Quadriceps tendon tear

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Quadriceps tendon tear

Definition

A quadriceps tendon tear is a tear of the distal tendon which is attached to the basis of the patella. The tear can be a partial or complete, complete tears mostly appears unilateral. Also bilateral tear is possible but is less common.


Clinically relevant anatomy

The quadricepsmuscle is composed of 4 muscle groups: the m. rectus femoris, the m. vastuslateralis, the m. vastusmedialis and the m. intermedius.[12] All of them have their insertion on the basis of the patella but the m. vastuslateralis, the m. vastusmedialis and the m. vastusintermedius have also an insertion on the distal tendon of the m. rectus femoris. The tendon is multilayered. The rectus femoris is the most superficial layer inserting on to the patella and the vastuslateralis en medialis are the middle layers.[12]


Epidemiology/ etiology

Unilateral ruptures are relatively rare when all types of knee injuries are considered; bilateral ruptures are even less common.
However, quadriceps tendon ruptures are more common than are patellar tendon ruptures, although quadriceps tendon ruptures are more likely to be misdiagnosed.
Partial and complete tears occur predominantly in males.
Ruptures of the quadriceps tendon occur relatively infrequently and usually occur in patients older than 40 years. But these ruptures may be seen in nearly any age group.
[12]


What about the etiology of the condition?
A muscle rupture often happens during a high impact action with a bad landing. During a landing there is a heavy load on a knee in flexion and the foot is planted on the ground (Jump). The Quadriceps muscle makes a rapid, eccentric contraction. Other mechanism is caused by a force straight on the anterior side of the knee(fall). Patients typically present with acute knee pain, swelling, and functional loss following a stumble, fall, or giving way of the knee.
[12]


Risk factors

Most quadriceps tendon tears happens because the tendon is weakened.[11]
- Tendinitis: inflammation of the tendon causes weakening and maybe even little strains.
- A poor blood supply to the tendon due to diseases also weakens the tendon.

Chronic diseases:
- Secondary hyperparathyrodisme4 which causes bone resorption which causes weakening of the fibro-cartilaginous junction between the tendon and bone tissue.
- Chronic renal failure[3],[4]: this can cause connective tissue elastosis which is suggesting for a weakening of the tendon.
- Systemic lupus erythematosus (SLE), gout, leukemia, rheumatoid arthritis, diabetes mellitus, obesity, infections and metabolic diseases have a negative effect on the strength of the tendons.

Drugs, - abuse also have/has a degenerative effect on muscle tendon:

- Corticosteroids usage has been linked to an increase of muscle and tendon weakness.
- Fluoroquinolones, a special antibiotic is related to tendon ruptures.[5]
Other factors such as knee surgery and immobilization also increase the chance, because the strength and flexibility of the muscle and tendon decreases.


Characteristics/ clinical presentation

There is often a popping or tearing feeling at the time of event. Some patients are able to walk following this injury, but many cannot. The patient will be unable to straight the knee without help when the tendon is completely ruptured. Most of the patients present with acute knee pain, swelling and there is a palpable defect at the site of the tear.You can feel a dent/gap just proximal of the patella (the suprapatellar area) where the quadriceps tendon was torn. The quadriceps will be sensitive and cramping. There is a hematoma visible around the knee.Usually, obvious suprapatellar swelling, ecchymosis, and tenderness are present. The patella may sag or droop as a result of the quadriceps tendon tear but swelling may obsure this finding. There is a function loss especially there will be a loss of extension and also loss of stability. If the patient is not seen in the acute phase, diagnosing the rupture becomes more difficult, and it can be easily missed. Many patients are thought to have only simple knee sprains during their examination in the emergency room and are not given appropriate, immediate follow-up. [12]

Differential diagnosis

The position of the patella can be used to differentiate between quadriceps tendon tear (lowered) and patellar ligament tear (raised) and active knee extension, lachmann test.


MRI is necessary to examine if the tendon is partially torn, for a complete tear a lateral X-ray might be sufficient due luxation of the patella.

Outcome measures

The Lysholm and Tegner-score and the ROM of the knee were used to determine the progress and outcome of the rehabilitation and have been proven consistent, responsive and reliable. [1]


Examination

During the inspection you can see swelling around the suprapatellar area, there is a hematoma.
When you start the active examination you can immediately see that there is functional loss.Patients may have frequent buckling of the knee and difficulty with stair climbing.Patients may be able to ambulate but will do so with a gait demonstrating knee stiffness and elevation of the hip to accommodate the swing-through phase.
Testing for full, active extension against gravity is the most important aspect of the examination. The patient will be unable to perform a straight leg raise.Extension lags of varying degrees are seen, depending on the amount of retinacular damage. In incomplete ruptures, the patient may be able to fully extend the knee from the supine position but not from the flexed position. If only tendinitis is present, no extension lag should be noted with any test position. It is also important that you examine the contralateral knee to rule out bilateral rupture.
Results of neurologic examination are normal except for decreased quadriceps motor function and an absent patellar reflex.
[12]

There is also the quadriceps tendon rupture diagnose test of Jolles BM et al. which is an minimal invasive an easy available technique[2]

Medical management

When there are only partial ruptures the knee must be immobilized(3-6 weeks), surgery is mandatory when the tendon is completely torn and is best started as early as possible (latest 72h after injury), so the tendon can be reattached to the patella, after the surgery the knee is immobilized for 4-6 weeks.


