THE KNEE JOINT

 Type & Articulation

The knee is the largest joint in the body. It's a modified complex hinge joint formed
by the articulation between the tibial plateaus & femoral condyles on one hand (hinge
tibiofemoral joint) and the femoral condyles with the posterior surface of the patella
on the other hand (saddle patellofemoral joint). Functionally, it moves as a hinge
joint.

((The patella is the largest seasamoid bone in the body lying within the tendon of quadriceps femoris.
The tendon continues from its lower border as the ligamentum patella. It's also held in position from
the medial side by horizontal fibers of vastus medialis. The bone is roughly an inverted triangle with a
smooth convex anterior surface. The posterior surface shows 2 articular facets. The lateral facet is large
& broad. The medial facet is narrow & comes in contact with the medial femoral condyle only in full
flexion.))

The knee is relatively unstable. This is overcome by 2 main factors: a) the presence of
a large bulk of supporting muscles and strong ligaments & b) the presence of the
menisci which increase the congruence of the articular surfaces.
 Ligaments
1. The fibrous capsule: is broad & thin posteriorly where it's strengthened by the
oblique popliteal & arcuate ligaments. Laterally, the attachment is proximal to
the lateral femoral condyle so that the origin of popliteus lies within the joint
capsule cavity. The capsule is short & thick on the sides where it's strengthened
by the medial & lateral collateral ligaments. Anteriorly, the capsule is deficient.
As it passes anteriorly, it blends with the patellar retinacula gaining attachment to
the sides of the patella & ascending upwards to the sides of the quadriceps tendon
and downwards to the sides of the ligamentum patellae & the sides of the tibial
tuberosity. The deep surface of
Posterior
the capsule attaches weaklyaspect
to of
the knee
the rims of the menesci as capsule
the
coronary ligament and helps
attaching them to the tibial
plateaus.
The fibrous capsule of the knee has
three thickenings:
i. The oblique popliteal ligament:
is an expansion of the
smimembranosus tendon
passing upwards & laterally to
be attached to the intercondylar
fossa & the posterior surface of
the lateral femoral condyle.
ii. The arcuate ligament: is a Y-
shaped thickening on the
posterior surface of the knee
joint capsule with its stem
attached to the fibular head, its
medial limb attached to the
posterior edge of the tibial
intercondylar area and its lateral
 limb attached to the posterior surface of the lateral femoral condyle.
iii. A medial capsular thickening: is firmly attached to the medial meniscus &
represents the deep part of the medial collateral ligament.
The knee capsule also has three perforations:
i. Posterolateral perforation (behind the lateral femoral condyle) for the emergence
of popliteus muscle (as the origin of the muscle lie within the joint cavity).
ii. Posteromedial perforation for extension of the synovial membrane into the bursa
of the medial head of gastrocnemius & semimembranosus.
iii. Anterosuperior perforation: for the extension of the synovial membrane into the
suprapatellar bursa.

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2. Extracapsular ligaments:
i. Ligamentum patellae: is the continuation of the quadriceps femoris tendon
passing from the front & the lower margins of the patella to the tibial tuberosity.
It's separated from the knee joint by the infrapatellar pad of fat, from the upper
part of the tibial tuberosity by the deep infrapatellar bursa and from the
overlying skin by the superficial infrapatellar bursa.
ii. The patellar retinacula: represent an expansion of fibers of quadriceps femoris
passing backwards to the collateral ligaments of the knee and downwards to the
tibial plateaus.
iii. The Lateral (fibular) Collateral ligament: is cord-like & passes from the lateral
femoral condyle to the head of the fibula piercing the tendon of biceps femoris.
It's separated from the lateral meniscus by the popliteus tendon & a bursa
intervening in between.
iv. The Medial (Tibial) Collateral ligament: is a broad band passing from the
medial femoral condyle to the upper part of the medial surface of the shaft of the
tibia deep to the tendons of the pes anserinus muscles. Its deep fibers are firmly
attached to the medial meniscus.
v. The oblique popliteal ligament.
vi. The arcuate ligament.

