As strong as my legs are, it is my mind that has made me a champion. Micheal Johnson, four times Olympic Gold Medal winner who suffered from a very publicized quadriceps strain.
The anterior thigh is the site of common sporting injuries such as quadriceps muscle contusion and strain of the quadriceps muscle. Referred pain from the hip, sacroiliac joint (SIJ) and lumbar spine can also cause anterior thigh pain. Stress fracture of the femur is an uncommon, but important diagnosis.
Clinical approach
The two most important aspects of the history of a patient with anterior thigh pain are the exact site of the pain and the mechanism of injury. The site of the pain is usually well localized in cases of conmsion or muscle strain.
Contusions can occur anywhere in the quadriceps muscle but they are most common anterolaterally and in the vastus medialis obliquus. Muscle strains generally occur in the midline of the thigh anteriorly.
The mechanism of injury may help differentiate between the two conditions. A contusion is likely to be the result of a direct blow, whereas a muscle strain usually occurs when an athlete is striving for extra speed when running or extra distance when kicking. In contact sports, however, the athlete may have difficulty recalling the exact mechanism ofinjury.
Whether the athlete was able to continue activity, the present level offunction, and the degree of swelling are all guides to the severity of the condition.
Determine whether the RICE regimen was implemented initially and whether there were any aggra- vating factors (such as a continued activity). Gradual onset of poorly localized anterior thigh pain in a distance runner worsening with activity may indicate stress fracture of the femur. If the pain is variable and not clearly localized, and if specific aggravating factors are lacking, consider referred pain. Bilateral pain suggests the pain is referred from the lumbar spine.
Quadriceps contusion
If the patient suffered a direct blow to the anterior thigh, and examination confirms an area of tender· ness and swelling with worsening pain on active contraction and passive stretch, thigh contusion with resultant hematoma is the most likely diagnosis. In severe cases with extensive swelling, pain may be severe enough to interfere with sleep.
Quadriceps contusion is an extremely common injury and is known colloquially as a “charley horse,” “cork thigh,” or “dead leg.” It is common in contact sports such as football and basketball. In sports such as field hockey, lacrosse, and cricket. a ball traveling at high speed may cause a contusion.
Assess the severity of the contusion to deter· mine prognosis (which can vary from several days to a number of weeks off sport) and plan appropri· ate treatment. The degree of passive knee flexion after 24 hours is a clinical indicator of the severity of the hematoma. For optimal treatment and accurate monitoring of progress, it is important to identify the exact muscle involved. MRI will show significant edema throughout the involved muscle.
Blood from contusions of the lower third of the thigh may track down to the knee joint and irritate the patellofemoral joint.
Treatment
The treatment of a thigh contusion can be divided into four stages:
Stage l-control of hemorrhage
Stage 2-restoration of pain-free range of motion
Stage 3-functional rehabilitation
Stage 4-graduated return to activity.
A summary of the types of treatment appropriate for each stage is shown in Tables . Progression within each stage, and from one stage to the next, depends on the severity of the contusion and the rate of recovery.
The most important period in the treatment of a thigh contusion is in the first 24 hours following hematoma (arrow) of the vastus intermedius muscle the injury. A player who suffers a thigh contusion should be removed from the field of play and receive the RICE regimen If full weight-bearing is painful for the sportsperson, crutches can help unload the muscle and it emphasizes the serious nature of the condition.
After the restriction, active pain-free isometric exercises can be started and the use of crutches cantinues until the athlete is able to resume full athletic activity. It is important that this management technique is not recommended for severe contusions. This technique may reduce time away from sport, improve pain-free range of movement, and reduce the rate of reinjury
The patient must be careful not to aggravate the bleeding by excessive activity, alcohol ingestion, or the application of heat.
Loss of range of motion is the most significant finding after thigh contusion, and range of movement must be regained in a gradual, pain-free progression before return to athletic activity is considered.
After a moderate-te-severe contusion, there is a considerable risk of re-bleed in the first 7-10 days. Therefore, care must be taken with stretching, electrotherapy, heat, and massage. The patient must be careful not to overstretch. Stretching should be pain-free.
