Chapter 19: Knee Joint

 Joint Structure and Motions

o The knee is supported and maintained entirely by muscles and ligaments with no bony stability, and
it frequently is exposed to severe stresses and strains.
o Therefore, it should be no surprise that it is one of the most frequently injured joints in the body.
o The knee joint is the largest joint in the body, and it is classified as a synovial hinge joint
o The motions possible at the knee are flexion and extension
 From 0 degrees of extension, there are approximately 120 to 135 degrees of flexion.
o Due to some ligament laxity, the knee may have a few degrees of hyperextension beyond 0;
 Beyond 5 degrees of hyperextension is considered genu recurvatum.
o Unlike the elbow, the knee joint is not a true hinge, because it has a rotational component.
 This rotation is not a free motion but rather an accessory motion that accompanies flexion
and extension.
o There are two types of end feel at the knee joint.
 With knee flexion, the end feel is soft (soft tissue approximation) due to the contact between
the muscle bellies of the thigh and leg.
 With knee extension, the end feel is firm (soft tissue stretch) due to tension of the joint
capsule and ligament

 Arthrokinematics
o All three types of arthrokinematic motion occur during knee flexion and extension.
o The convex femoral condyles move on the concave tibial condyles or vice versa, depending on
whether it is an open- or closed-chain activity.
 Open Chain Knee Extension
 The concave tibia glides anteriorly on the convex femur
 From 20 degrees to full extension, the tibia rotates laterally on the femur
 Open Chain Knee Flexion
 The concave tibia glides posteriorly on the convex femur
 The tibia rotates (spin) medially on the femur
 Closed Chain Knee Extension
 The femur glides posteriorly on the tibia
 The femur rotates medially on the tibia
 Closed Chain Knee Flexion
 The femur glides anteriorly on the tibia
 The femur rotates laterally on the tibia

o Screw-Home Mechanism
 Looking at the same spin, or rotational, movement during non–weight-bearing extension
(open-chain action), note that the tibia rotates laterally on the femur.
 These last few degrees of motion lock the knee in extension; this is sometimes called
the screw-home mechanism of the knee.
 With the knee fully extended, an individual can stand for a long time without using muscles.
 For knee flexion to occur, the knee must be “unlocked” by laterally rotating the femur on the
tibia.
 This small amount of rotation of the femur on the tibia, or vice versa, keeps the knee
from being a true hinge joint.

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  Because this rotation is not an independent motion, it will not be considered a knee
motion.

o The knee has a convex-on-concave relationship in the closed chain

 This is reversed when non–weight-bearing.
o In the open chain, the knee has a concave-on-convex relationship where the concave tibial condyles
glide posteriorly with flexion, and anteriorly with extension, while the distal end of the tibia moves
in the same direction.
o The knee is in the open-packed position when it is flexed to 25 degrees
 This is the position where most joint play is available.
 A mobilizing force applied to the proximal tibia in an anterior direction will facilitate knee
extension, whereas a posterior glide will promote flexion.

o Patellofemoral joint 
 The articulation between the femur and patella
 The smooth, posterior surface of the patella glides over the patellar surface of the femur.
 The main functions of the patella involve increasing the mechanical advantage of the
quadriceps muscle and protecting the knee joint. 

 Bones and Landmarks

o The knee is composed of the distal end of the femur articulating with the proximal end of the tibia.

 Important landmarks of the Femur

o Head
 The rounded portion articulating with the acetabulum.
o Neck
 The narrower portion located between the head and the trochanters.
o Greater Trochanter
 Large projection located laterally between the neck and the body of the femur
 Provides attachment for the gluteus medius and minimus and for most deep rotator muscles.
o Lesser Trochanter
 A smaller projection located medially and posteriorly, just distal to the greater trochanter;
 Provides attachment for the iliopsoas muscle.
o Body
 The long, cylindrical portion between the bone ends; also called the shaft. It is bowed slightly
anteriorly.
o Medial Femoral Condyle
 Distal medial end
o Lateral Femoral Condyle
 Distal lateral end
o Lateral Epicondyle
 Projection proximal to the lateral condyle
o Medial Epicondyle
 Projection proximal to the medial condyle
o Adductor Tubercle
 Small projection proximal to the medial epicondyle to which a portion of the adductor
magnus muscle attaches
o Linea Aspera

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  Prominent longitudinal ridge or crest running most of the posterior length
o Pectineal Line
 Runs from below the lesser trochanter diagonally toward the linea aspera.
 It provides attachment for the adductor brevis.
o Patellar Surface
 Located between the medial and lateral condyle anteriorly.
 It articulates with the posterior surface of the patella.

