Kines Chap 10

The Knee Joint • Knee joint – largest joint in body – very complex – primarily a hinge joint Chapter 10 The Knee Joint...

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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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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 10-7

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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 10-9

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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 © 2007 McGraw-Hill Higher Education. All rights reserved.

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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 10-11

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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 10-13

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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 © 2007 McGraw-Hill Higher Education. All rights reserved.

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Joints

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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 10-17

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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 10-19

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 > 10-21

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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 © 2007 McGraw-Hill Higher Education. All rights reserved.

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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 10-23

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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 10-27

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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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• • • • 10-29

Sartorius Gracilis Popliteus Gastrocnemius

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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 © 2007 McGraw-Hill Higher Education. All rights reserved.

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 © 2007 McGraw-Hill Higher Education. All rights reserved.

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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 10-51

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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 © 2007 McGraw-Hill Higher Education. All rights reserved.

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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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