KNEE JOINT

It is the largest joint in the human

body
The knee joint is the largest and
most complicated joint in the
body.
It is the major weight-bearing joint
in the body.
It is prone to undergo
degenerative changes with
The main movement of the knee
is flexion - extension. For that
matter, knee act as a hinge joint
Secondary movement is internal
- external rotation of the tibia in
relation to the femur, but it is
possible only when the knee is
flexed.
TYPE
It is a synovial joint of modified hinge
variety. It is not a typical hinge joint because
it undergoes some degree of automatic
(conjunct) rotation during flexion and
extension of the knee.
It is a compound joint consisting of
three articulations:
right and left condylar joints between the
condyles of the femur and tibia, and
one saddle joint between the femur and
LIGAMENTS
1. Fibrous capsule
2. Ligamentum patellae
3. Tibial / medial collateral lig.
4. Fibular / lateral collateral lig
5. Oblique popliteal lig
6. Arcuate popliteal lig
7. Anterior cruciate lig
8. Posterior cruciate lig
9. Medial meniscus
10. Lateral meniscus
11. Transverse ligament
 FIBROUS CAPSULE
Very thin and deficient anteriorly.
FIBROUS CAPSULE
Very thin and deficient anteriorly.
Femoral attachment :
Femoral attachment: It is attached about half to one centimetre
beyond the articular margins. The attachment has three special
features.
 Anteriorly, it is deficient
 Posteriorly, it is attached to the intercondylar line.
 Laterally, it encloses the origin of the popliteus
Tibial attachment: It is attached about half to one
centimetre beyond the articular margins. The attachment
has three special features.

1 Anteriorly, it descends along the margins of the condyles

to the tibial tuberosity, where it is deficient.
2 Posteriorly, it is attached to the intercondylar ridge which
limits the attachment of the posterior cruciate ligament.
3 Posterolaterally, there is a gap behind the lateral condyle
for passage of the tendon of the popliteus.
Openings

The capsule has two constant gaps.

1 One leading into the suprapatellar bursa.

2 Another for the exit of the tendon of the popliteus.

Extra capsular
Ligaments

1- The Ligamentum
patellae lig. (ant),
2- The oblique popliteal
ligament
3. Arcuate ligament
3- The lateral collateral
lig.,
4- The medial collateral
lig.
7.5 cm long and 2.5 cm broad.
It directed upwards and laterally
and blends with the posterior
surface of the capsule.
Attended to the intercondylar line
and lateral condyle of femur.
Tibial Collateral or Medial Ligament

This is a long band of great strength. Superiorly, it is attached to the medial epicondyle of
the femur just below the adductor tubercle. Inferiorly, it divides into anterior and posterior
parts.

The anterior or superficial part is about 10 cm long and 1.25 cm broad, and is separated
from the capsule by one or two bursae. It is attached below to the medial border and
posterior part of the medial surface of the shaft of the tibia (see Fig. 2.26). It covers the
inferior medial genicular vessels and nerve, and the anterior part of the tendon of the
semimembranosus, and is crossed below by the tendons of the sartorius, gracilis and the
semitendinosus (Fig. 12.11a)

The posterior (deep) part of the ligament is short and blends with the capsule and with the
medial meniscus. It is attached to the medial condyle of the tibia above the groove for the
semimembranosus.

Morphologically, the tibial collateral ligament represents the degenerated tendon of the
adductor magnus muscle.
This ligament is strong and cord-like. It is about 5 cm
long. Superiorly, it is attached to the lateral epicondyle
of the femur just above the popliteal groove. Inferiorly,
it is embraced by the tendon of the biceps femoris, and
is attached to the head of the fibula in front of its apex
(see Fig. 2.33). It is separated from the lateral meniscus
by the tendon of the popliteus. It is free from the
capsule. The inferior lateral genicular vessels and nerve
separate it from the capsule (Fig. 12.11a).

Morphologically, it represents the femoral attachment

of the peroneus longus.
 STRUCTURES INSIDE THE KNEE JOINT
Anterior cruciate ligament:
- From ant. intercondylar area of tibia --
 upward, backward and laterally to
the lat. condyle of the femur.
- It is relaxed in knee flexion, tense in
extension so it prevents hyper-
extension.

