European Journal of Radiology 81 (2012) 3763–3771

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Current concepts in MRI of rectus femoris musculotendinous (myotendinous)

and myofascial injuries in elite athletes
A. Kassarjian a,∗ , R.M. Rodrigo b , J.M. Santisteban c
a
Consultant Radiologist, Corades, S. L., Calle Galeon 2, 28220 Majadahonda, Madrid, Spain
b
Resonancia Magnetica Bilbao, Hospital San Francisco Javier, Gordoniz 12, 40010 Bilbao, Vizcaya, Basque Country, Spain
c
Medical Services, Athletic Club Bilbao, Basurto Medical Institute, Faculty of Medicine and Odontology, University of the Basque Country, Barrio de Garaioltza 147,
48197 Lezama, Vizcaya, Basque Country, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Rectus femoris injuries are extremely common in athletes, particularly in soccer players, rugby player, and
Received 16 February 2011 sprinters. Magnetic resonance imaging (MRI) plays a key role in diagnosis, prognosis, and rehabilitation
Accepted 22 March 2011 of these injuries. The current article discusses current concepts in the diagnosis and treatment of rectus
femoris injuries in elite athletes, including a discussion of the less well known myofascial injuries and
Keywords: key prognostic factors as seen at MR imaging.
Rectus femoris
© 2011 Elsevier Ireland Ltd. All rights reserved.
Magnetic resonance imaging (MRI)
Muscle
Quadriceps
Sports/athletic injuries
Treatment
Prognosis
Rehabilitation

1. Introduction 2. MR imaging technique

Injuries to the quadriceps muscles, and specifically the rec-
tus femoris, are extremely common in athletes and are reported
to represent the second most common lower extremity muscular
injury after hamstring injuries. In our experience, in soccer play-
ers, quadriceps injuries, and specifically rectus femoris injuries, are
more common than hamstring injuries. Although hamstring strains
often have a clear clinical presentation, rectus femoris injuries in
elite athletes may present with either acute or insidious symptoms
owing to the complex anatomy of the rectus femoris. This article
will describe the imaging strategies, risk factors, and the role of MR
imaging in determining prognosis and appropriate rehabilitation of
rectus femoris injuries in elite athletes with a focus on MR imaging
of myotendinous and myofascial injuries.
∗ Corresponding author.
E-mail addresses: Kassarjian@mac.com (A. Kassarjian),
rmrodrigo@resonanciamagneticabilbao.com (R.M. Rodrigo),
j.santisteban@athletic-club.net (J.M. Santisteban).
As with the evaluation of any athletic injury, the MR proto-
col must be tailored to the specific clinical scenario. In imaging
injuries of the rectus femoris, appropriate planes and fields of views
must be employed. (Although there is wide range of acceptable
sequences and planes of imaging, imaging of elite athlete justi-
fies using a slightly more extensive imaging protocol since acute,
sub-acute, and chronic injuries may all be present (and possibly
inter-related) therefore requiring appropriate imaging of all lesions
present.) Although there is wide range of acceptable sequences,
imaging rectus femoris injuries in elite players should be tailored
using appropriate planes and slightly extended protocol.
Our current protocol consists of initial wide field of view images
that include both hips and thigh and consists of: axial T1, axial
STIR, and axial gradient echo sequences all of which extend from
the anterior inferior iliac spine to the distal myotendinous junction
of the rectus femoris. These images are not meant to be of high
resolution but serve to accurately localize both acute and chronic
injuries and allow evaluation of the contra-lateral hip and thigh
both for comparison (e.g. of muscle bulk) and to assess for occult
additional injuries. Subsequently, higher resolution images with
a smaller field of view are obtained of the symptomatic rectus
femoris. This includes T2 weighted sequences with fat suppression

