THE KNEE

The Knee Joint

 Knee joint
• largest joint in
body
• very complex
• primarily a
hinge joint
 Bones
 Enlarged femoral condyles articulate on
enlarged tibial condyles
 Medial & lateral tibial condyles (medial &

lateral tibial plateaus) - receptacles for femoral

condyles
 Tibia – medial

• bears most of weight

 Bones
 Fibula - lateral
• serves as the
attachment for knee
joint structures
• does not articulate
with femur or patella
• not part of knee joint
 Bones
 Patella
• sesamoid (floating) bone
• imbedded in quadriceps &
patellar tendon
• serves similar to a pulley in
improving angle of pull,
resulting in greater
mechanical advantage in
knee extension
 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
 Tibiofemoral joint
 characteristics: - anterior and posterior stability is by
the anterior and posterior cruciate ligaments

 medial and lateral stability is provided by the medial

and lateral collateral ligaments

 the medial femoral condyle is longer than the lateral

femoral condyle, this contributes to external
rotation of the tibia at full knee extension which
locks the knee(screw - home mechanism)

 the concave tibial plateaus are covered by the

menisci, the medial plateau is larger that the lateral.

 the tibia rotates externally at full knee extension in

open kinematic chain movement.
 Tibiofemoral Joint
 the femur rotates internally on the
tibia in full extension in the closed
kinematic chain. (foot on the
ground).
 Screw home mechanism
 Knee “screws home” to fully extend due to the shape
of medial femoral condyle
• As knee approaches full extension tibia must externally
rotate approximately 10 degrees to achieve proper
alignment of tibial & femoral condyles
• In full extension
 close congruency of articular surfaces

 no appreciable rotation of knee

• During initial flexion from full extension

 knee “unlocks” by tibia rotating internally, to a degree,

from its externally rotated position to achieve flexion

 Patellofemoral joint
characteristics:
 patella articulates with the intercondylar
(trochlear)groove on the anterior aspect of the
femur.
 the patella slides inferiorly with knee flexion and
superiorly with knee extension.
 patella comes in contact with the femur at
approximately 20 -30 degrees of kneeflexion. As
flexion increases contact on patella goes superiorly
and ends on the odd facet (medial) at 135 degrees
of flexion.
 Tibial and femoral rotation can affect the
alignment of this joint and cause pathology of
the patella or femur's articular cartilage.
 Factors to be considered at the
patella femoral joint:
 Q angle is normally 15 degrees. measured by a
line drawn from the center of the patella proximally
to the ASIS and a second line drawn from the
center of the patella distally to the tibial tubercle
 the patellar alignment is maintained by the iliotibial
band and the lateral retinaculum (laterally) and the
pull of the vastus medialis (medially).
 malalignment of the patella can be caused by genu
valgum, wide pelvis, patella alta, lax medial
retinaculum, atrophy of Vmo, laterally placed tibial
tubercle, pronation of the subtalar joint and tight
lateral retinaculum.
 Patella Alta
• high riding patella
 Patella Baha
• low riding patella
 Tibiofemoral Joint
 Ligaments provide static stability
 Quadriceps & hamstrings contractions produce dynamic stability
 Articular cartilage surfaces on femur & tibia

 Menisci Functions
 attached to tibia
• deepen tibial fossa
• enhance stability
• - shock absorber
• - spreading stress over joint surface
• - decreasing cartilage wear
• - lubricate and provide nutrients to the joint
• - reduce friction during movement
 Meniscus
 Cartilage
• Medial Meniscus
• Lateral Meniscus
• Articular Cartilage
 Medial Meniscus
 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
 Menisci
 Medial
• the medial meniscus is firmly attached
to the tibia by the coronary ligament,
medial collateral ligament, anterior
cruciate ligament, semimembranosus.
• more subject to injury because of
attachments
• thicker posteriorly than anteriorly
 Menisci
• 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
 Knee Ligaments
 Ligaments
• Medial Collateral
• Lateral Collateral
• Anterior Cruciate
• Posterior Cruciate
 Cruciate Ligaments
 Anterior & posterior cruciate ligaments
• cross within knee between tibia & femur
• vital in respectively maintaining anterior & posterior
stability, as well as rotatory stability
 Anterior cruciate ligament (ACL) injuries
• one of most common serious injuries to knee
• mechanism often involves noncontact rotary forces
associated with planting & cutting, hyperextension, or by
violent quadriceps contraction which pulls tibia forward
on femur
 ACL
 prevents anterior displacement of the tibia on the
femur and checks internal rotation of the tibia on
the femur.

