Gait & Posture 91 (2022) 131–136

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Gait & Posture

journal homepage: www.elsevier.com/locate/gaitpost

Stability boots for the treatment of Achilles tendon injuries: Gait analysis of
healthy participants
Bettina Sommer, Andreas Hollenstein, Eveline Graf *
Zurich University of Applied Sciences, School of Health Professions, Institute of Physiotherapy, Katharina-Sulzer-Platz 9, 8401 Winterthur, Switzerland

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Achilles tendon injuries are commonly treated with stability boots that secure the ankle at a specific
Achilles tendon position and aim to reduce loading of the tendon. These boots allow full weight bearing by limiting the range of
Achilles tendon injury movement. It is, however, unknown, to what extent these boots can reduce tendon loading and if the biome­
Stability boots
chanics are altered during walking.
Gait analysis
Research question: How do orthopedic boots influence lower extremity biomechanics during walking?
Methods: For this cross-sectional study, ten healthy participants walked with three orthopedic boots (Oped
Vacoped, Kuenzli Ortho Rehab Absolut, Orthotech Variostabil) commonly used to treat Achilles tendon injuries.
Kinematics and kinetics of the lower extremity of the booted leg and spatiotemporal parameters of both sides
were collected using motion-capturing system and dynamometry. Each boot was tested in the maximally plan­
tarflexed position. Group differences between boot conditions were analyzed by means of repeated-measures
ANOVA and post-hoc paired t-test.
Results: The boot dorsiflexion range of motion differed significantly between boots with Vacoped (1.8◦ (0.3))
showing the smallest range, followed by Kuenzli (5.0◦ (1.3)) and Orthotech (7.9◦ (1.7)). Orthotech displayed a
higher peak plantarflexion moment (1.36 Nm/kg (0.09)) than both Kuenzli (1.06 Nm/kg (0.12)) and Vacoped
(1.04 Nm/kg (0.14)). Concerning loading over time, significant differences in the plantarflexion impulse were
found, with the highest impulse in Vacoped (0.42 Nms/kg (0.06)), followed by Orthotech (0.29 Nms/kg (0.03))
and Kuenzli (0.25 Nms/kg (0.05)). In addition, asymmetries were seen in stance and step length for the booted
and contralateral sides.
Significance: The lower extremity biomechanics were affected by the boots, with Kuenzli showing the lowest joint
loading, Vacoped the smallest joint motion and Orthotech the most natural gait pattern. Future research is
needed to determine the most relevant variable expressing the risk of re-rupture of the Achilles tendon in order to
conclude which boot may be most favorable to use in clinical practice.

1. Introduction week 1 after injury, and more than 50 % of all treatment protocols for
non-operative and operative treatment allow full weight bearing after 5
Achilles tendon injuries (ATI), such as a partial or complete rupture, weeks [5]. During functional rehabilitation, a plantarflexed ankle po­
are common injuries in middle-aged individuals. The incidence rate for sition and a limited range of motion are maintained to keep the two parts
Achilles tendon rupture ranges from 2.5–37.3 per 100′ 000 person years, of the Achilles tendon in close proximity (for non-operative treatment)
with an apparent upwards trend in recent years [1,2]. or reduce tension on the sutured section (for operative treatment). This,
Studies on treatment methods for acute ATI and their respective in combination with weight bearing, is crucial for effective functional
benefits are contradictory. Some studies show a lower risk of re-rupture rehabilitation [5,6], which has been shown to shorten the time of
as a result of surgical treatment, while others claim equal re-rupture returning to full daily life activities without increased incidence of
rates when compared to conservative treatments [3,4]. Regardless of re-rupture. Furthermore, early weight bearing has been found to
the form of treatment, full weight bearing is part of the functional improve patient satisfaction [7–9]. With regard to the incidence of
rehabilitation for acute ATI patients. Full weight bearing may start at complications, immediate functional mobilization with weight bearing

* Corresponding author.
E-mail address: [email protected] (E. Graf).

