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Rectus femoris muscle injuries in football: A clinically relevant review of

mechanisms of injury, risk factors and preventive strategies

Article  in  British Journal of Sports Medicine · August 2012

DOI: 10.1136/bjsports-2012-091250 · Source: PubMed

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Review

Rectus femoris muscle injuries in football:

a clinically relevant review of mechanisms of injury,
risk factors and preventive strategies
Jurdan Mendiguchia,1 Eduard Alentorn-Geli,2 Fernando Idoate,3 Gregory D Myer4,5,6,7

and blends anteriorly with the muscle’s fascia.14

1
Department of Physical ABSTRACT
Therapy, Zentrum Rehab and Quadriceps muscle strains frequently occur in sports that The indirect head contributes to the fibres of the
Performance Center, Barañain,
Navarre, Spain
require repetitive kicking and sprinting, and are common deep, intramuscular component of the conjoined
2
Department of Orthopedic in football in its different forms around the world. This tendon and forms a deep myotendinous junction
Surgery, Hospital del Mar i paper is a review of aetiology, mechanism of injury and that extends downward approximately two-thirds
l’Esperança, Parc de Salut the natural history of rectus femoris injury. Investigating of the muscle belly of the rectus.14
MAR, Barcelona, Spain the mechanism and risk factors for rectus femoris The rectus femoris extends the knee, flexes the
3
Department of Radiology,
Clinica San Miguel, Pamplona, muscle injury aims to allow the development of a hip and stabilises the pelvis on the femur in
Spain framework for future initiatives to prevent quadriceps weight-bearing.15 16 In addition, the rectus femoris
4
Sports Medicine Biodynamics injury in football players. has a high demand for eccentric muscle contrac-
Center and Human Performance tion and has a high percentage of type II fibres
Laboratory, Cincinnati Children’s
Hospital Medical Center,
(approximately 65%) that can make it more prone
Cincinnati, Ohio, USA INTRODUCTION to injury.17
5
Departments of Pediatrics and Muscle injury is the most common injury type in
Orthopaedic Surgery, College of football.1–4 Quadriceps muscle strains frequently IMAGING AND GRADING OF INJURY SEVERITY
Medicine, University of
Cincinnati, Cincinnati, Ohio, USA
occur in sports that require repetitive kicking and In acute rectus femoris muscle strain injuries the
6
Athletic Training Division, sprinting efforts and are common in football in its player feels a tearing sensation and stops playing. In
School of Allied Medical different forms around the world.1 5–7 The rectus subacute injuries the player reports gradual onset of
Professions, The Ohio State femoris is the most commonly injured muscle of
University, Columbus, Ohio,
pain during running and kicking. Examination
the quadriceps muscle.7–11 reveals that stretching, palpation at the site of
USA
7
Departments of Athletic The mechanism of lower extremity muscle injury and resisted knee extension are painful.
Training, Sports Orthopaedics, injuries in football remains to be fully elucidated. Differential diagnosis includes assessment of neural
and Pediatric Science Rocky The incidence of injury varies across the season; a tension of the femoral nerve,18 where the athlete
Mountain University of Health higher risk of posterior thigh muscles exists during
Professions, Provo, Utah, USA may complain of a burning or stinging sensation
the in-season,1 12 while rectus femoris strains located in the anterior aspect of the thigh.
Correspondence to (29%) were more frequent than biceps femoris Classically, the most common site of rectus
Dr Jurdan Mendiguchia, (11%) muscle injuries in the pre-season of the femoris injury was the distal myotendinous junc-
Department of Physical Therapy, English Premier League13 and the Australian tion near the knee joint.11 19 20 Other locations for
Zentrum Rehab and Football League.7 In contrast, Ekstrand et al found
Performance Center, Calle B rectus femoris injuries may be at the junction of
Nave 23, Barañain, Navarre, that quadriceps muscle strains were fairly constant the conjoined tendon with the muscle belly (rectus
Spain; throughout the season.1 Quadriceps muscle injur- femoris peripheral area (RF-Peri); figure 2A),8 or at
[email protected] ies cause more missed games than do hamstring the deep myotendinous junction of the indirect
and groin muscle injuries,1 and reinjury rates head, referred to as the central part of the tendon
Received 3 April 2012
Accepted 4 July 2012
(17%) are high. We reviewed the literature on by some authors (figure 2A).6 8 9 14 15 21 22 The
rectus femoris muscle injuries and discuss the latter is the most common location of rectus
underlying biomechanical mechanisms and risk femoris tendon tears in soccer.6
factors with a view to injury prevention. Importantly, two recent reports that monitored
injury incidence in soccer and Australian Football
ANATOMY players showed that the rectus femoris central
Anatomy appears to play an important role in tendon injury is associated with a significantly
quadriceps muscle prognosis. The rectus femoris is longer rehabilitation time (especially proximal)
a fusiform and biarticular long muscle located in and delayed return-to-sports compared with more
the anterior aspect of the quadriceps muscle, these peripheral injuries.6 8 Reinjury of the muscle
types of muscles are designed to execute move- (17%), myositis ossificans, acute compartment
ments that require significant length change or syndrome and residual weakness are complications
high shortening velocity. This biarticulate muscle associated with rectus femoris tears.23–28
is innervated by the femoral nerve and has two Muscle injuries can be imaged with ultrasonog-
heads of origin: the direct or straight head, which raphy and MRI, to diagnose and monitor the reso-
arises from the anterior inferior iliac spine, and the lution of rectus femoris injuries. Plain radiographs
indirect or reflected head, which arises from the may be important to rule out associated bone
superior acetabular ridge (figure 1).14 15 The two injuries such as avulsion of the anterior inferior
heads form the conjoined tendon slightly below iliac spine in the skeletally immature player.
their origin. The direct head contributes mostly to Myotendinous strains may be graded by MRI.29
the superficial component of the conjoined tendon A grade I tear where the integrity of the

