KNEE JOINT

STRUCTURE OF THE KNEE

• Knee complex is composed of two distinct articulation located within a single

joint capsule the tibiofemoral joint and patellofemoral joint.

• Tibiofemoral joint: articulation between distal femur and the proximal tibia.
• Patellofemoral joint: articulation between posterior patella and the femur.

• Proximal Tibiofibular Joint

– (not part of knee, has soft-tissue connections, slightly influence knee
motion)
 MENISCI
• Accessory joint structures
• Tibiofemoral congruence is improved by the medial & lateral menisci,
which act to convert the convex tibial plateau into concavities for the
femoral condyle.

• Also play an important role in

– distributing weight-bearing forces,
– reducing friction between tibia & femur,
– joint stress (F/A) is reduced on joint’s articular cartilage
– serving as shock absorbers
 MENISCI
• The menisci are fibro cartilaginous disks with a semicircular shape.
• Medial Meniscus
– C-shaped
• Lateral Meniscus
– forms four fifths of a circle

• Covering one half to two thirds of

articular surface of tibial plateau
• The open anterior and posterior ends of the menisci are called
Anterior and Posterior horns
 MENISCI
• Medial condyle has a greater susceptibility to the enormous compressive loads
– that pass through the medial condyle during routine ADLs

• Menisci assume 50% to 70% of this imposed load

• These loads can be influenced by the presence of frontal plane mal alignment.
– The greater the degree of genu varum, the greater is the compression on the medial meniscus
• Anteriorly, the menisci are connected to each other, by the Transverse Ligament.
• Both menisci are also attached directly or indirectly to the patella via Patellomeniscal Ligaments
• At the periphery, the menisci are connected to the tibial condyle by the Coronary Ligaments
 MEDIAL MENISCUS

MEDIAL MENISCUS [MM]

• has greater ligamentous and capsular restraints, limiting translation to a greater
extent than LM
• Relative lack of mobility of medial meniscus may contribute to its greater
incidence of injury
• Ant. & Post. Horns of medial meniscus are attached to the ACL & PCL
 LATERAL MENISCUS [LM]

LATERAL MENISCUS [LM]

• Posteriorly, attaches to the PCL and medial femoral condyle through the
meniscofemoral ligaments.
• Tendon of popliteus muscle attaches to lateral meniscus.
• Popliteus tendon help restrain or control the motion of lateral meniscus.
• Addition of menisci
– Contact at the tibiofemoral joint is increased
– joint stress (F/A) is reduced on joint’s articular cartilage
• After the removal of a meniscus
– Contact area in TFJ is decreased,
– Increases joint stress

• Doubles the articular cartilage stress on the femur, and 6 to 7 times forces on
the tibial plateau.
• Increase in joint stress may contribute to degenerative changes within the
tibiofemoral joint .
• Location of a meniscal lesion along with the age and health of the patient ,
options available after injury because of the capacity of meniscus to heal.
• During first year of life
– meniscus contains blood vessels throughout the meniscal body.
• Once weight-bearing is initiated,
– vascularity begins to diminish, until only outer 25% to 33%
• After 50 years of age,
– only periphery of meniscal body is vascularized
• Horns & periphery -- well innervated
– with free nerve endings (nociceptors) & 3 different mechanoreceptor
 CAPSULE
• Joint capsule that enclose the tibiofemoral and patelofemoral joint is large and
lax
• Joint capsule is reinforced medially , laterally and posteriorly by capsular
ligaments.
• Capsule and ligaments restricting excessive joint motions to maintain joint
integrity and normal function
• And muscle play a role in stabilization
 LIGAMENT OF KNEE JOINT

• Resist or Control:
– excessive knee extension
– varus and valgus stresses at the knee
– Attempted adduction or abduction of the tibia, respectively
– anterior or posterior displacement of the tibia beneath the femur
– medial or lateral rotation of the tibia beneath the femur
– combinations of anteroposterior displacements and rotations of the tibia,
together known as rotatory stabilization of the tibia
 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
 MEDIAL COLLATERAL LIGAMENT (MCL)

• Medial collateral ligaments can be divided into a superficial portion and a deep
portion that are separated by a bursa.
• superficial portion,
• primary restraint to excessive abduction (valgus) and lateral rotation
stresses at the knee.
 MCL FUNCTION
• Resist a valgus stress at full extension
– because the MCL is taut in this position.
• As joint flexion is increased,
– MCL becomes more lax and greater joint space opening is allowed
(medially gapping)
• With the knee flexed,
– MCL plays a more significant role in resisting valgus stress, despite the
permitted joint gapping
• MCL also plays a supportive role in resisting anterior translation of the
tibia on the femur
• MCL has the capacity to heal when ruptured or damaged
– rich blood supply
 LCL FUNCTION

• primarily responsible for checking varus stresses

• primary role is to resist varus stresses,

– most successfully at full extension

• limit excessive lateral rotation of the tibia

 ANTERIOR CRUCIATE LIGAMENT (ACL)

