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Rectus Femoris Muscle Injuries

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(Redirected from Rectus Femoris Strain)

Other Names

  • Rectus Femoris Strain
  • Rectus Femoris Tear
  • Rectus Femoris Avulsion
  • Rectus Femoris Myotendinous Injury
  • Rectus Femoris Muscle Injuries
  • Rectus Femoris Contusion

Background

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Case of rectus femoris muscle tear
  • This page refers to injuries to the Rectus Femoris (RF) muscle, a continuum of disease including contusions, strains, myotendinous injuries and avulsion fractures

History

  • Tear of the deep myotendinous junction of the indirect head of the rectus femoris muscle was first described by Hughes in 1995[1]

Epidemiology

  • In English Premier league and Australian Football league, rectus femoris strains (29%) were more common than biceps femoris (11%)[2]
  • Quadriceps muscle injuries caused more missed games than hamstring and groin injuries[3]
  • Reinjury rates are high at 17%

Introduction

Normal anatomy of the rectus femoris muscle. The direct head (green) originates at the anterior inferior iliac spine (AIIS), while the indirect head (yellow) originates at the superolateral aspect of the acetabulum. Both heads join to form the conjoint tendon just distal to the AIIS, and each contributes to the muscle substance (red) more distally.[4]
Schematic illustrations of different proximal rectus femoris tear patterns. (A) Normal anatomy. (B) Complete 2-tendon avulsion. (C) Complete rupture of the proximal common tendon. (D) Partial tear of the proximal rectus femoris (direct head)[5]

General

  • The rectus femoris is the most commonly injured muscle in the quadriceps group
  • The injury typically is acute, ocurring due to eccentric muscle action
  • Despite the frequency of injury, there is little literature or data to guide management
  • Diagnosis is clinical, although MRI and US can help characterize the degree of injury
  • Most patients will respond well to non-surgical management

Mechanism of Injury

  • Usually occur during eccentric muscle action[6]
    • Sprinting and kicking require eccentric rectus femoris activation
    • When combined with biarticular nature, it is particularly vulnerable to injury
  • Sprinting
    • Can occur during acceleration or deceleration phase
  • Kicking
    • Most common mechanism for rectus femoris muscle injury
    • Controversial whether injury occurs during ball contact, swing phase or ground contact phase during the step before backswing

Location of Injury

  • Classically thought to occur at the distal myotendinous junction, near the knee joint[7]
  • Can also occur at
    • junction of conjoined tendon with the muscle belly
    • Deep myotendinous junction at indirect head

Myotendinous Injuries

  • Myotendinous injuries[3]
    • Occurs with kicking and sprinting
    • Most kicking injuries occur at the myotendinous region

Tendon Tears

  • Rectus Femoris Tears[8]
    • Mostly reported during kicking manuevers
    • 72% involve the direct tendon

Anterior Inferior Iliac Spine Avulsion Fracture

  • Most RF avulsion fractures occur at the AAIS[9]
  • In adolescent males from a kicking mechanism

Associated Conditions

Anatomy of the Rectus Femoris

  • Biarticular muscle which contributes to the Quadriceps Muscle Group
  • Helps with knee extension, hip flexion, stabilization of pelvis during weight bearing
  • Direct/straight head: arises from anterior inferior iliac spine
    • Contributes mostly to superficial component of conjoined tendon, blends with muscle fascia
  • Indirect/reflected head: arises from the acetabular ridge
    • Contributes to the fibers of the deep, intramuscular component of the conjoined tendon
  • The deep myotendinous junction extends downwards approximately two thirds of the muscle belly
  • Insertion: Quadriceps Tendon
  • High precentage of type II muscle fibers (65%) makes it prone to injury[10]

Risk Factors

General

  • History of previous rectus femoris injury[11]
  • Shorter height
  • Heavier mass
  • More common in dominant kicking leg
  • Weaker eccentric strength of the quadriceps muscles[12]
  • Decreased quadriceps flexibility

Sports

  • Soccer
  • Americal Football
  • Rugby
  • Baseball
  • Martial Arts

No Increased Risk

  • Age
    • Curiously, 3 seperate studies found no association between age and RF injuries[13]

Differential Diagnosis

Differential Diagnosis Groin Pain

Differential Diagnosis Thigh Pain

Clinical Features

Popeye" type sign: This is a clinical image of the thigh demonstrating the popeye like sign resulting from the rupture rectus femoris muscle.[14]