https://doi.org/10.1016/j.gaitpost.2021.10.009
Received 26 November 2020; Received in revised form 5 October 2021; Accepted 7 October 2021
Available online 11 October 2021
0966-6362/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
B. Sommer et al. Gait & Posture 91 (2022) 131–136

in an orthopedic boot was shown to be as safe as cast immobilization 2.2. Objects and material
treatment [9]. Activation of the triceps surae muscle group, or stretching
of the tendon by increased dorsiflexion angle, generates load, thereby Ten healthy participants (5 female, age 32.5 ± 10.0 years, height
promoting the healing processes that strengthens the tendon [9,10]. 173.79 ± 7.93 cm, weight 71.93 ± 13.1 kg) were recruited by word-of-
One treatment option for ATI is wearing an orthopedic boot, mouth. The sample size was determined with a power analysis based on
commonly used in the first 8–12 weeks after injury. The aim of this boot data from a pilot study (G*Power, Germany). Participants were free of
is to reduce Achilles tendon loading while allowing full weight bearing. any acute or chronic musculoskeletal, neurological or cardiological
Loading can be investigated by measuring the sagittal ankle angles and diseases, had never before experienced issues with their Achilles ten­
moments. Today, several commercial boots are available for use in dons, and were not pregnant.
functional rehabilitation in both postoperative and conservative treat­ Three commercially available stability boots were used: Ortho Rehab
ments. A harder boot shaft decreases the ankle range of motion while, Absolut (short: Kuenzli, Künzli SwissSchuh AG, Switzerland); Vario-
conversely, a soft boot results in a greater range of motion and enables Stabil (short: Orthotech, Orthotech GmbH, Germany); and VACOped
the ankle joint to generate more power [11]. To date, the amount of (OPED AG, Switzerland). VACOped consists of a hard external shell,
ankle mobility and tendon loading allowed by these boots is unclear. while the others are normal (artificial) leather boots. All three boots are
These boots allow different ankle plantarflexion positions within the recommended for the management of ATI [16–18]. For Kuenzli and
boot. How the plantarflexed position is maintained differs between Orthotech, the plantarflexion positions are achieved by inserting wedges
boots. Some utilize wedges placed under the heel while others utilize a underneath the insole to increase the heel. For VACOped, the shaft can
hard shell with a hinge joint, that can be secured at different angles, and be set to different plantarflexion positions and a wedged outsole is added
a vacuum cushion inside. It is unknown if the different boot designs vary (details in Appendix 1). The investigated stability boots were size 6
in their ability to keep the Achilles tendon in a position of reduced (females) and size 9 (males).
loading. The most plantarflexed position of the ankle within the boot is
the most crucial in terms of reduced loading of the Achilles tendon as 2.3. Procedure
patients will be required to bear load on the foot in this position at the
beginning of rehabilitation. All data were collected in a single session. After recording the
Several research groups have evaluated Achilles tendon loading anthropometric data, markers were placed on the lower extremities and
during walking with an orthopedic boot via invasive optic fiber. When the pelvis by one of the three examiners, according to a customized
compared to barefoot walking, one group found a trend towards strain cluster marker model [19]. The examiners were either trained physio­
relief, while another group showed increased Achilles tendon load [12, therapists or human movement scientists instructed on marker place­
13]. But noninvasive methods, such as 3D motion analysis and ultra­ ment. The stability boot was worn on the left side. On the right side, the
sonography, have also been used to investigate Achilles tendon prop­ participants wore the provided compensating solution for the contra­
erties. These showed a decreased ankle plantarflexion moment two to six lateral side. For VACOped, the participants wore a neutral running shoe
