We’ve all heard of the dreaded sport injuries such as a meniscus tear, ACL tear, LCL/MCL tear, and most of us has had some sort of patellar tendinopathy, but a quad tear? That doesn’t happen very often. But when it does, it is devastating and can be even harder to come back 100% than an ACL tear. Ill break down what it is, why it happens, rehab/surgical treatment and how we can help.
The quad tendon (or patellar tendon) is a tendon made from the converging of the quadricep muscles: Vastus Medialis, Vastus lateralis, Rectus femoris and Vastus intermedius. There is 2 parts of the quadriceps tendon, the superior quad tendon, which is the tendinous part above the patella (kneecap), and the inferior quad tendon (commonly known as the patellar tendon), which is the tendinous part below the patella (kneecap) that attaches onto our shin bone (tibia). Underneath the superior and inferior quadriceps tendon is the patella (kneecap) which functions to provide proper tracking of the tendon with knee and hip movement.
The action of the quadriceps muscles has 2 parts:
- The vastus lateralis and vastus medialis function to extend the knee, meaning that they move the knee from a bent position to a straight position, such as the motion of kicking a soccer ball or jumping.
- The rectus femoris and vastus intermedius function to extend the knee AND flex the hip, meaning that it moves the hip from a straight position and moves it to a position closer to our chest. This motion would be the descending movement of a squat or jump.
The quadricep tendons’ function during these movements is to act as a lever, where the muscle belly of the particular muscle contracts and the quadriceps tendon helps to move that particular joint the muscle is acting on.
What is a quad strain and how does it rupture?
A quad strain (or strain of any muscle) is the tearing of the muscle belly/tendon due to either a forceful contraction, excessive stretch of the muscle, or repetitive overload of that particular muscle to the point where it fails under load.
A muscle strain is usually classified into 3 grades, and treatment/rehabilitation depends on the grade the person has suffered.
Grade 1: There is minor tearing of the muscle fibers with only minimal or no loss in strength. Pain is usually mild to moderate. Grade 1 strain and tendinitis are essentially the same idea. Small, microtears of the particular injured tissue.
Grade 2: There is more severe disruption to the muscle fibers with significant pain and loss of strength. A defect in the muscle tissue may sometimes be felt.
Grade 3: There is complete tearing of the muscle with associated severe pain and complete loss of strength. A palpable defect in the muscle tissue can frequently be felt. Surgical repair is often needed.
Complete tearing and tendon rupture go hand in hand, so Victor Oladipo suffered and grade 3 strain of his quadriceps tendon, which is the worst case scenario.
Quadriceps tendon strains typically occur due to sudden forceful eccentric contraction of the quadriceps muscle during regulation of knee flexion. What does that mean? Well if concentric muscle contraction means the muscle contracts and it shortens, eccentric muscle contraction is the muscle contraction that occurs while the muscle is lengthening. This eccentric contraction opposes the muscle that is undergoing concentric contraction to help control movement.
As you can see here, as the individual lands on the ground, the hamstrings are CONCENTRICALLY contracting to bend the knee, and the quadriceps are ECCENTRICALLY contracting to oppose the hamstrings to help with shock absorption and balance.
If this occurs too quickly and forcefully, the combination of a lengthening muscle that is undergoing contraction results in excessive pull occurring at the tendon, resulting in tearing or rupture. The 3 mechanisms for this to occur is
- Sudden deceleration of the leg (kicking)
- Violent contraction of the quadriceps (sprinting)
- Rapid decleration of an overstretched muscle.
How do you recover from a quad tear?
If you are lucky enough to suffer a grade 1 or grade 2 strain, treatment can be done conservatively with a chiropractor or physio through exercise rehabilitation and manual therapy, with the goal of improving function/strength, improving range of motion, and decreasing pain.
If you suffer a grade 3 strain, surgical repair is often needed to bring the disconnected tissues back together. In Oladipos’ case, he suffered a grade 3 strain and has opted for surgery. As shown below, they drill holes in the kneecap and re-attach the quad tendon to the patella.
There are 3 phases of quad tear rehabilitation for grade 1 and 2 tears, where grade 1 tears will take less time to heal (<12 weeks) and grade 2 will take around the 12 week range. In Oladipos’ case, since he opted for surgery his timetable will be much longer.
Phase 1 (24-48hrs):The goal of the first phase is to decrease pain and inflammation while improving flexibility and range of motion, and improve muscular healing. This is done through ice, and manual therapy techniques done by your chiropractor or physio such and joint mobilization and muscle work. Exercises such as isometric quadricep and hamstring contractions are implemented.
Phase 2 (weeks 3-12):The goal of this phase is to regain pain free quadriceps strength, progressing through full knee range of motion, as well as regaining neuromuscular control of the knee and pelvis, and preparing for functional movements. Exercises done in phase 1 are further progressed to add heavier weight, with eventual graduation to move advanced functional exercises. Cycling is introduced when ability to move the knee is above satisfactory levels.
Phase 3 (weeks 12+): The goal at 12 weeks is to be symptom free during all activities and to have normal strength of the knee. Plyometric exercises, sprinting, single leg training, and sport specific drills that improve sport performance.
Oladipo’s path to recovery will be much longer. Post-surgery, he will have to keep his knee in a brace for 6 weeks in order to allow the new tendon repair to properly heal. Compared to ACL surgery or meniscus repair, rehabilitation can be started relatively early, but in the case of a quad tear, rehabilitation is halted for those 6 weeks to allow for the tendon to completely heal back onto the bone. That makes a quad tear a tougher injury to come back from.
Once 6 weeks passes, his phase 1 training will be extended longer than a grade 1 or 2 strain due to the amount of atrophy and strength loss due to the lack of use over that 6 weeks in a cast. Once he can adequately regain some quad and hamstring strength, he can progress to phase 2 and 3, and then hopefully make it back to the court for the start of the 2019-2020 season.
Grade 1 and 2 quad strains are easily managed, but grade 3 strains are no fun, of any region of the body. While we at Spine and Sports don’t do surgery in house, we are well equipped to managed grade 1 and 2 strains of any region of the body with manual therapy, exercise, and home care advice.
Thanks for reading, tune in next month for the most recent injury in the sport world. Email us with any questions or injuries you want to hear about next @ firstname.lastname@example.org.
Stay strong, stay heathy.
Doctor of Chiropractic, B.HKin.