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Anatomy, Function, and Rehabilitation of The Popliteus Musculotendinous Complex
Anatomy, Function, and Rehabilitation of The Popliteus Musculotendinous Complex
We present a clinical commentary of existing evidence regarding popliteus musculotendinous ment in the nonimpaired
complex anatomy, biomechanics, muscle activation, and kinesthesia as they relate to functional knee.18,44 Appropriate lateral me-
knee joint rehabilitation. The popliteus appears to act as a dynamic guidance system for niscus orientation is essential to
monitoring and controlling subtle transverse- and frontal-plane knee joint movements, controlling
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attachments that approximate the borders of both collateral ligaments, it has the potential for Common weight-bearing mecha-
providing instantaneous 3-dimensional kinesthetic feedback of both medial and lateral nisms of noncontact posterolateral
tibiofemoral joint compartment function. Enhanced popliteus function as a kinesthetic knee joint knee joint injury are either a di-
monitor acting in synergy with dynamic hip muscular control of femoral internal rotation and
rect varus force, while the tibia is
adduction, and ankle subtalar muscular control of tibial abduction-external rotation or adduction-
internal rotation, may help to prevent athletic knee joint injuries and facilitate recovery during
externally rotated, or a sudden
rehabilitation by assisting the primary sagittal plane dynamic knee joint stabilization provided by forced knee hyperextension with
the quadriceps femoris, hamstrings, and gastrocnemius. J Orthop Sports Phys Ther 2005;35:165- the tibia internally rotated.6,8,56
179. Clinical signs of posterolateral
knee joint injury may be subtle
Key Words: knee, lateral meniscus, lower extremity
Journal of Orthopaedic & Sports Physical Therapy®
W
eight acceptance during walking commonly involves
or posterior cruciate ligament
tibial internal rotation as the knee joint flexes.29,34,58
(PCL) injury.31 Combined injury
Concurrently, the knee joint generally undergoes a
of the popliteus muscle-tendon
small but important amount of abduction.29,35 In con-
complex (PMTC) and lateral (fibu-
junction with these kinematics the resultant line of
lar) collateral ligament (LCL) re-
force during walking is located primarily in the medial joint compart-
sults in serious posterolateral knee
instability, which, if unrecognized,
1
Assistant Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, University of contributes to postsurgical cruciate
Louisville, Louisville, KY; Frazier Rehabilitation Institute, Louisville, KY.
2
Assistant Professor, Department of Human Biology, Tecnikon Natal, Durban, South Africa. ligament reconstruction failure or
3
Research Fellow, Division of Sports Medicine, Department of Orthopaedic Surgery, University of chronic knee instability.17,27,30,70
Louisville, Louisville, KY. According to Last,32 popliteus
4
Associate Professor, Bellarmine University, Louisville, KY.
5
Visiting Professor, Hospital of Sanliurfa, Sanliurfa, Turkey. activation primarily internally ro-
6
Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, tates the knee and its tendinous
Louisville, KY. bands retract the posterior arch of
Address correspondence to John Nyland, Division of Sports Medicine, Department of Orthopaedic
Surgery, University of Louisville, 210 East Gray Street, Suite 1003, Louisville, KY 40202. E-mail: the lateral meniscus. Lateral me-
john.nyland@louisville.edu niscus movement guidance by the
evidence regarding PMTC anatomy, biomechanics, the intricacy of their attachments. Watanabe et al71
muscle activation characteristics, and kinesthesia, and identified 7 variants for anatomic popliteus attach-
relate these findings to functional rehabilitation.
Functional rehabilitation is operationally defined as
the use of therapeutic exercises to simulate the Popliteomeniscal
weight-bearing and non–weight-bearing components fascicles
of specific daily activities in a manner that replicates
3-dimensional lower extremity function within joint
ranges and velocities that facilitate the desired physi-
Journal of Orthopaedic & Sports Physical Therapy®
CLINICAL COMMENTARY
femoral condyle and a filmy, almost translucent
attachment to the lateral meniscus, and 18 specimens
(45%) had an isolated popliteus tendon insertion to
the lateral femoral condyle, with no connection to
the lateral meniscus. These results suggest that the
capacity for the PMTC to directly influence lateral
meniscus movement is highly variable between indi-
viduals.
