Quadriceps Muscle Contusion


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Contents

• 1 Search Strategy
• 2 Definition/Description
• 3 Clinically Relevant Anatomy
• 4 Epidemiology /Etiology
• 5 Characteristics/Clinical Presentation
• 6 Differential Diagnosis
• 7 Diagnostic Procedures
• 8 Outcome Measures
• 9 Examination
• 10 Medical Management
• 11 Physical Therapy Management
• 12 Key Research
• 13 Resources
• 14 Clinical Bottom Line
• 15 Recent Related Research (from Pubmed)
• 16 References

1) Search Strategie

We started our research by using electronic databases from Pubmed, Web Of Knowledge, VUB- library. As search topics we used “quadriceps muscle contusion” or relevant synonyms. To find more specific information we used targeted terms like “examination muscle contusion”, “healing process quadriceps contusion”. To expand our research for each subdivision we used synonyms of the related subject.

2) Definition/Description

Definition

Charley horse/cork thigh/dead leg
A quadriceps contusion is a traumatic blow, a deep bruise to the anterior lateral or medial aspect of the thigh. If examination confirms an area of swelling and tenderness with (terrible) pain on passive stretch and active contraction, the diagnosis is a Quadriceps contusion with resultant hematoma. ^{[1] [5]}
The contusion is the result of an external force that can damage the muscle but can’t eliminate its function completely. 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. ^[9] Quadriceps contusions can lead to two serious complications: compartment syndrome Compartment Syndrome and myositis ossificans.^{[1] [6]}

Description

A contusion is the most common acute thigh injury in contact sport such as football, rugby and basketball. In sports such as football, cricket, soccer and lacrosse, a ball, helmet or shoulder pad at high speed may cause a contusion. These sports regularly require sudden forceful eccentric contraction of the quadriceps during regulation of knee flexion and hip extension. Higher forces across the muscle-tendon units with eccentric contraction can lead to strain injury. Localized bleeding may increase tissue pressure and tissue damage. The bleeding can be intramuscular or intermuscular. The intramuscular hematoma is more painful and restrictive of range of motion than the intermuscular hematoma. Of the quadriceps muscles, the rectus femoris is the most frequently strained. ^{[4] [5] [1]}

3) Clinical Relevant Anatomy

The Quadriceps femoris is a hip flexor and a knee extender. It’s located in the anterior compartment of the thigh. This muscle is composed of 4 subcomponents:

-M. Rectus femoris (lies in the anterior portion of the thigh)
-M. Vastus medialis (on the inner portion of the thigh)
-M. Vastus lateralis (on the outer portion of the thigh)
-M. Vastus intermedius (is located posteriorly)

The vastus muscles originate from the anterior, medial, and lateral aspects of the femur. The m. rectus femoris originates from the spina iliaca anterior inferior and it has three proximal tendons. The 4 bellies of the QM converge distally to form the thick quadriceps tendon, which inserts into the superior pole of the patella. The m. rectus femoris is the only muscle that is participating in both functions; flexion of the hip and extension of the knee. The other three parts are only involved in the extension of the knee. The M. rectus femoris is even the most superficial part of the Quadriceps and it crosses the hip and the knee joints. Innervation of these muscles is by the femoral nerve. The quadriceps are primarily active in kicking, jumping, and running.^{[2] [1]}

4) Epidemiology/Etiology

Quadriceps contusions are mainly common by contact sports like rugby, football, basket, kick boxing ^[1]. A systematic review resulted in a frequency from 10% to 40% of all football injuries were categorized as contusion, strains or sprains.^[9] The injury is caused by a sudden force to the quadriceps muscle causing significant muscle damage. This force is usual due to another player (in sports), a sport attribute or a misplaced fall on a severe object.

5) Clinical Presentation

A massive blunt force mostly to the anterior or lateral thigh causes rupture to the muscle fibers. In the beginning there are negligible symptoms, but after 24 hours this will lead to hematoma formation within the muscle causing: pain, swelling, stifness and impairment of functional quadriceps excursion.^{[3] [4]}

6) Differential Diagnosis

Quadriceps contusions:
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. ^{[1] [7] [2]}
There are three grades in contusions: ^[7]

1. Mild
A person experiencing a mild quadriceps contusion will usually be able to continue playing. Sometimes they may feel some soreness after cooling down or the following day. The injured area may be tender to touch and the ability to stretch the muscle may be reduced slightly. The strength of the muscle may also be slightly affected.

2. Moderate
A moderate contusion may stop an athlete from continuing. There may be a minimum stiffening feeling and a swelling may become visual. Also as in grade one, the person may experience some pain and the affected area will be tender to touch. Someone with a moderate quadriceps contusion will walk with a limp feeling and a reduced range of motion of 50%.

