Vastus intermedius lies behind the rectus femoris.
It originates on the shaft of the femur.
Pectineus:This muscle originates on the superior ramus of the pubis portion of the hip bone and inserts on the pectineal line of the femur.
It's innervated by the femoral nerve and adducts and flexes the thigh.
Sartorius:Originating on the anterior superior iliac spine,
this muscle inserts on the medial surface of the tibia.
It's innervated by the femoral nerve,
and it flexes,
abducts,
and laterally rotates the thigh.
It also flexes the leg at the knee.
Iliopsoas:The iliopsoas is made up of two muscles that flex the thigh.
One of those muscles,
the psoas major,
is also important for posture: psoas major originates on the 12th thoracic and the five lumbar vertebrae.
It inserts onto the lesser trochanter of the femur and is innervated by the first three lumbar spinal nerves.
Iliacus originates on the iliac crest,
sacrum,
and sacroiliac ligaments.
It inserts onto the tendons of the psoas major and the lesser trochanter of the femur.
It's innervated by the femoral nerve.
The medial thigh muscles
The muscles of the medial part of the thigh include muscles that bring the thigh toward the midline and rotate it,
the adductor longus is the most commonly injured:
Fig. 2: Medial compartment of the thigh.
Adductor longus:This muscle originates on the pubis and inserts onto the middle of the linea aspera of the femur.
It's innervated by the obturator nerve and adducts the thigh.
Adductor brevis:Originating on the pubis and inserting on the pectineal line and linea aspera of the femur,
this muscle is innervated by the obturator nerve.
It adducts the thigh.
Adductor magnus:This muscle originates on the pubis and the ischial tuberosity.
It inserts onto the gluteal tuberosity,
linea aspera,
and the adductor tubercle of the femur.
It's innervated by the obturator nerve and the sciatic nerve.
It adducts the thigh and assists in both flexion and extension of the thigh.
Gracilis:This muscle originates on the pubis and inserts on the medial tibia.
It's innervated by the obturator nerve.
It adducts the thigh and flexes the leg at the knee.
Obturator externus:Originating at the obturator foramen and membrane of the hip bone,
this muscle inserts onto the femur.
It's innervated by the obturator nerve and laterally rotates the thigh.
The posterior thigh muscles
The three muscles of the posterior thigh are known as the hamstring muscles.
Hamstrings cross both hip and knee joints,
and integrate extension at the hip with flexion at the knee.
Biceps femoris is the most commonly injured muscle in the hamstring muscle group.
The semitendinosus muscle is a thin,
band-like muscle with a long tendon distally,
which may predispose the muscle to lesion.
The semimembranosus arises from the superolateral part of the ischial tuberosity,
its tendon has to be distinguished from the semitendinosus tendon.
Fig. 3: Posterior compartment of the thigh.
Semimembranosus:The most medial of the three hamstring muscles,
this muscle originates on the ischial tuberosity and inserts on the medial condyle of the tibia.
It functions with the semitendinosus to extend the thigh and flex and medially rotate the leg.
It's innervated by the tibial portion of the sciatic nerve.
Semitendinosus:This muscle originates on the ischial tuberosity and inserts onto the superior part of the medial tibia.
It's innervated by the tibial portion of the sciatic nerve and extends the thigh and flexes and medially rotates the leg.
Biceps femoris:The most lateral of the hamstrings,
the biceps femoris has two heads: the long and the short.
The long head originates on the ischial tuberosity,
and the short head originates on the linea aspera of the femur.
They insert onto the lateral side of the fibula.
The long head is innervated by the tibial portion of the sciatic nerve,
and the short head is innervated by the fibular portion of the sciatic nerve.
It extends the thigh and flexes and laterally rotates the leg.
Cross-sectional thigh anatomy
Fig. 4: Cross-sectional anatomy of the thigh
Fig. 5: TSE T1W axial scan of the thigh at a upper level. S: Sartorius; P: Pectineus; PS: IlioPsoas; V: Vastus Intermedius; R: Rectus femoris; T: Tensor fasciae latae; OE: Obturator externus; QF: Quadratus femoris; G: Gluteus magnus; H: Proximal insertion of hamstrings on the posterior ischiatic tubercle; AL, AB, AM: Proximal insertions of adductor longus, brevis and magnus respactively.
Fig. 6: TSE T1W axial scan of the thigh at an intermediate level. S: Sartorius; V: Vastus Intermedius; VM: Vastus medialis; VL: Vastus lateralis; R: Rectus femoris; femoris; AL: Adductor longus; AB: Adductor brevis; AM: Adductor magnus; G: Gracilis; SM: Semimembranosus; ST: Semitendinosus; BF: Biceps femoris.
Fig. 7: TSE T1W axial scan of the thigh at a lower level. S: Sartorius; V: Vastus Intermedius; VM: Vastus medialis; VL: Vastus lateralis; R: Rectus femoris; femoris; AM: Adductor magnus; G: Gracilis; SM: Semimembranosus; ST: Semitendinosus; BF: Biceps femoris.
