Working Diagnosis:
Full thickness (grade 3) proximal rectus femoris tear

Treatment:
She was referred to orthopedic sports surgery for surgical repair of a full thickness proximal rectus femoris tear using an open approach. Intraoperatively, the tear was visualized immediately distal to the musculotendinous junction extending into the muscle belly, with 6 cm of retraction, and intact tendon origins at the anterior inferior iliac spine and superior acetabular ridge. There was full thickness muscle defect and retraction of the muscle belly distally, towards the right of the photograph. The filled arrow points to the proximal edge of the torn muscle at the proximal musculotendinous junction. The dashed arrow points towards the distal edge of the torn muscle belly which is retracted approximately 6 cm. Case Photo #5 The muscle tear was directly repaired side to side without complications Case Photo #6 .

Outcome:
Postoperatively, she was placed in a hinged knee brace locked in extension, with use of crutches for ambulation. 1 week after surgery, she started physical therapy focusing on range of motion (0-90 degrees). By 6 weeks, she was off crutches and was allowed to progress to strengthening and low impact exercises (bike and elliptical). At 12 weeks, she was cleared for gradual return to high impact and progressive sports-specific activities. At her final post-operative visit at 16 weeks, she had played in a soccer scrimmage without pain or limitations and was cleared for full activities without restrictions.

Author's Comments:
Among skeletally immature adolescents, bony anterior inferior iliac spine avulsions are more common than proximal myotendinous injuries of the rectus femoris, accounting for approximately 20-30% of acute pelvic avulsion fractures. Among adults, common injury locations include the musculotendinous junction and proximal tendons. Tears in the muscle belly, as discovered intraoperatively in our patient, are rarely reported in either adolescents or adults. Although rectus femoris tears can be treated non-operatively, surgical intervention was recommended due to the acute nature of the injury, the patient's young age and level of involvement in competitive athletics, and a faster return to high impact activities.

Proximal rectus femoris injuries are most often related to kicking and sprinting mechanisms with forceful eccentric contraction of the muscle. Our patient was simultaneously participating in competitive soccer and track seasons, which overlapped for a period of two weeks corresponding to the time of injury. In these sports, kicking and sprinting both require eccentric rectus femoris action, making the muscle more susceptible to overload and injury. Although playing multiple sports has benefits with regards to injury prevention, overscheduling without adequate rest and participating in overlapping sports or seasons can increase the risk for injuries.

Editor's Comments:
As illustrated by the case, there was no avulsion fracture seen on initial radiographs. The diagnostician should be set in looking for the most common injury, apophysitis, in which treatment would be non-operative. The pearl was that the patient failed to respond to conservative treatment, so the diagnosis was reexamined.

References:
1) Gamradt SC, Brophy RH, Barnes R, Warren RF, Thomas Byrd JW, Kelly BT. Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football. Am J Sports Med. 2009 Jul;37(7):1370-4.
2) Garcia VV, Duhrkop DC, Seijas R, Ares O, Cugat R. Surgical treatment of proximal ruptures of the rectus femoris in professional soccer players. Arch Orthop Trauma Surg. 2012 Mar;132(3):329-33.
3) Gyftopoulos S, Rosenberg ZS, Schweitzer ME, Bordalo-Rodrigues M. Normal anatomy and strains of the deep musculotendinous junction of the proximal rectus femoris: MRI features. AJR Am J Roentgenol. 2008 Mar;190(3):W182-6.
4) Hasselman CT, Best TM, Hughes C 4th, Martinez S, Garrett WE Jr. An explanation for various rectus femoris strain injuries using previously undescribed muscle architecture. Am J Sports Med. 1995 Jul-Aug;23(4):493-9.
5) Lempainen L, Kosola J, Pruna R, Puigdellivol J, Ranne J, Orava S. Operative Treatment of Proximal Rectus Femoris Injuries in Professional Soccer Players: A Series of 19 Cases. Orthop J Sports Med. 2018 Oct;6(10):2325967118798827.
6) Mendiguchia J, Alentorn-Geli E, Idoate F, Myer GD. Rectus femoris muscle injuries in football: a clinically relevant review of mechanisms of injury, risk factors and preventive strategies. Br J Sports Med. 2013 Apr;47(6):359-66.
7) Moeller JL, Galasso L. Pelvic Region Avulsion Fractures in Adolescent Athletes: A Series of 242 Cases. Clin J Sport Med. 2022 Jan;32(1):e23-9.
8) Ouellette H, Thomas BJ, Nelson E, Torriani M. MR imaging of rectus femoris origin injuries. Skeletal Radiol. 2006 Sep;35(9):665-72.

Return To The Case Studies List.