L I T E R A T U R E R E V I E W

Genu Recurvatum Svndrome

)anice K. l oudon, PhD, PT, SCS, ATC '
Heather 1. Goist, MS, PT2
Karen L. Loudon, MOMT, PT, A T C ~
he purpose of this paper
is to review the anatomy
and biomechanics of the
knee and to present clin-
ical signs/symptoms and
rehabilitation techniques associated
with genu recurvatum. Genu recurva-
tum is a position of the tibiofemoral
joint in which the range of motion
occurs beyond neutral or 0" of exten-
sion (2). Genu recurvatum clinically
appears to be more common in fe-
males than males and may exist due
to postural habit, increased joint lax-
ity, or knee injury. Physical therapist5
may only be called upon to address
this condition following injury or
postcerebral vascular accident when
poor muscle control of the knee ex-
ists. However, the question may arise:
does genu recurvatum predispose an
individual to knee injury?
Anatomy
The posterior structures of the
knee are likely to be stressed in an
individual who displays genu recurva-
tum. The following anatomical review
is designed to assist readers in under-
standing the effects of genu recurva-
tum on the knee joint complex.
The stability of the posterolateral
compartment of the knee is provided
by both capsular and noncapsular
soft tissue structures, including the
arcuate complex, posterior capsule,
lateral meniscus, fabellofibular liga-
ment, and biceps femoris muscle.
The arcuate complex is com-
posed of the arcuate ligament, lateral
collateral ligament, popliteus muscle/
tendon, and the lateral head of the
Genu recurvatum is a common entity found in the clinic that may have negativr!
consequence to knee structures. The purpose of this article is to review the anatomy,
biomechanics, and clinical effects associated with genu recurvatum. Genu recurvatum is
operationally defined as knee extension greater than 5'. Individuals who exhibit genu recurvatum
may experience knee pain, display an extension gait pattern, and have poor proprioceptive control
of terminal knee extension. An evaluative process and treatment program are discussed that
include muscle imbalance correction, proprioceptive practice, gait, and functional training. Taping
or knee bracing may be used initially to facilitate knee control. This article is intended to draw
attention to patients with genu recurvatum and presents a suggested treatment progression.
Individuals who are involved in athletic endeavors should be aware of knee position during
activities to help protect joint structures.
Key Words: knee, genu recurvatum, anterior cruciate ligament, rehabilitation
' Assistant Professor, Department of Physical Therapy Education, University of Kansas Medical Center, Kansas
City, KS. Address for correspondence: 9848 Outlook, Overland Park, KS 66207.
Director of Physical Therapy, Sports Medicine Institute, University of Kansas Medical Center, Kansas
City, KS
' Staff Physical Therapist, Watkins Health Center, University of Kansas, Lawrence, KS
gastrocnemius. These structures are
pictured in Figure 1. The arcuate
ligament consists of a Y-shaped sys-
tem of capsular fibers (14,28) that
supports the posterior capsule. The
lateral collateral ligament originates
from the lateral epicondyle of the
femur and runs postero-inferiorly to
insert on the head of the fibula. It
offers the majority of the varus re-
straint at 25" of knee flexion (4,20).
The popliteus has several attach-
ments, including the lateral aspect of
the lateral femoral condyle, the pos-
teromedial aspect of the head of the
fibula, and the posterior horn of the
lateral meniscus (29). The larger
base of this triangular muscle inserts
obliquely into the posteriosuperior
part of the tibia above the soleal line.
This muscle has several important
functions, including reinforcement of
the posterior third of the lateral c a p
sular ligament (28), unlocking of the
knee during flexion and extension by
externally rotating the femur on the
tibia, preventing impingement of the
posterior horn of the lateral menis-
cus by drawing it posteriorly, and,
with the posterior cruciate ligament,
preventing posterior glide of the tibia
(2,17,23). Attached to the popliteus
tendon is the popliteofibular liga-
ment which forms a strong attach-
ment between the popliteal tendon
and the fibula. This ligament adds to
posterolateral stability (19.30-32).
