post-operative instructions proximal hamstring repair · 2019-01-14 · post-operative instructions...

Laith M Jazrawi, MD

Professor of Orthopedic Surgery Chief, Division of Sports Medicine T 646-501-7223

NYU Langone Orthopedic Center 333 E 38th St, New York, NY 10016 T 646-501-7223 F 646-754-9505 www.NewYorkOrtho.com

Post-Operative Instructions Proximal Hamstring Repair

Dayofsurgery

A. DietastoleratedB. Painmedicationasneededevery4-6hours(refertopainmedicationsheet).C. Makesureyouhaveaphysicaltherapypost-opappointmentscheduledduringthefirstweekaftersurgery.D. Ifyouweregivenabracethisshouldbewornatalltimesexceptduringsleep.

FirstPost-OperativeDay

A. Painmedicationasneeded.SecondPost-OperativeDayUntilReturnVisit

A. Unlessotherwisenoted,weight-bearingistoe-touchingonlyforthefirst6weeksaftersurgery.After6weeks,youcanbearasmuchweightontheaffectedlegasyoucantolerate.Mostpatientsusecrutchesforthefirst2-3weeks.

B. Callouroffice@646-501-7223option4,option2toconfirmyourfirstpostoperativevisit,whichisusuallyabout1-2weeksaftersurgeryifyouhavenotbeengivenatime.Ifyouareexperiencinganyproblems,pleasecallourofficeorcontactusviatheinternetatwww.newyorkortho.com.

C. TheinitialAquaceldressingshouldbekeptonforthefirst2weeksaftersurgery.After2weeks,youmayremovetheAquaceldressingandshower.Apply4x4(orsimilarsize)TelfaorTegadermtothesewoundspriortoshoweringandwhenshoweringiscompleteapplyfreshdryTelfaorTegaderm.

D. Ifshoweringisbegunbefore2weeks(earliestallowedisthirdpostoperativeday),theAquaceldressingMUSTbekeptdry.

*TelfaAdhesiveIslandDressingsorTegaderm+Padsmaybepurchasedonlineandatselectpharmacies.

Dr. Laith M. Jazrawi Chief, Division of Sports Medicine Associate Professor Department of Orthopaedic Surgery

Rehabilitation Protocol FollowingProximalHamstringPrimaryRepair

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

Thehamstringmusclegroupconsistsofthreemuscles:thebicepsfemoris,semitendinosusandsemimembranosus.Allthreeofthesemusclesoriginatefromtheischialtuberosityofthepelvisandtheninsertbelowthekneewiththebicepsfemorisa=achingonthefibulaandthesemimembranosusandsemitendinosusa=achingonthe?bia(Figure1).Thesemusclescrossthehipandtheknee,andthereforecanaffectbothhipandkneemo?on.Acutehamstringstrainsarecommoninsportsthatinvolvesprin?ng,kickingandhigh-speedskilledmovements.ANa?onalFootballLeagueteampublishedinjurydatafortheirteamduringpre-seasontrainingcampfrom1998-2007.1Hamstringstrainswerethesecondmostcommoninjury,onlysurpassedby“kneesprains”.1Numerousstudieshaveshownthathamstringstrainsareoneofthemostcommoninjuriesinsprin?ngsports,soccer,rugbyandAustralianrulesfootball.1-12Hamstringstrainsprimarilyoccurattheproximalmusculotendonjunc?on.13Proximalmusculotendonstraininjurieshavebeenshowntobetreatedeffec?velywithrehabilita?on.1,8Muchlesscommon,butmostoUenmuchmoresevere,arethehamstringinjuriesinvolvingcompleteavulsionofthehamstringcomplexofftheischialtuberosity.Whenthisoccursalargeamountofbleeding(hematoma)willforminthebackofthethighandthetendonwillmovedownthethigh,retrac?ngawayfromtheischialtuberosity(Figures2and3).Almostallinjuriesoccurfromasliporafallthatcreatesforcefulhipflexionwithsimultaneouskneeextension,manyoftheseduringspor?ngac?vi?es.



