Quadriceps Tendon Rupture


Article Author:
Jacob Pope


Article Editor:
Mark Plexousakis


Editors In Chief:
Susan Jeno
Renato Vilella
Sarah Fabiano


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
3/27/2019 12:39:14 AM

Introduction

The quadriceps tendon is derived from the muscular junction of the rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius muscles at the anterior superior pole of the patella. The quadriceps tendon in combination with patellar tendon and the patella bone make up the extensor mechanism of the lower leg. These muscles derive their neurovascular innervation from the femoral nerve and artery. Specifically, the rectus femoris, vastus intermedius, and vastus lateralis gain their arterial supply from the lateral femoral circumflex artery. The vastus medialis gains its arterial supply from the femoral artery, superior medial genicular branch of the popliteal artery, and the profunda femoris artery. The vastus lateralis, vastus medialis, and the vastus intermedius act both as knee extenders as well as assist with patellar tracking. The vastus lateralis is the largest of the quadriceps muscles.  It helps to pull the patella laterally. This action must be counterbalanced by the vastus medialis, which is the smallest of the quadriceps muscles and acts to pull the patella medially. The vastus intermedius acts to help stabilize midline tracking of the patella. The combined contraction of this group of anterior thigh muscles causes extension of the lower leg. The rectus femoris also plays a role in hip flexion. A rupture of this central tendon drastically hinders knee extension and directly effects functionality. The degree that a quadriceps tendon rupture limits lower leg extension is based on the severity of tendon damage. Minor tendon tears may have minimal impact on extensor function, while complete tendon tears may totally impede lower leg extension.[1][2][3][4][5]

Etiology

Quadriceps tendon ruptures have a positive correlation with age and multiple medical comorbidities. This injury historically is more prevalent in males, with susceptibility increasing proportionally with age after 40 years. This is in opposition to patellar tendon ruptures, which commonly occur before age 40, and are often related to sports injuries. Medications and medical comorbidities associated with quadriceps tendon ruptures include fluoroquinolones, corticosteroids, anabolic steroids, hyperparathyroidism, gout, diabetes, obesity, chronic kidney disease, hypercholesterolemia, hyperuricemia, rheumatoid arthritis, systemic lupus erythematosus, and osteogenesis imperfecta.[1][2][3][4][5]

Epidemiology

Lower leg extensor mechanism ruptures as a whole are very rare, but are reported to have high morbidity and are often debilitating. [6] Quadriceps tendon ruptures are reported to have an incidence of 1.37/100,000 and 0.68/100,000 for patellar tendon ruptures. Extensor mechanism ruptures are most common unilaterally. However, there are several case reports of this injury occurring bilaterally, from one precipitating event.

Pathophysiology

Quadriceps tendon ruptures in athletes are the direct result of a sudden and strong contraction of the quadriceps muscles from a jump and land mechanism or sudden change in direction while running. Quadriceps tendon ruptures in non-athletes are usually the direct result of a fall or other trauma in individuals with predefined medical comorbidities which are thought to cause pathologic tendon degeneration. One proposed biomechanical mechanism involves knee flexion with simultaneous quadriceps contraction. Another proposed mechanism involves extensive rotation as well as hyperflexion of the lower leg. The majority of quadriceps tendon ruptures occur at the myotendinous junction with patellar tendon ruptures occurring most commonly within the tendon itself. End-stage renal disease patients on dialysis have the highest association with tendon degeneration resulting in ruptures. The pathophysiologic mechanism involved in chronic kidney disease is theorized to involve uremic toxins, renal osteodystrophy, and hyperparathyroidism. [7]As renal function declines, there is often a homeostatic imbalance of calcium, phosphorus, vitamin D, and parathyroid hormone. Elevated parathyroid hormone results in increased bone turnover. Over time, this is thought to weaken myotendinous junctions, resulting in increased potential for tendon rupture with minimal tensile stress. In patients receiving dialysis with insufficiently permeable filters, there has been higher reported serum beta-2 microglobulin. Beta-2-microglobulin collects in bones, joints, and tendons. This phenomenon is known as dialysis-related amyloidosis. Beta-2 microglobulin accumulation results in functional impairment in tissue elasticity and therefore a higher potential for tendon rupture with minimal trauma. The proposed mechanism involved in diabetes involves the accumulation of advanced glycation end products. Advanced glycation end products form covalent bonds with collagen fibers. This results in the release of inflammatory cytokines which cause progressive tendon damage. As one ages there is also decreased arterial capillaries per unit surface area. This results in a decreased healing potential after repeat microtrauma.