At the popliteus musculotendinous junction there
Ligament of are 2 popliteofibular ligament (PFL) divisions that
Wrisberg course laterally and distally, attaching on the
Popliteus Ligament of posteromedial aspect of the fibular styloid (Figure 4).
tendon Humphrey In addition to providing noncontractile restraint to
tibial external rotation, the PFL serves as a pulley,
Lateral MCL
helping to tether the tendon during popliteus activa-
meniscus Medial tion.60 Fuss13 reported that the PFL is under maxi-
meniscus
mum tension during flexion, possibly taking over the
LCL noncontractile knee joint stabilization function of the
LCL, which is not taut in most flexion positions.
PFL PCL During in vitro biomechanical testing, Maynard et
al40 reported a maximum load at failure of approxi-
mately 425 N for the PFL compared to 750 N for the
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neutral tibial rotation position were noted. Using 10 preventing excessive tibial external rotation.
cadaveric knee specimens, Harner et al17 reported During the initial 30° of knee flexion, the LCL
that the addition of a 44-N force to the popliteus provides a greater contribution to resisting tibial
muscle reduced PCL forces by 9% and 36% at 90° varus and the PMTC provides a greater contribution
and 30° of knee flexion, respectively. Considering to resisting tibial external rotation and posterior
these results, progressive PCL deficiency should be translation.45 As the posterolateral knee joint capsule
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
anticipated, following isolated and untreated slackens with increasing knee flexion, it contributes
posterolateral capsuloligamentous, or PMTC injury. less to resisting tibial external rotation (transverse
Krudwig et al28 suggested that isolated posterolateral plane), varus rotation (frontal plane), and posterior
capsuloligamentous injury should be reconstructed to translation. Nielsen et al45 also reported that the
protect the PCL from overstress. Veltri et al67 re- popliteal tendon provided maximal resistance to ex-
ported that cutting the PFL, after having cut the LCL cessive tibial external rotation between 20° and 130°
with the popliteus tendon intact, produced only small of knee flexion and to excessive tibial varus rotation
additional external tibial rotation increases (0.9° between 0° and 90° of knee flexion. Due to the
versus 1.9°). However, when the PFL was cut last, influence of knee joint angle on capsuloligamentous
Journal of Orthopaedic & Sports Physical Therapy®
after the LCL and the popliteus tendon had been tightness, the contractile component of the PMTC
cut, 7° to 10° increases in tibial external rotation subsumes a greater dynamic responsibility for provid-
were reported. They concluded that both the ing knee joint stability as knee flexion angles in-
popliteal tendon and the PFL were important to crease. Pasque et al50 recommended that surgical
prevent excessive tibial external rotation and poste- inter ventions should address each of these
rior translation.67 Shahane et al60 reported that posterolateral capsuloligamentous structures individu-
isolated popliteus muscle sectioning did not cause ally because the absence of load sharing between all
significant posterolateral knee joint instability; how- components may lead to residual instability and
ever, PFL sectioning produced 3° and 9° increases in unacceptably high loads.
tibial external rotation at 60° and 90° of knee flexion, Wang et al70 and others43 have reported that
respectively, in addition to increased posterior transla- current popliteus tendon surgical techniques tend to
tion. They concluded that the PFL was the primary restore only ‘‘static’’ or noncontractile function. Ide-
noncontractile restraint to tibial external rotation and ally, surgical PMTC repair should produce improved
the LCL was the secondary restraint. dynamic function in addition to a slight tenodesis
Recently, Pasque et al50 suggested that the order of effect on adjacent capsuloligamentous tissues. Im-
tissue transection influenced the results reported by proving our understanding of PMTC function may
Shahane et al.60 When controlling for cutting order, aid the development of knee injury prevention condi-
Pasque et al50 reported that isolated PFL sectioning tioning programs and functional rehabilitation ap-
did not produce increased tibial external rotation proaches for patients who display posterolateral knee
CLINICAL COMMENTARY
only near full extension. During unilateral stance, 4+
POPLITEUS MUSCLE FUNCTION popliteus activation amplitudes were also observed for
the non–weight-bearing lower extremity during inter-
Electromyographic study of popliteus activation nal rotation of the lower extremity with the knee
requires the use of intramuscular electrodes. This extended.39 Repeated studies using quantitative intra-
section will review electromyographic investigations muscular electromyographic techniques and concur-
performed during non–weight-bearing and weight- rent segmental 3-dimensional kinematic and kinetic
bearing activities. The use of categorical popliteus assessments are needed during the performance of
activity grading in 2 of these studies2,39 and the functionally relevant tasks.
