Folia Morphol.

Vol. 80, No. 3, pp. 505–513

DOI: 10.5603/FM.a2020.0106
REVIEW ARTICLE Copyright © 2021 Via Medica
ISSN 0015–5659
eISSN 1644–3284
journals.viamedica.pl

Current concepts on the morphology of

popliteus tendon and its clinical implications
J. Zabrzyński1, 2, G. Huri3, A. Yataganbaba3, Ł. Paczesny1, D. Szwedowski4,
A. Zabrzyńska5, Ł. Łapaj2, M. Gagat6, M. Wiśniewski7, P. Pękala8, 9, 10
1
Department of Orthopaedics, Orvit Clinic, Citomed Healthcare Centre, Torun, Poland
2
Department of General Orthopaedics, Musculoskeletal Oncology and Trauma Surgery,
University of Medical Sciences, Poznan, Poland
3
Orthopaedics and Traumatology Department, Hacettepe Universitesi, Ankara, Turkey
4
Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation Milan, Italy
5
Department of Radiology, Multidisciplinary Hospital, Inowroclaw, Poland
6
Department of Histology and Embryology, Faculty of Medicine, Nicolaus Copernicus University in Torun,
Collegium Medicum in Bydgoszcz, Poland
7
Department of Normal Anatomy, Faculty of Medicine, Nicolaus Copernicus University in Torun,
Collegium Medicum in Bydgoszcz, Poland
8
International Evidence-Based Anatomy Working Group, Department of Anatomy, Jagiellonian University
Medical College, Krakow, Poland
9
Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
10
Lesser Poland Orthopaedic and Rehabilitation Hospital, Krakow, Poland

[Received: 28 July 2020; Accepted: 11 August 2020; Early publication date: 2 September 2020]

In this review we described the anatomy and biomechanics of popliteus muscle and
its tendon. Furthermore, we combined the anatomy with clinics and discussed a wide
spectrum of disorders regarding the popliteus and its musculotendinous complex.
There are three main anatomical regions of the popliteus musculotendinous com-
plex: the proximal origin, the mid-portion, the distal part on the tibia. The unique
localisation and various origins of the tendon, connected with structures such as
fibular head, Wrisberg, Humphrey and posterior cruciate ligament, lateral meniscus,
medial collateral ligament, give an implication to diagnosis and treatment. Popliteus
dysfunction is often overlooked, that is the reason why diagnosis and treatment of
its injuries is mostly insufficient. Repetitive or acute direct varus forces, when the
tibia is in external rotation, and knee hyperextension or flexion with forced external
rotation of the tibia, are the main mechanisms of trauma. Popliteus injuries mainly
affect the athletic population and lead to severe activity limitations. Chronic disorders
of the popliteus tendon, less known, are often described as tendinopathy and are
frequently seen in runners. Their symptoms can mimic the lateral meniscal tears.
On the other hand, high-energy traumatic injuries of the popliteus tendon often
accompany complex, multi ligamentous injuries seen in competitive sports. We also
presented the implication of popliteus tendon in knee arthroplasty, due to its par-
ticular exposition to iatrogenic trauma during surgery. The issues such as proper tibial
component location and well-designed cut systems are crucial to avoid the popliteus
impingement and preserve its structure. (Folia Morphol 2021; 80, 3: 505–513)

Key words: popliteus muscle, tendinopathy, posterolateral corner,

popliteus reconstruction, popliteus tendon

Address for correspondence: J. Zabrzyński, MD, PhD, Orvit Clinic, ul. Marii Skłodowskiej-Curie 73, 87–100 Toruń, Poland, tel: +48 513094738,
e-mail: [email protected]
This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to down-
load articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