 Important Landmarks of the Tibia

o Intercondylar Eminence
 A double-pointed prominence on the proximal surface at about the midpoint, which extends
up into the intercondylar fossa of the femur
o Medial Tibial Condyle
 Proximal medial end
o Lateral Tibial Condyle
 Proximal lateral end
o Tibial Plateau
 Enlarged proximal end, including the medial and lateral condyles and the intercondylar
eminence
o Tibial Tuberosity
 Large projection at the proximal end on the anterior surface in the midline
o The fibula is lateral to, and smaller than, the tibia.
 It is set back from the anterior surface of the tibia, allowing a large space for muscle
attachment
 This feature gives the lower leg its rounded circumference.
 The fibula is not part of the knee joint because it does not articulate with the femur.
 Although it provides a point of attachment for some of the knee structures, it has a
larger role at the ankle.
o The patella is a triangular sesamoid bone within the quadriceps muscle tendon
 It has a broad, superior border and a somewhat pointed distal portion.
o The calcaneus is the most posterior of the tarsal bones and is commonly known as the heel. 
 It is identified here because it provides attachment for the gastrocnemius muscle.

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 Ligaments and Other Structures
o The cruciate and collateral ligaments are the two main sets of ligaments for this task
o The cruciates are located within the joint capsule and are therefore called intracapsular ligaments. 
o Situated between the medial and lateral condyles, the cruciates cross each other obliquely
(cruciate means “resembling a cross” in Latin).
o They are named for their attachment on the tibia 

 Anterior Cruciate Ligament

 Attaches to the anterior surface of the tibia in the intercondylar area just medial to the
medial meniscus.
 It spans the knee lateral to the posterior cruciate ligament, and it runs in a superior
and posterior direction to attach posteriorly on the lateral condyle of the femur.

 Posterior cruciate ligament

 Attaches to the posterior tibia in the intercondylar area, and it runs in a superior and
anterior direction on the medial side of the anterior cruciate ligament.
 It attaches to the anterior femur on the medial condyle.
 In summary, the anterior cruciate runs from the anterior tibia to the posterior femur, and the
posterior cruciate runs from the posterior tibia to the anterior femur.

o The cruciates provide stability in the sagittal plane.

 The anterior cruciate ligament keeps the femur from being displaced posteriorly on the tibia.
 Conversely, it keeps the tibia from being displaced anteriorly on the femur.
 It tightens during extension, preventing excessive hyperextension of the knee.
 When the knee is partly flexed, the anterior cruciate keeps the tibia from moving anteriorly.
 Conversely, the posterior cruciate ligament keeps the femur from displacing
anteriorly on the tibia or the tibia from displacing posteriorly on the femur.
 It tightens during flexion and is injured much less frequently than the anterior cruciate
ligament.

o Collateral Ligaments
 Located on the sides of the knee
 Medial Collateral Ligament, or tibial collateral ligament,
 Is a flat, broad ligament attaching to the medial condyles of the femur and tibia.
 Fibers of the medial meniscus are attached to this ligament, which contributes to
frequent tearing of the medial meniscus during excessive stress to the medial
collateral ligament.
 The medial collateral ligament provides medial stability and prevents excessive
motion if there is a blow to the lateral side of the knee (valgus force).

 Lateral Collateral Ligament, or fibular collateral ligament

 This round, cordlike ligament attaches to the lateral condyle of the femur and runs
down to the head of the fibula, independent of any attachment to the lateral meniscus.
 It provides stability to the lateral side of the knee against medial-to-lateral forces
(varus force).
 The lateral collateral ligament provides lateral stability and prevents excessive motion
if there is a blow to the medial side of the knee (varus force).

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  The collateral ligaments supply stability in the frontal plane.
 Because their attachments are offset posteriorly and superiorly to the knee joint axis,
the collateral ligaments tighten during extension, contributing to the stability of the
knee, and slacken during flexion.

o Meniscus
 Located on the superior surface of the tibia, the medial and lateral menisci (plural
of meniscus) are two half-moon, wedge-shaped fibrocartilage disks.
 They are designed to absorb shock
 Because they are thicker laterally than medially and because the proximal surfaces are
concave, the menisci deepen the relatively flat joint surface of the tibia.
 Perhaps because of its attachment to the medial collateral ligament, the medial meniscus is
torn more frequently.

o Bursa
 The purpose of a bursa is to reduce friction, and approximately 13 of them are located at the
knee joint.
 They are needed because the many tendons located around the knee have a relatively
vertical line of pull against bony areas or other tendons. 

o Popliteal Space 
 The area behind the knee
 It contains important nerves (tibial and common fibular) and blood vessels (popliteal artery
and vein).
 This diamond-shaped fossa is bound superiorly on the medial side by the semitendinosus and
semimembranosus muscles and by the biceps femoris muscle on the lateral side
 The inferior boundaries are the medial and lateral heads of the gastrocnemius muscle.

