Anatomy of the Knee

Bones and Articulations

The knee joint is the largest joint in the body. The knee is a synovial hinge type joint. The
entire weight-bearing load is transferred through the knee joints. When describing the
knee, four bones and their articulations should be discussed: the femur, the tibia, the
fibula, and the patella. Each articulation surface is covered with hyaline cartilage. The
primary articulation of the knee is between the condyles of the femur and tibia. This
articulation is separated by the medial and lateral menisci, which serve to deepen the
articular surfaces and aid in lubrication and cushioning of the joint (Jenkins, 1991, pp.
233-239). Although not a part of the knee joint, the articulation of the tibia and fibula is
significant due to its importance in weight bearing. The patellofemoral joint is a synovial
gliding type joint. The patella is a sesamoid bone contained in the tendon of the
quadriceps muscle. The articulation consists of the underside of the patella and the
patellar grove of the femur. The gliding of the patella in the femoral grove allows for
increased efficiency of the quadriceps muscle.

Musculature

Many muscles acting on the thigh have their insertions around the knee. Although not
participating in gross knee movements these muscles are significant in the dynamic
stabilization of the knee joint. Only the muscles specifically participating in knee flexion,
extension, internal, and external rotation are discussed here.

The anterior muscles of the knee act primarily as knee extensors. The quadriceps femoris
muscle is the principle muscle involved in knee extension. This muscle can be divided
into four distinct parts: the rectus femoris, vastus medialis, vastus lateralis, and the vastus
intermedius. All four parts of this muscle come together to insert on the proximal edge of
the patella, which then transfers their action, by way of the patellar tendon, to the tibia.

The principle muscles involved in knee flexion are the hamstring muscle group. This
group is comprised of the biceps femoris, semitendinosus, and the semimembranosus
muscles. Their insertion occurs on the proximal tibia and head of the fibula. The biceps
femoris muscle has an additional action of externally rotating the tibia. While the
semitendinosus and semimembranosus muscles also have an additional role of internally
rotating the tibia. Other muscles participating in knee flexion and internal rotation are the
sartorius, and gracilis muscles. The popliteus muscle also serves to internally rotate the
knee in a non-weight bearing position. Additional muscles involved in isolated knee
flexion include the gastrocnemius and plantaris muscles.

Range of Motion

The principle motions of the knee joint are flexion and extension; however, it does allow
for some degree of rotation (Hoppenfeld, 1976, pp. 186-188). The arc of motion of the
knee defined by Hoppenfeld (1976) is typically about 0 extension to 135 of flexion.
The amount of internal and external rotation about the knee is approximately 5 to 10 in
each direction (Hoppenfeld, 1976, pp. 186-188). It is in extension that the rotational
component of the knee joint is necessary. The knee is unable to reach full extension
without a small amount of external rotation of the tibia on the femur. This need for
external rotation is due to the fact that the medial femoral condyle is approximately 1/2-
inch longer than the lateral femoral condyle (Hoppenfeld, 1976, pp. 186-188). The
external rotation of the tibia allows the knee to achieve full extension. This mechanism is
known as the "screw home" mechanism and it allows the knee to be held in full extension
without undue fatigue of the surrounding musculature (Hoppenfeld, 1976, pp. 186-188).

Static Stabilizers

Static stabilization of the knee is provided by the ligamentous structures and to a lesser
extent the joint capsule surrounding the knee articulations. The principle stabilizing
ligaments of the knee are discussed here.

The anterior portion of the knee joint is stabilized partly by the medial and lateral patellar
retinacula, which are extensions of the quadriceps femoris muscle (Tortora, 1992, pp.
202-205). The patellar tendon gives added support to the anterior portion of the knee.

The oblique popliteal ligament and the arcuate popliteal ligament stabilize the posterior
aspect of the knee (Tortora, 1992, pp. 202-205). The oblique popliteal runs from the
intercondylar fossa of the femur to the head of the tibia. While the arcuate popliteal rises
from the lateral condyle of the femur to attach to the styloid process of the head of the
tibia.

The tibial (medial) collateral and the fibular (lateral) collateral ligaments serve to
stabilize the medial and lateral aspects of the knee joint respectively. These ligaments
also serve to restrain rotation of the knee (Jenkins, 1991, pp. 233-239). The tibial
collateral ligament is a broad, flat ligament that runs from the medial condyle of the
femur to the medial condyle of the tibia. A deep portion of this ligament blends
posteriorly with the joint capsule of the knee, which is also attached to the medial
meniscus. The fibular collateral ligament is more rounded and cordlike and extends from
the lateral epicondyle of the femur to the lateral aspect of the head of the fibula. These
ligaments are especially important stabilizers of rotational and lateral movement when
the knee is in the extended position (Jenkins, 1991, pp. 233-239).

Two important intra-articular ligaments that provide static support to the knee are the
anterior (ACL) and posterior (PCL) cruciate ligaments. Although the ligaments are intra-
articular they are not contained within the joint capsule of the knee (Hall-Craggs, 1990,
pp. 400-406). The ACL extends from the anterior area between the condyles of the tibia
in a posterior and lateral direction to a posterior area on the medial surface of the lateral
condyle of the femur (Hall-Craggs, 1990, pp. 400-406). The ACL functions to prevent
anterior displacement of the tibia on the femur. The PCL runs from a posterior depression
between the condyles of the tibia in an anterior and medial direction to the lateral side of
the medial femoral condyle (Hall-Craggs, 1990, pp. 400-406). The PCL functions to
prevent posterior translation of the tibia on the femur. Additionally both the ACL and
PCL serve to reduce rotation of the femur on the tibia. The ligaments are tense in all
positions, but increase their tension in the extremes of flexion and extension (Jenkins,
1991, pp. 233-239).

Arteries, Nerves, and Bursa

Blood is supplied to the knee via the popliteal artery. The popliteal artery originates from
the external iliac artery, which gives rise to the femoral artery in the proximal thigh. The
femoral artery passes posterior to the knee and becomes the popliteal artery.

The knee joint and surrounding musculature is innervated by a number of nerves of the
lower limb. Originating from the lumbosacral plexus the femoral and obturator nerves
innervate the front and anteromedial sides of the thigh. The sciatic nerve, which rises
from the sacral plexus supplies the posterior thigh and divides above the knee to form the
common peroneal and tibial nerves.

Various bursae are located about the knee joint for purposes of decreasing friction over
tendons and bones. The suprapatellar bursa is located between the deep surface of the
quadriceps muscle and the distal part of the femur. This bursa is in communication with
the joint capsule of the knee. The prepatellar bursa is located between the superficial
surface of the patella and the skin. An infrapatellar bursa is located between the patellar
ligament and the skin. The deep infrapatellar bursa is situated between the proximal tibia
and the patellar ligament. Other bursae decrease friction at the attachment sites of the
gastrocnemius, gracilis, sartorius, semitendinosus, and semimembranosus muscles
(Jenkins, 1991, pp. 233-239).

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