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Chapter
Anatomy of the Knee

Bradley J. Margo∗ , Craig S. Radnay∗ , Giles R. Scuderi∗

The human knee evolved from that of Eryops, the common ancestor of rep-
tiles, birds, and mammals, over 320 million years ago. The Eryops knee was
bicondylar, with a femorofibular articulation, cruciate ligaments, and asym-
metric collateral ligaments. As evolution continued, the fibula migrated dis-
tally and the femur articulated with the tibia. The osseous patella was a later
development, occurring about 70 million years ago. At that time the anterior
femoral condyle extended proximally beneath the patella to form the sulcus
and completed the development of the patellofemoral joint. This evolution-
ary process led to the development of the knee, the human hinged joint.1−3
The embryonic development of the human knee joint begins with limb
buds, whose earliest appearance is in week 4. These limb buds are formed
from somatic mesoderm covered by an ectodermal layer. The somites dif-
ferentiate into three segments: the dermatome, which becomes skin; the
myotome, which becomes muscle; and the sclerotome, which becomes car-
tilage and bone. The earliest signs of the knee joint appear in week 6, as the
femur and tibia arise as a cartilage anlagen. At this time chondrification of
the femur, tibia, and fibula begins along with the early differentiation of the
patella and patella tendon. The collateral ligaments and cruciate ligaments
form in week 7, by week 10 the medial meniscus can be seen, and differen-
tiation continues with increased vascularity up to the 40th (full term) week.
At the end of the embryonic period, the knee resembles the adult structure.4

∗ Department of Orthopaedics Surgery, Insall, Scott, Kelly Institute for Orthopedics and

Sports Medicine, New York, NY 10065, USA.

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The knee joint at 12 weeks of gestation is a single synovial cavity.


Between 11 and 20 weeks of gestation the suprapatellar plica forms in about
30% of fetuses and separates the suprapatellar pouch from the main joint
cavity. The epiphyses of the distal femur and proximal tibia are both present
at birth. The proximal fibular epiphysis and patellar ossification center are
not present until age 3 years for females and age 4 years for males.3
The distal femoral and proximal tibial physes contribute the most to
longitudinal growth of the lower extremities. The distal femoral physis
contributes 70% of the total femoral growth and provides an average growth
of 1 cm per year. Closure of this physis is variable, but usually occurs at
12–14 years in girls and 14–16 years in boys. The proximal tibial physis
contributes 55% of the total tibia growth and grows 0.6 cm per year. The
proximal tibial physis closes around the same time as the distal femur.4

Bony Structures
The knee comprises three bones: the femur, tibia, and patella. The distal
femur has an asymmetric shape and is slightly cuboid. It provides areas of
attachment for the many ligaments and tendons about the knee (Fig. 1). The
medial epicondyle has a convex eminence in which the medial (tibial) col-
lateral ligament (MCL) attaches. The lateral epicondyle is smaller and less
prominent than its medial counterpart. It serves as the femoral attachment
for the lateral (fibular) collateral ligament (LCL).4 The epicondylar axis has
been defined, in normal knees, as a line that passes through the sulcus of the
medial epicondyle and the prominence of the lateral epicondyle. This line
in relation to the posterior condylar axis is externally rotated about 3.5◦ in
males and 1◦ in females.5
The tibia consists of medial and lateral condyles with which the dis-
tal femur articulates.4 The medial side is nearly flat, while the lateral side
is convex.6 The central aspect of the tibia has a spine that is between the
plateaus. This spine has a depression anteriorly that provides attachments
for the anterior horn of the medial meniscus, the anterior horn of the lat-
eral meniscus and the anterior cruciate ligament (ACL). Behind this are the
medial and lateral tubercles. These two structures do not appear to have any

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Anatomy of the Knee

Fig. 1. (A–D) Tendon and ligament attachments about the knee. (Copyright 2006 by
Elsevier. With permission.)

attachments. Anteriorly, the tibia has a tubercle for insertion of the patella
tendon. Two-to-three centimeters lateral to this tubercle is Gerdy’s tubercle,
which is the insertion site of the iliotibial band (ITB).4
Finally, the patella is considered a sesamoid bone that articulates with
the trochlea of the distal femur. The articular surface is divided into a
medial and a lateral facet, with the lateral side being broader and deeper.

