Definitive management of thigh contusions in athletes: but how definitive? A systematic review

Definitive management of thigh contusions in athletes: but how definitive? A systematic reviewDefinitive management of thigh contusions in athletes: but how definitive? A systematic review Brittany E Haws, T David Luo, Ian M Al’Khafaji, Jason P Rogers, Daniel B Botros, Michael T Freehill
ABSTRACT Importance Thigh contusion is a common injury reported in athletes; however, the optimal treatment guidelines for thigh contusions, potentially leading to haematoma, in the athletic population remain ill-defined. To the best of our knowledge, this is the most comprehensive review of the literature. Objective A systematic review of the literature was performed regarding the appropriate management and timing of non-surgical and surgical intervention of thigh haematomas in athletes to determine an optimal treatment algorithm. Specifically, we aimed to compare these treatment options with respect to time to return to sport. Evidence review Two databases (PubMed and SPORTdiscus) were used in this systematic review. Search terms included ‘thigh contusion’, ‘thigh hematoma’, ‘quadriceps contusion’, ‘quadriceps hematoma’, ‘treatment’, ‘athlete’ and ‘sports’. The inclusion criteria were (1) athletes of any age that sustained thigh contusions caused by sports-related trauma, (2) data relating to treatment outcomes of thigh haematomas, (3) clinical studies with level I–IV of evidence from any year of publication and (4) studies published in English. Findings 7 studies met our inclusion criteria and were reviewed, all of which were level IV evidence. 6 of the studies involved non-operative management of the patients, and only one study involved surgical intervention. The average time until return to play across the studies with non-operative treatment was 29.3 days (range of 2– 180 days). In the study that treated contusions with surgery, time to return to play was not included in the results. Conclusions and relevance While thigh haematomas are common in sports, sparse literature exists regarding the appropriate timing of conservative management and when surgical intervention is warranted. On average, time to return to play following conservative management of a thigh haematoma is 29.3 days; however, it is currently unknown if operative management may provide an earlier return. This information can be used as baseline expectations when non-operative treatment is employed. If an athlete fails to return to sport at the expected time, further work-up for retained haematoma with the possible need for surgical intervention should be considered. Level of evidence IV.
INTRODUCTION Soft tissue injury is common in sports, with a reported incidence as high as 90% of all sports injuries.1–5 Thigh contusions reportedly account for 10% of all injuries sustained from illegal contact among professional association football players.6 Approximately 12% of all thigh muscle
injuries in these athletes were direct contusion injuries.7 American rules football had the highest incidence of thigh contusions despite a higher overall rate of reported injuries in rugby, karate and judo participants.8 These injuries are typically caused by a direct blow, usually from another player’s knee, foot or head.9 Diagnosis of thigh contusion is initially clinical with the patient pre- senting with pain, localised swelling and ecchym- osis at the site of blunt trauma. Soft tissue contusions and haematomas of the thigh can lead to compartment syndrome in the acute injury setting, but fortunately this occurs much less fre- quently in the thigh due to the larger compartment volumes.10 This increased compartment volume can, however, lead to a delayed presentation of compartment syndrome, especially in the setting of contact-induced contusions in sports,11–16 which further complicates physician decision-making. In high-level, competitive athletes, failure to return to
What is already known
While thigh contusions occur commonly in the athletic population, little information is available regarding optimal treatment and the role of surgical management.
In high level, competitive athletes, these injuries can lead to a delayed presentation of compartment syndrome and failure to return to previous performance levels.
What are the new findings
The literature addressing treatment of thigh contusions in athletes is very limited. The present systematic review yielded seven level IV evidence studies addressing this question, only one of which involved surgical management.
On average, time to return to play following conservative management of a thigh haematoma is 29.3 days, while comparable data for surgical management is currently unknown.
Clinical suspicion for retained haematoma and the need for possible surgical intervention should be considered if an athlete fails to improve at 3–4 weeks following conservative management.
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To cite: Haws BE, Luo TD, Al’Khafaji IM, et al. JISAKOS 2017;2:67–74.
Additional material is published online only. To view please visit the journal online (h t t p : / / d x . d o i . o r g / 1 0 . 1 1 3 6 / j i s a k o s - 2 0 1 6 - 0 0 0 1 0 7 ).
Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston- Salem, North Carolina, USA
Correspondence to Dr Michael T Freehill, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston- Salem, NC 27157, USA; [email protected]
Received 30 August 2016 Revised 5 December 2016 Accepted 13 December 2016 Published Online First 20 January 2017
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previous performance levels has been demonstrated even after treatment with fasciotomy and compartment release.17 Thigh contusions can be further complicated by myositis ossificans: a proliferation of bone and cartilage in a muscle previously exposed to trauma and haematoma. This can lead to continued pain, swelling and decreased range of motion.18
It may be common perception that this topic has been suffi- ciently researched. However, the overall breadth of literature for treatment of thigh contusions in sports is considerably sparse. Furthermore, debate exists as to the optimal treatment for an evolving thigh haematoma in the athletic population and to what extent surgical intervention may be helpful or harmful. The objective of our study was to perform a systematic review of the literature regarding the modality and timing of treatment for thigh haematomas in athletes. Specifically, we aimed to compare the effects of non-surgical and surgical management on time to return to sport and any reported adverse outcomes to determine an optimal treatment algorithm.
METHODS Literature search According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed by two separate authors in duplicate by search- ing two databases (PubMed and SPORTdiscus). No date restric- tions or filters were used to avoid omitting relevant studies. Search terms included ‘thigh contusion’, ‘thigh hematoma’, ‘quadriceps contusion’, ‘quadriceps hematoma’, ‘treatment’, ‘athlete’ and ‘sports’, (see online supplementary appendix 1). Additionally, the reference lists of all articles that passed the primary screen were also reviewed. The inclusion criteria were (1) athletes of any age that sustained thigh contusions caused by sports-related trauma, (2) data relating to treatment outcomes of thigh haematomas, (3) patient studies with level I–IVof evidence from any year of publication, and (4) studies published in English. Case reports and expert opinions were excluded. Assessment of eligibility was performed by two reviewers in duplicate.
Data extraction Information was extracted from each study on (1) characteristics of study participants (including age, body mass index, gender, activity level, sport, country of origin) and the study’s inclusion criteria, (2) treatment (non-operative vs operative, rehabilitation protocol and methods for monitoring progress), and (3) outcome measures (including time to return to sport, incidence of myositis ossificans and complications). Return to sport was defined as the number of days from onset of injury until the first date of full sport participation. Descriptive statistics were pre- sented as means, ranges and percentages.
Methodological quality A methodological quality tool was used for appraisal of all studies included in review (see online supplementary appendix 2).19 This is a 20-item checklist rated by yes, no or partial/unclear answers used to assess the quality of study findings and potential sources of bias. Two authors independently assessed all included articles using this tool and disagreements were discussed until consensus was reached.
RESULTS Literature search Initial search in PubMed and SPORTdiscus identified 31 full text articles that focused on treatment of thigh contusions. Of
those, 24 studies were excluded because they were review arti- cles18 20–31 or case reports.14 17 32–40 No previous systematic reviews to the best of our knowledge have been published. Thus, seven studies met our inclusion criteria and were included in this study (figure 1).8 9 11 41–44 All of the included studies were of level IV evidence. Countries of origin for the reviewed articles included Australia, Israel, Sweden, New Zealand and three from the USA. The included studies involved a total of 404 athletes with an average age of 21.6 (range 12–52) years of those reported. Male athletes made up 97.5% of study partici- pants. Patient demographics for the included studies are pre- sented in table 1.
Treatment of thigh contusions and outcomes Non-operative management was utilised in six studies, com- pared to one study that reviewed outcomes after surgical treat- ment. The principle inclusion criterion for each study was the presence of a quadriceps contusion. In general, this was defined by external trauma to the thigh during a sporting activity result- ing in localised tenderness, pain with muscle flexion or decreased range of motion. Two of the studies further divided contusions into mild, moderate and severe categories.8 43 They classified severity of quadriceps contusions based on active knee range of motion 12 hours after initial injury. Mild contusions had active range of motion >90°, moderate contusions 45–90°, and severe contusions <45°. The mainstays of non-surgical management across studies included cryotherapy, use of crutches with progression to weight bearing as tolerated, stretching and strengthening, and modified training with gradual increases in activity.
The results of the seven studies are summarised in table 2. In four of the six studies involving conservative treatment,8 42–44
time until return to sport was monitored. Another study involving conservative treatment reported return to work out- comes. The authors stated this typically represented the time at which an athlete was ready to return to sport; however, the actual date of return was not documented.9 The average time until return to sport across all of these studies was 29.3 days (range of 2–180 days). In the study that treated contusions with surgery, time to return to sport was not included in their results.11 With respect to complications, myositis ossificans was described by four of the included studies, with a reported inci- dence of 35 of 289 total cases (12.1%).8 9 42 43 No study reported significant limitation secondary to development of myositis ossificans.
