Download Chapter 10 The Knee Joint

The Knee Joint
• Knee joint
– largest joint in
body
– very complex
– primarily a hinge
joint
Chapter 10
The Knee Joint
Manual of Structural Kinesiology
Modified for Prentice WE:
Arnheim’s principles of
athletic training, ed 12, New
York, 2006, McGraw-Hill;
from Saladin, KS: Anatomy
&physiology: the unity of
forms and function, ed 2,
New York, 2001, McGrawHill.
R.T. Floyd, EdD, ATC, CSCS
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10-2
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Bones
Bones
• Fibula - lateral
• Enlarged femoral condyles articulate on
– serves as the
attachment for
knee joint
structures
– does not articulate
with femur or
patella
– not part of knee
joint
enlarged tibial condyles
• Medial & lateral tibial condyles (medial &
lateral tibial plateaus) - receptacles for
femoral condyles
• Tibia – medial
– bears most of weight
Modified from Anthony CP, Kolthoff NJ: Textbook of anatomy and
physiology, ed 9, St. Louis, 1975, Mosby.
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Bones
Bones
• Key bony landmarks
• Patella
– Superior & inferior patellar poles
– Tibial tuberosity
– Gerdy’s tubercle
– Medial & lateral femoral
condyles
– Upper anterior medial tibial
surface
– Head of fibula
– sesamoid (floating) bone
– imbedded in quadriceps
& patellar tendon
– serves similar to a pulley
in improving angle of
pull, resulting in greater
mechanical advantage in
knee extension
© 2007 McGraw-Hill Higher Education. All rights reserved.
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Modified from Anthony CP, Kolthoff NJ: Textbook of anatomy and
physiology, ed 9, St. Louis, 1975, Mosby.
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Bones
Bones
• Semimembranosus inserts posteromedially on
medial tibial condyle
• Biceps femoris inserts primarily on fibula head
• Popliteus originates on lateral aspect of lateral
femoral condyle
• Tibial collateral ligament originates on medial
aspect of upper medial femoral condyle &
inserts on medial tibial surface
• Fibula collateral originates on lateral femoral
condyle very close to popliteus origin & inserts
on fibular head
• Three vasti muscles of quadriceps originate
on proximal femur & insert on patellar
superior pole
– insertion is ultimately on tibial tuberosity via
patella tendon
• Iliotibial tract of tensor fasciae latae inserts
on Gerdy’s tubercle
• Sartorius, gracilis, & semitendinosus insert
just below the medial condyle on upper
anteromedial tibial surface
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Joints
Joints
• Ligaments provide static stability
• Quadriceps & hamstrings contractions produce
dynamic stability
• Articular cartilage surfaces on femur & tibia
• Menisci form cushions between bones
• Knee joint proper (tibiofemoral joint)
– classified as a ginglymus joint
• Sometimes referred to as trochoginglymus
joint internal & external rotation occur during
flexion
• Some argue for condyloid classification
– attached to tibia
– deepen tibial fossa
– enhance stability
• Patellofemoral joint
– arthrodial classification
– gliding nature of patella on femoral
condyles
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Joints
Modified from Anthony CP, Kolthoff NJ: Textbook of anatomy and
physiology, ed 9, St. Louis, 1975, Mosby.