 attaches to the anterior medial tibia and runs

superiorly, posteriorly and laterally to the medial
aspect of the lateral femoral condyle
 ACL
 helps control rolling and gliding of
the femur during knee movement

 ACL is taught in all positions of knee

motion, with greatest tension in full
extension

 least taught at 30-60 deg of flexion

 PCL
 Posterior cruciate ligament
(PCL) injuries
• not often injured
• mechanism of direct contact
with an opponent or playing
surface driving tibia
posterior
 PCL
 runs form the posterior intercondylar area
of the tibia forward medial and upward to
the lateral aspect of the medial femoral
condyle

 prevents posterior displacement of the

tibia on the femur
 twists around the ACL with internal tibial
rotation
 acts as center axis of rotation
 Medial Collateral Ligament
 Two layers:
 deep layer is a thickening of the
medial joint capsule

 superficial layer is a strong broad

triangular band that run from
just below the adductor tubercle
to about 4-6cm below the medial
joint line

 checks valgus and external

rotation of the tibia on the femur
most taut in full extension

 attaches to the medial meniscus

 Medial Collateral Ligament
 Tibial (medial) collateral ligament (MCL)
• 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
 Lateral Collateral Ligament
 round band of
fibers running
from the lateral
femoral epicondyle
to the fibular head
 tight on extension
of the knee,
adduction and
external rotation
of the tibia on the
femur
 Ligaments
 Arcuate and
Popliteal complex
• thickening of the
capsule in the posterior
lateral aspect

 Posterior oblique
ligament
• help support the
posterior medial aspect
of the knee
 Coronary ligament
• attaches menisci to the
tibia
 Synovial cavity
 Synovial cavity
• supplies knee with synovial fluid
• lies under patella and between surfaces of tibia &
femur
• "capsule of the knee”
 Fat Pat
 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

 Anatomy Review
 Joint Capsule
 Bursae
 Bursae
• more than 10 bursae
in & around knee
• some are connected
to synovial cavity
• they absorb shock or
prevent friction
 Bursae
 Anteriorly:
 Quadriceps
• between the quad and
femur
 Prepatellar
• lies on top of the
patella (Housemaid’s
knee)
 Deep infrapatella
bursa
• between the patella
tendon and tibia
 Superfisical
infrapatella bursa
• between the patellar
tendon and skin
 Anatomy Review
 Bursae
 Bursae
 Posteriorly:
 Baker’s Cyst
• lies between the
semimembranosus
tendon and the
medial head of the
gastroc muscle.
 bursae also exist
beneath the ITB
tendon and Pes
Anserine proximal
to their insertions.
 Joints
 Extends to 180 degrees (0 degrees of
flexion)
 Hyperextension of 10 degrees or > not
uncommon
 Flexion occurs to about 140 degrees
 With knee flexed 30 degrees or >
• internal rotation 30 degrees occurs
• external rotation 45 degrees occurs
 Movements
 Flexion
• bending or decreasing
angle between femur &
leg, characterized by heel
moving toward buttocks
 Extension
• straightening or increasing
angle between femur &
lower leg
 Movements
 External rotation
• rotary movement of leg
laterally away from midline
 Internal rotation
• rotary movement of lower
leg medially toward midline
 Neither will occur unless
flexed 20-30 degrees or >
 Bones
 Key bony landmarks
• Superior & inferior patellar poles
• Tibial tuberosity
• Gerdy’s tubercle
• Medial & lateral femoralcondyles
• adductor tubercle
• Upper anterior medial tibial surface
• Head of fibula
 Soft tissue palpation
 infrapatella tendo  prepatella bursa
 quad tendon  infrapatella bursa
 pes anserine insertion
 fat pad
 ITB insertion
 biceps femoris
tendon
 medial and lateral  popliteal vein and
joint line artery(popliteal
 gastroc heads fossa)
 medial and lateral  common peroneal
collateral ligaments nerve
 Knee Evaluation (Palpation)
 Palpation - Soft  Medial and lateral
collateral ligaments
Tissue
• Vastus medialis
 Pes anserine
• Vastus lateralis  Medial/lateral joint
• Vastus intermedius capsule
• Rectus femoris  Semitendinosus
• Quadriceps and patellar  Semimembranosus
tendon
• Sartorius
 Gastrocnemius
• Medial patellar plica  Popliteus
• Anterior joint capsule  Biceps Femoris
• Iliotibial Band
• Arcuate complex
 Knee Evaluation (Palpation)
 Palpation of Swelling
• Intra vs. extracapsular swelling
• Intracapsular may be referred to as joint
effusion
• Swelling w/in the joint that is caused by synovial
fluid and blood is a hemarthrosis
• Sweep maneuver
• Ballotable patella - sign of joint effusion
• Extracapsular swelling tends to localize over the
injured structure
 May ultimately migrate down to foot and ankle
 Special Tests
 - valgus stress test  - Anterior drawer
 - posterior drawer  - McMurray’ test
 - Appley distractio  - Pivot shift
 - Nobles compression  - Patellar Apphresion
 - varus stress test  - lachman’s test
 - Godfrey’s test  - Appley compression
 - Slocum drawer  - Stutter test
 - Wilson’s sign
COMMON INJURIES TO
THE KNEE
 Quad contusion:
 etiology:
• trauma to the quad

