110 學年度第二學期

肌動學 1

KNEE 膝關節
Learning objectives
 Describe the structures and function of the knee complex
 Describe motions and ranges of motion available and forces transmitted through
the knee complex
 Realize muscular function and joint interaction of the knee complex
References
 Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for
Rehabilitation. 3rd ed., St. Louis: ELSEVIER, 2017: 538-594.
 Houglum PA, Bertoti DB. Brunnstrom's Clinical Kinesiology. 6th ed.,
Philadelphia: F.A.Davis, 2012: 423-466.
 Levangie PK, Norkin CC. Joint Structure and Function: a Comprehensive
Analysis. 4th ed., Philadelphia: F.A. Davis, 2005: 393-432.

I. OSTEOLOGY (Fig.13.1~13.5)
A. Distal Femur
B. Proximal Tibia and Fibula
C. Patella
D. General Alignment
1. Frontal plane alignment (Fig.13.6)
 Longitudinal axis of rotation throughout the entire lower extremity
 The knee forms an angle on its lateral side of about 170˚ to 175˚
→ 5˚ to 10˚ of genu valgum
 A lateral angle less than 170˚ is called excessive genu valgum, or
“knock-knee”
 In contrast, a lateral angle that exceeds about 180˚ is called genu
varum, or “bow-leg”
2. Sagittal plane alignment (Fig.13.37)
 The knee may be extended beyond neutral an additional 5˚ to 10˚
 Hyperextension beyond 10˚ of neutral is called genu recurvatum

II. JOINT STRUCTURES AND FUNCTION

A. Capsule, Synovial Membrane, Bursae, and Fat Pads
 The fibrous capsule encloses the tibiofemoral joint and the
patellofemoral joint
 The internal surface of the capsule is lined with synovial membrane
 The knee has as many as 14 bursae, which form at inter-tissue
junctions that encounter high friction during movement
高雄醫學大學物理治療學系 濟世大樓 CS517 劉玫舫助理教授
TEL:07-3121101ext2668 Email: mefali@kmu.edu.tw
110 學年度第二學期
肌動學

 Fat pads are often associated with bursae around the knee; the most
extensive fat pads are associated with the suprapatellar and deep
infrapatellar bursae

B. Ligaments (Fig.13.12)
1. Medial (tibial) and lateral (fibular) collateral ligaments
Anatomic considerations
 Medial collateral ligament (MCL) is a flat, broad structure; has
superficial and deep parts
 Lateral collateral ligament (LCL) consists of a round, strong cord
Functional considerations (Table 13.4)
 The primary function of the collateral ligaments is to limit
excessive knee motion within the frontal plane
 The MCL provides the primary resistance (almost 80%)
against a valgus (abduction) force when knee is in 25˚ of
flexion (Table 13.3)
 When a varus (adduction) force is applied to the knee when
it is in 25˚ of flexion, the LCL provides almost 70% of the
protective restraining force
 A secondary function of the collateral ligaments is to produce a
generalized stabilizing tension at the knee in full extension
 Most fibers of the collateral ligaments are positioned slightly
posterior to the medial-lateral axis of rotation of the knee
and therefore are pulled relatively taut in full extension
(Fig.13.18)
 The collateral ligaments and adjacent capsule also provide
resistance to the extremes of axial rotation
2. Anterior and posterior cruciate ligaments (Fig.13.19)
General considerations
 The cruciate ligemants are intracapsular and extrasynovial
 General functions of the cruciate ligaments
 Provide multiple plane stability to the knee, most notably in
a anterior-posterior direction between the tibia and femur
 Help guide the knee’s arthrokinematics
 Provide the proprioceptive feedback
Anatomy and function of anterior cruciate ligament (ACL)
 The ACL attaches from the anterior intercondylar area of the tibial
plateau to the medial side of the lateral femoral condyle; include

