Updated: 5/29/2021

Quadriceps Tendonitis

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  • Summary
    • Quadriceps tendonitis is inflammation of the suprapatellar tendon of the quadriceps muscle associated with activity-related anterior knee pain.
    • Diagnosis is made clinically with tenderness to palpation at the quadriceps tendon insertion at the superior pole of the patella.
    • Treatment is generally nonoperative with resting, ice, activity modifications and physical therapy to focus on hamstring, quadriceps and core strengthening.
  • Epidemiology
    • Demographics
      • 8:1 male-to-female ratio
      • more common in adult athletes
    • Risk factors
      • jumping sports
        • basketball
        • volleyball
        • athletics (e.g., long jump, high jump, etc)
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • occurs as the result of repetitive eccentric contractions of the extensor mechanism
      • pathoanatomy
        • microtears of the tendon most commonly at the bone-tendon interface
    • Associated conditions
      • Jumper's knee
        • patellar tendonitis
          • more commonly affects the insertion of the patella tendon at the patella.
          • less commonly the insertion at the tibial tubercle
      • Quadriceps tendinosis
        • chronic quad tendon degeneration with no inflammation
  • Anatomy
    • Knee extensor mechanism
      • quadriceps muscles
        • rectus femoris, vastus medialis, vastus lateralis, vastus intermedius
      • quadriceps tendon
        • common trilaminar tendon of quadriceps muscles
          • anterior layer = rectus femoris
          • middle layer = vastus medialis and vastus lateralis
          • deep layer = vastus intermedius
    • Vascular supply
      • medial, lateral and peripatellar arcades
    • Innervation
      • innervated by muscular branches of the femoral nerve (L2, L3, L4)
  • Presentation
    • History
      • overuse injury in a jumping athlete
      • recent increase in athletic demands or activity
      • often a recurring injury
    • Symptoms
      • pain localized to the superior border of patella
      • worse with activity
      • associated swelling
    • Physical examination
      • inspection
        • knee alignment
        • swelling
      • palpation
        • tenderness to deep palpation at quadriceps tendon insertion at the patella
        • palpable gap would suggest a quads tendon tear
        • patellar subluxation
      • motion
        • pain with resisted open chain knee extension
        • able to actively extend the knee against gravity
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral of knee
      • optional views
        • Sunrise or Merchant views for patella instability
      • findings
        • usually normal
        • may see tendon calcinosis in chronic degeneration
      • measurement
        • evaluate knee alignment for varus/valgus angle
        • evaluate for patellar height (patella alta vs baja) for suspected quadriceps tendon rupture
          • Blumentsaat's line should extend to inferior pole of the patella at 30 degrees of knee flexion
          • Insall-Salvati method
            • normal between 0.8 and 1.2
    • Ultrasound
      • indications
        • suspected acute or chronic
      • findings
        • effective at detecting and localizing disruption in tendon
        • operator and user-dependent
    • MRI
      • indications
        • most sensitive imaging modality
      • findings
        • intrasubstance signal and thickening of tendon
  • Treatment
    • Nonoperative
      • activity modification, NSAIDS, and physical therapy
        • indications
          • mainstay of treatment
        • technique
          • rest until pain is improved
          • physical therapy starting with range of motion and progressing to eccentric exercises
          • cortisone injections contraindicated due to risk of quadriceps tendon rupture
    • Operative
      • quadriceps tendon debridement
        • indications
          • very rarely required
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