Anterior cruciate ligament attaché distally to tibia on the lateral and anterior
aspect of medial intracondylor tibial spine.
 ACL FUNCTION

• primary restraint against

anterior translation (anterior shear) of the tibia on the femur
• secondary restraint against either varus or valgus motions
– (adduction and abduction rotations respectively) at the knee
• also responsible for resisting hyperextension of the knee
 POSTERIOR CRUCIATE LIGAMENT (PCL)
Shorter and less oblique structure than the ACL
cross-sectional area 120% to 150% greater than that of the ACL
PCL blends with the posterior capsule and periosteum as it crosses to its
tibial attachment
 PCL FUNCTION

• PCL serves as the primary restraint to posterior displacement/posterior shear, of

the tibia beneath the femur

• role in restraining varus & valgus stresses at knee

• role in both restraining and producing rotation of the tibia

 Taut with following
Ligament Function of ligament
Knee Position

 primary restraint against anterior

ACL  Full Extension translation (shear) of tibia on
femur.

 primary restraint against posterior

 intermediate positions and in
PCL translation (shear) of tibia on
maximal flexion.
femur.
 LIGAMENTS OF THE POSTERIOR CAPSULE

• Oblique Popliteal Ligament

• Posterior Oblique Ligament (POL)
• Arcuate Ligament
 LIGAMENTS OF THE POSTERIOR CAPSULE

• Posteromedial corner of capsule is reinforced by

– semimembranosus muscle
– Oblique Popliteal Ligament,
– stronger and more superficial Posterior Oblique Ligament

• The posterolateral corner of capsule is reinforced by

– Arcuate ligament,
– LCL,
– Popliteus muscle and tendon
 LIGAMENTS OF THE POSTERIOR CAPSULE

• Posterior oblique ligament & Arcuate Ligaments

• taut in full extension
• assist in checking hyperextension of the knee;
• check valgus force

• Oblique popliteal ligament

• Reinforce posteromedial knee joint capsule obliquely medial to lateral diagonal
from proximal to distal

• Arcuate ligament
• check varus forces
TIBIOFEMORAL
JOINT
 TIBIOFEMORAL JOINT STRUCTURE

• It is a double condyloid joint with three degree freedom of angular ( rotatory

motion)
• Flexion extension: sagittal plane ,coronal axis
• Abduction/ adduction: frontal plane sagittal axis
• Medial lateral rotation: transverse plane vertical axis.
TIBIOFEMORAL ALIGNMENT AND WEIGHT BEARING FORCES

• The anatomical longitudinal axis of femur is oblique directed inferiorly and

medially from its proximal to distal end
• Femoral and tibial longitudinal axis normally form an angle medially at the
knee joint that is femur is angled upto 5 degree off vertical creating normal
physiological valgus angle at the knee.
 FLEXION/EXTENSION
ROLLING AND GLIDING OF THE FEMORAL CONDYLES ON A FIXED TIBIA.

Flexion Extension
Femoral condyles roll posteriorly while Femoral condyles roll anteriorly while
simultaneously gliding anteriorly. simultaneously gliding posteriorly.
 FLEXION/EXTENSION
• Initiation of knee flexion (0o to 25o),
– 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,
– rolling of the femoral condyles is accompanied by a simultaneous anterior
glide
• Femur was moving on a fixed tibia
– e.g., during a squat
 FLEXION/EXTENSION

• The tibia is also capable of moving on a fixed femur during a seated knee extension
• e.g. the swing phase of gait
• When the tibia is flexing on a fixed femur
• Tibia both rolls and glides posteriorly on the relatively fixed femoral condyles
• Extension of the tibia on a fixed femur anterior roll and glide of the tibial plateau on
the fixed femur
 EXTENSION

TIBIA ON FEMUR FEMUR ON TIBIA

 FLEXION/EXTENSION - RANGE OF MOTION
• Passive range of knee flexion: 130o to 140o

• During an activity such as squatting, knee flexion may reach as much as 160 o

• Normal gait on level ground requires approximately 60o to 70o of knee flexion

• Ascending stairs requires about 80o

• Sitting down into and arising from a chair requires 90o of flexion or more.

• Knee joint extension (or hyperextension) up to 5 o is considered within normal limits

• Excessive knee hyperextension ( beyond 5o of hyperextension) genu recurvatum

 ROLE OF THE CRUCIATE LIGAMENTS IN
FLEXION/EXTENSION

In flexion of the femur In extension of the femur

Posterior rolling of the femoral condyles Anterior rolling of the femoral condyles
creates tension in the “rigid” ACL that creates tension in the “rigid” PCL that
results in an anterior translational force results in a posterior translational force
imposed by the ACL on the femur. imposed by the PCL on the femur.
 ROLE OF THE MENISCI IN FLEXION/EXTENSION
• Schematically represented, the oblique contact of the femur with the wedge-
shaped meniscus results in the forces of meniscus-on-femur (MF) and
femur-on-meniscus (FM).
• These can be resolved into vertical and shear components.
• Shear 1 assists the femur in its forward glide during flexion
• Shear 2 assists in the posterior migration of the menisci that occurs with knee
flexion.
• The posterior deformation of the menisci is assisted by muscular mechanisms
to ensure that appropriate meniscal motion occurs.
• During knee flexion
– semimembranosus exerts a posterior pull on the medial meniscus
– whereas the popliteus assists with deformation of the lateral meniscus
 MEDIAL/LATERAL ROTATION

