Working Diagnosis:
Almost complete high-grade partial tear of right quadriceps tendon and partial right ACL tear

Almost complete high-grade partial tear of left quadriceps tendon and partial left ACL tear

Treatment:
The patient was initially managed conservatively with bilateral knee immobilizers and non-weight bearing.

Outcome:
After orthopaedic surgery evaluation, primary repair of his quadriceps tendon with semitendinosus allograft augmentation was recommended. The patient reported some improvement in his mobility and strength with his initial conservative management and he desired to continue with physical therapy and avoid surgery if possible.

At 3 month follow up, he reported improved strength, stability, and pain with physical therapy. He planned to continue with physical therapy as he continued to improve symptomatically. He will revisit any surgical intervention only if there are significant deficits in stability and function after completing therapy.

Author's Comments:
Complete quadriceps tendon tears are rare injuries. However, there are multiple case reports that describe bilateral quadriceps tendon tears occurring in patients with minimal trauma. Most of these reports involved patients with some predisposing medical conditions or prior tendinopathy.

Our patient has multiple risk factors for quadriceps tendon tears, including age, gender, testosterone replacement therapy, and tendinopathy. His mechanism of injury, landing on flexed knees after a jump, is consistent with eccentric contraction of the quadriceps and then tendon tear. He could actively flex his knees but not extend.

Editor's Comments:
Acute quadriceps tendon tears are relatively rare injuries with a reported incidence of 1.37/100,000. (1) The quadriceps tendon itself is a trilaminar structure with the rectus femoris tendon forming the most superficial layer, followed by an intermediate layer formed by the vastus medialis and lateralis, and a deep layer formed by the vastus intermedius tendon. (2) The superficial and intermediate layers are injured most frequently and a majority of tendon tears occur in close proximity to the patella. (2, 3) MRI and musculoskeletal ultrasound can be used to confirm diagnosis of quadriceps tendon tear. Full thickness tears of the quadriceps tendon are typically managed surgically with either transosseous sutures or newer techniques utilizing suture anchors. (3) Partial thickness tears can be managed conservatively with a hinged knee brace locked in full extension followed and by progressive increases range of motion and strengthening with aggressive management of effusions to prevent inhibition of quadriceps firing. (3, 4)

References:
1. Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury. 2008 Dec;39(12):1338-44.
2. Falkowski AL, Jacobson JA, Hirschmann MT, Kalia V. MR imaging of the quadriceps femoris tendon: distal tear characterization and clinical significance of rupture types. Eur Radiol. 2021 Oct;31(10):7674-7683. Epub 2021 Apr 16.
3. Arnold EP, Sedgewick JA, Wortman RJ, Stamm MA, Mulcahey MK. Acute Quadriceps Tendon Rupture: Presentation, Diagnosis, and Management. JBJS Rev. 2022 Feb 7;10(2).
4. Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg. 2003 May-Jun;11(3):192-200.

Return To The Case Studies List.