INTRODUCTION

 Largest and one of the most

complex joints
 Major stability and mobility
roles
Functions of knee are :-
1. Provide mobility.
2. Support body during dynamic and static
activities.
3. In closed kinamatic chain; it works with hip &
ankle joint to support body weight in static erect
posture.
4. Dynamically ; Support during sitting and
squatting activities and transfering body weight
during locomotor activities.
5. In open kinamatic chain knee provides mobility
for joint in space.
ARTICULATION
Knee complex composed of two articulation within a
single capsule
Tibiofemoral joint
 The Patellofemoral joint
RANGE OF MOTION ( KNEE JOINT)
 Flexion : 135‫ﹾ‬
 Hyperflexion: 0‫ﹾ‬-10‫ﹾ‬
-“Screw Home” = approx.
10‫ﹾ‬external rotation to
align condyles
 With knee flexed 30‫ﹾ‬or
more:
- 30‫ ﹾ‬internal rotation &
45‫ ﹾ‬external rotation
TIBIO FEMORAL JOINT
 Double condyloid knee joint is also refferedt as medial &
lateral compart of the knee.
 Double condyloid joint with 3 degree fredom of angular
(rotatory) motion.
 Flexion / Extension
Plane – Sagittal plane
Axis - Coronal axis
 Medial / Lateral (int/ext) rotation
Plane – Transverse plane
Axis - Longitudinal axis
 Abduction / Adduction
Plane - Frontal plane
Axis - Antero-posterior axis
TIBIOFEMORAL ALLIGNMENT AND WEIGHT
BEARING FORCE
 The anatomical / Longitudinal axis
Femur – Oblique, directed inferiorly and medially
Tibia – directed vertically
The femoral & tibial longitudinal axis form an angle
medially at the kneejoint of 185 degree – 190 degree,
ie, 5 – 10 degree creating physiological valgus at knee
 In bilateral static stance :-
Equal weight distribution on medial & lateral condyle
Deviation in normal force distribution

 TF ANGLE > 190‫ ﹾ‬- GENU VALGUM – Compress lateral condyl

 TF ANGLE < 180‫ ﹾ‬- GENU VARUM - Compress medial condyl

TF JOIN REACTION FORCE

 2-3 times body weight in normal gait

 5-6 time body weight in activities (like running,stair
climbing etc).
 This time menesci assume 40-60% of imposed load
 In the absence of menesci knee joint reaction force double
on femur and increases 6-7times on tibial condyl.
MEDIAL MENISCUS
 C-shaped and is attached to
the medial collateral ligament
and to the semimembranosus muscle.
It is more firmly attached and less
movable so it is more torn than the
lateral meniscus

LATERAL MENISCUS
 4/5 of a ring ,is much loose and mobile than the medial
meniscus
 The ante anterior horns of the two menisci are linked by
the transverse ligament.
Function Medial Meniscus &
Lateral Meniscus
 Distribute weight
 Increase the joint congruency
 Lubricate the articular cartilage
 Reduce friction between joint surface
 Shock absorber
Role of the menisci during flexion
and extension
 During flexion :- the menisci move posteriorly; the
MM moves posteriorly by the semimembranosus
while the LM is drawn posteriorly by the popliteus
 During extension:- the menisci are pulled anteriorly
by the meniscopatellar fibres. The posterior horn of
the LM is pulled anteriorly by tension in the
meniscofemoral ligament.
KNEE JOINT CAPSULE
 Restrict various movements
 To maintain joint integrity and normal joint function.
ATTACHMENT
 Outer portion :- Firmly attached to the inferior aspect
of femur & superior portion of tibia
 Posteriorly :-Proximal to posterior margin of the
femur condyles and intercondylar
` notch
Distally to posterior tibial condyle
KNEE JOINT CAPSULE
 Anteriorly :- superior–patella , tendon of quadriceps
muscle
Inferiorly – patellar tendon complete the
anterior portion of the joint capsule
 Medial &Lateral:-Proximal above femoral condyl of
dismargin of tibial condyl
 Collateral ligament reinforces sides of capsule.
 The antero medial & antero-lateral portion of the capsule are
often seperately identified as the medial & lateral patellar
retinaculum or together as the extensor retinaculum
 SYNOVIAL LINING
 Most extensive and involved in the body.
 Anteriorly synovium adheres to inner wall of the joint.
 Posteriorly synovium invaginate anteriorly following the
contour of femoral intercondylar notch & adheres to the
anterior aspect and sides of ACL &PCL.
 Embryonically synovial lining is divided by septa in to 3
compartments.
 Superior PF compartment.

