One Kick Too Many: Thigh Pain In A Kickball Player

HISTORY: A 29-year-old male presented to a sports medicine clinic for acute proximal right thigh pain. He was playing kickball and while making contact with the ball, he immediately felt a pop with right anterior hip and thigh pain. He was able to run a few steps, but slowly fell to the ground. No bruising, no bulges or swelling. PHYSICAL EXAMINATION: No palpable defect or deformity on examination. Tenderness along proximal to mid anterior thigh. Range of motion of hip flexion and extension was limited by pain. Hip internal and external rotation was normal. Hip flexion strength was 4 out of 5, knee extension was 5 out of 5. DIFFERENTIAL DIAGNOSIS: Proximal rectus femoris tendon tear Quadriceps muscle strain Avulsion fracture of the AIIS Hip labrum tear TEST AND RESULTS: X-ray of the right hip and femur were normal. MRI of the hip showed complete rectus femoris tendon tear near the origin with 4 cm of retraction. FINAL WORKING DIAGNOSIS: Complete rectus femoris tendon tear TREATMENT AND OUTCOMES: Initial treatment included conservative management including ice, compression, ACE bandage and partial non weight-bearing with crutches. The initial course of physical therapy included stretching and gentle range of motion exercises for the first 2-4 weeks. Week 4-6 included isometric strengthening and light resistance exercises. At 6-10 weeks, the activities were advanced to dynamic lunges, box jumps, kicking, jogging and running. At week 12, he was able to fully return to sport with full function. Unlike the well-established protocols for early operative repair in hamstring avulsions and tears, evidence for the operative management of rectus femoris rupture is mixed. A recent review demonstrated that 59% of athletes will be treated conservatively, although details regarding type and duration of rehabilitation are not clear. Operative indications are variable in the literature, including patient preference, retraction of the tendon more than 2 cm and those failing conservative treatment. Rehabilitation following surgical repair can take athletes up to 4-10 months to reach pre-injury level of play. Our case illustrates the successful management of a complete tendon rupture with >4 cm retraction using a non-operative approach, highlighting the need for more standardized operative and non-operative protocols.