0720-048X/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2011.04.002
3764 A. Kassarjian et al. / European Journal of Radiology 81 (2012) 3763–3771
Fig. 1. Lines showing orientation of parasagittal images that will subsequently help
better demonstrate the origins of the direct (wide arrow) and indirect (thin arrow)
heads of the rectus femoris.
in the following planes: axial images in all cases, sagittal oblique
images (paralleling the anterior inferior iliac spine) when proximal
tendinous injuries are suspected, sagittal images when myotendi-
nous injuries of the direct (superficial) component are suspected or
when myofascial injuries are suspected, and coronal images when
myotendinous injuries to the indirect (deep) component are sus-
pected (Fig. 1).
3. MR imaging anatomy
The rectus femoris has somewhat complex anatomy that can be
elegantly demonstrated with MR imaging [1–3]. Proximally, there
are two origins to the rectus femoris which consist of the direct
and indirect (reflected) tendons or heads (Fig. 2). The direct tendon
arises from the anterior inferior iliac spine (AIIS) and the indirect
tendon arises from the later margin of the supra-acetabular sur-
face and the lateral acetabular rim. These short tendons give rise to
a complex set of myotendinous transitions. The direct head and
indirect head join just below and anterior to the AIIS with the
direct head contributing to the anterior and slightly medial aspect
of the proximal rectus femoris while the indirect head contributes
to the posterior and slightly lateral aspect of the rectus femoris.
The myotendinous junction of the direct head actually is very proxi-
mal, thin, and broad based with the tendinous fibers comprising the
anterior surface of the proximal rectus femoris muscle where they
imperceptively blend with the anterior fascia of the proximal rec-
tus femoris muscle. Although according to anatomical studies the
tendinous contribution from the direct head of the rectus femoris
can extend down the proximal third of the muscle belly, at MR
imaging, in the absence of edema or fluid, the tendon of the direct
head is only typically visualized as a distinct entity to the level
of the hip joint [1–3]. In contrast, the tendon of the indirect head
initially has a somewhat rounded, coma shaped or ovoid config-
uration, propagates into the substance of the muscle where, as it
descends inferiorly, rotates into an essentially sagittal orientation
and acquires a flattened or linear configuration, extending along
the rectus femoris muscle till the distal third of the muscle [1].
4. Risk factors and clinical presentation
There has been extensive study into the risk factors for rectus
femoris injuries in elite athletes, particularly Australian rugby and
soccer players [4,5]. Multiple factors may contribute to a specific
injury, certain patterns have emerged in the study of rectus femoris
injuries. Both extrinsic and intrinsic factors seem to play a role. The
factors can be divided into four major categories: muscle, player,
venue, and match.
The rectus femoris is a bi-articular muscle in that it crosses two
joints (hip and knee). In addition, it has a high proportion of fast
twitch (type II) muscle fibers thereby also increasing the risk of
injury. Finally, during running and kicking, it is exposed to signifi-
cant and often extreme stresses in the form of stretching, powerful
eccentric contraction, and power concentric contraction [4]. All of
these factors place the rectus femoris at risk for injuries, in partic-
ular myotendinous, myofascial, and tendinous injuries.
Players of shorter stature are at higher risk for rectus femoris
injuries. Also, injuries appear to be more common during pre-
season training and when there has been either improper warm-up
or overtraining. According to prior publications, a prior rectus
femoris injury or recent hamstring injury also increases the risk of
a new rectus femoris injury although the new rectus femoris injury
may not be in the same location as the previous rectus femoris
injury [4,5].
Environmental/pitch factors also seem to play a role. Rectus
femoris injuries are more common in cold humid conditions when
there has been no significant rainfall in the previous week. Thus,
fields with a harder ground and thus increased ground traction are
associated with rectus femoris injuries.
During actual training or a match, injuries are more common
when there is a fast run-up to a kick possibly related to under-
striding which results in the player leaning back and the leg moving
further behind the body. This places extra stress on the rectus
femoris. The injury is more common in the kicking leg. There is
some debate as to exactly when the injury occurs as some believe
it occurs during the late backswing while others believe it occurs
during the under-striding while trying to slow down. Even with
video analysis, debate is ongoing [5].
The presentation of a rectus femoris injury typically takes one
of two forms. Acute injuries such as acute tendon tears, acute
myotendinous injuries, or acute myofascial injuries may present
with an acute onset of pain immediately after the inciting event.
Depending on the severity of injury, there may or may not be
associated loss of muscle strength. However, certain acute injuries,
such as myotendinous strains of the indirect head of the rectus
femoris and some myofascial injuries, may have a more insidi-
ous onset and begin as a mild discomfort along the anterior thigh.
These myotendinous injuries of the indirect head may present as
increased tone and mild spasm/contraction of the muscle, partic-
ularly when the injury has associated soft tissue fluid. This may
initially be thought to represent a mild overuse injury or very mild
strain with the player only noticing mild discomfort while kicking
the ball. They may be able to withstand the discomfort and thus
keep playing for days. However, as they do so, the pain and dis-
comfort increase to the point that it finally warrants imaging at
which point MRI (or ultrasound) demonstrates the true nature and
extent of the injury. Unless, there has been a direct impact such as
getting kicked in the thigh, rectus femoris injuries do not typically
present with a focal hematoma or mass.
5. MR appearance of rectus femoris injuries
The MR appearance of injuries to different portions of the rectus
femoris varies depending on the location of the injury. In general, a
three point grading system may be used for myotendinous injuries
(strains) with a grade I lesion presenting as peritendinous edema
without a focal or discrete tear, a grade II lesion presenting as a
partial tear of the myotendinous junction with a partial thickness
defect visible, and a grade III lesion presenting as a complete tear
at the myotendinous junction. However, such three point grading
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Fig. 2. (a) Axial fat suppressed T2-weighted image showing the tendons of the direct (wide arrow) and indirect (thin arrow) heads of the rectus femoris. (b) Axial fat
suppressed T2-weighted image (inferior to a) again showing the tendons of the direct (wide arrow) and indirect (thin arrow) heads of the rectus femoris. (c–e) Consecutive
parasagittal fat suppressed T2-weighted image showing the tendons of the direct (wide arrow) and indirect (thin arrow) heads of the rectus femoris.

