Anatomy in Practice Anatomy in practice: the Popliteus muscle Stephanie Woodley BPhty MSc PhD student Department of Anatomy & Structural Biology University of Otago Dunedin New Zealand Susan Mercer BPhty(Hons) MSc PhD Department of Anatomy & Developmental Biology School of Biomedical Sciences The University of Queensland Australia ABSTRACT Examination for trigger points in the popliteus muscle involves palpation of its muscle belly and proximal tendon of attachment. Review of the popliteus muscle in situ revealed its location on the oor of the popliteal fossa and the association of overlying soft tissues and neurovascular bundles. While the premise in clinical texts is that this muscle is easily accessible, the clinical anatomy of popliteus highlights that palpation is not as straightforward as often depicted. Woodley S, Mercer S (2006): Anatomy in practice: the Popliteus muscle. New Zealand Journal of Physiotherapy 34(1): 25-29. INTRODUCTION The differential diagnosis for posterior knee pain can be complex, and vascular and neurologic pathology needs to be considered alongside musculoskeletal disorders (Muche and Lento 2004). From a musculoskeletal perspective, popliteus has been implicated in complaints of posterior knee pain that is exacerbated with activities such as crouching and either walking or running, downhill or downstairs. One suggestion regarding the pattern of pain referral from popliteus is that it arises from an active trigger point located within the middle of its muscle belly. In addition, if symptomatic, the popliteal tendon and the region of its femoral attachment may be tender when palpated. When describing techniques of palpation it has been proposed that the tibial attachment, the upper lateral end of popliteus and the femoral attachment are palpable (Chaitow and Walker DeLany 2002, Travell and Simons 1999). Interestingly, the topography of the muscle is not included in these clinical descriptions. As the morphology of the popliteus muscle in situ is rarely discussed in relationship to musculoskeletal assessment of the knee region, the purpose of this paper was to present the clinical anatomy of this muscle. Morphology Popliteus is described as a thin or attened triangular shaped muscle. Its broad muscle belly attaches medially to the posterior surface of the tibia above the soleal line, tapering to an apex as it approaches the knee joint (Figure 1) (Grant and Basmajian 1965, Hollinshead 1969, Gardner et al 1975). From their distal attachment, the fascicles of popliteus pass superiorly and laterally, running beneath the arcuate ligament (Last 1948, Watanabe et al 1993). Becoming tendinous, it then passes between the brous and synovial layers of the knee NZ Journal of Physiotherapy – March 2006, Vol. 34 (1) joint capsule, and continues upwards towards its proximal insertion. Attachment proximally is into the lateral surface of the lateral condyle of the femur, below the attachment of the lateral collateral ligament (Figure 2) (Frazer 1940, Hollinshead 1969, Watanabe et al 1993). A bursa is found deep to the tendon where it passes between the lateral collateral ligament and the lateral meniscus. Clear associations between popliteus and surrounding structures have been identied. A feature of its eshy attachment to the tibia is that it is covered by dense fascia, which is particularly thick medially, thereby acting as an aponeurosis for the semimembranosus muscle (Grant and Basmajian 1965, Moore and Dalley 2006). Associations have also been observed with the joint capsule, lateral meniscus, posterior cruciate ligament, ligaments of Wrisberg and Humphrey, oblique popliteal ligament, the arcuate ligament complex, and to the head of the bula (Figure 1) (Jones et al 1995, Kimura et al 1992, Last 1948, Last 1950, Terry and LaPrade 1996, Tria et al 1989, Ullrich et al 2002, Wadia et al 2003, Watanabe et al 2003). Function Popliteus provides posterolateral stability to the knee joint and aids in stabilising the lateral meniscus and controlling tibial rotation (Jones et al 1995, Muche and Lento 2004, Nyland et al 2005, Ullrich et al 2002). This muscle is not thought to contribute signicantly to exion of the knee joint (Fuss 1989, Kaplan 1962, Moore and Dalley 2006). However, it has been suggested that popliteus aids in unlocking and internally rotating the knee joint when initiating exion, and that it may control antero-posterior motion of the