A male, 27 year old athlete presents to you with right anterior thigh pain one-day post injury. He reports feeling a sharp pain on kicking in the later stages of his soccer match. He was unable to continue playing and acute (RICE) management was administered.
Following a thorough clinical assessment and further subjective questioning you diagnose the athlete with grade 2 mid portion rectus femoris strain. The team is 25 days from grand final and your athlete is a key player. The head coach phones and asks you, “ Will he be alright to play?
What is your answer?
The body of existent literature pertaining to quadriceps strains is limited in comparison to the extensive evidence available on their antagonist counterpart; the hamstrings.
Quadriceps muscle strains commonly occur during activities such as, kicking and sprinting. The most commonly occuring quadriceps strain is within the Rectus Femoris. This is due to the Rectus Femoris crossing two joints, in addition to its high proportion of Type 2 fibers.
Strains are typically incomplete tears which occur along the Musculo-Tendinous Junction (MTJ). These incomplete tears occur more deeply within the muscle belly as opposed to the ends of the muscle.
The Rectus Femoris muscle is innervated by the Femoral Nerve has two separate heads.
1) The direct head (straight), originates from the Anterior Inferior Iliac Spine
2) The indirect head, (reflected), originates from the Superior Acetabular ridge and travels parallel and deep to the direct head tendon.
These two heads then form a conjoined tendon which progresses along the muscle, plateaus and then migrates to the middle of the muscle belly.
A strain of this conjoined tendon, also known as the central tendon, is imperative in your consideration in determining how you will best respond to the coach.
An accurate assessment of the central tendons degree of involvement is difficult to ascertain due to the depth of pathology. The athlete will require an MRI for accurate diagnosis. Axial T2 images will demonstrate a clear hyper-intense signal surrounding the central tendon if pathology is present. This appearance is regarded as; the acute ‘bulls eye’ lesion
Previous research conducted by Cross et al., (2004) illustrated that cases with a strain about the central tendon resulted in a rehabilitation interval of approximately 26.9 days, whereby cases with straining in the periphery upheld rehabilitation interval’s of approximately 9.2 days.
Furthermore, Cross et al.,concluded that injuries which involve more than 15% of the Rectus Femoris cross-sectional area resulted in longer rehabilitation interval’s.
Balius et al., (2009) proposed the following key prognostic indicators following their study on Rectus Femoris central tendon injuries and Sports Participation Absence (SPA) in elite soccer players.
- Injury at the proximal level of the central tendon indicates the SPA time is approximately 45.1 days if the injury length is 4.0 cm. This value increases by 5.3 days with each 1 cm increase in the length of injury.
- In the case of distal central tendon injury, the SPA time is approximately 32.9 days if the injury length is 3.9 cm. This value increases by 3.4 days with each 1 cm increase.
Due to the results derived from the study, a more conclusive, scientifically informed decision can now be made. That is, if the athlete has sustained a lesion of the peripheral fibres of the rectus femoris, there is a high probability that with thorough rehabilitation, he will play the Grand Final.
However, if the sustained lesion is of central tendon involvement, the likelihood of the athlete recovering for the Grand Final is exponentially lowered as his risk of injury re-occurrence is heightened. However, due to the strain occurring in the middleportion of the Rectus Femoris, his recovery will be quicker in comparison to that of a proximal strain. Furthermore, the length and cross-sectional area of the strain can be determined by further prognostic measures.
Decisions on return to play should be made on functional return to sports testing, sound clinical reasoning and collaboration with other medical personal, coaching staff and the athlete him self.
This case study highlights the importance of imaging for Acute Rectus Femoris Strains in order to ensure optimal recovery, in addition to providing well-informed timeframes, which will work to minimise the potential for reoccurrence of the injury.
Tune in to the next Sportsmedicinephysiotherapy.com education tutorial focusing on rehabilitation and athlete management post a Rectus Femoris strain.
Balius, R., Maestro, A., Pedect, C., Estruch, A., Mota, J., Rodriguez, L., Garcia, P., Mauri, E. (2009) Central aponeurosis tears of the rectus femoris: practical sonographic prognosis. Br J Sports Med. 2009 Oct;43(11):818-24. doi: 10.1136/bjsm.2008.052332. Epub 2009 Jan 27.
Cross, T., Gibbs, N., Houang, M., Cameron, M. (2004) Acute Quadriceps Muscle Strains; Magnetic Resonance Imaging Features and prognosis. Am J Sports Med. 2004 Apr-May;32(3):710-9.
Boutin,R.D.(2008) A Radiological Perspective: Magnetic Imaging of the muscle. Magnetic Resonance Imagining in Orthopaedic Sports
Acknowledgment: Editing by Kelly Taylor Lewis