Thigh Injuries

Mark E. Lavallee, MD, CSCS, FACSMDirector, York Sports Medicine Fellowship, York, PA

Team Physician, Gettysburg College, Gettysburg, PA

Chairman, USA Weightlifting, Sports Medicine Society, Colorado Springs, CO

• I have no relevant conflicts of interest or business relationships in relation to the topic of this lecture.

• All persons imaged in talk have given their consent

DISCLOSURES

OBJECTIVES

After this presentation, the learner will gain an understanding for injuries relating to the leg

Skin (lacerations, contusions, infection)Quadriceps (muscle, tendon, hematomas)Hamstring (muscle, tendon)Ilio-Tibial Band Syndrome (ITBS)Myositis OssificansCompartment Syndrome (Traumatic vs. Exertional)Bone Issues (Occult vs. Stress Fractures, tumors, Physeal Injuries)

SKIN: Lacerations/Abrasions

• Skin Lacerations: irrigate, prevent infection. close wound using• Cyanoacralate• Suture• Steri-Strips• Occlusive dressing (Tegaderm)• Surgical staples• prevent infection

• Skin Abrasions: irrigate water, clean soap/Hibiclens, prevent infection

Tetanus immunization status of athlete

SKIN: Lacerations/Abrasions

• Penetrating injuries : Ascertain if object• Retained (Stingray barb or GSW)

or Not-retained (Bicycle Spoke)• Size of object

• Large Retained Object: Secure object and transport, DO NOT TRY TO REMOVE!!

• Extent of muscular, bony, neurologic or vascular injury,

• Tetanus immunization status of athlete

• Prevent infection

SKIN: Superficial Minor Contusions

• Local treatment as you would treat any contusion

• Common in FB, Rugby

• Thigh protectors seem to decrease incidence

• Ice, rest, protection from further injury, stretching

• If deep quadriceps contusion, more rigorous protocol is warranted.

SKIN: DEEP Quadriceps Contusions

• If deep quadriceps contusion, like FB helmet to quadricep• Place knee hyperflexed position (120

degrees) for 12-24 hours• Assess for Traumatic compartment

syndrome for first 24 hours• Crutches• ICE• Image with ultrasound daily for first 3

days to assess size of contusion/ hematoma

• Avoid meds that inhibit platelet/ clotting cascade (NSAIDs)

Mountain Biker thrown hit handlebars and root (MEDS: Advil 600mg prior to rides)

SKIN: DEEP Quadriceps Hematoma

• If ultrasound shows a substantial quadriceps hemtoma and after 24 hours of of knee hyper-flexion• Reassess with U/S to see is growing.• Generally, you want to attempt to drain these

after 24 hours or when it has tampanaded off.• Contoversy: simple aspiration vs aspiartion with

intra-luminal corticosteroid or PRP?• Place knee hyperflexed position (120 degrees)

for 12-24 hours immediately AFTER aspiration.• Crutches• ICE• Image with ultrasound daily for first 3 days to

assess size of hematoma for re-accumilation• Avoid meds that inhibit platelet/ clotting cascade

(NSAIDs)

SKIN: Quadriceps Myositis Ossificans (MO)

• Myositis ossificans: intramuscular formation of bone (heterotopic bone formation)

• MO can develop as LATE complication from a deep quadriceps hematoma.

• These develop weeks to months AFTER at quadriceps hematoma has been sustains.

• Most are mid-substance of quadriceps and are asymptomatic.

• If sxs arise, treatment options should start with stretching, mobilization, and physical therapy.

• Treatment with Indomethacin can help stem progress and pain

• Surgical excision is rarely needed

• Investigational: U/S guided percutaneous ultrasonic debridement (TX1 by TENEX)

QUADRICEPS: Strain

• Most common areas of injury are musculotendinous junctions proximally and distally

• Muscle belly can also be injured

• Treatment with RICE, stretching, HEP

• Can take weeks to get over

• Less common than hamstring injuries

QUADRICEPS: Tendon Rupture

• Younger Athletes: Usually an avulsion from the proximal pole of the patella

• Older Athletes: Tend to be an inter-tendinous rupture

• Inquire about uses of anabolic steroids, creatine, or fluoroquinolonesin past 6-12 months

