WEEK NO.

13 - THE KNEE
OUTLINE TIBIOFEMORAL JOINT
● Proximal articulation: distal portion of the femur: medial
I. Joints and Soft Tissues of the Knee and lateral femoral condyles
a. Tibiofemoral Joint ○ M/L femoral condyles are separated by the
b. Meniscus intercondylar notch (fossa)
II. Joint Capsule & Ligaments ○ joined anteriorly by an asymmetric, shallow,
a. Knee Joint Capsule saddle-shaped groove
b. Extensor Retinaculum ▪ patellar groove (surface)
c. Collateral Ligaments ▪ patellar sulcus
d. Cruciate Ligaments ▪ femoral sulcus – articulation of the patella
e. Iliotibial Band ▪ in this sulcus – location where the patella sits
f. Posterior Capsular Ligaments ○ lateral condyle lies more directly in line with the shaft
g. Knee Joint Bursae than does the medial condyle
III. Arthrokinematics ▪ lateral condyle absorbs the force
a. Flexion-Extension ▪ common degenerative changes – osteoarthritis
b. Rotation ▪ meniscus - fibrocartilage because of the
c. Valgus-Varus Moment imbalance; this helps in dissipation of forces;
d. Locking-Unlocking prevent concentration of forces in one location
IV. Muscles ● Distal Articulation: Medial and lateral tibial condyles or
a. Flexors plateaus
b. Extensors ○ intercondylar tubercles - separated by a roughened
c. Stabilization area and two bony spines; has medial and lateral
V. Clinical Knee Conditions portions
○ articulating surface of the medial tibial condyle is 50%
REFERENCES larger than that of the lateral tibial condyle
(anteroposteriorly)
● Professor: ○ articular cartilage of the medial tibial condyle is 3x
● Other references such as books/ videos/ lecture videos/ thicker than that of lateral tibial condyle – because
PPT, etc (list niyo lang here) lateral femoral condyle accepts bigger force for
resistance of premature degenerative changes (OA)
○ seen inside: proximal tibia is larger compared to the
JOINTS AND SOFT TISSUES OF THE KNEE shaft
THE KNEE ▪ (N) overhanging of tibial shaft proximally –
● One of the most often injured joints in the human body protrude more posteriorly
○ tibial plateau posterior sloping – (N) around 7-10 deg
KINESIOLOGIC FUNCTIONS ● Type of joint
● To provide stability for weight bearing ○ Double condyloid joint
○ knee is responsible for stabilization of LE – ▪ Defined by its medial and lateral articular
specifically in the tibiofemoral joint (static stabilizer) surfaces, also referred to as the medial and
○ (N) when knee is extended (standing - weight bearing lateral compartments of the knee.
position) – almost all of knee muscles are electrically ● Degree of freedom
silent (do not contract) ○ 2 or 3 degrees of freedom
○ when a standing individual – hits popliteal fossa – to ● Motions
induce knee flexion because dynamic stabilizers ○ flexion/extension- occur in the sagittal plane around
cannot control the knee joint a coronal axis through the epicondyles of the distal
○ popliteal fossa – for flexion femur
○ abduction/adduction- occur in the frontal plane
● To allow mobility of the legs in space around an anteroposterior axis.
○ provide ROM so an individual can be functional ○ medial/lateral rotation- occur in the transverse plane
○ in need for adequate knee flexion for walking (60 deg about a longitudinal axis through the lateral side of the
for normal gait) medial tibial condyle
○ 90 degree knee flexion for sitting
○ important in functional tasks for movement in space

● To transmit the loads from the upper body and thigh to the
lower leg
○ weight of HAT and thigh – up to down (downward
force)
○ ground reaction force (GRF) – down to up (upward
force)
○ two opposing forces converge in the knee joint – KJ is
needed to transmit/absorb shock from the two forces

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 ● Two small grooves that run obliquely across the
condyles separate the patellar surface (light pink)
from the femur's tibial articular surface (dark pink).
● The lateral femoral condyle is longer than the medial
femoral condyle, and the lateral lip of the patellar
surface is larger than the medial lip.
○ Pull of gravity downward and;
○ Ground reaction forces (GRF) upward
● Anatomic axis
○ Deviation of 5° from the vertical
○ Normal genu valgum

