Quadriceps Tendon Rupture

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Quadriceps Tendon Rupture 2017-12-02T15:06:25+00:00

Quadriceps Tendon Rupture

By Brian J. Ludwig, MD

A quadriceps tendon rupture occurs relatively infrequently and usually occur in athletes older than 40 years old. Injuries to the quadriceps tendon can be very disabling. They can cause significant loss of time from sport and work.  If not treated appropriately, these injuries can have many negative long-term sequelae, however if diagnosed quickly and treated appropriately, one can expect a full recovery from a quadriceps tendon rupture. 

What is the quadriceps tendon and why is it important? 

The quadriceps tendon is the strong tendon that inserts on the top of the patella (knee cap). The quadriceps tendon is a confluence (coming together) of the four muscles that make up the muscles that extend the knee. These four muscles are: vastus medialis, vastus intermedius, vastus lateralis and rectus femoris. These muscles are the strong muscle on the anterior (front) side of the femur (thigh bone). Their main action is to extend the knee and leg. All four of these muscles come together just above the patella and form a strong, thick tendon.

The quadriceps tendon is important because it allows the knee to be extended. If the quadriceps tendon is injured then the patient will not be able to extend their knee.

How does one suffer quadriceps tendon rupture? 

The quadriceps tendon is injured most commonly from a forced eccentric contraction (contracting while lengthening) against an outside force. This can happen during high-energy accidents such as motor vehicle crashes and during sporting activities, or during low energy injuries such as falls from a standing position.

What are some risk factors for a quadriceps tendon rupture? 

Really there are very few risk factors. Most quadriceps tendon ruptures are the result of either direct or indirect trauma. There are some medical problems that can increase a person’s chance of having a quadriceps tendon rupture including renal (kidney) disease, rheumatoid arthritis, chronic steroid use and diabetes mellitus. However, even in patients with these disorders, the incidence of quadriceps tendon ruptures is still very low.


What are the signs and symptoms of a quadriceps tendon rupture? 

quadricep tendon rupture

Source: orthoinfo.aaos.org

Most people with a quadriceps tendon rupture will note the acute onset of pain and disability in the affected leg. Usually this is precipitated by a fall or other traumatic event. The pain will be located at the level of the knee or just above the knee joint. The patient with a complete rupture is unable to do a straight leg raise or extend their knee. These patients will have a difficult time walking on the affected leg.

On physical examination the patient will be acutely tender to palpation directly above the patella. There is oftentimes a palpable defect in this area when compared to the contralateral side (uninjured knee). The knee will have a large effusion (swelling in the knee). The patient will be unable to extend their knee. Some patients with a partial tear may still be able to extend their knee, but will have significant weakness when compared to the other leg.

What imaging studies are needed for a quadriceps tendon rupture? 

Initially a patient who presents with pain and swelling in the knee should undergo plain radiographs (x-rays) of the affected knee. This will help to rule out a fracture as the cause of the problem. If these are negative, then a MRI scan can be obtained to evaluate the integrity of the quadriceps tendon.

The x-rays of a patient with a quadriceps tendon rupture may show patellar baja (a knee cap that is lower than normal). There may also be a small piece of bone that is torn off of the patella with the tendon that can be visualized on x-ray. The gold standard for diagnosis would be a MRI scan of the knee, which would evaluate all of the soft tissue structures in the knee including all of the cartilage and ligaments. This would also help to distinguish between a complete and partial tear.

What are some other injuries that can mimic a quadriceps tendon rupture? 

There are many injuries to consider when a patient may have a quadriceps tendon rupture. These include: patellar (knee cap) fracture, patellar tendon rupture, fracture of the end of the femur (thigh bone) or top of the tibia (shin bone), torn ACL, and patellar dislocation. The diagnosis is confirmed by doing an appropriate physical examination and also through imaging studies.

What are the different types of quadriceps tendon ruptures and how are they treated? 