o Pes Anserine muscle group (Latin for “goose foot”) 

 Is made up of the sartorius, gracilis, and semitendinosus muscles.
 Each muscle has a different proximal attachment.
 The sartorius muscle arises anteriorly from the iliac spine
 The gracilis muscle arises medially from the pubis
 The semitendinosus muscle arises posteriorly from the ischial tuberosity.
 They all cross the knee posteriorly and medially, then join together to attach distally on the
anterior medial surface of the proximal tibia.
 Because of their angle of pull, their size in relation to other muscles, and other factors, they
do not have a prime mover function.
 However, they do provide stability to the joint.
 Orthopedic surgeons sometimes alter this common attachment to provide medial stability to
the knee.

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 Muscles of the Knee
o All of the knee muscles, except the popliteus, cross the joint in a relatively vertical fashion.
 Anterior muscles extend the knee
 Posterior muscles flex the knee
 Muscles crossing the medial and lateral sides help provide medial and lateral stability. 

 Anterior Muscles of the Knee

o The quadriceps muscles are comprised of four muscles that cross the anterior surface of the knee

o Rectus Femoris Muscle 

 The only one of this group to cross the hip.
 Its proximal attachment is on the AIIS.
 It runs almost straight down the thigh, where it is joined by the three vasti muscles
and blends into the quadriceps tendon (also called the patellar tendon).
 This tendon encases the patella, crosses the knee joint, and attaches to the tibial tuberosity.
 The rectus femoris muscle is a prime mover in hip flexion and knee extension.

o The three vasti muscles are one-joint muscles, which come together with the rectus femoris in the
lower part of the thigh to form a single, very strong, quadriceps tendon before crossing the knee to
attach to the tibial tuberosity.

 Vastus Lateralis Muscle 

 Located lateral to the rectus femoris muscle.
 It originates from the linea aspera of the femur and spans the thigh laterally to join the
other quadriceps muscles at the patella.

 Vastus Medialis Muscle 

 Also comes from the linea aspera, but it spans the thigh medially.
 Both the vastus lateralis and medialis “wrap around” the femur on their respective
sides.

 Vastus Intermedialis Muscle 

 Located deep to the rectus femoris muscle
 It arises from the anterior surface of the femur and spans the thigh anteriorly in a very
vertical direction.
 It blends together with the other vasti muscles along its length.
 All four quadriceps muscles attach to the base of the patella and the tibial tuberosity
via the patellar tendon. 
 All four muscles span the knee anteriorly, and all extend the knee.
 Because the rectus femoris muscle also spans the hip anteriorly, it also flexes the hip.

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 Posterior Muscles of the Knee
o Three muscles that are known collectively as the hamstring muscles cover the posterior thigh.
o They consist of the semimembranosus, the semitendinosus, and the biceps femoris muscles
o They have a common site of origin on the ischial tuberosity.

o Semimenbranosus Muscle
 Runs down the medial side of the thigh deep to the semitendinosus muscle and inserts on the
posterior surface of the medial condyle of the tibia.

o Semitendinosus Muscle 
 Has a much longer and narrower distal tendon that moves anteriorly after spanning the knee joint
posteriorly.
 It attaches to the anteromedial surface of the tibia with the gracilis and sartorius muscles.

o Biceps Femoris Muscle 

 Has two heads and runs laterally down the thigh on the posterior side.
 The long head arises with the other two hamstring muscles on the ischial tuberosity, but the short
head arises from the lateral lip of the linea aspera.
 Both heads join together, spanning the knee posteriorly to attach laterally on the head of the
fibula and, by a small slip, to the lateral condyle of the tibia.
 The short head of the biceps femoris is the only part of the hamstring muscle group that has a
function only at the knee.
 The other parts have a function at both the hip and the knee.

o Popliteus Muscle
 A one-joint muscle located posteriorly at the knee in the popliteal space, deep to the two heads of
the gastrocnemius muscle
 It originates on the lateral side of the lateral condyle of the femur and crosses the knee
posteriorly at an oblique angle to insert medially on the posterior proximal tibia.
 Because it spans the knee posteriorly, it flexes the knee.
 Because it has an oblique line of pull, it creates the rotational pull needed to “unlock” the knee as
it initiates knee flexion.

o Gastrocnemius Muscle
 A two-joint muscle that crosses the knee and the ankle
 It is an extremely strong ankle plantar flexor but also has a significant role at the knee.
 It attaches by two heads to the posterior surface of the medial and lateral condyles of the femur.
 After descending the posterior leg superficially, it forms a common Achilles tendon (often called
the heel cord by laypersons) with the soleus muscle and attaches to the posterior surface of the
calcaneus.
 Although its major function is at the ankle, it does span the knee posteriorly, has a good angle of
pull, and is a large muscle.
 Therefore, its contribution as a knee flexor cannot be overlooked.
 In addition, its unusual contribution to knee extension has been demonstrated in individuals with
no quadriceps muscle function
 In a closed kinetic chain action with the foot planted on the ground so that the distal segment
(leg) is stationary, the proximal segment (thigh) becomes the movable part.

