The knee joint is the largest joint of the body (Picture 1). It actually consists of three articulations:
- The femoropatellar joint is found between the patella and the distal femur.
- The medial tibiofemoral joint that is located between the medial condyle of the femur and the medial condyle of the tibia.
- The lateral tibiofemoral joint are located between the lateral condyle of the femur and the lateral condyle of the tibia.
All of these articulations are enclosed within a single articular capsule.
The knee functions as a hinge joint, allowing flexion and extension of the leg. This action is generated by both rolling and gliding motions of the femur on the tibia. In addition, some rotation of the leg is available when the knee is flexed, but not when extended. The knee is well constructed for weight bearing in its extended position, but is vulnerable to injuries associated with hyperextension, twisting, or blows to the medial or lateral side of the joint, particularly while weight bearing.
When the knee is flexed it can also rotate (lateral and medial rotation). If the knee is not flexed, the medial/lateral rotation of the leg occurs at the hip joint.
The Femoropatellar Joint
At the femoropatellar joint, the patella slides vertically within a groove on the distal femur. The patella is a sesamoid bone incorporated into the tendon of the quadriceps femoris muscle, the large muscle of the anterior thigh. The patella serves to protect the quadriceps tendon from friction against the distal femur. Continuing from the patella to the anterior tibia just below the knee is the patellar ligament. Acting via the patella and patellar ligament, the quadriceps femoris is a powerful muscle that acts to extend the leg at the knee. It also serves as a “dynamic ligament” to provide very important support and stabilization for the knee joint.
Medial and lateral tibiofemoral joints
The medial and lateral tibiofemoral joints are the articulations between the rounded condyles of the femur and the relatively flat condyles of the tibia. During flexion and extension motions, the condyles of the femur both roll and glide over the surfaces of the tibia. The rolling action produces flexion or extension, while the gliding action serves to maintain the femoral condyles centered over the tibial condyles, thus ensuring maximal bony, weight-bearing support for the femur in all knee positions. As the knee comes into full extension, the femur undergoes a slight medial rotation in relation to tibia. The rotation results because the lateral condyle of the femur is slightly smaller than the medial condyle. Thus, the lateral condyle finishes its rolling motion first, followed by the medial condyle. The resulting small medial rotation of the femur serves to “lock” the knee into its fully extended and most stable position. Flexion of the knee is initiated by a slight lateral rotation of the femur on the tibia, which “unlocks” the knee. This lateral rotation motion is produced by the popliteus muscle of the posterior leg.
Located between the articulating surfaces of the femur and tibia are two articular discs, the medial meniscus and lateral meniscus (see Picture 1 b). Each is a C-shaped fibrocartilage structure that is thin along its inside margin and thick along the outer margin. They are attached to their tibial condyles, but do not attach to the femur. While both menisci are free to move during knee motions, the medial meniscus shows less movement because it is anchored at its outer margin to the articular capsule and tibial collateral ligament. The menisci provide padding between the bones and help to fill the gap between the round femoral condyles and flattened tibial condyles. Some areas of each meniscus lack an arterial blood supply and thus these areas heal poorly if damaged.
The knee joint has multiple ligaments that provide support, particularly in the extended position (see Picture 1 c). Outside of the articular capsule, located at the sides of the knee, are two extrinsic ligaments:
- The fibular collateral ligament (lateral collateral ligament) is on the lateral side and spans from the lateral epicondyle of the femur to the head of the fibula.
- The tibial collateral ligament (medial collateral ligament) of the medial knee runs from the medial epicondyle of the femur to the medial tibia. As it crosses the knee, the tibial collateral ligament is firmly attached on its deep side to the articular capsule and to the medial meniscus, an important factor when considering knee injuries. In the fully extended knee position, both collateral ligaments are taut (tight), thus serving to stabilize and support the extended knee and preventing side-to-side or rotational motions between the femur and tibia.
The articular capsule of the posterior knee is thickened by intrinsic ligaments that help to resist knee hyperextension.
Inside the knee are two intracapsular ligaments:
- The anterior cruciate ligament and
- The posterior cruciate ligament.
These ligaments are anchored inferiorly to the tibia at the intercondylar eminence, the roughened area between the tibial condyles. The cruciate ligaments are named for whether they are attached anteriorly or posteriorly to this tibial region. Each ligament runs diagonally upward to attach to the inner aspect of a femoral condyle. The cruciate ligaments are named for the X-shape formed as they pass each other (cruciate means “cross”). The posterior cruciate ligament is the stronger ligament. It serves to support the knee when it is flexed and weight bearing, as when walking downhill. In this position, the posterior cruciate ligament prevents the femur from sliding anteriorly off the top of the tibia. The anterior cruciate ligament becomes tight when the knee is extended, and thus resists hyperextension.
Movements of the knee: a complex mechanism for a stunning result
The movements which take place at the knee-joint are flexion and extension, and, in certain positions of the joint, internal and external rotation. The movements of flexion and extension at this joint differ from those in a typical hinge-joint, such as the elbow:
- the axis around which motion takes place is not a fixed one, but shifts forward during extension and backward during flexion;
- the commencement of flexion and the end of extension are accompanied by rotatory movements associated with the fixation of the limb in a position of great stability.
The movement from full flexion to full extension may therefore be described in three phases:
- In the fully flexed condition the posterior parts of the femoral condyles rest on the corresponding portions of the meniscotibial surfaces, and in this position a slight amount of simple rolling movement is allowed.
- During the passage of the limb from the flexed to the extended position a gliding movement is superposed on the rolling, so that the axis, which at the commencement is represented by a line through the inner and outer condyles of the femur, gradually shifts forward. In this part of the movement, the posterior two-thirds of the tibial articular surfaces of the two femoral condyles are involved, and as these have similar curvatures and are parallel to one another, they move forward equally.
- The lateral condyle of the femur is brought almost to rest by the tightening of the anterior cruciate ligament; it moves, however, slightly forward and medialward, pushing before it the anterior part of the lateral meniscus. The tibial surface on the medial condyle is prolonged farther forward than that on the lateral, and this prolongation is directed lateralward. When, therefore, the movement forward of the condyles is checked by the anterior cruciate ligament, continued muscular action causes the medial condyle, dragging with it the meniscus, to travel backward and medialward, thus producing an internal rotation of the thigh on the leg. When the position of full extension is reached the lateral part of the groove on the lateral condyle is pressed against the anterior part of the corresponding meniscus, while the medial part of the groove rests on the articular margin in front of the lateral process of the tibial intercondyloid eminence. Into the groove on the medial condyle is fitted the anterior part of the medial meniscus, while the anterior cruciate ligament and the articular margin in front of the medial process of the tibial intercondyloid eminence are received into the forepart of the intercondyloid fossa of the femur. This third phase by which all these parts are brought into accurate apposition is known as the “screwing home,” or locking movement of the joint.
The complete movement of flexion is the converse of that described above, and is therefore preceded by an external rotation of the femur which unlocks the extended joint.
The axes around which the movements of flexion and extension take place are not precisely at right angles to either bone; in flexion, the femur and tibia are in the same plane, but in extension the one bone forms an angle, opening lateralward with the other.
In addition to the rotatory movements associated with the completion of extension and the initiation of flexion, rotation inward or outward can be effected when the joint is partially flexed; these movements take place mainly between the tibia and the menisci, and are freest when the leg is bent at right angles with the thigh.