Quadriceps tendon ruptures come in two main types: partial and complete tears. Distinguishing between the two is very important, as the treatment is vastly different.

Partial tears can sometimes be treated non-operatively. In order for a partial tear to be treated without surgery, the patient must be able to do a straight-leg raise and have good strength with this physical exam finding. If this is the case, treatment should commence immediately with immobilization of the leg in full extension (out straight) for a short period of time. Then range of motion exercises are started at between 3-6 weeks from the injury. After six weeks, quadriceps strengthening is begun. Typically, after 10-12 weeks the injury has healed. The patient may resume normal activities after they have full range of motion and quadriceps strength. This can be anywhere from 3-6 months after the injury. Return to sport is governed by the ability to pass functional tests specific to the sport (example: jumping for a basketball player). 

Complete tears, as well as partial tears when the patient is unable to perform a straight-leg raise, are always treated with surgery. Without surgery, the patient will be unable to extend their knee and have significant long-term disability. Surgery is typically recommended within a few days to a week after the injury. If the patient’s other medical problems prohibit the opportunity to perform the surgery safely in the first week, it can be delayed until the patient is medically fit for surgery.

What does the surgery involve for repair of a quadriceps tendon rupture? 

Typically surgery involves making an incision on the front of the knee. Then strong sutures are placed into the tendon and tied back down to the top of the patella. Surgery generally takes between one and two hours. The patient is then placed into a knee immobilizer keeping the knee straight after surgery.

What type of rehabilitation is needed after surgery? 

After surgery, the patient will start with gentle passive range of motion with their physical therapist. The patient will be able to weight bear with all of their weight on their leg after a week or two, but will have to wear the brace they received after surgery locked straight for the first six weeks, except when doing their therapy. By six weeks post-op, the patient should have 90 degrees of flexion (bending) of the knee. After six weeks, progressive strengthening is started as well as increasing range of motion. Typically, the brace is discontinued at eight weeks from surgery. Light running is generally started at four months from surgery. Return to sport is governed by the ability to perform sport specific exercises and having adequate range of motion and strength. This is generally between 6-8 months from the day of surgery. It should be noted that rehabilitation protocols are often very specific to the type of injury and the type of repair that was achieved at the time of surgery. The above protocol is just an outline of “typical” rehabilitation.

Quad Exercises

What if I do not seek treatment for my quadriceps tendon rupture right away? 

When quadriceps tendon ruptures are not identified early, it can be more difficult to fix with surgical repair. The quadriceps muscle is very powerful, therefore the tendon retracts proximally (up the thigh) and becomes harder to fix back to the patella with surgery. Surgical repair is still possible but may require special techniques to do so and an extended rehabilitation protocol.

What is the long-term prognosis for a quadriceps tendon rupture? 

Most people who undergo treatment of a quadriceps tendon rupture will do well long-term. They will be able to return to work and sport after the appropriate rehabilitation. It is important to be very diligent with the appropriate prescribed physical therapy to ensure a good outcome. Re-tear of the tendon after surgical repair is rare unless something unexpected happens (ex: a fall during the early post-operative phase). The most common complication is loss of motion in the knee after surgical repair. 

Professional athletes with quadriceps tendon ruptures:

http://www.espn.com/blog/philadelphia-eagles/post/_/id/21355/darrelle-revis-kyle-fuller-among-potential-options-for-corner-needy-eaglesRon Brooks is coming off a ruptured quad tendon, second-round pick Sidney Jones is rehabbing a torn Achilles, and there is just very little in terms of proven, healthy talent in the room right now. “We have some positions where we have solid starters … Darrelle Revis, Kyle Fuller among options for corner-needy Eagles – ESPN (blog)

http://www.pennlive.com/philadelphiaeagles/index.ssf/2017/07/philadelphia_eagles_ron_brooks.htmlPHILADELPHIA — After a ruptured right quadricep tendon sidelined Ron Brooks for the final 10 weeks of the 2016 season, the Eagles’ veteran cornerback returned to the practice field for training camp this week with a goal in mind: to prove negative …Eagles WireNBC 10 PhiladelphiaFanRag Sports (blog) Philadelphia Eagles’ Ron Brooks takes offense to negative talk about team’s cornerbacks – PennLive.com

