Quadriceps tendinopathy (tendinitis) is inflammation or more likely degeneration of the quadriceps tendon at the top of the patella.
On this page:
- Causes & anatomy
Symptoms of quadriceps tendinopathy
Quadriceps tendinopathy symptoms consist of pain over the top of the patella (kneecap) which is felt during and after exercise. There may be pain when simply contracting the quadriceps muscles which sitting in a straight leg position and pressing in (palpating) along the top of the patella, where the muscle attaches to the bone will be tender. The patient is likely to feel stiffness the day after exercise and will likely have pain when standing up from a squat position.
Quadriceps tendinopathy causes & anatomy
The quadriceps muscle group are the four large muscles at the form of the thigh and consist of the rectus femoris, vastus lateralis, vastus medialis and the vastus intermedius. When they contract the bend (flex) the knee. The rectus femoris is the largest muscle and also flexes the hip (lifts the thigh) because it originates from the pelvis, crossing both the hip joint and the knee joint (called a biaxial muscle). The quadriceps muscles join together in a common tendon which attaches to the patella or kneecap, which in turn inserts into the front of the tibia or shin bone.
Quadriceps tendonitis vs quadriceps tendinopathy
Tendonitis is inflammation of a tendon (‘itis’ means inflammation). If an injury is fairly recent or acute then it may be inflamed, but many long term, chronic injuries are more likely to have wear and tear or degeneration of the tendon rather than the presence of acute inflammatory cells. The word tendinopathy simply means ‘diseases of the tendon’ and so describes a range of conditions, which include tendonitis (inflammation of the tendon), tenosynovitis (inflammation of the sheath surrounding the tendon) as well as degeneration of the tendon. The term tendinopathy is used to cover most tendon injuries.
The insertion of a muscle is its lower attachment point and the quadriceps muscles insert along the top of the patella (kneecap). This injury is an overuse injury, as the pain tends to develop gradually over a period of time, rather than at a specific point. Pain in this area is more common in older athletes and in weightlifters. This is because of the high strain on the muscle insertion during deep squats.
Treatment of quadriceps tendinopathy
The aims of treatment and rehabilitation are:
- Decrease pain and inflammation.
- Improve condition of tendon and quadriceps muscles.
- Strengthen the muscles involved.
- Gradual return to full fitness.
What can the athlete do?
Apply cold therapy or ice if it is acutely painful. Ice can be applied for 10 to 15 minutes every hour for the first 24 to 48 hours. Do not apply ice directly to the skin as it may burn. Use a wet tea towel or a commercially available cold pack. Later once any acute inflammation has calmed down applying heat and wearing a heat retainer may be more beneficial.
Rest! This is very important. This may mean simply modifying the type of training done for a less severe injury, for example, avoiding explosive jumping or plyometric activities. For injuries that cause pain during training then a complete period of rest may be required and if the injury is chronic then a sustained period of rest may be required. For more recent acute injuries a rest period of 2 to 4 weeks may be sufficient. After the acute stage and for more long term chronic injuries, apply heat and wear a heat retainer.
Stretching the quadriceps muscles is important and should be done regularly throughout the day. A sports injury professional can advise on a full rehabilitation program. Rest is unfortunately also very important. If you do not rest, it will not get better!
For particularly chronic tendinopathies, cross friction sports massage techniques can be particularly effective. Self-massage can be done by applying short, frictions across the tendon along the top of the patella for 5 to 10 minutes. The aim is to gradually apply firmer frictions to reduce adhesions between the tendon and tendon sheath and aid healing. It is likely the patient will feel particularly sore spots as thicker areas of the tendon.
What can a Sports Injury Professional do?
A doctor may prescribe anti-inflammatory medication (e.g. Ibuprofen) in the early acute stages, however, if this injury is a long-term chronic problem then anti-inflammatory medication may not be beneficial and may even hinder recovery.
In persistent cases, a doctor may give a corticosteroid injection. Recovery from chronic quadriceps tendinopathy can take weeks or even months.
