Download physiotherapeutic modalities in quadriceps

African Journal of Science and Research,2016,(5)4:35-47
ISSN: 2306-5877
Available Online: http://ajsr.rstpublishers.com/
PHYSIOTHERAPEUTIC MODALITIES IN QUADRICEPS REHABILITATION:
A SYSTEMATIC REVIEW.
Somsankar Mukherjee
Department of Sports Sciences, College of Natural and Computational Sciences, P.O.Box 231, Mekelle University,Ethiopia.
Email:[email protected]
Received:21,July,2016
Accepted: 26,Aug,2016
Abstract
In sports, the fun, recreation and muscle injuries are two side of a coin. Depending on the frequency of physical a ctivities and their nature in
sports, different kinds of muscle injury do exist. The main objective of the present work is to know the physiotherapeutic mo dalities utilization in
Quadriceps injury. Before understanding the therapeutics usage, the author focused on anatomical structure of quadriceps muscles, its origin,
insertion and any alteration in course of muscle, with special emphasis on subcrures muscles. Furthermore, the presentation h ighlighted the
architectural design, muscle morphology, muscle tendon dynamics along with several aspects of muscle biomechanics. Moreover, in present
review the efforts made to discuss the muscle metabolism such as activity of creatine phosphate, adenosine triphosphate, temp erature and so
on. After thorough discussion on Anatomy, the scholar discussed about the types of injuries on quadriceps muscles such as tendinitis, sprain
and strain, partial or complete rupture of fibers, soreness, fatigue, cramp, contusion, compartment syndromes and related issues. Several
interesting causes of the injuries and related syndromes are presented in it. Recently, literature reported several interesting views regarding
therapeutic modalities for quadriceps treatment and rehabilitation such as effects of different type of exercises and stretches, electrotherapy
equipments- high frequency as lazers, diathermies, ultra sounds; low frequencies- as vibrators, shockwave therapy; and other modalities as hot
therapy, cold therapy and contrast therapy. Massage benefit on quadriceps discussed in the last phase of the article.
Keywords: Quadriceps Muscle; Anatomy; sports injuries; Physiotherapy Modalities.
INTRODUCTION
Sports and games are the best part of human life. From era of
ancient to modern world, sports and games have its own unique
standing. In earlier time, these tricks are consider as a part of
entrainment and recreational activities only, but now a day’s these
have several dimensions, which begins from professional activities to
health and fitness arena. It is a competition of an art to perform skills
and abilities to one’s best. To improvise the skills and abilities,
several scientific experiments are in progression. On the other side,
as the competitions are becoming tougher, the incidence of injuries
is also increasing. The injuries depend on several factors such as the
nature of game or sports such as contact or non-contact sports;
intensity of the sports activity such as sprint, jump or throw;
endurance of activities such as long distance, marathon and so on.
Depending on nature of sports, several or specific muscles are more
prone to injuries such as rotator cuff for Javelin throwers, fast bowers
in cricket, pitcher in baseball and so on. Similarly, in this article we
tried to summaries the physical therapy for injured quadriceps
muscles. Before going into its detailed study, it is an essential for a
therapist or a coach that one should have the accurate knowledge on
Quadriceps femoris muscle’s location, architecture, structure,
function, causes of injuries. After summarizing about these,
researcher has tried to compare the utility of different modalities
being used by physical therapist for curing the injured muscle, with
the best efficacy and efficiency approach to solve the inflammatory
problems.
Anatomy of quadriceps muscles
The quadriceps femoris, also known as quadriceps, quadriceps
extensor, or quads. It is a large, bulky and fleshy mass of four
muscles present in anterior and lateral part of the thigh with sole
function of knee extension.
The sub-division of muscles has received idiosyncratic names as
follows - Rectus femoris (RF)muscles which is a superficial muscle
occupies the middle part of the thigh, which covers most of the other
three quadriceps muscles. It originates on the ilium part of pelvic
bone. The other three deep muscles are Vastus Lateralis present at
lateral side of thigh, whereas Vastus Medialis (VM) is at inner part of
thigh, and Vastus Intermedius (VI) is between Vastus lataralis (VL)
and Vastus Intermedius(VI) muscles. These three muscles originates
from Trochanters of Femur to Condyles of Femur bone, whereas it
insert into Tibial-tuberosity via Patella, where quadriceps become
ligamentum patella. A few researchers consider Subcrureus
(articularis genus) muscle as a fifth part of Quadriceps muscles.
Moreover, Tensor of Vastus Intermedius (TVI) is the one more new
muscles presented in resent findings.
Subcrureus muscles
Agur A. M. R., (2009) pointed out that Subcrureus muscles
present deeper to Vastus Intermedius muscle. In an article by Darryl
Hosford (2010) “Thigh To Foot Musculature” mentioned that the
muscle originates from distal portion of anterior femoral surface,
close to the knee and from the deeper fibers of the vastus
intermedius where as its insertion is at synovial membrane of the
knee joint. He further claimed that the main action of this muscle is to
pulls the synovial membrane of the knee superior with knee
extension, which helps to prevents impingement of the synovial
membrane between patella and the femur. The blood supply is from
Lateral Femoral Circumflex Artery and its innervated by the branches
of femoral nerve (L3,4).
Even B. Reider et al. (1981) describe that this muscles is a flat,
wispy & highly variable and sometimes consisting of several
separate muscular bundles. In the book named, Gray Henry (1918)
mentioned that this muscle has unclear distinct investing fascia but
width size range 1.5 – 3 cm. The main function of the muscles is to
pull the suprapatellar bursa superiorly during knee extension and
same statement has been re-proven by Agur A.M.R. (2009) and
Darry Hasford (2010)
Tensor vastus Intermedius
Switzerland medical researches Grob K. et al. (2016) claims of
another muscles in quadriceps group, and named as tensor of
36
vastus intermedius. After dissection of twenty six lower limb
cadaver muscles, they explain that it is an independent muscular and
vascular branche of the femoral nerve and lateral circumflex femoral
artery. Morphologically four different types were distinguished as
independent type, vastus intermedius type, vastus lataralis type and
common type. Their study demonstrate that the quadriceps femoris
is architecturally different from previous description: there is an
additional muscle belly between the vastus intermedius and vastus
lataralis, which cannot be clearly assigned to the former or the latter.
Distal exposure shows that this muscle belly becomes its own
aponuorisis, which continues distally as part of the quadriceps
tendon.
Rectus femoris
The Rectus femoris situated in the inner-front of the thigh. The
shape of the muscle noted as fusiform while its superficial fibers are
arranged in a bipenniform manner and the deep fibers running
straight to form aponeurosis. It is found in the 40 thedition of Gray’s
anatomy that the Rectus femoris has two tendons origin with an
acute angle from each other. The first one is the straight to the thigh
bone, which arises from the Anterior Inferior Iliac Spine and the other
is the reflected head, arises from a groove above the rim of the
Acetabulum of Pelvic bone. Further two muscles tendon spread into
an aponeurosis, which is prolonged downward on the anterior
surface of the muscle and from the muscular fibers, which becomes
a broad and thick aponeurosis and occupies the lower two-thirds of
posterior surface of thigh, and, gradually becoming narrowed into a
flattened tendon, and inserted into the base of the patella. When
author tried to analyze the exact location of neural supply, he foundin
one of the Kenneth Saladin (2009) book where he mentioned that
the neurons for thigh muscles originate from the Pre-central Gyrus.
