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contracture of the rectus femoris muscle: Diagnosis and follow-up with sonography
Joint Bone Spine 78 (2011) 92–93
Case report
Isolated fibrosis/contracture of the rectus femoris muscle: Diagnosis and follow-up with sonography Müfit Akyüz a , Ays¸egül Baltacı a , Aydan Kurtaran a , Barın Selc¸uk a , Cem Hatipo˘glu b , Levent Özc¸akar c,∗ a
Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey Department of Radiology, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey c Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey b
a r t i c l e
i n f o
Article history: Accepted 29 July 2010 Available online 18 September 2010 Keywords: Rectus femoris Contracture Sonography
a b s t r a c t Reported here is a 21-year-old female with isolated contracture of the rectus femoris muscle. Its possible relation to breech positioning, and the role of sonography for its diagnosis and close follow-up are discussed in the light of the relevant literature. © 2010 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction Isolated fibrosis/contracture of the rectus femoris muscle is quite rare in the literature. Possible causes include intramuscular injections, spasticity, trauma or other congenital factors [1–7]. Although the diagnosis can be clinical, further studies – often with magnetic resonance imaging (MRI) – are generally performed to illuminate the underlying cause. Herein, we report a young female with rectus femoris contracture most probably due to a delivery complication. The role of musculoskeletal ultrasonography (MUS) is also emphasized both with regard to the diagnosis and follow-up.
culoskeletal examination was unremarkable and routine laboratory tests were non contributory. The left patella was found to be a little higher than the right side on knee X-rays. Static and dynamic sonography – performed by a physiatrist experienced in MUS (LÖ) – displayed fibrosis of the left rectus femoris muscle (Fig. 2A). The diagnosis was also confirmed with MRI. Accordingly, the patient was diagnosed to have fibrosis/contracture of the rectus femoris. Since the patient refused surgery, she was commenced on a physiotherapy program that included hot pack, ultrasound and stretching exercises. After 6 weeks, knee flexion increased from 30◦ to 55◦ . Follow-up sonography revealed Grade I strain on the area where the patient described pain (sonographic palpation) (Fig. 2B,C). This
2. Case report A 21-year-old female was seen for inability to bend her left knee and gait disturbance. Her medical history comprised caesarean section due to breech positioning and walking difficulties since infancy. Mental and motor development was otherwise normal. She denied any history of trauma or injection in her left thigh. During physical examination, limitation in passive/active flexion of the left knee could easily be observed in prone position (Fig. 1). When the knee was further forced for flexion, flexion of the ipsilateral hip joint also accompanied. In the supine position with the hip in flexion, the knee flexion was found free. During walking (especially at high speed), she had to abduct and externally rotate the ipsilateral hip in order to compensate knee flexion deficiency. Similarly, she had the most difficulty during climbing the stairs. The rest of the neuromus-
∗ Corresponding author. Tel.: +90 312 3094142; fax: +90 312 3105769. E-mail address: [email protected] (L. Özc¸akar).
Fig. 1. Photograph of the patient in prone position demonstrating the limitation in left knee flexion.
1297-319X/$ – see front matter © 2010 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2010.07.013
M. Akyüz et al. / Joint Bone Spine 78 (2011) 92–93
93
Fig. 2. Comparative sonography of the patient’s thighs, left side of the images corresponding to the right thigh, (A) (axial view) white arrow demonstrating the irregular hyperechoic area consistent with fibrosis. (B) (axial view) and (C) (longitudinal view) white arrows showing the irregular anechoic area consistent with a strain lesion. R: rectus femoris; VI: vastus intermedius; F: femur.
lesion was considered to have ensued during intense physiotherapy. Thereafter, she was discharged with a home-based exercise regimen and was called for controls.