3. Severe
A severe contusion is characterized by rapid swelling and bleeding. Both may not be able to be controlled. The loss in movement will be striking and putting full weight on the affected leg will be not possible. The tenderness of the affected area will very high and the muscle strength will be temporary lost.

7) Diagnostic Procedures

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

The physical examination implies:

- Palpation along the injured muscle: to localize the pain and exact site of muscle damage and also to determine if there is any associated injury.
- Strength testing of the quadriceps: that contains resisting knee extension and hip flexion, compared to the uninjured side. This will help 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:

• Mild : Mild contusions are characterized by a little or no loss of range of motion and minimal loss of strength. There is an intramuscular bruising that produces mild bleeding and swelling, little pain and mild point tenderness along the injury site. The patient may or may not remember the incident and was able to continue the activity. Tenderness to palpation is finding. Overall the mild contusion will result in a disability of about 13 days. Active knee flexion greater than 90°.

• Moderate: There is an increase in bleeding into the muscle tissue, a noticeable limp, more bruising and swelling, and an inability to flex the knee past 90 degrees without significant pain. The patient usually remembers the incident but can continue the activity although may stiffen up with rest. Tenderness to palpation is finding. Overall the moderate contusion will result in a disability of about 19 days. Active knee flexion is between 45° to 90°.

• Severe: Severe contusions are characterized by a severely antalgic gait, noticeably swollen and tender muscle mass, functional loss of strength and tenderness to palpation over a large area. The patient will be unable to walk properly without the aid of crutches. The patient will remember the incident and was not able to control rapid onset of swelling or bleeding. Overall the severe contusion will result in a disability of about 21 days. Active knee flexion is less than 45°.
Imaging techniques such as ultrasound and MRI can be useful to provide additional information regarding the nature of muscle injury. It can identify localized discontinuities in the normal striated pattern of the muscle associated with hematomas or identify the calcifications of mysositis ossificans.  ^{[1] [2]}

8) 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.

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9) Examination

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. ^{[5] [3]}

Other methods are: ^[5]
Palpation of the injured area. The patient will immediate give response to the pain when the physiotherapist palpates. It’s important to make sure there isn’t any associated injury.
Measuring of range of motion (ROM) can also be used to determine the severity of the contusion injury. A pain response from the patients as a criterion. The result of ROM has to be compared to the uninjured side to determinate the decrease.

The tap test is a good test to adopt in your examination, it is likely to be attributable to the ready discriminability of the other tests.

The brush-swipe test is a method to determine if there is any fluid or oedema in the knee caused by the contusion injury.

Physiotherapists can measure the thigh circumference to follow up the muscle decreasing due by the injury. You can do this at suprapatellar border, 10cm proximal to suprapatellar border and 20cm procimal to suprapatellar border. This measurements must be compared to the uninjured thigh circumferences.

Passive methods to examine the severity of pain-level, range of motion and prognosis are likely testing passive knee flexion and extension, strength testing of the quadriceps, by resisting knee extension and hip flexion compared to the uninjured side.

10) Medical Management

Forty-eight hours after incurring a quadriceps muscle contusion, weight bearing actions are very painful and swelling occurs. Then it’s recommended to treat with compressive wraps en nonsteroidal anti-inflammatory drugs. Corticosteroids should be discommended, but nonsteroidal anti-inflammatory drugs may reduce edema and the risk of myositis ossificans.^[6]

At the beginning of the treatment, patients with quadriceps muscle contusion should be checked frequently for symptoms and signs of anterior thigh compartment syndrome.

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. Myositis ossificans results in lasting pain and limited knee flexion. Surgical excision is then recommended. An MRI should also be considered to check for the presence of intramuscular hematoma or seroma. An MRI can also determine osteomyelitis of the femur. In that case, the solution is a resection of the infected bone and antibiotics. ^{[3] [4]}

11) Physical Therapy Management

For patients with a quadriceps muscle contusion, there are several treatments from which a physical therapist can choose. The first option is cryokinetics. It is a revalidation technique that consists out of ice application followed by progressive, active exercises. Once the affected thigh is getting numbed, you can begin with passively stretch the leg. A second aspect of the treatment program can be soft tissue massage around the periphery of the contusion. This leads to a better fluid resolution. A third option is electrotherapy in order to reduce the pain. Very important is that the patient avoid activities that excessively load the quadriceps during the physical therapy.^[5]

So the main goals of therapy with patients with a quadriceps muscle contusion are relieving the pain and improving the ROM. The treatment is mostly non-operative and exists out of three phases:^[3]

1) Rest, ice, compression.
Compression is important in order to limit the hemorrhage for the first 24 to 48 hours.
If the patient rests with his knee flexed, it helps to avoid muscle stiffness.
2) Active and passive quadriceps muscle stretching with emphasis on knee flexion.
3) Improve the functionality and a return to sport when full motion and strength are achieved.

