Anatomy and Physiology

The musculoskeletal system is made up of the body’s bones (the skeleton), muscles,

cartilage, tendons, ligaments, joints, and other connective tissue that supports and binds
tissues and organs together. It gives human the ability to move, using the muscular and
skeletal systems. It provides form, support, stability, and movement to the body.

Tendons, Joints, Ligaments, and Bursae:

A tendon is a tough, flexible band made of fibrous connective tissue, and functions to
connect muscle to bone. Joints are the bone articulations allowing movement. A ligament
is a dense, white band of fibrous elastic tissue.
Ligaments connect the ends of bones together in order to form a joint. These help to limit
joint dislocation and restrict improper hyperextension and hyperflexion. Also made of
fibrous tissue are bursae. These provide cushions between bones and tendons and/or
muscles around a joint.

The knee joint is a synovial joint which connects the femur (thigh bone), the longest
bone in the body, to the tibia (shin bone).  There are two main joints in the knee: 1) the
tibiofemoral joint where the tibia meet the femur 2) the patellofemoral joint where the
kneecap (or patella) meets the femur. These two joints work together to form a modified
hinge joint that allows the knee to bend and straighten but also to rotate slightly from
side to side.

Again, the knee joint is a hinge type joint. The part of the door that keeps it secured to
the wall and allows it to open and close is called a hinge. The majority of the movement
allowed by the knee is the same type of motion allowed by a door hinge. It additionally
allows for a small amount of rotational movement.

If you think of the knee in layers, the deepest layer is bone and ligaments, then ligaments
of the joint capsule, then muscles on top. Various nerves and blood vessels supply the
muscles and bones of the knee.

Bones of the Knee

There are four bones around the knee:

Femur (thigh bone) – the longest bone in the body

Tibia (shin bone) –  runs from the knee to the ankle
Patella (kneecap) – a semi-flat, triangular bone that is able to move as the knee bends.
It’s main function is to increase the force generated by the quadriceps muscle (which
straightens or extends the knee). It also protects the knee joint from trauma.
Fibula— a long, thin bone in the lower leg on the lateral side which runs along side the
tibia from the knee to the ankle. While about 80-90% of weight is carried by the
tibia, the fibula does help to carry some weight as well. It serves as an attachment for
muscles like the biceps femoris (one of the hamstring muscles), lateral collateral
ligament, and also helps to form the ankle joint.

Ligaments in the knee

Ligaments are strong, tough bands that are not particularly flexible.

Function of ligaments:

In the knee, they give stability and strength to the knee joint as the bones and cartilage of
the knee have very little stability on their own.
Medial Collateral Ligament (or the tibial collateral ligament) – attaches the medial side
of the femur to the medial side of the tibia and limits sideways motion of your knee.

Lateral Collateral Ligament (or the fibular collateral ligament) – attaches the lateral side
of the femur to the lateral side of the fibula and also limits sideways motion of your
knee.

Anterior cruciate ligament (ACL) – attaches the tibia and the femur. It also limits some
rotation and sideways motion of the knee. The ACL can be torn with sudden pivoting
motions of the knee.

Posterior cruciate ligament (PCL) – like the ACL, it attaches the tibia and the femur. It
lies behind the anterior cruciate ligament. It mainly limits backward motion of the
tibia relative to the femur.

Patellar ligament (or tendon) – attaches the kneecap to the tibia. It is less of ligament and
actually a continuation of the quadriceps tendon.

Joint Capsule – a thick, fibrous structure that wraps around the knee joint. Inside the
capsule is the synovial membrane which is lined by the synovium, a soft tissue
structure that secretes synovial fluid, the lubricant of the knee.

The pair of collateral ligaments keeps the knee from moving too far side-to-side. The
cruciate ligaments crisscross each other in the center of the knee. They allow the tibia to
“swing” back and forth under the femur without the tibia sliding too far forward or
backward under the femur. Working together, the 4 ligaments are the most important in
structures in controlling stability of the knee.

Cartilage of the Knee

Medial Meniscus

The medial meniscus is a crescent shaped structure that exists on the inside of the knee. It
is made of fibrocartilage. It acts as a shock absorber in the knee and adds stability to the
knee joint.  It is attached to the tibia as well as to the joint capsule of the knee.

Lateral Meniscus

The lateral meniscus sits on the lateral tibial plateau. It is a crescent shaped structure that
is also made up of fibrocartilage. It acts as a shock absorber in the knee and adds stability
to the knee joint.  It is attached to the joint capsule of the knee as well.  It is somewhat
more mobile than the medial meniscus.

In a healthy knee, the rubbery menisci act as shock absorbers. They both sit on top of the
tibia and help to spread the load of the femur over a larger surface area on the tibia.
Muscles Around the Knee
-help to keep the knee stable, well aligned, and moving

There are two main muscle groups around the knee:

Quadriceps - collection of 4 muscles on the front of the thigh and are responsible for
straightening the knee by bringing a bent knee to a straightened position.

Hamstrings - group of 3 muscles on the back of the thigh that provide the opposite
motion by bending the knee from a straightened position.
Tendons in the Knee
Tendons are elastic tissues made up of collagen.

They are the continuations of muscles and allow them to connect to bones.

There are numerous tendons around the knee that also help to stabilize the knee.

One of the most important tendons is the quadriceps tendon. This lies on the front of
the knee and connects the quadriceps muscles of the thigh to the tibia via the patella
and patellar ligament (or tendon). It provides the power necessary to straighten the
knee.