History and Physical

Patients presenting with potential quadriceps tendon ruptures usually report hearing an audible pop or experiencing a tearing sensation. This is immediately followed by a decreased ability to bear weight and is commonly accompanied by swelling and effusion. A palpable defect can usually be felt at the superior pole of the patella. Patients with complete tears have an impaired ability to perform a straight leg raise. With partial tears, there is impaired knee extension. With complete tears, knee extension is usually absent. There is usually no impaired range of motion at the hip or ankle.

Evaluation

History and physical exam usually diagnose quadriceps tendon ruptures. Imaging is usually not indicated in quadriceps tendon injuries. However, ultrasound may have some clinical utility. Ultrasound can be used to detect a tendon defect, and to assess the degree of tendon gap with knee flexion.[8][9] Ultrasound has also been used serially to assess healing and to determine the presence of associated hematomas, effusions, or calcifications. Plain radiographs are usually not helpful in making this diagnosis but may have some clinical utility in ruling out other associated injuries or conditions. Plain radiography may be helpful in determining patella position. A superior patella may be indicative of a patellar tendon rupture, while an inferior patella may be suggestive of a quadriceps tendon rupture. Plain radiography may also rule in or out associated patella avulsions or other associated patellar fractures. MRI may be used preoperatively but is usually not necessary due to advances in musculoskeletal ultrasound. Due to the low prevalence of quadriceps tendon ruptures, there is limited data comparing ultrasound with MRI in diagnostic superiority. Both imaging modalities have a high sensitivity for patellar and quadriceps tendon injuries. However, ultrasound may be slightly more specific for patellar tendon ruptures, while MRI may have slightly higher specificity for quadriceps tendon ruptures. This difference is likely not clinically significant.

Treatment / Management

Like most musculoskeletal injuries, initial management of suspected quadriceps tendon ruptures includes rest, ice, compression, and elevation. Partial quadriceps tendon ruptures may be managed non-operatively. However, the majority of complete quadriceps tendon ruptures require early diagnosis and surgical treatment to limit long-term morbidity and disability. The timing of surgical repair has been attributed to optimal recovery and functionality than the specific surgical approach.[10][11]

Limited data directs the optimal surgical technique. Historically, surgical repair has been based on anecdotal evidence and surgeon experience. However, there is a trend toward the application of transosseous patellar drill holes if the tendon rupture is located near the patellar poles. More recently, suture anchors have replaced traditional patellar drill holes. Suture anchors require smaller skin incisions and result in shorter operative times. The effectiveness of this trend is unknown. Intratendinous ruptures have been repaired classically by way of an end to end sutures. Despite the specific surgical approach, a delayed recognition or operative intervention results in tendon retraction and reduced tissue quality. These factors both impair surgical success and hinder recovery. Operative repair is advised within the first 48 to 72 hours after complete tendon ruptures. If there is a delay in treatment, tendon retraction makes surgical repair more technically challenging, and may limit functional recovery. If there is significant tendon retraction resulting in a large tendon gap, allograph reconstruction may be necessary.

Few studies have evaluated optimal postoperative management.  Historically, the knee was immobilized at full extension for 6 weeks postoperatively to allow complete tendon healing before stressing extensor mechanism. There has been a trend toward early post-operative joint mobilization to reduce joint stiffness and quadriceps atrophy. In more recent literature, early mobilization has been shown to result in more adverse outcomes and additional operative interventions when compared to 6 weeks of full knee extension. However, due to the low incidence of this injury, there is limited statistically significant evidence to direct gold standard operative interventions or post-operative management.

Despite the surgical approach or postoperative course, the most common complications involve pain and quadriceps weakness. Patients report pain and weakness most commonly associated with prolonged standing, squatting, or ascending and descending stairs. However, few patients who receive timely medical intervention report significant functional debility.

