Surgical Treatment of Proximal Ruptures of the Rectus Femoris in Professional Soccer Players

Arch Orthop Trauma Surg (2012) 132:329–333 DOI 10.1007/s00402-011-1372-8

ARTHROSCOPY AND SPORTS MEDICINE

Surgical treatment of proximal ruptures of the rectus femoris in professional soccer players

Vıćtor Vaquerizo Garcıá • Daniel Casas Duhrkop • Roberto Seijas • Oscar Ares • Ramoń Cugat

Received: 29 March 2011 / Published online: 13 August 2011 Ó Springer-Verlag 2011

Abstract with non-absorbable sutures. In four cases, where there had Introduction Muscle injuries are very common in ath- been complete avulsion, bone anchoring sutures were used. letes. Depending on the type of sport, muscle injuries There is no consensus regarding the optimal treatment for represent approximately 9–54% of total injuries. The rectus ruptures of the rectus femoris muscle. There are a few femoris muscle is very important in specific sports, such as reports in the literature based on isolated experiences of soccer and American football, because it is the muscle different surgeons. involved in movements, such as sprinting and kicking the Conclusion Surgical treatment has a lower recurrence ball. Therefore, we believe that these disabling injuries rate in our hands; we believe that surgical treatment is need special and prompt treatment to enable athletes to indicated in these cases, for a complete functional recovery return to their sporting activities. for professional soccer players. Aim The aim of our study is to assess the results of surgical treatment of ruptures of the rectus femoris in pro- Keywords Rectus femoris injury Á Soccer players Á fessional soccer players by reattachment of the tendon. We Surgical treatment Á Reattachment identified ten proximal rectus femoris ruptures in professional soccer players belonging to the Spanish Football League. Introduction Results Mean follow-up was 34.8 months (SD ? 28.72). The mean age of the players was 27.4 years (SD ? 4.14). Muscle injuries are very common in athletes and they, In six cases (60%), the tendon was repaired by direct suture represent approximately 9–54% of total injuries [1, 2]. The most frequent injuries involve the hamstring and quadriceps muscles; in case of soccer the incidence of hamstring V. V. Garcıá(&) Hospital Universitario Prıńcipe de Asturias, Cr Alcala´-Meco s/n, injuries is 37% and quadriceps 19% according to the lit- Alcala´ de Henares, 28805 Madrid, Spain erature [3, 4]. The structure of the quadriceps muscle has e-mail: [email protected] been described by various authors, for example Hasselman et al. [5], who have described its different origins and D. C. Duhrkop Hospital Universitario Marque´s de Valdecilla, biomechanics. The direct head of the rectus femoris orig- Avda. Valdecilla s/n, 39008 Santander, Spain inates in the anterior inferior iliac spine (AIIS), and the other portion in the upper region of the acetabulum. Its R. Seijas Á O. Ares Á R. Cugat tendon stretches from the distal third of the quadriceps Orthopaedic Surgery Department, Fundacioń Garcıá Cugat, Hospital Quiroń Barcelona, ISAKOS Approved Teaching muscle forming an extensive miotendinous structure down Center, Pza. Alfonso Comıń 5–7, 08023 Barcelona, Spain to the tendinous insertion at the upper pole of the patella, e-mail: [email protected] The rectus femoris muscle is very important in specific sports, such as soccer and American football, because it is R. Cugat Spanish Soccer Federation, Catalonian Soccer Players Insurance the muscle involved in movements, such as sprinting and Company, Catalonia, Spain kicking the ball. The incidence of rectus femoris injuries in 123 330 Arch Orthop Trauma Surg (2012) 132:329–333

Table 1 Patient cohort Case Age (years) Injury Delay (days) Time to play Follow-up Complications (months) (months)

