[ CASE REPORT ]

DAVID A. KRAUSE, PT, MBA, DScPT, OCS¹šC?9>7;B@$IJK7HJ" MD²

Snapping Popliteus Tendon

in a 21-Year-Old Female

D
etermining the cause of painful snapping on the lateral aspect agement are indications for surgery. The
of the knee can be a challenge. While incidence estimates purposes of this case report are to illus-
trate the clinical presentation of a patient
of lateral knee snapping vary, it is a common condition of
with a long history of a painful snapping
the lower extremity.10 The differential diagnosis includes popliteus tendon that had been misdiag-
iliotibial band friction syndrome,10,12 lateral meniscus tear,7 intra- nosed, to describe the challenges in se-
articular loose body,5 discoid lateral meniscus,13 snapping biceps curing an accurate differential diagnosis
femoris tendon,3,16 degenerative joint disease,22 proximal tibiofibular based on signs and symptoms, and to
describe intervention options. Given the
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joint instability,6,25 and snapping are difficult to interpret and imag- role of the physical therapist in screening
popliteus tendon.4,8,9,20 In the case ing studies may not be helpful.20 musculoskeletal conditions,2 awareness
of a snapping popliteus tendon, SUPPLEMENTAL Persistent symptoms combined of the condition will assist the clinician in
VIDEOS ONLINE
physical examination findings with failure of conservative man- management of patients presenting with
lateral knee pain and snapping.
TIJK:O:;I?=D0 Case report. not successful.
T879A=HEKD:0 Determining the cause of TEKJ9EC;I0 The patient underwent a surgical
97I;:;I9H?FJ?ED
painful snapping on the lateral aspect of the knee procedure consisting of removal of a prominent

A
can be a challenge. The differential diagnosis tubercle on the lateral femoral condyle and 21-year-old female patient
includes iliotibial band friction syndrome, lateral tenodesis of the popliteus tendon to the proximal presented with a 7-year history of
J Orthop Sports Phys Ther 2008.38:191-195.

meniscus tear, intra-articular loose body, discoid aspect of the fibular (lateral) collateral ligament, painful snapping on the lateral as-
lateral meniscus, snapping biceps femoris tendon, followed by a postoperative program of physical pect of her left knee. The snapping oc-
degenerative joint disease, proximal tibiofibular therapy including range-of-motion and progres-
curred with all activities involving knee
joint instability, and snapping popliteus tendon. sive strengthening exercises. At 6 weeks following
surgery, the patient had returned to all activities flexion and extension, including running
T97I;:;I9H?FJ?ED0 A 21-year-old female
with complete resolution of her symptoms. and walking. Despite a previous athletic
presented with a 7-year history of a painful snap-
ping on the lateral aspect of her left knee. She T:?I9KII?ED0 Painful snapping at the lateral lifestyle participating in a variety of youth
reported the snapping occurred with all activities aspect of the knee may be caused by a variety of sports, she did not recall any history of
involving knee flexion and extension, including disorders, including the popliteus tendon. Clinical trauma. Since the onset of the persistent
running and walking. With a diagnosis of snapping diagnosis is challenging. Clinical suspicion of a painful snapping, she had stopped par-
iliotibial band, she had received a variety of physi- snapping popliteus tendon as a source of the signs ticipation in most sports and recreational
cal therapy interventions, including various lower and symptoms of the condition is important for
extremity stretching and strengthening exercises. pursuits. She had seen several physicians
inclusion in the differential diagnosis.
Nonsteroidal anti-inflammatory medications were and physical therapists over the past sev-
TB;L;BE<;L?:;D9;0 Differential di-
also prescribed by her physician. Conservative and eral years and had been diagnosed as hav-
agnosis, level 4. J Orthop Sports Phys Ther
pharmacological interventions were unsuccessful ing a snapping iliotibial band. A variety of
2008;38(4):191-195. doi:10.2519/jospt.2008.2698
in improving her symptoms. Similarly, our attempt
physical therapy interventions had previ-
with conservative treatment consisting of ice, TA;OMEH:I0 differential diagnosis, iliotibial
taping, and a short period of immobilization was band, knee ously been attempted, including modali-
ties and lower extremity stretching and

