ANATOMY AND BIOMECHANICS OF THE KNEE
JOHN P. GOLDBLATT, MD, and JOHN C. RICHMOND, MD
Successful treatment of the injured knee depends on a fundamental understanding of the anatomy and
biomechanical function of the structures that comprise the knee. The major structures of the knee are presented
anatomically, followed by a brief review of the biomechanics of each. Normal function, as well as the expected
result of injury is presented. This review is intended to assist in clinical diagnosis, as well as treatment planning
for the injured knee.
KEY WORDS: knee, anatomy, biomechanics
© 2003 Elsevier Inc. All rights reserved.
A thorough knowledge of the complex anatomy and
biomechanical function of the structures of the knee is
essential to make accurate clinical diagnoses and decisions
regarding the treatment of the multiple-ligament-injured
knee. The following review is intended to provide the
essential information required for an understanding of the
anatomy and biomechanics of the normal knee, and the
consequence of injury.
Various techniques are utilized by researchers attempt-
ing to evaluate the biomechanics of the knee as a whole, as
well as the function of individual structures. Mathematical
modeling, experimental testing of knee specimens, ana-
tomic dissection studies, and strain or force measurements
in individual structures are a few of the possible methods.
The two most commonly utilized experimental ap-
proaches have been termed the "flexibility method" and
the "stiffness method."
The flexibility method utilizes selective ligament sec-
tioning, followed by observation of the response of the
specimen to an applied load or moment. The process first
measures the laxity in the intact knee in response to an
applied force. A specific ligament, or combination of liga-
ments, is then transected, and the resulting increase in
translation or rotation is measured. This increase reflects
the loss of the sectioned structure, as well as the change in
the interaction among the remaining structures.
The stiffness method attempts to define the contribution
of individual structures to overall restraint in response to
predetermined displacements. Initially, the intact knee is
translated, or rotated, a precise amount, and the restrain-
ing force that must be overcome to produce this displace-
ment is measured. Next, a structure is sectioned, and the
remaining force required to reproduce the original dis-
placement is determined. The change in total restraining
force represents the percentage contribution of the sec-
From the Department of Orthopaedics, Tufts-New England Medical
Center, Boston, MA.
Address reprint requests to John P. Goldblatt, MD, Tufts-New England
Medical Center, Department of Orthopaedics, 750 Washington Street,
Boston, MA 02111.
© 2003 Elsevier Inc. All rights reserved.
1060-1872/03/1103-0002530.00/0
doi:10.1053/otsm .2003.35911
172 Operative Techniques in Sports Medicine, Vol 11, No 3 (July), 2003: pp 172-186
tioned structure to the overall stability of the knee in the
direction tested.
Certainly, each method provides useful information,
and each has inherent limitations. The information ob-
tained from studies utilizing each technique must be inte-
grated. Taken together, one can define the expected results
of deficiency. The following summary, therefore, utilizes
information from many types of studies in an effort to
compile the consensus regarding the anatomy and func-
tion of the structures of the knee.
BONE ANATOMY
The knee is a modified hinge joint that must allow flexion
and rotation, yet provide complete stability and control
under a great range of loading conditions. The knee con-
sists of 2 joints: the femorotibial joint and the patellofemo-
ral joint. The bony architecture of the femur, tibia, and
patella contribute to the stability of the knee joint, along
with static and dynamic restraints of the ligaments, cap-
sule, and musculature crossing the joint. 1 The architecture
of the bones dictates, to a certain extent, the allowed
motion of the joint.
FEMOROTIBIAL JOINT
The femorotibial joint is the largest joint in the body, and
is comprised of 2 condyloid articulations. The medial and
lateral femoral condyles articulate with the corresponding
tibial plateaus. Intervening medial and lateral menisci
serve to enhance the conformity of the joint, as well as to
assist the rotation of the knee.
Simplistically, the femoral condyles are cam-shaped in
lateral profile. The medial condyle has a larger radius of
curvature than the lateral, and extends distal to the lateral
on the anteroposterior (AP) projection. The lateral condyle
extends anterior to the medial on the lateral projection,
and can be identified by its terminal sulcus and groove for
the popliteus insertion. 2 The proximal tibia is separated by
the intercondylar eminence into an oval, concave medial
plateau, and a circular, convex lateral plateau. The medial
and lateral compartments are asymmetrical, particularly
anteriorly.3
 The lateral condyle of the femur is smaller than the
medial, both in the AP and proximodistal directions. This
contributes to the valgus and AP alignment of the knee.
These shapes allow the medial femur to rotate on the tibia
through 3 axes, and the medial femur to translate, to a
limited extent, in the AP direction. Laterally, the femur can
freely translate in the AP direction, but can rotate around
a transverse axis only near extension, s The 3-degree lateral
inclination of the tibial plateau in relation to the joint line,
and 9 ° posterior slope, creates an overall valgus and pos-
terior-inferior alignment of between 10° to 12 ° in most
knees.l,4
PATELLOFEMORAL JOINT
The patellofemoral articulation is a sellar joint between the
patella and femoral trochlea. This joint is important to
knee stability primarily through its role in the extensor
mechanism. The patella increases the mechanical advan-
tage of the extensor muscles by transmitting the extensor
force across the knee at a greater distance from the axis of
rotation. This increased moment arm reduces the quadri-
ceps force required to extend the knee by 15% to 30%. The
contribution of the patella to increasing the moment arm
of the quadriceps varies over the range of motion. At full
flexion, the lever arm of the quadriceps is increased ap-
proximately 10%, and this increases to 30% by 45 ° from
full extension, and then once again decreases as the knee
passes to terminal extension. 1
The stability of the patella in the trochlear groove is a
combination of bony, ligamentous, and muscular re-
strain,s. The patella responds to a set of 3 forces: the pull
of the quadriceps, hamstrings, and a net compressive force
on the patellofemoral surfaces. In addition, several soft-
tissue constraints contribute to the tracking of the patella
within the trochlear groove. The constraints include the
medial patellofemoral ligament, medial patellomeniscal
ligament, medial patellotibial ligament, medial retinacu-
lum, and lateral retinaculum. These ligaments are dis-
cussed in detail in later sections.
ANTERIOR CRUCIATE LIGAMENT (ACL)
ANATOMY
The complex structure of the ACL reflects its important
contribution to knee-joint function. Originally referred to
as a crucial ligament because of the cruciate, or crossed,
arrangement of the anterior and posterior ligaments
within the knee, the irony of the ACL being crucial to the
well-being of the knee joint has more recently been dem-
onstrated, s An elegant anatomical dissection study by Gir-
gis 6 of 20 cadavers and 24 fresh knees helped elucidate the
complex anatomy of the ACL. The details of the footprints
on the femur and tibia, as well as fiber bundle orientation
are clearly described.
The ACL femoral attachment is to the posterior part of
the medial surface of the lateral femoral condyle, and is
primarily oriented in line with the longitudinal axis of the
femur with the knee in extension. 4,6 The footprint is in the
shape of a segment of a circle. The anterior border is nearly
straight. The posterior margin is convex, and follows the
ANATOMY AND BIOMECHANICS OF THE KNEE
contour of the posterior curvature of the condyle, 4 mm
anterior to the articular margin. The long axis of the fem-
oral attacl~nent is tilted obliquely, slightly forward from
the vertical. 6 The origin of the ACL is 16 to 24 mm in
largest diameter, s-7 11 mm in lesser diameter, 7 and is well
posterior in the intercondylar notch. 5,6
The tibial attachment of the ACL is to a wide depressed
area in front of, and lateral to, the medial tibial spine. The
fiber insertion to the tibia is oval, 7 and occupies approxi-
mately one third of the sagittal width of the tibial plateau. ~
The overall footprint includes insertions to the base of the
tibial spine, and a well-defined slip to the anterior horn of
the lateral meniscus. Also variably present are additional
attachments posteriorly that blend with the attachment of
the posterior horn of the lateral meniscus, and to bone in
front of the posterior horn of the medial meniscus. The
average distance from the anterior border of the tibia1
articular surface to the anterior attachment of the ACL is
15 mm. 6 The reported average AP length of the ACL
attachment ranges from 17 mm 7 to 30 ram, 6 and the width
is 11 mm (Fig 1). 7 The tibial attachment is nearly twice the
bulk width of the ACL, and has a distinct anterior toe at
this attachment that adapts to the contour of the intercon-
dylar roof in full extension. 8,9
From the femoral attachment, the ACL passes anteri-
orly, distally, and medially to the tibia. The ACL is in-
clined an average 25 ° from the tibial plateau, when viewed
laterally. 1° The average length of the ACL is reported from
26 m m to 38 ram, and the average width is 11 ram. 4,6 The
length of the ACL changes less than 2.5 mm through the
arc of motion. 4
In the AP projection, the center of the tibia1 ACL attach-
ment is just lateral to the exact center of the tibia. In the
lateral projection, the center of the tibial attachment is at
the junction of the anterior 40% and posterior 60% of the
AP length of the tibial plateau, and spans 30% of this
width. On the AP view, the entire ACL femoral insertion
is lateral to the midline. The femoral attachment occupies
the posterosuperior region of the intercondylar notch on
the lateral view in extension, and extends posterior to
Blumensaat's line (the roof of the intercondylar notch).
