Rectus Femoris Avulsion of the Direct and Reflected Heads in a Kickball Player: the long-term positive nonoperative outcome presented with MRI findings Park CK^, Zlomislic V*, Du J **, Chang EY **, & Chang DG* University of Queensland – Ochsner Clinical SoM^ New Orleans, LA University of California, San Diego - Department of Orthopaedics*& Radiology** San Diego, CA Abstract MR Imaging Furthermore, surgical management does not appear to yield superior end results compared to non-surgical treatment2. Since RF avulsion is a rare injury, there is no set guideline or protocol about how to treat this injury. This case justifies non-surgical management of RF avulsion injuries involving both heads. The recovery images show gross healing of the tendon. However, the MRI pixel values in the tendon remain quantitatively different compared to normal tendon. To what extent novel MRI sequences may differentiate type III collagen seen in scar versus the type I collagen seen in normal tendon represents a future direction of imaging development. A B C D Case Description: A 37-year-old man was playing kickball and ruptured his rectus femoris (RF) muscle. MRI revealed a grade III musculotendinous junction injury with complete tearing of the musculotendinous junctions at the direct and reflected heads. The patient elected for non-operative management.  Results: After 12 weeks of physical therapy rehabilitation, the patient returned to full sport activity. He occasionally expressed tenderness over the traumatic area with intense activity, but this did not limit him from sports activities. Discussion: This report summarizes a rarely documented case of musculotendinous junction rupture at the direct head and reflected head of the RF in non-adolescent and non-professional athletes setting. It is rare to encounter literature showing nonoperative management and MRI images of pre and post recovery from such an injury. This case compared return to field time of nonoperative management versus surgical management. Conclusions: There has been an increased number of organized recreational sports leagues. Of note kickball is gaining popularity among adults, which may result in a greater injury occurrence of in the general population. Our case demonstrates that the return to play time table in elite athletes and this recreational athlete was similar with nonoperative management. Conclusion Fig 2. T2-weighted MR images showing grade III injury to the rectus femoris immediately after the injury (A and B) and 28 months later (C and D). (A) Sagittal image shows complete tearing of the rectus femoris at the proximal myotendinous junction (arrow) with surrounding hemorrhage and edema. (B) Axial image at the level of the myotendinous junction confirm discontinuous muscle and tendon fibers (arrow). (C) Sagittal image shows complete healing of the proximal myotendinous junction (dashed arrow), including intact direct (small arrow) and reflected (arrowhead) tendons of the rectus femoris. (D) Axial image confirms an intact, but thickened intramuscular tendon at the myotendinous junction (dashed arrow).MRI dates: 3/26/14, MRI 8/6/16 We present the first report of an RF avulsion injury of the direct and reflected heads in a recreational kickball participant, along with post recovery MRI and outcome information with nonoperative management. With rehabilitation therapy a full recovery was possible without surgical intervention, suggesting that non operative management is an acceptable protocol for this type of injury. Case Report Discussion Recreational kickball leagues are becoming popular. The increased number of players could translate into higher numbers of RF injuries, even in social, recreational leagues7. There are well documented cases of ruptures originating from AIIS and occurring at the distal tendon junction4. However, RF origin injuries represent only 0.5% of all of hip and pelvic injuries9. However, to our knowledge there is a lack of documented cases of direct and reflected head ruptures at the musculotendinous junction. The current literature is split on non-operative versus surgical options as the preferred treatment method. Comparison studies show no difference in RF function between operatively and non-operatively managed athletes3,5. Hse and colleagues report that NFL athletes are able to return to competitive play in 6 to 12 weeks, with non-surgical rehabilitation5. Our recreational athlete took 12 weeks of rehabilitation to return to play. This case demonstrates that the return to play time table for elite athletes and recreational