Chapter 10

Structure and Function of the Knee

Copyright 2014, 2009 by Mosby, an imprint of Elsevier Inc.
Distal Femur
Medial and lateral condyles
Projections of distal femur articulating with medial and lateral
condyles of tibia
Intercondylar groove
Smooth, rounded area between femoral condyles articulating
with posterior surface of patella
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Distal Femur contd
Intercondylar notch
Located on posterior-inferior aspect of distal femur,
separating medial and lateral condyles
Forms passageway for anterior and posterior cruciate
ligaments
Medial and lateral epicondyles
Bony projections on medial and lateral femoral condyles,
serving as attachments for medial and lateral collateral knee
ligaments
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Proximal Tibia
Tibial medial and lateral condyles articulate with
condyles of femur; flattened superior surfaces of
condyles are often called tibial plateau
Intercondylar eminence
Double-pointed projection of bone separating medial and
lateral tibial condyles; attachment for anterior and posterior
cruciate ligaments and medial and lateral meniscus
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Proximal Tibia contd
Tibial tuberosity
Protrusion of bone located on anterior aspect of proximal
tibia
Distal attachment for quadriceps muscles
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Proximal Fibula contd
Long slender bone that courses along lateral shaft of
tibia
Fibular head
Rounded superior portion of fibula that articulates with tibia,
forming proximal tibiofibular joint
Distal attachment of lateral collateral ligament and biceps
femoris muscle
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Patella
Small sesamoid bone embedded within quadriceps
tendon
Superior pole accepts quadriceps tendon; inferior
pole accepts proximal side of patella ligament
The posterior articular surface articulates with
intercondylar groove of femur through medial and
lateral facets

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Arthrology: Normal Alignment
Angle of inclination
125-degree angle of proximal femur directs shaft toward
midline, to articulate with tibia at knee
Femur usually meets tibia to form lateral angle of
170-175 degrees, normal genu valgum
Less than 170 degrees is genu valgum, or knock-kneed
Greater than 180 degrees is genu varum, or bow-legged
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Supporting Structures: Anterior
and Posterior Cruciate Ligaments
Cruciate describes X shape of anterior and posterior
cruciate ligaments as they interconnect tibia with
femur
These cruciate ligaments are most important
stabilizers of knee in sagittal plane
Anterior cruciate ligament is frequently injured during
sporting events that generate a combination of
rotational, valgus, and hyperextension-producing
forces through knee