system may not be necessarily for rectus femoris injuries, par- simulate an aggressive bone lesion (Fig. 5). The typical location in
ticularly for injuries of its direct head when myofascial injury is skeletally immature athletes helps to avoid misdiagnosing.
present.

5.2. Myotendinous injuries of the direct head

5.1. Proximal tendon injuries
As previously mentioned, although a tendon tear is often visible
on the axial images, the exact degree of the tear, whether one or
both tendons are involved, and the size of a gap in the tendon (if
present) are often better delineated using oblique sagittal images
that are oriented parallel to the iliac wing (Fig. 3). Tendon injuries
are classified as partial or complete tears with the description speci-
fying whether one or both tendons are involved and to what degree.
If a complete tear of either is present, a description of the tendon
margin quality and the gap in the tendon should be included [2,3,6].
In skeletally immature athletes, it is not uncommon for the
apophysis of the anterior inferior iliac spine to be avulsed in lieu
of the tendon tearing [2,3] (Fig. 4). As with other sites (e.g. lesser
trochanter or ischial spine), the weak link in the muscle-tendon-
bone chain in younger athletes is the unfused physis. In these cases,
one should describe the size of the avulsed apophysis and the gap
between the avulsed bone fragment and the donor site. In the
case of subacute or chronic apophyseal avulsion injuries, the MR
appearance of the lesion may be confusing and, in many cases, may
The direct head of the rectus femoris has a relatively short ten-
don that fans out and blends with the anterior fascia of the proximal
third of the muscle belly of the rectus femoris [1,2,7,8]. Given this
short transition, injuries to the myotendinous portion of the direct
head of the rectus femoris often present as edema and fluid along
the anterior portion of the rectus femoris muscle belly, predom-
inantly located between the anterior fascia and the belly of the
muscle (Fig. 6). It may be difficult to differentiate between a grade
I and II tear since the tendon itself blends so quickly with the mus-
cle fascia. However, with high quality axial, sagittal and sagittal
oblique images, the location of the injuries can accurately be iden-
tified and graded as either a partial or complete tear. In addition, the
amount of fluid and hematoma that has accumulated between the
fascia and the muscle belly can be visualized and should be men-
tioned when reporting these injuries particularly since this fluid can
track inferiorly along the deep surface of the anterior fascia. Some
studies suggest that the exact location and extent of the injury are
important because if a prominent component is located immedi-
ately deep to the sartorius (as it crosses over the rectus femoris),
3766 A. Kassarjian et al. / European Journal of Radiology 81 (2012) 3763–3771

