Operative Treatment of Proximal Rectus Femoris Injuries in Professional Soccer Players: A Series of 19 Cases

Quadriceps injuries

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Indirect Rectus Femoris Injury Mechanisms in Professional Soccer Players: Video Analysis and Magnetic Resonance Imaging Findings

OBJECTIVE

To describe injury mechanisms and magnetic resonance imaging (MRI) findings in acute rectus femoris (RF) injuries of soccer players using a systematic video analysis.

DESIGN

Descriptive case series study of consecutive RF injuries from November 2017 to July 2022.

SETTING

Two specialized sports medicine hospitals.

PARTICIPANTS

Professional male soccer players aged between 18 and 40 years, referred for injury assessment within 7 days after a RF injury, with an available video footage of the injury and a positive finding on an MRI.

INDEPENDENT VARIABLES

Rectus femoris injury mechanisms (specific scoring based on standardized models) in relation to RF muscle injury MRI findings.

MAIN OUTCOME MEASURES

Rectus femoris injury mechanism (playing situation, player/opponent behavior, movement, and biomechanics), location of injury in MRI.

RESULTS

Twenty videos of RF injuries in 19 professional male soccer players were analyzed. Three different injury mechanisms were seen: kicking (80%), sprinting (10%), and change of direction (10%). Isolated single-tendon injuries were found in 60% of the injuries. Of the kicking injuries, 62.5% included complete tendon ruptures, whereas both running injuries and none of the change of direction injuries were complete ruptures. The direct tendon was involved in 33% of the isolated injuries, and the common tendon was affected in all combined injuries.

CONCLUSIONS

Rectus femoris injuries typically occur during kicking among football players. Most of the RF injuries involve a complete rupture of at least one tendon. Kicking injuries can also affect the supporting leg, and sprinting can cause a complete tendon rupture, whereas change of direction seems not to lead to complete ruptures.

The capsular head of the proximal rectus femoris muscle: a review of the imaging anatomy of proximal muscle injury in professional athletes – early experience

The detailed anatomy of the rectus femoris and corresponding injury appearances were first described in 1995. Since then, there has been little published to change our understanding of this complex anatomical area. More recent anatomical dissection work in 2004 and 2006 alluded to the presence of an altered configuration of the proximal tendon anatomy. Whilst widely accepted that the proximal rectus femoris muscle has two distinct tendon slips, the authors in 2006 described a third separate tendon slip arising from the anterior femoral capsule and this has been widely termed the ‘capsular head’. We provide evidence that imaging features corroborate this revised anatomical concept. Whilst the clinical relevance of these findings is yet to be established, it remains important that our understanding of the radiological anatomy in this area advances with the forward growth of imaging clarity. In this review, we revisit anatomical concepts and present atypical injury cases that may be explained by the presence of a separate capsular head.

A newly discovered membrane at the origin of the proximal tendinous complex of the rectus femoris

PURPOSE

The rectus femoris (RF) forms the anterior portion of the quadriceps muscle group. It has a proximal tendinous complex (PTC) which is constituted by a direct tendon (DT), an indirect tendon (IT), and a variable third head. Direct and indirect tendons finally converge into a common tendon (CT). All the PTC shows a medially sloping in its proximal insertion.We investigated several anatomical specimens and discovered a new component: a membrane connecting the CT with the anterior superior iliac spine. Such membrane constitutes a new origin of the PTC. The aim of this study was to clarify whether this membrane was an anatomical variation of the PTC or a constant structure and to describe its morphology and trajectory.

MATERIAL AND METHODS

We dissected 42 cadaveric lower limbs and examined the architecture of the PTC. We paid special attention to the morphology and interaction patterns between the tendons and the membrane.

RESULTS

We demonstrated that the membrane is a constant component of the PTC. It has a lateral to medial trajectory and is in relation to the common tendon, the DT, and IT, which present a medial slope. This suggests that the membrane has an stabilizer role for the PTC, acting as a corrector of the inclined vector of the complex.

