Journal of Orthopaedic & Sports Physical Therapy

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

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CLINICAL COMMENTARY
Anatomy, Function, and Rehabilitation of
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complex anatomy, biomechanics, muscle activation, and kinesthesia as they relate to functional knee.18,44 Appropriate lateral me-
kneePhone
joint rehabilitation. The popliteus appears to act as a dynamic guidance system for niscus orientation
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is essential to
monitoring and controlling subtle transverse- and frontal-plane knee joint movements, controlling
avoid impingement as the knee
anterior-posterior
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(tibia) during flexion initiation, assisting with 3-dimensional dynamic lower extremity postural
joint flexes and the tibia internally
stability during single-leg stance, preventing forward femoral dislocation on the tibia during rotates during weight acceptance
flexed-knee stance, and providing for postural equilibrium adjustments during standing. These or as the knee joint extends and
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most important during mid-range knee flexion when capsuloligamentous the tibia externally rotates during
structures are unable to function optimally. Because the popliteus musculotendinous complex has propulsion.

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attachments that approximate the borders of both collateral ligaments, it has the potential for Common weight-bearing mecha-
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both medial and lateral nisms of noncontact posterolateral
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tibiofemoral joint compartment function. Enhanced popliteus function as a kinesthetic knee joint knee joint injury are either a di-
monitor acting in synergy with dynamic hip muscular control of femoral internal rotation and
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subtalar muscular control of tibial abduction-external rotation or Date _________________________________________
adduction-
internal rotation, may help to prevent athletic knee joint injuries and facilitate recovery during
externally rotated, or a sudden
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rehabilitation by assisting the primary sagittal plane dynamic knee joint stabilization provided by forced knee hyperextension 6,8,56 with
the quadriceps femoris, hamstrings, and gastrocnemius. J Orthop Sports Phys Ther 2005;35:165- the tibia internally rotated.
179. Clinical signs of posterolateral
knee joint injury may be subtle
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anterior cruciate ligament (ACL)

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eight acceptance during walking commonly involves
29,34,58 or posterior cruciate ligament
tibial internal rotation as Thank the knee youjoint
forflexes.
subscribing!(PCL) injury.31 Combined injury
Concurrently, the knee joint generally undergoes a
of the popliteus muscle-tendon
small but important amount of abduction.29,35 In con-
complex (PMTC) and lateral (fibu-
junction with these kinematics the resultant line of
lar) collateral ligament (LCL) re-
force during walking is located primarily in the medial joint compart-
sults in serious posterolateral knee
instability, which, if unrecognized,
1
Assistant Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, University of contributes to postsurgical cruciate
Louisville, Louisville, KY; Frazier Rehabilitation Institute, Louisville, KY.
2
Assistant Professor, Department of Human Biology, Tecnikon Natal, Durban, South Africa. ligament reconstruction failure or
3 17,27,30,70
Research Fellow, Division of Sports Medicine, Department of Orthopaedic Surgery, University of chronic knee instability.
Louisville, Louisville, KY. According to Last, 32
popliteus
4
Associate Professor, Bellarmine University, Louisville, KY.
5
Visiting Professor, Hospital of Sanliurfa, Sanliurfa, Turkey. activation primarily internally ro-
6
Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, tates the knee and its tendinous
Louisville, KY. bands retract the posterior arch of
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: the lateral meniscus. Lateral me-
john.nyland@louisville.edu niscus movement guidance by the

