Download Unusual case of chronic tear of the Iliacus and Rectus

Indian Journal of Basic and Applied Medical Research; June 2015: Vol.-4, Issue- 3, P. 166-170
Case report
Unusual case of chronic tear of the Iliacus and Rectus Femoris muscle
origins in old age.
1Dr.
Joy Agnees , 2Dr. Senthilnathan
1M.B.B.S.
, Post Graduate in MD Radiology , Vinayaka Mission medical college and hospital , Salem.
2M.D.R.D.,
P.D.C.C., Asst.Professor , Annapoorana Medical College and Hospital , Salem.
Corresponding author : Dr. Joy Agnees
Abstract:
To highlight and report the occurance and the radiological features of chronic avulsive muscle tear in a moderately
built 57 year old male patient with history of slip and fall and chronic pain in the right hip. We describe the role
of MRI in diagnosing the case with chronic partial avulsion tear of the right iliacus and the right proximal rectus
femoris muscles as an approach to management and rehabilitation of multiple tears of the hip muscles.
Keywords : non-athlete, trauma, avulsion, intrasubstance tear, physiotherapy
Introduction:
Injuries of the iliopsoas muscle and intra-
bathroom 6 months before following which he
substance tendinous tears of the proximal rectus
took analgesics and continued routine daily
femoris
activities.
muscle
occur
in
young
athletic
individuals during activities like sprinting and
1
After 10 days he reported to a
hospital and there was no evidence of fracture
This type of muscle injuries
in X-ray hip and pelvis. With prolonged use of
rarely occur in non- sportsperson. Very few
medications the patient had temporary relief but
cases
later
kicking sports.
are
reported
in
medical
literature
developed
severe
low
backache
and
describing the tear of iliacus and rectus femoris
restricted hip movements. Hence MRI hip was
muscles. This kind of injury in a person with
advised to rule out the cause of chronic pain
no pre-existing disease is unique. Nil cases are
which was helpful in diagnosing chronic partial
reported
the
avulsion tear of the right iliacus muscle at its
interesting MRI findings of the combined tear
insertion and chronic partial intrasubstance tear of
of the
the right rectus femoris muscle at its origin possibly
muscle.
in
literature
iliacus
and
to
limelight
proximal
on
rectus femoris
2
due to lack of bed rest and muscle over activity.
Case History:
A 57 year old male presented to the hospital
with complaints of low back and hip pain. He
had a past history of slip and fall in the
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Indian Journal of Basic and Applied Medical Research; June 2015: Vol.-4, Issue- 3, P. 166-170
A
B
C
Figure 1:
MR T2 weighted coronal image of the hip shows A) thickening of the right rectus
femoris indirect head tendon at anterior inferior iliac spine origin, B) Chronic partial
intra-substance tear with mild inhomogenous signals within the tendon, C) with
adjoining fat interstitial edema.
Figure 2 :
MR T2 weighted coronal image of the hip shows hyperintense signals
indicating
edema around the rectus femoris muscle origin on the right side. Normal findings on
the left side.
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Indian Journal of Basic and Applied Medical Research; June 2015: Vol.-4, Issue- 3, P. 166-170
[Figure 3:
MR T2 weighted axial image shows partial avulsion and retraction of the outer iliacus
muscle fibres at its insertion on the right side. Note that the iliacus appears partially
torn and bulky at its origin on anterior inferior iliac spine.
[Figure 4:
MR T2 weighted axial image at the level of hip joint shows partially retracted
iliopsoas muscle fibres indicating grade II tear. The retracted fibres are replaced by fat
because of chronic tear.
The patient was treated conservatively since
movement.
The
iliopsoas
is
there were no signs of hematoma in the
walking
muscle fascia and hence the patient was treated
disables locomotion, so it is considered to be
non-operatively. Bed rest was advised to reduce
one of the most important muscles in the
stress on the hip until symptoms decreased.
body.
Regular
and running and
important
palsy
for
of which
months
and
Acute iliopsoas muscle pain is usually caused
functionally based therapeutic exercises
like
by
physiotherapy
for
3
stretching of the hip and thigh muscles were
done
for
successful
correction
of
muscle
inflammation
ruptured
belly
intramuscular
of
of
the
the
hematoma.
muscle
insertion,3
muscle
and
4
Partial
the
iliopsoas
dysfunction.