 Medial TF compartment.

 Lateral TF compartment.
 SYNOVIUM (Cont….)
 By 12 weeks of gestation synovial septa resorbed resulting in a
single joint cavity.
 The superior compartment remain as a superior recess of
capsule known as suprapatellar bursa.
 Posteriorly the synovial lining may invaginate:
 Laterally between popliteus muscle and lat.femoral
condyle.
 Medially invaginate between semimembranosus tendon,

Med.head of gastrocnemius tendon and med.femoral

condyle.
PLICAE
 Synovial septa which are not resorbed in to adulthood
exist as folds or pleats of synovial tissue known as plicae.
 They are composed of loose,pliant and elastic fibrous
connective tissue.
 They easily passes back and forth over femoral condyles
as the knee flexes and extends.
 Observed in 20-60% of population.
PLICAE (cont…)
 Commonly known plicae are:
 Inferior / Infrapatellar plica extends from ant.portion of
intercondylar notch to infrapatellar fat pad.
 Superior / Suprapatellar plica is located between
suprapatellar bursa and knee joint.
 Medial /Mediopatellar plica arises from medial wall of
retinaculum to infrapatellar fat pad.
 Plica can become irritated and inflammed, leads to pain
,effusion and changes in joint structure and function.
 LIGAMENTS OF KNEE JOINT
 COLLATERAL LIGAMENT
 MEDIAL COLLATERAL LIGAMENT
 LATERAL COLLATERAL LIGAMENT
 CRUCIATE LIGAMENT
 ANTERIOR CRUCIATE LIGAMENT
 POSTERIOR CRUCIATE LIGAMENT
 POSTERIOR CAPSULAR LIGAMENT
 MENISCO FEMORAL LIGAMENT
 ILIOTIBIAL BAND
MEDIAL COLLATERAL LIGAMENT

 Position : Medial aspect of the joint

 Attachment : Medial femoral epicondyl and
upper end of tibia
 Orientation: Inferior & Anterior
 Function :

Resist valgus stress especially when knee is

extended
Resist lateral rotation of tibia
Restrict anterior displacement of tibia
Resist excessive knee extension
LATERAL COLLATERAL LIGAMENT

 Position : lateral aspect

 Attachment : lateral epicondyl – Head of fibula
 Orientation : Inferior and Posterior
 Function :
Resist varus stress
Resist axial rotation
Resist posterior displacement of tibia
Resist knee extension
 NB :- Both collateral ligaments are relaxed at 20-30 flexion .so
it is the position of immobilization after injury
POSTERIOR CAPSULAR LIGAMENT

 OBLIQUE POPLITEAL LIGAMENT

Position : Posteromedial aspect

Attachment : Medial tibial condyl
 central part of posterior aspect of the joint
capsule
Orientation : Upward & laterally
Function : Check valgus stress
Tight in full extension
ARCUATE POPLITEAL LIGAMENT

Position : posterolateral aspect

Attachment : posterior aspect of head of
fibula
lateral epicondyle
Orientation : upward &medially
Function : Check varus stress
Tight in full extension
 ANTERIOR CRUCIATE LIGAMENT

