Novel Operation of Snapping Biceps Femoris Tendon

Snapping biceps femoris tendon (BFT) over the fibular head is an uncommon cause of lateral knee pain, with few case reports in the literature.1–12 Reported causes include anomalous tendon insertion, tears at the tendon insertion site, abnormality of the fibular head, and tendon subluxation despite normal anatomy. When nonoperative management fails, various surgical treatment techniques have been used, including partial fibular head resection, partial release of an offending BFT, and anatomic reductions of anomalous tendon insertions and tears. Surgical treatment of a snapping BFT requires a thorough understanding of the complex tendon anatomy at the knee. In 1955, Sneath13 described the insertion as a confluence of three layers in a fan-like orientation. Marshall et al14 later described the common biceps tendon as having superficial, middle, and deep layers. The middle layer was found to envelope the lateral collateral ligament (LCL) such as a sling, providing tautness and stability to the LCL during flexion. Terry and LaPrade15 have promoted the anatomical study of the BFT. The long head of the biceps femoris originates from the ischial tuberosity and terminates in two tendinous insertions—a direct arm that inserts on the posterolateral edge of thefibular head, lateral to the styloid and an anterior arm that inserts along the lateral edge of the fibular head, lateral to the fibular LCL.15 Fascial components include the reflected arm, lateral aponeurosis, and anterior aponeurosis. The short head of the biceps femoris originates immediately medial to the linea aspera of the distal femur and similarly has the two direct tendinous insertions of direct arm and anterior arm. We report on a painful snapping BFTwith hypertrophy of the anterior arm of the long head of the BFT that was treated with the novel surgical technique of partial fibular head resection and tenodesis of the anterior arm to the popliteofibular ligament (PFL).