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

PurposeThis 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.MethodsA 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.ResultsSeven 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.ConclusionBased 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 EvidenceLevel III.