Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

Anatomy, Function, and Rehabilitation of the Popliteus Musculotendinous Complex

John Nyland, PT, EdD, SCS, ATC, FACSM 1 Narusha Lachman, PhD 2 Yavuz Kocabey, MD 3 Joseph Brosky, PT, MS, SCS 4 Remziye Altun, MD 5 David Caborn, MD 6

CLINICAL COMMENTARY

We present a clinical commentary of existing evidence regarding popliteus musculotendinous complex anatomy, biomechanics, muscle activation, and kinesthesia as they relate to functional knee joint rehabilitation. The popliteus appears to act as a dynamic guidance system for monitoring and controlling subtle transverse- and frontal-plane knee joint movements, controlling anterior-posterior lateral meniscus movement, unlocking and internally rotating the knee joint (tibia) during flexion initiation, assisting with 3-dimensional dynamic lower extremity postural stability during single-leg stance, preventing forward femoral dislocation on the tibia during flexed-knee stance, and providing for postural equilibrium adjustments during standing. These functions may be most important during mid-range knee flexion when capsuloligamentous structures are unable to function optimally. Because the popliteus musculotendinous complex has attachments that approximate the borders of both collateral ligaments, it has the potential for providing instantaneous 3-dimensional kinesthetic feedback of both medial and lateral tibiofemoral joint compartment function. Enhanced popliteus function as a kinesthetic knee joint monitor acting in synergy with dynamic hip muscular control of femoral internal rotation and adduction, and ankle subtalar muscular control of tibial abduction-external rotation or adductioninternal rotation, may help to prevent athletic knee joint injuries and facilitate recovery during rehabilitation by assisting the primary sagittal plane dynamic knee joint stabilization provided by the quadriceps femoris, hamstrings, and gastrocnemius. J Orthop Sports Phys Ther 2005;35:165179.

Key Words: knee, lateral meniscus, lower extremity

eight acceptance during walking commonly involves tibial internal rotation as the knee joint flexes.29,34,58 Concurrently, the knee joint generally undergoes a small but important amount of abduction.29,35 In conjunction with these kinematics the resultant line of force during walking is located primarily in the medial joint compart1 2

Assistant Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, KY; Frazier Rehabilitation Institute, Louisville, KY. Assistant Professor, Department of Human Biology, Tecnikon Natal, Durban, South Africa. 3 Research Fellow, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, KY. 4 Associate Professor, Bellarmine University, Louisville, KY. 5 Visiting Professor, Hospital of Sanliurfa, Sanliurfa, Turkey. 6 Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, KY. 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: john.nyland@louisville.edu Journal of Orthopaedic & Sports Physical Therapy

ment in the nonimpaired knee.18,44 Appropriate lateral meniscus orientation is essential to avoid impingement as the knee joint flexes and the tibia internally rotates during weight acceptance or as the knee joint extends and the tibia externally rotates during propulsion. Common weight-bearing mechanisms of noncontact posterolateral knee joint injury are either a direct varus force, while the tibia is externally rotated, or a sudden forced knee hyperextension with the tibia internally rotated.6,8,56 Clinical signs of posterolateral knee joint injury may be subtle and are often masked by the more extensive symptoms associated with anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) injury.31 Combined injury of the popliteus muscle-tendon complex (PMTC) and lateral (fibular) collateral ligament (LCL) results in serious posterolateral knee instability, which, if unrecognized, contributes to postsurgical cruciate ligament reconstruction failure or chronic knee instability.17,27,30,70 According to Last,32 popliteus activation primarily internally rotates the knee and its tendinous bands retract the posterior arch of the lateral meniscus. Lateral meniscus movement guidance by the
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ligaments of Humphrey and Wrisberg and the meniscal fibers of the popliteus helps to prevent meniscal injury.32 The PMTC contributes to both static and dynamic posterolateral knee joint stabilization.32,62,66 During concentric activation, the popliteus internally rotates the tibia on the femur. During eccentric activation, it serves as a secondary restraint to tibial external rotation on the femur.50 Higgins23 proposed that the popliteus either caused the tibia to internally rotate on the fixed femur or it assisted with femoral external rotation on the fixed tibia during weight bearing. Based on the work of Versalius,68 modeling techniques were used by Furst12 and Fuss13 to confirm that in the sagittal plane the popliteus muscle is not a knee flexor, but instead provides a small extensor function through the flexion-extension range of motion (only conceivably serving a flexor function at hyperextension angles of greater than or equal to 30) in addition to its transverse-plane role as a tibial internal rotator or a femoral external rotator. These findings suggest that the popliteus serves a more essential functional role in the transverse plane. Because knee joint injury frequently displays some component of transverse-plane rotation and the popliteus muscle has been described as an important, primary, dynamic, transverse-plane, rotatory knee joint stabilizer,1,2,32,50 improving our understanding of its function in relation to other posterolateral knee joint structures would be beneficial. The purpose of this clinical commentary is to summarize existing evidence regarding PMTC anatomy, biomechanics, muscle activation characteristics, and kinesthesia, and relate these findings to functional rehabilitation. Functional rehabilitation is operationally defined as the use of therapeutic exercises to simulate the weight-bearing and nonweight-bearing components of specific daily activities in a manner that replicates 3-dimensional lower extremity function within joint ranges and velocities that facilitate the desired physiological results (improved neuromuscular responsiveness and connective tissue integrity).

