THE KNEE JOINT AND THE SCREW-HOME MECHANISM IN SQUAT

INTRODUCTION
The knee, the biggest joint in the human body, has extraordinarily complex kinematics. It
is a compound joint comprising the femur, tibia, patella, and fibula, with a sophisticated soft
tissue arrangement via two menisci, a synovial membrane, a fibrous capsule, ligaments, and
numerous bursae.
The structure of the knee joint is highly complicated, consisting of a double-joint
configuration of the tibiofemoral and patellofemoral joints (Affatato, 2012; Gray & Bannister,
1999). As a modified hinge joint that consists of two articulations, held together by a fibrous
capsule and linked by a network of ligaments, the knee lacks potential stability, which makes the
knee prone to injury, often due to misalignment and poor mechanics, but also due to sudden
trauma or overuse, as well as a poor form during knee motions.
The knee joint primarily involves flexion and extension movement. However, the area
and length of the articular surface of the femur and tibia differ. Specifically, the articular surface
of the medial condyle of the femur is greater than the articular surface of the lateral condyle. As
a result, a complex movement, including "sliding," occurs during the last 30 degrees of knee
extension, allowing the knee joint to move smoothly in addition to rolling between the two bones
(Goodfellow & O'Connor, 1978). The knee joint is hyperextended at the terminal extension and
stabilized by tightening the cruciate and collateral ligaments. Because the medial femoral
condyle is longer than the lateral condyle, the tibia rotates externally on the femur during the
final degrees of extension. This is a well-known kinematic phenomenon known as the screw-
home movement (Bytyqi et al., 2014; Wretenberg et al., 2002). This mechanism gives the knee
the needed stability in weight-bearing and non-weight-bearing postures, including squatting.

PURPOSE OF THE MOVEMENT

Humans use squatting to pick things up off the ground, sit and relax comfortably, and
even use the restroom. It is the most common form of lower-limb movement in everyday life and
sports. Consequently, the squat is one of the most commonly used exercises in the field of
strength and conditioning. Because it shares biomechanical and neuromuscular similarities with a
wide range of athletic movements, it is a core exercise in many sports routines designed to
improve athletic performance (Escamilla et al., 2001a; Senter & Hame, 2006). It is also used in
competitive weightlifting and powerlifting and is widely regarded as the ultimate test of lower-
body strength (Escamilla, 2001a; Escamilla et al., 2001b).
In the knee, the screw-home mechanism is a critical mechanism that plays an essential
role in the knee's terminal extension. This can occur in all daily and athletic movements requiring
the knee to flex and extend, especially in closed-chain conditions, such as squats. While the
screw-home mechanism is thought to be important for knee stability when standing upright, it is
also vital when squatting.

PROPER BIOMECHANICS
 The medial head of the gastrocnemius is thought to act as a dynamic knee stabilizer,
assisting to offset knee valgus moments and limiting posterior tibial translation (Rasch & Burke,
1978). The quadriceps femoris perform concentric knee extension and eccentrically resisting
knee flexion during the squat, while the hamstrings are technically antagonists of the quadriceps,
opposing knee extensor moments (Schoenfeld, 2010). However, during closed-chain exercise,
they behave conversely and co-contract with the quadriceps, to improve knee joint integrity. The
gluteus maximus is thought to help stabilize the knee (and pelvis) during squatting (Rasch &
Burke, 1978).
The knee receives much attention in the squat. The quads, hamstrings, and adductors are
some of the primary movers that help with knee and hip extension when standing up from the
bottom of the squat and control the descent downwards into the squat. Despite its appearance as
a simple hinge joint, the knee has a rotational component in which the tibia internally rotates
during flexion and externally rotates during extension to ensure the highest level of joint contact
and stability - this is the screw-home mechanism, and it plays an essential role in stability. The
knee must be flexed and extended to achieve a full-depth squat. Furthermore, the knee must track
in line with the midfoot to reduce excessive shear forces and avoid collapsing too far inward or
outward. The knees going over the toes are not highly unsafe. This is required to achieve an
upright position. If one does not have forward knee travel, more loading is placed on the hips,
posterior chain, and low back.
The screw-home mechanism allows the knee to rotate slightly internally and externally.
The tibia or femur must externally or internally rotate by about 10 degrees during the last 30
degrees of knee extension. Tibial-on-femoral rotation (tibia externally rotates) occurs in open-
chain exercises such as leg extension on a weight bench, whereas femoral-on-tibial rotation
(femur internally rotates) occurs in closed-chain exercises such as in the ascent phase of squats.
