Quadriceps Tendonitis

Quadriceps tendonitis will usually start with a pain in the front (anterior) of the knee, usually along the top (superior) border of the patella. Characterised by pain on a resisted contraction of the quadricep muscles, in initial stages, this pain may improve with activity, once the tendon “warms up” however as the inflammation progresses, pain can worsen with the aggravating activity until it is constant and can negatively impact performance and function of the knee. There may also be swelling present and the knee may not feel as strong when trying to push off, change directions or accelerate. Often the tendon is quite tender on firm palpation and there may be pain when bending the knee especially into full range of motion as with any stretching of the quadriceps, the tendon is placed under tension.

Physiotherapists can usually make an accurate diagnosis of quadriceps tendonitis after a thorough subjective and objective assessment. While investigations such as X-ray, Ultrasound, MRI or CT Scan aren’t routinely required, they may be useful in confirming the diagnosis or establishing the severity of the inflammation.

As with any inflammation-based injury, initial treatment should prioritise avoiding any aggravating activities or positions e.g., kicking, running or squatting and taking measures to reduce the inflammation.

It is advised to adopt the RICE principle for the first 48-72 hours to reduce inflammation:

Rest

Avoid any aggravating activities/positions and try to limit load placed through the leg/knee. It is best to think of this advice as “active rest” and not become completely immobile. Complete rest and immobility can risk joint stiffness and muscle atrophy through disuse, so it is recommended that some activity continues as tolerated. Try to maintain range of movement and muscle strength if possible, during the rest period

Ice

Use either an ice pack, bag of frozen vegetables (peas work well as they mould to the knee) or cryo-cuff. Ensure you only apply for a maximum of 20 minutes at a time and never apply directly to the skin due to risk of ice burn. Make sure you check your skin in between applications and allow it time to recover (look for a return to normal skin colour and temperature) before re-applying ice. A good general rule of thumb is one hour in between each 20-minute session

Compression

This helps to reduce or prevent any swelling, use either a knee sleeve, Tubigrip, crepe bandage or even firm “activewear” leggings. If you are applying bandages, ensure compression isn’t too tight that it pushes swelling down (distally) towards the shin. Compression should not cause any irritation to skin and should not be so tight that it cuts in, leaving indents

Elevation

The knee ideally needs to be above the level of the heart, again to assist with swelling reduction as it uses gravity to facilitate drainage. Prop the knee up on pillows while lying in bed/on the couch.

Anti-inflammatory medications (such as ibuprofen) can also be useful during initial stages of injury however always consult with your pharmacist or doctor especially if you are taking any other medications.

While early tendonitis may resolve on its own with the elimination of aggravating activity, recovery can be hastened with treatment by a physiotherapist. Physiotherapy treatment will usually comprise of releasing any tight muscles (often the quadriceps but also possibly including the Iliotibial Band) including trigger points and teaching appropriate stretching techniques, mobilising stiff joints, electrotherapy such as ultrasound and advice of the use of braces or taping of the patella to offload the tendon. Self-applied transverse friction massage across the tendon is a manual technique that a patient can perform independently at home to assist healing.

Not only does treatment focus on the affected knee but also correcting any muscle imbalances throughout the entire lower limbs and pelvis, ensuring correct alignment of the patella, activation of the core and glute muscles, potentially also a biomechanics assessment, balance assessment and gait analysis. Although a knee injury, the cause of quadriceps tendonitis can sometimes originate in an adjacent joint such as the foot, ankle or the hip and for this reason, footwear analysis and orthotic prescription may also prove beneficial.

If the tendonitis does not respond to conservative physiotherapy, in consultation with a medical professional, a corticosteroid injection or autologous blood injection (where a patient’s blood is injected into the tendon to facilitate healing,) may be considered.

Rehabilitation for quadriceps tendonitis follows a similar pathway for other forms of tendonitis and is understandably very similar to that of patella tendonitis (sometimes referred to as Jumper’s Knee.) While there is a large amount of theoretical research into the best approach for tendonitis rehabilitation, the physiotherapy/medical community is, unfortunately, lacking in any high-quality clinical trials. Depending on the length of injury and severity, recovery time can vary. Early treatment is imperative to avoid the inflammation becoming chronic which leads to a longer recovery time. Once the condition increases in severity, recovery time understandably increases. Keep in mind that while muscles take 6-8 weeks to respond to a strength program, tendons take 3-4 months to respond so patience is required and rehab programs should progress over 12 weeks at least with a gradual return to exercise/activity, monitoring for any symptoms and trying to avoid re-injury.