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 3. Intracapsular ligaments:
i. Anterior Cruciate ligament: passes from the anterior intercondylar area of the
tibia upwards, backwards & laterally to attach to the posteromedial surface of
the lateral femoral condyle. It prevents backward movement of the femur on the
tibia (i.e. prevents forward gliding of the tibia on the femur).
ii. Posterior Cruciate ligament: is stronger, shorter & less oblique than the anterior
one. It passes from the posterior intercondylar area of the tibia upwards,
forwards & medially to be attached to the anterolateral surface of the medial
femoral condyle. It prevents anterior movement of the femur on the tibia (i.e.
prevents backward gliding of the tibia on the femur). Fibers from the lateral
meniscus pass in front & behind it to the medial femoral condyle as the anterior
& posterior meniscofemoral ligaments.

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ANTERIOR POSTERIOR

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 The Menesci
The menisci are 2 C-shaped fibrocartilagenous cushions that deepen the articular
surface of the tibial plateaus and act as shock absorbents & lockers of the knee (in
extension).
Each meniscus is attached by its elevated thick periphery to the margins of the tibial
condyle via fibers that blend with the fibrous capsule (coronary ligaments). The inner
margins of the menisci are thin & concave. Each meniscus attaches to the anterior &
posterior parts of the intercondylar area by its anterior & posterior horns. The
posterior fibers of the anterior horns of both menisci are joined together forming the
transverse ligament of the knee.
o The lateral meniscus is smaller, more deeply concave, more circular (4/5 of a
circle) & has a more regular breadth than the medial meniscus. Its horns are more
closely attached to each other.
o The medial meniscus is larger, less concave, more oval anteroposteriorly & less
regular in breadth than the lateral meniscus. Its horns are more widely separated in
their attachments. Because of its shape and because the medial femoral condyle is
larger than the lateral one, the medial meniscus is 20 times more liable to be
irreversibly damaged than the lateral meniscus. This type of injury occurs when
the tibia is rotated on the femur in the weight-bearing partially flexed knee
resulting in crushing of the meniscus under the weight of the femoral condyles &
irreparable tears (since the menisci are avascualr).

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  Synovial membrane & related bursae
The synovial cavity of the knee may be regarded in 4 parts: Two tibiofemoral cavities
between the tibial & femoral condyles which are separated from each other
posteriorly by a synovial membrane septum but communicate with each other & with
the third infrapatellar cavity anteriorly. The infrapatellar cavity is the third part which
extends upwards as the fourth suprapatellar cavity represented by the suprapatellar
bursa.
The septum that separates the 2 tibiofemoral cavities posteriorly consists of the
synovial membrane that covers the upper surface & the sides of the cruciate ligaments
(which appear as if they herniated into the joint cavity from behind) isolating them
from the synovial fluid. The septum extends anteriorly and reflects on the infrapatellar
pad of fat as the infrapatellar fold. The fold has 2 free crescenteric margins called the
alar folds. Thus, the 3 folds surround the infrapatellar pad of fat.
The synovial membrane has three extensions through perforations in the fibrous
capsule:
i. The suprapatellar bursa: extends 3 fingerbreadths above the patella deep to the
quadriceps femoris tendon. It becomes elevated during knee extension by the
articularis genu fibers of vastus intermedius.
ii. The popliteus bursa: lies between popliteus & the lateral femoral condyle and
sometimes extends between popliteus & the lateral collateral ligament.
iii. The bursa that lies between the medial femoral condyle & the medial head of
gastrocnemius. It usually communicates with the semimembranosus bursa (deep
to semimembranosus).
Bursae related to the knee joint are:
o Anteriorly:
i. Suprapatellar: posterior to quadriceps femoris tendon (anterior to the femur).
ii. Prepatellar: between the patella & the overlying skin.
iii. Superficial infrapatellar: between the ligamentum patellae (tibial tuberosity) &
the overlying skin.
iv. Deep infrapatellar: between the ligamentum patellae & the upper part of the
tibial tuberosity.
o Laterally:
i. A bursa between the fibular collateral ligament & the fibrous capsule
ii. A bursa between the fibular collateral ligament & the tendon of biceps.
o Medially:
i. A bursa between the tibial collateral ligament & the tibia & fibrous capsule.
ii. A bursa between the tibial collateral ligament & the pes anserinus muscles.
o Posteriorly:
i. A bursa between the capsule & the medial head of gastrocnemius.
ii. A bursa between the capsule & the lateral head of gastrocnemius.
iii. A bursa between semimembranosus & the medial head of gastrocnemius
(semimembranosus bursa).
iv. A bursa between popliteus & the upper parts of the back of the tibia & fibula
(extension of the synovial membrane).