Br Copyright Articledoi:10.1136/bjsports-2012-091250
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Figure 1 Three-dimensional reconstructions (A: anteroposterior proyection, B: lateral proyection) of muscle (blue) and tendons of rectus femoris,
and iliac and femur bones (orange) obtained from segmentation of multiple series of MRI of a professional soccer player. Surface models of the
bones, tendons and muscles were generated from two-dimensional outlines (C: image obtained at the level of proximal coxofemoral joint, green
arrow at A; D: image obtained at level of distal major trochanter, grey arrow at B) that were drawing manually using an specific software
(SliceOmatic, Montreal). The proximal tendon is composed of a superficial, anterior portion from the direct head (yellow) that originates from the
anterior-inferior iliac spine, and a deep intramuscular portion from the indirect head (red) emerging from the posterior-superior acetabular ridge. This
figure is only reproduced in colour in the online version.

myotendinous junction is maintained is defined by the presence to unrestricted activity have been recently demonstrated after a
of a high-intensity signal either focally or diffusely at the myo- non-operative treatment.30–32
tendinous junction on fluid-sensitive images. A feathery appear- Hughes et al22 defined the term ‘bull’s eye sign’, to describe
ance of the muscle on all pulse sequences is consistent with the increased signal around the rectus femoris intrasubstance
interstitial haemorrhage and oedema. Acute grade II tears show tendon, seen in 65% of players (figure 3). Gyftopoulos et al10
partial disruption of the myotendinous junction with interstitial suggested this sign represented evolving stages of injury (early
feathery high-intensity signal or haematoma. Low signal repre- oedema and haemorrhage, later increased vascularity and scar-
senting either fibrosis or haemosiderin can be seen in chronic ring) around the deep tendon. A bull’s eye sign with secondary
injuries (figure 2). Grade III tears are complete myotendinous atrophy and fatty infiltration of the muscle around the tendon
disruption with or without retraction, and even that surgical reflects an old injury. Occasionally, a pseudo cyst, produced by
intervention has been classically recommended, successful return serous fluid in the haematoma, is noted at the site of tear.