3. Discussion In the literature, quadriceps muscle contractures have been reported as either congenital [1–4] or acquired (mainly due to injections or trauma) [5–6]. Herewith, congenital cases generally display bilateral involvement and acquired ones show unilateral involvement. Quadriceps contractures have been classified into three types: rectus femoris type, vastus type and mixed type [8]. Vastus type is the most common form and rectus type has been reported as quite rare [8–9]. In our patient, both clinically and sonographically, we have detected isolated contracture/fibrosis of the rectus femoris muscle possibly due to breech positioning. Although bilateral injury could also be expected in such cases; it is noteworthy that the extent/type of involvement would indisputably depend on the maneuver(s) applied during such deliveries. To our best notice, any relationship between pre/antenatal trauma and rectus femoris fibrosis has not been mentioned before in the literature. The second reason we report our patient was to demonstrate the role of MUS in the diagnosis and follow-up of such muscle pathologies. In the aforementioned cases of quadriceps contractures, MRI has mainly been used to confirm the diagnosis and to uncover any possible underlying cause [10–12]. On the other hand, we have used MUS in our patient for imaging since it is inexpensive, convenient and it provides capability for repetitive and dynamic imaging. Likewise, during the follow-up after physical therapy, we could also disclose a strain lesion in the same muscle possibly due to intense
stretching. In this regard, it is noteworthy that MUS is very useful not only in the diagnosis but also in the close follow-up of relevant cases with muscle pathologies. Conflicts of interest None of the authors has any conflicts of interest to declare. References [1] Hnevkovsky O. Progressive fibrosis of the vastus intermedius muscle in children. J Bone Joint Surg 1961;43B:318–25. [2] Fairbank TJ, Barrett AM. Vastus intermedius contracture in early childhood. J Bone Joint Surg 1961;43B:326–34. [3] Karlen A. Congenital fibrosis of the vastus intermedius muscle. J Bone Joint Surg 1964;46B:488–91. [4] Chiu SS, Furuya K, Arai T, et al. Congenital contracture of the quadriceps muscle. Four case reports in identical twins. J Bone Joint Surg Am 1974;56:1054–8. [5] Lloyd-Robert GC, Thomas TG. The etiology of quadriceps contracture in children. J Bone Joint Surg 1964;46B:498–502. [6] Gunn DR. Contracture of the quadriceps muscle. A discussion on the etiology and relationship to recurrent dislocation of the patella. J Bone Joint Surg Br 1964;46:492–7. [7] McCloskey JR, Chung MK. Quadriceps contracture as a result of multiple intramuscular injection. Am J Dis Child 1977;131:416–7. [8] Sano S, Kokubun S. Report of the diagnosis and treatment of muscular contracture – the Ad Hoc Committee of the Japanese Orthopaedics Association of Muscular Contracture. J Jpn Orthop Ass 1985;59:223–53. [9] Stark WA. Quadriceps contracture in children. Am J Dis Child 1970;120:349. [10] Nozawa S, Tanaka C, Shikata J, et al. Congenital contracture of the quadriceps muscle: a case report with magnetic resonance imaging. Arch Orthop Trauma Surg 2004;124:272–4. [11] Özdemir O, Atalay A, C¸eliker R, et al. Congenital contracture of the quadriceps muscle: confirming the diagnosis with magnetic resonance imaging. Joint Bone Spine 2006;73:554–6. [12] Suksathien R. Idiopathic fibrosis of the quadriceps muscle: a case report with magnetic resonance imaging and pathological findings. J Med Assoc Thai 2008;91:568–73.
Case report
Isolated fibrosis/contracture of the rectus femoris muscle: Diagnosis and follow-up with sonography Müfit Akyüz a , Ays¸egül Baltacı a , Aydan Kurtaran a , Barın Selc¸uk a , Cem Hatipo˘glu b , Levent Özc¸akar c,∗ a
Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey Department of Radiology, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey c Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey b
a r t i c l e
i n f o
Article history: Accepted 29 July 2010 Available online 18 September 2010 Keywords: Rectus femoris Contracture Sonography
a b s t r a c t Reported here is a 21-year-old female with isolated contracture of the rectus femoris muscle. Its possible relation to breech positioning, and the role of sonography for its diagnosis and close follow-up are discussed in the light of the relevant literature. © 2010 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction Isolated fibrosis/contracture of the rectus femoris muscle is quite rare in the literature. Possible causes include intramuscular injections, spasticity, trauma or other congenital factors [1–7]. Although the diagnosis can be clinical, further studies – often with magnetic resonance imaging (MRI) – are generally performed to illuminate the underlying cause. Herein, we report a young female with rectus femoris contracture most probably due to a delivery complication. The role of musculoskeletal ultrasonography (MUS) is also emphasized both with regard to the diagnosis and follow-up.
culoskeletal examination was unremarkable and routine laboratory tests were non contributory. The left patella was found to be a little higher than the right side on knee X-rays. Static and dynamic sonography – performed by a physiatrist experienced in MUS (LÖ) – displayed fibrosis of the left rectus femoris muscle (Fig. 2A). The diagnosis was also confirmed with MRI. Accordingly, the patient was diagnosed to have fibrosis/contracture of the rectus femoris. Since the patient refused surgery, she was commenced on a physiotherapy program that included hot pack, ultrasound and stretching exercises. After 6 weeks, knee flexion increased from 30◦ to 55◦ . Follow-up sonography revealed Grade I strain on the area where the patient described pain (sonographic palpation) (Fig. 2B,C). This
2. Case report A 21-year-old female was seen for inability to bend her left knee and gait disturbance. Her medical history comprised caesarean section due to breech positioning and walking difficulties since infancy. Mental and motor development was otherwise normal. She denied any history of trauma or injection in her left thigh. During physical examination, limitation in passive/active flexion of the left knee could easily be observed in prone position (Fig. 1). When the knee was further forced for flexion, flexion of the ipsilateral hip joint also accompanied. In the supine position with the hip in flexion, the knee flexion was found free. During walking (especially at high speed), she had to abduct and externally rotate the ipsilateral hip in order to compensate knee flexion deficiency. Similarly, she had the most difficulty during climbing the stairs. The rest of the neuromus-
∗ Corresponding author. Tel.: +90 312 3094142; fax: +90 312 3105769. E-mail address: [email protected] (L. Özc¸akar).