Tom Goom, a well-regarded physiotherapist who specialises in running injuries developed the following Tendinopathy Rehab Progression

Stretching

The tendon is part of the muscle which is why muscle strengthening and stretching plays such a pivotal role in tendonitis rehabilitation. A tight muscle is going to cause pulling and tension on the tendon insertion, resulting in inflammation or overload.

Stretches for the quadricep muscles

Choose the best option for you in any position where there is bending of the knee and the heel is brought towards the bottom.

1)          Kneeling quadriceps stretch

While kneeling on one knee (with the leg you want to stretch, knee and shin on the ground) By lunging or shifting your weight forward you should feel a stretch in the quadriceps of the back leg, up towards the hip flexor and the front of the hip. To increase the stretch (and if you have the balance) you can grab your back ankle and gently bring it towards your bottom.

2)          Standing quadriceps stretch

Hold on to a stable surface (such as a table or back of a chair) for balance, bending your knee, bring your heel up behind you towards your bottom and grab hold of it by the ankle. Try and keep your knees together and squeeze your bottom muscles to increase the stretch

3)          Prone quadricep stretch

Lying on your stomach, bend your knee to bring your heel up to your bottom, holding on to it around the ankle. To increase the stretch, bring the heel closer, and even try and lift the knee off the ground

Strengthening

Historically, the focus of rehab was placed on eccentric exercises where the muscle undergoes strengthening stimulus while it is lengthening. However, isometric exercises have been found to be more beneficial (especially as they can be performed pain-free) as well as Heavy Slow Resistance Training (HSRT.) HSRT involves higher load being placed through the tendon for fewer repetitions, resulting in greater time under tension and greater tendon adaptation. Keep in mind that it is common for a patient or athlete to “unload” their affected leg due to pain resulting in weakness through that limb. Most will find that they can commence weight-bearing strengthening exercises once pain has improved if the tendonitis is severe and pain is still present on weight-bearing then hydrotherapy provides a good option to allow strengthening in a low impact setting.

Strengthening for the Quadriceps Muscles

1)          Inner range quads

With a rolled-up towel or jumper placed under your knee, contract the muscles of your knee, squeezing the leg straight and lifting the heel off the bed. Hold for 3-5 seconds squeezing the towel down, before lowering heel back to the bed

2)          Straight leg raises

Contracting the quadriceps muscles to straighten the knee, keep the knee straight and then lift it off the bed. Hold for 3-5 seconds before slowly lowering it back down to the starting position

3)          Seated knee extension

Sitting in a chair or on the edge of a bed/couch, contract the quadriceps muscles lifting the foot until the knee is completely straight. Hold for 3-5 seconds  and then slowly lower down

4)          Drop squats

Standing in an upright position with feet hip-width apart, drop into a squat position and when you reach a 90-degree angle at your hips and knees, stop yourself as quickly as possible. Hold in the bottom position for approximately 3 seconds and then return to the starting position. This is a great exercise for eccentric control of the knee joint

If any of the above exercises cause pain or an increase in symptoms, then cease immediately

Core exercises

1)          Abdominal activation

Lying on your back with knees bent up and feet flat on the ground (in a position known as crook lying.) Gently draw in your lower, deep layer of abdominal muscles.

Try and visualise drawing your belly button down towards your spine. By placing a finger on your abdomen, just inside your hip bone, you should feel the core muscles firming and drawing in. Try and build the length of your contractions, aiming for 10 seconds

2)          Glute bridges

Again, in crook lying, contract your bottom (gluteal) muscles and slowly lift your hips off the bed. Hold for a few seconds at the top. Keep your hips steady and level throughout and slowly lower back down

3)          Plank

One of the most popular core strengthening exercises. Position yourself on your forearms with your elbows under your shoulders. You can either start on your knees or progress to your toes to make it harder, holding your body in a straight line. Engage your entire trunk by stabilising through the shoulders, drawing in your core abdominals and squeezing your gluteals to tuck your bottom in. Try and hold for as long as you can but stop as soon as you feel your back arching.

Once an athlete has been deemed ready to return to sport, care needs to be taken to prevent reinjury. Unfortunately, the rate of recurrence is high especially if the initial cause of the overload is not adequately addressed.  Consideration needs to be given to the playing surface, a gradual progression to full activity, appropriate footwear, adequate warm-up and cool downtime as well as recovery time post-training/match play.

While best results are seen when treatment is guided by a physiotherapist, frequent visits are usually not required as an effective rehab program can easily be done at home or in the gym with periodic follow-ups with your therapist to check and progress your program.