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B.J. Margo, C.S. Radnay and G.R. Scuderi

Fig. 2. Morphologic variants of the patella.

Six different shapes of the patella have been described (Fig. 2). The first
two are considered stable, while the rest are considered variants that can
lead to instability. Considering the anterior position of the patella in the
extensor mechanism, the patella acts to protect the front of the knee and
increase leverage for the quadriceps femoris tendon.4

Soft Tissues
Muscles
The anterior aspect of the knee contains the quadriceps muscle group, which
comprises four distinct muscles with a common tendon insertion. The rec-
tus femoris muscle begins proximally as two heads from the ilium that
ultimately connect and form a muscle belly in the anterior thigh. It then
narrows to a tendon 5–8 cm above the patella. The vastus lateralis, the
largest muscle of the quadriceps group, begins as a broad aponeurosis at
the proximal part of the intertrochanteric line and extends to halfway down
the linea aspera on the femur. The distal aspect of the muscle has a fibrous
expansion into the lateral patellar retinaculum, which ultimately has con-
nections to the tibia. The vastus medialis may be divided into the vastus
medialis obliquus (VMO) and the vastus medialis longus. The fibers run
from the lower half of the intertrochanteric line to the medial lip of the

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Anatomy of the Knee

linea aspera. The VMO fibers arise more distally and are more oblique
in orientation, varying from 55◦ to 70◦ relative to the longus fibers. The
distal insertion is similar to the lateralis, with a fibrous expansion into the
medial patellar retinaculum. Finally, the vastus intermedius originates at
the anterior and lateral shaft of the femur. The quadriceps insertion into the
superior border of the patella is trilaminar, with the rectus femoris respon-
sible for the most superficial layer, the vastus medialis and vastus lateralis
contributing to the middle layer, and finally the insertion of the intermedius
forming the deepest layer. This insertion extends over the patella and then
becomes the patellar tendon. The patellar tendon travels from the inferior
border of the patella to the tibial tubercle. It is a strong, flat band of tissue
that measures about 5 cm in length.4,7
The medial side of the knee contains the sartorius, gracilis, semi-
tendinosus, and semimembranosus muscles, as well as the medial head
of the gastrocnemius. The pes anserinus muscles (sartorius, gracilis, and
semimembranosus muscles) are the dynamic medial stabilizers, which flex
and internally rotate the knee. The lateral side contains the iliotibial band
(ITB), biceps femoris, popliteus, and lateral gastrocnemius muscles.4

Menisci
The menisci are two crescent-shaped structures that act to deepen the tibia
surface for articulation of the distal femur. They are composed primar-
ily of collagen (75%) and noncollagenous proteins (8–13%). Type I col-
lagen is the primary collagen and accounts for about 90% of the total
collagen.6 It is largely arranged in a circumferential pattern that aids in
absorbing compressive loads about the knee. There are also radial fibers
parallel to the plateau that provide rigidity and help to decrease longitudinal
splitting.8
Each meniscus covers roughly the peripheral two-thirds of the matching
articular surface of the tibia. The peripheral border of each meniscus is
thick, convex, and attached to the inside of the capsule of the joint. The
inner border is thin, concave, and has a free edge.4 The menisci serve
many functions, including load transmission by increasing the contact area,

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distribution of synovial fluid, enhancement of articular conformity, and


prevention of soft tissue impingement during motion.6 The medial meniscus
can also provide anteroposterior stability in an ACL deficient knee, while
the lateral meniscus does not.9,10
The medial meniscus is C-shaped (almost semicircular), and is broader
posteriorly. The posterior attachment is firmly connected to the intercondy-
lar fossa of the tibia directly anterior to the posterior cruciate ligament (PCL)
insertion. The anterior attachment is usually at the anterior intercondylar
fossa just in front of the ACL insertion. The peripheral attachment is firm,
and continuous with the capsule. There is an intermeniscal ligament that
connects the anterior horn of the medial meniscus with the lateral meniscus
(Fig. 3).
In contrast to the medial meniscus, the lateral meniscus is almost cir-
cular; it covers a larger surface area than the medial meniscus. The lateral
meniscus has a posterior attachment just behind the posterior eminence
of the tibia which lies just in front of the posterior end of the medial
meniscus. Anteriorly, the lateral meniscus attaches on the front side of
the lateral process of the intercondylar eminence. Laterally, there is a
groove for the popliteus tendon which makes for a noncontinuous insertion

Fig. 3. Superior view of the tibial plateau. (Copyright 2006 by Elsevier. With permission.)

