2. Check list
Direct Mechanism … … … … .. Clinical findings
Indirect Mechanism … … … … MR and/or US
- RF origin injuries
- RF MTJ injuries
Check list
Direct Mechanism … … … … .. Clinical findings
Indirect Mechanism … … … … MR and/or US
- RF origin injuries
- RF MTJ injuries
3. Direct Mechanism. Quadriceps Muscle
Clinical diagnosis
Vastus lateralis & vastus intermedius
Different degrees of injury
Aponeurosis & subcutaneous tissue involved
Contusion Grade I Contusion Grade II
Contusion Grade III
4. Contusion grade I
• Full Flexion
• Capillary rupture: Blood into connective tissue
• Classical bruise (ecchymosis)
Direct Mechanism. Quadriceps Muscle
Clinical diagnosis
Vastus lateralis & vastus intermedius
Different degrees of injury
Aponeurosis & subcutaneous tissue involved
5. Contusion grade II
• Knee Flexion over 90° but not complete
• Crushing of muscle fibers with vasomotor reaction
• Can exist extravasated blood produces a hematoma
24 hours6d15d (asymptomatic)
Direct Mechanism. Quadriceps Muscle
Clinical diagnosis
Vastus lateralis & vastus intermedius
Different degrees of injury
Aponeurosis & subcutaneous tissue involved
6. Contusion grade III
Flexion <90 °
Usually muscle in contraction
Hematological and vascular manifestations
Potential complications
2d 6d21d (symptomatic)
Direct Mechanism. Quadriceps Muscle
Clinical diagnosis
Vastus lateralis & vastus intermedius
Different degrees of injury
Aponeurosis & subcutaneous tissue involved
7. Check list
Direct Mechanism … … … … .. Clinical findings
Indirect Mechanism: … … … … MR and/or US
- RF origin injuries
- RF MTJ injuries
8. SYMPTOMS
Disabling acute pain or
Minimum initial acute pain (progressive functional disability)
Depression of muscle profile (“hacked form”)
Variable Stump depending on MTJ
Rarely Bruise
“Muscular tight tension”
9. Rectus Femoris Origin
• Indirect tendon (IT): Anterolateral acetabular ridge & capsule
• Direct tendon (DT): Anteroinferior Iliac Spine (AIIS)
• Conjointed tendon: it forms a conjoined tendon with the direct one around
2cm distal to the attachment. Hsu et al. 2005
• Recurrent tendon (RT)
iliopsoas
Carlo Martinoli
IT
DT
RT
First suspicion by echo
MR is mandatory Different situations:
different management
10. • 0.5% of muscle injuries (Ouellette et al, 2006)
• Direct tendon: surgery. Indirect tendon: conservative
• Current trend: elite athletes: surgery
• Frequency: DT > IT. (Hsu, 2005; Bordalo-Rodrigues, 2005)
• There is a lesional cadence (Ouellette et al, 2006)
INDIRECT
DIRECT
CONJOINED
1
2
Carlo Martinoli
1 to 3 ... increasing severity
Rectus Femoris Origin Injuries
Dr. Pedret
11. In elite athletes, depending on outcome, very different treaments
• Mistakes are not allowed
• US only for experts (IT described by Martinoli, published by Pesquer et Al. (2016)
• MR mandatory
FH
Short-
axis
AIIS
1
1
2
2
*
*
Long-
axis
eccentric comet tail
Images by Carlo Martinoli
13. “A Rodas and Balius case” (1999)
29 y.o. Hockey goalkeeper.
Non surgical treatment.
Conjoint tendon rupture
14. 2014 follow-up. Spontaneous reconstruction of both tendons
Muscular body “fallen”
Thin Indirect Tendon
Muscular
Body
“fallen”
Direct tendon
reconstructed
16. Rectus femoris musculotendinous injury
Depending on Musculotendinous Junction
Muscular Injuries settle over musculo-tendinous junctions
1. Central Aponeurosis. Central Tendon Injury (CTI)
2. Direct Tendon Expansion. Superficial Injury
3. Distal Posterior Fascia. Distal Peripheral Injury
4. Proximal Posterior Fascia. Proximal Peripheral Injury
17. 1. Central Aponeurosis. Central Tendon Injury
Little stump
Palpable pasting
Palpable depression
18. 1. Central Aponeurosis. Central Tendon Injury
Acute Injury
Little Hematoma
Tendinous Band
Palpation like a “canaloni”
Bad Prognosis Image
19. 1. Central Aponeurosis. Central Tendon Injury
Acute Injury
Little Hematoma
Tendinous Band
Bad Prognosis Image
Fibrous/Calcified Scar
Soft scar
20. 1. Central Aponeurosis. Central Tendon Injury
Acute Injury
Little Hematoma
Tendinous Band
Bad Prognosis Image
Fibrous/Calcified Scar
Soft scar
21. Soft Scar Contralateral
1. Central Aponeurosis. Central Tendon Injury
Acute Injury
Little Hematoma
Tendinous Band
Bad Prognosis Image
Fibrous/Calcified Scar
Soft scar
22. 2. Direct Tendon Expansion. Superficial Injury
Rare
Poor symptoms
No stump
Minimal myofascial hematoma
MR/US careful: not be confused with avulsion
23. 3. Posterior Fascia. Distal Peripheral Injury
Large and sometimes high stump
Frequent myofascial hematoma
Cystic hematoma
Laminar fibrous scar
Better prognosis than CTI