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Quadriceps Tendonitis

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Other Names

  • Quad Strain
  • Quad Tendinopathy
  • Quadriceps Tendinosis
  • Quadriceps Tendinopathy
  • Jumper's knee

Background

  • This page refers to acute strains and chronic tendinopathies of the Quadriceps tendon

Definition

  • Jumper's knee may refer to
    • Quadriceps Tendinopathy
    • Patellar Tendinopathy, which is reviewed seperately
    • Affects proximal Patellar Tendon (65%), Quadriceps Tendon (25%) and patelar insertion on tibial tuberosity (10%)[1]
    • Note: There is a lot of overlap in the literature on these subjects, and although distinct entities, not always referred to separately

History

Epidemiology

  • Overall prevalence estimated to be seen in about 14.2% of athletes
  • Zwerver et al cross sectional survey[2]
    • Overall prevalence 8.5%
    • Highest prevalence volleyball (14.4%), handball (13.3%), basketball (11.8%), track and field (6.9%), field hockey (5.1%), korfball (4.8%), and soccer (2.5%)
    • Males (10.2%) more common than females (6.4%)

Pathophysiology

  • See: Tendinopathies (Main)
  • Clinical diagnosis of anterior knee pain, most commonly at the proximal pole of the patella
    • Typically worse with activities that activate the quadriceps
  • Quadriceps tendonitis
    • Due to chronic, eccentric overload of knee extensor mechanism
  • Quadriceps strain
    • Acute injury, occurs due to forceful eccentric contraction of the muscle with knee flexed, hip extended
    • Can occur due to overstretching as well
    • Typically occurs at the musculotendinous junction[3]
    • Rectus Femoris most commonly implicated because it is bi-arthrodial

Etiology

  • Most commonly seen in athletes due to chronic degenerative tendon changes from repetitive loading, stress, and extension of the knee
  • Occur with chronic overuse and overloading due to jumping and running activities
  • May be associated with increase or change in athletic activities or intensity

Associated Conditions

Pathoanatomy


Risk Factors

  • General
    • Male > female (need citation)
  • Sports
    • Volleyball (most common)
    • Basketball
    • Handball
    • Track and field, especially high jump and long jump
    • Field hockey
    • Korball
    • Soccer
  • Individual
    • Increased weight
    • Increased height
    • younger age
  • Training
    • Increased frequency of weight training
    • Increased frequency of jump training

Differential Diagnosis

Differential Diagnosis Knee Pain

Differential Diagnosis Thigh Pain


Clinical Features

  • History
    • Onset is often insidious and progressive
    • May be acute onset
    • Patient will endorse anterior thigh or knee pain
  • Physical Exam: Physical Exam Knee
    • Tenderness on distal quadriceps muscle or proximal patellar pole
    • Edema may or may not be present
    • Strains can have contusions
    • Pain and sometimes weakness with resisted knee extension
    • Grade II strains may have a small palpable defect
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Knee
    • Routine screening tool to evaluate for other pathology
    • Typically normal
  • May demonstrate
    • Enthesopathy or osteophyte formation at proximal patellar pole
    • Calcification of quadriceps tendon
  • Patella Baja
    • Can occur in complete tear
    • Inferior migration of patella due to intact patella tendon

MRI

  • Between 75-90% of asymptomatic basketball players had MRI findings of quadriceps tendinopathy[4]

Ultrasound

  • May demonstrate[5]
    • Hypoechoic or hyperechoic changes
    • Neovascularization
    • Increased baseline tendon thickness
    • Loss of fiber visibility
    • Increased power doppler signals
    • Hematoma (sprains, partial tears)
  • Findings can be seen in asymptomatic patients[6]
    • Asymptomatic patients have a 3.3 OR of developing symptoms
  • Diagnostic accuracy for patallar tendinopathy (diagnsotic accuracy/ sensitivity/ specificity)[7]
    • Grey-scale US (60%/ 72.5%/ 43.3%)
    • Power Doppler (50%/ 12.5%/ 100%)
    • US elastography (62%/ 70%/ 53.3%)
    • Grey-scale + elastrography had a sensitivity of 82.5%, diagnostic accuracy of 61.4%
    • Grey-scale + doppler had a sensitivity of 72.5%, diagnostic accuracy of 60.0%
  • Compared to MRI, US has a higher[8]
    • Diagnostic Accuracy (83% vs. 70%; P=0.04)
    • Sensitivity (87% vs. 57% P=0.01)

Classification

Modified Blazina Classification for Tendinopathy

  • Stage 0: no pain
  • Stage 1: pain only after intense sports activity with no functional impairment
  • Stage 2: moderate pain during sports activity with no restriction on sports performance
  • Stage 3: pain with slight restriction on performance
  • Stage 4: pain with severe restriction of sports performance
  • Stage 5: pain during daily activity and unable to participate in sport at any level

Muscle Strain Classification

  • Grade I
    • Injury: minor tearing
    • Symptoms: mild-moderate pain, full strength, no defect
  • Grade II
    • Injury: more severe tearing
    • Symptoms: significant pain, decreased strength, possible defect
  • Grade III

Management

Nonoperative

  • Indications
    • Virtually all cases
  • Relative rest
    • Includes activity modification
  • Physical Therapy
    • Emphasis on eccentric exercises, quadriceps stretching
  • Iontophoresis
  • Phonophoresis
  • Therapeutic Ultrasound
  • Ice Therapy
  • Platelet Rich Plasma
    • Superior to dry needling at 12 weeks with no difference at 26 weeks[9]
    • In Blazina grade III, PRP was superior to physical therapy for sport activity, pain at 6 months[10]
  • Sclerosing Polidoconol
    • Hoksrud et al Compared to lido/epi controls, patients with patellar tendinopathy had significant improvements in knee function, pain reduction after Polidocanol at 4 months[11]
    • No difference was noted at 12 months