CONCLUSION

The RF injuries are frequent in football. The newly discovered membrane is a constant component of the PTC and its integrity should be included in the algorithm to diagnose injuries.

Management of anterior thigh injuries in soccer players: practical guide

Most of the anterior thigh injuries are contusions or strains, however, some of these injuries can be career ending. Early diagnosis and correct treatment are key to successful outcome. Analyzing injury mechanism and adding both clinical and imaging findings, clinicians can make the right treatment decisions already often in the acute phase of the injury. Low grade contusions and muscle strains are treated well with planned rehabilitation, but complete tendon injuries or avulsions can require operative treatment. Also, neglected minor injuries could lead to chronic disabilities and time lost from play. Typical clinical presentation of anterior thigh injury is swelling and pain during hip flexion or knee extension. In more severe cases a clear gap can be palpated. Imaging methods used are ultrasound and magnetic resonance imaging (MRI) which are helpful for clinicians to determine more exact the extent of injury. MRI can identify possible tendon retractions which may need surgery. Clinicians should also be aware of other traumatic lesions affecting anterior thigh area such as myositis ossificans formation. Optimal treatment should be coordinated including acute phase treatment with rest, ice, and compression together with designed return-to-play protocol. The anatomical structure involved lines the treatment pathway. This narrative review describes these more common reasons for outpatient clinical visits for anterior thigh pain and injuries among soccer players.

Arthroscopic and Endoscopic Treatment of Proximal Rectus Femoris Avulsion

Proximal rectus femoris avulsion (PRFA) is an uncommon injury that is poorly reported in the literature. Historically, these injuries have been treated nonoperatively or with open techniques. This is the first study showing endoscopic treatment of this injury. We present a systematic review of PRFA treatment and a case report of a patient whose injury was treated endoscopically. Sixty-four injuries were reported across several sports. Patients underwent nonoperative management, suture repair, suture anchor repair, or excision of the tendon stump. Surgical complications included lateral femoral cutaneous nerve injury and wound complications. The patient who underwent arthroscopic treatment had a good outcome. [Orthopedics. 2022;45(1):e1-e6.].

Midterm outcome and strength assessment after proximal rectus femoris refixation in athletes

PURPOSE

Proximal rectus femoris avulsions (PRFA) are relatively rare injuries that occur predominantly among young soccer players. The aim of this study was to evaluate midterm postoperative results including strength potential via standardized strength measurements after proximal rectus femoris tendon refixation. It was hypothesized that the majority of competitive athletes return to competition (RTC) after refixation of the rectus femoris tendon without significant strength or functional deficits compared to the contralateral side.

METHODS

Patients with an acute (< 6 weeks) PRFA who underwent surgical refixation between 2012 and 2019 with a minimum follow-up of 12 months were evaluated. The outcome measures compiled were the median Tegner Activity Scale (TAS) and mean RTC time frames, Harris Hip Score (HHS), Hip and Groin Outcome Score (HAGOS) subscales, International Hip Outcome Tool-33 (iHOT-33), and Visual Analog Scale (VAS) for pain. In addition, a standardized isometric strength assessment of knee flexion, knee extension, and hip flexion was performed to evaluate the functional result of the injured limb in comparison to the uninjured side.

RESULTS

Out of 20 patients, 16 (80%) patients were available for final assessment at a mean follow-up of 44.8 ± SD 28.9 months. All patients were male with 87.5% sustaining injuries while playing soccer. The average time interval between trauma and surgery was 18.4 ± 8.5 days. RTC was possible for 14 out of 15 previously competitive athletes (93.3%) at a mean 10.5 ± 3.4 months after trauma. Patients achieved a high level of activity postoperatively with a median (interquartile range) TAS of 9 (7-9) and reported good to excellent outcome scores (HHS: 100 (96-100); HAGOS: symptoms 94.6 (89.3-100), pain 97.5 (92.5-100), function in daily living 100 (95-100), function in sport and recreation 98.4 (87.5-100), participation in physical activities 100 (87.5-100), quality of life 83.1 ± 15.6; iHot-33: 95.1 (81.6-99.8)). No postoperative complications were reported. Range of motion, isometric knee flexion and extension, as well as hip flexion strength levels were not statistically different between the affected and contralateral legs. The majority of patients were "very satisfied" (56.3%) or "satisfied" (37.5%) with the postoperative result and reported little pain (VAS 0 (0-0.5)).