years after surgical treatment due to greater tendon stiffness indicating with the provided even up sole. Shank (left side) and foot (left and right
the long-term effects of the injury to the tissue properties and conse­ side) markers were placed on the boots (see Appendix 2). The examiners
quently the movement pattern [14]. tightened the boots to ensure proper grip. After participant preparation,
Gait analysis comparing physiological walking patterns in orthope­ a functional calibration, including neutral standing, was performed to
dic boots, casts and normal shoes, showed significant kinematic and estimate hip and knee joint centers for each boot [19]. The participants
kinetic changes in knee and hip during walking with a cast. The reduced were then given time to familiarize themselves with the boot. For the
knee flexion angle during stance, the decreased external knee flexion test, they walked with full weight bearing within a delineated area of 10
moment and the reduced external hip abduction moment could result in m length at two different speeds: 1.2 m/s ± 5 % and at a self-selected,
altered joint loading that may lead to adverse effects on the ipsi- or constant speed. The walking speed was defined by the average time
contralateral side. The orthopedic boots resulted in only minor changes necessary to cross the distance between two light barriers 3.5 m apart
of the gait pattern compared to walking in a normal shoe which led to (MicroGate, Bozen, Italy). Data from ten trials were collected. In­
the conclusion that boots are less likely to cause unwanted effects [15]. structions from the examiners consisted only of “walk faster/slower”
The aim of this study is to investigate the influence of different or­ (when the targeted speed was not achieved) or “look straight ahead“.
thopedic boots on lower extremity biomechanics during walking. Three The trials with self-selected speed were recorded to compare the speed
types of orthopedic boots that are commonly used for patients with between boots while the trials with 1.2 m/s allow for comparison of the
acute Achilles tendon injuries were tested by healthy participants: Oped biomechanics without speed as confounding factor. Boot order was
Vacoped, Kuenzli Ortho Rehab Absolut, Orthotech Variostabil. The randomized, the self-selected speed was performed first in each boot.
boots have different designs which may alter their ability to stabilize the
ankle. Boots were compared while the ankle was placed at the maxi­ 2.4. Data collection and analysis
mally plantarflexed position. It was hypothesized that the boot with an
external shell resulted in less ankle movement but larger deviations of Data were collected using a marker-based, optoelectronic motion
the knee joint from normal gait compared to the other boots, which were capture system (Vicon Motion System, UK, 240 Hz) consisting of 12
built internal structures to provide stability. Further, no differences were infrared cameras and two in-ground force plates (AMTI, USA, 1200 Hz,
hypothesized for the comparison of the two boots without external shell. 50 × 46 cm). Matlab R2018 (MathWorks Inc., USA) was used to process
the data and to calculate joint center and kinematics. Marker data were
2. Materials and methods filtered with a 4th order Butterworth filter with a cut-off frequency of 7
Hz. Joint kinetics were determined in Bodybuilder (Vicon Motion Sys­
2.1. Study design tem, UK) by an inverse dynamics calculation, using the data from the
force plates and the marker trajectories. Center of pressure (COP) data
This study was designed as a monocentric cross-sectional study, were expressed in percentage of total boot length.
approved by the Ethics Committee of Canton Zurich (BASEC-NR. 2018- The neutral position for angle calculations was a static upright stance
01101). Measurements were taken at the Movement Laboratory of the with parallel feet. Peak values for angles and internal moments, as well
Zurich University of Applied Sciences in Winterthur, Switzerland. All as range of motion (ROM), for the boot-ankle, knee and hip joints were
participants provided written informed consent prior to inclusion. calculated. Additionally, boot-ankle angular impulse and spatiotem­
poral parameters were extracted for further data evaluation. The self-

