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Integrated functional anatomy of the knee joint - Bones, joints, palpation, ligaments, nerves, joint anatomy, joint actions, arthrokinematics, muscles, fascia, and range of motion of the knee joint. Highlighting the behaviors in postural dysfunction, knee pain, jumpers knee, runners knee, ACL tears, MCL tears, meniscus tears, tendonitis, and common interventions for the knee joint.

Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joints

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I have taken both the Human Movement Specialist and Certified Personal Trainer certificate programs and have found the value in understanding the how and ways the body moves and functions and from evidence, non-biased, outcome, conceptual, theoretical, and practical approach to helping my clients/patients look better, feel better, and move better.

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This course describes knee joint anatomy including the tibiofemoral and patellofemoral joints. That is knee anatomy includes the tibiofemoral joint which is the approximation of the tibia (shin bone) and femur (thigh bone), and the patellofemoral joint with is the approximation of the patella (knee cap) and the femur. This course includes descriptions of the bones, synovial joints, joint actions, ligaments (e.g. anterior cruciate ligament and posterior cruciate ligament), bursae, relative location, the relationship between the bones of the tibia (shin bone) and femur, and the muscles that cross them. Further, this course discusses palpation and introduces knee joint specific exercises, manual techniques, and interventions for dysfunction, pain, posture, and movement impairment. The knee joint is included in the common compensation patterns known as functional pes planus (flat feet), pronation distortion syndrome, knee bow out (varus), feet turn out, functional valgus (knee bow in), asymmetrical weight shift (AWS), and 

. Sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) with advanced knowledge of the knee joint will improve their ability to analyze human movement and develop sophisticated exercise programs and therapeutic (rehabilitation) interventions. Further, this course is essential knowledge for future courses discussing injury prevention and physical rehabilitation/physical therapy (e.g. knee pain, knee injury, knee arthritis, meniscus (cartilage), anterior cruciate ligament injury, posterior cruciate ligament injury, knee instability, knee replacement surgery), the effect the knee joint has on lower extremity alignment (e.g. the relationship between tibial external rotation and hip internal rotation), and tibiofemoral specific techniques for enhancing sports performance (e.g. lower body (leg) stability, strength, hypertrophy, agility, and power).

Brookbush Institute's most recommended techniques for the Knee Joint (see videos below):

Self-administered Knee Joint Mobilization

Knee Joint Anterior to Posterior Manual Mobilization

A cadaver showing the boney landmarks and ligaments of the knee

Course Description: Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joint

Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joints Course Study Guide 

Study Guide: Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joints

Etymology, Bones and Alignment

: "joint between the principal bones of the leg," Old English cneo, cneow "knee," from Proto-Germanic *knewam (source also of Old Norse kne,Old Saxonkneo, Old Frisian kni, Middle Dutch cnie, Dutch knie, Old High German kniu, German Knie, Gothic kniu), from PIE root *genu- (1) "knee; angle" (source also of Sanskrit janu, Avestan znum, Hittite genu "knee;" Greek gony "knee," gonia "corner, angle;" Latin genu "knee") (

joint (n): "c. 1300, "an (anatomical) joint, a part of a body where two bones meet and move in contact with one another, the structure that holds such bones together," from Old French joint "joint of the body" (12c.), from Latin iunctus "united, connected, associated," past participle of iungere "join" (see 

The knee joint with bones (femur, tibia, fibula, and patella) and ligaments labeled

From http://pennstatehershey.adam.com/graphics/images/en/21744.jpg

Modified Hinge Joint: considered "modified" due to its capacity to flex and extend in the sagittal plane, as well as rotate in the transverse plane - sometimes referred to as a condyloid joint.

The knee consists of 2 joints: the tibiofemoral Joint and the patellofemoral joint enclosed within the same capsule.

