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Review
. 2025 Jul 13;12(3):e70327.
doi: 10.1002/jeo2.70327. eCollection 2025 Jul.

No difference in patient-reported outcomes between operative and non-operative management of proximal hamstring injuries, but return to sports is higher in operative treatment: A systematic review and meta-analysis

Napatpong Thamrongskulsiri  1   2   3 , Danaithep Limskul  2   3 , Thanathep Tanpowpong  2   3 , Somsak Kuptniratsaikul  2 , Anil S Ranawat  4 , Thun Itthipanichpong  2   3
Affiliations
Review

No difference in patient-reported outcomes between operative and non-operative management of proximal hamstring injuries, but return to sports is higher in operative treatment: A systematic review and meta-analysis

Napatpong Thamrongskulsiri et al. J Exp Orthop. .

Abstract

Purpose: This study aimed to compare the patient-reported outcome score, return-to-sports rate, knee flexion strength and complications of operative and non-operative treatments for proximal hamstring tendon avulsions.

Methods: A comprehensive search of PubMed, Ovid and Scopus was conducted to identify clinical comparative studies with Levels 1-3 evidence on operative versus non-operative management for proximal hamstring tendon avulsions. Studies were included if they reported post-treatment clinical outcomes and met inclusion criteria: comparative design, English language, full-text availability, and patient-reported outcomes. Data were analyzed using odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with heterogeneity assessed by chi-square tests.

Results: Seven studies, encompassing 8 cohorts and 592 cases (256 operative, 109 non-operative), met the inclusion criteria. The Methodology Index for Non-Randomized Studies scores for these studies ranged from 14 to 22, indicating a fair to good methodological quality. The operative group demonstrated a statistically significantly higher return-to-sport rate at pre-injury performance levels compared to non-operative management (65.2% vs. 50.7%; OR = 1.83; p = 0.005). Pooled meta-analyses revealed no statistically significant differences in post-treatment patient-reported outcomes, as measured by the Lower Extremity Functional Scale (MD = 2.32; 95% CI: -0.41 to 5.05; p = 0.10) and the Perth Hamstring Assessment Tool (MD = 0.37; 95% CI: -3.61 to 4.35; p = 0.86). Neurological complications, including sciatic nerve symptoms, were similar between the two groups.

Conclusion: Based on fair to good-quality studies, findings apply mainly to active, middle-aged recreational athletes. The operative and non-operative treatments yield similar patient-reported outcomes in proximal hamstring avulsions, though operative management may facilitate a higher return-to-sport rate.

Level of evidence: Level III.

Keywords: conservative treatment; hamstring muscles; proximal hamstring injuries; surgical procedures, operative; treatment outcome.

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Conflict of interest statement

Anil S. Ranawat has received education payments from Gotham Surgical; consulting fees from Anika Therapeutics, Arthrex, Bodycad, Flexion Therapeutics, Heron Therapeutics, Smith & Nephew and Stryker; speaking fees from Smith & Nephew; and royalties from ConforMIS. The remaining authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
The 2020 Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram depicting the inclusion process for the studies.
Figure 2
Figure 2
Forest plot comparing operative and non‐operative management of proximal hamstring injuries. (a) Return to sports at pre‐injury level. (B) Lower Extremity Functional Scale. (C) Perth Hamstring Assessment Tool. CI, confidence interval; IV, inverse variance; M–H, Mantel–Haenszel; SD, standard deviation.
Figure 3
Figure 3
Forest plot comparing neurological complications between operative and non‐operative management of proximal hamstring injuries. CI, confidence interval; M–H, Mantel–Haenszel.
See this image and copyright information in PMC

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