George KoulourisMBBS, GrCertSpMed, MMed, FRANZCR

Melbourne Radiology ClinicMelbourne, VIC, AUSTRALIA

MR Imaging of the Quadriceps Muscle Complex

(QMC)

INTRODUCTION

• No financial disclosures

• 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

INTRODUCTION• Non-Rectus

Femoris (RF) injuries

• Vastus:– Lateralis– Medialis– Intermedius

• Mono-articular muscles– crossing the knee

joint only• Unlike RF (hip &

knee)• Broad myofascial-

aponeurotic origin

INTRODUCTION

INTRODUCTION• Type I (slow twitch

fibres)• Similar to soleus vs

gastrocnemius• Low gear muscles• Slower generation

of forces Less susceptible to strain

VASTUS LATERALIS• Largest• Most powerful of all

quadriceps• Origin:– Intertrochanteric

line– Anterior border

greater trochanter– Upper half lateral

linea aspera– (glut max, SHBF)

VASTUS MEDIALIS• Origin:– Anteromedial

intertrochanteric line

– Pectineal line– Medial linea aspera – Medial

supracondylar ridge

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

INTRODUCTION• Insertion:

QTTrilaminar

morphology

retinacula

REVIEW• 7 years of thigh

injuries• 66 vastus injuries• Excluded:– RF (Dr Kassarjian)– PF & hip instability– QT rupture

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

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

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

REVIEW – ALL VASTI• Single:

• Multiple injuries:– VL VM– VI VM– VI VL– VI VL VM

• 59 (8 contusions)

– 2– 1– 2 (1 contusion)– 2

REVIEW – ALL VASTI• 25 proximal 1/3

• 11 mid 1/3

• 30 distal 1/3

• myofascial

• Intra-muscular

• MTJ

REVIEW - ALL VASTI• Average age 26.6

(range 7-50)• Scar tissue– 10– 8 at site of previous

injury– 2 different site

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

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

Cross et al, Am J Sp Med 2004

THE ULTIMATE QUESTION

THE ULTIMATE QUESTION

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

13%; 8D+/-3 57%%; 17+/-10

27%%; 22+/-11 3%%; 73+/-60

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

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.

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

• Excellent prognosis– RTP– SHBF, soleus

• Be aware of:– DDx– Complications &

imaging features (MO)

• Low threshold to follow up, re-image &/or biopsy

CONCLUSION

THANK YOU

GeorgeK@melbourneradiology.com.au