The tibia rolls anteriorly during knee extension, elongating the posterior cruciate ligament (PCL),
and the PCL's pull on the tibia causes it to glide anteriorly. The tibia rolls posteriorly during knee
flexion, elongating the anterior cruciate ligament (ACL), and it is the ACL's pull on the tibia
causes it to glide posteriorly. The popliteus muscle unlocks the knee with open-chain motions,
whereas external hip rotation unlocks the knee with closed-chain motions (Epomedicine, 2020).
The popliteus originates on the lateral femoral condyle and runs obliquely into the tibia directly
above the soleal line, an important landmark on the back of the tibia. The popliteus rotates the
tibia internally relative to the femur during open-chain activities.
On the other hand, closed-chain activities require the popliteus to rotate the femur
externally relative to the tibia, "screwing it home" and locking the knee joint. The patellar-
femoral joint increases joint stability. The patella is a sesamoid bone in the quadriceps muscle
that performs complex gliding movements during flexion and extension. The function of the
patella is universally agreed upon to be to effectively increase the movement arm of the patella
tendon about the tibiofemoral joint, thereby magnifying the movement and force of the
quadriceps muscle group around the knee(DeFrate et al., 2007).
In a study about the screw-home movement of the tibiofemoral joint during normal gait,
the knee joint flexes about 15 degrees during the loading response. In comparison, the tibia
rotates about 6 degrees externally around the femur (Kim et al., 2015). Because of the
tibiofemoral joint's unique anatomical shape, the screw-home movement occurred (Hill et al.,
2000). Because the articular surface of the tibial medial condyle is longer than that of the lateral
side, the anterior tibial glide persists during the last 20 to 30 degrees of knee extension. External
tibial rotation, or the screw-home mechanism, is produced by a prolonged anterior glide on the
medial side. When the knee flexes from 0 degrees of extension to 20 degrees of flexion, posterior
tibial glide begins first on the longer medial condyle. It results in relative tibial internal rotation,
reversing the screw-home mechanism. If the tibia is rotated externally concerning the femur
when the knee joint is extended, the ACL and PCL become tangled and tightened. As a result,
the knee joint becomes locked in place, with the tibia becoming more stable than the femur. As a
result, the screw-home movement stabilizes the knee joint when it extends.
When the foot is free to move, the normal tibial internal rotation in knee flexion and
external rotation in knee extension change during the squat exercise. Instead, the femur rotates
externally and internally during knee flexion and extension. During the descent, the tibia
attempts to rotate as the femur does externally. A significant femoral external rotation at early
flexion was seen in normal knees during squatting (Hallén & Lindahl, O. (1966). In addition, the
femur internally rotates on the tibia during the ascent from a squat position. When the smaller
lateral femoral condyle stops rolling and gliding posteriorly during a closed kinematic chain
extension from 30-degree knee flexion, the more prominent medial femoral condyle continues
rolling and gliding posteriorly. The final degrees of the extension causes the femur to rotate
medially on the tibia. A medial rotation of the femur at the final stage of extension is not
voluntary or produced by muscular force, often referred to as "automatic" or even "terminal
rotation." A rotation within the knee joint places the joint in a closed, packed or locked position -
specifically termed as the "locking mechanism."

FAULTY BIOMECHANICS
Like any other exercise, squats have injury risks; therefore, it is critical to perform proper
squat biomechanics. As previously stated, everyone squats differently due to anatomical
differences. For example, the bony anatomy will determine whether an individual is a narrow or
wide squatter; the rest of the squat is determined by stability and mobility. As a result, to avoid
injury, one must ensure stability and mobility when performing the squat on top form.
The knees may track inwards for stability, especially in individuals with weak gluteals.
This, however, will increase the risk of injury, such as chronic knee syndromes and knee
osteoarthritis (Contreras, 2019). When squatting, pain in the knee is most likely caused by a lack
of gluteal muscle strength, which can be overpowered by the hip adductors, resulting in valgus
knees to stabilize the femur (Contereas, 2019). In addition, impaired hamstring and vastus
medialis function, such as decreased strength, will result in valgus knees due to decreased knee
stabilization, increasing knee joint overloading. If the ankle range of motion, especially
dorsiflexion, is reduced, the knees will be unable to track over the feet, resulting in
compensations in other areas. For example, the feet will pronate (rotate inwards) to allow knee
movement. However, this will result in hip internal rotation and hip adduction, resulting in knee
valgus collapse (Contereas, 2019).