Fig. 3. (a and b) Consecutive parasagittal fat suppressed T2-weighted images in a professional European football (soccer) player demonstrate complete tears of the direct
(wide arrow) and indirect (thin arrow) tendons of the rectus femoris. This injury was sustained during kicking. (c and d) Consecutive parasagittal fat suppressed T2-weighted
images in a (different) professional European football (soccer) goalie demonstrate a partial tendon tear of the direct head (wide arrow) and complete tendon tear of the
indirect (thin arrow) head of the rectus femoris. This injury was sustained during kicking.

the prognosis may be more guarded since the sartorius may com-
press this region and prevent adequate clearance of metabolites
and healing of the underlying injury [8,9]. Finally, given the inti-
mate relationship of the tendon of the direct head of the rectus
femoris and the anterior fascia of the muscle, it may be difficult
to differentiate between a myotendinous injury and a myofascial
injury at this location. Although in the absence of injury the ten-
don may be difficult to distinguish from the fascia, in the setting
of an injury, the tendon of the direct head may appear as a slightly
more prominent hypointense component of the fascia. It is possible
that these direct head injuries begin as a myotendinous injury and
extend/propagate thereby having a myofascial component as well
[8].
5.3. Myotendinous injuries of the indirect head
The myotendinous junction of the indirect head of the rectus
femoris is quite long, is embedded within the substance of the rec-
tus femoris muscle belly and therefore its injury classically present
as edema or fluid tracking along the course of this tendon and
may be quite extensive in the cranio-caudal axis [2,3,8,10] (Fig. 7).
These lesions are often seen along the proximal and middle thirds of
the muscle. In addition, on T1-weighted images, with more severe
injuries, the rectus femoris may have a larger cross sectional area
when compared with the contra-lateral thigh and there may be
blurring of the myotendinous junction [8].
In grade I strains, there is feathery edema typically on both sides
of the tendon, thereby reflecting the bi-pennate configuration of
the muscle at this level. The tendon itself remains intact. In grade
II strains (partial tears), one begins to see architectural distortion
of the muscle fibers and possibly the tendon. There may be a small
fluid filled gap within the torn muscle fibers or a portion of the
tendon. With both (more severe) grade I and II strains, the edema is
centered around the tendon in a pattern that has been referred to as
“bull’s eye” although some have reserved this description for grade
II strains. With grade II strains, some fibers of the myotendinous
junction and the tendon remain intact. In grade III strains (complete
tears), there is a complete disruption of the myotendinous junction
 A. Kassarjian et al. / European Journal of Radiology 81 (2012) 3763–3771 3767

Fig. 4. (a) Parasagittal fat suppressed T2-weighted image in a 15-year-old semiprofessional European football (soccer) player shows an acute apophyseal avulsion (arrow)
which occurred at the beginning of a sprint. (b) Parasagittal fat suppressed T2-weighted image in the same player obtained three months later shows the avulsed apophysis
(arrow) to better advantage and demonstrates interval narrowing of the fluid filled gap between the apophysis and the physis.

Fig. 5. (a) Axial T1 weighted image shows a mass-like lesion (thin arrow) along the anterior inferior iliac spine. Note proximity of rectus femoris tendon (wide arrow). (b)
Coronal STIR image shows lobular mass-like lesion (thin arrow) along anterior inferior iliac spine. Note proximity of rectus femoris tendon (wide arrow). (c) Sagittal fat
suppressed proton density image shows direct tendon (wide arrow) of rectus femoris entering the “mass” while the indirect tendon (thin arrow) projects toward its origin
along the lateral aspect of the acetabulum.
3768 A. Kassarjian et al. / European Journal of Radiology 81 (2012) 3763–3771

Fig. 6. (a and b) Axial fat suppressed T2-weighted images in two different young semi-professional European football (soccer) players demonstrate an injury to the direct
tendon of the rectus femoris (wide arrow) with associated perifascial fluid (thin arrow) predominantly along the anterior aspect of the rectus femoris muscle.

with a discrete tendon gap that is filled with fluid, blood, debris
and/or granulation tissue depending on the age of the injury. The
muscle and tendon can have variable degrees of proximal retraction
[2,3,8,10]. With both grade II and III strains, there may be associated
hypo- or hyper-intensities on T1-weighted images depending on
the composition and quantity of blood products. Because of the long
myotendinous union, the complexity of the injuries with frequent
associated myofascial lesions and its extension through the fascia
makes difficult adequately graded with the classic 3 points system.
The presence of fluid intermuscular and along the fascial planes
should be mentioned in the report since its appears to indicate a
longer recovery time [8] (see below).