Journal of Orthopaedic & Sports Physical Therapy 165

ligaments of Humphrey and Wrisberg and the menis-
cal 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 con-
firm 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 trans-
verse 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 non–weight-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 physi-
ological results (improved neuromuscular responsive-
ness and connective tissue integrity).
POPLITEUS ANATOMY AND BIOMECHANICS
During weight bearing, the tibiofemoral joint has
distinctly differing functions at its medial and lateral
compartments. The arthrological characteristics cre-
ated 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-plane–movement perspec-
tive.18,44 Both osseous and capsuloligamentous struc-
tures within each tibiofemoral joint compartment
support these functions. Increased tibial size, gener-
ally flatter and broader shaped capsuloligamentous
structures,18,32,47 and a less mobile, larger meniscus at
166
the medial tibiofemoral joint are suggestive of a
primary compressive loading function.32,42,47 In con-
trast, the smaller lateral tibiofemoral joint has more
ropelike primary capsuloligamentous structures, sug-
gesting a predominant tensile loading function,18,44
and a highly mobile meniscus, suggesting the pres-
ence 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 architec-
ture 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 cre-
ated by the popliteus tendon along the lateral femo-
ral 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
Tendon
Muscle LCL
FIGURE 1. Popliteus muscle, tendon, and popliteomeniscal fas-
cicles (LCL, lateral collateral ligament).
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005
 femoral condyle and the lateral meniscus, 15 speci-
mens (37.5%) had both an attachment to the lateral

CLINICAL COMMENTARY
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 indi-
viduals.
At the popliteus musculotendinous junction there
Ligament of are 2 popliteofibular ligament (PFL) divisions that
Wrisberg course laterally and distally, attaching on the
Popliteus Ligament of posteromedial aspect of the fibular styloid (Figure 4).
tendon Humphrey In addition to providing noncontractile restraint to
tibial external rotation, the PFL serves as a pulley,
Lateral MCL
helping to tether the tendon during popliteus activa-
meniscus Medial tion.60 Fuss13 reported that the PFL is under maxi-
meniscus
mum tension during flexion, possibly taking over the
LCL noncontractile knee joint stabilization function of the
LCL, which is not taut in most flexion positions.
PFL PCL During in vitro biomechanical testing, Maynard et
al40 reported a maximum load at failure of approxi-
mately 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
Popliteus individuals greater than 70 years of age, they con-
cluded that it was an important noncontractile stabi-
lizing 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 sequen-
FIGURE 2. Popliteus musculotendinous complex (PMTC) and ad- tial PFL and LCL transection, they reported gradually
joining structures. (LCL, lateral collateral ligament; PFL,
popliteofibular ligament; MCL, medial collateral ligament; PCL,
posterior cruciate ligament.)
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
Popliteomeniscal
ligament, the ligaments of Wrisberg and Humphrey,
fascicles
and the PCL (Figure 2).25 Two or 3 (anteroinferior,
posteroinferior, and posterosuperior) clearly delin-
eated 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 devel-
opment.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 menis-
cus. They reported that only 7 specimens (17.5%)
displayed a strong dual attachment to both the lateral FIGURE 3. Popliteomeniscal fascicles.