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ANATOMY
Popliteus muscle originates from the lateral fem-
oral condyle. It connects with the proximal fibula as
a popliteofibular ligament and the posterior horn of
the lateral meniscus as a tendinous attachment, and
inserts into the posterior surface of tibia above the
soleal line [8, 34]. Taylor and Bonney [48] in their com-
parative study concluded that the popliteus muscle is
analogous to the deep portion of the pronator teres
muscle. They both originated primitively from the
fibula and the ulna, respectively. During the evolution,
the origins of these muscles migrated proximally to
the lateral femoral condyle and medial humeral epi-
condyle. Moreover, in reptiles and primitive mammals,
the fibula articulates with the femur and subsequently,
during the evolution, the fibula has moved distally to
the proximal tibiofibular articulation [11].
Figure 1. Scheme of the popliteus musculotendinous unit; FH —
The popliteus tendon, forming a strong cord, is fibular head; LCF — lateral condyle of the femur; LCL — lateral col-
intra-capsular structure that runs deep to the lateral lateral ligament; LCT — lateral condyle of the tibia; ML — lateral
collateral ligament (LCL), and passes through the pop- meniscus; PLT — popliteus tendon.

liteal hiatus [37]. Nevertheless, the popliteus tendon

lies extra-articular and extra-synovial [19, 34]. The anterosuperior, posterosuperior, and posteroinferior
average total length of the popliteus tendon to its popliteomeniscal fascicles, serve as struts, stabilising
musculotendinous junction is 54.5 mm [26]. the posterior horn of the lateral meniscus [2, 37].
There are three main anatomical regions of the popli- Nevertheless, numerous variabilities of the origins
teus musculotendinous complex: the proximal origin (A), were observed [3]. Tria et al. [49], in cadaveric study,
the mid-portion (B), the distal part on the tibia (C). reported that 18/40 specimens (45%) had an isolat-
A. The proximal origin. The popliteus tendon ed popliteus tendon insertion to the lateral femoral
passes beneath the LCL, and its fibres are attached condyle, with no connection to the lateral meniscus.
to the popliteal groove, however, the main fascicle of However, this results could be biased by the dissec-
fibres is inserted underneath the LCL (Fig. 1, 2) [50]. tion technique or previous morbidities, and on the
Moreover, it was found that the centre of the femoral other hand, Aman et al. [2] revealed the presence
insertion of the popliteus muscle–tendon complex is of minimum 2/3 of popliteomeniscal fascicles in all
situated posterior and distal to the lateral epicondyle examined by them cadaveric limbs. Disruption of the
of femur [50]. popliteomeniscal fascicles may lead to the abnormal
B. The mid-portion. The popliteus complex has mobility of the lateral meniscus. Simonnet et al. [42]
mainly the following origins: the small pit on the later- identified the three types of meniscal attachments
al femoral condyle, the posterior aspect of the fibrous of the popliteus complex. The authors showed fewer
capsule of the knee joint, the ligamentous band ex- alterations in the lateral meniscus and tibiofemoral
tending between the popliteal tendon and the supe- cartilage in specimens with more popliteomeniscal
rior portion of the posterior horn of the lateral menis- fascicles. However, injuries to the popliteomeniscal
cus and the popliteofibular ligament [34]. Moreover, fascicles are extremely difficult to identify by physical
the connections with the ligaments of Wrisberg and examination and even magnetic resonance imaging
Humphrey, and the posterior cruciate ligament (PCL) (MRI). The MRI is a well-established non-invasive im-
were described [33]. The presence of a fibular attach- aging technique in recognition of normal poplite-
ment of the popliteus, known as popliteofibular (PFL) omeniscal fascicles; however, the gold standard for
ligament, was described by numerous authors and is diagnosis and treatment of their tears is arthroscopy
considered as part of the normal anatomy now [8]. [17]. The popliteus tendon is localised in the postero-
Popliteomeniscal fascicles are synovial structures be- lateral corner of the knee (PLC), in the bony groove,
tween the lateral meniscus and popliteus tendon. The which also has an essential impact on further clinical

