A quadriceps tendon rupture occurs relatively infrequently and usually occurs in athletes older than 40 years. Injuries to the quadriceps tendon can be very disabling. They can cause significant loss of time from sport and work. If not treated appropriately, these injuries can have many negative long-term sequelae, however if diagnosed quickly and treated appropriately, one can expect a full recovery from a quadriceps tendon rupture.
The quadriceps tendon is the strong tendon that inserts on the top of the patella (knee cap). The quadriceps tendon is a confluence (coming together) of the four muscles that make up the muscles that extend the knee. These four muscles are: vasts medialis, vasts intermedius, vasts lateralis, and rectus femoris. These muscles are the strong muscle on the anterior (front) side of the femur (thigh bone). Their main action is to extend the knee and leg. All four of these muscles come together just above the patella and form a strong, thick tendon. The quadriceps tendon is important because it allows the knee to be extended. If the quadriceps tendon is injured, the patient will not be able to extend their knee.
The quadriceps tendon is injured most commonly from a forced eccentric contraction (contracting while lengthening) against an outside force. This can happen during high-energy accidents such as motor vehicle crashes and during sporting activities, or during low energy injuries such as falls from a standing position.
There are very few risk factors for this injury. Most quadriceps tendon ruptures are the result of either direct or indirect trauma. There are some medical problems that can increase a person’s chance of having a quadriceps tendon rupture including renal (kidney) disease, rheumatoid arthritis, chronic steroid use, and diabetes mellitus, However, even in patients with these disorders, the incidence of quadriceps tendon ruptures is still very low.
Most people with a quadriceps tendon rupture will note the acute onset of pain and disability in the affected leg. Usually this is precipitated by a fall or other traumatic event. The pain will be located at the level of the knee or just above the knee joint. The patient with a complete rupture is unable to do a straight leg raise, or extend their knee. These patients will have a difficult time walking on the affected leg. On physical examination the patient will be acutely tender to palpation directly above the patella. There is often times a palpable defect in this area when compared to the contralateral side (uninjured knee). The knee will commonly have a large effusion (swelling in the knee). The patient will be unable to extend their knee. Some patients with a partial tear may still be able to extend their knee, but will have significant weakness when compared to the other leg.
Initially a patient who presents with pain and swelling in the knee should undergo plain radiographs (x-rays) of the affected knee. This will help to rule out a fracture as the cause of the problem. If these are negative, then an MRI scan can be obtained to evaluate the integrity of the quadriceps tendon. The x-rays of a patient with a quadriceps tendon rupture may show patellar baja (a knee cap that is lower than normal). There may also be a small piece of bone that is torn off of the patella with the tendon that can be visualized on x-ray. The gold standard for diagnosis would be an MRI scan of the knee, which would evaluate all of the soft tissue structures in the knee including all of the cartilage and ligaments. This would also help to distinguish between a complete and partial tear.
There are many injuries to consider when a patient may have a quadriceps tendon rupture. These include: patellar (knee cap) fracture, patellar tendon rupture, fracture of the end of the femur (thigh bone) or top of the tibia (shin bone), ACL tear, and patellar dislocation. The diagnosis is confirmed by doing an appropriate physical examination and also through imaging studies.
Quadriceps tendon ruptures come in two main types: partial and complete tears. Distinguishing between the two is very important, as the treatment is vastly different.
Partial tears can sometimes be treated non-operatively. In order for a partial tear to be treated without surgery, the patient must be able to do a straight-leg raise and have good strength with this physical exam finding. If this is the case, treatment should commence immediately with immobilization of the leg in full extension (out straight) for a short period of time. Then, range of motion exercises are started between 3-6 weeks after the injury. After six weeks, quadriceps strengthening has begun. Typically, after 10-12 weeks, the injury has healed. The patient may resume normal activities after they have full range of motion and quadriceps strength. This can be anywhere from 3-6 months after the injury. Return to sport is governed by the ability to pass functional tests specific to the sport (example: jumping for a basketball player).
Complete tears, as well as partial tears when the patient is unable to perform a straight-leg raise, are always treated with surgery. Without surgery, the patient will be unable to extend their knee and have significant long-term disability. Surgery is typically recommended within a few days to a week after the injury. If the patient’s other medical problems prohibit the opportunity to perform the surgery safely in the first week, it can be delayed until the patient is medically fit for surgery.