J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005 167


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 addition-
ally 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 re-
ported 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 poste-
rior translation.67 Shahane et al60 reported that
isolated popliteus muscle sectioning did not cause
significant posterolateral knee joint instability; how-
ever, PFL sectioning produced 3° and 9° increases in
tibial external rotation at 60° and 90° of knee flexion,
respectively, in addition to increased posterior transla-
tion. 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
168
between 30° and 12° of knee flexion, while isolated
PFL sectioning and sectioning of the femoral attach-
ment 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 in-
creases. 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 exter-
nal 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 func-
tioned together as the principal noncontractile struc-
tures 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 ex-
cessive 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 provid-
ing knee joint stability as knee flexion angles in-
crease. Pasque et al50 recommended that surgical
inter ventions should address each of these
posterolateral capsuloligamentous structures individu-
ally 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. Ide-
ally, surgical PMTC repair should produce improved
dynamic function in addition to a slight tenodesis
effect on adjacent capsuloligamentous tissues. Im-
proving our understanding of PMTC function may
aid the development of knee injury prevention condi-
tioning programs and functional rehabilitation ap-
proaches for patients who display posterolateral knee
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005
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 non–weight-bearing and weight-
bearing 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 kine-
matic 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 combina-
tion with electrogoniometric measurements,
Basmajian and Lovejoy2 reported popliteus activation
levels during isometric knee extensor or flexor activa-
tion 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 align-
ment. 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 de-
creased as 90° of knee flexion was reached.2 During
both knee extension and flexion isometric contrac-
tion, 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, moder-
ate; 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 non–weight-bearing,
lower extremity with the knee extended during
contralateral stance on a small box, (4) internal and
external lower extremity rotation of the weight-
bearing lower extremity with the knee extended
during unilateral stance, (5) squatting, and (6) nor-
mal pace walking, followed by walking with internally
or externally rotated lower legs.39 They reported 4+
popliteus activity during seated, non–weight-bearing
lower-leg internal rotation, and trace activity with
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005
external rotation. During seated non–weight-bearing
flexion/extension, 4+ popliteus activity was reached
CLINICAL COMMENTARY
only near full extension. During unilateral stance, 4+
popliteus activation amplitudes were also observed for
the non–weight-bearing lower extremity during inter-
nal rotation of the lower extremity with the knee
extended.39 Repeated studies using quantitative intra-
muscular electromyographic techniques and concur-
rent 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 in-
creased 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.
Activation During Weight Bearing
In a detailed biomechanical analysis of transverse-
plane knee joint muscle moment arms, using 17
cadaveric hemipelvis specimens, Buford et al3 identi-
fied a mechanical advantage for tibial external rota-
tors over internal rotators throughout the flexion-
extension 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 through-
out 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 inter-
nal 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 activa-
tion serves as a dynamic knee joint guidance substi-
tute for the action of crossed and tensed cruciate
169
ligaments. A 30° to 50° knee joint flexion alignment
correlates with the position commonly assumed with
sudden stopping during running and cutting activi-
ties.33,37,48
Barnett and Richardson1 observed consistent
popliteus activation when subjects assumed a crouch-
ing or ‘‘knee-bent’’ standing posture. This activation
was believed to assist the PCL with preventing ante-
rior femoral dislocation on the fixed tibia. Similar
activation was not noted during standing on ex-
tended 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 (pre-
sumably 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 lev-
els were greatest with the subject’s 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 activa-
tion. Mann and Hagy39 reported that, during unilat-
eral stance with the knee extended, 4+ popliteus
activation amplitudes were observed at the weight-
bearing lower extremity during external trunk rota-
tion and medial hip rotation.39 With internal trunk
rotation and lateral hip rotation, 2+ popliteus activity
was observed during unilateral stance at the weight-
bearing extremity at maximum rotation.39 Squatting
down and returning to an upright position produced
3+ popliteus activity during the entire movement
cycle.
170
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 activa-
tion occurs during all walking gait-cycle phases, ex-
cept 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 re-
sponse, and preswing.52 The variability in popliteus
activation levels reported by Perry52 suggests that a
primarily sagittal plane locomotion pattern per-
formed at walking velocity may not provide the most
relevant environment for studying a muscle that
conceivably displays greater importance during move-
ments 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) back-
pack, 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 associ-
ated with other activities, such as running downhill.
Considering the findings of Buford et al,3 because
the popliteus muscle displays a maximum transverse-
plane 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 perfor-
mance of athletic movements, such as running direc-
tional 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 transla-
tion during eccentric function (thereby protecting
the PCL), and by producing tibial internal rotation
and posterior translation during concentric function
(thereby protecting the ACL).
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005
 TABLE 1. Absolute and relative muscle spindle density of select lower extremity musculature.69

CLINICAL COMMENTARY
Composite Relative
Muscle-
Spindle–Density
Muscle Ratio
Spindles/Muscle (Popliteus:Functional
Weight (g) Muscle Group)
Direct tibial internal rotators 7.85:1.18
Semimembranosus 0.60
Semitendinosus 1.40
Sartorius 1.20
Gracilis 1.50
Tibial internal rotators via the subtalar joint 7.85:2.99
Extensor digitorum longus 3.73
Fibularis (peroneus) longus 1.88
Fibularis (peroneus) brevis 3.37
Tibial external rotators via the subtalar joint 7.85:2.16
Tibialis anterior 2.02
Tibialis posterior 1.64
Flexor hallucis longus 1.70
Flexor digitorum longus 2.94
Extensor hallucis longus 3.73
Soleus (medial calcaneal insertion) 0.94
Knee extensors 7.85:0.83
Vastus medialis 0.80
Vastus intermedius 0.90
Vastus lateralis 0.70
Rectus femoris 0.90
Femoral external rotators 7.85:2.45
Gluteus maximus 0.80
Gemellus inferior 3.40
Gemellus superior 3.90
Piriformis 3.50
Quadratus femoris 1.90
Sartorius 1.20