Patellofemoral Joint: Patella and femur (1)

The tibial plateau showing the medial and lateral condyle

Note: The "Lateral Condyle" and "Medial Condyle" labels are not the condyles of the femur, but rather the depressions for the condyles on the tibial plateau.
By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body, invalid ID (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 257, Public Domain, https://commons.wikimedia.org/w/index.php?curid=792106

Femoral Condyles: The femur, at its distal end, divides into large, convex medial and lateral condyles, which articulate with the medial and lateral plateau of the tibia. The intercondylar notch between the two condyles allows room for the anterior cruciate ligament (ACL) and posterior cruciate ligaments (PCL), and extends anteriorly to create the intercondylar groove, which articulates with, and helps to stabilize the patella. The intercondylar groove (trochlear groove), which is concave medial to lateral and slightly convex superior to inferior, creates facets for the posterior surface of the patella. The lateral facet is larger, extends further proximally and anteriorly than the medial facet, and has a steeper slope. This helps maintain the patella within the groove, by resisting lateral glide. Due to the angle of inclination of the femoral shaft, the lateral condyle is more closely aligned with the center of the hip joint. To create an even joint surface the larger medial condyle must extend further, to meet the relatively flat medial plateau. The surface of the condyles are covered with hyaline cartilage, the inferior surface is separated from the facets of the intercondylar notch by intercondylar grooves etched into the cartilage, which allows for the approximation of the anterior ridge of the tibial plateau during full extension.

Tibial Plateau: The proximal tibia matches the distal end of the femur by flaring into a broad tibial plateau. The tibial plateau is divided into compartments for the medial and lateral condyles. The slightly concave medial and slightly convex lateral articular surfaces are covered in hyaline cartilage and are cushioned and made more concave by the medial and lateral menisci. Each meniscus terminates at the rather irregularly shaped intercondylar eminence, formed by medial and lateral tubercles. The intercondylar eminence provides attachment for the ACL and PCL and matches the intercondylar groove of the femur. The anterior edge of the tibial plateau has a groove in its center to allow for the inferior pole of the patella, but as it extends inferiorly becomes raised to end in a fairly prominent tibial tuberosity a few centimeters below the joint line. The tibial tuberosity is the attachment for the thick patellar ligament (insertion of thequadriceps).

Patella: The patella is buried in the quadriceps tendon, and is the largest sesamoid bone in the body. Distally, the inferior pole of the patella forms a near pointed apex and the proximal pole forms a more broad curve. The posterior articular surface is covered by a 4-5 mm layer of articular cartilage (the thickest in the human body) to help attenuate the large compressive forces of the patellofemoral joint (1). A vertical ridge along the entire length of the posterior patella separates the lateral and medial facets. The larger concave lateral facet matches the lateral facet of the intercondylar groove of the femur; however, the shape of the medial facet varies between individuals and is often flanked by an "odd" 3rd facet medially. Anteriorly, the patella is convex in all directions and easily palpated through the skin.

Alignment of the knee is intimately tied to the alignment of the femur, alignment of the tibia, and alignment of the ankle. You may note that some of the angles described below were also mentioned in the article -

Femoral angle of inclination including coxa valga, coxa norma, and coxa vara

Femoral Angle of Inclination (Frontal Plane):

The angle between the femoral neck and medial side of the femoral shaft in the frontal plane. This angle is roughly 140 – 150° at birth but is reduced to an average of 125° in adults (primarily due to the force across the femoral neck during walking) (1, 3). Significant deviations may alter biomechanics leading to increased risk of degeneration or in severe cases dislocation and stress-induced degeneration of the joint (1).

Coxa Valga: > 125º (structurally “longer leg”)

Coxa Vara: < 125º (structurally “shorter leg”)

An example of the Q-angle, or the angle the femur makes in relation to the pelvis

The angle is formed by the medially inclined femur and the nearly vertical tibia. Measured on the lateral aspect of the knee, this angle is normally 170° - 175° (1). A decrease in the genu valgum angle may result in excessive stress and eventual osteoarthritis of the lateral compartment of the knee, and an increase in the genu valgum (genu varum) angle may result in excessive stress and eventual arthritis of the medial compartment of the knee (3, 38). This is greatly affected by the angle of inclination discussed in the 

Excessive Genu Valgum (Knock-kneed) < 170°

Interesting Note: The occurrence of genu valgum and genu varum is relatively rare. In a study of 1500 male and 1500 female, 7 - 11-year-olds, less than 10% exhibited abnomal genu valgum angles (7.2% exhibiting genu vaglum, 2% exhibiting genu varum) (15).