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 


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 Arterial supply
Arterial supply of the knee comes from the genicular anastomosis derived from the
flowing arteries:
o From above:
i. Descending genicular branch of the femoral artery (medially).
ii. Descending genicular branch of the lateral circumflex femoral artery (laterally).

o From below:
i. Anterior & posterior recurrent genicular branches of the anterior tibial artery.
ii. Ascending genicular branch of the circumflex fibular artery (from the posterior
tibial artery).
o From behind:
The sup, middle & inferior medial and lateral genicular branches of the popliteal
artery.

 Nerve supply
Articular branches to the knee are derived from:
i. Genicular branch of the anterior division of the obturator nerve.
ii. Articular branches of the femoral nerve (via its branches to the vasti).
iii. Sup, middle & inferior medial genicular branches of the tibial nerve.
iv. Superior & inferior lateral genicular and recurrent genicular branches of the
common peroneal nerve.

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  Movements
The knee is a functionally hinge joint allowing flexion & extension. However, there's
some degree of rotation of the tibia on the femur in flexion because of the unequal
size of the medial & lateral femoral condyle & the menisci.
Movement Muscles
Popliteus (unlocking)
Biceps femoris
Flexion Semitendinosus
Semimembranosus
Adductor magnus (hamstring part)
Sartorius
Gastrocnemius
Plantaris
Extension Quadriceps femoris
Tensor fascia latae (maintains tightness of the iliotibial tract)
Medial rotation Semitendinosus
(in flexion) Semimembranosus
Lateral rotation Popliteus
(in flexion) Biceps femoris

During extension, the femoral articular surfaces approach their full fitness into the
meniscotibial surfaces. Because the lateral femoral condyle is smaller & rounder than
the medial and because the lateral meniscus is more circular and more concave than
the medial, the lateral tibiofemoral surfaces reach their full congruence (fitness) 30˚
before the medial surfaces do. For extension to continue the medial femoral condyle
(& the femur) must rotate medially on the medial meniscotibial surface pushing the
lateral tibiofemoral surfaces & the anterior horn of the lateral meniscus forwards to
disrupt their fitness & continue on moving until full congruence of both medial &
lateral sides. When full fitness is achieved in both tibiofemoral surfaces, the cruciate
& collateral ligaments and the iliotibial tract and skin & fascia all become taught and
the knee is said to be LOCKED in extension (i.e. the femur cannot be rotated on the
tibia and the knee is 5˚-10˚ hyperextended).
To flex an extended knee, the ligaments must be slackened & the knee UNLOCKED.
This is done by popliteus which pulls the lateral femoral condyle backwards &
laterally & rotates the femur on the tibia (pulling the posterior part of the lateral
meniscus backwards with it so it wouldn't be crushed). This will unlock the knee &
allow the flexors to continue knee flexion.
 Relations
o Anteriorly: Quadriceps femoris tendon, ligamentum patellae & related bursae.
o Laterally: biceps femoris (&bursa), common peroneal nerve, & lateral head of
gastrocnemius (& bursa).
o Posteriorly: popliteus (&bursa), popliteal vessels, tibial & common peroneal
nerves, popliteal lymph nodes, skin & fascia.
o Medially: pes anserinus muscles, semimembranosus and medial head of
gastrocnemius (& related bursae).

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 THE ANKLE (TALOCRURAL) JOINT
 Type & Articulation
The ankle is a synovial hinge joint formed by the articulation of the trochlea tali with
the distal end of the tibia & the 2 malleoli. The posterior transverse ligament of the
distal tibiofibular joint deepens the articular socket. The ankle is a strong stable joint
whose stability is maintained by: a) the good fitness of the talar head with the distal
end of the tibia & its grasping by the 2 malleoli and, b) the strong ligaments &
tendons around the joint.

