Popliteus Tendinitis in a Softball Player
by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
History and Presenting SymptomsThe patient is a 27-year-old male who participates in an adult softball league on weekends. He describes recurring episodes of pain and swelling along the back and outside of his right knee, which has limited his knee extension for the past several years. Upon questioning, he also reports episodes of lower back pain,with occasional limitations of activity. He presents for treatment of his lower extremity biomechanical faults, and hopes to improve his athletic performance with chiropractic care. Exam FindingsVitals. This athletic male weighs 185 lbs., which, at 6’2’’, results in a BMI of 23; he is large, but not overweight. He is a non-smoker, and his blood pressure and pulse rate are at the lower end of the normal range. Posture and gait. Standing postural evaluation finds generally good alignment, with good muscular development and intact spinal curves. There is a slightly lower iliac crest on the right, and also a lower right greater trochanter. Weightbearing evaluation of his knees and lower extremities identifies right calcaneal eversion and a low medial arch on the right (hyperpronation), amplified with dynamic examination of thegait cycle. Chiropractic evaluation. Motion palpation identifies moderate limitation in right sacroiliac motion, with slight tenderness and loss of endrange mobility. Several compensatory fixations are identified throughout the lumbar region. Otherwise, all orthopedic and neurological testing of the spine is negative. Primary complaint. Examination of his right knee finds all ranges of motion to be full and pain-free, and all ligament tests are solid and non-painful. Manual testing of the knee support muscles finds moderate weakness in the right popliteus muscle, when compared to the left side. In addition, moderate pain (4/10) is elicited when stress testing the right popliteus muscle. ImagingBecause of his prior chronic low back symptoms, a radiographic evaluation of the lumbosacral region was ordered. The basic (AP, lateral, right and left lateral obliques) lumbosacral series found approximately 20% anterior slippage of L5 on the sacrum, (Grade I spondylolisthesis) with bilateral defects in theL5 pars interarticularis. Clinical ImpressionThis healthy athlete presents with occasional episodes of right knee pain and previous low back pain. Examination found evidence of right popliteus tendinitis and right sacroiliac fixation, with right foot/ankle instability. This is accompanied by compensatory lumbar fixations and evidence of an inactive spondylolytic spondylolisthesis. Treatment PlanAdjustments. Specific, corrective adjustments for the SI joints and lumbar region were provided as needed. The right knee was adjusted into internal rotation.Support. Custom-made, flexible orthotics were provided to support the arches and decrease calcaneal eversion, and to reduce the asymmetrical biomechanical forces being transmittedto the spine and pelvis.Rehabilitation. This patient received specific exercise recommendations to strengthen his popliteus muscle and also for lumbar spinal stabilization. He was initially instructed to perform daily internal rotation exercises of his lower leg against the resistance of elastic tubing. After two weeks, daily strengthening of the transverse abdominis muscles in the upright weightbearing position was initiated, using resistance from anat-home rehabilitative device. Response to CareThe spinal and pelvic adjustments were well-tolerated, and this active athlete required very few re-adjustments. He wore the stabilizing orthotics in his athletic shoes anddaily footwear without difficulty. He reported an immediate subjective improvement in his athletic performance, saying that his knee and leg felt “more stable.” He was released from acute care to a self-directed maintenance program after a total of eight visits over two months. DiscussionThe popliteus muscle assists in flexing the lower leg upon the thigh; when the leg is flexed, it also rotates the tibia medially. It is called into action at the beginning of knee flexion, inasmuch as it produces the slight medial rotation of the tibia that is essential in the early stage of this movement. This athlete was frustrated by the lack of answers and recommendations from various providers regarding his recurrent knee problems. He hadn’t recognized the pre-existing spondylolisthesis condition or the impact of his lower extremity mal-alignment. The asymmetry in his ankles (calcaneal eversion and poor medial support) exacerbatedand contributed to his recurring knee problems. The combination of specific adjustments, custom-madeorthotic support, and strengthening of the knee and pelvis support musculature quickly brought about an excellent response. Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program.
Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation. He can be reached at [email protected]