12) Key Research

- Trojian TH. Muscle contusion (thigh). Clin Sports Med. 2013 Apr;32(2):317-24. (http://www.ncbi.nlm.nih.gov/pubmed/23522512)
- Aronen JG, Garrick JG, Chronister RD, McDevitt ER. Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee flexion. Clin J Sport Med. 2006 Sep;16(5):383-7.
(http://www.ncbi.nlm.nih.gov/pubmed/17016112)
- 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.
( http://www.ncbi.nlm.nih.gov/pubmed/1867338)
- Kary JM. Diagnosis and management of quadriceps strains and contusions. Curr Rev Musculoskelet Med. 2010 Jul 30;3(1-4):26-31. (http://www.ncbi.nlm.nih.gov/pubmed/21063497 or http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941577/ )
- Alonso A, Hekeik P, Adams R. Predicting a recovery time from the initial assessment of a quadriceps contusion injury. Aust J Physiother. 2000;46(3):167-177.
(http://ajp.physiotherapy.asn.au/AJP/46-3/AustJPhysiotherv46i3Alonso.pdf )
- J. Albert Diaz,* MD, David A. Fischer,*† MD, Arthur C. Rettig,‡ MD, Thorpe J. Davis,‡ MD and K. Donald Shelbourne,‡ MD. Severe quadriceps muscle contusions in athletes - A report of three cases. American journal of sports medicine. 2003;31(2):289-293. (http://ajs.sagepub.com.ezproxy.vub.ac.be:2048/content/31/2/289.full.pdf+html )
- Shawn Bonsell,* MD, Paul T. Freudigman, MD, and Howard A. Moore, MD. Quadriceps Muscle Contusion Resulting in Osteomyelitis of the Femur in a High School Football Player. American journal of sports medicine. 2001;29(6)818-820.
(http://ajs.sagepub.com.ezproxy.vub.ac.be:2048/content/29/6/818.full.pdf+html )
- Quadriceps contusion (cork thigh). Sports Medicine Australia. 2010; 719.
(http://sma.org.au/wp-content/uploads/2011/01/719-SMA-InjuryBrochure-Quadriceps_web.pdf )
- Christopher M. Larson, MD; Louis C. Almekinders, MD; Spero G. Karas, MD; William E. Garrett, MD, PhD. Evaluating and managing muscle contusions and myositis ossificans.2002 Feb;30(2):41-50.
(https://physsportsmed.org/doi/10.3810/psm.2002.02.174 )

Anatomy

The Quadriceps femoris is a hip flexor and a knee extender. This muscle is composed of 4 subcomponents:
-M. Rectus femoris
-M. Vastus medialis
-M. Vastus lateralis
-M. Vastus intermedius
The rectus femoris originates at the ilium, it is the only muscle that is participating in both functions; flexion of the hip and extension of the knee. The other three parts are only involved in the extension of the knee.
The M. rectus femoris is even the most superficial part of the Quadriceps and it crosses the hip and the knee joints. Innervation of these muscles is by the femoral nerve.

  

Clinical Presentation

Definition

A quadriceps contusion is a traumatic blow, a deep bruise to the anterior lateral or medial aspect of the thigh. If examination confirms an area of swelling and tenderness with terrible pain on passive stretch and active contraction, the diagnosis is a Quadriceps contusion with resultant hematoma. The contusion is the result of an external force that can damage the muscle but can’t eliminate its function completely. Quadriceps contusions can lead to two serious complications: compartment syndrome Compartment Syndrome and myositis ossificans. 

