Quadriceps Tendon Tears: What You Need to Know
Third-Place Article (Tied), 2016 Paper of the Year Competition
by Daniel R. Hinely, MEd, LAT, ATC, OTC
A quadriceps tendon rupture can be a debilitating injury. Many older adults have had their active lifestyles put on hold due to this impairment. To fully comprehend its magnitude, one should not only be familiar with its cause, treatment, and rehabilitation, but with surrounding anatomy that can be effected as well.
This thick tendon is what connects the distal portion of the four quadriceps muscles to the superior aspect of the patella. The four quadriceps muscles consist of the vastus lateralis, vastus intermedius, vastus medius, and the rectus femoris. These muscles lay anterior to the femur and function to extend the knee. Since the rectus femoris originates off the ilium, it also acts as a hip flexor. These muscles are innervated by the femoral nerve and vascularized from the femoral artery (Ludwig, Brian). With so many anatomical structures associated with the quadriceps tendon, it is easy to understand how damaging it can impact the overall function of the leg.
Quadriceps tendon ruptures can be either the result of a partial or complete tear of the quadriceps tendon. The most common cause of this injury is a forced eccentric contraction of the quadriceps muscle group. Events as catastrophic as an automobile accident to something as mundane as falling from a standing position can results in this injury (Ludwig, Brian). The older the individual, the greater the chance of quadriceps tendon rupture. This is exhibited in the results of one study which reported 88% of all quadriceps tendon ruptures occur in individuals 40 years of age and older (Sherry, Marc). Quadriceps tendon weakness can also increase an individual’s susceptibility to this injury. Tendon weakness can be caused by a number of factors, including tendonitis, steroid use, immobilization, and use of fluoriquinolones. Chronic renal failure, hyperthyroidism, gout, rheumatoid arthritis, diabetes mellitus, metabolic disease, and others diseases that disrupt blood supply can also weaken the tendon (Wilkerson, Rick).
While both partial and complete tears can drastically impair leg function, their immediate treatment and long term care can vary greatly. Individuals sustaining a partially torn quadriceps tendon may have the ability to extend their knee, however strength in the effected leg will be significantly reduced (Ludwig, Brian). Also, partial tears can, depending on severity, be treated non-operatively. To determine severity, strength is assessed as well as radiographic images, such as X-rays and MRI’s are obtained. Immediate treatment will consist of being immobilized in either a cylinder cast or a straight leg immobilizer brace for 3 to 6 weeks. Crutches or a wheelchair will need to be used during this time to assist in ambulating. Once pain and edema have subsided, extensive physical therapy can begin. Therapy will start slow with basic range of motion exercises being incorporated into rehab and will progress to strengthening and return to sport activities (Wilkerson, Rick).
Complete quadriceps tendon tears are, for obvious reasons, much more severe than partial tears. Just as with partial tears, there will be a popping sensation followed by intense pain, moderate to severe swelling and significant strength reduction. Signs that are consistent with only complete tears include a drooping or sagging patella as well as a depression superior to the patella where the tendon ruptured. As with the partially torn tendon injury, radiographic evidence will be required for proper diagnosis. Unlike some partially torn quadriceps tendon injuries, complete tears will require surgery (Wilkerson, Rick).
Quadriceps tendon repair is a procedure commonly performed in an outpatient setting, however some patients may, for medical reasons, stay in the hospital for a night before being discharged. The surgery involves a vertical incision along the patella and extends proximally to the distal femur. Drill holes are made in the patella and sutures are placed in the distal tendon. The sutures running through the tendon are then threaded though the holes in the patella and proper tension are placed upon them to ensure the patella is in proper alignment. The sutures are then tied off at the bottom of the patella. Another method of surgery involves the use of anchors at the ends of the sutures. Instead of drill holes, anchors are placed at the proximal end of the patella and the ruptured end of the quadriceps tendon is sewn directly to the anchors. This method of repair is still relatively new and not as commonly found as the repair involving drill holes (Sherry, Marc).
When it comes to surgically repairing a quadriceps tendon rupture, time is of the essence. Surgical procedures are traditionally recommended to occur in as little as a couple days to one week post injury (Wilkerson, Rick). If the patient is medically unfit to have surgery performed safely soon after the injury, the procedure will need to be delayed until the patient is medically fit. The longer time passes without surgical intervention, the chance of less than optimal recovery increases (Ludwig, Brian).
Recovery from partial or complete tears can take as long as 12 months before pre-injury status is achieved. Some of the complications that rehabilitation during this time will address include muscle weakness, decreased range of motion, and a lack of proprioception. Once out of surgery, the patient will be placed in either a long leg cylinder cast or a straight leg immobilizer to keep stress off the repair as the initial healing begins. After approximately two weeks the cast or immobilizer will be removed for a follow-up visit with the surgeon so that the sutures or staples can be removed. The leg will be placed back into an immobile state, usually in a straight leg immobilizer, and the patient will begin physical therapy. Depending on success with physical therapy, the patient will begin to be allowed to bear weight and even start to work on increasing their range of motion. As time passes, physical therapy will shift focus to more muscle strengthening type exercises. Multiple factors contribute to the speed and success of physical therapy, including age, pre-injury health, tissue quality, rehabilitation compliance, and the existence or absence of any associated injuries. On average, recovery will take at least four months, while most repairs are nearly healed at six months following the surgery. While this may be true for some, many patients do not reach all of their recovery goals until 12 months after the procedure (Wilkerson, Rick).
As told, a quadriceps tendon tear, whether partial or complete, can have a major impact on an active lifestyle. With proper, prompt care the detrimental effects will only be temporary and many patients can resume activities to a pre-injury level.
About the Author:
Daniel Hinely is a 2003 graduate of Valdosta State University with a B.S. in Sports Medicine/Athletic Training and a 2005 graduate of Georgia College and State University with a M.Ed. in Physical Education with an emphasis in Health Promotion. Since 2003, Daniel has been a practicing Certified Athletic Trainer in both Georgia and North Carolina. Since fall of 2014, he has worked as a Certified Athletic Trainer in outpatient Orthopaedics at Wake Forest Baptist Medical Center.