Physiotherapy Protocol

HAMSTRING REATTACHMENT

Phase 1: Acute Phase (0 – 2 weeks)

Goals:

  • Reduce pain and swelling
  • Wound care
  • Restore standing posture and weight bearing
  • Maintain sciatic nerve mobility

Guidelines:

  • Physiotherapy intervention is at a minimum
  • No muscle tension passive or active – i.e. hip flexion must only occur with simultaneous knee flexion
  • Gentle neural mobilisations (off-loading – not stretching)

Phase 2: Continued Healing and repair (2 – 6 weeks)

Goals:

  • Scar management and protection
  • Restore normal gait pattern and full weight bearing status
  • Pain free, non-resisted full hip AROM with the knee >90° flexion
  • Pain free, non-resisted full knee AROM with the hip at 0° in supine or side lying.
  • Dynamic core stability and gluteal strengthening
  • No scar massage until 4 weeks post-op. Use Micropore tape and other scar management treatments such as Cica Care or Kelocote)

Guidelines:

  • Massage Hamstring belly plus trigger points (after 4 weeks)
  • Lying: Supine heel slides – hip and knee flexion to hip and knee extension: progression = gradually sit up as doing the heel slides
  • Supine crook lying single leg press against theraband: progression= supporting leg can hover or be raised whilst affected leg performs the leg press motion
  • Supine over the bed Knee extensions – open chain progressive resistance for quads strengthening and neural mobilisation. NB: Not sitting
  • Standing: Double leg calf raises: progression = single leg calf raises
  • Glute strengthening: standing hip hitching and standing to side-lying straight leg abduction

Phase 3: Continued Repair Phase (6 – 12 weeks)

Goals:

  • Begin gravity-only resisted hamstring strengthening in neutral hip position
  • Start gentle proprioception/balance workout

Guidelines:

  • Standing: Walking on flat ground as able but not as form of exercise. (Comfortable pace for 10 mins, progressing to 30min by week 12)
  • ¼ squats with light hand-weights adding up to < ¼ of body weight
  • Standing theraband exercises (hip Abd/Ext). Theraband attached to ankle, pulling involved leg out to side and backwards against a gentle resistance
  • Exercise bike as tolerated
  • Lying: Double leg bridging in crook lying with feet on the floor. Progression:
    • a) Decrease arm support from by side to across chest
    • b) Add a box under feet then progress to legs on chair
  • Lumbar spine mobility with lower legs on a Swiss ball. Rolling the ball forward and back and side-to-side.
  • Core stability progressions: Pilates reformer leg press (light springs)
  • Prone leg curls, no added weight resistance. Progression = standing leg curls – (No weights until 12 weeks)

Phase 4: Remodeling Stage (12 – 16 weeks)

Goals:

  • Increase strength of hip/knee/ankle and kinetic chain
  • Full range of motion at hip and knee
  • Begin hamstring stretches
  • Begin strengthening Hamstring with added weight resistance
  • Progress proprioception/balance work

Guidelines:

  • Standing: Fast walking (flat ground – no hills)
  • Walk and balance on mini-tramp/foam balance
  • Pilates scooter and home scooter with Theraband. Slow and controlled with progressive increase in resistance
  • Lying: Continue standing Theraband exercises (increase resistance)
  • Stretching: Straight leg raise or sitting knee extension to a gentle discomfort (2/10 VAS)
  • Hamstring strengthening with added resistance. Progression – prone – standing – machine leg curls
  • Swiss ball double leg bridges with core pre-activation
  • Single leg ¼ squats holding up to ¼ body weight
  • Progress gluteal strengthening: Supine theraband hamstring pull downs
  • Leg press: initially double leg and progress to single leg. Progressive resistance

Phase 5: continued remodeling and strengthening stage (16 – 24 weeks)

Goals:

  • 60-70% hamstring strength of involved side vs. non-involved side
  • Progress to eccentric hamstring strengthening
  • Jogging to 75% pace
  • Progress hamstring resisted weight training: Suggestions

Guidelines:

  • Lying: Swiss Ball bridges: Progression – Double leg on Swiss ball, pull heels towards buttock, slow and controlled. Maintain a stable pelvis and slowly decrease arm support.
  • Increasing core stability exercises (advanced Pilates)
  • Sitting: Continue leg press > body weight
  • Hamstring curls in positions gradually increasing hip flexion
  • Standing: Fast walking up hills
  • Progress hamstring resisted weight training: suggestions – double leg – single leg – 2 up concentric and 1 down eccentric. Gradually increase the speed.
  • Balance on involved straight leg; bend over to touch the floor in front of you, then to the left, right and with alternate hands. Return to standing and repeat.
  • Scooter: resistance on pilates reformer machine or with theraband
  • Plyometrics: jumping, hops and landing with ¼ – ½ turns
  • Sciatic neural mobilisation: Swinging leg and head nods
  • Light jogging on flat surface, starting with intervals of 100m with walking in between. Eg: 30m acceleration / 40m jog at 50% / 30m deceleration. Increase intensity as appropriate
  • Backwards striding. Increase speed gradually, focusing on deceleration control.

Phase 6: Sports Specific phase (24 weeks plus)

Goals:

  • Return to sport
  • Running to sprinting
  • >80% hamstring strength of involved side vs non-involved side by 24 weeks
  • >85% hamstring strength of involved side vs non-involved side by 18-24 months

Guidelines:

  • Sport specific drills
  • Plyometrics: alternate jump/split/scissor mini squats and mini lunges. Progression: add hand weights
  • Running drills: increase speed work and multi-directional
  • Straight leg dead lifts
  • Nordic Hamstring curls (eccentric then concentric and eccentric)