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Figure 3 Bull’s eye sign. (a) Transverse axial fat-suppressed T2-

weighted MRI of a 30 soccer player shows increased signal (white
arrows) around the rectus femoris intrasubstance tendon (black arrow)
consistent with acute strain. (b) Corresponding color-Doppler US image
Figure 2 Fibrous scarring after remote rectus femoris injury has low
shows areas of increased vascularity (arrows) surrounding the rectus
signal intensity with all pulse sequences and appears as hypointense
femoris intrasubstance tendon (arrowhead).
area at the previous tear site. (a) Re-torn of deep myotendinous
junction of the indirect head in a 23-year-old soccer player. MRI shows
an area of hyperintensity (white arrows) surrounding the deep
myotendinous junction consistent with a strain tear. A focal area of through an eccentric muscle action.42 Maximum elongation
irregular hypointensity of the indirect tendon (arrowhead) is takes place near 55% of sprint cycle just after the initial
characteristic of scar tissue. (b) A 19-year-old soccer player who contact of the contralateral leg, and just in the transition from
presented with persistent thigh pain after remote rectus femoris injury. maximal hip extension (40%) to maximum hip and knee
Transverse axial fat-suppressed T2-weighted MRI shows a laminar scar flexion (65%).42 Therefore, high angular velocities of the hip
(arrows) due to former posterior peripheral tear.
and knee during the swing phase of sprinting combined with
high eccentric activation make rectus femoris more prone to
injury. During the first half of the swing phase of sprinting, the
MECHANISM OF INJURY
hip and knee are both flexed, generating a flexor moment at
Muscle strain injuries usually occur during eccentric muscle
the hip while an extensor moment at the knee is created. The
action.33–40 Sprinting and kicking require eccentric rectus
energy harnessed from a moving body segment is then trans-
femoris action and combined with its biarticular nature leave it
ferred to the adjacent joint.42 43 This forces the rectus femoris
vulnerable to injury.
to lengthen to decelerate the tibia as the knee flexes during
early swing phase of sprinting.
Sprinting injury mechanisms
Acceleration Deceleration
The maximum length of rectus femoris occurs during early Football players repeatedly change in direction, decelerate or
swing phase,41 where the hip-flexor muscles generate force at stop suddenly. The forces applied to the body when decelerat-
the same time as the knee-extensor muscles absorbed energy ing can be exceptional, especially when the time over which

