KNEE COMPLEX

Sagar Naik, PT

2
KNEE COMPLEX

Sagar Naik, PT

Knee complex plays a major role in supporting the body during dynamic
and static activities. In a closed kinematic chain the knee joint works in conjunction
with the hip joint and ankle to support the body weight in the static erect posture.
Dynamically, the knee complex is responsible for moving and supporting the body in
sitting and squatting activities and for supporting and transferring the body weight
during locomotor activities. In an open kinematic chain the knee provides mobility for
the foot in space. The knee is not only one of the largest joints in the body but also the
most complex.
The knee complex is composed of two distinct articulations within a
single joint capsule:
Tibiofemoral joint
The tibiofemoral joint is the articulation between the distal femur and the
proximal tibia.
Patellofemoral joint
The patellofemoral joint is the articulation between the patella and the
femur.

Tibiofemoral Joint:
The tibiofemoral, or knee joint, is a double condyloid joint with 2 of freedom
of motion.
Flexion and extension occur in the sagittal plane around a coronal axis;
medial and lateral rotation occurs in the transverse plane about a vertical
axis.
Femoral Articular Surface:
The large medial & lateral condyles on the distal femur form the proximal
articular surfaces of the knee joint.
The condyles have a large and very obvious curvature anteroposteriorly but
are also each slightly convex in the frontal plane.
The two condyles are separated by the intercondylar notch or fossa through
most of their length, but are joined anteriorly by an asymmetrical, shallow,
saddle-shaped groove called the patellar groove or surface; the patellar
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Sagar Naik, PT

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surface is separated from the tibial articular surface by two slight grooves
that run obliquely across the condyles.
The shaft of the femur is not vertical but is angled in such a way that femoral
condyles do not lie immediately below the femoral head, but somewhat
medial.
Given the obliquity of the shaft of the femur, the lateral condyle lies more
directly in line with the shaft than does the medial condyle.
The articular surface of the lateral condyle is also not as long as the articular
surface of the medial femoral condyle.
When the patellofemoral surface is excluded, it can be seen that the lateral
tibial surface stops before the medial.
The medial condyle extends further distally than the lateral so that, despite
the angulation of the shaft of the femur, the distal end of the femur is
essentially horizontal.
Tibial Articular Surface:
The articulating surfaces on the tibia that correspond to the femoral
articulating surfaces are the two concave, asymmetrical medial and lateral
tibial condyles or plateaus.
The proximal tibia is enlarged as compared to the shaft and overhangs the
shaft posteriorly.
The articulating surface of the medial tibial condyle is 50% larger than that
of the lateral condyle and the articular cartilage of the medial tibial condyle
is three times thicker.
A roughened area and two bony spines called the intercondylar tubercles
separate the two tibial condyles.
These tubercles become lodged in the intercondylar notch of the femur
during knee extension.

Tibiofemoral Articulation:
When the large articular condyles of the femur are placed on the shallow
concavities of the tibial condyle, the incongruence of the knee joint is
evident.
Each of the condyles of the knee joint has its own accessory joint structure,
together known as the menisci of the knee.
Menisci:
Two asymmetrical fibrocartilaginous joint discs called menisci are
located on the tibial condyles.
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Sagar Naik, PT

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The medial meniscus is a semicircle; the lateral meniscus is four-fifths of
a ring.
Both menisci are open toward the intercondylar area, thick peripherally
and thin centrally, forming concavities into which the respective
femoral condyles can sit.
The wedge-shaped menisci increase the radius of curvature of the tibial
condyles and, therefore, joint congruence.
By increasing congruence, the menisci also play an important part in
distributing weight-bearing forces, in reducing friction between the joint
segments, and serving as shock absorbers.
The menisci have multiple attachments to surrounding structures, some
common to both and some unique to each.
Each meniscus is connected around its periphery to the tibial condyle by
the coronary ligaments, which are composed of fibres from the knee joint
capsule.
Both menisci are also attached directly or indirectly to the patella via the
so-called patellomeniscal or patellotibial ligaments, which are anterior
capsular thickenings.
The open ends of the menisci, which are attached to their respective tibial
intercondylar tubercles, are called horns. Each meniscus has an anterior
and a posterior horn.
The anterior horns of the two menisci are joined to each other by the
transverse ligament, which may be connected to the patella via the joint
capsule.
The attachment site of the posterior horn of the more mobile lateral
meniscus had a greater zone of uncalcified fibrocartilage than the
attachment site of the posterior horn of the medial meniscus.
The attachment site of the anterior horn of the lateral meniscus had a
thicker zone of cortical calcified cartilage than the attachment site of the
anterior horn of the medial meniscus.
The lateral meniscus, in addition to the connections it shares with the
medial meniscus, is attached to the posterior cruciate ligament (PCL) and
popliteus muscle via the coronary ligaments and posterior capsule, and
to the somewhat variable posterior meniscofemoral ligaments.
Some fibres from the anterior cruciate ligament (ACL) may also join the
anterior and posterior horns.
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Sagar Naik, PT

