High Yield Overview

QUADRICEPS CONTUSIONS - CLASSIFICATION and MANAGEMENT

Direct Impact Injury | Flexion Key Prognostic Factor | Myositis Ossificans Prevention Critical

2ndMost common sports injury after strains

120°Flexion = mild grade, 90° = moderate

9-17%Develop myositis ossificans

48-72hCritical window for RICE

RYAN CLASSIFICATION (by ROM at 24h)

Mild

PatternFlexion greater than 90 degrees

TreatmentRTS 2-3 weeks

Moderate

PatternFlexion 45-90 degrees

TreatmentRTS 3-6 weeks

Severe

PatternFlexion less than 45 degrees

TreatmentRTS greater than 6 weeks, consider MO

Critical Must-Knows

Knee flexion at 24 hours is the key prognostic indicator
Immediate 120 degree flexion position reduces hematoma and speeds recovery
Myositis ossificans develops in 9-17%, more common with severe grades
Avoid early aggressive ROM and massage - increases MO risk
NSAIDs and aspiration have role in preventing myositis ossificans

Examiner's Pearls

"
Jackson and Feagin showed military cadets in flexion splints recovered 3x faster
"
Never massage a quadriceps contusion - promotes MO development
"
Heterotopic ossification appears on X-ray at 3-4 weeks post-injury
"
Compartment syndrome rare but possible - monitor tight thighs

Clinical Imaging

Imaging Gallery

Picture demonstrating a swollen and tense right thigh. It was 8 cm bigger than the left side.Credit: How MI et al. via Int J Surg Case Rep via Open-i (NIH) (Open Access (CC BY))

MRI of the right thigh (sagittal view) showing grossly swollen vastus intermedius muscle (small arrows) and a large hematoma displacing surrounding structures (large arrow). — MRI of the right thigh (sagittal view) showing grossly swollen vastus intermedius muscle (small arrows) and a large hematoma displacing surrounding stCredit: How MI et al. via Int J Surg Case Rep via Open-i (NIH) (Open Access (CC BY))

An intraoperative photo showing the vastus lateralis bulge through the lateral thigh fasciotomy incision, and the muscle appeared swollen and contused distally. — An intraoperative photo showing the vastus lateralis bulge through the lateral thigh fasciotomy incision, and the muscle appeared swollen and contusedCredit: How MI et al. via Int J Surg Case Rep via Open-i (NIH) (Open Access (CC BY))

A 21-year-old football player presenting 5 days after a direct contusion injury to the left anterior thigh. a Coronal fat-suppressed (FS) T2-w TSE image reveal severe contusion injury of the vastus in — A 21-year-old football player presenting 5 days after a direct contusion injury to the left anterior thigh. a Coronal fat-suppressed (FS) T2-w TSE imaCredit: Hayashi D et al. via Insights Imaging via Open-i (NIH) (Open Access (CC BY))

Critical Quadriceps Contusion Exam Points

24-Hour ROM Classification

Flexion at 24 hours determines grade: greater than 90 degrees = mild, 45-90 degrees = moderate, less than 45 degrees = severe. This predicts recovery time and MO risk.

Flexion Position Treatment

Immediate 120 degree flexion (Jackson-Feagin protocol) shown to reduce recovery time from 88 to 13 days in military study. Compress hematoma between muscle bellies.

Myositis Ossificans Prevention

Avoid heat, massage, aggressive stretching in first 2-3 weeks. Consider indomethacin prophylaxis in severe grades. Aspiration of large hematomas may help.

Compartment Syndrome Risk

Anterior thigh compartment syndrome rare but described. High index of suspicion with severe contusions, anticoagulated patients, or coagulopathy.

