Quadriceps tendon injuries occur in a spectrum that ranges from
tendinosis, to partial tears, to complete full thickness ruptures. Complete
traumatic rupture of the quadriceps tendon is a relatively uncommon but
disabling injury. Clinical findings usually include acute pain, inability to
actively extend the knee, and a palpable suprapatellar defect in the quadriceps
tendon. Incomplete tears and tendinosis (jumper’s knee) can be managed
nonoperatively, but complete quadriceps tendon ruptures require surgical repair
for optimal outcomes.
The knee extensor mechanism consists of the quadriceps muscle with its 4
muscle bellies (rectus femoris, vastus lateralis, vastus medialis, and vastus
intermedius). The quadriceps tendon is composed of contributions from each of
these muscles, forming a common trilaminar tendon insertion at the patella. The
anterior layer is formed by the tendon of the rectus femoris, the intermediate
layer by the vastus medialis and lateralis, and the deep layer by the vastus
intermedius. The vastus medialis and lateralis have a fibrous expansion that
blends with the medial and lateral retinaculum.1
Three major vascular arcades (medial, lateral, and peripatellar arcades)
provide the blood supply to the quadriceps tendon. A relatively hypovascular
zone is present between 1 and 2 cm superior to the patella, making this area
more susceptible to rupture.2
While tendonitis implies the presence of an acute inflammatory process,
the term tendinosis is used to signify a pathology of chronic degeneration
without inflammation, which is more appropriate for what is commonly seen in
patients presenting with a chronic quadriceps tendon injury. Peri-patellar
tendinosis is commonly referred to as jumper’s knee. It is felt to be due
to an overload injury commonly seen in athletes who perform intense and
repeated jumping such as in volleyball, basketball, high jumping, and long
jumping. This pathological process involves microtears at the bone-tendon
junction, resulting in degenerative inflammation and replacement of the tendon
by scar tissue. This condition most commonly affects the insertion of the
patella tendon on the patella (65%), but can also affect the quadriceps tendon
insertion on the patella (25%), and the patella insertion on the tibial
Patients presenting with quadriceps tendinosis usually report an
insidious onset of pain over the proximal pole of the patella. This is often
associated with a history of an increase of change in athletic activities.
Localized tenderness may be found on direct palpation of the insertion of the
distal quadriceps on the proximal pole of the patella. Pain can be elicited
knee extension against resistance.
Partial Quadriceps Tendon Tears
Patients presenting with a partial quadriceps tendon tear usually report
an acute onset of pain during sports or a fall. This injury may be associated
with a knee hemarthrosis. Unlike complete quadriceps tendon ruptures, the are
able to actively extend their knee against gravity. Occasionally the severity
of pain may initially limit the patient’s ability to fully contract their
quadriceps muscle, making differentiation from a complete tendon rupture
Complete Quadriceps Tendon Ruptures
Complete quadriceps tendon ruptures usually result from indirect trauma,
often occurring when a patient is trying to regain their balance. When a
patient rapidly contracts their quadriceps muscle with their knee flexed, it
places the quadriceps under its greatest tensile stress, which may exceed the
Patients commonly provide a history of a sudden onset of suprapatellar
pain combined with a fall, followed by inability to actively extend the knee.
However, when asked precisely many will report having experienced a sudden pain
and loss of stability when trying to prevent a fall with the knee extended
against resistance. The tendon rupture is therefore probably not the result of
the fall but of maximum quadriceps contraction with the fall being the result
of a rupture.5
On physical examination a suprapatellar gap can be palpated in the early
phase following rupture. With later examination the gap might be masked from
swelling, hematoma, and fibrosis. Most patients present with inability to
actively extend the knee, although in some cases intact retinaculum will allow
some active extension and obscure the diagnosis. Ambulation is usually not
possible due to inability to fully extend and stabilize the knee.
Some patients presenting with inability to ambulate due to bilateral
quadriceps tendon ruptures are sometimes misdiagnosed as a neurologic problem
resulting in delayed treatment.6 Since these patients frequently
have severe associated systemic diseases, the failure to consider an orthopedic
diagnosis is understandable.
