Joint Capsule:

• Encloses the tibiofemoral & patellofemoral

joints
• It is large complex and possess several
recesses
• Collaterals reinforce the sides of the capsule
• Anteromedial and anterolateral portions of
capsule are known as medial and lateral
patellar retinacula
Ligaments:
• As the joint lacks bony restraint to any motions,
ligaments are credited with resisting or controlling
c. Excessive extension
d. Varus and valgus stress
e. Anterior and posterior displacement of tibia
beneath the femur
f. Medial or lateral rotation of of tibia beneath the
femur
g. Combinations of anteroposterior displacements
and rotations of tibia – rotatory stabilization
I. Collateral Ligaments:
• Are taught in full extension and help
resist hyper extension of knee joint
3. Medial collateral ligament:
• Extends from medial femoral epicondyle
to medial aspect of proximal tibia
• Resists valgus stress
• Backup restraint to
pure anterior displacement
of tibia when ACL is absent
1. Lateral collateral ligament:
• Extends from lateral femoral epicondyle
to head of fibula
• Resists varus stress
I. Cruciate ligaments:
• Two in number and named according to
their tibial attachments
1. Anterior cruciate ligament:
• arises from anterior aspect of tibia passes
under the transverse ligament and extends
superiorly and posteriorly and attaches to
posterior part of inner aspect of lateral
femoral condyle
• primary restraint to anterior displacement
of tibia on femoral condyles
• fascicles are grouped into anteromedial
band (AMB) and posterolateral
band(PLB)
1. Posterior cruciate ligament:
• arises from posterior aspect of tibia and
attaches to inner aspect of medial femoral
condyle
• is shorter and less oblique
• primary restraint to posterior displacement
of tibia beneath the femur
• fascicles are grouped into anteromedial
band (AMB) and posterolateral
band(PLB)
I. Posterior Capsular Ligaments:
• Postero medial aspect of capsule is
reinforced by oblique popliteal
ligament expansion of semimebranous
muscle
• Postero lateral aspect of
capsule is reinforced by
arcuate popliteal ligament
expansion of popliteus muscle
• Both check hyperextension
I. Meniscofemoral Ligaments:
• Two in number, arise from posterior horn
of lateral meniscus and insert on the
lateral aspect of medial femoral condyle
near insertion site of PCL
• Ligament that runs anterior to PCL is lig.
of Humphrey/anterior meniscofemoral
ligament
• Ligament that runs posterior to PCL is
lig.of Wrisberg/ posterior
meniscofemoral ligament
Bursae:
• Supra patellar bursa
• Sub popliteal bursa
• Gastronemius bursa
• Prepatellar bursa
• Infrapatellar bursa
• Deep infrapatellar bursa
• Synovial fluid contained in knee capsule
moves from recess to recess during
movements of knee
• In extension fluid is shifted anteriorly
• In flexion fluid is forced posteriorly
• In semiflexed position fluid is under least
tension
Knee Joint Motion:
• Primary movements are flexion/extension
and to lesser extent medial/lateral rotation
Osteokinematics:
Flexion/extension:
• As many two joint muscles pass knee they
can affect the ROM with changes in hip
position
Knee Flexion: Passive 130° - 140°.
• Range is limited to 120° if hip is
hyperextended as hamstring becomes
actively insufficient
• Gait requires about 60° of knee flexion
• This increases to about 80° for staircase
climbing and 90° for sitting down into a
chair

