Review on Quadriceps Strains

Introduction

The musculature of the anterior femur is called the quadriceps musculature. It is made up of the rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis (1). These muscles all come together within the distal portion of the femur to make up the quadriceps tendon (1). The rectus femoris is unique, as it has two heads and thus two different tendon origins (2). The straight head arises from anterior superior iliac spine and the indirect head arises from the superior acetabular ridge (6).

Anatomy of the rectus femoris with two origins of insertion (3)

The quadriceps muscle aids in extension of the knee, hip flexion, and pelvis stabilization (2). Injuries in this area can include avulsions, strains, musculature tears, myotendinous junction tears, and tissue calcification (1). An injury to the quadriceps muscle has been found to be more common in football, soccer, and other sprinting sports (2). In a study looking at English Premier League lower extremity muscle injuries, rectus femoris strains accounted for 29% of all injuries (2).

Diagnosis

Diagnosis is typically made clinically. A patient will complain of an acute tear in the anterior thigh (2). However, some patients have more gradual and subacute injury and will complain of pain with running and kicking (2).

Physical exam will evaluate for any evidence of muscle retraction and ecchymosis to the anterior thigh. A bulge can also be seen in certain injury patterns (7). Patients will typically have pain with resisted knee extension and pain to palpation over the quadricep musculature (2). Assessing the patient in prone position can improve accuracy in assessing range of motion and flexibility (7).

Imaging can help aid in the visualization of a quadriceps injury. A standard radiograph is typically performed to help discriminate from a bony injury (7).  An ultrasound can be performed to evaluate for tendon injury, muscle tearing, and hematoma formation. However, an MRI will provide even more detail than an MRI (1). An MRI can grade injuries to the myotendinous junction of the rectus femoris (2). The different grades include a grade I injury, which includes a high-intensity signal seen at the myotendinous junction, a grade II injury shows partial tendon disruption, and grade III are complete myotendinous junction tears (2).

Grades of quadricep injury (7)

The most common muscle of the quadriceps musculature that is injured is the rectus femoris (4).

There is an MRI finding known as a “bulls-eye” appearance, where there is enhancement within the central tendon of the rectus femoris on a gadolinium enhanced scan (6). This is thought to occur when a quadriceps strain within the muscle belly disrupts the deep myotendinous fibers of the indirect head of the rectus femoris with distal fiber retraction (6). These injuries are attributed to longer times to return to play (6).

Bulls eye MRI finding (6)

Treatment

Treatment is typically conservative and rarely involves surgery. However, treatment is made more difficult by reinjury occurring in 17% of quadriceps injuries (2). A study looking at reinjury in Australian League Football Players found the majority of reinjury episodes occurred within the first two months.

Reinjury of quadriceps muscle (4)

Most grade I and grade II injuries are treated with anti-inflammatories, rest, and then physical therapy (3). In the acute phase of the injury to prevent further bleeding, compression and cryotherapy can be performed (7). After 3-5 days, a patient typically begins gentle range of motion and will progress to strengthening when they have pain free motion (7). Patients will be considered candidates for a return to play protocol when they are pain free, have a normal range of motion, have similar strength on the contralateral side, and can perform sports specific drills without pain (7).

Prevention of these injuries is important and will include flexibility exercises and core strengthening (2).

Conclusion

Injury to the quadriceps musculature is commonly seen in running sports. They are typically diagnosed clinically, but further detail can be obtained with ultrasound and MRI. The rectus femoris is most commonly injured and reinjured. Most patients will not require surgery and can progress back to play through a return to play protocol.

By Gregory Rubin, DO
rubinsportsmed.com

– Quad strain @ Wiki Sports Medhttps://wikism.org/Quadriceps_Tendonitis

References

1)      Park, C. Kevin, et al. “Nonoperative Management of a Severe Proximal Rectus Femoris Musculotendinous Injury in a Recreational Athlete: A Case Report.” PM & R: The Journal of Injury, Function, and Rehabilitation, vol. 10, no. 12, Dec. 2018, pp. 1417–21. PubMed, https://doi.org/10.1016/j.pmrj.2018.05.005.

2)      Mendiguchia, Jurdan, et al. “Rectus Femoris Muscle Injuries in Football: A Clinically Relevant Review of Mechanisms of Injury, Risk Factors and Preventive Strategies.” British Journal of Sports Medicine, vol. 47, no. 6, Apr. 2013, pp. 359–66. PubMed, https://doi.org/10.1136/bjsports-2012-091250.

3)      Gyftopoulos, Soterios, et al. “Normal Anatomy and Strains of the Deep Musculotendinous Junction of the Proximal Rectus Femoris: MRI Features.” AJR. American Journal of Roentgenology, vol. 190, no. 3, Mar. 2008, pp. W182-186. PubMed, https://doi.org/10.2214/AJR.07.2947.

4)      Pietsch, Samuel, et al. “Epidemiology of Quadriceps Muscle Strain Injuries in Elite Male Australian Football Players.” Scandinavian Journal of Medicine & Science in Sports, vol. 34, no. 1, Jan. 2024, p. e14542. PubMed, https://doi.org/10.1111/sms.14542.

5)      Herzog, Mackenzie M., et al. “Lower Extremity Strains in the US National Football League, 2015-2019.” The American Journal of Sports Medicine, vol. 51, no. 8, July 2023, pp. 2176–85. PubMed, https://doi.org/10.1177/03635465231175479.

6)      Brukner, Peter, and David Connell. “‘Serious Thigh Muscle Strains’: Beware the Intramuscular Tendon Which Plays an Important Role in Difficult Hamstring and Quadriceps Muscle Strains.” British Journal of Sports Medicine, vol. 50, no. 4, Feb. 2016, pp. 205–08. PubMed, https://doi.org/10.1136/bjsports-2015-095136.

 

7)      Kary, Joel M. “Diagnosis and Management of Quadriceps Strains and Contusions.” Current Reviews in Musculoskeletal Medicine, vol. 3, no. 1–4, July 2010, pp. 26–31. PubMed, https://doi.org/10.1007/s12178-010-9064-5.