Functional outcome and return to sport following surgical treatment of distal hamstring tears

Pierre Denis-Aubrée; Alexandre Hardy; Eugénie Valentin; Mohamad Moussa; Alain Meyer; Nicolas Lefevre

DOI: 10.70885/hmsj.2026.02.005

Abstract

Background: Distal hamstring tears are rare, but recovery and rehabilitation are long, and this event is associated with a risk of loss of function. Surgery is often necessary for complete tears. The long-term results and the return to sport (RTS) have not been extensively studied in these cases.Purpose: The goal of this study was to evaluate the functional outcome, the RTS and the complications two years after surgical management of distal hamstring tears. We hypothesized that surgical treatment of these distal tears would be associated with a good functional outcome and a satisfactory RTS with few complications or recurrent tears.Methods: A retrospective cohort study was performed in 22 patients who underwent surgery for an acute or chronic distal hamstring tear between 2008 and 2022. At least two years after surgery the UCLA, PHAS and Tegner scores were recorded as the primary outcome criteria. The Return to sport rate, the time to return to sport, and any complications were recorded as secondary criteria.Results: There were two lost to follow-up. Twenty patients were analyzed. The mean follow-up was 4.5 years. Injuries were acute at surgery in 80% of cases. At the final follow-up the median PHAS score was 99.5, the median UCLA score was 10.0 and the median Tegner score was 7.0. Most patients (90%) had returned to their preinjury sport at the same level or higher than before surgery. The mean RTS time was 4.0 months. There was no significant difference between functional scores before and after surgery. One patient presented with a postoperative flexion deformity that was successfully treated with physiotherapy. There were no recurrent injuries.Conclusion: This retrospective cohort study shows that surgical treatment of distal hamstring tendon ruptures yields good functional results, a high and rapid return to sports, and few complications.What this study adds: This study provides mid-term outcome data on a rare injury, showing that surgical repair of distal hamstring tendon ruptures results in excellent functional outcomes, a high rate of return to sport (90%), a rapid mean return-to-sport time of 4 months, and a low complication rate without recurrent tears.Potential impacts on research, practice, or policy: These findings support surgical management—particularly in active patients seeking return to sport—and provide benchmark functional scores and return-to-sport timelines to guide patient counseling and rehabilitation planning. Study Design: Retrospective cohort study Level of evidence: Level IIIKeywords: Hamstring; Avulsion tear; Reinsertion; Excision; Kneehttps://doi.org/10.70885/hmsj.2026.02.005