Fig. 7. (a and b) Axial (a) and coronal (b) fat suppressed T2 weighted images in a 16-year-old semiprofessional European football (soccer) player injured during hyperextension
of the non-kicking leg show a very long myotendinous injury (thin arrow) involving the indirect component of the rectus femoris. The myotendinous component of the
muscle is almost striped way from the remainder of the muscle with a fluid filled plane seen between the majority of the muscle fibers and the myotendous component (open
arrow). This nearly resembles an intra-muscular degloving injury. The myotendinous injury has extended to the fascia resulting in perifascial fluid as well (wide arrow). (c)
Axial T1 weighted images in a professional European football (soccer) player show slight increase in the size of the left rectus femoris muscle (arrow) when compared to
the right. An injury to the indirect myotendinous junction is clearly seen on the axial fat suppressed T2 weighted image (inset). (d) Images from coronal (upper) and axial
(lower) fat suppressed T2 weighted images in another professional European football (soccer) player show a complete disruption of the distal myotendinous junction of the
rectus femoris with retraction of the muscle (white arrow) and a fluid/hemorrhage filled gap (open arrow) between the retracted muscle and the distal stump. (Images c and
d courtesy of Javier Mota, MD, Barcelona, Spain.)
 A. Kassarjian et al. / European Journal of Radiology 81 (2012) 3763–3771
It should also be noted that there can be an overlap in the imag-
ing appearance of acute, subacute, and chronic lesions. Therefore,
it is critical to correlate the imaging findings with the clinical sce-
nario. Myotendinous injuries of the indirect head seem to be more
common than myotendinous injuries of the direct head.
5.4. Myofascial injuries
Although descriptions of myofascial injuries are sparse in the
literature, they may represent a clinically and anatomically dis-
tinct injury and, we believe, should be considered separate from
myotendinous injuries because of its significance on management
and prognosis. In our experience, myofascial injuries represent
approximately 15% of all rectus femoris injuries in professional
soccer players (8, additional unpublished data).
Myofascial injuries of the rectus femoris are those that are
not centered along the myotendinous junction. Myofascial injuries
appear as edema, fluid, and architectural distortion of the mus-
cle fibers and sometimes the fascia adjacent to but not necessarily
contiguous with the myotendinous junction. In these cases, the
myotendinous junction itself is often intact (Fig. 8). The fibers
that are torn are muscle fibers up to and sometimes including the
epimysium and fascia. MR imaging shows edema and fluid within
the substance of the muscle with extension to the fascia of the mus-
cle, typically along the posterolateral aspect of the muscle [8]. If the
fascia is intact, the fluid may dissect along the undersurface of the
fascia creating a plane between the muscle and the fascia. If the fas-
cia is disrupted, the edema and fluid will extend beyond the muscle
and fascia dissecting along the inter-muscular planes in addition
to the previously described dissection between the fascia and the
muscle.
Myofascial injuries may occur along any portion of the rectus
femoris although they appear to be more common in the proximal
and middle thirds. Those that occur anteriorly and very proximally
may be difficult to differentiate from myotendinous injuries of the
direct head of the rectus femoris at MR imaging, and often may
represent myotendinous injuries that extend to the fascia.
Myofascial injuries further down the rectus femoris can more
easily be differentiated from myotendinous injuries of the indirect
head. With myofascial injuries, the edema and fluid are most com-
monly eccentrically located along the posterior and lateral aspect
of the muscle and not centered along the sagitally oriented intra-
muscular tendon of the indirect head of the rectus femoris.
It should be noted that anterior myofascial injuries can be
extrememly difficult to see with ultrasound if macroscopic fiber
disruption is limited. Even after an MR has demonstrated these
proximal anterior myofascial injuries, they may not be clearly visi-
ble at second look ultrasound [unpublished data]. If only ultrasound
is used and these proximal anterior lesions are missed, inappro-
priate treatment may actually aggravate the lesion and result in
seromas. As such, it is imperative to accurately diagnose these
lesions, often with MR, prior to implementing a treatment proto-