the medial tibiofemoral joint are suggestive of a primary compressive loading function.32,42,47 In contrast, the smaller lateral tibiofemoral joint has more ropelike primary capsuloligamentous structures, suggesting a predominant tensile loading function,18,44 and a highly mobile meniscus, suggesting the presence of more varied rotatory loads.32,42 The popliteus originates from the lateral femoral condyle near the LCL and inserts along the proximal 10 to 12 cm of the posteromedial tibial surface, forming the floor of the popliteal fossa. Some of its distal fibers are interconnected with fascial fibers attached to the distal region of the medial (tibial) collateral ligament (MCL). By attaching into their tendon at an angle oblique to the resultant line of pull, popliteus muscle fibers enable uniform force distribution over a greater area.2 Popliteus architecture assessments by Wickiewicz et al72 and Lieber,36 however, suggest that the ratio of cross-sectional area to muscle fiber length of the popliteus only enables force production over a relatively short distance. Higgins23 suggested that the horizontal groove created by the popliteus tendon along the lateral femoral condyle was formed by a bowstring effect from popliteus muscle activation during mid-range knee flexion. To appreciate how the PMTC (Figure 1), lateral meniscus, arcuate ligament, posterior capsule, and the ligaments of Wrisberg and Humphrey contribute to knee joint stability it is important to understand the intricacy of their attachments. Watanabe et al71 identified 7 variants for anatomic popliteus attach-

Popliteomeniscal fascicles

POPLITEUS ANATOMY AND BIOMECHANICS

During weight bearing, the tibiofemoral joint has distinctly differing functions at its medial and lateral compartments. The arthrological characteristics created by the longer and larger medial femoral condyle dictates a preeminence for compression load control, primarily during sagittal plane motion, while the shorter and smaller lateral femoral condyle dictates a preeminence for tensile load control, primarily from a transverse- and frontal-planemovement perspective.18,44 Both osseous and capsuloligamentous structures within each tibiofemoral joint compartment support these functions. Increased tibial size, generally flatter and broader shaped capsuloligamentous structures,18,32,47 and a less mobile, larger meniscus at
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Popliteus Tendon Muscle LCL

FIGURE 1. Popliteus muscle, tendon, and popliteomeniscal fascicles (LCL, lateral collateral ligament).
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Ligament of Wrisberg Popliteus tendon Lateral meniscus LCL PFL PCL Ligament of Humphrey MCL Medial meniscus

Popliteus

FIGURE 2. Popliteus musculotendinous complex (PMTC) and adjoining structures. (LCL, lateral collateral ligament; PFL, popliteofibular ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.)

femoral condyle and the lateral meniscus, 15 specimens (37.5%) had both an attachment to the lateral 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 individuals. At the popliteus musculotendinous junction there are 2 popliteofibular ligament (PFL) divisions that course laterally and distally, attaching on the posteromedial aspect of the fibular styloid (Figure 4). In addition to providing noncontractile restraint to tibial external rotation, the PFL serves as a pulley, helping to tether the tendon during popliteus activation.60 Fuss13 reported that the PFL is under maximum tension during flexion, possibly taking over the noncontractile knee joint stabilization function of the LCL, which is not taut in most flexion positions. During in vitro biomechanical testing, Maynard et al40 reported a maximum load at failure of approximately 425 N for the PFL compared to 750 N for the LCL. Because a mean force of greater than 400 N was needed to achieve PFL failure in cadaveric knees of individuals greater than 70 years of age, they concluded that it was an important noncontractile stabilizing structure. Krudwig et al28 reported that 50 N of PMTC tension produced increases of 4 to 5 of tibial internal rotation as the knee neared full extension and increases of up to 12 at 90 of knee flexion. During cyclic biomechanical testing following sequential PFL and LCL transection, they reported gradually

CLINICAL COMMENTARY

ments to the fibular head in addition to the primary popliteus tendon attachment to the proximal fifth of the popliteal sulcus of the lateral femoral condyle. The PMTC has major attachments to the lateral femoral condyle, the fibula, and the posterior horn of the lateral meniscus, and smaller attachments to the arcuate ligament complex, the oblique popliteal ligament, the ligaments of Wrisberg and Humphrey, and the PCL (Figure 2).25 Two or 3 (anteroinferior, posteroinferior, and posterosuperior) clearly delineated but highly variable popliteomeniscal fascicle attachments blend into the lateral meniscus to help control its motion (Figure 3).26,56,57,63,71 Variations in popliteomeniscal fascicular attachments are believed to reflect differences in embryonic knee joint development.23,71 Tria et al65 in a dissection of 40 cadaveric knees reported that 82.5% of the knees they evaluated failed to display any major attachment between the popliteus tendon and the lateral meniscus. They reported that only 7 specimens (17.5%) displayed a strong dual attachment to both the lateral
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Popliteomeniscal fascicles

FIGURE 3. Popliteomeniscal fascicles.

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PFL

Popliteus

Soleus

FIGURE 4. Popliteofibular ligament (PFL) divisions.

