Dr. Frank van Hellemondt Sports Medicine Physician PRP for Quadriceps Muscles Injuries 8th MuscleTech Network Workshop 3rd - 4th October, Barcelona

1. Epidemiology of Rectus Femoris injuries
in Qatar Professional Football
Dr. Frank van Hellemondt
Sports Medicine Physician

2. Disclosure
No conflict of interests to declare

3. Why ask a Dutchman to comment on
Football?

4. Incidence
Lower limb muscle injuries in football
• UEFA1
à Quadriceps: 17%
• Qatar Stars league (QSL)
à Quadriceps: 17%
1Ekstrand et al. (Am J Sports Med 2011)

5. Rectus Femoris (RF) injuries in football
What are the issues?
• Re-injuries
– UEFA: 17%1
– Aspetar: 30%
• Return to sport (RTS) criteria
1Ekstrand et al. (Am J Sports Med 2011)

6. Aspetar’s RF case series
Daily Athlete RegistraXon (DAR) 2010-2014
• RegistraXon of all injury visits
• 27,000 visits
• 320 RF injuries
• N = 92 RF injuries in professional footballers
with imaging (US/MRI)

7. Approach
Anatomy / Imaging1-3
– Direct vs. Indirect head/tendon
– Proximal vs. Distal
– Tendinous vs. Myotendinous vs. Fascial
Mechanism4
– SprinXng vs. Stretching in hamstrings
1Hasselman et al. (Am J Sports Med 1995), 2Ballius et al. (Br J Sports Med 2009), 3Kassarjian et al. (EJOR 2012),
4Askling et al. (Br J Sports Med 2012).

8. Anatomy & ClassificaXon
Type
• Proximal free tendon
• Central Myotendinous JuncXon (Central MTJ)
• Posterior Myotendinous JuncXon (Posterior MTJ)
Grading1
• Grade 1 – Edema without tear
• Grade 2 – ParXal tear
• Grade 3 – Complete tear
1Peetrons (Eur Radiol 2002)

9. Free tendon Posterior MTJ Central MTJ
Anterior view
Posterior view

10. Direct head
Caudal
L M
Cranial
Indirect head

12. Imaging (MRI) – Free tendon

13. Imaging (MRI) – Central MTJ

14. Imaging (MRI) – Posterior MTJ

15. Kicking type

16. SprinXng type

17. 6,7
34,5
52,4
33,3
47,3 47,6
60
18,2
0
0
10
20
30
40
50
60
70
Proximal free tendon
(N=15)
Central MTJ (N=56) Posterior MTJ (N=21)
Percentage (%)
ProporXon of RF injuries by grade and locaXon among QSL
footballers (2010-2014)
Grade 1 Grade 2 Grade 3
N = 92
P < 0.001

18. 80
64,3
90,5
20
35,7
9,5
0
10
20
30
40
50
60
70
80
90
100
Proximal free tendon (N=15) Central MTJ (N=56) Posterior MTJ (N=21)
Percentage (%)
ProporXon of reinjury of RF by locaXon among QSL footballers
(2010-2014)
No re-injury
Re-injury
N = 92
P = 0.056

19. N = 92
P = 0.400
Days to discharge
Proximal free tendon
Central MTJ
Posterior MTJ

20. 28%
46%
26%
Proximal free tendon (N=15)
Central MTJ (N=56)
Posterior MTJ (N=21)
84%
16%
N = 92
P = 0.005 Kicking SprinXng

21. Take home message
• Largest and homogeneous study on RF injuries
(N=92) to date
• Proximal free tendon injury only with kicking
• AssociaXon between locaXon and injury grade
– Proximal free tendon more likely to be grade 3
– No grade 3 injury of posterior MTJ

22. Rectus Femoris (RF) injuries in Football
What are the issues?
• Re-injury
– UEFA : 17%1
– Aspetar: 30%
• Return to sport (RTS) criteria
1Ekstrand et al. (Am J Sports Med 2011)

23. P.A.R.T. Study
QSL professional football players
• ProspecXve cohort of acute RF injuries
• Start in 2014
• 28 inclusions unXl now
• Outcome measures
– RTS
– Re-injuries “same” muscle within 1 year

24. Future
• Clinical relevance!
• Consensus
– Type/classificaXon
– RTT/RTP/RTS criteria
– Prevent recurrence, re-injury mechanism
– RehabilitaXon protocol
• important role for kicking skills
– Injury mechanism
• Video analysis
– Strive for mulX-centre approach