Quadriceps tendinopathy exercises
Stretching exercises are most important in the rehabilitation of quadriceps tendinopathy. Strengthening may also be beneficial but emphasis is on rest and stretching in the early stages. The muscles in particular that need to be stretched are the Quadriceps group at the front of the thigh.
This can be tested by performing Thompson’s test. Laying on the back, pull one knee up as high as it will go. The thigh of the free leg should be horizontal. If it rides up, this indicates possible tight hip flexor muscles (Rectus femoris or Iliopsoas). The shin of the free leg should hand vertically. If not then this may indicate tight Quadriceps muscles.
Quad Stretch 1:
Hold the foot of the leg to be stretched and gently pull up behind. Aim to keep the knees together and pull the leg up straight not twisted. A stretch should be felt at the front of the leg. It should not be painful. In the early acute stages of treatment, hold stretches for around 10 seconds. Later on, when the inflammation has gone stretches should be held for around 30 seconds. Repeat 3-5 times and stretch at least 3 times a day.
Quad Stretch 2:
Kneel on one knee with a very padded cushion for support. Pull the foot up behind as shown. This stretch will target the Rectus femoris more. If you have any pain on the knee when performing this stretch, avoid it. This stretch places a lot of pressure on the kneecap when kneeling down so it is essential to have plenty of padding for support. Again hold for 10 seconds initially and progress to 30 seconds. repeat the stretch 3-5 times, at least 3 times a day.
Strengthening exercises should begin as soon as pain will allow. If it hurts, don’t do it. Also if you find you have more pain in the morning after doing strengthening exercises then you may need to reduce the workload.
Static contractions (isometric exercises)
These are simply performed by contacting the Quadriceps muscles at the front of the thigh and can be performed in standing, or in sitting with the knee straight or with a foam roller or rolled up towel under the knee so that the foot lifts off the floor when you contract the quads. An example program might be – contract for 10 seconds, relax for 3 seconds and do 10 repetitions. Rest for a minute and repeat up to five times. Although this exercise is boring it will maintain muscle bulk and ensure you are back to full fitness faster. Continue with this exercise on a daily basis until you are able to perform the eccentric exercises below.
Eccentric double leg drop squats
Eccentric exercises are when the muscle contracts but also lengthens at the same time. This occurs to the quadriceps muscles during the downwards phase of a squat.
Eccentric strengthening exercises are thought to be beneficial in treating chronic tendon injuries including quadriceps tendinopathy. Perform a squat by moving slowly from a standing position to a squat position and back.
The exercises can be progressed by increasing the range of movement the knee goes through and also the speed at which the exercises are done. Eventually, they can be progressed to single leg drop squats, using both legs on the up phase. Start with the bad leg and then do no more with the good leg than you managed with the bad leg. Again the aim is to produce mild pain in the tendon on the final set of repetitions. This is believed to stimulate the healing process.
Following exercises remember to stretch properly. Applying ice for 10 minutes can also help in reducing/preventing inflammation.
Return to Full Fitness
The length of time that is required to return to full fitness will depend on the severity of the injury and whether or not it is a recurrent injury or a first-time injury. For a first time injury, recovery may take 2 to 3 months. A longer term chronic, recurring injury may need 4 to 6 months.
Gradually return to sports specific training. Again depending on severity, this may be days, it may be weeks. Pain should be the guide. Begin with gentle jogging. When the athlete can jog 20 minutes without pain during or after then progress to running and sprinting.
An example of a speed session might be 10x50m sprints at 50% effort. Next session perform 10x50m at 75% of full speed and so on. Continue to stretch and perform specific strengthening exercises throughout this phase of rehabilitation.
I am really having trouble shaking quadriceps tendinopathy off!
- Rigorously stretch the muscles at least 3 times a day.
- Cross friction massage to the tendon at the site of pain can be applied on a daily basis. This has proved valuable in the recovery of even chronic cases.
- Seek professional advice.