Bursae
up to 13 bursa of various sizes in and around the knee

fluid filled sacs cushion the joint and reduce friction between muscles, bones, tendons
and ligaments.

There are bursa located underneath the tendons and ligaments on both the lateral and
medial sides of the knee.

The prepatellar bursa is one of the larger bursae of the knee and is located on the front of
the patella (hence pre-patellar) just under the skin. It protects the patella.

The pes bursa is another important bursa that overlies some of the hamstring tendons
which attach to the medial side of the tibia.  It too can sometimes become irritated,
causing pes bursitis, which can be painful.

Plicae
Plicae are folds in the synovium within the knee joint itself

Knee Arteries and Veins

blood supply to the knee is that it is very abundant

many collateral vessels (basically extra vessels) that give blood supply to the structures
of the knee

Knee calf muscle

The muscles within the calf correspond to the posterior compartment of the leg.
The two largest muscles within this compartment are known together as the calf
muscle and attach to the heel via the Achilles tendon.

Adductor magnus muscle

It powerfully adducts the hip, while the hamstring portion of the adductor magnus
rotates the leg medially

Biceps femoris muscle

The long head of biceps muscle originates from the lower end of the ischium to
cross the front of the knee and insert on the tibia and fibula. This muscle
functions to flex and rotate the leg laterally and to extend the thigh
Extensor digitorum muscle
The extensor digitorum longus muscle is situated along the outside of the lower
leg, just behind the tibialis anterior. The actions of this muscle include
dorsiflexion of the foor, eversion of the foot, and extension of the toes.

Gastrocnemius muscle
The lateral head of the gastrocnemius muscle together with the medial head,
makes up the gastrocnemius muscle that forms the calf. The gastrocnemius is a
powerful plantar flexor of the foot, that aids in pushing the body forward when a
person walks or run, it also works to flex the leg at the knee.

Gracilis muscle
The gracilis muscle is a long, strap-like muscle that passes from the pubic bone
to the tibia in the lower leg. It functions to adduct the thigh and to flex and rotate
the leg medially at the knee.

Iliotibial tract
A thick stip of connective tissue connecting several muscles in the lateral thigh. It
plays an important role in the movement of the thigh by connecting hip muscles
to the tibia of the lower leg.

Lateral patellar retinaculum

Allows muscle and tissue to pass through the femur. The patellar ligament is the
center of the common tendon, which continues from the patella (knee cap) to the
tibia. It is a very strong, flat band, the fibers of which are continuous over the
front of the patella with tendons that extend and pass down the sides of the
patella into the extremity of the tibia along the sides of its rounded prominence. It
is separated from the joint by a large padding of fat.

Oblique popliteal ligament

The oblique popliteal ligament connects the lateral condyle of the femur
(thighbone) to the margin of the head of the tibia at the knee.

Peroneus longus muscle

A major muscle of the lower leg that plantar flexes and everts the foot at the
ankle. It is the longest muscle that attaches to the fibula and is used specifically
when balancing one’s weight on one foot.

Plantaris muscle
The plantaris muscle is a weak flexor of the leg at the knee joint and a plantar
flexor of the foot at the ankle joint. It is a rudimentary muscle, which is
sometimes compared to the one in the forearm

Popliteus muscle
The popliteus muscle arises from femur and inserts on the tibia posteriorly to flex
the leg and rotate it inward.

Quadriceps femoris tendon

The quadriceps femoris tendon connects the four muscles of the quadriceps
femoris muscle to the ilium and femur. This includes a common patellar tendon,
which passes over the front of the knee and attaches to the patella. This tendon
then continues as the patellar ligament to the tibia

Sartorius muscle
Longest muscle in the entire human body. It function as an important flexor and
rotator of the thigh at the hip joint,
Semimembranosus muscle
The semimembranosus muscle is the third hamstring muscle and is the most
inner-located muscle in the back of the thigh. It connects the ischium to the tibia
and functions to flex and rotate the leg medially and to extend the thigh.

Semitendinosus muscle
The semitendinosus muscle is another of the hamstring muscles. It is a long,
band-like muscle on the back of the thigh toward the inside, connecting the
ischium to the proximal end of the tibia. It functions to flex and rotate the leg
medially and to extend the thigh.

Soleus muscle
The soleus muscle is a thick, flat muscle located beneath the gastrocnemius.
These two muscles make up the calf of the leg. The soleus rises from the tibia
and fibula, and it extends to the heel by way of the Achilles tendon. It acts with
the gastrocnemius to cause plantar flexion of the foot.

Superior extensor retinaculum

The superior extensor retinaculum is a sheet of connective tissue that crosses
over the front of the shin above the ankle, attached to both the tibia and fibula.
The tissue formations in various regions of the ankle are thickened to form such
retinacula in sheaths to hold tendons down as they are crossing the front of the
ankle.

Tibialis anterior muscle

The tibialis anterior muscle is a long, narrow muscle in the anterior compartment
of the lower leg. The tibialis anterior functions as a dorsiflexor of the foot by
pulling the top, or dorsum, of the foot towards the shin.

Vastus intermedius muscle

The vastus intermedius muscle is one part of the large, fleshy group called the
quadriceps femoris, which occupies the front and sides of the thigh and is
primary extensor of the knee. It is composed of four parts - rectus femoris,
vastus lateralis, vastus medialis, and vastus intermedius. This tendon then
continues as the patellar ligament to the tibia.

Vastus medialis muscle

The vastus medialis muscle is one of the quadriceps femoris muscle’s four
muscle divisions. It occupies the sides and front of the thigh and its function is
being the primary extensor of the knee.