When Surgery Isn’t the Answer: Nonoperative Management of Partial Proximal Hamstring Avulsions in Contact Athletes

Introduction 
Partial hamstring tears are among the most common injuries in contact sports, accounting for 12% to 26% of all athletic injuries. When a contact athlete sustains an injury, the reflexive question from the sideline is often, "Does this need surgery?" The evidence consistently points to a different starting point: structured nonoperative management produces reliable outcomes for most partial tears, avoids surgical morbidity, and preserves the option for delayed repair should conservative treatment fail.^1,2 

Most Partial Tears Heal Without a Scalpel
The American College of Sports Medicine (ACSM) and the American Medical Society for Sports Medicine (AMSSM) affirm that most hamstring muscle injuries are treated nonoperatively, with progression individualized to pain, gait, severity, and function.³ Current consensus reserves operative intervention for two-tendon injuries with more than 2 cm of retraction, three-tendon injuries, or injuries refractory to six months of nonoperative treatment—not for partial tears at initial presentation.¹ Recent Current Concepts reviews reaffirm this framework, noting that many hamstring injuries, including partial avulsions, are successfully managed with activity modification and physical therapy, with surgery reserved for these same defined thresholds.^1,2,4 

Partial proximal hamstring avulsions are treated nonsurgically as a first-line approach.² Even when operative and nonoperative treatment of proximal hamstring tendon avulsions are compared in a shared decision-making model, both groups achieve comparable outcomes at one year, with mean Perth Hamstring Assessment Tool scores of 80 in each.⁵ More recent mid-term data reinforce this. In physically active individuals with acute proximal hamstring avulsions and more than 2 cm of retraction, nonsurgical and surgical management produce comparable VISA-H and FASH scores and comparable return-to-sport rates at nearly three years of follow-up.⁶ Notably, the nonoperative cohort achieves these results without the risks of surgical complications, which occur in up to 23% of hamstring repairs.⁷

The Reinjury Problem Is Real, But Surgery Does Not Clearly Solve It 
For Grade 1–2 hamstring strains, return to play with nonoperative management ranges from two to 12 weeks across RCTs.⁸ Surgical repair of partial proximal hamstring avulsions, by contrast, requires an average of 11.1 months before return to sport.⁷ Even accounting for the fact that these represent different injury severities, the time cost of surgery is substantial for a contact athlete whose career window may be narrow.

Furthermore, no single conservative intervention has proven superior to structured, exercise-based rehabilitation alone. A living systematic review found that no single exercise-based intervention or adjunct achieved faster return to sport or lower reinjury rates, with only eccentric lengthening exercises showing limited evidence for a shorter time to return to full training.⁹ 

The ACSM consensus statement notes there is no high-quality clinical evidence supporting PRP or corticosteroid injection as initial treatment.³ The evidence on PRP specifically is evolving and mixed: a 2026 meta-analysis of six randomized controlled trials found that PRP may modestly shorten return to play by roughly 8.6 days (21.4 vs. 30.0 days), but did not reduce reinjury risk, a benefit further tempered by high heterogeneity and low-to-moderate certainty of evidence.¹⁰ 
In other words, any acceleration in return offered by PRP appears small and does not address the central problem of reinjury. The simplicity and accessibility of evidence-based rehabilitation is itself an advantage: eccentric strengthening, neuromuscular training, and graduated sport-specific drills require no operating room, no anesthesia, and no post-surgical restrictions.¹¹

Surgery Remains the Safety Net, Not the Starting Line 
The strongest argument for nonoperative management may be that it does not foreclose on surgery. Surgical repair of partial proximal hamstring avulsions after failed conservative treatment produces excellent outcomes: 97% patient satisfaction, 92% return to strenuous activity, and a mean total proximal hamstring score of 94% at 6.5-year follow-up.⁷ Acute and delayed repairs showed no difference in outcomes in this series. 

Notably, the evidence base is not uniform: a matched comparative study with mean follow-up beyond four years reported significantly higher functional scores, return-to-sport rates, and satisfaction among surgically treated patients, underscoring that surgical candidacy and patient selection matter.¹² 
The option to operate is preserved; the morbidity of unnecessary surgery is not. 

Conclusion 
For partial hamstring tears in contact athletes, the evidence supports a nonoperative-first approach grounded in structured, progressive rehabilitation.^1-3 Surgery should be reserved for clearly defined indications: significant retraction, multi-tendon involvement, or failure of six months of conservative treatment.^1,4 The contact athlete is best served by the most appropriate treatment, not necessarily the most aggressive one.

