Quadriceps Injury Clinical Presentation
- Author: Thomas M DeBerardino, MD; Chief Editor: Craig C Young, MD more...
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).
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.
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.
- 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.
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
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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