PARS Achilles Tendon Repair

The Achilles tendon is the strongest and thickest tendon in the body. It attaches the calf
muscles (soleus and gastrocnemius) to the heel bone (calcaneus). The tendon transmits
force from the contracting calf muscles to the calcaneus to cause the foot action of plantar
flexion (foot pointed down) that is important in walking, running, jumping and change of
direction activities.

Although the Achilles tendon is the strongest tendon in the body, it is also the tendon most
commonly torn or ruptured. The most common causes of rupture are:
• Sudden plantar flexion (foot moving downward) such as taking off to jump.
• Unplanned or forced dorsiflexion (foot moving upward) such as landing a jump or
stepping into a hole.
• Direct trauma to the tendon.

Most Achilles tendon ruptures occur in sports that require running, jumping and change of
direction. The typical age for rupture occurs between 30–40 years of age and is
significantly more common in males than females. Older adults can also rupture the Achilles
tendon and are more inclined to have degenerative partial tearing of the tendon. Other risk
factors for Achilles tendon rupture include use of Fluoroquinolone antibiotics and direct
steroid injections into the tendon. The diagnosis of an Achilles tendon rupture is made
from clinical history, physical exam and diagnostic testing. Most patients who sustain an
Achilles tendon rupture report a pop and a feeling of being kicked or shot in the back of
the leg. On exam, there is a palpable divot or gap in the area of the rupture along with
significant swelling. If the Achilles is torn, when the calf is squeezed the foot will not point
down (plantarflex). Diagnostic testing such as an Ultrasound or MRI (magnetic resonance
imaging) may be used to determine if there is a complete or partial tear.
Historically, open techniques have been utilized for repair of the rupture but can be
complicated by wound-healing issues and infection. This percutaneous and
minimally invasive technique minimizes this concern. The PARS (see figure 1) technique
provides the opportunity for consistently reliable capture both parts of the torn
Achilles tendon and utilizes color-coded FiberWire suture. The healed tendon achieves
a more natural contour, unlike the typical large scarred tendon resulting from open
repair. This minimally invasive technique is ideal for the middle-aged individual, where
there may be a heightened concern for wound-healing issues.

Figure 1: Arthrex PARS Achilles Jig system (www.arthrex.com)

Rehabilitation following Achilles tendon repair is vital in regaining motion, strength and
function. Initially a walking boot is used for the first 6-8 weeks. Gradually more weight
bearing and mobility is allowed to prevent stiffness post-operatively. The rehabilitation
progresses slowly into strengthening, gait and balancing activities. Rehabilitation
guidelines are presented in a criterion-based progression. General time frames refer to
the usual pace of rehabilitation. Individual patients will progress at different rates
depending on their age, associated injuries, pre-injury health status, rehab compliance,
tissue quality and injury severity. For Achilles repairs it is essential that the tendon
does not heal “long”……… ie stretching or lengthening the tendon early in the rehab
process an result in a longer less elastic tendon. This should be monitored during the
rehab process through repeated assessments of resting equinous position in a prone
knee flexed position.
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PARS Achilles Tendon Repair

Phase I (0 to 6 weeks after surgery)

• Physician appointment at 2 weeks post-op

Rehabilitation appointments
• One Rehabilitation appointment immediately following the
physician 2-week post op appt.
• Reduce pain and swelling after surgery
Rehabilitation goals
• Protect healing of repaired tissues and implanted devices
• Safe use of crutches for non-weight bearing
Precautions
• Non-weight bearing

• Bledsoe boot:
o At 2 weeks post op =20° of plantar flexion.
o At 3 weeks postop = 10° of plantar flexion.
o At 4 weeks the boot will be transition to neutral,
and place 2 6-layered heel lifts into the boot, and
begin partial weight-bearing advancing to full
weight-bearing by 6 weeks. Begin peeling 1 layer
of the heel lifts off each week.

Suggested therapeutic exercise • Quad sets

• 4-way straight leg raises
• Core exercises
• Active ankle dorsiflexion to neutral / 0 degrees (must not go
past neutral until minimum 3 months post-op)

• Passive plantarflexion

Cardiovascular exercise • Upper body

• Bike with boot on, starting at 8 weeks, low resistance initially
Progression criteria • 6 weeks

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PARS Achilles Tendon Repair
Phase II (6 to 12 weeks after surgery)

• Physician appointment ~8 weeks post-op

Rehabilitation appointments
• Rehabilitation appointments begin 2 weeks post-op
• Reduce pain and swelling after surgery
Rehabilitation goals
• Protect healing of repaired tissues and implanted devices
• Ensure appropriate gait in the boot
Precautions • No ankle dorsiflexion range of motion past neutral

• Submaximal and gradual resisted ankle plantarflexion

• Weight-bearing in boot until 9-10 weeks post-op (after

being seen by MD), then transition out of boot over 1-2
weeks with at least one 3-layer heel lift in shoe

Suggested therapeutic exercise • Gentle AAROM to neutral dorsiflexion

• AROM for inversion / eversion
• Continue quad, hip and core strengthening

Cardiovascular exercise • Upper body

• Bike with boot on, starting at 8 weeks, low resistance
initially
Progression criteria • 12 weeks

