- SPECIALIST ORTHOPAEDIC SURGEON | MELBOURNE, VIC | ALBURY, NSW | MORNINGTON, VIC |
- 03 9421 6133
- Melbourne & Mornington VIC |
- Albury, NSW
Proximal Hamstring Tears and Open Repair
Understanding tendon tears at the top of the hamstring and when surgical repair may be appropriate
The hamstring muscles run down the back of the thigh and help extend the hip, bend the knee and control the leg during walking, running and sport. At the top of the thigh, the hamstring tendons attach to the ischial tuberosity, sometimes described as the sitting bone.
A proximal hamstring tear occurs when one or more of these tendons are damaged or pulled away from the pelvis. Tears range from partial injuries that remain attached to complete avulsions in which the tendons retract away from the bone.
Many partial tears can be managed without surgery. Open proximal hamstring repair may be considered for a complete or substantially retracted tear, significant weakness or loss of function, persistent symptoms despite appropriate non-operative treatment, or chronic pain associated with tendon retraction or irritation around the sciatic nerve.
What is a proximal hamstring tear
The proximal hamstring attachment includes the semimembranosus tendon and the joined attachment of the semitendinosus and biceps femoris tendons. Injury can affect one, two or all three tendons.
An acute avulsion often occurs when the hip is forcefully flexed while the knee is straightening, such as during slipping, sprinting, waterskiing, kicking or a sudden sporting movement. Chronic tears may follow an older injury that did not heal in an effective position or progressive partial tendon damage.
Common symptoms
- A sudden sharp pain or tearing sensation in the lower buttock or upper back of the thigh
- Bruising and swelling extending down the back of the thigh
- Weakness when bending the knee, climbing stairs, running or pushing off
- Difficulty walking normally after an acute injury
- Pain when sitting, particularly on a firm chair
- Persistent lower-buttock pain during exercise or longer periods of sitting
- Tingling, numbness or pain travelling down the leg if the sciatic nerve is irritated
How is it diagnosed
Diagnosis begins with a detailed history and examination. Dr Hockings will assess the site of pain and bruising, hamstring strength, walking pattern, nerve symptoms and the effect on daily activities or sport.
Investigations may include:
- X-rays to look for a small piece of bone pulled away with the tendon and to assess other causes of pain
- MRI to identify which tendons are torn, the degree of retraction, tissue quality, muscle change and the relationship to the sciatic nerve
- Ultrasound in selected cases to assess the tendon dynamically
Non-surgical treatment
Non-surgical treatment is appropriate for many partial tears and some complete tears, depending on the number of tendons involved, retraction, strength, symptoms, age, activity goals and general health.
Treatment may include:
- Temporary activity modification and protection from painful loading
- Ice and appropriate pain-relieving or anti-inflammatory medication
- Physiotherapy progressing from movement and gait restoration to hamstring, gluteal and trunk strengthening
- Gradual return to work, exercise and sport according to symptoms and objective function
The decision is not based on the MRI alone. The pattern of injury must be considered together with weakness, pain, functional loss and the patient’s goals.
When might surgery be considered
Open repair may be recommended when the likely functional benefit justifies the risks of surgery.
Factors commonly considered include:
- A complete or multi-tendon avulsion with meaningful retraction
- Marked weakness or loss of function after an acute injury
- Persistent pain, sitting intolerance or weakness after an adequate rehabilitation program
- A chronic retracted tear with scar tissue or sciatic nerve symptoms
- The patient’s work, sporting demands and treatment goals
Early specialist assessment is useful after a suspected complete avulsion because the tendons can retract and develop scar tissue. This does not mean that every tear requires urgent surgery; the appropriate timing is individualised.
What open proximal hamstring repair involves
The operation is performed through an incision beneath the buttock crease. The torn tendon ends are identified and mobilised, scar tissue is removed as required and the sciatic nerve is carefully protected. The attachment site on the ischial tuberosity is prepared and the tendons are secured back to the bone using strong sutures and surgical anchors.
In a chronic tear, the tendons may be more difficult to mobilise and the sciatic nerve may be surrounded by scar tissue. A nerve release or graft reinforcement may occasionally be required. Dr Hockings will discuss this if it is relevant to the MRI and operative plan.
What results can be expected
Many appropriately selected patients obtain meaningful improvement in pain, strength and function after repair. Recovery varies, particularly between an early repair and a chronic retracted tear. Residual weakness, sitting discomfort or nerve symptoms can persist, and surgery cannot guarantee a return to the patient’s previous level of sport.
Factors that may influence recovery include the number of tendons involved, degree of retraction, time from injury, tissue and muscle quality, sciatic nerve symptoms, smoking, general health and participation in rehabilitation.
Recovery after surgery
The repaired tendon needs time to heal securely back to the pelvis
Dr Hockings uses a protective initial rehabilitation phase:
- A hinged knee brace is worn with the knee maintained in flexion and movement limited to the prescribed range, initially to 60 degrees. Full knee extension is avoided because it places tension on the repair.
- Patients remain non-weight bearing during the initial protected phase, usually for 6 weeks, using crutches or another gait aid.
- The brace settings must not be changed unless directed by Dr Hockings or the treating physiotherapist.
- Hamstring stretching, active hamstring loading and combined hip flexion with knee extension are avoided until cleared.
- After the initial phase, weight bearing, knee extension and hamstring activation are restored gradually under physiotherapy guidance.
- Running and sport-specific training are introduced only after adequate healing, strength and movement control have been demonstrated.
Return to full activity commonly takes at least 6 months and may take 6 to 9 months or longer for demanding sport. The exact timeline depends on the injury, repair and progress against functional milestones.
All surgery has potential risks. These may include:
- Infection, bleeding, haematoma or wound-healing problems
- Blood clots in the leg or lungs
- Injury or irritation of the sciatic nerve, causing numbness, tingling, pain or weakness
- Temporary or persistent numbness around the incision
- Failure of the tendon to heal, re-tear or recurrent weakness
- Persistent sitting pain, stiffness or loss of function
- Prominent or painful scar tissue
- The need for further surgery
- Anaesthetic or medical complications
Your individual risks, expected recovery and alternatives will be discussed before surgery is recommended.
Assessment of a proximal hamstring injury
If you have experienced a sudden lower-buttock injury with extensive bruising or weakness, or have persistent pain when sitting and loading the hamstring, assessment can clarify which tendons are involved and whether non-operative treatment or repair is more appropriate.
Treatment recommendations are tailored to the injury pattern, timing, symptoms, work and sporting demands, and individual goals.
Contact Dr Jason Hockings
reception@drjasonhockings.com.au
(03) 9421 6133
If you’re experiencing ongoing pain, stiffness, or reduced movement that is affecting your daily activities or quality of life, a thorough orthopaedic assessment can help determine the cause and guide the most appropriate treatment options for your situation.