(aspects of sports medicine)

Proximal Rectus Femoris Avulsion in an Elite, Olympic-Level Sprinter Phillip R. Langer, MD, and F. Harlan Selesnick, MD

Abstract uadriceps injuries, rang- mal rectus femoris avulsion in Quadriceps injuries, ranging from ing from simple strains an elite, Olympic-level 100-meter simple strains to disabling muscle to disabling muscle sprinter, acutely managed with sur- ruptures, are common athletic inju- ruptures, are common gical repair. We have obtained the ries. The rectus femoris is the most Q among athletes who participate in patient’s informed written consent commonly injured portion of the quadriceps musculature. sports, such as football, basket- for print and electronic publication 1 This article is, to our knowledge, ball, rugby, and soccer. The rec- of this case report. the first report of a proximal rectus tus femoris is the most commonly femoris avulsion in an elite, Olympic- injured portion of the quadriceps Case Report level 100-meter sprinter, acutely musculature because of its anterior The patient was a 24-year-old elite- managed with surgical repair. location, high percentage of type II level sprinter who had been train- Several key factors must be con- muscle fibers, and biarticular span ing for the 2008 Summer Olympics sidered and carefully assessed when determining the appropri- ate course of management (ie, deciding between operative and “...proximal avulsions of the rectus nonoperative treatment): amount of distal retraction of the tendon, femoris in skeletally mature athletes severity of associated soft-tissue are rare.” trauma, physical examination, and postoperative goals (eg, return to elite-level competitive sports involv- across the and joints.2 when he felt a sharp pain in the ing running or kicking vs resum- Diagnoses are made for specific left at the 50-meter mark of ing basic activities of daily living). areas of the quadriceps. The classic his qualifying 100-meter dash. He We believe that these factors in our elite, high-performance athlete dic- quadriceps strain (jumper’s knee) was unable to continue running. tated an operative course of man- occurs at the conjoined muscle– He was referred from an outside 2-4 agement. tendon junction. A partial tear institution after being told he had of the quadriceps most commonly a quadriceps muscle tear, specifi- affects the indirect distal head of cally of the rectus femoris, and was the rectus femoris.2-4 Unlike these initially treated with a knee immo- Dr. Langer is Assistant Team Physician more common clinical entities, bilizer, crutches, and rehabilitation. and Orthopedic Surgeon, Atlanta proximal avulsions of the rectus He was otherwise healthy, with no Falcons and Atlanta Thrashers, Atlanta femoris in skeletally mature athletes pertinent past medical or surgical Sports Medicine and Orthopedic are rare.5-7 Case reports document Center, Atlanta, Georgia. the surgical repair of a chronic Dr. Selesnick is Head Team Physician and Orthopedic Surgeon, Miami Heat, proximal rectus femoral rupture at Orthopedic Institute of South Florida, the myotendinous junction in a soc- Coral Gables, Florida. cer player,7 the natural history and clinical outcome of rectus femoral Address correspondence to: Phillip avulsions treated nonoperatively in R. Langer, MD, Atlanta Sports Medicine and Orthopedic Center, 3200 2 National Football League (NFL) Downwood Cir, Suite 500, Atlanta, GA kickers,5 and the surgical repair of 30327 (tel, 404-352-4500; fax, 404-350- 5 proximal rectus femoris avulsions 0722; e-mail, [email protected]). (4 in soccer players and 1 in a 110- meter hurdler).6 Am J Orthop. 2010;39(11):543-547. Figure 1. Twelve-centimeter exposure Copyright Quadrant HealthCom Inc. This article is, to our knowl- extending from anterior inferior iliac 2010. All rights reserved. edge, the first report of a proxi- spine.