MENISCUS
● Asymmetric fibrocartilaginous joint disk
● Wedge-shaped meniscus that increases the radius of the
tibial condyles
● Open (horn) toward the intercondylar area
● Thick peripherally and thin centrally
● Forms the concavities into which the respective femoral
condyles can sit
● Functions:
○ Distributes the weight bearing forces
○ Reduces friction b/w joint segments
● Medial Meniscus
○ Semicircular in shape (more “C” shape)
○ Remember “MCLO” ● Femur and tibia form an angle laterally, creating a
● Lateral Meniscus physiologic valgus angle at the knee
○ 4/5s of a ring and circular in shape (more “O” shape) ● Pathologic genu valgum
○ Remember “MCLO” ○ “Knock knees” or “piki”
● Removal of menisci increases the magnitude of stresses ○ Medial tibiofemoral angle is > 185°
on the cartilage of the tibia plateau ○ Unequal weight distribution
● Changes the size and location of tibiofemoral contact area ○ Increased compression at lateral portion
movements of meniscus ○ Increased compressive forces on the lateral condyle
○ Both menisci is distorted and moved posteriorly ○ Increased tensile stressed on the medial structures
during knee flexion and anteriorly during knee ○ Premature degeneration
extension ● Genu varum
○ If knee moves towards flexion, the tibia translates ○ “Bow legs”
posteriorly, so menisci also moves posteriorly ○ Medial tibiofemoral angle is 175° or less
○ In extension, there is anterior translation of tibia, so ○ Increased compressive stresses on the medial tibial
meniscus moves anteriorly condyle
○ In rotation, both menisci follow the motions of the ○ Increased tensile stresses laterally
femoral condyles ○ Osteoarthritis (degeneration of medial portion of
○ Femur MR = MR of menisci femoral condyle and tibial plateau)
○ Femur LR = LR of menisci
● Meniscus is not completely vascularized. The nutrition it
gets is dependent on the location
○ Peripheral portion is well-vascularized with blood
vessels, so it gets proper nutrition
○ Central portion is avascular so only gets its nutrition
through diffusion of synovial fluid during
weight-bearing or muscle contraction
○ Clinical significance:
▪ When there is meniscal tear in the inner/central
portion, its remodeling and healing process is
poor and slow due to poor oxygen supply
▪ No choice but to do partial meniscectomy
● Movement of meniscus is dependent on its point of
attachment
○ Medial meniscus is more firmly attached to tibia ● Compressive forces in the dynamic knee joint may reach
○ Lateral meniscus is more moveable to:
○ Clinical significance: ○ 3x body weight in normal gait
▪ Medial meniscus can’t accommodate ○ 5-6x body weight in activities such as running and
stair-climbing
TIBIOFEMORAL ALIGNMENT AND ● The menisci assume 40-60% of the imposed load
WEIGHT-BEARING FORCES ● Removal of menisci
● Anatomic axis of the femur is oblique ○ Average load per unit area nearly DOUBLES on the
○ Direct inferiorly and medially from its proximal to its femur
distal end ○ 6-7x greater on the tibial condyle
○ Directed almost vertically ● Mild genu varum (“sakang”)
○ Form an angle medially at the knee joint of 180° to ○ Increase the compression on the medial meniscus by
185° 25%
● Mechanical axis

