Is surgery my best option? with Peter Fuller

Understanding Proximal Hamstring Tendinopathy and Surgery Options


In this podcast episode, we delve into the complex world of proximal hamstring tendinopathy, a condition that can be debilitating for athletes and non-athletes alike. Host Brodie Sharp, an online physiotherapist and recreational athlete, welcomes musculoskeletal specialist Peter Fuller, a former elite middle-distance runner and cyclist. Together, they explore the intricacies of this condition and discuss the often-controversial topic of surgery as a potential solution.

The Basics of Proximal Hamstring Tendinopathy

Proximal hamstring tendinopathy is a condition that affects the tendons in the buttocks, where the hamstrings attach to the ischial tuberosity (sit bone). It can cause significant pain and limit a person’s ability to engage in physical activities. This episode aims to shed light on the condition, effective treatments, and common misconceptions.

Meet Peter Fuller: A Specialist in the Field

Peter Fuller’s extensive background as a musculoskeletal specialist and his career as a former elite athlete make him a valuable resource on the topic. He has worked as a general practitioner and sports doctor, providing insights into the field from multiple perspectives. Additionally, Peter has collaborated closely with surgeon David Young, who is a prominent figure in the world of proximal hamstring tendinopathy surgery.

Understanding Surgical Options

When it comes to surgical interventions for proximal hamstring tendinopathy, there are several factors to consider. Surgery typically becomes necessary when conservative treatments fail to provide relief. The decision to opt for surgery is a complex one, influenced by various factors, including the patient’s age, the severity of the condition, and their willingness to commit to a lengthy rehabilitation process.

Types of Surgery for Proximal Hamstring Tendinopathy

The type of surgery needed depends on the specific condition of the tendon. In cases where the tendon is mostly intact but requires some reinforcement, a surgeon may opt for a less invasive approach. This involves creating vertical incisions in the tendon to stimulate healing and remove any mucoid degeneration.

In more severe cases where a significant portion of the tendon has pulled away from the bone, the surgeon may perform a “take down” procedure. This involves detaching the tendon from the bone, removing damaged tissue, and reattaching the tendon with anchors and sutures. This type of surgery necessitates a more extended recovery period, often ranging from three to five months.

The Role of Scar Tissue

While some scar tissue is necessary for the healing process, excessive scar tissue around the tendon can be problematic. It can potentially impact the sciatic nerve, leading to symptoms such as radiating pain down the leg. Surgeons routinely conduct a “neural lysis” procedure to ensure that the hamstring tendon is not bound by scar tissue, thus preventing nerve irritation.

Factors Influencing the Decision for Surgery

The decision to undergo surgery for proximal hamstring tendinopathy is a complex one. There is no one-size-fits-all answer, and various factors come into play. Patients must work closely with their healthcare providers to determine the most suitable course of action. These factors include the patient’s age, the severity of the condition, the response to conservative treatments, and personal preferences. Some individuals are more patient with rehabilitation, while others may seek surgery early, hoping for a quicker resolution to their pain.

The Nerve-Tendon Relationship

Peter explains the intricate relationship between the sciatic nerve and the hamstring tendon. He clarifies that excessive scar tissue around the sciatic nerve is not the primary issue. Patients often experience sciatic nerve symptoms either due to direct irritation or as a result of proximal hamstring tendinopathy. Misinterpretation can also occur during MRI scans, making it crucial for healthcare professionals to communicate effectively with patients.

Debunking the Scar Tissue Myth

While there’s a common belief that scar tissue accumulates around the sciatic nerve, Peter emphasizes that there is little evidence to support this claim. When surgical intervention is necessary for hamstring tendinopathy, the primary goal is to visualize and protect the nerve, freeing it from any potential scar tissue. Patients should not be overly concerned about scar tissue but rather focus on addressing the underlying irritation and inflammation.

Surgery and Alternatives

Peter discusses the possibility of surgery for patients with irritated sciatic nerves alongside proximal hamstring tendinopathy. However, he highlights that the decision to undergo surgery depends on the individual case. There are conservative alternatives, such as ultrasound-guided injections to alleviate nerve irritation, which can be explored before considering surgery. Such non-invasive approaches are often the first line of treatment.

Avulsion Fractures and Surgery

In cases where avulsion fractures are present, Peter outlines how the severity of the injury may determine the need for surgery. Smaller fractures, around one centimeter in size, may heal with conservative methods, while larger fractures may require surgical intervention. This decision should be made after careful assessment and consultation with a medical professional.

Surgical Success Rates

Peter suggests that surgical success rates for proximal hamstring tendinopathy are approximately 80%. However, the outcome may vary depending on the individual’s case. Some factors, such as the presence of degenerative tendon tissue, can affect the long-term success of surgery. Patients should be prepared for the possibility of post-operative complications and be patient during their recovery.

Chronic Pain and the Brain

Chronic pain can be a challenging aspect of proximal hamstring tendinopathy, and Peter acknowledges the role of the brain in processing and perpetuating pain signals. Patients who have experienced pain over an extended period may need reassurance and education on the brain’s response to persistent pain. Techniques to manage and reduce central sensitization should be explored alongside physical rehabilitation.

Post-Surgery Expectations

The ability to return to high-quality exercise post-surgery depends on various factors, including the type of surgery and the individual patient. While some may need to adjust their exercise routines, the goal of surgery is often to enable patients to resume their preferred activities. Peter emphasizes the importance of a gradual return to high-impact exercise and cross-training to minimize the risk of re-injury.

Patience in Recovery

Finally, Peter stresses the need for patience during recovery from proximal hamstring tendinopathy. While surgery is an option, conservative treatments, including rest, strength training, and avoiding aggravating activities, should be explored first. This path may require several months of dedicated effort for optimal results.


Proximal hamstring tendinopathy can be a challenging condition to manage. Surgery is often a last resort, and patients are encouraged to explore conservative treatments first. Understanding the intricacies of the condition, the potential benefits and drawbacks of surgery, and the role of scar tissue is crucial for making informed decisions regarding treatment options. Patients should work closely with healthcare providers to create a personalized plan for managing proximal hamstring tendinopathy.

Proximal hamstring tendinopathy is a complex condition that requires careful assessment, treatment, and post-operative care. Surgery can be an effective option for some patients, but conservative approaches should be the first choice. Patience, education, and a well-structured rehabilitation plan are essential components of a successful recovery. Remember, knowledge and a proactive approach are your allies on the path to healing and restored function.