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The connections of the lateral meniscus are considered to be fairly loose,
leaving the lateral menisci a fair amount of mobility on the lateral tibial
condyle.
The medial meniscus is attached to the medial collateral ligament and to
the semimembranosus muscle through its capsular connections.
The medial meniscus is more firmly attached and less movable on the
tibial condyle than the lateral meniscus.
The menisci and meniscoligamentous complex are well established in
the 8-week-old embryo and during the first year of the life the menisci
are well vascularized throughout.
The vascularity of the meniscal body gradually reduces from 18 months
to 18 years. Over age 50 years only periphery of meniscal body is
vascularized.
The horns remain completely vascularized throughout life.
In young children whose menisci have ample blood supply, the incidence
of meniscal injuries is low. In adult the only the peripheral vascularized
region of the meniscal body is capable of inflammation, repair, and
remodeling following a tearing injury.
The horns of the menisci and the peripheral vascularized portion of the
meniscal bodies are well innervated with free nerve endings and three
different mechanoreceptors.
The meniscal innervation pattern indicates that the menisci are a
source of information about joint position, direction of movement, and
velocity of movement as well as information about tissue deformation.
Tibiofemoral Alignment & Weight-Bearing Forces:
The anatomic (longitudinal) axis of the femur is oblique, directed
inferiorly and medially from its proximal to its distal end. The anatomic
axis of the tibia is directed almost vertically. Consequently, the femoral
and tibial longitudinal axes normally form an angle medially at the
knee joint of 185 to 190; i.e., the femur is angled off vertical 5 to 10,
creating a physiologic (normal) valgus angle at the knee.
The mechanical axis of the lower extremity is the weight-bearing line
from the center of the head of the femur to the center of the superior
surface of the head of talus. This line normally passes through the center
of the knee joint between the intercondylar tubercles and averages 3 from
the vertical given the width of the hip joints as compared to spacing of the
feet.
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Sagar Naik, PT

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Because the weight-bearing line (ground reaction force) follows the
mechanical rather than the anatomic axes, the weight-bearing stresses
on the knee joint in bilateral static stance are equally distributed
between the medial and lateral condyles, without any concomitant
horizontal shear forces.
This is not necessarily the case in unilateral stance or once dynamic forces
are introduced to the joint.
If the medial tibiofemoral angle is greater than 195 (165 or less
measured laterally), an abnormal condition called genu valgum (knock
knees) exists. This condition will increase the compressive force on the
lateral condyle while increasing the tensile stresses on the medial
structures.
If the medial tibiofemoral angle is 180 or less (exceeding 180 as
measured laterally), the resulting abnormality is called genu varum (bow
legs). In this condition, the compressive stresses on the medial tibial
condyle are increased, whereas the tensile stresses are increased laterally.
In genu valgum or genu varum, constant overloading of, respectively, the
lateral or medial articular cartilage may result in damage to the cartilage.
The menisci of the knee are important in distributing and absorbing the
large forces crossing the knee joint.
Although compressive forces in the dynamic knee joint ordinarily may
reach two to three times body weight in normal gait and five to six times
body weight in activities such as running and stair climbing, the menisci
assume 40% to 60% of the imposed load.
If the menisci are removed, the magnitude of the average load per unit
area on the articular cartilage nearly doubles on the femur and is six to
seven times greater on the tibial condyles.
Elimination of any angulation between the femur and tibia (a mild genu
varum) will increase the compression on the medial meniscus by 25%.
Five degrees of genu varum (medial tibiofemoral angle of 175) will
increase the forces by 50%.

Knee Joint Capsule:
Given the incongruence of the knee joint, even with the compensation of the
menisci, stability is heavily dependent on the surrounding joint structures.
In knee flexion when surrounding passive structures tend to be lax, the
incongruence of the joint permits at least some anterior displacement,
posterior displacement, and rotation of the tibia beneath the femur.
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KNEE COMPLEX
Sagar Naik, PT

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The knee joint capsule and its associated ligaments are critical to restricting
such motions to maintain joint integrity and normal joint function. Although
muscles clearly play a role in stabilization, it is almost impossible to
effectively stabilize the knee with active muscular forces alone in the
presence of substantial disruption of passive restraining mechanisms.
The joint capsule that encloses the tibiofemoral and patellofemoral joints
is large, complexly attached, and lax with several recesses.
Posteriorly, the capsule is attached proximally to the posterior
margins of the femoral condyles and intercondylar notch and distally
to the posterior margins tibial condyle. The capsule is reinforced
posteriorly by a number of muscles and by oblique popliteal and arcuate
ligaments.
Medially & laterally, the capsule begins proximally above the femoral
condyles to continue distally to the margins of the tibial condyle. The
collateral ligaments reinforce the sides of the capsule.
Anteriorly, the patella, the tendon of the quadriceps muscles
superiorly, and the patellar ligament inferiorly completes the anterior
portion of the joint capsule.
Anteromedially and anterolaterally, expansions from the vastus
medialis and vastus lateralis muscles extend from the patella and
patellar ligament to the corresponding collateral ligaments and tibial
condyles.
The anteromedial and anterolateral portions of the capsule are known as the
extensor retinaculum or the medial and lateral patellar retinacula.
Extensor Retinacula:
Extensor retinaculum appear to be two layers,
The deeper of the two layers having longitudinally oriented fibres
connecting the capsule anteriorly to the menisci and tibia via the
coronary ligaments. These connections may be called the
patellomeniscal or patellotibial bands.
The more superficial second layer consists of transversely oriented
fibres of which the more proximal blend with fibres of the vastus
medialis and lateralis muscles and the more distal continue to the
posterior femoral condyles.
The transverse fibres connecting the patella and the femoral condyles are
known as the patellofemoral ligaments.
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Sagar Naik, PT