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 JOINT CAPSULE & LIGAMENTS
● Covers the diarthrodial joint and adds to the stability of the
joint
● Ligaments can be found within that resist excessive
movement of knee joint
KNEE JOINT CAPSULE
● Stability is heavily dependent on the surrounding joint
structures (especially in knee extension)
○ Not much contraction so its stability is dependent on
static stabilizers
● During knee flexion, the surrounding passive structures
tend to be lax (not contracted, not restricting movement)
● Joint capsule of TFJ and PFJ is large, complexly attached,
lax with several recesses
○ Open packed position of TFJ
- Slight flexion around 25-3°
● Attachment: Posteriorly
○ Proximally: to the posterior margins of the femoral
condyles
○ Distally: to the posterior tibial condyle
● Attachment: Medially and Laterally
○ Proximally: above the femoral condyles
○ Distally: to the margins of the tibial condyle
● Attachment: Anteriorly
○ Patella, the tendon of the quadriceps muscles
superiorly
○ Patellar ligament inferiorly complete the anterior
portion of the joint capsule
● Reinforcement (for additional protection):
○ Posteriorly: by a # of muscles and by the oblique
popliteal and arcuate ligament
○ Mediolaterally: collateral ligaments
▪ MCL = prevents lateral translation
▪ LCL = prevents medial translation
○ Anterolaterally: medial patellar retinacula
▪ Prevents lateral translation
○ Anteromedially: lateral patellar retinacula
▪ Prevents translation medially
● 3 important functions:
○ Stabilizes the knee and acts as passive stabilizers
since pure active muscular forces are not enough for
stability
○ It has mechanoreceptors that are sensitive to the
movement of the knee joint
○ Keeps the synovial fluid intact w/in the joint space.
The synovial fluid gives supply of nutrients to the
central portion and the bursa
EXTENSOR RETINACULUM
● Anterior portion of knee joint capsule:
● 2 layers:
○ Deeper layer is longitudinally oriented fibers
▪ Patellomeniscal or patellotibial bands
○ Superficial layer is transversely oriented fibers
▪ Patellofemoral ligaments
PATELLOFEMORAL LIGAMENT
● The transverse (oblique) fibers connecting the patella and
the femoral condyles
● Medial patellofemoral ligament
○ Thickest and clinically the MOST important band
within the medial retinaculum
○ Attached to the adductor tubercle, blends with the VM
and terminates at the patella
● Lateral patellofemoral ligament
○ Travel obliquely from the ITB to the patella
● Patellofemoral Pain Syndrome (PFPS)
○ Patella is translated to lateral portion
○ Pulled by ITB and lateral PF ligament laterally
○ Vastus medialis oblique is strengthened, ITB is
stretched
● Ligaments are credited with resisting or controlling:
1. Excessive knee extension
2. Varus and Valgus stresses at the knee (adduction or
abduction of the tibia)
3. Anterior or Posterior displacement of the tibia beneath
the femur
4. Medial or Lateral rotation of the tibia beneath the
femur
5. Rotatory stabilization
COLLATERAL LIGAMENTS
MEDIAL COLLATERAL LIGAMENTS
● Superficial portion
○ Originates from medial femoral epicondyle into the
proximal tibia
● Deep Portion
○ Originates from medial femoral condyle into the
proximal portion of the medial tibial plateau
● Protrudes another extension called, posterior medial
fiber.
○ MCL attaches on medial meniscus via posterior
medial fiber
○ Medial meniscus attaches on ACL via posterior and
anterior horn
○ A sequence of injuries is possible when an injury
occurs - Injuring the MCL can also cause injury to the
meniscus up to the ACL or vice versa (when ACL is
Injured, it could run up to the MCL and cause
injuries).
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● Roles of MCL
○ Primary role: Since it is located in the medial portion,
it is the primary restraint against valgus
stress/medially directed force/ abduction stress -
When knees are flexed, almost 78% of resistance
against valgus force is from MCL (Norkin). At the
same time, based on its orientation/point of
attachment, it can also resist excessive lateral tibial
rotation.
○ Secondary role: secondary restraints against the
excessive anterior translation of tibia when ACL is
absent.
LATERAL COLLATERAL LIGAMENTS
● AKA Fibular Collateral Ligament
● Attaches from the lateral condyle of the femur and inserts
into the fibular head (together with biceps femoris)
● Considered extracapsular - LCL is distinctly separate from
the joint capsule itself (Norkin)
● Roles of LCL (Norkin)
○ Primary role: restraint against Varus stresses. When
knees are flexed for around 25o, 69% of resistance
against varus force is from LCL.
○ Secondary role: Secondary restraint against
posterior displacement and lateral rotation of the tibia.
CRUCIATE LIGAMENTS
● Intracapsular - located within the articular capsule but lies
outside the synovial fluid
● Both ligaments have main posterolateral and smaller
anteromedial bands that behave differently in different
movements
● Named base on their point of origin; they originates in tibia
ANTERIOR CRUCIATE LIGAMENTS
● Originates from the anterior aspect of the intercondylar
tibial spine, and moves SLP (superiorly, laterally, and
posteriorly) to attach on the posterior/posteromedial
aspect of the lateral femoral condyle
● Divided into:
○ Anteromedial band (AMB)
▪ Lax/loose during extension
▪ Tensed/taut during flexion
▪ Tends to be injured with trauma during knee
flexion
○ Posterolateral band (PLB)
▪ Tight/taut during extension
▪ Lax/loose during flexion
▪ Tends to be injured with excessive knee
hyperextension
This condition (opposite functions of the bands),
allows some portion of ACL to remain tight at all times
(Norkin)
● Primary restraint to anterior displacement of the tibia on
the femoral condyle
● Secondary restraint on varus and valgus stresses (e.g
when collateral ligaments are injured) especially during
knee flexion
● ACL also checks/resists excessive medial rotation
● ACL carries 87% of the load of the force in an extended
knee
● Maximal excursion/open-packed position of the tibia at
about 30o of knee flexion with anterior translation.
● The ACL is most commonly injured when the knee is
flexed, and the tibia is rotated in either direction.
● In flexion and medial rotation, the ACL is tensed as it
winds around the PCL
● In flexion and lateral rotation, the ACL is tensed as it is
stretched over the lateral femoral condyle
○ OKC= tibia moves, ACL prevents anterior
displacement of tibia
▪ Quadricep femoris induces stress against ACL
▪ Hamstring assist ACL to prevent anterior
translation of tibia
○ CKC= femur moves, ACL prevents posterior
displacement of femur
▪ Gastrocnemius induces stress against ACL
▪ Soleus assist ACL to prevent posterior translation
of femur
POSTERIOR CRUCIATE LIGAMENTS
● Attaches at posterior tibia travels superiorly-anterior on
lateral aspect of femoral condyle
● Shorter and less oblique than the ACL
○ Although shorter, the cross-sectional area of PCL is
around 120-150% greater than ACL
● Its fascicle is divided into:
○ Anteromedial band (AMB)
▪ Lax during extension
▪ Maximally taut at 80-90o flexion
○ Posterolateral band (PLB)
▪ Taut during extension
▪ Relaxed at 80-90o flexion
● Primary restraint to posterior displacement of the tibia
beneath the femur during OKC. While during CKC, it
prevents excessive anterior translation of the femur in
relation to the tibia.
● The PCL restrains approximately 90% of the posterior load
directed along the tibia in flexion
● 93% of the load is carried by the PCL if a posterior
translational force is applied in the extended knee
● Maximal displacement of the tibia of the posterior
translational force occurs at 75 to 90o of flexion
● Secondary/Slightly restrains varus and valgus stresses
at the knee
ILIOTIBIAL BAND
● Aka iliotibial tract which provides additional stabilization of
the knee
● Essentially a passive structure (stabilizer)at the knee joint
○ Iliotibial band is the distal connection of the TFL,
gluteus maximus and gluteus Medius muscles
● Portions of iliotibial band
○ Tendinous portion= proximally near the muscle.
Movement occurs when muscles attached proximally
contracts.
○ Ligamentous portion= distally near the bone (Gerdy’s
tubercles). Little to no movement occurs as the
influence of the proximal muscles diminishes hence, it
provides passive stabilization to the knee joint.
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● Taut regardless of position of the hip joint or knee joint
● Direction of the ITB is comparable to that of the MCL
● Its strength comparable to that of the ACL
● It form a sling behind the lateral femoral condyle
● Assists ACL when
○ The tibia is fixed
○ The knee joint is near extension
● Posterior migration of the ITB in flexed knee:
○ When ITB contraction occurs, it pulls the tibia
posteriorly. Hence, ITB helps ACL to prevent anterior
translation
POSTERIOR CAPSULAR LIGAMENTS
POSTEROMEDIAL PORTION
● Posteromedial is reinforced by the tendinous expansion of
the semimembranosus muscle
● Reinforced by the ff:
○ Semimembranosus muscle
○ Oblique popliteal ligament (the tendinous expansion
of the semimembranosus muscle)
▪ From a point posterior to the medial tibial condyle
and attaches to the central part of the posterior
aspect of the joint capsule.
○ Posterior oblique
▪ Attached to the adductor tubercle and then to the
tubercle where MCL is also attached it protects
the posteromedial capsular ligament
POSTEROLATERAL PORTION
● Posterolateral aspect of the capsule is reinforced by the
arcuate popliteal ligament, LCL and ITB
● Reinforced by the ff:
○ Arcuate ligament - Capsular thickening; expansion of
the joint capsule
○ Lateral collateral ligament
○ Ilio-tibial band
○ Posterolateral portion of the joint capsule
○ Popliteus complex - Composed of the popliteus
muscle, popliteus tendon, and the popliteofibular
ligament
● Post oblique and the arcuate ligaments are taut in full
extension
○ A assist in checking hyperextension of the knee
● Checks varus and valgus stresses in the extended knee
KNEE JOINT BURSAE
● Composed of:
○ Suprapatellar bursa
○ Subpopliteal bursa
○ Gastrocnemius bursa
○ Prepatellar bursa
○ Superficial infrapatellar bursa
○ Deep infrapatellar bursa
The first three bursa specifically have important
kinesiologic functions. These bursae are direct extensions of
our synovial capsule, and the fluids inside of the bursae and of
the capsule are connected. Therefore, movement of the joint
capsule has a direct influence on the aforementioned bursae.
● In extension, the three bursae, and the synovial capsule,
are compressed posteriorly. Specifically, the
gastrocnemius and the subpopliteal bursa. The
synovial fluid translates anteriorly.
● Flexion induces the opposite. The anterior portion of the
bursa, specifically the suprapatellar bursa, is stretched
anteriorly. This pushes the fluid posteriorly.
● Clinical significance: If the pt. has bursitis, the optimal
position/position of comfort for the patient is in the
semiflexed position, in order to avoid stress on all of the
bursa.
ARTHROKINEMATICS
FLEXION/EXTENSION
● Hip joint position can influence knee ROM.
○ Reason: d/t some knee muscles being double-jointed,
ie. Biceps fem, participating in knee flexion & hip
extension; Rectus femoris, knee ext. & hip flex.
● Knee flexion is limited to 120o (Instead of the usual 135) or
less during hip hyperextension.
○ Reason: d/t passive insufficiency of the rectus
femoris. May also occur d/t other variables, eg.
extreme limb girth.
● Knee flexion has specific requirements in certain activities,
such as:
○ Normal gait on level ground: 60o
○ Stair climbing: 80o
○ Sit to stand: 90o
○ Beyond simple mobility tasks (ie. deep squats,
running, etc.): 115o
● Knee extension/hyperextension requirements
○ Less than/equal to 5o is considered WNL, otherwise,
pt. may have potential Genu recurvatum.
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● Closed kinematic chain (CKC) knee flexion activities, like
squats, will induce pure posterior rolling of the femur, FUNCTIONS OF THE MUSCLES ON MENISCUS DURING
leading to potential displacement. To compensate, the FLEXION/ EXTENSION
knee also undergoes anterior gliding to maintain contact of
femoral conduct on the tibial plateau. Vice versa for knee
extension, wherein it causes pure anterior rolling + Role of muscles on meniscus @ F/E:
concomitant posterior gliding for compensation. Actions posteriorly pulls to avoid the damage of the meniscus
are visualized below.
Muscle that contracts Menisci affected in
contraction