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 J. Zabrzyński et al., Current concepts on the morphology of popliteus tendon and its clinical implications

Figure 2. A. Lateral view of the knee

joint showing the femoral attachments
of popliteus tendon (PLT) and fibular col-
lateral ligament (FCL) to the lateral con-
dyle of the femur (LCF). The PLT passes
beneath the FCL, which distal attach-
ment is the fibular head (FH). Moreover,
the relation between the lateral menis-
cus (ML) and the popliteus tendon is
visible. Lateral condyle of the tibia (LCT);
lateral head of the gastrocnemius mus-
cle (LHGM); B. The sonographic scan of
the lateral aspect of the knee joint with
the proximal attachments of FCL and
beneath the PLT origin; C. Lateral view
of the knee joint showing the PLT and its
relation to ML, the FCL is separated by
the probe. Posterior capsule (PC);
D. Arthroscopic view of the lateral
compartment of the knee joint and the
relations of the PLT to concomitant
structures.

issues [11, 27]. The proximal part of the popliteus unit BIOMECHANICS
is separated from the lateral collateral ligament, cap- The popliteus complex acts as static and dynamic
sule, and lateral femoral condyle by a synovial bursa. stabilizer of the knee joint. Its primary function is
If the bursa becomes inflamed, a fluid collection can to rotate the femur externally when the foot is in
be seen on MRI or ultrasound imaging [12]. contact with the ground and to internally rotate the
C. The distal part on the tibia. The muscle belly tibia when the foot is not fixed, which is crucial while
of the popliteus inserts above the soleal line at the walking. During concentric activation, the popliteus
proximal and posterior part of the tibia, forming the internally rotates the tibia; contrary, during eccentric
floor of popliteal fossa [13, 14]. Song et al. [43] with activation, it serves as a secondary restraint to external
a three-dimensional reconstruction of the human tibial rotation [33]. This dynamic and static resistance
knee showed that the popliteus tendon is divided to external rotation is more noticeable, with higher
into two bundles (medial and lateral) at the popliteal degrees of knee flexion [39].
fossa. The popliteus muscle is composed of deep and When the foot is in contact with the ground and
superficial layers [37]. Some of its distal fibres are the knee is in full extension, the knee is “locked”, and
interconnected with fascial fibres attached to the initiation of the flexion of the joint requires the popli-
distal region of the medial (tibial) collateral ligament teus function. It plays a key role that unlocks the knee
(MCL) [33]. by rotating the femur externally on the tibia while the

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Popliteus tendon
complex disorders

Popliteus musculo- Popliteus muscle Popliteus tendon

tendinous unit tear tear tear

Acute Chronic Acute Chronic Acute Chronic

Isloated Acute PLC Chronic PLC

Tendinopathy
complex injury complex injury

Figure 3. The general classification of the popliteus complex disorders; PLC — posterolateral corner of the knee.