To consider the other side of this debate, read the counterpart article, “When Surgery Is the Right Call: Early Surgical Repair of Partial Proximal Hamstring Avulsions in Contact Athletes"

References

1. Allahabadi S, Salazar LM, Obioha OA, Fenn TW, Chahla J, Nho SJ. Hamstring Injuries: A Current Concepts Review: Evaluation, Nonoperative Treatment, and Surgical Decision Making. Am J Sports Med. 2024;52(3):832-844. doi:10.1177/03635465231164931
2. Arner JW, Rothrauff B, Bradley JP. Hamstring Injuries in Athletes: Anatomy, Pathology, and Treatment. J Am Acad Orthop Surg. 2025;33(13):e703-e714. doi:10.5435/JAAOS-D-24-01162
3. Herring SA, Kibler WB, Putukian M, Boyajian-O'Neill LA, Chang CJ, Franks RR, Hutchinson M, Indelicato PA, O'Connor FG, Powell A, Roach R, Safran M, Statuta SM, Sutton K. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. Curr Sports Med Rep. 2024;23(3):86-104. doi:10.1249/JSR.0000000000001151
4. Yetter TR, Halvorson RT, Wong SE, Harris JD, Allahabadi S. Management of Proximal Hamstring Injuries: Non-operative and Operative Treatment. Curr Rev Musculoskelet Med. 2024;17(9):373-385. doi:10.1007/s12178-024-09911-0
5. van der Made AD, Peters RW, Verheul C, Smithuis FF, Reurink G, Moen MH, Tol JL, Kerkhoffs GMMJ. Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model. Br J Sports Med. 2022;56(6):340-348. doi:10.1136/bjsports-2021-104588
6. Maffulli N, Hassan R, Poku D, Chan O, Oliva F. Non-surgical management of acute proximal hamstring avulsions can produce clinically acceptable results. Knee Surg Sports Traumatol Arthrosc. 2024;32(9):2386-2394. doi:10.1002/ksa.12368
7. Bodendorfer BM, Curley AJ, Kotler JA, Ryan JM, Jejurikar NS, Kumar A, Postma WF. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Am J Sports Med. 2018;46(11):2798-2808. doi:10.1177/0363546517732526
8. Kjær M, Petersen J, Dünweber MR, Andersen JL, Engebretsen L, Magnusson SP. Dilemma in the Treatment of Sports Injuries in Athletes: Tendon Overuse, Muscle Strain, and Tendon Rupture. Scand J Med Sci Sports. 2025;35(2):e70026. doi:10.1111/sms.70026
9. Afonso J, Olivares-Jabalera J, Fernandes RJ, Clemente FM, Rocha-Rodrigues S, Claudino JG, Ramirez-Campillo R, Valente C, Andrade R, Espregueira-Mendes J. Effectiveness of Conservative Interventions After Acute Hamstrings Injuries in Athletes: A Living Systematic Review. Sports Med. 2023;53(3):615-635. doi:10.1007/s40279-022-01783-z
10. Nakagawa H, Krochmal P, Thomas I, Rabinowitz JB, Kruse RC, Bowers R, Sussman WI. Effects of percutaneous platelet-rich plasma injection on return-to-play after acute hamstring muscle injury: a systematic review and meta-analysis. Br J Sports Med. 2026;60(5):370-378. doi:10.1136/bjsports-2025-110683
11. Paton BM, Read P, van Dyk N, Wilson MG, Pollock N, Court N, Giakoumis M, Head P, Kayani B, Kelly S, Kerkhoffs GMMJ, Moore J, Moriarty P, Murphy S, Plastow R, Stirling B, Tulloch L, Wood D, Haddad F. London International Consensus and Delphi study on hamstring injuries part 3: rehabilitation, running and return to sport. Br J Sports Med. 2023;57(5):278-291. doi:10.1136/bjsports-2021-105384
12. Lefèvre N, Moussa MK, El Otmani L, Valentin E, Meyer A, Grimaud O, Bohu Y, Hardy A. Surgical Treatment of Proximal Hamstring Avulsion Injuries Compared With Nonsurgical Treatment: A Matched Comparative Study With a Mean Follow-up of >4 Years From the Proximal Hamstring Avulsion Surgery Cohort Study. Am J Sports Med. 2024;52(11):2718-2727. doi:10.1177/03635465241270139