athletes may be approximately similar with non-operative management. Comparison studies also demonstrate that RF avulsion of both heads does not translate to a slower recovery process than a single head avulsion. Documented literature results of surgical treatment outcome are positive. Patients have been able to return to pre-injury level of activity within 4-10 months after the injury 1,6,10. Comparing literature cases, the non-operative management recovery time period is 6-12 weeks5. This indicates that surgical management may lead to a longer road to recovery than non-operative management. A previously uninjured 37-year-old right leg dominant male with no significant past medical history was playing recreational kickball. He was standing most of the day and he felt that his legs were stiff before the game. When he made contact with the kickball he felt popping sensation, noticed edema, bruising, and felt 8/10 pain in his right groin area. The patient presented to clinic 3 days after the injury. Physical examination assessed: gait, lumbar & hip ROM, muscle strength, pain with movement, sensation, reflex, and palpation of injured area. Differential diagnoses were RF avulsion, acetabular labral tear, rectus femoris strain, rectus femoris partial tear, and inguinal hernia. After initial injury, the patient used ice, an ace bandage and he started ibuprofen 800 mg TID x 2 weeks. MRI was performed 2 weeks post injury, demonstrating a grade III injury to the direct and indirect tendons of the RF. The patient was treated with 12 weeks of physical therapy rehabilitation. Initial rehab started with stretches, deep tissue massages, scar mobilization and hip capsule mobilization to restore range of motion. PT aimed for a gradual increase in strengthening using quad and iliopsoas isometric strengthening exercises. In the last stage, rehab progressed to plyometrics sports goal directed exercises. He continued to use ice throughout recovery. Post-recovery detached muscle heads was unnoticed and patient returned to full sports activity. MRI follow-up at 28 months after injury confirmed complete healing of the direct and reflected tendons of the RF. References Introduction Bottoni C, et al. Operative Treatment of a Complete Rupture of the Origination of the Rectus Femoris. 2009 Esser S, et al. Proximal Rectus Femoris Avulsion: Ultrasonic Diagnosis and Nonoperative Management. 2015 Gamradt S, et al Nonoperative Treatment for Proximal Avulsion of the Rectus Femoris in Professional American Football. 2009 Hasselman CT, et al. An explanation for various rectus femoris strain injuries using previously undescribed muscle architecture.1995 Hsu JC, et al. Proximal rectus femoris avulsions in national football league kickers: a report of 2 cases. 2005 Irmola T, et al. Total proximal tendon avulsion of the rectus femoris muscle. 2007 Marshall S, et al. Sports and recreational injury: the hidden cost of a healthy lifestyle. 2003 Metzmaker JN, et al. Avulsion fractures of the pelvis. 1985 Ouellette H, et al. MR imaging of rectus femoris origin injuries. 2006 Straw R, et al. Surgical repair of a chronic rupture of the rectus femoris muscle at the proximal musculotendinous junction in a soccer player. 2003 Rectus femoris, with vastus medialis, vastus intermedius, and vastus lateralis form the quadriceps muscles. The RF has two origin sites; the direct head originates from Anterior Inferior Iliac Spine (AIIS) and the reflected head originates from a grove above the rim of the acetabulum. Rare ruptures of the RF direct head at the site of AIIS have been documented3,5,8,10. It is even more rare to encounter a case with musculotendinous junction rupture involving both the direct and reflected heads of the RF.3 The majority of documented RF avulsion cases are from adolescents and elite level athletes. To our knowledge, the literature does not describe the history and clinical outcome of the RF injury in the older, recreational sports athlete. Furthermore, regardless of injury type and age of the patient, there are a limited number of long-term MRI outcome images available documenting a non-operatively managed avulsion injury. Fig 1. The direct head of the rectus femoris originates from the anterior inferior iliac spine and travels posteriorly and distally to insert by way of the common quadriceps tendon at the patella4  Acknowledgements We thank John Guido DPT, Gustavo Godoy M.D. and Scott Montgomery M.D. at Ochsner Health System and Christopher Wahl M.D. at Swedish Medical Center for helpful discussion, guidance, suggestions and input.