The angle of inclination of the femur in relation to the pelvis and tibia

By OpenStax College - Anatomy & Physiology, Connexions Website. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30131521

Q-Angle (Quadriceps Angle) (Frontal Plane):

Used as an indicator of the net effect of the pull of the quadriceps, the Q-angle is measured with the knee in full or near full extension from a line from the anterior superior iliac spine (ASIS) to the center of the patella (quadriceps angle), and a line extending up from the medial tibial tuberosity to the center of the patella (3). An excessive Q-angle may be an indicator of patellofemoral mal-alignment and potential risk of injury.

Interesting Note: An increase in tibial internal rotation during flexion reduces the Q-angle (39)

An image of anteversion in the left head of a femur 

Anteversion angle of the Left Femur, formed between a line bisecting the femoral neck and a medial/lateral axis through the condyles. http://www.pediatric-orthopedics.com/Topics/Cerebral_Palsy/Intervention/Inter_Anteversion.jpg

Formed between the bones shaft (lateral axis between the femoral condyles) and the femoral neck. 15° of anteversion is normal, with more or less representing an abnormal amount of femoral torsion (twisting). Both excessive anteversion and retroversion may lead to changes in biomechanics, secondary dysfunction (for example, osteoarthritis), and changes in one gait pattern (1, 3).

Anteversion (1, 3): > 15 – 20º (may present with “toe-in” 

Retroversion (1): < 9º (may present with “toe-out” posture)

Interesting Note: Despite some variations among adults, the occurrence of anteversion outside of a standard mean is relatively low; less than 7% in a pathological population (17). We may be able to presume lower percentages in an asymptomatic/non-pathological population.

Illustration demonstrating examples of femoral torsion

Illustration of the femoral torsion (anteversion) on the left, and tibial torsion angle on the right.

Is a medial rotation of the tibia that is formed between a line through the center of the malleoli and a line through the center of the knee joint. 15 – 20º is considered normal; a larger than normal tibial torsion angle may result in "toeing in", gait impairments, and place excessive stress on the hip and knee.

Excessive: > 20º (may present with "toeing in")

An image of the muscles and ligaments which surround the knee joint 

Introduction to the Knee (Tibiofemoral and Patellofemoral) Joint

Palpation

Note it is helpful to learn the palpations below in the order listed:

: The anterior surface of the patella is superficial and can be palpated with your partner in sitting or supine. In supine with the leg extended, the quadriceps tendon is shortened and on slack allowing for movement in the patella. Palpate the edges of the patella and notice its wide proximal base and more narrow distal apex. In this position, the patella can be easily moved from side to side. In sitting, you can passively flex and extend the knee while feeling the patella glide inferiomedially and superolaterally, respectively.

: The term "condyles" is used to refer to the cartilage-covered joint surface, whereas the term epicondyle is used to refer to the rest of the round prominence at the end of the femur. The femoral condyles can be palpated with your partner in supine, or with your partner sitting with legs hanging off the end of a table (knee flexed). Locate the patella. By falling off the patella either medially (medial condyle) or laterally (lateral condyle) you will run into the large, roundish condyles. Explore the smooth surface of the condyles distally as they disappear into the joint line; you can even trace the condyles under the patella to the 

, by gently shifting the patella medial or lateral. Note: The patella will be easier to move with your partner supine.

Now that you know where the condyles are, explore the rest of the bone that makes up the large, roundish "knuckles" at the distal end of your femur. You should notice that the condyles have a bumpier, rougher surface than the epicondyles. You can trace the epicondyles posteriorly to the hamstring tendons and proximally as they narrow into the femoral shaft under the large muscle of the thigh.