The superior margin is at the approximate level of Blu-
Fig 1. Tibial plateau showing the menisci and their relation-
ship to the ACL and PCL attachments. Reprinted with per=
mission. TM
173
 mensaat's line. 9 These radiographic landmarks are of ob-
vious use to the surgeon in evaluating tunnel placement
during reconstruction.
Girgis 6 identified a functionally distinct fascicular ar-
rangement of the ACL, and divided these into anterome-
dial and posterolateral bands, named for their tibial ori-
gins. Subsequent authors confirm the fascicular arrange-
ment of the ACL, 4,~1 and have included a possible
intermediate band. 1~
The anteromedial fibers form the shortest band of the
ACL and are tense in flexion.6,12 The remaining bulk of
fibers originate from the distal femoral attachment, and
insert posterolaterally on the tibia. This posterolateral
band is taut in extension and lax in flexion (Fig 2). 4-6,I1,12
The orientation of the ACL becomes nearly horizontal
with flexion, and the anteromedial band becomes taut
almost immediately after flexion begins. 6 The more hori-
zontal orientation of the ACL with flexion enables the
ligament to function as a primary restraint to anterior
tibial translation. This functional description of the ACL is
somewhat of an oversimplification. The ACL is actually
comprised of a continuum of fascicles, each of a different
length. Therefore, a different portion of the ligament is
taut and functional throughout the range of motion. 7,13
Minimum ACL strain occurs between 30 ° to 35 ° under
normal passive motion. The anteromedial fiber strain re-
laxes from full extension to 30 ° to 35 °, and then tightens
with further flexion to 120 °. The strain in the posterolateral
fibers decreases immediately from full extension, with
marked laxity between 15 ° to 70 ° flexion. The posterolat-
eral fibers of the ACL, for angles greater than 15°, do not
control anterior displacement of the tibia on the femur.
When simulated quadriceps contraction is added, the an-
teromedial ACL strain significantly increases in the range
of 0 ° to 45 ° of flexion. Quadriceps activity does not strain
the ACL when the knee is flexed beyond 60 °. The clinical
implication of this is 2-fold. First, in attempting to clini-
cally evaluate the function of the ACL, the Lachman ex-
amination is most sensitive because it is performed at the
position of the least amount of inherent strain in the liga-
ment. Second, this suggests that rehabilitation of an in-
jured or reconstructed ligament should be performed at
angles greater than 60 ° until healed. 62
/ a'- - B' ~,\
\ / ,, /
Fig 2. Changes in the shape and tension of the ACL in
extension and flexion, in extension, lengthening of the pos-
terolateral band B-B'. In flexion, lengthening of the antero-
medial band A-A'. Reprinted with permissionA
174
Because the ACL is arranged anatomically and function-
ally into distinct bands, it is evident that the ligament, as a
whole, is not isometric. 14,15 During passive flexion of the
knee, the anteromedial portion of the ACL lengthens while
the posterolateral portion shortens, and the intermediate
fibers do not change in length. 15 Odensten 7 measured the
distance between the central points of the insertion areas
on the tibia and lateral femoral condyle, and found that
this distance was isometric over the entire range of mo-
tion. Recognition of this is important when trying to re-
construct the ligament.
Many authors attempt to seek the position of femoral
and tibial attachments whose separation distances remain
nearly constant, or isometric, as the knee is flexed. Hefzy 14
showed that altering the femoral attachment had a much
greater effect than the tibial attachment on ACL graft
length. No femoral attachments were completely isomet-
ric. The axis of least variability in graft length was prox-
imal-distal oriented, located near the native ACL femoral
insertion. Fibers anterior to this line lengthen with flexion,
and posterior to this line, slacken with flexion. Therefore,
AP orientation has the greatest effect on fiber length. The
widest part of the most isometric region is located proxi-
mally, along the roof of the intercondylar notch. 14
The overall configuration of the ligament is flat in ex-
tension. When flexed, the ACL twists on itself approxi-
mately 90°. 6,7,13 Samuelson ~2 demonstrated in an anatom-
ical dissection study that the normal rotation of the ACL
was due to the orientation of the 2 major bundles. A lateral
twist developed in the ACL and became more pronounced
as knee flexion increased. This inherent twist caused the
tibia to rotate internally with respect to the femur approx-
imately 55 ° . To recreate this inherent internal rotation with
an ACL graft, the graft required 90 ° of lateral rotation on
insertion.
The anterior cruciate ligament is covered by a fold of
synovial membrane that resembles a mesentery. 13,16 This
synovial fold originates from the posterior intercondylar
area, and completely envelops both the ACL and posterior
cruciate ligament (PCL). 5 Thus, although the ligament is
intra-articular, it is actually extrasynovial. The synovial
envelope is richly endowed with vessels that originate
from the middle geniculate artery, as well as a few smaller
terminal branches of the medial and lateral inferior genic-
ulate artery. 5,x3These vessels arborize to form a plexus that
ensheaths the length of the ligament, and penetrates the
ligament transversely to anastomose with the network of
endoligamentous vessels. The blood supply to the liga-
ment is largely of soft-tissue origin, and the ligament-
osseous junctions contribute little to the vascular supply of
the ligament. 5,16
The ACL is innervated by branches of the tibial nerve.
Nerve fibers penetrate the joint capsule posteriorly, and
travel with the periligamentous vessels surrounding the
ligament. Smaller nerve fibers and end organs have also
been identified within the substance of the ligament itself.
Schutte 17 found that 3 morphological types of mechanore-
ceptors and free nerve endings were present within the
substance of the ACL. Two of the slow-adapting Ruffini
type subserve speed and acceleration. One rapidly adapt-
ing Pacinian corpuscle type signals motion. Free nerve
GOLDBLATT AND RICHMOND
endings responsible for pain were also identified within
the ligament, although relatively small in total number.
This may explain w h y isolated injury to the ACL often
results in little initial pain. The nerve supply is postulated
to serve a vasomotor function, as well as a possible pro-
prioceptive or sensory function to sense speed, accelera-
tion, position, and direction of motion.
BIOMECHANICS
The ACL is a keystone to controlled, fluid, and stable
flexion and rotation of the normal knee. The ACL is a
primary restraint to anterior translation of the tibia on the
femur, and a secondary restraint to internal rotation, va-
rus, valgus, and hyperextension.4,6,1°,11,13,1s,I8-22 The ACL
does not resist posterior d r a w e r . 1°,2°,21,23,24
Sectioning the ACL produces a significant increase in
anterior knee instability. The greatest amount of anterior
translation after isolated ACL sectioning occurs between
15° and 450.20,23,25 During the clinical examination, the
most effective position to conduct an anterior instability
test is at 30 ° of flexion.2° The ACL reaches ultimate stress
at approximately 15% strain, and gross failure is expected
to occur when strain exceeds 15% to 30%, or displacement
of about 1 cm. 15,1s
Levy24 subjected knees to a 100 N anterior force. Intact
knees demonstrated, on average, 3.4 m m anterior transla-
tion at full extension, and maximum, 4.7 m m at 30 ° flexion.
After isolated sectioning of the ACL, maximum anterior
displacement at 30 ° was 18.1 mm. In a similar study,
Fukubayashi2° found that isolated sectioning of the ACL
produced a greater than 2-fold increase in anterior dis-
placement of the tibia, compared with the intact knee,
when loaded in an anterior direction. As the flexion angle
increased, the displacement decreased; however, section-
ing did result in increased laxity at all angles. Later sec-
tioning of the PCL did not alter translation in the anterior
direction.
Utilizing the stiffness method, Butler 1° ranked the liga-
mentous restraints to anterior-posterior motion in the hu-
man knee when displacement was fixed at 5 mm. The ACL
provided 85% to 87% of the restraining force to anterior
translation at 30 ° and 90 ° of knee flexion, when rotation
was eliminated.
Takeda is utilized a 5 ° of freedom kinematic linkage
system, which allowed rotation, to investigate the contri-
bution of the ACL to resistance against anterior drawer.
The ACL restraint dropped to 74% to 83% of the total,
indicating that constrained motion altered the normal
function of the structures tested.
ACL deficiency results in the disintegration of the nor-
mal rolling-gliding movement of the femur on the tibia.
Rolling predominates in the initial 30 ° of flexion, and this
shifts the contact point of the femur and tibia posteriorly.
