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Postoperative Rehabilitation of Proximal Hamstring Tendon Tears
Postoperative Rehabilitation of Proximal Hamstring Tendon Tears Scott F. Hamersly, MS, PT, SCS, ATC, CSCS, and Monica Schrader, MS, PT, ATC Complete proximal tears of the hamstring tendon are uncommon. The available literature is sparse in regard to postoperative rehabilitative programs and the published protocols are variable. Our purpose is to outline and discuss the program currently implemented by the authors for proximal hamstring tendon injuries as well as to review and contrast it with other published protocols. Authors pose different opinions in 3 important areas: (1) early postoperative protection and/or restrictions, (2) details on the specific phases of rehabilitation, and (3) how to determine successful outcomes and the criteria used to allow full return to previous levels of activities. We discuss our program in detail and support it with our clinical observations and experiences. Oper Tech Sports Med 17:219-224 © 2009 Elsevier Inc. All rights reserved. KEYWORDS rehabiliatation, proximal hamstring tear, postoperative, surgical repair, protocol
P
roximal tears of the hamstring tendon are as uncommon as the rehabilitation guidelines for their postoperative care. Information in the current literature is scarce, and the postoperative rehabilitation programs that are published are variable.1-7 Most programs are collaborations between surgeons and therapists and are not evidence-based. Common to the few programs that are published are the immediate postoperative immobilization with a brace or device to protect the repair, early weight bearing restrictions, and the initiation of resistance exercise beginning at 6 weeks postoperatively.1-7 Differences among the programs can be seen in regard to range of motion (ROM) allowed at the knee joint, the use of hamstring stretching, and the time to return to athletic activities. We have developed the following protocol by collaborating with 1 surgeon over a period of 11 years who has completed more than 80 complete proximal hamstring repairs to date. Although the protocol has been mentioned in a previous publication, it has not been described in its entirety.7
Proximal Hamstring Repair Rehabilitation Rehabilitation for proximal hamstring rupture repairs is divided into 5 phases. The preoperative phase includes active Physical Therapy Department, Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN. Address reprint requests to Scott F. Hamersly, MS, PT, SCS, ATC, CSCS, Methodist Sports Medicine/The Orthopedic Specialists, 201 Pennsylvania Pkwy., Ste. 325, Indianapolis, IN 46280. E-mail: shamersly@ methodistsports.com
1060-1872/09/$-see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1053/j.otsm.2009.12.005
participation of both patient and caregiver and determines how well the immediate postrehabilitative phase progresses. Time lines for postoperative rehabilitative phases are phase 1 (0-4 weeks), phase 2 (4-8 weeks), phase 3 (8-16 weeks), and phase 4 (4-6 months).
Preoperative Phase The preoperative phase includes 2 critical points; patient and caregiver education as well as practice with the hamstring sling during gait and transfers. Both the patient and the caregiver must be mindful of 2 postoperative precautions; avoiding active hamstring contraction and hip flexion beyond approximately 60°. If these precautions are not heeded, they may result in tearing of the repaired hamstring tendon. Therefore, the involved foot is passively raised and suspended in the sling with the assistance of a caregiver for all upright activities. Both patient and caregiver are given instruction on and asked to demonstrate correct techniques for transferring supine-tositting and sitting-to-standing without exceeding 60° of hip flexion. Although the foot of the surgical leg is allowed to gently rest on the floor, the patient is cautioned not to weight bear on the leg during transfers. When rising from a sitting to a standing position, the patient leads with the hips and shifts their weight through the upper extremities and noninvolved leg. Transitioning from standing to sitting, the patient’s torso must lean back while lowering the hips into a seat. Gait training on level surfaces and stairs with the sling in place is practiced until the patient demonstrates safe execution. Practicing the aforementioned strategies in the patient’s own home is strongly encouraged (Fig. 1). 219
S.F. Hamersly and M. Schrader
220
Figure 1 Transitioning from sitting to standing (A). Gait training on level surfaces and stairs with the sling in place (B).
At this time, the patient and his or her family members present with many questions. Explanation of the rehabilitative process, including physician and physical therapy (PT) visits, physical performance testing, timeline for return to functional activities, and expected outcomes are all addressed during the preoperative visit.
