Returning to Sport After a Quadriceps Contusion: Physiotherapy Guidelines

A quadriceps contusion is an extremely common sports injury and is known colloquially as a "charley horse," "cork thigh," or "dead leg." It occurs when there is a direct blow to the quadriceps muscle group on the front of the thigh. This trauma causes the muscle fibers and connective tissue to be crushed without breaking the skin, leading to pain, swelling and sometimes bruising (hematoma).

Quadriceps Contusions can lead to two serious complications, Compartment Syndrome and Myositis Ossificans.

Compartment Syndrome

Compartment syndrome occurs when pressure within a closed muscle compartment increases to the point that it compromises blood flow, leading to muscle and nerve damage. The anterior part of thigh is prone to it, intramuscular hematoma of the thigh after a blunt contusion increases the intracompartment pressures.

Myositis Ossificans

When the hematoma calcifies usually after the injury to anterior part of thigh, this is known as "myositis ossificans". It is seen in the form of palpable lump; after few weeks of injury.

 

Symptoms of Quadriceps Contusion

The symptoms of a quadriceps contusion include:

• sharp pain at the site of the injury which worsen after 24-48 hours
• immediate or gradual swelling in the anterior part of the thigh
• visible bruising (hematoma) that may appear immediately or develop over time
• muscle stiffness
• tenderness around the injured area
• reduced range of motion
• muscle weakness in the quadriceps muscles, making it hard to walk or bear weight
• altered gait or limping to avoid putting pressure on the injured leg

 

Causes of Quadriceps Contusion

The primary causes of a quadriceps contusion include:

• Direct Blow - such as being struck by an object (e.g., a ball or helmet) or another person during contact sports like football, rugby, soccer, or basketball.
• Falling directly onto the thigh, which can cause the muscle to be compressed against the underlying bone
• Accidental collisions - with objects (like a bike or car) or other players during combat sports

 

Diagnosing Quadriceps Contusion

Physiotherapy diagnosis for a quadriceps contusion involves a comprehensive assessment to determine the extent of the injury and guide appropriate treatment. Here’s an outline of the process:

Patient History:

• Incident Description: Details about how the injury occurred (e.g., direct blow, fall, etc.).
• Symptom Onset: When symptoms started and their progression.
• Pain Level: Description of pain intensity, location, and any exacerbating or relieving factors.
• Functional Impact: How the injury is affecting daily activities and mobility.

Physical Examination:

• Observation: Look for visible signs of swelling, bruising, or deformity.
• Palpation: Gently feel the affected area to assess tenderness, swelling, and the presence of a hematoma. Note any differences in muscle texture compared to the uninjured side.
• Range of Motion (ROM): Assess knee and hip movements. Limited knee flexion due to pain or muscle stiffness is common.
• Strength Testing: Evaluate the strength of the quadriceps muscle. Weakness may be present due to pain or muscle damage. Resisted knee extension and hip flexion, compared to the uninjured side, helps in assessing severity of injury.
• Functional Tests: Observe the patient’s ability to perform activities like walking, squatting, or climbing stairs. Look for any compensatory movements or limping.

Special Tests:

• Swelling Assessment: Use techniques to measure swelling, such as circumferential measurements of the thigh compared to uninjured leg.
• Pain Assessment: Use pain scales or questionnaires to gauge the intensity and impact of pain on function i.e. Visual Analog Scale.
• Provocative Tests: Use active straight leg raise to test integrity of extensor muscles.
• Neurovascular Assessment: Evaluate for thigh compartment syndrome usually the distal part.

Imaging Studies:

• Ultrasound: Can help assess the extent of muscle damage and the presence of a hematoma.
• MRI: In severe cases, an MRI may be used to evaluate muscle damage and rule out more serious injuries.

 

Differential Diagnosis

• Quadriceps Strain
• Quadriceps Tear
• Muscle Hematoma
• Anterior Cruciate Ligament (ACL) Tear
• Medial Collateral Ligament (MCL) Sprain
• Patellar Fracture
• Patellar Tendon Rupture
• Bursitis
• Deep Vein Thrombosis (DVT)
• Compartment Syndrome
• Hip Flexor Strain

 

Physiotherapy Management for Quadriceps Contusion

Physiotherapy management for a quadriceps contusion is done on the basis of grading criteria i.e. mild, moderate and severe. Here's a detailed approach:

Mild Quadriceps Contusion

• Icing(Cryotherapy) is done and bandage is applied for first 24-48 hours in 120 degrees of knee flexion.
• ROM Exercises are performed which is then progressed towards Strengthening Exercises.
• Soft tissue therapy and electrotherapy is also effective

 

Moderate Quadriceps Contusion

The treatment of a moderate thigh contusion can be divided into four stages:

Stage 1

The most important period in the treatment of a thigh contusion is in the first 24 hours following the injury.

•  RICE regime is prescribed, compression to  knee joint is include
• Electrotherapy includes Electrical Stimulation and Pulsed mode of Therapeutic Ultrasound
•  Gentle stretch is applied within pain free rang
• Static muscle contraction is performed if tolerated by the patient
• Crutches can be prescribed if patient is unable to perform full weight bearing

Stage 2

• Use of Compression bandages is continued along with icing(performed after the exercises).
• Pulsed Ultrasound is used with slight increase in intensity
• Static muscle contraction is performed within pain free range
• Stationary Exercise using a stationary bike can be performed
• Concentric and eccentric exercise are also advised
• Patient is progressed towards Partial Weight Bearing

Stage 3

• RICE regime is discontinued
• All stage 2 exercises are performed but with gradual increase in repetitions, speed and resistance
• Include pulleys, wall squats and step-down exercises
• Increase intensity of eccentric exercises

Stage 4

• Perform kicking action with pulleys
• Multidirectional activities are incorporated
• Figure of eight is performed in supine position initially
• Plyometrics Exercises are advised
• Graduated specific sporting activities are included according to patients improvement
• Heat-retaining brace may be helpful

Severe Quadriceps Contusion

• Cryotherapy is performed regularly for2-3 days
• Active Stretching exercises are performed after 2-3 days
• Therapeutic Ultrasound and application of excessive pressure is avoided for around 10 days due to chances of re-bleeding