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PARS Achilles Tendon Repair

Phase III (begin 12 weeks after surgery)

• Physician appointment 16-18 weeks after surgery

Rehabilitation appointments
• Rehabilitation appointments 1-2x week
• Normalize gait out of boot on level surfaces
Rehabilitation goals
• Use of one or two 3-layer heel lifts PRN
• Protection of the post-surgical repair
• Gradual restoration of ankle range of motion
• Single leg stand control for 10 seconds
Precautions • Gradually wean out of boot based on tolerance, fatigue and gait
mechanics (usually over 2-3 weeks)
• Avoid over-stressing the repair (avoid large movements in the sagittal
plane; any forceful plantarflexion while in a dorsiflexed position;
aggressive passive ROM; and impact activities)

Suggested therapeutic • Frontal and sagittal plane stepping drills (side step, cross-over step,
exercise
grapevine step)
• Active ankle ROM within ROM precautions
• Static balance exercises (begin in 2 foot stand, then 2 foot stand on
side to side balance board or narrow base of support and gradually
progress to single leg stand)
• Ankle strengthening with resistance
• Low velocity and partial ROM for functional movements (squat, step
back, lunge)
• Hip and core strengthening
Cardiovascular exercise • Stationary bike
• Elliptical
• Flat treadmill – no incline, no running
• Swimming with pull buoy, chest- level water walking

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Progression criteria • Normal gait mechanics without the boot
• Squat to 30° knee flexion without weight shift using heel lifts to keep
ankle dorsiflexion to neutral
• Single leg stand with good control for 10 seconds
• Active ROM between 0° of dorsiflexion and 40° of plantarflexion

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PARS Achilles Tendon Repair
Phase IV (begin after meeting phase III criteria, usually 18 weeks after surgery)

Rehabilitation appointments • Physician appointment 24-28 weeks after surgery

• Rehab every 1-2 weeks
Rehabilitation goals • Normalize gait on all surfaces without boot or heel lift
• Single leg stand with good control for 10 seconds
• Active ROM between 15° of dorsiflexion and 50° of plantarflexion
• Good control and no pain with functional movements, including
step up/down, squat and lunges
Precautions • Avoid forceful impact activities
• Do not perform exercises that create movement compensations
Suggested therapeutic exercises • Frontal and transverse plane agility drills (progress from low
velocity to high, then
• gradually adding in sagittal plane drills)
• Active ankle ROM
• Gastroc/soleus stretching
• Multi-plane proprioceptive exercises – single leg stand
• 1 foot standing nose touches
• Ankle strengthening – concentric and eccentric gastroc
strengthening
• Functional movements (squat, step back, lunge)
• Hip and core strengthening
Cardiovascular exercise • Walking and stationary bike
• Swimming
• Avoid running and jumping because of landing impact
Progression criteria • Normal gait mechanics without the boot on all surfaces
• Squat and lunge to 70° knee flexion without weight shift
• Single leg stand with good control for 10 seconds
• Active ROM between 15° of dorsiflexion and 50° of plantarflexion

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PARS Achilles Tendon Repair

Phase V (after surgery if meeting phase IV goals)

Rehabilitation appointments • Physician appointment 9 months after surgery (if needed)

• Rehab every 2-3 weeks
Rehabilitation goals • Good control and no pain with sport/work specific movements,
including impact
Precautions • Post-activity soreness should resolve within 24 hours
• Avoid post-activity swelling
• Avoid running with a limp
Suggested therapeutic exercises • Impact control exercises beginning 2 feet to 2 feet,
progressing from 1 foot to
• other and then 1 foot to same foot
• Movement control exercise beginning with low velocity, single
plane activities and
• progressing to higher velocity, multi-plane activities
• Sport/work specific balance and proprioceptive drills
• Hip and core strengthening
• Stretching for patient specific muscle imbalances
Cardiovascular exercise • Replicate sport/work specific energy demands
Progression criteria • Patient may return to sport after receiving clearance from the
orthopedic surgeon and the physical therapist/athletic trainer.
Progressive testing will be completed. The patient should
have less than 15% difference in Biodex strength test, force
plate jump and vertical hop tests, and functional horizontal hop
tests.

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 These rehabilitation guidelines were developed by the UW Health Sports Medicine group.

References:

Hsu AR, Jones CP, Cohen BE, Davis WH, Ellington JK, Anderson RB. Clinical Outcomes and
Complications of Percutaneous Achilles Repair System Versus Open Technique for Acute
Achilles Tendon Ruptures. Foot Ankle Int. 2015 Nov;36(11):1279-86.

At UW Health, patients may have may receive direction or educational materials that vary from this
information. This information is not intended to replace the care or advice given by your physician or
health care provider. It is neither intended nor implied to be a substitute for professional advice. Call your
health provider immediately if you think you may have a medical emergency. Always seek the advice of
your physician or other qualified health provider prior to starting any new treatment or with any question
you may have regarding a medical condition.