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Thigh Injuries in American Football A Review Paper Thigh Injuries in American Football Joseph D. Lamplot, MD, and Matthew J. Matava, MD volume of the anterior and posterior thigh, as well Abstract as the activities and maneuvers necessitated by Quadriceps and hamstring injuries occur the various football positions, it is not surprising frequently in football and are generally that the thigh is frequently involved in football-re- treated conservatively. While return to lated injuries. competition following hamstring strains The purpose of this review is to describe the is relatively quick, a high rate of injury clinical manifestations of thigh-related soft-tissue recurrence highlights the importance of injuries seen in football players. Two of these targeted rehabilitation and conditioning. conditions—muscle strains and contusions—are This review describes the clinical man- relatively common, while a third condition—the ifestations of thigh-related soft-tissue Morel-Lavallée lesion—is a rare, yet relevant injury injuries seen in football players. Two of that warrants discussion. these—muscle strains and contusions— are relatively common, while a third Quadriceps Contusion condition—the Morel-Lavallée lesion—is Pathophysiology a rare, yet relevant injury. Contusion to the quadriceps muscle is a common injury in contact sports generally resulting from a direct blow from a helmet, knee, or shoulder.8 Bleeding within the musculature causes swell- merican football has the highest injury rate ing, pain, stiffness, and limitation of quadriceps of any team sport in the United States at excursion, ultimately resulting in loss of knee the high school, collegiate, and professional flexion and an inability to run or squat. The injury is A 1-3 8 levels. Muscle strains and contusions consti- typically confined to a single quadriceps muscle. tute a large proportion of football injuries. For The use of thigh padding, though helpful, does not example, at the high school level, muscle completely eliminate the risk of this injury. strains comprise 12% to 24% of all injuries;2 at the collegiate level, they History and Physical Examination account for approximately 20% of Immediately after injury, the athlete may complain all practice injuries, with nearly half only of thigh pain. However, swelling, pain, and of all strains occurring within the diminished range of knee motion may develop thigh.1,4 Among a single National within the first 24 hours depending on the severity Football League (NFL) team, Feeley of injury and how quickly treatment is instituted.8 and colleagues5 reported that Jackson and Feagin9 developed an injury grading muscle strains accounted for 46% system for quadriceps contusions based on the of practice and 22% of preseason limitation of knee flexion observed (Table 1). Fortu- game injuries. The hamstrings, nately, the majority of contusions in these athletes followed by the quadriceps, are the are of a mild to moderate severity.9,10 most commonly strained muscle groups among both professional and Imaging amateur athletes,5,6 with hamstring and A quadriceps contusion is a clinical diagnosis quadriceps injuries making up approximate- based on a typical history and physical examina- ly 13% of all injuries among NFL players.7 tion; therefore, advanced imaging usually does Given the relatively large surface area and muscle not need to be obtained except to gauge the Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. E308 The American Journal of Orthopedics ® September/October 2016 www.amjorthopedics.com J. D. Lamplot and M. J. Matava severity of injury, to rule out concurrent injuries (ie, phase lasts approximately 2 days and consists of tendon rupture), and to identify the presence of a rest, ice, compression, and elevation (RICE) to limit hematoma that may necessitate aspiration. Plain hemorrhage. The knee should be rested in a flexed radiographs are typically unremarkable in the acute position to maintain quadriceps muscle fiber length setting. Appearance on magnetic resonance imag- in order to promote muscle compression and limit ing (MRI) varies by injury severity, with increased knee stiffness. For severe contusions in which signal throughout the affected muscle belly and a there is a question of an acute thigh compartment diffuse, feathery appearance centered at the point syndrome, compression should be avoided with of impact on short TI inversion recovery (STIR) appropriate treatment based on typical symptoms and T2-weighted images reflecting edema and and intra-compartmental pressure measurement.12 possibly hematoma (Figures 1A-1C).8,11 Resolution Nonsteroidal anti-inflammatory drugs (NSAIDs) of these MRI findings may lag behind functional may be administered to diminish pain as well as