Severe or complete tears of the proximal hamstring tendon may require surgery if symptoms persist despite conservative measures or if overall function is limited. Surgery for hamstring injuries involves reattaching the proximal hamstring tendon back to its insertion on the pelvis bone (ischial tuberosity). Surgery can be performed either endoscopically (minimally invasive) or as an open procedure, that is typically an outpatient procedure.  When there is also an avulsion injury, meaning the tendon pulled off a piece of bone, surgery is almost always indicated. Surgery may be recommended for active and professional athletes when conservative measures fail to relieve pain, or if time lost to conservative treatment is too costly to the athlete.

Hamstring tendons can be repaired through an open minimally invasive hamstring repair technique or with the assistance of a camera (endoscopic hamstring repair). For small tears without significant retraction, endoscopic hamstring repair can be performed. A special camera, called an endoscope, is inserted into the buttock area where the hamstring is torn. Small surgical instruments are also inserted through separate incisions and are used to perform the repair using a minimally invasive approach. Alternatively, a minimally invasive repair through a small incision hidden in the gluteal crease can be performed. This technique is indicated for tears that involve more than one tendon, chronic tears, or tears with significant retraction.

The best results are achieved when the hamstring tendon injury is treated as soon after the injury as possible. Optimal results are achieved when the repair is performed within 4-6 weeks from injury. When left untreated, hamstring tendon injuries can progress in severity and may involve irritation to the sciatic nerve from scar tissue or tension from the retracted tendon. Repair also becomes more difficult and less reliable as time from injury progresses.