Physiotherapeutic treatment

Immediately after the injury, the RICE-treatment (Rest, Ice, Compression, Elevation) can be started. Partial tear are commonly treated with ultrasound and TENS (Transcutaneous Electric Nerve Stimulation), heat and ice therapy, muscle strengthening, proprioception exercises and manual therapy (massage, passive extension, flexion). To rehabilitate a complete tendon rupture you can choose between the conservative or a more aggressive treatment after surgery. The conservative treatment consisted of 4 to 6 weeks of immobilization in 10° of flexion. Two days after surgery intensive isometric quadriceps exercises can start. During the immobilization period, the weight bearing will be increased so full weight bearing will be reached after 6 weeks , then will be started with mobilizations to regain the full range of motion of the knee[9]. The more aggressive treatment which is not appropriate for every patient, consists of immediate mobilization and after 7 to 10 days full weight bearing,quadriceps settings, heel slides, massage, heel prop, ankle pumps. Brace-free ambulation was reached after 7 to 8 weeks, which lead to a faster rehabilitation.
[6,7,8,13]

Prognosis

Rehabilitation of quadriceps tendon tears have good outcomes,Gender, mechanism of injury, tear location, time to diagnosis and repair weren’t relevant to the outcomes. Most patients regained their full ROM, muscle strength, sports participation and ADL[10].

Pain and swelling decrease over time, and quadriceps function can improve.
Athletes treated for partial or complete ruptures may return to play when several conditions are met, including the following:
-The patient should have nearly full, painless ROM.
-Knee strength should be at least 85-90% of the other knee.
-Completion of a sport-specific agility program is highly recommended for athletes involved in vigorous sports, such as football, basketball, soccer, or tennis.[13]

Studies generally have reported good results following early repair of complete unilateral and bilateral quadriceps tendon ruptures.The type of repair, the location of the tear, the patient's age and sex, and the mechanism of injury do not appear to affect the results. Good ROM usually can be regained, but some persistent quadriceps weakness is fairly common. Most patients can return to their previous occupation, but many cannot return to their pre-injury activity level.[13]


Key research/ resources

Keywords: Quadriceps tendon tear, quadriceps tendon rupture, quadriceps tendon tear rehabilitation


the resources were PubMed, Web of knowledge and Medscape

Clinical bottom line

Rehabilitation of quadriceps tendon tears have good outcomes,Gender, mechanism of injury, tear location, time to diagnosis and repair weren’t relevant to the outcomes. Most patients regained their full ROM, muscle strength, sports participation and ADL.
[10]


References

[1]. Briggs K.K. et al.;The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later.;Am J Sports Med.; 2009 May
Evidence level: 2A, [PubMed]

[2]. Jolles B.M. et al.; A new clinical test in diagnosing quadriceps tendon ruptures; Ann R CollSurgEngl; 2007; 89: 259-261
Evidence level:D,[PubMed]

[3]. Kim Y.H. et al.; Spontaneous and simultaneous rupture of both quadriceps tendons in a patient with chronic renal failure; KneeSurg Sports TraumatolArthrosc; 2006; 14: 55–59 Evidence level:D[Link]

[4]. Kricun R. et al.; patellar tendon rupture with underlying systemic disease; AJR ; 1980 October; 135: 803-807;
Evidence level: D, [PubMed]

[5]. Van Der Linden P.D. et al.; Tendon Disorders Attributed to Fluoroquinolones: A Study on 42 Spontaneous Reports in the Period 1988 to 1998; ARTHRITIS CARE & RESEARCH; 2001; 45: 235–239
Evidence level: C, [Link]

[6]. West J et al.; Early Motion After Quadriceps and Patellar Tendon Repairs: Outcomes With Single-Suture Augmentation; The American Journal of Sports Medicine; 2008 February, 36 (2): 316-323;
Evidence level: C, [Link]

[7]. Yilmaz C. et al.; Tendon lengthening repair and early mobilization in treatment of neglected bilateral simultaneous traumatic rupture of the quadriceps tendon; Knee Surg Sports TraumatolArthrosc.; 2001 May; 9(3):163-166;
Evidence level:D, [PubMed]

[8]. Levy M. et al.; A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization.Preliminary report; ClinOrthopRelat Res.; 1987 May;(218):297-301
Evidence level:D, [PubMed]

[9]. Gaheer R.S. et al.; Rapid recovery from spontaneous and simultaneous bilateral quadriceps tendon rupture in an active, healthy individual; Orthopedics.; 2010 July; 13;33(7):512Evidence level:D, [PubMed]

[10]. O’Shea K. et al.; Outcomes following quadriceps tendon ruptures; Injury.; 2002 April ;33(3):257-260
Evidence level: B, [PubMed]

[11]. Shah M.K.; Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations; South Med J.; 2002 Aug;95(8):860-866;
Evidence level:B, [PubMed]

[12]. James Edin Lyle et al.; quadriceps tendon rupture; Medscape; 2011
Evidence level:C   [Medscape]

[13]. James Edin Lyle et al.; quadriceps tendon rupture; Medscape; 2011
Evidence level:B   [Medscape]

[14]. Vigneswaran N, Lee K, Yegappan M, spontaneous bilateral quadriceps tendon rupture, case report, Singapore Med J, 2007.
Evidence level: 4 [Link]