Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.

com

Review

Rectus femoris muscle injuries in football: a clinically relevant review of mechanisms of injury, risk factors and preventive strategies
Jurdan Mendiguchia,1 Eduard Alentorn-Geli,2 Fernando Idoate,3 Gregory D Myer4,5,6,7
Department of Physical Therapy, Zentrum Rehab and Performance Center, Baraain, Navarre, Spain 2 Department of Orthopedic Surgery, Hospital del Mar i lEsperana, Parc de Salut MAR, Barcelona, Spain 3 Department of Radiology, Clinica San Miguel, Pamplona, Spain 4 Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio, USA 5 Departments of Pediatrics and Orthopaedic Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA 6 Athletic Training Division, School of Allied Medical Professions, The Ohio State University, Columbus, Ohio, USA 7 Departments of Athletic Training, Sports Orthopaedics, and Pediatric Science Rocky Mountain University of Health Professions, Provo, Utah, USA Correspondence to Dr Jurdan Mendiguchia, Department of Physical Therapy, Zentrum Rehab and Performance Center, Calle B Nave 23, Baraain, Navarre, Spain; jurdan24@hotmail.com Received 3 April 2012 Accepted 4 July 2012 Published Online First 3 August 2012
1

ABSTRACT Quadriceps muscle strains frequently occur in sports that require repetitive kicking and sprinting, and are common in football in its different forms around the world. This paper is a review of aetiology, mechanism of injury and the natural history of rectus femoris injury. Investigating the mechanism and risk factors for rectus femoris muscle injury aims to allow the development of a framework for future initiatives to prevent quadriceps injury in football players.

INTRODUCTION
Muscle injury is the most common injury type in football.14 Quadriceps muscle strains frequently occur in sports that require repetitive kicking and sprinting efforts and are common in football in its different forms around the world.1 57 The rectus femoris is the most commonly injured muscle of the quadriceps muscle.711 The mechanism of lower extremity muscle injuries in football remains to be fully elucidated. The incidence of injury varies across the season; a higher risk of posterior thigh muscles exists during the in-season,1 12 while rectus femoris strains (29%) were more frequent than biceps femoris (11%) muscle injuries in the pre-season of the English Premier League13 and the Australian Football League.7 In contrast, Ekstrand et al found that quadriceps muscle strains were fairly constant throughout the season.1 Quadriceps muscle injuries cause more missed games than do hamstring and groin muscle injuries,1 and reinjury rates (17%) are high. We reviewed the literature on rectus femoris muscle injuries and discuss the underlying biomechanical mechanisms and risk factors with a view to injury prevention.

blends anteriorly with the muscles fascia.14 The indirect head contributes to the bres of the deep, intramuscular component of the conjoined tendon and forms a deep myotendinous junction that extends downward approximately two-thirds of the muscle belly of the rectus.14 The rectus femoris extends the knee, exes the hip and stabilises the pelvis on the femur in weightbearing.15 16 In addition, the rectus femoris has a high demand for eccentric muscle contraction and has a high percentage of type II bres (approximately 65%) that can make it more prone to injury.17

IMAGING AND GRADING OF INJURY SEVERITY

In acute rectus femoris muscle strain injuries the player feels a tearing sensation and stops playing. In subacute injuries the player reports gradual onset of pain during running and kicking. Examination reveals that stretching, palpation at the site of injury and resisted knee extension are painful. Differential diagnosis includes assessment of neural tension of the femoral nerve,18 where the athlete may complain of a burning or stinging sensation located in the anterior aspect of the thigh. Classically, the most common site of rectus femoris injury was the distal myotendinous junction near the knee joint.11 19 20 Other locations for rectus femoris injuries may be at the junction of the conjoined tendon with the muscle belly (rectus femoris peripheral area (RF-Peri); gure 2A),8 or at the deep myotendinous junction of the indirect head, referred to as the central part of the tendon by some authors ( gure 2A).6 8 9 14 15 21 22 The latter is the most common location of rectus femoris tendon tears in soccer.6 Importantly, two recent reports that monitored injury incidence in soccer and Australian Football players showed that the rectus femoris central tendon injury is associated with a signicantly longer rehabilitation time (especially proximal) and delayed return-to-sports compared with more peripheral injuries.6 8 Reinjury of the muscle (17%), myositis ossicans, acute compartment syndrome and residual weakness are complications associated with rectus femoris tears.2328 Muscle injuries can be imaged with ultrasonography and MRI, to diagnose and monitor the resolution of rectus femoris injuries. Plain radiographs may be important to rule out associated bone injuries such as avulsion of the anterior inferior iliac spine in the skeletally immature player. Myotendinous strains may be graded by MRI.29 A grade I tear where the integrity of the
1 of 9

ANATOMY
Anatomy appears to play an important role in quadriceps muscle prognosis. The rectus femoris is a fusiform and biarticular long muscle located in the anterior aspect of the quadriceps muscle, these types of muscles are designed to execute movements that require signicant length change or high shortening velocity. This biarticulate muscle is innervated by the femoral nerve and has two heads of origin: the direct or straight head, which arises from the anterior inferior iliac spine, and the indirect or reected head, which arises from the superior acetabular ridge ( gure 1).14 15 The two heads form the conjoined tendon slightly below their origin. The direct head contributes mostly to the supercial component of the conjoined tendon and

To cite: Mendiguchia J, Alentorn-Geli E, Idoate F, et al. Br J Sports Med 2013;47:359366.