limited use,2,39 or absence,1,10,55 of concurrent kine- In evaluating 4 patients with anterolateral knee
matic assessment in many of these studies makes it rotatory instability, Peterson et al53 reported in-
difficult to derive definitive conclusions. creased popliteus activity during volitional knee joint
pivot shift tests. In evaluating the popliteus activity of
Activation During Non-Weight Bearing 10 patients with posterolateral knee instability, who
In testing right-side popliteus activity in combina- were capable of volitional tibial subluxation, Shino et
tion with electrogoniometric measurements, al61 reported that the biceps femoris muscle created
the major tibiofemoral joint subluxation force and
Basmajian and Lovejoy2 reported popliteus activation
levels during isometric knee extensor or flexor activa- the popliteus created the major joint reduction force.
tion at differing knee flexion angles (0°, 5°, 20°, 45°, They concluded that popliteus activation was the
and 60°), with the tibia either in full internal dynamic key to the treatment of posterolateral knee
rotation, full external rotation, or in neutral align- joint instability.
ment. Popliteus activation levels were reported as a
Activation During Weight Bearing
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With subjects positioned in prone, beginning with the extension range of motion. The external rotation
knee in full extension, popliteus activation markedly moment arms of the long and short heads of biceps
increased over the initial 20° of knee flexion when femoris peaked near full external rotation. The
the lower leg was maintained in a full internal moment arms for tibial internal rotators, the
rotation position. Activation levels gradually de- semimembranosus and semitendinosus, peaked near
creased as 90° of knee flexion was reached.2 During 10° of internal rotation, while the gracilis and
both knee extension and flexion isometric contrac- sartorius moment arms remained constant through-
tion, popliteus activation remained constant with low out the internal-external rotation range of motion. As
amplitudes when tested with the tibia in full external a tibial internal rotator, the popliteus displayed a
Journal of Orthopaedic & Sports Physical Therapy®
Right-side popliteus activity levels were consistently (23.5°) walking compared to level (16.5°) walking.
greater during left-shoulder rotation than during Increased popliteus activity at midstance during
right-shoulder rotation, with the feet in the same weighted downhill walking was believed to be in
positions. Using a 1-to-4 categorical rating of left-side response to increased weight bearing on a flexed
popliteus activity, Prado Reis and Ferraz de knee.7 The finding of Davis et al7 that popliteus
Carvalho55 reported increased popliteus activity when displayed considerable activation during midstance
subjects performed anterior-posterior weight shifting, with weighted downhill walking, as compared to
or when they experienced loss of standing balance. standing or level walking, suggests that it may also be
Prado Reis and Ferraz de Carvalho55 confirmed the considerably active during the forceful loads associ-
Journal of Orthopaedic & Sports Physical Therapy®
findings of Basmajian and Lovejoy2 with increased ated with other activities, such as running downhill.
popliteus activation when the trunk was rotated Considering the findings of Buford et al,3 because
toward the side of the examined muscle during the popliteus muscle displays a maximum transverse-
standing, particularly when the femur tended to plane moment arm at 30° to 50° of knee flexion
externally rotate while the tibia was maintained in when noncontractile knee joint stabilizers do not
internal rotation. This movement created a composite provide optimal knee joint postural control, it may
internal rotation of the lower leg at the knee joint,2 also serve an important function during the perfor-
presumably with concentric popliteus muscle activa- mance of athletic movements, such as running direc-
tion. Mann and Hagy39 reported that, during unilat- tional changes.
eral stance with the knee extended, 4+ popliteus Given the coupled movement of tibial external
activation amplitudes were observed at the weight- rotation/posterior translation and tibial internal
bearing lower extremity during external trunk rota- rotation/anterior translation,11 the popliteus is ideally
tion and medial hip rotation.39 With internal trunk positioned to assist with 3-dimensional dynamic knee
rotation and lateral hip rotation, 2+ popliteus activity joint control by monitoring and controlling tibial
was observed during unilateral stance at the weight- external rotation and, consequently, posterior transla-
bearing extremity at maximum rotation.39 Squatting tion during eccentric function (thereby protecting
down and returning to an upright position produced the PCL), and by producing tibial internal rotation
3+ popliteus activity during the entire movement and posterior translation during concentric function
cycle. (thereby protecting the ACL).
