Bilateral Quadriceps Tendon Rupture: A Rare Finding in a Healthy Man

Bilateral Quadriceps Tendon Rupture: A Rare Finding in a Healthy Man After Minimal Trauma
By Michael Chiu, BS; Edward S. Forman, DO
ORTHOPEDICS 2010; 33:203

March 2010
Abstract

Quadriceps tendon rupture is an uncommon injury; the incidence of simultaneous bilateral quadriceps tendon rupture is extremely rare. Two distinct categories—individuals older than 50 years and between 27 and 54 years—have been described. Bilateral quadriceps tendon rupture is more common in patients older than 50 years and is thought to be the result of tendon weakening due to obesity and arteriosclerosis-induced fibrotic changes, or previous injury.

In younger individuals, bilateral simultaneous quadriceps rupture is less frequent and has been associated with anabolic steroid use, but more frequently with underlying comorbid medical conditions such as chronic renal failure, hyperparathyroidism, endocrine disorder, gout, diabetes and obesity, which predispose the patients to tendon rupture. Our case report is unique because we report the simultaneous bilateral quadriceps tendon rupture following minor trauma in an otherwise healthy 43-year-old man with no predisposing comorbidity.

Quadriceps tendon rupture is an uncommon injury; simultaneous bilateral quadriceps tendon rupture is extremely rare. First described by Steiner and Palmer1 in 1949, bilateral quadriceps tendon rupture is more common in patients older than 50 years and is thought to be the result of tendon weakening due to obesity and arteriosclerosis-induced fibrotic changes, or previous injury.1 In younger individuals, bilateral rupture is less frequent and has been associated with anabolic steroid use,2,3 but more frequently with underlying comorbid medical conditions, such as chronic renal failure,4,5 hyperparathyroidism,5 endocrine disorder, gout, diabetes and obesity, which predispose the patients to tendon rupture.6 This article presents a case of simultaneous bilateral quadriceps tendon rupture following minor trauma in an otherwise healthy 43-year-old man with no predisposing comorbidity.
Case Report

A 43-year-old man with no significant past medical history presented with bilateral knee pain, claiming to have stubbed his toe and fallen. He reported having felt his right quadriceps tendon rupture, and while trying to catch his balance, felt the left side rupture as well. The patient also reported having muscle cramps in addition to burning in his thighs during the weeks leading up to the injury. Upon physical examination, he was unable to extend his knees bilaterally. Magnetic resonance imaging confirmed the clinical diagnosis of bilateral quadriceps tendon rupture.

Surgical repair was conducted under spinal anesthetic, and a standard midline incision revealed complete rupture of the right tendon. It is important to note that the rupture on the right occurred at the musculotendinous junction. No. 5 Ethibond sutures in a Bunnel-type fashion were passed through drill holes in the patella for the repair. Due to the fact that this was a musculotendinous rupture, No. 5 Mersilene tape was passed through the quadriceps musculature in a “pants-over-vest” fashion to augment the repair.

Subsequently, the left quadriceps tendon was exposed through a standard midline incision and repaired in similar fashion. No. 5 Ethibond sutures were passed through the drill holes in the patella. No. 5 Mersilene tape was also used to augment the left quadriceps tendon repair. Both legs were locked in full extension with hinged knee immobilizers for 6 weeks before supervised physical therapy was started. Weight bearing was allowed as tolerated on the bilateral lower extremities with crutches.

At 2-week follow-up, the patient was ambulating with knee immobilizers and crutches without difficulty. He was able to maintain a straight leg raise bilaterally.

At 4-week follow-up, his active range of motion (ROM) was 0° to 100° bilaterally. Quadriceps tone was good when firing on full extension.

At 6-week follow-up, he was doing well, with bilateral ROM of 0° to 110°. Formal physical therapy was started at this time.

At 10-week follow-up, he was ambulating independently without difficulty and had returned to his activities of daily living without complications. He had some mild crepitance over the left knee, consistent with mild scar tissue formation.

At 5-month follow-up, the patient had persistent crepitance in his left knee, which was symptomatic. Therefore, a left knee arthroscopy for debridement of arthrofibrotic tissue was scheduled for the left knee.

Eight days after arthroscopy, the patient reported having a fever (temperature, 101°-102°F) and had received antibiotic injection and pills from his primary physician. Physical examination of the left knee demonstrated a moderate effusion, increased warmth to the touch, and decreased ROM. Aseptic aspiration revealed a turbid yellow fluid. Arthroscopic lavage was performed.