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The lateral patellofemoral ligament is connected not only to the vastus
lateralis muscle but also to the iliotibial band either directly or indirectly
via an iliopatellar band.
The tendon of the biceps femoris muscle to provide superficial
reinforcement to the capsular and retinacular layers accompanies the
iliotibial band and its associated fascia lata posteriorly.
Synovial Lining:
The intricacy of the fibrous layer of the knee joint capsule is surpassed by
its synovial lining, the most extensive, and involved in the body.
The synovium adheres to the inner wall of the fibrous layer except
posteriorly where the synovium invaginates anteriorly following the
contour of the femoral intercondylar notch.
The invaginated synovium adheres to the anterior aspect and sides of
the anterior cruciate ligament and the posterior cruciate ligament.
Thus, anterior cruciate ligament and posterior cruciate ligament are
intracapsular but extrasynovial.
Embryonically, the synovial lining of the knee joint capsule is actually
divided by septa into three separate compartments. There is initially a
superior patellofemoral compartment and two separate medial and lateral
tibiofemoral compartments.
By 12 weeks of gestation, the synovial septa are resorbed to some degree,
resulting in a single joint cavity, but retaining the posterior invagination
of the synovium that forms some separation of the condyles.
The superior compartment continues to be recognizable as a superior
recess of the capsule known as the suprapatellar bursa.
Posteriorly, the synovial lining may invaginate laterally between the
popliteus muscle and lateral femoral condyle. It may also invaginate
medially between the semimembranosus tendon, the medial head of the
gastrocnemius muscle, and the medial femoral condyle.
When the synovial septa, which exist embryonically, are not completely
resorbed but persist into adulthood, they exist as folds or pleats of
synovial tissue known as plicae or patellar plicae.
These vestiges have been observed in 20% to 60% of the normal
population and are referred to, in order of most frequently to least
frequently found, as the inferior plica (infrapatellar plica), the superior
plica (suprapatellar plica), and the medial plica (mediopatellar plica).
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Sagar Naik, PT

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The inferior plica, which also has been described as the infrapatellar fold
or ligamentum mucosum, is located below the patella anterior to the
anterior cruciate ligament.
The inferior plica extends from the anterior portion of the intercondylar
notch to attach the infrapatellar fat pad.
The superior plica is located between the suprapatellar bursa and the knee
joint. This plica is often bilateral and symmetrical and extends from
synovial pouch at the anterior aspect of the femoral metaphysis area to
attach to the posterior aspect of the quadriceps tendon above the patella.
The medial plica arises from the medial wall of the pouch of the
retinaculum and runs parallel to the medial edge of the patella to attach
to the infrapatellar fat pad and synovium of the inferior plica.
Occasionally, however, the plica may become irritated and inflamed,
which leads to pain, effusion, and changes in joint structure and
function.
The plica syndrome generally does not arise from the most common
infrapatellar plica, but from the medial or superior plicae.
The knee joint capsule is reinforced by a number of ligaments that play an
important part not only in knee joint stability but also in knee joint
mobility.
Knee Joint Ligaments:
Given the lack of bony restraint to virtually any of the knee motions, the
ligaments are credited with resisting or controlling:
Excessive knee extension
Varus and valgus stresses at the knee
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, known as rotatory stabilization
It is also possible that the stresses may occur on the femur while the tibia is
fixed (weight-bearing). In such instances, the anteroposterior displacements
and rotations will reverse; that is, anterior displacement of the tibia is
equivalent to posterior displacement of the femur and so forth.
Collateral Ligaments:
The medial (tibial) collateral ligament (MCL) attaches to the medial
aspect of the medial femoral epicondyle, sloping anteriorly to insert into
the medial aspect of the proximal tibia.
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Sagar Naik, PT

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The posterior medial fibres of the ligament blend with fibres of the joint
capsule and some fibres extend medially to attach to the medial
meniscus.
The lateral (fibular) collateral ligament (LCL) is a strong cordlike
structure extending from the lateral femoral epicondyle and attaching
posteriorly to the head of the fibula.
Unlike the medial collateral ligament, the lateral collateral ligament has
no attachment either to the meniscus or to the joint capsule.
Both collateral ligaments are taut in full extension and, therefore, help
resist hyperextension of the knee joint.
Medial Collateral Ligament (MCL):
The medial collateral ligament resists valgus stresses (attempted
abduction of the tibia) across the knee joint, being especially
effective in the extended knee when the ligament is taut.
However, it may play a more critical role in resisting valgus stresses
in the slightly flexed knee when other structures make a lesser
contribution.
The medial collateral ligament is also aligned in such a way as to
check lateral rotation of the tibia.
The medial collateral ligament is also a backup restraint to pure
anterior displacement of the tibia when the primary restraint of the
anterior cruciate ligament is absent.
Lateral Collateral Ligament (LCL):
The lateral collateral ligament resists varus stresses (attempted
adduction of the tibia) across the knee.
Given its alignment, it also appears to limit lateral rotation of the
tibia, making its most substantial contribution at about 35 of flexion,
in conjunction with the posterolateral capsule.
The lateral collateral ligament also resists combined lateral rotation
with posterior displacement of the tibia in conjunction with the
tendon of the popliteus muscle.
Iliotibial Band:
The iliotibial band (ITB) or iliotibial tract is formed proximally from
the fascia investing the tensor fascia lata, the gluteus maximus, and the
gluteus medius muscle.
The iliotibial band continues distally to attach to the linea aspera of the
femur via the lateral intermuscular septum and inserts into lateral
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Sagar Naik, PT