 If you explore the proximal portion of the medial epicondyle, you will notice that most of the epicondyle is roundish and follows a predictable path as it slopes toward the more narrow femur. However, you will also notice that the proximal anterior epicondylar ridge (top of the epicondyle if your partner is prone) comes to a point. You may also notice a tendon inserting into this bony point. That is the adductor tubercle and the tendon belongs to the posterior fibers of the 

The tibial plateaus are easiest to palpate with your partner sitting with legs hanging off the end of a table (knee flexed). Although the plateaus themselves cannot be reached, the anterior and lateral edges of the tibial plateau can be palpated. Using both hands, wrap your fingers around the back of the upper calf, and place your thumbs on either side of the patella. By falling off the lateral edges of the patella, gently pulling the lower leg forward (anterior glide, not flexion), and moving your thumbs down slowly, you should run into the anterior edge of the tibial plateau. You should notice a soft space between the condyles (palpated above) and the bony ridge of the tibial plateau. This soft space is occupied by the meniscus. The edge of the tibial plateau can be traced around the knee until it disappears under the gastrocnemius and hamstring tendons

 The attachment site of the patella tendon, the tibial tuberosity is a small but defined protuberance a few centimeters distal to the bottom edge (apex) of the patella. Palpate the patella and follow the tendon distally until it ends in a distinct bump.

Patella attachment on the knee joint from an anterior view

Patella and attachments. Anterior view of the knee.

Knee Joint Palpation

Capsule, Ligaments, and Menisci

 Max extension with maximal tibial external rotation ("knee locked")

Soft tissues of the knee joint including the patella and knee ligaments

Soft tissue structures of the knee. From: http://blog.corewalking.com/wp-content/uploads/2011/11/knee-patella.jpg

Bursae & Plicae

The suprapatellar, superfiical prepatellar, deep infrapatelar, and superficial intrapatellar bursa of the knee

The lateral, medial, infrapatellar, and suprapatellar plica of the knee joint

Knee Joint Bursae & Plicae

Knee Joint Connective Tissues: Capsule, Ligaments, and Menisci

Nerves

Sensory Innervation: Primarily supplied through the posterior tibial branch of the sciatic nerve - this branch supplies the posterior capsule and associated ligaments, internal structures of the knee, as well as the infrapatellar fat pad. The obturator nerve carries sensation from the posterior medial and medial capsule, and the femoral nerve innervates most of the anteromedial and anterolateral capsule - the common peroneal also supplies branches that are involved in the sensation of the anterior capsule (41). The obturator nerve supplies the skin over the medial aspect of the knee along with some of the posterior and posterior medial capsules. Sensory information from the internal structures of the knee and the knee capsule are received by nerve roots L3-L5.

A cadaver dissection of the knee joint with connective tissue labeled

From: https://upload.wikimedia.org/wikipedia/commons/thumb/0/0f/Slide2DADE.JPG/800px-Slide2DADE.JPG[/caption]

Knee Nerves

Joint Actions (Osteokinematics)

Flexors: Semimembranosus, Semitendinosus, 

Limited by: Quadriceps femoris, articularis genu, anterior fascia lata, anterior capsule, posterior cruciate ligament, neural restriction (common femoral nerve)

Optimal Range of Motion (ROM): 135-150° (

Extensors: Quadriceps femoris, articularis genu

Limited by: Semimembranosus, semitendinosus, 

, gastrocnemius, posterior capsule, anterior cruciate ligament, medial collateral ligament, lateral collateral ligament, oblique popliteal ligament, iliotibial band, posterior fascia lata, posterior crural fascia, popliteal fascia, neural restriction (sciatic nerve: common fibular and tibial nerves)

, semimembranosus, semitendinosus,
Medial Gastrocnemius

 (long and short head), lateral gastrocnemius, medial collateral ligament, lateral collateral ligament, anterior cruciate ligament, posterior cruciate ligament