• Medial condyle acts as the pivot point while the lateral condyles move through
a greater arc of motion
• With internal/external rotation of the tibia, There is more motion of the lateral
tibial condyle than of the medial tibial condyle in both directions; that is, the
longitudinal axis for medial/lateral rotation appears to be located on the medial
tibial plateau.
 VALGUS (ABDUCTION)/VARUS (ADDUCTION)

• Frontal plane motion at the knee, minimal, does exist and can contribute to
normal functioning of the tibiofemoral joint.
• Frontal plane ROM is typically only 8o at full extension, and 13o with 20o of
knee flexion
• Excessive frontal plane motion could indicate
ligamentous insufficiency.
 SCREW-HOME MECHANISM
• Screw-home mechanism of the tibio-femoral joint describes its rotation around
the longitudinal axis of the tibia.
• As the tibia moves on femur from fully flexed to the fully extended position, it
rotates externally
• This motion is reversed as the tibia moves back into fully flexed position.
• This screw-home mechanism provides more stability to the knee in any
position than would a simple hinge configuration of tibio-femoral joint.
 MUSCLES OF KNEE

• In non–weight-bearing activities,
• The hamstrings generate a posterior shearing force of the tibia on the femur that
increases as knee flexion increases, peaking between 75o and 90o of knee flexion.
• This posterior shear or posterior translational force can reduce strain on the ACL,
and increase strain on the PCL.
• the actions of the soleus and gluteus maximus muscles can influence knee
motion in weight-bearing.
• although they do not cross the knee joint, these muscles are capable of assisting
with knee extension.
 MUSCLES

• with the foot fixed on the ground by weight-bearing, soleus

muscle contraction can assist with knee extension by pulling
the tibia posteriorly
• gluteus maximus produce posterior shear of the femur on the
tibia (or a relative anterior shear of the tibia on the femur) that
would increase tension in the acl without offsetting co-
contraction of other muscles.
 MUSCLES

• Resultant pull of Vastus Lateralis muscle is 35o laterally

• Resultant pull of the Vastus Medialis muscle is 40o medially
• V L and VM muscles have a posterior attachment site, which results in a net
posterior or compressive force that averages 55o in the extended knee
• The compressive force from these muscles is present throughout the ROM but is
minimized at full extension and increases as knee flexion continues.
 MUSCLES

A. With the knee close to full extension, a forceful quadriceps contraction is

capable of inducing an anterior tibial translation.
B. Once the knee is flexed to greater than 60o, little to no anterior translation
occurs.
 THE PATELLA AS AN ANATOMIC PULLEY
• The quadriceps muscle belly lies parallel to the femur.
• The tendon of the muscle passes over the knee joint and attaches to the leg (tibia) via the patellar
tendon at the tibial tubercle.
• For knee joint extension, the joint axis is considered to be located through the femoral condyles.
• The MA for the quadriceps muscle force lies in space between the vector and the joint axis.
• Without the patella, The line of pull of the quadriceps muscle on the leg-foot segment would
follow the patellar tendon at the tibial tubercle and would lie parallel to the leg-foot segment

The line of pull and MA of the quadriceps muscle

without the patella

41
 THE PATELLA AS AN ANATOMIC PULLEY

• The patella
• Lies between the quadriceps tendon and the femur,
• Changing the angle that the patellar tendon makes with the leg (tibia), and
• Changing the line of pull of the quadriceps muscle away from the knee joint axis

With the patella’s pulley effect, the line of pull of the

muscle is deflected away from the joint axis, increasing
the MA of the muscle force.

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 PATELLOFEMORAL JOINT REACTION FORCES

• Patellofemoral joint reaction forces by the knee flexion angle

• As the knee is flexed further, the patellofemoral compressive load is
increased.
 Q - ANGLE (QUADRICEPS ANGLE)

• The Q-angle is the angle between

– a line connecting the anterior superior iliac spine to the
midpoint of the patella and
– the extension of a line connecting the tibial tubercle and the
midpoint of the patella
• 10o to 15o with the knee either in full extension or slightly flexed
is considered normal
 LOADS ON THE KNEE

• Knee is also a major weight bearing joint.

• The potential for torque development at the joint is large
• Joint is loaded in both compression and shear during daily activities.
• Weight bearing and muscle tension development contribute to these forces
• Compression dominant in fully extended knee
• Compressive Force : the increase in knee flexion increases the compressive
component of force acting at the joint. Second, as flexion increases, a larger
amount of quadriceps tension is required to prevent the knee from buckling
against gravity.
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