Conservative treatment employed by the reviewed studies included variations with respect to management strategy and adherence to a specific protocol. Jackson and Feagin43 devel- oped a treatment protocol for West Point cadets that emphasised resting the leg in extension to allow for early restoration of full knee extension, while flexion was initiated slowly at the patient’s own pace. They discovered that normal flexion was the slowest parameter to return, causing prolonged disability. In response, Ryan et al8 devised a three-phase therapy programme that focused on restoring early knee flexion to tolerance. Inpatient and outpatient therapy protocols are summarised in tables 3 and 4. This variation in protocol led to improved rehabilitation time for moderate and severe contusions.
Of greatest concern is the possibility for development of com- partment syndrome, which was explored in two of the studies. Robinson et al44 successfully treated athletes who sustained a contusion to the thigh and developed intracompartmental pres- sures >60 mm Hg with conservative management. Conversely, surgical management of thigh haematoma complicated by
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compartment syndrome was described by Rooser et al11 without any reported adverse effect. Time to return to sport, however, was not reported.
Monitoring of participants was highly variable among studies. Examples of data monitored include knee range of motion, thigh circumference, thigh compartment pressures, radiographs and creatinine phosphokinase (CPK) levels. Outcomes assessed by these studies included time to return to sport and complica- tions such as myositis ossificans. No study was able to directly compare outcomes between patients treated non-operatively versus operatively.
Methodological quality All of the reviewed papers were case series and were assessed using an appraisal tool.19 Major limitations and potential sources of bias were identified. The primary limitation was the inability of any study to provide a comparison in outcomes
between surgical and non-surgical treatment. Additionally, only three studies8 9 43 stratified patients based on injury severity and only four studies8 9 42 44 appeared to adhere to a strict treat- ment protocol, both of which could be significant confounders for time to return to sport. Furthermore, assessment of out- comes was limited by variations in reporting as three studies either did not use11 41 or did not report time to return to sports9 as we previously defined. Finally, data on adverse out- comes such as myositis ossificans were inconsistently reported in the included studies, with some that either failed to investigate or report incidence11 41 44 and others that did not have enough follow-up to detect these outcomes.9 43
DISCUSSION The present systematic review summarises the existing litera- ture regarding treatment of thigh contusions and evolving haematomas in the athletic population. Overall, the small
Figure 1 PRISMA flow diagram of study selection process.
Table 1 Summary of key articles included for systematic review
Author Year of publication
Average age (range)
Per cent male
Level of evidence
Alonso et al41 2000 Australia Rugby 101 Not reported 99 IV
Aronen et al42 2006 USA Football 47 19.2 (18–22) 100 IV
Jackson and Feagin43
1973 USA Football (military) 65 Not reported 100 IV
Robinson et al44 1992 Israel Handball 6 23.3 (19–28) 100 IV
Rööser et. al11 1991 Sweden Handball, soccer 8 24.8 (12–36) 87.5 IV
Rothwell9 1982 New Zealand Rugby 60 (12–52) 100 IV
Ryan et al8 1991 USA Football (military) 117 19 (17–23) 93.2 IV
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number of case series does not allow for effective comparison in outcomes between surgical and non-surgical management. There were no studies that directly compared these treatment options. Furthermore, the only study involving surgical man- agement did not report time to return to sport.11 Additionally, stratification of injury severity, rehabilitation protocols, follow-up regimens and assessment of complications varied widely among studies. Therefore, conclusions regarding time to return to sport or adverse outcomes between surgical and non-surgical treatment are difficult to determine. Additionally, the low level of evidence (IV) currently available on this topic significantly limits the strength of recommendations which can be made.
Conservative treatment From the current evidence, expectations for conservative man- agement can be better extrapolated. In the studies included for
analysis, conservative therapy entailed cryotherapy, immobilisa- tion and physical therapy. Cryotherapy, a mainstay of acute management, decreases oedema and pain by inducing vasocon- striction; however, this effect has been shown to be transient as there are no long lasting microvascular changes that can sig- nificantly affect swelling and pain.45 Non-steroidal anti- inflammatory drugs (NSAIDs) and corticosteroid treatment are aimed at reducing inflammation associated with the injury.
