THE KNEE JOINT

BY

DR. OJEWALE AO
 OUTLINES
2
Intro’
Articular surfaces of the knee joint
Stability of the knee joint
The relations of the knee joint
Bursae around the knee joint
Blood supply
Movements of the knee joint
Locking and unlocking of the knee joint
Applied Anatomy
 THE KNEE JOINT
3
 It is the largest and most  Is strengthened mainly by
complicated joint in the muscles and ligaments
body. that are associated with it.
 Is a complex hinge type of  It is the major weight-
synovial joint, which bearing joint in the body.
essentially permits flexion
and extension on a
transverse axis.
 Is formed between the
femoral and tibial condyles
and also between the
femur and patella.
 It has a single joint cavity
A, condylar type of medial and lateral femorotib
(despite its complexity). joints; B, saddle type of patellofemoral joint.
 Articular Surfaces
 The articular surfaces of the  2. Trochlear surface of
4
knee joints are: the femur.
 Trochlear surface of the
 1. Articular surfaces of
femur is located on the
anterior aspect of the
medial and lateral condyles of lower end of the femur. It
the femur. articulates with the
 The convex femoral condyles posterior surface of the
articulate with the concave patella. It is pulley-
shaped, consisting of
tibial condyles. medial and lateral sloping
 The articular surfaces of the surfaces meeting with
femoral and tibial condyles each other in a median
are covered by articular vertical groove. The
hyaline cartilage (to prevent
lateral sloping surface is
longer than that of
friction). medial.
 3. Articular surface of the 4. Articular surfaces of medial and
patella. lateral condyles of the tibia
5
 It is on the posterior aspect of
They are concave centrally but
patella and articulates with the flattened peripherally (where each
trochlear surface of the femur. is covered by the corresponding
It has a larger lateral area and a meniscus.
smaller medial area.
The presence of a meniscus on
each tibial condyle helps to deepen
 The femur also articulates with the concavity of the articular
the patella (patellofemoral joint) surface of this condyle.
through the concave patellar
surface of femur.

superior aspect of the tibia

Inferior aspect of the patella and
lower end of the femur
 The fibrous capsule of the knee joint
6
 forms a strong investment  Is also lined internally to the
for the joint. margins of the menisci by the
 Is complex, being thin and
deficient in some regions short coronary ligaments.
but strenghtened by
ligaments elsewhere.
 Posteriorly, the fibrous capsule
 Isdeficient posterolaterally,
where the tendon of of the knee joint
popliteus emerges from • Is attached above to the
the cavity of the knee joint. posterior margin of femoral
 Is lined internally by a
condyles and intercondylar
complex synovial
membrane. fossa.
• Is attached below to the
posterior margins of tibial
condyles and intercondylar
area.
 Continued’
 Anteriorly, the fibrous
 Blends with the proximal 7
capsule of the knee joint
attachment of  Is formed by the patella and
gastrocnemius. ligament; hence, it is limited
 Is strengthened by the
above by the base of the
patella and below by the
oblique popliteal tibial tuberosity.
ligament; this is an
extension of the tendon
 Blends, at the margins of the
of insertion of
patella and patellar ligament,
semimembranosus. with the medial and lateral
 Is interrupted (deficient) patellar retinacula; these
where the popliteus stretch from the medial and
tendon emerges from the lateral vasti respectively, to
joint cavity. the corresponding condyles
of the tibia, below.
 Continued’
 Laterally, the fibrous capsule  Medially, the fibrous
8
of the knee joint capsule of the knee joint
• Is attached above to the  Is attached above and
lateral condyle of femur, below to the medial
above the popliteus. condyles of the femur
• Is attached below, to the and tibia respectively.
lateral condyle of tibia and
 Blends with, and is
head of fibula.
strengthened by the
• Is strengthened by the fibular
tibia collateral ligament.
collateral ligament (which
lies lateral to it).
• Is separated from the fibular
collateral ligament by the
inferior lateral genicular nerve
and vessels.
 The synovial membrane of the knee joint
 Is the most complexly arranged 9 Covers a large infrapatellar pad
synovial membrane in the body. of fat that lies between it and
the patellar ligament (below the
 Lines the joint cavity (and thus patella).
separates the intra-articular
ligaments and fat from it).  Is reflected from the
infrapatellar pad of fat onto the
 Is attached to the margins of margin of the patella, on each
the menisci and patella. side, as the alar fold.

