Martha Kurnia Kusumawardani

Dept Kedokteran Fisik dan Rehabilitasi

Fakultas Kedokteran Universitas Airlangga
§ Must be large  heavy weight stress to bear
§ Must be wide ROM  shorten & lengthen
extremity for ambulation
§ Between 2 long lever arm
§ When ambulate, bipedal need rotatory
motion  Simple hinge joint 
trochoginglymus joint  two degree of
freedom of motion
 Bones :
- Distal End Femur
- Proximal End Tibia
- Patella
 Meniscus
 Ligament
 Bursae
 Muscles of Knee Joint
Distal End Femur
1. Patellar surface (anteriorly)
- saddle-shaped
- asymmetrical
- lateral face (larger, more convex)
2. Tibial surface (inferiorly)
Viewed laterally : ante: flattened
poste : curved
- 2 condyles (medial : smaller transverse, longer
longitudinal diameter)
- separated deep U-shaped (intercondylar fossa)
Tibial Plateu
 2 articulating surface:
- medial: oval, deeper,
more concave
- lateral : rounded
 Separated by eminence
intercondylaris
- sesamoid bone
- function : increase leverage of knee extensors
- adjust oblique direction of quadriceps  its
insertions conform with the axis of the leg
- Lateral dislocation more common :
straightening tendon cause quadriceps laterally
directed
- to offset this tendency  lateral condyle of
femur more anterior

All articulating surface covered thick

layer of cartilage
 Joint capsul is shallow & large
(could hold up 40cc air without tension)

Synovial sac & capsule:

 Anterior : Suprapatellar pouch  up & behind
patella (Housemaid’s knee)
 Posterior : Origin of gastrocnemius (Baker’s
Cyst)
 Lateral : to femur (junction of condylar cartilage)
 Inferior : to tibia (1/4 inch below att collateral
lig)
 Semiulnar cartilages
 To compensate the asymmetry of femoral
condyles >< tibial condyles
 Wedged, curved, fibrocartilagenous structure
& avascular, except outer 3rd ( artery popliteal)

 Function :
- Assist distributing pressure femur >< tibia
- Increase elasticity of the joint
- Assist in lubrication
 approx. 10mm
 poste horn >> middle
 wider curve
 anterior horn 
- anterior ridge tibia
- ventral intercondylar
 Connect to :
- Anterior cruciate lig (ante horn)
- Ante horn lateral meniscus (lig transversus)
- Joint capsule (outer surface)
- Medial collateral lig (outer surface)
- Tendinous semimembranous muscle (poste)
 apprx 12-13mm.
 Greater curvature  closed ring
 Ante & poste horn insert into eminentia
intercondylaris
 Fibrous connection to poste cruciate lig (lig
menisci fibularis)
 Most poste horn insert femur through fossa
intercondylar  via strong fasciculus upward
& medially (Wrisberg lig)  blend with poste
cruciate lig
1. Cruciates Ligament
- paired, namely according to the
attachment
a. Anterior Cruciate Lig  superior &
posterior from anterior medial tibia
attachment  lat femoral condyle
b. Posterior Cruciate Lig  back of tibia &
extends forward, upward & inward  medial
femoral condyle
 Function Cruciate Lig:
- prevent shear motion
- guide flexion – extension of knee joint
§ Anterior Cruciate Lig :
- prevents abnormal external rotation
- prevents hyperextension
- stabilize the knee extension
§ Posterior Cruciate Lig :
- prevents excessive internal rotation
- turn aids normal knee flexion
2. Capsular & Collateral
 Medial capsular ligament :
a. deep section :
- anterior : parallel fibers (anteriorly
attach the medial meniscus)
- middle : 2 division :
superior : thicker, meniscofemoral
inferior : meniscotibial
- posterior : oblique, fanned, thin,
indistinct
b. superficial section
 Collateral Ligament :
- Medial = Tibial collateral ligament
- flat
- broad ligament, attach to medial
condyles of femur & tibia
- connect with medial meniscus
- Lateral = Fibular collateral ligament
- round, cordlike
- attach to lateral condyle of femur, run
down to head of fibula
- no attachment of the lateral meniscus
 Arcuate Ligament : lateral femoral condyle to
head of fibula
 Locates at sites of moving tissue to permit
friction-free action
 11 or more bursae in the knee joint region:
◦ 3 communicated with knee joint  quadriceps,
popliteus, medial gastrocnemius
◦ 3 related to patella & patellar tendon 
prepatellar, superficial infrapatellar, deep
infrapatellar
◦ 2 related to semimembranosus tendon
◦ 2 lie supperficially to the collateral ligaments
◦ 1 between superficial & deep parts of tibial
collateral lig.
1. SYNOVIAL FLUID

 Clear, colorless, or slightly yellow liquid

 Most joint : 0,2 ml
 For large joint (knee, hip, shoulder) : up to 5 ml
 Normal condition : enough to moisten &
lubricate the articular & synovial surface