increased tibial external rotation and a lateral shift of the position of neutral tibial alignment.28 By additionally cutting the popliteus tendon, substantially greater external rotation and a more externally rotated neutral tibial rotation position were noted. Using 10 cadaveric knee specimens, Harner et al17 reported that the addition of a 44-N force to the popliteus muscle reduced PCL forces by 9% and 36% at 90 and 30 of knee flexion, respectively. Considering these results, progressive PCL deficiency should be anticipated, following isolated and untreated posterolateral capsuloligamentous, or PMTC injury. Krudwig et al28 suggested that isolated posterolateral capsuloligamentous injury should be reconstructed to protect the PCL from overstress. Veltri et al67 reported that cutting the PFL, after having cut the LCL with the popliteus tendon intact, produced only small additional external tibial rotation increases (0.9 versus 1.9). However, when the PFL was cut last, after the LCL and the popliteus tendon had been cut, 7 to 10 increases in tibial external rotation were reported. They concluded that both the popliteal tendon and the PFL were important to prevent excessive tibial external rotation and posterior translation.67 Shahane et al60 reported that isolated popliteus muscle sectioning did not cause significant posterolateral knee joint instability; however, PFL sectioning produced 3 and 9 increases in tibial external rotation at 60 and 90 of knee flexion, respectively, in addition to increased posterior translation. They concluded that the PFL was the primary noncontractile restraint to tibial external rotation and the LCL was the secondary restraint. Recently, Pasque et al50 suggested that the order of tissue transection influenced the results reported by Shahane et al.60 When controlling for cutting order, Pasque et al50 reported that isolated PFL sectioning did not produce increased tibial external rotation
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between 30 and 12 of knee flexion, while isolated PFL sectioning and sectioning of the femoral attachment of the popliteus tendon produced a small (5-6) increase in external rotation in that same range (30-12) of knee flexion. Even when the other ligamentous structures were cut first, cutting the PFL produced only negligible tibial external rotation increases. Pasque et al50 emphasized that because the orientation of each noncontractile, posterolateral capsuloligamentous knee joint component changes with progressive flexion, the PMTC, LCL, and other posterolateral structures must function together as a 3-dimensional load-sharing unit to resist tibial external rotation and varus loading. In a similar biomechanical study that controlled for the order of tissue cutting, Gollehon et al15 reported that the LCL and the popliteus-arcuate ligament complex functioned together as the principal noncontractile structures that prevent tibial varus and external rotation at all knee flexion angles. Nielsen et al46 reported that the LCL and the posterolateral part of the knee joint capsule resisted tibial varus and external rotation, with the former having a greater role preventing tibial varus and the later having a greater role preventing excessive tibial external rotation. During the initial 30 of knee flexion, the LCL provides a greater contribution to resisting tibial varus and the PMTC provides a greater contribution to resisting tibial external rotation and posterior translation.45 As the posterolateral knee joint capsule slackens with increasing knee flexion, it contributes less to resisting tibial external rotation (transverse plane), varus rotation (frontal plane), and posterior translation. Nielsen et al45 also reported that the popliteal tendon provided maximal resistance to excessive tibial external rotation between 20 and 130 of knee flexion and to excessive tibial varus rotation between 0 and 90 of knee flexion. Due to the influence of knee joint angle on capsuloligamentous tightness, the contractile component of the PMTC subsumes a greater dynamic responsibility for providing knee joint stability as knee flexion angles increase. Pasque et al50 recommended that surgical inter ventions should address each of these posterolateral capsuloligamentous structures individually because the absence of load sharing between all components may lead to residual instability and unacceptably high loads. Wang et al70 and others43 have reported that current popliteus tendon surgical techniques tend to restore only static or noncontractile function. Ideally, surgical PMTC repair should produce improved dynamic function in addition to a slight tenodesis effect on adjacent capsuloligamentous tissues. Improving our understanding of PMTC function may aid the development of knee injury prevention conditioning programs and functional rehabilitation approaches for patients who display posterolateral knee
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joint instability either in isolation or in combination with cruciate ligament injury.

POPLITEUS MUSCLE FUNCTION

Electromyographic study of popliteus activation requires the use of intramuscular electrodes. This section will review electromyographic investigations performed during nonweight-bearing and weightbearing activities. The use of categorical popliteus activity grading in 2 of these studies2,39 and the limited use,2,39 or absence,1,10,55 of concurrent kinematic assessment in many of these studies makes it difficult to derive definitive conclusions.

Activation During Non-Weight Bearing

In testing right-side popliteus activity in combination with electrogoniometric measurements, Basmajian and Lovejoy2 reported popliteus activation levels during isometric knee extensor or flexor activation at differing knee flexion angles (0, 5, 20, 45, and 60), with the tibia either in full internal rotation, full external rotation, or in neutral alignment. Popliteus activation levels were reported as a percentage of the maximal values produced by each subject during testing. During seated isometric knee extension with the tibia maintained in full internal rotation, the greatest popliteus muscle activation levels were observed between 60 and 20 of knee flexion, and decreased as full extension was reached. With subjects positioned in prone, beginning with the knee in full extension, popliteus activation markedly increased over the initial 20 of knee flexion when the lower leg was maintained in a full internal rotation position. Activation levels gradually decreased as 90 of knee flexion was reached.2 During both knee extension and flexion isometric contraction, popliteus activation remained constant with low amplitudes when tested with the tibia in full external rotation positions.2 Mann and Hagy39 categorized popliteus activity collected in synchrony with a motion picture, using a 1-to-4 categorical rating scale (1, slight; 2, moderate; 3, marked; 4, very marked). In their study, subjects performed a series of 6 tasks in a consistent order: (1) internal and external lower leg rotation in sitting, (2) seated knee extension and flexion with neutral lower leg rotation, (3) internal and external lower extremity rotation of the nonweight-bearing, lower extremity with the knee extended during contralateral stance on a small box, (4) internal and external lower extremity rotation of the weightbearing lower extremity with the knee extended during unilateral stance, (5) squatting, and (6) normal pace walking, followed by walking with internally or externally rotated lower legs.39 They reported 4+ popliteus activity during seated, nonweight-bearing lower-leg internal rotation, and trace activity with
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external rotation. During seated nonweight-bearing flexion/extension, 4+ popliteus activity was reached only near full extension. During unilateral stance, 4+ popliteus activation amplitudes were also observed for the nonweight-bearing lower extremity during internal rotation of the lower extremity with the knee extended.39 Repeated studies using quantitative intramuscular electromyographic techniques and concurrent segmental 3-dimensional kinematic and kinetic assessments are needed during the performance of functionally relevant tasks. In evaluating 4 patients with anterolateral knee rotatory instability, Peterson et al53 reported increased popliteus activity during volitional knee joint pivot shift tests. In evaluating the popliteus activity of 10 patients with posterolateral knee instability, who were capable of volitional tibial subluxation, Shino et al61 reported that the biceps femoris muscle created the major tibiofemoral joint subluxation force and the popliteus created the major joint reduction force. They concluded that popliteus activation was the dynamic key to the treatment of posterolateral knee joint instability.