Radiographs, which can rule out other injuries, may show inferior
displacement of the patella (Figure 1). Several criteria based on lateral knee
radiographic measurements have been described to define abnormal position of
the patella. The Insall-Salvatti ratio compares the length of the patellar
tendon with the length of the patella.7 This ratio should normally
be approximately 1.0. Citing difficulty in identifying the tibial tubercle and
variation in the size of the nonarticular portion of the patella, Blackburne
and Peel8 recommended using a ratio that compared the perpendicular
distance between the lowest part of the articular surface and the joint line
with the length of the articular surface of the patella.8 With the
knee flexed 30° this ratio should normally be between 0.80 and 0.95. Bony
avulsions may occasionally be seen, but are usually absent when the rupture
occurs solely within the hypovascular tendinous region. Both ultrasound and MRI
can assist in the diagnosis in uncertain cases. The quadriceps tendon defect
can be readily visualized on ultrasound examination (Figure 2). With
combination of physical examination and ultrasound 100% diagnostic sensitivity
can be achieved, thus avoiding the more expensive MRI examination (Figure
3).9 Magnetic resonance imaging can be helpful in detecting
additional intra-articular injuries, but considering that this is the case in
<10% of="" cases="" it="" is="" only="" recommended="" if="" strong="" suspicion="" for="" additional="" injuries="">10%>10 Partial tendon ruptures are usually hyperintense
on T2-weighted images, and may sometimes be confused with a
Figure 1: Lateral radiograph showing bony
avulsion associated with an acute quadriceps tendon rupture (A). Postoperative
radiograph following quadriceps tendon repair. Note the presence of a anterior
superior bone spur on the patella suggesting prior injury or prior partial
Figure 2: Ultrasound of a ruptured and a
nonruptured quadriceps tendon.
Figure 3: MRI of a chronic quadriceps
tendon rupture showing a lack of quadriceps tendon attachment to the superior
An epidemiologic study from the United Kingdom reported an incidence of
1.37/100,000 per year, with a mean age of 50.5 in males and 51.7 in
females.12 Quadriceps tendon ruptures are more common in patients
older than 40 years, with a peak incidence seen in the sixth and seventh decade
of life. Men are affected 4 to 8 times as often as women.4,12 Racial
differences also have been described with a >10 times increased risk of
major tendon ruptures in black men.13,14
The quadriceps tendon is normally remarkably strong and resistant to
rupture. It has been commonly accepted that quadriceps tendon ruptures rarely
occur in the absence of some pre-existing degeneration of the tendon. However,
a recent study found that only 64% of cases analyzed showed histologic
abnormalities.15 Histologic analysis of ruptured quadriceps tendons
found the most frequent pathological change to be hypoxic degeneration and
focal regions with decreased collagen fiber thickness.16,17 However,
degeneration alone may not completely explain the rare incidence of this
injury, since cadaveric studies observed degenerative changes in up to 100%
even in nonruptured tendons.2,18 Most quadriceps tendon ruptures are
located in the hypovascular zone, which is 1 to 2 cm superior to the
Patients with certain systemic diseases that may cause pathologic
degeneration of the quadriceps tendon have an increased risk of quadriceps
tendon ruptures. These systemic diseases include renal disease, diabetes,
rheumatoid arthritis, gout, obesity, hyperparathyroidism, systemic lupus
erythematosis, and osteomalacia. Systemic diseases have been reported to be
present in 10% to 20% of patients sustaining a quadriceps tendon
rupture.4,20 In addition the use of steroids or fluroquinolone
antibiotics has been reported in patients sustaining quadriceps tendon
ruptures.21 Iatrogenic weakening of the quadriceps muscle and
quadriceps tendon, which can be the case in quadriceps release for total knee
arthroplasty or in patella lateralization, have also been reported to result in
a quadriceps tendon rupture.22,23 While bilateral quadriceps tendon
ruptures occur in <5% of="" cases,="" associated="" systemic="" disease="" such="" as="" renal="" insufficiency,="" diabetes,="" or="" chronic="" steroid="" use="" is="" almost="" universal="" in="" these="">5%>4,20,24-26
The mainstay of quadriceps tendinosis treatment is rest, activity
modification, and a physical therapy program that focuses on aggressive
hamstring stretching. Additional treatment modalities include ice, massage,
ultrasound, iontophoresis and phonophoresis.
Some surgeons have promoted the use of platelet rich plasma injections
into injured tendons, proposing that the growth factors present in the
concentrated plasma are beneficial in tendon healing and recovery.27
Another proposed treatment is directed at the hypervascularity of the affected
tendon, which is oblitered by injection of a sclerosing agent.28
Surgical treatment of quadriceps tendinosis is rarely needed, but may be
considered in selected patients who fail conservative therapy. The location and
extent of the affected tendon can be imaged with an MRI. The degenerative
tissue is excised, along with any calcifications.29 If a significant
portion of tissue is excised, reattachment of the quadriceps tendon to the
patella may be required.