Soft tissue therapy is contraindicated for 48 hours following contusion. Subsequently. soft tissue therapy may be used. but great care must be taken not to aggravate the condition. Treatment must be light and it must produce absolutely no pain. Excessively painful soft tissue therapy will cause bleeding to recur and is never indicated in the treatment of contusion.
It has been suggested that athletes in high-risk sports should consider wearing thigh protection routinely, Players such as ruckmen in Australian Rules football, forwards in basketball, and running backs in American football may sustain a series of minor contusions during the course of a game. These appear to have a cumulative effect and may impair performance later in the game. Protective padding helps to minimize this effect.
Acute compartment syndrome of the thigh
Intramuscular hematoma of the thigh after a blunt contusion may result in high intracompartment pres- sures and a diagnosis of compartment syndrome of the thigh. Symptoms often include pain and paresthe- sia, and occur with intra-comparhnental pressures greater than approximately 20 mmHg. Pressures of greater than 30 mmHg over a duration ofmore than six hours can lead to irreversible damage.
Unlike other acute compartment syndromes, this condition does not usually need to be treated by sur- gical decompression. This recommendation is based on clinical evidence from cases where surgery was performed.
When the muscle was viewed during surgery, there was no evidence of necrotic tissue. Also, there were no subsequent adverse effects ofthe compartment syndrome, such as restricted motion or loss of function.6 In a case study of an amateur soccer player who sustained a high impact injury from an opposing player,’ conservative treatment included rest from any lower limb activity for the first 48 hours, followed by gentle range of motion exercises of the hip and knee. This routine was slowly progressed over the following months and the athlete returned to soccer after six months.
Myositis ossificans
Occasionally after a thigh contusion, the hematoma calcifies. This is known as “myositis ossificans” and can usually be seen on a plain X~ray a minimum of three weeks after the injury. If there is no convinc- ing history of recent trauma, the practitioner must rule out the differential diagnosis ofthe X-ray-bone tumor in myositis ossificans, osteoblasts replace some of the fibroblasts in the healing hematoma one week fonowing the injury and lay down new bone over a number of weeks. After approximately six or seven weeks, this bone growth ceases. At this stage, a lump is often palpable. Slow resorption of the bone then occurs, but a small amount ofbone may remain.
Why some contusions develop calcification is not known. Incidence rates range from 9% to 20% in athletes with a thigh contusion. The more severe the contusion, the more likely is the development of myositis ossificans.Intramuscular contusions appear to be more susceptible than intennuscular. Inappropriate treatment of the contusion, such as heat or massage, may increase the risk of myositis ossificans arising.
The risk is especially high if the contusion results in prone knee flexion of less than 45° two to three days after the injury. Thus, particular care should be taken when managing these severe contusions. A significant rebleed may also result in the development of myositis ossificans.
The incidence of myositis ossificans appears to be increased when a knee effusion is present.
Symptoms of developing myositis ossificans include an increase in morning pain and pain with activity. Patients often also complain of night pain. On palpation, the developing myositis ossificans has a characteristic “woody” fee. Initial improvement in range of motion ceases with subsequent deterioration.
Once myositis ossificans is established, there is very little that can be done to accelerate the resorptive process. Treatment may include local electrotherapy to reduce muscle spasm and gentle, painless range of motion exercises. Shock wave therapy has been sug- gested to improve function.
Indomethacin, which reduces new bone forma- tion,R has been prescribed as a preventative measure in high-risk presentations} Corticosteroid injec- tion is absolutely contraindicated in this condition.
Surgery is contraindicated in the early stages and only considered when the margins of the ectopic bone are smooth on investigations, suggesting bone maturity.
Quadriceps muscle strain
Strainsofthequadricepsmuscleusuallyoccurduring sprinting, jumping, or kicking. In football, quadri- ceps strains are often associated with over-striding when decelerating during running, or understriding during the deceleration phase ofthe kicking leg when kicking a football on the run.Fatigue, weakness, and muscle imbalances can impact on performance, and are therefore risk factors for muscle strains.
Strains are seen in all the quadriceps muscles but are most common in the rectus femoris, which is more vulnerable to strain as it passes over two joints the hip and the knee.