tendon tears occur with athletic injuries and
Discussion:
falls and complete iliopsoas tendon tears are
Iliopsoas has three muscles units : psoas major,
most
psoas minor and iliacus. The iliacus arises from
iliopsoas
the iliac crest and the anterior inferior iliac
causes
spines, fills the iliac fossa and ends as a
football players or those practising taekwondo ),
direct
lesser
trauma, senility, complications from total hip
trochanter of the femur. The iliopsoas is a
arthroplasty, chronic diseases ( e.g., rheumatoid
strong flexor of the hip joint. The psoas major
arthritis, diabetes, hyperparathyroidism, chronic
has the ability of higher amplitude movement
renal failure, obesity ) and chronic corticosteroid
and the iliacus provides higher strength of the
therapy.5 Tendon tears rarely can be associated
muscular
attachment
onto
the
common
in elderly women.5 Isolated
tendon rupture is
include
athletic
uncommon
injuries
and
( cyclists,
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Indian Journal of Basic and Applied Medical Research; June 2015: Vol.-4, Issue- 3, P. 166-170
with an intraarticular hip infection like abscess
adults with atraumatic
which extends via the iliopsoas bursa into the
avulsion injuries.
lessert
rochanteric
iliopsoas tendon.The injuries of the iliopsoas
The rectus femoris is a long fusiform
muscle occur quite seldom and the development
thigh muscle forming the anterior superficial
of radiological imaging techniques like MRI
portion of the quadriceps muscle. Its main
and musculoskeletal sonography generates more
functions
accurate diagnosis of any pathology. Imaging
flexion. The proximal rectus femoris has two
features
fluid
tendinous origins: the direct head, arising from
collection within a portion of the tendon or
the anterior–inferior iliac spine and the indirect
focal discontinuity of the tendon fibers close to
head, arising inferiorly and posteriorly from the
the
of
lesser
partial
tendon
trochanter
various
are
attachment.
tendon tears will show
and
tear
5
include
knee
extension
and
hip
Complete
superior acetabular ridge and hip joint capsule.
complete discontinuity
The two heads join to form a conjoined
degrees
of
retraction
with
tendon.
The
direct
head
constitutes
the
haematoma collection of the tendinous remnant.
superficial part and the indirect head forms the
Underlying metastatic disease must be ruled out in
deep part of the conjoined tendon called the
intrasubstance.
Predisposing factors for proximal rectus femoris
hemorrhage
tear
exercises,
junction and spreads into the adjacent muscle
muscle
by tracking along muscle fascicles to create a
fatigue due to overuse syndromes and previous
feathery pattern.8 On TI-weighted images, the
tear.6 Acute deep musculotendinous
muscle and tendon may appear entirely normal
include
overall
insufficient
warm-up
muscle
conditioning,
poor
junction
that
surround
injuries presents as sudden onset of thigh pain
because
and
completely.Second-degree
a
tearing
sensation.
Persistent
pain,
the
the
myotendinal
myotendinous
strain
unit
heals
MR
images
tenderness and rectus femoris asymmetry may
show irregular thinning and mild laxity of
also be associated. A discrete anterior thigh
tendon fibers. Tendon retraction and muscle
mass
bunching may be minimal or absent because
related
mistaken
to
muscle
retraction
for a soft-tissue neoplasm.
can
2
be
In a
the
myotendinal
chronically inflamed and degenerated tendon
intact.
low stress loading of the myotendinous junction
hemorrhage
itself causes complete muscle rupture. Deep
planes
musculotendinous
junction
injuries
Hematoma
proximal
femoris
are
rectus
of
difficult
the
to
Here
of
acute
of
peripheral
the
injury
and
associated
nonspecific
physical findings.
Muscle strain is
as
remains
muscular
collection
partially
edema
between
the
and
fascial
prominent.9,10
muscles
are
at
the
myotendinal
junction
is
of
second-degree
strain.
In
injury,
extracellular
clinically graded
the
patho-gnomonic
clinically diagnose because of the deep location
junction
the
more
hematoma
may
show
a
high-signal-intensity
rim
(due
to
methemoglobin)
on
TI-weighted
first
images and heterogeneously decreased signal
degree (stretch injury), second degree (partial
intensity on T2-weighted images. Later, the
7
tear), and third degree (complete rupture). First-
hematoma decreases in size and develops a
degree strain on T2-weighted and STIR images
characteristic central fluid collection surrounded
shows high-signal-intensity due to edema and
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Indian Journal of Basic and Applied Medical Research; June 2015: Vol.-4, Issue- 3, P. 166-170
by a rim of low signal intensity due to
conservative management to restore the muscle
hemosiderin deposition and scar formation.
strength and range of motion is done for grade
Third-degree strain MR images show extensive
I and II strains. Professional athletes require
hemorrhage
further
that
obscures
visualization
of
intensive physical therapy to avoid
1,11
anatomic structures and creates difficulty in
reinjury.
differentiation of complete myotendinous rupture
grade III strains for evacuation of hematoma to
from
large
partial
7
rupture. In
non-athletes,
Surgical intervention is required for
avoid muscle atrophy and fatty infiltration.
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4.
Muttarak M., Peh WC. CT of unusual iliopsoas compartment lesions. Radiographics. 2000; Oct;20
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Garrett WE Jr. Muscle strain injuries. Am J Sports Med 1996; 24[suppl 6]:S2–S8.
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