Ligament Injuries
Proximal Hamstring Injuries
Speed of treatment is crucial for the best outcome.
The hamstring tendons attach the powerful muscles at the back of your thigh to your pelvis at the sitting bone (ischial tuberosity). Injuries here can range from a low-grade strain that settles with rehabilitation to a complete tendon avulsion that benefits from surgical repair. Mr Rehmatullah has chosen not to perform the surgery for these injuries as they are extremely rare but was taught by a surgeon who does perform these operations and is happy to advise after consultation or refer you to this particular surgeon.
The anatomy
Understanding the Proximal Hamstring
The hamstring is made up of three muscles — semitendinosus, semimembranosus and the long head of biceps femoris — which all share a common tendon origin on the ischial tuberosity (the bone you sit on). A proximal hamstring injury is a tear or degeneration of this tendon close to its attachment. Complete injuries can pull a fragment of bone off with the tendon (an avulsion), while partial tears leave some fibres intact.
Acute tears
Sudden, forceful injuries seen in sprinters, dancers and water skiers, often felt as a pop or tearing sensation high in the back of the thigh with immediate pain and bruising.
Chronic tendinopathy
Gradual-onset pain from repetitive overload, common in distance runners. The tendon becomes thickened and degenerate rather than torn through.
Complete avulsions
The tendon pulls completely off the bone, sometimes with a bony fragment. These cause weakness, pain on sitting and difficulty sprinting, and often benefit from early repair.
Symptoms
What it feels like
Proximal hamstring injuries cause pain in the lower buttock and high posterior thigh. The pattern depends on the severity of the injury.
- Sudden pain or a pop in the buttock during a sprint or stretch, followed by bruising down the thigh.
- Pain that worsens on sitting, especially on a hard surface, or when stretching the leg out.
- Weakness when pushing off, sprinting or climbing stairs.
- For chronic tendinopathy, a deep ache that builds during running and eases with rest.
Diagnosis
How it is diagnosed
Diagnosis starts with a careful history and examination, assessing where the pain is, how it started, and testing hamstring strength and flexibility. Imaging confirms the diagnosis and grades the injury.
Ultrasound
Useful as a quick, dynamic assessment of the tendon and to guide injections, though it is operator-dependent.
MRI scan
The gold standard. MRI shows the location and size of any tear, whether a bony fragment has avulsed, and the quality of the tendon — key for planning surgery.
Treatment
Non-Operative and Surgical Treatment
Treatment is tailored to the type of injury, your activity level and your goals. Many low-grade strains and chronic tendinopathies do well without surgery, while complete avulsions in active patients are best treated with early repair.
Rest & rehabilitation
Low-grade strains settle with a period of relative rest, followed by a progressive eccentric strengthening programme guided by physiotherapy.
Injections
For chronic tendinopathy, image-guided steroid or PRP injections can settle inflammation and support rehabilitation when used alongside a loading programme.
Surgical repair
Complete avulsions with significant retraction, and failed conservative management of large partial tears, are treated by reattaching the tendon to the ischium using suture anchors.
Tendon debridement
For chronic degenerative tendinopathy that has not responded to rehab, surgical debridement of the diseased tendon can stimulate healing.
Recovery
Recovery and Rehabilitation
After surgical repair, the tendon needs time to heal before it is loaded. A typical pathway protects the repair in a brace, then gradually restores movement and strength before a controlled return to sport.
0–4 weeks
Brace protection, limited weight bearing with crutches, and gentle range-of-motion exercises to protect the repair.
4–8 weeks
Wean the brace and crutches, increase range of motion, and begin light strengthening and core stability work.
8–16 weeks
Progressive hamstring and gluteal strengthening, with functional exercises and a gradual return to running.
4–6 months
Return to sprinting, cutting sports and agility work as strength and control allow, with a monitored return-to-play plan.
6–9 months
Full return to competitive sport once strength is near-equal to the uninjured side and functional tests are passed.
Important points after surgery
- Driving: Not insured for 6 weeks minimum from the date of surgery.
- Flying: Advise not to fly for 3 months after surgery due to increased risk of blood clots.
After surgery if you or anyone have concerns about your wound please contact my secretary or myself and do not start any antibiotics unless advised by myself.