Semimembranosus Medial

Popliteus Lateral

ROTATION
● Axis of rotation:
○ Longitudinal axis that runs through the medial tibial
intercondylar tubercle
○ Medial is the pivot point
○ Movement is on the lateral portion
○ The femur follows in the opposite direction

Point of reference: The tibia

ROLES OF THE CRUCIATE LIGAMENTS DURING
FLEXION/ EXTENSION
Direction of lateral portion Rotation that occurs
● ACL prevents excessive anterior displacement of tibia on point
the fixed femur, or excessive posterior displacement of
femur on a fixed tibia. Towards the big toe Medial
● PCL has an opposite function, preventing excessive
posterior displacement of tibia on the fixed femur, or
Away from the big toe Lateral
excessive anterior displacement of femur on a fixed tibia.

Movement of the tibial condyles on the femoral condyle

Condyle Rotates

Medial tibial condyle Slightly anteriorly

Lateral tibial condyle A large distance

posteriorly

RANGE OF KNEE ROTATION

● Is dependent on the position of the knee
● Closed pack position: full extension (knee is locked),
● At 90o flexion
ROLE OF THE MENISCUS DURING FLEXION/ EXTENSION ○ The ligaments are lax
● The meniscus’ natural wedge shape (which forms a ○ Thus, tibia has rotatory movement in relation to the
concavity) prevents posterior/anterior rolling of the femur femur
during flexion/extension activities by helping to facilitate ○ (Norkin) A total of 35° of rotation is possible either
the concomitant glide. passively or actively done at 90° flexion

ROM

Combined (Med + Lat) 35°

Medial rotation 0° - 15°

Lateral rotation 0° - 20°

VALGUS-VARUS MOMENT
● Valgus: abduction; Varus: aDDuction
● Happens on the frontal plane, however is not that evident

