Bilateral quadriceps tendon rupture in a healthy 56- year old male after using home weightlifting equipment

Authors: Martyna Jankowska, Houssam Ghazzawi 

Abstract

We present a rare and noteworthy case of bilateral quadriceps tendon rupture in a fit and healthy middle-aged man who required an urgent surgical intervention of a bilateral open repair of the quadriceps mechanism. Early recognition and appropriate surgery resulted in a good outcome and allowed the return to his previous mobility status and lifestyle. Through this case we are hoping to highlight how important the right diagnosis and management is, and how rare this type of injury is in a view of no significant past medical history.


Summary

A healthy 56 year old male presented to Emergency Department (ED) with bilateral knee pain, swelling and reduced range of movement. The onset of symptoms was sudden and occured when the patient was performing his routine set of excercises involving weighted squats. On examination patient was unable to straight leg raise and there was a palpable gap above both patellas. The patient was otherwise well. Investigations revealed bilateral quadriceps tendon rupture visible on the radiograph. 

Open quadriceps tendon repair was performed bilaterally and patient was discharged with a total range of motion (TROM) brace and a follow-up regime. Two months after the admission knee function improved with a good range of movement and almost full extension in both joints. 


Background

Quadriceps muscles are attached to the knee joint with a quadriceps tendon, a muscular junction at the anterior superior pole of the patella. All of these structures make up the extensor mechanism of the lower leg, which is crucial for walking, standing, climbing and maintaining posture. Any injury, partial or complete, results in serious disabilities. It is a very painful and debilitating injury but early recognition, diagnosis and surgical repair lead to good outcomes and a good quality of life. 

Injury such as bilateral quadriceps rupture is a very rare finding, especially in young and healthy individuals. It’s most frequently related to advanced age, metabolic disorders, renal disease, obesity and steroid use. Most of the published cases report a unilateral rupture, bilateral findings are extremely uncommon.  

Early diagnosis is fairly straightforward and based on a clinical picture with a very typical examination findings, but should be confirmed by simple and easy imaging techniques (USS, plain film). Follow up images will not only differentiate between a full and partial tear, but will also reveal any elements of calcification or foreign bodies.


Case presentation

56 year old male brought in to the hospital ED by ambulance with bilateral leg pain and limited range of movements related to knee injury.   

Mechanism of injury: patient was exercising in his home gym, performing squats. He was in a squat position carrying a 70kg weight bar. On standing up, the bar went forward then backwards, patient lost balance, stepped one of his feet forwards and collapsed. Immediately after, patient noted severe pain in both knees, limited range of movement bilaterally and was not able to weight bare.


Examination and investigations

On examination of lower limbs a marked suprapatellar tenderness was noted bilaterally. The patient was able to flex both knee joints with pain present, but was unable to extend legs in knee joints as well as unable to straight leg raise. Neurovascular status was intact and there was no bony tenderness present. 

Radiographs of both knees were performed and a bilateral rupture of the quadriceps tendon with inferior displacement and rotation of the patella were noted. Multiple loose bodies in keeping with bilateral secondary synovial chondromatosis were reported within the prepatellar spaces. The patient had a full set of bloods done including full blood count, urea and electrolytes, liver function and renal profile, all of which were unremarkable.  


Treatment

The patient underwent a bilateral open repair of the quadriceps mechanism via the parapatellar approach. Haematomas were washed out and a Krackow stitch (medial and lateral) was applied in both knees. Tunnels were drilled through the patella, sutures were passed through and tied at the distal pole. A continous circumerential suture was used to complete the tendon repair. The patient was discharged and instructed to be full weight bearing in TROM brace with fracture clinic follow-up.  


Outcome and follow-up

The repair was successfull and patient was discharched home in TROM brace. The rehabilitation protocol involved the patient being full weight-bearing in the brace with two weeks in full extension, two weeks 0-30° flexion, two weeks 0-60° flexion and two weeks of 0-90° flexion. After two months, the patient was discharged from fracture clinic with a good range of motion and almost full extension in knee joints bilaterally. Follow up with a physiotherapist was arranged  to increase the range of motion and extension power. 


Discussion 

Bilateral quadriceps tendon ruptures are a very rare finding in ED presentations. Most of complete quadriceps tendon ruptures are reported in young patients and are associated with major trauma. Elderly patients who present with this condition, often suffer from multiple comorbidities such as diabetes, renal failure, previous injuries and chronic tendinopathy. 

In this case the patient had no known medical conditions prior to admission and all of the above had been excluded. There was no known comorbidities predisposing the patient to suffer from a quadriceps tendon rupture. On further investigation a bilateral secondary synovial chondromatosis was noted and could be considered as a possible risk factor. The patient also mentioned being a semi professional athlete 30 years prior to the accident and confirmed anabolic-androgenic steroid use for two years throughout his career in the past. He denied any steroid use since then.  

Previous anabolic steroid use, assumed to be associted with tendon ruptures, is an extremely rare single cause for bilateral quadriceps rupture. Most of the cases debated to be directly correlated with anabolic steroids involved upper body injuries (triceps brachii and biceps brachii tendons). 

Due to lack of other predisposing factors it is reasonable to associate this rupture with previous anabolic steroid use and probable synovial chondromatosis.


Take home messages

  • - Diagnosis is easy to make based mostly on clinical presentation. 
  • - Incidence is higher in elderly patients with comorbidities such as diabetes, renal failure, endocrine disorders or chronic tendinopathy. 
  • - Anabolic steroids use is a major risk factor in tendon ruptures (although in most cases it is a single tendon rupture). 
  • - Early surgery is proven to have a better outcome than delayed repair. 
  • - Early surgical intervention followed up by adequate physiotherapy have shown positive outcomes and patients returning to previous mobility status.


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