Hamstring consist of three muscles: biceps femoris (BF), semitendinosus and semimembranosus, and is the most common muscle-tendon injury in football.

Most injuries are mild strains, partial tears or contusions that are treated by conservative means. Surgery can be carried out as an early treatment (in the acute phase, within 3 weeks) when proximal 1-tendon (BF/SM) avulsion with a retraction, 2-tendon or 3-tendon avulsions are presented in top level players, but also with distal tendon avulsions where a complete distal rupture at the musculotendinosus joint area is presented, when BF free/central tendon ruptures with a clear gap or with apophyseal avulsion fractures.

On the other hand, delayed surgery should be considered when unsuccessful conservative treatments facilitate recurrent injuries and when chronic symptoms are presented, but also in special cases such as in chronic compartment syndrome, heterotopic ossification, chronic apophysitis and when hamstrings symptoms persist after semitendinosus-harvesting

The rehabilitation after injury should focus on functional mobility, strength, velocity, endurance, coordination and proprioception without forgetting athlete’s self-confidence, always carried out in a progressive loading way, activating compensatory muscles and respecting tissues biological healing time.

Functional strengthening/physiotherapy starts normally after 2-4 weeks gradually increasing load of the hamstrings while working on gluteus, calf muscles and pelvis core training. Light aqua training can be started after 3-4 weeks, stationary biking or cross trainer after 5-6 weeks, Alter-G running after 8-10 weeks, normal running after 2-3 months, return to field after 3-5 months and return to high level of sports after 4-6 months from the operation.

To summarise, hamstrings injuries can be a career ending injury for elite athletes where the most severe are tendon injuries. When complete proximal or distal tendon avulsions or a big gap in injured tendon is diagnosed, early surgery treatment should be considered.

Key words: hamstrings injuries, surgery, return to play, biceps femoris, elite athletes.