Anatomy of the Knee Joint Lateral Retinaculum
M.D.,*
JOHN P. FULKERSON, AND
The lateral knee retinaculum can be
defined as fibrous, connective tissue struct-
ures o n the lateral side of the knee that
limit motion of the knee joint in some way.
While numerous anatomic studies have been
done on the lateral knee,1~9-11*'5-17,22 no
comprehensive analysis of the lateral
retinacular structures has been found. A
detailed understanding of the lateral reti-
naculum is becoming more important now
that anterolateral rotatory instability of
the knee has been d e ~ ~ T i b e d . ~ ,along ~ , ~ , ~ ~fibers
with several surgical procedures designed
t o prevent anterior subluxation of the
lateral tibia1 plateau o n extension of the
anterior cruciate-deficient knee.
MATERIAL AND METHODS
Twenty-three cadaver knees and one fresh
knee were dissected with particular attention
to the lateral retinacular structures. After re-
moval of the skin, each retinacular layer was dis-
sected carefully to preserve the integrity and align-
ment of its fibers. Interconnections of these
layers were noted, and the origins and inser-
tions of each retinacular structure were de-
termined.
* Assistant Professor of Surgery, University of
Connecticut School of Medicine, and Director,
Sports Injury and Knee Clinic.
** Professor of Surgery and Chairman of Ortho-
paedic Surgery, University of Connecticut School
of Medicine.
Reprint requests to John D. Fulkerson, M.D.,
Sports Injury and Knee Clinic, Section of Ortho-
paedic Surgery, University of Connecticut School of
Medicine, Farmington, CT 06032.
Received: December 27, 1979.
0009-921X/80/1100/183$00.80 0 J. B. Lippincott Co.
183
HARRYR. GOSSLING, M.D.**
ANATOMY
Starting at the lateral border of the patella,
the fibrous expansion of the vastus lateralis
along the lateral patella is first encountered
(Fig. 1); its fibers are oriented longitudinally
along the lateral patella and proceed distally
to become part of the patellar tendon. This
band of vastus lateralis fibers varies in width
from a few fibers adhering to the patella to a
4 to 5 mm-wide band distinctly separate from
the patella.
A superficial oblique retinaculum is next
encountered as one proceeds posteriorly. The
, ~ ~of, ~this
~ superficial retinaculum originate
from the iliotibial band, interdigitating with
the longitudinally oriented fibers of the vastus
lateralis and patellar tendon. While most fibers
of the superficial oblique retinaculum proceed
into the anterior part of the patellar tendon,
some fibers may go deep to patellar tendon
and overlap capsule anteriorly. The density of
this superficial oblique retinaculum decreases
distally.
If the insertion of the superficial oblique
retinaculum is carefully freed from its insertion
into the quadriceps mechanism and reflected
posteriorly, a deeper layer of dense transverse
fibers is consistently found running from the
deep portion of fascia lata directly to the
lateral patella. Although this layer is distinctly
separate from the superficial oblique retinaculum,
it also proceeds less far distally so that at
the level of the patellar tendon, one finds only
superficial oblique retinaculum with no underly-
ing deep transverse fibers. At the lower border
of the deep transverse retinaculum, a distinct
patellotibial ligament can be found which is
closely associated with the deep transverse
retinaculum. Its fibers, however, proceed di-
rectly out of the distal patella and proceed
more obliquely and inferiorly to insert in the
lateral meniscus and proximal tibia. These

184 Fulkerson and Gossling
Vastus Lateralis
lliotibial Tract
FIG.1. Superficial lateral knee retinaculum. Note interdigitation of superficial oblique retinaculum
fibers with vastus lateralis expansion on the patella.
fibers are demonstrated diagrammatically in
Figure 2 along with the deep transverse
retinaculum. At this level of dissection, a
tendinous expansion can be found running from
the lateral intermuscular septum and lateral
epicondyle (proximally) to the lateral patella at
its proximal to mid portion (distally). This
band is probably the same as the epicondylo-
patellar ligament described by Kaplan.8
Beneath the deep transverse retinaculum is
the thin capsulosynovial layer. Although the
capsule and synovium can be separated into two
distinct layers, they are quite adherent and
relatively thin even as a combined structure.
This layer gives little retinacular support to the
lateral side of the knee.