knee is locked, facilitating the initial flexion [19]. Mean- rotation is observed. In type B, the PFL, popliteus
while, the popliteus’ connections to the lateral menis- tendon, and LCL are affected. In this group, a lateral
cus and posterior capsule protect the lateral meniscus gapping occurs under the varus stress test at 30° of
from impingement during movement. LaPrade et al. knee flexion along with an increase in tibial external
[27] defined the popliteus tendon as the “fifth major rotation. In type C, the injury to the PFL, popliteus
ligament of the knee”. Some studies emphasized that tendon, LCL, lateral capsule (avulsion) and cruciate
popliteus helps PCL and quadriceps muscle carrying the ligament tear are observed. Severe varus instability at
load, which prevents the femur from excess dislocation. 30° of knee flexion and in extension is typical. The lack
The connection between popliteus and PCL is provided of a comprehensive, prognostic classification system
by the Wrisberg and Humphrey ligaments and the main was one of the concepts of the consensus on PLC
role plays the medial aponeurosis of the popliteus of the knee presented by Chahla et al. [9]. A future
complex [35, 36]. In a biomechanical in vitro study, classification system should allow differentiation be-
it has been shown that when the popliteus tendon is tween structure involved, the type of injury (avulsion
stretched with 50 N, the tibia rotates 4–5 degrees (°) versus intrasubstance), the chronicity, the treatment
while the knee is fully extended. The amount of rota- strategy, and it should reflect the prognosis.
tion increases up to 12° as the knee is flexed 90° [23].
Moreover, authors transected the popliteofibular MECHANISM OF TRAUMA
ligament, LCL, popliteus tendon sequentially during There are various types of specific pathomecha-
cyclic biomechanical testing. They noted gradually nisms that cause popliteus injury. These are: a direct
increased tibial external rotation with a lateral shift varus force when the tibia is in external rotation and
of the position of neutral tibial alignment. During the knee hyperextension or flexion with forced external ro-
first 30-degree knee flexion, LCL contributes more to tation of the tibia [11, 32, 38]. Brown et al. [6] empha-
prevent the tibial varus, while the popliteus contrib- sized that the mechanism of trauma is more complex
utes more to limit the external rotation and posterior than thought and still has unknown aspects. While
translation of the tibia [33]. the musculotendinous junction is the weakest part of
the popliteus complex, the tendon is the most durable
CLASSIFICATION OF THE PATHOLOGY structure. The strength of the muscle belly is between
Commonly, the popliteus muscle and tendon dis- these two. The tendon is susceptible to strain at the
orders are classified into isolated pathology of ten- joint line or avulsion at its origin on the lateral femoral
don, muscle belly and complex posterolateral corner condyle. Moreover, complications related to the pop-
injuries of the knee (Fig. 3). Posterolateral corner liteus may also occur during total knee arthroplasty.
injuries are divided into three groups: A, B, and C, Takubo et al. [47] revealed that the femoral origins
according to lesions occurring in different structures of LCL and popliteus tendon are especially exposed
[13]. Type A involves the PFL and popliteus tendon; to iatrogenic trauma during the knee arthroplasty,
in this group, only an increase in the external tibial due to anatomic conditions. Furthermore, Takakashi