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tubercle of the tibia, reinforcing the anterolateral aspect of the knee
joint.
The iliotibial band appears to be consistently taut regardless of
position of the hip joint or knee joint, although it falls anterior to the
knee joint axis in extension and posterior to the axis in flexion.
The fibrous connections of the iliotibial band to the biceps femoris and
vastus lateralis muscles through the lateral intermuscular septum form
a sling behind the lateral femoral condyle, assisting the anterior
cruciate ligament in preventing posterior displacement of the femur
when the tibia is fixed and the knee joint is near extension.
With knee flexion iliotibial band moves posteriorly, while with knee
extension iliotibial band moves anteriorly.
The iliotibial band sends fibres from its anterior margin to attach to the
patella, forming an iliopatellar band.
When the iliotibial band moves posteriorly in knee flexion it exert a
lateral pull on the patella resulting in a progressive laterally tilting
as flexion increases. This is prevented by vastus medialis muscle.
Cruciate Ligaments:
The anterior cruciate ligament and posterior cruciate ligament are
intracapsular but extrasynovial ligaments.
These ligaments are named according to their tibial attachments.
The anterior cruciate ligament arises from the anterior aspect of the tibia;
the posterior cruciate ligament arises from the posterior aspect of the
tibia.
Usually both ligaments are described to have main posterolateral and
smaller anteromedial bands that behave differently in different
movements.
Anterior Cruciate Ligament (ACL):
The anterior cruciate ligament attaches to the anterior tibia, passes
under the transverse ligament, and extends superiorly and posteriorly
to attach to the posterior part of the inner aspect of the lateral femoral
condyle.
Generally, the numerous fascicles of the anterior cruciate ligament are
grouped into an anteromedial band (AMB) and a posterolateral band
(PLB).
Changes in the lengths of the various bands or fibres during joint
motion are used as indicators of the ligaments functions.
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At 0 of knee flexion the anteromedial band is at its shortest length
(lax) while the posterolateral band is at it longest length (taut).
Therefore, at 0 the lax anteromedial band would be able to offer the
least restraint and the taut posterolateral band would be able to offer
the most restraint.
Under valgus loading the length of both bands of the anterior cruciate
ligament increases as knee flexion increases.
Anterior loading alone or combined with valgus loading causes an
increase in length of all portions of the anterior cruciate ligament with
increases in knee flexion.
In anterior loading some portion of the anterior cruciate ligament is
tight throughout the knee joint range.
In knee flexion, the anteromedial band is taut and posterolateral
band is lax.
The anterior cruciate ligament is generally considered the primary
restraint to anterior displacement of the tibia on the femoral
condyles.
There would appear to be essentially no anterior translation of the tibia
possible in full extension when many of the supporting passive
structures of the knee are taut.
Forces producing anterior translation of the tibia will result in maximal
excursion of the tibia at about 30 of flexion when neither of the
anterior cruciate ligament bands is particularly tensed.
The posterolateral band tends to be injured with excessive knee
hypertension, whereas the anteromedial band tends to be injured
with trauma to the flexed knee.
The anterior cruciate ligament would also appear to make at least a
minor contribution to restraining both varus and valgus stresses
across the knee joint. When the medial collateral ligament is damaged
and knee is flexed, the anterior cruciate ligament will make a more
major contribution to restraining varus and valgus stresses.
Both cruciate ligaments appear to play a role in producing and
controlling rotation of the tibia.
The anterior cruciate ligament appears to twist around the posterior
cruciate ligament in medial rotation of the tibia, thus checking
excessive medial rotation.
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Injury to the anterior cruciate ligament appears to occur most
commonly when the knee is flexed and tibia rotated in either
direction.
In flexion and medial rotation, the anterior cruciate ligament is
tensed as it winds around the posterior cruciate ligament.
In flexion and lateral rotation, the anterior cruciate ligament is
tensed as it is stretched over the lateral femoral condyle.
When attempting to determine whether there has been a tear of the
anterior cruciate ligament, the presence of both anteromedial and
anterolateral instability is the most diagnostic.
Hamstrings can be considered to act synergistically with the anterior
cruciate ligament.
Posterior Cruciate Ligament (PCL):
The posterior cruciate ligament, which runs superiorly and somewhat
anteriorly from its posterior tibial origin to attach to the inner aspect of
the medial femoral condyle, is shorter and less oblique than the
anterior cruciate ligament.
The posterior cruciate ligament blends with the posterior capsule and
periosteum as it crosses to its tibial attachment.
Usually posterior cruciate ligament is divided into an anteromedial
band (AMB) and a posterolateral band (PLB) named by the tibial
origin.
The anteromedial band is lax in extension, and the posterolateral
band is taut. At 80 to 90 of flexion, the anteromedial band is
maximally taut and the posterolateral band is relaxed.
The posterior cruciate ligament is primary restraint to posterior
displacement of the tibia beneath the femur, with little or no
displacement possible in full extension.
In the flexed knee, maximal displacement of the tibia with a posterior
translational force occurs at 75 to 90 of flexion.
The posterior cruciate ligament also has some role in restraining
varus and valgus stresses at the knee.
The posterior cruciate ligament appears to play a role in both
restraining and producing rotation of the tibia.
Posterior translatory forces on the tibia are consistently accompanied
by concomitant lateral rotation of the tibia, with little or no rotation
produced at the femur.
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Sagar Naik, PT

