Weeks 4-6: Progressive Recovery

You've made it through the initial shock and the treatment decision. Now you're in the phase where real progress becomes visible. Weeks 4-6 are about gradual progression: removing wedges, improving your walking, and starting to feel more like yourself again. But these weeks also require continued vigilance - your tendon is still healing and remains vulnerable.

Understanding Your Healing Tendon

What's Happening Inside Your Achilles (Proliferative Phase)

By weeks 4-6, your tendon has moved from the initial inflammatory phase into the proliferative phase of healing. Here's what's happening at the cellular level:

What this means for you:

• The tendon is getting stronger each day, but it's still fragile
• The new tissue is like a patch - functional but not yet as strong as the original
• Proper positioning (maintaining equinus) is still crucial
• The healing tissue is responsive to how you use it - controlled stress helps it organise

Why These Weeks Are Critical for Tendon Length

How elongation happens:

• Can occur at surgery (if positioned incorrectly)
• During boot immobilization (if foot position isn't maintained)
• After boot removal when walking (if tendon isn't strong enough)
• Throughout the first 12 months - it's a "plastic" process that can go either way

Prevention strategies:

• Keep your boot on at all times (24/7)
• Follow the wedge removal schedule exactly - don't speed up
• Your protocol may delay wedges (6-7 weeks, 8-9 weeks, 10-11 weeks instead of 4, 6, 8)
• Early aggressive strengthening in safe positions (plantarflexion) helps
• Protected walking after boot removal (heel wedge, reduced step length)
• Never stretch your Achilles during this phase

The Danger of Cutting Corners

You're probably feeling much better by now. The initial pain is gone, you're walking more confidently, and it's tempting to think you can speed things up. Don't.

Recovery is a game of Snakes and Ladders: Each week sees you climbing closer to the finish. But one mistake - one moment of unprotected dorsiflexion, one premature wedge removal, one slip without your boot - is like landing on the big snake that takes you right back to the beginning.

What "cutting corners" looks like:

• Taking the boot off "just for a minute"
• Removing wedges before scheduled
• Walking without the boot to "test" your ankle
• Stretching or massaging the tendon
• Ignoring swelling or pain signals

Wedge Removal Protocol

When and How Wedges Are Removed

Wedge removal is an exciting milestone - each wedge removed means you're getting closer to a neutral foot position and, eventually, life without the boot.

How to remove wedges:

1. Open your boot
2. Locate the wedges under your heel
3. Remove the top wedge only (usually marked or colour-coded)
4. Ensure remaining wedges are flat and stable
5. Re-secure your boot snugly

What to Expect as Your Foot Position Changes

As your foot gradually moves towards neutral, you'll notice changes:

Physical changes:

• Your gait will feel different as your ankle angle changes
• Initial slight discomfort or "pulling" sensation (normal)
• Improved ability to walk more naturally
• Calf muscle may feel tighter

What's NOT normal (contact your medical team):

• Sharp pain during wedge removal or afterwards
• Sudden increase in swelling
• A "pop" or snapping sensation
• Feeling like the tendon has "given way"

Walking Progress

Full Weight-Bearing Guidelines

By weeks 4-6, most people are fully weight-bearing in their boot. This means putting your full body weight through the boot when walking.

How to walk well in the boot:

1. Heel strike first (just like normal walking)
2. Roll through the foot
3. Push off gently (the boot limits this anyway)
4. Keep your stride length comfortable - don't overreach
5. Maintain an upright posture

Common mistakes:

• Limping or avoiding loading the injured side
• Taking very short steps
• Leaning away from the injured side
• Walking on tiptoes on the other foot
• Rushing or moving too quickly

Using the EVENup to Protect Your Back and Hips

The EVENup shoe leveler is one of the most important purchases you can make during boot wearing.

Why you need it:

• Your boot adds 3-5cm of height to one leg
• This creates uneven hips during walking
• Over time, this causes back, hip, and knee pain
• The EVENup equalises your leg length

Results: More comfortable walking, less back and hip pain, more natural gait pattern, reduced fatigue.

The Night Splint Transition

When to Start Using a Night Splint

If you haven't already, weeks 4-6 is typically when you can transition from sleeping in your boot to using a night splint.

Prerequisites for using a night splint:

• Your specialist has approved its use
• Any surgical wounds are fully healed (usually 2-3 weeks post-surgery)
• You understand correct application
• You have an Achilles-specific night splint (not a plantar fasciitis splint!)

