SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Case
report
Surgical
treatment
of
rectus
femoris
injury
in
soccer
playing
athletes:
report
of
two
cases
夽
Leandro
Girardi
Shimba
∗,
Gabriel
Carmona
Latorre,
Alberto
de
Castro
Pochini,
Diego
Costa
Astur,
Carlos
Vicente
Andreoli
UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received11May2016 Accepted4October2016 Availableonline17January2017
Keywords:
Muscle,skeletal/injuries Quadricepsmuscle/injuries Orthopedicprocedures Athleticinjuries
a
b
s
t
r
a
c
t
Muscleinjuryisthemostcommoninjuryduringsportpractice.Itrepresents31%ofall lesionsinsoccer,16%intrackandfield,10.4%inrugby,17.7%inbasketball,andbetween 22%and46%inAmericanfootball.Thecicatrizationwiththeformationoffibrotictissue cancompromisethemusclefunction,resultinginachallengingproblemfororthopedics. Althoughconservativetreatmentpresentsadequatefunctionalresultsinthemajorityofthe athleteswhohavemuscleinjury,theconsequencesoftreatmentfailurecanbedramatic, possiblycompromisingthereturntosportpractice.
ThebiarticularmuscleswithprevalenceoftypeIImusclefibers,whicharesubmittedto excentriccontraction,presenthigherlesionrisk.Thequadricepsfemorisisoneexample. Thefemorisrectusisthequadricepsfemorismusclemostfrequentlyinvolvedinstretching injuries.Theruptureoccursintheaccelerationphaseofrunning,jump,ballkicking,orin contractionagainstresistance.Althoughtheconservativetreatmentshowsgoodresults,it iscommonthatthepatienthaslowermusclestrength,difficultyinreturntosports,anda permanentandvisiblegap.Surgicaltreatmentcanbeanoptionforamoreefficientreturn tosports.
©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Tratamento
cirúrgico
da
lesão
do
reto
femoral
em
jogadores
de
futebol:
um
relato
de
dois
casos
Palavras-chave:
Músculoesquelético/lesões Músculoquadríceps/lesões Procedimentosortopédicos Traumatismosematletas
r
e
s
u
m
o
Aslesõesmuscularessãoumadasmaiscomunsocorridasportraumasnosesportes.Elas constituem 31%de todasaslesõesnofutebol,16%noatletismo,10.4%norugby,17.7% nobasqueteede22%a46%nofutebolamericano.Representamumproblemadesafiador natraumatologia,jáqueosmúsculoslesadossecuramvagarosamenteecomeventual recuperac¸ão incompleta da func¸ão.Emboraotratamentoconservador resulteem bons
夽
StudyconductedattheUniversidadeFederaldeSãoPaulo,DepartmentofOrthopedicandTraumatology,SãoPaulo,SP,Brazil. ∗ Correspondingauthor.
E-mails:[email protected],[email protected](L.G.Shimba).
http://dx.doi.org/10.1016/j.rboe.2017.01.001
excêntricaecontêmprincipalmentefibrasdecontrac¸ãorápida(tipo2).Umrepresentante dessegrupoéoquadrícepsfemoral,queconstitui-sepelosmúsculosretofemoral,vasto medial,vastointermédioevastolateral.Oretofemoraléomúsculodoquadrícepsmais envolvidonaslesõespor estiramento.É maislesadonasfasesdeacelerac¸ão do“tiro”, saltodeexplosão,chutedabolaouquandoháumacontrac¸ãocontraresistência.Mesmo queotratamentoconservadorapresentebonsresultados,écomumqueopacientetenha diminuic¸ãodaforc¸amuscular,dificuldadederetornoaoesporteegappermanenteevisível. Otratamentocirúrgicopodeserumaopc¸ãoparaumretornomaiseficienteaoesporte.
