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THE KNEE JOINT

The knee joint is a hinge type synovial joint, which mainly allows for flexion and
extension (and a small degree of medial and lateral rotation). It is formed by
articulations between the patella, femur and tibia.The knee joint is surrounded by
synovial fluid which keeps it lubricated. The bones are covered by smooth joint
surface (articular) cartilage that allows them to glide smoothly together without
friction. If the joint surface is damaged through wear and tear or a knee injury,
arthritis can develop.
Articulating Surfaces:

The knee joint consists of two articulations – tibiofemoral and patellofemoral.

The joint surfaces are lined with hyaline cartilage and are enclosed within a single
joint cavity.
Tibiofemoral – medial and lateral condyles of the femur articulate with the tibial
condyles. It is the weight-bearing component of the knee joint.
Patellofemoral – anterior aspect of the distal femur articulates with the patella. It
allows the tendon of the quadriceps femoris (knee extensor) to be inserted
directly over the knee – increasing the efficiency of the muscle.
Patella: At birth, the kneecap is just formed from cartilage, and this will ossify
(change to bone) between the ages of three and five years.
As the patella is both formed and resides within the quadriceps femoris tendon, it
provides a fulcrum to increase power of the knee extensor and serves as a
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stabilising structure that reduces frictional forces placed on femoral

condyles.patella – like all sesamoid bones – prevents the tendons from being
damaged by compressive stress when moving back and forth over the joints.By
the way: If we had no kneecaps, incidentally, our thigh muscles would probably
be much bigger and we would probably not be able to walk.
Blood Supply of knee joint:The blood supply to the knee joint is through the
genicular anastomoses around the knee, which are supplied by the genicular
branches of the femoral and popliteal arteries.

Nerve supply of knee joint: The nerves that supply sensation to the back of the
knee joint itself are the posterior (back) articular branches of the tibial and
obturator nerves. The equivalent nerves in the front are the articular branches
of the femoral, common peroneal and saphenous nerves.
The Obturator Nerve (L2,3,4) supplies the adductor muscles on the inner side of
the thigh.The femoral nerve (L2,3,4) supplies the main muscles at the front of the
thigh (motor) as well as the knee joint (sensory).
The Sciatic Nerve (L4,5, S1,2,3) is a large nerve which runs down the back of the
leg. It is made up of the tibial and common peroneal nerves which branch at
different levels of the leg. The tibial nerve supplies the hamstring muscles (which
bend the knee). It also supplies the muscles in the back if the calf (gastrocnemius
and soleus). The common peroneal nerve supplies the front compartments of the
leg including the peroneal muscles.
The Tibial Nerve is the larger of the two branches of the sciatic nerve and runs
down the back of the knee.
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Meniscus or minisci: The medial and lateral menisci are fibrocartilage structures
in the knee that serve two functions:
1.To deepen the articular surface of the tibia, thus increasing stability of the joint.
2.To act as shock absorbers by increasing surface area to further dissipate forces.
They are C shaped and attached at both ends to the intercondylar area of the tibia.
In addition to the intercondylar attachment, the medial meniscus is fixed to the
tibial collateral ligament and the joint capsule. Damage to the tibial collateral
ligament usually results in a medial meniscal tear.
Bursa: A bursa is synovial fluid filled sac, found between moving structures in a
joint – with the aim of reducing wear and tear on those structures. There are four
bursae found in the knee joint:

# Suprapatellar bursa – an extension of the synovial cavity of the knee, located

between the quadriceps femoris and the femur.
# Prepatellar bursa – found between the apex of the patella and the skin.
# Infrapatellar bursa – split into deep and superficial. The deep bursa lies
between the tibia and the patella ligament. The superficial lies between the
patella ligament and the skin.
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# Semimembranosus bursa – located posteriorly in the knee joint, between the