The neurons, runs down through the internal capsule followed the
cerebral peduncle and into the medulla. In the medullary pyramid,
the corticospinal tract decussates and becomes the lateral
corticospinal tract. The nerve signal will continue down the lateral
corticospinal tract until it reaches spinal nerve, L4. At this point, the
nerve signal will synapse from the upper motor neurons to the lower
motor neurons. The signal will travel through the anterior root of L4
and into the anterior rami of the L4 nerve, leaving the spinal cord
through the lumbar plexus. The posterior division of the L4 root is the
Femoral nerve. The femoral nerve innervates the quadriceps femoris,
a fourth of which is the rectus femoris. When the rectus femoris
receives the signal that has traveled all the way from the medial side
of the precentral gyrus, it contracts, extending the knee and flexing
the thigh at the hip.
In general, Sports Medicine expert Elizabeth Quinn (2015)
mentioned that its functions are to flex the hip joint and to extend the
knee joint. On searching the exact function of Rectus femoris
muscles, it’s detail found in the book by Clippinger,(2007) “ Dance
Anatomy and Kinesiology; 2 nd Edition”. He said that the Rectus
femoris is a weaker hip flexor when the knee extended because it
has already shortened and thus suffers from active insufficiency.
Similarly, in essence the action of extending the knee from a seated
position mainly determined by the vastus lateralis, vastus medialis,
and vastus intermedius, and less by the rectus femoris. In the other
extreme, the muscle's ability to flex the hip and extend can be
compromised in a position of full hip extension and knee flexion, due
to passive insufficiency.The rectus femoris is a direct antagonist to
the hamstrings, at the hip and the knee. Rectus femoris be torn, can
be extremely painful and potentially debilitating if there is a complete
rupture.
Vastus Lateralis
Somsankar Mukherjee
The Vastus lateralis sometime known as ''vastus externus’’. It
originates from femur which include in the upper part of the intertrochanteric line, the lower & anterior borders of the greater
trochanter, the outer border of the gluteal tuberosity and the upper
half of the outer border of the linea aspera. After origin, it shapes
itself as a series of flat & broad tendons and forms an aponeurosis,
which covers the upper three-quarters of the muscle. These fibers
convert into large fleshy mass and further it constricted and
thickened into a flat tendon that attaches to the outer border of the
patella. Consequently, it adds with the quadriceps femoris tendon
and expanding as the capsule of the knee-joint. On looking the nerve
and blood supply, in general several books mentioned that Lateral
Circumflex Femoral Artery and Innervated by Posterior Division of
the Femoral Nerve (L3 – 4) supply the muscle.
On critical analyzing of nerve innervations, the scholar found a
detailed description of neural supply as mentioned in S. Patil et al.
(2007) work. After his study in-detailed about the anatomy of the
nerve supply to the Vastus Lateralis muscle, on the basis of
dissection of ten cadaveric lower limbs, they concluded that all the
specimens have a single nerve trunk arose from the femoral nerve
which is most subsequently divided into two main divisions. These
divisions gave two branches each. These branches move from
anteriorly and proximally to posteriorly and distally within the muscle.
On opening, the Vastus laterallis found that the denervation of nerve
is mainly to the posterior half of the muscle.
Vastus medialis
The vastus medialis also known as Vastus Internus or Teardrop
muscle. Regarding the location, Drake et al. (2005) describes that
the Vastus Medialis is a muscle present in the anterior compartment
of thigh. He further stated that it originates from the antero-medially
on the inter-trochanteric line of the femur, continued on posteroinferiorly along the pectineal line and then descends along the inner
lip of the linea aspera and the medial supracondylar line of the femur.
The fibers converge onto the inner part of the Quadriceps Femoris
tendon and the inner border of the Patella. On the other hand an
interesting hypothesis quoted by Smith et al.(2009) that vastus
medialis muscle can be divided into two groups of fibers viz. a long
and relatively inline group of fibres with the quadriceps ligament, the
Vastus Medialis Longus (VML) and a shorter and more obliquely
oriented with group of fibers, the Vastus Medialis Obliquus (VMO).
Though Drake et al. (2005) stated that the continuous part of distal
segment of the Vastus Medialis muscle is known as Obliquus Genus
(OG) muscle which play an important role in maintaining patella
position and limiting injuries to the knee, but we didn’t found any
clear explanation on this issue. Moreover, a few scholars stated that
the vastus medialis involved in knee extension (Drake et al. 2005),
and also contributes to correct tracking of the patella (Sheehan et al
2012).
Regarding the neural activity of Vastus Medialis, researcher
studies from book Human Anatomy by B.D.Chaurasia and Greys
anatomy that the nerves supplied to this muscle are from Femoral
nerve (L2, L3. L4). But the recent studies made by Jojima H. et al.
(2004) on thirteen cadaver knees without deformity, were used to
learn about the nerve branches along the femoral nerve, distally until
they ended in muscle. From this study, they observed two patterns of
nerve distribution. In three specimens, the main trunk ran in the midportion of the vastus medialis and then divided into multiple branches,
which entered the distal oblique fibers of the muscle at multiple
points in the area where it blended with the main body of the muscle.
In the remaining specimens, the main trunk run in the posterior
segment of the muscle and branched to the distal oblique fibers, but
African Journal of Science and Research , 2016,(5)4:35-47
many branches entered these distal oblique fibers diffusely through
the proximal area from branches in the main body of the muscle. The
vascular supply to vastus medialis are Femoral artery, profundafemoris artery, and superior medial genicular branch of popliteal
artery.
Vastus Intermedius
The vastus intermedius also known as Cruraeus muscle. This
arises from the anterior and lateral surfaces of the femur of its upper
two-thirds. It present under the Rectus Femoris muscle and the lower
part of the lateral inter-muscular septum. Its fibers inserts in a
superficial aponeurosis, which forms the deeper part of the
quadriceps femoris tendon.
The vastus medialis and vastus intermedius appear inseparable,
but a narrow interval observed which is extending upward from the
medial border of the patella between the two muscles, and the
separation may be continued as far as the lower part of the intertrochanteric line. Due to being the deeper middle-most muscle, the
intermedius is the most difficult to stretch once maximum knee
flexion is attained. It cannot be further stretched by hip extension as
the rectus femoris can, nor accessible to manipulate with massage
therapy to stretch the fibres sideways as like the vastus lateralis and
vastus medialis.
BIOMECHANICS OF QUADRICEPS FEMORIES
Architecture Of Quadriceps Muscles
Every muscles has its own shape, size and structure depend on
several factors, such as working ability, working style, action and so
on. If the muscles do not work according to its structural and
physiological abilities, then muscles are more prone to injure during
activities. To know the exact structural design, we surf and found few
interesting findings. Silvia S. Blemker & Scott L. Delp (2005) tried
to determine the extent to which the complex features of the rectus
femoris and vastus intermedius architectures affect the fiber changes
lengthwise. Thus, the researchers created three-dimensional finiteelement models of the rectus femoris and vastus intermedius
muscles based on magnetic resonance (MR) images and compared
the fiber excursions predicted by the finite-element models with fiber
excursions predicted by lumped-parameter models of these muscles.
The finite-element models predicted over a range of 1001 knee
flexion found as Rectus Femoris fiber excursions that varied from
55% to 70% whereas and vastus intermedius fiber excursions that
varied from 55% to 98% of the excursion muscle–tendon unit.
