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Using an orthopaedic boot for Achilles tendinopathy or pain

Sometimes, people with Achilles pain or Achilles tendinopathy are prescribed orthopaedic boots – those big, chunky boots. However, in most cases this is not necessary. In this article, I explain why they may be prescribed to you, why it’s bad for you if you wear one for too long, and how to deal with it if you have been wearing a boot. You’ll also see that there is a better option for recovering from Achilles pain or Achilles tendinopathy than sticking your foot into one of these boots.


I've also discussed it in this video:



Orthopaedic boots: the good and the bad


Why would somebody prescribe an Achilles boot for you? This happens most often when someone has a really, really painful Achilles tendon. A doctor would prescribe the boot to see whether that can calm the tendon down. As soon as you immobilize the foot in the boot, it means that you don't use it, and that does decrease the pain because we know that rest is a good way of calming pain down in an Achilles tendon.


However, the Achilles pain was most probably caused in the first place because the tendon was not strong enough. It needs to be strengthened up to be able to cope with the loads from walking and running and all the everyday activities you want to be doing. If you stick it in that boot for too long, the pain might calm down, but you actually start to weaken the tendon even further due to its inactivity and you're losing its remaining strength. That is why wearing an orthopaedic boot to calm the pain down should only ever be used as a short-term solution – never more than two weeks.


Remember that the above applies only to Achilles tendinopathy and Achilles pain. If you’ve torn your Achilles tendon, then a boot is the correct way to treat it initially – you can read more about it in this article.


The double whammy of a boot plus steroids


I’ve recently seen a worrying trend that some of my patients, before they came to see me, had been prescribed not only to wear a boot for as long as four weeks, but have also been told to take corticosteroid tablets.


Steroids are very good at reducing pain, but we also know that they're very good at damaging tendons, because they stop the tendon from producing enough collagen fibres to actually heal itself. We've made a video about corticosteroids and why it's not good to take these when you have an Achilles injury. The combination of wearing a boot for four weeks, which degrades your Achilles tendon because you're not using it, plus steroids, which make the tendon produce fewer collagen fibres, means that your tendon is in quite a bad shape when it comes out of the boot eventually.


What then often happens, is that the patient gets back to the doctor after four or six weeks and they're not really any better because they haven't done anything to make it better, they've just offloaded it the whole time. And then the doctor says, "Oh, I think you probably need surgery!" Now that is ridiculous, because the patient has not done anything yet to strengthen the tendon.


So, you should not go directly from wearing a boot and steroids to surgery. You need to test first whether you can somehow progress to walking without pain – even if you have to wear a shoe with a heel or a heel lift inside your shoe (see below) – and whether you can start with some gentle strength training.



Take it easy after the boot


Another problem of using the boot is that people get prescribed exercises directly afterwards that are just too hard for their Achilles tendon to cope with. They are often told to do single leg heel raises or heel raises over the side of a step immediately, and the tendon is just not ready for that because it has been in a boot the whole time. You have to start with gentle double leg heel raises, probably in shoes with a heel on them to start with, to get the strength back into your tendon gradually.


How you can give the boot the boot


We never prescribe boots to our patients because you do not need to wear a boot to get the pain in your Achilles tendon to calm down. All you need is to understand how to effectively take the strain off the tendon and decrease those activities that really irritate it.


A really good way of doing this is to wear a shoe with a slightly raised heel, for example trainers, which typically have a heel-to-toe drop of 10 to 12 degrees. You can go further and put an insole with a raised heel in your shoe. By elevating the heel in this way, you take the strain off your Achilles tendon and allow it to recover.


Second, reduce your activities. It may be that you're currently just walking more than your Achilles tendon can handle, or that you’re trying to run with a painful Achilles, so please stop doing that. This doesn’t mean you should not be doing any activities. Your tendon needs some gentle movement for good blood circulation and to maintain its strength until you are ready for exercises to take it back to its normal strength.


To summarise: If you've been prescribed an orthopaedic boot, make sure you do not wear it for longer than two weeks. And when you come out of it, ease into activity. Start wearing a shoe with a heel on, get the tendon used to gentle movement again, and make sure you get good rehab advice which should include a carefully graded strength training programme that does not cause an increase in hour pain.


Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.

Best wishes

Maryke


Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram.


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