CLINICAL COMMENTARY
Composite Relative
Muscle-
Spindle–Density
Muscle Ratio
Spindles/Muscle (Popliteus:Functional
Weight (g) Muscle Group)
Direct tibial internal rotators 7.85:1.18
Semimembranosus 0.60
Semitendinosus 1.40
Sartorius 1.20
Gracilis 1.50
Tibial internal rotators via the subtalar joint 7.85:2.99
Extensor digitorum longus 3.73
Fibularis (peroneus) longus 1.88
Fibularis (peroneus) brevis 3.37
Tibial external rotators via the subtalar joint 7.85:2.16
Tibialis anterior 2.02
Tibialis posterior 1.64
Flexor hallucis longus 1.70
Flexor digitorum longus 2.94
Extensor hallucis longus 3.73
Soleus (medial calcaneal insertion) 0.94
Knee extensors 7.85:0.83
Vastus medialis 0.80
Vastus intermedius 0.90
Vastus lateralis 0.70
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approximate the borders of both the MCL and LCL, density ratio (RMSD) (muscle spindles per gram of
it is ideally positioned for providing instantaneous muscle weight) between the human plantaris and the
3-dimensional kinesthetic feedback, helping to moni- triceps surae muscles. Comparisons between the
tor medial and lateral tibiofemoral joint compart- popliteus muscle and other muscles that provide at
ment function. For example, during a running least 1 of its functions (tibial internal rotation,
directional change excessive MCL tensile stress and modulation of tibial external rotation via eccentric
increased lateral tibiofemoral compartment compres- activation, femoral external rotation, knee extension)
sion may produce immediate PMTC activation to are presented in Table 1. With consideration for
facilitate tibiofemoral joint internal rotation and ma- these muscle spindle densities in combination, a
neuver the lateral meniscus to a functionally effective preeminent sensory feedback role is suggested for the
and protected position. Concurrently, eccentric popliteus to provide kinesthetic feedback to the CNS
popliteus activation during excessive LCL tensile during transverse-plane knee joint movements.51,69
stresses and increased medial compartment compres- A predominant kinesthetic function for the
sion associated with knee flexion and internal rota- popliteus is supported by several comparative basic
tion at the end of weight acceptance during gait may science studies.16,41,54 In a muscle spindle study of
provide the primary kinesthetic cues to the central the cat knee joint, McIntyre et al41 confirmed the
nervous system (CNS) to facilitate a knee joint presence of slowly adapting popliteus muscle spindles
extensor/external rotation response to prevent knee that discharged tonically when the knee joint was
joint injury. positioned in intermediate flexed positions or during
CLINICAL COMMENTARY
are associated with genu valgus. Transverse-plane A
external femoral rotation and internal tibial rotation,
and frontal-plane hip joint abduction and knee joint
adduction are associated with genu varus. Therefore,
dynamic frontal-plane hip joint control via the abduc-
tor (gluteus medius) and adductor musculature may
also influence knee joint position. From this perspec-
tive, there may be considerable normal variability in
how subjects of differing lower extremity postural
alignments achieve 3-dimensional dynamic lower ex-
tremity postural stability during the performance of
functional movements, particularly during sudden,
single lower extremity loading. The key should be to B
train patients to perform tasks such as these using a
technique that is natural for them, while avoiding the
tissue stresses associated with moving too far into a
genu varus or valgus posture, or too fast if they have
poor 3-dimensional dynamic lower extremity postural
stability.