November 2010 543 Proximal Rectus Femoris Avulsion in an Elite, Olympic-Level Sprinter

Figure 2. Lateral femoral cutaneous Figure 3. Side-to-side repair of rectus Figure 4. Repair of proximal rectus identified and preserved. Rectus performed proximal to distal. femoris tendon. avulsion tagged. history, and there was no steroid The majority of the tendon was also was medial soft-tissue edema use or recent account of use of retracted approximately 8 cm, and along the knee. A small longitudi- quinolone antibiotics. there was a large (10-cm) hemor- nal tear was seen in the superior Physical examination did not rhagic fluid collection encasing the fibers of the lateral patellar retinac- reveal an abnormal swelling, mass, retracted tendon edge and the rec- ulum. This tear minimally extended or defect in the groin. In fact, there tus muscle–tendon junction. Fairly into the distal muscle–tendon junc- appeared to be a palpable defect extensive hemorrhage and edema tion of the vastus lateralis. approximately 4 cm proximal to the also was found extending through- After thorough discussion of the insertion into out the proximal half to two-thirds surgical and nonsurgical risks and the . The patient was unable of the in the benefits of treatment, the patient to perform a straight-. He anterior left thigh. There was asso- was brought to surgery 11 days had mild swelling of the left thigh, ciated prominent anterior and lat- after injury. The patient, an elite, a normal neurovascular examina- eral soft-tissue edema. Less severe Olympic-level 100-meter sprinter, tion, and a stable knee. edema, compatible with muscle wanted to return to competitive The report of the patient’s origi- strain injury, was seen in the mid to track. Given the significant (8-cm) nal magnetic resonance imaging (MRI) study from the outside “ institution documented a grade The majority of the tendon was retracted 2 muscle tear of the rectus femo- approximately 8 cm, and there was a ris muscle with a likely partial tear of the rectus femoris tendon large (10-cm) hemorrhagic fluid collection and a focal hematoma within the encasing the retracted tendon edge and proximal rectus femoris muscle. According to the report, there was the rectus muscle–tendon junction.” no evidence of complete disrup- tion of the rectus femoris mus- distal . There retraction of the proximal rectus cle or retraction of any muscu- was overlying anterolateral subcu- femoris tendon, the large (10-cm) lar segments. Yet, we believed the taneous hematoma extending down hemorrhagic fluid collection encas- findings of the patient’s physical the mid and distal portions of the ing the retracted tendon edge and examination at our institution 8 left thigh. Mild edema, compatible the rectus muscle–tendon junction days later, specifically his inability with mild muscle strain injury, also providing an interpositional bar- to extend the knee against grav- was found in the mid to distal fibers rier to potential healing and/or scar ity, warranted further investiga- of the . formation, and the massive edema tion. Therefore, we ordered MRI Additional fluid and edema, indi- in the entire rectus femoris muscle, for the knee, thigh, and hip. These cating strain injury, surrounded which extended distally to a point studies showed a complete tear in the in the medial just proximal to the knee joint, we the proximal rectus femoris ten- aspect of the left thigh. Distally, felt that surgical repair afforded the don. The tear appeared to have the quadriceps tendon was intact best chance for a return to competi- a longitudinal split component at its insertion onto the patella. tive running and sports. involving a small tuft of tendon Prominent soft-tissue edema was After initial exposure through a tissue that was still attached to the seen anteriorly and laterally along 12-cm longitudinal incision, which left anterior inferior iliac spine. the distal quadriceps tendon. There extended distally from the anterior

544 The American Journal of Orthopedics® P. R. Langer and F. H. Selesnick inferior iliac spine, the lateral femo- (Figure 5). After copious irrigation, Rectus femoris strain has been ral cutaneous nerve was identified, the was approximated with shown to occur most commonly in and then was preserved throughout interrupted sutures (Vicryl No. 2), either the distal musculotendinous the procedure (Figures 1, 2). The and the surgical wound was closed junction or in the mid-muscle belly interval between the sartorius and in standard fashion. The opera- as a lesion of the intramuscular the tensor was identi- tive extremity was placed in a knee indirect head tendon.2-4 fied and developed. Subsequently, immobilizer, which was maintained Various factors predispose the a very large hematoma was evacu- for 6 weeks before initiation of a rectus femoris to strain injuries and ated from the proximal to mid- rehabilitation program. During this eventual failure in sports such as dle third of the thigh. This area time, the patient was restricted to sprinting. Anatomy plays a large was copiously irrigated. The rec- toe-touch weight-bearing precau- role. The direct head of the rectus tus femoris tendon was noted to tions. The postoperative protocol femoris originates on the anterior be completely torn and retracted approximately 8 cm. A longitudinal split in the tendon had left approxi- “...the rectus femoris is