In order to ensure that the knees are in appropriate position for squat, one must keep the
feet straight while attempting to "screw in" the heels. However, when using this "screw-in"
mechanism, keep the midfoot pressure constant throughout the movement. It is too easy to push
the pressure to the outside of the foot, causing the big toe to lift off the floor. A good rule of
thumb is to keep things simple and the pressure on the foot centred. When squatting, the knees
must track straight over the toes to ensure proper loading and avoid excessive shear on the knee.
To maximize depth and strength, a squat should be at least between hip and shoulder width, with
the feet relatively straight between 0 to 15 degrees, regardless of anthropomorphic and flexibility
differences. To find the proper pelvic position, squeeze the gluteals like a bridge and brace the
core by squeezing the abdominals and low back muscles.
The absence of the screw-home mechanism may affect joint stability, disrupting knee
flexion-extension motion and increasing joint load. The faulty screw-home mechanism may have
an impact not only on joint stability but also on knee motion at the end of the extension. An
impaired screw-home mechanism in standing or squatting can lead to knee buckling.
Helfet's test is a technique for evaluating the screw-home mechanism (Rossi et al., 2011).
In this procedure, the subject sits with his or her legs free. The centres of the patella and the tibial
tuberosity are then marked. The subject then extends the knee while the tester takes note of the
position of these two points at full extension. Usually, the tibial tuberosity moves laterally,
indicating external tibial rotation. Failure to move the prominent tibial tuberosity indicates
ligamentous instability, meniscal damage, or muscular imbalance.
Because of factors such as screw-home rotation, form is an essential component of low
body activity. To help individuals correctly line up the lower body for optimal function during
squatting motion, it is always advised to maintain a foot forward position with the knees lined up
over the second and third toes. Lining up the lower extremities correctly ensures that the tibia
and femur are appropriately positioned to allow for healthy and natural knee movement. If the
tibia is fixed in an external position or the femur is fixed in an internal position, the mechanics of
the knee are altered, increasing the risk of injury.
There were valgus and varus alignments at the knee in squatting due to different foot and
hip positions (Han et al., 2013). The neutral squat has the feet pointing straight ahead; the
squeeze squat has the feet 30 degrees adducted; and the outward squat has the feet 30 degrees
abducted. The squeeze squat showed a valgus knee, whereas the outward squat showed a varus
knee. At the initial upright position, changes in rotation angles were also observed for the
squeeze and outward squat. A 30-degree foot abduction demonstrated an internally rotated knee,
while a 30-degree foot adduction demonstrated an externally rotated knee.
Furthermore, the screw-home mechanism changed during the squat exercise, with the
femur and tibia rotating externally during the descent phase and internally during the ascent
phase (Escamilla, 2001). This was true for the neutral and squeeze squats. The knee joint was
internally rotated as the knee flexed and externally rotated as the knee extended in the outward
squat. During walking, similar findings were observed. During the swing phase, the knee with
valgus alignment was externally rotated, whereas the knee with varus alignment was internally
rotated (Werner et al., 2005). The extreme external or internal rotation at maximal knee flexion
during the squeeze and outward squat would compress the anterior or posterior portions of the
menisci. This could cause a twisting strain on the collateral ligaments and harm the meniscus
(Escamilla, 2001). As a result, the neutral squat is healthier and safer for the knee, whereas the
squeeze and outward squat may cause meniscus injury.
It is worth noting that different populations perform the squat differently due to
differences in lifestyle, physical characteristics, or sports activity requirements. Females, for
example, consistently demonstrated hip adduction and knee valgus during the squat, which was
described as a "squeeze squat" (Earl et al., 2001; Zeller et al., 2003; Yamazaki et al., 2010). On
the other hand, weightlifters frequently place their hips and feet in an abducted position while
performing a squat snatch (Werner, 1983). This position could also be demonstrated by Asians
while resting or using the restroom (Hemmerich et al., 2006). In addition, load distributions at
the knee would be altered by valgus and varus alignment, contributing to the occurrence of joint
pathologies (e.g., knee osteoarthritis (OA) (Brouwer et al., 2007; Kujala et al., 1995), anterior
cruciate ligament (ACL) injury (Zeller et al., 2003)). Furthermore, previous research has shown
that quadriceps, hamstrings, and gastrocnemius activities were unaffected by foot position during
the squat (Hung & Gross, 1999; Escamilla et al., 2001; Murray et al., 2013).