Quick Decision Guide by Grade

Grade	ROM at 24h	Expected Recovery	Key Management
Mild	Greater than 90 degrees flexion	2-3 weeks	RICE, active ROM, progress when pain-free
Moderate	45-90 degrees flexion	3-6 weeks	Flexion splinting, protected rehab, monitor MO
Severe	Less than 45 degrees flexion	Greater than 6 weeks	Flexion splinting, consider NSAIDs prophylaxis, MRI
Myositis ossificans	Persistent pain, palpable mass	3-6 months natural history	Wait for maturation, excise if symptomatic

Mnemonic

FLEX - Acute Management

Flexion position

120 degrees knee flexion immediately

Limit activity

Crutches, protected weight bearing

Early ice

20 min every 2 hours for 48-72h

X-ray if severe

Rule out fracture, baseline for MO

Memory Hook:Keep it FLEXED to compress the hematoma between muscle bellies

Mnemonic

RICE Plus - First 48 Hours

Rest

Non-weight bearing initially

Ice

20 min on, 20 min off

Compression

Elastic wrap in flexed position

Elevation

Above heart level

Plus NSAIDs

Indomethacin for MO prophylaxis if severe

Memory Hook:RICE is not enough for severe contusions - add NSAIDs for protection

Mnemonic

MO RISK - Myositis Ossificans Risk Factors

Massage

Never massage acute contusion

Over-aggressive rehab

Passive stretching too early

Recurrent injury

Return to sport too soon

Inadequate rest

Insufficient immobilization

Severe grade

Less than 45 degrees ROM at 24h

Keep playing

Continuing activity after injury

Memory Hook:These factors put you at MO RISK for heterotopic bone formation

Mnemonic

RTS Criteria - Return to Sport

Range equal to uninjured

Full symmetric ROM

Thigh girth equal

Less than 1cm difference

Strength 90 percent plus

Isokinetic testing symmetry

Memory Hook:RTS when ROM, Thigh circumference, and Strength are symmetric

Overview and Epidemiology

Quadriceps contusions are the second most common injury in contact sports after muscle strains. They result from direct blunt trauma to the anterior thigh, causing intramuscular hemorrhage and tissue damage.

Mechanism of injury:

Direct blow - knee or helmet strike to anterior thigh (most common)
Contact sports - rugby, Australian football, martial arts, football
Falls - direct impact onto hard surface
Motor vehicle accidents - dashboard injury

Sports distribution:

Rugby and Australian Rules Football - highest incidence
American football - common in receivers/running backs
Hockey - puck or stick trauma
Combat sports - knee strikes

Anatomical Vulnerability

The vastus intermedius is most commonly injured as it lies directly on the femur with no muscle posterior to provide cushioning. The rectus femoris is protected by the intermedius layer.

Pathophysiology and Mechanisms

Quadriceps muscle group:

Rectus femoris - only biarticular muscle, hip flexor
Vastus lateralis - largest, lateral aspect
Vastus medialis - medial aspect, VMO critical for patella tracking
Vastus intermedius - deepest, directly on femur

Blood supply:

Branches of profunda femoris (lateral and medial circumflex femoral)
Rich vascular supply explains significant hematoma formation
Intramuscular bleeding contained by fascia

Pathophysiology of contusion:

Contusion Evolution

0-6 hours

Acute hemorrhage into muscle belly. Vasospasm initially limits bleeding. Hematoma begins forming in the intramuscular space.

6-24 hours

Inflammatory response peaks. Edema develops. ROM rapidly decreases. Critical window for classification by flexion.

24-72 hours

Hematoma organization begins. Fibroblast migration starts. Continued inflammation. Key period for flexion positioning.

3-14 days

Granulation tissue formation. Early scar tissue. Risk period for myositis ossificans if tissue is reinjured or aggressively mobilized.

2-4 weeks

Muscle regeneration phase. Satellite cell activation. Progressive strengthening safe to begin if pain-free.

Myositis Ossificans Development

Heterotopic bone forms when pluripotent mesenchymal cells differentiate into osteoblasts instead of myoblasts. Risk factors include re-injury, massage, aggressive passive stretching, and large hematoma size.

Why Flexion Works

120 degree flexion compresses the hematoma between the rectus femoris and vastus intermedius, limiting expansion. It also maintains muscle length, preventing adaptive shortening. Jackson and Feagin demonstrated recovery in 13 days vs 88 days with extension splinting.

