The Knee Joint

• Knee joint
– largest joint in
body
Chapter 10 – very complex
The Knee Joint – primarily a hinge
joint
Manual of Structural Kinesiology Modified for Prentice WE:
Arnheim’s principles of

R.T. Floyd, EdD, ATC, CSCS athletic training, ed 12, New

York, 2006, McGraw-Hill;
from Saladin, KS: Anatomy
&physiology: the unity of
forms and function, ed 2,
New York, 2001, McGraw-
Hill.

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-1 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-2

Bones Bones

• Enlarged femoral condyles articulate on • Fibula - lateral

enlarged tibial condyles – serves as the
attachment for
• Medial & lateral tibial condyles (medial & knee joint
lateral tibial plateaus) - receptacles for structures
femoral condyles – does not articulate
with femur or
• Tibia – medial
patella
– bears most of weight – not part of knee
joint
Modified from Anthony CP, Kolthoff NJ: Textbook of anatomy and
physiology, ed 9, St. Louis, 1975, Mosby.

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-3 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-4

Bones Bones

• Patella • Key bony landmarks

– sesamoid (floating) bone – Superior & inferior patellar poles
– imbedded in quadriceps – Tibial tuberosity
& patellar tendon – Gerdy’s tubercle
– serves similar to a pulley – Medial & lateral femoral
in improving angle of condyles
pull, resulting in greater – Upper anterior medial tibial
mechanical advantage in surface
knee extension – Head of fibula Modified from Anthony CP, Kolthoff NJ: Textbook of anatomy and
physiology, ed 9, St. Louis, 1975, Mosby.

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-5 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-6

1
 Bones
• Three vasti muscles of quadriceps originate
on proximal femur & insert on patellar
superior pole
– insertion is ultimately on tibial tuberosity via
patella tendon
• Iliotibial tract of tensor fasciae latae inserts
on Gerdy’s tubercle
• Sartorius, gracilis, & semitendinosus insert
just below the medial condyle on upper
anteromedial tibial surface
© 2007 McGraw-Hill Higher Education. All rights reserved.
Joints
• Knee joint proper (tibiofemoral joint)
– classified as a ginglymus joint
• Sometimes referred to as trochoginglymus
joint internal & external rotation occur during
flexion
• Some argue for condyloid classification
• Patellofemoral joint
– arthrodial classification
– gliding nature of patella on femoral
condyles
© 2007 McGraw-Hill Higher Education. All rights reserved.
Joints
• Medial meniscus forms receptacle for medial
femoral condyle, Lateral meniscus receives
lateral femoral condyle
– Thicker on outside border & taper down very thin
to inside border
– Can slip about slightly, but held in place by
various small ligaments
– Medial meniscus - larger & more open C
appearance
– Lateral meniscus - closed C configuration
© 2007 McGraw-Hill Higher Education. All rights reserved.
Bones
• Semimembranosus inserts posteromedially on
medial tibial condyle
• Biceps femoris inserts primarily on fibula head
• Popliteus originates on lateral aspect of lateral
femoral condyle
• Tibial collateral ligament originates on medial
aspect of upper medial femoral condyle &
inserts on medial tibial surface
• Fibula collateral originates on lateral femoral
condyle very close to popliteus origin & inserts
on fibular head
10-7 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-8
Joints
• Ligaments provide static stability
• Quadriceps & hamstrings contractions produce
dynamic stability
• Articular cartilage surfaces on femur & tibia
• Menisci form cushions between bones
– attached to tibia
– deepen tibial fossa
– enhance stability
10-9 © 2007 McGraw-Hill Higher Education. All rights reserved. Modified from Anthony CP, Kolthoff NJ: Textbook of anatomy and 10-10
physiology, ed 9, St. Louis, 1975, Mosby.
Joints
– Either or both menisci may be torn in
several different areas from a variety
of mechanisms, resulting in varying
degrees of problems
• Tears often occur due significant
compression & shear forces during
rotation while flexing or extending
during quick directional changes in
running
10-11 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-12
2
 Joints Joints

• Anterior & posterior cruciate ligaments • Posterior cruciate

– cross within knee between tibia & femur ligament (PCL) injuries
– vital in respectively maintaining anterior & – not often injured
posterior stability, as well as rotatory stability – mechanism of direct
• Anterior cruciate ligament (ACL) injuries contact with an opponent
– one of most common serious injuries to knee or playing surface
– mechanism often involves noncontact rotary • Fibular (lateral)
forces associated with planting & cutting, collateral ligament (LCL)
hyperextension, or by violent quadriceps
contraction which pulls tibia forward on femur – infrequently injured Modified from Anthony CP, Kolthoff NJ: Textbook of anatomy and
physiology, ed 9, St. Louis, 1975, Mosby.