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these forces must be absorbed is short.44 Body positioning in Ground contact phase
the deceleration phase is adjusted to allow for the substantial The association between muscle injuries and dry weather sug-
eccentric forces to be absorbed and dispersed throughout the gests that the mechanism of quadriceps muscle strain may
body. The trunk assumes a more erect posture (in relation to involve a closed kinetic chain activity. In fact, foot to ball
the lower body) and posterior lean during deceleration, moving contact is much lower than ground reaction forces in the decel-
the centre of mass posterior to the base of support.45 46 This eration at the final step of the kicking leg. Ground contact
results in additional horizontal braking forces and consequently during kicking is associated with high external forces (ground
more eccentric force imposed on the quadriceps, though reaction force) but at the same time less angular velocity
increasing its moment arm in actions like kicking or sudden because the large muscle moments are opposed by the ground
changes of direction hypothetically predisposing the rectus reaction forces. Deceleration during a kicking motion causes
femoris to injury. the body to lean backwards and the leg to move farther
behind the body than normal, which places extra stress and
Kicking strain on the rectus femoris. Upper body extension may result
The most common mechanism of rectus femoris muscle injury in increased external knee flexion and internal quadriceps
in soccer is kicking.13 47 Kicking is a momentum-assisted moments during kicking. This may be explained by an increase
motion, with much of the work performed eccentrically in the in the quadriceps moment arm and may be related to
early phases by proximal muscle groups and the resulting injury.1 51
momentum transferred to distal segments just before ball
contact. Although quadriceps strains related to kicking were RISK FACTORS
thought to occur on the kicking leg side, controversy exists as Several risk factors have been suggested for quadriceps muscle
to whether rectus femoris muscle strains primarily occur during injuries. These factors may be classified in intrinsic and
ball contact, swing phase of kicking or ground contact phase extrinsic.
during the step before the backswing.
Intrinsic factors
Ball contact Age
During the ball contact phase of kicking the rectus femoris is Although the incidence of muscle injuries in the athletic popu-
in a relatively shortened state, and muscles need to be in a rela- lation generally increases with age,1 this does not seem true of
tively stretched state to induce a strain injury.48–50 Although the quadriceps muscle. Three large prospective studies including
maximum knee extension moment occurs during the ball one of 485 injures in almost 2300 players found no association
contact phase, the quadriceps muscles are not in danger of between age and this muscle injury.1 51 61
strain injury because they are not lengthened or eccentrically
contracting during this phase. This may be modified by varia- Previous injury
tions in ball-foot impact forces that depend on the distance Previous muscle injury is a risk factor for quadriceps muscle
kicked and the weight of the ball, which would be greater in strains.51 Increased risk of rectus femoris injury was found in
wet conditions. The fact that most injuries occur in preseason players with a previous injury of the quadriceps muscle. Also, a
(good weather) and after low rainfall argues against an associ- recent hamstring strain significantly increases the risk of quadri-
ation between increased impact forces generated by ball ceps strain.51 Altered gait patterns that occur after hamstring
wetness and ball contact mechanism.51 muscle strains, such as a reduction in the stride length, may
Conversely, lower ball pressure has been shown to decrease protect the injured hamstring muscle from re-strain but
impact forces and increase contact time but a study of increase the chance of a quadriceps strain.51
Australian Rules Football players found no correlation between
muscle injuries and ball pressure.52 Short height and high body weight
Two studies suggested a potential relationship between height
Swing phase and weight, and rectus femoris injuries.51 62 A recent study fol-
The rectus femoris is contracted eccentrically during the early lowed 100 professional soccer players (aged 19.4–27.8 years) for
swing phase and the wind-up phase of the swing phase of a season where a trend ( p=0.06) was observed for shorter
kicking where it may be predisposed to injury. During the back- players (OR=0.08; 95% CI 0.00 to 1.35) and heavier players
swing phase (early swing phase), the thigh angular velocity is (OR=10.70; 95% CI 0.73 to 156.37) to suffer more muscle
minimal while the shank velocity is negative due to its back- strains compared to taller and thinner subjects.62 The authors
ward movement, rectus femoris acts to decelerate hip extension attributed the lack of statistical significance to the small
and knee flexion.53 54 Furthermore, the thigh was mainly decel- number of injuries (seven rectus femoris injuries). Similarly,
erated by interactive moments exerted by the shank rather Orchard et al51 reported that Australian football players with a
than a hip extension or flexion moment.55 height below 1.82 cm had a significant increase in the risk of
During the initial part of the forward swing phase (wind-up quadriceps muscle injury (relative risk of 1.48 (95% CI 1.09 to
phase), the hip starts to flex and the thigh angular velocity is 2.02) 183 quadriceps muscle injuries) compared to taller indivi-
positive whereas the knee is still flexing and a negative shank duals. In contrast, Bradley and Portas61 in a one season pro-
angular velocity is observed.56 At maximal knee flexion (85–90° spective study in 36 English premier league soccer players
at 70% of swing phase), the rectus femoris contracts eccentric- found weight was not a significant contributing factor for
ally to counteract excessive knee flexion (wind-up phase).54 57–60 injury.
Because slightly greater angular velocities and greater knee
flexion are present during the wind-up phase, we believe that Dominance
this part of the kicking action may be related to rectus femoris Leg dominance may be a risk factor for injury, as the majority of
injury. quadriceps muscle strains (60%) involve the dominant leg