2. MENISCUS TEAR  ANATOMICAL STRUCTURE

 Divided into
Extensor : Anterior
Flexor : Posterior
Abductor : Lateral
Adductor : Medial
EXTENSOR
 Main muscle : QUADRICEPS FEMORIS
 Inserts to patella & tibia (3 layers):
- Superficial : rectus femoris
- Middle: vastus medialis & lateralis
- Deep: vastus intermedius
 The fibers:
- Some passes anterior / over patella
- From lateral & medial border patella  fan
out to either side  insert to femoral
condyles
- Some fibers  attach to menisci, collateral
lig & capsular lig

 Patellar tendon is the main site for knee jerk

FLEXOR
 Main muscle : HAMSTRINGS
 Divided into : lateral & medial group
 Medial : (flex & internal rotate)
- Semimembranosus  inserts :
1. posteromedial side of tibial condyle
medail capsule, posterior popliteal
capsule, deep branch to poste horn
meniscus medial
Branch to meniscus medial (poste horn) 
pull it back when the knee going into flexion
- Semitendinosus (anserine tendon, with
sartorius & gracillis)
Lateral : biceps femoris (flex & external rotate)
 Insert : fleshy (about 10 cm)
- from knee (flat tendon)  fibula, lateral coll
lig, lat tibia plateau, capsule
- split to 3 parts:
- superficial
- middle
- deep
 Knee flexes  biceps pulls on coll lig &
capsule  slacken lig & allow more flexion,
also avoid impingement of the capsule
 Gastrocnemius
- Plantar flexion
- Posterior knee 
* flexs in free knee
* extends a weight bearing or anchored
- Origo : medial & lateral epicondyles
- Insert : to calcaneus (tendon Achilles)
 Popliteus muscle
- small muscle 
main function to pull the synovial pouch out
(avoid being pinch in flexion)
 Medial meniscus more commonly affected by
injuries
 The most probable reason  anatomical
reason :
attachment of medial meniscus to many
structures, such as:
- medial collateral lig
- tendinous semimembranous muscle
- anterior cruciate lig
- Joint capsule (outer surface)
 prone to be pulled
 Occur when foot is fixed in the ground & knee
moving  clipping
 Femur is oblique
 Tibia is perfectly vertical

Normal : 5 – 10º valgus (female > male)

Measured : draw horizontal line through knee
 Mechanical axis (a line drawn from center of
head femur  midpoint between femoral
condyles)
 Anatomical axis ( a line drawn between two
trochanter  between two femoral condyles)

 The lines were intersected :

- Tibia 90º
- Femur (anatomical 81º, mechanical 87º)
 Obliquity of anatomical axis femur 
- Lateral condyle (pressure stresses)
- Medial condyle (tension stresses)
 Alteration of mechanical axis  genu
valgus/genu varus (depends on the angle)
 Transverse axis : perfectly horizontal 
however external rotation tibia against femur
in full extension : 5-6º
 Torsion angle of tibia : prox (medial-lateral
plateau) with distal (medial-lat maleoli) in
transverse axis  external rotated 20 - 25º
 Total tibial torsion : 25 - 30º
 (A) Transverse CT
section through
proximal tibia, just
below proximal
articular surface. A
line is drawn bisecting
the tibia. (B)
Transverse CT section
through distal tibia,
just above distal
articular surface. A
line is drawn bisecting
the tibia. (C) The
angle between these
two lines is calculated.
KNEE FLEXION + internal rotation

 Usually accompanied by an internal rotation

 1st 20º  rocking motion
 After 20º  gliding motion
- Lig become relaxed  gliding & axial
rotation
- Most rotation : - final phase of full flexion
- last 30-40º extension

 At 90º : possible 40º rotation

 Flexion (from fully extended) begins with
simultaneous internal rotation by contraction
of popliteus muscle.
 Active flexion by hamstring contraction
 Capsular lig relax as flexion begins
 Femur glides forward upon the tibia placing
smaller rounded poste surface of femoral
condyle upon tibia plateau
 Poste cruciate lig becomes taut  acts as a
drag to any further gliding
KNEE EXTENSION + gliding motion of the
femur

 Quadriceps contraction
 Patella is forcefully pulled upward
 Full extension  no axial rotation, no
significant lateral or medial add-abd of tibia
 Screw home mechanism :
The last 20º of extension  external rotation
of tibia  due to condylar configuration,
muscle pull in torque & lig guidance
 Rotation tibia upon
femur during flexion-
extension  passive
 Tibia follows the
configuration of the
medial condyle of femur
(longer than lateral)
 Femur glides upon tibia
 stops when the
lateral condyle
traversed  continue to
move along medial
condyle (longer & more
curved)
THE MENISCI

 Fixed to tibia (flexion-extension)

 Rotation (knee flexed)  menisci move with
the femur upon tibia
 Upper femoral-meniscal joint moves during
flexion-extension
 Rotation occurs at the lower meniscotibial
joint
 Medial meniscus  at both horns; outer
circumferential border
 Lateral meniscus  at both horns; border
free
THE LIGAMENTS
 Cruciate lig crisscross.
 Anterior taut in extension, unwind & relaxes
in flexion
 Coll lig  taut during extension
relaxes during flexion
 Axial rotation move posteriorly
 Anterior cruciate:
Tibia fixed from foot (weight bearing) 
guide wire as knee approach to extension
Femur fixed  control lateral rotation of tibia