• Will be unable to do a straight raise or extend the knee

• Will see defect when contract quadricep

• Requires operative repair

64yo lifter after WR attempt in C&J, 2014 IWF Worlds, Copenhagen (POD#2)

1) Patella Alta S/P Patellar Tendon Tear2) Patellar Tilt seen in Quad Tendon Rupture

1 2

LEFT quad tendon rupture & RIGHT patellar tendon ruptureIWF World Masters, Bordeaux, France 2006

Polish Lifter, C&J 130 kg

Can see Quad retracting, femur

Pat tdn tears

Same Lifter 8 years laterCopenhagen, DEN 2014

Josef Esmont, ended up winning GOLD medal in age/weight class in 2014 Worlds!

THIGH Compartment Syndrome: ACUTE

ACUTE is often related to TRAUMA• Seen in combat and collision sports

and alpine skiing• Can be associated with:

• Large thigh contusion/hematoma• With or without fracture • Blood thinner, ASA, some NSAIDs

• EXAM: know the 5 P’s• Pain, Pressure, Pulselessness, Palor,

Paresthesia• tense compartment, inability to move

or activate muscle• Higher likelihood of hematoma

Surgical Fasciotomy used for ACUTE, TRAUMATIC COMPARTMENT SYNDROME

THIGH Compartment Syndrome: CHRONIC

• CHRONIC or EXERTIONAL • Reports of exercise induced

compartment syndrome of the thigh

• NOT a medical emergency• NOT trauma related• SXS: worsen predictably with

exercise/activity

• EXAM: the 5 Ps AFTER exercise, occasionally at REST, can usually still activate involved muscle, but painful. Rarely involved hematoma

CHRONIC Compartment syndrome shows up MORE in LEG than THIGH

THIGH Compartment Syndrome: TESTING

• TEST for EITHER ACUTE or CHRONIC:

Compartment pressure testing (STRYKER UNIT)

• ABNORMAL: resting pressure >30mmHg

• ANATOMY: (know your compartments)

• Anterior, Lateral, Medial

THIGH: Compartment Syndrome: ANATOMY

• Anterior : quadriceps, iliopsoas, Sartorius, femoral nerve and artery, femur. Gr Saphaneous vein

• Posterior : Biceps Femoris, Semi-membranosis, Semi-tendinosis, sciatic nerve

• Medial : adductors, cutaneous branch of the obturator nerve, recurrent superficial br. of femoral nerve, deep femoral Artery & vein

Less common than chronic exertionalcompartment syndrome of the calf/leg as there is more space in the compartments of the thigh

THIGH: Compartment Syndrome: TREATMENT

• TREATMENT:• SURGICAL FASCIOTOMY:• More common in acute vs. chronic

• Open fasciotomy• Mini-open (small dermal incision

over larger fasciotomy) fasciotomy• Laproscopic fasciotomy

• DECONDITIONING (for Chronic Exertional ONLY)• 3-6 months off of intense exercise

that caused CECS.• ATROPHY with Fascial planes

ILIO-TIBIAL BAND SYNDROME

• Most common cause if “Lateral Hip Pain”• Runners, Overuse?

• Non-Athletes: Trauma? Weakness?

• Tender to palp, can’t sleep on that side

• LATERAL aspect of thigh• PROXIMAL: tensor fascia latta

• Greater trochanteric bursa

• DISTAL: lateral femoral condyle, near Gerdy’s tubercle

ILIO-TIBIAL BAND SYNDROME

• Exam: TIGHT ITB on • OBER’s TEST• Tender to deep palpation• Test for “Snapping Hip” in younger

athletes• MOST HAVE POOR PIRIFORMIS

STRENGTH

• TRMT: NSAIDs, HEP, formal PT, piriformis strengthening

• Cortisone injection, if above treatments ineffective,(USE at least a 3.5 inch spinal needle!!)

• SURGERY: rarely needed• Bursectomy with Elliptical excision

HAMSTRING: Strain

MECHANICISM

• Very common sports injury

• Avulsion (hyperflexion at the hip)

• Waterskiing injury

• Football, soccer, hockey, LAX

• Sprinters

• General population (slip on ice or wet floor)

HAMSTRING: Strain

LOCATION

• Mid substance injury (usually at the myotendinous junction)

• Distal injuries less common

• Rapid acceleration and maximum speed running

• Often feel a “pop” in back of thigh or near buttocks.

