The Rectus Femoris—The “Rodney Dangerfield Muscle”

I can’t get no respect.

—The famous line from the monologues of comedian Rodney Dangerfield (Figure 11-1).

If you have ever watched David Lee play basketball, you might wonder how someone that big can jump that high, that quickly. Lee is a rebounding machine, and when he gets the ball close to the basket, opponents tend to get the hell out of the way, lest they show up on a poster featuring one of his monster dunks.

But all of that was in jeopardy before the 2012 playoffs, when Lee tore off his rectus femoris muscle.¹ That’s the big boy in the quadriceps, the main muscle that runs from above the knee to the hip and is important for stability. The conventional wisdom was 3 to 5 months of rest and rehab to recover from the injury. So, Lee went back and played, despite the serious problem, which was repaired during the off-season. He even helped Golden State in its first playoff berth in 6 years.¹

Figure 11-1. Rodney Dangerfield, the famous comedian who “gets no respect.” (Reprinted with permission from AP Photo/Douglas C. Pizac.)

Injuries like this one should not have preset solutions. A savvy group of docs allowed Lee to play through his problem. Meanwhile, the athletic Sacramento Kings’ Carl Landry tore his rectus femoris before the 2013-14 campaign and opted for surgery.2,3 He missed 3 months of the season but came back healthy and worked his way back into the team’s rotation. It’s an individual thing.

Sometimes the prevailing belief needs be challenged, particularly when it’s based on broad-spectrum data and no logic. Consider the NHL player who tore the muscle. Advised against surgery, he never got back on the ice. Finally, he went over the boards with frustration and sought new opinions. His hip had become compromised by unwelcome bone growth spurred by the torn muscle.

INTRODUCING THE RECTUS FEMORIS MUSCLE

More than any other muscle in the body, and just like Rodney Dangerfield’s persona, the rectus femoris muscle needs a new or proper introduction to the sports medicine and fitness worlds at large (Figure 11-2). Those worlds have largely ignored this muscle.

For years, the muscle has gotten no respect and it still gets no respect. Come on, people…this muscle is important. Recognize that fact. That should be obvious simply from the massive position it occupies in the thigh. Not only does it command a huge presence, it also is the main muscle directly connecting the pelvis to the knee. It guards the hip. It compensates for the knee and the hip. It originates from one of the 3 pelvic bones, the ilium, and becomes the most anterior knee attachment, the patella.

Steve Martin was right: “A day without sunshine is like, you know, night.” The rectus femoris muscle is so large and obvious (Figure 11-3). It’s like night and day, some things are just so obvious.

Figure 11-2.

Figure 11-3. A more complete view of the rectus femoris.

And just like center/power forward David Lee or the massive players Shaquille O’Neal or Kendrick Perkins have such presence on the NBA court, we have to take notice of this big muscle. We must respect the presence in the thigh of this muscle, if only simply for the fact that it takes up so much space. It should be overstating the obvious to say that this muscle must be important for overall core or thigh stability. It’s like day and night.

But that has not been the case. Its importance has been incredibly downplayed. When the rectus femoris gets ripped off, most surgeons have just said, “Oh, the rectus femoris doesn’t matter, the thigh will function fine without it.” Now, sit back in your chair, take a swig on your whiskey and puff of your cigar and ask the 2 obvious questions, “Where are the data for this lack of importance of the rectus femoris muscle?” And, “Who are these laissez-faire promoters kidding?” (See Figure 11-4.)

Simply said, the rectus femoris muscle gets no respect. That’s why we call it the “Rodney Dangerfield muscle.”

Figure 11-4.

I was such an ugly kid, when I played in the sandbox the cat kept covering me up.

I remember the time I was kidnapped and they sent a piece of my finger to my father, he said he wanted more proof.

—Rodney Dangerfield.

SO…WHY NO RESPECT?

So, where did our cheeky attitude come from with respect to the rectus femoris muscle? We’re not sure. It probably came from us surgeons generally never attributing much importance to fixing muscles. For the most part, orthopedists have focused on the traditional joints and not on soft tissues; historically, orthopedists casted off soft tissue work to general surgeons. And as mentioned before, general surgeons don’t generally think about biomechanics. In other words, the specialties of medicine exist as little fortresses without much communication between them. A lot of territory exists between the fortresses. The final reason for the attitude comes from the same terrain: surgeons just hadn’t paid enough attention to develop the techniques for repairing the rectus femoris and other core muscles.

Whatever the case, a 2009 article in the American Journal of Sports Medicine certainly bolstered the same laissez-faire brashness. The conclusion in that article was: “Proximal avulsions of the rectus femoris can be treated nonoperatively with a high degree of predictability for return to full, unrestricted participation in professional American football.”⁴

That oft-quoted conclusion became sports medicine dictum: Leave all ripped-off rectus femoris muscle alone.

Now consider 4 facts about that paper.

