Bilateral Quadriceps Rupture in an Elite Weight Lifter: A Case Report and Review of Literature

Abstract

Simultaneous bilateral quadriceps tendon ruptures (QTR) are rare injuries in sportspersons; weightlifting, involving sudden eccentric contraction of the bilateral quadriceps, has the potential to cause this injury. We present a case of an elite weightlifter with bilateral quadriceps tear occurring during the “jerk” part of clean and jerk phase of weightlifting; single stage bilateral end to end repair was done, followed by 3 weeks of cast immobilisation. He then underwent a supervised rehabilitation protocol, leading to graduated strengthening of the muscles. He went back to competitive sport after 2 years and participated in a national championship after 5 years. Detailed questioning revealed a history of anabolic steroid use in the early phase of his career; a literature review showed only seven cases of this injury pattern in weightlifting/bodybuilding sports, and five of these seven had a definitive history of anabolic steroid use. Bilateral QTR may be a pointer to predisposing factors like use of steroids, which should be diligently identified. Good outcomes are possible after early surgical repair and rehabilitation, with high rates of return to sports.

Introduction

Quadriceps tendon ruptures (QTR) are relatively rare with a documented incidence of 1.37/100,000 [1, 2]. Bilateral QTR, first reported in 1949, are even rarer [3]. The largest published series of extensor mechanism disruptions reported 235 cases, only 14 of which were bilateral, and almost all had a significant systemic co-morbidity and /or a predisposing factor [4]. Closed traumatic QTR can occur by direct or indirect mechanisms; the latter occurs due to a forced eccentric contraction of the quadriceps muscle against resistance, starting with the knee in squatting position [5, 6]. If the tendon is unhealthy, even low intensity indirect forces can rupture it [7]. The healthy quadriceps tendon can resist considerable loads, and more often than not tears occur in tendons with disrupted microscopic integrity because of different risk factors; chronic renal disease, hyperparathyroidism, diabetes, obesity, gout, alcohol, steroids, etc. [8, 9]. This association is more in bilateral QTR than in unilateral cases [10].

Injuries in sports are often specific to that particular game. Weightlifters have issues in relation to the back, shoulder and knee, many of which are overuse injuries of a chronic nature [11]. Acute injuries are uncommon, and bilateral simultaneous bilateral QTRs are very rare; one specific scenario in weightlifting, where this can occur when the knee is flexed more than 60–90° (the “Clean and Jerk manoeuvre”); the “Jerk” part involving the use of knee extension to become upright and bringing the weight from the shoulders to the upright position leads to excessive load concentrations [12]. In eccentric activation, muscle length increases against a resisting force which is more than that generated by the muscle itself, and this increases the risk of injury with high tensile forces within [12].

A survey of the published literature revealed 11 cases of sports related bilateral QTR, 5 of which were weightlifters and 2 were in body builders (Table 1). Five of these seven had a history of steroid use, influencing the extensor mechanism strength. We report a case of an elite weightlifter who ruptured both his quadriceps muscles/tendons during his weightlifting trials, and retrospectively was found to have a history of anabolic steroid use. A review the literature to assess the risk factors, types of presentation and management of such cases is presented.

Table 1.

Reported cases of simultaneous bilateral quadriceps sports injuries in English Literature