Three weeks after his repeat lavage, he had no complaints, was walking well, and had full ROM of his knees. Six months after the bilateral quadriceps tendon repair surgeries, the patient had recovered and returned to full activities without further complication.
Discussion

Simultaneous bilateral quadriceps tendon rupture is a rare injury. It is usually associated with chronic renal failure,6 hyperparathyroidism, diabetes, long-term dialysis, rheumatoid arthritis, systemic lupus, and gout.4 In addition, cases of anabolic steroid use,2,3 “pseudogout,”7 alkaptonuria,8 and severe osteomalacia9 have also been reported.

Due to its rare incidence, simultaneous bilateral quadriceps tendon rupture is often misdiagnosed,10,11 and many patients have been initially treated for osteoarthritis,12 strokes, rheumatoid arthritis, and bilateral effusions.10 As a result, surgical complications of scar formation and soft tissue retraction may occur, which can lead to poor postoperative recovery.4,7,13 Early surgical treatment is thought to be important for good outcome and full recovery.6

Although many comorbidities are associated with this injury, there is one general mechanism of quadriceps tendon rupture. The most common cause of simultaneous bilateral quadriceps tendon rupture appears to be a sudden, violent contraction of the quadriceps mechanism with the knees slightly flexed and the feet in a fixed position.10 According to the 31 cases reported by Ribbans and Angus,11 the age of patients with simultaneous bilateral quadriceps tendon rupture varies extensively; nonetheless, 2 distinct categories, individuals older than 50 years and those aged 27 to 54 years, have been described.11,14-17

When the population of patients with simultaneous bilateral quadriceps tendon rupture is considered, it is evident that the injury occurs more readily in persons older than 50 years. It typically entails a history of diabetes, obesity, and age-related predisposing factors acquired over time.11 These changes can include fatty degeneration of the tendon, decreased tendon collagen composition, tendinosclerosis, and fibroid degeneration.11 Obesity may cause fatty degeneration of the tendon and increased loading of the semi-flexed knee tendon.13 Diabetes can include all the previously mentioned transformations, as well as atherosclerosis, fibrinous necrosis, and microvascular changes that affect the tendon vascularity.4

Simultaneous bilateral quadriceps tendon rupture occurs less commonly in individuals between ages 27 and 54.14-16 The patient history in this age group is characteristic of chronic renal failure, hyperparathyroidism, anabolic steroid use, gout, and previous unilateral rupture.11 In chronic renal failure and chronic metabolic acidosis, tendon collagen content alteration and elastosis result, which predisposes the patient to tendon rupture. Hyperparathyroidism, however, is thought to cause calcification of the tendon and subperiostal bone reabsorption, thus leading to rupture by weakening the tendon at the site of insertion.5,10 Steroid usage alters collagen cross-linking, especially in conjunction with exercise, and can lead to dysplasia and excess buildup of collagen fibers.2,3 In patients with gout, the disorder is associated with fibrinous necrosis as with diabetes and chronic inflammatory reactions, leading to similar tendon content modifications, which ultimately predispose the patient to tendon rupture, even at a low tendon tension.4,14

Our patient, an otherwise healthy 43-year-old man who simultaneously ruptured both quadriceps tendons following minor trauma, falls into this latter, younger category. However, he had no predisposing comorbidity. To our knowledge, simultaneous bilateral quadriceps tendon rupture of in individuals belonging to the younger age category without any known comorbidity has been reported in only 2 other cases: a patient who was playing basketball18 and a weightlifter.19 Both patients, ages 39 and 40 years, respectively, are within the younger category limits, with the former being undercut by another player during a shot and landing with flexed knees beneath his own body weight, and with the weightlifter falling while squatting 650 lb.

Our case, however, provides a distinct situation in which the patient was injured performing a considerably less strenuous activity—walking. This circumstance has not yet been reported in a case of bilateral quadriceps tendon rupture in a patient without any comorbidity. Compared with the 2 athlete cases,15,16 much less tendon tension was present, with our patient stubbing his right toe on extension and rupturing the first quadriceps tendon, and then rupturing the second as he attempted to catch his fall with his left leg; both ruptures occurred solely under his own body weight without any additional stress.
References

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Authors

Mr Chiu is from Chicago Medical School, and Dr Forman is from the Illinois Bone and Joint Institute, Chicago, Illinois.

Mr Chiu and Dr Forman have no relevant financial relationships to disclose.

Correspondence should be addressed to: Edward S. Forman, DO, Illinois Bone and Joint Institute, 2740 W Foster Ave, Chicago, IL 60625 (eforman@ibji.com).

doi: 10.3928/01477447-20100129-32

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