1
Assistant Professor, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN. 2 Professor, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN. This case was seen at
the Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, MN. The project was reviewed by the Mayo Clinic Institutional Review Board. Address correspondence to David
A. Krause, 200 First Street SW, Rochester, MN 55905. E-mail: [email protected]

journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | 191
 [ CASE REPORT ]
strengthening exercises. Nonsteroidal eliminated during both active and pas-
anti-inflammatory medications had also sive knee flexion and extension motion.
been prescribed. All interventions to date A trial of tape fixation at the distal fibula
were unsuccessful in relieving her symp- in a posterior direction, as described by
toms. While she had a desire to return to Mulligan,21 and taping of the proximal
running, her primary goal was to be able fibula in an anterior direction reduced
to walk without pain. but did not completely eliminate the
The patient was initially assessed by painful snapping with both knee motion
an orthopedic surgeon in our clinic and and gait (<?=KH;().
subsequently referred for a trial of physi- When the patient returned for her sec-
cal therapy. Physical examination by the <?=KH;'$Manual glide of the distal fibula in a ond visit 3 days later, she reported that
posterior direction.
physical therapist revealed a normal gait she was not able to tolerate the tape for
pattern, normal lower extremity align- more than a few hours, which limited the
ment, mild increased foot pronation bi- utility of this intervention. Given that the
laterally, and an audible click of the left tape and mobilization did not provide
knee late in each swing phase as the knee lasting benefit, a 2-week trial of a knee
was extending prior to heel contact. No immobilizer was initiated to maintain
limitations were noted with hip, knee, and the knee in extension to eliminate the
ankle range of motion, or with lower ex- snapping and subsequent irritation that
tremity muscle length tests, including test- occurred with knee flexion and exten-
ing of the iliotibial band using the Ober sion. She was allowed to bear full weight
Downloaded from www.jospt.org by 37.162.201.59 on 04/12/19. For personal use only.

test.23 The Noble compression test was during gait. Knee immobilization was
negative.10 Strength of the hamstrings and effective at eliminating the lateral snap-
quadriceps, assessed using manual muscle <?=KH;($Tape fixation of the distal and proximal ping. It was hypothesized that preventing
fibula.
testing, was symmetric with no deficits the mechanical snapping for this period
noted. Tenderness was present over the of time, combined with icing, might de-
lateral tibiofemoral joint line and lateral crease local inflammation and possibly
epicondyle of the femur. A palpable click have a lasting effect.
over the lateral knee region occurred at ap- After 2 weeks of immobilization the
proximately 20° to 30° of flexion with both patient returned for a third visit. She re-
passive and active knee flexion and exten- ported that the trial of immobilization
J Orthop Sports Phys Ther 2008.38:191-195.

sion. No intra-articular effusion was de- was effective in eliminating the lateral
tected through visual inspection. The knee knee snapping. Unfortunately, the painful
was stable based on ligamentous testing lateral knee snapping returned as soon as
and provocative meniscal tests were nega- the knee immobilizer was removed with
tive. No abnormal laxity of the proximal <?=KH;)$Identification of the tendon of the
both knee flexion and extension range of
tibiofibular joint was noted. Knee radio- popliteus through a lateral incision and longitudinal motion and gait.
graphs and magnetic resonance imaging splitting of the distal ilitotibial band
were interpreted as unremarkable. Based Ikh][ho
on these findings, the differential diagno- previously. As the painful snapping oc- Following the unsuccessful trial of the
ses included a snapping popliteus tendon, curred late in the swing phase of gait, most recent nonoperative treatment
snapping epicondylopatellar ligament, it was decided that foot orthotics would program, coupled with her previously
and a possible snapping iliotibial band. not be effective. Although no obvious unsuccessful attempts to treatment,
swelling was noted, the patient was in- the patient was interested in surgical
?DJ;HL;DJ?EDI structed to ice the area on a daily basis. options and was referred back to the
During the initial treatment session, a orthopedic surgeon. After consultation
F^oi_YWbJ^[hWfo trial of sustained manual posterior glide with the surgeon, the patient opted for
of the distal fibula was attempted to in- surgical management. Diagnostic ar-