Knee Extension: 5° - 10° normal

• Excessive hyperextension is called as Genu
Recurvatum
Rotation:
• Knee rotates in 2 different directions
• Axial rotation provides second degree of freedom
to tibiofemoral joint
• Medial and lateral rotation are named for the
relative motion of tibia
• Occurs due to ligament laxity and articular
incongruencies
• Depends on joint position
• In full extension there is no axial rotation
• As the knee flexes towards 90° the ligaments lax
and the condyles are free to move
• Maximum axial rotation is available at 90°
• Lateral Rotation: 0 - 40°
• Medial Rotation: 0 - 30°
Arthrokinematics :
• Large articular surface of femur and relatively small
tibial condyle creates a potential problem as femur
begins to flex on tibia
• If femoral condyles were
permitted to roll posteriorly
on tibial condyle femur would
run out of tibial condyles
before much flexion could
occur – this would result in
limitation of flexion or femur
would roll of tibia
• For femoral condyles to continue to roll with
increased flexion of the femur the condyles
must simultaneously glide anteriorly on tibial
condyle to prevent them from rolling
posteriorly off the tibial condyle
Knee flexion:
• First part of flexion of femur from full extension
(0-25°) is primarily rolling of femoral condyles on
the tibia bringing the contact of femoral condyles
posteriorly on tibial condyle
• As flexion continues the rolling is accompanied by
an anterior glide just sufficient to create a nearly
pure spin of the femur
• That is, the magnitude of posterior displacement
that would occur with the rolling of condyles is
offset by the anterior glide
• This results in a linear displacement after 25° of
flexion
• The anterior glide is controlled by tension
encountered in the ACL as the femur rolls
posteriorly only on the tibial condyles
• The glide is facilitated by the wedge shape of
the meniscus
• The femur and the menisci create shear force
with respect to one another, thus the menisci
accompany the femoral condyles as they
move posteriorly on the tibial condyles
• The lateral meniscus moves more than the
medial
Knee extension:
• Occurs initially as a rolling of the femoral
condyles over the tibial condyles displacing
the femoral condyles anteriorly back to the
neutral position
• After the initial forward rolling, femoral
condyles glide posteriorly just enough to
continue extension of the femur as a pure spin
• Tension in the PCL and the shape of the
menisci facilitate the intra articular
movements of femoral condyles during knee
extension
• Motion (or distortion) of menisci are an
important component of the movements
• Failure to distort would result in limitation
of ROM
Locking and unlocking:
• Although the incongruence of the femoral
condyles and the tibial condyles results in a
rolling and gliding of the condylar surfaces
on each other, the asymmetry in the size of
medial and lateral condyles also causes
complex intra-articular motions
Locking:
• In weight bearing closed chain position
extension of the femur on a fixed tibia
results in additional motion to the earlier
explained ones
• As the femur extends to about 30° of flexion, the
shorter lateral condyles complete its rolling – gliding
motion
• As extension continues the longer medial femoral
condyle continues to roll and glide posteriorly
although the lateral condyle has halted
• This continued motion of medial femoral condyles
results in medial rotation of the femur on tibia,
pivoting about the fixed lateral condyle
• This medial rotation is most evident in the final stages
of knee extension (5°)
• Increasing tension in the joint ligaments as the knee
approaches full extension may also contribute to the
rotation with in the joint
• Since the medial rotation of the femur that
accompanies the final stages of knee extension
is not voluntary or produced by muscular
forces, it is referred to as automatic or terminal
rotation
• This rotation brings the knee in close-packed or
locked position
• The tibial tubercles are lodged in the
intercondylar notch, the ligaments become taut
and the menisci are interposed tightly between
the condyles - locking mechanism or screw
home mechanism
Unlocking:
• To initiate flexion knee must be unlocked
• For the knee to flex, unlocking occurs by
lateral rotation of the femur
• A flexion force will automatically result in
lateral rotation since the longer medial side
will move before the shorter lateral side
• The longer medial side moves just compared
to the lateral side
• In open chain - Tibia rotates laterally on a fixed
femur during the last 30° of
extension –LOCKING
• Tibia rotates medially on a fixed femur before
flexion can proceed - UNLOCKING
Muscles
II. Flexors:
c. Semimembranosus
d. Gastrocnemius
• Sartorius
f. Gracilis
∗ Gracilis, semitendinosis and sartorius are
inserted on the tibia by means of a
common tendon called as ‘Pes
Anserinus’
h. Popletius
I. Extensors:
 Quadriceps femoris
 Only muscle which crosses two
joints is rectus femoris
Patella increases the efficiency of quadriceps
• Efficiency of the quadriceps muscle is
affected by the patella
• Patella lengthens the moment arm of
quadriceps by increasing the distance of
the quadriceps tendon and patellar
ligament from the axis of the knee joint
• Patella acting as an anatomic pulley deflects
the action line of the quadriceps femoris
away from the joint that increases the angle
of pull and the ability of the muscle to
generate torque
• It helps to reduce friction between the tendon
and the condyles
• Substantial decreases in the strength of
quadriceps of upto 49% occurs following
patellectomy
Patellofemoral joint :
• Patella is primarily an anatomic pulley and reduces
friction between quadriceps and femoral condyles
• Ability of patella to perform its functions with out
restricting the knee motion depends on its mobility
Patellar flexion:
• In full extension patella sits on anterior surface on
distal femur
• With knee flexion patella slides distally on femoral
condyles,seating itself between femoral condyles
• In full flexion patella sinks into the intercondylar
notch
Patellar extension:
• Knee extension reverses the sliding of the
patella and brings it back to the patella
surface of femur
Patellar tilt:
• Tilts medially from
0°-30°
• Tilts laterally between
20° -100°
Patellar Rotation :
• Medial rotation of the patella involves
movement of the inferior patellar pole with
medial rotation of the tibia
• Lateral rotation of the patella involves
movement of the inferior pole of patella
with lateral rotation of the tibia
Patellar Shift:
• Mediolateral translation that the patella
under goes during knee movement
• Patella shifts medially in flexion and
laterally in extension
• Failure of patella to slide,tilt,rotate,or shift
can lead to restriction of ROM,instability,or
pain
∀ ∴ passive mobility of patella is often
assessed clinically
Articular surfaces:
• Patellofemoral joint is the least congruent
joint in the body