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-13 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-14

Joints Joints

• Tibial (medial) collateral ligament (MCL) • Synovial cavity

– maintains medial stability by resisting
valgus forces or preventing knee from
being abducted
– injuries occur commonly, particularly in
contact or collision sports
– mechanism of teammate or opponent may
fall against lateral aspect of knee or leg
causing medial opening of knee joint &
stress to medial ligamentous structures
© 2007 McGraw-Hill Higher Education. All rights reserved.
– supplies knee with synovial fluid
– lies under patella and between surfaces of tibia &
femur
– "capsule of the knee”
• Infrapatellar fat pad
– just posterior to patellar tendon
– an insertion point for synovial folds of tissue
known as “plica”
• an anatomical variant that may be irritated or
inflamed with injuries or overuse of the knee
10-15 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-16

Joints Joints

• Bursae • Extends to 180 degrees (0

– more than 10 degrees of flexion)
bursae in & • Hyperextension of 10 degrees or
around knee > not uncommon
– some are • Flexion occurs to about 140
connected to
degrees
synovial cavity
– they absorb • With knee flexed 30 degrees or >
shock or prevent – internal rotation 30 degrees occurs
friction – external rotation 45 degrees occurs

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-17 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-18

3
 Joints Movements
• Knee “screws home” to fully extend due to the • Flexion
shape of medial femoral condyle
– bending or decreasing
– As knee approaches full extension tibia must
externally rotate approximately 10 degrees to angle between femur &
achieve proper alignment of tibial & femoral leg, characterized by heel
condyles moving toward buttocks
– In full extension
• close congruency of articular surfaces • Extension
• no appreciable rotation of knee – straightening or
– During initial flexion from full extension increasing angle between
• knee “unlocks” by tibia rotating internally, to a femur & lower leg
degree, from its externally rotated position to
achieve flexion
© 2007 McGraw-Hill Higher Education. All rights reserved. 10-19 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-20

Movements Muscles
• Quadriceps muscle group
• External rotation – extends knee
– rotary movement of leg – located in anterior
laterally away from midline compartment of thigh
• Internal rotation – consists of 4 muscles
– rotary movement of lower • rectus femoris
leg medially toward midline • vastus lateralis
• Neither will occur unless • vastus intermedius
• vastus medialis
flexed 20-30 degrees or >

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-21 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-22

Muscles Muscles
• Q angle • Q angle
– Central line of pull for entire – Higher Q angles generally
quadriceps runs from ASIS to the predispose people in varying
center of patella degrees to a variety of potential
– Line of pull of patella tendon runs knee problems including lateral
from center of patella to center of patellar subluxation or dislocation,
tibial tuberosity patellar compression syndrome,
– Angle formed by the intersection of chondromalacia, and ligamentous
these two lines at the patella is the injuries
Q angle – For people with above normal Q
– Normally, angle will be 15 degrees angles, it is particularly important
or less for males & 20 degrees or to maintain high levels of strength
less in females & endurance in vastus medialis so
as to counteract lateral pull of
– Generally, females have higher vastus lateralis
angles due to a wider pelvis

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-23 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-24

4
 Muscles Muscles
• Hamstring muscle group • Two-joint muscles
– responsible for knee flexion – most effective when either origin or
– located in posterior compartment of thigh insertion is stabilized to prevent movement
– consists of 3 muscles in direction of the contacting muscle
• semitendinosus - medial, internal rotator – To a degree, muscles are able to exert
• semimembranosus - medial, internal rotator greater force when lengthened than when
• biceps femoris - lateral, external rotator shortened
– Hamstring muscles & rectus femoris are
• Popliteus assist medial hamstrings in
biarticular (two-joint) muscles
knee internal rotation