MUSCULOTENDINOUS KINESTHESIA Based on the extensive work of Voss,69 Peck et al51

The term musculotendinous kinesthesia refers to
the capacity for musculotendinous structures to con-
tribute 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 moni-
tor medial and lateral tibiofemoral joint compart-
ment function. For example, during a running
directional change excessive MCL tensile stress and
increased lateral tibiofemoral compartment compres-
sion may produce immediate PMTC activation to
facilitate tibiofemoral joint internal rotation and ma-
neuver the lateral meniscus to a functionally effective
and protected position. Concurrently, eccentric
popliteus activation during excessive LCL tensile
stresses and increased medial compartment compres-
sion associated with knee flexion and internal rota-
tion 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.
proposed that in the extremities, smaller muscles with
high muscle spindle concentrations, arranged in
parallel with larger, less spindle-dense muscles, func-
tion 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

J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005 171

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 syner-
gistic muscle function and interlimb coordination.
However, Grillner16 reported that built-in viscoelastic
neuromuscular control mechanisms within individual
muscles also provide instantaneous stiffness regula-
tion with considerable precision following sudden
stretching. From this observation they surmised that
these viscoelastic responses might be of greater rel-
evance to injury prevention than the motor control
program changes that eventually occur in association
FIGURE 5. Sudden, running, stop-directional change.
with kinesthetic musculotendinous input to the CNS.
Due to the time lags required for neuromuscular tions. During sudden running directional changes,
impulse initiation, conduction, and electromechanical the supporting tibia is relatively fixed, compared to
coupling,16 kinesthetic input must serve a greater the femur, usually with the help of a rubber-soled or
role during later motor program adjustments than for
cleated shoe; therefore, the tibia cannot effectively
immediate, dynamic 3-dimensional joint control pur-
undergo transverse-plane rotation on the femur, so
poses.
the femur must rotate on the tibia (Figure 5).62
A muscle-fiber–typing study has also provided sup- Levens et al34 and Reischl et al58 evaluated the
port for the role of the popliteus in providing transverse-plane biomechanical relationships between
instantaneous stiffness regulation across both tonic the foot, tibia, and femur during walking, and re-
and phasic activation conditions. Pierrynowski and ported considerable femoral rotation variability
Morrison54 estimated that the human popliteus had among subjects during early stance phase, with some
50% slow oxidative, 15% fast oxidative glycolytic, and
displaying external femoral rotation and others dis-
35% fast glycolytic muscle fibers. This fiber distribu-
playing internal rotation. Heiderscheit et al19,20 re-
tion supports both tonic regulatory postural control ported similar disparities during running. Tiberio,64
and phasic sudden–position-change functions. In con- in agreeing with Levens et al,34 suggested that relative
trast, they estimated that the adjacent human soleus knee joint internal rotation could be accomplished,
consisted of approximately 75% slow oxidative, 17% even when tibial internal rotation was blocked or
fast oxidative glycolytic, and 10% fast glycolytic delayed, by increased femoral external rotation.
muscle fibers, suggesting a more tonic, postural Levens et al34 surmised that these lower extremity
regulatory-control function. rotations appeared to be absorbed in the articulations
of the foot and their related ligamentous structures.
FUNCTIONAL REHABILITATION AND THE PMTC The femoral rotation variability reported by Reischl
Levens et al34 reported that composite pelvic, et al,58 Tiberio,64 Heiderscheit et al,19,20 and Levens
femoral, and tibial internal rotation occurs between et al34 may partially expose the influences of variable
the early walking stance phase and full weight bear- lower extremity postural alignment49,59 on long-axis
ing, and composite external rotation of the same tibial and femoral rotation and associated popliteus
structures occurs between full weight bearing and the function. Conceivably, when the tibia is relatively
terminal stance phase. Mann and Hagy39 agreed that fixed and the femur is in the same relative starting
during gait the entire distal segment of the body, position, subjects with increased external tibial tor-
including the pelvis, femur, and tibia, begins to sion may require increased femoral external rotation
internally rotate following toe-off and continues to to achieve relative knee joint internal rotation during
internally rotate through the swing phase, ceasing at stance phase. In contrast, subjects with increased
foot flat (12% of the gait cycle). External rotation of internal tibial torsion may be able to attain the same
the pelvis, femur, and tibia begins thereafter. transverse-plane functional endpoint during stance
Anatomically, transverse-plane knee joint rotation is phase, with less femoral external rotation or even
a combination of long-axis tibial and femoral rota- internal rotation. Transverse-plane internal femoral

