Proximal Hamstrings Injury

Patient information — Dr Christopher Spelman, Orthopaedic Surgeon

Overview

The hamstrings are a group of three muscles at the back of the thigh that originate from the ischial tuberosity – the bony prominence you sit on. A proximal hamstring injury is a tear where these tendons attach to the pelvis. It ranges from a partial strain to a complete avulsion, where the tendons are pulled entirely off the bone. It commonly occurs during a sudden forceful stretch of the hamstrings, such as a slip, a water-skiing fall or a lunge, and causes sudden pain and bruising in the back of the thigh and buttock.

Symptoms and diagnosis

Typical features include a sudden “pop” or tearing sensation, bruising down the back of the thigh, tenderness over the sitting bone, and difficulty with activities such as walking uphill, running or sitting. Magnetic resonance imaging (MRI) is used to confirm the diagnosis, determine how many of the three tendons are involved and measure how far they have retracted – information that guides treatment.

Treatment

Partial tears and many complete tears can be managed non-operatively with rest, crutches, activity modification and a structured rehabilitation programme. Surgery to reattach the tendons to the bone (using strong sutures anchored into the ischial tuberosity) is considered particularly for complete, retracted tears in more active patients, or where non-operative treatment has not restored function. When surgery is chosen, earlier (acute) repair is technically easier and associated with better outcomes than delayed repair.

Outcomes and what the evidence shows

For many years surgery was widely recommended for complete proximal hamstring avulsions, but recent high-quality evidence has challenged this. A multicentre randomised trial in patients aged 30 to 70 found that non-operative treatment was not inferior to surgery at two years, with similar functional scores and fewer complications in the non-operative group. This supports an individualised approach: many patients do well without surgery, while operative repair remains a reasonable option for selected patients, particularly younger, active people with complete retracted tears.

Complications

Non-operative treatment avoids surgical risk but may leave some patients with weakness or discomfort when sitting. For those who undergo surgical repair, a systematic review reported an overall complication rate of around 15%, most of which are minor. Recognised risks include:

●      Peri-incisional numbness – reduced sensation around the scar, the most common issue (around 5%).

●      Sciatic nerve irritation or injury – the sciatic nerve lies close to the repair; irritation or, less commonly, injury (around 1–2%) can cause pain, altered sensation or weakness. The risk is higher with delayed repair of chronic, scarred tears.

●      Re-rupture – uncommon after repair (in the order of 1–2%), but possible with an early return to strenuous activity.

●      Wound problems and infection – reported in around 3% of cases.

●      Blood clots – deep vein thrombosis is uncommon but recognised after this surgery.

●      Reoperation – a small proportion of patients require further surgery.

Summary

Proximal hamstring injuries range from strains to complete tendon avulsions. Many are managed successfully without surgery, and recent evidence shows non-operative treatment can match surgery for many patients. Surgical repair remains valuable for selected complete, retracted tears, ideally performed early. Dr Spelman will discuss which approach best suits your injury and goals.