Table 2 Clinical results of thigh contusion treatment
Study Injury type
Return to activity/ sport, days (range)
Myositis ossificans Comments
Alonso et al41 Contusion No No Thigh circumference, muscle firmness
NA NA Created equation to predict return to training
Aronen et al42 Contusion No Immediate passive flexion, immobilisation in 120° flexion for 24 hours,
Radiographs at 3 and 6 months (stopped mid-study)
3.5 (2–5) 1
13 Focus on restoration of extension
Robinson et al44 CST No No Compartment pressure, CK levels, thigh circumference
35 (21–56) NA
Rööser et al11 CST Yes No NA NA All regained normal function within 4 weeks
Rothwell9 Contusion No Three-phase plan Thigh circumference Inpatient-47.6 Outpatient-18.9
10 Data reported as time to return to work
Ryan et al8 Contusion No Three-phase plan Radiograph at 6 months, thigh circumference
Mild-13 (2–42) Moderate-19 (7–60) Severe-21 (7–35)
11 Focus on restoration of flexion
*Cryotherapy, weight bearing as tolerated, ROM exercises, graduated strengthening programme. ROM, range of motion; NA, not applicable.
Table 3 Inpatient quadriceps contusion therapy8
Phase 1 Phase 2
Interventions Bed rest, cryotherapy, compression with thigh length support hose and Ace wrap, hip and knee elevation, knee flexion as tolerated. Purpose is to reduce haemorrhage.
Ambulation using crutches, cryotherapy, Ace wrap, continuous passive motion, supine and prone active knee flexion. Purpose is to regain painless motion.
Criteria for advancement to next phase
Stabilisation of thigh girth; patient is comfortable and pain-free at rest.
Crutch ambulation with weight bearing as tolerated and negotiating steps, pain-free passive range of motion 0–90° and good quadriceps control. Continue phase 2 as outpatient
Table 4 Outpatient quadriceps contusion therapy8
Phase 1 Phase 2 Phase 3
Interventions Weight bearing as tolerated, ambulation using crutches, cryotherapy, Ace wrap entire thigh, elevation, flexion as tolerated, isometric quadriceps contractions. Purpose is to reduce haemorrhage.
Cryotherapy, isometric quadriceps exercises, supine and prone active flexion. Remove crutches when range of motion >90, good quadriceps control and pain-free with flexed weight bearing gait. Remove Ace wrap when thigh girth is equal bilaterally Purpose is to regain painless motion.
Static cycle with increasing resistance, Increasing activity (swim, walk, jog, run) as tolerated without pain. Purpose is functional rehabilitation of strength and endurance.
Criteria for advancement to next phase
Stabilisation of thigh girth; patient is comfortable and pain-free at rest.
Thigh girth is equal bilaterally; active knee motion >120° without pain.
All activities without pain, full active range of motion. Wear thigh girdle with thick pad during contact sports for 3–6 months.
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Inflammation is beneficial for attracting reparative cells that initiate soft tissue healing, but is also responsible for pain and swelling, which restricts mobility, increases stiffness and can disrupt the healing process.26 Jarvinen et al46 demonstrated that NSAIDs and hydrocortisone decreased the acute inflam- mation, but decreased the tensile properties of the soft tissues in a rat contusion model. Hydrocortisone, in particular, caused delayed elimination of haematoma and necrotic tissue and muscle regeneration. Early mobility in animal contusion models have also demonstrated efficacy by reducing granula- tion tissue proliferation into muscle and improving tensile strength.47 48 Thus, these medications can be used in the early treatment of this condition; however prolonged usage could have deleterious effects with return to sporting activity. Additionally, when to prescribe or initiate NSAIDs is debat- able as it could theoretically increase bleeding in the acute state.21 These properties, however, have not been established in human studies and the use of NSAIDs or hydrocortisone was not discussed in any of the reviewed articles. Current recommendations for NSAID use in the treatment of muscle injuries include a short 3–7-day course for pain relief, muscle strength preservation and possible prevention of myositis ossificans.49
While the components of conservative therapy were largely similar among the studies, there were some important differ- ences. Jackson and Feagin43 emphasised early restoration of knee extension, but subsequently noted that knee flexion was the greatest contributor to delayed return of function. Consequently, Ryan et al8 focused on early restoration of knee flexion with improved results. Furthermore, Aronen et al42
immobilised athletes in 120° of flexion for the first 24 hours fol- lowing injury, resulting in earlier return to play. However, injury severity was not categorised, limiting the ability to compare these results to previous studies. While monitoring of rehabilita- tion protocols varied across the studies, they all examined knee range of motion in order to quantify improvement and to detect potential complications.
Potential complication: compartment syndrome The greatest concern in the acute period with conservative man- agement is the potential for development of compartment syn- drome of the thigh (CST). Compartment syndrome is chiefly a clinical diagnosis; its presentation includes paresthesias, pain with passive stretching, pain out of proportion to examination, pulselessness, pallor, poikilothermia and paresis.31 50 Despite this, clinical presentation has a low sensitivity…