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Review

Figure 1 Three-dimensional reconstructions (A: anteroposterior proyection, B: lateral proyection) of muscle (blue) and tendons of rectus femoris, and iliac and femur bones (orange) obtained from segmentation of multiple series of MRI of a professional soccer player. Surface models of the bones, tendons and muscles were generated from two-dimensional outlines (C: image obtained at the level of proximal coxofemoral joint, green arrow at A; D: image obtained at level of distal major trochanter, grey arrow at B) that were drawing manually using an specic software (SliceOmatic, Montreal). The proximal tendon is composed of a supercial, anterior portion from the direct head (yellow) that originates from the anterior-inferior iliac spine, and a deep intramuscular portion from the indirect head (red) emerging from the posterior-superior acetabular ridge. This gure is only reproduced in colour in the online version.

myotendinous junction is maintained is dened by the presence of a high-intensity signal either focally or diffusely at the myotendinous junction on uid-sensitive images. A feathery appearance of the muscle on all pulse sequences is consistent with interstitial haemorrhage and oedema. Acute grade II tears show partial disruption of the myotendinous junction with interstitial feathery high-intensity signal or haematoma. Low signal representing either brosis or haemosiderin can be seen in chronic injuries ( gure 2). Grade III tears are complete myotendinous disruption with or without retraction, and even that surgical intervention has been classically recommended, successful
2 of 9

return to unrestricted activity have been recently demonstrated after a non-operative treatment.3032 Hughes et al22 dened the term bulls eye sign, to describe the increased signal around the rectus femoris intrasubstance tendon, seen in 65% of players ( gure 3). Gyftopoulos et al10 suggested this sign represented evolving stages of injury (early oedema and haemorrhage, later increased vascularity and scarring) around the deep tendon. A bulls eye sign with secondary atrophy and fatty inltration of the muscle around the tendon reects an old injury. Occasionally, a pseudo cyst, produced by serous uid in the haematoma, is noted at the site of tear.

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Review

Figure 2 Fibrous scarring after remote rectus femoris injury has low signal intensity with all pulse sequences and appears as hypointense area at the previous tear site. (a) Re-torn of deep myotendinous junction of the indirect head in a 23-year-old soccer player. MRI shows an area of hyperintensity (white arrows) surrounding the deep myotendinous junction consistent with a strain tear. A focal area of irregular hypointensity of the indirect tendon (arrowhead) is characteristic of scar tissue. (b) A 19-year-old soccer player who presented with persistent thigh pain after remote rectus femoris injury. Transverse axial fat-suppressed T2-weighted MRI shows a laminar scar (arrows) due to former posterior peripheral tear.

Figure 3 Bulls eye sign. (a) Transverse axial fat-suppressed T2-weighted MRI of a 30 soccer player shows increased signal (white arrows) around the rectus femoris intrasubstance tendon (black arrow) consistent with acute strain. (b) Corresponding color-Doppler US image shows areas of increased vascularity (arrows) surrounding the rectus femoris intrasubstance tendon (arrowhead). This gure is only reproduced in colour in the online version. through an eccentric muscle action.42 Maximum elongation takes place near 55% of sprint cycle just after the initial contact of the contralateral leg, and just in the transition from maximal hip extension (40%) to maximum hip and knee exion (65%).42 Therefore, high angular velocities of the hip and knee during the swing phase of sprinting combined with high eccentric activation make rectus femoris more prone to injury. During the rst half of the swing phase of sprinting, the hip and knee are both exed, generating a exor moment at the hip while an extensor moment at the knee is created. The energy harnessed from a moving body segment is then transferred to the adjacent joint.42 43 This forces the rectus femoris to lengthen to decelerate the tibia as the knee exes during early swing phase of sprinting.

MECHANISM OF INJURY
Muscle strain injuries usually occur during eccentric muscle action.3340 Sprinting and kicking require eccentric rectus femoris action and combined with its biarticular nature leave it vulnerable to injury.

Sprinting injury mechanisms Acceleration

The maximum length of rectus femoris occurs during early swing phase,41 where the hip-exor muscles generate force at the same time as the knee-extensor muscles absorbed energy

Deceleration
Football players repeatedly change in direction, decelerate or stop suddenly. The forces applied to the body when decelerating can be exceptional, especially when the time over which these
3 of 9

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Review
forces must be absorbed is short.44 Body positioning in the deceleration phase is adjusted to allow for the substantial eccentric forces to be absorbed and dispersed throughout the body. The trunk assumes a more erect posture (in relation to the lower body) and posterior lean during deceleration, moving the centre of mass posterior to the base of support.45 46 This results in additional horizontal braking forces and consequently more eccentric force imposed on the quadriceps, though increasing its moment arm in actions like kicking or sudden changes of direction hypothetically predisposing the rectus femoris to injury.

Ground contact phase

The association between muscle injuries and dry weather suggests that the mechanism of quadriceps muscle strain may involve a closed kinetic chain activity. In fact, foot to ball contact is much lower than ground reaction forces in the deceleration at the nal step of the kicking leg. Ground contact during kicking is associated with high external forces (ground reaction force) but at the same time less angular velocity because the large muscle moments are opposed by the ground reaction forces. Deceleration during a kicking motion causes the body to lean backwards and the leg to move farther behind the body than normal, which places extra stress and strain on the rectus femoris. Upper body extension may result in increased external knee exion and internal quadriceps moments during kicking. This may be explained by an increase in the quadriceps moment arm and may be related to injury.1 51

Kicking
The most common mechanism of rectus femoris muscle injury in soccer is kicking.13 47 Kicking is a momentum-assisted motion, with much of the work performed eccentrically in the early phases by proximal muscle groups and the resulting momentum transferred to distal segments just before ball contact. Although quadriceps strains related to kicking were thought to occur on the kicking leg side, controversy exists as to whether rectus femoris muscle strains primarily occur during ball contact, swing phase of kicking or ground contact phase during the step before the backswing.

RISK FACTORS
Several risk factors have been suggested for quadriceps muscle injuries. These factors may be classied in intrinsic and extrinsic.