Contrary to this, the lumped-parameter model of the rectus femoris
predicted fiber excursions that were 86% whereas vastus
intermedius fiber excursions that was 97% of the excursion of the
muscle–tendonunit. These results suggested that fiber excursions of
many fibers over-estimated in lumped-parameter models of these
muscles. These new presentations of muscle architecture can
improve the accuracy of computer simulations of movement and
provide insight into muscle design. Further, they found that the peak
knee extension moment arms according to the three-dimensional
model were 3.5 cm for the rectus femoris in the range from 3.1 to 4.0
cm and correspond to 55–70% of the excursion of the whole
muscle–tendon unit. The proximal aponeurosis of the rectus femoris
changed lengthwise 1.6 cm (9%), the distal aponeurosis by 0.7 cm
(4%), and the external tendon by 0.4 cm (3%). The lumpedparameter model predicted fiber excursions 86% of the excursion of
the whole muscle–tendon unit. In the case of vastus intermedius the
moment arm is 3.3 cm, range 2.7 to 4.7 cm. These excursions
correspond to 55–98% of the excursion of the whole muscle–tendon
unit. The aponeurosis of the vastus intermedius changed length by
37
1.8 cm (10%), and the external tendon by 0.3 cm (1%). The lumped
parameter model predicted fiber excursions 97% of the excursion of
the whole muscle–tendon unit.
Muscle Morphology and Muscle-Tendon Dynamics of Quadriceps.
In one of the handpicked study conducted by Finni et al. (2008),
observed the associations between morphology and muscletendondynamics of the quadriceps femoris muscle. They have used
velocity-encoded phase-contrast magnetic resonance imaging (MRI)
and thigh muscle electromyography. At first the joint range of motion
exercise performed, as knee extension-flexion tasks at a rate of 40
times/min with elasticbands providing peak resistance of 5.2 kp (SD
0.4) to the extension for a moment.
The same movement was repeated inside the velocity-encoded
phase-contrast MRI scanner where, tissue velocities and muscle
morphology were recorded. The average displacement in the
proximal and distal halves of the rectus femoris and aponeurosis of
vastus intermedius found different, i.e. reflecting shortening (1.6%),
but the tensile strain along the length of the aponeuroses was
uniform. The aponeurosis behavior varied among individuals and
these individual patterns best explained by the differences in relative
cross-sectional area of rectus femoris to vastus muscles.
During dynamic contraction, considerable deformation of
muscles in the axial plane caused an anatomic measure such as
muscle thickness to change differently (decrease or increase) indifferent sites of measurement. For example, when analyzed from
the axial images, the vastus lateralis thickness did not change in the
frontal plane through femur but increased in an oblique plane of 45°
between the frontal and sagittal planes. The present observations of
the heterogeneity and individual behavior emphasize the fact that
single-point measurements do not always reflect the overall behavior
of muscle-tendon unit.
Length and measurements of muscles
The above said researcher predicted that the volume of the
vastus muscle group was 1,748 ± 565 cm 3 and the volume of Rectus
femoris was 257 ± 85 cm 3. There was no detectable difference in
the cross secession analysis of the vasti between relaxed and submaximally contracted conditions when measured from the magnitude
images of VE-PC (velocity-encoded cine phase-contrast) sequence.
When measured from the proximal axial MR image, a significant
change in muscle thickness due to contraction was observed in
Vastus Intermedius in the sagittal plane was from 1.9 to 2.2 cm.
In the proximal section the aponeuroses between the Vastus
Intermedius and Vastus Lataralis are not always visible, so their
common thickness measured. Between the relaxed and contracted
conditions in a plane of 45°, it differ 4.7 to 5.1 cm. When measured
from the distal axial MR image, a significant change in muscle
thickness observed from relaxed to contracted condition in the
Vastus Lateralis muscle at the 45° plane from 2.0 to 2.3 cm; in
Vastus Intermedius in the 45° plane is from 1.4 to1.5 cm and in the
sagittal plane is from 1.6 to 1.9cm. When the change in muscle
thickness compared between the sites of observation, there were
differences in Vastus Latralis between the frontal and the 45° plane
and in Vastus Intermedius among all three planes. Mean Rectus
Femoris tendon length was 82.1 ± 15.1 mm in range 62.5–102.0 mm.
The ratio of Rectus Femoris tendon length to thigh length was 0.18
with accuracy 0.03. The quadriceps tendon moment arm was 52.8 ±
2.4 mm.
Quadriceps Muscle Mass
The mass of muscles depend on different factors, such as food
habits, physical structures, daily activities, age, gender and so on.
38
According to Peter Krustrup et al (2004) the knee-extensor muscle
mass was determined 2.49 ± 0.11 Kg by MRI where as
anthropometry measurement reported 3.19 ± 0.12 kg. The mass of
Vastus Latralis was 0.76 ± 0.05 Kg, Vastus Intermedius was 0.67 ±
0.04 Kg, Vastus Medialis was 0.57 ± 0.03 Kg and Rectus Femoris
was 0.33 ± 0.04 kg, as per found in the available subjects. The
difference may be as MRI has the ability to calculate the lean muscle
mass, i.e. fat free mass, where as anthropometric calculation may
not be able to calculate as lean body mass.
Muscle Activity
An EMG activity level during the knee extension-flexion exercise
was evaluated as maximum voluntary isometric contraction
strategies (MVC). The activity during the dynamic exercise was 9.1±
8.4% in Rectus Femoris and 5.0 ±3.4% in the vastus muscles. For
half of the subjects the Rectus Femoris muscle was predominantly
activated, whereas other subjects showed predominance of Vastus
Lateralis and Vastus Medialis. Peak cross-correlation coefficient and
phase shift were not different between VL-RF and VM-RF muscles.
Muscle Velocity
The analysis of the distal and proximal locations of the sagittal
section, the velocity in both Rectus Femoris and Vastus Intermedius
was greater in the distal than the proximal part, illustrating that the
mid muscle bellies, as measured from the regions of interest were
shortening during low-load concentric contraction. The peak muscle
velocities measured from the site of the distal cross section Rectus
Femoris is 41 ± 15mm/s whereas 56 ± 19 mm/s for Vastus
Intermedius.
Aponeurosis Displacement and Strain
The aponeurosis measured, shift from the muscle just adjacent
to the aponeurosis. On the average, the Vastus Intermedius and
Rectus femoris side of the aponeurosis moved the same distance
during the concentric phase of the movement. The difference in
mean displacement of the distal and proximal halves of the
aponeurosis was significant which reflect its non-uniform behavior.
A derivative of the linear fit to the maximum displacement data
showed that the average strain in the aponeurosis was 1.6%, which
means that the aponeurosis shortened slightly. Moreover, the
researcher found a correlation between the displacement-derived
shear type and the relative volume of Rectus Femoris to all Vastus;
but no correlation between the strain derived shear type and the
relative volume was found.
Recruitment of fiber types and Quadriceps muscle
For exercises, it is always important to have a basic idea on the
types of muscles fibers available in Quadriceps muscles as different
types of exercises has its own effects. Peter Krustrup et al. (2004),
investigate recruitment of slow-twitch (ST) and fast-twitch (FT)
muscle fibers, as well as the involvement of the various quadriceps
femoris muscle portions during repeated, intense, one-legged kneeextensor exercise. From the study, they conclude that both types of
fibers and all the portion of quadriceps muscle recruited at the onset
of intense knee-extensor exercise, which is essential for all
quadriceps muscle fibers. Similarly, metabolism activities seem
higher in Vastus Laterals muscle during repeated, intense, onelegged knee-extensor exercise. However, they found a significant
increase in muscle temperature in all quadriceps muscle sites.
MUSCLE METABOLITES
Creatine Phosphate Content
Peter Krustrup et al. (2004), also found that the Creatine
Phosphate content in slow twitch and fast twitch fibres was ~65
mmol/kg d.w., during rest. He found that the level has declined upto
~75% and ~30% respectively, after 15 and 180 s of during exercises.
Somsankar Mukherjee
Before starting next set of exercises, they re-found that Creatine
Phosphate had returned to resting level in both fibre types. During
this phase of exercise, the Creatine Phosphate concentration in Slow
Twitch and Fast Twitch fibres decreased to ~10% of resting value.