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Joints
• Medial meniscus forms receptacle for medial
femoral condyle, Lateral meniscus receives
lateral femoral condyle
– Either or both menisci may be torn in
several different areas from a variety
of mechanisms, resulting in varying
– Thicker on outside border & taper down very thin
to inside border
– Can slip about slightly, but held in place by
various small ligaments
– Medial meniscus - larger & more open C
appearance
– Lateral meniscus - closed C configuration
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degrees of problems
• Tears often occur due significant
compression & shear forces during
rotation while flexing or extending
during quick directional changes in
running
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Joints
Joints
• Anterior & posterior cruciate ligaments
• Posterior cruciate
– cross within knee between tibia & femur
– vital in respectively maintaining anterior &
posterior stability, as well as rotatory stability
ligament (PCL) injuries
– not often injured
– mechanism of direct
contact with an opponent
or playing surface
• Anterior cruciate ligament (ACL) injuries
– one of most common serious injuries to knee
– mechanism often involves noncontact rotary
forces associated with planting & cutting,
hyperextension, or by violent quadriceps
contraction which pulls tibia forward on femur
• Fibular (lateral)
collateral ligament (LCL)
– infrequently injured
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Joints
• Synovial cavity
• Tibial (medial) collateral ligament (MCL)
– supplies knee with synovial fluid
– lies under patella and between surfaces of tibia &
femur
– "capsule of the knee”
– maintains medial stability by resisting
valgus forces or preventing knee from
being abducted
– injuries occur commonly, particularly in
contact or collision sports
– mechanism of teammate or opponent may
fall against lateral aspect of knee or leg
causing medial opening of knee joint &
stress to medial ligamentous structures
• Infrapatellar fat pad
– just posterior to patellar tendon
– an insertion point for synovial folds of tissue
known as “plica”
• an anatomical variant that may be irritated or
inflamed with injuries or overuse of the knee
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Joints
Joints
• Extends to 180 degrees (0
degrees of flexion)
• Hyperextension of 10 degrees or
> not uncommon
• Flexion occurs to about 140
degrees
• With knee flexed 30 degrees or >
• Bursae
– more than 10
bursae in &
around knee
– some are
connected to
synovial cavity
– they absorb
shock or prevent
friction
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Joints
© 2007 McGraw-Hill Higher Education. All rights reserved.
Modified from Anthony CP, Kolthoff NJ: Textbook of anatomy and
physiology, ed 9, St. Louis, 1975, Mosby.
– internal rotation 30 degrees occurs
– external rotation 45 degrees occurs
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Joints
Movements
• Knee “screws home” to fully extend due to the
shape of medial femoral condyle
– As knee approaches full extension tibia must
externally rotate approximately 10 degrees to
achieve proper alignment of tibial & femoral
condyles
– In full extension
• close congruency of articular surfaces
• no appreciable rotation of knee
– During initial flexion from full extension
• knee “unlocks” by tibia rotating internally, to a
degree, from its externally rotated position to
achieve flexion
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• Flexion
– bending or decreasing
angle between femur &
leg, characterized by heel
moving toward buttocks
• Extension
– straightening or
increasing angle between
femur & lower leg
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Movements
Muscles
• Quadriceps muscle group
• External rotation
– extends knee
– located in anterior
compartment of thigh
– consists of 4 muscles
– rotary movement of leg
laterally away from midline
• Internal rotation
•
•
•
•
– rotary movement of lower
leg medially toward midline
• Neither will occur unless
flexed 20-30 degrees or >
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rectus femoris
vastus lateralis
vastus intermedius
vastus medialis
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Muscles
Muscles
• Q angle
• Q angle
– Central line of pull for entire
quadriceps runs from ASIS to the
center of patella
– Line of pull of patella tendon runs
from center of patella to center of
tibial tuberosity
– Angle formed by the intersection of
these two lines at the patella is the
Q angle
– Normally, angle will be 15 degrees
or less for males & 20 degrees or
less in females
– Generally, females have higher
angles due to a wider pelvis
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– Higher Q angles generally
predispose people in varying
degrees to a variety of potential
knee problems including lateral
patellar subluxation or dislocation,
patellar compression syndrome,
chondromalacia, and ligamentous
injuries
– For people with above normal Q
angles, it is particularly important
to maintain high levels of strength
& endurance in vastus medialis so
as to counteract lateral pull of
vastus lateralis
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Muscles
Muscles
• Hamstring muscle group
• Two-joint muscles
– responsible for knee flexion
– located in posterior compartment of thigh
– consists of 3 muscles
– most effective when either origin or
insertion is stabilized to prevent movement
in direction of the contacting muscle
– To a degree, muscles are able to exert
greater force when lengthened than when
shortened
