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Popliteus Tendinopathy

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Other Names

  • Popliteus Tendonitis
  • Popliteus Tendonosis
  • Popliteus Tendinopathy
  • Popliteus Tenosynovitis
  • Popliteus muscle‐tendon unit (PMTU) tendinopathy
  • Snapping popliteus tendon
  • Popliteus strain
  • Popliteus tendon tenosynovitis
  • Popliteus tendon rupture

Background

  • This page refers to tendinopathies of the Popliteus muscle
    • This is a rare and poorly described cause of knee pain with multiple etiologies
    • Discusses all forms of tendinopathy, including tendon rupture

History

  • First described following total knee arthroplasty by Barnes in 1995[1]

Epidemiology

  • No papers describing the epidemiology are currently available

Pathophysiology

  • General
    • Difficult to recognize, treat due to relatively deep location, close proximity to adjacent structures[2]
  • Popliteal tendon ruptures
    • Rarely occur in insolation, in one study, 92% associated with other posterolateral corner injuries[3]

Mechanism

  • For tendinopathy, uncommon injury pattern has been reported in the following
    • Following moderate or greater knee trauma
    • Minor twisting injuries
    • Tendon instability
    • Impingement against osteophytes
    • Impingement against total knee arthroplasty components[1]
    • Calcific tendinopathy[4]
    • Overuse among runners, especially running downhill[5]
  • Tendon rupture
    • Overall, poorly described and mostly theorized
    • Direct anteromedial force associated with other posterolateral corner injuries
    • Forcible external rotation of the tibia in a partially flexed knee
    • Direct blow to anteromedial knee
    • Sudden varus force in externally rotated leg
    • Forced hyperextension with the tibia in internal rotation
    • Falls or car accidents in which the knee is hyperextended
  • Pediatrics
    • Pediatric injuries tend to involve avulsion fractures of the popliteus tendon from the femur

Etiology

  • Among athletes
    • Those who run on hills, banked surfaces[6]
  • Force vector
    • Direct varus force while the tibia is externally rotated
    • Sudden forced knee hyperextension with the tibia internally rotated

Associated Conditions

Pathoanatomy

  • Popliteus
    • Helps 'unlock' knee by internally rotating Tibia, externally rotating Femur
    • Intimately associated with posterolateral corner

Risk Factors


Differential Diagnosis


Clinical Features

  • History
    • History can vary widely from insidious, acute, post-operative, etc
    • Onset is usually insidious
      • If acute rupture, patients may report a 'popping' sensation
    • Patient will endorse knee pain, usually posterolateral
      • Worse during early swing phase of gait or when knee is between 15-30° of flexion[10]
    • There may be crepitus
    • Popping sensation during flexion or extension
    • Provocative activities include walking, running and going up stairs
    • If other structural injuries, laxity or instability may be present
  • Physical Exam: Physical Exam Knee
    • Swelling, redness may be present, although inspection is often grossly normal
    • There may be tenderness at the lateral epicondyle of the femur wrapping around posteriorly into the muscle
    • Crepitus may be palpable with movement of the tendon
  • Special Tests
    • Garrick Test: Hip and knee flexed to 90° and patient externally rotates leg against resistance
    • Shoe Removal Maneuver: Patient tries to remove contralateral shoe by internally rotated affected leg to reach heel of contralateral leg
    • Unknown Test: the patient sits in ‘ a figure 4’ position with the affected leg in a crossed-legged position, the hip flexed, abducted and externally rotated and the knee flexed with the leg crossed over the opposite extremity. The therapist palpates the posterior lateral corner looking for tenderness.
    • Important to evaluate all ligaments of the knee

Evaluation

Radiographs

  • Standard Radiographs Knee
    • Screening Tool
  • Findings are usually normal
    • In some cases, associated with underlying pathology such as history of TKA or calcific tendinitis
    • Acutely, avulsed fragment from femoral condyle can be seen

CT

  • Utility is not definitely established

MRI

  • Utility is not definitely established
  • Findings
    • Focal tendon enlargement
    • Increased intratendinous or myotendinous signal on fluid-sensitive sequences
    • Complete tendon rupture or avulsion from the femur
  • Other findings may be present depending on mechanism

Ultrasound

  • Utility is not definitely established
  • However, can definitively evaluate the popliteal tendon
  • Potential findings
    • Focal tendon enlargement
    • Hyper- or hypoechoic signal within the tendon
    • Fluid within the tendon sheath

Classification

  • Not applicable

Management

Nonoperative

Operative

  • Indications
  • Technique
    • Primary repair with recess procedure
    • Delayed reconstruction

Rehab and Return to Play

Rehabilitation

  • Initially, non weight bearing stability exercises
  • Advance to weight bearing exercises as tolerated

Return to Play

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Unknown

Complications

  • Chronic pain
  • Inability to return to sport

See Also


References

  1. 1.0 1.1 Barnes CL, Scott RD. Popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty. 1995 Aug;10(4):543-5.
  2. Garrick J, Webb D. Sports Injuries: Diagnosis and Management. Philadelphia, PA: WB Saunders Co; 1990.
  3. Guha, A. R., K. A. Gorgees, and D. I. Walker. "Popliteus tendon rupture: a case report and review of the literature." British journal of sports medicine 37.4 (2003): 358-360.
  4. Tibrewal SB. Acute calcific tendinitis of the popliteus tendon: an unusual site and clinical syndrome. Ann R Coll Surg Engl 2002; 84:338–341.
  5. Cooper DE. Snapping popliteus tendon syndrome: a cause of mechanical knee popping in athletes. Am J Sports Med 1999; 27:671–674.
  6. SAFRAN M. et al., Instructions for sports medicine patients., second edition, Elsevier, 2012; 822
  7. Radhakrishna M, Macdonald P, Davidson M, Hodgekinson R, Craton N. Isolated popliteus injury in a professional football player. Clin J Sport Med 2004; 14:365–367.
  8. Allardyce TJ, Scuderi GR, Insall JN. Arthroscopic treatment of popliteus tendon dysfunction following total knee arthroplasty. J Arthroplasty 1997; 12:353–355.
  9. Miller, Mark D., and Stephen R. Thompson. DeLee & Drez's Orthopaedic Sports Medicine E-Book. Elsevier Health Sciences, 2014.
  10. English, S., and D. Perret. "Posterior knee pain." Current reviews in musculoskeletal medicine 3.1 (2010): 3-10.
Created by:
John Kiel on 7 July 2019 06:14:15
Authors:
Last edited:
4 October 2022 15:47:05
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