CLINICAL COMMENTARY

Activation During Weight Bearing

In a detailed biomechanical analysis of transverseplane knee joint muscle moment arms, using 17 cadaveric hemipelvis specimens, Buford et al3 identified a mechanical advantage for tibial external rotators over internal rotators throughout the flexionextension range of motion. The external rotation moment arms of the long and short heads of biceps femoris peaked near full external rotation. The moment arms for tibial internal rotators, the semimembranosus and semitendinosus, peaked near 10 of internal rotation, while the gracilis and sartorius moment arms remained constant throughout the internal-external rotation range of motion. As a tibial internal rotator, the popliteus displayed a small moment arm that peaked near neutral transverse-plane alignment. All other transverse-plane tibial rotators displayed maximum moment arm lengths with the knee flexed 70 to 90. In contrast, the popliteus displayed its maximum moment arm at 30 to 50 of flexion, essentially when the LCL, PFL, and ITB14 were no longer capable of providing optimal noncontractile knee joint postural control. Using intramuscular electrodes, Prado Reis and Ferraz de Carvalho55 reported that the popliteus was most active during standing, when the ACL and PCL became uncrossed and relaxed during relative internal tibial rotation, and particularly with the knee flexed between 30 and 50. This relaxed cruciate ligament position brings the knee joint to a critical point of poor noncontractile tissue contributions to joint stability. At this interval, popliteus muscle activation serves as a dynamic knee joint guidance substitute for the action of crossed and tensed cruciate
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ligaments. A 30 to 50 knee joint flexion alignment correlates with the position commonly assumed with sudden stopping during running and cutting activities.33,37,48 Barnett and Richardson1 observed consistent popliteus activation when subjects assumed a crouching or knee-bent standing posture. This activation was believed to assist the PCL with preventing anterior femoral dislocation on the fixed tibia. Similar activation was not noted during standing on extended knees when dislocation was not threatening the joint.1 Del Torto10 observed that the popliteus displayed 2 primary activation phases during walking and stair climbing: (1) to produce tibial internal rotation during swing phase (a concentric action), and (2) to brake or halt tibial external rotation during stance phase (an eccentric action). With subjects in standing with their knees completely extended, and then with their knees flexed to 30, Basmajian and Lovejoy2 reported constant right-side popliteus muscle activation when subjects rotated their right shoulder anteriorly (presumably rotating their body to the left), regardless of whether the feet were in a neutral, toed-in, or toed-out alignment. When the left shoulder was rotated anteriorly (presumably rotating the body to the right), with the feet positioned in a toed-out alignment, right-side popliteus activity increased. With the feet in neutral or toed-in alignment, right-side popliteus activity levels were greatest with the subjects knees flexed. Right-side popliteus activity levels were consistently greater during left-shoulder rotation than during right-shoulder rotation, with the feet in the same positions. Using a 1-to-4 categorical rating of left-side popliteus activity, Prado Reis and Ferraz de Carvalho55 reported increased popliteus activity when subjects performed anterior-posterior weight shifting, or when they experienced loss of standing balance. Prado Reis and Ferraz de Carvalho55 confirmed the findings of Basmajian and Lovejoy2 with increased popliteus activation when the trunk was rotated toward the side of the examined muscle during standing, particularly when the femur tended to externally rotate while the tibia was maintained in internal rotation. This movement created a composite internal rotation of the lower leg at the knee joint,2 presumably with concentric popliteus muscle activation. Mann and Hagy39 reported that, during unilateral stance with the knee extended, 4+ popliteus activation amplitudes were observed at the weightbearing lower extremity during external trunk rotation and medial hip rotation.39 With internal trunk rotation and lateral hip rotation, 2+ popliteus activity was observed during unilateral stance at the weightbearing extremity at maximum rotation.39 Squatting down and returning to an upright position produced 3+ popliteus activity during the entire movement cycle.
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During level walking at 1.2 to 3.2 km/h, with normal, toed-in, or toed-out gait patterns, Basmajian and Lovejoy2 reported that popliteus activity was greatest at heel contact, and between foot-flat and toe-off, regardless of gait pattern. Mann and Hagy39 reported greatest popliteus activity during the early part of stance phase (0%-12%), presumably as a response to increased subtalar joint forces as the tibia internally rotated on the femur, and at the end of swing phase. Perry52 reported that popliteus activation occurs during all walking gait-cycle phases, except during initial swing and midswing, with considerable variability between subjects. The largest amplitude popliteus activity she reported, based on percentage of maximal manual muscle test values, occurred during terminal swing, the loading response, and preswing.52 The variability in popliteus activation levels reported by Perry52 suggests that a primarily sagittal plane locomotion pattern performed at walking velocity may not provide the most relevant environment for studying a muscle that conceivably displays greater importance during movements that challenge frontal- and transverse-plane knee joint function. In combining electromyographic and kinematic techniques during level and downhill walking, with and without an 18.14-kg (40-lb) backpack, Davis et al7 reported more than doubled popliteus activity at midstance with only a slight increase in knee flexion during weighted downhill (23.5) walking compared to level (16.5) walking. Increased popliteus activity at midstance during weighted downhill walking was believed to be in response to increased weight bearing on a flexed knee.7 The finding of Davis et al7 that popliteus displayed considerable activation during midstance with weighted downhill walking, as compared to standing or level walking, suggests that it may also be considerably active during the forceful loads associated with other activities, such as running downhill. Considering the findings of Buford et al,3 because the popliteus muscle displays a maximum transverseplane moment arm at 30 to 50 of knee flexion when noncontractile knee joint stabilizers do not provide optimal knee joint postural control, it may also serve an important function during the performance of athletic movements, such as running directional changes. Given the coupled movement of tibial external rotation/posterior translation and tibial internal rotation/anterior translation,11 the popliteus is ideally positioned to assist with 3-dimensional dynamic knee joint control by monitoring and controlling tibial external rotation and, consequently, posterior translation during eccentric function (thereby protecting the PCL), and by producing tibial internal rotation and posterior translation during concentric function (thereby protecting the ACL).
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TABLE 1. Absolute and relative muscle spindle density of select lower extremity musculature.69

