Disorders of the contractile structures 54 CHAPTER CONTENTS and is felt as a sudden, painful ‘giving way’ at the front of the Extensor mechanism 713 thigh. Alternatively, the muscular lesion may result from a direct contusion during contact sports (judo or American foot- Quadriceps strains and contusions . 713 ball), known as ‘Charley Horse’. Adherent vastus intermedius . 714 Patients who suffer an acute quadriceps strain will usually Tendinous lesions about the patella . 714 know right away. They are typically involved in sports requiring Rupture of the quadriceps tendon . 718 kicking, jumping, or initiating a sudden change in direction while running. Frequently, a sharp pain is felt, associated with Lesions of the infrapatellar tendon . 718 a loss in function of the quadriceps. Sometimes pain will not Lesions of the insertion at the tibial tuberosity . 719 fully develop during the athlete’s activity while the thigh is Patellar fracture . 719 warm; consequently, the extent of the injury is underesti- Patellofemoral disorders 719 mated. Stiffness, disability and pain then set in some time Introduction . 719 afterwards, e.g. late at night, and the following morning the patient can walk only with a limp.1 Mechanical theory . 719 Clinical examination shows a normal hip and knee, although Neural theory . 720 passive knee flexion is painful or both painful and limited, Clinical examination . 720 depending on the size of the rupture. Resisted extension of the Clinical manifestations . 722 knee is painful and slightly weak. As a rule, the lesion is in the 2 Strained iliotibial band 724 rectus femoris, usually at mid-thigh level. The affected muscle belly is hard and tender over a large area. Sometimes a hae- Flexor mechanism 725 matoma can be palpated. In serious lesions, a space can be Hamstring strains . 725 detected by palpation. This is particularly the case in major Biceps tendinitis . 726 ruptures just above the suprapatellar tendon, which occur mainly in patients over 40 years of age.3 In such cases, there is Lesions of the upper tibiofibular joint . 726 not only pain but also weakness during resisted extension, and Lesions of the pes anserinus . 727 the patient is unable to straighten the knee actively over the Strained popliteus muscle . 727 last 30°. Lesions of the gastrocnemius . 729 Ultrasonography is an excellent imaging modality for visual- izing the quadriceps muscles; it has the ability to image the muscles dynamically and assess for bleeding and haematoma.4 Extensor mechanism Development of myositis ossificans as a complication of a thigh contusion is not uncommon in adolescents and young adults.5 It occurs in 9% of quadriceps contusions and seems to Quadriceps strains and contusions be associated with five risk factors (knee motion less than 120°, injury occurring during American football, previous quadriceps A muscular tear of one of the quadriceps bellies is a common injury, delay in treatment of more than 3 days and ipsilateral disorder in sprinters and soccer players. An abrupt, vigorous knee effusion).6 Early diagnosis is important and is usually contraction during a sprint breaks some of the muscle fibres made with the help of sonography.7,8 There is no proper © Copyright 2013 Elsevier, Ltd. All rights reserved. The Knee treatment but the lesion undergoes spontaneous cure After the friction, active isometric contractions are done within 2 years.9 Therapy with deep transverse massage is over 5–10 minutes. Again, this is carried out in a fully relaxed contraindicated. position, so that the contraction cannot exert tension on the healing tissue (see Ch. 5). Treatment Treatment with deep friction and contractions is given daily for the first week and on alternate days from the second Initial haemorrhage may be reduced by elastic strapping and week onwards. In athletes, there is a significant tendency an ice bag over the lesion. In the case of a contusion, holding for the lesion to recur and the patient should not restart a the knee in 120° of flexion for 24 hours following a quadriceps training programme until a week after complete clinical cure. contusion also appears to shorten the time needed for the In the meantime, treatment should continue. The training 10 patient to return to unrestricted full athletic activities. programme must be built up gradually over the following Minor ruptures in the quadriceps muscle require the same 3–4 weeks. treatment as muscular lesions elsewhere. As soon as the patient is seen, the lesion is infiltrated thoroughly with 50 mL of pro- caine 0.5%. From the next day on, deep transverse friction is Adherent vastus intermedius given, followed by active isometric contractions with the muscle in a shortened position. This condition occurs typically after a fracture of the femur. When the rupture is major, operative suture may be advised, There is gross limitation of flexion, whereas the other knee especially if