Phase 1 (0-4 Weeks) Unique to phase 1 is the use of a hamstring sling to passively maintain knee flexion of the involved limb while non–weight bearing (NWB) with crutches. The sling is constructed of a 2 inch nylon strap that fastens around the waist and connects to a loop on the heel of the shoe. The sling holds the knee between 70° and 90°, effectively placing slack on the hamstring to protect the repair. Considered the protective phase, this time frame focuses on alleviating tension stress on the repair, as well as, pain and swelling control. During the first week after surgery, the patient remains supine or in a sidelying position with the hip in neutral and the knee either extended or in slight flexion. A gentle semi-reclined position can be assumed with a small towel roll (2-3 inches) under the knee to reduce hamstring tension and avoid knee joint stiffness. Complying with the “no active hamstring contraction” rule means that all the knee flexion positions must be achieved passively. This precaution is imperative and is adhered to during the entire first phase. A cryotherapy unit with a large foot cuff is placed under the involved hip and used consistently during the first week for pain and swelling control. Therapeutic exercises are kept simple. Quadriceps sets (4 ⫻ 20 reps/day) prevent neuro-
muscular shut down of the muscle. In addition to reducing the risk of deep vein thrombosis formation, ankle pumps (20-30 reps/hour) provide early gentle neural gliding to prevent scar adherence and development of abnormal nerve symptoms (Fig. 2). Additionally, light, desensitization massage to the incision and posterior hip is employed to ease discomfort and reduce the occurrence of hypersensitivity issues. Postoperative weeks 2 through 4 allow for gradual resumption into limited upright activities of daily living (ADLs). Again, the involved leg is suspended in the sling anytime the patient is ambulating for the entire first postoperative month. Patients may lower the involved foot and al-
Figure 2 Ankle pumps provide early general neural gliding and help reduce the risk of deep venous thrombosis.
Proximal hamstring tendon tears
221
Figure 5 Gluteus medius strengthening is started in a sidelying position and is progressed to the upright position.
Figure 3 Standing hamstring curls.
low it to touch the ground during transfers and with showering. A shower stool is advised for patient safety. Other useful equipment recommendations given to patients include toilet safety handrails, an extended reacher, a long shoehorn, and an elevated toilet seat for tall individuals. Postoperative clinical follow-up with the physician is at 1 week for suture removal. Bedside PT is carried out postoperatively the first day with the patient and caregiver demonstrating all exercises, transfers and gait training with the hamstring sling, and NWB crutches on level surfaces. The next PT visit coincides with the physician’s 1 month postoperative visit.
Phase 2 (1-2 Months) Clinical goals during phase 2 include restoration of normal gait and return of pain-free functional ADLs. At the 1 month
postoperative visit, the hamstring sling is discontinued and the patient begins to wean off the crutches as active quadriceps muscle control is achieved. Hamstring curl strengthening is initiated in standing with the hip joint held in neutral position and the lower leg moving against gravity in pain-free arcs (Fig. 3). Resistance is increased a pound at a time as tolerated with emphasis on high repetitions (50 reps) and high frequency (4-5 times/d). When the patient is able to move through a full and pain-free knee flexion arc with 8-10 lbs at high reps, patients can transition from standing to machine hamstring curls (Fig. 4). Other total leg and hip strengthening exercises are also incorporated into the home exercise program (HEP). Quarter squats and heel raises progress from bilateral to unilateral status. Step down exercises using a progressively higher step not only further enhances leg and hip strength but also improves proprioceptive deficits. Gluteus maximus strength exercises progress from prone (heel pushes with the knee flexed at 90° to hip extension with the flexed at 90° to hip extension with an extended knee) to supine (bilateral to unilateral bridging). Gluteus medius strengthening is started in a sidelying position and is progressed to the upright position (Fig. 5). The patient can begin unilateral knee extension and leg press activities with light resistance and increase resistances as the surgical hip
Figure 4 Patients can transition from standing to machine hamstring curls.
S.F. Hamersly and M. Schrader
222 tolerates. Because cocontraction of the hamstrings occurs during the leg press, starting hip position should be below 90° and pain free. Hamstring flexibility exercises are contraindicated for the first 3 months after surgery. Formal hamstring stretching may produce excessive tissue creep resulting in an inappropriate tissue length—tension relationship. Lengthening of repaired muscle tissue and return of normal hamstring flexibility are typically not a problem and will naturally progress on its own through ADL tasks. However, patients often claim their repaired hamstring feels tight and will want to stretch it. Patients who had a chronic hamstring rupture typically express this more so than patients who had an acute hamstring rupture. Upon examination, supine passive hip flexion with the knee flexed on the involved side is often found to be less than the noninvolved side. Patients are allowed to perform a gentle single knee to chest stretch on the involved side to relieve posterior hip tightness (Fig. 6). This also serves as a neural glide exercise to prevent scar adhesions about the sciatic nerve. Postoperative clinical follow-up with the physician is at 2 months. Postoperative PT follow-up is generally at 6 weeks and 2 months.
Phase 3 (2-4 Months) Phase 3 clinical goals include return to unrestricted ADL’s at home and work, continued hamstring strengthening, and pain-free performance of nonimpact aerobic activities. Hamstring strengthening can advance from machine-based to exercises, combining strength and balance. Patients are encouraged to gradually progress to 30 minutes of nonimpact aerobic exercise 3-5 times a week and then advance exercise intensity as proximal hamstring comfort dictates. In general, patients with repaired chronic hamstring ruptures initially tolerate upright and aquatic therapy activities better than cycling because of compression forces caused from sitting on the bicycle seat.