With ACL deficiency, the tibia moves into an anteriorly
subluxated position, and then relocates with further flex-
ion (pivot--shift phenomenon). This reduction is guided
by the secondary restraints to anterior translation, notably
the iliotibial band. The abnormal movement is suggested
as a cause of potential injury to the menisci, as well as
chondral surfaces. 26
ANATOMY AND BIOMECHANICS OF THE KNEE
The posterior fibers of the ACL are the principal re-
straint to hyperextension, and are expected to fail first in
injuries occurring in extension¢ 8 Isolated ACL sectioning
allows an increase in hyperextension by 250.6,19
Because the pattern of tibial rotation also changes dras-
tically after sectioning of the ACL, it is apparent that this
ligament plays a vital role in the natural rotation of the
tibia during AP motion. After ACL sectioning, the result-
ing secondary internal rotation that accompanies anterior
translation is eliminated. The ACL constitutes a primary
mechanism to control and produce internal rotation dur-
ing AP motion. 2°
POSTERIOR CRUCIATE LIGAMENT (PCL)
ANATOMY
The same study of 44 knees by Girgis 6 that provided much
of the information regarding the ACL serves as an excel-
lent resource, with elaboration by others, for the anatomy
of the PCL. Once again, the details of the footprints on the
femur and tibia, as well as fiber bundle orientation are
clearly described.
The femoral attachment of the PCL is to the lateral
surface of the medial condyle. The attachment is in the
form of a segment of a circle, and horizontal in its general
direction, with the knee extended. The upper boundary is
horizontal, and the lower boundary convex, and parallel
to the lower articular margin of the condyle. The distal
margin of the PCL is proximal to the articular surface by 3
mm. 6 Fibers attach to the femur in an anterior to posterior
direcfion.27
The tibial attachment of the PCL is into a depression
between the 2 plateaus, approximately 1 cm distal to the
articular surface of the tibia, and extends distally several
millimeters onto the posterior surface of the tibia. Fibers
attach to the tibia in a medial to lateral direction. The PCL
attaches with several additional slips, including a slip to
blend with the posterior horn of the lateral meniscus.
When the meniscofemoral ligaments from the lateral me-
niscus are absent, this slip from the PCL is quite promi-
nent. The width of the tibial attachment averages 13 ram,
and is noted to depend on the width of the intercondylar
notch.6, 27
The average length of the PCL is 38 ram, and the aver-
age width is 13 mm. 6 The ligament is enclosed within
synovium and is, therefore, extra-articular in an anatomic
sense, aT,2s The synovium is reflected from the posterior
capsule, and covers the medial, lateral, and anterior as-
pects of the PCL. Distally, the posterior portion of the PCL
blends with the posterior capsule and periosteum, as The
vascular supply to the PCL is from the middle genicular
artery, which arises from the popliteal artery behind the
popliteal surface of the femur. It runs anteriorly and pen-
etrates the posterior capsule of the knee joint in the inter-
condylar notch. The artery supplies blood to both cruci-
ates, synovial membrane, posterior capsule, and the
epiphyses of the tibia and femur. The synovial tissue
around the PCL is also a major blood source for the
ligament. The base of the PCL is supplied by capsular
vessels arising from the popliteal and inferior genicular
arteries.13,27
175

I dicular to each other in the longest dimension. The liga-
Fig 3. Changes in the shape and tension of the PCL. In
extension, lengthening of the posteromedial band A-A'. In
flexion, lengthening of the anterolateral band B-B'. C-C' is
the ligament of Humphrey attached to the lateral meniscus.
Reprinted with permission. 6
The overall position of the ligament in the joint is lo-
cated near the longitudinal axis of rotation, just medial to
the center of the knee. It is directed vertically in the frontal
plane, and angles forward 30 ° to 56 ° in the sagittal plane,
depending on the degree of knee flexion. The PCL as-
sumes a more vertical orientation in extension, and a more
horizontal position in flexion.a7,28
The PCL is narrowest in the midsubstance, and fans out
superiorly to its widest dimension, an average 32 mm, and
to a lesser extent inferiorly.6 The medial fibers from the
tibia insert posteriorly on the femur, and the lateral fibers
from the tibia insert anteriorly on the femur. 27 Function-
ally, the PCL appears to be arranged in 2 inseparable
bands, named for their insertion positions. 6,27 The antero-
lateral band is more robust, and arises from the convex
portion of the femoral attachment. The anterolateral band
is lax in extension, and becomes taut as flexion increases
past 300.6,11,27 The posteromedial band is thinner, runs a
more oblique course, and attaches more distally on the
tibia. 6,27The posteromedial fibers are taut in extension and
lax in flexion (Fig 3). 11"27
The bands are not entirely separable, and represent a
simplification of the architecture. 23 No part of the PCL is
totally isometric during range of motion. The bulk of the
fibers of the PCL lengthen with flexion from 0 ° to 90 °. The
femoral attachment of the fibers is the primary determi-
nant of a given fiber's isometry during flexion and exten-
sion, particularly the proximal and distal (versus anterior
and posterior) location. Therefore, the function of fibers of
the PCL is determined primarily by the femoral attach-
ment location.
Grood 29 performed a study using an instrumented spa-
tial linkage for measuring the length of discrete bundles
within the ligament, and found that the most isometric
location for graft placement was at the base of the bullet-
shaped region whose base is against the roof of the inter-
condylar notch. These results help define attachments that
do not cause the substitute to become excessively tense or
slack when the knee is flexed. Error in AP placement on
the femoral side may be accepted; however, this is not true
for proximal-distal orientation. The PCL substitute should
be placed along the proximal attachment of the PCL.
176
In chronically deficient knees with no identifiable foot-
print, the average distance to the native femoral origin is
11 m m from the junction of the notch with the trochlear
groove. The region that results in 2 mm length variance
through the range of motion extends approximately 1 cm
from the roof in a posterior and slightly distal direction.
The PCL length pattern is relatively insensitive to either
proximal-distal or medial-lateral placement on the tibia.
Therefore, a widely exposed tibial fossa is not as necessary
during fixation on the tibial side. 29
The ACL and PCL tibial insertions are oriented perpen-
ments are separate in the sagittal plane in extension, and
wind around each other in flexion.6
BIOMECHANICS
The PCL is a primary restraint to posterior translation of
the tibia on the femur, and a secondary restraint to varus-
valgus and external rotation.6,10,13,20,25,27,30 The PCL is the
only isolated ligament to provide primary restraint to
posterior translation at all angles of flexion.25 The PCL
does not resist anterior d r a w e r . 1°,2°,23,24
Utilizing the stiffness method, Butler 10 ranked the liga-
mentous restraints to anterior-posterior motion in the hu-
man knee when displacement was fixed at 5 mm. The PCL
provided 90% to 95% of the total restraining force to
posterior translation at 30 ° and 90 ° of knee flexion. No
other structure contributed more than 2% to the total
restraint. Therefore, abnormal posterior tibial translation
cannot occur without injury to the PCL.
Grood s° utilized the flexibility method in a study that
allowed 6° of freedom to determine the effect of sectioning
the PCL and posterolateral structures (lateral collateral
ligament, popliteus, and arcuate complex) on knee motion
from 0 ° to 90 °. Isolated sectioning of the PCL resulted in an
increase in posterior translation, and this increased as the
knee was flexed, to a maximum at 90 °. These results reflect
the increasing slackness in the remaining secondary re-
straints to posterior translation as the knee flexes. Con-
versely, if the knee demonstrated a similar increase in
posterior translation at both 30 ° and 90 °, this suggested
that the medial and lateral extra-articular ligaments may
have lost some of their functional capacity.
In a similar sectioning-type study, Fukubayashi2° dem-
onstrated that isolated sectioning of the PCL produced an
almost 3-fold increase in the amount of posterior displace-
ment versus the intact knee, without affecting anterior
displacement. Before sectioning, a 100 N posteriorly di-
rected force resulted in 6-mm translation. Translation in-
creased to over 15 m m with sectioning of the PCL. In
PCL-deficient knees, the greatest posterior translation
with a posteriorly directed force occurred at 75 ° flexion.
Later sectioning of the ACL did not alter the translation in
the posterior direction. During the clinical examination,
the most effective position to conduct a posterior drawer
test is at 75 ° knee flexion.
After sectioning the PCL, the resulting secondary exter-
nal rotation disappears. Therefore, it is apparent that this
ligament plays a vital role in the natural rotation of the
tibia during AP motion. The PCL causes coupled external
rotation during posterior translation. In other words, the
GOLDBLATT AND RICHMOND
PCL constitutes a primary mechanism controlling and
producing external rotation during posterior translation. 2°
The central location of the PCL makes it the center for
rotational instability patterns of the knee. 28,3~
The PCL functions as a secondary restraint to external
rotation and varus-valgus rotation. Isolated sectioning of
the PCL yields no effect on varus-valgus or external rota-
tion at any angle as long as the LCL and deep ligament
complex are intact. 25 External rotation increases only 8°
with the knee flexed and isolated PCL sectioning, and
internal rotation increases only 3 °. Rotation is not affected
in the extended position, and extension is unaffected as
well. 6 Neither isolated nor combined sectioning of the PCL
or posterolateral structures increase anterior transla-
tion.6,25,30,32
THE MENISCI AND MENISCOFEMORAL
LIGAMENTS
ANATOMY
The medial and lateral compartments of the knee each has
an intervening meniscus located between the femur and
tibia. Grossly, the menisci are peripherally thick and con-
vex,, and centrally taper to a thin free margin. The meniscal
surfaces conform to the femoral and tibial contours.
