(Also known as Quadriceps Tear, Strained Quadriceps Muscle, Torn Quadriceps Muscle, Pulled Quadriceps)
What is a quadriceps strain?
A quadriceps strain is a condition that is frequently seen in kicking and running sports and is characterised by partial or complete tearing of the quadriceps muscle located at the front of the thigh (figure 1).
Figure 1 – Relevant Anatomy for a Quadriceps Strain (Vastus Intermedius Muscle Not Shown)
The large muscle group at the front of your thigh is called the quadriceps (figure 1). The quadriceps comprises of 4 muscle bellies which originate from the pelvis and thigh bone (femur) and attach to the shin bone (tibia) via the knee cap (patella). They are:
- rectus femoris
- vastus medialis
- vastus lateralis
- vastus intermedius
The quadriceps is responsible for straightening the knee during activity and controlling knee and hip movements and is particularly active during sprinting, jumping, hopping or kicking. Whenever the quadriceps muscle contracts or is put under stretch, tension is placed through the quadriceps muscle fibres. When this tension is excessive due to too much repetition or high force, the quadriceps muscle fibres may be torn. When one or more parts of the quadriceps muscle tear, the condition is known as a quadriceps strain. The rectus femoris is the most commonly affected muscle belly in a quadriceps strain.
Tears to the quadriceps can range from a small partial tear whereby there is minimal pain and minimal loss of function, to a complete rupture whereby there is a sudden episode of severe pain and significant disability. Quadriceps strains range from a Grade 1 to a Grade 3 tear and are classified as follows:
- Grade 1 Quadriceps Tear: a small number of fibres are torn resulting in some pain, but allowing full function.
- Grade 2 Quadriceps Tear: a significant number of fibres are torn with moderate loss of function.
- Grade 3 Quadriceps Tear: all muscle fibres are ruptured resulting in major loss of function.
The majority of quadriceps strains are grade 2 tears.
Causes of a quadriceps strain
Quadriceps strains most commonly occur due to a sudden contraction of the quadriceps muscle (particularly when the muscle is on stretch – e.g. kicking). They often occur during sprinting, jumping, hopping or kicking activities. This is particularly so during explosive acceleration (e.g. sprinting), when a footballer is kicking on the run or performs a long kick, or, following an inadequate warm-up. Quadriceps strains are commonly seen in running sports such as football and athletics.
Signs and symptoms of a quadriceps strain
Patients with a quadriceps strain usually feel a sudden sharp pain or pulling sensation in the quadriceps muscle at the time of injury. In minor cases, the patient may be able to continue activity only to have an increase in symptoms upon resting later (often that night or the next morning). In more severe cases, patients may experience severe pain, muscle spasm, weakness and an inability to continue the activity. Patients with a severe quadriceps strain may also limp or be unable to walk off the playing field.
Patients with a quadriceps strain usually experience an increase in pain during activities which place tension on the quadriceps muscle. These activities may include squatting, going up and down stairs, running, jumping, hopping, kicking or performing a quadriceps stretch. It is also common for patients to experience pain or stiffness after these activities with rest, especially upon waking in the morning.
Patients with this condition may also experience swelling, pain on firmly touching the affected region of the quadriceps muscle and bruising in the front of the thigh. In severe cases, a visible deformity in the quadriceps muscle may also be detected.
Diagnosis of a quadriceps strain
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a quadriceps strain. Further investigations such as an MRI scan or Ultrasound may be required, in rare cases, to confirm diagnosis.
Treatment for a quadriceps strain
Most patients with a quadriceps strain heal well with an appropriate physiotherapy program. The success rate of treatment is largely dictated by patient compliance. One of the key components is that the patient rests sufficiently from any activity that increases their pain until they are symptom free (the use of crutches may be required). Activities which place large amounts of stress through the quadriceps should also be minimized, these include: running, jumping, hopping, squatting, going up and down stairs, lunging and kicking. Rest from aggravating activities ensures the body can begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms, or adopting a ‘no pain, no gain’ attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with a quadriceps strain is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.