Posterior cruciate ligament:

- From post. Intercondylar area of tibia
 upwards, forward and medially to
ant. part of medial femoral condyle.
- It is relaxed in extension, tense in
flexion so it prevents hyperflexion and
anterior femoral dislocation.
1- The medial semilunar cartilage (Medial meniscus): C-
shaped, fixed to the capsule of the knee joint and to the medial
collateral ligament (liable to injury), its ant. Horn is attached to
the most ant. part of the intercondylar area of the upper end tibia
and connected to the lat. semilunar cartilage by the transverse lig.
2- The lateral semilunar cartilage (lat. Meniscus): Circular in
shape, more mobile (separated from capsule and lat. collateral
lig. by popliteus tendon, so it is more adaptive to twisting
movement and less liable to injury.
 THE SYNOVIAL MEMBRANE
1- lines the capsule,
2- attaches to the margins of
the articular surfaces,
3- attaches to the peripheral
edges of the menisci
(semilunar cartilages),
4- covers the front of the ant.
cruciate ligament, and the
back of posterior cruciate
ligament.
5- communicates with:
- suprapatellar bursa,
- popliteus bursa,
- semimembranosus burse,
- gastrocnemius bursa.
MOVEMENTS OF THE KNEE JOINT:

1- Flexion: By the Hamstring muscles + gracilis,

gastrocnemius, sartorius, popliteus, plantaris

2- Extension: By the Quadriceps femoris + tensor fascia

latae.

3- Locking of the knee joint = medial rotation of the

femur on the tibia in full extension (or lateral rotation
of the tibia) . It occurs by Biceps femoris.

4- Unlocking of the Knee: In standing (tibia fixed) =

lateral rotation of femur on tibia, In supine or sitting
(tibia free) = Medial rotation of tibia. By popliteus +
sartorius, gracilis, semitendinosus and semimembrenosus.
RELATIONS OF THE KNEE JOINT:
BURSAE RELATED TO THE KNEE JOINT:
1- Anterior to the knee:
1. supra-patellar bursa
2. prepatellar bursa
3. superficial infra-patellar bursa
4. deep infrapatellar bursa

2- Posterior to the knee:

1. popliteus bursa
2. semimembrenosus bursa
3. semitendinosus bursa
4. gastrocnemius bursa
5. gracilis bursa
6. biceps bursa
7. sartorius bursa
Secondary movement is internal - external
rotation of the tibia in relation to the femur, but it is
possible only when the knee is flexed.[
IMAGING OF THE KNEE JOINT:

A- Plain X- Ray
AP view.

B- X- Ray of Patella
(knee flexed).

C- Transverse MRI
Showing the patello-
femoral joint.
RADIOGRAPH OF THE KNEE JOINT (CONT.):
PATELLAR DISLOCATION
Add figure
Apprehension test

https://youtu.be/lm0Xw_29A5k
PATELLAR
APPREHENSION SIGN
The clinician will instruct the patient to be positioned in a
supine or sitting position on the bench with his/her knee
flexed to 30 degrees. The quadriceps should be relaxed to
allow passive movements of the patella. The clinician will
perform this technique by using their thumb of both hands,
and pressing on the medial side of the patient's patella.
The test is positive if it produces pain and apprehension. If
the test is positive, take notice of the patient's facial
expression, as he/she maybe surprised by the amount of
lateral displacement of the patella, and may feel
uncomfortable or apprehensive, as the patella reaches the
maximal lateral displacement. The patient may even reach
for the clinician hands or attempt to straighten his/her knee
in an attempt to pull the patella back to the relative normal
position.[2
Arthroscopy of Knee Joint