Optimal ROM: 0-15° at 90° of knee flexion (Goniometry Unreliable)

 (long and short head), Lateral gastrocnemius

, semimembranosus, semitendinosus, Medial gastrocnemius, medial collateral ligament, lateral collateral ligament, oblique popliteal ligament, anterior crutiate ligament, posterior crutiate ligament

Optimal ROM: 0-20° with 90° of knee flexion (Goniometry Unreliable)

Limited by: Pes anserinus group (sartorius, 

, semitendinosus), semimembranosus, medial gastrocnemius, medial collateral ligament, anterior cruciate ligament, posterior cruciate ligament, arcuate popliteal ligament, posterior oblique ligament

Optimal ROM: 8° with full knee extension, 13° with 20° knee flexion

Adductors: Pes anserinus group (sartorius, 

, semitendinosus), semimembranosus, medial gastrocnemius

 via Iliotibial Band, lateral gastrocnemius, lateral collateral ligament, anterior cruciate ligament, posterior cruciate ligament, arcuate popliteal ligament, posterior oblique ligament

Note: Even though fewer muscles produce knee extension, the quadriceps femoris collectively produce a force 2/3 greater than knee flexors which is due to the large mass of the quadriceps and the mechanical advantage provided by the patella.

See Kinesiology of the Knee for a list of prime mover, synergists, antagonists, neutralizers, stabilizers, and fixators for all joint actions.

Illustration of the knee during tibia on femur and femur on tibia extension, with lines of force labeled

Arthrokinematics

A cross sectional view of the leg muscles from an anterior view

Integrated Function

Knee valgus (knee bow in) during squatting, jumping, and running

Knee Joint Actions 

Postural Dysfunction

The knee has a propensity toward a compensation pattern described as a "functional valgus". This movement impairment is a combination of joint actions - 

excessive femoral internal rotation and adduction, and tibial external rotation and abduction 

(approximation of lateral femoral condyle and lateral tibial plateau). Clinically, the Brookbush Institute has noted less stiffness and arthrokinematic dysfunction at the knee than seen at the hip or ankle, but when present is exhibited as 

excessive tibial external rotation (lateral spin), the inadequate anterior glide of the tibia on the femur, and increased compression of the lateral compartment

It is also common to note arthrokinematic hyper-mobility of the knee

, as compensation for hip and ankle stiffness. Further, this compensation pattern often results in the 

patella adopting a relatively superior and lateral position

 in the trochlear groove. The term "relative" has been chosen carefully, as it is believed that it is not the patella that adopts a new position, but rather the femur moving medially under a patella that is relatively fixed by the iliotibial band and tonicity of the quadriceps, especially the rectus femoris.

These changes may result in, or be the result of altered length and activity of one, or many of the muscles crossing the knee joint, and maladaptive changes in length and/or extensibility of passive soft tissues (capsule, ligaments, and fascial structures). Although this section will describe dysfunction from the perspective of the knee; the knee could be viewed as a "victim joint". That is the architecture of the knee seems to predispose it to injury and pain stemming from dysfunction at the hip and/or ankle (a "victim" of "monkey in the middle"). Careful assessment of the hip and the ankle should be included for every patient/client exhibiting dysfunction of the knee.

It should also be noted that additional compensatory patterns exist and are relevant to practice; however, in this article, the focus will be given to this pattern, which is presumed to be "most common."


Excessive femoral internal rotation and adduction, and tibial external rotation and abduction

Excessive lateral spin, inadequate anterior glide, and compression of the lateral compartment

Relative superior and lateral glide of the patella.

