Quadriceps Strains & Contusions

Normal Anatomy• Quadriceps – 4 muscles

– Rectus femoris– Vastus lateralis– Vastus medialis– Vastus intermedius

• Common insertion into superior aspect of patella via quadriceps tendon and tibial tuberosity via patella tendon

• Rectus femoris origin on AIIS – hip flexion & knee extension

• Vastus muscles origin on femur – knee extension only

Mechanism of InjuryStrains

• Commonly occurs in sport e.g. rugby, tennis, football

• Sudden high force with eccentric contraction of hip flexion/knee extension e.g. deceleration

• Excessive passive stretching• Activation of maximally stretched

muscle e.g. kicking• Muscle fatigue may play a role• Rupture most often at

musculotendinous junction• Rectus femoris most commonly

strained

Contusions

• Direct blow to quadriceps causing significant muscle damage

• Rupture of muscle fibres directly in or adjacent to area of impact

• Haematoma formation within muscle

• Contracted muscle absorbs force better and commonly results in less severe injury

Classification

StrainsGrade % fibre

disruptionPain Strength Physical exam

1 None/a few/Less than 5%

Mild None or minimal loss

No palpable muscle defect

2 Moderate/5-50% fibres with/without fascial injury

Moderate Moderate loss May feel a small palpable muscle defect, partial muscle retraction

3 Many/complete rupture/up to 100%/with fascial injury

Severe Usually complete loss

Often feel a palpable muscle defect, with or without muscle retraction

Adapted from Mueller-Wohlfahrt et al (2012) and Kary (2010)

Classification

Strains• Due to the extent of inconsistency and

insufficiency of the existing classification system, several other classification models have been proposed

• e.g. Mueller-Wohlfahrt et al (2012)

Classification

ContusionsGrade/pain Active knee flexion Gait

Mild >90° Normal

Moderate 45-90° Antalgic

Severe <45° Severely antalgic

Taken from Kary (2010)

Associated Pathologies

Myositis Ossificans• Occurs as complication in approx 20% large haematomas

associated with strains/contusions• Prolonged pain, reduced flexibility, local tenderness and

stiffness – lasts average 1.1 years• Suspected when patient unresponsive to conservative

management and demonstrates increasing pain and loss of ROM

• Proliferation of bone and cartilage tissue at site of injury• Commonly found in muscle belly, but can also be present in

tendons, joint capsules, ligaments and fascia

Subjective

Strains• Sudden traumatic onset• Usually due to kicking, jumping, deceleration, change of direction• Often immediate sharp pain in quadriceps associated with loss of function• Sometimes pain does not develop until end of sporting activity• Associated localised swelling, loss of motion, development of bruising• Localised pain anywhere in quadriceps, however commonly in distal

portion (at MTJ) or mid to proximal portion of rectus femoris • Pain increased on activities requiring passive/eccentric hip extension/knee

flexion or concentric hip flexion/knee extension• Pain eased with ice/NSAIDs in acute stage• History of previous strain/contusion

Subjective

Contusions• Sudden traumatic onset• Direct blow to thigh e.g. opponents knee, foot• Immediate localised pain at site of injury and possible loss of

function• Depending on severity, athlete may be able to continue play• Associated localised swelling, loss of motion, development of

bruising• Pain increased on activities requiring passive/eccentric hip

extension/knee flexion or concentric hip flexion/knee extension• Pain eased with ice/NSAIDs in acute stage

Subjective

Myositis ossificans• Strain or contusion mechanism of injury• Progressive increase in pain and loss of

function/ROM• Non responsive to conservative treatment or

10-14 days rest

Objective

Strains• Possible antalgic gait• May be signs of inflammation and bruising• Possible deformity to muscle e.g bulge or defect to muscle

belly or retraction of muscle if severe• Pain/tenderness on palpation to whole/part of muscle belly,

with increased pain at site of injury.• Pain/loss of strength on resisted knee extension/hip flexion• Test knee extension with hip flexed (sitting) and extended

(prone) - rectus femoris• Pain and loss of ROM on passive testing of quadriceps

Objective

Contusions• Possible antalgic gait• May be signs of inflammation and bruising• Possible deformity to muscle• Pain/tenderness on palpation to whole/part of muscle belly,

with increased pain at site of injury• Pain/loss of strength on resisted knee extension/hip flexion• Test knee extension with hip flexed (sitting) and extended

(prone) - rectus femoris• Pain and loss of ROM on passive testing of quadriceps – loss of

ROM will help classification and provide prognostic indicator

Objective

Myositis ossificans (MO)• Similar to strain/contusionPLUS• Possible palpable mass at site of injury which develops over the

weeks following injury• Often severe pain/loss of strength on resisted knee extension/hip

flexion• Often severe pain and loss of ROM on passive testing of

quadriceps• Radiographic signs of ectopic bone usually develop

approximately 3-5 weeks after injury• MO tends to shrink as it matures over a 6 month period

Further Investigation

X-ray• May be helpful in differentiating between bony (femoral

stress fracture, tumor, or myositis ossificans) and muscular etiologies of quadriceps pain in chronic cases

MRI• Provides detailed images of muscle injury and can be

quite helpful in characterizing quadriceps injuries• Can sometimes be difficult to distinguish between

muscular contusion and strain on MRI(Kary, 2010)

Further Investigation

Ultrasound imaging– Allows different planes of investigation to allow more

effective visualisation of muscle & tendon due to variations in orientation & thickness

– Allows positioning of the joint in different positions for optimal viewing of diff structures

– can be used to identify localised bleeding/haematoma formation form a contusion and provide real-time imaging for needle aspiration can be used to image muscles dynamically

– highly operator dependent, requires experienced, skilled clinician

(Kary, 2010)

Management

Goal of therapy is to • protect site of injury• promote healing• reduce pain and oedema• restore ROM • restore strength • prepare for return to sport

Conservative Management - Strains

• PRICE• NSAIDs• Soft tissue techniques

– reduce pain and inflammation, restore full ROM, optimise healing– Early aggressive manual therapy may prolong recovery (Stainsby et al, 2012)

• Active mobilisations – within pain free range• Strengthening – pain free

– isometric, then isotonic– SLR, leg extension, leg press, squat, lunge, lateral lunge, deadlift

• Stretching techniques – Active, active-passive, passive, METs, dynamic– Emphasis on active and pain-free in acute/sub-acute stage

• Neuromuscular control and proprioception• Specific drills to prepare for return to full function/sport

Conservative ManagementContusions• Management is essentially the same as for strains, except:

– Place injured leg in position of 120° knee flexion for 24 hours to limit haematoma formation – use hinged knee brace or compression wrap (Kary, 2010)

Myositis ossificans• Management is similar to strains, focusing on stretching, ROM and

strength.• Patients may still be able to participate in sport, but may find they have

restricted ROM and occasional flare-ups• May require surgical excision

– Not until ectopic bone formation has matured – 12-24 months

• ESWT may be beneficial in reducing symptoms and facilitating a return to full function (Torrance et al., 2011)

Surgical Management

Surgical intervention is indicated for:• Compartment syndrome (decompressive fasciotomy)• Haematoma removal• Complete quadriceps muscle rupture• Chronic partial tears non-responsive to conservative

treatment• Bony avulsion of muscle insertion at the patellar

tendon• Ectopic bone formation in myositis ossificans