Elizabeth limped into the emergency department complaining of left leg pain after falling on some ice.
She had made a New Year’s resolution to get at least 30 minutes of walking in every day, and despite a recent bought of cold and icy weather, she was determined to get outside and get her exercise done. She was walking her dog on his leash when she slipped on a patch of black ice that she didn’t see. She fell forward awkwardly but was able to get her hands out in front of her, and she thankfully did not hit her head or face on the ground.
She was initially worried she had broken one of her wrists, but she moved them around and realized they were OK. She pushed herself up and brushed the snow off her pants and jacket as her dog, who clearly realized something was wrong, was licking her hand. As she tried to walk she realized most of her pain was in her left knee and thigh, and she was having a lot of difficulty walking. Luckily, she was only a block away from home, so she slowly limped home and got herself on the couch.
Elizabeth’s sister came over to check on her and gave her an ice pack and a dose of ibuprofen. After a few hours, she seemed to be feeling better, but when she tried to walk to the bathroom she almost fell because her left leg wasn’t cooperating with her. She realized that she needed to go to the emergency department for evaluation because she couldn’t get around safely without nearly falling.
The ED was very busy when Elizabeth and her sister arrived. Elizabeth had her vital signs obtained and the triage nurse ordered X-rays of her left hip and knee and put her back in the waiting room as there were several patients who were sicker than Elizabeth and needed to be evaluated more quickly. Unfortunately, Elizabeth had to wait for a few hours before she could be brought back to a room to be seen. Her X-rays had been completed and they showed no fracture or dislocation of her hip or knee. She had considered leaving and following up with her family doctor, but her sister insisted she be patient and wait to be seen. She begrudgingly agreed to wait.
Elizabeth was frustrated when I finally saw her in the exam room. She had an ice pack on her left hip and knee, but the ice had melted. She hadn’t taken any pain medication for several hours. I asked the nurse to get her more ice and pain medication as I gave her a physical exam.
I checked the pulses in her foot and ankle and assessed for tenderness in her foot, ankle and lower leg. I could see swelling at her knee, and she was very hesitant for me touch her knee. I gently pushed on the sides of the knee, which were not painful. I pressed below her patella, which also didn’t bother her. There was a lot of swelling above her patella and when I pressed there, I noticed that there was a gap where there should not be one. I asked Elizabeth to lift her leg off the bed and straighten her knee. She tried but couldn’t do it. She put her right shin under her left ankle and lifted her left leg up with her right leg. I could see a smirk under her face mask as she knew that wasn’t how I wanted her to lift her left leg.
Based on my exam, I knew that Elizabeth had ruptured her quadriceps tendon. The four quadriceps muscles on the front of the thigh join together above the kneecap to form the quadriceps tendon. This tendon attaches the quadriceps muscle to the patella (kneecap). The patella is attached to the lower leg at the tibia by the patellar tendon.
The quadriceps muscle, quadriceps tendon and patellar tendon work together to form a pulley mechanism to straighten the knee. A tear of the quadriceps tendon can occur when there is a heavy load placed on the leg with the foot planted and the knee partially bent. The force of the landing was too much for the tendon, causing it to tear.
I consulted our orthopedic surgeon to see Elizabeth. We put her into a knee immobilizer to keep her knee straight, and he scheduled her to have surgery the next day to repair the tendon. The surgeon pulled down the tendon that had retracted into her thigh and stretched it toward the patella. He then sutured the tendon into the patella to secure it. Elizabeth was able to go home the same day as her surgery and had to keep her knee completely straight for six weeks using a rigid knee brace.
Elizabeth said the first few days were rough because of pain and getting used to her big brace that kept sliding down. She had to learn how to get the brace back into appropriate position and secure it with Velcro straps. Keeping her leg completely straight while walking and using the bathroom was also quite the challenge. Her surgeon was very pleased with how her wound looked at her post-operative visit and had her start physical therapy after several weeks. The physical therapist worked with Elizabeth on gradually flexing her knee again, being careful not to put too much stress on the surgical repair while also encouraging gentle movement at the knee to prevent stiffness.
She continued to work with physical therapy, gradually increasing her knee flexibility and mobility. Once her surgeon allowed, she started cycling on a stationary bike in her home. She was very motivated to get back to walking with her dog and was looking forward to the warmer spring and summer months to get back outside.
Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.