Quadriceps Tendinosis With Partial Tear

A 62-year-old woman complained of right knee pain that had developed 1 year earlier after she had slipped on ice and fallen on the knee. Initial radiographs of the knee had shown mild degenerative changes. Treatment with NSAIDs for 10 months had failed to alleviate the pain.

The patient had a history of type 2 diabetes mellitus, hypertension, osteoarthritis of the knees, and obesity. She stated that her knee was "giving out on her" while she walked, causing her to fall. Use of a rolling walker enabled her to walk only 2 to 3 blocks. She described the pain as 3/10 on a visual analog scale; it was located about 2 inches above the patella and was exacerbated by walking.

Franklin Caldera, MD, of New York and Kristeen R. Ortega, MD, of Corona, Calif, noted a marked difference between the patient's right and left knees. An indentation (1 cm deep, 3 cm wide) above the right knee had been present since the fall (A); she was unable to extend the knee. Quadriceps tendinosis and posterior patellar and anterior femoral chondromalacia were suspected. An MRI scan of the knee demonstrated a partial tear of the quadriceps tendon (B, arrow).

Although a rare knee injury overall, quadriceps tendon injury is the second most common injury to the extensor mechanism after patellar fracture.¹ Quadriceps tendon injuries range from tendinosis to partial-thickness tears and complete tendon rupture. In older adults, quadriceps tendon tears usually occur after a slip and fall. Preexisting degenerative changes, caused by aging or repetitive microtrauma, are often apparent within the tendon.² Older patients with a history of trauma, diabetes, chronic renal failure, or hyperthyroidism are prone to tendon and ligament injuries.

Rupture of the quadriceps tendon is most common in older persons (of about 65 years) and young athletes (between 15 and 30 years).³ It is associated with sports such as high jump, basketball, and weight lifting.⁴ A chronic patellar apicitis (jumper's knee) may predispose to ruptures.⁵ Quadriceps rupture is not uncommon in patients with renal failure.

Patients with quadriceps rupture (or tear, depending on the thickness) can have a large hemarthrosis of the knee, a freely mobile patella, and an impressive loss of extensor function of the knee. They are unable to walk and may have a palpable defect above the knee, because the quadriceps tendon usually ruptures transversely just proximal to the patella. Many cases of quadriceps rupture can be diagnosed clinically; partial tendon tears may be more difficult to assess. The absence of a palpable gap because of soft tissue swelling may limit the clinical evaluation.⁶

MRI is the diagnostic modality of choice. Ultrasonography has been used to diagnose partial-thickness tears of the quadriceps tendon and may help differentiate such cases from complete tears, particularly in the acute setting.⁷

Tendinosis is usually managed conservatively. Partial tears of the quadriceps tendon may be treated with immobilization and early range of motion training or repaired surgically, depending on the degree of the tear and the loss of function.⁸

Surgery is recommended for patients who have complete quadriceps tendon rupture or partial tears that do not improve with rehabilitation. When surgery is indicated, the rupture should be repaired within 48 hours.

This patient was given a hinged right knee brace. Thereafter, she was able to ambulate safely with a rolling walker and had no more falls.

References:

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