Isolated, full-thickness proximal rectus femoris injury in competitive athletes

Key points

1. 01Soccer players accounted for 70.5% of cases, with kicking and forced hip extension/knee flexion the most frequent injury mechanisms
2. 0286% of injuries were proximal avulsions; 80.3% of athletes underwent operative repair
3. 03Operatively treated athletes achieved 100% return to play vs 93.3% for conservatively managed athletes
4. 04Mean return-to-play time was 22.1 weeks after surgery and 11.7 weeks after conservative management
5. 05Complications occurred in 18% of surgically treated athletes, mainly lateral femoral cutaneous nerve neurapraxia, vs 7.7% recurrent pain in conservatively managed athletes

How it was conducted

Design

Systematic review (PRISMA 2020); Level of evidence 4

Studies included

18 articles meeting inclusion criteria, drawn from 132 initially identified

Participants

132 competitive athletes, mean age 24.0 +/- 5.4 years (range 12-43), 94% male

Sports represented

Soccer 70.5%, rugby 15.2%, American football 12.1%

Injury types included

Isolated full-thickness proximal rectus femoris tears or bony avulsions during sporting activity, confirmed on clinical and imaging evaluation

Study quality

Mean Modified Coleman Methodology Score 34.8 (range 24-59), classified as poor; all included studies were level 3-5 evidence

What they found

• Return-to-play rate: 100% (106/106) in operatively treated athletes vs 93.3% (14/15) in nonoperatively treated athletes
• Mean return-to-play time: 22.1 weeks (range 14.0-37.6 weeks) after operative management vs 11.7 weeks (range 5.5-15.2 weeks) after nonoperative management
• 86% of athletes (114/132) sustained proximal avulsion injuries; 8 had musculotendinous junction ruptures; 10 had bony avulsion fractures
• Operative management was performed in 80.3% of athletes (106/132); nonoperative in 19.7% (26/132)
• Complications in operative group: 18% (19/106), including LFCN neurapraxia (8 athletes), LFCN injury (4 athletes), recurrent injury (4%), hematoma (1 athlete)
• Complications in nonoperative group: 7.7% (2/26), limited to recurrent pain
• Kicking was the most common mechanism (47.6%; 30/63 athletes with reported mechanism), followed by excessive knee flexion/forced hip extension (42.9%; 27/63) and sprinting (9.5%; 6/63)
• Mean follow-up: 21.4 +/- 11.4 months (range 1.5-48 months)

Limitations

• All 18 included studies were small case series or retrospective reviews (level 3-5 evidence) with a mean poor MCMS quality score of 34.8, severely limiting generalizability
• No prospective randomized controlled trials exist comparing operative and nonoperative treatment, so surgical indications rest on expert opinion rather than objective criteria
• Strong selection bias toward reporting surgical cases makes direct comparison between treatment groups unreliable
• Heterogeneous outcome measures and small nonoperative cohort (n=26) prevented meaningful statistical comparison between management strategies

Why it matters

For patients

Athletes who completely tear the proximal rectus femoris tendon have a high chance of returning to their sport whether treated with surgery or rehabilitation, though surgery involves a longer recovery of roughly five to six months.

For clinicians

Operative repair achieved 100% return to play versus 93.3% with conservative care, but with double the recovery time and an 18% complication rate; in the absence of RCTs, surgical indications should be weighed on a case-by-case basis using MRI severity, degree of retraction, and athlete goals.

For readers

This review provides the best available summary of a rare but serious sports injury, though all source data come from small, low-quality case series, so individual results may vary considerably.