 Is evaginated (drawn upwards)

 Is also reflected from the
proximal to the base of the
patella and deep to the tendon infrapatellar pad of fat into the
of quadriceps femoris to form a intercondylar fossa of the
large suprapatellar bursa. femur as the infrapatellar fold;
this is continuous anteriorly
with the alar folds.
 Is reflected onto the intra-
10
articularcruciate
ligaments , from the
posterior aspect of the
joint, thereby separating
these ligaments from the
joint cavity.
 Forms a subpopliteal
recess deep to the tendon
of popliteus, (and
posteroinferior to the
lateral meniscus.
 Factors Maintaining the Stability of the Knee Joint
11

 The stability of the knee joint is maintained by the following

factors:
• Strength and actions of the surrounding muscles and
tendons.

• Medial and lateral collateral ligaments maintain side-to

side stability.

• Cruciate ligaments maintain anteroposterior stability.

• Iliotibial tract helps in stabilizing a partly flexed knee

 Ligaments of the knee joint
 Ligaments are found within 12 The cruciate ligament
and outside the knee joint
cavity. The intracapsular  Are strong fibrous bands
ligaments of the knee joint
located within the capsule of
(those within the fibrous
the knee joint; they connect the
capsule) include the anterior
tibia and femur together.
and posterior cruciate
ligaments, transverse  Criss-cross each other
ligament of the knee joint, obliquely along their length,
medial and lateral menisci. hence their name.
 Are two in number: anterior
 Extracapsular ligaments of
and posterior cruciate
ligaments.
the knee joint (those outside
the fibrous capsule) include  Through within the fibrous
the tibial and fibular capsule of the joint, they are
collateral, capsular, patellar, not exposed to the joint cavity.
oblique popliteal and arcuate (as each of them is covered by
popliteal ligaments. synovial membrane).
 Continued’
 The anterior cruciate Becomes taut when the knee is
ligament 13 fully extended; this prevents
backward displacement of the
 Is the weaker of two cruciate femur on the tibia.
ligaments.
 Is attached below to the The posterior cruciate ligament
anterior intercondylar area of Is much stronger than the
tibia (behind the attachment of anterior cruciate ligament; thus,
the anterior horn of the medial it is less frequently damaged in
meniscus knee injuries.
 Ascends backwards and Is attached below to the
laterally to the (posteromedial posterior intercondylar area of
the tibia (behind the lateral
aspect of the) lateral condyle meniscus).
of femur, to which it is attached Ascends anteromedially, to be
above. attached above to the (lateral
 Is more frequently involved in surface of the) medial condyle
injuries of the knee, as does the of femur.
tibial collateral ligament. Becomes taut during flexion of
the joint, thereby preventing
14
 Menisci
 Each meniscus 15 Is joined to its fellow across
 Is a fibrocartilagenous plate the midline by the transverse
associated with the ligament of the knee joint; this
connects the anterior horns of
articular surface of the the (medial and lateral)
respective tibial condyle. menisci.

 Possesses a thick convex  The medial meniscus

and vascular peripheral • Is roughly semicircular in
border, which is attached to outline; it is located on the
the fibrous capsule of the medial condyle of the tibia.
knee joint. • Is less extensive (i.e. covers
less condylar area) than the
 Has a thin, free concave
lateral meniscus.
• Is attached at its periphery to
inner border, which is
avascular. the margin of the medial
condyle of tibia by the
coronary ligament (a reflection
 Serves as a shock absorber of the fibrous capsule.
for the knee joint during
movement
 Continued’
 Is also attached by its anterior  The lateral meniscus
horn to the anterior 16•Is almost circular in outline
intercondylar area of tibia
(anterior to the anterior • Is more extensive (i.e. covers a
cruciate ligament). larger area than the medial
 Is connected to the lateral meniscus.
meniscus by the transverse
ligament of knee; and it • Is attached, through its anterior
stretches between the end, to the anterior intercondylar
anterior ends of the two area of tibia (posterolateral to the
menisci. point of attachment of the
 Is attached posteriorly, anterior cruciate ligament.
through its posterior horn, to
the posterior intercondylar • Is attached posteriorly, through its
area of the tibia. (behind the posterior end, to the posterior
attachment of the lateral intercondylar area of tibia
meniscus).
(anterior to the posterior end of
 Is less freely movable than the
lateral meniscus; hence, it is the medial meniscus).
more frequently torn in knee
injuries.
 Continued’
 Is separated from the fibular  Is less frequently injured
collateral ligament by 17 (owing to its ability to
tendon of popliteus.
move more freely).
 Gives rise to theposterior
meniscofemoral ligament
(Ligament of Wrisberg). This
stretches superomedially
from the posterior end of the
lateral meniscus to the
medial condyle of the femur.