Fig. 1. Photograph of the patient in prone position demonstrating the limitation in left knee flexion.
1297-319X/$ – see front matter © 2010 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2010.07.013
M. Akyüz et al. / Joint Bone Spine 78 (2011) 92–93
93
Fig. 2. Comparative sonography of the patient’s thighs, left side of the images corresponding to the right thigh, (A) (axial view) white arrow demonstrating the irregular hyperechoic area consistent with fibrosis. (B) (axial view) and (C) (longitudinal view) white arrows showing the irregular anechoic area consistent with a strain lesion. R: rectus femoris; VI: vastus intermedius; F: femur.
lesion was considered to have ensued during intense physiotherapy. Thereafter, she was discharged with a home-based exercise regimen and was called for controls.
3. Discussion In the literature, quadriceps muscle contractures have been reported as either congenital [1–4] or acquired (mainly due to injections or trauma) [5–6]. Herewith, congenital cases generally display bilateral involvement and acquired ones show unilateral involvement. Quadriceps contractures have been classified into three types: rectus femoris type, vastus type and mixed type [8]. Vastus type is the most common form and rectus type has been reported as quite rare [8–9]. In our patient, both clinically and sonographically, we have detected isolated contracture/fibrosis of the rectus femoris muscle possibly due to breech positioning. Although bilateral injury could also be expected in such cases; it is noteworthy that the extent/type of involvement would indisputably depend on the maneuver(s) applied during such deliveries. To our best notice, any relationship between pre/antenatal trauma and rectus femoris fibrosis has not been mentioned before in the literature. The second reason we report our patient was to demonstrate the role of MUS in the diagnosis and follow-up of such muscle pathologies. In the aforementioned cases of quadriceps contractures, MRI has mainly been used to confirm the diagnosis and to uncover any possible underlying cause [10–12]. On the other hand, we have used MUS in our patient for imaging since it is inexpensive, convenient and it provides capability for repetitive and dynamic imaging. Likewise, during the follow-up after physical therapy, we could also disclose a strain lesion in the same muscle possibly due to intense
stretching. In this regard, it is noteworthy that MUS is very useful not only in the diagnosis but also in the close follow-up of relevant cases with muscle pathologies. Conflicts of interest None of the authors has any conflicts of interest to declare. References [1] Hnevkovsky O. Progressive fibrosis of the vastus intermedius muscle in children. J Bone Joint Surg 1961;43B:318–25. [2] Fairbank TJ, Barrett AM. Vastus intermedius contracture in early childhood. J Bone Joint Surg 1961;43B:326–34. [3] Karlen A. Congenital fibrosis of the vastus intermedius muscle. J Bone Joint Surg 1964;46B:488–91. [4] Chiu SS, Furuya K, Arai T, et al. Congenital contracture of the quadriceps muscle. Four case reports in identical twins. J Bone Joint Surg Am 1974;56:1054–8. [5] Lloyd-Robert GC, Thomas TG. The etiology of quadriceps contracture in children. J Bone Joint Surg 1964;46B:498–502. [6] Gunn DR. Contracture of the quadriceps muscle. A discussion on the etiology and relationship to recurrent dislocation of the patella. J Bone Joint Surg Br 1964;46:492–7. [7] McCloskey JR, Chung MK. Quadriceps contracture as a result of multiple intramuscular injection. Am J Dis Child 1977;131:416–7. [8] Sano S, Kokubun S. Report of the diagnosis and treatment of muscular contracture – the Ad Hoc Committee of the Japanese Orthopaedics Association of Muscular Contracture. J Jpn Orthop Ass 1985;59:223–53. [9] Stark WA. Quadriceps contracture in children. Am J Dis Child 1970;120:349. [10] Nozawa S, Tanaka C, Shikata J, et al. Congenital contracture of the quadriceps muscle: a case report with magnetic resonance imaging. Arch Orthop Trauma Surg 2004;124:272–4. [11] Özdemir O, Atalay A, C¸eliker R, et al. Congenital contracture of the quadriceps muscle: confirming the diagnosis with magnetic resonance imaging. Joint Bone Spine 2006;73:554–6. [12] Suksathien R. Idiopathic fibrosis of the quadriceps muscle: a case report with magnetic resonance imaging and pathological findings. J Med Assoc Thai 2008;91:568–73.