Acute Quadriceps Muscle Strains MRI features and prognosis

1
Acute Quadriceps Muscle StrainsMRI features and
prognosis

• Dr Tom Cross
• MBBS, FACSP, DCH
• The Stadium Orthopaedic and Sports Medicine Centre

2
Acute Quadriceps Muscle StrainsMRI features and
prognosis

• Dr T Cross
• Dr N Gibbs
• Mr M Cameron
• Dr M Houang
• AJSM, April 2004

3

• Introduction
• Literature review
• Methods
• Results and Discussion
• Conclusions
• Questions??

4
Clinical Scenarioe.g.. Anterior thigh pain 7
days before World Cup FinalCan he play??
5
1. Introduction
6
Objective

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

7
Objective

• To assess any relationship between the MRI
  findings and the time taken to return to sport

8
Setting

• Sydney Swans Football Club
• 1 of 16 clubs
• in the National competition

9
Design

• Prospective study over 3 years (1999-2001)
• Both in-season and pre-season periods

10
Patients

• 40 professional footballers
• Consent from Club and individual players

11
Australian Rules Football

• Athletes at risk
• Repetitive sprinting efforts
• Repetitive kicking
• Repetitive jumping landing
• Game time approximately 100 minutes

12
Australian Rules Football

• Ideal sport ( outdoor laboratory) to
  study muscle strain injury

13
Australian Rules Football

• Hamstring strain is the most significant injury
  in ARF
• (Quadriceps strain in top 10)

14
Motivation for research

• To better understand/diagnose quadriceps muscle
  strains
• To better manage/rehabilitate quadriceps muscle
  strains

15
Motivation for research

• To make an EARLY ACCURATE PROGNOSIS
• (i.e. we were unable to clinically
  differentiate benign from serious quadriceps
  strains)

16
2. Literature Review
17
Literature review

• Pomeranz (1993)
• Retrospective study of Hamstring strains
• n14
• Prognosis associated with size (cross-sectional
  area) of muscle strain injury on MRI scan

18
Literature review

• No research (i.e. series of cases) on,
• Clinical behavior
• MRI findings
• of acute quadriceps strains

19
Literature review

• No mention of Vastus quadriceps muscle strains
  in the literature

20
Literature review

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

Distal rupture of RF
21
Literature review

• 3 retrospective studies on chronic muscle strain
  injuries of rectus femoris
• all cases were proximal injuries
• Rask and Lattig (1972) n5
• Hughes and Hasselman (1995) n10
• Temple et al (1998) n7

22
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
23
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???
24
Literature review

• Hughes and Hasselman (1995, AJSM)

Rectus femoris- cadaveric dissection
25
Literature review
Special anatomy of rectus femoris
Left thigh

• Hughes and Hasselman (1995)

Superior acetabulum
AIIS
26
Literature review
Unipennate structure proximal 1/3 of RF
Central tendon
Bipennate structure Middle and distal 2/3 of RF
27
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 bulls eye lesion
Fibrotic scar
New muscle-tendon junctions
28
Chronic Bulls Eye" lesion
Normal Central Tendon
29
Chronic symptomatic bulls 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
30
Literature review continued.

• Rectus femoris, an at-risk muscle
• Acts eccentrically
• Crosses two joints
• High fast twitch fibres

31
Literature review

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

32
3. Methods
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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

34
Methods

• Exclusion criteria
• History of trauma to anterior thigh (Contusion)
• Delayed onset of anterior thigh pain (DOMS)

35
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)

36
Methods

• Muscle strain injury high signal on T2 weighted
  images

37
Methods

• MRI diagnosis
• Location (MRI category)
• Which quadriceps muscle (s) injured
• Location of injury with respect to known
  musculotendinous junctions

38
Methods

• MRI diagnosis
• Size
• Cross sectional area (CSA)
• Length (cm)

39
Methods

• CSA estimation (dot method)

40
Methods

• MRI diagnosis miscellaneous features
• T2 hyper intensity
• muscle fibre disruption
• Perifascial fluid
• Scarring/fibrosis

41
Methods

• What if more than one muscle injured?
• (i.e. double injury etc.)
• Primary muscle injured greatest CSA
• Secondary muscle injury smaller CSA

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Results of acute MRI images

• 25 acute clinical quadriceps strains were imaged
• Authors were not blinded to these MRIs

43
MRI negative n3
Central tendon
Central tendon
44
RF-CTn7
High signal on both sides of CT an acute
bulls eye lesion
45
RF-CT (coronal)
feather-like pattern
46
RF-CT
High signal on only one side of CT
47
RF-CT
High signal on one side of CT
48
RF-peripheral n8
No high signal about Central Tendon
High signal in periphery
49
RF-periphery
High signal about posterior lamina of RF
50
Vastus Intermedius n6
Anterior lamina of VI
High signal in VI
51
Vastus intermedius
High signal about anterior femoral shaft
52
Vastus Lateralisn1
Perifascial fluid
Anterior lamina of VL and adjacent high signal in
VL muscle
53
Double injury n1
Secondary injury RF-peri
Primary injury RF-CT
54
MRI look-alikes