 May give rise to an anterior

meniscofemoral ligament
(Ligament of Humphrey);
this also stretches
superomedially from the
posterior end of the lateral Medial and lateral menisci of the knee joint
meniscus to the medial
condyle of femur (anterior to
the posterior cruciate
 Functions of the menisci  The transverse ligament
 The menisci increase the of the knee joint
concavities of the tibial 18  Connects the anterior
condyles for better harmony ends of the medial and
with the femoral condyles. lateral menisci across
 They act as swabs to
the midline.
lubricate the joint cavity.
 Varies in thickness and
 They act as shock absorber
to protect the articular may be absent.
cartilage during weight
transmission.
 They adapt to the varying
curvatures of the different
parts of the femoral
condyles.
Extracapsular ligaments
19
of the knee joint
 Capsular ligament: It is a  Patellar ligament
thin fibrous sac which • Is the strong flat distal part of
surrounds the joint. It is quadriceps femoris tendon; it
measures about 8 cm in length;
deficient anteriorly, where it thus, it
is replaced by the patella, • Is continous proximally with
quadriceps femoris, medial the tendon of quadriceps
and lateral patellar femoris, anterior to the patella.
retinacula, and ligamentum • Stretches from the apex of the
patella above, to the tibial
patellae. tuberosity below.
• Forms the anterior part of the
fibrous capsule of the knee
joint (below the patella); an
infrapatellar pad of fat
separates it from the synovial
membrane of the joint.
 Continued’
 Is flanked at the sides by 20 The tibial collateral
medial and lateral patellar ligament
retinacula (from the • Is a flat broad fibrous band
tendons of the medial and that strengthens the fibrous
lateral vasti respectively. capsule of the knee joint
 Is separated from the tibia medially. A bursa may
by the deep infrapatellar separate it from the capsule.
bursa, over which it slides. • Stretches from the medial
epicondyle of femur above,
to the medial condyle of
tibia, medial meniscus and
upper part of the medial
surface of the tibia, below.
 Continued’
 Is separated from the
21
tendons of
semitendinosus, gracilis
and sartorius (at its distal
tibial attachment) by the
bursa anserina
 Sends some fibres from
its deep surface-the deep
fibres of tibial collateral
ligament to the medial
meniscus.
 Is weaker than the fibular
collateral ligament; hence,
it is more frequently torn
 Measures about 10 cm in
length.
 The fibular collateral  Pierces the tendon of
ligament bicep femoris near its
 Is a strong fibrous cord; it is fibular attachment.
much stronger than the 22
tibial collateral ligament.  Is less commonly torn in
 Stretches from the lateral knee injuries.
epicondyle of femur above,
to the head of the fibula
below.
 Strengthens the fibrous
capsule of the knee joint
laterally; it is separated
from this capsule by the
tendon of popliteus and the
inferior lateral genicular
nerve and vessels.
 Thus it is not attached to
the lateral meniscus of the
knee joint by any fibrous
tissue.
 Continued’
 The oblique popliteal ligament  The arcuate popliteal
 Is an extension of the tendon23 ligament
of insertion of
 Arises from the head
semimembranosus
 Stretches superolaterally,
of fibula below; it then
behind the knee joint, from the arches upward and
posterior aspect of the medial medially, superficial to
condyle of the tibia to the the tendon of popliteus,
lateral condyle of femur. to blend with the
 Blends with the fibrous fibrous capsule of the
capsule of the knee joint, knee joint.
which it strengthens
posteriorly  Strengthens the fibrous
 Forms part of the floor of the capsule of the knee
popliteal fossa. joint posteriorly.
 BURSAE AROUND THE KNEE
 There are about 12 bursae  Subcutaneous infrapatellar
24
around the knee, four bursa between the skin and
anterior, three lateral, three smooth lower part of the
medial, and two posterior. tibial tuberosity
 Anterior Bursae:
Subcutaneous prepatellar  Deep infrapatellar bursa,
bursa (bursa of between ligamentum
housemaid’s knee). It lies patellae and tibial tuberosity.
deep to the skin in front of
lower half of the patella
 Suprapatellar bursa between
and upper half of the
ligamentum patellae and the anterior surface of lower
tibial tuberosity. part of the femur and deep
surface of the quadriceps
femoris.
 Lateral Bursae Continued’
 Medial Bursae
 These are:
 These are:
25
 The bursa between the fibular  The bursa, which
collateral ligament and separates the tendons of
tendon of biceps femoris. sartorius, gracilis, and
semitendinosus from each
 The bursa between the fibular other and from the tibial
collateral ligament and collateral ligament (bursa
tendon of popliteus. anserine).
 The bursa between the
 The bursa between the tendon of
tendon of popliteus and semimembranosus and
lateral condyle of femur. This medial collateral ligament.
bursa is really a synovial tube  The bursa between the
around the tendon of tendon of
semimembranosus and
popliteus; hence it medial condyle of the tibia.
communicates with the joint It may communicate with
cavity. the knee joint.
 26

