achilles Rehabilitation Programme that has been linked by some here (Suddsy). I am 3 weeks post surgery today and doing pretty good at WBAT. Not FWB as the protocol suggests. Thanks in advance.

Youngrfpc

You’re doing well and I hope with no surgery side effects.

The setting that you quote was in my Exeter protocol and isn’t as difficult as you might expect. Are you still using the big wedge sole that you should have started with? If I remember correctly, you still wear this for 2 weeks at 30º - 15º PF hinged. Exeter’s results are quoted in the Suddsy blog and you’ll be able to understand how successful that was/is. I was non-op and full rupture but rehab schedule was identical for surgical cases.

A summary of the protocol follows below and all I can say is that it worked for me and very many others. I had physiotherapy from week 3 and after week 16 beefed this up by visiting a sports physio. Strength recovered to normal and allowed me to continue my mountain walking.

Week 0 – 2 Full equinous i.e. 1st period of 2 weeks In light cast, toes pointed down. Mobilising NON-weight bearing, using crutches or frame. May use toes to balance.

Week 2 – 4 review into Vaco Achilles boot set static at 30º PF

i.e. this was 2nd period of 2 weeks. Into boot at 30º PF toes still pointed.

Able to weight bear, can wean off walking aid as comfortable, probably use outside. Wear boot at night. Can remove for very gentle ACTIVE exercises.

Week 4 – 6 review. Boot ROM 30º – 15º PF.
Can remove at night. Mobility improving. Increase number of sessions of exercises.

Week 6 – 8 review. ROM 30º PF – 0º neutral. Theraband exercises (some start earlier, I did at week 4, and static bike).

Week 8 ROM -30º to +10º. May start gentle swimming if safe to get in and out of pool without using rung ladders. No pushing off from sides.

Week 9 Shoes ok indoors with heel pads.

Week 10 review. Out of boot indoors and out. Use heel pads as comfortable 4 – 6 weeks (I did this for about 2 weeks). Can take boot outside too as a precaution if desired or ‘hazardous’. Should be able to drive within couple of days of being in shoes – IF YOU CAN DO AN EMERGENCY STOP!

Arrange for additional physio work in coming weeks if required.

If reviewing between weeks 10 – 16 Start to increase exercise tolerance, concentrating on non-impact, non-explosive activities, such as swimming, walking, static bike or bike on the flat (nothing strenuous).

Thanks Hillie. Couple questions: When it mentions weaning off walking aid (ie. crutches) is it ok to sort of hop around since I am not FWB or do you only lose the crutches once FWB?

Tatyana, I had a bledsoe boot too. 4 wedges, each 10 degrees. If you have the same thing, with only the last wedge left, you only dropped 10 degrees to neutral, which should be ok around week 7 or 8. Some people go to neutral a week earlier or later. The Vaco boot is different because it hinges to allow plantar flexion while limiting dorsal flexion. Most protocols have that boot going in 15 degree increments, starting at 30, then to 15, then to 0.

Also, I experienced the same thing around week 8 my bledsoe started to essentially fall apart, the Velcro stopped gripping and the straps started to fray and loose all their shape. I just took it as a sign that I needed to get out of it. Once you’re neutral you should be able to stand up ok without the boot.

Keep with it, the tightness is normal and will subside and you’ll get back to walking soon.

Hey Youngrfpc, its ok to do a little hop step when weaning off crutches and transitioning to FWB. But that won’t work well if you have to walk any further than couch to kitchen. By weaning it means use the crutches to approximate FWB as much as you can until you can FWB without them. That might take a few weeks. Don’t go cold turkey off the crutches immediately.

Thanks Roark, that is helpful. Hillie, I am still using the wedge sole. Did you switch to the flat sole at week 4 or when?

Youngrfpc

With the crutches you can apply as much or as little weight to the leg as you are comfortable with - so you need to increase to fwb which you can probably do about now.

Try without the crutches for short distances indoors and try for more each day. First time you go out or on uneven ground you might want to have the crutches close to hand.

You also need to be even left to right by wearing a thicker soled shoe on the good side or add an even-up (also by Vaco). Not doing something like this can aggravate your good joints and your hips.

We’re hogging Tatyana’s blog - start one yourself with timeline etc?

I think that I must have moved to the flat sole at week 6 - if you have the little handbook there is information there - or even call the Vaco people in Devizes if still unsure (or your physio if knowledgeable enough as many are).

I assume you are in the Vacocast - I tried to switch to the smaller, wedge sole when I went to 10′, but without success. According to the Vaco folks, you should not make the switch until you are at 5′. I went straight from 10′ to 0′, and made the switch to the smaller sole at that time.

Thanks Sporti, Norm, and Roark! It’s my third day of torture and I am beginning to feel a little better. Probably, AT is getting used to the stretch. I noticed that I walk much easier and with less pain if I am without the boot, so I do it more and more!

You’re both in good hands with this advice!
I think a 15° jump in ankle angle, with or w/o ROM-boot hingeing, may be a stretch for many patients. Making the switch at bedtime and sleeping on (in) it should help, but splitting the jump into smaller bites should help too. The jumps aren’t for the benefit of the AT, they’re for the convenience of the people writing the protocols.