Intrinsic factors Age

Although the incidence of muscle injuries in the athletic population generally increases with age,1 this does not seem true of the quadriceps muscle. Three large prospective studies including one of 485 injures in almost 2300 players found no association between age and this muscle injury.1 51 61

Ball contact
During the ball contact phase of kicking the rectus femoris is in a relatively shortened state, and muscles need to be in a relatively stretched state to induce a strain injury.4850 Although maximum knee extension moment occurs during the ball contact phase, the quadriceps muscles are not in danger of strain injury because they are not lengthened or eccentrically contracting during this phase. This may be modied by variations in ball-foot impact forces that depend on the distance kicked and the weight of the ball, which would be greater in wet conditions. The fact that most injuries occur in preseason (good weather) and after low rainfall argues against an association between increased impact forces generated by ball wetness and ball contact mechanism.51 Conversely, lower ball pressure has been shown to decrease impact forces and increase contact time but a study of Australian Rules Football players found no correlation between muscle injuries and ball pressure.52

Previous injury
Previous muscle injury is a risk factor for quadriceps muscle strains.51 Increased risk of rectus femoris injury was found in players with a previous injury of the quadriceps muscle. Also, a recent hamstring strain signicantly increases the risk of quadriceps strain.51 Altered gait patterns that occur after hamstring muscle strains, such as a reduction in the stride length, may protect the injured hamstring muscle from re-strain but increase the chance of a quadriceps strain.51

Short height and high body weight

Two studies suggested a potential relationship between height and weight, and rectus femoris injuries.51 62 A recent study followed 100 professional soccer players (aged 19.427.8 years) for a season where a trend ( p=0.06) was observed for shorter players (OR=0.08; 95% CI 0.00 to 1.35) and heavier players (OR=10.70; 95% CI 0.73 to 156.37) to suffer more muscle strains compared to taller and thinner subjects.62 The authors attributed the lack of statistical signicance to the small number of injuries (seven rectus femoris injuries). Similarly, Orchard et al51 reported that Australian football players with a height below 1.82 cm had a signicant increase in the risk of quadriceps muscle injury (relative risk of 1.48 (95% CI 1.09 to 2.02) 183 quadriceps muscle injuries) compared to taller individuals. In contrast, Bradley and Portas61 in a one season prospective study in 36 English premier league soccer players found weight was not a signicant contributing factor for injury.

Swing phase
The rectus femoris is contracted eccentrically during the early swing phase and the wind-up phase of the swing phase of kicking where it may be predisposed to injury. During the backswing phase (early swing phase), the thigh angular velocity is minimal while the shank velocity is negative due to its backward movement, rectus femoris acts to decelerate hip extension and knee exion.53 54 Furthermore, the thigh was mainly decelerated by interactive moments exerted by the shank rather than a hip extension or exion moment.55 During the initial part of the forward swing phase (wind-up phase), the hip starts to ex and the thigh angular velocity is positive whereas the knee is still exing and a negative shank angular velocity is observed.56 At maximal knee exion (8590 at 70% of swing phase), the rectus femoris contracts eccentrically to counteract excessive knee exion (wind-up phase).54 5760 Because slightly greater angular velocities and greater knee exion are present during the wind-up phase, we believe that this part of the kicking action may be related to rectus femoris injury.
4 of 9

Dominance
Leg dominance may be a risk factor for injury, as the majority of quadriceps muscle strains (60%) involve the dominant leg ( preferred kicking leg), whereas only 33% affect the non-dominant leg (7% were reported in both legs or the leg dominance was

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Review
unknown).1 Quadriceps muscle strains in Australian Rules football players were more common in the dominant kicking leg (relative risk 2.13, 95% CI 1.59 to 28.6), whereas hamstring and calf injuries were almost equally distributed.51 generate more hip exion force, and fatigue and overload of the rectus femoris may occur. Second, roots of the femoral nerve directly pass through the psoas muscle. A restricted psoas may mechanically irritate the femoral nerve and cause tension further down the neurodynamic chain. Repeated lumbar extension and hip exion, as required during kicking, has been implicated in femoral nerve injury with concomitant weakness of the quadriceps strength in a modern dancer.65 Therefore, the femoral nerve may be implicated in rectus femoris injuries in a similar way that the sciatic nerve is implicated in hamstring strains. Therefore, knee extensors and hip exors exibility training in order to achieve optimal levels may be an appropriate focus in preventive programmes that aim to reduce rectus femoris muscle injuries in kicking sports.

Flexibility
Witvrouw et al63 and Fousekis et al62 examined whether a relative lack of quadriceps muscle exibility before the Belgium and Greek seasons could identify a professional soccer player at risk for a quadriceps muscle strain. A total of 146 and 100 male professional soccer players were assessed during each respective preseason. Results revealed that 13 of 146 players in the Belgium league and 7 of 100 players in Greek league sustained a clinically diagnosed quadriceps muscle injury. Witvrouw et al63 found statistically signicant lower quadriceps exibility in the injured players. Fousekis et al62 found a trend toward exibility asymmetries in those players who sustained an injury. In contrast, Bradley and Portas61 registered 6 injuries in 36 premier league soccer players and found exibility was not a signicant risk factor for quadriceps injury.

Strength
Improving proximal hip strength and knee extension strength at long muscle length may be areas to target to reduce rectus femoris injury.

Strength
One hundred professional soccer players had isokinetic concentric and eccentric knee extensor strength measures in preseason and were monitored until the end of the competition period. Seven players suffered a quadriceps muscle strain during the season. Concentric strength was not a risk factor for quadriceps injury.62 Eccentric strength differences at preseason were found between those injured compared to uninjured players (OR=5.01; 95% CI 0.92 to 27.14), although the difference was not statistically signicant, probably due to the low number of injuries.62 Further investigations are required.

