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
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