J
he focus of the interventions
was to eliminate or minimize the fluence the proximal fibula and struc- throscopy revealed normal menisci, ar-
mechanical lateral knee snapping. tures attaching to the head of the fibula ticular cartilage, and popliteus tendon.
Modalities such as ultrasound were not (<?=KH;'). With maintenance of the glide Open surgical exploration was then
used as she reported unsuccessful trials mobilization, the lateral snapping was performed through a lateral incision

192 | april 2008 | volume 38 | number 4 | journal of orthopaedic & sports physical therapy
 EKJ9EC;I

E
n the day of surgery, the pa-
tient was instructed in a program
of ice and elevation for pain and
swelling, the use of crutches to ambu-
late with weight bearing as tolerated,
knee range-of-motion exercises, and
straight-leg raises exercises for quadri-
<?=KH;*$The tendon of the popliteus and prominent ceps strengthening. She was able to am-
tubercle of the popliteus sulcus on the lateral femoral bulate with crutches and perform knee
condyle. The tubercle is adjacent to the anterior range-of-motion exercises without the
retractor with the tendon of the popliteus posterior to painful snapping.
the tubercle. (Online video available.)
At 1 week postsurgery, the patient re-
turned for re-evaluation and progression
of her exercise program. She had minimal
swelling in the surgical area. Her active
knee range of motion was 0° to 130°. She
was able to ambulate with a normal gait
<?=KH;,$Insertion of the popliteus and
pattern without crutches and without
popliteofibular ligament. LaPrade RF, Ly TV, Wentorf
the painful snapping. Her strengthening FA, et al. The posterolateral attachments of the knee:
Downloaded from www.jospt.org by 37.162.201.59 on 04/12/19. For personal use only.

program was advanced to weight-bearing a qualitative and quantitative morphologic analysis

exercises, including partial squats and of the fibular collateral ligament, popliteus tendon,
lunges. At 6 weeks following surgery, the popliteofibular ligament, and lateral gastrocnemius
tendon. Am J Sports Med. 2003;31:854-60. Reprinted
patient continued to be symptom free
by permission of Sage Publications, Inc.
with all exercises and daily activities and
was allowed to return to any activities in operated knee have been reported in the
which she chose to participate. literature.8,18,20 Cooper8 reported on a se-
ries of 6 patients with lateral knee snap-
:?I9KII?ED ping. On examination, he noted palpable
popping midway between the lateral
J Orthop Sports Phys Ther 2008.38:191-195.

<?=KH;+$Radiograph after surgical removal of the epicondyle and the lateral joint line. He

J
he popliteus tendon, fibular
tubercle of the popliteus sulcus collateral ligament, and popliteo- also found that the snapping was more
fibular ligament are the primary pronounced when the knee was loaded
and longitudinal splitting of the distal lateral and posterolateral stabilizers of with varus stress during passive flexion
iliotibial band (<?=KH;)). The tendon of the knee.14,19,26,27 The popliteus muscle and extension. Mariani et al18 described
the popliteus muscle was observed to originates from the posterior surface of snapping of the popliteus tendon in 3 pa-
snap over a prominent tubercle of the the proximal tibia. Its tendon courses tients. He found the Cabot sign was the
popliteus sulcus with passive knee flex- proximally and laterally within the knee most reliable clinical test in making the
ion and extension (<?=KH; *1 EDB?D; L?:- joint deep to the fibular collateral liga- diagnosis. With this maneuver, the lateral
;E). The mechanical snapping occurred ment and attaches to the anterior as- knee region is palpated while the knee
consistently at approximately 20° to 30° pect of the popliteal sulcus on the femur is extended against resistance with the
of flexion. The surgical procedure con- (<?=KH; ,).15 The popliteus functions to lower extremity in a figure-of-four posi-
sisted of removal of the tubercle on the internally rotate the tibia and “unlock” tion. This position would likewise impart
lateral femoral condyle (<?=KH; +), and the extended knee during the gait se- a varus stress to the knee.
tenodesis of the popliteus tendon to the quence.17 The popliteus also functions to Popliteus tendon dysfunction follow-
proximal aspect of the fibular (lateral) provide rotary stability to the femur on ing total knee arthroplasty has also been
collateral ligament to decrease excur- the tibia, assisting the posterior cruciate reported. The tendon can subluxate over
sion of the tendon.15 While in surgery, it ligament in restraining posterior trans- a retained lateral femoral condylar os-
was confirmed that the snapping was no lation of the tibia.11 teophyte or over the edge of the poste-
longer present when the knee was pas- Clinical findings associated with a rior condyle of the femoral component.1,4
sively flexed and extended. snapping popliteus tendon in the non- Similar to the nonoperated knee, clinical

journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | 193
 [ CASE REPORT ]
findings include discrete lateral tender- fibula, increasing tension on the popliteo- 1999;37:679-690.
 ,$ Bozkurt M, Yilmaz E, Akseki D, Havitcioglu H,
ness at the level of the joint line along fibular ligament, which provides a stabi-
Gunal I. The evaluation of the proximal tibiofibu-
with an audible snap with knee flexion lizing influence on the popliteus tendon, lar joint for patients with lateral knee pain. Knee.
and extension. Surgical intervention for thus reducing the patient’s symptoms. 2004;11:307-312. http://dx.doi.org/10.1016/j.
a snapping popliteus tendon after total The resultant limitation of proximal ten- knee.2003.08.006
7. Choi NH, Victoroff BN. Anterior horn tears of the
knee arthroplasty have included release of don excursion may have had an effect
lateral meniscus in soccer players. Arthroscopy.
the tendon from the femoral insertion.1 similar to surgical tenodesis. Additional 2006;22:484-488. http://dx.doi.org/10.1016/j.
In most cases of a snapping popliteus investigation is required to determine if arthro.2006.01.014
tendon in the nonoperative knee, radio- this maneuver is consistently helpful in 8. Cooper DE. Snapping popliteus tendon syn-
drome. A cause of mechanical knee popping in
graphs and magnetic resonance imaging the diagnosis and treatment of a snap- athletes. Am J Sports Med. 1999;27:671-674.
are unremarkable. Some authors have de- ping popliteus tendon. 9. Crites BM, Lohnes J, Garrett WE, Jr. Snapping
scribed limited image findings, such as a popliteal tendon as a source of lateral knee pain.
lateral femoral condyle osteophyte.8,11,18 9ED9BKI?ED Scand J Med Sci Sports. 1998;8:243-244.
10. Fredericson M, Weir A. Practical management of
Dynamic magnetic resonance imaging iliotibial band friction syndrome in runners. Clin
or ultrasound may best demonstrate

