What is a quadriceps contusion?
A quadriceps contusion is one of the more common injuries seen in athletes competing in contact sports and results from a direct blow to the front of the thigh. This type of injury often goes undertreated and may result in serious complications for the athlete.
The quadriceps muscle group is a group of four muscles that are located on the anterior thigh and are collectively responsible for hip flexion and knee extension. These muscles are at risk for a variety of injuries because of their surface location on the front of the thigh.
Because of the location of the quadriceps, they can be subject to direct blows during sports competitions. A deep quadriceps contusion can be one of the most disabling injuries for an athlete because injury to these muscles can severely impact an athlete’s ability to effectively use his/her leg.
Several physiological responses may occur after a deep thigh contusion including:
• Broken blood vessels resulting in bleeding (hematoma) into the injured area
• Crushed muscle tissue resulting in hip and knee dysfunction
If there is major untreated and/or unresolved bleeding deep in the muscle tissue, a serious condition known as myositis ossificans can occur. Myositis ossificans is the result of a hematoma within a muscle that calcifies rather than heals. Rather than the body healing the hematoma with fibroblasts (baby collagen fibers), the body lays down baby bone cells resulting in a bony growth deep in the muscle tissue.
A myositis ossificans located deep within a quadriceps muscle can cause significant pain and disability for the athlete. The specific cause of this occurrence is not known, but there seems to be a correlation between the severity of the quadriceps contusion and the incidence of myositis ossificans.
What are the classifications of quadriceps contusions?
Quadriceps contusions can be classified as mild, moderate, and severe. Mild injuries result in mild pain and swelling, but the athlete is able to walk without a limp. The athlete is able to bend his/her knee past 90 degrees (mildly painful, but doable), and can contract the muscle without significant pain.
A moderate muscle contusion results in an increase in bleeding into the muscle tissue and more damage to the actual muscle fibers. The signs and symptoms will be more pronounced including a noticeable limp, more bruising and swelling, and an inability to flex the knee past 90 degrees without significant pain.
With a severe contusion, the bleeding may actually track down into the knee area and down into the lower leg creating extensive discoloration (bruising). Swelling may continue to increase over a 24 hour period resulting in stiffening of the thigh and knee as the effusion increases.
Athletes with severe contusions may not be able to bend their knee past 45 degrees and may have significant difficulty walking. These athletes may need to be placed on crutches.
Last, a palpable hematoma may be felt in an athlete with a severe contusion. When the muscle is palpated, a firm mass may be felt (hematoma) with defined borders. This area will be very tender for the athlete so care should be taken when palpating a deep contusion.
How is a quadriceps contusion diagnosed?
Quadriceps contusions are easily diagnosed by sports medicine professionals using the signs and symptoms that the athlete presents in conjunction with a thorough medical evaluation.
If a myositis ossificans is suspected, a sports medicine physician may order an x-ray, MRI, or ultrasound to confirm the diagnosis.
Who gets quadriceps contusions?
Quadriceps contusions are common in contact sports due to player to player contact as in the sports of football and basketball. Contusions can also occur in the thigh due to the direct impact of a sports implement as can be seen in the sports of softball, baseball, and lacrosse (inside fastball).
What causes quadriceps contusions?
Quadriceps contusions are caused by direct impact forces to the front of the thigh. The force compresses the muscle tissue against the femur resulting in various amounts of bleeding and muscle tissue damage.
What can I do to prevent a quadriceps contusion?
In sports that require protective thigh equipment (football, hockey), athletes should take care in ensuring that protective pads are correctly sized to fit the front of the thigh and that they are correctly positioned prior to competition. However, in most sports, preventing a quadriceps contusion is not possible.
However, preventing a deep quadriceps contusion from developing into a myositis ossificans is possible. Although some deep thigh bruises may progress into a myositis ossificans even with proper treatment, myositis ossificans can result if:
• The athlete returns to participation too soon
• The thigh is re-injured before healing occurs
• Massage or heat are applied during the treatment phase
• The hematoma is improperly treated
With this in mind, the treatment of a deep quadriceps contusion is important in preventing complications deep within the thigh.
What is the treatment for quadriceps contusion?
The initial treatment is critical in the successful outcome of a moderate or severe quadriceps contusion. Proper adherence to treatment protocol can minimize the possible complications in this type of injury.
Immediate treatment includes utilizing the P.R.I.C.E. principle for treating sports injuries with a focus on the immediate application of ice to reduce bleeding and swelling in the muscle tissue. Because it is not possible to foresee how much bleeding will occur in the muscle, it is best to treat moderate thigh contusions conservatively.
The athlete should be immediately pulled from participation. Continued activity will result in increased bleeding into the thigh because the heart is pumping harder and faster during physical exertion. This may result in prolonged rehabilitation to remove the resulting hematoma and return function to the leg.