col. When compared to the anterior myofascial injuries, the more
posterior and lateral myofascial injuries are easier to see by ultra-
sound. It appears that the deeper myofascial injuries, which are
more common posterolaterally, have a greater tendency to be rein-
jured and form seromas if the player resumes training too soon after
the original injury.
5.5. Prior injuries and scars
The presence of prior thigh muscle injuries appears to be a signif-
icant risk factor for subsequent rectus femoris injuries. Specifically,
according to the literature, a history of a recent hamstring injury
(within the previous 8 weeks) or prior (recent or remote) rectus
femoris injury are risk factors for subsequent rectus femoris injuries
3769
[4,5]. However, in our experience, there is no clear association
between a prior hamstring injury and in increased risk for a sub-
sequent rectus femoris injury. Interestingly, a prior rectus femoris
injury is a risk factor for a subsequent rectus injury which more fre-
quently (but not always) occurs in a different location in the muscle.
If the re-injury is at the site of prior injury, in our experience, it
is commonly along the margins of the scar. Given the association
between prior rectus femoris injuries and subsequent injuries, it is
import to include a gradient echo sequence in the imaging protocol
as this will help identify areas of scarring due to the mild blooming
artifact that may be present at the site of scar from small regions
of hemosiderin deposition. This will present as a relatively focal
area of very low signal on gradient echo images with or without
focal architectural distortion of the muscle and/or tendon (Fig. 9).
Oftentimes, the architectural distortion, and underlying anatomy
can be better seen on the T1 weighted images. Occasionally, there
can be quite exuberant scar formation at the site of a prior injury.
Knowledge of prior injuries serves as a baseline for subsequent
imaging studies and an indicator that it may be necessary to do a
complete functional assessment of the player to determine if there
is an underlying cause for recurrent injuries.
6. Imaging findings and association with prognosis
As with any injury in elite athletes, one of the first questions to be
asked after a player is injured is, “how long before he (she) can play
again?” Time away from the sport has significant professional and
financial implication. In the case of rectus femoris injuries, recent
data suggests that imaging can play an important role in assess-
ing prognosis and expected time away from the sport. In a study
of 40 elite soccer players, certain imaging characteristics of rec-
tus femoris myotendinous and myofascial injuries were associated
with a longer recovery time [8].
The following four individual factors have a poor prognosis:
proximal injuries, presence of perifascial fluid, changes seen on
T1-weighted images, and involvement of more than 50% of the
cross-sectional area of the muscle. Of these four factors, the pres-
ence of perifascial fluid and lesions seen on T1-weighted images
were statistically significantly associated with a longer recovery
interval (p = 0.026 and p = 0.019, respectively). Although there was
a trend between proximal lesions and greater that 50% cross-
sectional area involvement and a longer recovery interval, it did not
reach statistical significance. When any three of these four factors
were present, there was an even greater association with a longer
recovery interval (37.7 days vs. 27.2 days, p = 0.012). The length of
the lesion was not correlated with a longer recovery interval.
Given these findings, it appears that MR images of rectus femoris
injuries should be carefully evaluated for the presence of perifas-
cial fluid, visibility of the injury on T1-weighted images, the exact
location injury, and the size (cross-sectional area) of the injury as
these four factors appear to help predict the recovery interval.
7. Rehabilitation
No uniform or universally applicable guidelines exist for the
treatment of muscular injuries [11]. One must always take into
account multiple factors including the type of surface, the time of
the season, the specific sport, the specific player position, the dom-
inant leg, and the level of play. If one takes too conservative of an
approach, the time away from the field would be excessive thereby
making it impossible to run a professional team. For this reason,
some prefer to have a protocol that allows 90% return to play within
3 weeks as opposed to using a protocol that allows 100% return to
play but requires waiting 8 weeks [11].
3770 A. Kassarjian et al. / European Journal of Radiology 81 (2012) 3763–3771

