This is the story of a 24-year-old male touring professional tennis player having suffered a twisting injury to his flexed right knee about 10 days prior to his visit at the doctors. He had continuous pain in the postero-lateral aspect of the knee, associated with difficult terminal extension. There were no complaints of swelling, locking, or giving way. He had continued to play since the injury, but had noticed a progressive impairment. The result in this tournament was a second round loss. Treatment had consisted of protected bracing, intermittent modalities, stretching exercises, and anti-inflammatories under the guidance of the ATP Tour athletic training staff. The player had no history of prior knee problems and no other complaints. Physical examination showed a male who appeared to be in good health, with no gross atrophy or asymmetry of the lower extremities. No effusion was present. The range of motion was 0-135 degrees, which equalled the left knee. There was palpable fullness in the postero-lateral aspect of the knee, but this did not have the classic fluctuant consistency of a Baker's cyst. The terminal 10-15 degrees of extension elicited increased posterior pain. The patello-femoral joint had painless crepitation with no instability. Clinically the collateral and cruciate were stable. Resisted external rotation was painful postero-laterally, just below the joint line. Appley's compression test and McMurray's manoeuvre were negative. The patient had normal neuro-vascular status. At the time, my impression was a postero-lateral corner strain with the possibility of a torn lateral meniscus. X-rays and an MRI were performed when the symptoms persisted. Review of the X-rays showed a skeletally mature knee with no signs of alignment problems, degenerative changes or acute bony trauma. An incidental finding was that of a small to moderate-sized non-ossifying fibroma of the distolateral femoral metaphysis. The MRI was reviewed, and at first showed only some local haemorrhage in the lateral aspect of the lateral femoral condyle. Special coned-down views then revealed a tear of the popliteus tendon. Ligament structures and menisci were normal. A popliteus tendon injury to the right knee was diagnosed, with intact ligaments and menisci. Treatment The patient was placed on an aggressive course of physical therapy, emphasising deep massage, flexibility exercises an strengthing of the muscles supporting the postero-lateral aspect of the knee. He was fitted with a brace to prevent hyperextension and told that an arthroscopy would be indicated if the symptoms did not improve over the next month. He followed through with his treatment and continued to improve subjectively and clinically. The most recent follow-up was three years post-injury. He was pain-free and had no observable clinical findings. he player has continued to enjoy success on the tour, in both singles and doubles. Discussion Isolated popliteus tendon injuries are not common but, as illustrated in this case, can be functionally disabling in an elite level athlete. The popliteus tendon is important in the postero-lateral aspect of the knee. It helps to support the postero-lateral capsule and form the arcuate ligament. The main function is to limit postero-lateral rotation and has been described by some as being the main dynamic stabiliser to prevent anterior femoro-tibial displacement when the knee is in a flexed weight-bearing position. As can be imagined, this is a very common position for a tennis player's knee. The additional importance of this case is to make sure that a thorough diagnostic evaluation of an uncommon injury is pursued. For the touring tennis professional, time off for surgery or a lack of formal treatment can affect the player's point standings and career. We must certainly not neglect to perform appropriate surgical management when it is needed, but an aggressive approach owards diagnosis is critical in saving the patient from a prolonged lay-off, enabling them to safely pursue their career.
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