Unlike most injuries, a quadriceps contusion needs to be treated with unique positioning of the athlete. The athlete needs to be positioned with the knee bent in maximal flexion while the ice pack is applied.
This is done to maintain the flexibility of the quadriceps muscle group while swelling may be present. The purpose of this position is not to stretch or enhance the flexibility of the muscle group, but only to maintain its functional integrity.
After the ice treatment is completed, a six inch compression wrap should be applied to the thigh using slightly overlapping circles beginning at the knee and working up the thigh. The compression wrap should be snug, but not too tight. The wrap will provide a mechanical barrier to help keep the swelling out of the muscle tissue.
If the athlete has pain while walking and is limping, the athlete should be placed on crutches and be non-weight bearing for the first 24 – 48 hours. Pushing through pain is not an option with this type of injury because of the seriousness of the complications. Athletes should be encouraged to continue the use of crutches moving from non-weight bearing to partial-weight bearing as pain diminishes.
Regaining Range of Motion and Strength
As the pain begins to diminish and the muscle begins to heal (usually after 48 hours), gentle range of motion exercises and muscle setting exercises can be started. The athlete should be careful not to overstretch the muscle (move through pain) or push too hard to regain the range of motion of the knee.
Overaggressive exercises can restart the bleeding in the thigh and complicate the healing process. If this occurs, the athlete should go back to the initial treatment protocol of P.R.I.C.E. and non-weight bearing crutch walking.
Quadriceps muscle setting exercises are isometric contractions (no movement of the knee or hip). The athlete is asked to tighten his/her quadriceps with the knee in an extended position. The athlete should hold the contraction for five to ten seconds and repeat ten times every hour.
It is important that the athlete understand that he/she does not contract the quadriceps past the point of pain. Early in the rehabilitation, the athlete might only be able to contract the quadriceps at 50% intensity. As the muscle heals, the athlete can increase his/her contraction intensity as able.
When the athlete can complete a quadriceps muscle set at full intensity without pain, the athlete can then progress to straight leg raises. These are performed with the athlete lying on a table, unaffected knee bent, upper body resting on elbows, and injured leg straight. The athlete then contracts the injured quadriceps, lifts the leg equal to the height of the uninjured knee, and then slowly returns the injured leg to its resting position.
The athlete can initially perform 3 sets of 5 repetitions of these exercises and gradually work up to 3 sets of 10 repetitions. When the athlete can perform 30 pain free repetitions, the athlete can add increasing increments of ankle weights for added resistance.
Once the athlete has full pain-free range of motion of the leg and strength equal to the uninjured quadriceps, the athlete may begin functional sport specific exercises in order to prepare the athlete to return to sports participation.
Functional Sport-Specific Training
The final component in any rehabilitation program is the addition of sport specific exercises. These are exercises specifically designed to put the athlete through the skills and demands of his/her sport in a progressive fashion so as to ensure that the muscle has completed healed and that the athlete has the confidence necessary to return to sport.
The athlete’s sport is analyzed for a breakdown of fundamental skills. The athlete is then asked to perform these skills beginning at 50% intensity. As the athlete continues through the list of basic skills, the intensity is gradually increased incrementally over time until the athlete performs the skills full out. Depending on the classification of the injury, this phase may take anywhere from several days to several weeks.
When can I return to play?
The athlete can return to sports when he/she has been released by a sports medicine professional and when they have cleared the return-to-sports criteria:
• Pain free full range of motion of the hip and knee
• Pain free full strength equal to the uninjured quadriceps
• Completion of sport-specific functional training
• Protective padding of the quadriceps if appropriate
Getting a Second Opinion
A second opinion should be considered when deciding on a high-risk procedure like surgery or you want another opinion on your treatment options. It will also provide you with peace of mind. Multiple studies make a case for getting additional medical opinions.
In 2017, a Mayo Clinic study showed that 21% of patients who sought a second opinion left with a completely new diagnosis, and 66% were deemed partly correct, but refined or redefined by the second doctor.
You can ask your primary care doctor for another doctor to consider for a second opinion or ask your family and friends for suggestions. Another option is to use a Telemedicine Second Opinion service from a local health center or a Virtual Care Service.
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Anderson, M.K., Hall, S. & Martin, M. (2005). Foundations of Athletic Training: Prevention, Assessment, and Management. (3rd Ed.). Lippincott Williams and Wilkins: Philadelphia, PA. Bahr, R. & Maehlum, S. (2004). Clinical Guide to Sports Injuries. Human Kinetics: Champaign, IL. Brukner, P. & Khan, K. (2002). Clinical Sports Medicine. (2nd Ed.). McGraw Hill: Sydney, Australia. Irvin, R., Iversen, D. & Roy, S. (1998). Sports Medicine: Prevention, Assessment, Management, and Rehabilitation of Athletic Injuries. (2nd Ed.). Allyn and Bacon: Needham heights, MA.