122 [4 cm, chronic 10 6 30 No 234 \3 cm, acute 13 5 56 No 325 [4 cm, chronic 7 5 63 No 4 32 Avulsion, acute 13 4 18 No 5 22 Avulsion, acute 8 5 25 No 6 28 2 cm, acute 14 4 13 No 7 32 4.5 cm, acute 7 3 14 No 8 26 Avulsion, acute 6 3 38 No 927 \2 cm, chronic 5 6 26 No 10 26 Avulsion, acute 8 3 20 No 27.4 (SD ± 4.14) 9.1 (SD ± 3.21) 3.8 (SD ± 0.79) 30.3 (SD ± 17.18) soccer players is less than 1%, it is at miotendinous union direct portion of the rectus femoris muscle, we were able to that injuries to the quadriceps most frequently occur [6]. measure the length of the proximal portion. In our study, There is no consensus in the treatment. The conservative the lesions were confirmed with MRI studies. To evaluate treatment presents recurrence rates of 18%. Therefore, we the results we considered return to play based on the time believe that these disabling injuries need special and between surgery and recovery allowing pain-free and prompt treatment to enable athletes to return to their unrestricted participation in an official match. Minimum sporting activities [3, 7–10]. The mechanism of injury is follow-up of patients once they had returned to sport at the usually a forceful contraction of the quadriceps against same pre-injury level was 12 months of practice at the excessive resistance, such as landing from a jump or highest level to detect possible recurrences. forcibly kicking the ball [2, 3, 7, 9, 10]. The aim of our study is the description of the surgical technique with the hypothesis that the surgical treatment of the rectus femoris Results tendon ruptures leads to full recovery and back to professional soccer without recurrence of injury. We identified ten proximal rectus femoris ruptures in professional soccer players belonging to the Spanish Football League (Table 1). 70% of cases involved acute Materials and methods ruptures, while chronic ruptures presented as a recurrence of previous injury treated orthopedically between 5 and We carried out a retrospective study of rectus femoris 7 months previously. All the patients were operated on by injuries in professional soccer players belonging to the the same surgical team. The patients were operated on with Catalonian Soccer Federation. We identified all the patients an average time of 9.1 days (SD ± 3.21) post-injury. diagnosed with rupture of the rectus femoris who were We used an anterior approach, through the fascia and operated on by our service between 1999 and 2009. We dissecting sartorius and quadriceps muscles, with patient analyzed the age, sex distribution, team position, physical supine and general anesthesia. Intraoperatively we were examination, type and mechanism of injury, diagnosis, able to confirm the level of the torn muscle (Fig. 1). Four treatment and complications during surgery and postoper- patients (40%) had a complete avulsion of the tendon from ative follow-up and finally time to return to play. The mean AIIS; three cases (30%) showed a rupture within 3 cm age of the players was 27.4 years (SD ± 4.14). All patients proximal to the tendon insertion; and three cases [30%] had were male. Two players were goalkeepers, three played in a rupture greater than 4 cm proximal to the tendon inser- defense, one was in midfield; and four players were for- tion, and with retraction of the muscle belly of more than wards. Physical examination showed a retraction of the 5 cm. In three cases (30%), the tendon was repaired by quadriceps muscle belly, which moved distally when direct suture with non-absorbable sutures with krackow contracted. In the case of the goalkeepers and defense stitches (Fig. 2). In four cases, where there had been players, this had occurred with the ball stop. In the complete avulsion, bone anchoring sutures were used with remaining cases, the injury occurred when kicking a ball in the same technique of stitches. In patient with a rupture motion. After initial ultrasonography showing the ruptured greater than 4 cm distal to the insertion (30%), the muscle 123 Arch Orthop Trauma Surg (2012) 132:329–333 331

Fig. 1 Rupture of rectus femoris within 3 cm proximal to the tendon Fig. 3 Plasma rich in growth factor (PRGF) application within the insertion suture

training with the ball at 2.5 months approximately. We did not do any ultrasonography during follow-up. The mean time to return to ofﬁcial match activities was 3.8 months (SD ± 0.79). Mean follow-up was 34.8 months (SD ± 28.72). At the end of follow-up, all the patients returned to play at the prior level, no patients had recurrence of the injury, pain or complications.