As on analysis, before exercise the content of Creatine Phosphate in
Slow Twitch fibres was below 45.8 mmol/kg d.w. whereas Fast
Twitch fibres has 50.5 mmol/kg d.w. In overall homogeneously the
muscle content was 83.5±5.1 and 86.5±3.2 mmol/kg d.w. of CreatinPhosphate prior to 1st and 2nd phase of exercise, respectively. After
15th second, 180th second of 1st phase of exercise and again on 180 th
second of 2nd phase of exercises the rate of declination of CreatinPhosphate was found 78%, 33% and 28% respectively low from
actual amount. On further the quantitative analysis the net CreatinePhosphate break-down during the first 15th second and next 165th
second of 1st phase of exercise as well as during 2 nd phase of
exercise measured as they found 18.3 ± 7.5, 37.9 ± 17.2 and 62.3 ±
4.5 mmol/kg d.w., respectively lower. On observing separately they
found similar rate of breakdown i.e. Slow Twitch 17.5 ± 3.8, 28.2 ±
8.8 and 57.7 ± 3.0 mmol/kg d.w.and Fast Twich: 17.2 ± 4.9, 29.8
± 9.8 and 59.2 ± 4.8 mmol/kg d.w., respectively. They concluded
that the rate of Creatine-Phosphate breakdown during the exercises
was similar between different muscles fiber irrespective of exercises.
ATP content
The researchers were interested to analyze the net content of ATP
and rate of utilization on prescribed set of exercises. On the available
samples quadriceps muscles they found net ATP content in Slow
Twitch fibres was below 20.1 mmol/kg d.w. and Fast Twitch fibres
20.8 mmol/kg d.w. On analyzing the rate of declination of ATP at rest,
after 15th second, after 180th second of 1st set of exercises and again
on 180th second of second set of exercises they noted that there was
decline of 11, 14, 47 and 44% respectively in slow twitch fibers
where as 10, 17, 51 and 41% respectively in fast twitch fibers.
They concluded that there was unaltered rate of declination of ATP
during the first 15 seconds of 1 st phase of exercise but at the end of
1st phase and 2nd phase of exercise there was ~75% and ~85%
decline as compare to resting values. Overall, on average the ATP
concentration was similar in Slow Twitch and Fast Twitch fibres
before and during both phases of exercises.
Quadriceps Muscle Temperature
Vastus Lateralis, Vastus Medialis and Rectus Femoris had same
temperature before both phase of exercise. At the end of 1 st phase of
exercise, the net increase in all muscles was observed and found
between temperature 0.93 to 1.00 °C. During both phases of
exercise they did not noted any change in temperature in Vastus
Lataralis, but found a little fluctuation in Rectus Femoris. They noted
that temperature of Rectus femoris is higher between 30 to 80
seconds of 1st phase of exercise, whereas the same muscles
temperature was lower in last 60 seconds of second phase of
exercises as compared to Vastus Latralis. Overall, they concluded
that there was 23 ± 8% rises in temperature of Vastus Lateralis than
in Rectus Femoris during 2nd phase of exercises.
Types and Incidence of quadriceps injuries
On listing the types of injuries one may found several, but our
review in basically focused on sports related injuries happened in
quadriceps muscles. Overall, this study focused on injuries such as
Quadriceps contusion, Quadriceps tendon sprain, Quadriceps strain,
Quadriceps muscle partial tear, Quadriceps tendon rupture,
Quadriceps Soreness, Quadriceps fatigue, Quadriceps cramp,
Quadriceps Muscle Contusion and a few special cases.
Quadriceps contusion / Anterior Thigh Compartment syndrome.
Quadriceps contusion is also known as Charley horse or cork thigh
African Journal of Science and Research , 2016,(5)4:35-47
or dead leg which is defined by Joel M. KaryIt (2010) as a result of
traumatic blow to the anterio-lateral aspect of the thigh. Tero A. &
Järvinen H. (2005) explained the cause of contusions as rupture to
the muscle fibers, at or directly adjacent to the area of impact,
whereas Beiner J. M. (2001) explain the incidence of quadriceps
muscle injury. He suggested that after strains, traumatic musclecontusions have found as the most frequent type of quadriceps injury
in sports.
It is a known fact that the mechanism of contusion is usually a
blow to the anterior thigh, such as hitting a high velocity objects or
human. A severe trauma and large contusion can lead to a
compartment syndrome. The incidence of thigh compartment
syndroms is very rare as compared to lower leg compartment
syndromes. This is because the thigh compartments have greater
opportunity to expand and allowing the tissue to move so that the
forces distributed over a larger area. The thigh compartment
syndrome can only happen if rapid bleeding occur to deep
perforating branches of the vastus intermedius, which may occur
because of untreated rupture or fracture in bone. If this condition has
not taken care properly it can leads to muscle necrosis, fibrosis,
scarring, and limb contractures. The players feels pain to anterior
thigh & unable to flex the knee with pain on weight-bearing.
Similarly Konstantinos Natsis et al. (2010) also noted that
hematoma formation in the quadriceps muscle rarely leads to
increased pressure (41 mmHg to 80 mmHg) within the muscle
compartment and thus develop compartment syndrome. Moreover,
their associates noted that Quadriceps hematoma predisposes to the
development of myositis ossificans. Myositis ossificans occurs after a
strain in deep muscles. Muscle ossificans occurs as the calcium
deposited within a muscle because of hematoma.
Quadriceps tendon sprain
As per the practical observation by author, quadriceps distal
tendon (patellar tendon) injuries are more common especially,
young’s, adolescent girls, tall structured and novice players. In
support of this observation, the quotation made by Blazina (1973)
and explained about peri-patellar tendinitis, affecting the patellar
tendon and termed it as jumper's knee. He observed that it
commonly occur in jumping athletes. The mechanism is sudden
stretching or repeated eccentric contraction of the muscle causing
pain and dysfunction immediately. Symptoms include pain with
ambulation, knee flexion and inability to extend the knee if the
quadriceps ruptured.
Quadriceps strain
Irregularities in training such as training load, intensity, frequency
& duration and relatively insufficient rest period are a few causes of
quadriceps strains. Moreover, sudden counter forces are also one of
the main causes for the injuries. Out of four quadriceps muscles,
rectus femoris is the most frequent strained muscles as quoted by
Hasselman C. T. et al. (1995). Joel M. Kary (2010) explained with
reason that sports, which regularly require sudden forceful eccentric
contraction on muscle-tendon, are more prone to strains. He further
suggested that quadriceps has to regulate eccentrically for two joints
as knee flexion as well hip extension.
Quadriceps muscle partial tear
The partial tear of quadriceps is very rare but seen mainly in high
contact sports such as rugby, kabaddi, football and so on. The
mechanism during sport is unclear but mainly seen the incidence as
sudden restriction during forceful movement of hip flexion or knee
extension. The location, of the injury is more frequent in the lateral
head of the proximal part of the rectus femoris, as compare to is
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distal quadriceps near the patellar insertion.
Quadriceps tendon rupture
Because of conclusion by most of the authors, the tendon usually
ruptures in an area of tendinosis. In patients with bilateral injuries or
injuries associated with trivial trauma and no history of previous
strain, consideration given to the associated use of anabolic steroidal
medications or utility of excess steroids during sports events.
Quadriceps Soreness
At initial part of training or training beyond the physiological limit
lead to muscle soreness, which is a routine for sports person.
Quadriceps soreness divided into two categories. If the pain felt
during or immediate after physical activities, believed as Acute
quadriceps muscle soreness. Jack H. Wilmore et al. (2008)
described as a perception of pain will felt within the minutes of
contraction of muscles and disappears as and when it relaxes. He
also noted that the cause for soreness may be due to excess
metabolic end product (H +) released by cell and thus cause the
shifting in blood plasma into muscle tissue during contraction. This
leads to tissue oedema. On the other side, Michael Kjaer et al.