The medial meniscus is semicircular and approximately
3.5 cm in length. The posterior horn is wider than the
anterior horn (Fig 1). The anterior horn has a variable
attachment to the tibial plateau in the area of the intercon-
dylar fossa in front of the ACL. Often, this attachment is to
the anterior surface of the tibial plateau. The posterior
fibers of the anterior horn merge with the transverse in-
terrneniscal ligament, which connects the anterior horns of
the 2 menisci. 33 The intermeniscal ligament, located ap-
proximately 8 m m anterior to the A C t , serves as the
primary attachment site for the anterior horn of the medial
meniscus in approximately one quarter of cases. 34 The
posterior horn of the medial meniscus is firmly attached to
the posterior intercondylar fossa of the tibia, anterior and
medial to the PCL tibial attachment site. The periphery of
the medial meniscus is attached to the capsule throughout
its length, and the tibial portion of this attachment is called
the coronary ligament. At its midpoint, the meniscus is
firmly attached to the femur and tibia through a conden-
sation of the joint capsule known as the deep medial
collateral ligament. 33
The lateral meniscus is almost circular in gross morphol-
ogy, and covers a larger portion of the tibial plateau than
the medial meniscus. The lateral meniscus is approxi-
mately the same width from front to back (Fig 1). The bony
attachments of the lateral meniscus are just anterior and
posterior to the ACL onto the tibia. There is a loose pe-
ripheral attachment of the lateral meniscus to the joint
capsule that allows greater translation of the lateral me-
niscus when compared with the medial meniscus. 33 The
area of the lateral meniscus with no coronary ligament
attachment, anterior to the popliteus tendon, is called the
b a r e a r e a . 35,36
Two meniscofemoral ligaments attach the lateral menis-
cus to the medial femoral condyle. The anterior menis-
cofemoral ligament (ligament of Humphrey) is less than
ANATOMY AND BIOMECHANICS OF THE KNEE
one third the diameter of the PCL, and arises from the
posterior horn of the lateral meniscus. It runs anterior to
the PCL to insert with the anterior fibers of the PCL on the
femur, at the distal edge of the PCL. The posterior menis-
cofemoral ligament (ligament of Wrisberg) is as large as
half the diameter of the PCL, and also arises from the
posterior horn of the lateral meniscus. It passes obliquely
behind the PCL, and inserts on the medial femoral con-
dyle, along with the posterior PCL fibers. 27,37The posterior
ligament has a more variable attachment to the meniscus.
It can originate solely from the tibia, or posterior capsule,
in which case it attaches indirectly to the lateral meniscus
via posterior capsular and popliteus attachments.
The meniscofemoral ligaments are variably present, and
both may be present in the same knee. Heller 37 found a
meniscofemoral ligament in 71% of 140 knees. Of all knees
studied, the anterior ligament was present in 36%, the
posterior in 35%, and both in 6%. In contrast, Girgis 6 never
observed the 2 ligaments together in a dissection of 44
knees. In 30%, the 2 ligaments were not found. Instead, a
prominent slip from the posterior cruciate ligament (PCL)
was inserted into the posterior horn of the lateral menis-
cus. In the remaining 70%, Wrisberg's ligament was more
commonly found, but when present, Humphrey's liga-
ment was more robust. Each meniscofemoral ligament is
identified by distinct femoral attachments readily distin-
guishable from those of the PCL. Their presence may be
confused secondary to the variable tibial-sided attach-
ments.
BIOMECHANICS
With knee flexion form 0° to 120°, the menisci move poste-
riorly. In the midcondylar, parasagittal plane, the medial
meniscus moves approximately 5.1 mm, and the lateral me-
niscus moves approximately 11.2 ram. Rotation of the knee
also affects meniscal motion. Posterior motion of the medial
meniscus is guided by the deep medial collateral ligament
(MCL) and semimembranosus, whereas anterior translation
is caused by the push of the anterior femoral condyle.1 The
medial meniscus lacks the controlled mobility of the lateral
meniscus.37 The posterior oblique fibers of the deep MCL
limit motion in rotation and, therefore, the medial meniscus
is at increased risk of tear. 33The lateral meniscus is stabilized,
and motion guided, by the popliteus tendon, popliteomen-
iscal ligaments, popliteofibular ligament, meniscofemoral
ligaments, and lateral capsule.37~39
The differential motion between the anterior and poste-
rior horns of each meniscus allows the meniscus to main-
lain conformity to the bony surfaces during flexion, as well
as to avoid any block to motion as the femorotibial contact
point moves with mofion. 13,26 In addition, meniscal mo-
tion allows continued load distribution during changes of
position of the joint, during which the radius of curvature
of the femoral condyles changes. 1,13,26,33
Although the menisci deepen the plateaus only slightly,
this deepening provides for a more congruent and con-
strained surface with the femoral condyles. 1,3s The medial
meniscus provides greater restraint to anterior translation
than does the lateral meniscus, by acting as a buttress. This
can be demonstrated by evaluation of the meniscus-deft-
177
 cient knee. A biomechanical study by Levy 24 of human-
cadaver knees compared intact knees to knees subjected to
isolated medial meniscectomy, isolated ACL sectioning, or
combined ACL sectioning and medial meniscectomy.
Compared with intact knees, isolated medial meniscec-
tomy did not significantly alter anterior-posterior dis-
placement, nor coupled internal rotation. ACL-deficient
knees demonstrate increased anterior translation when
subjected to an anteriorly directed force, and this transla-
tion increased significantly with combined meniscectomy
at all angles of flexion. The maximum anterior displace-
ment occurred at 60 °, and the greatest percentage increase
(58%) occurred at 90 °. The results confirm the role of the
ACL as a primary restraint to anterior translation, and
demonstrate that the medial meniscus acts as a secondary
stabilizer to resist anterior translation. With sufficient an-
terior translation (in the ACL-deficient knee), the posterior
horn of the medial meniscus is wedged between the tibial
plateau and the femoral condyle, and is the mechanism
suggested for the resistance provided by the meniscus.
Thus, sacrifice of the medial meniscus after injury to the
ACL may further compromise anterior stability. Meniscec-
tomy alone, or combined with ACL sectioning, does not
significantly affect posterior translation under 100 N pos-
teriorly directed load.
In contrast, the soft-tissue attachments of the lateral
meniscus do not affix the lateral meniscus as firmly to the
tibia. Levy 23 performed a similar study of the effect of
lateral meniscectomy in the unloaded knee. Changes in
motion in knees subjected to isolated lateral meniscec-
tomy, ACL sectioning, and combined lateral meniscec-
tomy and ACL sectioning were quantified. As expected,
isolated ACL sectioning resulted in increased anterior
translation when subjected to a 100 N anteriorly directed
force at all angles of flexion. Isolated lateral meniscectomy
did not significantly affect primary anterior or posterior
translation. Combined lateral meniscectomy and ACL sec-
tioning did not increase anterior translation significantly
over ACL sectioning alone. This implied that the greater
mobility of the lateral meniscus prevented it from contrib-
uting as efficiently as a posterior wedge to resist anterior
translation of the tibia on the femur. This test was per-
formed in unloaded knees, and should be extrapolated to
predict the effect under loaded conditions with caution.
Shoemaker 21 evaluated the role of the meniscus in an-
terior-posterior stability under loaded conditions in the
ACL-deficient knee. This study examined changes in AP
laxity due to progressive meniscectomy in the loaded knee
at 20 ° of flexion, under 320 N and 925 N compressive force.
After ACL sectioning, the resistance provided by the me-
nisci to an anteriorly directed force increased with increas-
ing axial load (57% at 925 N axial load). The higher the
applied joint load, the greater the meniscal compression,
and thus the greater the resistance to anterior force. The
contribution from the lateral meniscus was minimal. The
loaded menisci helped resist anterior translation in ACL-
deficient knees; however, they were easily overcome at
relatively low anteriorly directed forces of 200 N.