prone to strain mately 3 cm of the proximal tendon in the early swing phase of sprinting still attached to the anterior infe- rior iliac spine. The tendon tissue and in the early backward swing was in fair (shredded) condition. of the kicking motion.” Edges were débrided of this non- optimal tendon tissue. After appro- priate tensioning was established, used was that described by Straw inferior iliac spine, proximal to the side-to-side repair was performed, and colleagues,7 who reported surgi- hip joint, while its reflected head proximal to distal, with interrupted cal repair of a chronic rupture of the begins on the groove on the upper figure-of-8 sutures (Ethibond No. rectus femoris muscle at the proximal brim of the anterior 2) (Figure 3). Excellent repair was musculotendinous junction in a soc- and anterior joint capsule. noted (Figure 4). cer player. They believed that hip The rectus femoris combines At this point, a bioabsorb- immobilization was both impractical with the vastus muscle groups to able suture anchor (BioROC; and detrimental to the outcome, that become the extensor mechanism, Innovasive Devices, Marlborough, hip immobilization alone was insuffi- which inserts distal to the knee Massachusetts) was placed in the cient for protection of the repair, and joint at the tibial tubercle. It is the anterior inferior iliac spine, and a cir- that, even with hip immobilization, only quadriceps muscle that is biar- cumferential suture was weaved into knee immobilization would still be ticular. Clinical sports medicine the proximal rectus femoris tendon needed where the arc of movement asserts that 2-joint muscles strain to relieve any tension on the side-to- of the rectus femoris was larger than during sprint activities when under- side repair of the longitudinal split that of the hip. Therefore, we felt that going eccentric contractions 10,11; mus- knee immobilization alone would cle strain injuries occur when the satisfactorily protect the repair. muscle is either stretched passively or activated during stretch.10-12 This Discussion paradigm suggests that The quadriceps femoris, the larg- muscles are prone to strain injury est muscle of the body, is the main in the late swing phase (eccentric extensor of the knee joint. It has phase) rather than during early 4 parts: the rectus femoris and 3 ground contact, when hamstring vastus muscles (lateralis, interme- contraction is concentric.13 This dius, medialis). Forty years ago, model also would suggest that the Ryan8 described the seriousness of rectus femoris is prone to strain a quadriceps muscle strain injury. A in the early swing phase of sprint- previous radiologic study found the ing and in the early backward rectus femoris to be the site of clini- swing of the kicking motion. These cal quadriceps strains,9 confirm- phases are when the rectus femoris ing clinical suspicion.10 Multiple is eccentrically contracting.14 To Figure 5. Bioabsorbable suture authors have presented series of summarize, in real-life activities anchor (BioROC; Innovasive Devices, quadriceps muscle strain injuries, (eg, sprinting, kicking), the larg- Marlborough, Massachusetts) placed in anterior inferior iliac spine. and all have described rectus femo- est lengths (stretches or strains) of Circumferential suture was weaved into ris injuries, the most common and the hamstring and rectus femoris proximal rectus femoris tendon. serious of quadriceps strains.2-4 muscles occur during swing phas- November 2010 545 Proximal Rectus Femoris Avulsion in an Elite, Olympic-Level Sprinter es. Clinical teaching that stretch as the hip assumes a significantly ity 8 days after injury. We felt that (strain) is most responsible for mus- hyperextended position, such as surgical repair afforded this sprinter cle strain injuries11 suggests that at the start of the forward swing the best chance to return to com- the hamstring and rectus femoris phase of sprinting and the early petitive running. muscles are most prone to failure backward swing of the kicking Favorable outcomes of acute sur- when most stretched, which is when motion. This provides the sport- gical treatment of this rare injury they are contracting eccentrically specific biomechanical explana- have been documented.6 The prox- during the swing phases. Almost all tion for the proximal rectus femo- imal rectus femoris avulsions of 5 laboratory-simulated muscle strain ris avulsion sustained by our elite, patients6 (4 soccer players, a 110- injury experiments have found that Olympic-level 100-meter sprinter meter hurdler) were repaired using strain (amount of lengthening of and for those sustained by NFL Super Quick Anchors (Mitek, muscle or muscle fiber, expressed kickers,5 soccer players,6,7 and a Raynham, Massachusetts). All 5 in millimeters per millimeter) is 110-meter hurdler.6 patients returned to preinjury level

