Variability of United States Online Rehabilitation Protocols for Proximal Hamstring Tendon Repair

Abstract

Background: The optimal postoperative rehabilitation protocol following repair of complete proximal hamstring tendon ruptures is the subject of ongoing investigation, with a need for more standardized regimens and evidence-based modalities.

Purpose: To assess the variability across proximal hamstring tendon repair rehabilitation protocols published online by United States (US) orthopaedic teaching programs.

Study design: Cross-sectional study.

Methods: Online proximal hamstring physical therapy protocols from US academic orthopaedic programs were reviewed. A web-based search using the search term complete proximal hamstring repair rehabilitation protocol provided an additional 14 protocols. A comprehensive scoring rubric was developed after review of all protocols and was used to assess each protocol for both the presence of various rehabilitation components and the point at which those components were introduced.

Results: Of 50 rehabilitation protocols identified, 35 satisfied inclusion criteria and were analyzed. Twenty-five protocols (71%) recommended immediate postoperative bracing: 12 (34%) prescribed knee bracing, 8 (23%) prescribed hip bracing, and 5 (14%) did not specify the type of brace recommended. Fourteen protocols (40%) advised immediate nonweightbearing with crutches, while 16 protocols (46%) permitted immediate toe-touch weightbearing. Advancement to full weightbearing was allowed at a mean of 7.1 weeks (range, 4-12 weeks). Most protocols (80%) recommended gentle knee and hip passive range of motion and active range of motion, starting at a mean 1.4 weeks (range, 0-3 weeks) and 4.0 weeks (range, 0-6 weeks), respectively. However, only 6 protocols (17%) provided specific time points to initiate full hip and knee range of motion: a mean 8.0 weeks (range, 4-12 weeks) and 7.8 weeks (range, 0-12 weeks), respectively. Considerable variability was noted in the inclusion and timing of strengthening, stretching, proprioception, and cardiovascular exercises. Fifteen protocols (43%) required completion of specific return-to-sport criteria before resuming training.

Conclusion: Marked variability is found in both the composition and timing of rehabilitation components across the various complete proximal hamstring repair rehabilitation protocols published online. This finding mirrors the variability of proposed rehabilitation protocols in the professional literature and represents an opportunity to improve patient care.

Keywords: hamstring; physical therapy; rehabilitation; tendon repair; tendon rupture.

Figure 1.

(A) Postoperative variability in adjunctive therapy utilization between physical therapy rehabilitation protocols. More than 70% of protocols recommended some form of immediate postoperative brace; 34% recommended knee braces, while 23% recommended hip braces. While cryotherapy was recommended to decrease swelling and pain in just over 50% of protocols, few protocols advocated for the use of neuromuscular electric stimulation (NMES) or postrecovery functional bracing. (B) Of those protocols recommending postoperative knee bracing, the most common knee flexion lock limit was 90° of flexion. (C) Of those protocols recommending postoperative hip bracing, the most common hip flexion lock limit was 45° of flexion.

Figure 2.

(A) Strengthening exercises. Significant variation was found with regard to types of exercises included in rehabilitation protocols. (B) Significant variation was also found with regard to recommended start times. The numbered line within each range represents the mean of the data set. AROM, active range of motion; DL, double leg; HS, hamstring; PROM, passive range of motion; Quad, quadriceps; SL, single leg.

Figure 3.

(A) Proprioception exercises. Significant variation was found with regard to the inclusion of certain exercises. Nearly 25% of rehabilitation protocols recommended late-stage proprioceptive activities but did not specify exercises, represented in the chart as advanced proprioception. (B) Exercise start dates were marked by substantial variation. The numbered line within each range represents the mean of the data set.

Figure 4.

(A) Return to basic activity and (B) start dates. The numbered line within each range represents the mean of the data set.

Figure 5.

(A) Return to athletic activity, where the blue bars represent the percentage of protocols recommending the activity and the red bars represent the percentage of protocols in which the activity is well-defined. (B) Return to athletic activity start dates. Protocols rarely provided clear instructions for athletic activities or established criteria-based progression for return to training. The numbered line within each range represents the mean of the data set.