Figure 7 Advanced proprioceptive training.
The next postoperative physician follow-up occurs at 4 months. The patient’s frequency of follow-up with PT is determined on an individual basis and is largely dependent upon the patient’s need for pain management, rehabilitation compliance, and goals.
Phase 4 (4-6 Months) The primary clinical goal of phase 4 is the successful completion of a functional progression for the patient’s return to work tasks or sport activity. Advanced proprioceptive training is carried out as the patient masters previous challenges (Fig. 7). Total leg and hip strengthening exercises should continue to challenge the patient’s strength performance (Fig. 8). Closed kinetic chain hamstring exercises, such as advanced step downs, double to single leg Swiss ball hamstring curls, resisted incline hip extensions, roman dead-lifts, and half to full squat progression with progressive resistance, can gradually be introduced. Low-level plyometrics, such as jump rope, step lunges in multiple directions with progression to walking lunges, can be introduced. A light jogging progression is implemented with the physician’s permission. Single leg hop for distance and Cybex (Cybex International, Medway, MA) isokinetic tests (180°/s and 60°/s) are executed in this phase. Professional and high-level college athletes that need to return to competitive participation may be tested as early as 4 months postoperatively. However, most patients are tested postoperatively at 6 months. The patient may begin a functional progression to return to competitive activities once involved hamstring strength is 75% vs the noninvolved leg at 60°/s. We believe that the 60°/s isokinetic speed versus 180°/s is more indicative of hamstring readiness for high impact, agility, and speed drills.
Discussion Figure 6 Single knee to chest to stretch the posterior hip to prevent scar adhesions and provide neural gliding of the sciatic nerve.
As stated previously, the available literature in regard to proximal hamstring repairs, their surgical repair, and especially
Proximal hamstring tendon tears
223
Figure 8 Total leg and hip strengthening.
the details of postoperative rehabilitation is scarce. Various authors pose a variety of opinions in 3 important areas: (1) early postoperative protection and/or restrictions, (2) details on the specific phases of rehabilitation; and (3) how to determine successful outcomes and the criteria used to allow full return to previous levels of activities. The hamstring sling we developed holds the knee at 70°-90° of flexion and is used to prevent tension on the repair site due to muscle contraction or stretching while the patient is NWB on crutches for 4 weeks. We feel restricting the hip is unnecessary due to this NWB status. Although more challenging for the patient, we feel that mandating a NWB status is important to minimize the chance of damaging the repair made because of excessive muscle activation or unwanted lengthening. Marx et al8 reports on 2 cases of allograft repair for chronic ruptures. They kept their patients NWB in a custom-made hip-knee-ankle orthosis with the hip held in neutral and the knee at approximately 90° of flexion for 8 weeks. Brucker and Imhoff also used a hip-knee-ankle orthosis in their case series with the knee held at 90° for 6 weeks.1 Kirkland et al6 describe their rehabilitation program for a patient with a chronic repair using an allograft. This patient was weight bearing as tolerated during the first 4-6 weeks while using the BLEDSOE (Bledsoe Brace Systems, Grand Prairie, TX) hip spica-knee brace to limit hip and knee ROM, limit stride length, and minimize hip flexion. Chakravarthy et al3 used a custom-made thermoplastic splint to hold the knee at 90° for the first 2 weeks with gradual ROM adjustments during that time. The authors stated that these criteria were set on an individual basis during surgery once repair tension had been determined. Charmichael et al2 had the largest sample, reporting outcomes of 72 acute and chronic cases. They placed their patients on crutches for 2 weeks. The chronic repairs also used a knee brace with limited ROM that was gradually reduced over the course of 4-8 weeks depending on intraoperative findings. The details of each phase of rehabilitation are critical, not only to protect the repaired tendon, but to prevent unwanted complications and delays in recovery. Marx et al8 did not initiate rehabilitation until after phase I at 8 weeks with resistive hamstring strengthening not initiated until 12 weeks. Likewise, Brucker and Imhoff did not begin formal rehabilitation until after the initial protective phase.1 Intensive ther-
