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Quadriceps Strains and Contusions
Normal Anatomy
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Quadriceps comprised of 4 muscles
o Rectus femoris
o Vastus lateralis
o Vastus medialis
o Vastus intermedius
All 4 muscles have a common insertion into superior aspect of patella via quadriceps tendon
and into tibial tuberosity via patella tendon
Rectus femoris divides into two heads, with origins on AIIS and superior acetabulum. It is the
only quadriceps muscle that passes over the hip and the knee. Its action is hip flexion and
knee extension
Vastus muscle origins are on femur and therefore perform knee extension only
Mechanism of Injury
Strains
 Commonly occurs in sport e.g. rugby, tennis, football
o Sudden high force with eccentric contraction of hip flexion/knee extension e.g.
deceleration
o Excessive passive stretching
o Activation of maximally stretched muscle e.g. kicking
 Muscle fatigue may play a role
 Rupture most often at musculotendinous junction
 Rectus femoris most commonly strained
Contusions
 Direct blow to quadriceps causing significant muscle damage
 Rupture of muscle fibres directly in or adjacent to area of impact
 Haematoma formation within muscle
 Contracted muscle absorbs force better and commonly results in less severe injury
Classification
Strains
Widely accepted model for classification of strains:
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Grade 1 – up to 5% fibre disruption, mild pain, minimal loss of strength and no palpable
muscle defect
Grade 2 – up to 50% fibre disruption, with or without fascial injury, moderate pain,
moderate loss of strength and may be small palpable muscle defect or muscle retraction
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Grade 3 – up to 100% fibre disruption, fascial injury, severe pain, usually complete loss of
strength, often a palpable muscle defect and muscle retraction
However:
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Due to the extent of inconsistency and insufficiency of the existing classification system,
several other classification models have been proposed, including 4 or 5 classification grades
with sub-categories.
e.g. British Athletics muscle injury classification, Pollock et al. (2014) and Mueller-Wohlfahrt
et al (2012)
Contusions
 Mild – mild pain, greater than 90 degrees active knee flexion, normal gait
 Moderate – moderate pain, 45-90 degrees active knee flexion, antalgic gait
 Severe – severe pain, less than 45 degrees active knee flexion, severely antalgic gait
Associated Pathologies
Myositis Ossificans
 Occurs as complication in approximately 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
Examination
Subjective
Strains
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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
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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
Myositis Ossificans
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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 resisted knee extension hip flexed (sitting) and extended (prone) to help differentiate
between rectus femoris and vastus muscles
 Pain and loss of ROM on passive testing of quadriceps. Test knee flexion and hip extension
(rectus femoris)
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 resisted knee extension with hip flexed (sitting) and extended (prone)
 Pain and loss of ROM on passive testing of quadriceps. Test knee flexion and hip extension –
loss of ROM will help classification and provide prognostic indicator
Myositis Ossificans
 Similar to strain/contusion
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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 Investigations
X-ray
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MRI
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May be helpful in differentiating between bony (femoral stress fracture, tumor, or myositis
ossificans) and muscular etiologies of quadriceps pain in chronic cases
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
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Ultrasound imaging
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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 4ocalized bleeding/haematoma formation form a contusion and provide realtime imaging for needle aspiration can be used to image muscles dynamically
highly operator dependent, requires experienced, skilled clinician
Management
Goal of therapy is to:
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protect site of injury
promote healing
reduce pain and oedema
restore ROM
restore strength
prepare for return to sport
Conservative
Strains
 Reduce pain and Inflammation
o Protection
o Rest
o Ice
o Compression
o Elevation
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o NAID’s
o Soft Tissue Massage
Restore Normal Range of Movement
o Active mobilisation within a pain free range
o Passive joint mobilisations
o Soft tissue techniques
o Early aggressive manual therapy may prolong recovery (Stainsby et al, 2012)
Restore Normal Muscle Motor Control
o Isometric Exercises
o Strengthening pain free ranges and muscles
o Progress to Isotonic exercises
Restore Normal Dynamic Stability
o Exercises that challenge the entire lower limb kinetic chain
Return to Sport/Activity Specific
Contusions
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Management is essentially the same as for strains, except:
o 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
o Not until ectopic bone formation has matured (12-24 months post injury)
 Extracorporeal shock wave therapy may be beneficial in reducing symptoms and facilitating
a return to full function (Torrance et al., 2011)
Surgical
Surgical intervention is indicated for:
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Compartment syndrome (decompressive fasciotomy)
Hematoma removal
Complete quadriceps muscle rupture
Chronic partial tears non-responsive to conservative treatment
Bony avulsion of muscle insertion at the patellar tendon
Ectopic bone formation in myositis ossificans
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References
(Kary, 2010; Mueller-Wohlfahrt et al., 2013; Pasta et al., 2010; Pollock et al., 2014; Stainsby et al.,
2012; Torrance & deGraauw, 2011)
Kary JM. Diagnosis and management of quadriceps strains and contusions. Curr Rev Musculoskelet
Med 2010; 3(1-4): 26-31.
Mueller-Wohlfahrt HW, Haensel L, Mithoefer K, et al. Terminology and classification of muscle
injuries in sport: the Munich consensus statement. Br J Sports Med 2013; 47(6): 342-50.
Pasta G, Nanni G, Molini L, Bianchi S. Sonography of the quadriceps muscle: Examination technique,
normal anatomy, and traumatic lesions. Journal of Ultrasound 2010; 13(2): 76-84.
Pollock N, James SLJ, Lee JC, Chakraverty R. British athletics muscle injury classification: a new
grading system. Br J Sports Med 2014; 48(18): 1347-51.
Stainsby BE, Piper SL, Gringmuth R. Management approaches to acute muscular strain and
hematoma in National level soccer players: a report of two cases. J Can Chiropr Assoc 2012;
56(4): 262-8.
Torrance DA, deGraauw C. Treatment of post-traumatic myositis ossificans of the anterior thigh with
extracorporeal shock wave therapy. J Can Chiropr Assoc 2011; 55(4): 240-6.
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