It reported only 11 patients.
This was a pure data-based study.
It came from the NFL.
The proband of that paper (ie, the player who triggered the interest for the authors to write it in the first place) reportedly ended up having hip surgery due to a complication of not having repaired the muscle in the first place. He apparently developed heterotopic ossification (HO), which led to hip impingement.⁵

Let’s look even deeper into the printed observations in that paper. The careers of only 6 of the 11 injured players were available for analysis, and 2 of those 6 were place-kickers. We already mentioned the proband, who continued with symptoms. The second player interviewed was a long snapper, not exactly the most strenuous position, and he played for 2 more seasons. No mention was made about whether his avulsion was of the direct or indirect head of the rectus femoris for 9 of the 11 players. The authors recognized that most avulsions occur in the indirect head and not the direct head, the most important attachment. It turns out that avulsions of the indirect heads are relatively minor injuries and don’t usually require surgery. We have subsequently found that place-kickers suffer primarily indirect head avulsions. One of the only 6 players followed up in the paper persisted with symptoms. Interestingly, in the paper’s discussion, the authors mention multiple outside reports of failed attempts of nonoperative management. They also mention that these injuries are likely underreported.

So, let’s summarize. The primary paper in the literature bolstering a routine nonoperative approach to complete avulsions of the rectus femoris muscle had follow-up on only 6 patients, only 2 of whom were interviewed had surgery. Two others of the 6 likely had injuries that ordinarily never require surgery (ie, indirect head tears), and the 1 remaining player was a long snapper. Plus, 1 player, likely the one with persistent symptoms, played just 1 more year in the NFL. That means, using the most favorable possible statistics, the nonoperative approach, so eloquently endorsed by this article, had a 50% or 75% failure rate in the 4 patients with injuries possibly germane to the topic.

Plus, most of the case reports and small case series in the literature at that time and including the ones cited by the authors of that paper endorsed operative management of rectus femoris avulsions, usually after a trial of nonoperative therapy.2,3,6,7 It is difficult to find anything at all on acute operative repair of big avulsions, even though they happen frequently.

Therefore, judging from the data presented in that bolstering paper, it should be clear as day that the authors’ conclusion is just plain wrong. Not only that, but it also seems obvious that rectus femoris injuries ought to be associated with significant disability. It turns out that more information on this muscle simply does not exist in the medical literature.

So… bearing in mind how much space the rectus femoris muscle occupies in the thigh and how little attention this enormous muscle gets, what’s the story? Shouldn’t we take this muscle much more seriously?

Talk about no respect.

Rodney, move over…

RECTUS FEMORIS INJURIES

To be fair, the above NFL database study also does not say that these players do better with surgery. The paper simply concludes, albeit wrongly, that nonoperative treatment is the way to go. We docs sometimes jump to conclusions on the basis of bias or minimal data.

It is time to discard this attitude and keep an open mind about rectus femoris injuries. Treatment likely depends on the situation. We have not yet published our full experience, yet we know that selected patients with complete rectus femoris avulsions do very well with repairs. Plus, seeing more and more such injuries in high-performance athletes, we can say, without uncertainty, that certain types of injuries left untreated lead to suboptimal performance and premature retirement from sports. Like other core muscles, quite a variety of injuries befall the rectus femoris muscle. Here are a few examples.

Keep in mind the anatomy of the rectus femoris muscle. Its main head originates from the anterior inferior iliac spine (AIIS), and its minor (indirect head) originates from a small grove posteriorly in the acetabulum. They quickly join and become a big muscle bulk that flattens and narrows as it becomes the patella. Three muscles named vastus (medialis, lateralis, and intermedius) combine with the rectus femoris to become a large fleshy mass of muscle known as the quadriceps mechanism. Surgeons tend to give the 3 vastus muscles too much credit. But face it. Those 3 other muscles just don’t make up for loss of their leader, the Rodney Dangerfield muscle.

Case 1. Acute Complete Avulsion

A professional basketball player experiences a sudden pop in his right anterior thigh. The player still felt weak at 6 weeks after the injury. An initial MRI showed a “strain.” Figure 11-5 is the MRI 6 weeks after the event.

The player still underwent repair and was back at full performance at just 3 months postoperatively. There was considerable atrophy and retraction of the muscle stump. Yet, the repair went well, and the muscle was easily mobilized. Muscle mass and function fully returned. These repairs are much easier if they are done within the first week or two of the injury.

Figure 11-5. T2 coronal image of the NBA player with a complete rectus femoris avulsion. Arrow points to the main, now shredded stump of the muscle retracted 5 to 10 cm away from its origin on the pelvic bone. The white represents blood and reactive fluid. Note the shredded appearance, which represents that the muscle ripped like a telescope. Obviously, the entire rectus femoris is ripped off. It is not possible to discriminate between the direct and indirect heads, nor does that make a difference in treatment of this patient.

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