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.

Rehabilitation Variability After Elbow Ulnar Collateral Ligament Reconstruction

“…However, our methodology is in accordance with similar rehabilitation studies. 4 , 11 – 13 Second, it is common practice for orthopaedic surgeons to provide protocols directly to patients or to physical therapists. Such protocols are more likely to be individualized, incorporating preoperative considerations and intraoperative decisions.…”

“…This methodology is in line with prior rehabilitation-focused studies. 11 – 13 For ERAS protocols, a general web-based search ( www.Google.com ) was performed using the following search term: “[Program/affiliate hospital/affiliate medical school name] UCL reconstruction rehabilitation protocol.” Protocols from the published literature that primarily focused on rehabilitation were selected using PubMed using the search term “UCL reconstruction rehabilitation protocols.” This search accounted for overlapping protocols, identifying those original studies in which protocols were first proposed. Protocols were excluded from the review if they were designed for pediatric patients, involved concomitant procedures, or lacked sufficient detail such as commencement time points for rehabilitation components.…”

“…As such, rehabilitation after UCL reconstruction has been a topic of investigation in recent years. 5,6,18,20,21 We have previously assessed the quality and variability of postoperative rehabilitation protocols for anterior cruciate ligament reconstruction, 13 proximal hamstring repair, 11 and Achilles tendon repair 12 and found significant diversity among recommendations, many of which were not supported by evidence. Given that multiple orthopaedic studies have found a correlation between improved clinical outcomes and standardization of clinical care, 1,8 an initial investigation of the variability across UCL rehabilitation protocols is warranted.…”

Repair of Proximal Hamstring Tear Utilizing a Suture Bridge Knotless Construct

“…As for weight bearing, 40% of protocols advised non-weight bearing and 46% allowed toe-touch weight bearing. Advancement to full weight bearing was allowed at a mean of 7.1 weeks [16]. Gerhardt eliminated postoperative bracing and allowed his patients, following knotless suture anchor construct fixation, to eliminate weight bearing assistance at two weeks [10].…”

Proximal Hamstring Injuries: Review of Operative and Nonoperative Management

“…A recent study evaluated publicly available protocols following proximal hamstring repair. 114 The majority of rehabilitation protocols utilize a postoperative brace for up to 6 weeks postoperatively, coinciding with a period of toe-touch or foot-flat weight bearing. The type of brace is also variable, although knee braces are typically employed more frequently than hip braces, with the knee initially maintained in 45 to 90 degrees of flexion depending on the intraoperative assessment of the repair.…”