Ramon Balius - Quadriceps Muscle Injuries Diagnosis 8th MuscleTech Netework Workshop Monday 3rd October, 2016 #MT8th

1. Quadriceps Muscle
Injuries Diagnosis
Consell Català de l’Esport
Clínica Diagonal
Clínica Creu Blanca Level of Evidence IV
Ramon Balius
Xavier Alomar

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

12. Direct Tendon Rupture
INDIRECT
DIRECT
DIRECT
INDIRECT
INDIRECT
Indirect Tendon Rupture
CONJOINTED TENDON
Conjointed Tendon Rupture
NO DIRECT TENDON

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

15. “muscle-within-muscle”
RECTUS FEMORIS MTJ INJURY

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

24. Evolution: Cystic Hematoma

25. 09.01.2013
20.11.2012
13.11.2012
23.02.201309.01.2013 30.02.2013
Evolution: Laminar Fibrous Scar

26. Cross i cols, 2004

27. 4. Posterior Fascia. Proximal Peripherical Injury
 No stump
Often asymptomatic
Fluid Collection "in eye“
Characteristic fibrous scars
European Journal of Radiology, 2012