Apophyseal Avulsion of the Rectus Femoris Tendon Origin in Adolescent Soccer Players

Abstract

Apophyseal avulsions of the rectus femorus tendon (RFT) at the anterior inferior iliac spine (AIIS) can occur in adolescents, often while performing soccer. Patient-reported outcomes (PROMs) and time to return to sport of these patients are relatively unknown. Therefore, the aim of this study was to assess the PROMs and return to sports of patients with AIIS avulsions and compare the results with those reported in the literature. This is a case series of seven consecutive patients presenting at our hospital between 2018 and 2020 with an apophyseal avulsion of the RFT from the AIIS. The patients were assessed with use of the WOMAC and Tegner scores and return to sports was evaluated. All patients were male soccer players (median age 13 years; range, 12–17). They were all initially treated non-operatively. One of the patients subsequently needed excision surgery of a heterotopic ossification because of non-transient hip impingement. All other patients recovered after a period of relative rest. Median time to return to sports was 2.5 months (range, 2–3). At a median follow-up of 33 months (range, 18–45), the WOMAC (median, 100; range, 91–100) and Tegner scores (median, 9; range, 5–9) were high. In accordance with the existing literature, most patients with apophyseal avulsions of the AIIS recover well with non-operative treatment. However, the avulsion can lead to hip impingement due to heterotopic ossifications possibly needing surgical excision. Sport resumption is achievable after 2–3 months, and patient-reported outcomes are highly satisfactory in the long term.

Endoscopic Assisted Percutaneous Fixation of Anterior Inferior Iliac Spine Avulsion Fracture, Surgical Technique

“…The anterior inferior iliac spine (AIIS) is a frequent site of avulsion fracture in the pelvis in teenage athletes where the hormonally induced muscle strengthening coexists with secondary ossification at the apophyses [ 3 ]. Most pelvic avulsion fractures, including AIIS, are treated successfully nonoperatively, using analgesics, bed rest, immobilization of the affected muscle group, physical rehabilitation, and crutches for at least 3–6 weeks post-injury [ 1 , 6 – 8 ]. Although, avulsion fractures of the pelvis have been biologically assimilated to epiphyseal fractures and are naturally prone to bone healing [ 4 ], repetitive traumatism, due to muscle traction over the avulsed fragment, often leads to hypertrophic healing, bulking, and appearance that may mimic bone tumours, especially when a delayed diagnosis or no supervised conservative treatment is made [ 5 ].…”

The beauty of pediatric musculoskeletal ultrasound

“…Since the growth plate is biomechanically weaker than the tendon, direct injury during adolescence results in avulsion displacement of the epiphysis rather than tendon rupture. As there are at least two more proximal tendons (indirect head and reflected head), the apophyseal displacement in the case of direct tendon avulsion is small and usually recovers well with conservative treatment with rest [28]. Operative treatment is reserved for widely displaced fractures (> 2 cm displacement) or when late complications such as heterotopic ossifications occur [28].…”

“…As there are at least two more proximal tendons (indirect head and reflected head), the apophyseal displacement in the case of direct tendon avulsion is small and usually recovers well with conservative treatment with rest [28]. Operative treatment is reserved for widely displaced fractures (> 2 cm displacement) or when late complications such as heterotopic ossifications occur [28]. US allows imaging of the anatomy of the avulsion chain in detail due to high spatial resolution, thus allowing early diagnosis and recognition of the extent of apophyseal displacement [27].…”

Advances in Pediatric Fracture Diagnosis and Treatment Are Numerous but Great Challenges Remain

“…Descending further in the human body, two studies investigated lower extremity injuries. Weel et al [ 20 ], in a long-term retrospective study, obtained patient-reported outcomes of adolescent soccer players with avulsion fractures of the anterior inferior iliac spine at the origin of the rectus femoris. Of seven initially nonoperatively treated patients, one required surgical excision of a heterotopic ossification.…”