S no	Author	Journal	Year	Age(years)	Sex	Sports	Mechanism	Risk factor	Initial presentation	Diagnostic modality	Location of tear	Management	Prognosis/return to sports
1	Grenier et al. [15]	AJSM	1983	39	M	Weight lifting	Patient squatted with a weight of 250 lb on his shoulders; sharp pain, leaned back, felt loud cracks in knees	–	Pain, swelling, also had fracture of left distal both bones leg	Xray	At insertion into patellae with retinaculum tear	Surgical repair and ORIF of tibia Cylinder cast for right and long leg cast for left	At 7 months fully functional knees and united fractures. Resumed weight lifting
2	Fenelon et al. [16]	BMJ case reports	2016	29	M	Weight lifting	Injury while squatting with 280 Lb. (patient during knee extension fell to the floor)	Anabolic steroid	Swelling, suprapatellar gaps, pain	Xrays	Complete tear with retinacular involvement	Surgical repair f/b fixed extension brace for 6 weeks f/bphysiotherapy	At 8 months no symptoms. Associated partial ACL tear also healed
3	David et al. [17]	JBJS(Br)	1995	34	M	Body builder	While Squat lifting with 400 lb	Anabolic steroid (testosterone)	Pain, inability to stand	Xrays	Avulsions from patellae	Surgical repair f/b 6 weeks casts f/b physiotherapy	At 1 year, extension lag of 5–10 degrees
4	Liow et al. [18]	BJSM	1995	29	M	Body building	Jump from 15 feet; landed with knees flexed	Anabolic steroids; had quadriceps pain prior to injury	Pain, swelling, suprapatellar gaps	Xrays, USG	Osseotendinous junction with retinaculum tears	Surgical repair f/b 8 weeks casts f/b physiotherapy	At 4 months minimal lag with flexion upto 60 degrees
5	Lewis et al. [19]	Orthopaedics	2005	35	M	Weight lifting	While Squat lifting with 200 kg during extension phase	Anabolic steroids	Pain, swelling, palpable suprapatellar gaps	MRI	Avulsion on the right; on left partial attachment of VL was retained	Surgical repair f/b 6 weeks of fiberglass cylinder cast, f/b physiotherapy	At 6 months no symptoms but unable to return to sports
6	Bikkina et al. [20]	J Trauma	2002	40	M	Weight lifting	Fell down while squat lifting 600 lb	–	Pain in knees and right ankle	MRI	Avulsion on the right and tear at musculotendinous junction on left	ORIF of bimalleolar fracture; Surgical repair	Modified style of weight lifting with minimal squatting
7	Hill et al. [21]	AJSM	1983	24	M	Weight lifting	Knees gave way while squatting with 750 lb	Anabolic steroids	Pain, inability to walk	–	Complete tear at insertion in right knee; Minor partial tear on left	Surgical repair for right; conservative for left	Returned to competitive sports
8	Shah et al. [22]	BJSM	2002	39	M	Basketball	Fall while shooting the ball; fell with knees flexed	–	Pain, swelling, unable to extend knees, b/l supra patellar gap	Xrays	Disruption of quads unit on right and avulsion fracture on left	Surgical repair f/b 6 weeks casts f/b physiotherapy	Follow up 6 months. Patient had regained functions but avoided sports
9	Abduljabbar et al. [23]	Case reports in Orthopaedics	2016	24	M	Basketball	Patient jumped and eccentrically loaded left knee and while trying to balance hurt left knee as well	Obesity	Pain, inability to stand, suprapatellar gap	MRI	Osseotendinous junction	Surgical repair; knee immobilizer for 4 weeks f/b physiotherapy	At 2 years fully functional knees and patient resumed sports activities
10	Katz et al. [24]	JCR	2006	46	M	Lawn tennis	Fall while sprinting (quads contraction in semiflexed knees)	–	Swelling, suprapatellar gap	Plain Xrays	Complete rupture within the tendons	Surgicl repair f/b 6 weeks cylinder casts f/b physiotherapy	Follow up of 8 years. Patient was involved in sports and gym. Does not play tennis
11	Stephens et al. [25]	Journal of emergency medicine	1987	22	M	Football	Fell forward on flexed knees	Chronic renal disease with secondary parathyroidism, obesity	Sharp pain above patella, inability to stand, swelling, supra patellar depression	USG, MRI	Avulsion from superior pole of patellae	Surgical repair	At 14 weeks functional recovery
12	Natsis et al. [26]	Journal of Medical case reports	2010	21	F	Rowing athelete	Injured during field training (while sprinting)	–	Pain, swelling, no supra patellar gap	USG and MRI—Haematoma	Strains in bilateral rectus femoris	Conservative	At 8 weeks returned to sports
13	Present study (Dhillon et al.)	–	2020	26	M	Weight lifting	Injury while “jerk” (felt pops, fell to the floor)	Anabolic steroid	Pain, inability to stand	MRI	Musculo-tendinous (right incomplete; left complete)	End to end repair f/b customised rehab protocol	At 6 years fully functional knees and has returned to sports

Case

Written informed consent was acquired from the patient to publish this report.

History A 26-year-old elite weightlifter, presented to our outpatient department in September 2013, with a history of bilateral knee injury during his National/International selection trials. He was brought in on a stretcher, with pain and inability to bear weight. He had a history of acute onset of pain during practice; he felt a sudden pop in his knees on attempting the “jerk” phase of a “Clean and Jerk” power lift (Fig. 1) He fell down immediately and was unable to stand or walk; the clinical diagnosis made by the onsite physician was of bilateral extensor mechanism injury and he was referred to our institute for surgical management.