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Table 1
Total range of motion of the foot with the boot during walking at 1.2 m/s. Mean (SD), n = 10, ‡significant difference from Vacoped, †significant difference from
Orthotech, *significant difference from Kuenzli (p < 0.05).
Total range of motion [◦ ]

Kuenzli Vacoped Orthotech

Sagittal plane 5.0 (1.3) ‡† 1.8 (0.3) †* 7.9 (1.7) ‡*

Frontal plane 1.8 (0.6) ‡ 1.2 (0.5) †* 2.3 (0.7) ‡
Transverse plane 2.5 (0.6) 2.2 (0.8) 2.0 (0.6)

selected walking speed was compared between boots. stability boots used in the treatment of ATI. The main outcomes of the
Statistical analysis was performed using Matlab R2018. The main boot-ankle biomechanics showed differences between the boots.
variables were tested for normal distribution by the Lilliefors test. Group Regarding peak angles, Vacoped with its hard shell showed the smallest
differences were analyzed by a repeated-measures ANOVA (p < 0.05). In ROM, as hypothesized. However, also Kuenzli and Orthotech showed
case of differences, a post-hoc paired t-test was performed with Bon­ differences in boot-ankle plantarflexion which was opposite to the hy­
ferroni correction. pothesis. Good lateral stability in all boots was observed, with small
ROMs for boot-ankle inversion and internal rotation. Therefore, a high
3. Results boot stiffness, as in the hard shell Vacoped, influenced the ROM of
dorsiflexion.
3.1. Boot-ankle Footwear properties also influenced ankle moments, as well as
loading over time. Kuenzli displayed the smallest angular impulse and,
All boots showed significant differences in the sagittal plane, with therefore, the lowest joint loading over the gait cycle. Besides the boot
Vacoped displaying the smallest ROM, followed by Kuenzli and Ortho­ shell, also the rolling of the boot sole had an important influence on
tech (Table 1, Fig. 1). Foot inversion and internal rotation were shown to biomechanics, especially on the COP and, consequently, on the boot-
be <3◦ . ankle moments. Joint loading can be reduced with a rolling of the sole
Considering the whole stance phase, Vacoped showed a boot-ankle that keeps the COP closer to the joint, as was seen in Kuenzli. A rolling
plantarflexion moment from the beginning of the stance phase, while from heel to toe was seen in both Kuenzli and Orthotech, with Orthotech
the other two boots demonstrated an initial dorsiflexion moment having the COP on the front of the foot for a longer time. On the other
(Fig. 1). Significant differences were reported for the plantarflexion hand, Vacoped’s sole properties, with the missing heel contact, led to a
angular impulse, with the highest value in Vacoped (0.42(0.06) Nms/ COP which was constantly in front of the ankle joint. This is known to
kg), followed by Orthotech (0.29(0.03) Nms/kg) and Kuenzli (0.25 cause limping [20] and lead to a constant ankle plantarflexion moment.
(0.05) Nms/kg) (Table 2). Contrary to what has been reported on lacking heel support, higher
Differences were also observed for COP data (Fig. 2). The temporal plantarflexion moments did not occurred [12].
course is represented by the COP for each 1 % stance phase time point. To date, the optimal amount of movement to prevent tendon elon­
For Orthotech, this showed a longer period of anterior COP than Kuenzli, gation and allow tendon tissue healing is unknown. Following functional
which showed a more posterior and mid-foot COP with a short phase in rehabilitation with early weight bearing, some movement in the ankle is
the anterior (toe) position. From the initial contact, Vacoped showed a thought to be beneficial to the healing process and to prevent muscle
COP at approximately 30 % bootlength, which shifted immediately atrophy. It remains unclear which boot has the ideal ROM for ATI
anterior towards the toes. rehabilitation. As well as enhancing the healing process, the boots
should prevent tendon re-ruptures. The re-rupture mechanism of ATI
3.2. Knee and hip during rehabilitation might be influenced by the peak or continuous
loading. Which mechanism puts the tendon most at risk of re-ruptures
In the knee, flexion ROM was significantly lower in Vacoped (56.7 also remains unclear. In their study, Ecker et al. found that even
(8.2)◦ ) compared to Kuenzli (69.1(5.6)◦ ) and Orthotech (69.9(4.9)◦ ). though most re-ruptures occurred as a result of a traumatic event, some
Vacoped showed an increased flexion at initial contact, with the knee 3 out of 11 persons suffered a re-rupture during normal walking [8]. This
staying more flexed through the stance phase compared to the other implies that even during normal walking activity a small peak moment is
boots (Fig. 3). No difference in knee internal rotation and adduction was desirable. In this study, the peak moment was smallest in Vacoped and
seen between boots. For the hip, a decreased hip adduction ROM was Kuenzli.
observed in Vacoped (13.8(2.5)◦ ) compared with both Kuenzli (16.0 Regarding the knee, we found larger deviations from a natural gait
(2.1)◦ ) and Orthotech (16.1(2.3)◦ ). Vacoped showed a lower hip pattern with the Vacoped than with the other two boots. This could be
abduction and external rotation moment (0.8(0.1) Nm/kg and 0.1(0.0) due to the hard shell and / or the compensating outer sole, which is not
Nm/kg, respectively) than both Kuenzli (1.0(0.0) and 0.2(0.0) Nm/kg) identical with the booted side, as it was seen in Kuenzli and Orthotech
and Orthotech (1.0(0.1) and 0.2(0.0) Nm/kg). with the compensating shoes. Deviations from a natural gait pattern
were also found in Zellers et al. Increasing the number of wedges in
3.3. Spatiotemporal parameters orthopedic boots reduced vertical ground reaction force and knee
extension power [21]. Although these parameters were not collected in
Self-selected walking speed with Vacoped was significantly slower our study, altered knee and hip mechanics were observed. While Ker­
than with Kuenzli or Orthotech (Table 3). Left-right asymmetries in rigan et al. reported a normative peak knee flexion angle in the loading
stance time were observed for all boots, with a longer percental stance response of <20◦ [22], Vacoped showed a flexion angle of >30◦ in the
time on the contralateral leg. Step length of the ipsilateral leg differed loading response in this study. This flexed knee position, combined with
significantly for Kuenzli and Vacoped. Orthotech showed no difference the COP close to the toes, induced a flexion movement during loading
in step lengths (Table 3). response. The flexed knee in Vacoped might also have been the reason
for the lower hip adduction ROM and smaller hip moments observed in
4. Discussion Vacoped. This reduction in hip mechanics might be compensated by the
altered knee mechanics.
This study investigated the biomechanical effects of walking in three For all boots, self-selected walking speed was slower than in age-

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Fig. 1. Boot-ankle joint angle and moment for the side with the boot (left side) during walking at 1.2 m/s.
bold line = mean, shaded area = SD, n = 10, vertical line = toe-off, dividing stance phase (left side of line) and swing phase.