In addition to their role in joint stability, the menisci
serve additional functional roles, including load bearing
178
and shock absorption. The menisci transmit large loads
across the joint, and their contact areas change with dif-
ferent degrees of knee flexion and rotation. Up to 50% of
compressive load is transmitted through the menisci in
extension, and 85% at 90 ° of flexion. Removal of a portion
of the meniscus results in decreased contact area between
the femur and tibia. Medial meniscectomy decreases the
contact area by up to 70%. Resection of as little as 15% to
34% of the meniscus results in increased contact pressure
by more than 350%. The resulting increased peak stresses
and pressure concentrations lead to progressive degener-
ative changes closely resembling naturally occurring his-
tologic, biochemical, and biomechanical changes of osteo-
arthritis. The degree of change is proportional to the extent
of meniscectomy. 33,4°
MEDIAL STRUCTURES OF THE KNEE
The supporting structures of the medial side of the knee
can be divided into 3 discrete layers. 1,41 The most super-
ficial layer, layer I, is the deep or crural fascia. This fascia
is the first plane encountered deep to the subcutaneous
tissue, and extends from the patella to the midline of the
popliteal fossa. Anteriorly, this layer blends with layer II
in a vertical line, 1 to 2 cm anterior to the anterior edge of
the superficial MCLY The medial patellotibial ligament is
an oblique condensation of the medial retinaculum of
layer I. This ligament inserts 1.5 cm inferior to the joint
line, on the anteromedial border of the tibia, and coalesces
with the fibers of the medial patellofemoral ligament of
layer II, at the medial border of the patella. The medial
patellomeniscal ligament is deep to the patellotibial liga-
ment, and runs from the inferior two thirds of the patella
along the medial border of the infrapatellar fat pad to
insert on the anterior portion of the medial meniscus. 42
Posteriorly, layer I overlies the 2 heads of the gastrocne-
mius and serves to support the neurovascular structures of
the popliteal fossa. The sartorius inserts into the crural
fascia and does not have a distinct tendon of insertion, as
do the underlying gracilis and semitendinosus, which run
between layer I and II. Anteriorly and distally, layer I joins
the periosteum of the tibia, where the fibers of the sarto-
rius insert on the tibia, and posteriorly it becomes the deep
fascia of the leg.
Layer II contains the superficial MCL, and is clearly
defined by the parallel anterior fibers of this ligament (Fig
4). From the region of the femoral insertion of the anterior
fibers, a transverse band runs forward in the plane of layer
II from the adductor tubercle toward the patella, forming
the medial patellofemoral ligament. 41 The patellofemoral
ligament runs deep to the vastus medialis to insert on the
superomedial patella, and sends a slip to the undersurface
of the vastus medialis obliquus and vastus intermedius. 43
The posterior fibers of the superficial MCL are oblique in
orientation, and more posteriorly merge with fibers of
layer III at the posteromedial corner of the knee. These
posterior oblique fibers blend with the capsule posteriorly
to form a pouch. The pouch is augmented by contributions
from the semimembranosus sheath, as well as variably
from the semimembranosus tendon, to form the oblique
popliteal ligament (Fig 4).
GOLDBLATT AND RICHMOND

Fig 4o Structures of the medial side of the knee. Distinct
insertions of semimembranosus tendon (1,2) and tendon
sheath (3,4,5). The insert demonstrates sites of attachment
of the superficial and deep MCL. "C" indicates the oblique
popliteal ligament. Reprinted with permission. 41
The semimembranosus inserts to bone by a direct inser-
tion at the posteromedial corner of the tibia, just below the
joint line (Figs 4 and 7). Additional insertions of the semi-
membranosus include an anterior insertion around the
medial side of the tibia just below the joint line, deep to
layer II and distal to layer [II, as well as variable contri-
butions to the posteromedial capsule and oblique popliteal
ligament. The semimembranosus sheath contributes fi-
brous extensions into the posteromedial and posterior cap-
sule. These include a direct extension upward over the
medial condyle of the femur, a second extension across to
the lateral condyle, forming the oblique popliteal liga-
ment, and a third to blend with the oblique posterior fibers
of the superficial MCL (Fig 4).
Layer III is the true joint capsule. The lines of attachment of
the capsule follow the joint margins, except anteriorly, where
it extends cephalad to form the suprapatellar pouch. The
anterior capsule is thin and redundant to accommodate the
range of motion of the knee. Beneath the superficial MCL, the
capsule thickens to form the vertically oriented, short fibers
of the deep MCL (Fig 4). The meniscofemoral portion of the
deep ligament extends from the femur to the mid-portion of
the peripheral margin of the meniscus. The meniscotibial
portion of the ligament anchors the meniscus, and is readily
separated from the overlying superficial MCL. The remain-
der of the capsule is thin, and bulges as it extends from the
femur to the meniscus. The meniscus is attached distally,
along its margin, to the tibia by the coronary ligament, which
is slack but very short, so that it does not allow excessive
meniscal motion.~, 4~
ANATOMYAND BIOMECHANICSOF THE KNEE
MEDIAL COLLATERAL LIGAMENT (MCL)
Anatomy
The MCL is composed of a superficial portion and a deep
portion (Fig 4). 11 The superficial MCL originates on the me-
dial epicondyle, and runs downward as a broad triangular
band approximately 11 cm to its tibial insertion, deep to the
gracilis and semitendinosus tendons. 1,13,41 The superficial
MCL can be further subdivided into anterior and posterior
portions. The anterior margin lies free except at its attach-
ment sites to the tibia and femur, and is separated from the
medial meniscus and deep capsular ligament by a bursa,
where as the posterior margin passes obliquely backwards to
an insertion in the medial meniscus. The anterior portion is
taut in extension, and progressively tightens over the entire
range of motion, whereas the posterior portion slackens with
flexion. 41,44The inferior medial geniculate vessels and nerve
intervene between the ligament and bone as the insertion of
the collateral extends distal to the knee joint. 13 The deep
portion of the MCL also can be divided into 2 subdivisions,
the meniscofemoral and meniscotibial ligaments, defined by
their respective insertions. 44
Biomechanics
The MCL is an important restraint to valgus rotation and
a check against external rotation and straight medial and
lateral translation of the tibia. Warren 44 demonstrated that,
regardless the order of ligament sectioning, the superficial
portion of the MCL contributed greatest to stability. Sec-
tioning the superficial portion of the ligament, while leav-
ing the remainder intact, resulted in joint space opening
under valgus load, over the entire range of motion. In
addition, external rotation doubled in extension and pro-
gressed to a 3-fold increase by 90 °. Sectioning the deep
ligament and posterior capsule produced almost no
change in the behavior of the specimen under stress if the
superficial fibers were intact.
Utilizing the stiffness method, Grood 45 determined the
contribution of the MCL to valgus stability. The superficial
portion of the MCL provided the majority of the restraint to
valgus rotation, from 57% at 5° of flexion to 78% by 25 °
flexion. Laxity was greatly reduced with the knee in full
extension. The percentage contribution of the ligament in
extension was reduced even further as joint-space widening
increased. This was due to increasing tension in other pos-
teromedial structures, mainly the posteromedial capsule.
The role of the MCL increases with increasing flexion, as
the posterior capsular structures become slack. The in-
crease in valgus laxity after sectioning the MCL is greater
in a more flexed position, and largest at 30 °, with up to 5.5
mm of joint-space opening. This measurement points out
that a complete injury to the MCL may occur with even
subtle laxity, and a large increase in joint laxity likely
involves additional structuresol~, 44,45
MEDIAL PATELLOFEMORAL LIGAMENT
Anatomy
More recently, the medial patellofemoral ligament is rec-
ognized as a major restraint to lateral displacement of the
179
 1 - first layer
prepate!tsr bursa (I)
II. second layer
~atella III- third layer
;ulum (111
I tract (l)
ra! meniscus
joint capsule {lff}
popltteus tendon
" (entering jo!r~ through hiatus)
lateral ¢otlat~l ligament (Ill) in sup, lamina
~rcua~ ligament (Ill) in deep ~am!na
~ater~l inferior gentcutate a.
fabellof~buiar ligament (Ill}
biceps t e n o n (I}
common peroneal m
ligament Of fibular bead
Wrisberg
oblique'
poplitea! popliteus
ligament
distal knee-extensor mechanism. For this reason, it de-
serves separate mention. As described above, the hour-
glass-shaped ligament runs transversely in layer II from
attachments to the adductor tubercle, as well as femoral
epicondyle, and anterior bo~der of the superficial
MCL. 41-4~ The proximal fibers of the ligament proceed
anteriorly toward the vastus medialis obliquus, fanning
out proximally to insert on the undersurface of the vastus
medialis obliquus and the aponeurotic fibers of the vastus
intermedius. The distal fibers insert anteriorly on the su-
peromedial patella, extending inferiorly from the medial
process. 42,43 The width of the medial patellofemoral liga-
ment averages 1.3 cm. 43
Biomechanics
Conlan 43 utilized the stiffness method to evaluate the me-
dial soft-tissue restraints of the extensor mechanism in 25
fresh-frozen knee specimens performed in extension. The
major stabilizer preventing lateral displacement of the
patella was the medial patellofemoral ligament, followed,
in decreasing order, by the medial patellomeniscal liga-
ment, the medial retinaculum, and the medial patellotibial
ligament. The contribution to restraint from the medial
patellofemoral ligament was 23% to 80%, with an average
53% of the total restraint. Of note, the patellofemoral lig-
ament was variable in size, and the restraint provided
corresponded to the bulk of the ligament.
