In the athletic population, injuries to the hamstring muscle comprise one of the most common injuries reported in the literature. Because of the increased size, stress, and explosive ability of athletes today, these injuries have become relatively common. Over the last few years, complete hamstring avulsions from the ischial insertion have received greater attention because of advanced diagnostic capabilities. Conservative treatment for these pathologies may result in long-term dysfunction, secondary to the high-powered nature of the athlete today. When ineffective, nonoperative treatment results in continued complaints of pain, loss of explosive power, and an inability to return to previous level of function. It has been our experience that immediate and primary repair of the proximal hamstring avulsion from the ischial insertion yields a positive functional result with efficient return to activity. The mechanical force associated with this injury is forced hip flexion, with eccentric contraction of the hamstrings. The athlete perceives a “popping” or “snapping” sensation in the posterior buttocks, accompanied by immediate pain and asymmetrical gait. Diagnosis is based on the subjective history, which results in a high clinical suspicion. The clinical examination is consistent with a palpable defect in the hamstring insertion; ecchymosis over the posterior hamstring and definitive diagnosis is based on magnetic resonance imaging evaluation. Although traditional teachings assert that conservative treatment of tendon injuries is the standard, proximal hamstring tendon avulsion requires a completely different algorithm. Our current and more aggressive approach incorporates a surgical procedure, which leads to the best possible outcome for these athletes.