What is the recommended treatment for a patient with a partial thickness tear of the rectus femoris tendon and probable partial thickness tear of the common extensor tendon with a hematoma, as shown on a left hip ultrasound?

Treatment of Partial Thickness Rectus Femoris and Common Extensor Tendon Tears with Hematoma

Begin with a 3-6 month trial of conservative management including relative rest, ice therapy, NSAIDs, and eccentric strengthening exercises before considering surgical intervention. 1, 2

Initial Conservative Management (First 3-6 Months)

Immediate Interventions

• Implement relative rest by avoiding activities that reproduce the hip pain while maintaining some activity to prevent muscle atrophy and deconditioning 1, 2
• Apply ice therapy for 10-minute periods through a wet towel to provide short-term pain relief, reduce swelling, and blunt the inflammatory response 1, 2
• Prescribe NSAIDs (oral or topical) for acute pain relief, with topical formulations preferred to eliminate gastrointestinal hemorrhage risk associated with systemic NSAIDs 1, 2

Rehabilitation Protocol

• Begin eccentric strengthening exercises after the acute phase (typically 3-7 days) to stimulate collagen production and guide normal alignment of newly formed collagen fibers 1, 2, 3
• Incorporate stretching exercises as they are widely accepted for tendon rehabilitation and promote healing 1, 2
• Progress to active stretching and isometric exercises within the first week as tolerated 3

Expected Timeline

• Patients should be able to ambulate with crutches within 2-7 days of injury 3
• Full walking ability without assistive devices typically returns within 7 days 3
• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 2, 4

Hematoma Management

For the 4.3 x 2.8 x 2.2 cm hematoma associated with the common extensor tendon tear, consider ultrasound-guided aspiration if it causes significant symptoms or impedes rehabilitation. 5

• Compression bandages should be applied to limit hematoma expansion 3
• Elevation of the affected limb reduces swelling 3
• Large hematomas may benefit from ultrasound-guided aspiration to accelerate recovery 5

Second-Line Interventions (If Initial Management Fails)

After 4-6 Weeks of Conservative Treatment

• Consider corticosteroid injection with ultrasound guidance if pain persists, though use with caution as corticosteroids may inhibit healing, reduce tensile strength, and potentially predispose to tendon rupture 1, 2, 6
• Corticosteroid injections provide more effective acute pain relief than oral NSAIDs but do not alter long-term outcomes 2, 4
• Peritendinous injections are preferred over intratendinous injections to minimize deleterious effects on tendon substance 6

Alternative Modalities

• Extracorporeal shock wave therapy (ESWT) is a safe, noninvasive, and effective treatment option for chronic tendinopathies before considering surgery 2, 4, 6
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1

Surgical Intervention

Surgical evaluation is warranted only if pain and functional limitation persist despite 3-6 months of well-managed conservative treatment. 1, 2, 7

Indications for Surgery

• Failure of comprehensive conservative management for 3-6 months 1, 2, 6
• Complete tendon avulsion 8
• Chronic, nonhealing injury with recurrent symptoms 8, 7
• Persistent anterior thigh mass with chronic pain 9

Surgical Techniques

• Excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1, 2
• For chronic rectus femoris central tendon ruptures, direct repair or reconstruction with autograft/allograft may be necessary 8, 7
• Surgical removal of fibrous scar tissue encasing the deep tendon appears curative for intrasubstance tears 9
• Athletes can expect to return to preinjury level of sports 2.5-4 months postoperatively with good to excellent outcomes in 83-100% of cases 7

Critical Pitfalls to Avoid

• Do not rush to surgery before completing an adequate 3-6 month trial of conservative therapy, as most patients recover without surgical intervention 1, 2, 4
• Avoid complete immobilization as it leads to muscular atrophy and deconditioning; tensile loading of the tendon is necessary for healing 1
• Do not inject corticosteroids directly into tendon substance as this may cause tendon weakening and predispose to rupture 2, 4, 6
• Be aware that rectus femoris intrasubstance tears can present as chronic thigh pain with an anterior thigh mass and may be mistaken for soft tissue neoplasms 9
• Recognize that these injuries tend to reinjure if athletes return to sport prematurely, resulting in chronic symptoms 7

Return to Sport Criteria

• Pain-free function with normal MRI findings (typically 6 weeks for uncomplicated cases) 3
• Full restoration of quadriceps strength and function 3
• Gradual progression through training program before returning to competition 3
• For surgical cases, expect 2.5-4 months before return to preinjury level of sports 7