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● (Norkin) Is expected more in flexion than extension
○ 20° in knee flexion
○ 8° in full knee extension
● Valgus-varus test
○ Done to test the integrity of the collateral ligament
○ Knee is flexed to conduct this test
LOCKING-UNLOCKING
● Locking: Lateral rotation: allows knee to remain in
extension: at the end of extension
● Unlocking: Medial rotation: allows knee to flex: @
beginning of flexion
● Popliteus: unlocks the knee joint
LOCKING
● Screw home mechanism of the knee: automatic
rotation/ locking mechanism
OKC Locking
● Normal automatic/obligatory lateral rotation of the tibia that
accompanies the final stages of knee extension
● Happens at the last 30° of OKC/non-WB knee extension
● Due to the uneven femoral condyles & tibial plateau;
● Or one condyle stops, but the other continues to move
○ Lateral side stops
○ Medial side continues to roll and glide anteriorly
● This results in lateral rotation of tibia
CKC Locking
● (ex. Sit to stand)
● Is involuntary
● Continued medial femoral condyle movement= medial
rotation of femur on tibia
● Most evident in the final 5° of extension
● Static stabilizers (knee joint ligaments) increase in tension
when knee approaches full extension
UNLOCKING
● Medial rotation of tibia on the femur
● Popliteus is responsible for this
MUSCLES
● The muscles that cross the knee are commonly referred to
as flexors or extensors.
● Each muscle that flexes and extends the knee has a
moment arm (MA) that can generate both frontal and
transverse plane motions, although the MAs for these
latter motions are often minimal.
FLEXORS
● Semimembranosus
● Semitendinosus
● Biceps femoris
○ can laterally rotate the tibia (locking) – main external
rotator; inserted to the fibula
● Sartorius
○ A potential flexor of the knee and medial rotator of the
tibia
▪ activity is more common with hip motion than with
knee motion (FABER)
▪ very limited in knee movement
▪ (N): originates from the ASIS and inserts to the
anteromedial portion of the proximal tibia – can
be attached more anteriorly or posteriorly on tibia
– varies contribution in knee movement
▪ more anteriorly – changes line of axis – more
knee extension
▪ more posteriorly and the original – more knee
flexor
● Gracilis
○ A hip joint flexor and adductor
▪ Can also flex the knee joint and produce slight
medial rotation of the tibia
● Popliteus
○ a medial rotator of the tibia on the femur (primary
function) in an open kinematic chain
▪ play an important role in initiating unlocking of the
knee
▪ it reverses the direction of automatic rotation
(popliteus causes internal rotation) – external
rotation of the knee during the terminal 30 deg
● Gastrocnemius
○ Only muscle at the knee that crosses the ankle and
the knee
○ Makes relatively small contribution to knee flexion
▪ effective in preventing knee joint hyperextension
▪ not for the mobility of knee – but for dynamic
stabilization because it prevents knee joint
hyperextension
▪ increase stiffness of the knee joint – harder –
more stabilized – considered as dynamic
stabilizer than mobility
○ only effective as knee flexor when the knee is in full
extension
▪ heel raise (strengthening exercises) – knee
extension for gastrocnemius
▪ soleus – flex knee to isolate soleus
▪ gastrocnemius – plantarflex and knee full
extension to isolate gastrocnemius
● Additional: plantaris- commonly absent; not to much
force for knee flexion
● the short head for the biceps femoris and the popliteus are
two one-joint muscles
● long head of Biceps Femoris, Semitendinosus and
Semimembranosus – are two jointed muscles
● popliteus (most important for unlocking), gracilis, SM and
ST muscles can medially rotate the tibia on the fixed femur
– screw home mechanism (unlocking and locking)
● Valgus movement (lateral muscles) – biceps fem, lateral
head of gastrocnemius and part of popliteus – closer
medial portion knee joint(contract)
● Varus movement (medial muscles) – SM, ST, medial head
of gastrocnemius, gracilis
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● most of the hamstrings work most effectively and
efficiently (knee flexion) at the knee joint if they are
lengthened over a flexed hip as the initial position
○ because if we perform knee flexion with hip extension
– adaptive shortening/active insufficiency (fully
shortened) and stretching of the antagonist muscles
(rectus femoris) has passive insufficiency
● SM and the popliteus generates
○ flexion torque
○ moves/deforms/pulls the meniscus posteriorly in the
tibial plateau especially in active knee flexion to
prevent unwanted injury of the meniscus
○ they reinforce
▪ the movement of the menisci and
▪ minimizes the change that the menisci will
become entrapped and limit knee flexion
○ (N) two muscles that do not have direct attachment or
do not cross the knee joint but helps in knee
movements
○ gluteus maximus and soleus – helps the ACL
○ gluteus max contract – since majority of distal
attachment are near in the femoral shaft – pulls the
femur towards extension – assists in knee extension
especially during CKC or standing/squats
▪ sumo squats – active contraction of gluteus max
▪ deadlift – slight flexion and extension, arch back
– active contraction of g max
○ soleus contract – pulls the tibia posteriorly – helps in
extension – extension moment of the knee
▪ additional function: pulls the tibia posteriorly –
assist the ACL to prevent excessive anterior
translation of the tibia
○ VMO weakness causes imbalance in pull in patella. It
causes patella to translate laterally (this is called
lateral patellar squinting or Grasshopper's/Frog
eye deformity).
● Efficiency of the quadriceps muscle is affected by the
patella
○ Patella is important in actions of quads as knee
extensors
● Patella lengthens the MA of the quadriceps
○ It increases the distance of the pull of quads from the
axis
○ If no patella, the distance b/w the axis and the muscle
is too near. The moment arm is too short. The line of
pull of the quads becomes poor towards extension if
no patella.
○ If the quads contract with NO patella, the pull is
directly horizontal. Instead of extension, it promotes
compression of the knee joint.
○ Therefore, the patella directs the line of pull obliquely
superior rather than directly horizontal. It promotes
knee extension rather than compression.
○ Patella is an anatomical pulley. It acts as a pulley of
the quads.

