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Quadriceps Tendon Rupture
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(Redirected from Patellar Tendon Rupture)
Contents
Other Names
- Quad Rupture
- Patellar Tendon Rupture
- Extensor Mechanism Rupture
- Knee Extensor Mechanism Rupture
Background
- This page refers to complete or partial ruptures of the Quadriceps Tendon and Patellar Tendon
- Quadriceps strains and tendinopathies are discussed separately
- Patellar Tendonitis is also discussed separately
History
Epidemiology
- Overall scant literature published on the subject due to relative rare injury
- Greater occurrence with increased age (more common after age 40) and multiple medical comorbidities
- More prevalent in males
- Missed diagnosis rate reported to range from 10-50%[1]
- British study [2]
- Incidence of quad tendons and patellar tendon ruptures are 1.37 and 0.6 per 100,000 person years
- In this study, mean age for males was 50.5, females 51.7
- Quad ruptures[3]
- More common in patients older than 40 years
- Associated with degenerative tendon changes
- Quad tendon ruptures occur approximately 6 times more frequently than patellar rupture[4]
- Patellar tendon [5]
- Typically observed in patients younger than 40 years
- Associated with direct traumatic mechanisms or end-stage patellar tendinopathy
Pathophysiology
- Mechanism
- Can be spontaneous
- Minor direct trauma following progressive tendon degeneration
- Violent eccentric contraction of the extensor mechanism.
- Result of a tensile overload on the extensor mechanism and long-standing chronic tendon degeneration
- Quadriceps muscle suddenly contracts with the knee in a flexed position (flexed more than 60 degrees)
- Due to sudden, eccentric contraction of the quadriceps from
- Jump and land mechanism
- Sudden change in direction
- Less commonly, direct trauma
- Typically involving an eccentric load of the quads
- Tendon ruptures rarely occur mid substance, more commonly manifest as
- Avulsion fracture
- disruptions at the musculotendinous junction
- disruptions at the osseotendinous junctions
- Quadriceps Tendon
- Associated with degenerative changes
- Patellar Tendon Rupture
- Involves complete tear of the patellar tendon (connects from the patella's inferior pole to the tibial tubercle)
- Zernicke et al: a force of 17.5 times body weight is required to cause patellar tendon rupture in healthy patients[6]
Pathoanatomy
- Quadriceps Femoris formed by the confluence of 4 muscles into the quadriceps tendon:
- Extensor Mechanism
- Quadriceps tendon inserts into Patella, Patella Tendon in turn attaches to Tibial Tubercle
- Quad Tendon Injury Location
- Patellar Tendon Injury Location
- Most occur at the inferior patellar pole
- Proximal avulsion of the tendon, with or without bone from the inferior pole of the patella
- Midsubstance of the tendon
- Avulsion of the patellar tendon from the tibial tubercle
Risk Factors
- Demographic Risk
- Increasing age
- Obesity
- Orthopedic History of
- Patellar Tendonitis
- Previous ACL Repair
- History of Total Knee Arthroplasty[8]
- Systemic Illnesses
- End Stage Renal Disease[9]
- Diabetes Mellitus
- Rheumatoid Arthritis
- Hyperparathyroidism
- Gout
- Psuedogout (CPPD)
- Connective tissue disorders
- Iatrogenic risk factors
- Medication use such as fluoroquinolones, Statins
- History of Oral Corticosteroid use
- History of IA Corticosteroid Injections
Differential Diagnosis
Differential Diagnosis Thigh Pain
- Fractures
- Muscle and Tendon
- Neurological
- Other
Differential Diagnosis Knee Pain
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
Clinical Features
- History
- Acute injury
- Commonly hear a pop or tearing sensation
- Preceding tendinopathy symptoms is common
- Suprapatellar (quad tendon) or infrapatellar (patellar tendon) pain
- Inability to bear weight
- Exam: Physical Exam Knee
- Tenderness at site of rupture
- Quad: Palpable defect usually within 2 cm of superior pole of patella
- Patellar: Palpable defect between inferior pole and tibial tubercle
- Unable to extend the knee against resistance or gravity
- Patella: low riding (quad tendon), high riding (patellar tendon)
- Joint effusion is often present
- Weak knee extension or extension lag suggests incomplete disruption
- Decreased ROM
- Special Tests
- Straight Leg Raise: unable to perform due to loss of extensor mechanism
Evaluation
- Standard Radiographs Knee
- AP and lateral of knee
- Quad Tendon: Patella pulled inferiorly by the Patellar Tendon, termed patella baja
- Patellar Tendon: Patella is pulled proximally by quad tendon, termed patella alta
- Avulsion injuries present as patellar or tibial tubercle avulsion fractures
- Insall-Salvati Ratio is used to evaluate patellar height on the lateral view

US of the knee in quad tendon, long axis. There is a complete tear of the tendon approximately 4 cm proximal to its insertion with a 2.3 cm defect and hematoma[10]
Ultrasound
- Pathologic Findings
