This document discusses MRI imaging of injuries to the quadriceps muscle complex (QMC). It reviews 66 vastus muscle injuries over 7 years. Injuries were most common in the vastus lateralis, medialis, and intermedius muscles. Most injuries were grade 1 or 2 strains located in the proximal or distal thirds of the muscles. Injuries often involved multiple vastus muscles. MRI findings correlated with return to play time, with grade 1 injuries returning around 17 days on average. Differential diagnoses for quadriceps injuries include contusions, hematomas, and soft tissue masses. Prognosis is generally excellent, though complications like myositis ossificans may occur.

1. George Koulouris
MBBS, GrCertSpMed, MMed, FRANZCR
Melbourne Radiology Clinic
Melbourne, VIC, AUSTRALIA
MR Imaging of the
Quadriceps Muscle Complex
(QMC)

2. INTRODUCTION
• No financial disclosures

3. • Strains centred mainly at
musculotendinous
junction
• Bi-articular muscles
• Fast twitch (II) fibres
• Tendon involvement
poor prognostic indicator
– Comin J, et al. Return to competitive play
after hamstring injuries involving disruption
of the central tendon. Am J Sports Med.
2013 Jan;41(1):111-5
INTRODUCTION

4. INTRODUCTION
• Non-Rectus Femoris
(RF) injuries
• Vastus:
– Lateralis
– Medialis
– Intermedius

5. • Mono-articular
muscles
– crossing the knee joint
only
• Unlike RF (hip &
knee)
• Broad myofascial-
aponeurotic origin
INTRODUCTION

6. INTRODUCTION
• Type I (slow twitch
fibres)
• Similar to soleus vs
gastrocnemius
• Low gear muscles
• Slower generation of
forces
 Less susceptible to
strain

7. VASTUS LATERALIS
• Largest
• Most powerful of all
quadriceps
• Origin:
– Intertrochanteric line
– Anterior border greater
trochanter
– Upper half lateral linea
aspera
– (glut max, SHBF)

8. VASTUS MEDIALIS
• Origin:
– Anteromedial
intertrochanteric line
– Pectineal line
– Medial linea aspera
– Medial supracondylar
ridge

9. VASTUS INTERMEDIUS
• Origin with vastus
medialis
• Origin:
– Anterolateral femoral
shaft
– Lower part lateral
intermuscular septum
• Deepest & middle most
muscle, thus hardest to
stretch once maximal
knee flexion is attained

10. INTRODUCTION
• Insertion:
QT
Trilaminar morphology
 retinacula

11. REVIEW
• 7 years of thigh
injuries
• 66 vastus injuries
• Excluded:
– RF (Dr Kassarjian)
– PF & hip instability
– QT rupture

13. REVIEW – V.LATERALIS
• Single injury:
• Max mean dimension:
• Grade 1:
• Grade 2:
• Multiple injuries:
– VM
– VI
– VM VI
• 21 (2 contusions)
• 45mm
• 17
• 4
– 2
– 2 (1 contusion)
– 2

14. REVIEW – V.INTERMEDIUS
• Single injury:
• Max mean dimension:
• Grade 1:
• Grade 2:
• Multiple injuries:
– VM
– VL
– VM VL
• 20 (6 contusions)
• 35mm
• 12
• 8
– 1
– 2 (1 contusion)
– 2

15. REVIEW – V.MEDIALIS
• Single injury:
• Max mean dimension:
• Grade 1:
• Grade 2:
• Multiple Injuries:
– VI
– VL
– VI VL
• 18
• 87mm
• 12
• 6
– 1
– 2
– 2

16. REVIEW – ALL VASTI
• Single:
• Multiple injuries:
– VL VM
– VI VM
– VI VL
– VI VL VM
• 59 (8 contusions)
– 2
– 1
– 2 (1 contusion)
– 2

17. REVIEW – ALL VASTI
• 25 proximal 1/3
• 11 mid 1/3
• 30 distal 1/3
• myofascial
• Intra-muscular
• MTJ

18. REVIEW - ALL VASTI
• Average age 26.6
(range 7-50)
• Scar tissue
– 10
– 8 at site of previous
injury
– 2 different site

19. ASSOCIATED INJURIES
• RUPTURE:
– HO rupture (1)
– AO (1)
– PCL (1)
• STRAINS:
– MCL grade 1 (1)
– ST grade 1 (1)
– Pectineus (1)
– Gluteus maximus (1)
– Adductor brevis (1)
• DOMS
– RF (2)
– VL (1)
• MO
– 1

37. PROGNOSIS
• MRI negative
• Vastus (L, M, I)
• RF – non central
• RF – central Tendon

38. Cross et al, Am J Sp Med 2004

39. THE ULTIMATE QUESTION

40. THE ULTIMATE QUESTION

41. MRI & HAMSTRINGS
• N=516; 58% N=299 MRI+ HMS
• Grade: RTP: SD:
– 0: 13% 8 3
– 1: 57% 17 10
– 2: 27% 22 11
– 3: 3% 73 60
– Ekstrand J, et al. Hamstring muscle injuries in professional football: the correlation of MRI
findings with return to play. Br J Sports Med. 46(2):112-7, 2012
• No difference b/w grade 1&2
– Moen MH,et al. Predicting return to play after hamstring injuries. Br J Sports Med
48(18):1358-63, 2014

42. 13%; 8D+/-3 57%%; 17+/-10
27%%; 22+/-11 3%%; 73+/-60

44. DDx
• DOMS
• Contusion
• Fat necrosis
• Haematoma
• Myositis ossificans
• Seroma/pseudocyst
• Ozçakar L, et al. Rectus muscle strain akin to a mass lesion of the thigh: sonography
distinguishes the nuance. Am J Phys Med Rehabil. 2009 Sep;88(9):780.
• Temple HT, et al. Rectus femoris muscle tear appearing as a pseudotumor. Am J Sports
Med. 1998 Jul-Aug;26(4):544-8
• Morrel-Lavalee lesion

45. DDx
• Soft tissue masses
– benign mesenchymal lesions
– sarcoma
• Acute compartment syndrome
– Burns BJ, et al. Acute compartment syndrome of the anterior thigh following quadriceps
strain in a footballer. Br J Sports Med. 2004 Apr;38(2):218-20.
• Chronic compartment syndrome
– Orava S, et al. Chronic compartment syndrome of the quadriceps femoris muscle in athletes.
Diagnosis, imaging and treatment with fasciotomy. Ann Chir Gynaecol. 1998;87(1):53-8.

75. CONCLUSION
• Vastus injuries
relatively common
– Roughly equally
divided amongst the
three heads
• Morphology reverse
of the hamstring
muscle compartment
• Distribution of injuries
reflective of anatomy
– Myofascial proximally
– Intramuscular mid
aspect
– MTJ distally

76. • Excellent prognosis
– RTP
– SHBF, soleus
• Be aware of:
– DDx
– Complications &
imaging features (MO)
• Low threshold to
follow up, re-image
&/or biopsy
CONCLUSION

77. THANK YOU
GeorgeK@melbourneradiology.com.au