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Definition/Description

The popliteus muscle runs diagonally across the back of the knee joint. This muscle rotates the lower leg and plays a role in bending (flexing) the knee. The popliteus muscle helps to stabilize the back and outer back of the knee and is most often injured in downhill skiing and long-distance running.^[1] Popliteus strain is a muscle strain.

Clinically Relevant Anatomy

The Popliteus Muscle tendinous unit is unique in that the distal muscular attachment is designated the insertion and the tendinous proximal (femoral) attachment is designated the origin. The muscle inserts into a triangular area along the posteromedial aspect of the proximal tibial metaphysic above the soleal line. It forms the floor of the popliteus fossa. The tendon of the popliteus passes through the popliteal hiatus, entering the knee joint and inserting into the lateral femoral condyle at the end of the popliteal sulcus. The main tendinous component inserts into the lateral femoral condyle with variable aponeurotic attachments to the posterior horn of the lateral meniscus and the fibular head^[2]. The insertion into the lateral meniscus retracts and protects the meniscus in flexion, but this function has been disputed. The femoral insertion has a crescent shape, with the superior aspect being concave.^[3] The main tendon of the popliteus muscle consists of anterior and posterior fibers.^[4] The popliteus muscle is innervated by tibial nerves (L4-L5 and S1).

Epidemiology /Etiology

The popliteus muscle functions as a dynamic internal rotator of the tibia. For this reason rupture of the popliteus muscle is usually associated with acute of the chronic posterolateral instability of the knee. The isolated rupture of the popliteus tendon musculotendinous unit is an uncommon injury. ^[5] If isolated injury presents without significant instability.^[6]
In some cases the injury is extensive and may include disruption of the arcuate ligament complex, the lateral collateral ligament, both cruciates, and the menisci.^[7]

Characteristics/Clinical Presentation

Lesions have been reported occurring by a non -contact external rotational mechanism: a sudden external rotation to a partially flexed knee^[8] ,A forced external rotation with a varus force application in some cases, or a forced external rotation with femur fixed have been described. Considering the type of tear, an overuse or degenerative mechanism could be considered as responsible for the partial tear^[9][10][11]

Clinically the affected patients present with an unnatural outward rotation of the tibia when bending the knee. Additionally ,other general symptoms often occur such as muscle swelling, edema or bleeding^[12]

Distinctive signs and symptoms:
• Pain over the outer side or back of the knee
• Painful resisted knee flexion or internal rotation
• Popliteal space tender

Differential Diagnosis

1. biceps femoris tendon strain^[13]
2. the lateral meniscus Injury

Diagnostic Procedures

An acute haemarthrosis and lateral pain in a stable knee should lead to suspicion of an isolated injury to the popliteus muscle-tendon unit.^[14] The diagnosis should be entertained in any acutely swollen knee with posterolateral tenderness and pain on resisted internal tibial rotation.^[15]
MRI of the knee should be performed to evaluate the nature of the injury. The diagnosis may be confirmed by arthroscopic examination of the knee.
In some cases, the ruptured popliteus tendon retracts distally through the popliteal hiatus and can no longer be seen in the joint^[16][17][18].

Diagnostic Test

Popliteus injury may be suspected with tenderness over the proximal aspect of the popliteus tendon with the patient in the prone position. There may be pain with resisted external rotation of the lower leg with the hip and knee flexed to 90 degrees (positive Garrick test) ^[19]

A “shoe removal maneuver” in which the athlete internally rotates the injured lower leg to push off the contralateral shoe at the heel may also produce pain. 
^[20]

Outcome Measures

Knee outcome survey can be used as an outcome measure

Examination

Clinically the affected patients present with an unnatural outward rotation of the tibia when bending the knee. Additionally, other general symptoms often occur such as muscle swelling, edema or bleeding^[12]

Only a portion of the popliteus can be safely palpated due to the neurovascular structures that overlie it. The attachment on the tibial shaft can usually be reached as well as the tendon at the femoral condyle.

Rest described above in diagnostic tests.

Medical Management

Medical management as line with other muscle injuries as it is mostly associate with other ligament and meniscus injuries guideline is RICE with anti-inflammatory drugs with analgesic medicines.In case of sever associate injury arthroscopic repair/reconstruction may require.

Physical Therapy Management

The treatment of isolated popliteus tendon ruptures has not been very well defined. Review ^[21](Method: MRI, Arthroscopy; Keywords: Popliteus tendon, rupture)of the literature shows 15 cases. Four were treated conservatively, in one case the avulsed chondral fragment was excised without repair of the popliteus tendon. In the remaining 10 cases, there was an osteochondral fracture as a result of avulsion of the tendon from the femoral attachment, and this fragment was reposited and fixed with screws.