History

  • Acute: patient reports tearing sensation and stops playing sports
  • Subacute: gradual onset of pain during running and kicking
  • Acute injuries are more likely to present with thigh pain, chronic injuries with groin pain
  • Anterior hip pain may suggest AAIS strain or avulsion

Physical Exam: Physical Exam Hip

  • Stretching actively or passively is painful
  • Palpation at the site of injury is painful
  • Pain with resisted knee extension or hip flexion

Special Tests

  • Needs to be updated

Evaluation

Focused diagnostic ultrasound revealing a right rectus femoris midsubstance tear in the (a) long axis view and (b) short axis view. (c) Short axisview of scar tissue in the rectus femoris muscle belly.[15]
US assessment of the rectus femoris muscle at the level of the AIIS. (a) The patient is placed in a supine position with the hip in extension and the probe in a longitudinal plane over the AIIS. (b) US image shows the normal appearance of the rectus femoris origin, with the hyperechoic direct head (D) inserting on the AIIS. The indirect head (I) is obliquely oriented toward its origin along the lateral aspect of the acetabulum and appears hypoechoic because of anisotropy. (c) Corresponding diagram shows the normal anatomy of the rectus femoris (RF).[16]
Intramuscular isolated injuries of the rectus femoris. Axial and coronal/sagittal MR images in fluid-sensitive sequences. a Marginal or paraseptal muscular edema with gap of the muscle fibers (circles). b Edema, fiber distortion, and areas of tear surrounding the central septum (short arrows) without retraction. c Circumferential pattern of fibers rupture encompasses the entire central septum with loss of its tension (large arrows)[17]

Radiographs

Ultrasound

  • Rectus femoris is well visualized on ultrasound
  • AIIS injury
    • Can evaluate degree of seperation from the pelvis
    • Anechoic fluid collection
  • Typical features
    • Ill defined hyper/hypoechoic lesions with varying degrees of fibrillar disruption
  • Chronic proximal lesions
    • May show hypechoic tendon thickening
    • Calcification or heterotopic ossification
    • Scar formation apppears irregularityly delineated with focal retraction of adjacent muscle fibers

CT

  • Better evaluation of osseous injuries
  • Generally not indicated for rectus femoris muscle injuries

MRI

  • Typical findings
    • Fluid signal intensity tracking around the muscle fibers
    • Discontinuity of the respective muscle components
    • Can determine location, severity and extend of injury
  • Bull's Eye Sign[18]
    • Term used to describe the increased signal around the rectus femoris intrasubstance tendon
    • Seen in 65% of players
    • Represents evolving stages of injury, early edema/hemorrhage, lateral hypervascularity/scarring

Classification

MRI Classification

  • Grade I tear
    • Integrity of the myotendinous junction is maintained
  • Grade II tear
    • Partial disruption of the myotendinous junction
    • Interstitial feathery high intensity signal or hematoma
    • In chronic injuries, fibrosis or hemosiderin can be seen
  • Grade III tear
    • Complete disruption of the myotendinous junction
    • With or without retraction

Management

Prevention

  • Interventional studies to prevent rectus femoris injuries are lacking
  • General objective is to address known risk factors
  • Emphasis on flexibility, strength, core stability

Nonoperative

  • Indications
    • Vast majority of cases
    • Patients with strains
  • Patients may require a brief period of non-weight bearing
  • Relative rest
  • Symptomatic management with Ice, NSAIDS
  • Physical Therapy
  • Structured return to play

Operative

  • Indications
    • Failure of conservative management
    • Some displaced AIIS avulsion fractures
  • Technique
    • Unknown

Rehab and Return to Play

Rehabilitation

  • Early mobilization to prevent scar formation, loss of function
  • Rehabilitation emphasizes lumbopelvic stabilization, core strength, hip flexor strength
  • Sport specific exercises

Return to Play/ Work

  • Time frame
    • Mean RTP in elite athletes is approximately 20-25 days
    • Central or intratendinous injuries take longer, up to 2-3 months
  • RTP criteria
    • Pain free function
    • Full strength and range of motion
    • Ability to complete sport specific drills without compensation or apprehension

