Biomechanics

of the

Knee Dr. KARTHIKEYAN S

 Articulating surface

1. The tibiofemoral joint

2. The patellofemoral joint

 Ginglymus – (Hinge) ?
 A freely moving joint in which the bones are so articulated as to
allow extensive movement in one plane.
 Arthodial – (Gliding) ?
 6 degrees of freedom
 3 Rotations
 3 Translations
 Rotations
lex/Ext – 00 – 1400
 Varus/Valgus – 60 – 80 in extension
 Int/ext rotation – 250 – 300 in flexion
 Translations
 AP 5 - 10mm
 Compression/Distraction 2 - 5mm
 Medial/Lateral 1-2mm
 The lateral femoral condyle
 Shifted anteriorly in relation to medial
 Articular surface is shorter
 Inferiorly, the lateral condyle appears to be longer
 Two condyles are separated –
 Inferiorly by Intercondylar notch
 Anteriorly by an asymmetrical, shallow groove called
the Patellar Groove or Surface
Medial condyle is 50% larger than lateral condyle.
 Meniscus

 2 asymmetrical fibro cartilaginous joint disk called Menisci are located on tibial plateau.
 The medial meniscus is a semicircle & lateral is 4/5 of a ring
By increasing
congruence, menisci play in reducing friction between the joint segment & serve as
shock absorber.

 Unique attachment of medial menisci –

 Medial collateral ligament (MCL)
 Semitendinous muscle
 Unique attachment of lateral menisci –
 Anterior & posterior
meniscofemoral ligament
 Posterior cruciate ligament (PCL)
 Popliteus muscle
 The compression of the menisci by the tibia and the femur generates
outward forces that push the meniscus out from between the bones.
 The circumferential tension in the menisci counteracts this
radial force.

 Provision of stability
 Shock absorption
 Provision of increased congruity
 Aids lubrication
 Prevents synovial impingement
 Limits extremes of flexion & extension

 Transmits loads across the joint – 50- 100% of load

is transmitted through menisci
 Reduces contact stresses
 Ligament of knee joint

 Collateral ligament
 Medial collateral ligament (MCL)
 Lateral collateral ligament (LCL)
 Cruciate ligament
 Anterior cruciate ligament (ACL)
 Posterior cruciate ligament (PCL)
 Posterior capsular ligament
 Meniscofemoral ligament
 Posterior capsular ligament

 Oblique popliteal ligament

 Posterior oblique ligament
 Arcuate ligament:
 Arcuate ligament lateral branch
 Arcuate ligament medial branch
 Flexion/Extension

 The axis for tibiofemoral flexion and extension can

be simplified as a horizontal line passing through the
femoral epicondyles.

 Although this transepicondylar axis represents an

accurate estimate of the axis for flexion and
extension, it should be appreciated that this axis is
not truly fixed but rather shifts throughout the ROM.

 Much of the shift in the axis can be attributed to the

incongruence of the joint surfaces.
 The large articular surface of the femur and the
relatively small tibial condyle create a potential
problem as the femur begins to flex on the fixed
tibia.

 If the femoral condyles were permitted to roll

posteriorly on the tibial plateau, the femur would run
out of tibia and limit the flexion excursion (Fig. 11-
25).
 For the femoral condyles to
continue to roll as flexion
increases without leaving the
tibial plateau, the femoral
condyles must
simultaneously glide
anteriorly (Fig. 11-26A).
 The initiation of knee flexion (0 to 25), therefore,
occurs primarily as rolling of the femoral condyles on
the tibia that brings the contact of the femoral
condyles posteriorly on the tibial condyle.

 As flexion continues, the rolling of the femoral

condyles is accompanied by a simultaneous anterior
glide that is just sufficient to create a nearly pure
spin of the femur on the posterior tibia with little
linear displacement of the femoral condyles after 25
of flexion.
 Extension of the knee from flexion is essentially a
reversal of this motion.

 Tibiofemoral extension occurs initially as an anterior

rolling of the femoral condyles on the tibial plateau,
displacing the femoral condyles back to a neutral
position on the tibial plateau.
 After the initial forward rolling,
the femoral condyles glide
posteriorly just enough to
continue extension of the
femur as an almost pure spin
of the femoral condyles on the
tibial plateau (see Fig. 11-26B).
 This description shows- Femur was moving on a
fixed tibia (e.g., during a squat).

 The tibia, of course, is also capable of moving on a

fixed femur (e.g., during a seated knee extension or
the swing phase of gait).
 In this case, the movements would be somewhat
different. When the tibia is flexing on a fixed femur,
the tibia both rolls and glides posteriorly on the
relatively fixed femoral condyles.