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-25 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-26

Muscles
• Ex. sartorius muscle
– increases its total length & becomes a
better flexor at knee when pelvis is rotated
posteriorly & stabilized by abdominal
muscles
• exemplified by trying to flex knee & cross the
legs in the sitting position
• one usually leans backward to flex legs at
knees
– Football kicker invariably leans well
backward to raise & fix the rectus femoris
origin to make it more effective as a knee
extensor
© 2007 McGraw-Hill Higher Education. All rights reserved.
Muscles
• Gracilis, sartorius, & semitendinosus join
together distally to form pes anserinus
– attaches to anteromedial aspect of proximal tibia
below the level of tibial tuberosity
– Their attachment & posteromedially line of pull
enable them to assist with knee flexion particularly
once the knee is flexed & hip is externally rotated
• Medial & lateral gastrocnemius heads attach
posteriorly on medial & lateral femoral
condyles
– assist with knee flexion
10-27 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-28

Muscles Muscles
Knee joint muscles location Knee joint muscles location

• Anterior - primarily knee • Posterior - primarily knee flexion

extension – Biceps femoris
– Rectus femoris – Semimembranosus
– Vastus medialis – Semitendinosus
– Vastus intermedius • Sartorius
– Vastus lateralis • Gracilis
• Popliteus
• Gastrocnemius

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-29 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-30

5
 Nerves Nerves
• Femoral nerves • Sciatic nerve
innervates the knee – tibial division
extensors (quadriceps) • semitendinosus,
semimembranosus,
– rectus femoris
biceps femoris (long
– vastus medialis head)
– vastus intermedius – common peroneal
– vastus lateralis (fibular) division
• biceps femoris (short
head)

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-31 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-32

Quadriceps Muscles Quadriceps Muscles

• Quadriceps muscles - vital in jumping • Rectus femoris (two-joint), vastus medialis,
– functions as a decelerator vastus intermedius, vastus lateralis (largest)
• when decreasing speed to change direction • All attach to patella then to tibial tuberosity via
patellar tendon
• when coming down from a jump
• All superficial & palpable except vastus
– eccentric contraction during decelerating intermedius (under rectus femoris)
actions • Strength or power may be indicated by vertical
– controls slowing of movements initiated in jump test
previous phases of the sports skill • Generally desired to be 25% to 33% stronger than
hamstring group

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-33 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-34

Quadriceps Muscles Rectus Femoris Muscle

• Strength & endurance is essential for

maintenance of patellofemoral stability
– often a problem Flexion of hip
– quads are particularly prone to atrophy
when injuries occur Extension of
knee
– may be developed by resisted knee
extension activities from a seated position Anterior pelvic
– functional weight bearing activities such as rotation
step-ups or squats are particularly useful
for strengthening & endurance

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-35 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-36

6
 Vastus Lateralis Muscle Vastus Intermedius Muscle

Extension of Extension of
knee knee

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-37 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-38

Vastus Medialis Muscle Hamstring Muscles

• Hamstring muscle group

– Semitendinosus
Extension of – Biceps femoris
knee
– Semimembranosus

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-39 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-40

Hamstring Muscles Semitendinosus Muscle

Flexion of knee
• Hamstring muscle strains very common
• “Running muscles” function in acceleration Extension of hip

• Antagonists to quadriceps muscles at knee Internal

rotation of
• Named for cordlike attachments at knee hip
• All originate on ischial tuberosity of pelvis Internal
• Semitendinosus inserts on anteromedial tibia rotation of
flexed knee
• Semimembranosus inserts on posteromedial
Posterior pelvic
tibia rotation
• Biceps femoris inserts on lateral tibial condyle
& head of fibula
© 2007 McGraw-Hill Higher Education. All rights reserved. 10-41 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-42

7
 Semimembranosus Muscle Biceps Femoris Muscle
Flexion of knee Flexion of knee
Extension of hip Extension
of hip
Internal rotation External
of hip rotation
Internal rotation of hip
of flexed External
knee rotation
of flexed
Posterior pelvic knee
rotation
Posterior pelvic
rotation