Maladaptive Decrease In Length/Extensibility 

(Synergistically Dominant - Release Only)

Knee Dysfunction

Knee pain referral pattern

Knee Dysfunction and Signs of Dysfunction

Postural Dysfunction and the Knee Joint

Videos

Joint Structure and Function: A Comprehensive Analysis: Fifth Edition 

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani

Phillip Page, Clare Frank, Robert Lardner, 

NASM Essentials of Corrective Exercise Training

Diagnoses and Treatment of Movement Impairment Syndromes,

Manipulative Therapy: Musuloskeletal Medicine

Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004

Ezoe, M., Naito, M., Inque, T. (2006). The prevalence of acetabular retroversion among various disorders of the hip. 

Karimi-Mobarake, M., Kashefipour, A., Yousfnejad, Z. The prevalence of genu varum and genu valgum in primary school children in Iran 2003-2004. (2005) 

Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. 

Dos Reis, A. C., Correa, J. C. F., Bley, A. S., Rabelo, N. D. D. A., Fukuda, T. Y., & Lucareli, P. R. G. (2015). Kinematic and Kinetic Analysis of the Single-Leg Triple Hop Test in Women With and Without Patellofemoral Pain. journal of orthopaedic & sports physical therapy, 45(10), 799-807.

Noehren, B., Scholz, J., Davis, I. (2011) The effects of real-time gait retraining on hip kinematics, pain, and function in subjects with patellofemoral pain syndrome. Br Journal of Sports Medicine. 45:691-696

Ireland, ML., Wilson, JD., Ballantyne, BT., Davis, IM. (2003). Hip Strength in Females With
and Without Patellofemoral Pain. J Orthop Sports Phys Ther 2003. 33: 671-676

Noehren B, Hamill J, Davis I. Prospective Evidence for a Hip Etiology in Patellofemoral Pain. 

Smith, J. A., Popovich, J. M., & Kulig, K. (2014). The influence of hip strength on lower limb, pelvis, and trunk kinematics and coordination patterns during walking and hopping in healthy women. 

Journal of Orthopaedic & Sports Physical Therapy

Mauntel, T., Begalle, R., Cram, T., Frank, B., Hirth, C., Blackburn, T., & Padua, D. (2013). The effects of lower extremity muscle activation and passive range of motion on single leg squat performance. 

Journal Of Strength And Conditioning Research / National Strength & Conditioning Association

Padua, D. A., Bell, D. R., & Clark, M. A. (2012). Neuromuscular characteristics of individuals displaying excessive medial knee displacement. 

Bell, D. R., Oates, D. C., Clark, M. A., & Padua, D. A. (2013). Two-and 3-dimensional knee valgus are reduced after an exercise intervention in young adults with demonstrable valgus during squatting. 

Ramskov, D., Barton, C., Nielsen, R. O., & Rasmussen, S. (2015). High Eccentric Hip Abduction Strength Reduces the Risk of Developing Patellofemoral Pain Among Novice Runners Initiating a Self-Structured Running Program: A 1-Year Observational Study. 

journal of orthopaedic & sports physical therapy

Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joints

Related Courses:

Course Description: Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joint

Study Guide: Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joints

Introduction to the Knee (Tibiofemoral and Patellofemoral) Joint

Knee Joint Palpation

Knee Joint Connective Tissues: Capsule, Ligaments, and Menisci
1 Sub Section

Knee Nerves

Knee Joint Actions
2 Sub Sections

Postural Dysfunction and the Knee Joint
1 Sub Section

Videos
1 Sub Section

Bibliography

Related Courses:

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Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joints

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Course Description: Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joint

Study Guide: Knee Joint Anatomy: Tibiofemoral and Patellofemoral Joints

Introduction to the Knee (Tibiofemoral and Patellofemoral) Joint

Knee Joint Palpation

Knee Joint Connective Tissues: Capsule, Ligaments, and Menisci1 Sub Section

Knee Nerves

Knee Joint Actions 2 Sub Sections

Postural Dysfunction and the Knee Joint1 Sub Section

Videos1 Sub Section

Bibliography

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Knee Joint Connective Tissues: Capsule, Ligaments, and Menisci
1 Sub Section

Knee Joint Actions
2 Sub Sections

Postural Dysfunction and the Knee Joint
1 Sub Section

Videos
1 Sub Section