– Hamstring muscles & rectus femoris are
biarticular (two-joint) muscles
• semitendinosus - medial, internal rotator
• semimembranosus - medial, internal rotator
• biceps femoris - lateral, external rotator
• Popliteus assist medial hamstrings in
knee internal rotation
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Muscles
Muscles
• Ex. sartorius muscle
• Gracilis, sartorius, & semitendinosus join
together distally to form pes anserinus
– increases its total length & becomes a
better flexor at knee when pelvis is rotated
posteriorly & stabilized by abdominal
muscles
– attaches to anteromedial aspect of proximal tibia
below the level of tibial tuberosity
– Their attachment & posteromedially line of pull
enable them to assist with knee flexion particularly
once the knee is flexed & hip is externally rotated
• exemplified by trying to flex knee & cross the
legs in the sitting position
• one usually leans backward to flex legs at
knees
• Medial & lateral gastrocnemius heads attach
posteriorly on medial & lateral femoral
condyles
– Football kicker invariably leans well
backward to raise & fix the rectus femoris
origin to make it more effective as a knee
extensor
– assist with knee flexion
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Muscles
Muscles
Knee joint muscles location
Knee joint muscles location
• Anterior - primarily knee
• Posterior - primarily knee flexion
– Biceps femoris
– Semimembranosus
– Semitendinosus
extension
– Rectus femoris
– Vastus medialis
– Vastus intermedius
– Vastus lateralis
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•
•
•
•
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Sartorius
Gracilis
Popliteus
Gastrocnemius
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5
Nerves
Nerves
• Femoral nerves
• Sciatic nerve
– tibial division
innervates the knee
• semitendinosus,
semimembranosus,
biceps femoris (long
head)
extensors (quadriceps)
– rectus femoris
– vastus medialis
– vastus intermedius
– vastus lateralis
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– common peroneal
(fibular) division
• biceps femoris (short
head)
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Quadriceps Muscles
Quadriceps Muscles
• Rectus femoris (two-joint), vastus medialis,
vastus intermedius, vastus lateralis (largest)
• Quadriceps muscles - vital in jumping
– functions as a decelerator
• All attach to patella then to tibial tuberosity via
patellar tendon
• All superficial & palpable except vastus
intermedius (under rectus femoris)
• Strength or power may be indicated by vertical
jump test
• Generally desired to be 25% to 33% stronger than
hamstring group
• when decreasing speed to change direction
• when coming down from a jump
– eccentric contraction during decelerating
actions
– controls slowing of movements initiated in
previous phases of the sports skill
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Quadriceps Muscles
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Rectus Femoris Muscle
• Strength & endurance is essential for
maintenance of patellofemoral stability
– often a problem
– quads are particularly prone to atrophy
when injuries occur
– may be developed by resisted knee
extension activities from a seated position
– functional weight bearing activities such as
step-ups or squats are particularly useful
for strengthening & endurance
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Flexion of hip
Extension of
knee
Anterior pelvic
rotation
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Vastus Lateralis Muscle
Vastus Intermedius Muscle
Extension of
knee
Extension of
knee
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Vastus Medialis Muscle
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Hamstring Muscles
• Hamstring muscle group
– Semitendinosus
– Biceps femoris
– Semimembranosus
Extension of
knee
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Hamstring Muscles
Semitendinosus Muscle
Flexion of knee
•
•
•
•
•
•
•
Hamstring muscle strains very common
“Running muscles” function in acceleration
Antagonists to quadriceps muscles at knee
Named for cordlike attachments at knee
All originate on ischial tuberosity of pelvis
Semitendinosus inserts on anteromedial tibia
Semimembranosus inserts on posteromedial
tibia
• Biceps femoris inserts on lateral tibial condyle
& head of fibula
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Extension of hip
Internal
rotation of
hip
Internal
rotation of
flexed knee
Posterior pelvic
rotation
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Semimembranosus Muscle
Biceps Femoris Muscle
Flexion of knee
Flexion of knee
Extension of hip
Extension
of hip
External
rotation
of hip
External
rotation
of flexed
knee
Posterior pelvic
rotation
Internal rotation
of hip
Internal rotation
of flexed
knee
Posterior pelvic
rotation
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Knee Extension
Popliteus Muscle
Flexion of knee
• Agonists
– Rectus Femoris
– Vastus Lateralis
– Vastus Intermedius
– Vastus Medialis
Internal
rotation of
flexed knee
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Knee Flexion
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Knee Internal Rotation
• Agonists
• Agonists
– Biceps Femoris
(Long & Short
Head)
– Semitendinosus
– Semimembranosus
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– Semitendinosus
– Semimembranosus
– Popliteus
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Knee External Rotation
Web Sites
Radiologic Anatomy Browser
http://radlinux1.usuf1.usuhs.mil/rad/iong
– This site has numerous radiological views of the
musculoskeletal system.