Discussion

Proximal ruptures of the rectus femoris muscle are uncommon. Although hamstring muscle injuries are common in football players, quadriceps injuries are less common, and the most common being injuries to the rectus femoris [1, 4, 5]. However, proximal ruptures of the rectus Fig. 2 Tendon repair by direct suture with non-absorbable sutures with krackow stitches femoris diagnosed by MRI are not common and do not exceeding 1% of quadriceps injuries [12–15]. Rectus Femoris avulsions are described in pediatric and adolescent belly was fully mobilized and was brought proximally as populations as avulsions of the anteroinferior iliac spine. far as possible without a critical stress. Before closing, nine Proximal injuries are often overlooked and produce chronic patients (90%) were treated with plasma rich in growth strain injuries [8, 10]. Proximal ruptures are also described factor (PRGF) to improve recovery, using Anitua technique as occurring in other sports activities where sudden described in the literature (Fig. 3)[11]. To ensure the deceleration during sprinting, or resistance to hip flexion stability of the suturing, we made a forced extension and and knee extension occurs [2, 9, 10]. The rectus femoris flexion of the knee. There were no intraoperative compli- muscle is the only muscle within the quadriceps muscle cations. After surgery, the patient had NSAIDs to control that acts across two major joints: the hip joint and the knee pain. joint and is, therefore, thought to be more susceptible to We immobilized the knee with a splint in approximately strain injury through overloading. It should not surprise us 45 flexion for a week, maintaining similar flexion at the hip that injuries most commonly occur at the level of the joint, with relaxation of the quadriceps, which was subse- quadriceps tendon and musculotendinous junction, while quently reversed to start rehabilitation. This began with proximal avulsion injuries of the direct head of the rectus partial weight-bearing with crutches, increasing to full femoris are exceptional [2, 5, 9]. weight-bearing 3–4 weeks after surgery. Patients began In the literature, there are no studies discussing the gold eccentric exercise at 5–6 weeks, running at 2 months and standard for diagnosis, but in general it is believed that