Classification Systems

Ryan Classification (by ROM at 24 hours - most commonly used)

Grade	Knee Flexion at 24h	Gait	Swelling	Recovery Time
Mild	Greater than 90 degrees	Normal	Minimal	2-3 weeks
Moderate	45-90 degrees	Antalgic	Moderate	3-6 weeks
Severe	Less than 45 degrees	Unable to walk	Severe	Greater than 6 weeks

Clinical Application

The Ryan classification is the most practical as it uses a single objective measure (ROM) taken at a standardized time point (24 hours) to predict prognosis and guide treatment intensity.

This classification informs treatment intensity and helps you counsel athletes and coaches appropriately.

Clinical Assessment

History

Key history points:

Mechanism - direct blow, contact event, speed of impact
Immediate response - able to continue playing? (poor prognostic sign if yes - suggests ongoing bleeding)
Time since injury - critical for classification at 24 hours
Previous quad contusions - risk factor for recurrence
Anticoagulation status - increased bleeding risk

Red flag symptoms:

Severe pain out of proportion
Numbness in leg
Progressive swelling despite rest
Inability to weight bear at all

Documenting the history carefully guides prognosis and identifies high-risk patients.

Examination

Physical examination:

Inspection:

Swelling location and extent
Ecchymosis (may appear 24-48h later)
Muscle contour - bulge or defect

Palpation:

Point of maximal tenderness
Palpable hematoma or mass
Warmth

ROM testing (critical):

Active and passive knee flexion
Document angle at 24 hours for classification
Compare to uninjured side

Strength testing:

Resisted knee extension
Straight leg raise ability
Document any quad lag

Compartment Syndrome Signs

Pain with passive stretch, tense anterior compartment, paresthesias in saphenous nerve distribution, weak knee extension. Rare but requires urgent fasciotomy.

Investigations

X-ray:

Not routinely required for typical contusion
Indicated if fracture suspected (significant trauma)
Baseline for monitoring myositis ossificans
MO visible at 3-4 weeks post-injury

Ultrasound:

First-line imaging for soft tissue assessment
Quantifies hematoma size
Differentiates intramuscular vs intermuscular
Can guide aspiration
Dynamic assessment of muscle integrity

MRI:

Reserved for severe grades or diagnostic uncertainty
Quantifies extent of muscle damage
Identifies associated injuries
Useful for return-to-play decisions in elite athletes

Ultrasound Findings

Acute hematoma appears hypoechoic or anechoic. Organized hematoma becomes more heterogeneous. Early myositis ossificans shows increased echogenicity before calcification is visible on X-ray.

Management Algorithm

Clinical Algorithm— Quadriceps Contusion Management

Loading flowchart...

Immediate management:

Remove from play - do not continue with injury
RICE protocol immediately
120 degree flexion position - wrap knee flexed
Crutches - non-weight bearing to partial
Ice - 20 min every 2 hours

Jackson-Feagin Protocol:

Knee wrapped in maximal comfortable flexion
Elastic bandage over ice pack
Maintained for 24 hours initially
Shown to reduce recovery time significantly

Medications:

Analgesia as needed (paracetamol preferred)
NSAIDs controversial early - may increase bleeding
After 48-72h, indomethacin for MO prophylaxis in severe grades

This acute phase management is critical for optimal outcomes.

Surgical Technique

Surgical excision of myositis ossificans:

Surgery is rarely required for quadriceps contusions. The primary surgical indication is symptomatic mature myositis ossificans that fails conservative management.

Indications for excision:

Persistent pain limiting function after MO maturation
Mechanical symptoms (limited ROM, catching)
Large MO causing cosmetic concern
Failed conservative management for 6+ months

Contraindications:

Immature MO (less than 6 months, hot bone scan)
Asymptomatic MO
Active infection

Careful patient selection is essential for successful surgical outcomes.

