The distal biceps femoris tendon is a broad, thick tendon inserting onto the fibular head (styloid process and posterior surface), with a deep component attaching to the posterior fibular head and a superficial component to the fibular styloid. It is a key component of the posterolateral corner (PLC) of the knee, resisting varus stress, external tibial rotation, and posterolateral drawer. The common peroneal nerve runs posterior and medial to the tendon at the fibular head.
Biceps femoris distal tendon avulsion from the fibular head is a component of posterolateral corner injuries, which must be identified and repaired in combined ACL-PLC injuries to prevent graft failure. Isolated biceps femoris avulsion is uncommon but produces posterolateral knee pain, a palpable gap at the fibular head, and posterolateral instability. The common peroneal nerve adjacent to the tendon is at risk in both acute avulsion and PLC reconstruction surgery. Anatomic PLC reconstruction requires the biceps tendon as the fibular fixation point.
High-energy varus and external rotation knee injury avulses the biceps femoris from the fibular head, producing posterolateral instability with dial test asymmetry and a positive external rotation recurvatum test; repair or reconstruction of the PLC including biceps reattachment is required in combined ACL-PLC injuries to prevent ACL graft failure.
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