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肌動學

an anteromedial bundle and a posterolateral bundle

 Most fiber become increasingly taut as the knee approaches and
reaches full extension (Fig.13.18)
 The quadriceps muscle is often referred to as an “ACL antagonist”
(Fig.13.20)
 During the last approximately 50˚ to 60˚ of complete knee
extension, the active force generated by the contracting
quadriceps pulls the tibia anteriorly
 The resulting tension in the stretched fibers of the ACL helps
limit the extent of this anterior slide
Anatomy and function of posterior cruciate ligament (PCL)
 The PCL attaches from the posterior intercondylar area of the tibia
to the lateral side of the medial femoral condyle; include the
anterolateral bundle and the posteromedial bundle
 Majority of the ligament becomes increasingly taut with greater
flexion; tension peaks between 90˚ and 120˚ of flexion
 The hamstrings are referred to as a “PCL antagonist”, especially
at flexion angles closer to a 90-degree position (Fig.13.22)
 While a person actively flexes the knee against gravity, the
knee flexor muscle actively slide the tibia posteriorly
relative to the femur
 The extent of the posterior slide is limited, in part, by
passive tension in the PCL

C. Menisci (Fig.13.11)
Anatomic considerations
 Crescent-shaped, fibrocartilaginous structures; the lateral meniscus's
configuration is nearly a circle whereas the medial meniscus is more of
a C-shape (oval shape); each meniscus is wedge-shaped with the
thickest portion on the outer rim of the meniscus
 Stability of the menisci
 Anchored to the intercondylar region of the tibia by their free
ends, known as anterior and posterior horns
 External edge of each meniscus is attached to the tibia and the
adjacent capsule by coronary (or meniscotibial ) ligaments
 A slender transverse ligament connects the two menisci anteriorly
 The medial meniscus is attached to the deep surface of the medial
collateral ligament and adjacent capsule; the meniscofemoral

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ligament extends from the lateral meniscus (posteriorly) to the

inside of the medial condyle
 Several muscles help stabilize the position of the menisci:
quadriceps and semimembranosus attach to both menisci,
whereas the popliteus attaches to the lateral meniscus
 Blood supply is greatest near the peripheral (external) border, the
internal border of the menisci is essentially avascular
Functional considerations
 The primary function of the menisci is (1) to reduce the compressive
stress across the tibiofemoral joint by nearly tripling the area of joint
contact
 Other functions include (2) stabilizing the joint during motion, (3)
lubricating the articular cartilage, (4) providing proprioception, and (5)
helping to guide the knee’s arthrokinematics

III. JOINT MOTION

A. Tibiofemoral Joint
1. Osteokinematics at the tibiofemoral joint: two degrees of freedom
 Flexion and extension occur about a medial-lateral axis of rotation
(Fig.13.13)
 The healthy knee moves from 130˚ to 150˚ of flexion to
about 5˚ to 10˚ beyond the 0-degree position
 The medial-lateral axis of rotation is not fixed, but migrates
within the femoral condyles; the path of the axis is known as
an “evolute” (漸屈線) (Fig.13.14)
 Internal and external rotation occurs about a vertical or
longitudinal axis of rotation; also called “axial” rotation (Fig.13.15)
 In general, the freedom of axial rotation increases with
greater knee flexion; once the knee is in full extension, axial
rotation is maximally restricted
 A knee flexed to 90˚ can perform about 40˚ to 45˚ of total
axial rotation (ER ROM generally exceeds IR by a ratio of
nearly 2:1)
 Frontal plane motion (abduction/adduction) occurs passively only,
limited to about 6˚ to 7˚
2. Arthrokinematics at the tibiofemoral joint
Extension of the knee (Fig.13.16)
 During tibial-on-femoral extension, the articular surface of the

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tibia rolls and slides anteriorly on the femoral condyles

 During femoral-on-tibial extension, the femoral condyles
simultaneously roll anteriorly and slide posteriorly on the
articular surface of the tibia
 “Screw-home” rotation of the knee (Fig.13.16)
 The external rotation (about 10˚) of the knee during the last
30˚ or so of extension→ “screw-home” rotation or
mechanism; this locked position of full extension increases
joint congruence and favors stability
 During femoral-on-tibial extension, the knee locks into
extension as the femur internally rotates relative to the fixed
tibia
 The screw-home rotation mechanics are driven by at least
three factors (Fig.13.17)
- The shape of the medial femoral condyle (the most
important or at least obvious)
- The passive tension in the anterior cruciate ligament
- The slight lateral pull of the quadriceps muscle
Flexion of the knee
 The arthrokinematic of knee flexion occur by a reverse fashion as
that of knee extension
 For a knee that is fully extended to be unlocked, the joint must
first internally rotate slightly; the action is driven primarily by the
popliteus muscle