recovery.8 Therefore, the athlete is often able to the risk of myositis ossificans. While there is no return to competition once he has recovered full data on the efficacy of NSAIDs in preventing my- lower extremity motion and function despite the ositis ossificans following quadriceps contusions, persistence of abnormal findings on MRI. both COX-2 selective (ie, celecoxib) and nonselec- tive (ie, naproxen, indomethacin) COX inhibitors Treatment have been demonstrated to significantly reduce Treatment of a quadriceps contusion is nonopera- the incidence of heterotopic ossification following tive and consists of a 3-phase recovery.10 The first hip surgery—a condition occurring from a similar Table 1. Quadriceps Contusion Classification9 Knee Grade Physical Examination Motion Gait Activity 1 (mild) Localized tenderness >90° No alteration Able to deep knee bend 2 (moderate) Swollen, tender muscle mass ≤90° Antalgic Unable to deep knee bend, climb stairs, or rise from chair without severe pain 3 (severe) Markedly swollen, tender thigh; ≤45° Severe limp Prefers to walk with crutches contour of muscle cannot be defined by palpation; frequent knee effusion A B C Figure 1. Magnetic resonance imaging of the thigh following a quadriceps contusion. (A) Axial T1-weighted image. (B) Axial T2-weighted image with fat saturation. (C) Coronal short TI inversion recovery (STIR) image. www.amjorthopedics.com September/October 2016 The American Journal of Orthopedics ® E309 Thigh Injuries in American Football pathophysiologic process as myositis that results in an unnecessary biopsy which re- ossificans.13-17 However, this class of veals an “aggressive” lesion leading to an incorrect drugs should not be given any sooner diagnosis of a soft-tissue sarcoma. MRI and/or than 48 to 72 hours after injury to de- computed tomography scanning may confirm the crease further bleeding risk, given its diagnosis of a benign process in these question- inhibitory effect on platelet function.18 able cases as the lesion matures, with ossification Narcotic pain medications are rarely demonstrated on both T1- and T2-weight imaging.21 required. Even in the presence of myositis ossificans, most The second phase focuses on patients regain full knee and hip motion and return restoring active and passive knee to sports without residual weakness or pain.20 Very and hip flexion and begins when rarely, persistent symptoms and limitation of mo- permitted by pain.8 Icing, pain control, tion may warrant consideration for surgical excision and physical therapy modalities are of the symptomatic mass once it is considered Figure 2. Lateral radiograph of the also continued in order to reduce mature, which generally occurs within 6 months left thigh showing early myositis pain and swelling as knee motion is to 1 year, in order to avoid the risk of recurrence ossificans following a contusion to the quadriceps. progressed. The third phase begins resulting from the surgical trauma.9, 22 once full range of knee and hip motion Mani-Babu and colleagues23 reported a case of is restored and consists of quadriceps a 14-year-old male football player who sustained a strengthening and functional rehabilitation of the quadriceps contusion after a direct blow from an lower extremity.8,19 Return to athletic activities and opponent’s helmet to the eventually competition should take place when lateral thigh. Persistent pain and limitation of a full, painless range of motion is restored and motion at 2 months follow-up prompted imaging strength returns to baseline. Isokinetic strength studies that demonstrated myositis ossificans. testing may be utilized to more accurately assess The patient was treated with intravenous pamid- strength and endurance. Noncontact, position-spe- ronate (a bisphosphonate) twice over a 3-month cific drills are incorporated as clinical improvement period and demonstrated a full recovery within allows. A full recovery should be expected within 5 months. 4 weeks of injury, with faster resolution and return Acute compartment syndrome of the thigh has to play seen in less severe contusions depending also been reported following severe quadriceps on the athlete’s position.8 Continued quadriceps contusions, with the majority occurring in the stretching is recommended to prevent recurrence anterior compartment.12,24-28 When injury from blunt once the athlete returns to play. A protective hard trauma extends into and disrupts the muscular shell may also be utilized both during rehabilita- layer adjacent to the femur, vascular disruption can tion as well as once the athlete returns to play in cause hematoma formation, muscle edema, and order to protect the thigh from reinjury, which may significant swelling, thereby increasing intracom- increase the risk
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