High Yield Topics

Quadriceps Tear

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Ovid: 5-Minute Sports Medicine Consult, The


Quadriceps Tear
Jason P. Womack
Kinshasa Morton
Basics
Quadriceps strains are graded based on the degree of injury:
  • Grade I: Stretch injury of muscle fibers
  • Grade II: Partial tearing of muscle fibers
  • Grade III: Complete tear of muscle fibers:
    • Grade III tears most commonly involve the distal rectus femoris muscle.
    • Grade III tears may involve complete rupture of the extensor mechanism if the distal quadriceps tendon is involved (1).
    • Proximal ruptures may involve avulsion of anterior inferior iliac spine.
Epidemiology
  • Rectus femoris is the most common location of clinically significant quadriceps strains (2):
    • Majority of injuries around the muscle body, with distal and proximal injuries being rare (1)
  • Tears occur predominantly in males (3).
  • Partial tears occur on average at 28 yrs old (3).
  • Represents 10% of injuries to soccer players
  • Proximal rupture/avulsion is rare:
    • More commonly seen in adolescent, kicking athletes
    • Represents 1.5% of hip injuries (0.05% of all injuries) to National Football League (NFL) players since 1997 (4)
  • Distal quadriceps rupture is a rare event:
    • 88% of ruptures occur in those >40 yrs of age.
Risk Factors
Distal tendon rupture (5):
  • Age over 40
  • Hemodialysis patients
  • Anabolic steroid use
  • Diabetes
  • Gout
  • Hyperparathyroidism
  • Hypocalcemia
Etiology
  • Commonly affects athletes with repetitive functional overloading of the extensor mechanism (3):
    • The dominant kicking leg is at risk for quadriceps strain (2).
  • Complete tears most likely seen in basketball, weightlifting, and high jump (6).
Diagnosis
History
  • Strain to quadriceps muscle is most commonly associated with kicking or sprinting.
  • Strains are a noncontact injury. History of contact leads to diagnosis of quadriceps contusion.
Physical Exam
  • Appearance:
    • There may be swelling and possible ecchymosis around the area of injury.
  • Palpation:
    • Tenderness, spasm, or both at the area of muscle injury
    • A defect in the muscle tissue may be felt in Grade III strains.
    • If distal ruptured, the intercondylar notch may be palpated, as the quadriceps tendon is not present
  • Range of motion:
    • The extensor mechanism must be evaluated in all knee and quadriceps injuries.
    • Inability of any active extension of the knee is concerning for quadriceps rupture.
    • Strains show pain with active extension and passive knee flexion:
      • Grade I will show pain with resisted active extension.
      • Grade II and III will show pain with unopposed active extension.
Alert
Lack of active extension of the knee should raise concern of complete tendon rupture that requires prompt diagnosis and surgical consultation.
  • Strength exam:
    • Weakness of knee extension secondary to the injured muscle tissue
  • Neurological exam:
    • Sensation and reflexes are intact:
      • No reflex will be present in complete rupture.
Diagnostic Tests & Interpretation
Imaging
  • Plain radiographs:
    • Not helpful in the diagnosis of acute quadriceps strain
    • Complete ruptures may show patellar baja on lateral views.
  • MRI:
    • Not necessary in quadriceps strain, but will likely show edema and possible defects in the musculature (1)
    • Proximal ruptures may show avulsion of the anterior inferior iliac spine (AIIS) and degree of retraction from the pelvis.

    • P.501


  • US (7):
    • Partial tearing:
      • Hypoechoic cleft in the tendon
      • Scanning in the long and short axis helps to determine the extent of the strain.
    • Complete rupture:
      • Complete discontinuity in the long axis of scanning
Differential Diagnosis
  • Quadriceps tendonitis
  • Patellar tendinitis
  • Patellar tendon rupture
  • Patellofemoral pain syndrome
  • Patellar dislocation/subluxation
  • Osgood-Schlatter disease
  • Sinding-Larsen-Johansson disease
Treatment
  • Acute phase:
    • Rest, ice, compression, and pain control
    • Gentle stretching as permitted to maintain range of motion
    • Early surgery is indicated for complete distal rupture:
      • Proximal rupture/avulsion may be treated nonoperatively
    • NSAIDs:
      • NSAIDs may be used acutely to help with pain.
    • Controversy exists as to whether NSAIDs delay healing and collagen formation.
Alert
Be careful if there is a suspected quadriceps contusion NSAID used could theoretically increase bleeding.
  • Recovery phase:
    • Recovery of range of motion with stretching
    • Exercise to regain strength of the quadriceps and hamstring tendons
    • Padding should be worn to protect the injured portion of the quadriceps musculature.
  • Surgery indicated for quadriceps rupture at the patellar insertion as noted above. A recent study of NFL players with proximal quad tendon avulsion showed that conservative measures lead to good outcomes in these injuries.
Surgery/Other Procedures
  • Acute rupture of the distal quadriceps tendon:
    • Requires prompt surgical repair
    • Time from injury to repair is the greatest determinant of outcome in athletes with quadriceps tendon ruptures. Repair within 1–2 wks yields significantly better outcomes.
    • End-to end repairs and tendon-to-bone repairs are used, depending on the level of the rupture.
  • Proximal avulsion of the AIIS:
    • Vast majority are successfully treated nonoperatively
    • Surgery to reattach the avulsed AIIS may be successful treatment if there is continued pain, disability, or both after conservative measures have failed (8).
  • Intrasubstance rectus femoris Grade III strains:
    • Removal of the tear may benefit those who continue to have pain or dysfunction after physical therapy.
Ongoing Care
Return to play:
  • When quadriceps has 120 degrees of flexion
  • No signs of quadriceps weakness
  • May take days to months based on the degree of injury
References
1. Armfield DR, Kim DH, Towers JD, et al. Sports-related muscle injury in the lower extremity. Clin Sports Med. 2006;25:803–842.
2. Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med. 2001;29:300–303.
3. DeBerandino T, Milne l, DeMaio M. “Quadriceps Injury.” eMedicine. 2006 Jun 5. http://emedicine.medscape.com/article/91473-overview
4. Gamradt SC, Brophy RH, Barnes R, et al. Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football. Am J Sports Med. 2009.
5. Johnson AE, Rose SD. Bilateral quadriceps tendon ruptures in a healthy, active duty soldier: case report and review of the literature. Mil Med. 2006;171:1251–1254.
6. Rooks YL, Corwell B. Common urgent musculoskeletal injuries in primary care. Prim Care. 2006;33:751–777.
7. Miller T. Common tendon and muscle injuries: lower extremity. Ultrasound Clinics. 2007;2:595–615.
8. Irmola T Heikkila JT, Orava S, et al. Total proximal tendon avulsion of the rectus femoris muscle. Scand J Med Sci Sports. 2007;17:378–382.
Additional Reading
Ramseier LE, Werner CM, Heinzelmann M. Quadriceps and patellar tendon rupture. Injury. 2006;37:516–519.
Codes
ICD9
  • 843.8 Sprain of other specified sites of hip and thigh
  • 844.8 Sprain of other specified sites of knee and leg


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