semimembranosus muscle and the medial head of the gastrocnemius.
Ligaments: The major ligaments in the knee joint are:
Patellar ligament – A continuation of the quadriceps femoris tendon distal to the
patella. It attaches to the tibial tuberosity.
Collateral ligaments – Two strap-like ligaments. They act to stabilise the hinge
motion of the knee, preventing excessive medial or lateral movement
Tibial (medial) collateral ligament – Wide and flat ligament, found on the medial
side of the joint. Proximally, it attaches to the medial epicondyle of the femur,
distally it attaches to the medial condyle of the tibia.
Fibular (lateral) collateral ligament – Thinner and rounder than the tibial
collateral, this attaches proximally to the lateral epicondyle of the femur, distally
it attaches to a depression on the lateral surface of the fibular head.
Cruciate Ligaments – These two ligaments connect the femur and the tibia. In
doing so, they cross each other, hence the term ‘cruciate’ means 'cross'.
Anterior cruciate ligament (ACL) – Attaches at the anterior intercondylar region
of the tibia where it blends with the medial meniscus. It ascends posteriorly to
attach to the femur in the intercondylar fossa. It prevents anterior dislocation of
the tibia onto the femur.
Posterior cruciate ligament (PCL) – attaches at the posterior intercondylar region
of the tibia and ascends anteriorly to attach to the anteromedial femoral condyle.
It prevents posterior dislocation of the tibia onto the femur.
Movements: There are four main movements that the knee joint permits:
Flexion: Produced by the hamstrings, gracilis, sartorius and popliteus.
The three hamstring muscles are:
Biceps femoris, closest to the outside of body.
Semimembranosus, closest to the middle of body.
Semitendinosus, between the semimembranous and the biceps femoris.
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Extension: Produced by the quadriceps femoris, which inserts into the tibial
tuberosity.The four 4 sub-components being:
1.Rectus femoris. 2.Vastus lateralis. .
3.Vastus medialis. 4.Vastus intermedius.
Lateral rotation: Produced by the biceps femoris.
Medial rotation: Produced by five muscles; semimembranosus, semitendinosus,
gracilis, sartorius and popliteus.
NB: Lateral and medial rotation can only occur when the knee is flexed (if the
knee is not flexed, the medial/lateral rotation occurs at the hip joint).

Injury to the Knee Joint:

Collateral Ligaments: Injury to the collateral ligaments is the most common
pathology affecting the knee joint. It is caused by a force being applied to the side
of the knee when the foot is placed on the ground.
Damage to the collateral ligaments can be assessed by asking the patient to
medially rotate and laterally rotate the leg. Pain on medial rotation indicates
damage to the medial ligament, pain on lateral rotation indicates damage to the
lateral ligament. If the medial collateral ligament is damaged, it is more than likely
that the medial meniscus is torn, due to their attachment.
Cruciate Ligaments: The anterior cruciate ligament (ACL): Can be torn by
hyperextension of the knee joint, or by the application of a large force to the back
of the knee with the joint partly flexed. To test for this, you can perform an
anterior drawer test, where you attempt to pull the tibia forwards, if it moves, the
ligament has been torn.
Posterior cruciate ligament (PCL): Damage is the ‘dashboard injury’. This occurs
when the knee is flexed, and a large force is applied to the shins, pushing the tibia
posteriorly. This is often seen in car accidents, where the knee hits the dashboard.
The posterior cruciate ligament can also be torn by hyperextension of the knee
joint.
To test for PCL damage, perform the posterior draw test. This is where the
clinician holds the knee in flexed position, and pushes the tibia posteriorly. If
there is movement, the ligament has been torn.
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Bursitis: Friction between the skin and the patella cause the prepatellar bursa to
become inflamed, producing a swelling on the anterior side of the knee. This is
known as housemaid’s knee. Similarly, friction between the skin and tibia can
cause the infrapatellar bursae to become inflamed, resulting in clergyman’s knee,
caused by kneeling on hard surfaces during prayer).
Unhappy Triad (Blown Knee): As the medial collateral ligament is attached to the
medial meniscus, damage to either can affect both structure’s functions. A lateral
force to an extended knee, such as a rugby tackle, can rupture the medial
collateral ligament, damaging the medial meniscus in the process. The ACL is also
affected, which completes the ‘unhappy triad’.