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( preferred kicking leg), whereas only 33% affect the non- phase, the hip flexors utilise the stretch-shortening cycle,
dominant leg (7% were reported in both legs or the leg domin- thereby enhancing their capacity to generate greater hip flexion
ance was unknown).1 Quadriceps muscle strains in Australian moment. A lack of hip extension may require rectus femoris to
Rules football players were more common in the dominant generate more hip flexion force, and fatigue and overload of the
kicking leg (relative risk 2.13, 95% CI 1.59 to 28.6), whereas rectus femoris may occur. Second, roots of the femoral nerve
hamstring and calf injuries were almost equally distributed.51 directly pass through the psoas muscle. A restricted psoas may
mechanically irritate the femoral nerve and cause tension
Flexibility further down the neurodynamic chain. Repeated lumbar exten-
Witvrouw et al63 and Fousekis et al62 examined whether a rela- sion and hip flexion, as required during kicking, has been impli-
tive lack of quadriceps muscle flexibility before the Belgium and cated in femoral nerve injury with concomitant weakness of
Greek seasons could identify a professional soccer player at risk the quadriceps strength in a modern dancer.65 Therefore, the
for a quadriceps muscle strain. A total of 146 and 100 male pro- femoral nerve may be implicated in rectus femoris injuries in a
fessional soccer players were assessed during each respective similar way that the sciatic nerve is implicated in hamstring
preseason. Results revealed that 13 of 146 players in the strains.
Belgium league and 7 of 100 players in Greek league sustained a Therefore, knee extensors and hip flexors flexibility training
clinically diagnosed quadriceps muscle injury. Witvrouw et al63 in order to achieve optimal levels may be an appropriate focus
found statistically significant lower quadriceps flexibility in the in preventive programmes that aim to reduce rectus femoris
injured players. Fousekis et al62 found a trend toward flexibility muscle injuries in kicking sports.
asymmetries in those players who sustained an injury. In con-
trast, Bradley and Portas61 registered 6 injuries in 36 premier Strength
league soccer players and found flexibility was not a significant Improving proximal hip strength and knee extension strength
risk factor for quadriceps injury. at long muscle length may be areas to target to reduce rectus
femoris injury.
Strength
One hundred professional soccer players had isokinetic concen- Hip flexor strength
tric and eccentric knee extensor strength measures in preseason Kicking performance is influenced by both knee extension
and were monitored until the end of the competition period. moment,53 66 and hip flexion moment.67 68 Some investigations
Seven players suffered a quadriceps muscle strain during the have demonstrated that hip flexion moments were almost
season. Concentric strength was not a risk factor for quadriceps twice the corresponding knee extension moments during
injury.62 Eccentric strength differences at preseason were found kicking.57 69–71 In fact, peak hip flexion moment of the kicking
between those injured compared to uninjured players limb was the strongest predictor of peak foot velocity, suggest-
(OR=5.01; 95% CI 0.92 to 27.14), although the difference was ing that the ability to generate a greater hip flexion moment is
not statistically significant, probably due to the low number of critical to achieve a high foot velocity during kicking.
injuries.62 Further investigations are required. Conversely, Naito et al68 reported that centrifugal force-
dependent moment of the kicking leg at the knee as a conse-
quence of the hip flexion angular velocity was the primary con-
Extrinsic factors
tributor to rapid knee extension and, thus, foot velocity.
Dry field Studies using electromyography and MRI for the evaluation of
Quadriceps muscle strains are more common after a week with kicking motion support this finding, and show a high activa-
low rainfall.64 A study of Australian Rules football players tion of iliacus and psoas muscles during kicking concomitantly
revealed that quadriceps strains (like many other non-contact with rectus femoris.60 72
lower-limb injuries) were relatively more likely on dryer and Both iliopsoas and rectus femoris muscles generate hip
harder northern grounds where ground traction was a greater. flexion force. Recently, the contribution of the proximal rectus
Moreover, Woods et al13 found more rectus femoris strains asso- femoris to hip flexion moment suggest that divergent regions of
ciated with a dry field during preseason of two consecutive muscle fibres within rectus femoris have different functions
English soccer seasons involving 1200 players. depending on force direction.73 As a consequence, a reduction
in the strength and/or activation of the iliopsoas muscle may
PREVENTION OF RECTUS FEMORIS INJURY result in rectus femoris compensation to generate more hip
Intervention studies that specifically alter risk factors for rectus flexion force, and has been recently demonstrated through
femoris injury in football players are sparse, therefore one pre- three-dimensional musculoskeletal models.74 When the iliop-
vention strategy is to address known risk factors and injury soas muscle force contribution was reduced by 50%, rectus
mechanism biomechanics. The parameters that may afford the femoris force increased to compensate for the iliopsoas weak-
best opportunity to prevent rectus femoris injury are flexibility, ness.74 In football, this may result in an overload of the rectus
strength and core stability. Because of the lack of data, we share femoris and, thus, increase the risk of injury. Therefore, good
recommendations that are largely ‘expert opinion’ (level 5 function of hip flexor muscles is necessary to prevent quadri-
evidence). ceps muscles injuries.
The conjoined distal tendon of the iliopsoas muscle crosses
Flexibility anterior and slightly medial to the femoral head as it courses
Quadriceps muscle flexibility (>128°) should be a cornerstone downward to its insertion on the lesser trochanter. In this
of any prevention programme targeted to reduce rectus femoris distal part, the broad tendon is deflected posteriorly at 35°–45°
injury, at least in soccer.62 63 However, we believe that hip as it crosses the superior ramus of the pubis. With the hip
flexor length must be optimal too as for the following reasons. in full extension, this deflection raises the tendon’s angle of
First, tight iliopsoas muscle restricts hip extension. As the insertion relative to the femoral head, thereby increasing
kicking action requires hip extension during the early swing the muscle’s leverage for hip flexion.75 As the hip flexes to 90°,