 Ligaments
1. The fibrous capsule: is thickened medially & laterally. The anterior & posterior
parts are made-up of thin transverse fibers extending anteriorly: from the anterior

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 margins of the distal end of the tibia to the upper surface of the talar neck and,
posteriorly: from the posterior margin of the distal end of the tibia & the posterior
tibiofibular ligament to the posterior surface of the talar body.
2. The medial (deltoid) ligament: is a very strong ligament attached by its apex to the
medial malleolus and radiates to attaché at its base to the medial side of the talus,
the sustentaculum tali, the medial edge of the spring ligament, the navicular bone
& the neck of the talus. So, in addition to strengthening the ankle joint, it holds the
calcaneum; talus & navicular to each other & supports the medial longitudinal
arch of the foot.
3. The lateral ligament: is weaker than the medial one and consists of 3 bands:
a. The anterior talofibular ligament: from the lateral malleolus to the lateral
surface of the talus.
b. The calcaneofibular ligament: from the tip of the lateral malleolus to the lateral
surface of the calcaneum

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c. The posterior talofibular ligament: from the lateral malleolus to the posterior
tubercle of the talus

 Synovial membrane
The synovial membrane lines the articular capsule but is separated from it anteriorly
& posteriorly by pads of fat. It extends upwards between the tibia & fibula for a short
distance just to be inferior to the interosseous tibiofibular ligament (= the thickened
lower border of the interosseous ligament).
 Blood supply
The arterial anastomosis around the ankle joint is derived from the following arteries:

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 o Anteriorly: the perforating branch of the peroneal artery with the lateral tarsal
branch of the dorsalis pedis artery.
o Posteriorly: the medial calcanean branch of the posterior tibial artery with the
lateral calcanean branch of the peroneal artery.
o Medially: the medial malleolar rete is formed by the anterior medial malleolar
branch of the anterior tibial artery with the posterior medial malleolar branch of
the posterior tibial artery.
o Laterally: the lateral malleolar rete is formed by the anterior lateral malleolar
branch of the anterior tibial artery with the posterior lateral malleolar branch of
the peroneal artery.

 Nerve supply
This is provided by articular branches from the tibial & deep peroneal nerves.
 Movements
- Dorsiflexion is limited by the tension of
Movement Muscle
tendocalcaneus, the calcaneofibualr
Tibialis anterior
ligament & the posterior fibers of the
Dorsiflexion EHL deltoid ligament.
EDL Excessive eversion in dorsiflexion causes
partial tearing of the deltoid ligament
(medial ankle sprain).
- Plantar flexion is limited by the tension of
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the extensors, the anterior talofibular
ligament & anterior fibers of the deltoid
 PT
Gastrocnemius
Soleus
Plantaris
Plantar flexion TP
FHL
FDL
Peroneus longus & brevis

 Relations
o Anteriorly: the superior extensor retinaculum and all related structures.
o Posteriorly: tendocalcaneus & plantaris.
o Posterolaterally (behind the lateral malleolus): peroneus longus & brevis.
o Posteromedially (behind the medial malleolus): the flexor retinaculum & all
related structure.

THE TARSAL JOINTS

The small joints among the tarsal bones can be divided into 3 groups:
1. The proximal tarsal joint: is the subtalar joint.
2. The midtarsal (transverse) joints: include the talocalcaneonavicular (TCN) &
calcaneocuboid (CC) joints.
3. The distal tarsal joints: include the cuneionavicular, cuboidonavicular,
cuneiocuboid & intercuneiform joints.

The subtalar & midtarsal joints are multiaxial joints (i.e. multiple plane joints that
have to move together) permitting gliding & rotation. All the remaining joints are
simple plane joints (except the cuboidonavicular joint which is a fibrous joint).

The subtalar joint is formed by the articulation between the inferior surface of the
talar body & the superior surface of the calcaneum at 2 pairs of articular facets
(anterior & post). It's supported by the med, lateral & interosseous ligaments.

The TCN joint is a complex joint formed by the articulation between the talar head,
the upper surface of the sustentaculum tali & the posterior concave surface of the
navicular bone. The strength of the joint depends on the plantar calcaneonavicular
(spring) ligament passing from the sustentaculum tali to the inferior surface &
tuberosity of the navicular bone supporting the talar head above it.

The CC joint is formed by the articulation between the anterior end of the calcaneum
& the posterior surface of the cuboid. It's supported by the short & long plantar
ligaments & by the bifurcate ligament.

The subtalar & midtarsal joints move as a single unit through slight gliding and
rotation creating the movements of inversion & eversion.
Inversion is achieved by the following muscles:
TA, EHL, TP & the medial tendons of EDL.
Eversion is the action of the following muscles:

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 Peroneus longus & brevis, PT and the lateral tendons of EDL.

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