- Complete tear: Hypoechoic area between the two tendon fragments
- Partial tear: hypopoechoic area with some intact tendon fibers
- Assess the degree of tendon gap with knee flexion
- Normal
- Quad tendon is 6–11 mm thick
- Linearly oriented homogeneous echoes extending through the length of the tendon
MRI
- May show
- Differentiates between partial and complete tears
- Obtain if uncertainty regarding diagnosis
- Can evaluate for other intra-articular injuries
Classification
- Partial
- Complete
Management
Prognosis
- Surgical
- Return to sport
Nonoperative
- General
- Partial quadriceps tendon ruptures may be managed non-operatively if extensor mechanism intact
- Partial patellar tendon ruptures may be managed non-operatively if extensor mechanism intact
- Consider in patients who are poor surgical candidates due to comorbidities
- Acute Management
- Rest
- Ice Therapy
- Compression
- Immobilization in Knee Immobilizer
- Quad Tendon
- Immobilized in full extension for 6 weeks
- Patellar Tendon
- Fully immobilized in extension for 2 weeks
- Begin active/ passive flexion/extension at 4 weeks, strengthening at 6 weeks
- Effusion should be aggressively managed to minimize tension on extensor mechanism
Operative
- Indications
- Complete tear
- Partial or incomplete tear with functional deficit
- Poor response to conservative measures
- Technique
- Primary repair of acute rupture
- Primary repair of chronic rupture
Rehab and Return to Play
Rehabilitation
- In Hinged Knee Brace postoperatively
- Historically, knee was immobilized in full extension for 6 weeks postoperatively to allow complete tendon healing before stressing extensor mechanism
- Trend toward early post-operative joint mobilization to reduce joint stiffness and quadriceps atrophy
- Range of motion
- Surgeon dependent but can begin as early as week 1 limiting to 45° active flexion and passive extension only
- On week 2-3 can begin progressive range of motion past 45°, moving only 15° per week
- Strength
- Isometric quadriceps and hamstring exercises begin on post op day 1
- Active knee extension starts at 6 weeks
- Ambulation
- Full weight bearing in locked brace, with crutches at 6 weeks
- Brace and crutches discontinued when adequate quadriceps strength is achieved, usually around 12 weeks[15]
Return to Play
- Needs to be updated
Complications
- Pain and stiffness
- Extensor mechanism weakness
- Functional impairment
- Strength deficit
- Re-rupture
- Extensor lag, inability to fully extend knee
- Loss of full knee flexion
- Quadriceps Atrophy
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Rauh M, Parker R. Patellar and quadriceps tendinopathies and ruptures. In: DeLee JC, ed. DeLee and Drez’s Orthopaedic Sports Medicine. Philadelphia, PA: Saunders; 2009:1513–1577
- ↑ Clayton RAE, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury. 2008;39:1338–44.
- ↑ Ramsey RH, Muller GE. Quadriceps tendon rupture: a diagnostic trap. Clin Orthop Relat Res 1970; 70: 161-164
- ↑ Saragaglia, D., A. Pison, and B. Rubens-Duval. "Acute and old ruptures of the extensor apparatus of the knee in adults (excluding knee replacement)." Orthopaedics & Traumatology: Surgery & Research 99.1 (2013): S67-S76.
- ↑ Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am 1991; 73 (10) 1507-1525
- ↑ Zernicke RF, Garhammer J, Jobe FW. Human patellar-tendon rupture. J Bone Joint Surg Am 1977;59(2):179–183
- ↑ Yepes H, Tang M, Morris SF, Stanish WD. Relationship between hypovascular zones and patterns of rupture of the quadriceps tendon. J Bone Joint Surg Am. 90:2135–41
- ↑ Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism complications following total knee arthroplasty. J Arthroplasty 1987; 2 (2) 135-140
- ↑ Loehr J, Welsh RP. Spontaneous rupture of the quadriceps tendon and patellar ligament during treatment for chronic renal failure. Can Med Assoc J 1983; 129 (3) 254-256
- ↑ Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 48031
- ↑ Boudissa, M., et al. "Acute quadriceps tendon ruptures: a series of 50 knees with an average follow-up of more than 6 years." Orthopaedics & Traumatology: Surgery & Research 100.2 (2014): 217-220.
- ↑ Lee, Dennis, Daniel Stinner, and Hassan Mir. "Quadriceps and patellar tendon ruptures." The journal of knee surgery 26.05 (2013): 301-308.
- ↑ Nguyen, Michael V., et al. "A comprehensive return-to-play analysis of national basketball association players with operative patellar tendon tears." Orthopaedic journal of sports medicine 6.10 (2018): 2325967118800479.
- ↑ Boublik M, Schlegel T, Koonce R, Genuario J, Lind C, Hamming D. Patellar Tendon Ruptures in National Football League Players. The American Journal of Sports Medicine. 2011;39(11):2436-2440.
- ↑ Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg 2003;11(3):192–200
Created by:
John Kiel on 7 July 2019 06:18:01
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Last edited:
4 October 2022 15:48:59
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