Identifying Rupture of the Quadriceps Tendon

                                                                                         

It is not common for the quadriceps tendon to rupture and when it does it mostly presents in those older than 40 years. Certain diseases and previously existing degeneration in the knee extensor apparatus makes this condition more likely to occur. A rupture on one side is the most common occurrence and bilateral ruptures indicate there are very likely to be underlying causative factors. Patellar tendon ruptures are less frequent than ruptures of the quads tendon and present in younger people under 40. It is important to make an early diagnosis of this problem and operate as soon as possible afterwards as delay makes the outcomes poorer.

The typical mechanism of injury is for the damage to occur during a rapid contraction of the quadriceps whilst it is lengthening and with the foot on the ground. Falls, direct blows to the knee, cuts and lacerations are all possible causes. Since normal tendons have been shown not to typically rupture and that the quadriceps can rupture after relatively minor trauma, it follows that rupture most likely occurs through an abnormal area in the tendon. Many medical conditions can increase the likelihood of tendon rupture including immobilisation, long term steroid use, infections, rheumatological conditions and obesity. Steroid injections in the knee can weaken tendons and rupture can occur secondary to various knee operations.

Rupture of the quadriceps tendon usually occurs through abnormal tissue in the first two centimetres just above the patella. Medical conditions can damage the blood supply to the tendon or alter the structure of the tendon. Diabetes can cause changes in blood vessels and obesity leads to increased tendon forces and degeneration within the tendon by replacement with fatty tissues. In the microscopic examination of ruptured tendons the vast majority were suffering from degenerative changes without inflammatory changes and commonly showing abnormalities of blood vessels and supply. Decreased blood flow leading to poor nutrition and low oxygen levels may be crucial factors in tendon degeneration.

On presentation patients show a loss of the ability to use the knee functionally, swelling in the suprapatellar region and severe knee pain after a traumatic event such as a fall or stumble, or after the knee giving way without falling. There can be a clearly audible pop at the time and the patient may never have complained of knee pain before. Walking will be difficult due to pain and knee instability and a physical exam will show bruising, tenderness and the suprapatellar swelling. On manual examination a tissue gap may be found above the patella and the patella itself may lie rather lower than is normal.

The ability to extend the knee actively against gravity is the key aspect of the determination of the diagnosis. If there is a rupture then there should be an extension lag, an inability to straighten the knee up on its own. This will be of varied severity depending on the degree of rupture, with partial ruptures needing more careful assessment to discover them. It's more difficult to diagnose this condition if there is a delay in assessing the patient and many inaccurate diagnoses are given, with simple knee strains a common diagnosis with the consequent incorrect treatment and follow-up.

As time passes patients may regain the ability to walk and the ability to use their quadriceps to some extent as the pain and swelling settles. As the knee can routinely give way patients hip hitch to carry the leg through and hyperextend the knee to attain weight bearing stability. Without this the knee gives way frequently and in most cases climbing hills or stairs is problematical. Acute and complete ruptures are treated by primary and early surgical repair although chronic ruptures can be successfully repaired. Plaster cast immobilisation can be used for partial tendon ruptures with the knee kept in extension for three to six weeks followed by physiotherapy rehab.

4-6 weeks in a cylinder plaster in full knee extension is the common management after this operation and weight bearing is usually permitted early with a frame or crutches. After the plaster is taken off then a hinged knee brace can be applied which can be adjusted to limit flexion range which can be gradually increased to allow greater and greater knee bend. Patients are then referred to physiotherapy to work at gradual increases in knee strength and ranges of motion until the knee is rehabilitated close to the function of the other knee.

About the author:
Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for Physiotherapists in Bournemouth visit his website.

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