Introduction

Quadriceps tendon rupture typically occurs in patients over the age of forty. It is approximately three times more frequent than patellar tendon rupture in adults in this age group. Patients may be predisposed to ruptures due to calcific tendonitis, fatty degeneration, arthritis, infection, and gout.

Classification

Quadriceps tendon rupture can be classified as incomplete or complete.  When the tendon has been ruptured for 6 weeks or more, it is considered neglected and has likely retracted proximally will be more difficult to treat.  

Presentation

Patients present with acute onset of knee pain, swelling, and substantial weakness and difficulty walking.  Occasionally, patients may report an audible pop.  Many authors have described patients with increasing suprapatellar knee pain prior to rupture, suggesting a degenerative process leading to rupture.

Diagnosis

A palpable defect may be present.  Straight leg raise testing will reveal complete inability to extend the knee or extension lag if the extensor mechanism is still intact.  Ecchymosis and swelling may be present.  The patella may be able to be displaced inferiorly.  Patella baja may be detectable on lateral knee radiographs.  If the diagnosis is in doubt, MRI or ultrasound can be utilized. 

Treatment

Operative:  For ruptures treated in a timely manner, a direct repair can be used.  Mid-substance tears can be repaired end to end with a large (no. 5), nonabsorbable, locking stitch.  For ruptures at the osteotendinous junction, there may be a small sleeve of tendon remaining.  However, this is not sufficient to support an end to end repair.  Instead, the distal fixation should be run through the patella (often through longitudinally oriented drill holes).  Postoperative treatment includes a cylinder cast worn for four to six weeks, with advancement of weight-bearing at approximately three weeks.  Knee bracing with gradual progression of range of motion is then begun.  Aggressive physical therapy with strengthening is necessary for an optimal outcome.

Non-operative:  If the quadriceps is torn, but the extensor mechanism is intact, non-operative treatment is a possibility.  Treatment consists of a cylinder cast followed by knee bracing with gradual increases in range of motion.  

Complications

Quadriceps atrophy, extensor lag, and decreased passive range of motion are complications experienced after treatment.  Infection and wound complications can also result, especially with subcutaneous placement of nonabsorbable sutures and with incisions placed directly over the tibial tubercle.  Patellar tracking can also be affected if malalignment occurs after quad tendon repair.

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