The fourth structure of the arcuate
complex is the lateral head of the
gastrocnemius which originates on
the posterior a..pect of the lateral
femoral condyle and inserts into the
posterior surface of the calcaneus.
The gastrocnemius checks knee ex-
tension when the foot is fixed. Ken-
dall et a1 advocates that weakness of
the gastrocnemius causes knee hyper-
extension (1 5).
Further support of the posterior
knee is given by the posterior joint
JOSPT Volume 27 Number 5 May 1998
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L I T E R A T U R E R E V I E W
Plantaris m. Femur7C n /
\ I' '/ "
Lat. Collateral lig.
Gastrocnemius m.
mimembranosus m.
lique Popliteal lg.
Fabellof ibular
~op~i teus m.
7 Poptiteus bursa
FIGURE 1. Anatomy of the posterolateral comer of the knee.
capsule. The capsule forms two
pouches that extend over the articu-
lar surface of the femoral condyle
and tibial plateaus (29). The capsule
is thin over the posterior aspect of
the femoral condyles but is s u p
ported by the two heads of the gas-
trocnemius and reinforced by the
oblique popliteal ligament. The c a p
sule is also reinforced by the arcuate
ligament laterally.
Stability is further enhanced in-
ternally by the lateral meniscus,
which forms a concave articular sur-
face for articulation with the convex
lateral femoral condyle (13). The
periphery of the lateral meniscus at-
taches to the tibia, the capsule, and
coronary ligament but not the lateral
collateral ligament. Posteriorly, the
lateral meniscus is separated from
the joint by the popliteus tendon
(Figure 2). The mensicofemoral liga-
ments of Humphrey and Wrisberg
also attach to the lateral meniscus
(13) (Figure 2). The Ligament of
Humphrey runs anteriorly from the
lateral meniscus to the posterior cru-
ciate ligament. The Ligament of
Wrisberg extends from the medial
femoral condyle and attaches to the
posterior horn of the lateral menis-
cus, posterior to the posterior cruci-
ate ligament (33). Gray describes
these structures as giving support to
the capsule during rotational move-
ment of the tibia and stabilization of
the meniscus (6).
A fabella is an accessory sesamoid
bone located in the posterolateral
corner of the knee. It may be osseous
or cartilagenous in makeup and is
Popliteus
absent in 15-20% of the population
(26). When the fabella is present,
there is a fabellofibular ligament which
courses superiorly and obliquely from
the latelal head of the gastrocnemius
to the fibular styloid (14). The fabelle
fibular ligament helps prevent exces-
sive internal rotation of the tibia and
adds further ligamentous support on
the lateral and posterolateral aspects of
the knee (34). Seebacher et al found
through dissection that the arcuate
ligament was quite large in the absence
of a fabella (26).
The biceps femoris muscle has
two heads that originate from the
inferomedial facet of the ischial tu-
berosity (long head) and from the
lateral lip of the linea aspera of the
femur (short head). The muscle in-
serts on the lateral condyle of the
tibia and the head of the fibula. The
superficial layer of the common ten-
don has been identified as the major
force creating external tibial rotation
(5). The biceps' pull on the tibia re-
tracts the joint capsule and pulls the
iliotibial tract posteriorly, keeping it
taut throughout flexion. The tendon
is also important in controlling inter-
nal rotation of the femur.
The stability of the posteromedial
portion of the knee is provided by
the oblique popliteal ligament, semi-
membranosus tendon, and medial
FIGURE 2. Anatomy of the posterior knee.
/
Post. Cruciate lig.
Ant. Cruciate lig.