 Position : Intracapsular ligament

 Attachment : Anterior part of
intercondylar eminence
Posterior part of inner aspect of
lateral femoral condyl
ACL divides in to two bands :-
Anterior medial band
Postero lateral band
 Orientation : Posterior,superior, lateral
 ANTERIOR CRUCIATE LIGAMENT
 Function : prevent anterior displacement of tibia
85%
Limit full knee extension
Resist varu and valgus stresses
minor contribution
Control medial rotation (axial) of the
tibia
NB :- Injury to the ACL occurs when the knee is flexed
and the tibia rotates in either direction
 Role : During flexion :- ACL causes the femoral
condyl to slide anterior while the femur
rolls posteriorly
 PATHOMECHANICS OF ACL
MECHANISM OF INJURY
 Foot firmly planted and femur vigourously
externally rotated or translated posteriorly.
 Excessive hyper extension of knee
 Following injury : Hamstring spasm
POST SURGICAL REHABILITATION
 Exercises for hamstring and quadriceps to keep the
ratio of 0: 7:1
 Avoid open kinetic chain exercises for the first 3
months
 Closed kinetic chain exercises are the choice for early
post operative rehabilitation
MECHANISM OF INJURY
POSTERIOR CRUCIATE LIGAMENT
 Position : Intracapsular ligament
 Attachment : Posterior part of inter
condylar eminance.
Anterior part of inner
aspect of medial
femoral condyl.

 Orientation : Anteriorly, superiorly & medially

 Function : Prevent posterior displacement of tibia 95%
Tight during full extension
Resist varus and vagus
stress(minorcontribution)
 BIOMECHANICS OF PCL
 MECHANISM OF INJURY
 Fallingover hyper flexed knee
 Dash board injury

Rehabilitation program directed for strengthening

quadriceps to prevent posterior displacement of tibia.
 ROLE :- PCL Causes the femoral condyl to slide
posterior while the femur roll anterior.
 FUNCTION OF CRUCIATE LIGAMENT
DURING KNEE MOTION

 Full Extension :- ACL is more vertical & PCL is

relaxed
 During Hyper Extension :- ACL is stretched
PCL is relaxed.
 Full Flexion :- PCL raised up vertically making 60
degree with tibia and become taut
 Medial Rotation :- ACL wind around PCL ( ACL stretched
and PCL relaxed)
 Lateral Rotation :- Parallel ACL relax & PCL stretched
 ILIOTIBIAL BAND
 Position :- Anterior aspect of the knee joint
 Attachment :- Fascia of tensor fascia lata
gluteus maximus and
gluteus medius , and lateral tubercle of tibia
 Orientation :- Two band ; one downward & other anterior
and lateral to patella “iliopatellar band”
 Function :- Tight regardless the position of
the hip on the knee.
Prevent posterior displacement of
femur when the tibia is fixed and
knee extended
BURSA ASSOCIATED WITH KNEE
 Pre-patellar bursae
 Located between the skin &
anterior surface of the patella.
 They allows free movement of
skin over patella during
flexion & extension.
 Subcutaneous bursae
 Located between patellar ligament and
over laying skin
 Deep infrapatellar
 Located between patellar ligament & tibial tuberosity
 Helps in reducing friction between the patellar ligaments
&tuberosity.
 ARTHROKINAMATICS
OPEN KINETIC CHAIN
 It is based on the rules of concavity and convexity and
described in term of open and closed chain
 During knee extension tibia glides anteriorly on femur
from 20 degree knee flexion to full extension tibia rotates
externally.
 During knee flexion tibia glides posteriorly on femur and
from full knee extension to 20 degree flexion tibia rotates
internally
CLOSED KINETIC CHAIN

