Snapping biceps femoris tendon: a dynamic real-time sonographic evaluation

Evaluation of the knee joint with ultrasound and magnetic resonance imaging

The knee joint relies on a combination of deep and superficial structures for stability and function. Both ultrasound and high-resolution magnetic resonance imaging are extremely useful in evaluating these structures and associated pathology. This article reviews a combination of critical anatomic structures, joint abnormalities, and pathologic conditions at the knee joint, while highlighting the merits, limitations, and pitfalls of the two imaging modalities. A clear appreciation of each method paired with its relative strengths will aid in expediting diagnosis and appropriate treatment for a wide range of knee joint conditions.

Biceps femoris accessory tendon tenodesis: A case report

Key Clinical Message

We present a case of lateral knee pain from snapping of an accessory tendinous insertion of the biceps femoris. After failure of conservative treatment options, tenodesis of the accessory band to the direct arm insertion at the posterolateral edge of the fibular head effectively resolved symptoms.

Abstract

There are several distinct causes of lateral knee pain including IT band syndrome, meniscus tears, or other soft tissue pathologies; however, a few case reports have shown the biceps femoris as a cause of lateral knee pain and snapping. Conservative treatment is of modest benefit to the patient in these scenarios, and an MRI is not always able to identify the accessory band, as in our case. Intraoperatively, we discovered an accessory band of the biceps femoris attaching to the anterolateral tibia, causing pain and snapping during knee flexion as the band passed over the fibular head. There have been various surgical attempts to address this pathology; however, we report a successful outcome after tenodesis of the accessory band to the direct insertion at the posterolateral fibular head.

Hearing and Seeing Nerve/Tendon Snapping: A Systematic Review on Dynamic Ultrasound Examination

Nerve/tendon snapping can occur due to their sudden displacement during the movement of an adjacent joint, and the clinical condition can really be painful. It can actually be challenging to determine the specific anatomic structure causing the snapping in various body regions. In this sense, ultrasound examination, with all its advantages (especially providing dynamic imaging), appears to be quite promising. To date, there are no comprehensive reviews reporting on the use of dynamic ultrasound examination in the diagnosis of nerve/tendon snapping. Accordingly, this article aims to provide a substantial discussion as to how US examination would contribute to 'seeing' and 'hearing' these pathologies' different maneuvers/movements.

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Knee

ABSTRACT

In this dynamic scanning protocol, ultrasound examination of the knee is described using various maneuvers to assess different conditions. Real-time patient examination and scanning videos are used for better simulation of the daily clinical practice. The protocol is prepared by several/international experts in the field of musculoskeletal ultrasound and within the umbrella of European Musculoskeletal Ultrasound Study Group in Physical and Rehabilitation Medicine/Ultrasound Study Group of the International Society of Physical and Rehabilitation Medicine.

Biceps femoris snapping and friction on the fibular head secondary to abnormal distal tendon insertion: 15 cases and a literature review

INTRODUCTION

Abnormal biceps femoris distal tendon insertion can cause tendon snapping, as is well-known in the literature. The presenting symptom is lateral knee pain, often during sports activities and cycling in particular. The present study tested two hypotheses: abnormal biceps femoris insertion on the fibular head may cause painful friction without clinical snapping, whether visible, audible or palpable; surgical correction achieves good results for pain and return to sport, regarding both snapping and friction.

MATERIAL AND METHODS

Between 2006 and 2017, 11 patients were managed for pain secondary to abnormal biceps femoris insertion. In 4 cases, pain was bilateral, resulting in a total of 15 knees: 9 with snapping (in 6 patients), and 6 with friction syndrome without snapping (in 5 patients). All 6 patients with snapping were male, with a mean age of 29 years. Friction without snapping concerned 3 female and 2 male patients, with a mean age of 30 years. Study data included type and level of sport, clinical signs, imaging, type and results of treatment, and type of abnormality.

RESULTS

The insertion abnormality consisted in excessively anterior insertion in the fibular arm in 6 cases, in predominantly tibial insertion in 2 cases, and in isolated tibial insertion in 4 cases. Surgery mainly consisted inrelease and reinsertion of the distal biceps femoris tendon (in 7 cases). All patients were able to return to sport. The mechanism underlying snapping and friction was the same: distal biceps tendon friction on the fibular head secondary to unduly anterior fibular or predominantly or exclusively tibial insertion.

DISCUSSION

The literature reports 24 cases, all of snapping, with between 1 and 3 cases per author. These findings were compared with the present results. With or without snap, symptoms are secondary to abnormal tendon insertion and to activity or sport requiring repeated knee flexion greater than 90°.

CONCLUSIONS

(1) Case studies show that lateral knee pain by friction on the fibular head is not systematically accompanied by snapping. (2) In all reports and in the present series, surgery was highly effective on snapping and pain, and patients returned to sport at their previous level.

LEVEL OF EVIDENCE

IV.

