Working Diagnosis:
Complete rupture of distal quadriceps tendon,
Partial tear to the distal vastus medialis,
Partial tear to the distal vastus lateralis tendons.

Treatment:
The patient improved with a couple sessions of physical therapy, but his function remained below baseline and he still required a cane for ambulation.
After receiving the MRI results, the orthopedic surgeon strongly recommended urgent surgical intervention to prevent long term deficits. Due to the patient's lack of appropriate insurance, he was unable to proceed with surgery.
The patient chose to continue managing his injury with quad strengthening and a home exercise program.

Outcome:
Three months after injury, the patient was much improved. He returned to work full time, using a cane occasionally for long distance walking. He was able to 'dolly' cars without difficulty and could carry the dolly on his own.
He chose to forgo surgery as his functionality was much improved.
He continued with his home exercise program and was followed closely with conservative treatment.
6 months after injury, the patient is still functioning well. He is able to walk without a cane, though he occasionally has a small limp. He is able to 'dolly' cars and carry the dolly on his own without accommodations. He has continued exercises for his leg and is able to almost fully extend his knee.

Author's Comments:
Complete quadriceps tendon rupture is not commonly seen in clinical practice and can be very disabling.
Incidence is rare at 1.37/100,000/year.
Most quadriceps tendon ruptures occur in males with a mean age of 50.5 years with predisposing factors, including tendinopathy, systemic illnesses, and obesity.
Partial ruptures may be managed conservatively with knee immobilization in full extension for 6 weeks followed by therapy.
Complete ruptures require open repair and reconstruction, and earlier repair is recommended to avoid retraction and atrophy of the muscle.
There is very limited literature available on conservative management of complete rupture of the quadriceps tendon.
This case gives reason for the need of further research on possible conservative treatment options for complete quadriceps tendon ruptures.

Editor's Comments:
Very interesting case. Complete quadricep rupture is as described a very uncommon injury. I agree that there is no clear literature recommending or considering conservative management of complete rupture. While the patient here seemed to gain some functionality from PT, it seems clear he is quite limited and has ongoing significant disability relative to preinjury function levels. Perhaps one of the strongest points of this case is how insurance/access to standard of care can have a profound effect on someone’s life even in a single non life-threatening event. There are some cheaper, simpler procedures that may have a role (ref 2).

References:
Olmo J, Aramberri M, Almaraz C, Nayler J, Requena B. Successful conservative treatment for a subtotal proximal avulsion of the rectus femoris in an elite soccer player. Phys Ther Sport. 2018 Sep;33:62-69. doi: 10.1016/j.ptsp.2018.07.004. Epub 2018 Jul 11. PMID: 30014969.

Verdano MA, Zanelli M, Aliani D, Corsini T, Pellegrini A, Ceccarelli F. Quadriceps tendon tear rupture in healthy patients treated with patellar drilling holes: clinical and ultrasonographic analysis after 36 months of follow-up. Muscles Ligaments Tendons J. 2014 Jul 14;4(2):194-200. PMID: 25332935; PMCID: PMC4187582.

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