CLINICAL COMMENTARY

Muscle Spindles/Muscle Weight (g) Direct tibial internal rotators Semimembranosus Semitendinosus Sartorius Gracilis Tibial internal rotators via the subtalar joint Extensor digitorum longus Fibularis (peroneus) longus Fibularis (peroneus) brevis Tibial external rotators via the subtalar joint Tibialis anterior Tibialis posterior Flexor hallucis longus Flexor digitorum longus Extensor hallucis longus Soleus (medial calcaneal insertion) Knee extensors Vastus medialis Vastus intermedius Vastus lateralis Rectus femoris Femoral external rotators Gluteus maximus Gemellus inferior Gemellus superior Piriformis Quadratus femoris Sartorius 0.60 1.40 1.20 1.50 3.73 1.88 3.37 2.02 1.64 1.70 2.94 3.73 0.94 0.80 0.90 0.70 0.90 0.80 3.40 3.90 3.50 1.90 1.20

Composite Relative MuscleSpindleDensity Ratio (Popliteus:Functional Muscle Group) 7.85:1.18

7.85:2.99

7.85:2.16

7.85:0.83

7.85:2.45

MUSCULOTENDINOUS KINESTHESIA
The term musculotendinous kinesthesia refers to the capacity for musculotendinous structures to contribute to proprioception through the activation of muscle spindles and golgi tendon organs. Because the PMTC has connective tissue attachments that approximate the borders of both the MCL and LCL, it is ideally positioned for providing instantaneous 3-dimensional kinesthetic feedback, helping to monitor medial and lateral tibiofemoral joint compartment function. For example, during a running directional change excessive MCL tensile stress and increased lateral tibiofemoral compartment compression may produce immediate PMTC activation to facilitate tibiofemoral joint internal rotation and maneuver the lateral meniscus to a functionally effective and protected position. Concurrently, eccentric popliteus activation during excessive LCL tensile stresses and increased medial compartment compression associated with knee flexion and internal rotation at the end of weight acceptance during gait may provide the primary kinesthetic cues to the central nervous system (CNS) to facilitate a knee joint extensor/external rotation response to prevent knee joint injury.
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Based on the extensive work of Voss,69 Peck et al51 proposed that in the extremities, smaller muscles with high muscle spindle concentrations, arranged in parallel with larger, less spindle-dense muscles, function primarily as kinesthetic monitors. The example they cited was a 3.71:0.67 relative muscle-spindle density ratio (RMSD) (muscle spindles per gram of muscle weight) between the human plantaris and the triceps surae muscles. Comparisons between the popliteus muscle and other muscles that provide at least 1 of its functions (tibial internal rotation, modulation of tibial external rotation via eccentric activation, femoral external rotation, knee extension) are presented in Table 1. With consideration for these muscle spindle densities in combination, a preeminent sensory feedback role is suggested for the popliteus to provide kinesthetic feedback to the CNS during transverse-plane knee joint movements.51,69 A predominant kinesthetic function for the popliteus is supported by several comparative basic science studies.16,41,54 In a muscle spindle study of the cat knee joint, McIntyre et al41 confirmed the presence of slowly adapting popliteus muscle spindles that discharged tonically when the knee joint was positioned in intermediate flexed positions or during
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passive tibial external rotation. They suggested that kinesthesia provided by popliteus muscle spindles compensated for the comparative paucity of capsuloligamentous joint mechanoreceptors that could be activated at intermediate knee joint flexion angles due to reduced capsuloligamentous tension.41 Using a cat knee joint model, Grillner16 suggested that a primary role of kinesthetic lower extremity musculotendinous input during locomotion is, for motor control purposes, making subsequent phases of repetitive, successive movement cycles more efficient through the spinal interneuron modulation of synergistic muscle function and interlimb coordination. However, Grillner16 reported that built-in viscoelastic neuromuscular control mechanisms within individual muscles also provide instantaneous stiffness regulation with considerable precision following sudden stretching. From this observation they surmised that these viscoelastic responses might be of greater relevance to injury prevention than the motor control program changes that eventually occur in association with kinesthetic musculotendinous input to the CNS. Due to the time lags required for neuromuscular impulse initiation, conduction, and electromechanical coupling,16 kinesthetic input must serve a greater role during later motor program adjustments than for immediate, dynamic 3-dimensional joint control purposes. A muscle-fibertyping study has also provided support for the role of the popliteus in providing instantaneous stiffness regulation across both tonic and phasic activation conditions. Pierrynowski and Morrison54 estimated that the human popliteus had 50% slow oxidative, 15% fast oxidative glycolytic, and 35% fast glycolytic muscle fibers. This fiber distribution supports both tonic regulatory postural control and phasic suddenposition-change functions. In contrast, they estimated that the adjacent human soleus consisted of approximately 75% slow oxidative, 17% fast oxidative glycolytic, and 10% fast glycolytic muscle fibers, suggesting a more tonic, postural regulatory-control function.