• DOMS and muscle contusions similar MRI
  appearance to muscle strain injuries
• Inclusion and exclusion criteria were strictly
  adhered to

55
Quadriceps Contusion
High signal in all 4 quadriceps
56
Only one Double injury in series (RF-CT was the
primary injury, RF-peri was the secondary injury)
57
Methods (rehabilitation phase)

• No universally accepted rehabilitation regimen
  exists for muscle strain injuries

58
Methods (rehabilitation phase)

• Rehabilitation was standardised
• Phase 1 Acute management
• RICE/crutches first 48 hours
• Intensive Physiotherapy
• soft tissue therapy
• flexibility
• strengthening

59
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

60
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

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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

62
Rehabilitation interval (RI)

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

63
4. Results Discussion
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Statistical analysis

• Statistician analyzed data
• t-tests independent samples (dependent vs.
  independent variables)
• Two-way analysis of variance

65
Results Statistical analysis
(days)
RI
RF- CT
RF- Peri
negative
Vasti
66
RF-CT acute bulls eye lesion

• n7
• Mean RI27 days
• significantly longer RI (p0.001)

67
RF-CT acute bulls eye lesion

• Is the RED FLAG diagnosis that heralds a
  protracted rehabilitation

68
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
69
RF-peri

• n8
• Mean RI9 days
• shear phenomenon between two heads of proximal
  tendon does not occur
• Benign quadriceps strain category

70
Vastus muscle strains

• VI (n6), VL (n1)
• Mean RI 4 days
• Benign quadriceps strain category

71
Vastus muscle strains

• Hypothesis
• Slow twitch muscle
• Crosses only one joint
• Large bulk of synergistic muscles

72
MRI negative cases

• n3
• Mean RI 6 days (benign injury)
• Less common phenomenon than in clinical Hamstring
  strains

73
MRI negative cases

• Hypotheses
• MRI done too early
• Strain injury too small to resolve
• Pain mediated by neuro-meningeal structures (e.g.
  femoral nerve)

74
Does size matter??

• CSA (greater than 15) p0.033
• Length (greater than 13cm) p 0.038

75
Location (MRI category) most important
RF-CT CSA 42
RF-peri CSA 46
vs
RI 32 days
RI 12 days
76
Clinical evaluation

• History (onset, mechanism, preferred kicking leg)
  is unhelpful
• Examination- not analyzed

77
??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

78
Were any follow-up MRI done?

• Yes
• N11 available for study
• 4 out of interest when player considered
  rehabilitated
• 7 incidental
• Not routinely done, no statistical analysis

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RF-CT acute
Acute bulls eye lesion
80
RF-CT day 32
Fibrosis about Central tendon and surrounding
high signal
81
RF-CT day 63
Scarring about CT Minimal high signal about scar
82
RF-peri acute
CSA 46 Length13cm
83
RF-peri day 10
Decreased T2 high signal Decreased
CSA37 Length6 cm
84
Follow-up MRI findings

• 4 MRIs 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

85
Follow-up MRI

• 7 incidental follow-up MRIs available
• 4 (two VI, two RF-CT) had complete resolution
• 3 ( RF-CT) had scarring (Grade 2 muscle strain
  injury) but were asymptomatic

86
RF-CT (8 months) VI (acute)
Fibrosis about Central tendon
Acute VI strain
87
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 bulls eye lesion
88
Chronic symptomatic bulls eye lesions
Chronic symptomatic bulls eye

89
CONCLUSIONS
90
Conclusions

• MRI defines muscle strain injury objectively
• probe beneath the surface of the skin

91
Conclusions

• All 22 MRI positive cases of muscle strain
  injury occurred about known muscle-tendon
  junctions
• (This concurs with basic science studies)

92
Conclusions

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

93
Conclusions

• Tenderness over the anterior thigh does not
  always rectus femoris muscle strain
• (could be Vastus muscle strain or MRI negative)

94
Conclusions

• No cases of distal rupture of RF

95
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

96
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
97
Conclusions

• Size ( CSA and length) of muscle strain injury
  is also predictive of RI

98
Conclusions

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

99
Conclusions
Soccer World Cup 2002

• Indications for MRI
• Acute MRI for elite athletes

100

e.g. Anterior thigh pain 7 days before FinalCan
he play??YES if Benign MRINO if RF-CT
(acute bulls eye)
101
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
102
Thank-you

• Questions?