Delp et al,9 using a 3-dimensional computer model
based on the cadaveric moment arm measurements
of several hip muscles at varying hip flexion angles,
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CLINICAL COMMENTARY
3-dimensional knee joint kinematics during weight-
bearing activities. In general, with a genu varus/
internal tibial torsion knee joint alignment, the
posterolateral capsuloligamentous structures (LCL
and PFL) and the iliotibial band (ITB)14,18,44 would
tend to be preloaded, while the posteromedial
capsuloligamentous structures, including the MCL,
would tend to be preloaded with a genu valgus/
external tibial torsion knee joint postural align-
ment.18,44 Femoral external rotation during early
stance phase (among individuals with a genu varus/
internal tibial torsion) and via femoral internal rota-
tion (among individuals with a genu valgus/external
tibial torsion) may enable more effective mainte-
nance of naturally balanced knee joint
capsuloligamentous and popliteus musculotendinous
length-tension relationships. These examples repre-
sent opposite ends of a postural continuum that may
A B C
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Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
D E
Journal of Orthopaedic & Sports Physical Therapy®
without excessive or abduction during tion, knees touch or ion during con- ion during con- minimal hip flexion
adduction or abduc- controlled, soft flare outward (ex- trolled soft landing trolled soft landing during poorly con-
tion during con- landing treme coxa varus or trolled landing
trolled, soft landing valgus) during a
poorly controlled
landing
2 1 0 2 1 0
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Knee-Leg Alignment
Symmetrical align- Symmetrical abduc- Asymmetrical ab- Symmetrical with Symmetrical with Asymmetrical or
ment over feet with- tion or adduction, duction or adduc- moderate knee flex- excessive knee flex- with excessive or
out visible wobble slight wobble or tion, knees touch or ion during con- ion during con- minimal knee flexion
or sway during con- sway during con- flare outward (ex- trolled soft landing trolled soft landing during poorly con-
trolled, soft landing trolled, soft landing treme genu valgus trolled landing
or varus) noted dur-
ing a poorly con-
trolled landing
2 1 0 2 1 0
Journal of Orthopaedic & Sports Physical Therapy®
Ankle-Foot Alignment
Symmetrical with Symmetrical with Asymmetrical with Symmetrical with Symmetrical with Asymmetrical or
feet aligned with feet moderately one or both feet, moderate ankle excessive ankle with excessive or
toes pointing forward toed out or toed in extremely toed out dorsiflexion during dorsiflexion during minimal ankle
or slightly toed out during controlled, or toed in, or a sec- controlled soft land- controlled soft land- dorsiflexion during
during controlled, soft landing ondary hop during ing ing poorly controlled
soft landing a poorly controlled landing
landing
2 1 0 2 1 0
Total Frontal Plane Score = /12 Total Sagittal Plane Score = /12
Overall Qualitative Jump Landing Score = /24 = %
substantially affect a patient’s capacity for performing clinician assist the patient to achieve his or her own
certain athletic movements. Fortunately, more subtle individualized level of optimal 3-dimensional dynamic
representations predominate, better enabling the lower extremity postural stability.
clinician to effectively facilitate safer athletic move- Females more commonly display genu valgus/
ment patterns. Performance variability among external tibial torsion, coxa varus/adduction, and
patients is to be expected, necessitating that the genu recurvatum postural alignments than males,37,49
CLINICAL COMMENTARY
ately balanced knee joint capsuloligamentous tension. kinesthesia characteristics of the PMTC suggest that it
Although either gender may be affected by the warrants greater attention during the design and
influence of knee joint postural alignment, hormonal implementation of lower extremity injury prevention
changes,73 a narrower femoral notch,5 more frequent and functional rehabilitation programs.
displays of improper jump landing biomechanics with
suboptimal quadriceps and hamstring muscle group
use,21,22,33,37 and more frequent use of an upright ACKNOWLEDGMENT
posture during jump landings24,33 and cutting37 sug-
gest that females would be more notably affected The authors thank Dr Robert Acland at the Univer-
than males, possibly predisposing them to greater sity of Louisville Fresh Tissue Dissection Laboratory
3-dimensional dynamic lower extremity postural sta- for his assistance with this project. We also thank Kim
bility difficulties during intense athletic maneuvers. Caborn, PT, MS, ATC for reviewing the manuscript.
Reports suggest that improving dynamic transverse-
and frontal-plane hip joint control over long-axis
femoral internal rotation and adduction,3,9 and
ankle-subtalar joint control over long-axis tibial REFERENCES
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Journal of Orthopaedic & Sports Physical Therapy®
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