Verletzungen der proximalen Rectus-femoris- und Adductor-longus-Sehne

Zusammenfassung

Sehnenrupturen der proximalen Rectus-femoris- und Adduktorensehne sind in der breiten Bevölkerung zwar sehr selten, jedoch in Sportarten wie Fußball oder Sprinten aufgrund sportspezifischer und immer wiederkehrender Bewegungsabläufe häufiger und von großer Relevanz, da sie zu langen Ausfallzeiten bis hin zum Karriereende führen können.

Anatomisch sind der 2-gelenkige (diarthrodiale) Verlauf des M. rectus femoris (RF) und der lange Verlauf des M. adductor longus (AL), vom oberen Schambeinast zum dorsalen Femur, charakteristisch. Durch schnelle, kraftvolle Hüftflexionsbewegungen und abrupte Adduktionsbewegungen bei schnellen Richtungswechseln in diversen Sportarten sind beide Muskeln häufig von Verletzungen betroffen.

Die Anamnese und klinische Untersuchung sind meist wegweisend, eine anschließende bildgebende Diagnostik jedoch für beide Muskeln essenziell. Die Sonografie und die Magnetresonanztomografie (MRT) sind dabei der Goldstandard. Die Therapie kann sowohl konservativ als auch operativ durchgeführt werden und ist abhängig vom Schweregrad der Verletzung.

Eine konservativ behandelte RF-Ruptur birgt die Gefahr von persistierenden Beschwerden und einem relevanten Kraftdefizit bei Wiederaufnahme der sportlichen Belastung, weshalb bei sportlich hohem Anspruch die Indikation zur operativen Refixation großzügiger gestellt werden sollte.

Im Bereich der proximalen AL zeigt die operative Therapie nach derzeitigem Stand keinen Vorteil. Eine Besonderheit stellt der Apophysenabriss bei Kindern und Jugendlichen dar und bedarf nicht selten einer osteosynthetischen Versorgung.

Sehnenrupturen der proximalen Rectus-femoris- und Adduktorensehne sind typische Sportverletzungen und bedürfen zur vollständigen Wiederherstellung von Kraft und Funktion nebst klinisch-radiologischer Diagnostik einer kritischen und erfahrenen Beurteilung hinsichtlich der Art und Schwere der Verletzung sowie der Heilungschance in Bezug auf eine operative und nicht operative Behandlung, um Risiken wie persistierende Schmerzen und Funktionseinschränkungen zu vermeiden. Der folgende Themenbeitrag dient als Übersicht über aktuelle Behandlungsstrategien und deren Indikationsgrenzen.

Abstract

Traumatic tendon tears of the proximal rectus femoris (RF) and adductor longus tendon (AL) are rare in general population but more frequently observed in athletes e.g. soccer or sprinting due to sport-specific movements and relevant to long lasting downtimes.

For accurate diagnosis detailed knowledge of anatomy and kinematics are essential for better understanding of injury mechanism and individual treatment.

RF is the only biarthrodial muscle in the quadriceps complex and important in aforementioned athletes functioning as both as hip flexion and knee extension. Proximal RF injuries mainly occur in sprinting and kicking ball sports including components of forced hip flexion or eccentric hip extension. The AL originates from the upper ramus ossis pubis to the dorsi side of the femur. Injury mechanism of proximal AL tears typically involve combined forced hip abduction and hip extension with or without contact.

Detailed clinical examination and trauma history are often indicative to the type of injury.

Ultrasonography is a real-time evaluation and has practical advantages over magnetic resonance imaging (MRI) including instant availability and relatively low-cost equipment. However, MRI is the gold standard for evaluating RF and AL tendon injuries.

Optimal management of proximal RF and AL tendon tear injuries remain controversial due to limited numbers of studies with treatment outcomes.

In general, both nonoperative and operative treatment lead to good functional results. Awareness should be given to athletes in demanding sports whereas in cases with retracted tendon surgical treatment is more indicated than for others thus chronic pain and residual hip flexor weakness is common complication after nonoperative therapy.