Benefits Over Sleeping in the Boot

Switching from the boot to a night splint for sleeping can dramatically improve your quality of life:

• Comfort: Much lighter weight, more breathable, less sweating
• Sleep quality: Easier to fall asleep, fewer wake-ups, better overall rest
• Practical: Boot lasts longer, stays cleaner, easier to get comfortable
• Doesn't damage or dirty your sheets
• Allows more natural sleeping positions

Switching to the night splint was life-changing. I finally got a proper night's sleep after weeks of struggling in the boot.

Safety rules:

• Never walk in the night splint - it's for lying down only
• Keep your boot next to the bed
• If you need to get up at night, put the boot back on first
• Don't use the splint until approved by your specialist

Common Challenges in Weeks 4-6

Swelling Management

Swelling often increases during weeks 4-6 as you become more active. This is normal but should be managed.

How to manage swelling:

1. Elevation: Still important - elevate after walking and in the evening
2. Ice: Can still be helpful after periods of activity
3. Compression: Your boot provides some compression
4. Activity modification: If swelling is excessive, reduce walking temporarily
5. Monitoring: Track swelling patterns to understand your limits

When to be concerned:

• Sudden increase in swelling (could indicate DVT)
• Swelling accompanied by increased pain, redness, or warmth
• Swelling that doesn't improve with elevation overnight
• Asymmetric swelling compared to your other leg

Skin Care Under the Boot

After weeks in a boot, skin problems are common but preventable.

Common issues: Dry, flaky skin; pressure marks from straps; heat rash; fungal infections (especially between toes); minor blisters or rubbing.

Prevention and treatment:

1. Daily skin checks: Remove boot briefly to inspect skin (quickly and carefully)
2. Moisturise: Use a non-fragranced moisturiser on dry areas (not between toes)
3. Antifungal powder: Apply between toes and to the foot to prevent fungal growth
4. Clean socks: Change your sock daily; use moisture-wicking materials
5. Adjust straps: Ensure straps aren't too tight or positioned on bony prominences
6. Keep it dry: Use a towel to dab away sweat

Dealing with "Hot Foot" and Hygiene

One of the most common complaints is that the boot makes your foot hot and sweaty.

Solutions:

• Merino wool socks are excellent (moisture-wicking and temperature-regulating)
• Thin, breathable socks work well
• Change socks at least daily
• Avoid thick cotton socks (they hold moisture)
• When resting with boot off briefly, let your foot air out
• Use a fan to cool your foot when stationary

Mental Health and Frustration

Weeks 4-6 can be mentally challenging. The initial "drama" of the injury has passed, but you're still very restricted.

Common feelings: Frustration at the slow pace of recovery, cabin fever from reduced mobility, anxiety about the future, guilt about relying on others, low mood, boredom.

Coping strategies:

1. Acknowledge your feelings: It's normal to struggle. This is a significant life event.
2. Set small goals: Focus on weekly progress rather than the final destination.
3. Stay connected: Talk to friends, family, or online communities.
4. Maintain routine: Structure your day even if you're not working.
5. Find seated hobbies: Reading, puzzles, gaming, crafts, online courses.
6. Stay as active as possible: Upper body exercises, seated movements.
7. Seek help if needed: If you're struggling significantly, talk to your GP.

Early Strengthening Exercises (Evidence-Based Approach)

Why Early Loading Matters

Modern research shows that aggressive loading early in safe positions (with your foot pointed down) helps strengthen the tendon and prevent elongation. This is done OUT of the boot for exercises, but the boot goes back on immediately after.

Seated Calf Raises (Week 2-3 Onwards)

What this involves:

• Remove boot briefly for exercises only (boot stays on for everything else)
• Sit in a chair with your foot flat on the floor
• Place weight on your knee (start with 10-15kg, progress to 0.8-1x your body weight)
• Push through your big toe and lift your heel
• Hold at the top, then lower slowly
• This creates ~2x body weight force in your Achilles tendon (due to lever mechanics)

Progression:

• Week 2-3: Body weight only, get used to the movement
• Week 3+: Add weight gradually (10kg, 15kg, 20kg...)
• Target: 0.8-1x body weight on your knee by weeks 8-10
• This prepares your tendon for walking (which requires ~1.5x body weight force)

Safety: Always done seated, foot pointed down, with supervision initially. Your specialist will guide you on when to start and how to progress.

Maintaining Upper Body and Core Strength

Don't let the rest of your body decline while your ankle heals.

Upper body exercises: Seated bicep curls, seated shoulder press, resistance band rows, wall push-ups, tricep dips using a sturdy chair.

Core exercises: Seated core rotations, pelvic tilts, modified planks, seated oblique twists, breathing exercises for deep core activation.

Why this matters: Maintains overall fitness, prevents muscle loss, improves mood, makes later rehabilitation easier, helps maintain a healthy weight.

FAQs for Weeks 4-6

Summary: Your Weeks 4-6 Checklist