25. Dr. Johannes
Tol (visiXng
SMP)
Dr. Adam
Weir
(visiXng
SMP)
Olympics: 13
WC: 4
2012
Chief of Sports Medicine
Dr . Frank van Hellemondt
2011
Dr. Aston Ngai
SMP
2007
Dr. CrisXano Eirale
SMP
2011
Dr. Celeste Geertsema
SMP
2012
Dr. Liesel Geertsema
SMP
2012
Dr. Stephen Targeo
SMP
2013
Dr. Juan-Manuel Alonso
SMP
2012
Prof. Yorck Schumacher
SMP
2013
Dr. Paul Dijkstra
Director of EducaXon
2015
Dr Roger
Palfreeman
SMP 2016
Dr Louis Holtzhausen
SMP
2016
Dr. Maria C Romero
SMP
2016
Dr. Jomar Souza
SMP
Dr. Eduardo M
Montero
(visiXng SMP)
Dr. Bruce
Hamilton
(visiXng
SMP)
Dr. Elsbeth
van Dorssen
(visiXng
SMP)
Dr. Robbart
v.Linschoten
(visiXng SMP)
Dr. Anne van
der Made
(Research)
Dr. Per
Hölmich
(Head of
Groin Pain
Center)
Andreas Serner
(Research/
Groin Pain
Center)
Dr. Eduardo
Yamashiro
(Radiology)
Dr. Rod Whitely
(Physiotherapy)

27. Proximal
free tendon
Central MTJ
Posterior
MTJ
p-
value
(n=15) (n=56) (n=21)
Age (Years) 22.2±5.95 23.98±5.69 23.0±6.42 0.538
Weight (Kg) 70.86±8.84 71.46±14.11 76.63±14.25 0.335
Height (cm) 177.18±7.09 174.67±7.49 178.51±11.04 0.225
Dominant
leg
Both 0(0.0) 3(5.4) 0(0.0) 0.095
Let 0(0.0) 9(14.3) 5(23.8)
Unknown 0(0.0) 13(23.2) 2(9.5)
Right 15(100.0) 32(57.1) 14(66.7)
Side injured
Let 3(20.0) 21(37.5) 7(33.3) 0.444
Right 12(80.0) 35(62.5) 14(66.7)

28. Proximal free tendon Central MTJ Posterior MTJ

29. Proximal free
tendon
Central MTJ
Posterior MTJ

30. Kicking Other SprinRng p-value
(n=54) (n=7) (n=32)
Age (Years) 23.6±5.6 22.4±6.9 23.5±6.2 0.924
Grade
1 17(31.5) 3(42.9) 12(37.5) 0.170
2 20(37.0) 4(57.1) 16(50.0)
3 17(31.5) 0(0.0) 4(12.5)
Recurrent injury
No 38(69.1) 6(85.7) 22(68.8) 0.699
Yes 17(30.9) 1(14.3) 10(31.3)
Dominant leg
Both 1(1.8) 0(0.0) 2(6.3) 0.547
Let 8(14.5) 0(0.0) 5(15.6)
Not known 7(12.7) 1(14.3) 7(21.9)
Right 39(70.9) 6(85.7) 17(53.1)
Side injured
Let 16(29.1) 3(42.9) 15(46.9) 0.231
Right 39(70.9) 4(57.1) 17(53.1)
Type
Proximal free tendon 14(25.5) 1(14.3) 0(0.0) 0.002
Central MTJ 23(41.8) 3(42.9) 27(84.4)
Proximal free tendon + Central MTJ 5(9.1) 0(0.0) 0(0.0)
Posterior MTJ 13(23.6) 3(42.9) 5(15.6)
DuraRon (Injury to clearance) (days) 44.4±30.3 45.2±30.2 43.3±27.8 0.979

31. History
Intrinsic factors associate with RF injuries1
• Muscle strength2
– Eccentric RF strength (trend, small sample size)
• Muscle flexibility3
– Flexibility ↓ = Injury risk ↑ (p<0.05)
• Previous muscle injury4
– Quadriceps or Hamstring injury = Injury risk ↑ (p<0.05)
1Mediguchian et al. (Br J Sports Med 2013), 2Fouseka et al. (Br J Sports Med 2001),
3Witvrouw et al. (Am J Sports Med 2004), 4Orchard et al. (Am J Sports Med 2001)

32. Eccentric strength
• (Pre-season) eccentric strength shows a trend
to significance, cave low numbers 1
• Lack of matching pre-season data in our study
• (Sixng) posiXon during the Biodex test may
not be correlated with the injury mechanisms
1Fouseka et al. (Br J Sports Med 2011)

33. Most long kicks in football
• Central defenders
• In our study no disXnguish in central and wide
defenders