Distal quadriceps muscle strain
Like all muscle strains, distal quadriceps strains (Fig. )0.8a) may be graded into mild (grade I). mod- erate (grade II), or severe, complete tears (grade III). The athlete feels the injury as a sudden pain in the anterior thigh during an activity requiring explosive muscle contraction. There is local pain and ten- derness and, if the strain is severe, swelling and bruising.
Grade I strain is a minor injury with pain on resisted active contraction and on passive stretching. An area of local spasm is palpable at the site of pain. An athlete with such a strain may not cease activity at the time ofthe pain, but will usually notice the injury after cooling down or the following day.
Moderate or grade II strains cause significant pain on passive stretching as well as on unopposed active contraction. There is usually a moderate area of inflammation surrounding a tender palpable lesion. The athlete with a grade II strain is generally unable to continue the activity.
Complete tears of the rectus femoris occur with sudden onset of pain and disability during intense activity. A muscle fiber defect is usually palpable when the muscle is contracted. In the long term, they resolve with conservative management, often with surprisingly little disability.
QUADRİCEPS STRAIN TREATMENT
The principles of treatment of a quadriceps muscle strain are similar to those of a thigh contusion. It is important that the athlete regain pain-free range of movement as soon as possible. Loss of strength may be more marked than with a thigh contusion and strength retraining requires emphasis in the rehabilitation program. As with the general principles of muscle rehabilitation. the program should commence with low-resistance. high-repetition exercise. Concentric and eccentric exercises should begin with very low weights.
General fitness can be maintained by activities such as swimming (initially with a pool buoy) and upper body training. Functional retraining should be incorporated as soon as possible. Full training must be completed prior to return to sport. Unfortunately, quadriceps strains often recur, either in the same season, or even a year or two later.
Proximal rectus femoris strains
Asymptomatic individuals showed that the proximal tendon of the rectus femoris muscle has two com- ponents-the direct (straight) and indirect (reflected) heads. The tendon of the direct head originates from the anterior inferior iliac spine; the tendon of the indirect head arises from the superior acetabular ridge and the hip joint capsule, initially deep to the direct head. The two heads then form a conjoined tendon. As it progresses along the muscle it flattens out, laterally rotates, and migrates to the middle of the muscle belly. This has been termed the “central tendon.”
Complete tears are uncommon, which is thought to be due to the extreme length of the musculo- tendinous junction (approximately two-thirds of the muscle belly).’s Diagnosis is often difficult, because the pathology is deep and the physical assessment findings are non·specific.
Patients complained of a tender anterior thigh mass and/or weakness and pain with activities such as running and kicking. Initial injury was described as a “deep tearing sensation.” The anterior thigh mass may be associated with muscle retraction.
These signs and symptoms are likely to be due to the indirect and direct heads of the proximal tendon acting independently, creating a shearing phenom· enon, in contrast to what occurs in the normal rectus femoris.’ Unlike typical strains which present as focal lesions on MRI, rectus femoris proximal musculotend· inous junction injuries have a longitudinal distribution ofincreased signal along the tendon
Proximal rectus femoris strains treatment
Management of proximal rectus femoris strains depends on the severity of the injury and the athletic demands ofthe individual. Conservative management aimed at symptom relief and avoidance of re-injury is recommended for grade I and II strains. Surgical intervention is typically reserved for grade III strains, which can involve resection ofscar tissue. One series diagnosed on MRps showed an average return to full training in professional footballers after a compre- hensive rehabilitation program of 27 days for central tendon lesions, compared to nine days for peripheral rectus femoris strains and 4-5 days for strains of the vastus muscles.
Differentiating between a mild quadriceps strain and a quadriceps contusion
Occasionally, it may be difficult to distinguish between a minor contusion and a minor muscle strain; however, the distinction needs to be made as an athlete with a thigh strain should progress more slowly through a rehabilitation program than should the athlete with a quadriceps contusion.
The athlete with thigh strain should avoid sharp acceleration and deceleration movements in the early stages ofinjury. Some ofthe features that may assist the clinician in differentiating these conditions are shown in Table .MRI or ultrasonography may also help differentiate the two conditions.