Partial Quadriceps Tears
Incomplete tears are usually treated nonoperatively. Evacuation of the
intra-articular hemarthrosis has been recommended to reduce pain and promote
faster recovery.4 Rest, ice, compression, and anti-inflammatory
medication are commonly recommended. However, the use of anti-inflammatory
medications may delay or impair the tendon healing process, so it is
recommended to minimize or avoid their use. The patient’s knee is commonly
immobilized in full extension. Duration of immobilization is controversial, but
6 weeks is a commonly chosen duration of immobilization. A shorter period of
immobilization may be feasible for smaller tears and while allow more rapid
rehabilitation. To determine whether to discontinue immobilization, the
patients comfort and ability to perform a straight leg raise are assessed. If
the patient’s recovery is deemed satisfactory progressive knee range of
motion and strengthening exercises are begun.
Operative treatment may be indicated if nonoperative management is
unsuccessful. With >1 of the 3 tendon layers intact, ruptures
involving only 1 portion can usually be treated with excision of the scar
tissue and side-to-side closure of the tendon.30 If more extensive
debridement results in removal of the majority of the tendon, then suture
repair to the patella should be considered.31
Complete Quadriceps Tendon Ruptures
Complete quadriceps tendon ruptures require open repair or
reconstruction, since nonoperative treatment results in poor outcomes. Early
repair is recommended because delay in surgery is correlated with retraction
and atrophy of the quadriceps muscle resulting in decreased functional
outcome.32 No consensus exists on what constitutes “early”
repair and in different reports has ranged from 24 hours to 1 month following
During surgical repair the patient is positioned supine after induction
of general or regional anesthesia. The use of a tourniquet is optional. A
midline incision beginning just distal to the superior patellar pole and
extending proximally for approximately 5 cm is used (Figure 4). The quadriceps
tendon rupture is exposed, and hematoma and fibrous granulation tissue
debrided. A tissue sample for histologic analysis may be taken to identify the
degree of preexisting degeneration.
Figure 4: Intraoperative photograph of
quadriceps tendon rupture. Note associated disruption of medial and lateral
joint capsule (A). Following repair of quadriceps tendon rupture using #5
FiberWire (Arthrex, Naples, Florida) passed through longitudinal drill holes in
the patella, and repair of medial and lateral retinaculum (B).
Several surgical techniques for repair of quadriceps tendon ruptures
have been described (Figure 5A). The most common used method is a transosseous
suture through vertical patellar drill holes. Alternatively, some surgeons have
advocated placing the transosseous suture through a transverse drill hole
through the patella (Figure 5B). Some form of locking suture technique, such as
those described by Kirchmayr, Krakow, Bunnell or a figure of eight technique is
used to anchor the quadriceps tendon.
Figure 5: Diagram of longitudinal (A) and
transverse (B) transosseous quadricepts tendon repair.
Different suture materials have been used, with most authors
recommending use of a nonabsorbable material, however good results have also
been reported with the use of absorbable polydioxane (PDS).32,34-36
Additional repair of the medial and lateral retincaculum, which are torn in
most cases, should be performed. It is often easiest to place the retinacular
repair sutures in position before repairing the quadriceps tendon. More
proximal ruptures in which a portion of intact tendon remains attached to the
patella, can occasionally be repaired with end-to-end sutures. Ruptures
occurring at the patella insertion often have avulsion bone fragments attached
to the tendon. In this situation the bone fragments should be maintained to
achieve bone to bone healing. A horizontal trough can be made in the superior
border of the patella and suture repair completed as described above.
Alternative methods of repair include additional use of wire cerclages,
screw augmentation, or suture anchors instead of drill
holes.26,37-39 Some surgeons recommend placement of a
circumferential suture that encompasses and “protects” the repair and
might provide additional strength if early postoperative mobilization is
planned.40 Such a circumferential suture is usually places with the
knee in 30° of flexion. Prior to skin closure, a “stress test” of
the repair should be performed by passively flexing the knee to at least
Scuderi19 advocated reinforcement of the defective tendon
zone by turning down a flap of the proximal, and presumably nondegenerative,
quadriceps tendon. Following direct repair of the tendon rupture, a triangular
flap approximately 1/8-inch thick can be elevated from the anterior portion of
the distal quadriceps tendon and turned down to reinforce the weakened area. By
using only the superficial portion of the tendon the remainder of the tendon is
not substantially weakened.
