Hamstring tendon rupture: when surgery is the right choice

What is a hamstring tendon rupture?

The hamstrings are a group of three muscles — the biceps femoris, semimembranosus, and semitendinosus — that run along the back of the thigh. Together they are responsible for bending the knee and extending the hip. At their upper end, they attach to a bony prominence at the base of the pelvis called the ischial tuberosity. This is the proximal attachment, and rupture here is a distinct and often debilitating injury.

A proximal hamstring avulsion occurs when the tendons tear away from the ischial tuberosity, either partially or completely. It is a different injury to the far more common mid-substance hamstring “strain” that affects recreational and professional athletes regularly — and it carries a different prognosis and a different treatment pathway.

How does it happen?

The typical mechanism is a combination of forceful hip flexion with a simultaneous eccentric load through the hamstring — in other words, the hip is moved forward while the knee is either straight or extending. Water skiing is a classic example: a fall where the ski catches water and the leg is pulled forward suddenly. A stumble on stairs, a fall during sport, or a sudden lunge or kick can produce the same injury in the right circumstances.

The injury tends to affect active adults in their forties, fifties, and sixties, though it can occur at any age. It is not exclusively a sporting injury — it can happen in everyday situations when the force is sufficient.

What does it feel like?

A complete proximal hamstring avulsion is usually immediately obvious. There is a sharp, severe pain in the buttock at the moment of injury, often described as a tearing or popping sensation. Bruising typically appears over the back of the thigh within 24 to 48 hours and can be striking in extent. Walking is painful and the patient often adopts a limp to protect the injured side.

Sitting on a hard surface is particularly uncomfortable because the ischial tuberosity — which we normally sit on — has lost its tendon covering. Patients describe a deep, nagging ache in the sitting position that can persist for months if the injury is not repaired.

Proximal avulsion versus mid-substance tear

It is worth distinguishing proximal avulsion clearly from mid-substance hamstring tears, because the treatment approach is different. Mid-substance tears — the type that happens to sprinters and footballers — almost always heal well with physiotherapy and do not require surgery. Proximal avulsions, particularly when all three tendons are involved and the tendon end has retracted significantly, fare substantially better with surgical repair in active patients.

Partial tears at the proximal attachment are more nuanced. Many will heal with conservative management, but those involving more than 50 per cent of the cross-sectional area of the tendon, or with significant retraction, may benefit from repair.

When is surgery recommended?

The decision to operate depends on several factors: the degree of tendon involvement (partial versus complete), the amount of retraction of the torn tendon end, the patient’s activity level and expectations, and the timing from injury to presentation.

Surgery is generally recommended for:

Complete proximal hamstring avulsions in active patients who wish to return to physical activity at a meaningful level. The evidence consistently shows better functional outcomes with repair than with non-surgical treatment in this group, particularly in terms of hamstring strength, endurance, and return to sport.

Tears with significant retraction — defined as the tendon end sitting more than two centimetres away from its attachment on the ischium. The greater the retraction, the harder it becomes to achieve a tension-free repair as time passes, because the tendon and muscle contract and scar. Early surgery, ideally within four to six weeks of injury, produces the most reliable results.

Patients who have failed a genuine course of non-surgical rehabilitation, including formal physiotherapy, but continue to experience significant weakness, pain with sitting, and inability to return to activity.

Older, less active patients, or those with significant medical comorbidities, may reasonably be managed without surgery. Non-surgical management with progressive loading under physiotherapy supervision can produce acceptable outcomes in the right patient, even for complete tears, though recovery of full strength is less predictable.

What does hamstring repair surgery involve?

Proximal hamstring repair is performed with the patient lying face down under general anaesthetic. An incision is made in the fold of the buttock, following the natural crease to minimise the visible scar. The torn tendon end is identified, freed from any scar tissue, and reattached to the ischial tuberosity using suture anchors — small titanium or bioabsorbable devices that are fixed into the bone and used to hold the tendon securely in place.

The sciatic nerve runs in close proximity to the proximal hamstring attachment and is carefully identified and protected throughout the procedure. This is one of the technical demands of the operation, and proximity to the nerve is one reason the surgery requires specific experience.

The procedure typically takes one to two hours and is performed under general anaesthetic as a day case or with an overnight stay.

Recovery and return to activity

Recovery after proximal hamstring repair is measured in months, not weeks. The tendon needs time to heal securely to the bone before it can be progressively loaded. Patients use crutches for the first four to six weeks and follow a structured rehabilitation programme guided by a physiotherapist.

Most patients are walking comfortably without aids by six to eight weeks. A return to light recreational activity — cycling, swimming, walking at pace — is typically possible from three to four months. Return to competitive sport or heavy physical work takes six to nine months from surgery.

Sciatic nerve symptoms — tingling or numbness down the back of the leg — are not uncommon in the weeks after surgery and usually resolve as the nerve settles. Persistent nerve symptoms are rare but warrant attention.

What happens if repair is delayed?

Timing matters. If a proximal hamstring avulsion is not repaired within the first few months, the retracted tendon end adheres in its retracted position and becomes progressively harder to retrieve and reattach without tension. Delayed or chronic repair is more technically demanding, carries a higher risk of incomplete restoration of length, and is associated with less predictable recovery of full strength.

This is why prompt assessment after the injury is important. If you or someone you know has had a significant injury to the back of the hip or upper thigh — particularly with the mechanism described above — it is worth seeking orthopaedic review promptly rather than waiting to see how it settles.

When to seek advice

An MRI is the investigation of choice for confirming a proximal hamstring tear, characterising the extent of the injury, and measuring retraction. It is readily available in Adelaide and provides the information needed to guide the treatment decision.

Dr Mooney consults at Orthopaedics 360, 204 Greenhill Road, Eastwood. Contact the rooms on (08) 7077 0157, or arrange a GP referral for Medicare rebate purposes.