(2008) states that pain subside after couple of minutes to several
hours after relaxing the muscles. Correspondingly, when the
soreness felt after two to three days of exercise, called delayed
onset of quadriceps muscle soreness. Nosaka Ken et al. (2008)
described the cause of delayed soreness is, due to the beyond
limitation of eccentric contraction of muscles, leads to micro trauma
to muscles fiber. As response to this injury, the muscles sores stop
the further destruction of the muscle.
Quadriceps fatigue
Muscle fatigue defined as an exercise-induced reduction in the
maximal force capacity of the muscle. The cause of muscle fatigue
has noted on several reasons, which results to distinguish between
neural and muscular mechanisms. Danny M. Pincivero and
associate (2001) studied on gender and limb dominance difference
on muscle fatigue. They found few interesting findings as they
estimate that the fatigue index for the dominant leg found lower than
non-dominating leg, in both genders. The results demonstrated that
peak quadriceps work normalized to body mass was significantly
higher in males than females. On the other hand, males displayed a
significantly greater reduction for quadriceps Peak Torque, Total
Work and Average Power across sets 1-2 with 1 min rest interval, as
compared to the other groups.
Quadriceps cramp
Marco Alessandro Minetto et al. (2013) reveled that muscle
cramp is a sudden, involuntary, painful contraction of a muscle or its
part. It subsided by itself within seconds to minutes and often
accompanied by a palpable knotting of the muscle. Norris et al.
(1957) reported a high prevalence of benign cramps in a wide group
of healthy young subjects enrolled in an exercise class.
Special cases
This category includes ruptures after surgery or else iatrogenic.
The surgeries that may be associated with this complication include
lateral release, total knee replacement, anterior or posterior cruciate
ligament reconstruction. Rupture of the quadriceps tendon after
surgery may be associated with the procedure to harvest the graft
used to reconstruct the cruciate ligaments or aggressive release of
soft tissues in case of lateral release and total knee replacement.
CAUSES OF QUADRICEPS MUSCLE INJURIES
Tero A. & Järvinen H. (2005) explained that Quadriceps injuries
are one of the most common injuries occurring in sports. According
40
to their statement, more than 90% of all sports-related injuries are
either contusions or strains. A muscle contusion occurs when a
muscle is subject to a sudden, heavy compressive force such as a
direct blow to the muscle. This kind of muscle trauma typically takes
place in contact sports, whereas sprinting and jumping are the most
common activities associated with muscle strains. In strains, an
excessive tensile force subjected to the muscle, leads to the
overstraining of the myofibres and consequently torn or rupture near
the musculo-tendenious junction. Muscle strains typically concerned
across double joints muscles, such as the rectus femoris,
semitendinosus, and gastrocnemius muscles.
According to John W. Orchard (2001), a few interesting outcome
such as shorter stature height had more prone to quadriceps injuries.
The chances of re-injure can occur if the player had a history of
quadriceps or hamstring injury within 8 week. The average age of the
injury is approximately 23.53 years. The dominating leg is more
prone to injury and the most interesting finding he coated as chance
of injury at the venues will be more where past week rainfall is less
than 13.28cm.
Several authors such as Hughes C. et al. (1995), Hasselman C.
T. (1995), Tero A. & Järvinen H. (2005), Best T. M. (1995) stated the
several factors predispose Quadriceps muscle are more frequent
strain injury. These include two join muscles, high percentage of
Type II fibers and muscles with complex musculo-tendinous
architecture. Mair S. D. et al. (1996) found that muscle fatigue also
play a role in acute muscle injury. Encardino J. T. R. et al. (2000)
and Ilcreest E. L. et al. (1939) discovered that the most frequent
cause of partial or complete muscle rupture is its eccentric overload.
On the other side, llison A. (1984) noted that the contusions result
from a direct impact against the muscle or from muscle over
stressing. Mink et al (1992) noted that excessive tensile forces
across the musculo-skeletal unit typically lead to failure near the
myo-tendinous junction. Nordin and Frankel (2001) illustrated that
muscle and tendon injury occurs at zones of anatomical or functional
transition as these sites generate the greatest concentrations of
intrinsic forces.
SYMPTOMS AND DIAGNOSIS
Based on several clinical orthopedics and medicine books, the
symptoms on quadriceps muscles injury listed as follow:
1. A sudden intense pain on anterior thigh as the injury occurs.
2. The quadriceps muscle may go into spasm.
3. There is intense tenderness over the anterior thigh or exact on
injured area.
4. Increasing pain and swelling occur on anterior thigh.
5. Knee or hip flexion Range of Motion loss.
6. Pain induced by contracting the quadriceps muscle against
resistance.
7. Incomplete or major partial rupture, a defect can be felt in the
Quadriceps.
8. A Rectus Femorus strain confirmed by eliciting pain when the
athlete is lying prone extends his hip and the knee flexed.
THERAPEUTIC MODALITIES FOR QUADRICEPS INJURE.
The quadriceps rehabilitation has several steps to bring injure
muscles to normal. During the rehabilitation there are several phases,
depending on short and long term goals. As mentioned that during
Quadriceps Rehabilitation several modalities were been used which
are based on electronic or electrical machines / therapeutics
Somsankar Mukherjee
instruments such as ultra sound, Interferential therapy,
electromagnative waves- short , micro, long waves therapy and
manual exercises with different ranges such as isometric to isotonic,
concentric to eccentric, free to resisted and so on which are being
discussed below.
Quadriceps exercise
Isometric vs. isotonic vs. Isokinetic
In isotonic contractions, the muscle contracts and shortens,
produce movement. Nearly all warm-up training considered as
isotonic. The basic advantage of isotonic contraction of quadriceps
muscles are it can strengthen the muscle throughout the range of
motion and it can me matched with the action which are needed for
sports activity and even weakest point of quadriceps will gain best
strength rather than through-out the range. However, the negative
side is shortening stage of muscle under stress leads to muscle
soreness.
In isometric contractions the muscle contracts but does not
shorten as a result, no movement. The most advantageous part of
this exercise is that one can perform at any time, at any place,
without any equipment, without hurting one’s thigh muscles or knee
joint. Such contractions, manly used for long-term activities like
standing, semi squat like on. However, some disadvantages are also
associated with this exercise such as rising in local systemic
pressure, stopping of blood flow to the local muscles and less blood
flow to the heart, leads to fatal drawbacks. In the field of exercise
science, it always recommended that training of quadriceps isotonic
training have to combine with isometric training to achieve
betterment of muscle function.
In isokinetic contractions, the muscle contracts and shortens at
constant speed. For isokinetic training, sophisticated equipmentis
required that detects muscle contraction force and can alter the load
as and when required. Though this equipment is very expensive
which is unaffordable by gyms, but the rate of quadriceps strength
gaining is too fast and evenly all through the range of motion.
Open vs. close- kinetic chain exercise for quadriceps muscles.
Basic objective of the open & close kinetic chain exercises is to
strengthen and rehabilitate the muscles. Open kinetic chain
exercises (OKC) or open chain exercises are those exercises, which
performed where the distal segment of the limb is free to move.