Immediately posterior to the oblique and
Vastus Lateralis
Epi
-
-;
lliotibial Tract
FIG.2. Deep to the superficial oblique retinaculum.
Clinical Orthopaedics
and Related Research
Fibers blend with Fibrous Expansion
of Vastus Lateralis
i
transverse retinacular ligaments lies the fascia
lata. With the knee extended, the fascia lata
runs longitudinally along the lateral side of the
knee inserting into Gerdy's tubercle. Some of
its fibers proceed across Gerdy's tubercle
to the tibia1 tuberosity. More proximally, the
fascia is firmly adherent to the lateral inter-
muscular septum. Consequently, the fascia lata
is fixed proximal and distal to the lateral
joint line, lending static as well as dynamic
support to the lateral knee.
The lateral collateral ligament originates on
the flair of the lateral epicondyle of the
femur just anterior to the origin of the
gastrocnemius and inserts into the head of the
fibula distally with some fibers coursing more
anteriorly to insert on the proximal tibia
Lateral Joint Line
Fibrous Expansion of Vastus Lateralis
Deep Transverse Retina4:ulum
Patellotibial Band
5uperficial 0ibdique Retin culum
- - - -- ,
Tubercle
5
Number 153
November-December, 1980
FIG.3. Relationships of lateral retinacular structures posterior to the iliotibial band.
immediately anterior to the fibular head. Most
of the lateral collateral insertion inserts into the
anterior half of the fibular head. The tendon
of the biceps femoris blends with the lateral
collateral ligament to form the so-called con-
joint tendon. Although partially located deep to
the iliotibial band, the lateral collateral ligament
is best considered as part of the outer
retinaculum, superficial to the capsulosynovium.
A smaller, obliquely oriented ligament can
be found inserting separately into the posterior
fibular head and originating from the postero-
lateral femur deep to the lateral gastrocnemius
(Fig. 3). This structure is probably the same
as the fabellofibular ligament described by
Kaplan.Io If this structure alone with the biceps
tendon and lateral collateral ligament are re-
flected off the fibular head and retracted
proximally, the popliteus tendon can be found
with its insertion immediately anterior to the
lateral collateral ligament on the femoral
condyle. Its fibers are somewhat adherent to
the lateral meniscus as described by Last.”
DISCUSSION
Lateral tracking of the patella, as dis-
cussed recently by Knight,14 may neces-
sitate release of the lateral knee retinac-
ulum. Taking our dissections into account,
a surgeon must be alert to the presence of
two distinct layers when releasing knee
retinaculum (Fig. 4). The superficial oblique
retinaculum alone may be released if care
Lateral Knee Retinaculum 185
is not taken to identify and transect
the dense adherent deep transverse fibers.
Because these deep fibers are immediately
adjacent to the thin capsulosynovial layer,
the joint may be entered in releasing
these fibers unless a particular effort is
made to avoid this. Larson et recently
discussed a method for lengthening the
lateral retinaculum by suturing the deep
transverse layer to the posterior edge of
the superficial layer, thereby producing
an elongated and intact lateral patellar
retinaculum.
While the epicondylopatellar and patello-
tibial ligaments have been identified pre-
viously, the descriptions of these fibers have
been somewhat nonspecific and even in-
accurate. As mentioned above, the patello-
tibial or meniscopatellar ligament is a dis-
tinct structure (Figs. 2 and 4), but it
should be made clear that this ligament
sends fibers both into the lateral meniscus
and into the underlying tibia. Also, it
should be noted that these fibers insert at
the level of Gerdy’s tubercle.
In the articles written by Jeffreys’ and
Williams,21 specific mention is made of an
“abnormal” band running from the ilio-
tibial tract to the superolateral patella in
patients with recurrent dislocation of the
 Chnical Orthopaedics
186 Fulkerson and Gossling and Related Research

FIG.4. Lateral retinacular structures: (A) Superficial oblique retinaculum; (B) vastus lateralis tendon
fibers; (C) capsulosynovium; (D) deep transverse retinaculum; (E) epicondylopatellar band; (F)
patellotibial band; (G) Gerdy’s tubercle; (H) biceps tendon; (I) iliotibial band; (L) lateral collateral
ligament.

