Management of anterior thigh injuries in soccer players: practical guide

Abstract

Most of the anterior thigh injuries are contusions or strains, however, some of these injuries can be career ending. Early diagnosis and correct treatment are key to successful outcome. Analyzing injury mechanism and adding both clinical and imaging findings, clinicians can make the right treatment decisions already often in the acute phase of the injury. Low grade contusions and muscle strains are treated well with planned rehabilitation, but complete tendon injuries or avulsions can require operative treatment. Also, neglected minor injuries could lead to chronic disabilities and time lost from play. Typical clinical presentation of anterior thigh injury is swelling and pain during hip flexion or knee extension. In more severe cases a clear gap can be palpated. Imaging methods used are ultrasound and magnetic resonance imaging (MRI) which are helpful for clinicians to determine more exact the extent of injury. MRI can identify possible tendon retractions which may need surgery. Clinicians should also be aware of other traumatic lesions affecting anterior thigh area such as myositis ossificans formation. Optimal treatment should be coordinated including acute phase treatment with rest, ice, and compression together with designed return-to-play protocol. The anatomical structure involved lines the treatment pathway. This narrative review describes these more common reasons for outpatient clinical visits for anterior thigh pain and injuries among soccer players.

Keywords: Quadriceps; Rectus femoris; Rehabilitation; Rupture; Soccer; Surgery; Thigh injury.

Fig. 1

Soccer player with a charley horse of the left thigh due to a quadriceps contusion. Coronal proton density fat saturated MRI image that shows desestructured rectus femoris and vastus lateralis, and a huge intra and intermuscular hematoma

Fig. 2

Coronal proton density fat saturated MRI image that shows a complete right proximal rectus femoris rupture at the conjoined tendon level with severe distal retraction of the muscle

Fig. 3

Complete proximal rectus femoris tendon rupture: operative imaging (A) and coronal proton density fat saturated image that shows distal retraction of the muscle and the “waving” pattern of the tendon lost tension MRI (B)

Fig. 4

Coronal proton density fat saturated image that shows a persistent hematoma and a rupture in the central tendon. Distal to the hematoma the connective tissue shows scar changes and a mild loss of tendinous tension (MRI)

Fig. 5

Complete rectus femoris midsubstance rupture: operative image (A) and sagittal proton density fat saturated image that shows a complete distal myotendinous junction rupture and an anterior myofascial rupture. Moderate proximal retraction of the muscle. Proximal to the rupture the distal tendon shows scar changes and the central septum is retracted with “waving” pattern due to the retraction. (B)

Fig. 6

Treatment strategy of different muscle—tendon lesions of anterior thigh

Fig. 7

Quadriceps tendon complete rupture: operative image (A) and sagittal proton density fat saturated MRI image (B)

Fig. 8

Sagittal gradient echo MRI image that shows patella-tendon complete proximal rupture. Proximal retraction of the patella

Fig. 9

Coronal MRI STIR image that shows a chronic hematoma adjacent to the iliotibial tract, Morel-Lavallee lesion