Quadriceps Tendinopathy
1. Introduction
The quadriceps are a group of four muscles found on the front of the thigh. They work together to extend or straighten the knee and control knee bending when you are on your feet. They play an important role in activities such as standing up from a chair, climbing stairs, running, jumping, squatting and kicking (2).
The quadricep tendon connects these four muscles to the top of the kneecap (patella). Historically, tendinopathies were referred to as ‘tendinitis’ based on belief that the condition was caused predominately by inflammation. However, our understanding has improved, and it is now accepted that most tendinopathies are caused by tendon degeneration (1).
Currently, the best evidence for treating a tendinopathy is based on progressive and appropriate loading of the tendon (5,6). Orthotics and analgesics can be effective in relieving symptoms (6). Most tendinopathies will respond well to activity modification and gradual strengthening. A corticosteroid injection or surgery can be considered on an individual basis, if all other treatment options have been exhausted (3).
Frequently Asked Questions
- Quadriceps tendinopathy is a condition usually caused by overuse of a group of 4 muscles that make up the front of the thigh. Pain is felt on activity at the top of the kneecap where the thigh muscles insert into it (2).
- It is a rare condition – affecting less than 1% of the population (7).
- It is more common in athletes (7); especially in basketball and volleyball players (2, 3).
- No
- With the correct rehabilitation approach tendinopathies generally recover well.
- They are not linked to other serious pathology (3).
- Slightly more common in males than females.
- More common in sporting groups.
- Risk of this condition increases in sports such as volleyball and basketball (2, 3,7).
- Pain in the front of your thigh where it meets kneecap.
- Stiffness, especially in the morning.
- Reduced range of movement.
- Swelling.
- Tenderness.
- Weakness.
Most tendinopathies respond well to non-invasive treatment (3)
- Activity modification – avoiding / pacing activities that aggravate symptoms.
- Physiotherapy programme to increase strength, flexibility and mobility.
- Exercise that involves progressive and appropriate loading of the tendon to increase its tensile strength.
With an appropriate physiotherapy programme:
- Mild tendon injuries can heal in two or three weeks.
- Persistent tendinopathies take longer, usually between 3-6 months (1, 6).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk. Book online with us today to get a programme tailored to your specific needs.
2. Signs and Symptoms
Quadricep tendinopathy causes pain in the front of the knee just above the kneecap. Usually, the pain is dull and gradually increases over time. It may get worse after sitting down for too long or jumping, squatting, and running. Stiffness and tightness in the quadricep tendon may also be experienced. These initial symptoms are often ignored as they quickly disappear with walking or the application of heat (3).
Tendon pain is ‘dose–dependent’, which means the pain will be aggravated based on the amount of load placed on it (6). This means if you load the tendon excessively or perform repetitive movements in a relatively short period of time, the tendon cannot adapt quick enough. The tendon may begin to break down leading to pain and developing a tendinopathy (1).
Avoid “boom and bust” with exercise!
Symptoms can be classified into 5 stages (3):
- Stage 0: No pain.
- Stage 1: Pain only after intense sports activities. No functional impairment.
- Stage 2: Moderate pain during sporting activities. No restriction on performance.
- Stage 3: Pain during sporting activities with slight restriction on performance.
- Stage 4: Pain with severe restriction of sports performance.
- Stage 5: Pain during daily activities. Unable to participate in sports activities.
3. Causes
The most common causes of quadricep tendinopathy are overuse or repeated actions such as (5):
- Sports, particularly jumping sports, like volleyball or basketball
- Overload from repeated jumping / running on hard surfaces and sudden increase in physical activity without sufficient recovery time
- Inefficient walking mechanics
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing a quadriceps tendinopathy (2,3). It does not mean everyone with these risk factors will develop symptoms:
- Age – as you get older, the tendons become less flexible and more prone to degeneration.
- Weight – excess body weight puts extra stress on the tendons.
- Tightness – tight hamstrings and quad muscles increase pressure on your tendons.
- Chronic disease – such as lupus and diabetes, reduce blood supply to the knee. This weakens the tendons and increases the risk of degeneration from poor healing ability.
- Alignment problems – if your joints or bones aren’t properly aligned, one leg will be placed under more stress. Muscular imbalances can have a similar effect.
- Height – Taller people are linked with an increased prevalence.
5. Prevalence
The prevalence of Quadriceps Tendinopathy is less than 1% in the general population. It has a higher prevalence in the athletes than in the general population. Its prevalence in elite athletes with knee pain is 14.2% which rises to 45% in sports like basketball or volleyball (3, 7).
More recent studies reveal quadriceps tendinopathy does exist in general population and there were associations linked to obesity, lifting heavier weights, and increased height. They show there is a clear need for further studies to identify risk factors and prevalence of quadriceps tendinopathy in the non-athlete population (2).
6. Assessment & Diagnosis
A musculoskeletal physiotherapist can provide you with an accurate diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other conditions and gain a greater understanding of your physical abilities.
Your physiotherapist will ask how your condition affects you day-to-day so that treatment can be tailored to your needs. Intermittent re-assessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Scans, like MRI or ultrasound, are usually not required to achieve a working diagnosis, but in unusual presentations they may be warranted.
