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Quadriceps Contusion
From WikiSM
Contents
Other Names
- Quadriceps bruise
- Quad bruise
- Quadriceps muscle contusion
- Thigh contusion
- Thigh Hematoma
- Soft tissue hematoma of thigh
- Thigh intramuscular hematoma
Background
- This page refers to quadriceps contusion
- Quadriceps Tendinopathies are discussed separately
History
Epidemiology
- Likely the second most common quadriceps injury after strain[1]
- Thigh contusions reportedly account for 10% of all injuries sustained from illegal contact among professional association football players.[2]
- Thigh contusions are estimated to represent about 12% of thigh muscle injuries[3]
Pathophysiology

Midthigh short axis illustration of anterior compartment illustration[4]
- General
- Occur as the result of a direct blunt force trauma to the muscle
- Most commonly occurs at the Rectus Femoris muscle belly[5]
- Diagnosis is primarily clinical
- Injury pattern
- Causes rupture of muscle fibers at or adjacent to point of contact
- Subsequently, there is swelling, a hematoma may form causing pain, restriction in motion
- Etiology
- Usually a direct blow from opponents knee, foot or head[6]
- Can also occur due to blow from a piece of equipment (racquet, ball, puck, etc)
Risk Factors
- Sports
- Football
- Soccer
- Karate
- Judo
- Rugby
- MMA
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
- History of direct trauma to quadriceps
- Will describe localized pain at the site of injury
- Athlete will complain of swelling, decreased range of motion
- Physical Exam: * Physical Exam Knee
- Ecchymosis, swelling may be observed
- Tenderness to palpation
- Range of motion is restricted
- Palpable hematoma is sometimes felt
- Special Tests
- Straight Leg Raise: Important to confirm extension mechanism is intact
Evaluation

Long axis thigh ultrasound showing a well defined hematoma[7]
Radiographs
- Standard Radiographs Knee, consider Standard Radiographs Femur
- Typically normal
- Findings
- May show soft tissue swelling
- Heterotopic Ossification (late finding)
Ultrasound
- Can be used to
- Evaluate hematoma
- Exclude other injuries
- Hematoma
- Can quantify size
- Coagulated blood vs liquified blood

Axial cuts of thigh MRI showing large mass on T1 (A) and T2 (B)[4]
MRI
- Can be used to
- Evaluate hematoma, extend of injury
- Exclude other injuries
- Preoperative planning
- Hematoma
- More sensitive than CT in showing active hemorrhage[8]
Classification
Jackson and Feagin Classification for Contusions
- Mild[9]
- ROM: >90°
- Gait: Normal
- Moderate
- ROM<: 45–90°
- Gait: Antalgic
- Severe
- ROM: <45°
- Gait: Severely antalgic
Management
Nonoperative
- Indications
- Virtually all cases
- Immobilization for first 24 hours post injury
- Aronen et al: keep knee flexed to 120°[10]
- Use elastic wrap or Ace Wrap to help maintain flexion
- Can also be placed in Hinged Knee Brace at 120°
- After 24 hours
- Maintain compression
- Begin gentle, passive, pain free range of motion
- Ice Therapy
- Particularly useful in first few days
- NSAIDS
- Consider delaying for 24-48 hours to avoid interference with coagulation
- Useful early for pain
- Long term effects on muscle healing are not well understood
- Consider for at least 7 days to reduce risk of heterotopic bone formation[11]
- Physical Therapy
- Initiate early, emphasis on range of motion, passive and active stretching
- Hematoma Aspiration
- Performed under ultrasound guidance
- Protective Thigh Padding
- Can be used for prevention
- Recommended prior to return to sport
- Additional considerations
- Delay in recovery or failure to improve should raise alarms
- Consider slowly expanding or non-resolving hematoma
- Not recommended
Operative
- Indications
- Hematoma refractory to percutaneous drainage
Rehab and Return to Play
Rehabilitation
- Early/ Passive
- Emphasis on passive and active range of motion
- Stretching
- Isometric quad strengthening
- Active
- Can begin when the athlete is pain free, actively flex knee to at least 120°
- Functional rehabilitation
Return to Play/ Work
- Athlete should be
- Pain free
- Have 120° knee flexion with hip in extension
- Strength at least 90% of contralateral limb
- Perform all aspects of functional testing without limitatiom
Complications and Prognosis
Prognosis
- Severity classification suggests longer disability time with increasing severity
- Ryan et al: 13 days (mild), 19 days (moderate), 21 days (severe)[12]
- Thigh hematoma
- Time to return to play following conservative management is 29.3 days[4]
- If compartment syndrome develops
- Increased likelihood athlete doesnt return to previous performance, even with fasciotomy and compartment release[13]
Complications
- Hematoma
- Myositis Ossificans
- Proliferation of bone and cartilage in a muscle previously exposed to trauma and haematoma
- Acute Compartment Syndrome
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Holbrook TL, Grazier K, Kelsey JL, Stauffer RN (eds): The Frequency of Occurrence, Impact, and Cost of Selected Musculoskeletal Conditions in the United States. Chicago: American Academy of Orthopaedic Surgeons, 1984.
- ↑ Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011;45:553–8.
- ↑ Ueblacker P, Müller-Wohlfahrt HW, Ekstrand J. Epidemiological and clinical outcome comparison of indirect (‘strain’) versus direct (‘contusion’) anterior and posterior thigh muscle injuries in male elite football players: UEFA Elite League study of 2287 thigh injuries (2001–2013). Br J Sports Med 2015;49:1461–5.
- ↑ 4.0 4.1 4.2 Haws, Brittany E., et al. "Definitive management of thigh contusions in athletes: but how definitive? A systematic review." Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine 2.2 (2017): 67-74.
- ↑ Ryan, Jack B., et al. "Quadriceps contusions: West point update." The American Journal of Sports Medicine 19.3 (1991): 299-304.
- ↑ Rothwell AG. Quadriceps hematoma. A prospective clinical study. Clin Orthop Relat Res 1982;171:97–103.
- ↑ https://radiopaedia.org/cases/24042
- ↑ Swensen SJ, Keller PL, Berquist TH, et al. Magnetic resonance imaging of hemorrhage. AJR Am J Roentgenol 1985;145:921–7.
- ↑ Jackson DW, Feagin JA. Quadriceps contusions in young athletes. J Bone Joint Surg. 1973;55A:95–105.
- ↑ Aronen, John G., et al. "Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee flexion." Clinical Journal of Sport Medicine 16.5 (2006): 383-387.
- ↑ Fijn R, Koorevaar RT, Brouwers RBJ. Prevention of heterotopic ossification after total hip replacement with NSAIDs. Pharm World Sci. 2003;25:138–145.
- ↑ Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusion: West Point update. Am J Sports Med. 1991;19:299–304
- ↑ 13.0 13.1 Mithöfer K, Lhowe DW, Altman GT. Delayed presentation of acute compartment syndrome after contusion of the thigh. J Orthop Trauma 2002;16:436–8.
- ↑ Ojike NI, Roberts CS, Giannoudis PV. Compartment syndrome of the thigh: a systematic review. Injury 2010;41:133–6.
Created by:
John Kiel on 9 August 2021 15:29:58
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Last edited:
4 October 2022 15:45:53
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