Summary

A brace-free and accelerated weight-bearing rehabilitation protocol after surgical repair of acute proximal hamstring tendon avulsions permits improved early physical health-related quality of life, without jeopardizing the integrity of the repair.

Abstract

Introduction

Proximal hamstring tendon avulsion from the ischial tuberosity is a significant injury and may result in an inability to successfully return to athletic activities, let alone activities of daily living. For this reason, surgical repair is generally advocated. However, limited data is available regarding the optimal post-rehabilitation regime with extensive variation in published protocols. Many of these protocols also advocate bracing and a lengthy period of restricted weight bearing, in the absence of evidence-based research that would suggest otherwise. This study investigated patient outcomes following a traditionally conservative (CR) versus accelerated (AR) rehabilitation regimen after proximal hamstring tendon repair.

Methods

This prospective randomized controlled trial (RCT) allocated 50 patients undergoing proximal hamstring tendon repair to either a braced, partial weight-bearing rehabilitation regime (CR=25) or an accelerated, unbraced regime, that permitted full weight-bearing as tolerated (AR=25). Patients were evaluated pre-operatively and at 3, 6 and 12 months post-surgery, via patient-reported outcome measures (PROMs) including the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT) and 12-item Short Form Health Survey (SF-12). Objective measures including the single (SHD), triple (THD) and triple crossover (TCHD) hop tests were assessed at 6 and 12 months, as was peak isometric hamstring strength (at 45 and 90 degrees of flexion) and peak isokinetic knee extensor and flexor torque. Limb symmetry indices (LSIs) were calculated for objective measures, with repeated measures analysis of variance employed to statistically analyze outcomes over time and between groups.

Results

All PROMs improved (p>0.05) and, while the AR group reported a significantly better Physical Component Score for the SF-12 at 3 months (p=0.022), as well as a lower severity of hamstring pain at 12 months (p=0.032), there were no other group differences. LSIs for peak isometric hamstrings strength and peak isokinetic quadriceps and hamstrings torque symmetry were not different between groups (p>0.05). While the AR group demonstrated a significantly higher (AR=98.6, CR=94.6, p=0.009) LSI for the THD at 6 months, no other hop test differences were seen between groups. Three re-injuries were observed (CR=2, AR=1).

Conclusions

The current study has shown that after proximal hamstring repair surgery, post-operative outcomes following an accelerated rehabilitation regimen were largely comparable to a traditionally conservative rehabilitation pathway, albeit demonstrating better early physical health-related quality of life scores. Importantly, the accelerated regimen did not adversely affect outcomes or jeopardize the integrity of the repair, which is a primary reason why many protocols and clinicians still advocate a conservative post-operative process.