Working Diagnosis:
Bilateral intramuscular rectus femoris degloving injury, worse on the left than the right

Treatment:
The patient was treated conservatively with naproxen 220 mg twice daily, activity modification, and gentle range-of-motion exercises. At three-week follow-up, she reported complete resolution of pain and began formal physical therapy focused on progressive strengthening while avoiding explosive activities. Four weeks after diagnosis, she advanced to stationary cycling and continued a structured return-to-sport progression under the supervision of her certified athletic trainer.

Outcome:
At five weeks, the patient remained pain-free with physical therapy and cross-training. She progressed through jogging, soccer-specific drills, and unrestricted practice without recurrence of symptoms. She returned to full soccer practice 42 days after diagnosis and successfully played in her first competitive game seven weeks after diagnosis without symptom recurrence.

Author's Comments:
Quadriceps injuries are among the most common muscle injuries encountered in soccer athletes, with the rectus femoris representing the most frequently involved quadriceps muscle. Unlike the other quadriceps muscles, the rectus femoris crosses both the hip and knee joints and possesses a unique dual-tendon architecture at the origin. The superficial unipennate muscle originates from the direct tendon at the anterior inferior iliac spine (AIIS), while the deeper bipennate muscle originates from the indirect tendon along the superior acetabular ridge. An intramuscular degloving injury occurs when the inner bipennate muscle tears and retracts within the intact outer unipennate muscle, creating a characteristic appearance on MRI. Because symptoms may mimic muscle strain or stress injury and physical examination findings are often nonspecific, MRI is essential for diagnosis. Bilateral intramuscular rectus femoris degloving injuries are exceptionally rare and, to our knowledge, have been infrequently reported in adolescent athletes.

Editor's Comments:
Persistent exertional thigh pain that fails to improve with an appropriate period of conservative treatment should prompt advanced imaging, even when plain radiographs and physical examination are relatively benign. Although femoral stress injuries remain an important diagnosis to exclude in adolescent female athletes, MRI can identify uncommon soft tissue injuries such as intramuscular rectus femoris degloving injuries that may otherwise be mistaken for routine quadriceps strains. Recognition of the rectus femoris’ unique anatomy is important, and ultrasound can be quite useful initial tool to scrutinize the origins of the rectus femoris at the AIIS and superior acetabular ridge when an injury is suspected. Also, these injuries often require a more gradual rehabilitation program than typical muscle strains to reduce the risk of recurrence and facilitate a safe return to sport.

References:
Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among US high school athletes. Acad Emerg Med. 2007;14(7):641-645.

Hasselman CT, Best TM, Hughes C, Martinez S, Garrett WE. An explanation for various rectus femoris strain injuries using previously undescribed muscle architecture. Am J Sports Med. 1995;23(4):493-499.

Kassarjian A, Rodrigo RM, Santisteban JM. Intramuscular degloving injuries to the rectus femoris: findings at MRI. AJR Am J Roentgenol. 2014;202(5):W475-W480. doi:10.2214/AJR.13.10931.

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