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the flexion leverage becomes even greater.75 Such a parallel

increase in leverage with increased flexion may partially offset
the muscle’s potential loss in active force (and ultimately
torque) caused by its reduced length. Therefore, effective train-
ing of hip flexors should include hip flexion angles above 90°.75

Knee extension strength at long muscle length

Muscle strain injuries are thought to occur when muscles are
contracted at greater than the optimal length.76 77 Eccentric
exercise is the only training that has been shown to consist-
ently increase the development of optimum length of tension
in knee extensors. Eccentric training has the capability to
enhance muscle mass, strength and power more than isometric
and concentric exercise,81 as eccentric contraction produces the
highest forces and requires less oxygen.82
Two interventions have reported a shift in the optimum
length of the knee extensors after acute eccentric training ses-
sions,78 79 however only one study assessed chronic adaptation
to eccentric training.80 In the preseason, soccer players did
eccentric strength training three times/week for 4 weeks in add-
ition to normal training. Compared to a control group, the
trained players increased the optimal length of the knee exten-
sors by 6.5°. Participants in the control group suffered two
central tears compared with no injuries in eccentric interven-
tion group.80
Eccentric quadriceps strength has been found to be reduced Figure 4 Reverse Nordic hamstring. Example of open kinetic chain
in some players in preseason, and improving the muscle’s stretch shortening cycle KNEE dominant exercise. Player kneeling on
ability to absorb more energy before failing may prevent the ground with his ankle fixed followed by slowly backward lowering
injury.81 Specifically, if the force threshold for muscle failure himself to the ground eccentrically contracting quadriceps muscle
increases and the attenuation of loads is enhanced, a protective followed by explosive return to start position. This figure is only
reproduced in colour in the online version.
effect may occur. Chronic exposure to eccentric muscle activity
results in an active spring structure(s) adaptation (ie, the
muscle stiffens) in addition to the above-mentioned absorbing In summary, eccentric training may increase the size and
and strength capabilities.81 strength of the rectus femoris, and may change muscle
The quadriceps muscle is actively lengthened during hip optimum length and stiffening of the muscle spring that can
extension and knee flexion, and the knee joint generated more occur independently of, or in addition to, increases in size and
change in the length of the rectus femoris than the hip.83 Prior isometric strength of the muscle.81 Therefore, knee extension
et al84 found that of the four muscles of the quadriceps eccentric muscle training may optimise interventions that aim
femoris, the biarticular rectus femoris muscle experienced to prevent rectus femoris injury in football players.
greater muscle damage compared to the other monoarticular
vasti muscles. Therefore, it might be speculated that rectus
femoris is more knee-dependent than hip-dependent (figure 4). Core stability
During deceleration movements in sprinting or support Core stability, which is the ability of passive (ligaments and
phase of kicking, the impulse must be greater than the momen- vertebral facets) and active stabilisers in the lumbopelvic region
tum for the body to decrease its velocity/momentum.44 to maintain appropriate trunk and hip posture, balance and
Therefore, increasing the body’s ability to produce greater
braking forces is desirable. This may be achieved by increasing
the eccentric strength of the muscle via strength training
emphasising eccentric loading and control using training
stimuli remain as representative of real sport actions as possible
(eg, drop jumps, resisting towing, vest decelerations, etc.)
(figure 5) and by extending the time during which the braking
force is applied on landing.
Lower-body eccentric exercises designed to increase the
optimum length and prevent muscle injuries should include the
following principles: closed and open kinetic chains, bilateral
and unilateral, involve multiple joints, progression based in
strain more than strength, easy to be implemented and cost-
effective (figure 6). Distances (sprinting and deceleration dis-
tances or body segment range of motions when performing
strength training), velocities (sprinting velocities or rate of
force development when performing strength training) and dir- Figure 5 Forward deceleration steps. Example of closed kinetic chain
ectional components similar to sport should also be incorpo- in order to promote proper deceleration technique. This figure is only
rated into the eccentric strength training programme. reproduced in colour in the online version.

