- This report details a case of proximal rectus femoris (RF) tendon tear involving both heads (the direct head attachment to the anterior inferior iliac spine and the indirect head attachment to the hip joint capsule) in a professional football placekicker
- The 23-year-old male athlete sought a second surgical opinion with an outside hip specialist and elected to undergo an open RF tendon repair two weeks after the injury with that specialist
- Following a graduated rehabilitation program, the athlete was able to return to kicking three months postoperatively; at six months, he had a minor strength deficit compared with the noninjured leg but had returned to pain-free running and kicking
- Successful return-to-play is also possible with nonoperative care, so decision-making should be shared with the patient; injury timing within the context of the athlete's career and goals should be considered
The rectus femoris (RF), the most superficial quadriceps muscle, acts as both a hip flexor and knee extensor. In sports such as American football and soccer, the terminal backswing of a kick, when the hip is hyperextended and the knee is flexed, involves a forceful eccentric contraction that places the RF tendon at high risk of injury.
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Proximally, the RF has two tendon origins: the direct head attachment to the anterior inferior iliac spine (AIIS) and the indirect head attachment to the hip joint capsule at the superior acetabular ridge. AIIS tendon avulsion injuries of the RF direct head are relatively uncommon, and proximal RF tears involving both the direct and indirect heads are even less frequent.
Mass General Brigham physicians have presented in Current Sports Medicine Reports the case of a proximal RF tendon tear involving both heads in a pure placekicker plying professional American football. The authors are Kayle Noble-Taylor, DO, former sports medicine fellow at Spaulding Rehabilitation Hospital, Mark D. Price, MD, PhD, an orthopedic surgeon with the Sports Medicine Service at Massachusetts General Hospital, and Kelly McInnis, DO, sports medicine physiatrist and co-director of the Mass General Brigham Women's Sports Medicine Program.
Introduction to the Case
The patient was a 23-year-old, right-leg dominant, male professional American-style football placekicker (soccer-style). He presented with a 10-day history of right hip pain, explaining he had felt a right anterior hip region clicking sensation while getting off an exercise bike. He then immediately went out to practice.
After several nonpainful practice kicks, he had substantial sudden-onset pain when his hip was in the extreme of the extension, with ball strike and follow-through. He was unable to continue practice. After the injury, he experienced right quadriceps weakness and pain with walking and hip flexion.
On physical examination, a soft tissue defect was visible at the anterior proximal thigh with quadriceps contraction and single-leg stance, which was tender to palpation. Hip flexion was limited to 100° secondary to pain. Otherwise, the hip range of motion was full but painful.
Ultrasound of the right hip region revealed near-complete musculotendinous disruption of the RF direct head tendon with approximately 1 cm of retraction. The RF indirect head was poorly visualized on ultrasound, as is often the case given its oblique path to the acetabulum. MRI detected a high-grade, near full-thickness partial tear of the direct and indirect attachments of the RF.
Management and Outcome
The patient was counseled about the risks and benefits of both nonoperative care and surgical repair. He sought a second surgical opinion with an outside hip specialist and elected to undergo an open RF tendon repair two weeks after the injury with that specialist.
Postoperatively the athlete underwent a graduated rehabilitation program: no weight-bearing for six weeks, physical therapy beginning at four weeks focused on hip motion and progressing to isometric strengthening, followed by eccentric strengthening at eight weeks. Return to kicking began at three months.
At six months, the athlete had a minor strength deficit with hip flexion compared with the noninjured leg but had returned to pain-free running and kicking.
Proximal RF tendon tears are typically managed nonoperatively with focused rehabilitation. Surgery is reserved for elite athletes with complete tears involving the direct and indirect heads or incomplete tears that fail nonoperative management.
This case highlights that operative management can lead to a return to pain-free kicking. Successful rehabilitation of professional soccer players after surgery has been described in the Orthopaedic Journal of Sports Medicine and was similarly prolonged—12 to 30 weeks versus the six to 12 weeks that's typical with nonoperative management.
Because a successful return to play is also possible with nonoperative care, decision-making for the elite athlete can be challenging. Factors to consider include injury timing and the athlete's career stage and goals. Shared decision-making is required to determine the best treatment path.
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