Differential Diagnosis

Differential diagnoses include:

  • Patellar tendon rupture
  • Patellar stress fracture
  • Femoral shaft stress fracture
  • Bone or soft tissue tumor
  • Compartment syndrome
  • Referred lumbar spine pain
  • Meralgia paresthetica
  • Femoral nerve injury or entrapment 

Enhancing Healthcare Team Outcomes

The diagnosis and management of quadriceps tendon rupture is best managed by a multidisciplinary team that includes an emergency department physician, physical therapist, nurse practitioner, radiologist, sports physician, and an orthopedic surgeon

Like most musculoskeletal injuries, initial management of suspected quadriceps tendon ruptures includes rest, ice, compression, and elevation. Partial quadriceps tendon ruptures may be managed non-operatively. However, the majority of complete quadriceps tendon ruptures require early diagnosis and surgical treatment to limit long-term morbidity and disability. The timing of surgical repair has been attributed to optimal recovery and functionality than the specific surgical approach.[10][11]

The outcomes for most patients are good but the recovery is often prolonged. Without physical therapy, recurrences are known to occur.

 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Quadriceps Tendon Rupture - Questions

Take a quiz of the questions on this article.

Take Quiz
What is the most important physical finding in the diagnosis of a quadriceps tendon rupture?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the modality of choice to clarify a questionable diagnosis of quadriceps tendon rupture or to differentiate between complete and partial ruptures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which comorbidity has the highest association with quadriceps tendon ruptures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In what time frame should complete quadriceps tendon ruptures be repaired to prevent tendon retraction?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
The quadriceps tendon is derived from the muscular confluence of which of the following muscles?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 70-year-old male with a past medical history of high blood pressure, diabetes mellitus, end-stage renal disease on hemodialysis, arthritis, coronary artery disease, who is undergoing current treatment for a urinary tract infection presents to the emergency department after falling from standing. The patient experienced an audible "pop" of his right knee. On physical exam, he has difficulty performing a straight leg raise on the right. He has a palpable defect in the right suprapatellar area. A quadriceps tendon rupture is suspected. Upon reviewing this patient’s medication list, which of his medications predisposes him to this injury?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Quadriceps Tendon Rupture - References

References

Barge-Caballero G,López-Bargiela P,Pombo-Otero J,Pardo-Martínez P, Quadriceps tendon rupture in wild-type transthyretin amyloidosis (ATTRwt). European heart journal. 2019 Mar 12;     [PubMed]
Wu W,Wang C,Ruan J,Wang H,Huang Y,Zheng W,Chen F, Simultaneous spontaneous bilateral quadriceps tendon rupture with secondary hyperparathyroidism in a patient receiving hemodialysis: A case report. Medicine. 2019 Mar;     [PubMed]
Leciejewski M,Królikowska A,Reichert P, Polyethylene terephthalate tape augmentation as a solution in recurrent quadriceps tendon ruptures. Polimery w medycynie. 2018 Jan-Jun;     [PubMed]
Hsu D,Chang KV, Biceps Tendon Rupture of the Lower Limb 2019 Jan;     [PubMed]
Colombelli A,Polidoro F,Guerra G,Belluati A, Patellar and quadriceps tendons acute repair with suture anchors. Acta bio-medica : Atenei Parmensis. 2019 Jan 14;     [PubMed]
Nori S, Quadriceps tendon rupture. Journal of family medicine and primary care. 2018 Jan-Feb;     [PubMed]
Glick R,Epstein DS,Aponso DT, Spontaneous bilateral quadriceps tendon rupture associated with norfloxacin. Internal medicine journal. 2015 Dec;     [PubMed]
Prado-Costa R,Rebelo J,Monteiro-Barroso J,Preto AS, Ultrasound elastography: compression elastography and shear-wave elastography in the assessment of tendon injury. Insights into imaging. 2018 Oct;     [PubMed]
Bhashyam AR,Weaver MJ, Knee pain after a fall. BMJ (Clinical research ed.). 2018 Mar 22;     [PubMed]
Boublik M,Schlegel TF,Koonce RC,Genuario JW,Kinkartz JD, Quadriceps tendon injuries in national football league players. The American journal of sports medicine. 2013 Aug;     [PubMed]
Schmickal T,Doleschal S, [Rupture of quadriceps and patellar tendon]. MMW Fortschritte der Medizin. 2010 Feb 11;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Physical Therapy. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Physical Therapy, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Physical Therapy, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Physical Therapy. When it is time for the Physical Therapy board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Physical Therapy.