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et al. [45] demonstrated the special design of the cut ing on preserved stability of the joint, the isolated
systems, preserves the popliteus tendon, particularly injury of the popliteus muscle-tendon unit should be
endangered in a female cohort. The size of the tibial evaluated. Avulsion of the femoral attachment of the
component in the knee arthroplasty also may have popliteus has also been reported [31, 32]. This form
an impact on popliteus biomechanics and disorders. of injury is rare (< 10%) and is often seen as part of
Bonnin et al. [5] presented in their cadaveric study, complex knee injuries [19]. The structure of the pos-
using the computed tomography, the importance of terolateral corner was once regarded as the “dark side
the tibial components location on the tibial plateau of the knee” due to the complex and variable anatomy
and the association with tibio-popliteus impingement. with inconsistent terminology used in the literature to
Regarding to knee arthroplasty and stability, Kesman describe the structures in this region [39]. However, in
et al. [22] showed that role of the popliteus complex recent years, a significant contribution was made to
in the stability of the knee joint during the arthroplasty understand the anatomy and biomechanics of the PLC
was not clinically important and significant. Contrary, [8]. Today, it is understood that inadequate diagnosis
Cottino et al. [10] in their laboratory study showed and treatment of injuries involving the posterolateral
that popliteus dissection caused both the lateral and corner are associated with poor results and knee
medial instability of the knee joint; however, the great- instability. Popliteus injury is seen in 60% to 68% of
er impact was in the lateral compartment. patients operated for posterolateral corner instability
[20, 27]. Moreover, complete tears of popliteus unit
ISOLATED POPLITEUS TRAUMA usually are linked with multi-ligamentous injuries
AND TENDINOPATHY of the knee and subsequently need more advanced
Isolated injuries of the popliteus are rare and usual- surgical procedures [8]. Cruciate ligament rupture
ly occur in athletes. Musculotendinous unit lesions are (ACL or PCL) can mask the presence of PLC instability.
divided into three groups according to the severity of Isolated ACL or PCL reconstruction without regard to
the trauma. Accordingly, grade-1 indicates microtrau- PLC injury may result in graft failure. Posterolateral
ma, while grade-3 corresponds to isolated high-energy corner injuries are commonly associated with ACL
injuries [30]. Repetitive stress and microtrauma can or PCL rupture, but also medial compartment bone
lead to popliteus tendinopathy. Patients present with bruises [8, 15]. Inadequate reconstructive surgery,
persistent and chronic pain in the posterolateral region omitting the PLC deficiency, can lead to early de-
of the knee, around the popliteus insertion site on the generative changes of the knee joint [8, 43]. There
femur, along the tendon and its attachment to the are three major static stabilizers, known as primary
muscle belly [16, 19, 38]. In some cases, symptoms can stabilizers of the PLC: the fibular (lateral) collateral
mimic the lateral meniscal tear. Sometimes, there may ligament, the popliteus tendon and the popliteofib-
be difficulty with walking on uneven ground or going ular ligament [26, 39]. In recent studies, the group
up and down stairs [8]. As stated above, the function of structures forming the PLC were extended and ac-
of the popliteal unit is to restrain the lateral femoral cording to these studies, the iliotibial tract, long and
condyle movements and maintain its relationship with short heads of the biceps femoris muscle, mid-third
lateral tibial plateau. The downhill running or walking lateral capsular ligament, fabellofibular ligament,
can exacerbate the pathology, causing increased stress also known as gastrocnemiofibular ligament, pop-
on popliteus musculotendinous unit [36]. Patients can liteofibular ligament, lateral meniscotibial ligament
run for short distances, but posterolateral knee pain and posterior capsule also form the PLC [20, 46]. LCL
can develop with continued running. In sports such as and PFL act as static stabilizers against varus stress
basketball, tennis, and running, the balance between and external tibial rotation during knee flexion below
the femur and the tibia may be impaired due to the 30°. Popliteus acts as a dynamic stabilizer against
development of quadriceps failure. In this case, the external rotation and posterior translation of the tibia
load on popliteus increases, and an injury may occur. [46]. The relationship between LCL and the insertion
of popliteus on the lateral femur condyle has been
COMPLEX POPLITEUS TRAUMA studied in detail [46]. LCL is usually inserted in the
AND PLC INJURY postero-distal slope of the apex of the lateral epicon-
On the other hand, high-energy trauma can cause dyle, while the popliteus is inserted to the anterior
acute haemarthrosis and lateral knee pain. Depend- end of the popliteal sulcus [46].

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DIAGNOSTICS high signal intensity changes due to oedema, or as