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Tension in the posterior cruciate ligament with knee extension may
be instrumental in creating the lateral rotation of the tibia that is
critical to locking of the knee for stabilization.
The popliteus muscle shares the function of the posterior cruciate
ligament in resisting posteriorly directed forces on the tibia and
contributes to knee stability when the posterior cruciate ligament is
absent.
The posterior cruciate ligament, posterior joint capsule, lateral
collateral ligaments, posterior oblique ligament, medial collateral
ligament with meniscus attached, posterior medial and posterior
lateral meniscotibial bands, and posterior meniscofibular ligament
comprise a complex restraining system for knee extension.
Posterior Capsular Ligaments:
The posteromedial aspect of the capsule is reinforced by the tendinous
expansion of the semimembranosus muscle, which is known as the
oblique popliteal ligament.
This ligament passes from a point posterior to the medial tibial condyle
and attaches to the central part of the posterior aspect of the joint capsule.
The arcuate popliteal ligament reinforces the posterolateral aspect of the
capsule.
The arcuate ligament arises from the posterior aspect of the head of fibula
and passes over the tendon of the popliteus muscle to attach to the
intercondylar area of the tibia and to the lateral epicondyle of the femur.
Both the oblique popliteal and the arcuate ligaments are taut in full
extension and assist in checking hyperextension of the knee.
The arcuate and oblique popliteal ligaments play an important role in
checking varus and valgus stresses, respectively, in the extended knee,
and in providing secondary restraint to other tibial motions.
The popliteofibular ligament becomes taut at 0, 30, 45, and 90 and
acts as a restraint to lateral rotation of the tibia when posterior force is
applied to the knee. The ligament also helps to limit posterior translation
of the tibia.
Meniscofemoral Ligaments:
The two meniscofemoral ligaments arise from the posterior horn of the
lateral meniscus and insert on the lateral aspect of the medial femoral
condyle near the insertion site of the posterior cruciate ligament.
The ligament that runs anterior to the posterior cruciate ligament is called
either the ligament of Humphrey or anterior meniscofemoral ligament. p
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Sagar Naik, PT

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The ligament that runs posterior to the posterior cruciate ligament is
called the ligament of Wrisberg or posterior meniscofemoral ligament. It
is also known as third cruciate ligament of Robert.
The meniscofemoral ligaments work in conjunction with the popliteus
muscle and become taut during femoral lateral rotation and may
prevent posterior translation of the tibia.

Knee Joint Bursae:
The extensive ligamentous apparatus of the knee joint and the large
excursion of the bony segments set up substantial frictional forces between
muscular, ligamentous, and bony structures.
However, numerous bursae prevent or limit such degenerative forces.
The suprapatellar bursa, the subpopliteal bursa, and the gastrocnemius
bursa are not usually separate entities but are either invaginations of the
synovium within the joint capsule or communicate with the capsule
through small openings.
The suprapatellar bursa lies between the quadriceps tendon and the anterior
femur; the subpopliteal bursa lies between the tendon of the popliteus
muscle and the lateral femoral condyle; and the gastrocnemius bursa lies
between the tendon of the medial head of the gastrocnemius muscle and the
medial femoral condyle.
The gastrocnemius bursa may also continue beneath the tendon of the
semimembranosus muscle to protect it from the medial femoral condyle.
The lubricating synovial fluid contained in the knee joint capsule moves
from recess to recess during flexion and extension of the knee, lubricating
the articular surfaces.
In extension, the posterior capsule and ligaments are taut and the
gastrocnemius and subpopliteal bursae are compressed. This shifts the
synovial fluid anteriorly.
In flexion, the suprapatellar bursa is compressed anteriorly by tension in
the anterior structures and the fluid is forced posteriorly.
When the joint is in the semiflexed position, the synovial fluid is under the
least amount of tension.
When there is an excess of fluid in the joint cavity due to injury or disease,
the semiflexed knee position helps to relieve tension in the capsule and
therefore helps to reduce pain.
Several other bursae are associated with the knee but do not communicate
with the synovial capsule. p
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Sagar Naik, PT

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The prepatellar bursa, located between the skin and the anterior surface of
the patella, allows free movement of the skin over the patella during flexion
and extension.
The subcutaneous infrapatellar bursa lies between the patellar ligament and
the overlying skin.
The subcutaneous infrapatellar bursa and prepatellar bursa may become
inflamed as a result of direct trauma to the front of the knee or through
activities like kneeling (House Maids Knee).
The deep infrapatellar bursa, which is located between the patellar ligament
and the tibial tuberosity, is separated from the synovial cavity of the joint by
the infrapatellar pad of fat. The deep infrapatellar bursa helps to reduce
friction between the patellar ligament and the tibial tuberosity.
There are also several small bursae that are associated with the ligaments of
the knee joint.
There is commonly a bursa between the lateral collateral ligament and the
tendon of the biceps femoris muscle and between the lateral collateral
ligament and the popliteus muscle.
There is a bursa deep to the medial collateral ligament protecting it from
the tibial condyle and one superficial to the medial collateral ligament
protecting it from the tendons of the semitendinosus and gracilis muscles
that cross the medial collateral ligament.