Table 2
Peak internal boot-ankle joint moments and angular impulse during walking at 1.2 m/s Mean (SD), ‡significant difference from Vacoped, †significant difference from
Orthotech, *significant difference from Kuenzli (p < 0.05).
Peak internal boot-ankle joint moments [Nm/kg] and angular impulse [Nms/kg]

Kuenzli Vacoped Orthotech

Plantarflexion 1.06 (0.12)† 1.04 (0.14)† 1.36 (0.09)*‡

Eversion 0.22 (0.12) 0.24 (0.11) 0.21 (0.13)
External rotation 0.10 (0.02) 0.10 (0.04) 0.09 (0.03)
Plantarflexion impulse 0.25 (0.05)‡† 0.42 (0.06)†* 0.29 (0.03)*‡

matched controls [23], where females had a mean gait speed of 1.34 m/s
and males 1.43 m/s. This is associated with the limited movement range,
which forced participants to walk more slowly. A natural walking
pattern also includes symmetric step length, which was only observed in
Orthotech. Step length asymmetries were seen for Kuenzli and Vacoped.
For all boots, the duration of the stance phase showed asymmetries,
where stance on the foot with the orthopedic boot was shorter than on
the contralateral side. Such asymmetries of step length and stance
duration were shown to indicate impaired walking performance [24]. It
can therefore be concluded that all boots partially showed an unnatural
gait pattern, with Orthotech being the closest to natural walking due to
its symmetric step lengths.
To have intact stability boots, the markers on the lower leg and foot
were attached to the boot and not on the skin of the participants.
Radiographic techniques could be used to record the skeletal movement
within the boots. However, such an approach was not feasible in the

Fig. 2. Center of pressure for all boots during walking at 1.2 m/s n = 10. Fig. 3. Knee joint angle during walking at 1.2 m/s.
Coordinates [0,0] correspond to the heel marker. Each point corresponds to 1% n = 10; bold line = mean, shaded area = SD, vertical line = toe-off, dividing
time of the stance phase. stance phase (left side of line) and swing phase.

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Table 3
Spatiotemporal parameters for the leg with boot (ipsilateral) and the compensatory side (contralateral), step length and stance for walking at 1.2 m/s, speed for self-
selected walking speed Mean (SD), ‡significant difference from Vacoped, †significant difference from Orthotech, *significant difference from Kuenzli; # significant
difference between ipsilateral and contralateral side (p < 0.05).
Spatiotemporal parameters

Step length ipsilateral [cm] Step length contralateral [cm] Stance time ipsilateral Stance time contralateral Self-selected speed
[% gait cycle] [% gait cycle] [m/s]

Kuenzli 72.9 (0.7)# 71.1 (0.8)# 61.2 (0.2)# 63.4 (1.3)# 1.31 (0.01)‡
Vacoped 68.7 (1.3)# 74.4 (0.6)# 59.1 (0.4)# 62.4 (0.2)# 1.17 (0.07)†*
Orthotech 71.5 (0.7) 71.5 (0.9) 61.6 (0.3)# 63.2 (0.2)# 1.31 (0.01)‡

given setting. All boots were tightened by the researchers to reduce Acknowledgements
variability between participants. This should reduce the amount of
movement of the foot/leg within the boot, but the amount could not be The authors would like to thank Nadine Häfliger for her assistance
quantified. Consequently, the actual joint angles and moments may be with the literature search, Karen Linwood for proofreading, all partici­
different from the recorded boot mechanics. pants for voluntarily taking part in this study and Kuenzli SwissSchuh
A strength of this study is that measurements were made under AG for providing the test boots. This study was funded by the Research
conditions comparable to a clinical setting. This means that the boots did Fund Aargau, Switzerland.
not have to be cut or adjusted, such as in studies measuring Achilles
tendon loading with percutaneously inserted optic fibres [12,13]. A Appendix A. Supplementary data
limitation of this study is that the movement between markers of the
same cluster could have occurred. By using four markers per cluster and Supplementary material related to this article can be found, in the
applying a singular value decomposition [25], the resulting error is online version, at doi:https://doi.org/10.1016/j.gaitpost.2021.10.009.
reduced compared to an approach with three markers per cluster. As
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