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MRI has greater sensitivity than ultrasonography in the consider that most of the cases underwent orthopedic diagnosis of musculotendinous pathology [13, 14]. In our treatment, and a significant percentage of orthopedically study, several patients presented with other diagnoses treated cases were ultimately treated surgically because of based on ultrasound studies from other hospitals, suggest- the orthopedic treatment failure. ing that reported findings depend largely on the medical In conclusion, surgical treatment has no recurrence rate experience. in our hands, we believe that surgical treatment is indicated There is no consensus regarding the optimal treatment in professional soccer players for a complete functional for ruptures of the rectus femoris muscle. In cases of recovery. avulsion of the AIIS, it clearly appeared that orthopedic treatment was successful by rest, initial immobilization and Conflict of interest The authors declare that they have no conflict subsequent rehabilitation, reserving surgery for cases with of interest. large initial retraction of the bone fragment, or patients for whom non-operative treatment had not been successful [2, References 16–20]. There are few published reports regarding the treatment, the exception being the series of 11 cases 1. Irmola T, Heikkila¨ JT (2007) Total proximal tendon avulsion of reported by Gamradt et al. [8]. There are a studies of iso- the rectus femoris muscle. Scand J Med Sci Sports 17:378–382 lated cases treated with different methods according to the 2. Zarins B, Ciullo JV (1983) Acute muscle and tendon injuries in experience of surgeons usually dealing with other injuries. athletes. Clin Sports Med 2:167–182 3. Arnason A, Sigurdsson SB, Gudmundsson A, Holme I, Enge- Gamradt et al. [8] and Hsu et al. [9] argued that rectus bretsen L, Bahr R (2004) Risk factors for injuries in football. Am femoris injuries can be treated non-operatively with return J Sports Med 32(1):5S–16S to full unrestricted participation in sports. 18% of the 4. Ekstrand J, Ha¨gglund M, Waldeń M (2011) Epidemiology of patients suffered a recurrence of symptoms at the end of muscle injuries in professional football (soccer). Am J Sports Med 39:1226–1232 their study. However, the average time for return to sports 5. Hasselman CT, Best TM, Hughes C et al (1995) An explanation activity was 55.3 days excluding one player who returned for various rectus femoris strain injuries using previously unde- to play in 7 months. Other authors preferred non-operative scribed muscle architecture. Am J Sports Med 23:493–499 treatment for cases with low functional demand or for 6. Hughes C 4th, Hasselman CT, Best TM, Martinez S, Garrett WE Jr (1995) Incomplete, intrasubstance strain injuries of the rectus inactive people [2, 15]. On the other hand, there are authors femoris muscle. Am J Sports Med 23(4):500–506 who report satisfactory results after surgical treatment and 7. Arnason A, Gudmundsson A, Dahl HA, Jo´hannsson E (1996) believe that surgical repair is indicated in these injuries [1, Soccer injuries in Iceland. Scand J Med Sci Sports 6(1):40–45 6, 10, 16, 21]. According to Irmola et al. [1], the mean time 8. Gamradt SC, Brophy RH (2009) Nonoperative treatment for proximal avulsion of the rectus femoris in professional American to return to sports activity was 9 months in the five patients football. Am J Sports Med 37:1370–1374 they operated on, while in other studies, details are not 9. Hsu JC, Fischer DA, Wright RW (2005) Proximal rectus femoris clearly reported, although in all cases there were no avulsions in national football league kickers: a report of 2 cases. problems with recurrence of symptoms at the end of fol- Am J Sports Med 33:1085–1087 10. Straw R, Colclough K, Geutjens G (2003) Surgical repair of a low-up [1, 16]. In our study, the mean time to return to play chronic rupture of the rectus femoris muscle at the proximal was 3.8 months and we did not have any recurrence. We musculotendinous junction in a soccer player. Br J Sports Med observed that patients with chronic injuries returned to play 37(2):182–184 on average 1.8 months later than patients operated on for 11. Sańchez M, Anitua E, Azofra J, Andıá I, Padilla S, Mujika I (2007) Comparison of surgically repaired Achilles tendon tears using acute rupture, although the finding is not statistically platelet-rich fibrin matrices. Am J Sports Med 35(2):245–251 significant. 12. Boutin RD, Fritz RC, Steinbach LS (2002) Imaging of sports- Like Straw et al. [10], we believe that immobilization of related muscle injuries. Radiol Clin North Am 40(2):333–362 the knee provides satisfactory protection to the repaired (vii) 13. Ehman RL, Berquist TH (1986) Magnetic resonance imaging of muscle, although in their study their patients were in musculoskeletal trauma. Radiol Clin North Am 24:291–319 extension for 6 weeks. We feel this time is too long, and is 14. Ouellette H, Thomas BJ, Nelson E, Torriani M (2006) MR poorly tolerated by patients. imaging of rectus femoris origin injuries. Skeletal Radiol Our study has the limitation that it is not a comparative 35:665–672 15. Renstrom PA (1992) Tendon and muscle injuries in the groin study, we have not analyzed the patients who have been area. Clin Sports Med 11:815–831 surgically operated on after being treated orthopedically. 16. Rajasekhar C, Kumar KS, Bhamra MS (2001) Avulsion fractures We are aware that the incidence of this lesion is small. In of the anterior inferior iliac spine: the case for surgical inter- his review of NFLISS survey data, Gamradt found only 10 vention. Int Orthop 24:364–365 17. Metzmaker JN, Pappas AM (1985) Avulsion fractures of the patients in 20 years of follow-up. In our review of cases as pelvis. Am J Sports Med 13:349–358 recorded in the Catalan Football Federation in the past 18. Rossi F, Dragoni S (2001) Acute avulsion fractures of the pelvis 10 years, only 10 cases have been operated on, so we in adolescent competitive athletes: prevalence, location and 123 Arch Orthop Trauma Surg (2012) 132:329–333 333

sports distribution of 203 cases collected. Skeletal Radiol 21. Cross MJ, Vandersluis R, Wood D et al (1998) Surgical repair of 30:127–131 chronic complete hamstring tendon rupture in the adult patient. 19. Saluan PM, Weiker GG (1997) Avulsion of the anterior inferior Am J Sports Med 26:785–789 iliac spine. Orthopedics 20:558–559 20. Temple HT, Kuklo TR, Sweet DE et al (1998) Rectus femoris muscle appearing as a pseudotumor. Am J Sports Med 26:544– 548

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