Knee Joint Function:
Osteokinematics of Knee Joint:
The primary motions of the knee joint are flexion / extension and, to
lesser extent, medial rotation / lateral rotation.
The knee joint can also undergo tibial or femoral displacement anteriorly
and posteriorly and some abduction and adduction through varus and
valgus forces.
The small amounts of anteroposterior displacement and valgus / varus
forces that can occur in the normal flexed knee are the result of joint
incongruence and variations in ligamentous elasticity.
Excessive amounts of such motions are abnormal and generally indicate
ligamentous incompetence.
Flexion / Extension:
The axis for flexion and extension at the tibiofemoral joint passes
horizontally through the femoral condyles at an angle to the
mechanical and anatomic axes.
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The obliquity of the axis causes the tibia to move from a position
slightly lateral to the femur in full extension to a position medial to
the femur in full flexion.
The axis of motion for flexion and extension at the knee is not
relatively fixed, but moves to a considerable extent through the ROM.
The pathway of the instant axis of rotation (IAR) of the tibiofemoral
joint for flexion and extension forms a semicircle, moving posteriorly
and superiorly on the femoral condyles with increasing flexion.
As many of the muscles associated with the knee are two-joint muscles
that cross both the hip and the knee, hip joint position can influence
knee ROM.
Passive range of knee flexion is generally considered to be 130 to
140. Knee flexion may be limited to 120 or less when the hip joint is
simultaneously hyperextended and the stretched rectus femoris
muscle becomes passively insufficient. Knee flexion may also reach
as much as 160 in activities like squatting when the hip and knee are
flexing at the same time and the body weight is superimposed on the
joint.
Normal gait on level ground requires approximately 60 of knee
flexion. This requirement increases to about 80 for stair climbing and
to 90 or more for sitting down into a chair and arising from it.
Activities beyond simple mobility tasks require 115 of knee flexion or
more.
Knee joint extension (hyperextension) of 5 to 10 is considered within
normal limits. Excessive knee hyperextension is termed genu
recurvatum.
When the lower extremity is weight bearing and the knee is part of a
closed kinematic chain, range limitations at ankle joint may cause
restriction in knee joint flexion or extension.
Eg A limitation in ankle dorsiflexion (due to tight plantarflexors)
may prevent the knee from being flexed; a limitation in
plantarflexion (due to tight dorsiflexors) may restrict the ability
of the knee to fully extend.
Rotation:
The knee joint rotates in two different ways that are quite different
both structurally and functionally.
Axial rotation provides the second degree of freedom to the
tibiofemoral joint.
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There is joint rotation involved in the locking mechanism of the knee
joint, also known as terminal or automatic rotation. Rotation
associated with the locking mechanism occurs with close packing of
the knee joint and does not contribute to degrees of freedom.
Axial rotation of the knee joint occurs around a longitudinal axis
that runs through or close to the medial tibial intercondylar tubercle.
Medial and lateral rotations of the knee joint are named for the motion
or relative motion of the tibia.
The medial and lateral rotations available in axial rotation occur
because of articular incongruence and ligamentous laxity.
The range of knee joint rotation depends on the position of the knee.
When the knee is in full extension, it is in close-packed (locked)
position and the ligaments are taut; no axial rotation is possible.
The tibial tubercles are lodged in the intercondylar notch and the
menisci are tightly interposed between the articular surfaces.
As knee flexes increasing toward 90; the capsule and ligaments
become more lax. The tibial tubercles are no longer in the
intercondylar notch and the condyles of the tibia and femur are free to
move on each other.
At 90 of knee flexion, approximately 60 to 70 of either active
or passive rotation is possible.
The range for lateral rotation (0 to 40) is slightly greater than the
range of medial rotation (0 to 30).
The maximum range of axial rotation is available at 90 of knee
flexion, with the magnitude of axial rotation diminishing as the knee
approaches both full extension and full flexion.
Arthrokinematics of Knee Joint:
Flexion / Extension:
The large articular surface of the femur and the relatively small tibial
condyle create a potential problem as the femur begins to flex on the
tibia.
If the femoral condyles were permitted to roll posteriorly on the tibial
condyle, the femur would run out of tibial condyle before much flexion
had occurred. This would result in a limitation of flexion, or the femur
would roll off the tibia.
For the femoral condyles to continue to roll with increased flexion of
the femur, the condyles must simultaneously glide anteriorly on the
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tibial condyle to prevent them from rolling posteriorly off the tibial
condyle.
The first part of flexion of the femur from full extension (0 to
25) is primarily rolling of the femoral condyles on the tibia,
bringing the contact of the femoral condyles posteriorly on the
tibial condyle.
As flexion continues, the rolling is accompanied by a
simultaneous anterior glide just sufficient to create a nearly pure
spin of the femur; that is, the magnitude of posterior
displacement that would occur with the rolling of the condyles is
offset by the magnitude of anterior glide, resulting in little linear
displacement of the femoral condyles after 25 of flexion.
The anterior glide of the femoral condyles results in part from the
tension encountered in the anterior cruciate ligament as the femur
rolls posteriorly on the tibial condyle.
The menisci whose shape forces the femoral condyle to roll uphill
as the knee flexes may further facilitate the glide.
The menisci accompany the femoral condyles as the condyles move
posteriorly on the tibial condyle, maintaining the increased
congruence the menisci provide in the fully extended knee.