FIGURE 5. Sudden, running, stop-directional change.

FUNCTIONAL REHABILITATION AND THE PMTC

Levens et al34 reported that composite pelvic, femoral, and tibial internal rotation occurs between the early walking stance phase and full weight bearing, and composite external rotation of the same structures occurs between full weight bearing and the terminal stance phase. Mann and Hagy39 agreed that during gait the entire distal segment of the body, including the pelvis, femur, and tibia, begins to internally rotate following toe-off and continues to internally rotate through the swing phase, ceasing at foot flat (12% of the gait cycle). External rotation of the pelvis, femur, and tibia begins thereafter. Anatomically, transverse-plane knee joint rotation is a combination of long-axis tibial and femoral rota172

tions. During sudden running directional changes, the supporting tibia is relatively fixed, compared to the femur, usually with the help of a rubber-soled or cleated shoe; therefore, the tibia cannot effectively undergo transverse-plane rotation on the femur, so the femur must rotate on the tibia (Figure 5).62 Levens et al34 and Reischl et al58 evaluated the transverse-plane biomechanical relationships between the foot, tibia, and femur during walking, and reported considerable femoral rotation variability among subjects during early stance phase, with some displaying external femoral rotation and others displaying internal rotation. Heiderscheit et al19,20 reported similar disparities during running. Tiberio,64 in agreeing with Levens et al,34 suggested that relative knee joint internal rotation could be accomplished, even when tibial internal rotation was blocked or delayed, by increased femoral external rotation. Levens et al34 surmised that these lower extremity rotations appeared to be absorbed in the articulations of the foot and their related ligamentous structures. The femoral rotation variability reported by Reischl et al,58 Tiberio,64 Heiderscheit et al,19,20 and Levens et al34 may partially expose the influences of variable lower extremity postural alignment49,59 on long-axis tibial and femoral rotation and associated popliteus function. Conceivably, when the tibia is relatively fixed and the femur is in the same relative starting position, subjects with increased external tibial torsion may require increased femoral external rotation to achieve relative knee joint internal rotation during stance phase. In contrast, subjects with increased internal tibial torsion may be able to attain the same transverse-plane functional endpoint during stance phase, with less femoral external rotation or even internal rotation. Transverse-plane internal femoral
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rotation and external tibial rotation, and frontalplane hip joint adduction and knee joint abduction are associated with genu valgus. Transverse-plane 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 abductor (gluteus medius) and adductor musculature may also influence knee joint position. From this perspective, there may be considerable normal variability in how subjects of differing lower extremity postural alignments achieve 3-dimensional dynamic lower extremity postural stability during the performance of functional movements, particularly during sudden, single lower extremity loading. The key should be to 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, reported that, in general, hip internal rotation moment arms increased and hip external rotation moment arms decreased with increasing hip flexion. The gluteus maximus had the greatest capacity for providing a hip external rotation moment, particularly for the posterior fibers up to approximately 50 of hip flexion.9 This finding suggests the need for further study of the capacity for training the hip extensor and external rotator musculature (particularly gluteus maximus) in synergy with knee and ankle joint musculature to facilitate enhanced long-axis femoral and tibial motion control during athletic movements. Synergistic gluteus maximus (sagittal- and transverseplane) and gluteus medius (frontal-plane) function during single lower extremity loading, as previously described, may be essential to attaining effective 3-dimensional dynamic lower extremity postural stability when quadriceps femoris and hamstring muscle group function is suboptimal due to excessive genu valgus. In designing exercises to improve 3-dimensional dynamic lower extremity postural stability, the clinician should consider postural differences between patients, common, single, lower extremity loading pathomechanics, hip, knee, and ankle joint positions for optimal muscle moment arm lengths, the interplay between global and local proprioceptive mechanisms, and the concept of rehabilitating movements that facilitate the development of synergistic lower extremity muscle function. Considering the role of the PMTC as a kinesthetic monitor, we provide a progressive functional rehabilitation strategy to improve integrated 3-dimensional dynamic lower extremity postural stability.
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FIGURE 6. (A) Initiation of popliteus musculotendinous complex (PMTC) exercise with resistance band attached to the forefoot of the nonweight-bearing lower extremity. (B) The foot on the non weight-bearing side moves behind the stance lower extremity via ipsilateral hip external rotation and knee flexion. (C) The foot on the nonweight-bearing side continues to move behind the stance lower extremity with increasing internal tibial rotation. (D) Completion of the concentric muscle action phase of the PMTC exercise. Return to start position provides eccentric muscle action.
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We suggest a multiplanar task progression that provides a PMTC training stimulus during both integrated nonweight-bearing and weight-bearing lower extremity function. An example of a non weight-bearing exercise is standing in unilateral knee flexion, in conjunction with tibial internal rotation and hip external rotation, performed either actively or with a resistive band (Figure 6A-D). To make efficient use of elastic resistance, quick concentric activation should be followed by a slower eccentric activation. For weight-bearing exercises we have the patient begin with 1 foot positioned on a 5.1- to 15.2-cm (2to 6-in) step with skidproof surfaces (creating approximately 20 to 40 knee flexion at the stance leg), the patient performs a series of stepping tasks. The task is initiated by moving the lower extremity that is off of the step forward (Figure 7A) to a

