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Proximal Rectus Femoris Avulsion in an Elite, Olympic-Level Sprinter Phillip R

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Proximal Rectus Femoris Avulsion in an Elite, Olympic-Level Sprinter Phillip R (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 hip and knee joints.2 when he felt a sharp pain in the ing running or kicking vs resum- Diagnoses are made for specific left thigh 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 nerve 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 quadriceps tendon insertion into out the proximal half to two-thirds surgical and nonsurgical risks and the patella. The patient was unable of the rectus femoris muscle in the benefits of treatment, the patient to perform a straight-leg raise. 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 vastus lateralis muscle. 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 semimembranosus muscle. 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 sartorius muscle 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 fascia 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 fascia lata 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.
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