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Quadriceps Injury Clinical Presentation

  • Author: Thomas M DeBerardino, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: May 13, 2014
 

History

Quadriceps contusion

The mechanism is usually a blow to the anterior thigh with an object (eg, bat) or contact with another athlete (eg, knee, head) or gear (eg, helmet).

A severe trauma and large contusion can lead to a compartment syndrome. This diagnosis should be considered in patients with crush injuries, in patients with fractures resulting from high-energy trauma, in patients on anticoagulants, in patients with bleeding disorders, and in patients with multiple traumas.

A compartment syndrome of the thigh is very rare compared to compartment syndromes of the lower leg. The thigh compartments are much larger, allowing for tissue expansion, and the forces are distributed over a greater area. Unless rapid bleeding has occurred, these patients generally present with a gradual increase in their symptoms. The blood vessels injured usually are the deep perforating branches of the vastus intermedius (because of the direct attachment of that muscle to the femur).

Untreated, a compartment syndrome may lead to muscle necrosis, fibrosis, scarring, and limb contractures. Nerve injury may result either from the direct blow or from compression within the compartment.

Symptoms include painful anterior thigh, painful weightbearing, and unwillingness to flex the knee because of thigh pain.

Quadriceps tendon sprain

Blazina first described peripatellar tendinitis affecting the quadriceps tendon or the patellar tendon and termed this jumper's knee in 1973. He noted that it commonly occurred in jumping athletes.

The mechanism is sudden stretching or repeated eccentric contraction of the muscle causing pain and dysfunction immediately or 1-3 days later.

Symptoms include pain with ambulation and knee flexion and inability to extend the knee if the quadriceps is ruptured.

Quadriceps muscle partial tear

The mechanism is kicking or sprinting.

Incomplete intrasubstance tears of the rectus femoris tendon occur at the deep portion of the indirect head and the muscle there. The location, while along the distal part of the rectus femoris, is more proximal than the quadriceps strain at the patellar insertion.

Quadriceps tendon rupture

Many authors have concluded that the tendon usually ruptures in an area of tendinosis. In patients with bilateral injuries or injuries associated with trivial trauma and no history of previous strain, consideration should be given to the associated use of anabolic steroids or the diagnoses of renal disease and metabolic bone disease (hyperparathyroidism).

Special cases

This category includes ruptures after surgery. The surgeries that may be associated with this complication include lateral release, total knee replacement, or anterior cruciate ligament or posterior cruciate ligament reconstruction. Rupture of the quadriceps tendon after surgery may be associated with the procedure to harvest the graft used to reconstruct the cruciate ligaments or aggressive release of soft tissues in the case of lateral release and total knee replacement.

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Physical

Quadriceps contusion

See the list below:

  • Normal medial and posterior thigh
  • Tensely edematous and tender anterior thigh
  • Limited knee flexion
    • Mild - Greater than 90°
    • Moderate - From 45-90°
    • Severe - Less than 45°
  • For ruptures (complete and partial): Extensor lag indicates partial and complete tears; no extension indicates complete tear.
  • Gait abnormalities
    • Mild - Normal
    • Moderate - Antalgic
    • Severe - Severe limp
  • Knee effusion: Effusion may or may not be present.
  • Exquisite anterior thigh tenderness with knee flexion
  • Increased circumference of affected thigh
  • Straight-leg raise: Patients are able to perform this unless the extensor mechanism is disrupted.
  • Normal sensation in distal extremity: If sensation is compromised, consider compartment syndrome. The anterior compartment contains the femoral nerve, and testing of the lateral, intermediate, and medial cutaneous nerves should be performed if compartment syndrome is suspected.
  • Pain: Disproportionately high level of pain for examination triggers suspicion of compartment syndrome.

Muscle strain

Tenderness is elicited by direct palpation of the quadriceps at the patellar insertion, or the patient reports pain when testing for resisted extension.

Quadriceps muscle hernia

A soft mobile mass, which may be tender, is palpated anteriorly with contraction of the quadriceps. A fascial defect may be appreciated.

Muscle partial tear

Thigh asymmetry with a nontender or mildly tender muscle mass at the distal aspect of the rectus femoris is a common finding.

Quadriceps tendon rupture

See the list below:

  • Inability to straight-leg raise (extensor mechanism disrupted)
  • Muscular defect in distal anterior thigh with mass in proximal thigh
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Causes

See the list below:

  • Quadriceps contusion or compartment syndrome - Direct blow to anterior aspect of thigh
  • Quadriceps strain or rupture - Acute stretch or repeated eccentric muscle contractions with immediate or delayed (1-3 d) presentation of pain, stiffness, and decreased function
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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Leslie Milne, MD Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine

Leslie Milne, MD is a member of the following medical societies: American College of Sports Medicine

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.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, Minnesota Medical Association, American College of Sports Medicine

Disclosure: Nothing to disclose.

References
  1. Ryan JB, Wheeler JH, Hopkinson WJ, Arciero RA, Kolakowski KR. Quadriceps contusions. West Point update. Am J Sports Med. 1991 May-Jun. 19(3):299-304. [Medline].

  2. Langenhan R, Baumann M, Ricart P, Hak D, Probst A, Badke A. Postoperative functional rehabilitation after repair of quadriceps tendon ruptures: a comparison of two different protocols. Knee Surg Sports Traumatol Arthrosc. 2012 Feb 4. [Medline].

  3. Almekinders LC. Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies. Sports Med. 1999 Dec. 28(6):383-8. [Medline].

  4. Aronen JG, Chronister RD. Quadriceps contusions: hastening the return to play. Phys Sportsmed. 1993. 20(7):130-6.

  5. Bennell K, Duncan M, Cowan S, et al. Effects of VMO retraining versus general quadriceps strengthening on vasti onset. Med Sci Sports Exerc. 2009 Dec 4. epub ahead of print. [Medline].

  6. Harvey LA, Fornusek C, Bowden JL, et al. Electrical stimulation plus progressive resistance training for leg strength in spinal cord injury: A randomized controlled trial. Spinal Cord. 2010 Jan 12. epub ahead of print. [Medline].

  7. Hughes C 4th, Hasselman CT, Best TM, Martinez S, Garrett WE Jr. Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med. 1995 Jul-Aug. 23(4):500-6. [Medline].

  8. Martinez SF, Steingard MA, Steingard PM. The compartment syndrome: a limb-threatening emergency. Phys Sportsmed. 1993. 21:94-104.

  9. Novak PJ, Bach BR, Schwartz JC. Diagnosing acute thigh compartment syndrome. Phys Sportsmed. 1992. 20(11):100-7.

  10. Saartok T. Muscle injuries associated with soccer. Clin Sports Med. 1998 Oct. 17(4):811-7, viii. [Medline].

  11. Staubli HU, Schatzmann L, Brunner P, Rincon L, Nolte LP. Mechanical tensile properties of the quadriceps tendon and patellar ligament in young adults. Am J Sports Med. 1999 Jan-Feb. 27(1):27-34. [Medline].

  12. Wahrenberg H, Lindbeck L, Ekholm J. Knee muscular moment, tendon tension force and EMG during a vigorous movement in man. Scand J Rehabil Med. 1978. 10(2):99-106. [Medline].

 
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Place knee passively in 120º of flexion and immobilize with a double elastic wrap in a figure-8 fashion. This should occur within minutes of the injury. Used with permission courtesy of John Aronen, MD.
Modified treatment of quadriceps contusion. Used with permission courtesy of John Aronen, MD.
 
 
 
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