apy was then begun for hamstring stretching and strengthening with a goal of full ROM by 14 weeks. Chakravarthy et al3 briefly described a general rehabilitation program that progressed from prone knee flexion exercises to isokinetic work. Charmichael et al2 gradually introduced resistance activity at 3 months in patients who had proximal avulsions of the hamstring. Kirkland et al6 provides the only detailed description of the rehabilitation of a chronic proximal hamstring repair. During their first phase of rehabilitation, they initiated soft tissue mobilization to the posterior thigh, patellar mobilization, quadriceps sets, ankle pumps, hip isometrics, lumbopelvic stabilization exercises, and lower extremity flexibility. Their second phase focused on proprioception, isotonic strengthening exercises, and neural flossing techniques. Phase 3 introduced more functional exercises and hydrotherapy. This led to phase 4 of light impact and sport-specific exercises. Our protocol begins with a detailed preoperative visit for patient education and gait training with the sling. At day 1, our instructions are for the prevention of postoperative complications, such as scar tissue adhesions, quadriceps shutdown, deep vein thrombosis, and neurological signs and symptoms. This is accomplished through patient education in regard to sling usage, gait and transfer training, as well as, simple exercises. At 1 month, we focus on proper gait mechanics, general lower extremity and core strengthening. Emphasis is placed on proprioception, hip control, and the gradual initiation of high frequency, high repetition, and low load hamstring contractions. This is critical to stimulate a dormant muscle and accelerate the healing process. Stretching is rarely prescribed. We feel an avulsed tendon repair has a tendency to “creep” over time. Only at 3 months postoperatively, if the patient is asymmetrical in muscle length and experiencing discomfort, would hamstring stretching be initiated. We establish a thorough progression of increasingly advanced hamstring strengthening exercises, from standing knee flexion to supine to seated to standing hip extension, as well as, neuromuscular stabilization exercises. The focus on total lower extremity strengthening for the quadriceps, hip, and core is also critical to resume normal function. Marx et al8 makes no mention of when sporting activities are first initiated. Final outcomes were measured by assessing bilateral hamstring flexibility tension and BIODEX (Biodex
S.F. Hamersly and M. Schrader
224 Corporation, Shirley, NY) isokinetic strength testing was performed, but not until 2 years postoperatively. Brucker and Imhoff had 7 of 8 patients return to preinjury levels of activity at an average follow-up of 33 months.1 Sporting activities were restricted postoperatively for 6-8 months. Clinical examination included hamstring flexibility, neurologic testing, Cybex strength testing, and subjective questionnaire scores. Chakravarthy et al3 reported excellent functional outcomes for 4 high level patients (3 chronic, 1 acute). All patients had a complete recovery with full return to work, no pain and return of normal strength (10% side-to-side difference on the Cybex). Three of the 4 returned to preinjury levels of sport. Carmichael et al allowed his patients to return to sporting activities at 6 months. Kirkland et al6 began functional testing at 5 months with the Sportcord test. They also used the Lower extremity functional scale as a subjective outcomes measure. Their patient achieved a normal score on these examinations at 7 months. We perform a Cybex isokinetic strength test for knee extension and flexion at 180°/s and 60°/s. A single leg hop for distance, comparison of hamstring tension/flexibility and joint ROM at the knee, hip, and back are also measured at 4 and 6 months postoperatively. If the patient achieves a minimum of 75% strength in bilateral comparison, our goal is to allow impact activities at 4 months with complete return to previous levels of participation by 6 months. The 4-6 month time frame is when more advanced, complicated and functionally specific exercises are initiated. These exercises, depending on the patient’s goals and desires, can include a Swiss ball, foam rollers, sport cords, slide boards, a jogging progression, and eventually plyometrics. The use of the Functional Movement Screen is also helpful to discern slight compensations that may have developed.
Conclusions We would like to emphasize that this is our standard protocol for all proximal hamstring repairs whether acute, chronic or ischial avulsion fractures. Our protocol is not evidence-
based, but a collaboration with 1 surgeon who has completed over 80 complete proximal repairs. The speed at which a patient will advance through our rehabilitation program will vary depending upon the nature of the injury and type of surgical repair. Individuals with acute ruptures tend to progress in a more timely and predictable fashion with fewer pain issues and nerve symptoms. Patients having undergone chronic proximal hamstring repair in conjunction with neurolysis of the sciatic nerve, or a repair using an allograft, or open reduction internal fixation of an ischial avulsion fracture will tend to progress more slowly through the rehabilitative process due to tension on the repair and sciatic nerve hypersensitivities. Also, problems with neuromuscular coordination between the quadriceps and hamstring muscle groups during reciprocal weight bearing movements seem to take longer time to resolve. Therefore, initiating a sport specific, impact progression may not be appropriate until the end of phase 4, at the 6 month time frame.
