Transcript Acute Quadriceps Muscle Strains

Acute Quadriceps Muscle Strains
MRI features and prognosis
Dr Tom Cross
MBBS, FACSP, DCH
The Stadium Orthopaedic and Sports Medicine Centre
Acute Quadriceps Muscle Strains:
MRI features and prognosis
Dr T Cross
Dr N Gibbs
Mr M Cameron
Dr M Houang
AJSM, April 2004
1.
Introduction
2.
Literature review
3.
Methods
4.
Results and Discussion
5.
Conclusions
6.
Questions??
Clinical Scenario
e.g.. Anterior thigh pain 7 days before
World Cup Final
Can he play??
1. Introduction
Objective
To describe the MRI findings of a series of
acute quadriceps muscle strains
Objective
To assess any relationship between the MRI
findings and the time taken to return to
sport
Setting

Sydney Swans
Football Club

1 of 16 clubs
in the National
competition
Design
Prospective study over 3 years
(1999-2001):
Both in-season and pre-season
periods
Patients
40 professional footballers
Consent from Club and
individual players
Australian Rules Football
“Athletes at risk”




Repetitive sprinting efforts
Repetitive kicking
Repetitive jumping &
landing
Game time approximately
100 minutes
Australian Rules Football
Ideal sport ( “outdoor laboratory”)
to study muscle strain injury
Australian Rules Football
Hamstring strain is the most
significant injury in ARF
(Quadriceps strain in top 10)
Motivation for research

To better understand/diagnose quadriceps
muscle strains

To better manage/rehabilitate quadriceps
muscle strains
Motivation for research

To make an EARLY ACCURATE
PROGNOSIS
(i.e. we were unable to clinically differentiate
benign from serious quadriceps strains)
2. Literature Review
Literature review
Pomeranz (1993)
•
Retrospective study of Hamstring strains
•
n=14
•
Prognosis associated with size (cross-sectional
area%) of muscle strain injury on MRI scan
Literature review
No research (i.e. series of cases) on,
Clinical behavior
MRI findings
of acute quadriceps strains
Literature review
No mention of Vastus quadriceps muscle
strains in the literature
Literature review
No research (i.e. series of cases) on “ distal
rupture of rectus femoris”
Distal rupture of RF
Literature review
3 retrospective studies on chronic muscle strain injuries of
rectus femoris :
all cases were “proximal injuries”
1.
Rask and Lattig (1972)
n=5
2.
Hughes and Hasselman (1995) n=10
3.
Temple et al (1998) n=7
Literature review
Chronic “proximal strain injury” of rectus
femoris
Tender anterior
thigh mass
Associated
anterior thigh
pain, weakness
and
dysfunction
Mean time to
presentation
= 7 months
Literature review
Chronic “proximal strain injury” of rectus femoris
The Dilemma!
Research: Basic science studies
found that muscle strain injury
occurs at/near muscle-tendon
junctions
Q. Where is this muscle strain
injury sited with respect to the
known musculotendinous
junctions???
Literature review

Hughes and Hasselman (1995,
AJSM)
Rectus femoriscadaveric dissection
Literature review
Special anatomy of rectus
femoris
Hughes and Hasselman (1995)
Superior
acetabulum
AIIS
Left thigh
Literature review
Unipennate structure:
proximal 1/3 of RF
Central tendon
Bipennate structure: Middle
and distal 2/3 of RF
Literature review
Chronic “proximal strain injury” of RF
Muscle strain injury about the “intramuscular tendon
of the indirect head” (the Central tendon)
Central tendon
Chronic “bull’s
eye lesion”
Fibrotic scar
New muscletendon junctions
Normal Central Tendon
Chronic “Bulls Eye"
lesion
Chronic symptomatic “bull’s eye
lesions”
Macroscopic
Microscopic
Histology: centrally dense mature fibrous tissue with surrounding
oedema, chronic inflammation, hemosiderin deposition, interspersed with
normal and degenerating muscle fibres about NEW MUSCLE-TENDON
JUNCTIONS
Literature review: continued….
Rectus femoris, an “at-risk muscle”

