Quadriceps Muscle Contusion


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Introduction

Hematoma progression Vastus lateralis

Contusion injuries to the quadriceps are common in athletics. Usually the mechanism of injury is a direct blow to the quadriceps causing significant muscle damage. Contusions cause rupture to the muscle fibers at or directly adjacent to the area of impact, usually leading to hematoma formation within the muscle causing pain and loss of motion. A contracted muscle will absorb force better and result in a less severe injury.

• In sports without padding for the thigh and upper leg, eg soccer and rugby, quadriceps contusions are a major disabling injury. Better protective equipment may decreasing the frequency of this injury, however, research is scant.
• Quadriceps contusions can lead to two serious complications: Compartment Syndrome and myositis ossificans.

Epidemiology

Demographics: 2:1 male: female ratio

Athletes: football, soccer, rugby most common sports; more common during competition than practice.

Pathophysiology

Muscle contusions are caused by direct trauma. Direct trauma can affect any part of the quadriceps femoris, with the vastus intermedius muscle most commonly affected.

The injury consists of a well-defined sequence of events

• Myonecrosis and hematoma forms followed by scar formation then muscle regeneration
• Small muscle fiber tears lead to hemorrhage and swelling into the anterior compartment
• If there is major untreated and/or unresolved bleeding deep in the muscle tissue, myositis ossificans can occur.

Clinical Presentation

Quadriceps muscle contusions are easily elucidated by a history of blunt trauma and clinical examination usually reveals skin discolouration, tenderness, swelling and varying degrees of pain and tenderness alongside a limited range of motion and difficulties to weight bear.

Classification

Next to muscle strains is traumatic muscle contusions the most frequent type of quadriceps injury in sports. A direct external forceful blow to the quadriceps causing significant muscle damage is the usual mechanism of this injury. In comparison to strains, contusions will cause rupture to the muscle fibers at or directly adjacent to the area of impact. This typically leads to hematoma formation within the muscle causing pain and loss of motion. The extent of pain and loss of movement will be dependent on the amount of fore and the impact of the force at the time of trauma. Quadriceps contusions are graded mild, moderate or severe between 12 and 24 hours. A mild contusion has more than 90 degrees of knee flexion; moderate between 45 and 90 degrees of knee flexion and severe less than 45 grades of knee flexion.
There are three grades in contusions:

Pain	Active knee flexion	Gait	Description	Average loss of activity
Mild	> 90degree	Normal	Capillary rupture: Blood into connective tissue Mild ecchymosis Feels soreness after cooling down or the following day The injured area may be tender to touch Ability to stretch the muscle may be reduced slightly. The strength of the muscle may also be slightly affected.	6 days
Moderate	45 - 90 degree	Antalgic	Crushing of the muscle fibres with vasomotor reaction Minimum stiffness after rest Swelling Pain Tenderness	56 days
Severe	< 45 degree	Severely antalgic	Rapid swelling and bleeding The patient will be unable to walk properly without the aid of crutches Pain Tenderness	> 60 days

Presentation

The diagnosis is made by questioning an accurate history from the patient and completing a physical examination.

Examination

• Pain: worsening severity over the first 24-48 hours; worse with dynamic movements and with knee flexion
• Observation: Antalgic gait
• Palpation: possible palpable defect indicating partial or complete muscle tear, swelling, ecchymosis, point tenderness.
• Circumference measures: compare thigh firmness and circumference to contralateral side
• Strength testing of the quadriceps: resist knee extension and hip flexion, compared to the uninjured side, helps in assessing severity of injury.
• Measurement of knee flexion is used as a prognostic indicator in quadriceps contusions. Based on this, thigh contusions can be graded into 3 groups that are based on the severity of injury
• Provocative tests: active straight leg raise to test integrity of extensor mechanism
• Neurovascular: distal neurovascular exam to evaluate for thigh compartment syndrome.

Outcome Measures

The ‘Lower Extremity Functional Scale’ is used to evaluate the functionality for a wide range of lower limb conditions to know whether the person is having any difficulty with certain activities.

Imaging

The best techniques for measuring the soft tissue damage and for complications caused by the initial injury are magnetic resonance imaging (MRI) and diagnostic ultrasound. Both have been highly sensitive to oedema and haemorrhage. These methods are expensive but can speed up the healing process by detecting the severity quick. Ultrasound can be used to identify a localized hematoma formation caused from a contusion and provide real-time imaging for needle aspiration. If there is concern for bony involvement, radiographs will evaluate for bony injury. Subsequently, radiographs are useful in identifying heterotopic bone formation, known as myositis ossificans (MO), which is a delayed complication of severe muscle contusions.

Risk factors

• Contact sports and sports that require quick starts, i.e. running races and other track events.
• Warm up and cool down habits.
• Off season/preseason/season training habits.
• Poor muscle conditioning.
• Playing position.
• Level of competition.
• Protective equipment use.
• Playing experience.
• Injury history, especially to the thigh, hip and/or knee.
• Medical history of any bleeding disorder.

Management

First line of treatment for acute injuries, begin immediately to minimize hematoma formation: immobilisation, cryotherapy, NSAIDs, physical therapy.

1. NSAIDs can be useful short term for decreasing pain, long-term use of NSAIDs for contusions is usually not necessary and is discouraged. NSAIDs have been promoted for prevention of myositis ossificans after severe quadriceps contusions. Evidence for this use is inferred from studies showing a decrease in heterotopic bone formation after total hip replacement in those patients given indomethacin for at least 7 days.
2. After three to four weeks, if the patient still moves with pain and isn’t able to perform a painless, full range of motion, radiographic imaging should be performed. This is to detect whether myositis ossificans is present.

Physical Therapy Management

The main goals of therapy with patient with a quadriceps muscle contusion are relieving the pain and improving the ROM. The treatment is non-operative and exists out of three phases:

1. Rest, ice, compression.Compression is important in order to limit the hemorrhage for the first 24 to 48 hours. Immobilization in 120 degrees of flexion using an ace wrap or hinged knee brace immediately after injury for 24-48 hours, frequent use of cold therapy. Knee flexed helps to avoid muscle stiffness
2. Active and passive quadriceps muscle stretching with emphasis on knee flexion.After 24 h, the brace or wrap should be removed and gentle, active, pain-free range of motion at the knee should be instituted along with stretching and isometric quadriceps strengthening. The active phase of treatment, including functional rehabilitation, can begin when pain-free, active knee flexion of at least 120° is attained.
3. Begin functional rehabilitation and sport-specific activities once full and pain-free ROM achieved

Return to sports criteria

The athlete should be pain free, attain 120° of knee flexion with hip extended, and perform all aspects of functional field testing without limitations . Protective thigh padding is recommended prior to resuming sports in order to reduce recurrence. See Return to Sport. A five step approach in aim to reach maximum functional recovery, see image below.

Viewing

1. How to treat a bruise / haematoma / swelling of the quadriceps using kinesiology tape (4 minutes viewing)

2. Steve Jurch of Jurch Performance Education Discusses Contusions & How to Speed up Recovery Time (15 minutes viewing)

Clinical Bottom Line

Contusions are one of the most common muscle injuries besides muscle-strains. They can sometimes evolve to a more complicated injury such as myositis ossificans or compartment syndrome, to which you have to pay attention. The options for treatment are mostly physiotherapy and in some serious complications an operation will be needed. Physiotherapy is designed to reduce the pain and improve the ROM of the patients, by giving cryokinetics, soft tissue massage and electrotherapy.