Fig. 1.

Images depicting sequence of events during weight lifting, leading to bilateral quadriceps tears

Clinical Examination The patient had bilateral knee swellings with a palpable supra-patellar gap, and significant bruising over the left knee. He was unable to perform straight leg raise (SLR) bilaterally. Even attempted isometric contraction of the quadriceps was painful, more so on the left side.

Investigation Since X-rays did not show any injury, MRI scan were ordered, which showed bilateral hyperintensity involving the vastus muscles, with fluid tracking along the medial and lateral aspects. The supra patellar bursa also showed presence of fluid. There was no evidence of bony oedema or contusion. The findings were more extensive on the left side (Fig. 2).

Fig. 2.

MRI images depicting bilateral quadriceps tears

Diagnosis The patient was diagnosed with right vastus lateralis (VL) musculo-tendinous tear and left Rectus Femoris + VL complete tears.

Detailed questioning revealed a vague history of use of anabolic steroids in the early phase of his career development, but nothing relevant in the recent past.

Treatment The patient was taken up for surgery 48 h after presentation and bilateral repairs were done. A midline longitudinal incision was given from lower thigh to lower pole of patella, first on the left side and subcutaneous tissues were dissected. The cut ends of the quadriceps were identified and debrided. Repair was done using non absorbable polyester sutures (5-0 Ethibond Excel). The wounds were closed in layers and an above knee POP slab was applied. These steps were repeated on the right side, and tear was repaired here also.

Follow Up and Rehabilitation The post-operative period was uneventful; bilateral cylindrical casts were subsequently applied on post-operative day 3. The casts were continued for 3 weeks after which he was started on a customised rehabilitation protocol with a lockable brace, along with graduated range of motion with quadriceps strengthening and resistance exercises. Further strengthening of the knee extensor apparatus was facilitated by proprioceptive training and plyometrics. He achieved full functional recovery and at 6 years follow up, has no problems in activities of daily living and has gone back to weightlifting (Fig. 3).

Fig. 3.

Clinical images at 6 years follow up; depicting healed scars and functional knee range of motion

Return to Sports Training for weightlifting started by 9 months and strengthening and resistance exercises were continued for 2 years; he could achieve 80–85% of his pre-injury peak performance levels and returned to competitive weightlifting in an All India weightlifting championship in 2018. Currently he is working abroad as a truck driver and trains for 4–6 days a week in a gym, with leg training at least twice a week, He intends to participate in the National championship of his host country in 2021 and is preparing for the same.

Discussion

The occurrence of sports injuries depends on multiple factors; suboptimal preconditioning and warmups, inadequate endurance and bad techniques on the part of the players are very relevant [13]. Extensor mechanism injuries, specifically QTR in sports are very rare, and indirect injuries are seen only in specific sports like weight lifting; bilateral QTRs are rarer still. The knee bears the brunt of the force during the snatch and the clean and jerk movements of weightlifters, especially in the eccentric phase of lifting [5, 14]. Raske et al. have calculated the prevalence and incidence of knee injuries in weight lifters to be less than 20%, and thigh injuries specifically were less than 0.1 per 1000 h of weightlifting [5].

A PubMed search for bilateral quadriceps tears, conducted on 21 December 2019, with keywords- bilateral[All Fields] AND ("quadriceps muscle"[MeSH Terms] OR ("quadriceps"[All Fields] AND "muscle"[All Fields]) OR "quadriceps muscle"[All Fields] OR "quadriceps"[All Fields]) AND ("rupture"[MeSH Terms] OR "rupture"[All Fields]), yielded 220 hits.

A second search for quadriceps tears in sports with keywords- ("quadriceps muscle"[MeSH Terms] OR ("quadriceps"[All Fields] AND "muscle"[All Fields]) OR "quadriceps muscle"[All Fields] OR "quadriceps"[All Fields]) AND ("tears"[MeSH Terms] OR "tears"[All Fields] OR "tear"[All Fields] OR "lacerations"[MeSH Terms] OR "lacerations"[All Fields]) AND ("sports"[MeSH Terms] OR "sports"[All Fields]), yielded only 148 hits. These included unilateral QTRs, patellar tendon ruptures and ruptures of the rectus femoris from the origin. We also searched the bibliography sections of relevant articles. Finally our search yielded 12 case reports featuring injuries during weight lifting, lawn tennis, basketball and football [15–26] (Table 1).