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Anatomy of the Knee

into the adjacent capsule.4 Finally, the lateral meniscus has fibrous bands
called meniscofemoral ligaments. While the significance of these struc-
tures is not fully understood, they serve to connect the lateral meniscus
to the intercondylar wall of the medial femoral condyle. The ligament of
Humphrey passes anteriorly to the PCL, while the ligament of Wrisberg
passes posteriorly. Several cadaveric studies have concluded that the pres-
ence of these ligaments is quite variable, with the ligament of Wrisberg
appearing more often.11

Ligaments
The ACL is the primary static stabilizer of the knee against anterior transla-
tion of the tibia on the femur. It originates from the medial femoral condyle
at the posterior aspect of the intercondylar notch. The ligament then travels
in an anterior, distal, and medial direction toward the tibia (Fig. 4). It aver-
ages 38 mm in length and 11 mm in width. The primary blood supply is by
the middle geniculate artery. The posterior tibial nerve supplies branches
to innervate the ACL that appear to have a proprioceptive function.4,7,12
The ligament is twisted through 90◦ and both the length and the tension of
different fibers in the ligament change as knee flexion occurs. The antero-
medial bundle fibers become tight in 90◦ of flexion, while the posterolateral
bundle fibers are tight in full extension. These changes in fiber length cor-
relate with their changing participation in the total ACL action as the knee
is flexed and extended.7,13−15
The PCL is believed to be the most important of the knee ligaments
because of its cross-sectional area, tensile strength, and location in the
central axis of the knee joint. It provides about 95% of the total restraint
to posterior translation of the tibia on the femur. The tensile strength of
the PCL is almost twice that of the ACL.16,17 Like the ACL, the PCL is
a continuum of fascicles with different portions being taut throughout the
ROM. The anterior portion, which forms the bulk of the ligament, tightens
in flexion, and the smaller posterior portion tightens in extension.18
The PCL originates posteriorly in the intercondylar notch off the medial
femoral condyle. The average length is 38 mm and the average width is

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B.J. Margo, C.S. Radnay and G.R. Scuderi

Fig. 4. Anterior and posterior views of the knee ligaments. (Copyright 2006 by Elsevier.
With permission.)

13 mm. The ligament travels posteriorly and distally to attach to the poste-
rior intercondyloid fossa of the tibia just posterior to the lateral meniscus,
1 cm below the articular surface. Lying anterior to the PCL, connecting the
posterior horn of the lateral meniscus to the medial femoral condyle, is the