References 1. Brucker PU, Imhoff AB: Functional assessment after acute and chronic complete ruptures of the proximal hamstring tendons. Knee Surg Sports Traumatol Arthrosc 13:411-418, 2005 2. Carmichael J, Packham I, Trikha SP, et al: Avulsion of the proximal hamstring origin: Surgical technique. J Bone Joint Surg Am 91:249-256, 2009 (suppl 2) 3. Chakravarthy J, Ramisetty N, Pimpalnerkar A, et al: Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull riders: A report of four cases and review of the literature. Br J Sports Med 39:569-572, 2005 4. Folsom GJ, Larson CM: Surgical treatment of acute versus chronic complete proximal hamstring ruptures. Am J Sports Med 36:104-109, 2008 5. Klingele KE, Sallay PI: Surgical repair of complete proximal hamstring tendon rupture. Am J Sports Med 30:742-747, 2002 6. Kirkland A, Garrison C, Singleton S, et al: Surgical and therapeutic management of a complete proximal hamstring avulsion after failed conservative approach. J Orthop Sports Phys Ther 38:754-760, 2008 7. Sallay PI, Ballard G, Hamersly S, et al: Subjective and functional outcomes following surgical repair of complete ruptures of the proximal hamstring complex. Orthopedics 31:1092, 2008 8. Marx RG, Fives G, Chu SK, et al: Allograft reconstruction for symptomatic chronic complete proximal hamstring tendon avulsion. Knee Surg Sports Traumatol Arthrosc 17:19-23, 2009
P
roximal tears of the hamstring tendon are as uncommon as the rehabilitation guidelines for their postoperative care. Information in the current literature is scarce, and the postoperative rehabilitation programs that are published are variable.1-7 Most programs are collaborations between surgeons and therapists and are not evidence-based. Common to the few programs that are published are the immediate postoperative immobilization with a brace or device to protect the repair, early weight bearing restrictions, and the initiation of resistance exercise beginning at 6 weeks postoperatively.1-7 Differences among the programs can be seen in regard to range of motion (ROM) allowed at the knee joint, the use of hamstring stretching, and the time to return to athletic activities. We have developed the following protocol by collaborating with 1 surgeon over a period of 11 years who has completed more than 80 complete proximal hamstring repairs to date. Although the protocol has been mentioned in a previous publication, it has not been described in its entirety.7
Proximal Hamstring Repair Rehabilitation Rehabilitation for proximal hamstring rupture repairs is divided into 5 phases. The preoperative phase includes active Physical Therapy Department, Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN. Address reprint requests to Scott F. Hamersly, MS, PT, SCS, ATC, CSCS, Methodist Sports Medicine/The Orthopedic Specialists, 201 Pennsylvania Pkwy., Ste. 325, Indianapolis, IN 46280. E-mail: shamersly@ methodistsports.com
1060-1872/09/$-see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1053/j.otsm.2009.12.005
participation of both patient and caregiver and determines how well the immediate postrehabilitative phase progresses. Time lines for postoperative rehabilitative phases are phase 1 (0-4 weeks), phase 2 (4-8 weeks), phase 3 (8-16 weeks), and phase 4 (4-6 months).
Preoperative Phase The preoperative phase includes 2 critical points; patient and caregiver education as well as practice with the hamstring sling during gait and transfers. Both the patient and the caregiver must be mindful of 2 postoperative precautions; avoiding active hamstring contraction and hip flexion beyond approximately 60°. If these precautions are not heeded, they may result in tearing of the repaired hamstring tendon. Therefore, the involved foot is passively raised and suspended in the sling with the assistance of a caregiver for all upright activities. Both patient and caregiver are given instruction on and asked to demonstrate correct techniques for transferring supine-tositting and sitting-to-standing without exceeding 60° of hip flexion. Although the foot of the surgical leg is allowed to gently rest on the floor, the patient is cautioned not to weight bear on the leg during transfers. When rising from a sitting to a standing position, the patient leads with the hips and shifts their weight through the upper extremities and noninvolved leg. Transitioning from standing to sitting, the patient’s torso must lean back while lowering the hips into a seat. Gait training on level surfaces and stairs with the sling in place is practiced until the patient demonstrates safe execution. Practicing the aforementioned strategies in the patient’s own home is strongly encouraged (Fig. 1). 219
S.F. Hamersly and M. Schrader
220
Figure 1 Transitioning from sitting to standing (A). Gait training on level surfaces and stairs with the sling in place (B).
At this time, the patient and his or her family members present with many questions. Explanation of the rehabilitative process, including physician and physical therapy (PT) visits, physical performance testing, timeline for return to functional activities, and expected outcomes are all addressed during the preoperative visit.
Phase 1 (0-4 Weeks) Unique to phase 1 is the use of a hamstring sling to passively maintain knee flexion of the involved limb while non–weight bearing (NWB) with crutches. The sling is constructed of a 2 inch nylon strap that fastens around the waist and connects to a loop on the heel of the shoe. The sling holds the knee between 70° and 90°, effectively placing slack on the hamstring to protect the repair. Considered the protective phase, this time frame focuses on alleviating tension stress on the repair, as well as, pain and swelling control. During the first week after surgery, the patient remains supine or in a sidelying position with the hip in neutral and the knee either extended or in slight flexion. A gentle semi-reclined position can be assumed with a small towel roll (2-3 inches) under the knee to reduce hamstring tension and avoid knee joint stiffness. Complying with the “no active hamstring contraction” rule means that all the knee flexion positions must be achieved passively. This precaution is imperative and is adhered to during the entire first phase. A cryotherapy unit with a large foot cuff is placed under the involved hip and used consistently during the first week for pain and swelling control. Therapeutic exercises are kept simple. Quadriceps sets (4 ⫻ 20 reps/day) prevent neuro-
muscular shut down of the muscle. In addition to reducing the risk of deep vein thrombosis formation, ankle pumps (20-30 reps/hour) provide early gentle neural gliding to prevent scar adherence and development of abnormal nerve symptoms (Fig. 2). Additionally, light, desensitization massage to the incision and posterior hip is employed to ease discomfort and reduce the occurrence of hypersensitivity issues. Postoperative weeks 2 through 4 allow for gradual resumption into limited upright activities of daily living (ADLs). Again, the involved leg is suspended in the sling anytime the patient is ambulating for the entire first postoperative month. Patients may lower the involved foot and al-
Figure 2 Ankle pumps provide early general neural gliding and help reduce the risk of deep venous thrombosis.