Fig. 8. (a) Axial fat suppressed T2-weighted image of a female professional European football (soccer) goalie shows myofascial disruption along the posterolateral margin of
the middle third of the rectus femoris (thick white arrow). Fluid is seen tracking along the fascia and the belly of the muscle (open arrows). This injury was sustained while
kicking the ball. There is also evidence of a small scar from prior myotendinous injury (long thin arrow). (b) Axial T1 weighted (b1) and T2 weighted (b2) images of another
professional European football (soccer) player show a posterior myofascial injury (arrow) with fluid accumulating between the posterior muscle fibers and the fascia. This
injury was sustained during a sprint.

Rehabilitation protocols are designed to aid in the rapid regen-
eration and recovery of muscles. Therefore, one begins with the
fundamentals of rest, ice, compression, and elevation (RICE) to min-
imize bleeding and minimize the release of inflammatory factors
which can cause edema and secondary tissue injury. Proper early
rehabilitation can accelerate the course of regeneration. Depend-
ing on the severity of the lesion, initial rest may be prescribed for
1–5 days. Early aggressive treatment of an edematous and inflamed
muscle can result in further tissue damage, prolonged inflamma-
tion, and delayed recovery/repair. Although platelet rich plasma
preparations may accelerate the rate of scarring, there is a cur-
rent paucity of randomized trials in humans to support their use
in muscle injuries [12,13]. Further research is needed in this area.
After 5 days, one can start physiotherapy regimens (massage
therapy, ultrasound, or other modalities). Initially, the regimen con-
sists of careful mobilization with unloaded isometric contractions
which are gently advanced in force until the onset of pain or dis-
comfort. This is followed by careful isotonic contractions. When all
the exercises can be completed without pain, eccentric exercises
are started beginning with manual resistance then progressing
to more complex exercises against differing types of resistance.
Once there is no longer any pain with resistance exercises, run-

Fig. 9. (a) Axial and coronal T1 weighted images show evidence of retraction of the rectus femoris muscle belly, scarring and fatty change (arrows) as a result of complete
tear of the direct tendon and partial tear of the indirect tendon. (b) Focal scar and minimal fatty change at site of prior injury to the indirect tendon of the rectus femoris.
The fat is only seen on the T1 weighted image (figure) while the gradient echo image (inset) shows the hypointense scar. (c) Axial T1 weighted image shows scarring and
fatty change along the posterolateral aspect of the right rectus femoris (arrow) from prior deep myofascial injury. Gradient echo image (inset) shows the hypointense scar
but not the fatty change. (d) Axial gradient echo images shows the typical hypointense laminar scar (arrow) from a prior deep myofascial injury. (e) Axial fat-suppressed
T2 weighted image shows a laminar hypointense scar (arrow) from prior myofascial injury. The edema in the muscle and trace perifascial fluid is from an acute adjacent
peripheral re-injury.
 A. Kassarjian et al. / European Journal of Radiology 81 (2012) 3763–3771
ning regimes are started. Running is stopped if there is any pain.
Initially, running is on alternate days with subsequent progres-
sion to differing stages of running until a full return is made to
pain free pre-injury status [6]. Once all these stages are completed
with return to pain-free pre-injury performance levels, the player
returns to training with the team.
Based on the exact type of lesion and our personal experience,
we pay special attention to the deep myofascial injuries as these
can be associated with seromas. In myofascial injuries, we forbid
any type of running or eccentric contractions until 10 days or until
ultrasound shows organization of the region of muscle disruption
in an attempt to prevent or minimize the development of a seroma.
With proximal lesions that involve the tendon, return to kicking
the ball is delayed because of the possibility of re-injury to the ten-
don and retraction. Such a re-injury to the proximal tendon can be
worse that re-injuries in other locations in the rectus femoris. For
the lesions that have a poor prognosis (see above), we do not allow
repetitive kicking or too many exercises that involve eccentric con-
tractions or a lot of rapid decelerations/stops for 4 weeks once the
player has started playing again. The reason is that although they
are able to play, excessive training with sprints and high intensity
interval training may overload the injured muscle. In these cases,
the player may be able to complete the high intensity exercises
but will have discomfort afterwards. In the next game, they may
re-injure the muscle. With this type of recovery regimen with lim-
itations on high intensity training, although the player is not doing
all the same training sessions as the uninjured players, he is able to
get back to play in a shorter amount of time overall.
8. Conclusion
MR imaging elegantly demonstrates the location and severity of
rectus femoris injuries. Careful analysis of the imaging findings can
3771
have significant prognostic and therapeutic implications. Specifi-
cally, the presence of perifascial fluid and injuries that are visible
on T1-weighted images indicate a poorer prognosis and a longer
recovery time.
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