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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 Injury
Strains
Contusions
• 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
• 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
Strains
Grade
% fibre
disruption
Pain
Strength
Physical exam
1
None/a
few/Less than
5%
Mild
None or minimal
loss
No palpable muscle defect
2
Moderate/550% fibres
with/without
fascial injury
Moderate
Moderate loss
May feel a small palpable
muscle defect, partial
muscle retraction
3
Many/complete Severe
rupture/up to
100%/with
fascial injury
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
Contusions
Grade/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/contusion
PLUS
• 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 Management
Contusions
• 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