bursae on the front of the knee

Bursae around the knee joint: A, bursae
on the medial and lateral aspects of the
knee
 Continued’
Relations Of The Knee Joint
 Posterior Bursae
27 Anteriorly: Tendon of the
 These are: quadriceps femoris, patella,
ligamentum patellae, patellar
 The bursa between the plexus of the nerves, and
lateral head of prepatellar synovial bursa.
Anteromedially: Medial patellar
gastrocnemius and capsule retinaculum.
of the joint. Anterolaterally: Lateral patellar
 The bursa between the retinaculum and iliotibial tract.
Posteriorly: Popliteal vessels,
medial head of tibial nerve, and oblique popliteal
gastrocnemius and capsule ligament.
of the joint (Brodie’s bursa). Posterolaterally: In the upper part,
tendon of biceps femoris and
common peroneal nerve; in the
lower part, lateral head of
gastrocnemius and plantaris.
Posteromedially:In the upper part,
sartorius, gracilis,
semimembranosus, and
semitendinosus.
 Cont’d
Relations of the knee joint
 Anteriorly: Tendon of the 28
quadriceps femoris, patella,
ligamentum patellae, patellar
plexus of the nerves, and
prepatellar synovial bursa.
 Anteromedially: Medial patellar
retinaculum.
 Anterolaterally: Lateral patellar
retinaculum and iliotibial tract.
 Posteriorly: Popliteal vessels,
tibial nerve, and oblique
popliteal ligament.
 Posterolaterally: In the upper
part, tendon of biceps femoris
and common peroneal nerve; in
the lower part, lateral head of
gastrocnemius and plantaris.
 Posteromedially: In the upper Relations of the knee joint (transverse
part, sartorius, gracilis, section of right knee joint).
 BLOOD SUPPLY  NERVE SUPPLY
• The knee joint is richly  The knee joint has rich nerve
29
supplied by the blood supply by:
through the arterial  (a) Femoral nerve through its
anastomosis around the branches to vasti, especially
knee, which is formed by: to vastus medialis.
(a) five genicular
branches of popliteal  (b) Tibial and common
artery, (b) descending peroneal nerves through their
genicular branch of genicular branches.
femoral artery, (c)  (c) Obturator nerve through
descending branch of the its posterior division
lateral circumflex femoral
artery, (d) two recurrent
branches of the anterior • .
tibial artery, and (e)
circumflex fibular branch
of the posterior tibial
artery.
 30
 MOVEMENTS
 The following movements
occur at the knee joints:
 Flexion
 Extension
 Medial rotation
 Lateral rotation.
 Movements of the knee joint
31

Muscles producing movements

Movements Chief muscles Accessory muscles
Flexion Semimembranosus Popliteus
Semitendinosus (initiates flexion)
Biceps femoris Sartorius
Gracilis
Gastrocnemius
Plantaris

Extension Quadriceps femoris Tensor fasciae latae

Medial Semitendinosus Sartorius
rotation Semimembranosus Gracilis
Popliteus
Lateral Biceps femoris Gluteus maximus
rotation Tensor fasciae latae
 Locking and unlocking of the knee
32
 Locking of the knee: When the  Unlocking of the knee: When
foot is on the ground, the the foot is on the ground, the
locking is defined as the unlocking is defined as the
medial rotation of femur on lateral rotation of the femur
the tibia during the terminal on the tibia during initial
phase of extension of the phase of the flexion. The
knee. When the knee is locked unlocking is brought about by
it becomes absolutely rigid the popliteus muscle.
and all the ligaments of the  When the knee is unlocked, it
joint are taut. This is known as can be further flexed by the
“screw home mechanism”. hamstring muscles.
 Cont’d
 The locking of knee is
33
essential for bearing
load during erect
posture. The locked
joint must be unlocked
to facilitate progress
of locomotion. Hence,
during locomotion,
locking and unlocking
of the knee takes place
alternatively and
rhythmically.
 The differences between the locking and
unlocking of the
knee
34