Although symptoms may be localized to the knee, it is always prudent to investigate the
source of the dysfunction and improve mobility and joint-loading capacity somewhere else. For
example, a supinated foot combines with an internally rotating hip and an externally rotating
tibia, whereas pronated foot couples with an externally rotating hip and an internally rotating
tibia. In addition, suppose any of these joint motions are not fully accessible or sequenced. In
that case, it may result in excessive motion at other joints, increasing mechanical stress and
causing compensations and adaptations that cause problems.
The screw-home mechanism will not work if the knee cannot fully extend. To properly
screw home and lock for gait, running, and squatting, the knees must be able to express rotation.
When one lacks that ability, he or she may encounter potential issues and, as a result, knee pain.
To fully understand and fix knee symptoms, one must consider rotational stability and how
things function above and below the hip and foot. Once this information is available, one can
integrate and couple foot, knee, and hip movements. If the legs cannot be fully straightened, the
quadriceps are always activated, causing the body to rely on muscles and ligaments for support
and stability, resulting in overwork, pain, and an increased risk of injury.
REFERENCES
Affatato, S. (2012). Wear of orthopaedic implants and artificial joints. Elsevier Science.
Brouwer, G. M., van Tol, A. W., Bergink, A. P., Belo, J. N., Bernsen, R. M., Reijman, M., Pols,
H. A., & Bierma-Zeinstra, S. M. (2007). Association between valgus and varus alignment
and the development and progression of radiographic osteoarthritis of the knee. Arthritis
and rheumatism, 56(4), 1204–1211. https://doi.org/10.1002/art.22515
Bytyqi, D., Shabani, B., Lustig, S., Cheze, L., Karahoda Gjurgjeala, N., & Neyret, P. (2014).
Gait knee kinematic alterations in medial osteoarthritis: three dimensional assessment.
International orthopaedics, 38(6), 1191–1198. https://doi.org/10.1007/s00264-014-2312-3
Contreras, B. (2017). Squat biomechanics: Butt Wink - what is it, what causes it, & how can it be
improved? Bret Contreras. Retrieved February 17, 2023, from
https://bretcontreras.com/squat-biomechanics-butt-wink-what-is-it-what-causes-it-how-
can-it-be-improved/
Contreras, B. (2019). Knee Valgus (valgus collapse), glute medius strengthening, band hip
abduction exercises, and ankle dorsiflexion drills. Bret Contreras. Retrieved February 17,
2023, from https://bretcontreras.com/knee-valgus-valgus-collapse-glute-medius-
strengthening-band-hip-abduction-exercises-and-ankle-dorsiflexion-drills/
DeFrate, L. E., Nha, K. W., Papannagari, R., Moses, J. M., Gill, T. J., & Li, G. (2007). The
biomechanical function of the patellar tendon during in-vivo weight-bearing flexion.
Journal of Biomechanics, 40(8), 1716–1722.
https://doi.org/10.1016/j.jbiomech.2006.08.009
Earl, J. E., Schmitz, R. J., & Arnold, B. L. (2001). Activation of the VMO and VL during
dynamic mini-squat exercises with and without isometric hip adduction. Journal of
electromyography and kinesiology : official journal of the International Society of
Electrophysiological Kinesiology, 11(6), 381–386. https://doi.org/10.1016/s1050-
6411(01)00024-4
Epomedicine. (2020, September 13). Screw-Home mechanism. Epomedicine. Retrieved
February 16, 2023, from https://epomedicine.com/medical-students/screw-home-
mechanism/
Escamilla R. F. (2001). Knee biomechanics of the dynamic squat exercise. Medicine and science
in sports and exercise, 33(1), 127–141. https://doi.org/10.1097/00005768-200101000-
00020
Escamilla, R. F., Fleisig, G. S., Lowry, T. M., Barrentine, S. W., & Andrews, J. R. (2001a). A
three-dimensional biomechanical analysis of the squat during varying stance widths.
 Medicine and science in sports and exercise, 33(6), 984–998.
https://doi.org/10.1097/00005768-200106000-00019
Escamilla, R. F., Fleisig, G. S., Zheng, N., Lander, J. E., Barrentine, S. W., Andrews, J. R.,
Bergemann, B. W., & Moorman, C. T., 3rd (2001b). Effects of technique variations on
knee biomechanics during the squat and leg press. Medicine and science in sports and
exercise, 33(9), 1552–1566. https://doi.org/10.1097/00005768-200109000-00020
Goodfellow, J., & O'Connor, J. (1978). The mechanics of the knee and prosthesis design. The
Journal of bone and joint surgery. British volume, 60-B(3), 358–369.
https://doi.org/10.1302/0301-620X.60B3.581081
Gray, H., Williams, P. L., & Bannister, L. H. (1999). Gray's anatomy the anatomical basis of
medicine and surgery. Churchill Livingstone.
