Hamstring Lengthening

Ask a PT

156 Posts
 
Posted - 11/05/2006 :  21:41:55  Show Profile  Reply with Quote
Our user asked: "Do you have a protocol to follow after a hamstring lengthening surgrey? If so what is it? Thanks"

Ask a PT Response: "Hamstring lengthening procedures are most commonly performed on individuals who have developmental or neurological disorders in order to help decrease spasticity and tightness. The release would hopefully help promote posture and function. As far as a protocol goes, there is no protocol that my colleagues I have spoken with or myself are aware of. The necessary interventions required will be determined by the surgeon and the specifics of the surgery. After the surgery, the individual who has undergone the surgery will most likely have the leg(s) casted or splinted in order to help prevent the knee(s) from going into flexion. I found a pretty informative website for you in regards to this info for children with CP: http://www.indegene.com/Ort/FeatArt/indOrtFeatArt4.html . For further information I'd recommend you consult with the surgeon. Thank you for using CyberPT "Your Onliine Physical Therapy Resource"."

D.R.

USA
6 Posts
 
Posted - 11/24/2006 :  09:49:28  Show Profile  Reply with Quote
I think it important to allow the surgeon to make a judgement following surgery, that the patient has reached a point of no longer needing restrictions on activity....to return to "activity as tolerated". The reasons for performing this surgery may vary in terms of expectation / outcome, and vary with the pre-surgery functional level of the individual. Some people with CP may be functional walkers, and orthopaedics may think that mild/moderate hs release could allow for improved ambulation. Physical therapists should be aware, that although there are functional problems with tight hamstrings (sense of movement "stiffness", decreased ROM, there could also be problems with release of the hamstrings, and here is an example; often within a developmental disability neuromuscular disability dx category, tight hamstrings are associated with posterior pelvic tilt and flattened lordotic posture, indeed, poor spinal extension generally. Yet the person has been able to gain standing stability, and eventually walking emerged. Releasing the hamstrings too aggressively will allow the pelvis to no go toward anterior pelvic tilt (often influenced by othe tight mm groups, like the quad [rectus femoris] and ileopsoas). And if the person does not have the spinal extension strength to overcome this now imbalanced anterior mm tightness pull, they will initially experience great difficulty with standing stability, which previously (when hamstrings and anterior trunk/leg mm groups were in "tightness" balance), worked fairly well functionally.

So the goal will be to re-strengthen (tighten!!) the newly released hamstrings, to regain pelvic stability upon which trunk extension is based.

True also with non-ambulatory individuals for whom hamstring release is chosen (always question: what is the functional outcome goal? Is the styated goal realistic and consistent with other factors you know about the child/person. For example, "hamstring release 'may' help allow the person to functionally walk one day". Is this consistent with their reflex picture which may be the prime reason ambulation has not emerged, not hamstring tightness. Do they have the other mm balance, isolated strength characteristics, balance and equilibrium reactions necessary for the emergence of ambulation? Just so all parties are clear.) Anyway back to the 1st sentence of this para., release of hamstrings will likely throw the individual into extreme anterior pelvic ilt and sometimes deep accentuated lordosis, becasue again, although the hamstrings are now elongated, the functional result is not necessarily functionally positive, as the anterior (also spastic and tight) mm groups are now allowed to dominate and pull into postural imbalance, from which they may have difficulty maintaining sitting balance, adaptive standing, movement.

So in conclusion, hamstring contracture and tightness has its functional problems, but overly aggressive release of hamstrings, brings with it, other functional problems that should be anticipated. The thought that "release the hamstrings and walking will be better, or something will be better", I believe needs greater analysis. If the hamstring tightness is compromised, and you find you have also lost the STABILITY role they played, you may be trending toward decreased functional outcome, just the opposite of what was projected. Patient selection and modification of the release procedure is all important. So....protocal? I would say recognize that hamstrings have an elongation roll in movement function (eccentric contraction activity), AND a stability role in postural control. A balance of these two is the key. Usually following hamstring release, the individual will spend the next many years, trying to re-develop the stability role the hamstrings provide, and trying to regain lower body mm balance posturally, and in movement skills.