lateral meniscus throughout the motion of exion (Fuss 1992, Last 1948, Moore and Dalley 2006). In instances when the knee adopts a static exed position, popliteus 25 Figure 2: Lateral view of a right knee joint. The tendon of popliteus (PT) is attaching to the lateral aspect of the lateral femoral condyle (LFC), below the proximal attachment of the lateral collateral ligament (LCL). Lateral meniscus (LM), head of the bula (F). Figure 1: Posterior view of a left knee joint. The popliteus muscle (P) runs superiorly from the tibial shaft medially above the oblique soleal line (S), to pass under part of the arcuate ligament complex (AL) and lateral collateral ligament (LCL). It attaches to the lateral femoral condyle via its tendon (PT). Note the groove for the popliteal tendon in the lateral femoral condyle (arrowhead). Fibula (F), posterior cruciate ligament (PCL), ligament of Wrisberg (LW), insertions of the lateral head of gastrocnemius (LG) and medial head of gastrocnemius (MG). is also thought to assist the posterior cruciate ligament in preventing anterior displacement of the femur on the tibia (Moore and Dalley 2006). As this paper is concerned with the morphology of the popliteus muscle, readers interested in the function of this muscle are referred to a recent review (Nyland et al 2005). Popliteal Fossa When contemplating palpation of popliteus, the muscle must be considered in situ. From a physiotherapy perspective, familiarity with the anatomy of the popliteal fossa is therefore necessary. 26 Located at the back of the knee, the popliteal fossa is a diamond shaped area which may be divided into an upper and a lower triangle. The upper triangle is bounded medially by the semimembranosus muscle and overlying semitendinosus tendon. The short head of biceps femoris, overlaid and fused with the long head of biceps femoris, forms the lateral border (Figure 3). These muscles and tendons embrace the proximal sides of the lower triangle which are comprised of the two heads of gastrocnemius and the very small plantaris muscle, which lies beneath the lateral head. The oor of the fossa is largely formed by the posterior aspect of the distal femur which is covered by fat, and the posterior capsule of the knee joint. The thick fascia covering the popliteus muscle completes the oor distally (Figure 4) (Grant and Basmajian 1965, Hollinshead 1969, Woodburne and Burkel 1988). Covering the fossa to form a roof are the dense, circularly arranged bres of the fascia lata, which pass distally to become continuous with the deep fascia of the leg. It has been suggested that this overlying popliteal fascia is tensioned when the knee joint is extended (Gardner et al 1975). The popliteal fossa contains numerous structures including the common peroneal and tibial nerves, popliteal artery and vein, posterior femoral cutaneous nerve, the genicular branch of the obturator nerve, the small saphenous vein, lymph nodes, bursae and fat (Figure 4). All of these various structures must be considered when attempting to palpate the popliteus muscle as they lie between the skin and the popliteus muscle (Hollinshead NZ Journal of Physiotherapy – March 2006, Vol. 34 (1) Figure 3: View of a right popliteal fossa from behind. The boundaries are: upper medial, the semimembranosus muscle (SM) and overlying tendon of semitendinosus (ST); upper lateral, the biceps femoris muscle anked by the common peroneal nerve (CP) and iliotibial band (ITB) with the vastus lateralis (VL) and fascia lata (FL); the lower lateral boundary, the lateral head of gastrocnemius (LG) and the lower medial boundary, the medial head of gastrocnemius. 1969, Gardner et al 1975, Woodburne and Burkel 1988) In the midline, the oor is crossed vertically by the tibial nerve and popliteal vessels (Figure 4). The popliteal artery lies on the fascia covering the popliteus. In the upper part of the fossa, the lateral and medial superior genicular arteries arise from the popliteal artery, while the middle genicular artery arises behind the knee joint. Important to the therapist considering the popliteus muscle, the medial and lateral genicular branches pass medially and laterally over popliteus to run deep to their corresponding collateral ligaments before NZ Journal of Physiotherapy – March 2006, Vol. 34 (1) Figure 4: Posteromedial view of a right popliteal fossa with the medial (MG) and lateral (LG) heads of gastrocnemius resected