Acts eccentrically

Crosses two joints

High % fast twitch fibres
Literature review
Vastus muscles

Act eccentrically

Cross only one joint

High % slow twitch fibres

Large bulk of synergistic muscles
3. Methods
Methods
Inclusion criteria
1.
2.
History
1.
acute or gradual onset of anterior thigh pain while training
or playing
1.
Mechanism of injury documented (running, kicking,
jumping/landing): if onset of symptoms were acute
2.
Preferred kicking leg was correlated with the side injured
Examination : tenderness over the anterior thigh
: other signs elicited but not the subject of this study
Methods
Exclusion criteria
1.
History of trauma to anterior thigh (Contusion)
2.
Delayed onset of anterior thigh pain (DOMS)
Methods
MRI within 24-72 hours
•
T1,T2 with fat suppression, STIR
•
Axial, coronal planes (both thighs imaged)
(Axial T2 with fat suppression most useful images)
Methods
Muscle strain injury= high signal on T2
weighted images
Methods
MRI diagnosis
Location (MRI category)
1.
2.
Which quadriceps muscle (s) injured
Location of injury with respect to known
musculotendinous junctions
Methods
MRI diagnosis
Size
1.
Cross sectional area % (CSA)
2.
Length (cm)
Methods

CSA% estimation (“dot” method)
Methods
MRI diagnosis: miscellaneous features…
•
T2 hyper intensity
•
muscle fibre disruption
•
Perifascial fluid
•
Scarring/fibrosis
Methods
What if more than one muscle injured?
(i.e. double injury etc.)
1.
Primary muscle injured= greatest CSA%
2.
Secondary muscle injury= smaller CSA%
Results of acute MRI images

25 acute clinical quadriceps strains were imaged

Authors were not blinded to these MRI’s
MRI negative
n=3
Central tendon
Central tendon
RF-CT
n=7
High signal on both
sides of CT
= an acute “bull’s
eye” lesion
RF-CT (coronal)
“feather-like”
pattern
RF-CT
High signal on
only one side of
CT
RF-CT
High signal on one
side of CT
RF-peripheral
n=8
High signal in
periphery
No high signal about
Central Tendon
RF-periphery
High signal about
posterior lamina of RF
Vastus Intermedius
n=6
Anterior lamina of VI
High signal in VI
High signal about
anterior femoral shaft
Vastus intermedius
Perifascial fluid
Vastus Lateralis
n=1
Anterior lamina of VL and adjacent high signal in VL muscle
Secondary
injury: RF-peri
Double injury
n=1
Primary injury :
RF-CT
MRI “look-alikes”

DOMS and muscle contusions: similar MRI
appearance to muscle strain injuries

Inclusion and exclusion criteria were strictly
adhered to
Quadriceps
Contusion
High signal in all 4
quadriceps
Clinical quadriceps strains
N=25
MRI positive
N=22
RF
N=15
RF-CT
N=7
MRI negative
N=3
Vasti
n=7
RF-peri
N=8
Only one “Double injury” in series (RF-CT was the
primary injury, RF-peri was the secondary injury)
Methods (rehabilitation phase)

No universally accepted rehabilitation regimen
exists for muscle strain injuries
Methods (rehabilitation phase)
Rehabilitation was standardised
Phase 1 : Acute management

RICE/crutches first 48 hours

Intensive Physiotherapy
•
•
•
soft tissue therapy
flexibility
strengthening
Methods (rehabilitation phase)
Phase 2: Remodeling phase


Eligible to start running program when,

Full pain free ROM (prone knee flexion)

Complete 3 x 10 repetitions of single leg hops pain free
4 Stage running/kicking program (sport specific to ARF) was
designed at beginning of study
Methods (rehabilitation phase)
4 stage running/kicking program

Run alternate days
Physiotherapist/Sports Scientist supervision
Combined with intensive physiotherapy

5 minute jog warm up/cool down

Stage 1 : jog 10 mins x 2

Stage 2 : 80m intervals ( 40-60 %) 3x 5 repetitions

Stage 3: 80m intervals (90-100%) 3 x 5 repetitions (staged kicking program
commenced)

Stage 4: 80m intervals (sport specific drills at 90-100%) 3 x 5 repetitions

Integrate into team training


Methods (rehabilitation phase)
4 stage running/kicking programs
•
Some advanced rapidly
•
Others delayed by symptoms of high grade anterior thigh
pain, weakness and dysfunction
Decision to return to Full Training : Collaborative
Rehabilitation interval (RI)
RI= time from the injury to the return to full
training (measured in days)
4. Results & Discussion
Statistical analysis
Statistician analyzed data

t-tests independent samples (dependent vs. independent
variables)

Two-way analysis of variance
Results: Statistical analysis
30
RF-CT (mean=27,
range 14-43 days )
25
RI
(days)
RF-peri (mean=9,
range 5-15 days)
20
15
RF-
Vasti (mean=4,range
2-7 days)
CT
10
5
0
RFPeri
Vasti
MRI Diagnosis
negative
MRI Negative
(mean=6,range 3-10
days)
RF-CT: “acute bull’s eye lesion”

n=7

Mean RI=27 days

significantly longer RI
(p=0.001)
RF-CT: “acute bull’s eye lesion”
Is the RED FLAG diagnosis that heralds a
protracted rehabilitation
Why do RF-CT injuries take longer??
Indirect and direct heads of
proximal tendon begin to act
independently