Eleven of these 12 cases were <  = 40 years of age; the 12th case who was 46-years-old, injured himself while playing tennis [24]. Seven of these 12 patients had predisposing risk factors that potentially degenerate the tendons [16–19, 21, 23, 25]. A history of intake of anabolic steroids was present in five cases [16–19, 21]. This has a significant bearing as corticosteroids induce apoptosis of tendon cells, leading to structural changes that can lead to rupture [27]. Animal studies have shown deleterious effects of steroids on collagen that could be the cause of disintegration of tendon micro structure [28, 29].

Looking specifically at weightlifters, 6 of 12 previously reported cases occurred during weight lifting [15–17, 19–21]. One of the body builders injured himself while jumping from a height of 15 feet and landed on flexed knees [18]. Only two cases did not have any associated predisposing risk factors, but both these patients were relatively older than other reported cases (39 and 40 years, respectively) [15, 20]. The mechanism of injury in all weightlifters was the same; the ruptures occurred during the attempted extension phase of the lift, from a significantly flexed knees position, leading to an eccentric overload. A similar mechanism was noted in our case; it is pertinent to note that despite being bilateral, the extensor mechanism disruption is often unequal on both sides. This may depend upon a subtle shift of pressures in the thigh at the stage when the extensor mechanism is disrupted.

Only one of the documented cases of bilateral QTR occurred in football, while two occurred during landing after jump in basketball (Table 1). All had eccentric loads applied in flexed knees. The case who got injured during tennis was the oldest sportsperson documented, and he had complete bilateral tendon ruptures while sprinting [24]. One rower had bilateral strains of the rectus femoris and was injured during field training involving sprints [26]. Six of the 12 cases had injuries during lifting weights and thus this sport becomes the leading cause of such an injury.

In weight lifting, 22–32% of overall injuries occur during squatting [30]. It involves lowering the body with weight on the shoulders, to bring the hip below the knees and then ascending to become upright. This causes immense eccentric strain on the knee extensors and potentially leads to injury. Other related factors that increase risk of injury are depth of squat, lifting speed and bouncing movements at the end of squat; all of these increase shear forces at the knee [30]. Weight lifters intrinsically have hypertrophied quadriceps owing to their long term high volume training and repetitive fitness regime, along with increased knee extension force or torque [31]. This also has the potential to lead to an overuse injury [11].

The most common location of a complete quadriceps tear is 2 cm above the superior pole of patella or the osseo-tendinous avulsion [32]. Tears can occur at the musculotendinous junction in frail patients [33]. On the other hand, it is well documented that organised sports activities can cause multiple episodes of overuse and micro-tears, which could ultimately fail with avulsion [30]. It is also reported that the Rectus femoris, which is the most superficial of the quadriceps with type 2 fibres, is also susceptible to tear at the myotendinous junction during eccentric strains [34].

Professional Sport has had a long association with anabolic steroid abuse to gain muscle and lose fat [35, 36]. Anabolic steroids are significantly associated with disruption of collagen under load. It is suggested that these agents cause muscular hypertrophy without enhancing the tendon strength, which are then unable to tolerate sudden increased muscular contractions. Additionally steroid abuse induces apoptosis of tendon cells leading to structural changes that can lead to rupture [27]. Animal studies have shown deleterious effects of steroids on collagen that could be the cause of disintegration of tendon micro structure due to increased stiffness [28, 29]. In weightlifters and body builders, the use of this drug is rampant despite WADA guidelines, and many athletes can keep the usage hidden, especially if it happened in the distant past.

In a study by Kanayama et al., Anabolic steroids have been described as a potential risk factor for bilateral QTR; 22% of sportsmen with anabolic steroid abuse experienced at least 1 tendon rupture in their lifetime, while it was only 6% for non abusers [35]. Five out of seven cases of bilateral QTR in weight lifters and body builders had a history of anabolic steroid abuse [16–19, 21] (Table 1). In the present case, detailed questioning after presentation revealed a history of steroid use in his younger years, which could have been the precipitating factor for bilateral injury. The two cases wherein steroid abuse is not mentioned, history could be spurious and the patient might have hidden the details because of the associated doping issues and we cannot be 100% certain [15, 20]. We believe that bilaterality of rupture could be an indirect indicator of steroid use, as was proven in our case by a diligent retrospective history.