Lig. of Humphrey and
Wrisberg
Lat. Meniscal Attachment
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L I T E R A T U R E R E V I E W
collateral ligament. The oblique p o p
liteal ligament is a dense thickening
in the posterior capsule made up of a
continuation of the popliteal tendon
and part of the insertion of the semi-
membranosus (7). It arises posterior
to the medial condyle of the tibia
and extends superiomedially to at-
tach to the posterior fibrous capsule.
The oblique popliteal ligament pro-
vides reinforcement to the lateral
capsule and limits anteromedial rota-
tion of the tibia.
The semimembranosus muscle
stems from the lateral facet of the
ischial tuberosity and receives slips
from the ischial ramus. This muscle
inserts on the posterior medial aspect
of the medial condyle of the tibia
and has an important expansion that
reinforces the posteromedial comer
of the knee capsule. The semimem-
branosus pulls the meniscus posteri-
orly and internally rotates the tibia
on the femur during knee flexion.
The medial collateral ligament is
divided into a superficial and a deep
layer. The deep layer (medial capsu-
lar ligament) is a continuation of the
capsule and blends with the medial
meniscus and consists of the upper
meniscofemoral portion and a lower
meniscotibial portion. The superficial
band is a thick, flat band. It has an
arc-like attachment proximally on the
medial femoral condyle just distal to
the adductor tubercle and extends to
the medial surface of the tibia a p
proximately 6 cm below the joint line
where it covers the medial inferior
genicular artery and nerve (6). The
supeficial band blends with the pos-
terior capsule and is separated from
the deep medial collateral ligament
by a bursa. Most of the posterior ob-
lique fibers of the superficial medial
collateral ligament blend with the
posteromedial comer of the capsule
and, when combined, are referred to
as the posterior oblique ligament (9).
Stability of the knee is also pro-
vided by the cruciate ligaments
shown in Figure 3. The posterior cru-
ciate ligament is attached to the pos-
terior part of the posterior intercon-
ACL
PCL
FIGURE 3. Anterior cruciate ligament (ACl) and pos-
terior cruciate ligament (PC[).
dylar fossa of the tibia, overlapping
the posterior rim of the upper sur-
face of the tibia, attaching posteriorly
to the insertion of the posterior
horns of the lateral and medial me-
nisci on the tibia (22). The posterior
cruciate ligament travels obliquely
medially, anteriorly and superiorly,
attaching to the lateral surface of the
medial femoral condyle. The majority
of the ligament is taut in flexion and
prevents anterior displacement of the
femur on the tibia.
The anterior cruciate ligament
(ACL) is attached to the anterior in-
tercondylar fossa of the tibia along
the edge of the medial condyle and
between the insertion of the anterior
horn of the medial meniscus anteri-
orly and the lateral meniscus posteri-
orly (3). The ACL travels obliquely
superiorly and laterally and attaches to
the posterior medial side of the lateral
condyle of the femur. Distinct portions
of the ACL are taut throughout the
range of knee motion (3). The ACL
guides the anterior gliding movements
of the femoral condyles on the menisci
and tibial plateaus and prevents ante-
rior tibial displacement. During inter-
nal rotation of the tibia, the cn~ciates
tighten around themselves and provide
stability (23).
Biomechanics
Movement at either the hip or
ankle joint will influence knee joint
mechanics. Normal arthrokinematics
of the weight-bearing knee, moving
from flexion to extension, consist of
the femur rolling anteriorly and glid-
ing posteriorly on the fixed tibia
(12). A relative internal rotation of
the femur on the tibia occurs near
terminal extension due to the contin-
ued anterior rolling of the lateral
femoral condyle. With knee hyperex-
tension, the femur does not continue
to roll anteriorly but tilts forward,
creating anterior compression be-
tween the femur and tibia (1 5). Two
radiographs are shown in Figure 4,
displaying normal knee alignment
and a hyperextended position. A hy-
perextended position in conjunction
with the normal femoral internal ro-
tation results in tension on the ACL
and posterior structures of the knee
(2), which is shown in Figure 5.
