Anterior Thigh Pain

 Symptoms and Treatment of Upper Thigh Pain:

The anterior thigh pain is the site of common sporting injuries such as quadriceps muscle contusion and strain of the quadriceps muscle .Referred pain from the hip, sacroiliac joint or lumbar spine may also cause anterior thigh pain. Stress fracture of the femur is an uncommon, but important, diagnosis.

Clinical Approach

History

The two most important aspects of the history of a patient with anterior thigh pain are the exact site of the pain and the mechanism of injury. The site of the pain is usually well localized in cases of contusion or muscle strain. Muscle strains occur in the mid belly. Contusions can occur anywhere in the quadriceps muscle but they are most common anterolaterally or in the vastus medialis obliquus.

The mechanism of injury may help differentiate between the two conditions. A contusion is likely to be the result of a direct blow, whereas a muscle strain usually occurs when an athlete is striving for extra speed running or extra distance kicking. In contact sports, however, the athlete may have difficulty recalling the exact mechanism of injury.

Whether the athlete was able to continue activity, the present level of function and the degree of swelling are all guides to the severity of the condition. Determine whether the RICE regimen was implemented initially and whether any aggravating factors, such as a hot shower, heat rub, excessive activity or alcohol ingestion were present. Gradual onset of poorly localized anterior thigh pain in a distance runner worsening with activity may indicate stress fracture of the femur. If the pain is variable and not clearly localized and if specific aggravating factors are lacking, consider referred pain. Bilateral pain suggests the pain is referred from the lumbar spine.

Examination

In anterior thigh pain of acute onset, the diagnosis is usually straight forward and examination is confined primarily to local structures. In anterior thigh pain of insidious onset, diagnosis is more difficult. Examination should include sites that refer pain to the thigh, such as the lumbar spine, SIJ and hip.

Investigations

Investigations are usually not required in athletes with anterior thigh pain. If a quadriceps contusion fails to respond to treatment, X-ray may demonstrate myositis ossificans. This is usually not evident until at least three weeks after the injury. Ultrasound examination will confirm the presence of a hematoma and may demonstrate early evidence of calcification. If a stress fracture of the femur is suspected, plain X-ray is indicated. If this is normal, an isotopic bone scan or MRI is required.

Quadriceps contusion

If the patient suffered a direct blow to the anterior thigh and examination confirms an area of tenderness and swelling with worsening pain on active contraction and passive stretch, thigh contusion with resultant hematoma is the most likely diagnosis. In severe cases with extensive swelling, pain may be severe enough to interfere with sleep.

Quadriceps contusion is an extremely common injury and is known colloquially as a ‘Charley Horse’ or ‘Cork Thigh’. It is common in contact sports as football and basketball. In sports such as hockey lacrosse and cricket, a ball traveling at high speed may cause a contusion.

Trauma to the muscle will cause primary damage to myofibrils, fascia and blood vessels. Localized bleeding may increase tissue pressure and cause relative regional anoxia that can result in secondary tissue damage. The contusion may be either intramuscular or intermuscular. In the intermuscular hematoma, the blood escapes through the fascia and is distributed between the compartments of the thigh. The intramuscular hematoma is confined to the muscle compartment which fills up with blood. The intra-muscular hematoma is more painful and restrictive of range of motion. Usually only a single quadriceps muscle will be affected.

It is important to assess the severity of the contusion to determine prognosis (this can vary from several days to a number of weeks off sport) and plan appropriate treatment. The degree of passive knee flexion after 24 hours is an indicator of the severity of the hematoma. For optimal treatment and accurate monitoring of progress, it is important to identify the exact muscle involved. MRI will show significant edema throughout the involved muscle. Blood from contusions of the lower third of the thigh may track down to the knee joint and irritate the patellofemoral joint.

Treatment

The treatment of a thigh contusion can be divided into four stages: stage I-control of hemorrhage; Progression within each stage and from one stage to the next, depends on the severity of the contusion and the rate of recovery.