Complications

Myositis Ossificans Traumatica (MOT)

Incidence: 9-17% of quadriceps contusions

Risk factors:

Severe grade (ROM less than 45 degrees)
Delay in treatment greater than 72 hours
Early massage or aggressive stretching
Re-injury before full healing
Large intramuscular hematoma
Previous MO

Clinical features:

Persistent pain beyond expected recovery
Palpable firm mass in muscle
Plateau or decrease in ROM
Pain with activity

Radiographic features:

Appears 3-4 weeks post-injury
Zoning phenomenon - mature bone peripherally
Matures over 3-6 months

Management:

Initially conservative - wait for maturation
NSAIDs may limit progression if caught early
Surgical excision only if symptomatic AND mature (6-12 months)
Pre-op bone scan to confirm maturity

Surgical Timing

Never excise immature myositis ossificans - high recurrence rate. Wait minimum 6 months, confirm maturity with bone scan (cold lesion), then excise with margin. Consider radiation prophylaxis post-excision in recurrent cases.

Rehabilitation and Return to Sport

Rehabilitation Phases

Phase 1: Acute (0-72 hours)

RICE protocol, 120 degree flexion positioning, crutches, ice every 2 hours. Goal is to minimize hematoma size and inflammation. No stretching or strengthening activities.

Phase 2: Subacute (3-14 days)

Begin active ROM exercises, continue ice, pain-free weight bearing progression. Stationary bike when 90 degrees flexion achieved. Avoid massage, heat, passive stretching.

Phase 3: Strengthening (2-6 weeks)

Progressive resistance exercises when ROM greater than 90 degrees pain-free. Isometrics progressing to isotonics. Pool running and swimming permitted.

Phase 4: Functional (4-8 weeks)

Sport-specific drills, agility training, plyometrics when strength greater than 80 percent. Non-contact training initially, then progress to contact with padding.

Phase 5: Return to Sport

Full ROM, strength greater than 90 percent, functional testing passed. Protective thigh padding for first 2-4 weeks of competition. Monitor for any symptoms.

Return to Sport Criteria (all must be met):

Criterion	Requirement	Testing Method
ROM	Equal to uninjured side	Goniometry
Strength	Greater than 90 percent	Isokinetic or 1RM
Thigh girth	Less than 1cm difference	Tape measure
Pain	None with activity	Functional testing
Functional	Pass hop tests	Single leg hop for distance

Elite Athlete Considerations

In professional athletes, MRI may be used to confirm complete muscle healing before return to sport. Some teams use isokinetic testing with peak torque and total work comparisons to uninjured side, requiring greater than 90 percent symmetry.

Outcomes and Prognosis

Prognosis by grade:

Grade	Expected Recovery	Return to Sport	MO Risk
Mild	2-3 weeks	Full recovery expected	Low (under 5%)
Moderate	3-6 weeks	Full recovery expected	Moderate (10-15%)
Severe	6+ weeks	May have prolonged course	High (15-20%)

Factors affecting outcome:

Time to treatment initiation (earlier is better)
Compliance with flexion positioning protocol
Avoidance of re-injury during recovery
Strict adherence to RTS criteria

Long-term outcomes:

Most athletes return to pre-injury level
Recurrent contusion possible if RTS too early
Myositis ossificans may require delayed surgical excision
Chronic pain rare if properly managed

Prognosis Summary

Key prognostic indicator is ROM at 24 hours. Athletes who follow the Jackson-Feagin flexion protocol and meet all RTS criteria have excellent outcomes with low recurrence rates. Premature return is the main risk factor for complications.