Bilateral snapping biceps femoris tendon: a case report and review of the literature

Snapping biceps femoris tendon is an uncommon cause of lateral knee pain. We report the case of a 15-year-old athlete with bilateral snapping biceps femoris tendons, painful over his right lateral leg during exercise. He underwent elective exploration of the right knee which revealed an accessory biceps femoris tendon with attachment to the anterolateral tibia. The accessory tendon was released and reinserted onto the fibular head with a Krackow suture. There were no perioperative complications, and he returned to full sporting activities within 3 months. We describe the operative technique used and summarise the existing literature. Restoring the anatomy with release of the accessory tendon and reinsertion onto the fibular head is an effective technique in the management of knee pain due to snapping biceps femoris tendon. Other approaches include simple release of the anomalous tendon without reinsertion or partial resection of the fibular head. Partial resection of the fibular head is the only technique described in the literature with complication requiring a further operation on the same site. There remains a paucity of evidence in the literature regarding long-term outcomes required to inform the best operative approach. Further anatomical, intraoperative and radiological studies are required to delineate the true pathology of this condition.

Surgical Repair of Dynamic Snapping Biceps Femoris Tendon

A snapping biceps tendon is an infrequently seen and commonly misdiagnosed pathology, leaving patients with persistent symptoms that can be debilitating. Patients will present with a visible, audible, and/or painful snap over the lateral aspect of their knee when performing squats, sitting in low seats, or participating in activities with deep knee flexion. A thorough knowledge of the anatomy is essential for surgical treatment of this pathology, which is caused by a detachment of the direct arms of the long and short heads of the biceps femoris off the fibular styloid. This Technical Note provides a diagnostic approach, postoperative management, and details of a surgical technique to treat a snapping biceps tendon with an anatomic repair of the long and short head attachments of the biceps femoris to the posterolateral fibular styloid.

Snapping Biceps Femoris: clinical demonstration and operative technique

Snapping biceps femoris syndrome has been reported in the literature in a handful of case reports but not yet with a demonstration of clinical examination and intraoperative findings. We present an educational clinical video of snapping biceps femoris with intraoperative demonstration of findings and surgical repair.

Unilateral Snapping Biceps Femoris Tendon with an Anomalous Insertion Treated with Anatomic Repositioning and Lengthening with a Single Suture Anchor: A Report of Two Cases

CASE

A snapping biceps femoris tendon, a rare etiology for symptomatic pain in the lateral aspect of the knee, has been reported infrequently. We report 2 cases of an acutely symptomatic unilateral snapping biceps femoris tendon with an intraoperatively intact anomalous insertion onto the tibia, which were treated with anatomic repositioning and "pie-crust" lengthening via a single suture anchor.

CONCLUSION

Anatomic repositioning and lengthening is a novel technique that successfully resolved the painful snapping and allowed full return to competitive sports by 6 months postoperatively, with maintenance of improvement at ≥14 months postoperatively.

Optimal Elbow Angle for Sonographic Visualization of the Ulnar Collateral Ligament

OBJECTIVE

To formally examine the sonographic appearance of the elbow ulnar collateral ligament (UCL) at 30° versus 70° of elbow flexion in asymptomatic baseball pitchers.

DESIGN

A prospective, cross-sectional design.

SETTING

Sports medicine clinic in a tertiary academic medical center.

PARTICIPANTS

Thirty asymptomatic adolescent baseball pitchers 13-18 years of age (mean 15.8 years), with at least 3 years of continuous pitching experience and no significant history of elbow pain or injury.

METHODS

Static sonographic images of the bilateral UCLs were obtained at 30° and 70° of elbow flexion by a single experienced examiner. Images were anonymized and randomized into a slide set. Three clinicians with different levels of ultrasound experience reviewed the static 30° and 70° images for each elbow and chose their preferred image based on UCL conspicuity. The clinicians reviewed a re-randomized slide set 1 week later. A different study co-investigator measured UCL cross-sectional area (CSA) on all images using ultrasound machine electronic calipers.

MAIN OUTCOME MEASURES

Preference for the sonographic conspicuity of the UCL at 30° versus 70° of elbow flexion, and UCL CSA at 30° versus 70° of flexion.

RESULTS

Each clinician demonstrated a significant preference for UCL images obtained at 70° of flexion when compared to those obtained at 30° (80.3% overall preference for 70°, P < .001). There was no statistically significant effect of clinician experience or arm dominance on image preference. The sonographically determined CSA of the UCLs were on average 1.4 mm(2) greater at 70° than at 30° of flexion (P < .001) when combining dominant and nondominant arms.

CONCLUSIONS

Static sonographic evaluation of the UCL at 70° of elbow flexion should be integrated into UCL imaging protocols. Furthermore, when performing sonographically guided procedures targeting the UCL, clinicians should consider positioning the elbow at >30° of flexion to optimize UCL conspicuity and CSA.

Snapping knee: imaging findings with an emphasis on dynamic sonography

OBJECTIVE

The purpose of this article is to illustrate the causes of snapping knee. The value of imaging techniques is discussed with an emphasis on dynamic sonography in light of the available surgical and radiologic literature.

CONCLUSION

Because of its dynamic capabilities, dynamic sonography provides real-time visualization of snapping knee syndrome and may be used as a first-line modality.

Imaging of snapping phenomena

Snapping phenomena result from the sudden impingement between anatomical and/or heterotopical structures with subsequent abrupt movement and noise. Snaps are variously perceived by patients, from mild discomfort to significant pain requiring surgical management. Identifying the precise cause of snaps may be challenging when no abnormality is encountered on routinely performed static examinations. In this regard, dynamic imaging techniques have been developed over time, with various degrees of success. This review encompasses the main features of each imaging technique and proposes an overview of the main snapping phenomena in the musculoskeletal system.