University of Arkansas Medical School Gross Anatomy for
Medical Students
http://anatomy.uams.edu/anatomyhtml/gross.html
– Dissections, anatomy tables, atlas images, links, etc.
Loyola University Medical Center: Structure of the Human Body
www.meddean.luc.edu/lumen/meded/grossanatomy/index.htm
– An excellent site with many slides, dissections, tutorials, etc.
for the study of human anatomy
Wheeless’ Textbook of Orthopaedics
www.wheelessonline.com/
– This site has an extensive index of links to the fractures,
joints, muscles, nerves, trauma, medications, medical topics,
lab tests, and links to orthopedic journals and other orthopedic
and medical news.
• Agonists
– Biceps Femoris
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Web Sites
Web Sites
Premiere Medical Search Engine
www.medsite.com
– This site allows the reader to enter any medical condition and
it will search the net to find relevant articles.
Arthroscopy.com
www.arthroscopy.com/sports.htm
– Patient information on various musculoskeletal problems of
the lower extremity
Virtual Hospital
www.vh.org
– Numerous slides, patient information, etc.
Human Anatomy Online
www.innerbody.com/image/musc08.html
– Interactive musculoskeletal anatomy
The Hip and Knee Institute
www.hipsandknees.com/knee/index.html
– Arthritis of the Knee Joint
Adam Healthcare Center
http://adam.about.com/surgery/100088.htm#
– Knee joint replacement
American Academy of Orthopaedic Surgeons
http://orthoinfo.aaos.org/category.cfm?topcategory=Knee
– Patient education library on the knee
Edheads Activities
www.edheads.org/activities/knee/
– Allows you to perform virtual knee surgery
Gross Anatomy: The Functional Anatomy of the Knee Joint
www.upstate.edu/cdb/grossanat/limbs8.shtml
– Functional Anatomy of the Knee
Knee Ligament Anatomy and Injury
www.orthoassociates.com/knee_lig.htm
– Anatomy and injuries of the Knee and its ligaments
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Web Sites
Web Sites
Duke Orthopaedics
www.wheelessonline.com/ortho/anatomy_and_kinematics_of_th
e_knee_joint
– Anatomy and Kinematics of the knee joint
Knee Injury: Meniscus
www.patient.co.uk/showdoc/27000672/
– Understanding the knee joint and purpose of meniscus
Smart Play: The Knee
www.smartplay.net/ouch/bodybits/b_bitsknee.html
– Anatomy, functions, injuries, etc. of the knee
Patellofemoral Instability
www.massgeneral.org/ortho/PatellofemoralInstability.htm
– Patella Femoral Alignment
Chiroweb.com
www.chiroweb.com/archives/21/24/03.html
– Abnormal Q Angle and Orthotic Support
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The Physician and Sportsmedicine
www.physsportsmed.com/issues/1997/05may/bach.htm
– Acute Knee Injuries: When to Refer
The Physician and Sportsmedicine
www.physsportsmed.com/issues/1999/10_01_99/laprade.htm
– Acute Knee Injuries: On-the-Field and Sideline Evaluation
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