Locking of the knee joint Unlocking of the knee joint

Medial rotation of the Lateral rotation of the

femur on tibia during femur on tibia during initial
terminal phase of extension phase of the flexion

It is brought about by It is brought about by the

quadriceps femoris popliteus muscle

Locked knee becomes Unlocked knee can be

absolutely rigid further flexed

All ligaments are taut All ligaments are relaxed

 APPLIED ANATOMY
 Meniscal tears: The injuries to menisci are commonly caused
35
by the twisting strains in a slightly flexed knee, as in kicking a
football. The meniscus may get separated from the capsule,
or it may be torn longitudinally (bucket-handle tear) or
transversely.

 The medial meniscus is more prone to injury than the lateral

because of its firm fixity to tibial collateral ligament, and
greater excursion during the rotatory movements. The lateral
meniscus is protected by the popliteus muscle because its
medial fibres pulls the posterior horn of meniscus backward,
so that it is not crushed between the articular surfaces. Pain
on the medial rotation of tibia on the femur indicates injury of
the medial meniscus; while pain on the lateral rotation of tibia
on the femur indicates injury of the lateral meniscus.
 Cont’d
36
Injuries to cruciate ligaments:  on the femur (anterior drawer
The anterior cruciate ligament sign) and if the posterior
is more commonly damaged
than the posterior ligament. cruciate ligament is torn, the
The anterior cruciate ligament tibia is pulled excessively
is injured in the anterior backward (posterior drawer
dislocation of the tibia; sign).
whereas, the posterior
ligament is injured in the  Unhappy triad of the knee
posterior dislocation of the joint: A combination of injury
tibia. Tear of the cruciate
ligaments leads to abnormal of the (a) tibial collateral
anteroposterior mobility, If the ligament, (b) medial meniscus,
anterior cruciate ligament is and (c) anterior cruciate
torn, the tibia is pulled ligament is called “unhappy
excessively forward
triad” of the knee joint.
 Osteoarthritis: Being a weight- after removal of the damaged
bearing joint, the knee joint is areas.
commonly involved in 37 Arthroscopy of the knee joint:
osteoarthritis(degenerative It is an endoscopic
wear and tear of articular examination (visualization) of
cartilages). The movements the interior of the knee joint
may be painful, limited, and cavity with minimal disruption
produce grating. Radiographs of the tissues. The ligament
of the knee region reveal repair or replacement can
osteophytes, i.e., peripheral also be performed by using an
lipping of the articular ends. arthroscope.
 Knee replacement: If the knee
joint is badly damaged by the
osteoarthritis, an artificial joint
consisting of plastic tibial
component and metal femoral
component is connected to the
tibial and femoral bone ends
 Housemaid’s knee: It is the  Clergyman’s knee: It is the
38
inflammation of the inflammation of
prepatellar bursa subcutaneous
(prepatellar bursitis). It infrapatellar bursa
occurs due to friction of (subcutaneous
bursa against the patella infrapatellar bursitis). It
when it comes in contact occurs due to the friction
with the ground during of bursa against the tibial
scrubbing of the floor by the tuberosity due to kneeling
housemaid. Such a bursa (e.g., kneeling during
may get very large and drop prayer by Christian
by its weight to much below priests/clergymen,
to its original position. roofers, and floor tilers).
 Baker’s cyst (also known as  Aspiration of the fluid can
popliteal cyst) : The chronic be done on either side of
inflammation of bursa deep 39 the ligamentum patellae.
to semimembranosus may But the joint is usually
present as cystic swelling in approached from its lateral
the medial part of the side using three bony
popliteal fossa called Baker’s points as landmarks for the
cyst. needle insertion:(a) tibial
tuberosity, (b) lateral
 Aspiration of the knee joint:
epicondyle of the femur,
The collections of fluid are and (c) apex of patella.
common in the knee joint. It This triangular area is also
gives rise to swelling above used for drug injection in
and at the sides of the patella. treating the knee pathology.
In such cases, patellar tap
often demonstrates a floating
patella.