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Anatomy of the Knee

ligament of Humphrey. The ligament of Wrisberg passes posteriorly to the


PCL to attach on the PCL12,18 (Fig. 4).
The medial side of the knee has been assessed in depth by Warren and
Marshall. It comprises three different layers with the investing structures.19
The first layer consists of the sartorius and the investing fascia. This is
encountered just below the skin. Layer 2 is the plane of the superficial
MCL, which is just under the pes muscles (Fig. 5). The proximal attach-
ment site of this important structure is somewhat circular and is on the
medial femoral epicondyle, near the instant center of rotation of the knee.
The superficial MCL consists of parallel and oblique components. The par-
allel fibers are anterior and begin at the medial epicondyle of the femur,
then continue as thick fibers that insert on the medial surface of the tibia.
The oblique fibers are posterior and start at the medial epicondyle, then
blend with layer 3 to form the posteromedial joint capsule.19−21 The liga-
ment is 10–12 cm in length, and the distal attachment site is much larger
and is 4.6 cm below the tibial articular surface, just posterior to the pes
anserinus insertion. As the knee goes into flexion, the anterior fibers of the
MCL tighten, whereas the posterior fibers relax. Also included in layer 2 is
the medial patellofemoral ligament, deep to the vastus medialis and super-
ficial to the joint capsule. This ligament connects the superomedial patella
to the medial femoral condyle and acts as the primary static restraint on
lateral patella excursion.19,22 Posterior and deep to the MCL is the posterior
oblique ligament, which is in fact a thickening of the deep posterior capsule
of the knee (layer 3). This ligament, which is tense in extension and loose
in flexion, helps prevent medial opening with valgus loading as well as
abnormal tibial external rotation with the knee in full extension. In a flexed
position, the anterior aspect of the posterior oblique ligament actually lies
underneath the MCL.
The deep MCL is found in layer 3, or the capsule, of the knee. This layer
is just below the superficial MCL. Anteriorly, there is a distinct separation
between the superficial and the deep MCL, while the two structures tend to
blend posteriorly. The deep MCL fibers are short, vertically oriented fibers
that extend from the femur to the midportion of the peripheral margin of the
meniscus and tibia16 (Fig. 5) Functionally, the superficial MCL appears to

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B.J. Margo, C.S. Radnay and G.R. Scuderi

Fig. 5. (A, B) Medial structures of the knee. (Copyright 2006 by Elsevier. With
permission.)

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Anatomy of the Knee

be the primary restraint on valgus stress and resists external rotation of the
tibia. The parallel fibers of the superficial MCL are under tension from full
extension to 90◦ of flexion but appear most taut from 45◦ to 90◦ of flexion.
The oblique fibers seem to have a minimal role in the overall function of
the superficial MCL. Finally, the deep MCL has only a weak, secondary
role in resisting valgus stress of the knee.20
The lateral knee has also been described in three layers. The most
superficial layer contains the iliotibial tract, biceps femoris, and peroneal
nerve. The second layer includes the patellar retinaculum and the lateral
collateral ligament (LCL). Finally, the third layer is the lateral part of the
joint capsule that is composed of a thin layer that circumferentially attaches
to the distal femur and proximal tibia23 (Fig. 6). The LCL itself is a strong,
round, fibrous cord which originates on the posterior part of the lateral
femoral condyle above the popliteus and inserts on the lateral fibular head,
just anterior to the styloid process.4 It is the major static support for varus
stress, whereas the iliotibial tract provides both dynamic and static support.
Next, the fabellofibular ligament is an expansion of fibers between the
LCL and the arcuate ligament. It runs from the fabella, a sesamoid bone
in the lateral head of the gastrocnemius, to the fibular head.24 The arcuate
ligament, also part of the posterolateral capsule, consists of the strongest and
most consistent fibers and forms a triangular sheet that extends proximally
from the fibular styloid. The lateral aspect of this is strong, with attachments
to the femur and popliteal tendon. The medial side is weaker and curves
around the popliteal muscle.
The popliteal muscle, included in layer 3, begins as a strong tendon
about 2.5 cm long from a depression anteriorly at the groove on the lateral
condyle of the femur. The tendon is surrounded by a synovial membrane
and passes under the arcuate ligament to form a flat, triangular muscle that
inserts on the posterior aspect of the proximal tibia. The primary function
of the popliteus appears to be to unlock the knee so as to allow flexion
by producing external rotation of the femur in the loaded position. These
structures, together with the PCL, act together to stabilize the posterolateral
corner against varus stress, posterior flexion, and external tibial rotation.6,25

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Fig. 6. (A, B) Lateral structures of the knee. (Copyright 2006 by Elsevier. With
permission.)

