Distal semitendinosus rupture is an uncommon occurrence. A treatment dilemma often arises as the condition is only briefly described in the literature and there is often a requirement to return to high level athletic pursuits. Both non-operative and operative management approaches have been described. Both options of care can be justified in individual cases. A patient focused algorithmic approach aids the clinician in providing the most informed decision-making process to their patient especially when definitive evidence is lacking. An algorithmic approach using best available evidence for distal semitendinosus rupture management was formulated. This allows the clinician to choose the potential treatment options depending on the time course since the injury and their current clinical presentation. This approach has since been used to successfully treat a semi-professional rugby union player as will be described.