As result of anatomical and biomechanical studies promoting early
mobilization to improve tendon healing and maintain joint motion, many authors
have recently advocated passive flexion between 30° and 90° starting on
the first postoperative day.35,41,42 Controversy exists regarding
postoperative weight bearing with most authors recommending partial weight
bearing for 6 weeks.32,37,39,40
The treatment of a chronic rupture can be significantly more challenging
because tendon retraction and scarring may preclude direct repair. The
quadriceps tendon must be mobilized by resecting adhesions and elevating the
quadriceps muscle off the femur. A lateral and medial quadriceps release can
help in tendon mobilization.43 If the quadriceps tendon can be
approximated to the patella then the above-mentioned techniques of primary
repair can achieve good results.44
If primary approximation of the tendon is not possible reconstruction
with a hamstring graft, V-shaped turn down flap and Leeds-Keio ligament, which
is a synthetic device that has the ability to induce a collagen rich capsule
around it, have all shown acceptable results.4,45-48
The Codvilla quadriceps lengthening technique has been recommended when
direct primary repair is not possible. A full-thickness inverted “V”
is made in the mid-substance of the proximal quadriceps tendon, ending
approximately 2 cm proximal to the rupture zone. The triangular flap is turned
down distally and attached to the patella. The upper portion of the quadriceps
tendon where the triangular flap was taken is repaired in a side to side
Outcome Following Repair of Complete Quadriceps Tendon Ruptures
A number of relatively small retrospective studies have reviewed the
outcome of patients following quadriceps tendon repairs (Table). Slightly
different repair techniques and postoperative protocols were used. Most studies
used 6 weeks of postoperative immobilization, but some allowed immediate
limited range of motion from 55° to 90°.35,40,49 Patients
generally reported satisfactory results following their surgical repair.
Loss of knee motion is common following complete quadriceps tendon
ruptures. Especially problematic is lack of full knee extension.4
While some studies have reported no deficit in muscle strength, most studies
report long-term decreases in muscle strength in 25% to 67% of
cases.26,33,34,35,49 Despite the frequency of muscle weakness most
patients seem to tolerate their strength deficit well.50
In one of the largest series of patients, Konrath et al34
reported on 51 quadriceps tendon ruptures, of which 50 were treated by primary
repair from 1 to 259 days after injury. The mean time from injury to surgery in
43 of the cases was 5.5 days, but in 7 cases the injury was initially missed,
and mean time from injury to surgery in those cases was 60 days. Most tendon
ruptures were repaired using transosseous non-absorbable sutures. Postoperative
management consisted of partial weight bearing and careful flexion during
physical therapy for 6 weeks. At a mean follow-up of 4 years a decrease in
muscle strength could be observed in more then half of the patients. In
addition to minor complications one re-rupture was reported. The authors
reported that no correlation between time of surgery and functional outcome
could be observed.34
Despite the frequency of medical comorbidities in many patients
sustaining quadriceps tendon ruptures, few serious complications have been
reported following quadriceps tendon repair. O’Shea et al26
reported 1 pulmonary embolism in 27 patients that were immobilized
post-operatively and allowed partial weight bearing for 6 weeks. Wenzl et
al49 reported 2 deep venous thromboses (DVTs) and 1 pulmonary
embolism leading to death in 35 patients that were either immobilized or
allowed up to 60° of knee flexion and partial weight bearing for 6
weeks.49 Another reported serious complication is a single
documented case of acute compartment syndrome of the thigh following quadriceps
Re-rupture is a significant concern because there is usually underlying
pathology within the substance of the tendon. In addition, to achieve the goal
for optimal outcome, progressive postoperative therapy with early range of
motion may lead to early stress of the repair. Ramseier et al33
reported 1 re-rupture in 21 patients that were immobilized in a long leg splint
for 6 weeks.
Konrath et al34 observed 1 re-rupture in 39 patients with
careful postoperative mobilization during physical therapy and 6 weeks of
partial weight bearing. There seems to be no correlation between the specific
surgical technique or the postoperative care on the rate of re-rupture.
However, re-rupture rates as high as 40% have been reported in patients with
total knee arthroplasty complicated by quadriceps tendon rupture.52
To date there have been no randomized controlled studies to evaluate specific
surgical techniques or postoperative protocols for quadriceps tendon ruptures.
Complete quadriceps tendon ruptures are uncommon injuries that usually
result from indirect trauma. Early diagnosis and prompt repair has been
associated with the best outcomes. Fixation with transosseous patellar sutures
is most common. Early range of motion within the tolerance of the repair may
provide better results, but there have been no large randomized studies that
have compared either the surgical technique or the postoperative treatment
regimen. Some loss of muscle strength is common, however good to excellent
functional results are usually achieved. Patients with associated
co-morbidities may be particularly susceptible to complications, which include
deep vein thrombosis, pulmonary embolism, and re-rupture.
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Drs Hak and Sanchez are from the Department of Orthopedic Surgery,
Denver Health Medical Center, University of Colorado School of Medicine,
Denver, Colorado; and Dr Trobish is from the NYU Hospital for Joint Diseases,
Department of Orthopedic Surgery, New York, New York, and the BG Trauma Center
Tuebingen, Tuebingen, Germany.
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Correspondence should be addressed to: David J. Hak, MD, MBA, 777
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