Whereas, closed kinetic chain exercises or closed chain exercises
(CKC) are physical exercises where the distal segment of the limb
fixed in space and cannot move. Graham V.L. et al. (1993) noted
that closed chain exercises are often multiple activities, that
generally gain compressive forces, while open-chain exercises are
often isolation movements that promote more shearing forces. Todd
Ellenbecker (2001) reported that single-joint versions of lower limb
exercises are typically non-weight bearing, with the movement
occurring at the knee joints. Blackburn J. R. et al. (1998) found that
Close Kinematic Chain exercises involve more than one muscle
group and joint simultaneously, such as Squats, deadlifts, lunges,
power cleans where along with quadriceps muscles, antagonist and
other supporting muscles activated together. On the other side,
Open Kinematic Chain exercise can concentrating solely on one
muscle group such as knee extension exercise focused only on
quadriceps muscle (single-muscle) training which, lend the former
to more functional and physical events. Blackburn J. R. et al. (1998)
conclude from several studies that at initial stage of rehabilitative
exercises, open kinetic exercises are preferred whereas closed chain
exercise preferred in functional training in rehabilitation exercises.
They also conclude that lower limb extensor CKC muscle strength is
more highly related to jumping performance than knee extensor OKC
African Journal of Science and Research , 2016,(5)4:35-47
strength, but he suggested for the further research required to
assess possible differences in training effectiveness for these two
regimes.
Stretching exercises effects
There are several types of stretching, such as static stretching,
dynamic stretching, proprioceptive neuromuscular (PNF) stretching,
ballistic stretching, active stretching, passive stretching and so on.
Static vs dynamic stretching
Khorasani M. A. and Kellis E. (2013 ) compared the effects of
static and dynamic stretching on quadriceps muscle activation,
during maximal soccer instep kicking. They suggested that dynamic
stretching is probably more effective in increasing quadriceps muscle
activity, as knee extension will improve in angular velocity during the
final swing phase of a maximal soccer instep kick.
Behm D. G. et al. (2001) tried to investigate the factors
underlying the force loss occurring after prolonged, static, passive
stretching. They found that Quadriceps inactivation improved by
2.8% as measured by the interpolated twitch technique (ITT) and
20.2% by surface integrated electromyography (iEMG). However,
there is significant 12% decrement in Maximum voluntary contraction
and 11.7% decrease in twitch forces. They concluded that although
possible increases in muscle compliance but affected twitch force
and a lack of tetanic force, which would reduce the post-stretch force
and are more effective by muscle inactivation than changes in
muscle elasticity.
Amiri-Khorasani, et al. (2011) tried to study the effects of static
and dynamic stretching within a pre-exercise warm-up on hip
dynamic range of motion (DROM) during instep kicking among
eighteen professional soccer players, by using 43-dimensional digital
video-cameras at 50 Hz. They concluded that professional soccer
players perform a higher DROM of the hip joint during the instep kick
after dynamic stretching incorporated in warm-ups, hence increasing
the chances of scoring and injury prevention during soccer games.
Erica Taylor Perrier (2009) put efforts to quantify the effects of a
warm-up with static or dynamic stretching on counter-movement
jump height, reaction time, muscle onsets for tibialis anterior (TA)
and vastus lateralis (VL) including hamstring flexibility. From their
study they concluded that counter movement jump height was
significantly higher during the Dynamic Stretch condition compared
to Static Stretch and No Stretch. Additionally, reaction time and
muscle onsets, were unaffected by either of the stretch technique.
They advised the athletes; in sports, requiring lower-extremity power,
should use dynamic stretching techniques in warm-up to enhance
flexibility while improving performance.
Kay A. D. and Blazevich A. J. (2012) tried to analyze on the
bases of systemic review regarding the effect of acute static stretch
on maximal muscle performance. After analyzing 106 articles they
concluded that the effects of static stretch are with longer durations
of 60 seconds, may not be typically used during pre-exercise as
routine in clinical, healthy or athletic populations. Whereas, short
durations of stretch of 30 seconds, can be performed as a preexercise routine without compromising maximal muscle performance.
Andrew D. Vigotsky et al. (2015) investigated the acute effects of
foam rolling on hip extension, knee flexion and rectus femoris length
during the modified Thomas test. They applied treatment on twentythree healthy participants of average age of 23 years and observed a
small change in hip extension. On the other hand, they found no
change in knee flexion or any alteration in rectus femoris length.
Their data revealed that it is benefiting only anterior thigh passive hip
extension and knee flexion ROM, especially if performed in
41
combination with a dynamic stretching protocol.
Stretching, commonly used as a technique for injury prevention
in the clinical setting. To get exact understanding of the
neuromuscular responses of stretching and helping clinicians in
making the decisions for rehabilitation; Sarah M. Marek et al.
(2005) had examined the short-term effects of static and
proprioceptive neuromuscular facilitation stretching- on peak torque
(PT), mean power output (MP), active range of motion (AROM) and
passive range of motion (PROM), on vastus lateralis and rectus
femoris muscles. They used sophisticated equipments such as
electromyographic (EMG) - and mechanomyographic (MMG) amplitude of the vastus lateralis and rectus femoris muscles during
voluntary maximal concentric isokinetic leg extensions. For this study,
ten female and nine male healthy and active volunteers selected.
The net result of the study they found are that the static and
proprioceptive neuromuscular facilitation stretching reduced Peak
Torque, Mean Power output and electromyography amplitude from
pre-stretching to post-stretching. The active range of motion and
passive range of motion both increased because of the static and
proprioceptive neuromuscular facilitation stretching. The Mechanomyo-graphic amplitude increased in the rectus femoris muscle in
response to the static stretching, but no changes seen after
proprioceptive neuromuscular facilitation stretching and no result
from vastus lataralis muscle. Thus, they concluded that both static
and proprioceptive neuromuscular facilitation stretching caused
similar deficits in strength, power output and muscle activation at
both - slow and fast velocities and suggests that the practitioners
need to consider a risk-to-benefit ratio when incorporating static
stretching or proprioceptive neuromuscular facilitation stretching.
In an overall G. Gremion (2005) compiles and mentioned that in
general it is accepted that increasing the flexibility of a muscle
tendon unit allows a better performance and decreases the number
of injuries when stretching is regularly included in warm-up and in
cooling-down phase in given exercises protocol. However,
contradictory findings reported in the literature. Since 1980, several
authors have suggested that stretching has a beneficial effect on
injury prevention. In contrast, since 1990, clinical evidence suggests
that stretching not only does not prevent injuries, but can also
decrease the level of performance. Some part of these contradictions
was explained by the various sports activities and the elite group of
athletes studied. Sports activities requesting an increased flexibility,
such as gymnastic, dancing, ice skating or diving, necessitate preexercise stretching to optimize the level of performance. In contrary,
for sports with slow stretch-shortening cycle (SSC) such as jogging
or cycling, there is no scientific data showing a positive effect of
stretching on performance, injury prevention and recovery. He further
reviewed the interest of the pre- and post-exercise stretching on the
different modalities such as range of motion improvement, injury
prevention and capacity of recovery.
ELECTROTHERAPY THERAPEUTIC AGENTS
Exercise has been consider the best for rehabilitation without any
side effects, but technically speaking during injuries, there are
several tissue and even cellular level problems appears which can’t
be resolved by only means of massage, exercise, activities or by
taking simply rest. For such cases one has to relay on physical
agents for therapeutics purpose such as temperature (hot and cold),
sounds (ultra sounds), lights (lasers, infra-red lights),
electromagnetic waves (short / medium / long waves diathermies).
Thus in this section we have review on different aspect of
electrotherapy agents for the quadriceps rehabilitation.
42
Diathermy effects on Quadriceps Muscles
Chastain P.B. (1978) found from her study that application of
Short wave diathermy improves the quadriceps strength and can be
maintained upto two hours. Similar studies made by Fábio Chittero
Boldrini et al. (2013) on the effects of shortwave diathermy on the
quadriceps femoris muscle torque during neuromuscular electrical
stimulation and voluntary contraction in healthy individuals. From
their study, they concluded that alone short wave diathermy did not
affect the maximum voluntary contraction, whereas there was rise in
torque noted in case of combined application electrical stimulation
after short wave diathermy in males but further study was not done
on females as they complaining of uneasiness. The above said
statement was justified by Morrison S. A. (2004) in terms of the
fact that heat can decrease the firing rate of the type II afferent fibers
of the muscle spindle and can increases the firing rate of the type 1b
fibers of the Golgi tendon organs. Therefore, that leading to
reduction of firing rate of the alpha and gamma moto-neurons and
hence decreasing the contractile activity.