In the normal knee, bony contact
does not limit hyperextension as it
does at the elbow. Rather, hyperex-
tension is checked by the soft tissue
structures. In the relaxed standing
position with the knee straight or
slightly flexed, the vector force is be-
hind the knee so there is a tendency
for further knee flexion unless the
quadriceps contracts (13). When the
knee hyperextends, the axis of the
thigh runs obliquely inferiorly and
posteriorly, which tends to place the
ground reaction force anterior to the
knee. In this position, the posterior
structures are placed in tension,
which helps to stabilize the knee
joint, and no quadriceps muscle activ-
ity is necessary. This can be seen in
individuals following a cerebral vascu-
lar accident who lose motor control
of the quadriceps and are still able to
stand.
Gait can also be affected by genu
recurvatum. During the loading re-
sponse in gait, an individual with
genu recurvatum transfers body
weight directly from the femur to the
tibia without the usual muscle energy
absorption and cushioning a flexed
knee provides. This may lead to pain
in the medial tibiofemoral joint
(compression) and posterolateral lig-
amentous structures (tensile). In indi-
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L I T E R A T U R E R E V I E W
FIGURE 4. A) Radiograph ofpatient with normal knee alignment. BJ Radiograph ofpatient with genu recurvatum.
Notice the tilt oi the femur on the tibia.
viduals with quadriceps weakness,
compensation may occur by hyperex-
tending the knee to provide greater
knee stability.
Clinical Implications
According to Kendall et al, "pos-
tural faults that persist can give rise
to discomfort, pain, or disability"
(15). If a patient presents with a for-
ward head posture and cervical pain,
part of the physical therapist's treat-
ment will be to focus on improving
the patient's posture. The same
should apply to the hyperextended
knee. The therapist should not only
strengthen muscles about the knee if
weak but also address knee posture.
Loudon et al found a positive corre-
lation between genu recumtum and
ACL injury in female athletes (16).
Hutchison and Ireland contributed
the recurvatum posture and laxity in
the posterior capsule to habitual pos-
ture that may lead to injury (1 1).
From the anatomical and biome-
chanical review, it appears that the pos-
sible consequence of genu recunatum
in the active individual may be stress
placed on the ACL, anterior joint, or
posterolateral comer of the knee.
Evaluation
Individuals with genu recumtum
may present with one of a variety of
lower extremity diagnoses. It is
doubtful, however, that their primary
diagnosis is genu recurvatum. Syrnp
toms attributable to genu recumtum
include anteromedial joint pain or
posterolateral knee pain. The antero-
medial pain is due to the compressive
forces at the medial tibiofemoral
compartment and is accentuated if a
varus alignment is present. The pos-
terior pain is due to the tension
placed on the posterior structures
and is aggravated by stepping or
forceful knee extension in weight
bearing (IS). The patient may also
complain of knee instability during
activities of daily living.
Patients may have a history of an
injury that forced them into hyperex-
tension. Examples include landing
from a jump on an extended knee, a
blow to the anteromedial aspect of
the proximal tibia forcing the knee
into hyperextension, or a noncontact
external rotation hyperextension in-
jury. Noyes et al have described pos-
terolateral syndrome as an injury to
the posterolateral structures in con-
junction with a tom ACL (21). The
unsuspecting individual with postero-
lateral syndrome may have no history
of injury but has developed knee
pain over a period of time. A thor-
ough subjective examination will
guide the clinician to suspect genu
recurvatum as a contributing factor.
Objectively, individuals with genu
recumtum will be easily spotted in
static standing. The sagittal view best
demonstrates this posture and is
demonstrated by the subject in Fig-
ure 6. Individuals may also present
with excessive femoral internal rota-
tion, genu varum or valgum, tibia1
varum, or excessive subtalar joint pro-
nation, which is more noticeable in
the frontal plane. Figure 7 depicts
the same individual in Figure 6 in
the frontal view.