EXTENSORS
● Quadriceps femoris w/ 4 distinct fibers:
○ Rectus femoris
▪ The only double-jointed muscle in quads
▪ Hip joint anteriorly (hip flexion)
▪ Knee joint superiorly
○ Vastus lateralis
○ Vastus medialis
▪ Have 2 distinct fibers (VML & VMO)
▪ VM longus = upper fibers
▪ VM oblique = lower fibers
▪ VMO does not function in knee extension but
serves only as a patellar stabilizer
○ Vastus intermedius
● Vastus medialis and vastus lateralis insert directly into the
medial and lateral aspects of the patella by way of the
retinacular fibers (extensor retinaculum) of the joint
○ Vastus medialis does not only actively act in ● Having a patella is more aesthetically pleasing (mas
tibiofemoral joint but also in patella maganda pag may tuhod XD)
● Vastus medialis and lateralis have slight angulation as ● It reduces friction b/w tendon and condyles
their fibers are obliquely-oriented, As they contract, there ○ It reduces the risk for degeneration and tendinitis
is diagonal angulation of pull so they don’t directly extend because the patellar tendon does not slide much on
the knee. There is a degree formed (Lib & Perry from the femoral condyle. The inner portion of the patella
Norkin). slides instead.
○ VL = 12-15 o lateral ● The patella is tied to the tibial tuberosity by the patellar
○ VML = 15-18 o ligament (aka patellar tendon)
○ VMO = as high as 50-55o ○ Makes the patella an anterior wall for the tibia
● Vastus medialis and vastus medialis can’t be considered
as pure extensors due to their oblique angulation of pull.
They are also attached to the patella, so they act more on
patellar movements.
○ So in quadriceps injury, the first muscle that atrophies
is vastus medialis (specifically VMO)

