Quadriceps Injury Workup
- Author: Thomas M DeBerardino, MD; Chief Editor: Craig C Young, MD more...
Blood studies are not generally indicated when the patient's history is that of overuse or sudden trauma. However, if the history and physical examination findings are suggestive of renal disease, hyperparathyroidism, soft tissue tumor, or diabetes mellitus, the appropriate studies should be sent.
The following are indicated for severe contusions and ill-appearing patients:
Coagulation studies - If patient develops spontaneous edema or is taking anticoagulants
Initially, imaging studies may not be indicated in patients with partial rectus tears, minimally symptomatic quadriceps contusions, and mild quadriceps tendinitis. These patients have a history of acute or repetitive trauma, and the history and physical examination findings are consistent with these working diagnoses. For patients in whom the history and physical examination findings are not consistent, for patients with night pain, patients with suspected complete quadriceps rupture, those with significant quadriceps contusion, and in patients where fracture (femur or patellar), metabolic disease, or tumor is suspected, radiography is indicated on the first visit.
For patients with mild tendinitis, mild contusions, and partial rectus tears who do not respond to activity modification, rest, and physical therapy, radiography is indicated on follow-up examination.
In patients with quadriceps contusion, plain radiography may show evidence of myositis ossificans at the site of the contusion several weeks to months after injury.
Patients who have quadriceps tendinitis or partial tears of the rectus tendon may have the radiographic findings of the so-called saw tooth patella along the proximal border of the patella.
Patients with complete rupture of the tendon may have an associated patellar fracture, particularly if the patient fell on the flexed knee at the time of the injury. The radiographs in patients with complete rupture show obliteration of the quadriceps tendon shadow, patella baja, and a large effusion. A suprapatellar mass (the retracted quadriceps muscle) or a suprapatellar calcific density may also be present.
If quadriceps tendon rupture is diagnosed clinically, anteroposterior (AP) and lateral views of the knee are the minimum views required. The lateral view shows a low-riding patella, patella baja, due to the unopposed pull of the patellar tendon.
CT scanning is not usually as helpful as MRI.
Ultrasonography is less expensive than the MRI and has a high sensitivity and specificity for complete tears. Its accuracy and predictive value in partial tears is not as good.
MRI has the highest sensitivity and specificity for disorders of the quadriceps. It shows both complete and partial ruptures, soft tissue hematomas, tendinopathies, soft tissue tumors, myositis ossificans, and fascial defects. Incomplete intrasubstance tears of the rectus femoris and complete tears of the rectus femoris and quadriceps tendon are visible as increased signal intensity on the T2 images. Incomplete intrasubstance ruptures of the rectus tendon and the quadriceps tendon image as focal disruptions of the normal laminated appearance of the tendon.
Compartment pressure measurements should be taken if compartment syndrome is suspected in the anterior thigh.
Compartment pressures should be measured if a compartment syndrome is suspected.
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].
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].
Almekinders LC. Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies. Sports Med. 1999 Dec. 28(6):383-8. [Medline].
Aronen JG, Chronister RD. Quadriceps contusions: hastening the return to play. Phys Sportsmed. 1993. 20(7):130-6.
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].
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].
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].
Martinez SF, Steingard MA, Steingard PM. The compartment syndrome: a limb-threatening emergency. Phys Sportsmed. 1993. 21:94-104.
Novak PJ, Bach BR, Schwartz JC. Diagnosing acute thigh compartment syndrome. Phys Sportsmed. 1992. 20(11):100-7.
Saartok T. Muscle injuries associated with soccer. Clin Sports Med. 1998 Oct. 17(4):811-7, viii. [Medline].
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].
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].