Extrinsic factors Dry eld

Quadriceps muscle strains are more common after a week with low rainfall.64 A study of Australian Rules football players revealed that quadriceps strains (like many other non-contact lower-limb injuries) were relatively more likely on dryer and harder northern grounds where ground traction was a greater. Moreover, Woods et al13 found more rectus femoris strains associated with a dry eld during preseason of two consecutive English soccer seasons involving 1200 players.

PREVENTION OF RECTUS FEMORIS INJURY

Intervention studies that specically alter risk factors for rectus femoris injury in football players are sparse, therefore one prevention strategy is to address known risk factors and injury mechanism biomechanics. The parameters that may afford the best opportunity to prevent rectus femoris injury are exibility, strength and core stability. Because of the lack of data, we share recommendations that are largely expert opinion (level 5 evidence).

Flexibility
Quadriceps muscle exibility (>128) should be a cornerstone of any prevention programme targeted to reduce rectus femoris injury, at least in soccer.62 63 However, we believe that hip exor length must be optimal too as for the following reasons. First, tight iliopsoas muscle restricts hip extension. As the kicking action requires hip extension during the early swing phase, the hip exors utilise the stretch-shortening cycle, thereby enhancing their capacity to generate greater hip exion moment. A lack of hip extension may require rectus femoris to

Kicking performance is inuenced by both knee extension moment,53 66 and hip exion moment.67 68 Some investigations have demonstrated that hip exion moments were almost twice the corresponding knee extension moments during kicking.57 6971 In fact, peak hip exion moment of the kicking limb was the strongest predictor of peak foot velocity, suggesting that the ability to generate a greater hip exion moment is critical to achieve a high foot velocity during kicking. Conversely, Naito et al68 reported that centrifugal force-dependent moment of the kicking leg at the knee as a consequence of the hip exion angular velocity was the primary contributor to rapid knee extension and, thus, foot velocity. Studies using electromyography and MRI for the evaluation of kicking motion support this nding, and show a high activation of iliacus and psoas muscles during kicking concomitantly with rectus femoris.60 72 Both iliopsoas and rectus femoris muscles generate hip exion force. Recently, the contribution of the proximal rectus femoris to hip exion moment suggest that divergent regions of muscle bres within rectus femoris have different functions depending on force direction.73 As a consequence, a reduction in the strength and/or activation of the iliopsoas muscle may result in rectus femoris compensation to generate more hip exion force, and has been recently demonstrated through three-dimensional musculoskeletal models.74 When the iliopsoas muscle force contribution was reduced by 50%, rectus femoris force increased to compensate for the iliopsoas weakness.74 In football, this may result in an overload of the rectus femoris and, thus, increase the risk of injury. Therefore, good function of hip exor muscles is necessary to prevent quadriceps muscles injuries. The conjoined distal tendon of the iliopsoas muscle crosses anterior and slightly medial to the femoral head as it courses downward to its insertion on the lesser trochanter. In this distal part, the broad tendon is deected posteriorly at 3545 as it crosses the superior ramus of the pubis. With the hip in full extension, this deection raises the tendons angle of insertion relative to the femoral head, thereby increasing the muscles leverage for hip exion.75 As the hip exes to 90, the exion leverage becomes even greater.75 Such a parallel increase in leverage with increased exion may partially offset the muscles potential loss in active force (and ultimately torque)
5 of 9

Hip exor strength

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Review
caused by its reduced length. Therefore, effective training of hip exors should include hip exion angles above 90.75

Knee extension strength at long muscle length

Muscle strain injuries are thought to occur when muscles are contracted at greater than the optimal length.76 77 Eccentric exercise is the only training that has been shown to consistently increase the development of optimum length of tension in knee extensors. Eccentric training has the capability to enhance muscle mass, strength and power more than isometric and concentric exercise,81 as eccentric contraction produces the highest forces and requires less oxygen.82 Two interventions have reported a shift in the optimum length of the knee extensors after acute eccentric training sessions,78 79 however only one study assessed chronic adaptation to eccentric training.80 In the preseason, soccer players did eccentric strength training three times/week for 4 weeks in addition to normal training. Compared to a control group, the trained players increased the optimal length of the knee extensors by 6.5. Participants in the control group suffered two central tears compared with no injuries in eccentric intervention group.80 Eccentric quadriceps strength has been found to be reduced in some players in preseason, and improving the muscles ability to absorb more energy before failing may prevent injury.81 Specically, if the force threshold for muscle failure increases and the attenuation of loads is enhanced, a protective effect may occur. Chronic exposure to eccentric muscle activity results in an active spring structure(s) adaptation (ie, the muscle stiffens) in addition to the above-mentioned absorbing and strength capabilities.81 The quadriceps muscle is actively lengthened during hip extension and knee exion, and the knee joint generated more change in the length of the rectus femoris than the hip.83 Prior et al84 found that of the four muscles of the quadriceps femoris, the biarticular rectus femoris muscle experienced greater muscle damage compared to the other monoarticular vasti muscles. Therefore, it might be speculated that rectus femoris is more knee-dependent than hip-dependent ( gure 4). During deceleration movements in sprinting or support phase of kicking, the impulse must be greater than the momentum for the body to decrease its velocity/momentum.44 Therefore, increasing the body s ability to produce greater braking forces is desirable. This may be achieved by increasing the eccentric strength of the muscle via strength training emphasising eccentric loading and control using training stimuli remain as representative of real sport actions as possible (eg, drop jumps, resisting towing, vest decelerations, etc.) ( gure 5) and by extending the time during which the braking force is applied on landing. Lower-body eccentric exercises designed to increase the optimum length and prevent muscle injuries should include the following principles: closed and open kinetic chains, bilateral and unilateral, involve multiple joints, progression based in strain more than strength, easy to be implemented and costeffective ( gure 6). Distances (sprinting and deceleration distances or body segment range of motions when performing strength training), velocities (sprinting velocities or rate of force development when performing strength training) and directional components similar to sport should also be incorporated into the eccentric strength training programme. In summary, eccentric training may increase the size and strength of the rectus femoris, and may change muscle optimum length and stiffening of the muscle spring that can occur
6 of 9