Lehmann J. F. et al. (1983) stated that Microwave diathermy have
good effect on muscle hematoma resolution though the experimental
success was found in pig. On this progress Italian researchers Maria
Conforti (2013) said that microwave diathermy induced hyperthermia
into the tissues and can stimulate the repair processes, allowing
more efficient relief from pain by helping the removal of toxic
metabolites, reducing the muscles and joints stiffness. Moreover,
hyperthermia induces hyperemia, which improves local tissue
drainage, increases metabolic rate and induces alterations in the cell
membrane. Thus, we can believe that microwave is one of the
solutions for quadriceps hematoma.
Laser therapy on quadriceps
From the University of Caxias do Sul, a research scholar Mônica
de Oliveira Melo (2013) stated that low level laser therapy (LLLT)
improves health status and quadriceps muscle. Ernesto Cesar Pinto
Leal Junior et al. (2008) investigated the direct effects of bilateral,
830 nm, low-level laser therapy (LLLT) on high- intensity exercise
and biochemical indicators of skeletal muscle recovery. They found
that the players, Creatine Kinase levels between before and after the
exercise test was significantly lower for those given active Low
Level Laser Therapy as compared to placebo group. These findings
suggest that low-level laser therapy may be of beneficial in
accelerating post-exercise recoveries.
Similar studies made by Filipe Abdalla dos Reis et al. (2014)
tried to investigate the effect of low-level laser therapy (LLLT) before
and after exercise on quadriceps muscle performance and to
evaluate the changes in serum lactate and creatine kinase (CK)
levels and a result they found that post-fatigue laser treatment
significantly decreased the serum lactate concentration relative to
placebo treatment and also within the group over time gap of 5, 10
and 15 minutes. The CK level was lower in the post-fatigue laser
group thus they concluded that the laser application either before or
after fatigue reduced the post-fatigue concentrations of serum lactate
and CK. The results were more noticeable in the post-fatigue laser
group.
Extracorporeal Shockwave Therapy (ESWT) for quadriceps
injuries.
Kristin Kirkby (2013) noted that extracorporeal shockwave
therapy (ESWT) is an acoustic energy modality and has become an
acceptable treatment modality for musculoskeletal injuries,
osteoarthritis (OA) and wound healing. Kenneth Craig & Andrea
Miller (year not available on unpublished paper) from New-Zealand
studied on extracorporeal shock wave therapy (ESWT) on chronic
Somsankar Mukherjee
unresponsive tendinopaties. After through study they found that the
appropriate energy flux density levels and treatment protocols ESWT
proves to be an effective treatment modality for chronic tendinitis.
ESWT should not used as a primary treatment option for any
condition but may be considered when at least two or three other
conservative treatment options have failed to resolve tendinopathic
issues. David Allen Torrance and Christopher de Graauw (2011)
claimed from their case study that two week of Extracorporeal
Shockwave Therapy cure post-traumatic myositis ossificans of
quadriceps muscles.
Ultra sound therapy for quadriceps injuries
Mikhled F. Maayah (2013) findings of his current study of
intervention program demonstrate that Mikhled knee exercise
program combined with ultrasound therapy reduces pain and
increases functioning in-patient with patella-femoral pain syndrome.
It is a known fact that arthrogenic muscle inhibition diminishes ability
to activate healthy peri-articular muscle tissue. A therapeutic
modality involving mechanical vibrations, such as low-intensity
continuous ultrasound may reduce muscle inhibition if it is able to
stimulate receptors in peri-articular tissue via mechanical stimulation.
To analyses this Norte G. E. et al. (2015) conducted an experiment
on knee injury and quadriceps dysfunction to compare quadriceps
spinal-reflexive excitability after a single treatment of non-thermal
ultrasound or a sham treatment. In this study, thirty recreational
active participants with a self-reported history of a diagnosed knee
injury and quadriceps dysfunction volunteered. The authors
measured a participant’s baseline quadriceps spinal-reflexive
excitability in both legs by measuring the Hoffman’s reflex using
electromyography and electrical stimulation to the femoral nerve. At
the end, the researcher found that participants’ knee extension
strength and quadriceps spinal-reflexive excitability both diminished
in the involved leg compared to the uninvolved leg. The ultrasound
group had 14-19% better quadriceps spinal-reflexive excitability after
20 minutes post ultrasound application compared with the sham
group. There were no differences detected during the baseline tests
or immediately after treatment. To support his study he states that
muscular dysfunction following an injury can lead to numerous
impairments detrimental to joint health. Modifying afferent signals to
the central nervous system could assist in altering quadriceps
dysfunction. For example, non-thermal ultrasound, which may
stimulate receptors in peri-articular tissues, led to less quadriceps
dysfunction after 20 minutes following treatment. This supports the
contribution of peripheral receptors to an arthrogenic response
among patients with persistent quadriceps dysfunction. This noninvasive modality demonstrated a significant effect from a wide
variety of knee injuries (anterior cruciate ligament, medial meniscus,
chondromalacia), which suggests it could work among a diverse
group of patients. It should note that the magnitude of change
between non-thermal ultrasound compared to sham was low. More
research is necessary to establish optimal treatment parameters and
determine clinical outcomes. In the meantime, this research
demonstrates that medical personnel could use non-thermal
ultrasound to stimulate reflex pathways, which could optimize
therapeutic rehabilitation exercise conditions after 20 minutes post
treatment.
Hot-cold-contrast therapy for injured quadriceps
It has been know from ancient old age and time to time observed
by many researchers and suggested that contrast therapy causes a
“pumping effect” due to a cycle of vasoconstriction and vasodilatation,
which help to facilitate the removal of oedema. However, controversy
exists around this theory. Current theory is that constriction of the
African Journal of Science and Research , 2016,(5)4:35-47
vessel walls increases intra-luminal pressure in the blood vessel
causes fluid to move within the valves, preventing back flow of fluid
and subsequent oedema accumulation.
According to historical prospect, the effects of contrast water
Immersion reported in the studies so far, include: Reduced lactate
accumulation in post exercise phase, improved maintenance of
exercise performance and possible effect on cardiovascular function.
Though, at present there is no evidence showing a dosage and the
duration of contrast water immersion and its response.
Superficial heat therapy on quadriceps injure
Superficial heat therapy such as paraffin wax bath, hydrocollateral packs, infra-red lamp has a vital role in rehabilitation. From
several references it has been noted that the effect of superficial
heating increases blood flow to the muscles & cellular metabolic rate
and promotes by inhibiting abnormal ossification and by preventing
adhesion formation and providing analgesics effects, but failed to
find out the specific effect on quadriceps muscles.
Cryo-therapy therapy on quadriceps injure
In the field of sports, cryo-therapy and hydrotherapy has big role
from first aid to rehabilitation, even ice therapy recommended after
cool-down phase of vigorous physical activity, such as in sports
training, post surgical rehabilitation and other related physical
activities.
Joseph M. Hart et al. (2014) studied on the comparison on
quadriceps muscle functional improvement among in-patients with a
reconstructed Anterior cruciate ligament which completed a 2-week
intervention including daily cryotherapy (ice bag), daily exercises and
both. To analyses the outcome they measured quadriceps Hoffmann
reflex, normalized maximal voluntary isometric contraction torque,
central activation ratio using the super-imposed-burst technique, and
patient-reported outcomes before and after the intervention period.