 Extension of the tibia on a fixed femur incorporates

an anterior roll and glide of the tibial plateau on the
fixed femur.
 Role of the Cruciate Ligaments and Menisci in
Flexion/Extension

 If the cruciate ligaments are assumed to be rigid

segments with a constant length, posterior rolling of the
femur during knee flexion would cause the “rigid” ACL to
tighten (or serve as a check rein).

 Continued rolling of the femur would result in the taut

ACL’s simultaneously creating an anterior translational
force on the femoral condyles (Fig. 11-27A).
During knee extension, the femoral condyles roll
anteriorly on the tibial plateau until the “rigid” PCL
checks further anterior progression of the femur,
creating a posterior translational force on the
femoral condyles (see Fig. 11-27B).
 The anterior glide of the femur during flexion may be
further facilitated by the shape of the menisci.

 The wedge shape of the menisci posteriorly forces the

femoral condyle to roll “uphill” as the knee flexes.

 The oblique contact force of the menisci on the

femur helps guide the femur anteriorly during
flexion while the reaction force of the femur on the
menisci deforms the menisci posteriorly on the tibial
plateau (Fig. 11-28).
 Posterior deformation occurs because the rigid
attachments at the meniscal horns limit the ability of
the menisci to move in its entirety.

 Posterior deformation also allows the menisci to

remain beneath the rounded femoral condyles as the
condyles move on the relatively flat tibial plateau.
 As the knee joint begins to
return to extension from full
flexion, the posterior margins
of the menisci return to their
neutral position.
As extension continues, the anterior margins of
the menisci deform anteriorly with the femoral
condyles.
 The motion (or distortion) of the menisci is an
important component of tibiofemoral flexion and
extension.

 Given the need of the menisci to reduce friction and

absorb the forces of the femoral condyles that are
imposed on the relatively small tibial plateau, the
menisci must remain beneath the femoral condyles
to continue their function.
 The posterior deformation of the menisci is assisted
by muscular mechanisms to ensure that appropriate
meniscal motion occurs.

 During knee flexion, for example, the

semimembranosus exerts a posterior pull on the
medial meniscus (Fig. 11-29), whereas the popliteus
assists with deformation of the lateral meniscus.
 Flexion/Extension Range of Motion
 Passive range of knee flexion is generally considered to
be 130° to 140°.

 During an activity such as squatting, knee flexion may

reach as much as 160° as the hip and knee are both flexed
and the body weight is super-imposed on the joint.

 Normal gait on level ground requires approximately 60°

to 70° of knee flexion, whereas ascending stairs requires
about 80°, and sitting down into and arising from a chair
requires 90° of flexion or more.
 hyperextension) up to 5° is
considered within normal
limits.
Excessive knee hyperextension (i.e., beyond 5° of
hyperextension) is termed genu recurvatum.
 Many of the muscles acting at the knee are two-joint
muscles crossing not only the knee but also the hip or
ankle.

 Therefore, the hip joint’s position can influence the knee

joint’s ROM. Passive insufficiency of the rectus femoris
could limit knee flexion to 120° or less if the hip joint is
simultaneously hyperextended.

 When the lower extremity is in weight-bearing, ROM

limitations at other joints such as the ankle may cause
restrictions in knee flexion or extension.
 Medial/Lateral Rotation

 Medial and lateral rotation of the knee joint are angular

motions that are named for the motion (or relative
motion) of the tibia on the femur.

 These axial rotations of the knee joint occur about a

longitudinal axis that runs through or close to the medial
tibial intercondylar tubercle.

 Consequently, the medial condyle acts as the pivot point

while the lateral condyles move through a greater arc of
motion, regardless of the direction of rotation (Fig. 11-
31).
 As the tibia laterally rotates on the femur, the medial
tibial condyle moves only slightly anteriorly on the
relatively fixed medial femoral condyle, whereas the
lateral tibial condyle moves a larger distance
posteriorly on the relatively fixed lateral femoral
condyle.

 During tibial medial rotation, the medial tibial

condyle moves only slightly posteriorly, whereas the
lateral condyle moves anteriorly through a larger arc
of motion.
During both medial and lateral rotation, the knee
joint’s menisci will distort in the direction of
movement of the corresponding femoral condyle
and, therefore, maintain their relationship to the
femoral condyles just as they did in flexion and
extension.
 Axial rotation is permitted by articular incongurence
and ligamentous laxity. Therefore, the range of knee
joint rotation depends on the flexion/extension
position of the knee.

 When the knee is in full extension, the ligaments are

taut, the tibial tubercles are lodged in the
intercondylar notch, and the menisci are tightly
interposed between the articulating surfaces;
consequently, very little axial rotation is possible.
 As the knee flexes toward 90,
capsular and ligamentous
laxity increase, the tibial
tubercles are no longer in
the intercondylar notch, and
the condyles of the tibia and
femur are free to move on
each other.
 The maximum range of axial rotation is available at
90 of knee flexion. The magnitude of axial rotation
diminishes as the knee approaches both full
extension and full flexion.