The menisci cannot move in there entirely because they are attached at
their horns to the intercondylar tubercles of the tibial condyle.
Extension of the knee from flexion occurs initially as a rolling of the
femoral condyles on the tibial condyle, displacing the femoral
condyles anteriorly back to neutral position.
After the initial forward rolling, the femoral condyles glide posteriorly
just enough to continue extension of the femur as an almost pure
spin (roll plus posterior glide) of the femoral condyles on the tibial
condyles.
Tension in the posterior cruciate ligament and the shape of the
menisci facilitate the intra-articular movements of the femoral
condyles during knee extension.
The condyles are once again accompanied in displacement by
distortion of the wedge-shaped menisci.
As extension begins from full flexion, the posterior margins of the
menisci return to their neutral position. As extension continues, the
anterior margins of the menisci move anteriorly with the femoral
condyles.
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The motion of the menisci with flexion and extension are an important
component of the motions. Given the need of the menisci to reduce
friction and absorb forces of the large femoral condyles on the small
tibial condyle, the menisci must remain beneath the femoral condyles
to continue their function.
Failure of the menisci to distort in the proper direction can also
result in limitation of joint motion.
If femur literally rolls up the wedge-shaped menisci in flexion
(without either the anterior glide of the femur or the posterior
distortion of the menisci), the increasing thickness of the menisci and
the threat of rolling off the posterior margin will cause flexion to be
limited.
Similarly, failure of the menisci to distort anteriorly with the femoral
condyles in extension will cause the thick anterior margins to become
wedged between the femur and tibia as the segments are drawn
together in the final stages of extension. The interposition of the
menisci will prevent extension from being completed.
Locking & Unlocking:
In weight bearing closed chain motion as an example, extension of the
femur on the relatively fixed tibia results in additional motions.
As the femur extends to about 30 of flexion, the shorter lateral
femoral condyle completes its rolling-gliding motion.
As extension continues, the longer medial femoral condyle continues
to roll and to glide posteriorly although the lateral condyle has
halted.
This continued motion of medial femoral condyle results in medial
rotation of the femur on tibia, pivoting about the fixed lateral condyle.
The medial rotatory motion of the femur is most evident in final 5 of
extension. Increasing tension in the knee joint ligaments as the knee
approaches full extension may also contribute to the rotation within the
joint.
As the medial rotation of the femur that accompanies the final stages
of the knee extension is not voluntary or produced by muscular forces,
it is referred to as automatic or terminal rotation of the knee joint.
This rotation within the joint that accompanies the end of extension
also brings the knee joint into the closed-packed or locked position.
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The tibial tubercles are lodged in the intercondylar notch, the menisci
are tightly interposed between the tibial and femoral condyles, and the
ligaments are taut.
Consequently, automatic rotation is also known as the locking
mechanism or screw home mechanism of the knee.
To initiate flexion, the knee must first be unlocked; that is, the
medially rotated femur cannot flex in the sagittal plane, but must
laterally rotate before flexion can proceed.
A flexion force will automatically result in lateral rotation of the
femur because the longer medial side will move before the shorter
lateral side of the joint.
If there is an external restraint to unlocking or derotation of the femur,
the joint, ligaments, and menisci can be damaged, as the femur is
forced into flexion oblique to the sagittal plane in which its structures
are oriented.
Automatic rotation or locking of the knee occurs in both open chain
and closed chain knee joint function.
In an open kinematic chain, the freely moving tibia laterally rotates
on the relatively fixed femur during the last 30 of extension.
Unlocking, consequently, is brought about by medial rotation of the
tibia on the femur before flexion can proceed.
Axial Rotation:
During axial rotation of the knee joint, the longitudinal axis for
motion lies at the medial intercondylar tubercle.
Consequently, the medial condyles act as the pivot point while the
lateral condyles move through a greater arc of motion than the
medial regardless of the direction of rotation.
When lateral rotation of the tibia occurs at the knee joint, the medial
tibial condyle moves only slightly anteriorly on the relatively fixed
medial femoral condyle while the lateral tibial condyle moves a large
distance posteriorly on the relatively fixed lateral femoral condyle.
In medial rotation the direction of motion of the tibial condyles
reverses, with the medial tibial condyle moving only slightly
posteriorly while the lateral condyle moves anteriorly through a larger
arc of motion.
When tibia is fixed and the femur is free to move, lateral rotation of
the femur occurs as the lateral femoral condyle moves posteriorly on
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the lateral tibial condyle while the medial femoral condyle moves
slightly anteriorly.
Lateral rotation of the femur on the tibia produces an opposite set of
motions.
When there is rotation between the femoral and tibial condyles
(either in axial or automatic rotation), the menisci of the knee joint
maintain their relationship to the femoral condyles just as they did in
flexion and extension; that is, in rotation of the knee, the menisci will
distort in the direction of movement of the corresponding femoral
condyle.
In medial rotation, the medial meniscus will distort anteriorly on
the tibial condyle to remain beneath the anteriorly moving
medial femoral condyle, and lateral meniscus will distort
posteriorly to remain beneath the posteriorly moving lateral
femoral condyle.
In this way, the menisci continue to reduce friction and distribute the
forces the femoral condyles create on the tibial condyle without
restricting motion.