• Occasional palpable defect.

3 days AFTER 10 days AFTER

HAMSTRING: Strain

BIOMECHANICS:

• Eccentric mechanism at the terminal swing phase of gait

• Rate of Injury:• Biceps Femoris >>SM>ST

• High rates of re-injury

• Predisposing factors:• poor or no warm up• poor flexibility, • quad:hamstring ratio of 50%• poor biomechanics

HAMSTRING: Strain

TREATMENT

• Long time to full recovery 16-50 weeks to pre-injury status

• STAGE 1: protect, rest, Ice, Compress, dry needling, meds

• STAGE 2: Stretching, modalities, manual therapy

• STAGE 3: Dynamic sport-specific drills & “Nordic Eccentric Exercise”

• STAGE 4: T/C TX-1 and PRP in recalcitrant cases

HAMSTRING: Avulsion fracture/ proximal tendon• Waterskiing hyperflexion injury:

Starting on the dock, getting up out of the water, fall

• Can happen in the general population

• XRAY: if avulsion bone off pubic ramisis < 2cm, referral to Orthopedist

• ULTRASOUND: look for amount of avulsion, hematoma

• Hamstring avulsion In Skeletally immature athletes avulsion form the apophysis of the ischial tuberosity and can be treated conservatively most often

• Rarely require surgical repair/fixation

ADDUCTORS: Strain

• Less common injury compared to hamstring injury• Hams>>Adductor>Quad

• Adductor injury can be seen with• Breast Stroke

• Soccer athletes esp. if they have poor hip ROM

• Hockey, speed skating, roller derby, figure skating, XC skiing

ADDUCTORS: Strain

• DIFF DX: Sports Hernia/Pubalgia• Look for tenderness over pubic

symphysis, distal rectus abdominus, conjoint tenden

• XRAY: to rule out avulsion

• U/S: to assess muscular integretity

• TRMT: PRICES, Stretch, Dry Needling, PRP, PT

BONE (FEMUR) ISSUES

• FEMUR• Traumatic/Incidental Fracture

• Stress Fracture

• Pathologic Fracture

BONE (FEMUR) ISSUES

• FEMUR• Traumatic/Incidental Fracture

• Open physes• Legg-Calve Perthes

• AVN of Epiphyses

• Slipped Femoral Capital epiphyses

• Salter-Harris

• Closed physes• Location, Location, Location

BONE (FEMUR) ISSUES

• FEMUR• Stress Fracture

• Normal Bone, Abnormal stress• Excessive exercise

• Military marching

• Abnormal Bone, Normal Stress• Osteoporosis

• Chronic corticosteroids

• Amenorrhea

• Vitamin D deficiency

• Osteogenic Imperfecti (COL1A1)

16 yo small wrestler with thigh pain after summer spent “running and cutting weight.”

BONE (FEMUR) ISSUES

• FEMUR• Pathologic Fracture

• BENIGN• Non-Ossifying Fibroma

• Cortical defect• Aneurysmal Bone Cyst

• MALIGNANT• Secondary more common than

primary tumors• Most primary occur BEFORE age of

30 years old• PRIMARY: Osteosarcoma,

SECONDARY: metastasis, Multiple myeloma, Lung CA, Prostate CA

Review

• Irrigate abrasions/ lacerations judiciously with WATER

• Small contusion ICE

• Large Contusions /Hematomas• Knee flexion for 24 hours• Assess with U/S

• Quadriceps tendons tears: SURGERY

• Hamstring tears: RARELY need surgery

• Compartment syndrome• Know the 5 Ps• Perform Compartment pressure testing• ACUTE/TRAUMA/EMERGENANT• CHRONIC/ Exertional/ Non-emergent

• Bone• Traumatic fracture

• Open vs closed physeal• Stress fracture

• Normal Bone, Abnormal stress• Abnormal Bone, normal stress

• Pathologic fractures: METS and OS

• Others Causes:• PMR, Rhabomyolysis, etc

Thank you for your time!

mlavallee@wellspan.org