Description
A contusion is the most common acute thigh injury in contact sport such as football, rugby and basketball. In sports such as football, cricket, soccer and lacrosse, a ball, helmet or shoulder pad at high speed may cause a contusion. Localised bleeding may increase tissue pressure and tissue damage. The bleeding can be intramuscular or intermuscular. The intramuscular hematoma is more painful and restrictive of range of motion than the intermuscular hematoma. &nbsp

Please also see Quadriceps Muscle Strain, Quadriceps Tendon Tear

Diagnostic Procedures

After obtaining a thorough history, a careful examination should ensue including observation, palpation, strength testing, and evaluation of motion. Strain injuries of the quadriceps may present with an obvious deformity such as a bulge or defect in the muscle belly. Ecchymosis may not develop until 24 h after the injury. Palpation of the anterior thigh should include the length of the injured muscle, locating the area of maximal tenderness and feeling for any defect in the muscle. Strength testing of the quadriceps should include resistance of knee extension and hip flexion. Adequate strength testing of the rectus femoris must include resisted knee extension with the hip flexed and extended. Practically, this is best accomplished by evaluating the patient in both a sitting and prone-lying position. The prone-lying position also allows for optimum assessment of quadriceps motion and flexibility. Pain is typically felt by the patient with resisted muscle activation, passive stretching, and direct palpation over the muscle strain. Assessing tenderness, any palpable defect, and strength at the onset of muscle injury will determine grading of the injury and provide direction for further diagnostic testing and treatment.

Grading

Thigh contusions are graded depending on how far you can bend your knee, your ability to walk, and if you are able to do a deep knee bend as follows: 

• Mild : Mild contusions are characterised by a little or no loss of range of motion and minimal loss of strength. There is an intramuscular bruising that produces mild bleeding and swelling, little pain and mild point tenderness along the injury site. The patient may or may not remember the incident and was able to continue the activity. Tenderness to palpation is finding.
Knee flexion >90°C

• Moderate: There is an increase in bleeding into the muscle tissue, a noticeable limp, more bruising and swelling, and an inability to flex the knee past 90 degrees without significant pain. The patient usually remembers the incident but can continue the activity although may stiffen up with rest. Tenderness to palpation is finding.
Knee flexion 45°C to 90°C

• Severe: Severe contusions are characterised by a severely antalgic gait, noticeably swollen and tender muscle mass, functional loss of strength and tenderness to palpation over a large area. The patient will be unable to walk properly without the aid of crutches. The patient will remember the incident and was not able to control rapid onset of swelling or bleeding.
Knee flexion <45°C

Imaging

Most acute injuries to the quadriceps musculature can be diagnosed with an adequate history from the patient and a thorough examination. Imaging can be a useful adjunct in those cases where the diagnosis is uncertain or further detail is needed regarding the type and location of the muscle strain. Radiographs, ultrasound (US), and magnetic resonance imaging (MRI) are the commonly used imaging tools for this area. Radiographs are routinely normal in acute muscle strains, but may be helpful in differentiating between bony (femoral stress fracture, tumor, or myositis ossificans) and muscular etiologies of quadriceps pain in chronic cases. US is an excellent imaging modality for visualizing the quadriceps muscles and tendons, but is highly operator dependent and requires a skilled and experienced clinician. US has the ability to image the muscles dynamically and assess for bleeding and hematoma formation via Doppler. MRI provides detailed images of muscle injury and can be quite helpful in characterizing quadriceps injuries. It can sometimes be difficult to distinguish between muscular contusion and strain on MRI, which simply re-enforces the importance of clinical history and examination in injury assessment. Prognostically, Cross et al. found strains of the central tendon of the rectus femoris, identified on MRI, correlated with a significantly longer rehabilitation period.

Outcome Measures

 (see Outcome Measures Database)

Management / Interventions

Mild and moderate

The purpose of treatment in Phase I is to minimize hemorrhage. The first 24 hours following the injury is the most important period in the treatment of a Quadriceps contusion. The earlier the treatment, the better the results. The treatment is based on the RICE principle (rest, apply ice and compression and elevate the affected area). Ice the thigh with an elastic bandage or brace for twenty minutes and keep the hip and knee in flexion as far as comfortable. 

This position increases counterpressure inside the injured muscle and contributes to hemostatis. Furthermore, it will help minimise range of motion loss and muscle bleeding. After twenty minutes of icing, wait at least forty minutes and repeat.
The reason of this aggressive treatment is to minimise the risk of developing myositis ossificans. If the knee is left in extension, the quadriceps starts to heal in a shortened position and the patient experiences a more painful and slower return to full flexion capacity. The athlete can use crutches to ensure adequate rest if full weight-bearing is painful. If the leg continues to swell, consideration should be given to the possibility of a developing compartment syndrome or continued hemorrhage.

The physiotherapist can start giving ultrasound, electrical stimulation, stretching and sport massage techniques. The massage techniques are useful to facilitate the removal of swelling and bruising but is not recommended for 48 hours following contusion. The athlete must be careful not to overstretch! Stretching should be pain free. Gradually build up the weight to strengthen the quadriceps. When the athlete gets back the full strength, motion and endurance of the quadriceps, he may be able to return to sports.

The most of the rehabilitation programs are based on the tissue’s theoretical healing response.