FIGURE 7. (A) Initiation of stepping task on a 5.1-cm (2-in) step with the nonweight-bearing lower extremity actively rotated posterior and lateral to the stance lower extremity. (B) First of 3 successive quick loading-unloading steps (crossover diagonal). (C) Return to begin push-off for the next quick loading-unloading step. (D) Second of 3 successive quick loading-unloading steps (forward). (E) Last of 3 successive quick loading-unloading steps (side diagonal).
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crossover foot plant position to the right (crossover diagonal) (Figure 7B). After quickly returning to the starting position (Figure 7C), the next forward movement ends with the foot planted straight ahead (Figure 7D). After returning to the starting position, the final forward movement in 1 standard cycle, places the foot to the left (side diagonal) (Figure 7E). Following completion of this series, the lower extremities should switch positions. Conceivably, the on-step lower extremity functions in a manner similar to that of athletic movement stance phase, particularly at midstance, while the off-step lower extremity experiences sudden loads that replicate initial and terminal stance phase transitions, leading into swing phase. Task speed can be progressively increased and spontaneous responses can be achieved by having the patient respond to random cues to direct the plant foot to the right, straight ahead, or to the left. Concurrent use of different size and weight balls for catching and tossing may increase task specificity and serve as a distractor to better assess the patients true ability to maintain appropriate, well-controlled, 3-dimensional dynamic lower extremity postural stability. Visual denial using a blindfold may also be useful to further challenge these capabilities. When the patient is able to maintain a level pelvis with minimal trunk lean and hip adduction (frontal plane), and controlled femoral and tibial rotation (transverse plane) within mid-range hip and knee flexion (sagittal plane) suggestive of adequate 3-dimensional dynamic lower extremity postural stability on the step, the same progression can be performed using variable-sized unstable surfaces (Figure 8). The final component of this task series uses a series of 3 cones and a zig-zag hopping progression. While standing to the side of the first cone (Figure 9A), the patient hops off 1 foot (example of involved right side) and either lands on the opposite foot for a concentric muscle activation bias (Figure 9B) or on the same foot (Figure 9C) for a concentric to eccentric muscle activation bias (sudden stop). To emphasize stretch-shortening cycle function, the concentric-eccentric muscle activation bias movement can be followed by a quick hop to the opposite side, landing on the same foot (Figure 9D). The final phase of this movement involves the performance of a series of 3 hops using alternating lower extremities followed by a series of 3 hops using the same lower extremity (Figure 9E) to further challenge the stretch-shortening cycle. Both the patient and the clinician critique the appropriateness of 3-dimensional dynamic lower extremity postural stability during both tasks, but especially during the hopping task. An example of qualitative criteria basedon frontal- and sagittal-plane observation38 of single- or double-leg hop performance by the clinician is presented in Table 2. Information gathered
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No studies to date have evaluated the influence of knee joint postural alignment on popliteus activity or 3-dimensional knee joint kinematics during weightbearing 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 alignment.18,44 Femoral external rotation during early stance phase (among individuals with a genu varus/ internal tibial torsion) and via femoral internal rotation (among individuals with a genu valgus/external tibial torsion) may enable more effective maintenance of naturally balanced knee joint capsuloligamentous and popliteus musculotendinous length-tension relationships. These examples represent opposite ends of a postural continuum that may

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FIGURE 8. Stepping task performed on an unstable surface (Dyna Disc; Exertools Inc, Novato, CA).

from this type of assessment can be used as (1) an injury prevention screening tool, (2) to identify functional movement deficiencies early in rehabilitation, and (3) to record the patients performance behavior at the end of the intervention. As with the stepping task, verbal or visual cues can be used to add spontaneity to the activity (including sudden stopping-starting and retromovements) to further challenge 3-dimensional dynamic lower extremity postural stability.
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FIGURE 9. (A) Starting position for the single-leg hopping task (to begin on either right or left foot following cue). (B) Contralateral (left foot, noninvolved side) landing following right (involved) lower extremity quick diagonal hop (right lower extremity concentric muscle action bias). (C) Ipsilateral (right foot, involved side) landing from right (involved) lower extremity quick diagonal hop (right lower extremity eccentric muscle action bias). Progression from this movement occurs in Figure 9D. (D) Right foot (involved side) quick diagonal hop to ipsilateral landing (stretch-shortening cycle bias). (E) Completion of series of 3 consecutive right lower extremity quick diagonal hops beginning with initial right (involved) foot take-off.
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TABLE 2. Sample qualitative scoring form to grade frontal and sagittal plane body alignment during single- or double-leg hop or jump landings. Frontal Plane Eye and Head Alignment Head centered, eyes looking forward 2 Well centered trunk 2 Symmetrical with slight, controlled arm-swing (abduction), with low guard 2 Symmetrical with alignment over feet without excessive adduction or abduction during controlled, soft landing 2 Symmetrical alignment over feet without visible wobble or sway during controlled, soft landing Head to one side, eyes looking forward 1 Slight trunk lean during landing 1 Symmetrical with moderate, controlled arm-swing (abduction), with low guard 1 Symmetrical with moderate adduction or abduction during controlled, soft landing Head to one side, eyes looking down at feet 0 Excessive trunk lean during landing 0 Arm Alignment Asymmetrical with poorly controlled arm swing (abduction) with high guard 0 Asymmetrical adduction or abduction, knees touch or flare outward (extreme coxa varus or valgus) during a poorly controlled landing 0 Asymmetrical abduction or adduction, knees touch or flare outward (extreme genu valgus or varus) noted during a poorly controlled landing 0 Asymmetrical with one or both feet, extremely toed out or toed in, or a secondary hop during a poorly controlled landing 0 /12 Symmetrical with slight, controlled arm-swing (flexion) with low guard 2 Symmetrical with moderate hip flexion during controlled soft landing Symmetrical with moderate controlled arm-swing (flexion) with low guard 1 Symmetrical with excessive hip flexion during controlled soft landing Asymmetrical with poorly controlled arm-swing (flexion) with high guard 0 Asymmetrical or with excessive or minimal hip flexion during poorly controlled landing Head up, eyes look- Head slightly down, Head down, eyes ing forward eyes looking down looking down at feet at feet 2 1 0 Slightly flexed, chest over knees 2 Excessively flexed, collapse with landing 1 Extended, not using hip extensors 0 Sagittal Plane