Inaddi?ontofallsthisinjurycanoccurwithwaterskiingstartsandbullriding.14-15Thesecompleteavulsionsresultinsignificantorcompletelossofhamstringfunc?ondependingonhowmanyofthetendonsareavulsed.Thiscanleadtopoorlegcontrolanddifficultyevenwalking.Becauseofthesignificantstructuraldamageandresultantdisability,theseinjuriesareoUentreatedwithopensurgicalrepair.Theclinicalindica?onsforsurgicalrepairarecompletehamstringavulsionofall3tendonsorsignificantretrac?onwithlessthan3tendonsavulsed.OutcomestudiesindicatethatifsurgeryisperformedshortlyaUerinjury,theoutcomeissuperiortothosewhosesurgerywasdelayedseveralmonths.Acutesurgicalrepairisperformedbysuturingthetorntendonstosutureanchorsplacedintheboneattheanatomicalorigin.Thisusuallyrequires2-4sutureanchorsandPanacrylorEthibondsutures(Figures4and5).16-17Inaddi?ontofallsthisinjurycanoccurwithwaterskiingstartsandbullriding.14-15Thesecompleteavulsionsresultinsignificantorcompletelossofhamstringfunc?ondependingonhowmanyofthetendonsareavulsed.Thiscanleadtopoorlegcontrolanddifficultyevenwalking.Becauseofthesignificantstructuraldamageandresultantdisability,theseinjuriesareoUentreatedwithopensurgicalrepair.Theclinicalindica?onsforsurgicalrepairarecompletehamstringavulsionofall3tendonsorsignificantretrac?onwithlessthan3tendonsavulsed.OutcomestudiesindicatethatifsurgeryisperformedshortlyaUerinjury,theoutcomeissuperiortothosewhosesurgerywasdelayedseveralmonths.Acutesurgicalrepairisperformedbysuturingthetorntendonstosutureanchorsplacedintheboneattheanatomicalorigin.Thisusuallyrequires2-4sutureanchorsandPanacrylorEthibondsutures(Figures4and5).16-17Post-opera?velycrutchesareusedtoassistinwalkingforthefirstfewweeks.Abraceorprotec?vedevicealsomaybeusedtoprotectthehamstring.Onefactorinthisdecisionisthe?meofyear(snow/ice),asmostreportedepisodesofearlyfailurearerelatedtoslippingandfalling.Anotherfactor,whichisassessedduringsurgery,istheeasewithwhichthetorntendoncanreachitsoriginalinser?ononthepelvis.Ifthetendonwassignificantlyretractedthereisagreaterlikelihoodoflongerpost-opera?veprotec?on.



Goals o  Protection of surgical repair o  Progress ROM by 30 degrees per week to full ROM by 8 weeks o  Cryotherapy unit to be used 4-6 times per day for 20 minutes o  Crutches/non-weight bearing for 4 weeks with progression to full-weight

bearing

Precautions o  Non-weight bearing with crutches for 6 weeks o  No active hamstring contraction o  No hip flexion greater than 45 degrees o  Knee extension limited pending intra-operative tension on the repair

Suggestions o  Cryotherapy for pain and swelling control 3-5x a day o  Light desensitization massage to the incision and posterior hip o  Scar massage o  Silicon patch over incision (if open repair)

Goals o  Restore normal gait o  Pain free and normal functional ADLs

Precautions o  Monitor tenderness of surgery site o  No hamstring flexibility or stretching exercises are to be performed during

this phase. Lengthening of the repair and return of normal hamstring flexibility will be allowed to occur on its own

Range of Motion Exercises

o  Increase Forward Flexion, Internal/External Rotation to full motion as tolerated

Therapeutic Exercises

o  Restore normal gait pattern (emphasize good leg control with extension of knee during swing phase and heel strike)

o  Improve ADL function i.e sit->stand, stairs, etc. o  Begin light hamstring strengthening with low loads, high reps and high

frequency by performing hamstring leg curls in standing with the hip extended. Start with zero resistance then progress as tolerated 1lb at a time 2 sets/20, 4-5x a day

o  Begin total leg strengthening: heel raises, quad sets, short arc squads, general hip strengthening in side lying, single leg balance for proprioception

Other Suggestions o  Light desensitization massage to the incision and posterior hip o  Scar massage

Phase I (Surgery to 6 weeks after surgery)

Phase II (6 weeks to 8 weeks following surgery)

Rehabilitation Protocol After Arthroscopic SLAP Repair


Goals o  Pain-free performance of non-impact aerobic activities o  Unrestricted ADLs at home or work

Precautions o  Monitor hamstring flexibility and tenderness of surgery site

Therapeutic Exercises

o  Begin non-impact aerobic conditioning as tolerated with any of the following: stationary bike, stairmaster, elliptical trainer, nordic track, aquatic therapy with swimming or functional activities in the water (avoid forceful, explosive, or repetitively strainful activities)

o  Continue to progress TLS as tolerated: ¼ squats, stepdowns, leg press, knee extensions, heel raises, hip abductor in standing with tubing or machine, balance and proprioceptive training

o  Progress hamstring strengthening in standing by increasing weight or initiating TheraBand

o  Patient may progress to prone positioning on a machine and then to seated leg curls (with hip flexed at 90 degrees) on a machine or with tubing

