Outcomes After Operative and Nonoperative Management of Hamstring Injuries: A Systematic Review

Hamstring injuries are common in sports involving rapid acceleration and directional changes. Despite extensive research, management remains primarily dependent on clinical judgment, owing to the absence of standardized, evidence-based protocols.

To compare the outcomes of operative versus nonoperative treatments, focusing on patient satisfaction, muscle strength, range of motion (ROM), activity level, and return to sport.

Systematic review; Level of evidence, 4.

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors performed a systematic search of the PubMed, Google Scholar, Web of Science, and ScienceDigest databases from January 2000 to May 2024. Reported outcomes measured were muscle strength, ROM, functional activity, pain levels, return to preinjury activity levels, and patient satisfaction. Additionally, any complications related to the intervention were documented. The authors identified 13 eligible studies involving adults with acute hamstring injuries, including 526 patients. Eleven studies specifically investigated operative treatment, 1 examined nonoperative management, and 1 directly compared both approaches.

Surgical intervention was consistently associated with superior outcomes across multiple domains. Postoperatively, the Lower Extremity Functional Scale score often exceeded 74, and strength recovery commonly approached 90.0% of the contralateral limb. ROM was preserved after surgery but was not evaluated in nonoperative cohorts. Functional activity was generally higher after operative treatment (mean Tegner Activity Scale [TAS] scores: 4.7 ± 0.8, 6.0 ± 1.47, 5.1, and 8.5 ± 2.4; Marx Activity Rating Scale scores: 3.5 ± 4.3 and 4.4 ± 4.4), whereas nonoperative treatment showed a decline in TAS score (6.9 ± 1.7 to 6.1 ± 1.9; P = .030). Pain levels were low overall (visual analog scale score: 0.7 ± 0.9 to 4.0 ± 4.0). Complications were more frequent after surgery (4.2%-36.6%, including hematomas, neurapraxia, and superficial infections), although mostly minor. Nonoperative complications were limited to ecchymosis.

This study demonstrated that operative treatment was associated with good functional recovery, muscle strength, and high return-to-sport rates. Complications rates within the operative group were mostly minor and not statistically significant when compared to nonoperative management, which yielded good outcomes in the limited available data. Further prospective studies using standardized outcome measures and clear subtype definitions are required to determine which patients benefit most from operative versus nonoperative management.