References

  • Ilan D, Tejwani N, Keschner M and Liebman, M. Quadriceps Tendon Rupture. Journal of the American Academy of Orthopaedic Surgeons. 2003;11:192-200.
  • Rauh, M and Parker, R. Patellar and Quadriceps Tendinopathies and Ruptures. DeLee and Drez Orthopaedic Sports Medicine: Principles and Practice. 2010. Chapter 22 1513-1525.
  • Karl Jensen

    I am recovering from surgery after a quadriceps tendon rupture and repair. I am 58 and very active in sports; biking, skiing and tennis. Physical therapy is going well but I have had significant loss of strength. I have also been told by the therapist that the tendon will not recover to full tensil strength (about 80%). Can I expect a full return to the same level of athletic ability and performance in my sports (e.g. aggressive skiing on advanced/expert level slopes, competitive tennis, daily bike commuting to work and touring etc..) ? Thank You Karl

  • SportsMD

    Karl, Sorry to hear about your injury. Be patient since most repairs heal in 6 months but many patients require 12 months before they reached their goals. At full recovery, most injured legs should be at 85-90% strength compared to non injured leg. The focus on physical therapy and how much you put into it, will play a major role in your ability to perform the sports you enjoy.

  • Lisa Carney

    I was misdiagnosed and had a complete Quad tendon rupture that was not surgically repaired until 9 weeks after the injury. After initially making progress I have regressed. I still cannot walk down stairs and have pain when trying to lift my leg when my knee is bent. The pain is above my knee. Any ideas? Lisa

    • nlcatter

      in case you read – who did your PT? not all the same. down stairs is still wobbly, need more treadmill I was told

  • Suzanne

    My husband had a complete tear of the quad muscle from his knee cap. Surgery went fine, but the dr wants to put him in a straight leg cast for 2+ months. I am concerned because he is a big man, who is very muscular construction worker, so a full leg cast will be VERY heavy. I read on your site that you brace your patients and have them moving with ninety degree motion by six weeks post op. I am not sold on a cast and think motion is better, but this dr “always does a full leg cast” according to the nurses at the hospital my husband’s surgery occurred at. Are there studies that support introducing motion sooner or utilizing straight leg casts? Thank you so much for your time and knowledge! – Suzanne

    • Everett Rodriguez

      Suzanne, I had a complete quad rupture and subsequent surgery last July. (I’m a 55 year old male.) Following surgery, I was put in a brace which was locked straight, but also had hinges to allow range of motion as I progressed thru recovery. The brace was awesome. After only a few weeks, they had me doing the passive motion machine and I worked up to 90 degrees ROM very quickly. After only 3 weeks or so I could remove the brace as long as I was laying on the couch or bed and had support under my leg. The doc and PT gave me goals for ROM during recovery and the hinged brace allowed me to control that. Even with all this, I had severe muscle atrophy and it took a lot of effort to build back strength. My surgery was July 1 and I could unlock the brace when I sat (as in when I drove) by beginning of Sept. I just could not imagine having a full cast for over 2 months. Anyway, that’s my personal experience.

  • Carrie Repucci

    Hi! I’m a big runner (run 50 miles a week) and during a run felt intense pain on the lateral side just above my knee cap. I tried to push through the run but my knee gave out and I fell. I am unable to comfortably straighten and stairs are basically impossible. After an x-ray and MRI my doctor determined I have a inter muscular tear of my vastus lateralis. Does this typically require surgery to be properly fixed?