Knee osteoarthritis: Osteoarthritis is the most common form of arthritis, and

often affects the knees. Caused by aging and wear and tear of cartilage,
osteoarthritis symptoms may include knee pain, stiffness, and swelling.
Knee effusion: Fluid buildup inside the knee, usually from inflammation. Any form
of arthritis or injury may cause a knee effusion.
Meniscal tear: Damage to a meniscus, the cartilage that cushions the knee, often
occurs with twisting the knee. Large tears may cause the knee to lock.
Patellar tendonitis: Inflammation of the tendon connecting the kneecap (patella)
to the shin bone. This occurs mostly in athletes from repeated jumping.
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Baker’s cyst: Collection of fluid in the back of the knee. Baker’s cysts usually
develop from a persistent effusion as in conditions such as arthritis.
Rheumatoid arthritis: An autoimmune condition that can cause arthritis in any
joint, including the knees. If untreated, rheumatoid arthritis can cause permanent
joint damage.
Gout: A form of arthritis caused by buildup of uric acid crystals in a joint. The
knees may be affected, causing episodes of severe pain and swelling.
Septic arthritis: An infection caused by bacteria, a virus, or fungus inside the knee
can cause inflammation, pain, swelling, and difficulty moving the knee. Although
uncommon, septic arthritis is a serious condition that usually gets worse quickly
without treatment.
Cartilage: Cartilage is a thin, elastic tissue that protects the bone and makes
certain that the joint surfaces can slide easily over each other. Cartilage ensures
supple knee movement.
Overuse: Overuse injuries of the knee include tendonitis, bursitis, muscle strains,
and iliotibial band syndrome. These injuries often develop slowly over weeks or
months. Activities that induce pain usually delay healing. Rest, ice and
compression do help in most cases.
Varus or valgus deformity:
HIP-KNEE-ANKLE (HKA) Angle. There are two disorders relating to an abnormal
angle in the coronal plane at the level of the knee:
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Genu valgum is a valgus deformity in which the tibia is turned outward in relation
to the femur, resulting in a knock-kneed appearance.
Genu varum is a varus deformity in which the tibia is turned inward in relation to
the femur, resulting in a bowlegged deformity.
The degree of varus or valgus deformity can be quantified by the hip-knee-ankle
angle, which is an angle between the femoral mechanical axis and the center of
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the ankle joint. It is normally between 1.0° and 1.5° of varus in adults. Normal
ranges are different in children.
Hip-knee-ankle angle by age, with 95% prediction interval.
Popliteal Fossa: The Popliteal Fossa is a diamond-shaped space behind the knee
joint. It is formed between the muscles in the posterior compartments of the
thigh and leg. This anatomical landmark is the major route by which structures
pass between the thigh and leg.
Boundaries: The Biceps Femoris tendon (superolateral) and Semimembranosus
reinforced by Semitendinosus (superomedial). The medial and lateral heads of
Gastrocnemius form the inferomedial and inferolateral boundaries, respectively.
Content: The Popliteal Artery; This is the deepest of the neurovascular structures
in the Popliteal fossa. It is a continuation of the Femoral artery and appears on
the upper medial side under the margin of the Semimembranosus muscle.
The Popliteal vein: It is superficial to the and travels with the Popliteal artery.
The Tibial nerve and common Fibular nerve: These are the two major branches
of the Sciatic nerve. They are the most superficial of the neurovascular structures
in the Popliteal fossa. They appear under the margin of the Biceps Femoris
muscles.
Clinical Significance:
#Baker's cyst#Popliteal Pulse#Popliteal Aneurysm#Popliteal nerve block.
Importance: The popliteal fossa is a diamond-shaped depression located
posterior to the knee joint. Important nerves and vessels pass from the thigh to
the leg by traversing through this fossa. These include the two terminal branches
of the sciatic nerve, the popliteal vessels and short saphenous vein.

THANK YOU....
MD: DULAL HOSEN,, LECTURER (KINESIOLOGY 104)
PRIME INSTITUTE OF MEDICAL TECHNOLOGY, RAJSHAHI.