Quadricep strain - an injury not to be missed

As the WAFL season comes to an end I’ve been reflecting on some of the injuries we’ve faced this year (and unfortunately, there have been plenty).

An injury we’ve had a slightly higher incidence of has been quadriceps strains / tears. in 2017 we’ve had 6 quadriceps tears, 5 of which have resulted in games-missed and a total of 13 games missed due to injury.

I thought I’d discuss the findings of a short literature review I completed with my colleague Richard Gonsalves about quadriceps strains and some of the potential risk factors for sustaining a quadriceps injury.

Quadriceps strains are notorious for being misdiagnosed as a cork or dismissed as tightness.

Although not as common and prevalent as hamstring strains, quadriceps strains are a significant injury in Australian Rules Football and one that is associated with high rates of recurrence.

This is largely due to a lack of evidence based treatment and the subsequent mismanagement in treatment and return to sport.

Quadriceps strains involve partial or complete tearing of the muscle fibres of one of the four quadriceps muscles.

Rectus femoris is most commonly involved and injured at the distal musculotendinous junction.

As with all injuries, diagnosis is based on a cluster of findings during the subjective and physical examination.

Subjective features

• Subjective awareness of injury at time of injury (i.e. patients usually know right away)
• Acute onset of sharp pain
• Pain in the anterior thigh (typically along the distal portion of rectus femoris at the musculotendinous junction)
• Mechanism of injury typically involves acceleration/deceleration component: kicking, jumping, sprinting or initiating a sudden change in direction whilst running

Objective features

• Bulge or defect in muscle belly
• Pain with resisted contraction
• Pain with passive stretch
• Tender on palpation at site of strain

The distal musculotendinous junction of rectus femoris is not the only possible site of a tear.

This is important as the location of the injury influences the treatment approach and focus of intervention.

Other less common sits of lesion include:

• The proximal musculotendinous junction
• The deep musculotendinous junction of the indirect head deep to within the muscle belly (central tendon known as the Bull’s eye lesion)

This last site of injury presents more similarly to a muscle contusion with an anterior thigh mass, pain and asymmetry.

This is an important differential diagnosis to consider as literature suggests this type of injury is poorly managed and leads to chronic pain and dysfunctional following misdiagnosis.

Treatment and management

There is a lack of literature and current evidence based treatment recommendations following quadriceps strains.

Minimal randomized controlled trials exist for quadriceps strains and therefore, treatment must focus on a combination of the available evidence based practice and expert opinion.

The literature suggests a more conservative treatment/management approach is appropriate due to the risk and prevalence of re-injury.

The use of controlled mobilisation and strengthening following a short period of immobilisation instead of prolonged immobilisation is strongly supported.

Early return to high loading activities appears to be the most accepted approach, however this may be delayed in young footballers to minimise the risk of re-injury.

Additionally, treatment should involve correction of associated risk factors for injury with increased emphasis on strengthening of the injured muscle.

The literature suggests rehabilitation should involve a combination of concentric and eccentric exercise rather than exclusively eccentric exercise, particularly given the quadriceps require explosive concentric capacities during running.

However, eccentric exercise is supported as greater tension is developed and there is less energy requirement.

The mechanism of injury appears to involve a fault during closed kinetic chain activity in acceleration or deceleration during sprinting or kicking, indicating the need for closed kinetic chain activities in the rehab program with components of changing speed and direction.

Risk factors/other factors to consider

• Iliopsoas trigger points or pathology
• Decreased muscle strength/endurance of hip flexors
• Femoral nerve pathology
• Thoracolumbar junction pathology
• Low muscle strength
• Decreased muscle flexibility
• Inadequate warm-up
• Long kicking prior to warm-up and running
• Over-training
• Excessive training load
• Sudden increases in training load

Although we’ve had a few more quad strains that we would expect to see in a single season, the good news is that we haven’t had any players have a recurrence of the same injury.

The next step will be looking back to see how we could have prevented these injuries from occurring in the first place.