The Hypothesis: Shearing
effect of Central Tendon
(indirect head) with direct
head:
a “muscle within a
muscle”
RF-peri

n=8

Mean RI=9 days

“shear” phenomenon
between two heads of proximal
tendon does not occur

Benign quadriceps strain
category
Vastus muscle strains

VI (n=6), VL (n=1)

Mean RI= 4 days

Benign quadriceps strain
category
Vastus muscle strains

Hypothesis
1.
Slow twitch muscle
2.
Crosses only one joint
3.
Large bulk of synergistic muscles
MRI negative cases

n=3

Mean RI= 6 days
injury)

Less common phenomenon
than in clinical Hamstring
strains
(benign
MRI negative cases
Hypotheses

MRI done too early

Strain injury too small to resolve

Pain mediated by neuro-meningeal structures (e.g.
femoral nerve)
Does size matter??

CSA% (greater than 15%) p=0.033

Length (greater than 13cm) p= 0.038
Location (MRI category): most important
RF-CT
RF-peri
CSA % = 42
CSA % = 46
vs
RI = 32 days
RI= 12 days
Clinical evaluation

History (onset, mechanism, preferred kicking
leg) is unhelpful

Examination- not analyzed
??Recurrent strains

No recurrences

5 players had more than one quadriceps strain in the
study period (different sites)

Why?


One on one Physiotherapy
Graded running/kicking program
Were any follow-up MRI done?

Yes

N=11 available for study
•
•

4 out of interest when player considered rehabilitated
7 incidental
Not routinely done, no statistical analysis
RF-CT
acute
Acute “bull’s eye”
lesion
RF-CT
day 32
Fibrosis about
Central tendon
and surrounding
high signal
RF-CT
day 63
Scarring about CT
Minimal high signal
about scar
RF-peri
acute
CSA%= 46
Length=13cm
RF-peri
day 10
Decreased T2 high signal
Decreased CSA%=37
Length=6 cm
Follow-up MRI findings
4 MRI’s repeated out of interest at conclusion of
rehabilitation,
None had returned to normal, but all had




Decreased CSA%
Decreased length
Decreased T2 signal
Resolution of perifascial fluid
Follow-up MRI
7 incidental follow-up MRI’s available

4 (two VI, two RF-CT) had complete resolution

3 ( RF-CT) had scarring (Grade 2 muscle strain
injury) but were asymptomatic
RF-CT (8 months)
VI (acute)
Fibrosis about Central tendon
Acute VI strain
Chronic asymptomatic “bull's eye
lesion”
chronic asymptomatic
bull’s eye lesion

None of the 7 RF-CT
cases were troubled by
chronic symptoms nor
recurrence

Hypothesis: Optimal
initial rehabilitation is
important
Chronic symptomatic “bull’s eye
lesions”
Chronic symptomatic “bull’s eye”
CONCLUSIONS
Conclusions
MRI defines muscle strain injury objectively:
“probe beneath the surface of the skin”
Conclusions
All 22 MRI positive cases of muscle strain injury
occurred about known muscle-tendon junctions
(This concurs with basic science studies)
Conclusions
The rectus femoris was the most commonly
injured muscle (15/22 cases)
Conclusions
Tenderness over the anterior thigh does not
always = rectus femoris muscle strain
(could be Vastus muscle strain or MRI negative)
Conclusions
No cases of “distal rupture of RF”
Conclusions
This research complements the research on
chronic symptomatic RF-CT injuries
regarding:
1.
How acute RF-CT injuries may behave
2.
How acute RF-CT injuries may look
Conclusions
RF-CT is the “RED FLAG” diagnosis that
heralds (1) protracted RI
(2) potential for chronicity
30
25
RI
20
(days)
15
RF-
RF-CT
RF-peri
Vasti
MRI Negative
CT
10
5
0
RFperi
Vasti
MRI Diagnosis
negative
Conclusions

Size ( CSA % and length) of muscle strain injury
is also predictive of RI
Conclusions
Follow-up MRI may be persistently abnormal
despite apparent functional recovery
Conclusions
Indications for MRI
Acute MRI for elite
athletes
Soccer World Cup
2002
e.g. Anterior thigh pain 7 days before
Final
Can he play??
YES : if Benign MRI
NO: if RF-CT (acute “bull’s eye)
Conclusions
Indications for MRI
If no MRI available? Suspect RF-CT if troubled
by high grade anterior thigh pain in
rehabilitation
All athletes : consider MRI for chronic anterior
thigh pain
Thank-you
Questions?