How Elite Physios Assess Anterior Thigh Injuries

Anterior thigh injuries are common in kicking and sprinting sports, but not all present the same way. With re-injury rates as high as 16–20%, the ability to recognise key assessment patterns early can be the difference between a smooth recovery and a prolonged, complicated return to play.

Within professional football, they’re a frequent cause of time loss. Adam Johnson, a physio in the English Premier League (EPL), takes us behind the curtain and shows us how he assesses anterior thigh injuries with his players. This blog gives you a little look inside the assessment approach which sets him apart as one of the leading experts in this field.

If you want to know exactly how an EPL physio assesses anterior thigh injuries, watch Adam’s full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

Listening for the key clues

Most anterior thigh injuries occur during sprinting, rapid deceleration, or ball striking. A clear acute mechanism is almost always present, and understanding it can help not only with assessment but also with treatment planning down the track.

Adam notes that, in his experience, one detail stands out: if an athlete reports feeling or hearing a “pop” or “click” at the time of injury, it’s a poor prognostic sign. It can indicate a potential full tendon rupture involving the direct or indirect head of the rectus femoris. What can make this deceptive is that athletes often report feeling surprisingly good a few days later. Because other muscles such as the iliopsoas and vasti can compensate, basic daily movement might be pain-free.

When you hear that story – a “pop” followed by minimal discomfort — suspicion for an intramuscular tendon rupture should rise, and imaging would be indicated, as these injuries require surgical intervention.

Imaging, grading and prognosis

Ultrasound is useful as it provides a dynamic view of the proximal tendon, but its accuracy depends heavily on the operator, so MRI remains the gold standard.

Injuries are graded using the British Athletics Muscle Injury Classification system, which runs from 0 to 4 for severity and adds letters A to C to describe the tissue involved — myofascial, myotendinous or intramuscular tendon.

This classification helps plan rehabilitation and gives a broad timeline: anterior thigh injuries have an average return to play of about 21 days, but with large variation. A grade 2 injury may resolve in 3 weeks, while a grade 4 can take 6-8 weeks, and a surgical 4C injury might mean 3 months or more. Understanding where an injury sits on that scale sets expectations for both clinician and athlete.

Objective assessment

The physical examination includes palpation (particularly over the direct and indirect heads of the rectus femoris), hip and knee range, and strength testing.

Adam uses a range of positions for strength testing including positions like: straight leg raise, bent-knee raise, and resisted hip flexion from hip extension off the edge of the bed. Variations in strength or pain between these positions help pinpoint which structure is involved. A femoral nerve test can be used if symptoms or history suggest neural contribution.

See Adam demonstrate how he assesses for severe proximal injuries in this clip from his Practical:

Objective testing then turns to numbers. The rectus femoris often compensates for weakness in other hip muscle groups, so strength profiling identifies where that load originates and helps with treatment planning.

Using a handheld dynamometer, Adam tests hip flexion, extension, adduction and abduction in different ranges. Ideally, in kicking sports, the adductors should produce approximately 110–120% of the force produced by the abductors. Symmetry within 10% side-to-side is the benchmark.

Testing function

Static strength alone doesn’t tell you if an athlete can handle the dynamic, eccentric demands of sport. Functional testing brings those forces back in a controlled way, and this is where understanding the mechanism of injury really comes in.

The drop lunge is one of Adam’s preferred assessments for the early return-to-activity phase. It combines hip extension and knee flexion under speed, replicating the high-load pattern that often caused the injury. Initially performed slowly, it progresses to repeated and reactive versions to assess control, confidence and fatigue tolerance.

See Adam demonstrate his assessment of return-to-run readiness in the below video from his Practical:

He then moves on to higher-demand testing including jumps — from double-leg counter-movement to single-leg and triple hops — as well as return-to-kicking tests. Check them out in his full Practical.

Wrapping up

Not all anterior thigh injuries are the same, and recognising that can make a huge difference in how you assess and ultimately manage them. By using some of these expert tips, you can improve your assessment skills and tailor your treatment to each patient’s unique injury.

If you want to see exactly how an expert physio assesses anterior thigh injuries, watch Adam’s full Practical here.