A 33-year-old recreational player experienced sudden pain in the anterior groin as he shot the ball. He presented to a physiotherapist shortly after the injury but did not make much progress. Five yard passes were tolerable but anything more than that that required power created pain. He presented to a sport and exercise physician four months after his initial injury because of ongoing pain and an inability to return to play.
On examination he was found to have a limitation of hip flexion (only tolerable to 100°) and with pain and restriction with internal rotation. A quadrant test was highly provocative. Resisted hip flexion was also painful.
X-rays show amorphous soft tissue mineralisation projected over the superolateral aspect of the right hip extending to the AIIS without a discrete avulsion fracture. Corresponding to the x-rays, there is heterogenous intermediate to low T1, intermediate high T2 amorphous material about both the direct and indirect heads of rectus femoris extending from its origin to the proximal tendon overlying the right hip anteriorly consistent with heterotopic ossification. There is a mild volume of surrounding soft tissue oedema and subcortical bone oedema adjacent to the AIIS.
This player was successfully managed with a three month period of relative rest. He avoided running and playing football during this period and trialled a course of oral NSAID. His pain gradually decreased and he was able to progressively return to normal activities.
Proximal rectus femoris tendon avulsions are relatively rare and appear to occur mostly in male players. The injury typically occurs during hip hyperextension and knee flexion or as a result of a sharp eccentric contraction of the quadriceps. There is limited literature to guide treatment decisions, although there are a number of case reports detailing surgical treatment for elite athletes. In most cases (with the possible exception of elite or professional players) non-operative management should be trialled. Surgical repair may be considered in high-level players or in patients for whom nonoperative treatment has failed.
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