Prognosis and Complications

Prognosis

  • Return to sport
    • Longer in RF injuries than other hamstring and groin injuries, High re-injury rate[19]
    • Central tendon injuries associated with a longer rehabilitatoin time and return to sport[20]

Complications

See Also

Groin

Thigh

External

References

  1. ↑ Hughes IV, Charles, et al. "Incomplete, intrasubstance strain injuries of the rectus femoris muscle." The American Journal of Sports Medicine 23.4 (1995): 500-506.
  2. ↑ Woods, Carol, et al. "The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of preseason injuries." British journal of sports medicine 36.6 (2002): 436-441.
  3. ↑ 3.0 3.1 Ekstrand, Jan, Martin Hägglund, and Markus Waldén. "Epidemiology of muscle injuries in professional football (soccer)." The American journal of sports medicine 39.6 (2011): 1226-1232.
  4. ↑ Lungu, Eugen, Johan Michaud, and Nathalie J. Bureau. "US assessment of sports-related hip injuries." Radiographics 38.3 (2018): 867-889.
  5. ↑ Lempainen, Lasse, et al. "Operative treatment of proximal rectus femoris injuries in professional soccer players: a series of 19 cases." Orthopaedic Journal of Sports Medicine 6.10 (2018): 2325967118798827.
  6. ↑ Glick, James M. "Muscle strains: prevention and treatment." The Physician and sportsmedicine 8.11 (1980): 73-77.
  7. ↑ Speer, Kevin P., John Lohnes, and William E. Garrett JR. "Radiographic imaging of muscle strain injury." The American journal of sports medicine 21.1 (1993): 89-96.
  8. ↑ Irmola, Tero, et al. "Total proximal tendon avulsion of the rectus femoris muscle." Scandinavian journal of medicine & science in sports 17.4 (2007): 378-382.
  9. ↑ Carr, James B., et al. "Operative fixation of an anterior inferior iliac spine apophyseal avulsion fracture nonunion in an adolescent soccer player: a case report." JBJS case connector 7.2 (2017): e29.
  10. ↑ Johnson, M_A, et al. "Data on the distribution of fibre types in thirty-six human muscles: an autopsy study." Journal of the neurological sciences 18.1 (1973): 111-129.
  11. ↑ Orchard, John W. "Intrinsic and extrinsic risk factors for muscle strains in Australian football." The American journal of sports medicine 29.3 (2001): 300-303.
  12. ↑ Fousekis, Konstantinos, et al. "Intrinsic risk factors of non-contact quadriceps and hamstring strains in soccer: a prospective study of 100 professional players." British journal of sports medicine 45.9 (2011): 709-714.
  13. ↑ 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 47.6 (2013): 359-366.
  14. ↑ Walsh, Jed, et al. "Isolated Rectus Femoris Rupture with Ipsilateral Femoroacetabular Impingement in a Collegiate Track Athlete: A Case Report." Journal of Orthopaedic Case Reports 12.7 (2022): 84.
  15. ↑ Patel, Shiv J., et al. "Rectus femoris intrasubstance tear in a collegiate football kicker and its mechanism." Baylor University Medical Center Proceedings. Vol. 33. No. 1. Taylor & Francis, 2020.
  16. ↑ Lungu, Eugen, Johan Michaud, and Nathalie J. Bureau. "US assessment of sports-related hip injuries." Radiographics 38.3 (2018): 867-889.
  17. ↑ Isern-Kebschull, Jaime, et al. "Sports-related lower limb muscle injuries: pattern recognition approach and MRI review." Insights into imaging 11.1 (2020): 108.
  18. ↑ Hughes IV, Charles, et al. "Incomplete, intrasubstance strain injuries of the rectus femoris muscle." The American Journal of Sports Medicine 23.4 (1995): 500-506.
  19. ↑ Serner, Andreas, et al. "Return to sport after criteria-based rehabilitation of acute adductor injuries in male athletes: a prospective cohort study." Orthopaedic journal of sports medicine 8.1 (2020): 2325967119897247.
  20. ↑ Cross, Thomas M., et al. "Acute quadriceps muscle strains: magnetic resonance imaging features and prognosis." The American journal of sports medicine 32.3 (2004): 710-719.
Created by:
John Kiel on 2 July 2025 23:04:53
Authors:
Last edited:
6 July 2025 17:07:24
Categories:
Lower Extremity | Groin | Hip | Thigh | Sprains And Strains | Acute
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