Introduction
Within elite sport there is a high incidence of rectus femoris injuries with 25% non-contact injuries reported (Bogwasi et al., 2023). Injuries within the quadricep group were found to be the second most prevalent muscle injury in professional football after hamstring injuries They are highly prevalent in professional football due to the kicking actions and repetitive sprinting actions required. Unfortunately, quadricep injuries also have a high re-injury rate of approximately 17% (Ekstrand et al., 2011).
Specifically looking at the rectus femoris (RF) which is a bi-articular muscle which assists with knee extension, hip flexion and acts as a stabiliser of the pelvis on the femur on weight bearing (Kassarjian et al., 2012). As mentioned, injuries to this location are high and this could be due to the high proportion of type II fibres within the RF (Irmola et al., 2007). Injuries to the RF are often because of kicking and the high eccentric loading that occurs during maximal ball striking (Mendiguchia et al., 2013). This often leads to intramuscular strains of the musculotendinous junctions which is a common site of RF injuries with one study reporting 94% of RF injuries involving the proximal tendon (Serner et al., 2018).
The purpose of this case study is to describe how a professional footballer progressed through a return to play (RTP) pathway under the guidance of King Performance Ideology (KPI) following surgical repair of the quadricep central tendon.
Case presentation
This 24-year-old professional footballer has a history of muscle injuries involving the adductor and quadriceps. This injury occurred during pre-season training when he felt a “sharp” pain through the middle of his left quadricep when passing the ball in a team possession drill which as previously discussed, places a high eccentric load on the RF.
From the onset, this player contacted KPI for support and medical evaluation. Within the first 24 hours of the injury the player underwent Magnetic resonance imaging (MRI) to determine the extent of the injury. The MRI revealed a complete transverse tear of the rectus femoris which was graded as BAMIC grade 4C (see pictures below). Following the MRI, a surgical opinion was sourced. This then led to subsequent repair of the left RF with a RTP time of 14-16 weeks. As a result of this player being out of contract, he completed his gym and pitch-based rehabilitation with KPI.
Surgical Management and Acute Management
Four days following the injury mechanism the player underwent surgery where there was a 3cm gap between the retracted central tendon and the muscle of the indirect head proximally and the central tendon distally which were secured using sutures. Then the rehabilitation process began initially following closely the post-operation guidelines set by the surgeon which were to be partial weight bearing and in a knee brace for up to 4-6 weeks. Post-surgery, KPI immediately provided post-operative management in relation to cryotherapy, wound care, and nutritional support. Collagen with vitamin C was recommended to be consumed prior to rehabilitation due to its association with tendon healing and an increase in collagen synthesis (Shaw et al., 2017). Following the surgery limb circumference measurements were taken which would be used as part of the return to run testing battery. This was along with body fat analysis.
Phase 1 – General Prep Phase
Closely following the surgeon’s guidelines for the first 2 weeks the player was braced and allowed to flex the hip to 30∞, during this time we looked to manually maintain passive flexion and rotation of hip as instructed by the surgeon. This was alongside maintaining activation of the VMO using neuromuscular stimulation (Compex). After 2 weeks the stitches had dissolved and the brace range was changed, allowing the player to actively access 60∞ of hip flexion. Once the stitches had dissolved and the risk of infection was minimal, we commenced a general preparatory phase with the aim to prepare the player to tolerate more intense training in the coming months. During this phase we utilised the compex and blood flow restriction (BFR) to maximise adaptations whilst still adhering to the post op guidelines set by the surgeon. Especially with evidence showing that combining NMES and BFR can help maintain limb circumference as well as improving isometric and isokinetic knee extension strength (Natsume et al., 2015).
Whilst we were unable to load the injured area with the hip in extension, we targeted other key areas to improve this player strength qualities. We would load the injured area isometrically alongside improving lateral hip and lumbo-pelvic strength region due to its association with ball striking – the injury mechanism. Focusing on the lumbo-pelvic region was a huge part of the rehabilitation based on the injury mechanism and the player’s injury history. Emphasis was placed heavily on gluteal activation, avoidance of anterior pelvic tilt and solid control of the trunk which would allow for optimal load distribution through the pelvis (King et al., 2018). Contralateral limb strength training was used whilst the player was still in a brace with evidence suggesting that the injured limb can benefit from contralateral limb training (Green & Gabriel., 2018).
Phase 2 – Specific Strength & Power
Once we had reached roughly 7 weeks post-surgery the player had a routine MRI as requested by the surgeon to assess the healing of the repair site. The MRI showed that there was good post-operative healing with no residual tear defect, normal longitudinal plane tension of the central tendon and there were no complicating features. Then followed a routine appointment with the surgeon who gave consent to remove the brace and start progressing the rehabilitation.
At this point we began loading and progressing through different strength and power continuums working towards beginning pitch-based rehabilitation at roughly 11-12 weeks post-surgery. Also, now we were able to begin stretching the injured site so restoring full range of movement was a big focus of the program at this time. A prone knee bend and thomas test were used to assess hip flexor and quadricep length. As we were preparing this player to recommence running, we also introduced movement skill sessions where we were gradually exposing the player to foot and ankle stiffness drills alongside force absorption and production exercises to prepare the body for running. Through different planes of motion.
Phase 3 – Return to Run Testing
To know that the player was ready to recommence pitch-based running and ensure minimal risk of re-injury during this phase where there would be an increased load on the RF various objective tests were carried out. The key tests used can be seen below with some of his testing scores.
- Muscular Endurance - Single leg squats, hamstring bridges and calf raises aiming for minimum 35 reps per limb with >10% asymmetry (Freckleton, Cook & Pizzari, 2014)
- Maximal Isometric Strength – Seated knee extension at 60∞ aiming for >10% asymmetry
- Maximal Strength – Utilising isokinetic dynamometer; Concentric knee extensor & flexor peak torques @ 60dps. Aiming for 2.6xBW for extensors and 1.6xBW for flexors (O’Malley et al., 2018). Single leg compound; Spilt squat >0.5xBW & Single leg press 1xBW.
- Explosive Strength – Double and single leg countermovement jump (CMJ), Hop for distance
- Reactive Strength – 10:5 Reactive Jump
This player satisfied all evidence-based standards with good asymmetry at roughly 10-11 weeks post-surgery which meant that the player commenced at just shy of 12 weeks surgery a graded pitch based reconditioning program which would work towards his individual positional GPS demands. Stay tuned for another article detailing his pitch based rehabilitation.
*Consent was provided by the player to write this article