In a similar study performed at 20 ° of flexion, Desio 42
found the contribution of the medial patellofemoral liga-
ment to be 60%. In combination, the restraint of the patel-
lofemoral and patellomeniscal ligaments accounted for
approximately 75% of the medial restraining force at ex-
tension, and 20 ° flexion.42,43
LATERAL STRUCTURES OF THE KNEE
The lateral compartment of the knee is divided into 3
sections. 46 The anterior one third of the lateral compart-
ment includes the capsular ligament, which extends pos-
teriorly from the lateral border of the patella to the ill-
180
Fig 5. Axial section of the anatomy of the
layers of the lateral knee. I: first layer; I1:
second layer; II1: third layer. Reprinted with
permission. 36
otibial band. This region is reinforced by the lateral exten-
sion of the quadriceps tendon (retinaculum). These join to
form a single layer at their attachment to the tibia. The
middle one third is composed of the more superficial
iliotibial (IT) band and a d ~ p e r capsuia~ Iigamen~. This
section extends posteriorly to the lateral collateral liga-
ment (LCL). The middle third capsular ligament attaches
proximally to the lateral epicondyle of the femur, and
distally to the tibial joint margin. The remaining posterior
one third is termed the posterolateral corner. This region
contributes significantly to the stability of the lateral knee
through the intricate arrangement of many structures. 46 It
is precisely this complexity that has resulted in so much
study and controversy.
Seebacher36 divides the lateral knee into 3 layers (Fig 5).
Layer I is the superficial layer comprised of the iliotibial
tract with its anterior expansion, and the superficial por-
tion of the biceps with its posterior expansion. The pero-
neal nerve lies on the deep side of layer I, just posterior to
the biceps tendon (Fig 6).
Layer II is formed anteriorly by the retinaculum of the
quadriceps, which extends along the anterolateral border
of the patella. Posteriorly, the layer is incomplete, and is
represented by 2 patellofemoral ligaments. The proximal
ligament joins the terminal fibers of the lateral intermus-
cular septum. The distal ligament ends posteriorly on the
fabella, or at the insertions of the posterolateral capsular
reinforcements, and the lateral head of the gastrocnemius
on the femoral condyle. Also part of layer II, the patello-
meniscal ligament travels obliquely from the patella to the
margin of the lateral meniscus, and terminates at Gerdy's
tubercle (Fig 6 ) . 36
Finally, layer III, the deep layer, includes the lateral joint
capsule, and its supporting ligaments (Fig 5). The coronary
ligament is formed by the capsular attachment to the
meniscus. Just posterior to the IT band, the underlying
capsule divides into 2 laminae. The more superficial, the
original capsule, encompasses the LCL and ends posteri-
orly at the fabellofibular ligament. B6 When a fabella is
present, the fabellofibular ligament is found coursing par-
GOLDBLATT AND RICHMOND

biccp
,ion~
*sho
Fig 5. Structures of the lateral side of the
knee. The figure on the left shows the major
i|i
structures of Layer 1. On the right, Layer I is
reflected from the lateral margin of the pa-
tella showing Layer 2. Reprinted with per-
mission. 36
allet to the LCL from the fabella to the fibula to insert
posterior to the insertion of the biceps tendon. If also
present, the short lateral ligament runs adjacent to the
lateral limb of the arcuate ligament from the femoral con-
dylar origin of the lateral head of the gastrocnemius to the
fibula.35 The deeper lamina runs along the edge of the
lateral meniscus, forming the coronary ligament and the
hiatus for the popliteus tendon, and terminates posteriorly
at the Y-shaped arcuate ligament. The arcuate ligament
spans the junction between the popliteus muscle and its
tendon from the fibula to the femur. The popliteus tendon
passes through the hiatus in the coronary ligament to
attach to the femur, anterior and distal to the attachment
of the LCL. The inferior lateral genicular artery runs in the
space between the 2 laminae. B6 The final component of
layer III is the popliteofibular ligament, which is found
deep to the lateral limb of the arcuate ligament. The pop-
liteofibular ligament arises from the posterior part of the
fibula, posterior to the biceps insertion, and joins the pop-
liteus at the musculotendinous junction. The popliteus
muscle-tendon unit, therefore, is a Y-shaped structure
with a muscle origin from the posterior part of the tibia, a
ligamentous origin from the fibula, and a united insertion
on the femur. 35
ILIOTIBIAL (IT) B A N D
Anatomy
The IT tract is formed proximally at the level of the greater
trochanter by the coalescence of fascial investments of the
tensor fascia lata, gluteus maximus, and gluteus medius. It
then attaches to the linea aspera of the femur through the
lateral intermuscular septum. At the knee, it separates into
2 functional components: the iliotibial tract, and iliopatel-
lar band. 47
The IT tract is divided into layers. The anterior portion
of the superficial IT tract attaches to Gerdy's tubercle. A
deep layer begins 5 cm proximal to the lateral epicondyle,
ANATOMY AND BIOMECHANICS OF THE KNEE
3ralis
ntem'~,~Sr;uiar
;uiar septum
~riOt 9enicut~te a,
z and lateral head of
'ocltem~u$
suprapatella~ r
pouch
palella
pa|oliat reli~'~ac~
ulum with at~ach-
r~er~t$ to:
.acr:r,,ssory vsstt~
-!at. intermuscular
sep~urn
4al~ila
4tio4ibia! trawl
4aL meniscus
-|aL tuberr;le
of tibia
\ fat pad
~t ca p.~ule
separate from the superficial, and continues in the coronal
plane to the lateral intermuscular septum of the distal
femur. The final layer of the IT tract, the capsuloosseous
layer, begins proximally as the lateral investing fascia of
the lateral gastrocnemius tendon and the medial investing
fascia of the short head of the biceps. Distally, the capsu-
loosseous, deep, and superficial layers of the tract merge
to insert on the lateral tibial tuberosity, just posterior and
proximal to Gerdy's tubercle. 4s
The iliopatellar component of the IT tract connects the
anterior aspect of the IT tract to the patella. The iliopatellar
band is layered in a similar fashion to the IT tract. At the
insertion into the patella, these layers are indistinct. How-
ever, on the femoral side, the layers are separate, and the
capsuloosseous layer is seen to arise from a bony connec-
tion to the supracondylar process. This layer serves as the
femoropatellar ligament, and travels parallel to the
oblique fibers of the vastus lateralis. The iliopatellar band
functions to resist a medially directed force to the patella,
and is dynamically influenced by the vastus lateralis. 47
Biomechanics
The IT tract is an important stabilizer of the lateral com-
partment, and is instrumental in preventing varus open-
ing of the knee. 49 In full extension, the IT tract may act as
an extensor as well as static stabilizer. 13,26 As the knee
flexes, the IT band tightens and moves posteriorly. The
biceps fascial communication aids in maintaining tension
over the range of motion. The IT tract, therefore, exerts a
posteriorly directed and external rotation force on the
lateral tibia. The tract is tightest at 10° to 30 ° of flexion and,
therefore, may be most vulnerable to injury at this posi-
tion. 38,5° Beyond 40 °, the tract becomes a flexor of the
krtee. 26 During extension, the IT tract moves anteriorly,
and is thus spared in most cases of varus stress and
posterolateral injury,ss
181
 LATERAL COLLATERAL LIGAMENT (LCL)
Anatomy
The LCL arises in a fan-like fashion in a fovea immediately
posterior to the lateral epicondyle at an average 3.7 m m
posterior to the apex of the epicondylar ridge. It is located
between the superior fovea for the lateral gastrocnemius
and the more distal popliteus. 2,48 The LCL is superficial to
the tendon of the popliteus. 5~
The average length of the ligament is reported from 59.2
to 71 ~,2,52,53 and has a minimum diameter at its mid-
point, where it is elliptical in shape. The average AP
diameter is 3.4 mm, and the average medial to lateral
dimension is 2.3 mm. The fibular attachment is into a
superior and laterally facing V-shaped plateau on the head
of the fibula. 2 The biceps tendon forms a semicircle around
the distal rim of this plateau and overlies the LCL attach-
ment, separated from the LCL by a bursa. 2,53 The lateral
fibers of the LCL then continue distally, medial to the
anterior arm of the biceps, to blend with the superficial
fascia of the lateral compartment of the leg. 48 The LCL
reinforces the posterolateral one third of the capsule. 38
Along its proximal course, the posterior aspect of the LCL
is directly connected to the lateral aponeurotic expansion
of the short head of the biceps. 48 The LCL differs from the
MCL in that it is separated from the lateral meniscus. 54
The angle the LCL makes with the long axis of the femur
changes with flexion. In full extension, the LCL is directed
posteriorly, from proximal to distal. As flexion proceeds,
this changes to an even greater anteriorly directed angle,
due to the posterior translation and internal rotation of the
tibia. 2 The LCL passes through vertical at 70 ° flexion, and
at this point may provide less restraint to posterolateral
rotation of the fibular head. 52
Biomechanics
Because the LCL is located posterior to the axis of flexion-
extension rotation, and the radius of curvature of the
lateral condyle decreases during flexion, it is tightest in
extension and progressively relaxes with flexion beyond
300.2,45,49,52,54Additionally, posterior translation of the fem-
orotibial contact point and coupled internal rotation of the
tibia with flexion contribute to the change in tension in the
LCL.2 The LCL appears to remain taut from 0° to 30 ° and,
therefore, is most important in resisting varus instability
over this range. However, the dynamic effect of the apo-
neurotic layers of the long and short heads of the biceps
femoris provide continuous tension in the LCL.49,5° This
may explain how the LCL continues to be a primary
restraint to varus at all angles.