to reveal its contents. The tendon of semitendinous (ST) passes over the semimembranosus muscle (SM) which anks the medial head of gastrocnemius. The thick distal expansion (E) of semimembranosus can be seen covering the medial muscle belly of popliteus (P). The midbelly and lateral aspect of the popliteus belly is covered by the tibial nerve (TN), popliteal vessels (PV), plantaris muscle (Pl), the common peroneal nerve (CP) and lateral head of gastrocnemius (LG) with its associated neurovascular bundle. The lesser saphenous vein (SV) can be seen approaching the popliteal vein. Soleus (S). joining the arterial anastomosis around the knee joint. The terminal branches of the popliteal artery, the anterior and posterior tibial arteries, arise at the lower border of popliteus. Typically the lesser 27 saphenous vein pierces the popliteal fascia, passing between the two heads of gastrocnemius to drain into the popliteal vein (Grant and Basmajian 1965, Hollinshead 1969, Gardner et al 1975, Woodburne and Burkel 1988, Moore and Dalley 2006). In the upper lateral corner the common peroneal nerve passes close to the medial border of biceps femoris. This nerve follows the biceps tendon as it passes out of the fossa, over the lateral head of gastrocnemius, to the back of the head of the bula (Figure 3). Located within the fossa, the tibial nerve lies in the midline on the popliteus muscle before passing distally, deep to the brous arch of the soleus muscle (Figure 4) (Hollinshead 1969). Implications for Palpation Palpation of the popliteus muscle must occur through the overlying structures of the popliteal fossa. Consequently the site of the midbelly trigger point (Chaitow and Walker DeLany 2002, Travell and Simons 1999) is buried deep beneath skin, subcutaneous tissue, deep fascia, the gastrocnemius muscle and the overlying dense fascia of the popliteus muscle (Figure 5). In addition the tibial nerve and popliteal vessels pass over the muscle (Figures 3 and 4). Popliteus is considered to be most accessible at two locations - close to the lower medial end, and to the upper lateral end of the muscle belly (Figure 1). It has been proposed that the lower medial end of the muscle can be palpated directly between the semitendinosus tendon and the medial head of the gastrocnemius muscle (Figures 3 and 4) (Travell and Simons 1999). To access this area, once, and if it is possible that the medial head of gastrocnemius can be pushed laterally, contact with popliteus would be restricted by overlying skin, subcutaneous tissue, the crural fascia, and the overlying dense aponeurosis of the semimembranosus muscle (Figures 4 and 5). The upper, lateral end of popliteus is said to be best palpated as it crosses the knee joint just above the head of the bula, between the tendon of biceps femoris and the lateral head of gastrocnemius (Travell and Simons 1999) (Figures 3 and 4). Laterally, the overlying skin, subcutaneous tissue, crural fascia, tendon of biceps femoris, common peroneal nerve and arcuate ligament complex would obstruct direct access to the muscle (Figures 1, 3-5). Travell and Simons (1999) have also stated that when popliteus is involved in the complaint of posterior knee pain, patient examination will reveal tenderness of its tendon as well as the region over its tendinous attachment to the femur. When palpating in the area of its proximal attachment the presence of other local structures also require consideration. These include the lateral collateral ligament, lateral meniscus, the bursa deep to popliteus, a tendinous expansion from vastus lateralis, the tendon of biceps femoris, fascia lata, and the joint capsule (Figures 2 and 3). 28 Figure 5: Transverse section through a left leg. The popliteus muscle (P) lies against the tibia (T), anked by the bula laterally (F). Covered from behind by the skin (S), subcutaneous tissue (ST), crural fascia (CF), medial (MG) and lateral (LG) heads of gastrocnemius. Passing in the midline are the popliteal vessels and the tibial nerve (TN). Patellar ligament (PL). CONCLUSIONS Examination of the popliteus muscle in situ reveals those soft tissues that would hamper specic palpation of the popliteus muscle. In addition to the skin and subcutaneous tissue supercially, a medial approach encounters the substantial crural fascia, medial head of gastrocnemius and the dense aponeurosis of semimembranosus. Laterally, tissues such as the