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Introduction

Knee Pain

Quadriceps Tendinopathy

The quadriceps tendon attaches your quadriceps muscles to your kneecap (patella). It works to straighten your knee and helps you walk, jump, and climb stairs.

If the tendon becomes inflamed, it’s called quadriceps tendinitis (tendonitis) or tendinopathy.

Inflammation of the tendon, or tendinitis, is most common in athletes whose sports involve frequent jumping, but people who don’t play any sport can get quadriceps tendinitis.

Physiotherapy treatment is often very successful but if persistent there are a lot of other treatments available, such as prolotherapy.

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Causes

The most common cause of quadriceps tendinitis is overuse. This occurs when the tendon repeatedly moves in a specific way, which leads to small tears.

Normally, your body tries to fix these tears. But if you continue repeating the same movement, more tears will develop.

Repeated actions can also cause quadriceps tendinitis, like:

  • sports

  • trauma, like jumping on a hard surface

  • sudden increase in physical activity

  • poor posture

  • poor walking habits

Any active person can get quadriceps tendinitis. But the risk is higher in athletes, especially if you:

  • run on hard surfaces

  • play jumping sports, like volleyball and basketball

  • exercise without warming up

  • exercise without enough recovery time

  • repeatedly squat or kneel 

Other factors that increase your risk include:

  • Age. As you get older, the tendons become less flexible and more prone to inflammation.

  • Weight. Excess body weight puts extra stress on the tendons.

  • Tight muscles. Tight hamstrings and quad muscles increase pressure on your tendons.

  • Chronic disease. Some diseases, like lupus and diabetes, reduce blood supply to the knee. This weakens the tendons and increases the risk of tendinitis.

  • 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.

Symptoms
  1. Activity-Related Anterior Knee Pain: pain at the bottom of the thigh, just above the kneecap that gets worse with activity

  2. Localised Tenderness: discomfort when you press on the top edge of the kneecap

  3. Knee Swelling: around the tendon and kneecap

  4. Knee Stiffness: particularly when you first get up in the morning or after sitting down for a while

  5. Weakness: in and around the knee, decreased power during “push-off” phase of running/jumping

Symptoms of quadriceps tendinopathy can be classified into 5 stages:

  • 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

Diagnosis

Generally, common symptoms of quadriceps tendon pain include:

  • Quad pain above kneecap that is worse during and after activity.

  • Often, there is no swelling, locking, or giving away of the knee.

  • It is often tender to touch the quadriceps tendon. 

Your doctor will perform a clinical examination to rule out other causes of pain above kneecap or at the front of the knee, such as kneecap arthritis, fat pad impingement, torn meniscus, pes bursitis,  housemaid’s knee, and patellar tendonitis. 

Often, we use imaging to diagnose quad tendonitis and rule out other causes. Usually, ultrasound and MRI scans can see changes in swelling and collagen breakdown of the tendon. Generally, ultrasound has advantages over MRI scans, including seeing calcification more clearly and at a lower cost.

Non-surgical treatments

Most people suffering from quadriceps tendonitis pain respond well to non-surgical treatment which typically includes:

  1. Rest: Avoiding activities that bring on your knee pain is vital. Modify your training so you are not exacerbating your symptoms e.g. reduce the frequency or duration of training sessions, or switch to things like cycling or swimming. In most cases, relative rest is best but in severe cases, complete rest may be necessary using a knee brace or splint 

  2. Ice: Regularly applying an ice pack to the knee throughout the day, especially before and after sports, for 10-15 minutes can help to reduce inflammation and quadriceps tendonitis pain 

  3. Physical Therapy: your physical therapist may use modalities such as ultrasound, acupuncture, electrical stimulation 

  4. Massage: Deep transverse friction massage can be extremely effective in chronic cases of quadriceps tendinopathy. It helps to break-down adhesions and realign the collagen fibres in the tendon so that tendon heals properly 

  5. Bracing/Taping: Your therapist may tape up your knee to avoid overloading the tendon and prevent pain during day to day activities. Many people find wearing a knee strap particularly helpful, especially when they returns to sports 

  6. Orthotics: Shoe orthotics help to address and biomechanical issues that may be contributing to your quadriceps tendonitis such as arch supports 

  7. Stretching Exercises: Knee stretches to improve the flexibility of the calves, hamstrings and quadriceps muscles to reduce the tension through the tendon 

  8. Strengthening Exercises: Strengthening exercises for the quadriceps muscles, particularly the VMO muscles which control kneecap movement, hamstrings and glutes muscles, helps reduce the strain on the tendon. Eccentric training for the quads is particularly effective – this is when you strengthen the muscle as it lengthens rather than contracts 

  9. Medication: your doctor may advise non-steroidal anti-inflammatory medication to help reduce quadriceps tendonitis pain and swelling in the knee 

  10. Injections: In more severe cases, your doctor may recommend either corticosteroid or plasma-rich protein (PRP) knee injections for quadriceps tendinopathy that is failing to resolve

Surgery