3.
TERMINOLOGY AND CLASSIFICATION
The combination of diagnostic modalities such as medical history,
inspection,
clinical examination and imaging will most likely lead to an accurate diagnosis.
History and clinical examination will help in diagnosing muscles injury in most cases.
The athlete typically describes sudden pain in a determined point of thigh,
resulting in the immediate cessation of the activity.
However,
not all muscular lesions manifest with this classic history.
Differentiating between injury and muscle soreness,
identifying recurrent tears in the rehabilitating athlete,
or diagnosing an acute injury against a background of prior chronic strain can be difficult clinically.
The goals of imaging are to confirm injury,
provide a comprehensive assessment of the nature of the injury,
and identify which patients may benefit from surgery.
Furthermore,
referred pain,
most commonly from the lumbar spine and the hip,
may further complicate the clinical picture in the professional soccer player.
Many previous muscle injury classification systems had been presented,
the currently most widely used classification is an MRI-based graduation defining four grades: grade 0 with no pathological findings,
grade 1 with a muscle oedema only but without evidence of tissue damage,
grade 2 as partial muscle tear and grade 3 with a complete muscle tear.
In a professional soccer club the majority of muscular injuries are classified as grade I- II lesions.
It is very important to have a clear definition of each type of muscle injury,
a differentiation according to symptoms,
clinical signs,
location and imaging in order to get a better collaboration between specialists of different fields and,
further,
to have better management of the injuried athletes.
Classification of acute muscle injuries
A.
Indirect muscle disorder/injury
• Functional muscle disorder
- Fatigue-induced muscle disorder
- Delayed-onset muscle soreness (DOMS)#
- Spine-related neuromuscular Muscle disorder - Muscle-related neuromuscular Muscle disorder
• Structural muscle injury
- Minor partial muscle tear(grade1)
- Moderate partial muscle tear#(grade2)
- Subtotal or complete muscle tear(grade3) - Tendinous avulsion
B.
Direct muscle injury - Contusion
- Laceration
FOCUS ON FOOTBALL PLAYERS MOST COMMON INJURIES
Minor partial muscle tear (Grade 1 tear)
Tear with a maximum diameter of less than muscle fascicle/bundle.
Clinical: Sharp,
needle-like or stabbing pain at time of injury.
Athlete often experiences a 'snap' followed by a sudden onset of localised pain; Well-defined localised pain.
Stretch- induced pain aggravation
Imaging: Positive for feathery pattern edema on high resolution MRI and possible fibers disomogeneity on dHRUS.
Moderate partial muscle tear (Grade 2 tear)
Tear with a diameter of greater than a fascicle/bundle
Clinical: Stabbing,
sharp pain,
often noticeable tearing at time of injury.
Athlete often experiences a 'snap' followed by a sudden onset of localised pain.
Possible fall of athlete; Well-defined localised pain.
Probably palpable defect in muscle structure,
often haematoma,
fascial injury.
Stretch-induced pain aggravation
Imaging: Positive for fibre disruption.
Possible fascial injury and intermuscular haematoma.
(Sub)total muscle tear/tendinous avulsion (Grade 3 tear)
Tear involving the subtotal/ complete muscle diameter/ tendinous injury involving the bone-tendon junction
Clinical:Dull pain at time of injury.
Noticeable tearing.
Athlete experiences a 'snap' followed by a sudden onset of localised pain.
Often fall; Large defect in muscle,
haematoma,
palpable gap,
haematoma,
muscle retraction,
pain with movement,
loss of function,
haematoma
Imaging: Subtotal/complete discontinuity of muscle/ tendon.
Possible wavy tendon morphology and retraction.
With fascial injury and intermuscular haematoma
Direct injury (Contusion)
Direct muscle trauma,
caused by blunt external force.
Leading to diffuse or circumscribed haematoma within the muscle causing pain and loss of motion
Clinical: Dull pain at time of injury,
possibly increasing due to increasing haematoma.
Athlete often reports definite external mechanism; Dull,
diffuse pain,
haematoma,
pain on movement,
swelling,
decreased range of motion,
tenderness to palpation depending on the severity of impact.
Athlete may be able to continue sport activity rather than in indirect structural injury
Site: Any muscle,
mostly vastus intermedius and rectus femoris Imaging: Diffuse or circumscribed haematoma in varying dimensions
Scar tissue
The great majority of muscle injuries don't heal with the formation of scar tissue.
However,
greater muscle tears can result in a scar formation which has to be considered in the diagnosis and prognosis of a muscle injury.
Usually partial tears of less than a muscle fascicle heal completely while moderate partial tears can result in a fibrous scar.
Recurrent muscle injures,
more severe than the first injury,
could occur for the premature return to full activity due to an underestimated injury.
Healing of muscle and other soft tissue is a gradual process: the connective tissue constituting the scar produced at the injury site is the weakest point of the injured skeletal muscle; full strength of the injured tissue needs time to return depending on the size and localisation of the injury.