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Quadriceps Tendon Rupture

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(Redirected from Patellar tendon rupture)

Other Names

  • Quad Rupture
  • Patellar Tendon Rupture
  • Extensor Mechanism Rupture
  • Knee Extensor Mechanism Rupture

Background

History

  • Needs to be updated

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

Introduction

Basic illustration of the extensor mechanism of the knee[6]
Lateral X-ray of a patient with quadriceps tendon avulsion from the proximal pole of the patella. Arrows indicate the boney fragment.[7]

General

  • Injury to the extensor mechanism resulting in inability to the extend the knee
  • Diagnosis is primarily based on clinical exam, confirmed with imaging
  • Treatment is universally surgical in complete ruptures

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[8]

Anatomy of the Quadriceps Tendon

Quad Tendon Injury Location

  • Relatively hypovascular zone exists about 1–2 cm superior to the patella, making it more susceptible to injury[9]
  • In younger folks, the most common sites of tear are between 1 cm and 2 cm of the superior pole of the Patella
  • In older folks, more distally at the osseotendinous junction

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

Differential Diagnosis

Differential Diagnosis Thigh Pain

Differential Diagnosis Knee Pain

Clinical Features

a Physical examination reveals a defect in the patellar tendon. b The patella on the rupture side may rest more proximally than normal side[12]

History

  • Acute injury which a mechanism that the patient can usually describe
  • 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

Evaluation

Patella alta and inferior patella pole avulsion fracture suspicious for patellar tendon rupture
Lateral knee radiograph showing significant radiographic patellar baja suggestive of quad rupture. No significant bony injury[13]

Radiographs

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[14]

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

Knee Immobilizer

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
  • 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

Prognosis and Complications

Prognosis

  • Surgical
    • Boudissa et al found good functional outcomes in 50 patients followed for 6 years for pain, function, range of motion [16]
    • Most studies report good or excellent results ranging from 80 to 92% following surgical repair[17]
  • Return to sport
    • Nguyen et al found NBA players returned to sport at a similar competition level[18]
    • Boublik et al also found NFL players were able to return to a high level of competition[19]

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

References

  1. ↑ 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
  2. ↑ Clayton RAE, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury. 2008;39:1338–44.
  3. ↑ Ramsey RH, Muller GE. Quadriceps tendon rupture: a diagnostic trap. Clin Orthop Relat Res 1970; 70: 161-164
  4. ↑ 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.
  5. ↑ 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
  6. ↑ Image courtesy of drerikhohmann.com, "Knee Extensor Mechanism"
  7. ↑ Tandogan, Reha N., et al. "Extensor mechanism ruptures." EFORT open reviews 7.6 (2022): 384-395.
  8. ↑ Zernicke RF, Garhammer J, Jobe FW. Human patellar-tendon rupture. J Bone Joint Surg Am 1977;59(2):179–183
  9. ↑ 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
  10. ↑ Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism complications following total knee arthroplasty. J Arthroplasty 1987; 2 (2) 135-140
  11. ↑ 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
  12. ↑ Chen, Shen-Kai, et al. "Patellar tendon ruptures in weight lifters after local steroid injections." Archives of Orthopaedic and Trauma Surgery 129 (2009): 369-372.
  13. ↑ Hartline, Braden E., et al. "Synthetic mesh reconstruction of chronic, native quadriceps tendon disruptions following failed primary repair." Case Reports in Orthopedics 2021.1 (2021): 5525319.
  14. ↑ Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 48031
  15. ↑ Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg 2003;11(3):192–200
  16. ↑ 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.
  17. ↑ Lee, Dennis, Daniel Stinner, and Hassan Mir. "Quadriceps and patellar tendon ruptures." The journal of knee surgery 26.05 (2013): 301-308.
  18. ↑ 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.
  19. ↑ 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.
Created by:
John Kiel on 7 July 2019 06:18:01
Last edited:
7 March 2026 00:24:54
Categories:
Tendinopathies | Knee | Lower Extremity | Trauma | Thigh | Acute
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