Quadriceps Tendon Tear

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Keywords: Quadriceps tendon tear, quadriceps tendon rupture, quadriceps tendon tear rehabilitation,
Resources: Pubmed, Web of knowledge, Medscape

Definition/ description:
A quadriceps tendon tear is a tear of the distal tendon which is attached to the basis of the patella and this tear can be a partial or complete, complete tears mostly appears unilateral but bilateral is also possible but is less common. A complete quadriceps rupture mostly happens with persons older than 40 year .

Clinically relevant anatomy:
The quadriceps exists out of 4 muscles: m. rectus femoris, m. vastus lateralis, m. vastus medialis and m. intermedius. All muscles have their insertion on the basis of the patella but the m. vastus lateralis, medialis and intermedius have also an insertion on the distal tendon of the m. rectus femoris.

Mechanism of injury:
A muscle rupture often happens during an 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),then the quadriceps has to do a fast eccentric contraction. other mechanism is caused by a force straight on the anterior side of the knee(fall).

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 hyperparathyrodisme[4] 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 increases the chance, because the strength and flexibility of the muscle and tendon decreases.

Characteristics/ Clinical presentations:
Symptoms of a quadriceps tendon tear:
- there is often a popping or tearing feeling
- pain and swelling
- dent/gap just proximal of the patella where the quadriceps tendon was torn
- a hematoma
- the quadriceps will be sensitive and cramping
- the patella may sag or droop
- there will be a loss of extension
- inability to bear weight and loss of stability.

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.
Diagnostic procedures:
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 has been proven consistent, responsive and reliable[1].

Examination:
First inspection of the weight acceptance on the injured knee, then inspection of active knee extension or/ and 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.

Physical therapy:
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. 2 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].

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
2.Jolles B.M. et al.; A new clinical test in diagnosing quadriceps tendon ruptures; Ann R Coll Surg Engl; 2007; 89: 259-261; evidence level: D
3.Kim Y.H. et al.; Spontaneous and simultaneous rupture of both quadriceps tendons in a patient with chronic renal failure; Knee Surg Sports Traumatol Arthrosc; 2006; 14: 55–59; evidence level: D
4.Kricun R. et al.; patellar tendon rupture with underlying systemic disease; AJR ; 1980 October; 135: 803-807; evidence level: D

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

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
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 Traumatol Arthrosc.; 2001 May; 9(3):163-166; evidence level: D
8. Levy M. et al.; A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report; Clin Orthop Relat Res.; 1987 May;(218):297-301; evidence level: D
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):512; evidence level: D
10.O’Shea K. et al.; Outcomes following quadriceps tendon ruptures; Injury.; 2002 April ;33(3):257-260; evidence level: B
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