7. Self-Management
As part of your treatment, your physiotherapist will help you understand the condition and what needs to be implemented to effectively manage your quadricep tendinopathy. This will include activity modification strategies and gradual strengthening as well as other useful treatments aimed at reducing discomfort. Regular adherence to a condition specific rehabilitation programme is important in the management of quadricep tendinopathy. It should be noted that rehabilitation exercises are not a quick fix but if adhered to on a consistent basis (weeks to months), over time they have been shown to yield positive outcomes.
8. Rehabilitation
Research is very clear that modifying the load on the tendon is the key element which stimulates recovery (6). Recovery can take some time as the speed of tendon regeneration is much slower than other structures in the body.
Your Physiotherapist will give guidance on the progression of your exercises to gradually increase the load being put through the tendon. For patients wanting to return to sports or achieve a high level of function, more demanding exercises will be introduced at the correct time to facilitate this.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing Quadricep tendinopathies. In some instances, a one-to-one assessment is appropriate to individual tailor targeted rehabilitation. However, these programs provide an excellent starting point as well as clearly highlighting exercise progression.
9. Quadriceps Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on maintaining a range of movement within the knee, appropriate loading of the affected tendon and maintenance of lower limb strength and stability.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next progression. More focus is given to progressive loading of the tendon and lower limb strengthening.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging progressive loading of the affected tendon complex.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport a consultation with a physiotherapist would be encouraged. As, you will likely require further progression beyond the advanced rehabilitation stage.
The best evidence currently for people returning to sporting activities require the inclusion of plyometric exercise, in which muscles exert maximum force in short intervals of time, with the goal of increasing power in your rehabilitation programme e.g., bounding, cutting and jumping (6).
As an adjunct to your progressive loading programme, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.
11. Other Treatment Options
Podiatry referral to address pronounced bio-mechanical alignment issues may be helpful in the short term. However, there is a lack of quality evidence regarding long-term value when it comes to tendon related injuries.
Corticosteroid injections should only be considered as a last resort if appropriate and progressive conservative management has failed. This will not fix the problem but gives the patient a ‘window of opportunity’ to start rehabilitation if symptoms are too painful. However, careful consideration is needed for each individual case due to the risk of side effects in some people (3,6).
Surgery – this should be the last option if all other treatment attempts have been exhausted. Arthroscopic and open surgical procedures have shown good outcomes in patients with severe symptoms who have failed non-operative treatment (3).
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References
- Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed. 2000 May; 28(5):38-48.
- King D, Yakubek G, Chughtai M, et al. Quadriceps tendinopathy: a review-part 1: epidemiology and diagnosis. Ann Transl Med. 2019;7(4):71. doi:10.21037/atm.2019.01.58
- King D, Yakubek G, Chughtai M, et al. Quadriceps tendinopathy: a review, part 2-classification, prognosis, and treatment. Ann Transl Med. 2019;7(4):72. doi:10.21037/atm.2019.01.63
- Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005 Apr;33(4):561-7. doi: 10.1177/0363546504270454. Epub 2005 Feb 8. PMID: 15722279.
- Lin, T. W., Cardenas, L. & Soslowsky, L. J. (2004). Biomechanics of tendon injury and repair. Journal of biomechanics, 37(6), 865-877.
- Malliaras, P., Cook, J., Purdam, C. & Rio, E. (2015). Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. Journal of orthopaedic & sports physical therapy, 45(11), 887-898
- M. Cassel H. Baur A. Hirschmüller A. Carlsohn K. Fröhlich F. Mayer, Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes, 11 September 2014 https://doi.org/10.1111/sms.12318
Other Conditions in
Hips & Pelvis, Upper Legs, Knees
Sacroiliac Joint Dysfunction
Pain originating from the sacroiliac joint at the base of your back where the spine joins the pelvis.
Proximal Hamstring Tendinopathy
Pain and weakness under the buttock or the back of your upper thigh caused by tendon issues.
Pelvic Girdle Pain
Typically seen in pregnancy causing pain, instability and limitation of mobility and functioning of the pelvic joints.
Pelvic Floor Dysfunction
The inability to effectively control the muscles of your pelvic floor, leading to issues with continence and pain.
Meralgia Paraesthetica
Pain on the outside thigh caused by compression and inflammation of the nerve that supplies that area
Lumbar Disc Injury
Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Hip Replacement Surgery
Replacement of the hip ball and socket joint, typically as a result of severe osteoarthritis or trauma.
Hip Osteoarthritis
Common age-related changes to the structure of the hip joint may be associated with pain, stiffness and loss of function.
Hamstring Strain/Tear
An over-stretch or tear to one or more of the muscles located at the back of the thigh.
Greater Trochanteric Pain Syndrome
A condition affecting the tendons that insert into outside of the hip. A common cause of pain felt around the hip and pelvis.
Femoroacetabular Impingement
A condition that results in pain in the groin, hip and down the front of the thigh.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Coccydynia
Coccydynia is the medical term used to describe pain in your coccyx (tail bone).
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Adolescent Hip Dysplasia
A result of an abnormality of the hip joint anatomy resulting in pain in the hip with occasional instability.
Adductor-Related Groin Pain
Localised discomfort to the inner upper thigh and groin.