Treatment of Distal Medial Quadriceps Tendon Tear with Superior Knee Swelling
Complete quadriceps tendon tears require immediate surgical repair to restore extensor mechanism function and achieve optimal outcomes, while partial tears with intact extensor mechanism may be managed conservatively. 1
Initial Assessment and Diagnosis
Determine if the tear is complete or partial through clinical examination:
- Complete tear: Loss of active knee extension, palpable suprapatellar defect, inability to perform straight leg raise 1, 2
- Partial tear: Maintained active extension (though possibly weakened), less pronounced defect 1
- Superior knee swelling suggests acute injury with hematoma formation 2
Imaging confirmation:
- Plain radiographs first to identify inferiorly positioned patella (pathognomonic sign) and rule out fractures 2, 3
- MRI is not required for clinical diagnosis but can confirm extent of tear if uncertain 1, 2
Treatment Algorithm
For Complete Tears (No Active Extension)
Proceed directly to surgical repair as soon as possible—delayed surgery worsens outcomes and increases complications: 1, 2
Surgical technique options:
- Transosseous tunnel repair (most common): Krackow sutures passed through longitudinal patellar bone tunnels with knee in full extension 1
- Suture anchor repair: FiberTape in Krackow pattern secured with knotless SwiveLock anchors—shorter operative time but higher cost 1
Critical surgical principles:
- Debride degenerative tissue and evacuate hematoma 1
- Roughen anatomic insertion site to expose fresh cancellous bone 1
- Repair concomitant medial/lateral retinacular tears (commonly present) 1
- Consider augmentation with wire, screws, or MERSILENE tape if primary construct appears unstable 1
Post-operative immobilization:
- Complete immobilization in extension for 4 weeks appears superior to early mobilization for achieving better muscle force recovery 2
- Begin physiotherapy after initial immobilization period 2, 3
For Partial Tears (Intact Active Extension)
Conservative management is appropriate: 1
- Relative rest: Reduce activities that provoke pain while maintaining some movement to prevent atrophy 4
- Hinged knee brace immobilization initially 1
- Ice therapy for acute swelling and pain relief 4
- NSAIDs (topical preferred to avoid GI complications) for pain control 5
- Eccentric strengthening exercises once acute phase resolves to stimulate collagen production and proper fiber alignment 4, 5
Duration: 3-6 months of conservative therapy before considering surgical intervention 4, 5
Expected Outcomes
Complete tears with surgical repair:
90% return to pre-injury function and work 1
- <5° range of motion deficit compared to contralateral knee 1
- Average recovery time: 4 months for daily activities, though complete recovery takes longer 2
- However, high-level athletes have only 50% return-to-play rate in professional sports 6
Complications (rare, <3%):
- Most common: knee stiffness and quadriceps atrophy (manageable with rehabilitation) 1
- Serious: DVT/PE, infection, re-rupture 1
Critical Pitfalls to Avoid
- Never delay surgery for complete tears—delayed repair (>3 weeks) significantly worsens outcomes due to tendon retraction, fibrosis, and degenerative changes 1, 2, 7
- Do not miss concomitant retinacular tears during surgical repair 1
- Avoid early mobilization protocols—complete immobilization for 4 weeks yields better muscle force recovery 2
- Do not assume bilateral injury is impossible—spontaneous bilateral ruptures occur, especially in patients with renal disease or on hemodialysis 3