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limbs yields to a release of this tension arc, which is a manifest-

ation of the stretch-shorten cycle. Core stability is necessary to
counteract torsion, side flexion and especially extension
moments during kicking and sprinting. Including core exercise
in training sessions may decrease the overload of the rectus
femoris and reduce the risk of injury (figure 7).

Training parameters
No studies in the literature compare different eccentric exercise
training protocols to prevent rectus femoris strains. Volume and
loading are often to the discretion of the strength and condi-
tioning coach or sport rehabilitation clinician. However, even
though we consider length more important than strength, we
strongly advise that training parameters should follow the
common guidelines applied to any strength or rehabilitation
programme.92 The optimal intensity of eccentric training pro-
grammes is not yet clear. Whereas some authors claim that
intensity should be high to provide the stimulus necessary to
produce further adaptations,93–95 others have found that the
protective effect of eccentric training may be observed even
using light resistance.96 97 If strength gains are required to
address a strength deficit, eccentric actions should be overloaded
from 20% to 80% beyond the maximal isometric strength.92
However, the volume and intensity of preseason eccentric train-
ing programmes should be gradually progressed to minimise the
effect of exercise-induced muscle soreness and to provide the
stimulus necessary to produce ongoing adaptations.98–100
Muscle fatigue should also be considered with implementing
a training programme, especially when dealing with eccentric
exercises because several studies have reported less energy costs
for eccentric contractions compared with concentric exer-
cise.101 102 However, given the important strength and neuro-
muscular impairments present immediately after eccentric

Figure 6 Overhead medicine ball reverse lunge example of a

multiarticular knee extensor eccentric exercise. This figure is only
reproduced in colour in the online version.

control during static and dynamic movements,85 appear as an

important possible factor in order to prevent lower-extremity
ligament and muscle injuries.85 86 Thus, abdominal and lumbar
muscles may be important in preventing quadriceps muscle
strains. During the foot–ball contact, the body is inclined back-
wards between 118° and 128°.55 87 88 Moving the mass of the
upper body posteriorly may result in an increased external knee
flexion and internal quadriceps moments during kicking.
Abdominal muscles are necessary to counteract these forces
and reduce quadriceps overload and help control the trunk as it
is directed laterally to the non-kicking side at foot to ball
contact.55 87 88 The quadratus lumborum muscle is a powerful
side flexor of the lumbar spine and provides frontal plane seg-
mental stabilisation during contralateral leg-loading as well as
spinal movements.89 Kicking movements are likely to require
high levels of asymmetric activation of the quadratus lum-
borum muscle, and may explain why Australian Rules football
players have hypertrophy of the quadratus lumborum of the
non-kicking side.90 The arm of the non-kicking side leads to a
twist in the torso during the backswing phase of the kick and
an untwist during the next phases of the kick. Shan and
Westerhoff identified a ‘tension arc’ across the body from the Figure 7 Tension arc. Example of dynamic core exercise in order to
kicking leg as it is withdrawn to the non-kicking side arm, reproduce kicking motion patters and moments at the trunk. This figure
which is extended and abducted.91 The forward motion of both is only reproduced in colour in the online version.

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Review

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Rectus femoris muscle injuries in football: a

clinically relevant review of mechanisms of
injury, risk factors and preventive strategies
Jurdan Mendiguchia, Eduard Alentorn-Geli, Fernando Idoate, et al.

Br J Sports Med published online August 3, 2012

doi: 10.1136/bjsports-2012-091250

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