the patient is an athlete with high functional movements are all full-range. Only surgical treatment can demand on the knee extensors. It is then important that surgi- achieve an acceptable outcome. cal treatment is undertaken as soon as possible. Technique: deep friction to the quadriceps muscle Tendinous lesions about the patella The patient sits with the knees outstretched. Flexion at the The quadriceps tendon has a superficial and a deep layer. The hips, together with maximal extension of the knees, induces superficial layer runs without interruption from the quadriceps complete relaxation of the quadriceps. The physiotherapist muscle, over the patella to the tibial tuberosity. The deep layer stands at the patient’s side. The correct level is sought. The inserts all around the patellar border, effectively making the fingers of one hand are placed deep to the affected fibres. The patella a sesamoid bone in the tendon. Tendinous lesions there- other hand can reinforce the palpating one. The thumbs are fore occur not only at the inferior aspect of the bone but also placed laterally to be used as a fulcrum. By flexion of the at the superior, medial and lateral borders. Tendinosis about fingers, during an upward-drawing movement, the physiothera- the patella is a typical overuse phenomenon in sports character- pist drives all the fibres between fingers and femur (Fig. 54.1). ized by high demands on leg extensor speed and power, such At the end of the movement, the fingers are slightly extended as volleyball, basketball, soccer and athletics. It was first and brought back to the previous spot, under the lesion. The described by Sinding-Larsen in 192111 and Johansson in 1924.12 skin must move with the fingers. Since this is an extremely Kulund13 and Ferretti14 also reported cases of tendinosis at the tiring technique, periods of rest must be built into the treat- upper border of the patella. Cyriax15 describes three possible ment session, which lasts about 20 minutes. sites: the upper border (suprapatellar tendinosis), the apex – the classic ‘jumper’s knee’ (infrapatellar tendinosis) and at either side of the patella (tendinosis of the quadriceps expan- sion) (Fig. 54.2). The lesion was uncommon until the mid- 1960s, when the syndrome of jumper’s knee became more and more frequent because of increased training and higher per- formance goals for athletes.16,17 During the last few decades, these lesions have reached epidemic proportions18; in sports medicine centres, patellar tendinopathy is one of the leading reasons for consultation and often contributes to the decision to give up an athletic career.19 The history is obvious: during or after exertion, there is localized pain at the front of the knee. In mild examples, there is probably only a little pain after activity, whereas in a severe case pain forces the athlete to stop, and pain at rest can also supervene. The patient also states that walking upstairs or standing up from sitting is painful. The lesion can be classified by its symptoms into four stages (Table 54.1).13,20,21 Clinical examination reveals a normal knee with a full and painless range of movement and normal ligamentous tests. Only resisted extension is painful or uncomfortable. When the history suggests a slight quadriceps tendinitis but resisted Fig 54.1 • Friction in minor rupture of the quadriceps. extension is negative, the patient should take part in a training 714 Disorders of the contractile structures C H A P T E R 5 4 and the hyaline inflammatory tissue (usually the middle portion of the patellar ligament) is removed.30,31 However, the benefits of open tenotomy can be questioned on the basis of the results, which show a success rate that varies between 58%14 and 78%.32 Sporting success is seen in about 50% of tenotomy patients, with a median time to return to pre-injury level of activity of 10 months.33 1 Eccentric training as a treatment option for tendinopathy has gained credit in recent decades. The technique was first 2 presented by Curwin and Stanish in 1984, with encouraging results.34 The programme is based on eccentric drop squats, 2 which are performed with some level of discomfort. During 3 the programme, the athlete should be removed from sports activity. When training becomes pain-free, load is increased by first increasing the speed of the eccentric phase and then adding weight.35,36 Our advice is to treat all peripatellar lesions with either a local infiltration of triamcinolone or a series of deep transverse friction.37 At the upper border and the apex, infiltration with triamcinolone can be used safely and with very good Fig 54.2 • Localizations of quadriceps tendinitis (with permission results, providing the injection is done exactly at the right 15 from Cyriax : p. 408): 1, suprapatellar; 2, expansion; 3, infrapatellar. spot, using a weak solution (10 mg/mL) and according to the general principles of infiltration.