Evidence Base

Jackson-Feagin Study (1973)

Key Findings:

Recovery time reduced from 88 to 13 days with flexion protocol
Flexion compresses hematoma between muscle bellies
Extension positioning led to prolonged disability

Clinical Implication: Flexion positioning is now standard of care for acute quadriceps contusions

Ryan et al Classification (1991)

Key Findings:

24-hour ROM is most reliable prognostic indicator
Three-tier classification predicts recovery timeline
Severe grade (ROM less than 45 degrees) highest MO risk

Clinical Implication: 24-hour ROM assessment is the key prognostic indicator and should guide treatment intensity

Aronen et al - NSAIDs for MO Prevention

III

Key Findings:

Indomethacin prophylaxis reduces MO development
Should be started after 48-72 hours (post-bleeding phase)
7-day course is standard protocol

Clinical Implication: Consider NSAID prophylaxis in severe grade contusions after acute bleeding phase (48-72h)

Diaz et al - Hematoma Aspiration

Key Findings:

Large hematomas (greater than 2cm) benefit from aspiration
Ultrasound guidance improves accuracy and safety
Reduces pressure and accelerates healing

Clinical Implication: Consider aspiration of large organized hematomas under ultrasound guidance

Beiner et al - MO Natural History

Key Findings:

MO visible on X-ray at 3-4 weeks post-injury
Zoning phenomenon distinguishes from malignancy
Most MO becomes asymptomatic without surgery

Clinical Implication: Wait for maturation before considering surgical excision - most cases resolve spontaneously

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Acute Severe Contusion

EXAMINER

"A 22-year-old rugby player presents 6 hours after a direct knee strike to his anterior thigh. He has marked swelling and can only flex his knee to 30 degrees. How would you manage this player?"

EXCEPTIONAL ANSWER

This patient has sustained a severe quadriceps contusion based on the mechanism and significantly limited ROM of 30 degrees, well below 45 degrees. My immediate management would follow the Jackson-Feagin protocol. First, I would apply ice and compression while positioning the knee in maximal comfortable flexion, ideally 120 degrees. The patient should be non-weight bearing with crutches. I would apply an elastic wrap to maintain this flexed position. I would reassess formally at 24 hours to confirm the grade classification. Given the severe presentation, I would obtain an X-ray to rule out femoral fracture and establish a baseline for monitoring myositis ossificans. After 48-72 hours, once acute bleeding has settled, I would commence indomethacin 75mg daily for 7 days for MO prophylaxis. I would counsel the athlete that recovery is likely to take greater than 6 weeks, and careful monitoring for myositis ossificans is essential.

KEY POINTS TO SCORE

Recognize severe grade by ROM less than 45 degrees at presentation

Immediate 120 degree flexion positioning is key intervention

NSAID prophylaxis after 48-72 hours for MO prevention

Baseline X-ray for future MO monitoring

COMMON TRAPS

✗Giving NSAIDs immediately - may increase acute bleeding

✗Aggressive stretching or massage - promotes MO

✗Allowing continued play or early return - worsens outcome

LIKELY FOLLOW-UPS

"What if the patient develops a palpable mass at 3 weeks?"

"How would you manage confirmed myositis ossificans?"

"What are the return-to-sport criteria for this athlete?"

VIVA SCENARIOChallenging

Scenario 2: Myositis Ossificans Development

EXAMINER

"A footballer returns 4 weeks after a moderate quadriceps contusion with persistent pain and a firm palpable mass in the anterior thigh. X-ray shows early calcification. How would you manage this?"

EXCEPTIONAL ANSWER

This presentation is consistent with myositis ossificans traumatica, which develops in 9-17% of quadriceps contusions. My management would be primarily conservative at this stage as the MO is immature. I would reassure the patient that MO typically matures over 3-6 months and often becomes asymptomatic. Current treatment includes rest from aggravating activities, gentle pain-free ROM exercises, and potentially NSAIDs to limit further ossification. I would avoid any massage or aggressive stretching. Serial X-rays every 4-6 weeks would monitor maturation. The key radiographic sign of maturity is the zoning phenomenon with corticated peripheral bone and central lucency. Surgical excision is only considered if the MO remains symptomatic after full maturation, typically at 6-12 months minimum. Pre-operative bone scan showing a cold lesion confirms maturity and reduces recurrence risk. I would counsel the athlete that return to sport is delayed, typically 3-6 months, and protective padding is essential.