Diligently following the R.I.C.E. Regime in the initial phase of injury (first 72 hours) will greatly assist in improving recovery time in patients with a quadriceps tear. This involves rest from aggravating activities (the use of crutches may be required), regular icing (i.e. 20 minutes every 2 hours), the use of a compression bandage, and keeping the injured leg elevated above the level of your heart. Anti-inflammatory medication may also help to reduce inflammation, pain and swelling.
Manual “hands-on” therapy from the physiotherapist such as massage, trigger point releases, joint mobilisation, dry needling, stretches and electrotherapy can also assist with improving range of movement and function following a quadriceps strain. This can generally commence once the physiotherapist has indicated it is safe to do so.
A graduated flexibility and strengthening program guided by a physiotherapist is essential to recondition the quadriceps muscle and reduce the likelihood of injury recurrence. Careful assessment by the physiotherapist to determine which factors have contributed to the development of the quadriceps strain, with subsequent correction of these factors is also important to ensure an optimal outcome. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they can be commenced.
For those patients who wish to return to running or sport, a graduated return to running program is required in the final stages of rehabilitation to recondition the quadriceps for running in a safe and effective manner. This should include the implementation of progressive acceleration and deceleration running drills, agility drills and match-specific drills before returning to training and eventually sport, with close monitoring of the athlete’s response and recovery between each session.
Prognosis of a quadriceps strain
With appropriate management, patients with minor quadriceps strains can usually recover in one to three weeks. With larger tears, recovery may take four to eight weeks or longer depending on the severity of the injury. Complete ruptures of the quadriceps muscles are rare and are usually managed conservatively. In these cases, recovery may be significantly longer.
Contributing factors to the development of a quadriceps strain
There are several factors which can predispose patients to developing a quadriceps strain. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:
- muscle tightness (particularly the quadriceps, hamstrings, gluteals, hip flexors)
- muscle weaknesses (such as the quadriceps or gluteals)
- inappropriate training
- excessive training or activity
- inadequate recovery periods from sport or activity
- inadequate warm up
- joint stiffness (especially the lower back, hip or knee)
- poor biomechanics
- inadequate rehabilitation following a previous quadriceps injury
- decreased fitness
- poor core stability
- muscle imbalances
Physiotherapy for a quadriceps strain
Physiotherapy for patients with a quadriceps strain is vital to hasten the healing process and ensure an optimal outcome. Treatment may comprise:
- soft tissue massage
- electrotherapy (e.g. ultrasound)
- joint mobilization
- dry needling
- anti-inflammatory advice
- the use of crutches
- ice or heat treatment
- progressive exercises to improve strength, flexibility (particularly of the quadriceps), core stability and balance
- biomechanical correction
- activity modification advice
- establishment of an appropriate return to activity or sport plan
Other intervention for a quadriceps strain
Despite appropriate physiotherapy management, some patients with a quadriceps strain do not improve adequately. When this occurs, your treating physiotherapist or doctor can advise on the best course of management. This may include investigations such as an ultrasound, CT scan or MRI, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition.
Exercises for a quadriceps strain
The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.
Static Inner Quadriceps Contraction
Tighten the muscle at the front of your thigh (quadriceps) by pushing your knee down into a towel (figure 2). Put your fingers on your inner quadriceps to feel the muscle tighten during contraction. Hold for 5 seconds and repeat 10 times as hard as possible provided there is no increase in symptoms.
Figure 2 – Static Inner Quadriceps Contraction (left leg)
Knee Bend to Straighten
Bend and straighten your knee as far as possible without pain and provided you feel either nothing, or, no more than a mild to moderate stretch (figure 3). Repeat 10 – 20 times provided the exercise is pain free.
Figure 3 – Knee Bend to Straighten (right leg)
Begin this exercise lying on your back in the position demonstrated (figure 4). Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for 2 seconds then slowly lower your bottom back down. Perform 10 – 20 repetitions provided the exercise is pain free.
Figure 4 – Bridging
Use a chair or table for balance. Take your heel towards your bottom, keeping your knees together and your back straight as far as you can go without pain and provided you feel no more than a mild to moderate stretch in the front of your thigh (figure 5). Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free.