 During knee extension ,femur glide posteriorly on tibia

from 20 degree knee flexion to full extension.femur rotates
internally on stable tibia
 During knee flexion femur glides anteriorly on tibia from
full knee extension to 20 degree flexion- femur rotates
externally on stable tibia
LOCKING AND UNLOCKING
DURING KNEE FLEXION
 When the knee begins to flex from a position of full extension ,
posterior tibial glide begins first on the longer medial condyl.
 Between o degree extension and 20 degree of flexion , posterior
glide on the medial side produces relative tibial internal rotation ,
a reversal of the screw –home mechanism
 Popliteus is the muscle that unlocks the knee at the beginning of
flexion of the fully extended . As the extended and locked knee
prepares to flex.(when beginning to descend in to a squat
position) , the popliteus provides an external rotation torque to
the femur that mechanically unlocks the knee . Since the knee is
mechanically locked by a combo of extension and slight IR of the
femur on a fixed tibia , unlocking the knee requires that the femur
ER on he fixed tibia.
LOCKING AND UNLOCKING
DURING KNEE EXTENSION
 The tibia glides anteriorly on the femur.
 During the last 20 degrees of knee extension ,
anterior tibial glide persists on the tibia’s medial
condyl because its articular surface is longer in
that dimension than the lateral condyle’s
 Prolonged anterior glide on the medial side
produces external tibial rotation , the “screw
home” mechanism.
 LOCKING UNLOCKING
 DURING LAST 30  DURING INITIAL
DEGREE OF EXTENSION STAGES OF FLEXION

 MEDIAL ROTATION OF  LATERAL ROTATION OF

FEMUR FEMUR

HELPED BY  HELPED BY POPLITEUS

QUADRICEPS FEMORIS

AS STANDING AT  AS STANDING AT CASE

ATTENTION

 LIGAMENTS ARE TAUT  LIGAMENTS ARE

RELAXED
 MUSCLES OF KNEE JOINT
AREA ONE –JOINT MUSCLE TWO-JOINT MUSCLE

VASTUS LATERALIS RECTUS FEMORIS

ANTERIOR VASTUS MEDIALIS
VASTUS INTERMEDIALIS

BICEPS FEMORIS (Long)

BICEPS FEMORIS SEMIMEMBRANOSUS
(Short) SEMITENDINOSUS
POSTERIOR SARTORIUS
GRACILIS
GASTROCNEMIUS

LATERAL TENSOR FASCIA LATAE

MUSCLES OF POSTERIOR KNEE
SEMIMEMBRANOSUS,
SEMITENDINOSUS,
BICEPS FEMORIS(LONG AND SHORT
KNEE FLEXORS
HEADS),SARTORIUS,GRACILIS,
POPLITEUS& GASTROCNEMIUS
MUSCLES
POPLITEUS,GRACILIS, SARTORIUS
FLEX+TIBIAL
SEMIMEMBRANOSUS
MEDIAL ROTATORS
SEMITENDINOSUS MUSCLES
FLEX+ TIBIAL BICEPS FEMORIS
LATERAL ROTATOR
BICEPS FEMORIS
FLEX + ABDUCTOR LATERAL HEAD GASTROCNEMIUS
POPLITEUS
SEMI MEMBRANOSUS
SEMITENDINOSUS
FLEX +ADDUCTOR
MEDIAL HEAD GASTROCNEMIUS
SARTORIUS & GRACILIS
KNEE FLEXOR GROUPS
 7 Muscles flex the knee
 ( Semimembranosus , Semitendinosus, Biceps Femoris( Long
& short heads) , Sartorius ,Gracilis , popliteus &
Gastrocnemius Muscles)
 5 muscles of flexors
 (Popliteus , gracilis ,sartorius , semimembranosus &
Semitendinosus Muscles)
 They have the potential to medially rotate the tibia on a fixed
femur
 Whereas the biceps femoris is capable for rotating the tibia
laterally
 Knee flexor group