Hallén, L. G., & Lindahl, O. (1966). The "screw-home" movement in the knee-joint.
ActaorthopaedicaScandinavica, 37(1), 97–106.
https://doi.org/10.3109/17453676608989407
Han, S., Ge, S., Liu, H., & Liu, R. (2013). Alterations in Three-dimensional Knee Kinematics
and Kinetics during Neutral, Squeeze and Outward Squat. Journal of human kinetics, 39,
59–66. https://doi.org/10.2478/hukin-2013-0068
Hemmerich, A., Brown, H., Smith, S., Marthandam, S. S., & Wyss, U. P. (2006). Hip, knee, and
ankle kinematics of high range of motion activities of daily living. Journal of orthopaedic
research : official publication of the Orthopaedic Research Society, 24(4), 770–781.
https://doi.org/10.1002/jor.20114
Hill, P. F., Vedi, V., Williams, A., Iwaki, H., Pinskerova, V., & Freeman, M. A. (2000).
Tibiofemoral movement 2: the loaded and unloaded living knee studied by MRI. The
Journal of bone and joint surgery. British volume, 82(8), 1196–1198.
https://doi.org/10.1302/0301-620x.82b8.10716
Hung, Y. J., & Gross, M. T. (1999). Effect of foot position on electromyographic activity of the
vastusmedialis oblique and vastuslateralis during lower-extremity weight-bearing
activities. The Journal of orthopaedic and sports physical therapy, 29(2), 93–105.
https://doi.org/10.2519/jospt.1999.29.2.93
Kim, H. Y., Kim, K. J., Yang, D. S., Jeung, S. W., Choi, H. G., & Choy, W. S. (2015). Screw-
Home Movement of the Tibiofemoral Joint during Normal Gait: Three-Dimensional
Analysis. Clinics in orthopedic surgery, 7(3), 303–309.
https://doi.org/10.4055/cios.2015.7.3.303
Kujala, U. M., Kettunen, J., Paananen, H., Aalto, T., Battié, M. C., Impivaara, O., Videman, T.,
& Sarna, S. (1995). Knee osteoarthritis in former runners, soccer players, weight lifters,
and shooters. Arthritis and rheumatism, 38(4), 539–546.
https://doi.org/10.1002/art.1780380413
Murray, N., Cipriani, D., O'Rand, D., & Reed-Jones, R. (2013). Effects of Foot Position during
Squatting on the Quadriceps Femoris: An Electromyographic Study. International journal
of exercise science, 6(2), 114–125.
Rossi, R., Dettoni, F., Bruzzone, M., Cottino, U., D'Elicio, D. G., & Bonasia, D. E. (2011).
Clinical examination of the knee: know your tools for diagnosis of knee injuries. Sports
medicine, arthroscopy, rehabilitation, therapy & technology : SMARTT, 3, 25.
https://doi.org/10.1186/1758-2555-3-25
Senter, C., & Hame, S. L. (2006). Biomechanical analysis of tibial torque and knee flexion angle:
implications for understanding knee injury. Sports medicine (Auckland, N.Z.), 36(8),
635–641. https://doi.org/10.2165/00007256-200636080-00001
Werner, F. W., Ayers, D. C., Maletsky, L. P., & Rullkoetter, P. J. (2005). The effect of
valgus/varus malalignment on load distribution in total knee replacements. Journal of
biomechanics, 38(2), 349–355. https://doi.org/10.1016/j.jbiomech.2004.02.024
Wretenberg, P., Ramsey, D. K., & Németh, G. (2002). Tibiofemoral contact points relative to
flexion angle measured with MRI. Clinical biomechanics (Bristol, Avon), 17(6), 477–
485. https://doi.org/10.1016/s0268-0033(02)00036-0
Yamazaki, J., Muneta, T., Ju, Y. J., & Sekiya, I. (2010). Differences in kinematics of single leg
squatting between anterior cruciate ligament-injured patients and healthy controls. Knee
surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 18(1), 56–63.
https://doi.org/10.1007/s00167-009-0892-z
Zeller, B. L., McCrory, J. L., Kibler, W. B., & Uhl, T. L. (2003). Differences in kinematics and
electromyographic activity between men and women during the single-legged squat. The
American journal of sports medicine, 31(3), 449–456.
https://doi.org/10.1177/03635465030310032101