During gait, there may be an ob-
vious varus-extension thrust that, ac-
cording to Noyes et al, is characteris-
tic of chronic injuries to the
FIGURE 5. Hyperextension and anterior cmciate liga-
ment (ACL) stress.
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L I T E R A T U R E R E V I E W
FIGURE 8. Varus-extension thrust gait (right leg).
FIGURE 6. Genu recurvaturn in standing.
posterolateral structures of the knee
(21). An example of a varus thrust in
gait is depicted in Figure 8. As in
standing, excessive femoral internal
rotation past the midstance of gait
will accentuate genu recurvatum as
seen in Figure 9.
Individuals with genu recurvatum
may have a functional strength deficit
in the quadriceps muscle or gastroc-
nemius that allows knee hyperexten-
sion (27). When performing activities
such as step-ups, patients will use m e
mentum to straighten the lower ex-
tremity and they will be unable to
control weight-bearing terminal knee
extension. Kendall et al report that
the hyperextension posture of the
knee is caused from weakness in the
gastrocnemius (1 5). The gamocne-
mius controls knee extension in
weight bearing.
Proprioception in individuals
with genu recurvatum may be defi-
FIGURE 7. Excessive iernoral internal rotation in
standing.
FIGURE 9. Excessive internal rotation of the left leg
during stance.
cient near the end range of exten-
sion. A pilot study done by the au-
thors demonstrated that individuals
who stood in hyperextension and
without knee injury were unable to
reproduce knee joint angles in the
last 15" of extension compared with
other knee angles of 45 and 60" on a
leg press machine. Individuals may
perceive the hyperextended knee po-
sition as "normal" and, when intro-
duced to more vigorous activity, they
may have a tendency to stay in hyper-
extension, putting their knee at risk
for injury (11.16).
Special tests that should be per-
formed during the knee examination
should focus on identifjmg postero-
lateral instability. The external rota-
tion recurvatum test provides a tool
to assess posterolateral instability.
There will be an external rotatory
subluxation in which the tibia rotates
around an axis in the intact posterior
cn~ciate ligament. Posterior subluxa-
tion of the lateral tibial plateau is
first reduced as the knee extends but
then, as the knee hyperextends, sub-
luxation recurs and the tibia again
rotates externally. As the subluxation
occurs, the tibia can be seen to rotate
externally and the lateral tibial pla-
teau can be felt to become promi-
nent posteriorly (1). Other tests that
may be clinically significant are the
posterolateral drawer and the varus
stress test at 30".
Treatment Progression
Rehabilitation of the individual
with knee problems and genu recur-
vatum should focus on biomechanical
correction, proprioception training,
muscle control, gait training, and
functional activities (24). The treat-
ment progression is displayed in the
Table. The rehabilitation process log-
ically builds on the results found in
the evaluation. The following section
illustrates a progressive treatment
plan for the individual with genu re-
curvatum.
A thorough biomechanical evalu-
ation of the lower extremity chain
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L I T E R A T U R E R E V I E W
- - - - - - - - .-.... - . - . .-- - -
- . - .
Treahnent Area Goal Treatment Examples
Biomechanical To improve biomechanical faults In-shoe orthotics
evaluation to alleviate tissue stress Correct muscle imbalances
Proprioception To teach the patient how to
identify good knee alignment
i n static and dynamic postures
Muscle control Improve absolute quadriceps
strength; improve synchrony of
lower extremity muscles
Gait To teach the patient of knee
awareness during gait
Functional activities To carry over good knee
alignment to function
Terminal extension holds
Posterior knee taping
Theraband terminal knee extension
Single leg balance
Mini-dips
Squats
Step-ups (front, lateral, back)
Lunges (forward, side, backward)
Jump landings
Minor walking with bent knee
Heel lift
Stair climbing
lump landing
Sports-specific skills
TABLE. Treatment considerations i or individuals with genu recurvatum.
should be performed first. If the pa-
tient presents with unilateral hyperex-
tension, assess the lumbar spine and
pelvis for obliquity or muscle imbal-
ance. The hip should be evaluated
for excessive internal rotation which
contributes to genu recurvatum in
stance. At the foot, the subtalar and
midfoot joints should be checked for
excessive pronation, which allows ex-
cessive internal rotation of the tibia.