B. Patellofemoral Joint
1. Arthrokinematics of the patellofemoral joint
 As the knee flexes and extends, a sliding motion occurs between
the articular surfaces of the patella and the intercondylar
(trochlear) groove of the femur
 The timing and occurrence of patellar rotation, medial-lateral
shifting, and medial-lateral tilting is yet to achieve consensus
among investigators
 Local stabilizers of this joint include (1) forces produced by the
quadriceps muscle, (2) the fit of the joint surfaces, and (3) passive
restraint from the surrounding retinaculum and capsule
2. Path and area of patellar contact on the femur (Fig.13.23)
 At 135˚ of flexion, the patella rests below the intercondylar

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groove, bridging the intercondylar notch of the femur; lateral

edge of the lateral facet and the “odd” facet of the patella share
articular contact with femur
 Between 90˚ and 60˚ of flexion, the patella is engaged within the
intercondylar groove of the femur; the contact area between the
patella and femur is greatest
 As the knee extends through the last 20˚ to 30˚ of flexion, the
primary contact point on the patella migrates to its inferior pole;
the patella loses much of its mechanical engagement with the
intercondylar groove
 Once in full extension, the patella rests completely proximal to
the groove and against the suprapatellar fat pad

IV. MUSCULAR FUNCTION

A. Extensors of the Knee: quadriceps femoris muscle
Anatomic considerations
 Quadriceps femoris consists of the rectus femoris, vastus lateralis,
vastus medialis (the upper fibers were designated the vastus medialis
longus (VML) and the lower fibers the vastus medialis oblique
(VMO)), and deeper vastus intermedius (Fig.13.24)
 All heads of the quadriceps unite to form a strong quadriceps tendon
that attaches to the base and sides of the patella
 Patellar tendon connects the apex of the patella to the tibial tuberosity
 The quadriceps muscle and tendon, patella, and patellar tendon are
referred to as the knee extensor mechanism (Fig.13.7)
Functional considerations
 The rectus femoris produces about 20% of the total extension torque at
the knee, and the large vastus group of muscles produces about 80%
 The patella acts as a “spacer” between the femur and quadriceps
muscle, which increases the internal moment arm of the knee extensor
mechanism→ augments the extension torque at the knee (Fig.13.40)
 Throughout the range of motion, the knee loses 15% to 30% strength
following a patellectomy

B. Role of the Quadriceps Muscle in Patellar Tracking

 As the knee is extending, the contracting quadriceps pulls the patella
not only superiorly, but also slightly laterally and posteriorly

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 The slight but omnipresent lateral line of force exerted by the quadriceps
 Vastus lateralis
 Quadriceps angle or Q-angle (Fig.13.29)
- The Q-angle is formed between (1) a line representing the
resultant line of force of the quadriceps, made by connecting
a point near the ASIS to the midpoint of the patella, and (2) a
line representing the long axis of the patellar tendon, made
by connecting a point on the tibial tuberosity with the
midpoint of the patella
- Q-angles average about 13˚ to 15˚ (± 4.5˚) when measured
across a healthy adult population; a larger Q-angle creates a
larger lateral bowstringing force (Fig.13.31)
 Factors that naturally oppose the lateral pull of the quadriceps on
patella (Fig.13.2, 13.30)
 Steeper slope of the lateral facet of the intercondylar groove
 Oblique fibers of the vastus medialis
 Medial patellar retinaculum (refers as the medial patellofemoral
ligament)
 Activation of the quadriceps as a whole also pulls and compresses the
patella posteriorly, thereby stabilizing its path of movement relative to
the distal femur
 Oblique fibers of the vastus medialis (Fig.13.29)
 The resultant joint compression force produced by the quadriceps
as a whole (Fig.13.28)
- Two interrelated factors associated with joint compression
force: quadriceps muscle force and knee flexion angle
- The patellofemoral joint is routinely exposed to high
magnitudes of compression force: 1.3 times body weight
(BW) during walking on level surface, 3.3 times BW during
climbing of stairs, and 7.8 times BW during performance of
deep knee bends