crural fascia, tendon of biceps femoris, common peroneal nerve and arcuate ligament impede direct access to the muscle. Potential pain generating structures such as the lateral collateral ligament, lateral meniscus, bursae and the joint capsule should also be considered when attempting to palpate the popliteal tendon near its femoral insertion. Physiotherapists assessing the posterior aspect of the knee joint should be aware of the morphology and relations of the popliteal muscle and its tendon. Key Points • The in situ morphology of popliteus is complex as this musculotendinous unit is associated with, and attached to, numerous soft tissues and neurovascular bundles • Popliteus is located deep, close to the oor of the popliteal fossa • Physiotherapists considering palpation of popliteus need to have an awareness of the location of this muscle in relation to tissues which overlie and surround it. ACKNOWLEDGEMENTS The authors which to thank Mrs Shannon O’Neill, Mr Brynley Crosado and Mr Russell Barnett for the preparation of the material used to illustrate this paper. This material forms part of the teaching collection of the Department of Anatomy and Structural Biology at the University of Otago. NZ Journal of Physiotherapy – March 2006, Vol. 34 (1) REFERENCES Chaitow L and Walker DeLany J (2002): Clinical Application of Neuromuscular Techniques. Volume 2 – the lower body. Edinburgh: Churchill Livingstone. Frazer JE (1940): The Anatomy of the Human Skeleton. 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Watanabe Y, Moriya H, Takahashi K, Yamagata M, Sonoda M, Shimada Y and Tamaki T (1993): Functional anatomy of the posterolateral structures of the knee. Arthroscopy 9: 57-62. Woodburne RT and Burkel WE (1988): Essentials of Human Anatomy. (8th ed.) Oxford: Oxford University Press. ADDRESS FOR CORRESPONDENCE Stephanie Woodley, Department of Anatomy & Structural Biology, University of Otago, Dunedin, New Zealand. Dr Susan Mercer, Department of Anatomy & Developmental Biology, School of Biomedical Sciences, The University of Queensland, Australia Q 4072. Email: s.mercer@uq.edu.au 29 NZSP Waipuna Lodge Auckland Life! – with physiotherapy Keynote speakers • Return to sport: Professor Richard Gajdosik Director of the Clinical Kinesiology Research Laboratory at the University of Montana. • Return to work: Professor Kathryn McPherson Professor of Rehabilitation Studies at the Auckland University of Technology. • Return to life: Professor Marilyn Moffat Professor of Physical Therapy at New York University, past president APTA and Executive Committee WCPT. • Dr Mihi Ratima Associate Professor in Maori Health at the Auckland University of Technology. A debate on Advancing the Profession will conclude the conference. Invited speakers • Professor David Baxter – Dean School of Physiotherapy, University of Otago. Research interest: LBP current management and evidence for effectiveness. • Dr Roslyn Boyd – Murdoch Children’s Research Institute, Melbourne. Research interests: the scientific foundation of neurological rehabilitation of children with CP. • Dr Brenda Button – University of Melbourne. Research interests: airways clearance therapy across the lifespan. • Dr Pauline Chiarelli - University of Newcastle. Research interests: women’s health and continence. • David Nicholls – Senior Lecturer AUT. Research interests: cardiopulmonary physiotherapy, the development of physiotherapy and future directions. • Dr Lynn Rochester – University of Newcastle, Northumbria. Research interests: motor control of gait and Parkinson’s disease. • Dr Michele Sterling - The Whiplash Research Unit, University of Queensland. Research interests: whiplash injuries and idiopathic neck pain. • Assoc Prof Leon Straker – Curtin University. Research interests: prevention of musculoskeletal disorders associated with computer use by children and adolescents. • Dr Denise Taylor – Senior Lecturer at AUT in neuro-rehabilitation and Researcher in the Physical Rehabilitation Research Centre. Research interests: motor control and motor learning, visuo-vestibular control of balance, falls prevention, upper limb rehabilitation. Early bird registration closes 13 April. There will be pre - or post - conference workshops with some of the speakers. The registration form, and current information about the conference and workshops, are on www.physiotherapy.org.nz - or available from the NZSP National Office.