Prefabricated shells, such as AliMed's
BFO, can be used initially to improve
foot position.
Next, proprioceptive awareness of
knee terminal extension should be
mastered. Patients need to learn that
0" of knee extension is normal knee
position. Verbal cueing is helpful but
other strategies, such as the use of
posterior knee taping, can give the
patient direct sensory feedback. Fig-
ure 10 presents the proper taping
technique to prevent hyperextension.
These devices need to be used only
temporarily until the patient recog-
nizes neutral knee position. This neu-
tral position should then be carried
over to dynamic strengthening exer-
cises.
Muscle strengthening exercises
are performed with good knee posi-
tion, and muscle balance is stressed
rather than absolute strength. Muscle
sequencing is the key with the ham-
strings and firing in
coniunction with the quadriceps to
'I"T
guide the knee into extension rather
than using the passive force of gravity
4
(10). The knee is kept in the same
plane as the foot and never allowed
to hyperextend as demonstrated in
b ,
Figure 1 1. Patients should progress
through weight-bearing exercises.
such as resistive terminal extension,
single leg balance, minidips, squats,
L
forward and backward step-ups. lung-
es, and jump landings. These exer-
n
cises require sequential use of eccen-
tric and concentric control of the
lower extremity.
Knee control during gait can be
.. ..
FIGURE 10. Posteriorkneeshapping toprevent hyper-
taught in conjunction with the previ-
extension. ouslv mentioned exercises. Noyes et
FIGURE 11. Subject performing mini-dip with good
knee alignment. The towel under the medial border of
the foot is used to limit subtalar joint pronation.
al recommend that the patient main-
tain knee flexion of 5" throughout
the stance phase of gait (21). Initial-
ly, walking speed will be very slow
and deliberate. A mirror can be used
to give visual feedback to the patient
to maintain the flexed knee posture.
The use of a 1- to 2-inch elevated
heel may be used in the initial train-
ing to create a flexion moment at the
knee. The trunk should be rnain-
tained in an upright position vs. a
forward lean or flexed hip during
midstance to avoid an anterior shift
of body weight (21.25). Excessive in-
ternal femoral rotation should also
be controlled during this phase of
gait (21).
Continued training of the patient
with genu recurvatum should focus
on more functional tasks such as stair
climbing. During the pull-up phase
of stair climbing, patients should be
trained to refrain from thrusting into
knee extension. Individuals may have
a tendency to hyperextend their
knees with other daily activities, such
as bending forward to brush their
teeth. Individuals should be trained
to avoid this knee position during
trunk forward bending.
The last phase of rehabilitation
focuses on more complex activities
Volume 27 Number 5 Mav 1998 JOSPT
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and sports-specific skills. For athletes
involved in jumping and cutting
sports, it is important that they mas-
ter a bent knee position. Henning et
al suggested that extreme loads are
placed on the ACL when the knee is
straight or near straight during plant-
ing and cutting, landing from jumps,
and sudden stops while running (8).
Emphasis should be placed on bend-
ing the knee during these sports ac-
tivities to prevent injuries to the ante-
rior cruciate ligament.
SUMMARY
This paper discusses a common
finding in athletes with knee pathol-
ogy. Genu recurvatum or knee joint
hyperextension is a malposition be-
tween the femur and tibia and
should be considered a postural fault.
Treatment of this fault will take time
and involves repetitive training of the
athlete to reestablish a more ideal
femorotibial alignment. JOSPT
ACKNOWLEDGMENTS
We thank Lisa Stehno-Rittel for
the graphic art work used in this
manuscript.
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