Figure 4 Reverse Nordic hamstring. Example of open kinetic chain stretch shortening cycle KNEE dominant exercise. Player kneeling on the ground with his ankle xed followed by slowly backward lowering himself to the ground eccentrically contracting quadriceps muscle followed by explosive return to start position. This gure is only reproduced in colour in the online version. independently of, or in addition to, increases in size and isometric strength of the muscle.81 Therefore, knee extension eccentric muscle training may optimise interventions that aim to prevent rectus femoris injury in football players.

Core stability
Core stability, which is the ability of passive (ligaments and vertebral facets) and active stabilisers in the lumbopelvic region to maintain appropriate trunk and hip posture, balance and control during static and dynamic movements,85 appear as an important possible factor in order to prevent lower-extremity ligament and muscle injuries.85 86 Thus, abdominal and lumbar

Figure 5 Forward deceleration steps. Example of closed kinetic chain in order to promote proper deceleration technique. This gure is only reproduced in colour in the online version.

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Review

Figure 7 Tension arc. Example of dynamic core exercise in order to reproduce kicking motion patters and moments at the trunk. This gure is only reproduced in colour in the online version. kicking and sprinting. Including core exercise in training sessions may decrease the overload of the rectus femoris and reduce the risk of injury ( gure 7).

Training parameters
Figure 6 Overhead medicine ball reverse lunge example of a multiarticular knee extensor eccentric exercise. This gure is only reproduced in colour in the online version. muscles may be important in preventing quadriceps muscle strains. During the football contact, the body is inclined backwards between 118 and 128.55 87 88 Moving the mass of the upper body posteriorly may result in an increased external knee exion and internal quadriceps moments during kicking. Abdominal muscles are necessary to counteract these forces and reduce quadriceps overload and help control the trunk as it is directed laterally to the non-kicking side at foot to ball contact.55 87 88 The quadratus lumborum muscle is a powerful side exor of the lumbar spine and provides frontal plane segmental stabilisation during contralateral leg-loading as well as spinal movements.89 Kicking movements are likely to require high levels of asymmetric activation of the quadratus lumborum muscle, and may explain why Australian Rules football players have hypertrophy of the quadratus lumborum of the nonkicking side.90 The arm of the non-kicking side leads to a twist in the torso during the backswing phase of the kick and an untwist during the next phases of the kick. Shan and Westerhoff identied a tension arc across the body from the kicking leg as it is withdrawn to the non-kicking side arm, which is extended and abducted.91 The forward motion of both limbs yields to a release of this tension arc, which is a manifestation of the stretch-shorten cycle. Core stability is necessary to counteract torsion, side exion and especially extension moments during No studies in the literature compare different eccentric exercise training protocols to prevent rectus femoris strains. Volume and loading are often to the discretion of the strength and conditioning coach or sport rehabilitation clinician. However, even though we consider length more important than strength, we strongly advise that training parameters should follow the common guidelines applied to any strength or rehabilitation programme.92 The optimal intensity of eccentric training programmes is not yet clear. Whereas some authors claim that intensity should be high to provide the stimulus necessary to produce further adaptations,9395 others have found that the protective effect of eccentric training may be observed even using light resistance.96 97 If strength gains are required to address a strength decit, eccentric actions should be overloaded from 20% to 80% beyond the maximal isometric strength.92 However, the volume and intensity of preseason eccentric training programmes should be gradually progressed to minimise the effect of exercise-induced muscle soreness and to provide the stimulus necessary to produce ongoing adaptations.98100 Muscle fatigue should also be considered with implementing a training programme, especially when dealing with eccentric exercises because several studies have reported less energy costs for eccentric contractions compared with concentric exercise.101 102 However, given the important strength and neuromuscular impairments present immediately after eccentric exercise, we advocate the use eccentric exercise at the end of training sessions.103105 On the basis of the literature and our clinical experience, we recommend strength and conditioning coaches reserve the
7 of 9