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Anatomy of the Knee

Nerves
The innervation about the knee can be thought of by location. There is a
posterior group, including the tibial nerve and obturator nerve. Anteriorly,
there is the femoral nerve, common peroneal nerve, and saphenous nerve.
The tibial nerve begins as a branch from the sciatic nerve in the pos-
terior aspect of the thigh. It runs distally through the popliteal fossa and
then continues in the interval between the two heads of the gastrocnemius
(Fig. 7). The sural nerve, a cutaneous branch, travels on the surface of
the gastrocnemius. The tibial nerve also has many muscular and articu-
lar branches. The largest articular branch is the posterior articular nerve,
which most consistently arises within the popliteal fossa and then trav-
els laterally to join the popliteal plexus. Fibers from this plexus penetrate
through the oblique popliteal ligament to innervate the posterior and per-
imeniscal capsule and synovial covering of the cruciates. There is some
evidence that the meniscus has innervation into the peripheral third of the

Fig. 7. Posterior view of the knee. (Copyright 2006 by Elsevier. With permission.)

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meniscus or the perimeniscal capsule. A final contributor to the popliteal


plexus is from the posterior division of the obturator nerve, a nerve that
follows the course of the femoral artery in the thigh.6,26
The saphenous nerve begins from the posterior division of the femoral
nerve. At the distal end of the sartorial canal, it penetrates the deep fascia
on the medial side of the knee between the sartorius and gracilis tendons.
The infrapatellar branch traverses the sartorius and joins the patellar plexus.
This branch provides innervation to the anteromedial capsule, anteromedial
skin, and patellar tendon.27 The patellar plexus lies in front of the patella
and patellar tendon. It has many origins, including the infrapatellar branch
and many branches from cutaneous nerves of the thigh.6
The common peroneal nerve enters the popliteal fossa lateral to the
tibial nerve and continues distally along the medial side of the biceps
femoris tendon. It passes between the biceps femoris tendon and the
lateral head of the gastrocnemius, and continues posterior to the fibu-
lar head (Fig. 7). It then travels superficially across the lateral aspect
of the fibular neck, before piercing the peroneus longus and dividing
into the superficial and deep peroneal nerves. The cutaneous branches
include the sural communicating and a smaller branch that innervates the
proximal anterolateral aspect of the leg. The articular branches are the lat-
eral articular nerve and recurrent peroneal nerve. The former innervates
the inferior lateral capsule and LCL; the latter innervates the anterolat-
eral joint.27

Blood supply
The femoral artery descends the anterior thigh through the adductor canal.
This canal is bounded by the vastus lateralis in front and laterally and behind
by the adductor longus and magnus. Before passing through the canal,
the femoral artery becomes the descending genicular artery. This artery
then splits into a saphenous branch and an articular branch. The saphenous
branch accompanies the saphenous nerve to the medial side of the knee
and passes between the sartorius and the gracilis before connecting with
the medial inferior genicular artery. The articular branch descends within

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Anatomy of the Knee

Fig. 8. Circulation and anterior anastomosis of the knee. (Copyright 2006 by Elsevier.
With permission.)

the vastus medialis and then forms an anastomosis with the medial superior
genicular artery and anterior recurrent tibial artery.4
The popliteal artery is the continuation of the femoral artery after it
exits the adductor canal, before entering the popliteal fossa. It continues
superficially to the popliteus fascia and then separates at the lower bor-
der of the popliteus into the anterior and posterior tibial arteries. It splits
into many muscular branches and five genicular arteries: medial superior,
lateral superior, middle, medial inferior, and lateral inferior.4 While all
four medial and lateral genicular branches supply blood to the menisci,
a majority comes from the superior and inferior lateral geniculates. Only
the peripheral third receives this blood supply. The middle genicular artery
splits into branches that pierce the synovium and form a plexus that covers
the ACL and PCL. These branches then anastomose with vessels that run
parallel to the collagen fibers.28
The anterior anastomosis around the knee is formed by the two medial
and the two lateral genicular branches, the descending genicular, the

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descending branch of the lateral femoral circumflex, and the anterior recur-
rent tibial (Fig. 8). This anastomosis essentially connects the femoral artery
with popliteal and anterior tibial arteries. It encircles the patella and then
splits into nutrient vessels at the inferior pole of the patella that ascend prox-
imally on the anterior surface of the bone. While the anterior skin of the
knee receives blood from both the medial and the lateral side, the primary
vascular supply comes from the medial side.4,6,29

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THE KNEE - A Comprehensive Review
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