©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Muscle injuriesarethe mostcommon lesionduringsports
activities,representing31%ofalllesionsinsoccer,10.4%in rugby,17.7%inbasketballpracticeandcanrangefrom22% to46%inAmericanfootball.1,2Dependingthemuscleinjury
type,fibrotictissueresulting frommuscle cicatrizationcan compromisemusclefunction,whichisachallengingproblem fororthopedics.3Althoughconservativetreatmentproduces
adequate functionalresultsinthemajority ofthe athletes, theconsequencesoftreatmentfailureorthenon-treatment ofmuscleinjuriescaninhibitreturntosports.1
Muscleinjurycanbeclassified byO’Donoghue4 inthree
grades according to size and functional loss: grade 1 for
irrelevanttissuelesions,grade2fortissuelesionsassociated withstrengthreductioninthemuscle-tendoncomplex,and grade3forcompleteruptureofthemuscle-tendoncomplex andcompletefunctionalloss.
Biarticular muscles with type II muscle fibers and sub-jected to eccentric contraction have a higher risk for new injuries.1,2,5,6Quadricepsfemorisisanexampleofthismuscle
type.Thefemorisrectusisthequadricepsfemorismusclethat ismostfrequentlyinvolvedinstretchlesions.6Ruptureoccurs
duringtheaccelerationphase ofrunning, jumping,kicking a ball, or during contraction against resistance. Although conservative treatments may lead to acceptable results, it
is common for patients to display lower muscle strength,
delayedreturntophysicalactivity,andapermanentvisible andpalpablegap.Surgicaltreatmentcanbeanoptionfora moreefficientreturntosports.
Case
presentation
Thisstudyreporttwocasesofsurgicaltreatmentforcomplete ruptureoftherectusfemorisinsoccerplayers.
Case1
Patient1wasa50yearoldmaleamateursoccerplayerwitha 38yearhistoryofplayingthesport.Thepatientusedtoplay soccerthreetimesaweekandhadusedanabolicsteroidsfive
yearsbeforelesion(oxandrolone60–80mgfor10days).The patientexperiencedanindirecttraumaduringsoccerpractice whenhekickedaball.Hedevelopedpain,edema,apalpable gap,andakneeextensiongap(Fig.1A).
Case2
Patient2wasa28yearold maleprofessionalsoccerplayer duringeightyears.Thepatientusedtopracticefour times
perweekandplaysoneortwotimesaweek.Hedeniedany
useofanabolicsteroids.Thispatientexperiencedanindirect traumaduringsoccertrainingwhenhekickedaball(eccentric contractionofthemuscle).Hedevelopedthefollowing symp-toms:pain,edema,apalpablegap,akneeextensiongap,and decreasedmusclestrength(Fig.1B).
Investigations
BothpatientswereexaminedbyX-ray,ultrasound,andMRIto confirmthepresenceofanintrasubstancelesionoftherectus femoris.ThelesionswereclassifiedasgradeIIIinbothcases. Bothpatientsdevelopedlargecontusionswiththepresenceof ahematoma(Fig.2).
Treatment
Bothsubjectswere immediatelytreatedwithanalgesia and
cryotherapy.Thepatientsweretreatedsurgicallyduetothe grade III injury with a significant gap, the presence of a hematoma,andtheirlimitedimprovementwithtime.Incase
1, the surgicalprocedure was performed22 daysfollowing
injury. Thesurgerywasconductedusinga10cm longitudi-nalanteriorincisioninthethigh.Agapwasidentifiedinthe
lesion,and the muscle wasrounded. Themusclewas
sur-rounded by ahematoma, and therewas scartissue atthe
proximalanddistaledgesofthelesion.Wereleasedthe mus-cleadhesionstothefascia,andthemuscleendsweremobile.