CONCLUSION

Surgical treatment of acute PRFA yields excellent postoperative results in a young and highly active cohort. Hip flexion and knee extension strength was restored fully without major surgical complications.

LEVEL OF EVIDENCE

Retrospective cohort study; III.

Rehabilitation after a Complete Avulsion of the Proximal Rectus Femoris Muscle: Considerations from a Case Report

BACKGROUND

A complete avulsion of the proximal rectus femoris muscle is a rare but severity injury. There is a lack of substantial information for its operative treatment and rehabilitation; in particular there is a lack of biomechanical data to evaluate long-term outcomes.

CASE PRESENTATION

The case report presents the injury mechanism and surgical treatment of a complete avulsion of the proximal rectus femoris muscle in a 41-year-old recreational endurance athlete. Moreover, within a one-year follow-up period, different biomechanical tests were performed to get more functional insights into changes in neuromuscular control, structural muscle characteristics, and endurance performance. Within the first month post-surgery, an almost total neuromuscular inhibition of the rectus femoris muscle was present. A stepwise reduction in inter-limb compensations was observable (e.g., in crank torque during cycling) during the rehabilitation. Muscular intra-limb compensations were shown at six months post-surgery and even one year after surgery, which were also represented in the long-term adaption of the muscle characteristics and leg volumes. A changed motor control strategy was shown by asymmetric muscle activation patterns during ergometer cycling, while the power output was almost symmetric. During rehabilitation, there might be a benefit to normalizing neuromuscular muscle activation in ergometer cycling using higher loads.

CONCLUSIONS

While the endurance performance recovered after six months, asymmetries in neuromuscular control and structural muscle characteristics indicate the long-term presence of inter- and intra-limb compensation strategies.

Avulsion Injuries and Ruptures of the Proximal Rectus Femoris in Skeletally Mature, High-Level Athletes: A Critical Analysis Review

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Injuries to the proximal rectus femoris remain rare, occurring primarily in soccer and American football athletes during kicking and sprinting because of its unique biarthrodial nature.

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The appropriate diagnosis is dependent on careful physical examination and imaging interpretation.

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While no universal treatment algorithm has been adopted for high-level athletes, recent investigations support operative repair using suture anchors to restore strength and function in order to allow an effective return to competition while minimizing the risk of injury recurrence.

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Complications following surgical management include injury to the lateral femoral cutaneous nerve and hematoma formation, and there are reports of residual pain and weakness with chronic injuries that fail the initial nonoperative treatment.

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Current investigations examining outcomes following treatment remain limited, warranting additional studies that examine patient-reported results, return-to-play rates, and the role of orthobiologics and accelerated rehabilitation protocols following injury to further improve athlete health and safety.

[Proximal avulsion of the rectus femoris muscle]

BACKGROUND

Injuries of the thigh muscles are among the most frequent sports injuries. For example, in soccer they represent nearly 30% of all injuries. The rectus femoris muscle is particularly exposed to injury due to its anatomical features. While distal ruptures involve the quadriceps tendon and are among the more frequent injuries not only in sports, proximal ruptures represent a rarity. Because of the mostly indifferent clinical signs, the diagnosis is often delayed. In the literature various versions of classifications on the grading of muscle injuries have been described.

OBJECTIVE

With respect to the rectus femoris muscle, there is no classification system from which a treatment decision or an algorithm can be derived. The problem is not only the unclear classification of the injury but also the variability of treatment options resulting from this.