 The Lateral Muscles ( Biceps Femoris , Lateral

Head of Gastrocnemius , & Popliteus )
Capable of producing valgus moments at
knee
 The Medial Muscles ( Semimembranosus ,
Semitendinosus , Medial Head of
Gastrocnemius,Sartorius & Gracilis)
Can generate varus moments
STABILIZATION OF KNEE JOINT
 The stability of the knee joint is dependent upon static and
dynamic factors.
 Static stabilizers
 Knee joint capsule
 Associated structures like menesci ,coronary
ligaments, menisco patella & patellofemoral
ligaments.
 Ligaments :
 Medial collateral ligament
 Lateral collateral ligament
 ACL
 PCL
 Oblique popliteal & arcuate ligament
 Dynamic stabilizers
The dynamic stabilizers of knee are all the
muscles and their aponeurosis including ;
 Quadriceps femoris & extensor retinaculum
 Pes anserinus
 Popliteus
 Biceps femoris
 Semi membranosis
 IT band
 Gastrocnemius
ANTERO-POSTERIOR STABILITY
 Provided by static and dynamic stabilizers and
lateral and medial compartment structures
 Anterior cruciate ligament provides resistance to
anterior tibial translation
 Posterior cruciate ligament provides rsistance to
posteriortibial translation
 Extensor retinaculum provide critical dynamic
support for antero medial and antero lateral
aspects of knee
 Gastrocnemius reinforce medial & lateral aspects
 Popliteus stabilizes postero-lateral
MEDIAL AND LATERAL STABILITY
 Provided by static and dynamic soft tissue structures
 Collateral ligament reinforce medial and lateral aspects.
 Collateral ligaments resists varus/valgus stresses
 Tibial collateral ligament restraint valgus angulation
at the knee
 Lateral collateral ligament restraint to varus
angulation at the knee
 Both cruciates and menesci contribute to medial /lateral
stability.
ROTATIONAL STABILITY
 It’s a complex issue
 Passive structures predominate over dynamic
mechanisms
 Cruciates provide rotational stability in extension
 Also collateral ligament ,postero-medial and postero
lateral capsule and popliteus tendon are important
structures provide rotational stability.
PATELLO FEMORAL JOINT
 The patellofemoral joint is unique and complex
structure consisting of static elements (bones and
ligaments) and dynamic elements(neuromuscular
system). Patella has a configuration of triangle with its
apex directed inferiorly.
 joint forces are variable and depend on the degree of
knee flexion and foot is contact with ground.
 The Q-angle and valgus vector explain predominance
of pathologic lesions on lateral side of joint as well as
the associated dislocations, subluxations, lateral
pressure syndrome,& patello femoral arthrosis.
PATELLO FEMORAL JOINT
REACTION FORCE
Complex loading ,
 Knee extension – it transmits almost all force of quadriceps
contraction &thus loaded primarly in tension.
 Knee flexion - its post surface contacts distal aspect of
femur and subjected to.
Compressive force – patellofemoral joint reaction force –
loading on surface creates 3 point bending configuration in
patella
quadriceps – relative contribution of these modes of loading
patella depends primarly on position of knee joint .knee
moves in to flexion , bending forces become increasing.
PATELLO FEMORAL JOINT
REACTION FORCE
 Magnitude of tensile forces in anterior surface of
patella reaches maximum near 45 degree of knee
flexion.
 Loads across patella have not been precisely
measured, probably an order of 3000 newtons of
tensile load. It may rise up to 6000 in young , trained
men during normal activities such as stair climbing, it
may equal 3 times body weight, and doing deep knee
bends can increase JRF to 7-8 times body weight.
Q- Angle
 Angle formed by a line drawn from
anterior superior iliac spine to the centre
of patella and second line from the
middle of the patella to the tibial tuberosity.
(lines representing the pull of the
quadriceps muscle and the axis of
the patellar tendon.)
 Males 10 -14 degree ,
 Females between 15 – 17 degree
 Q- angle of ≥ 20 degree is considered abnormal and creates a lateral
stress on the patella,predisposing it to pathologic changes ;