Initial protocol is POLICE Principle (Protection,optimal loading,Rest,EIce,Compression.elevation)
Physiotherapy treatment is on a line with other soft tissues and muscle injuries, mobility exercises, ,,strengthening exercis, eccentricic training and many more rehab protocols depending upon patholo, associatede injuriesandd patients condition.

spray-and-stretch techniques, as described by Travell & Simons (1992),  if trigger point of pain present may be effective^[22]

Case Reports

A.R.Guha, K.A. Gorgees, D.I. Walker: Popliteus tendon rupture: a case report and review of the literature. Br. J. Sports Med 2003; 37:358-360^[2]

Isolated rupture of the popliteus tendon in a professional athlete. Burstein DB, Fischer DA Arthroscopy. 1990; 6(3):238-41. ^[10]

Isolated avulsion of the popliteus tendon. A case report. Mirkopulos N, Myer TJ Am J Sports Med. 1991 Jul-Aug; 19(4):417-9^[11].

References

1. ↑ James SL. Running injuries to the knee. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 1995 Nov 1;3(6):309-18.
2. ↑ ^2.02.1 Guha AR, Gorgees KA, Walker DI. Popliteus tendon rupture: a case report and review of the literature. British journal of sports medicine. 2003 Aug 1;37(4):358-60.
3. ↑ Fox AJ, Bedi A, Rodeo SA. The basic science of human knee menisci: structure, composition, and function. Sports health. 2012 Jul;4(4):340-51.
4. ↑ Watanabe Y, Moriya H, Takahashi K, Yamagata M, Sonoda M, Shimada Y, Tamaki T. Functional anatomy of the posterolateral structures of the knee. Arthroscopy. 1993 Feb 1;9(1):57-62.
5. ↑ Mariani PP, Margheritini F. Partial isolated rupture of the popliteus tendon in a professional soccer player: a case report. BMC Sports Science, Medicine and Rehabilitation. 2009 Dec;1(1):18.
6. ↑ Guha AR, Gorgees KA, Walker DI. Popliteus tendon rupture: a case report and review of the literature. British journal of sports medicine. 2003 Aug 1;37(4):358-60.
7. ↑ Guha AR, Gorgees KA, Walker DI. Popliteus tendon rupture: a case report and review of the literature. British journal of sports medicine. 2003 Aug 1;37(4):358-60.
8. ↑ Mariani PP, Margheritini F. Partial isolated rupture of the popliteus tendon in a professional soccer player: a case report. BMC Sports Science, Medicine and Rehabilitation. 2009 Dec;1(1):18.
9. ↑ Popliteus tendon rupture. Case report and review of the literature.
   Rose DJ, Parisien JS
   Clin Orthop Relat Res. 1988 Jan; (226):113-7
10. ↑ ^10.010.1 Isolated rupture of the popliteus tendon in a professional athlete.
    Burstein DB, Fischer DA
    Arthroscopy. 1990; 6(3):238-41.
11. ↑ ^11.011.1 solated avulsion of the popliteus tendon. A case report.
    Mirkopulos N, Myer TJ
    Am J Sports Med. 1991 Jul-Aug; 19(4):417-9.
12. ↑ ^12.012.1 Kenhub.Popliteus Muscle. ↑ Study. Biceps Femoris Strain, Tear or Rupture: Symptoms & Treatment. ↑ 9 Nakhostine M, Perko M, Cross M. Isolated avulsion of the popliteus tendon. J Bone Joint Surg [Br] 1995;77:242–4.
13. ↑ Rose DJ, Parisien JS. Popliteus tendon rupture. Case report and review of the literature. Clin Orthop 1988;226:113–17.
14. ↑ Naver L, Aalberg JR. Avulsion of the popliteus tendon: a rare cause of chondral fracture and hemarthrosis. Am J Sports Med 1985;13:423–4
15. ↑ Garth WP, Martin MP, Merrill KD. Isolated avulsion of the popliteus tendon: operative repair. J Bone Joint Surg [Am] 1992;74:130–2.
16. ↑ Rose DJ, Parisien JS. Popliteus tendon rupture. Case report and review of the literature. Clin Orthop 1988;226:113–17.
17. ↑ Covey DC. Injuries of the posterolateral corner of the knee. JBJS. 2001 Jan 1;83(1):106-18.
18. ↑ Lubowitz JH, Bernardini BJ, Reid III JB. Current concepts review: comprehensive physical examination for instability of the knee. The American journal of sports medicine. 2008 Mar;36(3):577-94.
19. ↑ Ranawat A, Baker III CL, Henry S, Harner CD. Posterolateral corner injury of the knee: evaluation and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2008 Aug 1;16(8):506-18.
20. ↑ Travell JG, Simons DG. Myofascial pain and dysfunction, vols 1 and 2. Baltimore: Williams and Wilkins. 1992.