Appropriate selection of attachment sites during recon-
struction of the LCL may not simply be isometric, because
the LCL slackens with flexion and, therefore, normally
allows tibial external rotation. 2,45,54 Otherwise, a com-
pletely isometric graft may compromise this rotation. Ten-
sioning a graft in no more than 30 ° of flexion, close to
neutral rotation, is recommended. 2
The LCL is a primary restraint to varus at all positions of
f l e x i o n , 25"38'45"49"52"55 and a secondary restraint to external
rotation and posterior translation. 38,55 The LCL resists ap-
proximately 55% of applied varus load at full extension. 11
182
Ligament integrity can by tested with varus at 0 ° of flex-
i0n52; however, Veltri 56 showed that injury to the LCL was
best demonstrated at 30 ° of flexion. The magnitude of
increased varus rotation with isolated injury to the LCL is
small (2° to 4°), and may be difficult to detect clinically.
Sectioning of the popliteofibular ligament with an intact
LCL results in no significant increase in varus rotation
from 0° to 30 °, because the LCL is a primary restraint to
varus. Yet an increase in varus is seen from 60 ° to 90 ° due
to the slackening of the LCL with flexion. Combined sec-
tioning of the LCL and popliteofibular ligament yields a
very significant increase in varus rotation at all angles. 55
External rotation increases with isolated sectioning of the
LCL at all angles of flexion except 60 °. Isolated sectioning
of the LCL results in no change in primary internal rota-
tion, posterior translation, or coupled anterior-posterior
translation of the tibia on the femur. 25
POSTEROLATERAL CORNER
Anatomy
The complexity of the posterolateral corner stems largely
from the variable presence of many of the component
structures. The structures in this region provide both dy-
namic and static stability to the knee. The dynamic struc-
tures include the iliotibial band, the lateral head of the
gastrocnemius, biceps femoris, and popliteus. These com-
ponents are invariably present. Static structures are much
more variable in presentation, and include the lateral col-
lateral ligament, fabellofibular ligament, short lateral lig-
ament, popliteofibular ligament, arcuate ligament, pos-
terolateral capsule, posterior horn of the lateral meniscus,
and lateral coronary ligament. The contribution to overall
stability of several of these structures is debated. The
controversy is due in part to the confusing terminology
used to describe individual components. The short lateral
ligament, for example, is described with no fewer than 8
names. 57
Many authors note variability of the structures of the
posterolateral corner. In the dissections performed by See-
bacher, 36 3 anatomic variations were described: 1) the ar-
cuate ligament alone reinforced the capsule, 13%; 2) the
fabellofibular ligament alone reinforced the capsule, 20%;
and 3) both ligaments reinforced the capsule, 67%. The
variable presence of these structures was related to the
presence or absence of the fabella. If an osseous fabella
was present, then the fabellofibular ligament was robust; if
the fabella was absent, then the arcuate ligament was
robust; and if the fabella was cartilaginous, then both
ligaments were present and diminished in substance.
The oblique popliteal ligament is invariably present as a
wide band that runs diagonally from the distal tibial in-
sertion of the semimembranosus toward the more proxi-
mal femoral origin of the lateral gastrocnemius over the
lateral femoral condyle. It is formed from the oblique
popliteal expansion of the semimembranosus muscle and
the capsular arm of the posterior oblique ligament. 48 The
lateral border of the oblique popliteal ligament constitutes
the medial arch of the arcuate ligament over the popliteus
muscle (Fig 7). 57
GOLDBLATTAND RICHMOND

Fig 7. Posterior knee: 1) popliteus muscle; 2) semimembra-
nosus expansion; 3) posterior-superior popliteomeniscal
fascicle; 4) arcuate ligament; and 5) popliteofibular ligament
(curved arrow). Reprinted with permission. 39
The arcuate ligament is a complex arrangement of fibers
oriented in various directions, and appears to be a consol-
idation of several anatomic structures. 48 The ligament is
comprised of a lateral and medial limb, resulting in a
Y-shaped configuration overlying the popliteus muscle at
its musculotendinous junction (Fig 7). 35"38'48,51,57 The me-
dial limb, as mentioned above, arises from the posterior
part of the capsule at the distal part of the femur, proximal
to the joint line, and courses medially to cross the mid-
point of the joint at the level of the tibial insertion of the
PCL. It terminates into the oblique popliteal liga-
menL 35,38,39,48,51The lateral limb is not always distinct, and
appears less prominent in older specimens.4S, 57 The lateral
limb arises from the posterior part of the capsule, at the
level of the superior edge of the posterior horn of the
lateral meniscus, to span the junction between the lateral
femoral condyle and the posterior fibular styloid. 35,36,38,48It
courses laterally over the popliteus muscle and tendon,
deep to the lateral inferior geniculate vessels, to insert on
the posterior part of the fibula, posterior to the fabellofibu-
lar ligament.g5,4s, 5s The lateral limb frequently blends with
the posterior capsule to such an extent that it cannot be
dissected from the capsule or from the fascia covering the
popliteus. 57
The variable presence of the short lateral ligament and
the fabellofibular ligament results in significant contro-
versy in the literature. In an effort to clarify the anatomy of
these 2 ligaments, Kaplan 57 performed an extensive com-
parative anatomic dissection of human and nonhuman
specimens, in which he defined the fabellofibular ligament
as a distinct structure, homologous to the short lateral
ligament. The fabellofibular ligament differed from the
short lateral ligament in size and relationship to the LCL.
ANATOMY AND BIOMECHANICS OF THE KNEE
The short lateral ligament is attached proximally to the
posterior aspect of the supracondylar process of the femur,
where its fibers blend with the lateral gastrocnemius ten-
don, 48 and distally to the fibular styloid and medial border
of the fibular head. It blends with the capsule deep to the
popliteus as a thickening of the capsule. 57 When a fabella
is present, a strong ligament is found originating from the
fabella, almost equal in size to the LCL and running al-
most parallel to it, to the fibular head. It inserts posterior
to the insertion of the biceps tendon. The LCL inserts
anterior to the biceps at the fibular head. The distance
between the fabellar origin of this ligament and the fem-
oral origin of the LCL is approximately 2 cm. Of note, the
inferior lateral genicular vessels run over the capsule and
lateral arch of the arcuate ligament, and pass deep to the
LCL. In the presence of the fabellofibular ligament, the
vessels run deep to this ligament as well, thus indicating
the independence of the fabellofibular ligament from the
capsule. The fabellofibular ligament is present whenever a
fabella is found, and attenuated or absent when the fabella
is absent. A fabella is present in approximately 8% to 16%
of knees. In the absence of the fabellofibular ligament, the
short lateral ligament represents a homologue of the fa-
bellofibular ligament. 57
The mid-third LCL is a thickening of the lateral capsule
of the knee. 48,49The ligament is thought to be semiequiva-
lent to the deep MCL. This thickening extends from the
capsular attachments just anterior to the popliteus tendon
insertion on the femur to the lateral gastrocnemius attach-
ment. It then extends distally to its tibial attachment, from
slightly posterior to Gerdy's tubercle to the popliteus hi-
atus. The ligament is divided into 2 components. A me-
niscofemoral component extends from the femur to the
meniscus, and a meniscotibial component extends from
the meniscus to the tibia. °
The remaining structures of the posterolateral corner
(LCL, popliteus complex, IT band) receive individual de-
scription in separate sections.
Biomechanics
Taken as a whole, the structures crossing the posterolat-
eral corner of the knee provide resistance to tibial external
rotation, varus rotation, and posterior tibial transla-
tion. 25,28,38,49,50,52,55 Various sectioning studies provide in-
sight into the interaction among the ligaments of this
region.