MATERIAL AND METHODS

A selective search of the literature was carried out to construct a review article.

RESULTS

No standardized follow-up treatment after surgical interventions or an established procedure for conservative treatment is currently available.

CONCLUSION

The comparison of the individual studies is made difficult due to the low case numbers and nonuniform classification systems. A valid treatment algorithm can only be derived with difficulty based on the currently available data.

Bicortical Titanium Tenodesis Button With Double-Row Fixation for the Treatment of Proximal Rectus Femoris Avulsion: Review of Literature and Surgical Technique

In adult populations, rectus femoris avulsions are reported in professional soccer and football players but are noted to be exceptionally rare. No gold standard or recommendations exist for this injury; however, in cases of avulsion at the anterior inferior iliac spine, positive outcomes appear to result from rest, immobilization, and rehabilitation. Surgery is typically reserved for cases with large retractions of bone fragments or unsuccessful nonoperative treatment. Surgical treatment methods vary from direct suture repair to single- and double-row bone suture placement and even muscle-muscle repair. We present our technique using a bicortical tenodesis button with double-row fixation for the treatment of a severely retracted rectus femoris tendon avulsion in a high-level athlete.

Chronic and Recurrent Rectus Femoris Central Tendon Ruptures in Athletes: Clinical Picture, MRI Findings, and Results of Surgical Treatment

Background:

Severe rectus femoris central tendon rupture is an uncommon sports-related injury. Most rectus femoris central tendon injuries can be treated by nonoperative means, but some tend to reinjure, resulting in chronic symptoms. Physicians treating athletes with rectus femoris injuries should be aware of this clinical condition and know that surgical treatment could be beneficial to the athlete if the rectus femoris central tendon rupture becomes chronic.

Purpose:

To describe the clinical picture, magnetic resonance imaging (MRI) findings, and surgical treatment results of rectus femoris central tendon injuries.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included 12 patients who underwent successful repair of recurrent rectus femoris central tendon rupture. Presurgical MRI scans were obtained and compared with the surgical findings. The time of return to play was recorded, and the outcome of surgical treatment was evaluated with validated Subjective Patient Outcome for Return to Sports (SPORTS) criteria: good = full return to preinjury level of sports without any symptoms; moderate = return to preinjury level of sports with some residual symptoms (mild discomfort during sports); and poor = did not return to preinjury level of sports.

Results:

Overall, 10 patients had a good outcome (83%), and 2 had a moderate outcome (17%). All athletes included in the study were able to return to sport at their preinjury levels 2.5 to 4 months postoperatively. Presurgical MRI scans correlated well with the surgical findings.

Conclusion:

The surgical treatment of rectus femoris central tendon rupture seems to be a good option in chronic and recurrent cases. After surgery and successful rehabilitation, the athlete is expected to continue sports at the preinjury level.

Outcomes of Surgical Repair Versus Primary Tenodesis for Proximal Rectus Femoris Avulsion Injuries in Professional Athletes

BACKGROUND

Surgical repair of proximal rectus femoris avulsion injuries is associated with prolonged periods of rehabilitation and highly variable risk of injury recurrence. Surgical tenodesis of these injuries is often reserved for recurrent injuries or revision surgery. To our knowledge, the outcomes of proximal rectus femoris avulsion injuries treated with surgical repair versus primary tenodesis have not been previously reported.

HYPOTHESIS

Primary tenodesis of proximal rectus femoris avulsion injuries is associated with reduced risk of injury recurrence as compared with surgical repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 25 patients (22 male and 3 female) who underwent surgical repair versus 30 patients (26 male and 4 female) who received primary tenodesis for proximal rectus femoris avulsion injuries. Predefined outcomes were recorded at regular intervals after surgery. Mean follow-up time was 27.9 months (range, 24.0-31.7 months) from date of surgery.