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Review
highest intensities of eccentric exercise with athletes who are familiar with this type of training. An advanced programme of new exercises could cause injury. Also, avoid high-intensity and long-length eccentric exercise during important competition phases as the side effects of transient muscle soreness and strength decits may impair performance. In the context of relatively limited evidence, we recommend a greater use of concentric hip exion strengthening exercises in the preseason, and athletes should be limited in the number of kicks in the rst few days of training, which can be progressively increased. After the rst weeks of training, hip exor training should take place during warm-ups. The exibility training should occur before and after each training session in order to mitigate the decreased range of motion effects produced by training. In summary, rectus femoris injury in athletes has a multifactorial aetiology but occurs mainly during sprinting and kicking. In sprinting, the risk for rectus femoris injuries may be highest during acceleration (eccentric muscle actions in the early swing phase) and deceleration phases. In kicking, which is the most common mechanism of injury for rectus femoris muscle, the risk of rectus femoris injury during kicking is during the backswing and the wind-up phases for the kicking leg, and ground contact for the stance leg. The most likely intrinsic risk factors for rectus femoris muscle injuries include previous muscle injuries, shorter players, dominant leg and knee extensor exibility and strength. The most likely extrinsic risk factors for rectus femoris muscle injuries include a dry playing eld. Prevention strategies for rectus femoris muscle injuries include general exibility of muscles of the thigh and leg, adequate balance of concentric and eccentric strength of the hip exors and knee extensors and adequate core stability. Exercises based on deceleration under specic sport situations should be included in prevention programmes for rectus femoris muscle injuries.
Contributors All the authors contributed to writing and structure. Competing interest None. Provenance and peer review Not commissioned; externally peer reviewed.
35 36 14 Hasselman CT, Best TM, Hughes C, et al. An explanation for various rectus femoris strain injuries using previously undescribed muscle architecture. Am J Sports Med 1995;23:4939. Bordalo-Rodriguez M, Rosenberg ZS. Magnetic resonance imaging of the proximal rectus femoris musculotendinous unit. Magn Reson Imaging Clin N Am 2005;13:71725. Shu B, Safran MR. Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability. Clin Sports Med 2011;30:34967. Johnson MA, Polgar J, Weightman D, et al. Data on the distribution of bre types in thirty-six human muscles. An autopsy study. J Neurol Sci 1973;18:11129. Gallant S. Assessing adverse neural tension in athletes. J Sports Rehab 1998;7:12839. Comtet JJ, Genety J, Brunet B, et al. Traitement chirurgical des ruptures du droit anterieur (rectus femoris) chez le sportif. Nouv Presse Med 1978;7:238790. Chammout MO, Skinner HB. The clinical anatomy of commonly injured muscle bellies. J Trauma 1986;26:54952. Wittstein J, Klein S, Garrett WE. Chronic tears of the reected head of the rectus femoris: results of operative treatment. Am J Sports Med 2011;39:19427. Hughes C, Hasselman CT, Best TM, et al. Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:5006. Burns BJ, Sproule J, Smith H. Acute compartment syndrome of the anterior thigh following quadriceps strain in a footballer. Br J Sports Med 2004;38:21820. Jrvinen TA, Jrvinen TL, Kriinen M, et al. Muscle injuries: biology and treatment. Am J Sports Med 2005;33:74564. Beiner JM, Jokl P. Muscle contusion injury and myositis ossicans traumatica. Clin Orthop Relat Res 2002;403:S11019. Booth DW, Westers BM. The management of athletes with myositis ossicans traumatica. Can J Sport Sci 1989;14:1016. Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusions: west point update. Am J Sports Med 1991;19:299304. Aronen JG, Garrick JG, Chronister RD, et al. Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee exion. Clin J Sport Med 2006;16:3837. Boutin RD, Fritz RC, Steinbach LS. Imaging of sports-related muscle injuries. Radiol Clin North Am 2002;40:33362. Irmola T, Heikkil JT, Orava S, et al. Total proximal tendon avulsion of the rectus femoris muscle. Scand J Med Sci Sports 2007;17:37882. Gamradt SC, Brophy RH, Barnes R, et al. Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football. Am J Sports Med 2009;37:13704. Hsu JC, Fischer DA, Wright RW. Proximal rectus femoris avulsions in National Football League kickers: a report of 2 cases. Am J Sports Med 2005;33:10857. Glick J. Muscle strains: prevention and treatment. Physician Sportsmed 1980;8:737. Zarins B, Ciullo JV. Acute muscle and tendon injuries in athletes. Clin Sports Med 1983;2:16782. Stanton P, Purdham C. Hamstring injuries in sprintingthe role of eccentric exercise. J Orthop Sports Phys Ther 1989;10:3439. Stauber WT. Eccentric action of muscles: physiology, injury, and adaptation. Exerc Sport Sci Rev 1989;17:15785. Garrett WE. Muscle strain injuries: clinical and basic aspects. Med Sci Sports Exerc 1990;22:43643. Garrett WE. Muscle strain injuries. Am J Sports Med 1996;24:S28. Kellis E, Baltzopoulos V. Isokinetic eccentric exercise. Sports Med 1995;19:20222. Kujala UM, Orava S, Jrvinen M. Hamstring injuries. Current trends in treatment and prevention. Sports Med 1997;23:397404. Riley PO, Franz J, Dicharry J, et al. Changes in hip joint muscle-tendon lengths with mode of locomotion. Gait Posture 2010;31:27983. Schache AG, Dorn TW, Blanch PD, et al. Mechanics of the human hamstring muscles during sprinting. Med Sci Sports Exerc 2011;44:64758. Novacheck TF. The biomechanics of running. Gait Posture 1998;7:7795. Hewit J, Cronin J, Button C, et al. Understanding deceleration in sport. Strength Conditioning J 2011;33:4752. Kreighbaum E, Barthels K. A qualitative approach for studying human movement. Needham Heights, MA: Allyn and Bacon, 1996:13843. Andrews J, McLeod W, Ward T, et al. The cutting mechanism. Am J Sports Med 1977;5:11121. Orchard J, Wood T, Seward H, et al. Comparison of injuries in elite senior and junior Australian football. J Sci Med Sport 1998;1:838. Garrett WE, Safran MR, Seaber AV, et al. Biomechanical comparison of stimulated and nonstimulated skeletal muscle pulled. Am J Sports Med 1987;15:44854. Liebers RL, Friden J. Muscle damage is not a function of muscle force but active muscle strain. J Appl Physiol 1993;74:5206. Lieber RL, Friden J. Mechanisms of muscle injury gleaned from animal models. Am J Phys Med Rehabil 2002;81:S709. Orchard J. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med 2001;29:3003.