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● In weight bearing, quadriceps control knee flexion by
acting eccentrically during activities.
○ It regulates the movement of the knee
○ It controls the rate of contraction of the hamstrings by
contracting eccentrically (lengthening contraction)
○ When we walk (swing phase of gait), we need knee
flexion to clear the foot off the ground. There is a
shortening contraction of the hamstring from this.
Without the quads’ counteraction, the knee flexion
would be aberrant or exaggerated. The quads’
lengthening contraction is needed.
○ In heel strike when walking, as the heel reaches the
ground, there is knee extension. If there is no
hamstring that contracts eccentrically, the knee would
extend aberrantly since there is no counteraction.
○ During weight-bearing, like in squats, there is hip
flexion and knee flexion. When there is both hip and
knee flexion, the tendency of the patient is to sit. To
prevent sudden knee flexion, the quads should have a
lengthening contraction to regulate movement of
hamstring.
● Quadriceps then works concentrically in extension to
return the body to the erect posture.
○ If the initial position is in sitting position to standing
position, there should be concentric (shortening)
contraction of quads.
● No knee extensor muscle activity is necessary to maintain
the extension in normal erect stance (full standing
position).
○ Quads are ALMOST electrically silent when an
individual is standing.
○ The knee is extended all throughout while standing
due to the locking mechanism of the knee.
○ When we are lying (nakahiga) and the knee is
extended, we notice that the patella is easily
mobilized since the quads are really not active.
● The extensor muscles (quadriceps) are about two times
stronger than the flexor muscles
● In closed kinematic chain, movement of the knee is
accompanied by movement at the hip and ankle
○ Squats – knee flexion, concomitant hip flexion CKC of
ankle dorsiflexion
○ Tight hip extensors – difficulty in full squats
○ Knee flexion usually occurs in weight bearing in
conjunction with hip flexion and ankle dorsiflexion
According to Norkin,
● Forces vary generated by the quadriceps in OKC or CKC
○ OKC + knee flexion – negative force
○ OKC + knee extension – positive force
○ CKC + knee extension – negative force
○ CKC + knee flexion – positive force
STABILIZATION
● Classification system based on:
○ Function use a static/dynamic differentiation
○ Structure use a capsular/extracapsular method
○ Location use a compartmental approach
● Static stabilizers include the passive structures such as
the joint capsule and associated structures
○ Coronary ligament
○ Meniscopatellar ligament
○ Patellofemoral ligament
○ Extensor retinaculum – not a pure static stabilizer
● Ligaments that are static stabilizers include the
○ MCL/LCL - collateral
○ ACL/PCL - cruciate
○ Oblique popliteal ligament
○ Arcuate popliteal ligament
● Dynamic stabilizers of the knee include
○ Quadriceps femoris located at extensor retinaculum
(VML, VMO, VL)
○ Pes anserinus – helps in stabilization of the medial
aspect
○ Popliteus
○ Biceps femoris – stabilize in lateral portion
○ SM – stabilize meniscus; draws posteriorly in knee
flexion
● (Magee) the medial compartment structures include:
○ the medial patellar retinaculum
○ MCL
○ oblique popliteal ligament
○ PCL
○ the medial head of the gastrocnemius
○ pes anserinus
○ semimembranosus muscles
○ example: MCL injury
▪ Anteromedial instability
● (Magee) lateral compartment structures include:
○ ITB
○ Biceps femoris
○ Popliteus
○ LCL
○ meniscofemoral ligament
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 ○ arcuate ligament
○ ACL
○ lateral patellar retinaculum
PATELLOFEMORAL JOINT
● Patella and distal portion of femur (femoral condyle)
● patella – largest sesamoid bone; forms the anterior wall of
knee complex
● act as:
○ an anatomic pulley of quads\
○ the mechanism to reduce friction between the
quadriceps tendon and the femoral condyles
○ cosmesis – appearance
○ patella is the moving component of PFJ
● patellar movements exist
○ when the femoral condyle moves, the patella moves
inward the femoral condyle – then sits to the
intercondylar notch
● full knee extension
○ patella sits on the anterior surface on the distal femur
● knee flexion
○ patella slide distally on the femoral condyle
● full flexion
○ patella sinks into the intercondylar notch
○ 0-135°
● rotation of the patella
○ patellar tilting mediolaterally around the vertical axis
○ patellar rotation around antero-posterior axis
○ MR of the patella occurs during LR of the femur on
tibia
○ LR of the patella occurs during MR of the femur on
tibia
○ patella laterally rotates 6-7° as the knee flexed from
25-130° (most of the rotation oat 60° of knee flexion
● patellar tilt
○ an average of 11° as the knee flexes from 25° to 130°
○ medial and lateral translation of patella
○ patella superiorly and inferiorly slide
● knee flexion – inferior translation of patella (patellar
flexion)
● knee extension – superior translation of patella (patellar
extension)
● medially – medial patellar shifting
● laterally – lateral patellar shifting
● along vertical axis – tilt to be in contact medial condyle
(medial tilting) and lateral condyle (lateral tilting)
● patellar rotation
○ tibial tuberosity: point of reference
○ moving: superior portion of tibial tuberosity
○ movement happens superiorly, movement axis
happens inferiorly
○ named based on the adjacent portion of the inferior
pole of the patella
○ rotates to the lateral (fibula) – inferior pole of patella
faces medially (medial rotation)
○ rotates to the medial (tibia) – inferior pole of patella
faces laterally (lateral rotation)
○
PATELLOFEMORAL ARTICULAR SURFACES
● inverted triangularly shaped patella
○ the largest sesamoid bone in the body
● the least congruent joint in the body
○ the whole segment of the patella do not articulate to
the femoral condyle
● it is divided by a vertical ridge
○ lateral and medial facet
● small vertical ridge that separates the odd
PATELLOFEMORAL JOINT REACTION FORCES
● Force that patella absorbs during active contraction of
quadriceps muscle. For the reason that patella is
compressed against the femur.
● Patella is pulled on simultaneously by
○ The quadriceps tendon superiorly and
○ By the patellar tendon inferiorly
▪ Equal but opposing forces against the quadriceps
tendon and and patellar tendon to maintain the
position of the patella in place
● Even a strong contraction of the quadriceps in full
extension will produce little or no patellofemoral
compression.
● Use of SLR (straight leg raising) exercises to improve
quadriceps muscles strength without increasing
patellofemoral problems
● Pull of the quads and pull of patellar ligament will increase
the compression of the patella during knee flexion
○ Occurs either in active or passive tension
● Joint reaction force is influenced by
○ Magnitude of active and passive pull of the
quadriceps
▪ The greater the contraction of the quads, the
greater the compression force on the knee
○ By the angle of knee flexion
MEDIAL-LATERAL PATELLOFEMORAL JOINT STABILITY
● Two restraining mechanisms for the permanent control of
patellofemoral joint
● Transverse group of stabilizers
○ Medial and lateral extensor retinaculum
○ Vastus medialis and lateralis
○ Medial and lat patellofemoral ligament
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 ▪ Medial patellofemoral ligament is the thickest ▪ Intoeing of foot
portion of the medial retinaculum and it provides
60% (majority) of the passive restraint against
lateral translation of the patella
● Longitudinal group of stabilizers
○ Inferiorly: patellar tendon
▪ Patellar tendon prevent excessive superior
translation of patella
○ Superiorly: quadriceps tendon
▪ Quadriceps tendon prevent excessive inferior
translation of patella

MEDIAL-LATERAL FORCES ON THE PATELLA

● Determined by
○ The resultant pull of the four segments of the
quadriceps
▪ Since these are directly attached to the patella
▪ Lateral translation of patella may happen when
(1) VMO is weak, since vastus lateralis is
unopposed or (2) lateral patellofemoral ligament
and ITB are tight resulting to PFPS
○ By the pull of the patellar ligament
● Anything that might increase the obliquity of the resultant
pull of the quadriceps or the obliquity of the patellar
ligament in the frontal plane may increase the lateral force
on the patella
Q angle
● Use clinically to assess the net effect of the pull of the
quadriceps and the patellar ligament
○ Quadriceps angle
● An imaginary line formed between the ASIS to the
midpoint of the patella and to the line of pull of the
quadriceps muscle.
● N: 10° - 15°
● F>M
○ Since the female pelvis is wider wherein the ASIS is
translated more laterally
● Usually measured with the knee in extension
CLINICAL KNEE CONDITIONS
LIGAMENT INJURIES
ANTERIOR CRUCIATE LIGAMENT
● Most commonly injured ligament of the knee
● Can occur from contact (d/t external force ie. hits that
forces the ACL to tear) or non-contact (no external force;
d/t patient moving unnaturally or excessively into stressful
positions) mechanisms
○ Contact mechanisms
▪ The most common mechanism of injury (MOI)
occurs from a blow to the lateral side (valgus
force/medially directed force). May also
potentially injure the MCL and medial meniscus.
▪ The ACL, MCL, & medial meniscus form the
unhappy triad/terrible triad of o'donoghue.
○ Noncontact mechanism
▪ Most common MOI is the external rotation of the
tibia/external tibial torsion on a planted foot.
▪ May also occur d/t forceful hyperextension of the
knee
○ ACL injury pt's may develop “quadriceps avoidance
gait” wherein they do not allow for the full contracture
of the quad muscle.
▪ Reasoning: to avoid anterior translation of the
tibia (that further stresses the ACL) caused by
contraction of the quadriceps.
▪ Decreases the magnitude of the flexion moment;
the injured site is not moved as much.

