These injuries are most commonly seen in contact sports. In the United States, quadriceps contusions are typically seen in football where the helmet of a tackler hits a running back in the anterior thigh. The thigh pads are specifically designed to absorb this injury, but sometimes players do not like to wear them (against regulations) because they feel that they slow them down or they may slide off to one side. Quadriceps contusions cause immediate muscular damage,2 intramuscular bleeding, and pain. With severe injuries, the patient may be unable to continue playing. The trainer will typically place an Ace bandage around the thigh, an ice bag, and another Ace bandage over that, trying to apply compression and ice in order to avoid the development of a large hematoma and decrease the swelling. Depending on the position of the knee at contact and the degree of involvement, flexion (and/or extension) deficits may develop. The degree of difficulty with postinjury range of motion, most specifically regaining flexion, is a significant prognostic indicator.3 The amount of flexion at 48 hours after injury was found by Jackson and Feagin3 to be a predictor of and guide to rehabilitation prognosis and progression. The ice can be removed after about 20 minutes and reapplied every 2 hours. Radiographs are usually not needed immediately. They may be helpful after several weeks to evaluate for myositis ossificans. Immobilization in as much flexion as comfortable for the first 24 hours using an adjustable hinged knee brace may help maintain range of motion. Heat and ultrasound are not used in the initial phase. After the initial injury phase2 and swelling are resolved, the range of motion is gently reestablished without undo stressing of the extensor muscle mass. This may be begun in the inflammatory stage and continued through remodeling.4 Ice massage and soft-tissue techniques are used to try to mobilize the knee and reestablish dynamic functionality of the quadriceps musculature.
A progressive resistance exercise program may be undertaken when 90 degrees of flexion is obtained. Prognostic factors include regaining a range of motion of at least 45 degrees of flexion in the first 3 weeks.5 The trainer or therapist needs to be careful with regard to aggressively trying to establish range of motion, as scarring and increased contracture have been noted with aggressive or manipulative attempts to regain knee flexion. Generally, the prognosis is good with return to play at 2 to 3 weeks when the athlete passes isokinetic and functional testing, although in severe cases, it may take several months.
The overall outlook for functional return is good, and the risk of myositis ossificans is proportional to the amount of bleeding and degree of the original injury.1 If myositis ossificans becomes a significant factor, range of motion may be more difficult to obtain and the patient may develop a hard mass in that area on a long-term basis. Increased or specialized padding to protect that area for future contact may be appropriate. Excision of myositis ossificans deposits has met with limited success. Compartment syndrome after thigh contusion has been reported, and this entity is discussed later.
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