Articular surface of patella Femoral articular surface

Joint Congruence:
• In fully extended knee patella lies on femoral
sulcus
Patella alta – abnormally high position of patella on
femoral sulcus due to excessively long patellar
tendon
• In extended knee patella has little or no contact wit
femoral sulcus
• First consistent contact of patella is made at
10° – 20° of flexion
• Over all the range of knee flexion, medial patellar
facet normally receives the most consistent contact
with the femoral surfaces where as the odd facet
receive the least
• Most common cartilaginous changes on
patella are found on medial and odd facets
Patella femoral Joint Reaction Force:
• Patella is pulled on simultaneously by
quadriceps tendon superiorly and patellar
tendon inferiorly
• In extension when pulls of these two are
vertical or in line with each other patella
may be suspended between them making no
contact with the femur
• Even a strong contraction of quadriceps in
full extension will produce little or no
patellofemoral compression
• This is the basis for the use of SLR in
strengthening the quadriceps without increasing
forces on the joint
• As flexion occurs from full extension pull of
quadriceps(FQ) tendon and patellar ligament (Fpl)
becomes oblique compressing patella into the
femur
• Compression creates a joint reaction force across
the patellofemoral joint
• The magnitude of joint reaction force (R) depends
upon:
a. Magnitude of pull of quadriceps
b. Angle of knee flexion
• Patellofemoral joint reaction force in gait
when foot first contacts the ground and
knee flexes to 10°-15° is 50% of body
weight
• During stair case climbing and running hills
knee flexion goes up to 60° and thus
increases patellofemoral joint reaction force
to 3.3times body weight
• Joint reaction force many reach up to
7.8times of body weight at 130° of knee
flexion in such activities as deep knee bends
• Medial facet bears the brunt of compressive
forces
Joint stability:
• Two stabilizing groups are present
• Longitudinal stabilizers - quadriceps tendon
superiorly and patellar ligament inferiorly
• Transverse stabilizers - medial and lateral
patellar retinaculae join the vastus medialis
and vastus lateralis respectively
• Both structures help in medial-lateral
positioning of patella within the femoral
sulcus called as ‘Patellar Tracking’ from
extension to flexion
Q (quadriceps) angle:
• Defined as the angle between the quadriceps
muscle (primarily the rectus femoris) and the
patellar tendon and represents the angle of
quadriceps muscle force
• Used to clinically assess the net pull of quadriceps
and patellar tendon
• Angle formed between a line
connecting ASIS to the midpoint
of patella
• A line connecting the
tibial tubercle and
midpoint of patella
• Normal-men is 14° and in women is 17°
• > 20° considered to be abnormal, creating excessive lateral
forces on the patella
• An increased Q angle is a risk factor for patellar subluxation
and patellar dislocation
• Anything that may increase the obliquity of the resultant
pull of the quadriceps or the obliquity of the patellar
ligament may increase the lateral force on the patella
• Q angle is increased in
 genu valgum
 increased femoral anteversion
 external tibial torsion
 laterally positioned tibial tuberosity
 tight lateral retinaculum
Knee Injury and Disease
• Injury can be due to ligaments, menisci, bones,
soft tissue, bursae and tendon
• Menisci: Medial meniscus is more injured and is
due to medial rotation of the femur on a fixed tibia
on a flexed knee
• Ligaments: Motion exceeding normal can be due
to ligament laxity which can occur due to aging,
disease, immobilization, reduced vascularity
• Bursitis: Common in prepatellar and superficial
infrapatellar bursa (Housemaid’s Knee). This is
due to indirect blow/prolonged compressive stress
or areas of high friction
• PF Joint Instability: Due to
-Imbalance in Quadriceps muscle
-Tension/shortening of the lateral
retinaculum
-Tight IT band
• Chondromalacia Patella: softening of
articular cartilage of patella