Thelesionwasrepairedbyattachingthemuscleedgesand
Fig.1–Physicalexaminationofpatients1(A,B)and2(C,D).Frontview(A,C)andlateralview(B,D)fromthetightwhere
wecanseethefemoralmusculargapandpseudotumorlesion.
involvedanapproximately7cmlongitudinalandanterior inci-sioninthethigh.Thedissectionwasperformedpreservingthe fascia.Agapandlocalhematomawereidentified.Thelesion
wasrepairedbyconnectingthemuscleedgesand“mouthto
mouth”sutureswithVicryl®n◦02wireusinganchored
contin-uoussuturing.Bothpatientshadtheirlegimmobilizedwitha kneeextensionsplintfor6weeks(Fig.3).
Outcomeandfollow-up
Both patients underwent immobilizationwith non
weight-bearingandextensionofthekneeforthreeweeks.Afterthis period,thepatientsstartedphysiotherapytoimproverange ofmotionoftheknee;andpassiveandactivemovementwas
allowedaftersixweeks.Thepatientswere medicatedwith
analgesics,andcryotherapywasperformed.Patient evalua-tionsrevealednopainandprogressiverecoveryofmuscular strength after three months. Patient one returned to nor-malsportsactivities5monthsaftersurgery,andpatienttwo returnedtoplayingafter4months.
Discussion
Themajorityofthequadricepslesionscanbemanagedwith rehabilitationanddrugsincaseswithextensiveinjuriesand inolderandlessactivepopulations.7However,inrecreational
and competitive athletes, resuming activities quickly and musclecontractionareimportant.Thus,surgicalprocedures
shouldbeconsideredinthesecases.Theliteratureregarding thistypeofinjuryislimited,andthereisnostructured treat-mentprotocol.Thereareothermusclegroupinjuriesthatwere treatedusingasurgicalapproachwithsatisfactoryoutcomes reportedintheliterature.Pectoralismajormuscle8and the
gastrocnemiusmusclearesurgicallytreatedinmostcases.9
The rectus femoris is the mostsuperficial and anterior
muscleofthequadricepscomplex(anteriorcompartmentof
thethigh).Thisbiarticularmuscleoriginatesintheanterior iliacspineandthehipjointcapsuleandisimportantforhip flexionandkneeextension.7
The injury mechanism of this muscle usually involves
eccentricexplosivecontraction.7,10Thus,itisthemost
com-monlyinjuredmuscle.10,11Theinjurymechanismwasindirect
inthiscasereport.Theamateursoccerplayerwasinjuredas hekickedaball,andtheprofessionalsoccerplayerwasinjured
asheperformedanintenseshortrun.Thetrauma
mecha-nismsforbothcasesaresimilartopreviousresultspresented intheliterature.7,10,12
Avulsioninjuriesoriginatingatthedirectheadoftherectus femorisintheanteriorinferioriliacspinearewelldocumented inthetendonjunctionoftherectus femorisinthe quadri-cepstendon.8,10However,myotendinealtransitionlesionsare
lesscommon.10ThistypeoflesionwasidentifiedbyTemple
etal.Injuriespresentedaspseudotumorsinsevencases.10
Inthepresentstudy,patientshadsimilarlesion.Treatment resultsofthesecasesaresimilartotheresultsobservedby Strawetal.10 Theauthor believesthataftersurgicalrepair,
Fig.2–(A,B)MRIcoronalandaxialviewsshowinghipersignalintheanatomicalsiteoftherectusfemorismuscle,
respectively;(C,D)USimagesshowinghypoechoicsignal,sugestingpresenceofhematoma.
Fig.3–Intraoperatoryimages.(A)Femoralinjuryextremitiesidentificationandapproachprogramationintheanterior
femoralskin;(B)dorsalfasciaintergrityoftherectusfemorismuscle;(C)muscularinjuryidentification;(D)re-approachof
Thetreatmentofpatientsreportedinthepresentstudyin theacutephase(oneweek)wasnotdifferentfromthe pro-tocolrecommended bythe literature, withimmobilization,
cryotherapyand analgesia. Thepatientof case1was
sub-mittedtosurgicaltreatmentafter22daysofinjury.Theother patientunderwentsurgicalprocedure7daysafterlesion.
