Quad Pain Diagnosis

Looking for diagnosis possibilities:

52 year old athletic male incurred quad tendon injuries in Feb. 2009 due to one hour of high intensity bicycling on a trainer (felt pull in right leg about 10 cm above the kneecap at the end of the hour, then pain in the left quad tendon 10 cm above the kneecap a week later after favoring during daily activity). No inflammation or bruising on initial injury.

Stinging type pain above the knee was on and off initially, but now (Oct. 2009) is constant and escalates with minimal activity such as walking 50 meters. Thought it was tendonitis, but unable to remedy through 5 months of physio therapy and NSAIDs.

Have quadriceps and glute weakness / atrophy due to lack of activity to avoid pain. Have paresthesia in lower legs starting Sept. 2009. Pain now includes a dull ache in tendons 10 cm above the kneecaps along with the stinging pain with activity.

Tests with negative results include leg and hip x-rays, 2 thigh MRI's, lower back MRI, 2 EMG's, nerve conduction test and bloodwork. MRI's show no indication of tendinosis. Neurologists indicate no neuro-muscular disease.

Any thoughts or course of action are appreciated!

It sounds like he has had extensive tests... what has the physiotherapy entailed? and is there any news on his condition now or is much the same?

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Originally Posted by pudding_bowl

It sounds like he has had extensive tests... what has the physiotherapy entailed? and is there any news on his condition now or is much the same?

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Most recent physiotherapy has been straight leg exercises (now up to a four pound weight), leg clams with a resistance band, very low resistance leg presses, standing hip adduction.

Have also received autologous conditioned plasma injections (ACP) in the quad tendons to stimulate healing (also known as platelet rich plasma).

Current plan is to progress slowly with the physiotherapy and hopefully have the ACP injections restore the quad tendons to a pain free state. Condition has improved slightly - can walk short distances without pain, but still have trouble with stairs.

How far away is your patient from being able to do decline board squats? Though it would be going against the ACP theory. The research on neovascularisation in tendons that I'v seen showed that by reducing it the pain got better - hense eccentric exercises worked well. If getting better with ACP then best not to try the eccn work right away I suppose. But it's just a thought for later on perhaps. Keep up the good work though sounds like your getting somewhere with the patient. I'm often guilty of getting upset when I can't get the results I want within a month or so so your doing well! What are your thoughts on the Mechanotherapy approach?

On a leg press, he can do 30 reps at 55 pounds (about 30% of body weight) using both legs without developing subsequent tendon pain. Plan is to build quad strength below the pain threshold and eventually move into an eccentric program.

Most eccentric protocols I have seen call for single leg squats on a 25% - 30% decline board - so quite a ways to go for that.

3rd ACP injection is scheduled about 2 weeks out - so perhaps will build up to decline board squats over 6 months or longer.

Any thoughts on:
1) Continuing ACP injections if providing some benefit (will have had 3 spaced 2 weeks apart).
2) Effectiveness of eccentrics at less than optimal loading (i.e. 2 legged at 50% of body weight?).

Thanks for any thoughts.

I'm all for doing double leg if the patient can't manage single leg. But like you say they may be a bit far off that still.
If ACP provides benefit then definately pursue it. If your getting benefit then keep on doing what your doing. At which point a plateau is reached then we should look into the eccentric protocol perhaps. I would almost say they are contraindicated as the eccentric work is shown to reduce the vascularisation in the tendon and I think ACP is attempting to increase it? Fill me in if I'm wrong on that.

I think that you are right on the neovascularization / contraindication. Perhaps the ACP / vascularization is required in this instance to initially provide tendon cell proliferation for the healing which did not occur after the injury.

The eccentrics (and perhaps reduced vascularization) can be considered later when the tendon has progressed to better handle the load.

One thing is clear - - I'm way out of my league on this discussion!!:)

Haha, you and me both. Sounds like I know as much as you do.