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Supporting Structures: Medial
and Lateral Collateral Ligaments
Strengthen medial and lateral sides of knee capsule;
protect against excessive genu varus or genu valgus
Medial collateral ligament
Spans medial side of knee and resists valgus-producing
forces
Become taut at full extension, useful for locking
extended knee while standing
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Supporting Structures:
Medial and Lateral Meniscus
Crescent-shaped fibrocartilaginous discs at top of
tibial medial and lateral condyles
Absorb compressive forces across knee caused by
muscular contraction and body weight
Reduce pressure across knee
Deepen socket of knee, further stabilizing joint
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Supporting Structures: Posterior
Capsule
Prevents hyperextension of knee
Includes two major ligaments: arcuate popliteal
ligament and oblique popliteal ligament
Knee demonstrating marked hyperextension (genu
recurvatum) has strain on most knee structures
including posterior capsule
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Osteokinematics
of Tibiofemoral Joint
Allows 2 degrees of freedom
Flexion and extension occur in sagittal plane about a
medial-lateral axis of rotation
Internal and external rotation of knee occurs within
horizontal plane about a vertical or longitudinal axis
of rotation
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Arthrokinematics
at Tibiofemoral Joint
Open-chain arthrokinematics is based on concave
tibial condyles rotating around convex condyles of
femur
Closed-chain extension is based on a roll-and-slide
pattern occurring in opposite directions
Arthrokinematics for knee flexion are reversed for
knee extension
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Arthrokinematics
at Tibiofemoral Joint contd
Flexion and extension are accompanied by slight
rotational movements
As knee nears full extension, knee rotates externally
about 10-15 degrees
This automatic rotation assists in locking kneeso-
called screw-home mechanism
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Patellofemoral Joint
Articulation formed between posterior surface of
patella and intercondylar groove of femur
Patella enhances torque-producing capability of
quadriceps by about 25%
Following patellectomy, quadriceps must produce
25% more force
This increased muscle force may cause fatigue, or damage
to patellofemoral joints
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Innervation to Knee Muscles
Femoral nerve
Supplies sole source of innervation to quadriceps
Tibial portion of sciatic nerve
Innervates semitendinosus, semimembranosus, and long
head of biceps femoris
Peroneal portion of sciatic nerve
Innervates short head of biceps femoris
Obturator nerve
Innervates most of hip adductor muscles
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Knee Muscles
Divided into extensors and flexor-rotators
Although these muscles have important individual
actions, they often work in teams to maximize
movement control
e.g., standing from a seated position requires simultaneous
activation of quadriceps and hamstrings
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Knee Extensors: Quadriceps
Rectus femoris
Proximal attachment: anterior-inferior iliac spine
Distal attachment: tibial tuberosity
Actions: knee extension, hip flexion
Vastus medialis
Proximal attachment: medial lip of linea aspera and
intertrochanteric line of femur
Distal attachment: tibial tuberosity
Actions: knee extension
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Knee Extensors: Quadriceps contd
Vastus lateralis
Proximal attachment: linea asperas lateral lip,
intertrochanteric line, gluteal tuberositys lateral region
Distal attachment: tibial tuberosity
Vastus intermedius
Proximal attachment: upper two thirds of anterior femoral
shaft
Distal attachment: tibial tuberosity
Action of both muscles: knee extension
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Functional Considerations:
Lateral Tracking of Patella
Lateral tracking of patella increases pressure and
friction within patellofemoral joint
May result in pain, inflammation, joint degeneration, and
dislocation
Classifying factors contributing to laterally tracking as
intrinsic or extrinsic helps determine more effective
treatment strategies
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Functional Considerations:
Patellofemoral Joint and Deep Squats
Patellofemoral joint pain is characterized by inability
of patellofemoral joint to tolerate large compression
forces
Often, clinicians recommend that patients avoid
squatting motions to limit excessive compression
and damage to patella
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Knee Flexor-Rotators: Hamstrings
Semitendinosus, semimembranosus, and biceps
femoris (long and short heads)
Span posterior thigh, perform knee flexion, and most
perform hip extension
Most hamstrings cross hip, and hip position affects
their operational length
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Knee Flexor-Rotators:
Gracilis and Sartorius
Provide stability to medial aspect of knee
Assist with flexion and internal rotation of knee
Both muscles attach proximally to pelvis
Distally, they course posterior to medial-lateral axis of
rotation of knee
Tendons of gracilis, sartorius, and semitendinosus
join for collective insertion at pes anserinus
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Knee Flexor-Rotators:
Gastrocnemius and Plantaris
Gastrocnemius
Powerful two-headed muscle
Produces large plantar flexion torques across ankle
Knee flexor
Plantaris
Relatively small
Crosses posterior knee
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Knee Flexor-Rotators: Popliteus
Proximal attachment
Posterior aspect of lateral femoral condyle
Distal attachment
Posterior surface of proximal tibia
Innervation
Tibial nerve
Actions
Knee internal rotation
Knee flexion
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Functional Considerations:
Tight Hamstrings
Often due to spasticity, muscle irritability, or spending
extended time in a flexed-knee position
Tightness of hamstrings is often visibly observed by
inability to fully extend knee
Extreme hamstring tightness may also lead to
chronically flexed hips or posterior pelvic tilt and
flattened lumbar spine
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Functional Considerations:
Tight Hamstrings contd
Passive tension in hamstrings may posteriorly tilt
pelvis
Pelvis should be stabilized as stretch is being performed
Excessive posterior tilting may produce an unwanted
overstretching of connective tissues within lumbar
region
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Functional Considerations:
Rectus Femoris and Hamstrings
Most lower extremity activities combine hip flexion
and knee flexion or hip extension and knee extension
During combined hip and knee extension, both rectus
femoris and semitendinosus avoid maximum
shortening across hip and knee to prevent muscles
from becoming actively insufficient
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Internal and External
Rotators of Knee
Hamstrings, gracilis, popliteus, and sartorius control
active rotation of knee within transverse plane
Medial hamstrings, gracilis, and sartorius internally
rotate knee, whereas lateral hamstrings externally
rotate knee
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Functional Considerations:
Activation of Internal Rotators
Internal rotator muscles of knee far outweigh
strength of external rotator muscles
This disparity likely reflects need to either accelerate
knee into internal rotation (by concentric contraction)
or decelerate external rotation of knee (by eccentric
activation)
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Summary
Stability of knee maintained largely by ligaments and
surrounding musculature
Combination of large forces and lack of bony
constraint may account for high incidence of knee
joint injuries
Rehabilitation approaches usually involve knee itself,
as well as surrounding joints and muscles
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