presentation:
• possible ecchymosis
• pain with knee extension
• limited knee flexion
• tenderness over quad
 Patellofemoral Syndrome
 Etiology: dysfunction of the extensor
mechanism caused by :
 patella alta,
 lateral patellar tilt,
 Vmo dysplasia,
 Vastus lateralis hypertrophy
 increased Q angle
 squinting patella
 increased pain with prolonged sitting
 increased pronation.
 Presentation:
 anterior knee pain with descending
stairs,
 crepitus,

 pain with squatting or sitting for

prolonged periods,
 tenderness along the medial patellar

surface.
 Plica syndrome
 Etiology:
• remains of embryologic synovial tissue
around the patella that become irritated
with trauma causing anterior knee pain.
 Presentation:
 symptoms are similar to PFS, but
there is a palpable band on the
superior medial aspect of the patella
(most common)
 Patellar Tendonitis
 Etiology:
inflammation and or irritation of the
patellar tendon usually occurring in
athletes who have excessive
pounding through the knee
 Presentation:

 pain along the inferior pole of the

patella to palpation,
 pain with activity, jumping, stair

climbing
 tight quads/Hamstrings
 LIGAMENTOUS
INJURIES TO THE KNEE
 Anterior Cruciate Ligament
 prevents anterior displacement of
the tibia on the femur and checks
internal rotation of the tibia on the
femur.
 ACL is taught in all positions of knee

motion, with greatest tension in full

extension
 Etiology:
 hyperextension, internal rotation,
 hyperflexion by non-contact valgus

force with rotation can lead to ACL

rupture
 Presentation
 feeling of a "pop" inside of the knee
 unstable feeling

 positive ACL tests

 pain with movement.

 possibility of a hemarthrosis
 Posterior Cruciate Ligament
 prevents posterior displacement of
the tibia on the femur
 getting to be a more common injury
 Etiology:

 posterior force on the tibia,

 hyperextension with a varus or

valgus stress
 Presentation:

 positive PCL tests

 unstable feeling with activity

 possible hemarthrosis

 pain with movement

 Medial and Lateral Collateral

 prevent valgus(medial) and

varus(lateral) stress through the
knee.
 get taught with external rotation of

the tibia on the femur

 Etiology:

 varus or valgus stress through the

knee with the foot planted
 presentation:

 positive varus test (LCL)

 positive valgus test (MCL)

 unstable feeling with cutting

 pain over adductor tubercle

 possible swelling
 Meniscal Injury

 outer 1/3 of the meniscus is vascular

and can heal or be repaired
 act as shock absorbers, increase

joint congruency, aides to joint

lubrication
 etiology
 traction or compression with
rotation and slight flexion of the
knee
 Presentation

 pain along the joint line

 pain or clicking with McMurray's
 pain with squatting
 pain with stairs
 pain with hamstring contraction