 At 90°, the total medial/lateral rotation available is

approximately 35°, with the range for lateral rotation
being slightly greater (0° to 20°) than the range for
medial rotation (0° to 15°).
 Valgus (Abduction)/Varus (Adduction)

 Frontal plane motion at the knee, although minimal,

does exist and can contribute to normal functioning
of the tibiofemoral joint.

 Frontal plane ROM is typically only 8° at full

extension, and 13° with 20° of knee flexion.

 Excessive frontal plane motion could indicate

ligamentous insufficiency.
 Coupled Motions
 Typical tibiofemoral motions are, unfortunately, not
as straightforward.

 In fact, biplanar intra-articular motions can occur

because of the oblique orientation of the axes of
motion with respect to the bony levers.

 The true flexion/extension axis is not perpendicular

to the shafts of the femur and tibia.
 Therefore, flexion and extension do not occur as pure
sagittal plane motions but include frontal plane
components termed “coupled motions” (similar to
coupling that occurs with lateral flexion and rotation
in the vertebral column).

 As already noted, the medial femoral condyle lies

slightly distal to the lateral femoral condyle, which
results in a physiologic valgus angle in the extended
knee that is similar to the physiologic valgus angle
that exists at the elbow.
 Flexion is, therefore, considered to be coupled to a
varus motion, while extension is coupled with valgus
motion.
 Automatic or Locking Mechanism of the Knee
 There is an obligatory lateral rotation of the tibia
that accompanies the final stages of knee extension
that is not voluntary or produced by muscular forces.
This coupled motion (lateral rotation with
extension) is referred to as automatic or terminal
rotation.

 We have already noted that the medial articular

surface of the knee is longer (has more articular
surface) than does the lateral articular surface (see
Fig. 11-3).
 Consequently, during the last 30° of knee extension
(30° to 0°), the shorter lateral tibial plateau/femoral
condyle pair completes its rolling-gliding motion
before the longer medial articular surfaces do.

 As extension continues (referencing non–weight-

bearing motion of the tibia), the longer medial
plateau continues to roll and to glide anteriorly after
the lateral side of the plateau has halted.
 This continued anterior motion of the medial tibial
condyle results in lateral rotation of the tibia on the
femur, with the motion most evident in the final 5 of
extension.

 Increasing tension in the knee joint ligaments as the

knee approaches full extension may also contribute
to the obligatory rotational motion, bringing the
knee joint into its close-packed or locked position.
 The tibial tubercles become lodged in the intercondylar
notch, the menisci are tightly interposed between the
tibial and femoral condyles, and the ligaments are taut.

 Consequently, automatic rotation is also known as the

locking or screw home mechanism of the
knee.

 To initiate knee flexion from full extension, the knee

must first be unlocked; that is, the laterally rotated tibia
cannot simply flex but must medially rotate
concomitantly as flexion is initiated.
 A flexion force will automatically result in medial
rotation of the tibia because the longer medial side
will move before the shorter lateral compartment.

 If there is a lateral restraint to unlocking or

derotation of the femur, the joint surfaces, ligaments,
and menisci can become damaged as the tibia or
femur is forced into flexion.
 This automatic rotation or locking of the knee occurs
in both weight-bearing and non–weight-bearing
knee joint function.

 In weight-bearing, the freely moving femur medially

rotates on the relatively fixed tibia during the last
30 of extension.

 Unlocking, consequently, is brought about by

lateral rotation of the femur on the tibia before
flexion can proceed.
 The motions of the knee joint,
exclusive of automatic
rotation, are produced to a
great extent by the muscles
that cross the joint.
 Patellofemoral Joint
 Embedded within the quadriceps muscle, flat,
triangularly shaped patella is the largest sesamoid
bone in the body.

 The patella is an inverted triangle with its apex directed

inferiorly. The posterior surface is divided by a vertical
ridge and covered by articular cartilage (Fig. 11-39).

 This ridge is situated approximately in the center of the

patella, dividing the articular surface into approximately
equally sized medial and lateral facets.
  A second vertical ridge toward the medial border that
separates the medial facet from an extreme medial edge,
known as the odd facet of the patella.

 It reduce friction between quadriceps tendon & femoral

condyle.The patella functions primarily as an anatomic pulley for the
quadriceps muscle.

 The ability of patella to perform its function without restricting

knee motion depends on its mobility.

 Because of the incongruence of the patellofemoral joint, however, the

patella is dependent on static and dynamic structures for its stability.
 The posterior surface of the patella in the extended
knee sits on the femoral sulcus (or patellar surface)
of the anterior aspect of the distal femur (Fig. 11-40).