KEY POINTS TO SCORE

MO matures over 3-6 months - wait for maturation

Zoning phenomenon differentiates from osteosarcoma

Surgery only for symptomatic mature MO (6-12 months)

Conservative management is mainstay initially

COMMON TRAPS

✗Early surgical excision - high recurrence rate

✗Aggressive rehabilitation - worsens MO

✗Confusing with osteosarcoma - remember zoning pattern

LIKELY FOLLOW-UPS

"How do you differentiate MO from osteosarcoma radiographically?"

"What factors increase recurrence after surgical excision?"

"Would you use any adjunctive treatment post-excision?"

VIVA SCENARIOStandard

Scenario 3: Return to Sport Decision

EXAMINER

"A professional AFL player sustained a moderate quadriceps contusion 5 weeks ago. He has regained 100 degrees of knee flexion and wants to return for finals. The coach is putting pressure on medical staff. How do you approach this?"

EXCEPTIONAL ANSWER

This is a common scenario requiring objective assessment and clear communication. My approach would be systematic. First, I would complete a thorough clinical assessment including ROM compared to the uninjured side, thigh girth measurement, strength testing ideally with isokinetics, and functional testing such as single-leg hop for distance. For a professional athlete, I would also obtain an MRI to confirm muscle healing. The objective return-to-sport criteria are: full ROM equal to uninjured side, strength greater than 90% of uninjured side, thigh girth within 1cm, pain-free sport-specific activity, and passed functional testing. At 100 degrees with a normal side likely having 140+ degrees flexion, he does not meet ROM criteria. I would clearly document these findings and communicate to both the player and coach that premature return risks recurrence and myositis ossificans development, potentially ending his season entirely. I would provide a written timeline of 2-3 more weeks with structured rehabilitation milestones. Protective padding would be mandatory when he does return. The decision must be based on objective medical criteria, not external pressure.

KEY POINTS TO SCORE

Objective criteria must be met regardless of pressure

Full ROM, strength greater than 90 percent, functional testing required

Document clearly for medicolegal protection

Premature RTS risks MO and career-threatening recurrence

COMMON TRAPS

✗Yielding to coach pressure without meeting criteria

✗Not documenting the assessment and advice given

✗Failing to use objective measures

LIKELY FOLLOW-UPS

"What if the player insists on playing against medical advice?"

"What protective equipment would you recommend?"

"How would you modify RTS criteria for non-elite athletes?"

MCQ Practice Points

Ryan Classification

Q: What is the key prognostic indicator for recovery time in quadriceps contusions? A: Knee flexion at 24 hours. Recoveries vary from 2-3 weeks (greater than 90 deg) to greater than 6 weeks (less than 45 deg).

Jackson-Feagin Protocol

Q: What is the most important acute intervention? A: Immediate 120 degree knee flexion positioning. This compresses the hematoma and prevents stiffness.

Myositis Ossificans Signs

Q: What radiographic sign distinguishes Myositis Ossificans from malignancy? A: Zoning Phenomenon. MO has mature cortical bone peripherally with a central lucency. Osteosarcoma is the reverse (central ossification, indistinct margin).

Contraindications

Q: What modalities should be absolutely avoided in the acute phase? A: Heat and Massage. Both increase blood flow and risk of Myositis Ossificans.

Return to Sport

Q: What is a mandatory criterion for return to contact sports? A: Full ROM and greater than 90% Strength. Plus protective padding is essential.

Australian Context

Epidemiology in Australia:

High incidence in Australian Rules Football and Rugby League
Contact sports culture increases exposure to thigh contusions
AFL medical staff have developed sophisticated evidence-based protocols
Sports medicine clinics see this injury frequently during football season

Management approach:

Australian sports medicine emphasizes the Jackson-Feagin flexion protocol
Physiotherapy-led rehabilitation is standard of care
Imaging with ultrasound is commonly used for hematoma assessment
MRI reserved for elite athletes or diagnostic uncertainty

Return to sport considerations:

AFL and NRL have team-specific protocols developed by medical staff
Sports Medicine Australia provides general guidelines aligned with international evidence
Emphasis on objective criteria and functional testing before clearance
Protective thigh padding mandatory for initial return to contact

Medicolegal considerations:

Clear documentation essential for professional athletes
Written advice regarding risks of premature return should be provided
Player acknowledgment of risks if playing against medical advice
Team physician decisions may have significant financial implications

AFL Experience

AFL medical staff have documented that adequate acute management (flexion positioning) and strict RTS criteria have significantly reduced the incidence of myositis ossificans and recurrent injury in elite players. This has become the standard of care at all levels.