Muscles of the Knee Joint:
Flexors of Knee Joint:
There are seven muscles which flexes the knee joint that are follows:
Semimembranosus
Semitendinosus
Biceps Femoris
Sartorius
Gracilis
Popliteus
Gastrocnemius
All of the knee flexors, except for the short head of the biceps femoris and
the popliteus, are two-joint muscles. As two-joint muscles, their ability to
produce effective force can be influenced by the relative position of the
two joints over which they pass.
The popliteus, gracilis, semimembranosus, and semitendinosus muscles
are considered to medially rotate the tibia on the fixed femur, whereas the
biceps femoris is considered to be a lateral rotator of the tibia.


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Hamstring Muscles:
The semitendinosus, semimembranosus, and the biceps femoris
muscles are known collectively as the hamstrings.
These muscles all originate on the ischial tuberosity of the pelvis. The
semimembranosus and the semitendinosus insert on the posteromedial
and anteromedial aspects of the tibia, respectively.
The semimembranosus muscle has fibres that attach to the medial
meniscus. This attachment assists in knee flexion by facilitating
posterior motion of the medial meniscus during active knee flexion.
The semitendinosus muscle has a fibrous septum that separates it into
distinct proximal and distal compartments. This may give it some
specificity of action at the hip joint and at the knee joint.
Most of the hamstrings, crossing the hip (as extensors) and the knee
(as flexors), work most effectively at the knee joint if they are
lengthened over the flexed hip.
With active knee flexion with the body in the prone position, the
hamstrings muscles are forced to attempt to shorten over both the hip
(which will be extended) and over the knee.
The hamstrings will weaken as knee flexion proceeds because the
muscle group is approaching active insufficiency and must overcome
the increasing tension in the rectus femoris, which is approaching
passive insufficiency.
Biceps Femoris:
The biceps femoris muscle has two heads, both of which insert on the
lateral condyle of the tibia and the head of the fibula.
The biceps femoris tendon may be attached to the iliotibial band and
retinacular fibres of the lateral joint capsule, a set of attachments that
implies that the biceps femoris has a stabilizing role at the
posterolateral aspect of the joint.
The short head of the biceps femoris does not cross the hip joint and,
therefore, has a unique action at the knee joint.
Gastrocnemius:
The gastrocnemius muscle arises from the posterior aspects of the
medial and lateral condyles of the femur by two heads. It inserts into
the calcaneus by way of the calcaneal tendon.
Except for the plantaris muscle, the gastrocnemius is the only muscle
at the knee that crosses the ankle and the knee.
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Although the gastrocnemius generates a large plantarflexor torque at
the ankle, it makes a relatively small contribution to knee flexion.
Rather than working to produce knee flexion, the gastrocnemius
appears to be effective in preventing knee joint hyperextension.
Paralysis of the plantarflexors is classically accompanied by a
snapping back of the knee into hyperextension in the final stages of
single-limb support during walking.
The gastrocnemius appears to be less a mobility muscle at the knee
joint than a dynamic stabilizer.
Sartorius:
The sartorius muscle arises anteriorly from the anterior superior iliac
spine of the ilium and crosses the femur to insert the anteromedial
surface of the tibial shaft posterior to the tibial tuberosity.
Although a potential flexor and medial rotator of the tibia, activity in
the sartorius is more common with hip motion than with knee
motion.
When attached just anterior to its more usual location, it may fall
anterior to the knee joint axis, serving as a mild knee joint extensor
rather than as a knee flexor.
Gracilis:
The gracilis muscle arises from the inferior half of the symphysis pubis
arch and inserts on the medial tibia by way of a common tendon with
the sartorius and the semitendinosus muscles.
It is not only a hip joint flexor and adductor, but it can also flex the
knee joint and produce slight medial rotation of the tibia.
Pes Anserinus:
The gracilis, semitendinosus, and sartorius muscles attach to the tibia
by a common tendon on the anteromedial aspect of the tibia. The
common tendon is called the pes anserinus because of its shape.
The three muscles of the pes anserinus appear to function effectively
as a group to stabilize the medial aspect of the knee joint.
Popliteus:
Popliteus muscle originates on the posterior aspect of the lateral
femoral condyle and attaches on the medial aspect of the tibia.
The popliteus muscle is a medial rotator of the tibia on the femur in
an open kinematic chain (or a lateral rotator of the femur on the tibia
in a closed kinematic chain).
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The active popliteus muscle is considered to play an important role in
initiating unlocking of the knee because it reverses the direction of
automatic rotation that occurred in the final stages of knee extension.
The popliteus muscle is commonly attached to the lateral meniscus.
The lateral meniscus is drawn posteriorly by tension in the popliteus
expansion.
Extensors of Knee Joint:
The four extensors of the knee, namely
Rectus Femoris
Vastus Medialis
Vastus Intermedius
Vastus Lateralis
are known collectively as the quadriceps femoris muscle.
The only portion of the quadriceps that crosses two joints is the rectus
femoris, which originates on the inferior spine of the ilium.
The vastus intermedius, vastus lateralis, and vastus medialis muscles
originate on the femur and merge into a common tendon, the quadriceps
tendon.
The quadriceps tendon continues distally as the patellar ligament.
The patellar ligament runs from the apex of the patella, across the anterior
surface of the patella, into the proximal portion of the tibial tubercle.
The vastus medialis and vastus lateralis also insert directly into the medial
and lateral aspects of the patella by way of the retinacular fibres of the
joint capsule.
Together, the muscles of the quadriceps femoris extend the knee.
The different orientation of lower fibres of the vastus medialis muscle has
resulted in reference to the upper fibres as the vastus medialis longus
(VML) and the lower fibres as the vastus medialis oblique (VMO).
Mechanically, the patella affects the efficiency of the quadriceps muscle:
the patella lengthens the moment arm (MA) of the quadriceps femoris by
increasing the distance of the quadriceps tendon and patellar ligament
from the axis of the knee joint.
The patella, as an anatomic pulley, deflects the action line of the
quadriceps femoris away from the joint, increasing the angle of pull and
the ability of the muscle to generate a flexion torque.
Interposing the patella between the quadriceps tendon and the femoral
condyles also reduces friction between the tendon and condyles.
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The position of the patella relative to the joint axis varies as the
instantaneous axis shifts and as the contour of the femoral condyles
changes.
The effect of patella on the moment arm (MA) of the quadriceps muscle,
therefore, will vary through the knee joint ROM.















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