Quadriceps Tendinitis

Blazina Classification (Modified)

Originally described for Jumper's knee, applied to Quads tendon.

Simple, clinically relevant.

MRI Grading of Tendinosis

• Grade 1: Signal intensity change (T1/T2 increased) only. No dimension change.
• Grade 2: Signal change + Tendon thickening/fusiform swelling.
• Grade 3: Partial thickness tearing (fluid signal in tendon).
• Grade 4: Full thickness rupture.

Differentiation between Grade 2 (tendinosis) and Grade 3 (partial tear) is important for rehab aggression.

VISA-P Score Note

While designed for patellar tendinopathy, the questions (squatting, lunging, sitting) are highly relevant for quadriceps tendinopathy and it is often used as a surrogate outcome measure in studies, though technically validated for the patellar tendon.

• Interpretation: Less than 80 suggests significant functional deficit.

The VISA-P remains the standard outcome measure for clinical tracking.

Cornerstone of Treatment: Management mirrors patellar tendinopathy but focuses on deep flexion control.

Protocol:

1. Phase 1 (Analgesia): Isometric holds (e.g., wall sit at 60 deg). Ice. NSAIDs.
2. Phase 2 (Isotonic): Heavy Slow Resistance (HSR). Leg press, squats.
3. Phase 3 (Eccentric):
   • Note: Standard eccentric decline squats may impinge the superior pole if deep flexion is forced too early.
   • Controlled eccentric lowering (e.g., single leg press lowering).
4. Phase 4 (Plyometric): Return to jumping.

📊 Management Algorithm

Click to expand

Standard therapy duration: 3-6 months.

Injections:

1. PRP (Platelet-Rich Plasma): Secondary option for recalcitrant cases. Level 1 evidence is weak/mixed.
2. Prolotherapy: Hyperosmolar dextrose to stimulate healing.
3. Dry Needling: Stimulation of healing response.
4. Polidocanol: Sclerosing of neovessels (if present on Doppler).

Calcific Lavage:

• If calcific tendinitis is present (calcium deposit), US-guided barbotage (lavage) can be curative.

Interventional options should only be considered after adequate load management.

Indications:

• Failure of prolonged conservative care (greater than 6 months).
• Partial tear greater than 50% with functional deficit.
• Calcific tendinitis resistant to lavage.
• Rupture (acute).

Procedures:

1. Debridement: Excision of angiofibroblastic tissue.
2. Repair: If significant tendon removed, side-to-side suture or anchor repair.
3. Osteoplasty: Removal of prominent superior pole spur (if causing impingement).

Post-operative recovery is lengthy (4-6 months).

Open Debridement and Repair:

Approach:

• Midline longitudinal incision extending proximal to patella.
• Expose paratenon.

Technique:

1. Inspection: Incise paratenon. Pre-operative MRI guides location (often deep/central).
2. Tenotomy: Longitudinal split in tendon to access deep layers.
3. Debridement: Excise grey/friable/mucinoid tissue. "Scrape" the superior pole if cystic change present.
4. Spur Removal: If a traction spur exists ("tooth"), remove with rongeur/burr to prevent impingement.
5. Calcium: If calcific deposit, excise white, chalky material.
6. Closure:
   • Carefully repair the longitudinal split (Vicryl/PDS).
   • If debridement leaves a defect, side-to-side closure.
   • Close paratenon to prevent adhesions.

Post-op:

• Protected weight bearing in brace (locked extension) for 2 weeks.
• Gradual ROM increase.
• Slower than arthroscopic patellar procedures due to muscle violation.

Open debridement provides the most reliable access to the multi-layered pathology.

Arthroscopic Evaluation:

• Suprapatellar Pouch: View the articular side of the quadriceps tendon.
• Undersurface Tear: Can identify partial articular-sided tears (PASTA equivalent of knee).
• Debridement: Shaver debridement of articular surface fraying.
• Limitation: Cannot access the substance of the tendon or superficial layers easily. Open approach is generally preferred for classic tendinosis.

Arthroscopy is primarily diagnostic or for intra-articular pathology (plica).