Proximal hamstring tendon tears
221
Figure 5 Gluteus medius strengthening is started in a sidelying position and is progressed to the upright position.
Figure 3 Standing hamstring curls.
low it to touch the ground during transfers and with showering. A shower stool is advised for patient safety. Other useful equipment recommendations given to patients include toilet safety handrails, an extended reacher, a long shoehorn, and an elevated toilet seat for tall individuals. Postoperative clinical follow-up with the physician is at 1 week for suture removal. Bedside PT is carried out postoperatively the first day with the patient and caregiver demonstrating all exercises, transfers and gait training with the hamstring sling, and NWB crutches on level surfaces. The next PT visit coincides with the physician’s 1 month postoperative visit.
Phase 2 (1-2 Months) Clinical goals during phase 2 include restoration of normal gait and return of pain-free functional ADLs. At the 1 month
postoperative visit, the hamstring sling is discontinued and the patient begins to wean off the crutches as active quadriceps muscle control is achieved. Hamstring curl strengthening is initiated in standing with the hip joint held in neutral position and the lower leg moving against gravity in pain-free arcs (Fig. 3). Resistance is increased a pound at a time as tolerated with emphasis on high repetitions (50 reps) and high frequency (4-5 times/d). When the patient is able to move through a full and pain-free knee flexion arc with 8-10 lbs at high reps, patients can transition from standing to machine hamstring curls (Fig. 4). Other total leg and hip strengthening exercises are also incorporated into the home exercise program (HEP). Quarter squats and heel raises progress from bilateral to unilateral status. Step down exercises using a progressively higher step not only further enhances leg and hip strength but also improves proprioceptive deficits. Gluteus maximus strength exercises progress from prone (heel pushes with the knee flexed at 90° to hip extension with the flexed at 90° to hip extension with an extended knee) to supine (bilateral to unilateral bridging). Gluteus medius strengthening is started in a sidelying position and is progressed to the upright position (Fig. 5). The patient can begin unilateral knee extension and leg press activities with light resistance and increase resistances as the surgical hip
Figure 4 Patients can transition from standing to machine hamstring curls.
S.F. Hamersly and M. Schrader
222 tolerates. Because cocontraction of the hamstrings occurs during the leg press, starting hip position should be below 90° and pain free. Hamstring flexibility exercises are contraindicated for the first 3 months after surgery. Formal hamstring stretching may produce excessive tissue creep resulting in an inappropriate tissue length—tension relationship. Lengthening of repaired muscle tissue and return of normal hamstring flexibility are typically not a problem and will naturally progress on its own through ADL tasks. However, patients often claim their repaired hamstring feels tight and will want to stretch it. Patients who had a chronic hamstring rupture typically express this more so than patients who had an acute hamstring rupture. Upon examination, supine passive hip flexion with the knee flexed on the involved side is often found to be less than the noninvolved side. Patients are allowed to perform a gentle single knee to chest stretch on the involved side to relieve posterior hip tightness (Fig. 6). This also serves as a neural glide exercise to prevent scar adhesions about the sciatic nerve. Postoperative clinical follow-up with the physician is at 2 months. Postoperative PT follow-up is generally at 6 weeks and 2 months.
Phase 3 (2-4 Months) Phase 3 clinical goals include return to unrestricted ADL’s at home and work, continued hamstring strengthening, and pain-free performance of nonimpact aerobic activities. Hamstring strengthening can advance from machine-based to exercises, combining strength and balance. Patients are encouraged to gradually progress to 30 minutes of nonimpact aerobic exercise 3-5 times a week and then advance exercise intensity as proximal hamstring comfort dictates. In general, patients with repaired chronic hamstring ruptures initially tolerate upright and aquatic therapy activities better than cycling because of compression forces caused from sitting on the bicycle seat.
Figure 7 Advanced proprioceptive training.
The next postoperative physician follow-up occurs at 4 months. The patient’s frequency of follow-up with PT is determined on an individual basis and is largely dependent upon the patient’s need for pain management, rehabilitation compliance, and goals.
