Updated: 10/6/2016

Quadriceps Tendonitis

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Introduction
  • Inflammation of the suprapatellar tendon of the quadriceps muscle
  • 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)
  • 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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