From this study they found that after the two-week intervention
period, patients who performed rehabilitation exercises immediately
after cryotherapy had higher normalized maximal voluntary isometric
contraction torques
compared with those who received
cryotherapy alone or performed exercise alone. Moreover, the key
point they found that by applying ice to the knee joint for 20 minutes
before therapeutic exercises facilitated strength gains in the
quadriceps muscles of patients after anterior cruciate ligament
reconstructions and the patients with persistent muscle weakness
secondary to joint injury may benefit from the strategy of treating
arthrogenic muscle inhibition before performing therapeutic exercises.
Costello J. T. et al. (2011) tried to investigate the effects of
whole-body cryotherapy (WBC) on proprioceptive function, muscle
force recovery following eccentric muscle contractions and tympanic
temperature. They conducted on thirty-six volunteer subjects. They
analyses pre and post test measurement on knee joint position
sense (JPS), maximal voluntary isometric contraction (MVIC) of the
knee extensors, force proprioception and tympanic temperature
recorded before and immediately after the exposure and again after
15 minutes. The net result, drawn the attention that neither joint
position senses, maximal voluntary isometric contraction nor was
force proprioception not affected even after whole body cryotherapy.
They concluded from this study that there is no increased risk of
proprioceptive-related injury following Whole body cryotherapy.
In routine activity it is noted that ice therapy after post exercises
has been practiced but in an interesting investigation done by Blaine
C. Long et al. (2005) tried to find the effect of ice bag treatment of a
large muscle group prior to the exercise. They found that application
of seven minutes of crushed ice bag treatment prevent the raise in
43
temperature for approximately forty minutes. At last they concluded
that exercise before cooling with a crushed-ice bag enhanced the
removal of intramuscular heat.
Vibration therapy on quadriceps femoris
The maximal force output of muscles following pre-performance
stretching has been reported. Even in several studies have
suggested that localized vibration may enhance or replace stretching
benefits for gaining flexibility. It is important to know if localized
vibration also compromise muscle functional output. Thus, Chris
Dickerson et al. (2012) tried to explain the immediate effects of
localized vibration on hamstrings (HAM) and quadriceps (QUAD)
performance on volunteer individual. After the experiment they didn’t
found any significant differences in means between vibration and
sham treatment for any outcomes on either leg for all comparisons of
strength and flexibility.
A similar study done by Somayeh Mohamadi et al. (2014) to
assess the changes in muscle torque, balance, pain perception and
physical function after local quadriceps muscle vibration in women
suffering with osteoarthritis with age between 35 to 73 years. After
15 sessions of intervention within four-week they found that the knee
pain relief, better balance performance and more active knee flexion
ROM were achieved in the vibration group in comparison with the
control group. Thus based on their result they concluded that local
vibration increase the effectiveness of conventional physiotherapy
protocol by reducing pain perception and improving balance control
and active knee flexion ROM in women with knee osteoarthritis.
More studies needed to determine the effectiveness of different
protocols of local vibration training on knee osteoarthritis syndromes.
Gerard Moras et al. (2006) analyze the exposure to whole-body
vibrations (WBV) of different frequencies (30, 35, 40 and 50 Hz) with
none or additional loads (20, 30, 40 and 50 kg) alteration in EMGrms activity of the quadriceps and gastrocnemious muscles. At the
end of the study they found that on average normalized EMG rms
from Vastus Medialis was significantly higher as compared to other
in No Vibration condition. The same behavior observed in Vastus
Laterals muscle except in the 50 Hz with 20 kg condition. In Rectus
Femoris there was no significance change as compared with No
Vibration condition. However, Gastrocnemious presented a different
behavior as only seven out of twenty four combination were
significantly different compared with the no vibration condition. The
highest EMG rms found at 30 Hz for all muscles, except from
Gastrocnemious but with or without vibrations, a significant linear
relationship was found between external load increments and
percentage EMG rms signal increments.
A similar studies carried by P. Wang et al. (2015) compare the
effects of whole-body vibration training (WBVT) with quadriceps
strengthening exercise (QSE) with QSE alone on functioning and
gait parameters in patients with medial compartment knee
osteoarthritis. For this study, thirty-nine patients with medial
compartment knee osteoarthritis assigned at random to one of two
groups. To find the outcome, the scales used are Visual analogue
scale (VAS) for pain, Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC), timed up and go test (TUG), 6minute walk distance test (6MWD) and three-dimensional gait
analysis during level walking at baseline, 12 weeks and 16 weeks
(follow-up). At the end the result they found with a significant
improvements in VAS, all WOMAC scales, TUG, 6MWD and all
spatio-temporal parameters were seen in both the WBVT + QSE
group and the QSE alone group at 12 and 16 weeks. However, the
WBVT + QSE group showed greater improvements than the QSE
44
alone group in WOMAC scales (physical function), TUG, 6MWD and
cadence at 12 weeks. No differences found between the WBVT +
QSE and QSE alone groups in VAS, WOMAC scales (pain, stiffness),
kinematic and kinetic gait parameters and other spatiotemporal
parameters at 12 weeks and 16 weeks. Thus, they concluded that a
combination, WBVT in combination with QSE improved symptoms,
physical function and spatiotemporal parameters in patients with
medial compartment knee osteoarthritis, and led to greater
improvement than QSE alone in WOMAC scales (physical function),
TUG, 6MWD and cadence. But, the still a big question left the
efficacy of Whole or partial vibration.
Massage effect on quadriceps
In general, the massage on soft tissues had special importance,
but at present, there is little scientific evidence that post exercise
manual massage has any effect on the factors associated with the
recovery process. Regarding this a research done by Hinds et al.
(2004) had analyzed the effects of massage against a resting control
condition upon femoral artery blood flow, skin blood flow, skin and
muscle temperature after dynamic quadriceps exercise. At the end of
the study they found a significant effects on all variables over time
due to effects of exercise. Now the massage to the quadriceps did
not significantly elevate Femoral Artery Blood Flow on Muscle
Temperature, Blood Lactate, Heart Rate, and Blood Pressure over
control values, whereas skin blood flow and skin temperature were
elevated after the application of massage compared with the control
trial. Thus, they concluded that without an increase in arterial blood
flow any increase in skin blood flow is potentially diverting flow away
from recovering muscle. Such a response would question the
efficacy of massage as an aid to recovery in post exercise settings.
In-contrast to above research findings, Hou.Y (2012) investigated
the effect of massage on quadriceps femoris repair and the
expressions of Desmin and alpha-Actin to explore the possible
molecular mechanisms of massage in repair of muscle injury. This
study operated on twenty-seven New Zealand white rabbits. He
concluded that the histomorphology and cytoskeletal structure
significantly improved after massage, which may help to repair
muscle injury by up-regulation of Desmin and alpha-Actin
expressions, but this research yet required in injured human.
CONCLUSION
It is not new to observe that incidence of injuries during sports and
physical recreational activities. Though, there may be several
approaches to cure or heal the injuries, but at the same time it is
important to know the exact mechanism and side effects of the
therapy. According to researcher, the therapeutic modalities used in
physiotherapy are safe. The side effects depend on the therapist
efficiency and efficacy of assessment and therapy provided by the
therapist. The rate of cure depend on extend of injuries and health
conditions of the players. An overall finding that therapist is more
focuses on as assisting the physiological aspect of healing. This
paper will help in future to the players, sports therapist and coaches
as approaches of caring and curing the injured quadriceps muscles.
Acknowledgement
Thanks to the Department of Sports Sciences and Ayder referral
Hospital of Mekelle University, Ethiopia for providing facilities such
as library and other accessories.
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