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Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model
  1. Anne D van der Made1,2,3,
  2. Rolf W Peters2,3,4,
  3. Claire Verheul2,3,5,
  4. Frank F Smithuis2,3,6,
  5. Gustaaf Reurink2,3,7,
  6. Maarten H Moen7,
  7. Johannes L Tol2,3,8,
  8. Gino M M J Kerkhoffs1,2,3
  1. 1Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
  2. 2Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands
  3. 3Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
  4. 4Department of Trauma surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
  5. 5Fysiokliniek Amsterdam, Amsterdam, The Netherlands
  6. 6Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
  7. 7The Sports Physicians Group, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
  8. 8Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  1. Correspondence to Anne D van der Made, Department of Orthopedic Surgery, Amsterdam UMC, Amsterdam, The Netherlands; a.d.vandermade{at}; Professor Gino M M J Kerkhoffs; g.m.kerkhoffs{at}


Objective To prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions.

Methods Patients with an MRI-confirmed proximal hamstring tendon avulsion were included. Operative or non-operative treatment was selected by a shared decision-making process. The primary outcome was the Perth Hamstring Assessment Tool (PHAT) score. Secondary outcome scores were Proximal Hamstring Injury Questionnaire, EQ-5D-3L, Tegner Activity Scale, return to sports, hamstring flexibility, isometric hamstring strength and MRI findings including proximal continuity.

Results Twenty-six operative and 33 non-operative patients with a median age of 51 (IQR: 37–57) and 49 (IQR: 45–56) years were included. Median time between injury and initial visit was 12 (IQR 6–19) days for operative and 21 (IQR 12–48) days for non-operative patients (p=0.004). Baseline PHAT scores were significantly lower in the operative group (32±16 vs 45±17, p=0.003). There was no difference in mean PHAT score between groups at 1 year follow-up (80±19 vs 80±17, p=0.97). Mean PHAT score improved by 47 (95% CI 39 to 55, p<0.001) after operative and 34 (95% CI 27 to 41, p<0.001) after non-operative treatment. There were no relevant differences in secondary clinical outcome measures. Proximal continuity on MRI was present in 20 (95%, 1 recurrence) operative and 14 (52%, no recurrences) non-operative patients (p=0.008).

Conclusion In a shared decision-making model of care, both operative and non-operative treatment of proximal hamstring tendon avulsions resulted in comparable clinical outcome at 1-year follow-up. Operative patients had lower pretreatment PHAT scores but improved substantially to reach comparable PHAT scores as non-operative patients. We recommend using this shared decision model of care until evidence-based indications in favour of either treatment option are available from high-level clinical trials.

  • tendon
  • rupture
  • tear
  • hamstring tendons

Data availability statement

Data are available on reasonable request.

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Data availability statement

Data are available on reasonable request.

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  • Contributors ADvdM (guarantor) was involved in study design, data collection, data analysis, data interpretation and drafting. RWP and CV were involved in data collection and drafting. FS was involved for his radiological expertise, assessment of MRIs and drafting. GR, MHM, JLT and GMMJK were involved in study design, data interpretation and drafting.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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