172 J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005

rotation and external tibial rotation, and frontal-
plane hip joint adduction and knee joint abduction

CLINICAL COMMENTARY
are associated with genu valgus. Transverse-plane A
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 abduc-
tor (gluteus medius) and adductor musculature may
also influence knee joint position. From this perspec-
tive, there may be considerable normal variability in
how subjects of differing lower extremity postural
alignments achieve 3-dimensional dynamic lower ex-
tremity postural stability during the performance of
functional movements, particularly during sudden,
single lower extremity loading. The key should be to B
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 mo-
ment arms increased and hip external rotation mo-
ment arms decreased with increasing hip flexion. The
C
gluteus maximus had the greatest capacity for provid-
ing 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 transverse-
plane) and gluteus medius (frontal-plane) function
during single lower extremity loading, as previously
described, may be essential to attaining effective D
3-dimensional dynamic lower extremity postural sta-
bility 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 clini-
cian 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 inter-
play between global and local proprioceptive mecha- FIGURE 6. (A) Initiation of popliteus musculotendinous complex
nisms, and the concept of rehabilitating movements (PMTC) exercise with resistance band attached to the forefoot of the
that facilitate the development of synergistic lower non–weight-bearing lower extremity. (B) The foot on the non–
weight-bearing side moves behind the stance lower extremity via
extremity muscle function. Considering the role of
ipsilateral hip external rotation and knee flexion. (C) The foot on the
the PMTC as a kinesthetic monitor, we provide a non–weight-bearing side continues to move behind the stance lower
progressive functional rehabilitation strategy to im- extremity with increasing internal tibial rotation. (D) Completion of
prove integrated 3-dimensional dynamic lower ex- the concentric muscle action phase of the PMTC exercise. Return to
tremity postural stability. start position provides eccentric muscle action.

J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005 173

 We suggest a multiplanar task progression that
provides a PMTC training stimulus during both
integrated non–weight-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 (2-
to 6-in) step with skidproof surfaces (creating ap-
proximately 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
A B C
D E
FIGURE 7. (A) Initiation of stepping task on a 5.1-cm (2-in) step
with the non–weight-bearing lower extremity actively rotated poste-
rior 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 diago-
nal).
174
crossover foot plant position to the right (crossover
diagonal) (Figure 7B). After quickly returning to the
starting position (Figure 7C), the next forward move-
ment 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, particu-
larly 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 patient’s true
ability to maintain appropriate, well-controlled,
3-dimensional dynamic lower extremity postural sta-
bility. 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 sta-
bility on the step, the same progression can be
performed using variable-sized unstable surfaces (Fig-
ure 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 sta-
bility 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 clini-
cian is presented in Table 2. Information gathered
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005