Trunk Alignment

Hip-Thigh Alignment

1 Symmetrical abduction or adduction, slight wobble or sway during controlled, soft landing

2 Symmetrical with moderate knee flexion during controlled soft landing

1 Symmetrical with excessive knee flexion during controlled soft landing

0 Asymmetrical or with excessive or minimal knee flexion during poorly controlled landing

Knee-Leg Alignment

2 Symmetrical with feet aligned with toes pointing forward or slightly toed out during controlled, soft landing 2

1 Symmetrical with feet moderately toed out or toed in during controlled, soft landing 1 Total Frontal Plane Score =

2 Symmetrical with moderate ankle dorsiflexion during controlled soft landing 2 Total Sagittal Plane Score = /24 = %

1 Symmetrical with excessive ankle dorsiflexion during controlled soft landing 1 /12

0 Asymmetrical or with excessive or minimal ankle dorsiflexion during poorly controlled landing 0

Ankle-Foot Alignment

Overall Qualitative Jump Landing Score =

substantially affect a patients capacity for performing certain athletic movements. Fortunately, more subtle representations predominate, better enabling the clinician to effectively facilitate safer athletic movement patterns. Performance variability among patients is to be expected, necessitating that the
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clinician assist the patient to achieve his or her own individualized level of optimal 3-dimensional dynamic lower extremity postural stability. Females more commonly display genu valgus/ external tibial torsion, coxa varus/adduction, and genu recurvatum postural alignments than males,37,49
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conceptually necessitating more frequent compensatory femoral internal rotation to maintain appropriately balanced knee joint capsuloligamentous tension. Although either gender may be affected by the influence of knee joint postural alignment, hormonal changes,73 a narrower femoral notch,5 more frequent 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 posture during jump landings24,33 and cutting37 suggest that females would be more notably affected than males, possibly predisposing them to greater 3-dimensional dynamic lower extremity postural stability difficulties during intense athletic maneuvers. Reports suggest that improving dynamic transverseand frontal-plane hip joint control over long-axis femoral internal rotation and adduction,3,9 and ankle-subtalar joint control over long-axis tibial abduction-external rotation or adduction-internal rotation at the knee joint1,2,7,11,39,55 may help prevent knee joint injuries by assisting the primary sagittal plane dynamic knee joint stabilization provided by the quadriceps femoris and hamstrings. These concepts should serve as vital components of lower extremity functional rehabilitation programs and the evaluation of patients prior to their return to athletic endeavors. Prospective studies of injury prevention training programs using wobble boards4 and jump landing biomechanical training21 have displayed encouraging results. However, these training methods alone may not provide the frontal- and transverseplane lower extremity loading challenges and the reaction time spontaneity needed to progressively and comprehensively train 3-dimensional dynamic lower extremity postural stability in preparation for athletic movements that require sudden directional changes.

unable to function optimally. The anatomic location, biomechanic function, muscle activation, and kinesthesia characteristics of the PMTC suggest that it warrants greater attention during the design and implementation of lower extremity injury prevention and functional rehabilitation programs.

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ACKNOWLEDGMENT
The authors thank Dr Robert Acland at the University of Louisville Fresh Tissue Dissection Laboratory for his assistance with this project. We also thank Kim Caborn, PT, MS, ATC for reviewing the manuscript.

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CONCLUSION
Previous studies have led to an improved understanding of the PMTC functioning as a kinesthetic monitor and controller of anterior-posterior lateral meniscus movement32 for unlocking and internally rotating the knee joint during flexion initiation1,2,10,55 and for balance or postural control during single-leg stance.1,2,10,55 Increased popliteus activity during tibial internal rotation under nonweight-bearing isometric and dynamic conditions, and during weight bearing with concomitant transverse-plane femoral and tibial rotation, lend support to the theory that it withdraws and protects the lateral meniscus, prevents forward dislocation of the femur on the tibia, and provides an equilibrium adjustment function. In conjunction with quadriceps femoris, hamstring, and gastrocnemius activation, and with synergistic hip and subtalar joint musculature activation to control long-axis femoral and tibial rotation, popliteus activation may be most essential during movements performed in mid-range knee flexion when capsuloligamentous structures are
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