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  This is also a reversal of muscle action in which the femur is pulled posteriorly, or into knee
extension. This feature of the gastrocnemius muscle makes it possible for a person to stand
upright without the use of the quadriceps muscles.
 Lateral Muscles of the Knee
o Tensor Fascia Lata Muscle
 Spans the knee laterally, essentially in the middle of the joint axis for flexion and extension.
 It contributes greatly to lateral stability.
 The gracilis and sartorius muscles span the knee medially, contributing greatly to medial
stability.
 The gastrocnemius and hamstring muscles provide posterior stability both medially and laterally,
and the quadriceps muscles provide anterior stability.

 Anatomical Relationships
o Muscles cross the knee either anteriorly or posteriorly.
o The rectus femoris is the most superficial muscle of the anterior group.
o At the mid- and lower thigh, the vastus lateralis and the vastus medialis are superficial on either side
of the rectus femoris.
o Deep to the rectus femoris and between the two vasti muscles is the vastus intermedialis
o The hamstring muscles are on the posterior thigh.
o Superficially, the biceps femoris (long head) is on the lateral side, and the semitendinosus is on the
medial side.
o Deep to these muscles is the short head of the biceps femoris (laterally) and the semimembranosus
(medially).
o The deepest muscle at the distal end of the thigh is the popliteus.
 It lies deep to the proximal heads of the gastrocnemius.
o The sartorius crosses the knee on the medial side, anterior to the gracilis, followed more posteriorly
by the semitendinosus
o The tensor fascia lata crosses the knee joint laterally by way of the iliotibial band.

 Summary of Muscle Action

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 Common Knee Pathologies
o Genu Valgum (“knock knees”)
 A malalignment of the lower extremity in which the distal segments (ankles) are
positioned more laterally than normal.
 The knees tend to touch while the ankles are apart.
o Genu Varum (bowlegs)
 Is the opposite malalignment problem in which the distal segments are positioned more
medially than normal.
 The ankles tend to touch while the knees are apart.
 Malalignment at one joint often affects alignment at an adjacent joint.
 Therefore, coxa varus is seen in conjunction with genu valgus, whereas coxa valgus may
be seen in conjunction with genu varus. 
o Genu Recurvatum (“back knees”)
 Is the positioning of the tibiofemoral joint in which range of motion goes beyond 0
degrees of extension.
o Patellar tendonitis (jumper’s knee)
 Characterized by tenderness at the patellar tendon and results from the overuse stress or
sudden impact overloading associated with jumping.
 It is commonly seen in basketball players, high jumpers, and hurdlers.
o Osgood-Schlatter disease 
 A common overuse injury among growing adolescents.
 It is an inflammation involving the traction-type epiphysis (growth plate) on the tibial
tuberosity of growing bone where the tendon of the quadriceps muscle attaches.
o Popliteal Cyst (Baker’s cyst)
 Is actually misnamed as a “cyst.”
 This general term refers to any synovial hernia or bursitis involving the posterior aspect
of the knee.
o Patellofemoral Pain Syndrome 
 No universal agreement on terminology and causation 
 Generally refers to a common problem causing diffuse anterior knee pain.
 It is generally considered the result of a variety of alignment factors, such as increased Q
angle, patella alta (high-riding patella), quadriceps weakness or tightness, weakness of
hip lateral rotators, and excessive foot pronation. 
o Chondromalacia Patella 
 The softening and degeneration of the cartilage on the posterior aspect of the patella,
causing anterior knee pain.
 Abnormal tracking of the patella within the patellofemoral groove causes the patellar
articular cartilage to become inflamed, leading to its degeneration. 
o Prepatellar Bursitis (housemaid’s knee)
 Occurs when there is constant pressure between the skin and the patella.
 It is commonly seen in carpet layers and is the result of repeated direct blows or sheering
stresses on the knee.
o Terrible Triad 
 A knee injury caused by a single blow to the knee and involves tears to the anterior
cruciate ligament, the medial collateral ligament, and the medial meniscus. 
o Miserable Malalignment Syndrome 
 An alignment problem of the lower extremity involving increased anteversion of the
femoral head and is associated with genu valgus, increased tibial torsion, and a pronated
flat foot.
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