Comparedwiththeliterature,whichreportsanaverageof threemonths,wehadanearliersurgicalintervention,which mayhaveinfluencedtheefficiencyofthetreatmentand accel-eratedthebeginningoftherehabilitationprotocol,sincethe patientofthecase2,treatedsevendaysAfterinjury,returned 1monthbeforethecase1patient,treated22daysafterinjury.
Therehab protocol was the same forboth cases. They
stayedimmobilizedforthreeweeks.Afterthat the priority wasgainofmotionwithpassivemobilization.Aftersixweeks theyweresubmittedtoactivemobilizationandinfivemonths, returnedtosportpractice.Itwasthereforeamoreearly reha-bilitationprotocolthanthatrecommendedbytheliteraturein thenon-surgicaltreatment,6whichmaydecreasetheathlete’s
timeoutsidethetrainingandcompetitions.
Patientsreturnedtosportspracticeafterthethirdmonth
but their rehabilitationprogram continued for six months
after surgery. Taylor reported results that were similar to ourfindings.Surgeryandaprogressiveandearly postopera-tivephysicaltherapyprogramallowpatientstoparticipatein sportswithoutanyrestrictions.7
Inthisstudy,wedemonstratedthat patientswithgrade IIImuscularlesionsoftherectusfemorismuscleandagap withahematomathatfailtorecoverafterashortphysical therapytreatmentperiodcanbetreatedbysurgicalrepairand postoperativephysicaltherapy.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
e
f
e
r
e
n
c
e
s
1.JärvinenTA,JärvinenTL,KääriäinenM,KalimoH,JärvinenM.
Muscleinjuries:biologyandtreatment.AmJSportsMed.
2005;33(5):745–64.
2.Mueller-WohlfahrtHW,HaenselL,MithoeferK,EkstrandJ,
EnglishB,McNallyS,etal.Terminologyandclassificationof
muscleinjuriesinsport:theMunichconsensusstatement.Br
JSportsMed.2013;47(6):342–50.
3.HuardJ,LiY,FuFH.Muscleinjuriesandrepair:currenttrends
inresearch.BoneJointSurgAm.2002;84A(5):822–32.
4.O’DonoghueDO.Treatmentofinjuriestoathletes.
Philadelphia:WBSaunders;1962.
5.AndersonK,StricklandSM,WarrenR.Hipandgroininjuries
inathletes.AmJSportsMed.2001;29(4):521–33.
6.NoonanTJ,GarrettWEJr.Musclestraininjury:diagnosisand
treatment.JAmAcadOrthopSurg.1999;7(4):262–9.
7.TaylorC,YarlagaddaR,KeenanJ.Repairofrectusfemoris rupturewithLARSligament.BMJCaseRep.2012;March(20),
http://dx.doi.org/10.1136/bcr.06.2011.4359,pii:bcr0620114359.
8.deCastroPochiniA,EjnismanB,AndreoliCV,MonteiroGC,
SilvaAC,CohenM,etal.Pectoralismajormusclerupturein
athletes:aprospectivestudy.AmJSportsMed.
2010;38(1):92–8.
9.ChengY,YangHL,SunZY,NiL,ZhangHT.Surgicaltreatment
ofgastrocnemiusmuscleruptures.OrthopSurg.
2012;4(4):253–7.
10.StrawR,ColcloughK,GeutjensG.Surgicalrepairofachronic
ruptureoftherectusfemorismuscleattheproximal
musculotendinousjunctioninasoccerplayer.BrJSports
Med.2003;37(2):182–4.
11.ZarinsB,CiulloJV.ACutemuscleandtendoninjuriesin
athletes.ClinSportsMed.1983;2(1):167–82.
12.HasselmanCT,BestTM,HughesC4th,MartinezS,GarrettWE
Jr.Anexplanationforvariousrectusfemorisstraininjuries
usingpreviouslyundescribedmusclearchitecture.AmJ