RESULTS

All patients returned to their preinjury levels of sporting activity. Primary tenodesis was associated with earlier return to preinjury level of sporting function as compared with surgical repair (mean ± SD, 12.4 ± 1.6 vs 15.8 ± 2.2 weeks; P < .001) and reduced risk of recurrence (0% vs 16%; P < .001). At 1-year follow-up, there was no difference in surgical repair versus primary tenodesis relating to patient satisfaction scores (12 very satisfied and 13 satisfied vs 16 very satisfied and 14 satisfied; P = .70), isometric quadriceps strength (95.6% ± 2.8% vs 95.2% ± 6.3%; P = .31), Tegner scores (median [interquartile range], 9 [8-9] vs 9 [8-9]; P = .54), and lower extremity functional scores (73 [72-76] vs 74 [72-75]; P = .41). High patient satisfaction, quadriceps muscle strength, and functional outcome scores were maintained and remained comparable between treatment groups at 2-year follow-up.

CONCLUSION

Primary tenodesis was associated with reduced time for return to preinjury level of sporting function and decreased risk of injury recurrence when compared with surgical repair for proximal rectus femoris avulsion injuries. There were no differences in patient satisfaction, functional outcome scores, and quadriceps muscle strength between the treatment groups at 1- and 2-year follow-up.

The management of proximal rectus femoris avulsion injuries

Injuries to the quadriceps muscle group are commonly seen in sporting activities that involve repetitive kicking and high-speed sprinting, including football (soccer), rugby and athletics.

The proximal rectus femoris is prone to avulsion injuries as rapid eccentric muscle contraction leads to asynchronous muscle activation and different force vectors through the straight and reflected heads.

Risk factors for injury include previous rectus femoris muscle or hamstring injury, reduced flexibility of the quadriceps complex, injury to the dominant leg, and dry field playing conditions.

Magnetic resonance imaging (MRI) is the preferred imaging modality as it enables the site of injury to be accurately located, concurrent injuries to be identified, preoperative grading of the injury, and aids surgical planning.

Non-operative management is associated with highly variable periods of convalescence, poor return to preinjury level of function and high risk of injury recurrence.

Operative treatment of proximal rectus femoris avulsion injuries with surgical repair or surgical tenodesis enables return to preinjury level of sporting activity and high functional outcomes.

Surgical tenodesis of proximal rectus femoris avulsion injuries may offer an avenue for further reducing recurrence rates compared to direct suture anchor repair of these injuries.

Cite this article: EFORT Open Rev 2020;5:828-834. DOI: 10.1302/2058-5241.5.200055

Operative versus conservative treatment of proximal rectus femoris avulsions: A systematic review with meta-analysis of clinical outcomes, complications and return to sports

PROSPERO REGISTRATION NUMBER

CRD42020198333.

OBJECTIVE

To compare the surgical and conservative treatment of proximal rectus femoris avulsions regarding clinical outcomes, rate of return to sports and incidence of complications.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane, Medline, Scopus and SPORTDiscus.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies reporting on outcomes of PRFAs or return to sports were included.

RESULTS

Nine studies consisting of a total eighty-two patients met the inclusion criteria. The mean age was 22.2 years and 75.9% of patients were male. Mean follow-up was 28.9 months and 65% avulsions were managed surgically. The overall outcomes were similar in surgical and conservative treatment group (p = 0.72) with similar incidence of complications (14%). The rate of return to sports was 95% in surgical and 92.7% in the conservative management groups (p = 0.93). Overall, the quality of the methodology of included studies was low, with a mean CMS of 45.6.

CONCLUSION

Both conservative and operative treatment provide excellent outcomes in proximal rectus femoris avulsions, with similar rates of return to sports and incidence of complications. More prospective and good quality studies are needed to compare surgical techniques and time to return to sports. Avulsions with retraction of more than 20 mm and high demand patients may benefit from surgical treatment. Patients should be counselled accordingly.

Management of hamstring injuries: current concepts review

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management. Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury. This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients. Cite this article: Bone Joint J 2020;102-B(10):1281-1288.