References

  1. Ahmad CS, Redler LH, Ciccotti MG, Maffulli N, Longo UG, Bradley J. Evaluation and management of hamstring injuries. Am J Sports Med. 2013 Dec;41(12):2933-47. doi: 10.1177/0363546513487063.
  2. Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg. 1998 Jul-Aug;6(4):237-48. doi: 10.5435/00124635-199807000-00005.
  3. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries. Sports Med. 2012;42(3):209–226. DOI: 10.2165/11594800-000000000-00000
  4. Matthews JR, Sonnier JH, Prodoehl JP, Saucedo ST, Avendano JP, Johns W, Freedman KB, Ciccotti MG, Cohen SB. Distal Hamstring Muscle Injuries. JBJS Rev. 2022 Mar 3;10(3). doi: 10.2106/JBJS.RVW.21.00215.
  5. Arner JW, McClincy MP, Bradley JP. Hamstring Injuries in Athletes: Evidence-based Treatment. J Am Acad Orthop Surg. 2019 Dec 1;27(23):868-877. doi: 10.5435/JAAOS-D-18-00741.
  6. Danielsson A, Horvath A, Senorski C, Alentorn-Geli E, Garrett WE, Cugat R, Samuelsson K, Hamrin Senorski E. The mechanism of hamstring injuries - a systematic review. BMC Musculoskelet Disord. 2020 Sep 29;21(1):641. doi: 10.1186/s12891-020-03658-8.
  7. Erickson LN, Sherry MA. Rehabilitation and return to sport after hamstring strain injury. J Sport Health Sci. 2017 Sep;6(3):262-270. doi: 10.1016/j.jshs.2017.04.001.
  8. Ernlund L, Vieira LA. Hamstring injuries: update article. Rev Bras Ortop. 2017 Aug 1;52(4):373-382. doi: 10.1016/j.rboe.2017.05.005.
  9. Doege J, Ayres JM, Mackay MJ, Tarakemeh A, Brown SM, Vopat BG, Mulcahey MK. Defining Return to Sport: A Systematic Review. Orthop J Sports Med. 2021 Jul 26;9(7):23259671211009589. doi: 10.1177/23259671211009589.
  10. Cohen SB, Towers JD, Zoga A, Irrgang JJ, Makda J, Deluca PF, et al. Hamstring injuries in professional football players: magnetic resonance imaging correlation with return to play. Sports Health. 2011;3(5):423–430. DOI: 10.1177/1941738111403107
  11. 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. 2023;24:036354652311649. DOI: 10.1177/03635465231164931
  12. Marín Fermín T, Aminake G, Vasiliadis AV, Kalifis G, Grabowski R, Macchiarola L, Al-Dolaymi AA. Surgical treatment of distal hamstring tendon injuries yield a higher return-to-sports rate: A systematic review. Knee Surg Sports Traumatol Arthrosc. 2024 Mar;32(3):763-776. doi: 10.1002/ksa.12075.
  13. Lempainen L, Sarimo J, Mattila K, Heikkilä J, Orava S, Puddu G. Distal tears of the hamstring muscles: review of the literature and our results of surgical treatment. Br J Sports Med. 2007 Feb;41(2):80-3; discussion 83. doi: 10.1136/bjsm.2006.031211.
  14. Ahearn N, Wood DG. Distal avulsion of reconstituted hamstring tendons. Knee Surg Sport Traumatol Arthrosc. 2020;29(6):1722-1727. DOI: 10.1007/s00167-020-06202-2
  15. Cooper DE, Conway JE. Distal semitendinosus ruptures in elite-level athletes. Am J Sports Med. 2010;38(6):1174–1178. DOI: 10.1177/0363546509361016
  16. Thompson JW, Plastow R, Kayani B, Baawa-Ameyaw J, Moriarty P, Asokan A, et al. Efficacy of surgical tenodesis for treatment of distal semitendinosus hamstring tendon injuries. Orthop J Sports Med. 2021;9:232596712110394. DOI: 10.1177/23259671211039461
  17. Alioto RJ, Browne JE, Barnthouse CD, Scott AR. Complete rupture of the distal semimembranosus complex in a professional athlete. Clin Orthop Relat Res. 1997;336:162–165. DOI: 10.1097/00003086-199703000-00023
  18. Lefevre N, Kassab Hassan S, Valentin E, Bohu Y, Gerometta A, Meyer A, Grimaud O, Hardy A. Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion. Am J Sports Med. 2024 Mar;52(4):1014-1021. doi: 10.1177/03635465241227434.
  19. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985 Sep;(198):43-9.
  20. Zahiri CA, Schmalzried TP, Szuszczewicz ES, Amstutz HC. Assessing activity in joint replacement patients. J Arthroplasty. 1998;13(8):890-895. DOI: 10.1016/s0883-5403(98)90195-4
  21. Metcalf KB, Knapik DM, Voos JE. Damage to or injury of the distal semitendinosus tendon during sporting activities: a systematic review. HSS J. 2019;15(2):185–189. DOI: 10.1007/s11420-018-9639-z
  22. Adejuwon A, McCourt P, Hamilton B, Haddad F. Distal semitendinosus tendon rupture: is there any benefit of surgical intervention? Clin J Sport Med. 2009 Nov;19(6):502-4. doi: 10.1097/JSM.0b013e3181bd09c7.
  23. Schilders E, Bismil Q, Sidhom S, Robinson P, Barwick T, Talbot C. Partial rupture of the distal semitendinosus tendon treated by tenotomy - a previously undescribed entity. Knee. 2006;13(1):45–47. DOI: 10.1016/j.knee.2005.05.004
  24. Ahmed I, Williams M, Murray J. Investigation and management of an isolated complete distal avulsion of semitendinosus. BMJ Case Rep. 2018;2018(4):244–250. DOI: 10.1136/bcr-2017-222239
  25. McGarvey CR, Montgomery JR, Spicer PJ. Isolated distal semitendinosus tendon tear in a collegiate athlete. Radiol Case Rep. 2022;17(12):4723–4726. DOI: 10.1016/j.radcr.2022.09.027
  26. Blakeney WG, Thaunat M, Ouanezar H, De Campos GC, De Padua VBC, Sonnery-Cottet B. Distal semimembranosus tendon avulsions: acute surgical repair in a professional rugby player. Orthop J Sports Med. 2017;5:232596711773110. DOI: 10.1177/2325967117731102
  27. Verburgh H, Keeman JN. Complete ruptur van de musculus biceps femoris pees. Ned Tijdschr Geneesk. 1991;135(42):1970.
  28. Jensen IH, Kramhøft M. Distal rupture of the biceps femoris muscle. Scand J Med Sci Sports. 2007;4(4):259–260.
  29. Valente M, Mancuso F, Alecci V. Isolated rupture of biceps femoris tendon. Muskuloskelet Surg. 2011;97(3):263–266. DOI: 10.1007/s12306-011-0171-2
  30. Sonnery-Cottet B, Daggett M, Gardon R, Pupim B, Clechet J, Thaunat M. Surgical Management of Recurrent Musculotendinous Hamstring Injury in Professional Athletes. Orthop J Sports Med. 2015 Oct 1;3(10):2325967115606393. DOI: 10.1177/2325967115606393

Full text PDF