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Quadriceps Injury

Quadriceps Injury

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Several types of quadriceps injuries can occur, the most common being the quadriceps contusion, which is painful and disabling. The usual cause of the quadriceps contusion is a direct blow to the anterior thigh from an object or another person (eg, helmet, knee). Very rarely, this injury can be severe enough to progress to an acute compartment syndrome.

Because the quadriceps is in contact with the femur throughout its length, it is susceptible to compression forces. The rectus femoris is the most commonly injured portion of the muscle because of its anterior location. Minimally, impact causes cellular edema of the muscle, but complete capillary disruption with localized hemorrhage leading to a tense anterior compartment can occur. The muscle is more resistant to injury if it is struck while in a contracted nonfatigued state. Other quadriceps injuries range from simple strains to more complex and disabling muscle ruptures. See the image below.

Other types of quadriceps injuries include strains of the quadriceps tendon, complete and partial tears of the quadriceps tendon, and fascial rupture of the quadriceps muscle. Specific areas of the quadriceps are affected for each of these diagnoses. The classic quadriceps strain occurs at the conjoined muscle tendon junction (jumper’s knee). The partial tear of the quadriceps most commonly affects the indirect (distal) head of the rectus femoris. Fascial rupture usually occurs anteriorly at the mid thigh and causes a muscle hernia.

United States

Although quadriceps strains are common, minimal information about the frequency with respect to specific sports is available. As for quadriceps contusions, the most detailed frequency data came from the US Military Academy at West Point, [1] and the distribution per year was reported as follows: rugby 4.7%, karate and judo 2.3%, football 1.6%, and all other sports fewer than 1%. Quadriceps muscle hernias are believed to be more common in soccer, basketball, and rugby.

A study by Eckard et al that analyzed data from the NCAA Injury Surveillance Program from 2009 to 2015 found that the on quadriceps strain injury rate was 1.07/10 000 athlete-exposures. Almost 78% of quadriceps strains were sustained during practice, however, the rate was higher during competition than during practice (approximately 1.3 versus 1.0/10 000 Athlete-exposures). The sports with the highest injury rates were women’s soccer (5.61/10 000 AEs), men’s soccer (2.52/10 000 AEs), women’s indoor track (2.24/10 000 AEs), and women’s softball (2.15/10 000 AEs). Overall, women had a higher rate of quadriceps strains than men. [2]

The incidence of jumper’s knee at the quadriceps insertion onto the patella is less common than patellar tendinitis. One study reported that of all tendinopathies affecting the extensor mechanism, the frequency of patellar tendinitis at its insertion was 65%, quadriceps tendinitis was 25%, and patellar tendinitis at its insertion into the tibial tuberosity was 10%.

Rupture of the quadriceps tendon is more common in both older patients and younger athletes. Several studies show that the mean age of patients with quadriceps rupture is about 65 years. However, in athletes, the mean age cited ranges from 15 to 30 years. Sports associated with quadriceps rupture are high jump, basketball, and weight lifting. Rupture is also not uncommon in patients with renal failure.

The quadriceps femoris acts as a hip flexor and knee extender. The quadriceps femoris is composed of the following:

Rectus femoris

Vastus lateralis

Vastus medialis

Vastus interomedialis

Origins/insertions of quadriceps components include the following:

Rectus femoris – Ilium/tibial tuberosity

Vastus lateralis – Femur/tibial tuberosity

Vastus medialis – Femur/tibial tuberosity

Vastus interomedialis – Femur/tibial tuberosity

The 3 thigh compartments are as follows:

Anterior – Quadriceps muscles, femoral nerve and artery

Posterior – Hamstring muscles, sciatic nerve

Medial – Adductor muscles, cutaneous branch of obturator nerve

The function of the quadriceps is primarily that of tibial (knee) extension. One electromyography (EMG) study showed that the maximum extension moment and maximum quadriceps EMG activity were early in the kicking action, as the initial flexion changes to extension. This moment occurs before the foot makes contact with the ball. The peak activity of the hamstring occurs after the quadriceps peak, shortly before the ball is struck. The largest extension moment in this study was 260 Nm; this corresponds to a calculated tensile force in the patellar tendon of 7 times body weight.

The mechanical properties of the quadriceps have been studied. The central aspect of 10-mm wide sections of the quadriceps was subjected to tensile loading and compared to a similar patellar tendon section. The ultimate load to failure of the unconditioned patellar tendon was higher (53.4 N/mm2) than the unconditioned quadriceps tendon (33.6 N/mm2). Strain at failure was also higher for the preconditioned patellar tendon (14.4%) than for the quadriceps tendon (11.2%).

Microscopic sections of human quadriceps tendon as it inserts into the patella show no crimping and no cement line. This is unlike other tendon insertion sites. The interdigitation between collagen fibers and the distinction between tendon and bone was least distinct along the anterior third of the patella.

A discussion of the biomechanics of specific injuries is as follows:

Strains, overuse, and rupture: The most common sites of injury correlate to the muscle tendon junctions both proximally and distally and to the muscle belly itself. Muscle strains are usually due to repetitive functional overload. Not surprisingly, quadriceps strains most commonly affect athletes who subject their knees to high levels of repeated loading of the extensor mechanism. The overuse trauma may range from microscopic failure of soft tissue with its associated inflammation or gross rupture. Gross rupture may be partial or complete. A large sudden load may cause the entire insertion to be compromised, leading to complete rupture. Repetitive loading, particularly eccentric loads, causes microfailure, usually at the muscle tendon junction. This microfailure can result in partial tears.

Contusion: Direct trauma to the quadriceps may cause muscle fiber and connective tissue rupture and formation of a hematoma. Trauma to the quadriceps causes muscle fiber rupture, disruption of connective tissue, and hematoma formation. Inflammatory cells and macrophages enter the site of injury and begin clearing necrotic muscle cells. This process occurs over 2-3 days. Then, muscle cells attempt to regenerate at the same time scar tissue is being formed. A severe thigh contusion can lead to a compartment syndrome.

Muscle hernia: The cause of this is not clear. It is usually associated with a sudden forceful kick, but it may be associated with a weakened or previously injured quadriceps fascia.

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].

Eckard TG, Kerr ZY, Padua DA, Djoko A, Dompier TP. Epidemiology of Quadriceps Strains in National Collegiate Athletic Association Athletes, 2009-2010 Through 2014-2015. J Athl Train. 2017 May. 52 (5):474-481. [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].

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Professor of Orthopedic Surgery, Baylor College of Medicine as Co-Director, Combined Baylor College of Medicine-The San Antonio Orthopaedic Group, Texas Sports Medicine Fellowship; Medical Director, Burkhart Research Institute for Orthopaedics (BRIO) of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Herodicus Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; MTF; Aesculap; The Foundry, Cotera; ABMT; Conmed; <br/>Received research grant from: Histogenics; Cotera; Arthrex.

Leslie Milne, MD Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine

Leslie Milne, MD is a member of the following medical societies: American College of Sports Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, Minnesota Medical Association, American College of Sports Medicine

Disclosure: Nothing to disclose.

Quadriceps Injury

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