Outcomes after surgical and non-surgical treatments!

Hopefully it’s fair to use an article for both this blog post and my presentation…

So this study looked at how patients believed their recovery went who underwent surgery to treat a proximal hamstring avulsion and those who had non-surgical treatment. For the purpose of this study, a proximal hamstring avulsion was defined to be “when at least one of three tendons were avulsed from their origin on the ischial tuberosity.” Treatment was determined based on age (younger more likely to get surgery), comorbidity (the presence of two chronic diseases or conditions in the patient), activity level of the patient (the more active patients got surgery), MRI findings (more severe injury received surgery), and clinical findings (if the patient was unable to extend their hip in the prone position, they received surgery).

Surgery consisted of reinserting the common proximal hamstring tendon into the footprint. Following surgery, the patients rehabbed. The non-surgically treated group were referred to a physiotherapist and used the same rehab protocol as the surgical group.

The experimental group consisted of 47 patients, 33 of which had surgery and 14 of which did not (would the results be skewed due to the imbalance of subjects?), who had a mean age of 51 years old. Following their treatment, whether it was surgical or non-surgical, the authors of the study followed up with them 3.9 years later (oddly specific time but okay). The experimental test consisted of a Lower Extremity Functional Scale to determine the range of motion following the injury, and questions from the Proximal Injury Questionnaire (more subjective measurement). The study made sure to account for the severity of the original injury, by looking at the MRI following the injury.

The only result that was significant was that the MRI from the surgically treated group had a larger proportion of tendons retracted more than 2cm (probably why they required surgery…). The Lower Extremity Function Scale resulted in a score of 74 (SD+/-12) for the surgical group and 72 (SD+/-16) for the non-surgical group. However, they looked at their average time of exercise following treatment, and the surgical group reported that they exercised more often and for longer durations than their counterparts. That being said, 94% of the surgical group considered themselves high-performance amateur athletes, and 74% of the non-surgical group did. Do we think this is because they were a more physically active group prior to the injury (which is why their injury required surgery?) or could it be because they experience less pain while exercising?

Overall, the study concluded that there was no significant difference in recovery between surgically treated and non-surgically treated groups. That being said, if you ever have a proximal hamstring avulsion, you should probably think twice about going into the OR since the risk doesn’t provide you with any statistically significant reward.

Some questions I had while reading the article. Both of the tests they used to determine functionality after injury were subjective (which was very clear). Is there any way to do an objective study? Any test to determine if the range of motion is impaired following recovery, or if maybe the non-surgically treated patients fatigue sooner than the surgically treated group? How would this study differ if it was done in younger individuals who have a quicker recovery time? What about the elderly – is surgery less common since the risk of complications is greater? Is the PT program they designed for rehabilitation really equivalent for both groups or should they have created an alternative PT program for the non-surgically treated group to target specific areas for recovery (seeing as though their tendons were never surgically reattached)?

The link to the article is below if you are interested:


Pihl ESkoldenberg ONasell H, et al. Patient-reported outcomes after surgical and non-surgical treatment of proximal hamstring avulsions in middle-aged patients.

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