Arthroscopy is an endoscopic examination that allows visualization of

the interior of the knee joint cavity with minimal disruption of tissue
(Fig. B7.36). The arthroscope and one (or more) additional
cannula(e) are inserted through tiny incisions, known as por tals.
The second cannula is for passage of specialized tools (e.g.,
manipulative probes or forceps) or equipment for trim ming,
shaping, or removing damaged tissue. This technique allows removal
of torn menisci, loose bodies in the joint (such as bone chips), and
débridement (the excision of devi talized articular cartilaginous
material) in advanced cases of arthritis. Ligament repair or
replacement may also be per formed using an arthroscope. Although
general anesthesia is usually preferable, knee arthroscopy can be
performed using local or regional anesthesia. During arthroscopy, the
articular cavity of the knee must be treated essentially as two
separate (medial and lateral) femorotibial articulations, owing to the
imposition of the synovial fold around the cruciate ligaments.
Force is applied to the back of the knee when the joint is partly
flexed.
Force is applied to the front of a bent knee (sometimes called
“dashboard injury” because it’s common in car accidents).
Force is applied to the side of the knee when the foot is on the
ground (for example, during a tackle).
The knee is hyperextended (straightens too much), usually by
force.
The knee joint twists in an unnatural way (for example, when
playing basketball or skiing).
LATERAL COLLATERAL
LIGAMENT SPRAIN
Not as common as the MCL sprain.
Caused by a medial force to the
knee joint or a twisting.
PCL
Coronal plane.....adduction and abduction.....collateral
ligaments
Sagital plane....flexion and extension...cruiciate
ligaments
Rotatory movements.....meniscus

Refer Next slide

STABILITY OF THE KNEE JOINT

Structurally, the knee joint is relatively weak because of the

incongruence of its articular surfaces. The tibial condyles are too small
and shallow to hold the large convex femoral condyles. The
femoropatellar articulation is also not quite stable because of their
shallow articular surfaces and due to an outward angulation between
the long axes of the femur and tibia.

Factors The stability of the knee joint is maintained by the following

factors:

1. Strength and actions of the surrounding muscles and tendons.

2. Medial and lateral collateral ligaments maintain side-to side

stability.

3. Cruciate ligaments maintain anteroposterior stability.

If the anterior cruciate ligament is torn the tibia
is pulled excessively forward on the femur
(anterior drawer sign) and if the posterior
cruciate ligament is torn the tibia is pulled
excessively backward
PCL injuries are produced by some sort of external
trauma, such as a "dashboard injury" in which a person
hits their flexed knee against the dashboard during a
motor vehicle accident.
A direct blow to the front of the shinbone or a fall onto
your knee with your foot pointing down can also cause
a PCL injury
ACL stretches and tears (either partial or complete) are
one of the most common injuries to the knee.6 ACL
injuries usually occur during a physical activity that
involves either suddenly stopping or changing
direction, such as football. While most ACL injuries are
non-contact injuries that occur from landing on the leg
funny or an abnormal twist, sustaining a direct hit to
the knee may also result in an ACL injury.5
Drawers sign….
Initial clinical assesment in cruciate ligament injury

Refer……
LCL injuries often occur as a result of a blow or hit to the inside of
the knee(medial side) which pushes the knee outward(laterally)
MENISCUS TEAR
Meniscus are cushions
in the knee joint that
help make it more
stable.
Medial meniscus is
attached to posterior
and medial side, it is
more often injured.
Lateral meniscus is
more freely moving,
less often injured.
Meniscal tears: The injuries to menisci are
commonly caused by the twisting strains in a
slightly flexed knee, as in kicking a football. The
meniscus may get separated from the capsule,
or it may be torn longitudinally (bucket-handle
tear) or transversely.
The medial meniscus is more prone to injury
than the lateral because of its firm fixity to tibial
collateral ligament, and greater excursion
during the rotatory movements. The lateral
meniscus is protected by the popliteus muscle
because its medial fibres pulls the posterior
horn of meniscus backward, so that it is not
crushed between the articular surfaces.
Pain on the medial rotation of tibia on the femur
indicates injury of the medial meniscus; while
pain on the lateral rotation of tibia on the femur
Examination of meniscal injury