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 rehabilita-
tion, and (3) to record the patient’s 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 pos-
tural stability.
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005
No studies to date have evaluated the influence of
knee joint postural alignment on popliteus activity or
CLINICAL COMMENTARY
3-dimensional knee joint kinematics during weight-
bearing 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 align-
ment.18,44 Femoral external rotation during early
stance phase (among individuals with a genu varus/
internal tibial torsion) and via femoral internal rota-
tion (among individuals with a genu valgus/external
tibial torsion) may enable more effective mainte-
nance of naturally balanced knee joint
capsuloligamentous and popliteus musculotendinous
length-tension relationships. These examples repre-
sent opposite ends of a postural continuum that may
A B C
D E
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.
175
 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 Sagittal Plane
Eye and Head Alignment
Head centered, eyes Head to one side, Head to one side, Head up, eyes look- Head slightly down, Head down, eyes
looking forward eyes looking for- eyes looking down ing forward eyes looking down looking down at feet
ward at feet at feet
2 1 0 2 1 0
Trunk Alignment
Well centered trunk Slight trunk lean Excessive trunk lean Slightly flexed, Excessively flexed, Extended, not using
during landing during landing chest over knees collapse with land- hip extensors
ing
2 1 0 2 1 0
Arm Alignment
Symmetrical with Symmetrical with Asymmetrical with Symmetrical with Symmetrical with Asymmetrical with
slight, controlled moderate, con- poorly controlled slight, controlled moderate controlled poorly controlled
arm-swing (abduc- trolled arm-swing arm swing (abduc- arm-swing (flexion) arm-swing (flexion) arm-swing (flexion)
tion), with low guard (abduction), with tion) with high with low guard with low guard with high guard
low guard guard
2 1 0 2 1 0
Hip-Thigh Alignment
Symmetrical with Symmetrical with Asymmetrical ad- Symmetrical with Symmetrical with Asymmetrical or
alignment over feet moderate adduction duction or abduc- moderate hip flex- excessive hip flex- with excessive or
without excessive or abduction during tion, knees touch or ion during con- ion during con- minimal hip flexion
adduction or abduc- controlled, soft flare outward (ex- trolled soft landing trolled soft landing during poorly con-
tion during con- landing treme coxa varus or trolled landing
trolled, soft landing valgus) during a
poorly controlled
landing
2 1 0 2 1 0
Knee-Leg Alignment
Symmetrical align- Symmetrical abduc- Asymmetrical ab- Symmetrical with Symmetrical with Asymmetrical or
ment over feet with- tion or adduction, duction or adduc- moderate knee flex- excessive knee flex- with excessive or
out visible wobble slight wobble or tion, knees touch or ion during con- ion during con- minimal knee flexion
or sway during con- sway during con- flare outward (ex- trolled soft landing trolled soft landing during poorly con-
trolled, soft landing trolled, soft landing treme genu valgus trolled landing
or varus) noted dur-
ing a poorly con-
trolled landing
2 1 0 2 1 0
Ankle-Foot Alignment
Symmetrical with Symmetrical with Asymmetrical with Symmetrical with Symmetrical with Asymmetrical or
feet aligned with feet moderately one or both feet, moderate ankle excessive ankle with excessive or
toes pointing forward toed out or toed in extremely toed out dorsiflexion during dorsiflexion during minimal ankle
or slightly toed out during controlled, or toed in, or a sec- controlled soft land- controlled soft land- dorsiflexion during
during controlled, soft landing ondary hop during ing ing poorly controlled
soft landing a poorly controlled landing
landing
2 1 0 2 1 0
Total Frontal Plane Score = /12 Total Sagittal Plane Score = /12
Overall Qualitative Jump Landing Score = /24 = %

substantially affect a patient’s capacity for performing
certain athletic movements. Fortunately, more subtle
representations predominate, better enabling the
clinician to effectively facilitate safer athletic move-
ment patterns. Performance variability among
patients is to be expected, necessitating that the
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

176 J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005

conceptually necessitating more frequent compensa-
tory femoral internal rotation to maintain appropri-
ately 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 sug-
gest that females would be more notably affected
than males, possibly predisposing them to greater
3-dimensional dynamic lower extremity postural sta-
bility difficulties during intense athletic maneuvers.
Reports suggest that improving dynamic transverse-
and 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 ro-
tation 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 con-
cepts 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 en-
couraging results. However, these training methods
alone may not provide the frontal- and transverse-
plane 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.
CONCLUSION
Previous studies have led to an improved under-
standing 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 non–weight-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
J Orthop Sports Phys Ther • Volume 35 • Number 3 • March 2005
unable to function optimally. The anatomic location,
biomechanic function, muscle activation, and
CLINICAL COMMENTARY
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.
ACKNOWLEDGMENT
The authors thank Dr Robert Acland at the Univer-
sity 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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