Phase 4 (4-6 Months) The primary clinical goal of phase 4 is the successful completion of a functional progression for the patient’s return to work tasks or sport activity. Advanced proprioceptive training is carried out as the patient masters previous challenges (Fig. 7). Total leg and hip strengthening exercises should continue to challenge the patient’s strength performance (Fig. 8). Closed kinetic chain hamstring exercises, such as advanced step downs, double to single leg Swiss ball hamstring curls, resisted incline hip extensions, roman dead-lifts, and half to full squat progression with progressive resistance, can gradually be introduced. Low-level plyometrics, such as jump rope, step lunges in multiple directions with progression to walking lunges, can be introduced. A light jogging progression is implemented with the physician’s permission. Single leg hop for distance and Cybex (Cybex International, Medway, MA) isokinetic tests (180°/s and 60°/s) are executed in this phase. Professional and high-level college athletes that need to return to competitive participation may be tested as early as 4 months postoperatively. However, most patients are tested postoperatively at 6 months. The patient may begin a functional progression to return to competitive activities once involved hamstring strength is 75% vs the noninvolved leg at 60°/s. We believe that the 60°/s isokinetic speed versus 180°/s is more indicative of hamstring readiness for high impact, agility, and speed drills.
Discussion Figure 6 Single knee to chest to stretch the posterior hip to prevent scar adhesions and provide neural gliding of the sciatic nerve.
As stated previously, the available literature in regard to proximal hamstring repairs, their surgical repair, and especially
Proximal hamstring tendon tears
223
Figure 8 Total leg and hip strengthening.
the details of postoperative rehabilitation is scarce. Various authors pose a variety of opinions in 3 important areas: (1) early postoperative protection and/or restrictions, (2) details on the specific phases of rehabilitation; and (3) how to determine successful outcomes and the criteria used to allow full return to previous levels of activities. The hamstring sling we developed holds the knee at 70°-90° of flexion and is used to prevent tension on the repair site due to muscle contraction or stretching while the patient is NWB on crutches for 4 weeks. We feel restricting the hip is unnecessary due to this NWB status. Although more challenging for the patient, we feel that mandating a NWB status is important to minimize the chance of damaging the repair made because of excessive muscle activation or unwanted lengthening. Marx et al8 reports on 2 cases of allograft repair for chronic ruptures. They kept their patients NWB in a custom-made hip-knee-ankle orthosis with the hip held in neutral and the knee at approximately 90° of flexion for 8 weeks. Brucker and Imhoff also used a hip-knee-ankle orthosis in their case series with the knee held at 90° for 6 weeks.1 Kirkland et al6 describe their rehabilitation program for a patient with a chronic repair using an allograft. This patient was weight bearing as tolerated during the first 4-6 weeks while using the BLEDSOE (Bledsoe Brace Systems, Grand Prairie, TX) hip spica-knee brace to limit hip and knee ROM, limit stride length, and minimize hip flexion. Chakravarthy et al3 used a custom-made thermoplastic splint to hold the knee at 90° for the first 2 weeks with gradual ROM adjustments during that time. The authors stated that these criteria were set on an individual basis during surgery once repair tension had been determined. Charmichael et al2 had the largest sample, reporting outcomes of 72 acute and chronic cases. They placed their patients on crutches for 2 weeks. The chronic repairs also used a knee brace with limited ROM that was gradually reduced over the course of 4-8 weeks depending on intraoperative findings. The details of each phase of rehabilitation are critical, not only to protect the repaired tendon, but to prevent unwanted complications and delays in recovery. Marx et al8 did not initiate rehabilitation until after phase I at 8 weeks with resistive hamstring strengthening not initiated until 12 weeks. Likewise, Brucker and Imhoff did not begin formal rehabilitation until after the initial protective phase.1 Intensive ther-
apy was then begun for hamstring stretching and strengthening with a goal of full ROM by 14 weeks. Chakravarthy et al3 briefly described a general rehabilitation program that progressed from prone knee flexion exercises to isokinetic work. Charmichael et al2 gradually introduced resistance activity at 3 months in patients who had proximal avulsions of the hamstring. Kirkland et al6 provides the only detailed description of the rehabilitation of a chronic proximal hamstring repair. During their first phase of rehabilitation, they initiated soft tissue mobilization to the posterior thigh, patellar mobilization, quadriceps sets, ankle pumps, hip isometrics, lumbopelvic stabilization exercises, and lower extremity flexibility. Their second phase focused on proprioception, isotonic strengthening exercises, and neural flossing techniques. Phase 3 introduced more functional exercises and hydrotherapy. This led to phase 4 of light impact and sport-specific exercises. Our protocol begins with a detailed preoperative visit for patient education and gait training with the sling. At day 1, our instructions are for the prevention of postoperative complications, such as scar tissue adhesions, quadriceps shutdown, deep vein thrombosis, and neurological signs and symptoms. This is accomplished through patient education in regard to sling usage, gait