Popliteal pain/posterior knee pain

[ugandanphys]

Hi all

I have a patient coming to me at the moment - female 20 years, hockey player. She was referred to me by sports GP with MCL sprain. After doing quick knee ligamentous assesment, she did appear to be MCL sprain, so I didn't continue to examine too much more - note to self dont ever rush assessment, or take referral as true! - however she was complaining of pain in posterior / popliteal fossa especially on full squat. Because she had some minor swelling I was presuming she was restricted by this at full squat and didnt investigate much more.

However after coming 2 more times since then I'm beginning to think she has a popliteal tendonitis. Her pain is mostly posterior. Symptoms are:

Pain into full extension, very end of range, posteriorly
Weak IRQ
Weak Hams through all ranges.
Tender on palpation popliteal muscle, however there are so many bursa around here I'm wondering what exactly I'm on.
Biomechanically she has femoral internal rotation, overpronates slightly on squatting, more so on her affected side.
Calf ok
Tender all through her medial quad / adductors

Treatment so far has been rest for aggravating acctivities all the usual precautions etc. I'm getting her to strengthen IRQ / hams / increase flexibility in tissues - hams adductors -

SHould I be going down the orthotic for anti - pronation road?
How do I diffentiate between this and bursitis?
How can I be sure its popliteal? I find the flex knee resisted external rotation very tricky to be sure I have it right?

Many thanks!

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[physiofixme]

What was her cause of injury?? When does she experience pain. I'd explore pes anserinus bursitis or medial meniscus depending on cause of injury and aggravating factors.
Additional Comment I forgot:
Actually I've just re-read your post and realise her pain is mostly posterior so flag the pes anserinus bursitis. continue with popliteal tenonitis but explore medial meniscus also medial gastroc upper attachment.

[Sports_Rx]

Pain on a deep squat is usually a good test for popliteus involvement.

Have you done popliteal testing? Pt prone with knee fully extended. MR tibia and ask pt to flex knee against resistance.

What's end feel like? With pop probs there will be a harder end feel in passive extn.

[physiofixme]

pain on deep squat could also be meniscus. I'd look at "duck walk" If they can do this then it's unlikely to be meniscus. Do McMurrays test also to rule out meniscus. Do the resisted tests suggested below to confirm if it's popliteus.

Cause of injury may also give clues as to whether it's meniscus or popliteus.

[ugandanphys]

Thanks everyone - definitely not meniscus. If it is popliteus, what line of treatment should I be following?

[BobbySports]

Hi,

I'm a student and I have a friend who I believe has a popliteus injury & would also love some suggestions on a treatment plan for this patient.

Much appriciated



Bobby.

[kimsoccer03]

Treatment: The best way to treat increased tone in the popliteus is through direct hands-on massage and ischaemic pressure. The popliteus is a very difficult muscle to stretch and will respond a lot better to hands-on treatment.

Direct massage is best done with the knee slightly flexed, as mentioned above. The bulk of the muscle belly lies in the postero-medial part of the knee under the medial gastrocnemius. Flush massage from medial to lateral tends to work best.

Direct pressure therapy is also best done with the knee slightly flexed. This will feel very uncomfortable to the patient and the therapist must be very wary of excessive pressure in the popliteal fossa, as some important nerves and blood vessels course through and down between gastrocnemius.

The above was taken from a web page (I'm not able to post links yet).

[roycar]

is there a mechanism of injury here anywhere?

hard to hypothesise without one.