Figure 5 – Quadriceps Stretch (left leg)
Squats with Swiss Ball
Begin this exercise in standing with your feet shoulder width apart and your feet facing forwards. Place a Swiss ball between a wall and your lower back (figure 6). Slowly perform a squat, keeping your back straight. Your knees should be in line with your middle toes and should not move forward past your toes. Perform 5 – 20 repetitions provided the exercise is pain free. Generally, you should begin with 5 shallow squats (i.e. only bending the hips and knees a little) and then build up to 20 repetitions over a number of days provided the exercise is pain free. Once you can perform 20 shallow squats for a few days consistently without pain, drop to 5 repetitions and increase the squat depth a little, again gradually building up to 20 slightly deeper squats over a number of days. Continue this process until you can eventually perform 20 squats to a 90 degree knee bend provided the exercise is pain free (figure 6).
Figure 6 – Squats with Swiss Ball
Single Leg Bridging
Begin this exercise lying on your back in the position demonstrated (figure 7). Slowly lift your bottom pushing through your foot, until your knee, hip and shoulder are in a straight line. Tighten your bottom muscles (gluteals) as you do this and hold for 2 seconds. Then slowly lower back down. Perform 10 – 20 repetitions provided the exercise is pain free.
Figure 7 – Single Leg Bridging (left leg)
Quad Stretch in Lunge Position
Begin in the lunge position as demonstrated. Take your heel towards your bottom, keeping your back straight and your bottom muscles clenched, as far as you can go without pain and provided you feel no more than a mild to moderate stretch in the front of your thigh (figure 8). Hold for 15 seconds and repeat 4 times at a mild to moderate stretch provided the exercise is pain free.
Figure 8 – Quad Stretch in Lunge Position (right leg)
Begin this exercise standing with your back straight in the position demonstrated (figure 9). Slowly lower your body until your front knee is at a right angle. Keep your knee in line with your middle toe and your feet facing forward. Perform 10 – 30 repetitions provided the exercise is pain free. Once you can comfortably perform 30 repetitions of this exercise consistently without pain, you can progress the exercise by performing it whilst holding light weights (figure 10). Begin with only a few repetitions (whilst holding light weights) initially and then build up to 30 repetitions gradually over a number of days provided there is no increase in pain. This process can then be repeated with a slightly heavier weight to further strengthen the quadriceps and lower limb.
Figure 9 – Lunges (right leg)
Figure 10 – Lunges with Weights
Place the foam roller under your quadriceps (front of your thighs) as demonstrated (figure 11). Using your arms, slowly move your body forward and backwards allowing the foam roller to massage the front of your thighs. Breathe normally keeping your legs relaxed. Repeat this process for 15 – 90 seconds provided it is comfortable and does not cause pain. This exercise can be performed on hands or forearms and can be progressed by crossing your legs and massaging one thigh at a time or placing the leg that is not being massaged in contact with the ground (via the toes).
Figure 11 – Quadriceps Release
Quadriceps Self Massage
Place the spikey massage ball under your quadriceps (front of your thigh) as demonstrated (figure 12). Using your arms and leg, slowly move your thigh forwards, backwards and side to side allowing the spikey ball to massage the front of your thigh. Breathe normally keeping your leg relaxed. Repeat this process for 15 – 90 seconds provided it is comfortable and does not cause pain. You can also apply sustained pressure to a particular tight spot for periods of 15 – 60 seconds or until the soft tissue relaxes.An effective progression for this quadriceps self massage exercise can also be performed in this position by slowly bending and straightening the knee provided it is comfortable and does not cause pain.
Figure 12 – Quadriceps Self Massage
Rehabilitation Protocol for a quadriceps strain
The following is a general rehabilitation protocol for a quadriceps strain. This needs to be tailored to each individual and should be discussed with your treating physiotherapist prior to commencing. Progression through this program can vary from several days to many weeks depending on injury severity and quality of treatment:
- See your physiotherapist as soon as possible to confirm diagnosis, establish the likely prognosis, identify any contributing factors to injury and begin appropriate treatment.
- Follow the R.I.C.E. Regime for the first 48 – 72 hours. This should primarily comprise:
- Rest from any activity that increases pain (if walking is painful or causing a limp, crutches are usually required, see How to Use Crutches)
- Ice the sore area for 20 minutes and repeat every 2 hours
- Compress the thigh using a compression bandage to minimise swelling (ensure this is not too tight and remove during sleep).