15

16 17 18 19 20 21 22 23 24 25 26 27 28

29 30 31

32 33 34

REFERENCES
1 2 3 4 5 6 7 8 9 10 Ekstrand J, Hgglund M, Walden M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011;39:122632. Ekstrand J, Hgglund M, Walden M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011;45:5538. Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a prospective study. Med Sci Sports Exerc 1983;15:26770. Inklaar H. Soccer injuries. I: incidence and severity. Sports Med 1994;18:5573. Brophy RH, Wright RW, Powell JW, et al. Injuries to kickers in American football: the National Football League experience. Am J Sports Med 2010;38:116673. Balius R, Maestro A, Pedret C, et al. Central aponeurosis tears of the rectus femoris: practical sonographic prognosis. Br J Sports Med 2009;43:81824. Orchard J, Seward H. Epidemiology of injuries in the Australlian Football League seasons 19972000. Br J Sports Med 2002;36:3944. Cross TM, Gibbs N, Houang MT, et al. Acute quadriceps muscle strains: magnetic resonance imaging features and prognosis. Am J Sports Med 2004;32:71019. Ouellette H, Thomas BJ, Nelson E, et al. Magnetic resonance imaging of rectus femoris origin injuries. Skeletal Radiol 2006;35:66572. Gyftopoulos S, Rosenberg ZS, Schweitzer ME, et al. Normal anatomy and strains of the deep musculotendinous junction of the proximal rectus femoris: MRI features. AJR Am J Roentgenol 2008;190:W1826. Speer KP, Lohnes J, Garrett WE. Radiographic imaging of muscle strain injury. Am J Sports Med 1993;21:8995; discussion 96. Hawkins RD, Hulse MA, Wilkinson C, et al. The association football medical research programme: an audit of injuries in professional football. Br J Sports Med 2001;35:437. Woods C, Hawkins RD, Hulse M, et al. The Football Association Medical Research Programme: an audit of injuries in professional footballanalysis of preseason injuries. Br J Sports Med 2002;36:43641. 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

