Standardized by: 
Denver T. Stanfield, MD

The quadriceps complex is a group of four large powerful muscles located on the anterior thigh. A forceful direct blow to the anterior thigh can result in a painful and debilitating deep contusion to the quadriceps. Quadricep contusions can be frustrating injuries because the time away from athletic activity is variable and unpredictable. Reported treatment regimens for managing quadricep contusions have had wide variations over the last several years. Injury to the quadriceps results in limited painful knee flexion. It is well documented that athletes typically can return to play when they have regained 120 degrees or more of knee flexion. Efforts to regain this amount of flexion without significant pain results in the above mentioned frustration.

I believe strongly in a treatment program which focuses not on regaining knee flexion but on proper urgent treatment which maintains knee flexion greater than 120 degrees immediately from the time of injury. This regimen eliminates the primary obstacle and minimizes the length of time before return to athletic activities.

The treatment of deep thigh contusions has traditionally focused on the treatment of the established hematoma. Although prevention of the hematoma has been attempted by the use of ice and compression, results have not been highly successful. Knowing the mechanism of injury and performing a quick on-field examination can help diagnose a quadriceps contusion and rule out a fracture. Patients treated immediately can tolerate early immobilization in 120 degrees of knee flexion. Early immobilization on the field, followed with conservative measures off the field will achieve quick results. If pain keeps an athlete from effectively tightening the injured quadriceps (for example, if a player lying on his back, cannot raise the leg against gravity with a fully extended knee), the contusion is severe enough to take the player out of the game. While on the field, I recommend immobilizing the injured leg in at least 120 degrees of knee flexion using an elastic wrap. Stretching the quadricep muscle over the injured area with knee flexion provides compression decreasing the amount of bleeding and hematoma formation. As soon as possible after injury the wrap should be removed and the leg immobilized in an adjustable knee brace in maximal flexion. Athletes should wear the brace continuously for the first 24 hours after injury along with local ice application to the injured site. Crutches are necessary for ambulation.

Remove the adjustable brace 24 hours after the injury and begin rehabilitation. Preferably a physical therapist or trainer is available for twice a day sessions consisting of electric stimulation followed by passive, pain-free quadricep stretching. Also active pain-free quadriceps stretching should be performed several times a day. In addition, I recommend isometric quadricep contractions (quad sets) for early strengthening. Crutches should be used until the quad sets are pain free and there is minimal if any limp.

Modified Treatment

Unfortunately, some patients are not seen until after significant intramuscular bleeding and spasms have occurred. Uncontrolled bleeding and spasms in the contused quadriceps frequently limits flexion of the knee. These patients need a modification of the above program.

I start with placing the athlete prone and passively flex the knee as much as tolerated, then ask the athlete to attempt knee extension against my resistance until there is fatigue in the contused quadriceps. (Fatiguing the contused quadricep will decrease the spasms that are limiting knee flexion). With the onset of fatigue, greater knee flexion can be obtained. This routine of knee flexion, fatigue and greater knee flexion is then followed by pain-free extension and rest for 10 minutes. The entire regimen is repeated a total of three times at the initial treatment. The knee is then immobilized in an adjustable knee brace in the maximum degree of pain-free flexion. The brace is worn continuously except for the the twice a day treatment sessions. Electric stimulation and ice packs are also incorporated in the treatment. The goals for return to activity are the same as above.