and transfer training, as well as, simple exercises. At 1 month, we focus on proper gait mechanics, general lower extremity and core strengthening. Emphasis is placed on proprioception, hip control, and the gradual initiation of high frequency, high repetition, and low load hamstring contractions. This is critical to stimulate a dormant muscle and accelerate the healing process. Stretching is rarely prescribed. We feel an avulsed tendon repair has a tendency to “creep” over time. Only at 3 months postoperatively, if the patient is asymmetrical in muscle length and experiencing discomfort, would hamstring stretching be initiated. We establish a thorough progression of increasingly advanced hamstring strengthening exercises, from standing knee flexion to supine to seated to standing hip extension, as well as, neuromuscular stabilization exercises. The focus on total lower extremity strengthening for the quadriceps, hip, and core is also critical to resume normal function. Marx et al8 makes no mention of when sporting activities are first initiated. Final outcomes were measured by assessing bilateral hamstring flexibility tension and BIODEX (Biodex
S.F. Hamersly and M. Schrader
224 Corporation, Shirley, NY) isokinetic strength testing was performed, but not until 2 years postoperatively. Brucker and Imhoff had 7 of 8 patients return to preinjury levels of activity at an average follow-up of 33 months.1 Sporting activities were restricted postoperatively for 6-8 months. Clinical examination included hamstring flexibility, neurologic testing, Cybex strength testing, and subjective questionnaire scores. Chakravarthy et al3 reported excellent functional outcomes for 4 high level patients (3 chronic, 1 acute). All patients had a complete recovery with full return to work, no pain and return of normal strength (10% side-to-side difference on the Cybex). Three of the 4 returned to preinjury levels of sport. Carmichael et al allowed his patients to return to sporting activities at 6 months. Kirkland et al6 began functional testing at 5 months with the Sportcord test. They also used the Lower extremity functional scale as a subjective outcomes measure. Their patient achieved a normal score on these examinations at 7 months. We perform a Cybex isokinetic strength test for knee extension and flexion at 180°/s and 60°/s. A single leg hop for distance, comparison of hamstring tension/flexibility and joint ROM at the knee, hip, and back are also measured at 4 and 6 months postoperatively. If the patient achieves a minimum of 75% strength in bilateral comparison, our goal is to allow impact activities at 4 months with complete return to previous levels of participation by 6 months. The 4-6 month time frame is when more advanced, complicated and functionally specific exercises are initiated. These exercises, depending on the patient’s goals and desires, can include a Swiss ball, foam rollers, sport cords, slide boards, a jogging progression, and eventually plyometrics. The use of the Functional Movement Screen is also helpful to discern slight compensations that may have developed.
Conclusions We would like to emphasize that this is our standard protocol for all proximal hamstring repairs whether acute, chronic or ischial avulsion fractures. Our protocol is not evidence-
based, but a collaboration with 1 surgeon who has completed over 80 complete proximal repairs. The speed at which a patient will advance through our rehabilitation program will vary depending upon the nature of the injury and type of surgical repair. Individuals with acute ruptures tend to progress in a more timely and predictable fashion with fewer pain issues and nerve symptoms. Patients having undergone chronic proximal hamstring repair in conjunction with neurolysis of the sciatic nerve, or a repair using an allograft, or open reduction internal fixation of an ischial avulsion fracture will tend to progress more slowly through the rehabilitative process due to tension on the repair and sciatic nerve hypersensitivities. Also, problems with neuromuscular coordination between the quadriceps and hamstring muscle groups during reciprocal weight bearing movements seem to take longer time to resolve. Therefore, initiating a sport specific, impact progression may not be appropriate until the end of phase 4, at the 6 month time frame.
References 1. Brucker PU, Imhoff AB: Functional assessment after acute and chronic complete ruptures of the proximal hamstring tendons. Knee Surg Sports Traumatol Arthrosc 13:411-418, 2005 2. Carmichael J, Packham I, Trikha SP, et al: Avulsion of the proximal hamstring origin: Surgical technique. J Bone Joint Surg Am 91:249-256, 2009 (suppl 2) 3. Chakravarthy J, Ramisetty N, Pimpalnerkar A, et al: Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull riders: A report of four cases and review of the literature. Br J Sports Med 39:569-572, 2005 4. Folsom GJ, Larson CM: Surgical treatment of acute versus chronic complete proximal hamstring ruptures. Am J Sports Med 36:104-109, 2008 5. Klingele KE, Sallay PI: Surgical repair of complete proximal hamstring tendon rupture. Am J Sports Med 30:742-747, 2002 6. Kirkland A, Garrison C, Singleton S, et al: Surgical and therapeutic management of a complete proximal hamstring avulsion after failed conservative approach. J Orthop Sports Phys Ther 38:754-760, 2008 7. Sallay PI, Ballard G, Hamersly S, et al: Subjective and functional outcomes following surgical repair of complete ruptures of the proximal hamstring complex. Orthopedics 31:1092, 2008 8. Marx RG, Fives G, Chu SK, et al: Allograft reconstruction for symptomatic chronic complete proximal hamstring tendon avulsion. Knee Surg Sports Traumatol Arthrosc 17:19-23, 2009