  1. The most important period in the treatment of a thigh contusion is in the first 24 hours following the injury.
  2. Upon suffering a thigh contusion, the player should be removed from the field of play and the RICE regimen instituted immediately.
  3. The importance of rest and elevation of the affected leg must be emphasized.
  4. The use of crutches ensures adequate rest if full weight-bearing is painful and encourages the athlete to recognize the serious nature of the condition.
  5. In the acute management of a thigh contusion, ice should be applied in a position of maximal pain-free quadriceps stretch.
  6. The patient must be careful not to aggravate the bleeding by excessive activity, alcohol ingestion or the application of heat.
  7. Loss of range of motion is the most significant finding after thigh contusion and range of movement must be regained in a gradual, pain-free progression.
  8. After a moderate-to-severe contusion there is a considerable risk of rebleed in the first seven to 10 days. Therefore, care must be taken with stretching, electrotherapy, heat and massage.
  9. The patient must be careful not to overstretch. Stretching should be pain-free.
  10. Soft tissue therapy is contraindicated for 48 hours following contusion. Subsequently, soft tissue therapy may be used but great care must be taken not to aggravate the condition.
  11. Treatment must be light and it must produce absolutely no pain. The aim of soft tissue therapy in the first few days after a thigh contusion is to promote lymphatic drainage.
  12. Quadriceps contusion is a condition that can be prevented. Patients who are recovering from a previous contusion may benefit from thigh protection.
  13. Athletes in high-risk sports should consider wearing thigh protection routinely.

Quadriceps Muscle Strain

Strains of the quadriceps muscle usually occur during sprinting, jumping or kicking. Strains are seen in all the quadriceps muscles but are most common in the rectus femoris, which is more vulnerable to strain as it passes over two joints: the hip and the knee. The most common site of strain is the distal musculotendinous junction of the rectus femoris. Management of this type of rectos femoris strain and of strains of the vasti muscles is relatively straightforward; rehabilitation time is short. Strains of the proximal rectus are not as straightforward and considered separately below.

  • Like all muscle strains, quadriceps strains may be graded into mild (grade I), moderate (grade II) or severe, complete tears (grade III).
  • The athlete feels the injury as a sudden pain in the anterior thigh during an activity requiring explosive muscle contraction. There is local pain and tenderness and, if the strain is severe, swelling and bruising
  • Grade I strain is a minor injury with pain on resisted active contraction and on passive stretching. An area of local spasm is palpable at the site of pain.
  • An athlete with such a strain may not cease activity at the time of the pain but will usually notice the injury after cooling down or the following day.
  • Moderate or grade II strains cause significant pain on passive stretching as well as on unopposed active contraction. There is usually a moderate area of inflammation surrounding a tender palpable lesion. The athlete with a grade II strain is generally unable to continue the activity.
  • Complete tears of the rectus femoris occur with sudden onset of pain and disability during intense activity.
  • A muscle fiber defect is usually palpable when the muscle is contracted. In the long term, they resolve with conservative management, often with surprisingly little disability.

Treatment

The principles of treatment of a quadriceps muscle strain are similar to those of a thigh contusion. The various treatment techniques shown in are also appropriate for the treatment of quadriceps strain; however, depending on the severity of the strain, progression through the various stages may be slower.

  • Although loss of range of motion may be less obvious than with a contusion, it is important that the athlete regain pain-free range of movement as soon as possible.
  • Loss of strength may be more marked than with a thigh contusion and strength retraining requires emphasis in the rehabilitation program.
  • As with the general principles of muscle rehabilitation, the program should commence with low resistance, high repetition exercise.
  • Concentric and eccentric exercises should begin with very low weights.
  • General fitness can be maintained by activities such as swimming (initially with a pool buoy) and upper body training. Functional retraining should be incorporated as soon as possible.
  • Full training must be completed prior to return to sport. Unfortunately, quadriceps strains often recur, either in the same season, or even a year to two later.

Less Common Causes:

Stress Fracture of the Femur

Stress fracture of the shaft of the femur, although uncommon, should be suspected in an athlete, especially a distance runner, who complains of a dull ache, poorly localized in the anterior thigh. Pain may be referred to the knee. There may be tenderness over the shaft of the femur that can be aggravated if the patient sits with the leg hanging over the edge of a bench, particularly if there is downward pressure placed on the distal femur, the so-called hang test or fulcrum test.

Treatment involves rest from painful activities and maintenance of fitness by cycling or swimming. Predisposing factors such as excessive training, biomechanical abnormality and, in females, menstrual disturbance should be sought, and corrected where possible. When the hang test is completely negative, on average after seven weeks, it is thought to be safe to return to sport gradually.


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