No previously reported bilateral case was seen in a female, perhaps due to lesser number of ladies involved in lifting sports. In a retrospective review of one of the biggest series on QTR from Rochester University, 90% of 221 unilateral cases were males, with no female in 14 bilateral cases [4]. In a study by Sagoe et al., global lifetime prevalence of abuse in males was 6.4% while it was only 1.6% in females [36]. Such anabolic steroid abuse in females is relatively less and this could be another factor for low incidence of QTR in them. Additionally, injury in female weight lifters is more common in the upper body [30]. Keogh et al. reported no injuries at the thigh in female lifters in their review of 20 eligible studies [11].

These injuries commonly present with the classical symptoms of swelling, palpable suprapatellar gap and loss of active knee extension; these are useful aids in diagnosis in unilateral QTR, where comparison can be made with the normal side. However, in bilateral cases the diagnosis can be confusing at times [37]; in incomplete tears, some of the classic signs may not be present, and in bilateral cases, injury on one side is usually more than the other. Even in our case the right sided injury was not as severe as the left side. In weightlifters this could be due to buckling of the knees when one side ruptures first, reducing the load on the other side which ruptures to a lesser degree.

The confirmatory imaging modality in such cases are MRI or USG [6, 38]. In our case, since plain radiographs were non-committal, MRI was used to confirm that there was a complete rupture on the left and a partial one on the right side. Rupture of the tendon can occur as an intra-substance tear or avulsion from the osseo-tendinous junction, and MRI helps in planning the surgery as the site of injury can be identified and localized [20]. Avulsion from the proximal patella seems to be fairly common; in the 12 previous cases (Table 1), the rower and tennis player had strain and tendinous tear respectively, while the basketball players after jump (2) and weightlifters during lifting (6 of 7) had avulsions on 1 or both sides, from tendo-osseous junction.

Early surgical repair is the treatment of choice in most of the cases [6, 39]. It is advised to repair the QTR within 2 weeks, otherwise chances of full recovery decreases from 50% to 21.4% [40]. This occurs owing to the fibrotic changes leading to tissue retraction, which hinders repair [6]. End to end or trans-osseous repair through the superior pole of patella are the most commonly done procedure in combination with modified Kessler suture technique [15, 16, 18]. The surgery is followed by 3–6 weeks of cast immobilisation after which physiotherapy with range of motion exercises and quadriceps strengthening is initiated. Conservative management should only be reserved for strains where recovery is prompt and the sports person can return to sports in 6–8 weeks [26].

Return to sports in complete rupture is a very crucial outcome that has to be given consideration during the management. Such injuries can easily finish a sportsman’s career, therefore, management should be moulded along patients’ sports specific rehab protocols. Eight of the 12 documented cases (Table 1) have given the status of sports activities post repair. Although most of the patients attained functional recovery, two patients avoided competitive sports [22, 24]. This may have to do more with psychological factors associated with the injuries; an important point to consider is that both these patients were amateurs. Five professional patients returned to their sports while the patient of Lewis et al. did not return to weightlifting [19].

An important factor that aids in successful return is modification of the style and techniques associated with the particular sport; in weight lifting squatting can be minimised for better results [20]. This could be aided exponentially by customising the rehabilitation protocols of individual patients according to the needs in the sports they play, along with the technical tweaks, to minimise chances of repeat injuries. Such customisation and modifications helped our patient, who had a very productive recovery, wherein he still participates in competitive sports even after 6 years.

Conclusion

We report a case of bilateral QTR in a weightlifter, where we could retrospectively identify previous use of anabolic steroids by the nature of the injury. The tears in our case were slightly more proximal than those reported previously, but the surgical repair was successful, and the athlete returned to competitive sports. MRI is an essential tool for diagnosis and localization, and customised rehabilitation protocols go a long way in functional recovery and return to sports. All coaches and weightlifting athletes should be made aware of this injury, and the negative role of steroids should be highlighted.

Compliance with Ethical Standards

Conflict of interest

The authors declare no conflict of interest and nil funding.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study informed consent is not required.