Popliteal Tendonitis

By admin On Oct 28, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Michael A. Krafczyk

Seth M. Burkey

Basics

The popliteus muscle originates from the popliteal saddle on the lateral femoral condyle. It then runs deep to the lateral collateral ligament (LCL) and then goes intraarticular. It courses through the popliteal hiatus of the coronary ligament and inserts on the posterior tibia under the tibial condyles (1).
There are also attachments to the fibula (popliteofibular ligament) as well as the lateral meniscus, posterior cruciate ligament (PCL), and posterior capsule.
The femoral origin of the popliteus is consistently anterior and distal to the femoral attachment of the LCL.
Its primary function is that of internal rotation of the tibia on the femur.
Also an important structure in preventing external tibial rotation
Also may help the PCL prevent forward displacement of the femur during deceleration and downhill running

Description

Popliteal tendinitis involves irritation, swelling, and pain along the length of the tendon that courses lateral around the femoral condyle.
It is often seen with downhill running. It presents as posterolateral knee pain that is worse with downhill running and sitting cross-legged.

Epidemiology

Uncommon

Risk Factors

May occur as overuse injuries or acutely such as in trauma.
Commonly seen in downhill running (cross-country), walking (backpacking)
Poor conditioning
Pes planus foot (hyperpronation)
Quadriceps weakness

General Prevention

Appropriate warm-up and stretching
Adequate rest and recovery during sports participation
Proper training technique
Foot orthoses for pes planus
Maintain good quadriceps strength.

Etiology

Usually due to repetitive stress, such as seen in runners
Almost always a result of quadriceps overuse
Also may be due to a blow to the anteromedial border of the knee, a hyperextension injury, or a varus noncontact injury

Diagnosis

History

The patient will complain of insidious lateral or posterolateral knee pain.
May elicit a history of walking, backpacking, and running, such as downhill or cross-country
Can be intermittent or constant
Worse with weight bearing when the knee is between 15 and 30 degrees of flexion
The patient also may describe trauma directed to the anteromedial border of the knee, hyperextension, or a varus injury.

Physical Exam

Palpation of the tendon insertion along the lateral femoral condyle will reveal pain. Tendon is best palpated with the patient in a figure-of-4 (cross-legged) position and palpating just posterior and just anterior to the LCL (2).
The Garrick test involves testing the popliteus with the patient supine and the hips and knees flexed to 90 degrees, in which resisted internal rotation of the knee provokes pain. Passive external rotation with the knee in the same position also can provoke pain (3)[C].
Shoe-removal maneuver, in which the sitting patient internally rotates the injured lower leg and foot to push the contralateral shoe off, also may produce pain.

Diagnostic Tests & Interpretation

Imaging

Plain films may reveal calcific deposits of the tendon in cases of calcific tendonitis or signs of possible avulsion fracture as in trauma.
MRI will reveal fluid and inflammation of the popliteus sheath and tendon.

Diagnostic Procedures/Surgery

Arthroscopic examination of the knee can reveal synovitis of the sheath or hydroxyapatite deposits (4).

Differential Diagnosis

Iliotibial tract tendinitis
Biceps femoris tendinitis
Lateral meniscal tear
Lateral collateral ligament injury

P.481

Treatment

Initial treatment: Rest, ice, anti-inflammatory medications
Followed by stretching and intensive strengthening exercises of the quadriceps and hamstrings (4)[C]
Modify activity: Limit downhill running or aggravating activity.
Arch support if pes planus is present

Medication

Anti-inflammatory medications, such as NSAIDs, either orally or topically
Glucocorticoids, either injected or via iontophoresis, may be beneficial for acute tendinitis of <3 mos (however, they should be avoided in chronic tendinopathies, possibly leading to tendon rupture) (5).
Topical glyceryl trinitrate patches placed directly over the tendon act as a potent signaling molecule that stimulates collagen synthesis in tendon cells.

Additional Treatment

Activity modification to limit the volume and intensity of loads placed on the tendon, such as running on more level ground or running in the opposite direction on a track
Eccentric and heavy-load exercises, guided by a therapist, appear to stimulate tissue remodeling and normalization of tendon structure.
Static or dynamic stretching following activity, when muscles are warm
Ice and/or heat may be beneficial for reduction in swelling and improved pain.
Joint mobilization may decrease stiffness, which can contribute to altered movement patterns and abnormal tendon loading.
Friction massage has been shown in animal studies to increase tendon fibroblast activity.
As with other injuries, gradual return to activities is encouraged.

Referral

Ruptured tendon
Calcific tendinitis
Failed conservative therapy

Additional Therapies

Additional treatment options include:

Prolotherapy
Sclerotherapy
Dry needling
Platelet-rich plasma therapy
Shock wave therapy

Complementary and Alternative Medicine

Acupuncture
Manipulative therapy

Surgery/Other Procedures

Surgery is indicated for tendon avulsion or complete tears.
For chronic tendinopathies, surgery includes incising the paratendon and removing the adhesions, followed by macroscopically degenerate tissue.
Longitudinal incisions can be made in the tendon in hopes of promoting a repair response.
Resection or drilling of the tendon's attachment points also has been described.
Minimally invasive arthroscopic surgical procedures have been developed to limit lengthy rehabilitation and include débriding the area of neovascularization.
In cases of calcific tendinitis, arthroscopic washout and removal of calcium deposits have proven helpful.

Ongoing Care

Complications

Tendon rupture
Calcific tendinitis

References

1. Blake SM, Treble NJ. Popliteus tendon tenosynovitis. Br J Sports Med. 2005;39:e42; discussion e42.

2. Mayfield GW. Popliteus tendon tenosynovitis. Am J Sports Med. 1977;5:31–36.

3. Olson WR, Rechkemmer L. Popliteus tendinitis. J Am Podiatr Med Assoc. 1993;83:537–540.

4. Radhakrishna M, Macdonald P, Davidson M, et al. Isolated popliteus injury in a professional football player. Clin J Sport Med. 2004;14:365–367.

5. Khan K. Overview of the management of overuse (chronic) tendinopathy. UpToDate; June 2009.

Codes

ICD9

726.69 Other enthesopathy of knee