The Steinmann I test is carried out with the knee flexed at 90 degrees and a
sudden external rotatory force is applied on the tibia to test the medial
meniscus. The result is pain along the medial joint line. Internal tibial rotation
is used for lateral meniscal pain

https://youtu.be/eFjuYxUpD-g

For meniscal injury

 McMurrays Test

IR of the tibia + Varus stress = lateral meniscus

ER of the tibia + Valgus stress = medial meniscus

OSGOOD-SCHLATTER
The femur is growing faster
than the quad muscle and
creates a traction on the tibial
tuberosity where the patellar
tendon attaches.
Affects males age 12-16
Affects females age 10-14
PATELLAR TENDONITIS
High force
repetitive injury
usually a result of
jumping and/or
abrupt change of
direction.
Osteoarthritis: Being a weight-bearing joint, the knee
joint is commonly involved in osteoarthritis
(degenerative wear and tear of articular cartilages). The
movements may be painful, limited, and produce
grating. Radiographs of the knee region reveal
osteophytes, i.e., peripheral lipping of the articular ends.
D/D BETWEEN OA AND RA

OA…involvement of articular cartilage

RA …..involvement of synovial membrane

But in later stages… in OA fibrosis of synovial

membrane leading to loose body formation
In the vascular zone beneath the stress area of the
cartilage, cysts are formed. Gradually these cysts
increase in size due to hyperaemia. These cysts usually
communicate with the joint through small openings.
The articular cartilage continues to the rubbed away
and the subjacent bone becomes unprotected and
exposed, which becomes eburnated containing cysts.
CHANGES IN THE SYNOVIAL MEMBRANE.-
RA
The synovial membrane of the joint is first affected. It
becomes hyperaemic, swollen and proliferated. There is
presence of numerous lymphocytes and plasma cells
(as mentioned above). An effusion accumulates so the
joint becomes swollen. From the edges of the synovial
membrane near its junction with the articular cartilage
an inflammatory granulation tissue spreads which is
known as 'pannus'. With the development of pannus
the articular cartilage is gradually destroyed. This is
caused by adhering to and penetrating into the
articular cartilage. It also prevents absorption of
nutrient synovial fluid. The inflamed synovial
membrane behaves in 'malignant' fashion. When
cartilage destruction has occurred, the subjacent bone
is also eroded by intrusion of pannus.
With the development of pannus the articular cartilage is gradually destroyed. This
is caused by adhering to and penetrating into the articular cartilage. It also prevents
absorption of nutrient synovial fluid. The inflamed synovial membrane behaves in
'malignant' fashion. When cartilage destruction has occurred, the subjacent bone is
also eroded by intrusion of pannus. The bone becomes rarefied as a consequence of
hyperaemia associated with the disease.As mentioned above synovial hypertrophy
with effusion result in swelling of the joint. The capsule and ligaments become
stretched and lax in some situations. There may be associated muscular spasm. The
tendons may be dislodged or even rupture leading to joint deformities, subluxation
and even dislocations.When healing occurs, inflammatory granulation tissue is
converted into fibrous tissue. This leads to fibrous rgical im ankylosis with
permanent restriction of movements. Secondary osteoarthritis may develop in
faulty mechan- ics of the joints and damaged cartilages. In extreme rare cases there
may be bony ankylosis by the formation of bony trabeculae between the component
bones due to eroded articular surfaces.The indirThe tendon sheaths often
hypertrophy so that nodules may develop on the tendons. Such thickening of the
tendon sheaths may cause triggering. At the wrist this may cause median nerve
compression. Tendon may be involved by invasion of the inflammatory process. This
alongwith ischaemic changes may cause tendon rupture. Subcutaneous nodules are
separate entity and is seen in 20% of cases. These nodules occur in the
subcutaneous tissue, most often in the extensor surface of the forearm, though
these may occur anywhere.Clinical
OA KNEE

Calcification on synovial m
On an X-ray, there's less space between the bones in
OA. But in RA, the bone is more eroded.
IN OA THERE IS
ASYMMETRICAL
JOINT SPACE
REDUCTION
ESPECIALLY
STARTS FROM
MEDIAL
PART,BECAUSE IN
OA ALREADY
WEIGHT BEARING
IS ONE OF THE
CAUSE. BUT
SYMMETRICAL
SPACE
REDUCTION IN RA
Frontal X-ray of the knees of a 72
year old female with osteoarthritis of
the knees. Osteoarthritis (or
arthrosis) is a common degenerative
disease characterised by a loss of the
cartilage that lines the joints between
bones. This leads to pain, swelling
and occasionally may result in the
loss of function of the affected joint.