“...strain (amount of lengthening of muscle or muscle fiber, expressed in millimeters per millimeter) is the property that correlates most with muscle damage.” the property that correlates most Surgical repair was recommend- of activity 5 to 10 months after with muscle damage. Muscle dam- ed for this sprinter in view of the surgery. Similar to our patient, age has been found to correlate significant (8-cm) retraction of the all 5 patients had notable pain, more with strain than with muscle avulsed proximal rectus femoris weakness, and inability to extend force,15 velocity,16 strain rate,17 or tendon, the large (10-cm) hemor- the knee against gravity. In addi- muscle contraction status.18 These rhagic fluid collection encasing the tion, as in our case, all 5 avulsions findings suggest that amount of retracted tendon edge and the rectus involved the direct head of the strain (muscle length) should be the muscle–tendon junction providing rectus femoris. Yet, contrary to property that correlates most with an interpositional barrier to poten- our case, the maximum amount risk for muscle strain injury in vivo. tial healing and/or scar formation, of tendon retraction in these 5 Muscle strain and tears occur and the massive edema in the entire athletes was only 3 to 4 cm. All most commonly at the myotendi- rectus femoris muscle spreading dis- 5 avulsed tendons were repaired nous junction.19-21 The structural tally to a point just proximal to to restore the normal anatomy, as design of the proximal myotendi- the knee joint. The notable differ- insufficient healing in the bone– nous rectus femoris junction con- ences between this case and the tendon interface is believed to lead sists of the anterior, superficial cases of the 2 nonoperatively treated to decreased strength and abnor- tendon from its direct head, which NFL kickers5 are amount of tendon mal function. travels down the proximal third of retraction, severity of soft-tissue The principal actions of the rec- the muscle, and an intramuscular, injury, and the physical examination. tus femoris muscle are knee exten- deep tendon from the reflected The NFL kickers presented with 1 sion and hip flexion. Given that the head, which travels down the prox- cm and 3.5 cm of distal retraction retracted edge of the avulsed rec- imal two-thirds of the muscle.2,5 of the rectus femoris tendon from tus femoris tendon in our patient Unipennate muscle fibers arise the anterior inferior iliac spine. In was 2 times the maximal distance from the tendon of the direct head. addition, within the kickers’ first previously reported,5,6 we felt sur- Muscle fibers arising from both week after injury, their acute pain gical treatment was imperative, as the medial and lateral surfaces of had resolved, and they were able to this sprinter depends on being able the tendon of the deep reflected extend their against resistance to maximize the function of this head create a bipennate structure. and walk with a moderately antalgic muscle in his explosive sport. The more common distal quadri- gait.5 In our patient’s case, the ten- ceps ruptures occur during squat- don was distally retracted 8 cm, a Summary ting, jumping, or lunging5 with massive amount of soft-tissue trau- We have presented the first report the hip in a flexed position dur- ma was seen on repeat MRI, and of a proximal rectus femoris avul- ing maximal quadriceps exertion. the patient, unlike the NFL kickers, sion injury in an elite, Olympic- Proximal avulsions, on the other was unable to perform a straight-leg level 100-meter sprinter and of the hand, occur when the rectus femo- raise (extend knee against gravity) immediate outcome of acute sur- ris is eccentrically contracting14 or place any weight on the extrem- gical treatment. Given the rarity 546 The American Journal of Orthopedics® P. R. Langer and F. H. Selesnick of this injury, several key factors for various rectus femoris strain injuries don injuries in athletes. Clin Sports Med. using previously undescribed muscle archi- 1983;2(1):167-182. must be considered and careful- tecture. Am J Sports Med. 1995;23(4):493- 13. Agre JC. Hamstring injuries. Proposed aetio- ly assessed when determining the 499. logical factors, prevention, and treatment. appropriate course of management 3. Hughes C 4th, Hasselman CT, Best TM, Sports Med. 1985;2(1):21-33. Martinez S, Garrett WE Jr. Incomplete, intra- 14. Mero A, Komi P, Gregor R. Biomechanics (ie, deciding between operative and substance strain injuries of the rectus femoris of sprint running: a review. Sports Med. nonoperative treatment): amount muscle. Am J Sports Med. 1995;23(4):500- 1992;13(6):376-392. of distal retraction of the tendon, 506. 15. Lieber RL, Friden J. Muscle damage is not 4. Rask MR, Lattig GJ. Traumatic fibrosis of the a function of muscle force but active muscle severity of associated soft-tissue rectus femoris muscle. Report of five cases strain. J Appl Physiol. 1993;74(2):520-526. trauma, physical examination, and and treatment. JAMA. 1972;221(3):268- 16. Brooks S, Faulkner J. Severity of contraction- postoperative goals (eg, return to 269. induced injury is affected by velocity only elite-level competitive sports involv- 5. Hsu JC, Fisher DA, Wright RW. Proximal during stretches of large strain. J Appl Physiol. rectus femoris avulsions in National Football 2001;91:661-666. ing running or kicking vs resuming League kickers: a report of 2 cases. Am J 17. Best TM, McElhaney JH, Garrett WE Jr, Myers basic activities of daily living). We Sports Med. 2005;33(7):1085-1087. BS. Axial strain measurements in skeletal believe that these factors in our 6. Irmola T, Heikkilä JT, Orava S, Sarimo J. muscle at various strain rates. J Biomech Eng. Total proximal tendon avulsion of the rectus 1995;117(3):262-265. elite, high-performance athlete dic- femoris muscle. Scand J Med Sci Sports. 18. 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