Apophyseal avulsion fractures are special forms of traumatic tendon injuries in adolescents and children and are of higher risk according to fragment dislocation and bone healing disorders.

Non-union of pelvic apophysis should be considered in management. Greater dislocated fragments are indicated to surgical fixation in order to avoid bone healing disorders.

Schlüsselwörter

Sehnenruptur - proximale Rectus-femoris-Sehne - proximale Adduktor-longus-Sehne - operative Refixation - Sehnenretraktion

Keywords

proximal rectus femoris tendon injury - proximal adductor longus tendon injury - tendon retraction - nonoperative treatment - operative treatment - surgical repair - anchor refixation

Publication History

Article published online:
06 July 2023

• Literatur

• 1 Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am 1991; 73: 1507-1525
• 2 Zarins B, Ctulio JV. Acute Muscle and Tendon Injuries in Athletes. Clin Sports Med 1983; 2: 167-182
• 3 Hallén A, Ekstrand J. Return to play following muscle injuries in professional footballers. J Sports Sci 2014; 32: 1229-1236
• 4 Mendiguchia J, Alentorn-Geli E, Idoate F. et al. Rectus femoris muscle injuries in football: a clinically relevant review of mechanisms of injury, risk factors and preventive strategies. Br J Sports Med 2013; 47: 359-366
• 5 Bottoni CR, D’Alleyrand JC. Operative treatment of a complete rupture of the origination of the rectus femoris. Sports Health 2009; 1: 478-480
• 6 Dean CS, Arbeloa-Gutierrez L, Chahla J. et al. Proximal Rectus Femoris Avulsion Repair. Arthroscopy Tech 2016; 5: e545-e549
• 7 Esser S, Jantz D, Hurdle MF. et al. Proximal Rectus Femoris Avulsion: Ultrasonic Diagnosis and Nonoperative Management. J Athl Train 2015; 50: 778-780
• 8 Gamradt SC, Brophy RH, Barnes R. et al. Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football. Am J Sports Med 2009; 37: 1370-1374
• 9 Fousekis K, Tsepis E, Poulmedis P. et al. Intrinsic risk factors of non-contact quadriceps and hamstring strains in soccer: a prospective study of 100 professional players. Br J Sports Med 2011; 45: 709-714
• 10 Witvrouw E, Danneels L, Asselman P. et al. Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players. A prospective study. Am J Sports Med 2003; 31: 41-46
• 11 Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med 2001; 29: 300-303
• 12 Woods C, Hawkins R, Hulse M. et al. The Football Association Medical Research Programme: an audit of injuries in professional football-analysis of preseason injuries. Br J Sports Med 2002; 36: 436-441
• 13 Muschaweck U, Gollwitzer H, Conze J. [Sportsmen’s groin. Definition, differential diagnostics and therapy]. Orthopade 2015; 44: 173-185
• 14 Morelli V, Smith V. Groin injuries in athletes. Am Fam Phys 2001; 64: 1405-1414
• 15 Willinger L, Siebenlist S, Lacheta L. et al. Excellent clinical outcome and low complication rate after proximal hamstring tendon repair at mid-term follow up. Knee Surg Sports Traumatol Arthrosc 2020; 28: 1230-1235
• 16 Orava S, Sinikumpu JJ, Sarimo J. et al. Surgical excision of symptomatic mature posttraumatic myositis ossificans: characteristics and outcomes in 32 athletes. Knee Surg Sports Traumatol Arthrosc 2017; 25: 3961-3968
• 17 Müller-Wohlfahrt HW. Terminologie und Klassifikation von Muskelverletzungen. Muskelverletzungen im Sport. In: Müller-Wohlfahrt HW, Ueblacker P, Hänsel L. . 2. Stuttgart: Thieme; 2014.
• 18 Hsu JC, Fischer DA, Wright RW. Proximal rectus femoris avulsions in national football league kickers: a report of 2 cases. Am J Sports Med 2005; 33: 1085-1087