increased radiolucency indicates

degeneration ….osteopo
Aspiration of the knee joint: The collections of fluid are
common in the knee joint. It gives rise to swelling above
and at the sides of the patella. In such cases, patellar tap
often demonstrates a floating patella. Aspiration of the
fluid can be done on either side of the ligamentum
patellae. But the joint is usually approached from its
lateral side using three bony points as landmarks for the
needle insertion: (a) tibial tuberosity, (b) lateral
epicondyle of the femur, and (c) apex of patella. This
triangular area is also used for drug injection in treating
the knee pathology.
Aspiration of Knee Joint
Fractures of the distal end of the femur, or lacerations of
the anterior thigh, may involve the suprapatellar bursa and
result in infection of the knee joint. When the knee joint is
infected and inflamed, the amount of synovial fluid may
increase. Joint effusions, the escape of fluid from blood or
lymphatic vessels, results in increased amounts of fluid in
the joint cavity. Because the suprapatellar bursa
communicates freely with the synovial cavity of the knee
joint, fullness of the thigh in the region of the
suprapatellar bursa may indicate increased synovial fluid.
This bursa can be aspirated to remove the fluid for
examination. Direct aspiration of the knee joint is usually
performed with the patient sitting on a table with the knee
flexed. The joint is approached laterally, using three bony
points as landmarks for needle insertion: the anterolateral
tibial (Gerdy) tubercle, the lateral epicondyle of the femur,
TIBIO-FIBULAR JOINTS

Tibo-fibular joints are three-superior, middle, and

inferior.
Superior tibio-fibular joint is a plane synovial joint. It is formed
by an oval or circular articular facet on the postero-lateral part
of lateral condyle of tibia and a reciprocal articular surface of
the head of fibula. Both surfaces are covered with hyaline
cartilage. The joint is enveloped by fibrous capsule and lined
by synovial membrane.It is supplied by the nerve to the
popliteus and a branch from the common peroneal nerve.The
joint permits some gliding movement during dorsi-flexion of
the foot (See mechanism of movements of ankle joint).
Middle tibio-fibular joint is a fibrous joint and formed by the
crural interosseous membrane connecting interosseous
borders of the shafts of both tibia and fibula. Traced below, the
membrane is continuous with the interosseous ligament of the
inferior tibio-fibular joint. Upper border of the interosseous
membrane is free, above which the anterior tibial vessels pass
in the anterior crural region along the medial side of the neck
of fibula. A little above the inferior tibio-fibular joint the
membrane is pierced by the perforating branch of the
peroneal artery.
Most of the fibres of the interosseous mem brane are
directed downward and laterally, except in the upper
part where they are directed medially and
downward.Relations: In front, tibialis anterior, extensor
hallucis longus, extensor digitorum longus, peroneus
tertius, anterior tibial vessels and deep peroneal
nerve;Behind, tibialis posterior and flexor hallucis
longus.
Inferior tibio-fibular joint is a syndesmosis type of
fibrous joint. It connects the concave triangular rough
surface of the lower end of tibia with the convex
triangular rough surface of the lower end of fibula. The
ligaments of the joint are interosseous, anterior and
posterior tibio-fibular.
The interosseous ligament is a strong and short band
which connects the opposing rough surfaces of the
tibia and fibula. A small synovial recess of ankle joint
extends upward for about 4 mm in the lower part the
interosseous ligament.
The anterior tibio-fibular ligament passes downward
and laterally in front of the interosseous ligament.
The posterior tibio-fibular ligament extends downward
and laterally behind the interosseous ligament. A few
fibres of the posterior ligament are continuous with the
inferior transverse ligament which extends horizontally
from the malleolar fossa of the fibula to the posterior
margin of the lower end of tibia and its malleolus. The
inferior transverse ligament extends below the
articular surface and accentuates the concavity of the
tibio-fibular mortise of the ankle joint.
During dorsi-flexion of the foot, the ligaments of the
inferior tibio-fibular joint are stretched and the lower
end of fibula is displaced laterally and slightly rotated
outward (See mechanism of movement of the ankle
joint).
The joint is supplied by the deep peroneal nerve, nerve
to the popliteus and tibial nerve.
AK datta