F
ainful snapping at the lateral J Sport Med. 2006;16:261-268.
the snapping structure and secure the aspect of the knee may be caused 11. Gaine WJ, Mohammed A. Osteophyte impinge-
diagnosis.24 by a variety of disorders, including ment of the popliteus tendon as a cause of
lateral knee joint pain. Knee. 2002;9:249-252.
When surgical management is select- a snapping popliteus tendon. Clinical di- 12. Khaund R, Flynn SH. Iliotibial band syndrome:
ed, diagnostic arthroscopy is essential agnosis is challenging. Knowledge of the a common source of knee pain. Am Fam Physi-
to rule out other conditions and allow anatomy of the posterolateral knee and cian. 2005;71:1545-1550.
')$ Kocher MS, Klingele K, Rassman SO. Meniscal
inspection of the intra-articular por- a clinical suspicion of a snapping popli-
disorders: normal, discoid, and cysts. Orthop
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tion of the popliteus tendon.8,18,20 The teus tendon as a source of the signs and Clin North Am. 2003;34:329-340.
surgical procedure of reported cases has symptoms are important for inclusion '*$ LaPrade RF, Bollom TS, Wentorf FA, Wills
been either arthroscopic excision of the of the condition in the differential diag- NJ, Meister K. Mechanical properties of the
posterolateral structures of the knee. Am J
osteophyte, or, as in our case, an open nosis. A careful history, focused physical
Sports Med. 2005;33:1386-1391. http://dx.doi.
procedure following the arthroscopic examination, radiographs, and magnetic org/10.1177/0363546504274143
investigation. resonance imaging are useful to rule out '+$ LaPrade RF, Ly TV, Wentorf FA, Engebretsen L.
Even though our patient did not im- other conditions and possibly to assist The posterolateral attachments of the knee: a
qualitative and quantitative morphologic analy-
prove with nonoperative management, an in identifying the involved structure. A
sis of the fibular collateral ligament, popliteus
initial course of physical therapy interven- snapping popliteus tendon may respond tendon, popliteofibular ligament, and lateral
tions is indicated.8,20 In Cooper’s8 series, to conservative care; however, unrespon- gastrocnemius tendon. Am J Sports Med.
J Orthop Sports Phys Ther 2008.38:191-195.

3 of 4 patients treated with conservative sive cases should be referred for consider- 2003;31:854-860.
',$ Lokiec F, Velkes S, Schindler A, Pritsch M. The
care had spontaneous resolution of symp- ation of possible diagnostic arthroscopy
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patients had a traumatic onset of their 17. Mann RA, Hagy JL. The popliteus muscle. J
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H;<;H;D9;I 18. Mariani PP, Margheritini F, Christel P, Bellelli
may have been due to the tissue trauma A. Evaluation of posterior cruciate ligament
and subsequent swelling and scarring. In healing: a study using magnetic resonance
1. Allardyce TJ, Scuderi GR, Insall JN. Arthroscopic
addition, the diagnosis of these patients treatment of popliteus tendon dysfunction fol-
imaging and stress radiography. Arthroscopy.
was made by clinical exam only and not 2005;21:1354-1361. http://dx.doi.org/10.1016/j.
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confirmed as with the surgical cases. 1997;12:353-355.
19. Maynard MJ, Deng X, Wickiewicz TL, Warren
While a definitive program has not 2. American Physical Therapy Association. Guide
RF. The popliteofibular ligament. Rediscovery of
to Physical Therapist Practice. Second Edition.
been outlined, nonoperative care general- a key element in posterolateral stability. Am J
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lower extremity malalignment, and anti-  )$ Bach BR, Jr., Minihane K. Subluxating biceps popliteus tendons. A case report. Am J Sports
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Sports Med. 2001;29:93-95. tape in the prevention of ankle injury in basket-
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We hypothesize that the posterior mobi- plasty. 1995;10:543-545. 22. Nadaud MC, Ewing JW. Proximal tibiofibular
lization of the distal fibula produced an  +$ Bianchi S, Martinoli C. Detection of loose arthritis: an unusual cause of lateral knee pain.
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associated anterior glide of the proximal

194 | april 2008 | volume 38 | number 4 | journal of orthopaedic & sports physical therapy
 [ CASE REPORT ]
()$ Reese NB, Bandy WD. Use of an inclinometer 2002;18:872-881. 27. Veltri DM, Deng XH, Torzilli PA, Maynard MJ,
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differences in magnitude and reliability of lateral knee pain: a review of proximal tibiofibu- chanical study. Am J Sports Med. 1996;24:19-27.
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@
(*$ Sekiya JK, Jacobson JA, Wojtys EM. Sonograph- (,$ Sugita T, Amis AA. Anatomic and biomechanical
ic imaging of the posterolateral structures of the study of the lateral collateral and popliteofibular
CEH;?D<EHC7J?ED
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J Orthop Sports Phys Ther 2008.38:191-195.

journal of orthopaedic & sports physical therapy | volume 38 | number 4 | april 2008 | 195