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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.

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acute quadriceps muscle strains mri features and prognosis

Acute Quadriceps Muscle StrainsMRI features and prognosis

Dr Tom Cross

MBBS, FACSP, DCH

The Stadium Orthopaedic and Sports Medicine Centre

acute quadriceps muscle strains mri features and prognosis2

Acute Quadriceps Muscle Strains:MRI features and prognosis

Dr T Cross

Dr N Gibbs

Mr M Cameron

Dr M Houang

AJSM, April 2004

slide3
Introduction
  • Literature review
  • Methods
  • Results and Discussion
  • Conclusions
  • Questions??
objective
Objective

To describe the MRI findings of a series of acute quadriceps muscle strains

objective7
Objective

To assess any relationship between the MRIfindings and the time taken to return to sport

setting
Setting
  • Sydney Swans Football Club
  • 1 of 16 clubs

in the National competition

design
Design

Prospective study over 3 years (1999-2001):

Both in-season and pre-season periods

patients
Patients

40professional footballers

Consent from Club and individual players

australian rules football
Australian Rules Football

“Athletes at risk”

  • Repetitive sprinting efforts
  • Repetitive kicking
  • Repetitive jumping & landing
  • Game time approximately 100 minutes
australian rules football12
Australian Rules Football

Ideal sport ( “outdoor laboratory”) to study muscle strain injury

australian rules football13
Australian Rules Football

Hamstring strain is the most significant injury in ARF

(Quadriceps strain in top 10)

motivation for research
Motivation for research
  • To better understand/diagnose quadriceps muscle strains
  • To better manage/rehabilitate quadriceps muscle strains
motivation for research15
Motivation for research
  • To make an EARLY ACCURATE PROGNOSIS

(i.e. we were unable to clinically differentiate benign from serious quadriceps strains)

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 review18
Literature review

No research (i.e. series of cases) on,

Clinical behavior

MRI findings

of acute quadriceps strains

literature review19
Literature review

No mention of Vastus quadriceps muscle strains in the literature

literature review20
Literature review

No research (i.e. series of cases) on “ distal rupture of rectus femoris”

Distal rupture of RF

literature review21
Literature review

3 retrospective studies on chronic muscle strain injuries of rectus femoris :

all cases were “proximal injuries”

  • Rask and Lattig (1972) n=5
  • Hughes and Hasselman (1995) n=10
  • Temple et al (1998) n=7
literature review22
Literature review

Chronic “proximal strain injury” of rectus femoris

Mean time to presentation

= 7 months

Tender anterior thigh mass

Associated anterior thigh pain, weakness and dysfunction

literature review23
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 review24
Literature review
  • Hughes and Hasselman (1995, AJSM)

Rectus femoris- cadaveric dissection

literature review25
Literature review

Special anatomy of rectus femoris

Left thigh

Hughes and Hasselman (1995)

Superior acetabulum

AIIS

literature review26
Literature review

Unipennate structure: proximal 1/3 of RF

Central tendon

Bipennate structure: Middle and distal 2/3 of RF

literature review27
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 muscle-tendon junctions

slide28

Chronic “Bulls Eye" lesion

Normal Central Tendon

chronic symptomatic bull s eye lesions
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
Literature review: continued….

Rectus femoris, an “at-risk muscle”

  • Acts eccentrically
  • Crosses two joints
  • High % fast twitch fibres
literature review31
Literature review

Vastus muscles

  • Act eccentrically
  • Cross only one joint
  • High % slow twitch fibres
  • Large bulk of synergistic muscles
methods
Methods

Inclusion criteria

  • History
          • acute or gradual onset of anterior thigh pain while training or playing
          • Mechanism of injury documented (running, kicking, jumping/landing): if onset of symptoms were acute
          • 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

methods34
Methods

Exclusion criteria

  • History of trauma to anterior thigh (Contusion)
  • Delayed onset of anterior thigh pain (DOMS)
methods35
Methods

MRI within 24-72 hours

  • T1,T2 with fat suppression, STIR
  • Axial, coronal planes (both thighs imaged)

(Axial T2with fat suppressionmost useful images)

methods36
Methods

Muscle strain injury= high signal on T2 weighted images

methods37
Methods

MRI diagnosis

Location (MRI category)

  • Which quadriceps muscle (s) injured
  • Location of injury with respect to known musculotendinous junctions
methods38
Methods

MRI diagnosis

Size

  • Cross sectional area % (CSA)
  • Length (cm)
methods39
Methods
  • CSA% estimation (“dot” method)
methods40
Methods

MRI diagnosis: miscellaneous features…

  • T2 hyper intensity
  • muscle fibre disruption
  • Perifascial fluid
  • Scarring/fibrosis
methods41
Methods

What if more than one muscle injured?

(i.e. double injury etc.)