C. Knee Flexor-Rotator Muscles

 The flexor-rotator group of the knee includes the hamstrings, sartorius,
gracilis, and popliteus (Fig.13.9, 13.10)
 In addition to flexing the knee, the medial hamstrings (i.e.,
semimembranousus and semitendinosus) internally rotate the knee; the
biceps femoris externally rotates the knee

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 The sartorius, gracilis, and semitendinosus travel across the medial

side of the knee to attach to the proximal shaft of the tibia using a
common, broad sheet of connective tissue known as the pes anserinus
→ flex and internally rotate the knee
 The popliteus is a triangular muscle located deep to the ganstrocnemius
within the popliteal fossa; the only muscle that attached within the
capsule of the knee joint

V. TORQUE OF MUSCLES ACTING AT THE KNEE

A. Knee Extensor Muscle Torque
Maximal torque production of the knee extensor muscles
 Knee extension torque is maintained at least at 90% throughout the
knee's ROM from 80˚ to 30˚, with less torque produced at the near
extremes of flexion and extension (Fig.13.26)
 Maximal knee extension torque typically occurs between 45˚ and 70˚
of knee flexion
Biomechanical interactions between external and internal torques
 In many upright activities, an external (flexor) torque is acting on the
knee (Fig.13.25)
 During tibial-on-femoral knee extension, the external moment
arm of the weight of the lower leg increases from 90˚ to 0˚ of
knee flexion
 During femoral-on-tibial knee extension, the external moment arm
of the upper body weight decreases from 90˚ to 0˚ of knee flexion
 External torques are relatively large from 90˚ to 45˚ of flexion
via femoral-on-tibial extension, and from 45˚ to 0˚ of flexion via
tibial-on-femoral extension
 The external flexor torque must often be met or exceeded by an
opposing internal (externsor) torque
 A general biomechanical match in the internal torque potential of
the quadriceps and the external torques applied during the last
approximately 45˚ to 70˚ of complete femoral-on-tibial knee
extension
 As the knee approaches terminal tibial-on-femoral extension, the
maximal internal torque potential of the quadriceps is least while
the opposing external flexor torque is greatest; patients with
quadriceps weakness often fail to produce the last 15˚ to 20˚ of
active extension→ “extensor lag”

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B. Knee Flexor Muscle Torque

Maximal torque production of the knee flexor-rotator muscles
 Maximal-effort knee flexion torque is generally greatest with the knee
in the last 20˚ of full extension and then declines steadily as the knee is
progressively flexed (Fig.13.33)
Hamstrings to quadriceps torque ratio
 In general, the knee extensor muscles produce a torque about two
thirds greater than that produced by the knee flexor muscles
 Knee extensors have over twice the cross-sectional area of the
knee flexors
 The knee extensors have a longer moment arm distance than the
flexor
 Strength imbalance between these muscle groups has been suggested
as a basis for injuries such as hamstring strains
 Normative values for hamstring/quadriceps ratios (peak torque of
hamstrings divided by peak torque of quadriceps)
 0.60-0.69 at 60˚/sec, increasing to 0.85-0.95 at 300˚/sec, not
corrected for gravity
 When force output is corrected for gravity, the ratio is lower (i.e.,
0.45-0.55) and does not change with speed

Summary
 The knee complex is composed of two distinct articulations: the tibiofemoral
joint and the patellofemoral joint
 These two joint work together to create knee function which is vital for body
mobility
 Many of the muscles that act at the knee are biarticular, so they are influenced by
other joints and their positions
 A thorough knowledge of normal structure and function can be used to predict or
understand the immediate impact of a specific injury and the secondary effects
on intact structures

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Posterolateral aspect of the knee “The evolute”

Smith et al: Brunnstrom's Clinical

Kinesiology. 5E. p.305

Levangie & Norkin: Joint Structure and Function. 4E. p.400

Attachment of the synovium Contact area and stress between the

articular surfaces

Smith et al: Brunnstrom's Clinical Kinesiology. 5E. p.309 Levangie & Norkin: Joint Structure and Function. 4E. p.399

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