 The femoral sulcus has a groove that corresponds to

the ridge on the posterior patella and divides the
sulcus into medial and lateral facets.
 Patellofemoral Articular Surfaces
and Joint Congruence

 In the fully extended knee, the patella lies on the

femoral sulcus.

 Because the patella has not yet entered the

intercondylar groove, joint congruency in this
position is minimal, which suggests that there is a
great potential for patellar instability.
  At 100 – 200 of flexion – contact with inferior
margin of medial & lateral facet.

 By 900 of flexion – all portion of patella contact

with femur except the odd facet.

 Beyond 900 of flexion – medial condyle inter the

intercondylar notch & odd facet achieves contact
for the first time.

 At 1350 of flexion – contact is on lateral & odd

facet with medial facet completely out of contact.

 At full flexion, the patella is lodged in the intercondylar

groove.
 Patello-femoral joint stability

 PFJ is under permanent control of 2 restraining

mechanism across each other at right angle.
 Transvers group of stabilizer
 Longitudinal group of stabilizer

 Transvers stabilizer –
 Medial & lateral retinaculum
 Vastus Medialis & Lateralis
 The lateral PF ligament contributes 53% of total force when in full
extension of knee
 Longitudinal stabilizer- quadriceps and patella tendon
 M e d i a l - l a t e r a l p o s i ti o n i n g o f
patella / patellar tracking

 When the knee is fully extended & relax, the patella should be
able to passively displaced medially or laterally not more then
one half of patella.

 Imbalance in passive tension or change in line of pull of

dynamic structures will substantially influence the patella.

 Abnormal force may influence the excursion ofpatella even in its

more secure location within intercondylar notch in flexion.
 Medial & l a t e r a l f o r c e on p a t e l l a

 Since the action line of quadriceps & patellar ligament

do not co-inside, patella tend to pulled slightly laterally
& increase compression on lateral patellar facets.
 Larger force on patella may cause it to subluxation
or dislocate off the lateral lip of femur.
 Genu valgum increase the obliquity of femur &oblique
the pull of quadriceps.
 Patellofemoral Joint Stress

 The patellofemoral joint can undergo very high

stresses during typical activities of daily living.

 Joint stress (force per unit area) can be influenced by

any combination of large joint forces or small contact
areas, both of which are present during routine
flexion and extension of the tibiofemoral joint.
 The patellofemoral joint reaction (contact) force is
influenced by both the quadriceps force and the knee
angle.

 As the knee flexes and extends, the patella is pulled

by the quadriceps tendon superiorly and
simultaneously by the patella tendon inferiorly.

 The combination of these pulls produces a posterior

compressive force of the patella on the femur that
varies with knee flexion.
 Despite the small contact area that the patella has
with the femur in full extension, the minimal
posterior compressive vector of the vastus lateralis
and vastus medialis muscles maintains low joint
stress at full extension.

 This is the rationale for the use of straight-leg raising

exercises as a way of improving quadriceps muscle
strength without creating or exacerbating
patellofemoral pain.
 Q - Angle

 Theangle between the extended

anatomical axis of the femur & the
linebetween the center of the patella
& the tibial tubercle

 Normal Q angle
› In flexion
 Males
 13 degrees

 Females
 18 degrees

› In extension
 8 degrees
 Q - Angle Line 1
Anterior
Superior
Limbs with larger Q angles
Iliac Spine
have a greater chance for
(ASIS) Q- Line 1
lateral patellar Angle ASIS to
subluxation.
Line 2
midpoint
Of patella
Midpo
 FACTOR INCREASING - Line 2
int of
 Genu valgum patella Tibial
 tubercle to
Increased femoral
Tibial midpoint of
anteversion
tubercle patella
 External tibial torsion
 Laterally positioned tibial
tuberosity
 Tight lateral retinaculum
 Tibio-Femoral joint forces

Position
 Standing on both feet - Same as body weight
 Swing phase - Half of body weight
 unilateral stance phase – 2-4 times body weight
 Jogging – 6 times body weight
 Patello-femoral joint loading

Walking
› 0.3 x body weight
 Ascending Stairs
› 2.5 x body weight
 Descending Stairs
› 3.5 x body weight
 Squatting
› 7 x body weight
 Goal of Knee replacement

 Restoring mechanical alignment

 Restoring the joint line

 Balancing ligaments

 Maintaining a normal Q-angle

 Vert
Mecha ica Femoral

VERTI nic l Shaft

al Axi Axis
Axis
CAL
s
6◦

AXIS
3◦

9◦

9
Trans
0◦
verse
Knee
Axis
3◦

3◦

Trans
verse
ANATOMICA
L Anatomic 6
Tibiofemoral
AXIS Axis ◦
Angle

Mechanical
Axis
Thank you