Operative

  • Indications
    • Failure of conservative management for minimum of 3 months
    • Calcific tendinopathy more likely to require surgical intervention
  • Technique
    • No consensus on best technique
    • Arthroscopic vs open shaving
  • Willberg et al compared scleroising pilodocanol to arthroscopic shaving in patients with patellar tendinopathy[12]
    • Compared to the polidocanol injection group, the arthroscopic treatment group had significant improvements in pain at rest, pain with activity, as well as increased patient satisfaction
  • Ferretti et al followed 32 surgical cases of refractory patellar tendinopathy with a minimum of 5 years of follow up[13]
    • Technique: longitudinal splitting of the tendon, excision of abnormal tissue, and resection and drilling of the inferior pole of the patella.
    • Final follow up: good or excellent results 28 (85%) knees, excellent in 23 (71%), good in 5 (16%), fair in 1 (3%), and poor in 4 (13%),
    • 80% of the unsatisfactory results were in volleyball players.
    • Eighteen patients (82%) were able to return to sports at a mean of approximately 6 months postop, of those, 11 (63%) were asymptomatic.

Rehab and Return to Play

Rehabilitation

  • Quadriceps strain
    • Rest for 3-5 days
    • Physical therapy with stretching, range of motion and progression to strengthening

Return to Play

  • Guided by patient tolerance/ pain
  • Quadriceps strain, athlete should be
    • Pain free
    • Full range of motion of hip, knee
    • Nearly full strength (compared to contralateral limb)

Complications and Prognosis

Prognosis

  • Nonoperative treatment is generally successful at providing symptomatic relief
  • Kettunen et al followed 20 athletes with quadriceps tendinopathy for 15 years found[14]
    • Higher mean visual analog scale scores for knee pain with squatting
    • Increased functional limitations measured by Kujala score
    • Increased early retirement of their sports careers because of their knee problems 9 (53%) vs. 1 (7%)
  • Ferretti et al evaluated 172 athletes with patellar tendinopathy[13]
    • All patients had good outcomes in early stages of the disease
    • In some cases, a prolonged period of rest, reduction of sporting activity was required
    • 16 Patients with Blazina stage 3 or 4 required surgical intervention of which 12 had good outcomes

Complications

  • Quadriceps Rupture
    • Can be seen in patients with severe tendinopathy that goes untreated[15]
  • Chronic knee pain
  • Inability to return to sport

See Also


References


  1. Ferretti A. Epidemiology of jumper’s knee. Sports Med. 1986; 3(4):289-295.
  2. Zwerver J, Bredeweg SW, van den Akker-Scheek I. Prevalence of Jumper’s Knee Among Nonelite Athletes From Different Sports: A Cross-Sectional Survey. Am J Sports Med 2011;39:1984-8.
  3. Järvinen, Tero AH, et al. "Muscle injuries: biology and treatment." The American journal of sports medicine 33.5 (2005): 745-764.
  4. Pappas GP, Vogelsong MA, Staroswiecki E, et al. Magnetic Resonance Imaging of Asymptomatic Knees in Collegiate Basketball Players: The Effect of One Season of Play. Clin J Sport Med 2016;26:483-9.
  5. Pfirrmann CW, Jost B, Pirkl C, et al. Quadriceps tendinosis and patellar tendinosis in professional beachvolleyball players: Sonographic findings in correlation with clinical symptoms. Eur Radiol 2008;18:1703-9.
  6. Visnes H, Tegnander A, Bahr R. Ultrasound characteristics of the patellar and quadriceps tendons among young eliteathletes. Scand J Med Sci Sports 2015;25:205-15.
  7. Ooi CC, Richards PJ, Maffulli N, et al. A soft patellar tendon on ultrasound elastography is associated with pain and functional deficit in volleyball players. J Sci Med Sport 2016;19:373-8.
  8. Warden SJ, Kiss ZS, Malara FA, et al. Comparative Accuracy of Magnetic Resonance Imaging and Ultrasonography in Confirming Clinically Diagnosed Patellar Tendinopathy. Am J Sports Med 2007;35:427-36.
  9. . Dragoo JL, Wasterlain AS, Braun HJ, et al. Platelet-rich plasma as a treatment for patellar tendinopathy: a doubleblind, randomized controlled trial. Am J Sports Med 2014;42:610-8.
  10. . Blazina ME, Kerlan RK, Jobe FW, et al. Jumper’s knee. Orthop Clin North Am 1973;4:665-78.
  11. Hoksrud A, Ohberg L, Alfredson H, et al. UltrasoundGuided Sclerosis of Neovessels in Painful Chronic Patellar Tendinopathy: A Randomized Controlled Trial. Am J Sports Med 2006;34:1738-46
  12. Willberg L, Sunding K, Forssblad M, et al. Sclerosing polidocanol injections or arthroscopic shaving to treat patellar tendinopathy/jumper’s knee? A randomised controlled study. Br J Sports Med 2011;45:411-5.
  13. 13.0 13.1 Ferretti A, Conteduca F, Camerucci E, et al. Patellar tendinosis: a follow-up study of surgical treatment. J Bone Joint Surg Am 2002;84-A:2179-85.
  14. Kettunen JA, Kvist M, Alanen E, et al. Long-term prognosis for jumper’s knee in male athletes. A prospective follow-up study. Am J Sports Med 2002;30:689-92.
  15. Kelly DW, Carter VS, Jobe FW, et al. Patellar and quadriceps tendon ruptures--jumper’s knee. Am J Sports Med 1984;12:375-80.
Created by:
John Kiel on 5 July 2019 08:46:54
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Last edited:
9 August 2021 15:26:19
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