  • Primary muscle injured= greatest CSA%
  • Secondary muscle injury= smaller CSA%
results of acute mri images
Results of acute MRI images
  • 25 acute clinical quadriceps strains were imaged
  • Authors were not blinded to these MRI’s
mri negative n 3
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-CTn=7

rf ct coronal

RF-CT (coronal)

“feather-like” pattern

rf ct
RF-CT

High signal on only one side of CT

rf ct47
RF-CT

High signal on one side of CT

rf periphery
RF-periphery

High signal about posterior lamina of RF

vastus intermedius
Vastus intermedius

High signal about anterior femoral shaft

vastus lateralis n 1

Perifascial fluid

Anterior lamina of VL and adjacent high signal in VL muscle

Vastus Lateralisn=1

double injury n 1
Double injury n=1

Secondary injury: RF-peri

Primary injury : RF-CT

mri look alikes
MRI “look-alikes”
  • DOMS and muscle contusions: similar MRI appearance to muscle strain injuries
  • Inclusion and exclusion criteria were strictly adhered to
slide56

Clinical quadriceps strains

N=25

MRI positive

N=22

MRI negative

N=3

RF

N=15

Vasti

n=7

RF-CT

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
Methods (rehabilitation phase)
  • No universally accepted rehabilitation regimen exists for muscle strain injuries
methods rehabilitation phase58
Methods (rehabilitation phase)

Rehabilitation was standardised

Phase 1 : Acute management

  • RICE/crutches first 48 hours
  • Intensive Physiotherapy
      • soft tissue therapy
      • flexibility
      • strengthening
methods rehabilitation phase59
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 phase60
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 phase61
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
Rehabilitation interval (RI)

RI= time from the injury to the return to full training (measured in days)

statistical analysis
Statistical analysis

Statistician analyzed data

  • t-tests independent samples (dependent vs. independent variables)
  • Two-way analysis of variance
results statistical analysis
Results: Statistical analysis

(days)

RI

RF-

CT

RF-

Peri

negative

Vasti

rf ct acute bull s eye lesion
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 lesion67
RF-CT: “acute bull’s eye lesion”

Is the RED FLAG diagnosis that heralds a protracted rehabilitation

why do rf ct injuries take longer
Why do RF-CT injuries take longer??
  • The Hypothesis: Shearing effect of Central Tendon (indirect head) with direct head:

a “muscle within a muscle”

Indirect and direct heads of proximal tendon begin to act independently

rf peri
RF-peri
  • n=8
  • Mean RI=9 days
  • “shear” phenomenon between two heads of proximal tendon doesnot occur
  • Benign quadriceps strain category
vastus muscle strains
Vastus muscle strains
  • VI (n=6), VL (n=1)
  • Mean RI= 4 days
  • Benign quadriceps strain category
vastus muscle strains71
Vastus muscle strains
  • Hypothesis
        • Slow twitch muscle
        • Crosses only one joint
        • Large bulk of synergistic muscles
mri negative cases
MRI negative cases
  • n=3
  • Mean RI= 6 days (benign injury)
  • Less common phenomenon than in clinical Hamstring strains
mri negative cases73
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
Does size matter??
  • CSA% (greater than 15%)p=0.033
  • Length (greater than 13cm) p= 0.038
location mri category most important
Location (MRI category): most important

RF-CT

CSA % = 42

RF-peri

CSA % = 46

vs

RI = 32 days

RI= 12 days

clinical evaluation
Clinical evaluation
  • History (onset, mechanism, preferred kicking leg) is unhelpful
  • Examination- not analyzed
recurrent strains
??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
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
RF-CT acute

Acute “bull’s eye” lesion

rf ct day 32
RF-CT day 32

Fibrosis about Central tendon and surrounding high signal

rf ct day 63
RF-CT day 63

Scarring about CT

Minimal high signal about scar

rf peri acute
RF-peri acute

CSA%= 46

Length=13cm

rf peri day 10
RF-peri day 10

Decreased T2 high signal

Decreased CSA%=37

Length=6 cm

follow up mri findings
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
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
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 asymptomatic bull’s eye lesion

chronic symptomatic bull s eye lesions88
Chronic symptomatic “bull’s eye lesions”

Chronic symptomatic “bull’s eye”

conclusions90
Conclusions

MRI defines muscle strain injury objectively:

“probe beneath the surface of the skin”

conclusions91
Conclusions

All 22 MRI positive cases of muscle strain injury occurred about known muscle-tendon junctions

(This concurs with basic science studies)

conclusions92
Conclusions

The rectus femoris was the most commonly injured muscle (15/22 cases)

conclusions93
Conclusions

Tenderness over the anterior thigh does not always = rectus femoris muscle strain

(could be Vastus muscle strain or MRI negative)

conclusions94
Conclusions

No cases of “distal rupture of RF”

conclusions95
Conclusions

This research complements the research on chronic symptomatic RF-CT injuries regarding:

  • How acute RF-CT injuries may behave
  • How acute RF-CT injuries may look
conclusions96
Conclusions

RF-CT is the “RED FLAG” diagnosis that heralds (1) protracted RI

(2) potential for chronicity

RI

(days)

RF-

CT

RF-peri

negative

Vasti

conclusions97
Conclusions
  • Size ( CSA % and length) of muscle strain injury is also predictive of RI
conclusions98
Conclusions

Follow-up MRI may be persistently abnormal despite apparent functional recovery

conclusions99
Conclusions

Soccer World Cup 2002

Indications for MRI

Acute MRI for elite athletes

slide100

e.g. Anterior thigh pain 7 days before FinalCan he play??YES : if Benign MRINO: if RF-CT (acute “bull’s eye)

conclusions101
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

Thank-you

Questions?