Typically, surgery involves making an incision on the front of the knee. Then, strong sutures are placed into the tendon and tied back down to the top of the patella. Surgery generally takes between one and two hours. The patient is then placed into a knee immobilizer keeping the knee straight after surgery.
After surgery, the patient will start with gentle passive range of motion with their physical therapist. The patient will be able to weight bear with all of their weight on their leg after a week or two, but will have to wear the brace they received after surgery locked straight for the first six weeks, except when doing their therapy. By six weeks post-op, the patient should have 90 degrees of flexion (bending) of the knee. After six weeks, progressive strengthening is started as well as increasing range of motion. Typically, the brace is discontinued at eight weeks from surgery. Light running is generally started at four months from surgery. Return to sport is governed by the ability to perform sport specific exercises and having adequate range of motion and strength. This is generally between 6-8 months from the day of surgery. It should be noted that rehabilitation protocols are often very specific to the type of injury and the type of repair that was achieved at the time of surgery. The above protocol is just an outline of “typical” rehabilitation.
When quadriceps tendon ruptures are not identified early, they can be more difficult to fix with surgical repair. The quadriceps muscle is very powerful, therefore the tendon retracts proximally (up the thigh) and becomes harder to fix back to the patella with surgery. Surgical repair is still possible but may require special techniques to do so and an extended rehabilitation protocol.
Most people who undergo treatment of a quadriceps tendon rupture will do well long-term. They will be able to return to work and sport after the appropriate rehabilitation. It is important to be very diligent with the appropriate prescribed physical therapy to ensure a good outcome. Re-tear of the tendon after surgical repair is rare unless something unexpected happens (ex: a fall during the early post-operative phase). The most common complication is loss of motion in the knee after surgical repair. If you suspect that you have a quadriceps tendon rupture, it is critical to seek the urgent consultation of a local sports injuries doctor for appropriate care.
Dr. Brian Ludwig, the author of this article, is one of our fellowship-trained sports medicine specialists at OrthoGeorgia. He is board-certified by the American Board of Orthopaedic Surgery with a subspecialty certificate in Orthopaedic Sports Medicine. He proudly covers sporting events and provides athletic screenings for high school and college athletes in Central Georgia while serving as the team physician for Mercer University’s baseball and softball program and the head team physician for Middle Georgia State University and Fort Valley State University. He has a strong interest in athletic injuries, ACL reconstruction, arthroscopy of the shoulder and knee, fracture care, and total knee and shoulder joint reconstruction. Dr. Ludwig sees patients at our offices in Warner Robins and Kathleen
Quadriceps tendon rupture is one of many orthopaedic injuries that can limit both athletes and non-athletes alike. If you think you may have a quadriceps tendon rupture or another orthopaedic injury, our orthopaedic specialists at OrthoGeorgia will work to help you get back to living your most active life. We proudly provide a wide range of orthopaedic care services, from diagnosis to surgery, to those of all ages in Central Georgia. Whether you are seeking spine, hand, sports medicine, foot & ankle, or total joint care, our team will provide care that is personalized to you and make sure all of your questions are answered every step of the way. To schedule an appointment or to learn more about the care we provide in Macon, Macon Spine and Orthopaedic Center, Warner Robins, Kathleen, Milledgeville, and Dublin, please contact OrthoGeorgia today!
Ilan D, Tejwani N, Keschner M and Liebman, M. Quadriceps Tendon Rupture. Journal of the American Academy of Orthopaedic Surgeons. 2003; 11:192-200
Rauh, M and Parker, R. Patellar and Quadriceps Tendinopathies and Ruptures. DeLee and Drez Orthopaedic Sports Medicine: Principles and Practice. 2010. Chapter 22 1513-1525
At OrthoGeorgia, we want to help you live a healthier and more comfortable life by giving those in Macon, Warner Robins, Kathleen, Milledgeville, Dublin, and the surrounding areas convenient access to the highest quality care. Whether you have been suffering from a sports injury or a common orthopaedic condition, we will determine the cause of your discomfort and craft a personalized treatment plan to bring you relief. To learn more about our services and our physicians, or to schedule an appointment at OrthoGeorgia, please contact us today.