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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