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-43 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-44

Popliteus Muscle Knee Extension

Flexion of knee • Agonists
– Rectus Femoris
Internal
rotation of
– Vastus Lateralis
flexed knee – Vastus Intermedius
– Vastus Medialis

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-45 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-46

Knee Flexion Knee Internal Rotation

• Agonists
– Biceps Femoris • Agonists
(Long & Short – Semitendinosus
Head) – Semimembranosus
– Semitendinosus – Popliteus
– Semimembranosus

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-47 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-48

8
 Knee External Rotation Web Sites
Radiologic Anatomy Browser
http://radlinux1.usuf1.usuhs.mil/rad/iong
• Agonists – This site has numerous radiological views of the
musculoskeletal system.
– Biceps Femoris University of Arkansas Medical School Gross Anatomy for
Medical Students
http://anatomy.uams.edu/anatomyhtml/gross.html
– Dissections, anatomy tables, atlas images, links, etc.
Loyola University Medical Center: Structure of the Human Body
www.meddean.luc.edu/lumen/meded/grossanatomy/index.htm
– An excellent site with many slides, dissections, tutorials, etc.
for the study of human anatomy
Wheeless’ Textbook of Orthopaedics
www.wheelessonline.com/
– This site has an extensive index of links to the fractures,
joints, muscles, nerves, trauma, medications, medical topics,
lab tests, and links to orthopedic journals and other orthopedic
and medical news.
© 2007 McGraw-Hill Higher Education. All rights reserved. 10-49 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-50

Web Sites Web Sites

Premiere Medical Search Engine Adam Healthcare Center
www.medsite.com http://adam.about.com/surgery/100088.htm#
– This site allows the reader to enter any medical condition and – Knee joint replacement
it will search the net to find relevant articles. American Academy of Orthopaedic Surgeons
Arthroscopy.com http://orthoinfo.aaos.org/category.cfm?topcategory=Knee
www.arthroscopy.com/sports.htm – Patient education library on the knee
– Patient information on various musculoskeletal problems of Edheads Activities
the lower extremity www.edheads.org/activities/knee/
Virtual Hospital – Allows you to perform virtual knee surgery
www.vh.org Gross Anatomy: The Functional Anatomy of the Knee Joint
– Numerous slides, patient information, etc. www.upstate.edu/cdb/grossanat/limbs8.shtml
Human Anatomy Online – Functional Anatomy of the Knee
www.innerbody.com/image/musc08.html Knee Ligament Anatomy and Injury
– Interactive musculoskeletal anatomy www.orthoassociates.com/knee_lig.htm
The Hip and Knee Institute – Anatomy and injuries of the Knee and its ligaments
www.hipsandknees.com/knee/index.html
– Arthritis of the Knee Joint
© 2007 McGraw-Hill Higher Education. All rights reserved. 10-51 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-52

Web Sites Web Sites

Duke Orthopaedics The Physician and Sportsmedicine
www.wheelessonline.com/ortho/anatomy_and_kinematics_of_th www.physsportsmed.com/issues/1997/05may/bach.htm
e_knee_joint – Acute Knee Injuries: When to Refer
– Anatomy and Kinematics of the knee joint The Physician and Sportsmedicine
Knee Injury: Meniscus www.physsportsmed.com/issues/1999/10_01_99/laprade.htm
www.patient.co.uk/showdoc/27000672/ – Acute Knee Injuries: On-the-Field and Sideline Evaluation
– Understanding the knee joint and purpose of meniscus
Smart Play: The Knee
www.smartplay.net/ouch/bodybits/b_bitsknee.html
– Anatomy, functions, injuries, etc. of the knee
Patellofemoral Instability
www.massgeneral.org/ortho/PatellofemoralInstability.htm
– Patella Femoral Alignment
Chiroweb.com
www.chiroweb.com/archives/21/24/03.html
– Abnormal Q Angle and Orthotic Support

© 2007 McGraw-Hill Higher Education. All rights reserved. 10-53 © 2007 McGraw-Hill Higher Education. All rights reserved. 10-54