11 12

13

8 of 9

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Review
52 Orchard J, McIntosh A, Landeo R, et al. Biomechanics of the running drop punt kick with respect to the development of quadriceps strains. Sports Med Aust 2007;25:1824. Nunome H, Ikegami Y, Kozakai R, et al. Segmental dynamics of soccer instep kicking with the preferred and non-preferred leg. J Sports Sci 2006;24:52941. Levanon J, Dapena J. Comparison of the kinematics of the full-instep and pass kicks in soccer. Med Sci Sports Exerc 1998;30:91727. Lees A, Nolan L. Three dimensional kinematic analysis of the instep kick under speed and accuracy conditions. In: Spinks W, Reilly T, Murphy A, eds. Science and football IV. London: E & FN Spon, 2002:1621. Lees A, Nolan L. The biomechanics of soccer: a review. J Sports Sci 1998;16:21134. Nunome H, Asai T, Ikegami Y, et al. Three-dimensional kinetic analysis of side-foot and instep soccer kicks. Med Sci Sports Exerc 2002;34:202836. Kellis E, Katis A. The relationship between isokinetic knee extension and exion strength with soccer kick kinematics: an electromyographic evaluation. J Sports Med Phys Fitness 2007;47:38594. Charnock BL, Lewis CL, Garrett WE. Adductor longus mechanics during the maximal effort soccer kick. Sports Biomech 2009;8:22334. Brophy RH, Backus SI, Pansy BS, et al. Lower extremity muscle activation and alignment during the soccer instep and side-foot kicks. J Orhop Sports Phys Ther 2007;37:2608. Bradley PS, Portas MD. The relationship between preseason range of motion and muscle strain injury in elite soccer players. J Strength Cond Res 2007;21:11559. Fousekis K, Tsepis E, Poulmedis P, et al. Instrinsic risk factors of non-contact quadriceps and hamstring strains in soccer: a prospective study of 100 professional players. Br J Sports Med 2011;45:70914. Witvrouw E, Danneels L, Asselman P, et al. Muscle exibility as a risk factor for developing muscle injuries in male professional soccer players. Am J Sports Med 2003;31:416. Orchard J. The northern bias for injuries in the Australian Football League. Aust Turfgrass Manag 2000;23:3642. Sanmarco GJ, Stephens MM. Neuropraxia of the femoral nerve in a modern dancer. Am J Sports Med 1991;19:41314. Kellis E, Katis A, Vrabas IS. Effects of an intermittent exercise fatigue protocol on biomechanics of soccer kick performance. Scand J Med Sci Sports 2006;16:33444. Dorge HC, Andersen TB, Sorensen H, et al. Biomechanical differences in soccer kicking with the preferred and the non-preferred leg. J Sports Sci 2002;20:2939. Naito K, Fukui Y, Maruyama T. Multijoint kinetic chain analysis of knee extension during the soccer instep kick. Hum Mov Sci 2010;29:25976. Dorge HC, Andersen TB, Sorensen H, et al. Electromyographic activity of the iliopsoas muscle and leg kinetics during the soccer place kick. Scand J Med Sci Sports 1999;9:195200. Luhtanen P. Kinematics and kinetics of maximal instep kicking in junior soccer players. In: Reilly T, Lees A, Davids K, Murphy W.J., eds. Science and Football. London: E & FN Spon, 1988:4418. Putnam CA. A segment interaction analysis of proximal-to-distal sequential segment motion patterns. Med Sci Sports Exerc 1991;23:13044. Baczkowski K, Marks P, Silberstein M, et al. A new look into kicking a football: an investigation of muscle activity using MRI. Australas Radiol 2006;50:3249. Hagio S, Nagata K, Kouzaki M. Region specicity of rectus femoris muscle for force vectors in vivo. J Biomech 2012;45:17982. Lewis CL, Sahrmann SA, Moran DW. Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. J Biomech 2007;40:372531. Neumann DA. Kinesiology of the hip: a focus on muscular actions. J Orthop Sports Phys Ther 2010;40:8294. Brockett CL, Morgan DL, Proske U. Predicting hamstring strain injury in elite athletes. Med Sci Sports Exerc 2004;36:37987. Brooks JH, Fuller CW, Kemp SP, et al. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med 2006;34:1297306. Bowers EJ, Morgan DL, Proske U. Damage to the human quadriceps muscle from eccentric exercise and the training effect. J Sports Sci 2004;22:100514. Yeung SS, Yeung EW. Shift of peak torque angle after eccentric exercise. Int J Sports Med 2008;29:2516. Brughelli M, Mendiguchia J, Nosaka K, et al. Effects of eccentric exercise on optimum length of the knee exors and extensors during the preseason in professional soccer players. Phys Ther Sport 2010;11:505. 81 LaStayo PC, Woolf JM, Lewek MD, et al. Eccentric muscle contractions: their contribution to injury, prevention, rehabilitation, and sport. J Orthop Sports Phys Ther 2003;33:55771. Bigland-Ritchie B, Woods JJ. Integrated electromyogram and oxygen uptake during positive and negative work. J Physiol 1976;260:26777. Visser JJ, Hoogkamer JE, Bobbert MF, et al. Length and moment arm of human leg muscles as a function of knee and hip-joint angles. Eur J Appl Physiol Occup Physiol 1990;61:45360. Prior BM, Jayaraman RC, Reid RW, et al. Biarticular and monoarticular muscle activation and injury in human quadriceps muscle. Eur J Appl Physiol 2001;85:18590. Mendiguchia J, Ford KR, Quatman CE, et al. Sex differences in proximal control of the knee joint. Sports Med 2011;41:54157. Goldman EF, Jones DE. Interventions preventing hamstring injuries. Cochrane Database Syst Rev 2010;(1):CD006782. Prassas SG, Terauds J, Nathan T. Three dimensional kinematic analysis of high and low trajectory kicks in soccer. In: Nosek N, Sojka D, Morrison W, et al., eds. Proceedings of the VIII sympsium of the International Society of Biomechanics in Sports. Prague: Conex, 1990:1459. Orloff H, Sumida B, Chow J, et al. Ground reaction forces and kinematics of plant leg position during instep kicking in male and female collegiate soccer players. Sports Biomech 2008;7:23847. McGill S, Juker D, Kropf P. Quantitative intramuscular myoelectric activity of quadratus lumborum during a wide variety of tasks. Clin Biomech (Bristol, Avon) 1996;11:1702. Hides J, Fan T, Stanton W, et al. Psoas and quadratus lumborum muscle asymmetry among elite Australian Football League players. Br J Sports Med 2010;44:5637. Shan G, Westerhoff P. Full-body kinematic characteristics of the maximal instep soccer kick by male soccer players and parameters related to kick quality. Sports Biomech 2005;4:5972. Fleck SJ, Kraemer WJ. Designing resistance training programs. 3 ed. Colorado Springs: Human Kinetics, 2003:4050. Brughelli M, Cronin J. Altering the length-tension relationship with eccentric exercise: implications for performance and injury. Sports Med 2007;37:80726. Hortobagyi T, Barrier J, Beard D, et al. Greater initial adaptations to submaximal muscle lengthening than maximal shortening. J Appl Physiol 1996;81: 167782. Friedmann-Bette B, Bauer T, Kinscherf R, et al. Effects of strength training with eccentric overload on muscle adaptation in male athletes. Eur J Appl Physiol 2010;108:82136. Chen TC, Chen HL, Lin MJ, et al. Potent protective effect conferred by four bouts of low-intensity eccentric exercise. Med Sci Sports Exerc 2010;42: 100412. Lavender AP, Nosaka K. A light load eccentric exercise confers protection against a subsequent bout of more demanding eccentric exercise. J Sci Med Sport 2008;11:2918. Friedmann B, Kinscherf R, Vorwald S, et al. Muscular adaptations to computer-guided strength training with eccentric overload. Acta Physiol Scand 2004;182:7788. Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors. Sports Med 2003;33:14564. Dudley GA, Tesch PA, Miller BJ, et al. Importance of eccentric actions in performance adaptations to resistance training. Aviat Space Environ Med 1991;62:54350. Ryschon TW, Fowler MD, Wysong R, et al. Efciency of human skeletal muscle in vivo: comparison of isometric, concentric, and eccentric muscle action. J Appl Physiol 1997;83:86774. Kraemer WJ, Gardiner DF, Gordon SE. Differential effects of exhaustive cycle ergometry on concentric and eccentric torque production. J Sci Med Sport 2001;4:3019. McHugh MP. Recent advances in the understanding of the repeated bout effect: the protective effect against muscle damage from a single bout of eccentric exercise. Scand J Med Sci Sports 2003;13:8897. Proske U, Morgan DL. Muscle damage from eccentric exercise: mechanism, mechanical signs, adaptation and clinical applications. J Physiol 2001;537:33345. Allen DG. Eccentric muscle damage: mechanisms of early reduction of force. Acta Physiol Scand 2001;171:31119.

53 54 55

82 83

84

56 57 58

85 86 87

59 60

88

61 62

89

90

63

91

64 65 66

92 93 94

67 68 69

95

96

70

97

71 72 73 74

98

99 100

101

75 76 77 78 79 80

102

103

104

105

Mendiguchia J, et al. Br J Sports Med 2013;47:359366. doi:10.1136/bjsports-2012-091250

9 of 9

Downloaded from bjsm.bmj.com on April 23, 2013 - Published by group.bmj.com

Rectus femoris muscle injuries in football: a clinically relevant review of mechanisms of injury, risk factors and preventive strategies
Jurdan Mendiguchia, Eduard Alentorn-Geli, Fernando Idoate, et al. Br J Sports Med 2013 47: 359-366 originally published online August 3, 2012

doi: 10.1136/bjsports-2012-091250

Updated information and services can be found at:

http://bjsm.bmj.com/content/47/6/359.full.html

These include:

References Email alerting service

This article cites 99 articles, 30 of which can be accessed free at:

http://bjsm.bmj.com/content/47/6/359.full.html#ref-list-1

Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/