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Quadriceps Tendon Rupture Workup

  • Author: James Edwin Lyle, MD; Chief Editor: Thomas M DeBerardino, MD  more...
 
Updated: Mar 02, 2015
 

Laboratory Studies

A preliminary laboratory workup to rule out rheumatologic, endocrine, and renal disease may be indicated in suspicious, presumably healthy individuals with quadriceps tendon ruptures.

Consider a laboratory workup in all cases of bilateral rupture.

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Imaging Studies

Several imaging studies are helpful to confirm the diagnosis of quadriceps tendon rupture.[38] Plain radiographs are usually the first imaging modality ordered.[20]

Several abnormalities may be seen on lateral radiographs. These include obliteration of the quadriceps tendon shadow, a suprapatellar mass, suprapatellar calcific densities, spurring of the anterior superior patella, joint effusion, patella baja, and anterior tilting of the superior patella. These findings may be quite subtle or even absent. Patella baja is diagnosed using the Insall-Salvati index, which is the ratio of the patellar tendon length to the length of the patella. This ratio should near 1 with no more than 20% variation.

On the axial view, the tooth sign, which represents vertical ridging of the osteophytes at the quadriceps insertion, may be seen on the anterior patella (see the image below). In 1977, this sign was first described by Greenspan et al as an incidental finding caused by tendon degeneration[39] ; in 1980, Kelly et al first reported it in association with a quadriceps tendon rupture.[40]

Toothlike ridging of the anterosuperior patella. R Toothlike ridging of the anterosuperior patella. Reproduced with permission from Greenspan A, Norman A, Tchang FK. "Tooth" sign in patellar degenerative disease. J Bone Joint Surg Am. Jun 1977;59(4):483-5.

Use other imaging modalities next to clarify a questionable diagnosis or to differentiate complete and incomplete ruptures.

In complete ruptures, arthrography reveals extravasation of contrast material from the suprapatellar bursa into the soft tissues anterior to the patella, but it is an invasive procedure.[41, 42]

Ultrasonography has high sensitivity and specificity in depicting complete quadriceps tendon ruptures.[43] An area of hypoechogenicity is seen across the entire thickness of the tendon. In partial tears, a focal hypoechoic defect is seen. In tendinitis, tendon thickening is visualized. Ultrasound is quick and noninvasive but is highly operator-dependent.

Magnetic resonance imaging (MRI) has probably become the imaging study of choice when there is any doubt about the diagnosis. MRI can clearly depict the laminated structure of the quadriceps tendon. Complete ruptures show transaction of all of the layers of the tendon. Incomplete ruptures show discontinuities of individual layers, with the remaining layers intact (see the image below).

Magnetic resonance imaging (MRI) scans of complete Magnetic resonance imaging (MRI) scans of complete and incomplete quadriceps tendon ruptures. Reproduced with permission from Zeiss J, Saddemi SR, Ebraheim NA. MR imaging of the quadriceps tendon: normal layered configuration and its importance in cases of tendon rupture. AJR Am J Roentgenol. Nov 1992;159(5):1031-4.
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Histologic Findings

Histologic study is usually not included in the preoperative workup. See Pathophysiology for histologic details.

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Contributor Information and Disclosures
Author

James Edwin Lyle, MD Orthopedic Surgeon, East Alabama Orthopedics and Sports Medicine, LLC

James Edwin Lyle, MD is a member of the following medical societies: Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

Phillip J Marone, MD, MSPH Clinical Professor, Department of Orthopedic Surgery and Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University

Phillip J Marone, MD, MSPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of Lynn A Crosby, MD, FACS, to previous versions of this article.

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Tendolipomatosis. Reprinted with permission from Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am. Dec 1991;73(10):1507-25.
Toothlike ridging of the anterosuperior patella. Reproduced with permission from Greenspan A, Norman A, Tchang FK. "Tooth" sign in patellar degenerative disease. J Bone Joint Surg Am. Jun 1977;59(4):483-5.
Magnetic resonance imaging (MRI) scans of complete and incomplete quadriceps tendon ruptures. Reproduced with permission from Zeiss J, Saddemi SR, Ebraheim NA. MR imaging of the quadriceps tendon: normal layered configuration and its importance in cases of tendon rupture. AJR Am J Roentgenol. Nov 1992;159(5):1031-4.
Exposure of a tendon rupture.
Drill holes through the patella.
Passing suture through patellar drill holes.
Tendon pulled down into the patellar bony trough with sutures.
Finished repair.
 
 
 
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