  • white trash religious scum

    just had mine operated on for the second time this year ( feb/march) and my 1st was 5 yrs ago. This time a grafting of hamstring tendon as needed as my quad tendon had significant damage. Bone was also harvested from below right ( surgery knee) to complete work. As all three were direct result on playing basketball; im DONE playiing in games. I do hope 2 return to shooting alone as I am a very good shooter and its fun with enough activity to hel my cardio– which now is going to be body surfing off of WPB (fl) coast when Im allowed to. I do hope I may also return to weight squatting ( free weights) Dr Uribe- Miami dolphins orthopedic did THIS surgery.

  • Zack

    Just had my surgery last week. Great information! Thanks for sharing.

  • LeperOutcast

    in 2007 I ruptured my right quad, after I slipped on some ice, the 1st repair failed and I changed Surgeons. and 8 months after the first surgery I had surgery again with positive results. In 2016, I fell and snapped my left quad, it was repaired by the same surgeon, but this time my Leg just isn’t right. I cant keep it bent, or I cant keep it straight. I don’t sleep well, because it hurts at night. after almost a year since the left repair, I still straight leg stairs, even walking sucks Anybody got a Idea?

    • nlcatter

      repaired how ? suture holes through patella?

      • LeperOutcast

        Right Patella repair has anchors into the Patella, the Left has what my Surgeon described as a Cable (a permanent suture?) that runs from above the rupture site (just above the patella) to below the Patella. It did react when at physical therapy, when they used a ultra sound wand it felt uncomfortable?, Hot?

  • brent

    I fell on ice 3 years ago and tore my right quad. Had surgery to reattach to the patella. I went through extensive physio and all seemed good for about a year. Now for about 2 years the swelling is constant everyday and the pain is 24/7. I went physio again but now he says he cant do anything more for me. I am hoping to see the specialist again but any ideas as to what the cause is? I do a ton of stairs for my job and now have to wear a custom brace all the time but the pain and swelling is there everyday. I’m frustrated and just want this to go away.

    • Bradley Hall

      Dear Brent, I tore my left quad tendon and it required surgery. About 4 weeks after that repair I fell down a stairway and tore that repair completely again. After the second surgery to repair the tendon my doctor informed me that the muscle and tendon looked like hamburger. I had a job where I stood for 10 hours daily. I lost that job because of the pain and swelling you are talking about. I started walking on a treadmill. I could only walk about 1/4 miles to begin. YES it was painful and it would swell up like a balloon. Over about 3 years I got to the point where I could walk about 5 miles. I switched to walking outdoors and before long (4 to 4 1/2 years) I was walking 80 to 100 miles a month. The swelling diminished but the pain didn’t go away. It has went down but I have accepted the fact I will live with pain for the rest of my life. Good luck to you and maybe walking will help you!

    • Zack

      Brent I had surgery to repair my quad tendon from a dirt bike accident back in March 2017. Once I was cleared for PT I jumped right in. It started very slow and as a ex 3 sport athlete it was very humbling and frustrating at first. When I learned what has actually happened to my body during the healing process (locked in brace for 6 – 8 weeks post op) I was able to level set and adjust expectations. I know the article says 4 months but in reality it’s case by case. For me I know it will be about a year before I get back to the gym full time. The quad will be repaired post op but the surrounding muscles have to be re-triggered and the opposite leg has to be treated for overcompensating. Ice/heat treatment, the pool, and massage therapy will be your best friend on the swelling front. Hope this helps! Just know you’re not alone!

      • Darren White

        Sounds just like me, Ruptured right Quad tendon 29th June this year, repaired 30th June. I am an avid mountain biker but won’t be getting back to it until spring 2018. At the present time the ROM is good, leg hyper extension isn’t anywhere near my left leg but the main thing i am getting is pain when trying squats, stairs etc… in the damaged knee and the now other is starting to play up too, so frustrating and devastating when you have always been fit and healthy. I also sort of prided myself on my leg aesthetics but now i have one reasonably muscly left leg and a Serrano ham the other side. People keep telling me to stick at it and it will improve but reading some stories on here doesn’t help. Hope yours mends fully as do for anyone who has suffered this horrible injury.

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