Quadriceps Contusions

High-Yield Exam Summary

Classification (Ryan)

•Mild: Flexion greater than 90 degrees at 24h - RTS 2-3 weeks
•Moderate: Flexion 45-90 degrees - RTS 3-6 weeks
•Severe: Flexion less than 45 degrees - RTS greater than 6 weeks
•Prognosis: 24h ROM is key predictor

Acute Management

•IMMEDIATE 120 degree flexion positioning
•RICE protocol - ice 20 min every 2 hours
•Non-weight bearing with crutches
•NSAIDs AFTER 48-72h only (bleeding risk earlier)

Jackson-Feagin Protocol

•Wrap knee in maximal comfortable flexion
•Elastic bandage over ice pack
•Reduced recovery 88 days to 13 days
•Compresses hematoma between muscle bellies

Myositis Ossificans

•Develops in 9-17% of quad contusions
•Visible on X-ray at 3-4 weeks
•ZONING phenomenon = mature bone peripherally
•Surgery only after maturation (6-12 months)

Return to Sport Criteria

•Full ROM equal to uninjured side
•Strength greater than 90 percent (isokinetic)
•Thigh girth within 1cm
•Pain-free with sport-specific activity

Key Exam Points

•Never massage acute quad contusion
•Avoid heat and aggressive stretching early
•MO vs Osteosarcoma: zoning phenomenon key differentiator
•Compartment syndrome rare but possible - high suspicion

Grade

ROM at 24h

Expected Recovery

Key Management

Mild

Greater than 90 degrees flexion

2-3 weeks

RICE, active ROM, progress when pain-free

Moderate

45-90 degrees flexion

3-6 weeks

Flexion splinting, protected rehab, monitor MO

Severe

Less than 45 degrees flexion

Greater than 6 weeks

Flexion splinting, consider NSAIDs prophylaxis, MRI

Myositis ossificans

Persistent pain, palpable mass

3-6 months natural history

Wait for maturation, excise if symptomatic

Grade

Knee Flexion at 24h

Gait

Swelling

Recovery Time

Mild

Greater than 90 degrees

Normal

Minimal

2-3 weeks

Moderate

45-90 degrees

Antalgic

Moderate

3-6 weeks

Severe

Less than 45 degrees

Unable to walk

Severe

Greater than 6 weeks

Surgical excision of myositis ossificans:

Surgery is rarely required for quadriceps contusions. The primary surgical indication is symptomatic mature myositis ossificans that fails conservative management.

Indications for excision:

Persistent pain limiting function after MO maturation
Mechanical symptoms (limited ROM, catching)
Large MO causing cosmetic concern
Failed conservative management for 6+ months

Contraindications:

Immature MO (less than 6 months, hot bone scan)
Asymptomatic MO
Active infection

Careful patient selection is essential for successful surgical outcomes.

Criterion

Requirement

Testing Method

ROM

Equal to uninjured side

Goniometry

Strength

Greater than 90 percent

Isokinetic or 1RM

Thigh girth

Less than 1cm difference

Tape measure

Pain

None with activity

Functional testing

Functional

Pass hop tests

Single leg hop for distance

Grade

Expected Recovery

Return to Sport

MO Risk

Mild

2-3 weeks

Full recovery expected

Low (under 5%)

Moderate

3-6 weeks

Full recovery expected

Moderate (10-15%)

Severe

6+ weeks

May have prolonged course

High (15-20%)