patella or quadriceps contracture. This time.13*18The retinacular orientation of the

band is probably not an abnormal band,
but rather a hypertrophied epicondylo-
patellar ligament. Since this ligament has
actually been found to originate at the
lateral intermuscular septum, and since the
lateral intermuscular septum is densely
adherent to the iliotibial band at this level,
it is likely that the “abnormal band”
noted by Jeffreys and Williams is the
epicondylopatellar ligament (Fig. 4).
Anterolateral rotatory instability of the
knee is now known to be highly correlated
with anterior cruciate ligament d e f i c i e n ~ y . ~ . ’ ~factors. The patient’s lateral hamstring de-
Although anterolateral instability may be
present acutely, at the time of anterior
cruciate disruption, it may also be absent
at the time of cruciate disruption but
develop insidiously and progressively with
lateral side of the knee is such that there is
little to hold the lateral tibia posteriorly
for long. Since the fibers of the lateral
retinaculum are oriented vertically with the
knee in extension, they do not offer an
appreciable vector of restraint to prevent
forward subluxation of the anterior cruciate-
deficient tibia once the fabellofibular liga-
ment has been torn or stretched.
When and how anterolateral rotatory in-
stability develops following anterior cruciate
disruption will clearly depend on many
velopment and tone, level of physical
activity, athletic involvement, general con-
nective tissue quality, bracing, and asso-
ciated injuries will certainly modify his
or her course after rupture of the anterior
Number 153
November-December, 1980
cruciate ligament. Chick and Jackson*
have clearly demonstrated that young
athletes younger than 30 years will do
well in the short run subsequent to com-
plete disruption of the anterior cruciate
ligament. Most orthopedic surgeons treating
young athletes have found this to be
true. Motivational factors, muscle tone, and
bracing may enable these young individuals
to return to sports before an appreciable
amount of anterolateral rotatory instability
develops. It is the thesis of this study,
however, that anterolateral rotatory in-
stability is likely to develop later in many
cases since there is such poor retinacular
restraint on the lateral side of the knee in
extension.
Finally, the present dissections appear to
be in conflict with current terminology
regarding the lateral knee capsule. It has
been customary to refer to the “lateral
capsular ligament,” and to divide this
ligament into thirds. The retinacular, or
restraining, structures on the lateral side of
the knee have been described earlier in this
report. A capsule is defined as being a
structure in which something is enclosed.
The lateral knee capsule is actually a very
thin structure adherent to synovium with
minimal supportive qualities. It is proposed
that the correct anatomic terms be used to
define parts of the lateral knee retinaculum
and that the term “lateral capsular liga-
ment” be discarded as anatomically incor-
rect and potentially misleading.
SUMMARY
Dissections of the fiber orientation and
interconnections of the lateral knee reti-
nacula in 23 cadaver knees and one fresh
knee demonstrate a superficial, oblique
retinacular ligament running from fascia
lata to patella. Deep to this structure
are a separate distinct transverse band to
the patella, an epicondylopatellar and a
patellotibial band. Awareness of these dis-
tinct structures should be helpful to the
Lateral Knee Retinaculum 187
surgeon performing a lateral retinacular
release. The lateral knee retinaculum is
oriented longitudinally with the knee ex-
tended. In view of this, there is little to
support the lateral tibia1 plateau posteriorly
once the anterior cruciate ligament has been
torn. The fabellofibular ligament gives
minimal supportive strength to the postero-
lateral corner. The lateral knee has two
distinct functional layers. The outer layer
consists of superficial and deep retinacular
fibers, iliotibial band, lateral collateral,
biceps tendon, and fabellofibular ligament;
these are the main restraining, retinacular
structures of the lateral knee. Deep to these
structures lie the popliteus tendon, the
true joint capsule, and synovium which
have little ability to prevent anterolateral
rotatory instability once the anterior cruciate
ligament has been disrupted. The term
“lateral capsular ligament” is anatomically
incorrect, and specific retinacular structures
should be designated in describing the
lateral knee.
ACKNOWLEDGMENTS
The authors express particular thanks to Dr.
Steve Pillsbury, Miss Kathy Krauskas, Miss Susan
Goodman, Mr. Romeo LeSage, Mr. Gary Golan, and
Ms. Joanne Andersen for their help in producing
this manuscript.
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