Proximal Hamstring Avulsions: Surgery vs Conservative Treatment - What 1-Year Outcomes Reveal
By Grant Frost, Physiotherapist with 20 Years of Experience
Published on 9th November, 2025
Proximal hamstring tendon avulsions can be a challenging injury to treat. For years, the treatment approach has been polarized - with many clinicians advocating for surgical intervention while others champion conservative management. Recent research published in the British Journal of Sports Medicine provides compelling evidence that may reshape our clinical decision-making process.
Key Research Finding
At 1-year follow-up, patients with proximal hamstring tendon avulsions showed comparable clinical outcomes regardless of whether they received surgical or conservative treatment, when managed through a shared decision-making model and structured rehabilitation program.
Study Design and Methodology
This prospective study followed 59 patients with MRI-confirmed proximal hamstring tendon avulsions over one year. The research employed a pragmatic design where treatment decisions were made through shared decision-making between patients and clinicians, rather than random assignment.
Participant Characteristics
| Characteristic | Surgical Group (n=26) | Conservative Group (n=33) |
|---|---|---|
| Median Age | 51 years | 49 years |
| Baseline PHAT Score | 32 ± 16 | 45 ± 17 |
| Time from Injury to Initial Visit | 12 days | 21 days |
| Two-Tendon Avulsions | 100% | 82% |
Treatment Protocols
Both groups followed a structured, criteria-based rehabilitation program progressing through four phases:
- Phase I: Protective phase (surgical patients only) with cast immobilization
- Phase II: Normalizing gait, balance training, and initial strengthening
- Phase III: Sport-specific movements and strength in lengthened positions
- Phase IV: High-velocity multi-plane activities and return to sport
Key Findings at 1-Year Follow-up
Primary Outcome: Perth Hamstring Assessment Tool (PHAT)
Both groups achieved identical mean PHAT scores of 80/100 at 1-year follow-up, despite surgical patients starting with significantly lower baseline scores (32 vs 45). The improvement was substantial in both groups, with surgical patients improving by 47 points and conservative patients by 34 points.
Return to Sport and Functional Outcomes
Return to sport rates and timing were comparable between groups:
- Time to return to any sport: 25 weeks (surgical) vs 24 weeks (conservative)
- Return to pre-injury level: 27% (surgical) vs 33% (conservative)
- No return to sport: 23% (surgical) vs 12% (conservative)
Both groups showed near-symmetrical hamstring flexibility but persistent strength deficits in specific testing positions.
Radiological Findings: The Surprise in Tendon Healing
MRI findings revealed a remarkable difference in structural outcomes:
- Surgical group: 95% showed proximal tendon continuity
- Conservative group: 52% showed spontaneous tendon continuity, mostly through formation of a "shared neotendon"
This finding challenges conventional wisdom about the necessity of surgery for structural restoration.
Critical Analysis: Study Limitations
Design Limitations
As the authors acknowledge, this study has several important limitations that affect how we interpret the results:
- Non-randomized design: Treatment allocation was through shared decision-making, introducing potential selection bias
- Lack of blinding: Clinical assessors were not blinded to treatment groups
- Small sample size: Limited power to detect smaller between-group differences
- Short follow-up: 1-year outcomes may not reflect long-term differences
Generalisability Considerations
The study's applicability to specific populations requires careful consideration:
- Elite athletes: The authors explicitly state findings cannot be generalized to elite athletes
- Age factors: Median age was 50 years - younger populations may have different outcomes
- Injury characteristics: Conservative group had fewer two-tendon avulsions (82% vs 100%)
Clinical Implications: An Evolving Approach to Hamstring Avulsions
This research supports several important shifts in how we manage these challenging injuries:
The Power of Shared Decision-Making
The study demonstrates that when patients are fully informed about treatment options, risks, and expected outcomes, they can participate meaningfully in treatment decisions. Notably, over 90% of patients in both groups stated they would make the same treatment choice again.
Conservative Management as a Viable Option
This study provides the strongest evidence to date that structured conservative management can yield excellent outcomes for many patients with proximal hamstring avulsions. The traditional assumption that surgery is universally superior is challenged by these findings.
Setting Realistic Expectations
Regardless of treatment choice, patients should be counseled that:
- Return to pre-injury sports level within one year is unlikely for most patients
- Persistent strength deficits are common with either approach
- Structural healing occurs differently between treatments but doesn't necessarily correlate with functional outcomes
Future Research Directions
The authors highlight several important areas for future investigation:
- Randomized controlled trials to eliminate selection bias
- Long-term follow-up to identify potential late differences between treatments
- Identification of specific factors predicting successful conservative management
- Studies focused on elite athletic populations
Conclusion: Changing Our Clinical Approach
This landmark study provides robust evidence that both surgical and conservative management of proximal hamstring tendon avulsions can yield excellent outcomes when delivered through a shared decision-making model and structured rehabilitation program.
For physiotherapists, this research empowers us to present conservative management as a legitimate first-line option for appropriate patients, while recognizing that surgical intervention remains valuable for specific cases. The critical factor appears to be not the treatment modality itself, but the quality of the rehabilitation and the alignment between treatment choice and patient expectations.
As we continue to seek the root causes of persistent dysfunction in our patients, this research reminds us that structural perfection on imaging doesn't always correlate with functional excellence - and that patient-centered care often yields the best outcomes regardless of the technical approach.
Struggling with a Complex Hamstring Injury?
If you're dealing with a persistent hamstring injury that hasn't responded to conventional treatment, consider booking in for an online consultation to find the underlying factors contributing to your pain and functional limitations.
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van der Made, A. D., Peters, R. W., Verheul, C., Smithuis, F. F., Reurink, G., Moen, M. H., Tol, J. L., & Kerkhoffs, G. M. M. J. (2022). Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model. British Journal of Sports Medicine, 56(6), 340-347.