Grade	Description	Key Features
Grade I	Minor contusion	Localized tenderness, full ROM
Grade II	Moderate contusion	Swelling, decreased ROM 45-90 degrees
Grade III	Severe contusion	Marked swelling, ROM less than 45 degrees, antalgic gait

Location	Muscle	Clinical Features
Proximal	Rectus origin	May involve AIIS, hip flexion weakness
Mid-belly	Central quadriceps	Most common, typical presentation
Distal	Near patella	May cause quad lag, patella tracking issues
Intramuscular	Within fascia	Contained, better prognosis
Intermuscular	Between muscles	Bruising tracks distally, faster recovery

Time	X-ray Finding	Clinical Correlation
0-2 weeks	Normal	Pain, mass may be palpable
3-4 weeks	Faint calcification	Zoning phenomenon begins
6-8 weeks	Mature peripheral bone	Central lucency visible
3-6 months	Mature MO	Corticated periphery

Grade	Description	Key Features
Grade I	Minor contusion	Localized tenderness, full ROM
Grade II	Moderate contusion	Swelling, decreased ROM 45-90 degrees
Grade III	Severe contusion	Marked swelling, ROM less than 45 degrees, antalgic gait

Location	Muscle	Clinical Features
Proximal	Rectus origin	May involve AIIS, hip flexion weakness
Mid-belly	Central quadriceps	Most common, typical presentation
Distal	Near patella	May cause quad lag, patella tracking issues
Intramuscular	Within fascia	Contained, better prognosis
Intermuscular	Between muscles	Bruising tracks distally, faster recovery

Quadriceps Contusions

Quadriceps Contusions

QUADRICEPS CONTUSIONS - CLASSIFICATION and MANAGEMENT

RYAN CLASSIFICATION (by ROM at 24h)

Critical Must-Knows

Examiner's Pearls

Clinical Imaging

Imaging Gallery

Critical Quadriceps Contusion Exam Points

24-Hour ROM Classification

Flexion Position Treatment

Myositis Ossificans Prevention

Compartment Syndrome Risk

Quick Decision Guide by Grade

FLEX - Acute Management

RICE Plus - First 48 Hours

MO RISK - Myositis Ossificans Risk Factors

RTS Criteria - Return to Sport

Overview and Epidemiology

Pathophysiology and Mechanisms

Contusion Evolution

Myositis Ossificans Development

Classification Systems

Clinical Assessment

History

Examination

Compartment Syndrome Signs

Investigations

MO vs Osteosarcoma

Management Algorithm

Surgical Technique

Maturity Confirmation

MO Excision Steps

Complications

High Index of Suspicion

Rehabilitation and Return to Sport

Rehabilitation Phases

Outcomes and Prognosis

Evidence Base

Jackson-Feagin Study (1973)

Ryan et al Classification (1991)

Aronen et al - NSAIDs for MO Prevention

Diaz et al - Hematoma Aspiration

Beiner et al - MO Natural History

Exam Viva Scenarios

Scenario 1: Acute Severe Contusion

Scenario 2: Myositis Ossificans Development

Scenario 3: Return to Sport Decision

MCQ Practice Points

Australian Context

Quadriceps Contusions

Classification (Ryan)

Acute Management

Jackson-Feagin Protocol

Myositis Ossificans

Return to Sport Criteria

Key Exam Points

Quadriceps Contusions

Quadriceps Contusions

QUADRICEPS CONTUSIONS - CLASSIFICATION and MANAGEMENT

RYAN CLASSIFICATION (by ROM at 24h)

Critical Must-Knows

Examiner's Pearls

Clinical Imaging

Imaging Gallery

Critical Quadriceps Contusion Exam Points

24-Hour ROM Classification

Flexion Position Treatment

Myositis Ossificans Prevention

Compartment Syndrome Risk

Quick Decision Guide by Grade

FLEX - Acute Management

RICE Plus - First 48 Hours

MO RISK - Myositis Ossificans Risk Factors

RTS Criteria - Return to Sport

Overview and Epidemiology

Pathophysiology and Mechanisms

Contusion Evolution

Myositis Ossificans Development

Classification Systems