• 19 Olmo J, Aramberri M, Almaraz C. et al. Successful conservative treatment for a subtotal proximal avulsion of the rectus femoris in an elite soccer player. Phys Ther Sport 2018; 33: 62-69
• 20 Kraeutler MJ, Garabekyan T, Mei-Dan O. The use of platelet-rich plasma to augment conservative and surgical treatment of hip and pelvic disorders. Muscles Ligaments Tendons J 2016; 6: 410-419
• 21 Park CK, Zlomislic V, Du J. et al. Nonoperative Management of a Severe Proximal Rectus Femoris Musculotendinous Injury in a Recreational Athlete: A Case Report. PM R 2018; 10: 1417-1421
• 22 Dalal S, Kotwal R, Chandratreya A. Operative versus conservative treatment of proximal rectus femoris avulsions: A systematic review with meta-analysis of clinical outcomes, complications and return to sports. J Clin Orthop Trauma 2020; 15: 83-92
• 23 Straw R, Colclough K, Geutjens G. Surgical repair of a chronic rupture of the rectus femoris muscle at the proximal musculotendinous junction in a soccer player. Br J Sports Med 2003; 37: 182-184
• 24 Taylor C, Yarlagadda R, Keenan J. Repair of rectus femoris rupture with LARS ligament. BMJ Case Rep 2012; 2012: bcr0620114359
• 25 Ueblacker P, Müller-Wohlfahrt HW, Hinterwimmer S. et al. Suture anchor repair of proximal rectus femoris avulsions in elite football players. Knee Surg Sports Traumatol Arthrosc 2015; 23: 2590-2594
• 26 Hinz M, Geyer S, Winden F. et al. Midterm outcome and strength assessment after proximal rectus femoris refixation in athletes. Arch Orthop Trauma Surg 2022; 142: 2263-2270
• 27 Lempainen L, Kosola J, Pruna R. et al. Operative Treatment of Proximal Rectus Femoris Injuries in Professional Soccer Players: A Series of 19 Cases. Orthop J Sports Med 2018; 6: 2325967118798827
• 28 Wittstein J, Klein S, Garrett WE. Chronic tears of the reflected head of the rectus femoris: results of operative treatment. Am J Sports Med 2011; 39: 1942-1947
• 29 Werner J, Hägglund M, Waldén M. et al. UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. Br J Sports Med 2009; 43: 1036-1040
• 30 Pezzotta G, Pecorelli A, Querques G. et al. MRI characteristics of adductor longus lesions in professional football players and prognostic factors for return to play. Eur J Radiology 2018; 108: 52-58
• 31 Matheson GO, Clement DB, McKenzie DC. et al. Stress fractures in athletes: A study of 320 cases. Am J Sports Medicine 1987; 15: 46-58
• 32 Best R, Gild A, Huth J. et al. Patient-related outcome measurements after operative and conservative management of traumatic proximal adductor longus avulsion injuries. Int Orthop 2020; 44: 965-971
• 33 Schlegel TF, Bushnell BD, Godfrey J. et al. Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes. Am J Sports Med 2009; 37: 1394-1399
• 34 White KK, Williams SK, Mubarak SJ. Definition of two types of anterior superior iliac spine avulsion fractures. J Pediatr Orthop 2002; 22: 578-582
• 35 Ferlic PW, Sadoghi P, Singer G. et al. Treatment for ischial tuberosity avulsion fractures in adolescent athletes. Knee Surg Sports Traumatol Arthrosc 2014; 22: 893-897
• 36 Kautzner J, Trc T, Havlas V. Comparison of conservative against surgical treatment of anterior-superior iliac spine avulsion fractures in children and adolescents. Int Orthop 2014; 38: 1495-1498
• 37 Schuett DJ, Bomar JD, Pennock AT. Pelvic Apophyseal Avulsion Fractures: A Retrospective Review of 228 Cases. J Pediatr Orthop 2015; 35: 617-623
• 38 Serbest S, Tosun HB, Tiftikçi U. et al. Anterior inferior iliac spine avulsion fracture: a series of 5 cases. Medicine (Baltimore) 2015; 94: e562
• 39 Eberbach H, Hohloch L, Feucht MJ. et al. Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskelet Disord 2017; 18: 162