- Elevate the affected leg to a level above the heart.
- Anti-inflammatory medication may be beneficial (discuss this with your doctor and/or pharmacist)
- If using crutches, walk normally, but take enough weight off the injured leg so walking is pain free and limp free. Sometimes smaller steps may be required for a period of time. Gradually increase weight through the injured side as tolerated provided there is no increase in pain or limp. Eventually progress to the use of one crutch (using the crutch in the opposite arm to the injured side i.e. right arm for left quadriceps injury) and eventually no crutches (see How to Use Crutches).
- Aim for pain free rehabilitation (i.e. gradually increase strength, flexibility and activity, provided there is no increase in symptoms during activity or upon rest following activity. This should take place over days to weeks).
- Begin “Initial Exercises” 72 hours following injury provided there is no increase in symptoms. Generally you should begin with one or two “Initial Exercises’ and then add the remaining ‘Initial Exercises’ after a few days provided there is no increase in symptoms.
- Heat treatment can usually commence 72 hours following injury provided there is no inflammation (i.e. night-time pain, morning ache/stiffness or pain at rest). Apply a heat pack to the injured area at a comfortable warmth for 20 – 30 minutes before exercises. If inflammation is still present (i.e. night-time pain, morning ache/stiffness or pain at rest), continue to use ice instead of heat.
- Increase walking distance, and eventually speed, gradually, and provided there is no increase in pain or limp (this should take place over days to weeks).
- Self massage can be performed by using your hands to massage the front of your thigh when sitting. This can be performed for approximately 5 minutes daily (with or without massage cream or oil) provided it is pain free.
- Progress to the “Intermediate Exercises” once the “Initial Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side. Ensure all new exercises do not increase symptoms. The ‘Intermediate Exercises’ should replace the ‘Initial Exercises’. Generally you should begin with one “Intermediate Exercise’ and then add the remaining ‘Intermediate Exercises’ after a few days provided there is no increase in symptoms.
- Hydrotherapy, swimming, cycling or use of a cross trainer may be included in your rehab to maintain fitness levels and assist in restoring range of movement and muscle strength during rehabilitation. All new exercises should generally begin gently and for a short duration and then gradually increased over a number of days provided symptoms do not increase. Ensure all new exercise do not increase symptoms.
- ‘Other Exercises’ may be added provided they do not cause or increase pain.
- Progress to the “Advanced Exercises” once the “Intermediate Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side. Ensure all new exercises do not increase symptoms. The ‘Advanced Exercises’ should replace the ‘Intermediate Exercises’. Generally you should begin with one “Advanced Exercise’ and then add the remaining ‘Advanced Exercise’ after a few days provided there is no increase in symptoms. These should generally be continued until the “Advanced Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side.
- A gradual Return to Running Program should be implemented for individuals who aim to return to running following injury provided there is no increase in symptoms. This should include the implementation of progressive sprinting, agility and match-specific drills before returning to running sports.
- A gradual return to sport and activity can occur provided there is no increase in symptoms.
- Ensure your physiotherapist has identified any contributing factors to your injury and appropriate intervention has taken place to address these issues to minimize the likelihood of injury recurrence.
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Find a physiotherapist in your local area who can treat this condition.
Physiotherapy products for a quadriceps strain
Some commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include:
Physiotherapy products that may be beneficial after the initial 72 hour period following injury and under guidance by the treating physiotherapist include:
- Heat Packs
- Resistance Band (for strengthening exercises)
- Spikey Massage Balls (for self massage)
- Foam Rollers (for self massage)
To purchase physiotherapy products for a quadriceps strain click on one of the above links or visit the PhysioAdvisor Shop.
- Quadriceps Stretches.
- Quadriceps Strengthening Exercises.
- Balance Exercises.
- How to use Crutches.
- R.I.C.E. Regime.
- Ice or Heat.
- Return to Running Program
- Thigh Diagnosis Guide.
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A quadriceps strain is a condition characterised by partial or complete tearing of the quadriceps muscle (located at the front of the thigh). It typically occurs during a forceful contraction of the quadriceps muscle, often when it is in a position of stretch (e.g. kicking or sprinting). Diagnosis and treatment by a physiotherapist is vital for an optimal outcome.
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