● Q angle determines if there is a pathologic Genu valgum

or Genu varum
● Other causes of obliquity of the pull quadriceps and
patellar ligament
● Genu valgum (>Q)
○ Hip anteversion= the femoral head is translated
anteriorly (prone to anterior dislocation of the hip)
○ Compensatory movement of LE
▪ Internal rotation of the femur (femoral
anteversion)
● Internal femoral torsion
▪ Patella translation medially since patella is SPECIAL TESTS FOR ACL INJURY
attached to femur ● Provocative test, so proceed with caution. Done
▪ External rotation of the tiba (lateral/external tibial immediately after injury in order to avoid muscle guarding
torsion) ● Anterior Drawer test

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 ○ Position: Flexion of the hip (45o) + flexion of the knee
(90o). Stabilize prox tibia, and draw tibia anteriorly.
○ Compare with the unaffected side, and see if
movement is more excessive. Or, translation can also
be seen radiographically, and pt. Is positive for ACL
tear if translation is more than 5mm.
● Lachman test
○ Position: 20o of knee flexion.
○ Excessive forward motion of tibia (More than 5mm) as
compared to unaffected side indicates a positive ACL
tear.
*Both tests are generally the same, with only a slight difference
in the positioning of the patient.

MENISCAL TEAR
PCL, MCL, AND LCL
Types
● PCL - "Dashboard injury." This type of injury is uncommon
due to its larger cross section, posterior translation of tibia Vertical tear Separates the meniscus into
being less common than anterior translation, and the ACL inner and outer fragments
winds around the PCL instead of vice versa. Occurs parallel to the outer
○ MOI: forceful blow (causing excessive posterior margin of the meniscus
translation) to the anterior tibia while the knee is
flexed.
● MCL - Occurs d/t an excessive valgus force; medially
directed force.
○ Usually partial or incomplete
● LCL - Excessive varus force; laterally directed force.
● Special tests
○ Valgus/varus stress test Bucket handle tear Tears are displaced vertical
▪ Valgus - Medially directed stress force, to extend longitudinal tears and
the MCL. Pain complaint or hypermobility usually involve the MM
indicates injury to the MCL. The separated central
▪ Varus - Laterally directed stress force; extends (inner) fragment when
the LCL. Pain complaint or hypermobility viewed axially, resembles
indicates injury to the LCL. the handle of a bucket

Radial tear/horizontal tear Vertical tears that propagate

perpendicular to the main
axis of the meniscus
Complete radial tear:
extends all the way
through the meniscus from
the apex of the periphery

Parrot beak Flap tears

Neglected Superomedial
oblique radial portion of
○ Posterior sag sign tears meniscus
▪ Knee & hip flexion; posterior translation of tibia separates from
during observation indicates injury in the PCL. inferomedial to
form a flap

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 Test

Apley’s Compression Test

Patient position: Procedure

Prone Compress the knee while
Knee flexed at 90o rotating the tibia internally
Leg is stabilized with and externally.
examiner’s knee

Apley’s Distraction Test

Patient position: Procedure

Prone Distract the knee while
Knee flexed at 90o rotating the tibia internally ● Often occurs with Sinding Larsen Johansson Disease: w
Stabilize hip and externally by pulling inflammation of the inferior pole of the patella
your foot superiorly. Mechanism of Injury
● Excessive contraction of quads
Indication for both tests
Patella Position
If pain is felt upon external or lateral rotation, then medial
meniscal tear is present.
If pain is felt upon internal or medial rotation, then lateral
meniscal tear is present.

● Anterior drawer/Lachman test: determines presence of

ACL injury
● Posterior drawer/Posterior sag sign: determines presence
of PCL injury
Mechanism of Injury
● Traumatic in origin
○ Rotation of a flexed femur on a fixed tibia
○ CKC + rotation
● Degenerative in origin: thinning of meniscus
○ Arthritic conditions
○ Elderly
Patella alta: Excessive superior translation
Pellegrini-Stieda Disease
Baja: Excessive inferior translation
● Ossification of the tibial collateral ligament or medial
collateral ligament

Osteochondritis Dissecans (OCD)

Patellar Squinting Frog eye/ Grasshopper’s eye
● Partial or complete detachment of fragmented hyaline
cartilage covering together w the subchondral bone Medial translation Lateral translation
Osgood-Schlatter Inc in the q angle Dc in the q angle

Bursitis
● Prepatellar bursitis: housemaid’s knee or nun’s knee
● Deep infrapatellar bursitis
● Popliteal bursitis : baker’s cyst

Genu Valgum, Varum & Recurvatum

● A.k.a. Patellar tendinitis or Jumper’s Knee

● Partial or complete separation of the epiphysis of the tibial
tuberosity
● Inflammation of the patellar tendon

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Valgum: IR + External tibial torsion + medial patellar
translation
Q angle inc

Varum ER + Internal tibial torsion + lateral

patellar translation
Q angle dc

Recurvatum Hyperextended knee

Results from
● tight/paralysis of quads: compensatory
deformity
● plantar flexion contracture

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