Tests that must be performed in evaluating PLC swollen disorganised muscle fibres with high signal
injuries and simultaneous popliteus injuries are: intensity changes within the popliteus muscle [19].
(1) varus stress test (in full extension: FCL, PLC and On the other hand, the avulsion of the head of the
cruciate ligament injury; in 20–30° of knee flexion: fibula (arcuate sign) may be an important indicator
FCL and potentially the secondary stabilizers of of posterolateral structures tear. This minor fractured
the PLC), (2) the dial test (conducted in 30 and 90° bone fragment is often associated with popliteofibu-
of knee flexion: an increase in the external tibial ro- lar and fabellofibular ligaments attachment rupture.
tation of more than 10° in 30° of flexion compared Moreover, it is an important clinical predictor of pos-
to the opposite knee suggests PLC injury and an terolateral instability and surgical outcomes [17].
increase in the external tibial rotation of more than
10° in 30 and 90° of flexion compared to the oppo- ANATOMICAL IMPLICATIONS
site knee suggests PLC and PCL injury), (3) reverse INTO TREATMENT
pivot shift test (valgus force is applied when the knee Regarding the extent of pathology, popliteus in-
is flexed at 90°, and the tibia is forced to external juries can be treated conservatively (grade-1–2 tears)
rotation, then the knee is slowly extended, if the or surgically (grade-3 tears and non-response to con-
subluxated lateral tibial plateau is reduced when the servative treatment after three months).
flexion is decreased to 35–40°, the test is positive), Non-operative treatment is usually recommend-
(4) the external rotation recurvatum test (the patient ed for grade-1 and -2 of popliteus injury with good
is in the supine position, knee joint extended, the clinical outcomes [8]. Minimal radiographic changes
great toe is grasped and the leg lifted from the table, at 8-year follow-up were found after conservative
while securing the femur to the table by applying gen- treatment with early mobilisation protocol [21].
tle pressure to the anterior distal femur, recurvatum Partial-thickness tendon or muscle tears can be
is measured by the amount of heel height in cm, test treated with open or minimally-invasive debridement
is performed bilaterally to compare) (Fig. 4) [8, 9]. [21]. The intraarticular part of the surgery can be done
If isolated popliteus pathology or complex PLC arthroscopically with favourable outcomes [4, 16,
lesion is suspected after medical interview and phys- 18]. However, in extra-articular cases, open surgery
ical examination, the proper radiological imaging can be necessary depending on the level of stumps
is necessary. Firstly, standard radiographic imaging retraction. In avulsion injuries, it is necessary to fix the
should be performed, including anteroposterior (AP), tendon the attachment site using a screw or anchor
lateral (LAT), and sunrise views of the knee [16]. Stress [7, 29, 31]. Isolated popliteus reconstruction can
radiographs are more sensitive for the diagnosis of be performed in PLC injuries with primary external
PLC injuries; however, taking these radiographs can be rotation instability pattern. Furthermore, early and
challenging due to pain in the acute phase of injury. aggressive treatment of grade-3 PLC injuries and
LaPrade et al. [25] showed that isolated FCL rup- surgical reconstruction improve long-term outcomes.
ture created an average of 2.7 mm gapping in the It prevents persistent instability, varus thrust, chronic
lateral joint space in the varus stress radiograph com- pain, and accelerated cartilage damage [39].
pared to the intact knee, and more than 4 mm gap- Doucet et al. [12] presented a clinical case of
ping was associated with grade-3 PLC injury. MRI is a patient with acute calcific tendinopathy of the
essential to assess concomitant injuries and to deter- popliteus tendon. On ultrasound imaging, hypoechoic
mine the exact location of the injured structures [24]. changes specific to tendinopathy and calcification
Standard MRI sequences are often sufficient to evalu- in the tendon were seen. The patient underwent ul-
ate complex knee injuries. Still, PLC structures can be trasound-guided glucocorticoid injection with good
better visualised using a coronal oblique plane view; clinical results.
however, one must be aware that PFL can be missed to Persistent instability and poor functional out-
the slice thickness. The popliteus musculotendinous comes were observed in grade-3 PLC injuries that
complex lesions are detected in 1% of all knee MRI were treated non-operatively [14]. Thus, several PLC
studies [19]. They may appear on MRI as an avulsion surgical reconstruction techniques were described in
of the femoral attachment, an irregular contour of the literature [8, 20, 27]. Better results are obtained
the tendon at the popliteal hiatus with surrounding when PLC injuries are repaired or reconstructed in the

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Figure 4. The varus stress test in full extension (A) and in

20–30° of knee flexion (B). The reverse pivot shift test with
the knee flexed to 90° (C) and slowly extended (D); E, F. The
external rotation recurvatum test; G. The dial test.

acute stage [41]. Shelbourne et al. [40] reported that significantly better outcome than a repair performed
repairing the PLC by 4 weeks post-injury resulted in between 4 to 6 weeks post-injury.

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