Phase III (8 weeks to 12 weeks following surgery)

References

Laith M Jazrawi, MD



Post-Operative Rehabilitation Protocol: Proximal Hamstring Tendon Repair PatientName:____________________________________________________________ Date:___________________________________

Weeks0-6:

Goal:• Protectionofsurgicalrepair

Precautions:• Non-weightbearingwithcrutchesfor6weeks

• Noactivehamstringcontraction

• Nohipflexiongreaterthan45degrees

• Kneeextensionlimitedpendingintra-operativetensionontherepair

DurableMedicalEquipment:

ProgressROMby30degreesperweektofullROMby8weeks

Cryotherapyunittobeused4-6timesperdayfor20minutespersession

Crutches/Non-weightbearingfor4weekswithprogressiontofull-weightbearingweeks5-7

Exercises:Cryotherapyforpainandswellingcontrol3-5x/day

Teachpatienthowtotransferfromsupinetosit,standtosit,aswellasperformADLssafely.(Avoidgreater

than45degreesofhipflexionwhenthekneeisextendedduringanyandallactivities,ie.sitting)

Heelpropswithquadsets,supinepositiononly,toavoidkneestiffnessandquadshutdown

Other:1. Lightdesensitizationmassagetotheincisionandposteriorhip

2. Scarmassage

3. Siliconpatchoverincision(ifopenrepair)

Clinicalfollow-up:Follow-upwithphysicianatapproximately2weekspostoperative

Weeks6-8:

Goal:• Restorenormalgait

• PainfreeandnormalfunctionalADLs

Precautions:• Monitortendernessofsurgerysite

• Nohamstringflexibilityorstretchingexercisesaretobeperformedduringthisphase.Lengthening

Laith M Jazrawi, MD



oftherepairandreturnofnormalhamstringflexibilitywillbeallowedtooccuronitsown.(Thisis

traditionallynotanissuefollowingthisprocedure)

Exercises:1. Restorenormalgaitpattern(emphasizegoodlegcontrolwithextensionofkneeduringswingphase

andheelstrike)

2. ImproveADLfunction,ie.Sit->stand,stairs,etc.

3. Beginlighthamstringstrengtheningwithlowloads,highrepsandhighfrequencybyperforming

hamsringlegcurlsinstandingwiththehipextended.Startwithzeroresistancethenprogressas

tolerated1lbatatime-2sets/20,4-5x/day

4. Begintotallegstrengthening(TLS):

a. Heelraises

b. Quadsets(activeheellift)

c. Shortarcquads

d. Generalhipstrengtheninginsidelying(gluteusmaximusandmedius)

e. Singlelegbalanceforproprioception

Other:• Lightdesensitizationmassagetotheincisionandposteriorhip

• Scarmassage

Clinicalfollow-up:Follow-upwithphysicianatapproximately8weekspostoperativetoadvancerehabandmonitorprogress

Weeks8-12:

Goal:• Pain-freeperformanceofnon-impactaerobicactivities

• UnrestrictedADLsathomeorwork

Precautions:• Monitorhamstringflexibilityandtendernessofsurgerysite

Exercises:1. Beginnon-impactaerobicconditioningastoleratedwithanyofthefollowing:

a. Stationarybike

b. Stairmaster

c. Ellipticaltrainer

d. Nordictrack

e. Aquatictherapywithswimmingorfunctionalactivitiesinthewater(Avoidforceful,

explosiveorrepetitivelystrainfulactivities)

2. ContinuetoprogressTLSastolerated:

a. ¼squats

b. Stepdowns

c. Legpress

d. Kneeextensions

Laith M Jazrawi, MD



e. Heelraises

f. Hipabductorinstandingwithtubingormachine

g. Balanceandproprioceptivetraining

3. ProgresshamstringstrengtheninginstandingbyincreasingweightorinitiatingTheraBand

4. Patientmayprogresstopronepositioningonamachineandthentoseatedlegcurls(withhipflexed

at90degrees)onamachineorwithtubing

Clinicalfollow-up:Follow-upwithphysicianatapproximately14weekspostoperativetoreleasetoallactivitiesastolerated.

Thepatient’sfrequencyoffollow-upwiththetherapistwillbedeterminedonanindividualbasisand

dependlargelyonthepatient’sadherence,aswellasthepatient’sandtherapist’scomfortlevel.

Signature:_____________________________________________________ Date:___________________________

post-operative instructions proximal hamstring repair · 2019-01-14 · post-operative instructions...

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