Reattachment of the torn hamstring tendons to the ischial tuberosity, restoring strength and function.
The hamstring muscles arise from the ischial tuberosity — the bony prominence at the base of the pelvis. A proximal hamstring avulsion occurs when one or more of the three hamstring tendons tear away from this bony attachment. It most commonly occurs during forced hip flexion with the knee extended — for example, water skiing, sprinting, or a sudden forward fall. The injury typically presents as a sudden, sharp pain felt deep in the buttock, often associated with a pop, followed by bruising that tracks down the back of the thigh. Some patients have a persistent lump (the retracted tendon end) and significant weakness in the back of the thigh.
Management depends on how many tendons are torn and how far they have retracted. A partial avulsion (one tendon torn) in a less active patient may be managed non-operatively with physiotherapy. Surgery is generally recommended for: complete avulsions (all three tendons); partial avulsions with significant retraction or persistent functional deficit; younger, active patients who want to return to sport; and patients in whom non-operative management has failed.
Surgery is performed under general anaesthesia with the patient face-down. Dr Mooney makes an incision in the buttock crease to expose the ischial tuberosity. The retracted tendon ends are identified, freed from surrounding scar tissue, and pulled back down to their bony origin. They are reattached using strong suture anchors inserted into the bone. The repair is protected postoperatively with a brace and graduated rehabilitation. Early surgical repair (within the first few weeks of injury) is technically easier and tends to produce better results — if surgery is indicated, it should ideally not be delayed.
Partial avulsions with minimal retraction in less active patients can often be managed with physiotherapy. However, complete avulsions rarely heal satisfactorily without surgical repair, and the longer surgery is delayed the more difficult the repair becomes.
The injury should ideally be assessed and a decision made about management within the first 2–3 weeks. After this, the tendon can retract further and adhere to surrounding structures, making repair technically more demanding. Dr Mooney aims to see urgent referrals promptly.
Return to sport is typically 9–12 months for a complete repair. Strengthening and physiotherapy are an essential part of recovery and significantly influence the outcome.
The early recovery from surgery can be uncomfortable, particularly because the position of the repair (hip flexion) is what loads the tendons during daily activity. Pain is well managed with medications in the early postoperative period, and most patients find it settles significantly by 4–6 weeks.
Most patients regain excellent hamstring strength and function after repair. Outcomes are generally better after early repair than after delayed repair.
Dr Luke Mooney is an Adelaide orthopaedic surgeon who has built his practice around hip, knee, and sports injury surgery. He holds the qualifications MBBS, FRACS, and FAOrthA, and is a Clinical Senior Lecturer at the University of Adelaide.
When you see Dr Mooney, you see Dr Mooney — at every appointment, at surgery, and at every follow-up.
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