Combined sectioning of the posterolateral structures,
with an intact PCL, result in maximum increased external
rotation, varus rotation, and posterior translation at 30 °.
At low flexion angles, the bulk of the PCL is lax. When the
PCL is sectioned along with these structures, posterior
translation, varus, and external rotation further increase at
all angles. 5°
Intact knees demonstrate increasing external rotation
with flexion to 90 ° when subjected to an external rotation
moment. On isolated sectioning of the popliteofibular lig-
ament, coupled external rotation increases at all angles, to
a maximum of 30 °, at which point posterior translation is
also maximum. Combined sectioning of the popliteofibu-
lar ligament and LCL yields continued increases in cou-
pled external rotation, at a peak of 30°. 25,50 The LCL is
183
slack with flexion; therefore, the popliteofibular ligament
is dominant versus external rotation with knee flexion
and, therefore, will fail first with external rotation. 52 As
knee flexion progresses, the femoral origin of the popliteus
moves upward from the tibial plateau, and the popliteo-
fibular ligament complex maintains a more efficient ten-
sion and orientation for resisting tibial external rotation
and posterior displacement than the LCL at all knee flex-
ion angles. 52 The LCL is a secondary restraint to coupled
external rotation. 25,5°
Sectioning the posterolateral structures has no signifi-
cant effect on the anterior limit of translation when an
anteriorly directed force is applied, but it does change the
posterior limit. This increase in posterior translation is
significant between 0 ° and 45 °, and is accompanied by an
increase in external rotation of the tibia. 3°
Gollehon 25 demonstrated that isolated sectioning of the
deep ligament complex (arcuate ligament, popliteus ten-
don, fabellofibular ligament, and posterolateral capsule)
or the LCL yielded a slight increase in primary varus.
Combined sectioning of the posterolateral complex and
LCL produced a significant increase in varus and was
clinically detectable, especially at 30 ° flexion.
The fabellofibular ligament is under greatest tension
when the knee is in full extension, but it relaxes with
flexion. This ligament, therefore, may have greatest func-
tion in extension. 59
POPLITEUS AND POPLITEOFIBULAR LIGAMENT
Anatomy
The popliteus muscle and popliteofibular ligament receive
much discussion regarding an accurate description of their
anatomy. Covey 5° uses the more functional term "poplite-
us complex" to describe these structures. The complex
consists of both a dynamic component (popliteus muscu-
lotendinous unit) and a static component (popliteofibular
ligament, popliteotibial fascicle, and popliteomeniscal fas-
cicle) .50
The popliteus muscle originates from the posteromedial
surface of the proximal 10 to 12 cm of the tibial metaphysis
(Fig 8). 60 The direct expansion of the semimembranosus
blends into the popliteus muscle fascia. The medial part of
the popliteus muscle inserts into the posterior horn of the
lateral meniscus and capsule via the superior popliteome-
niscal fascicle. The lateral part of the muscle joins the
arcuate ligament superficially, as well as deep connecting
fibers from the fibula, to form the musculotendinous junc-
tion. 39 The tendon then passes through a hiatus in the
coronary ligament, reinforces the posterior one third of the
lateral capsule, and then crosses under the LCL to insert
on the lateral femoral condyle. The insertion is crescent
shaped, near the articular cartilage border, 3 to 5 mm
above the superior aspect of the lateral meniscus, distal
and anterior to the LCL. 38,39,59In extension, the insertion of
the tendon into the femoral condyle creates a sinusoidal
cartilage indentation at the border of the lateral femoral
condyle called the sulcus statarius of Furst. In flexion, the
popliteus tendon gradually slides into the sulcus. 39
The popliteus muscle is invariably described with little
controversy; however, the popliteofibular ligament is only
184
Fig 8. Popliteus complex. The asterisk represents the pop-
liteofibular ligament. Reprinted with permission, ss
more recently receiving significant appreciation. The pop-
liteofibular ligament is a stout ligamentous structure, with
an average length of 42.6 mm. The average cross-sectional
area of the popliteofibular ligament measured 6.9 mm 2,
compared with 7.2 mm 2 for the LCL and 13.7 mm 2 for the
popliteus tendon. It descends from the musculotendinous
junction of the popliteus to the posterosuperior promi-
nence of the fibular head, adjacent to the insertion of the
LCL, partially covered by the LCL, and deep to the lateral
limb of the arcuate ligament (Fig 8).
The fiber orientation of the popliteofibular ligament is
oblique in its proximal third, where it fuses with the fibers
of the popliteus tendon. In its distal two thirds, the fibers
are oriented more vertically, similar in orientation to the
LCL. 38,52,55,58,61 The ligament is comprised of 2 fascicles.
The anterior fascicle originates from the tibia and anterior
aspect of the fibular head, adjacent to the tibiofibular joint
capsule. The posterior fascicle originates from the poste-
rior aspect of the fibular head, adjacent to the posterior tib-
iofibular joint capsule. The 2 fascicles join in an inverted-Y
pattern before insertion into the popliteus tendon and the
inferior popliteomeniscal fascicle. This description is
equivalent to the description by Seebacher 36 of the inner-
most lamina of the arcuate ligament (spanning the junc-
tion between the popliteus muscle and its tendon from the
fibula to the femur). 39,61
The ligament acts as a pulley fixing the popliteus tendon
during contraction, 51 and because it undergoes no signif-
icant length change during knee flexion, it becomes dom-
inant with knee flexion secondary to the slackening of the
LCL. 52 The biceps insertion is anterior to the popliteofibu-
lar ligament on the fibula, 38,52,55 which is important when
considering the biceps to reconstruct the ligament, s5
The combined anatomic dissection and videoarthro-
scopic evaluation conducted by Staubli 39 of 175 knees
taken through a range of motion and subjected to rota-
tional moments, established the relationship of 2 addi-
GOLDBLATT AND RICHMOND
tional supporting structures arising from the popliteus
tendon: the inferior and superior popliteomeniscal fasci-
cles. The anteriorly located inferior fascicle blended into
the middle segment of the lateral meniscus to form the
floor of the popliteal hiatus. The posteriorly located supe-
rior fascicle blended into the posterior horn of the lateral
meniscus to create the roof of the popliteal hiatus. The
medial excursion of the lateral meniscus with varus was
controlled by the popliteomeniscal fascicles and the pop-
liteofibular ligament, and the lateral excursion of the me-
niscus with valgus was limited by the popliteus tendon.
Biomechanics
The popliteus complex acts as a dynamic internal rotator
of the tibia and as a static restraint to posterior tibial
translation, varus rotation, and primary and combined
external rotation of the tibia on the femur. 28,38,49,50,52,55 The
popliteus appears to function both statically and dynam-
ically to prevent external rotation, rather than merely act-
ing as an active internal rotator of the tibia. It is the only
major structure positioned at an oblique angle in the pos-
terolateral corner of the knee, and thus is well suited to
prevent tibial external rotation during flexion from 20 ° to
130 °, as well as varus from 0 ° to 90o.50 When compared
with other components of the deep-ligament complex,
sectioning of the popliteus results in significant increases
in external rotation at 90 ° of flexion.25 The tendon appears
to be composed of 2 fiber bundles. The anterior fibers
become tense in flexion, and the posterior fibers tense in
extension. This phenomenon is exaggerated by the addi-
tion of external rotation. 59
The popliteus is actively responsible for the screw home
mechanism (tibial external rotation) during terminal ex-
tension. 55 In addition, the popliteus initiates flexion by
unscrewing the locked, extended knee, and retracts the
lateral meniscus to prevent its impaction by the femur. The
popliteus is the only muscle that has a rotation effect on
the j o i n t . 13,37,54 Once unlocked, the hamstrings can func-
tion to flex the knee. ls
A major contribution to the static function of the com-
plex is provided by the popliteofibular ligament. Several
investigators have demonstrated that the popliteofibular
ligament is a primary restraint to posterior translation,
varus rotation, and primary and coupled external rota-
tion. 39,52,55,56 Because the popliteofibular ligament is dom-
inant, and well aligned to resist tibial external rotation at
all angles of flexion, increased external rotation with test-
ing at any angle indicates damage to the popliteofibular
ligament. 52 Its role in preventing posterior translation is
greatest at 30 ° of flexion, secondary to decreased effective-
ness of the PCL in this position, ss
CONCLUSIONS
The information presented represents a brief outline of the
anatomy of the structures of the knee. The separate dis-
cussion of the biomechanics of these structures is impor-
tant for the surgeon who is attempting to recreate the
missing function in the injured knee. Accurate clinical
evaluation is based on the assessment of changes from
normal motion. Successful reconstruction requires precise
ANATOMY AND BIOMECHANICS OF THE KNEE
anatomical graft placement, as well as tensioning in the
appropriate degree of knee flexion and rotation. This re-
view is intended to assist with diagnosis and surgical
intervention.
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