PPT - The Citadel

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Chapter 10
The Knee Joint
The Knee Joint
10-1
The Knee Joint
• Knee joint
– largest joint in
body
– very complex
– primarily a hinge
joint
The Knee Joint
10-2
Bones
• Enlarged femoral condyles articulate on
enlarged tibial condyles
• Medial & lateral tibial condyles (medial &
lateral tibial plateaus) - receptacles for
femoral condyles
• Tibia – medial
– bears most of weight
The Knee Joint
10-3
Bones
• Fibula - lateral
– serves as the
attachment for
knee joint
structures
– does not articulate
with femur or
patella
– not part of knee
joint
The Knee Joint
10-4
Bones
• Patella
– 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
The Knee Joint
10-5
Bones
• Key bony landmarks
–
–
–
–
Superior & inferior patellar poles
Tibial tuberosity
Gerdy’s tubercle
Medial & lateral femoral
condyles
– Upper anterior medial tibial
surface
– Head of fibula
The Knee Joint
10-6
Bones
• 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
The Knee Joint
10-7
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
The Knee Joint
10-8
Joints
• 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
• Patellofemoral joint
– arthrodial classification
– gliding nature of patella on femoral
condyles
The Knee Joint
10-9
Joints
• Ligaments provide static stability
• Quadriceps & hamstrings contractions produce
dynamic stability
• Articular cartilage surfaces
on femur & tibia
• Menisci form cushions
between bones
– attached to tibia
– deepen tibial fossa
– enhance stability
The Knee Joint
10-10
Joints
• Medial meniscus forms receptacle for medial
femoral condyle, Lateral meniscus receives
lateral femoral condyle
– 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
The Knee Joint
10-11
Joints
– Either or both menisci may be torn in
several different areas from a variety
of mechanisms, resulting in varying
degrees of problems
• Tears often occur due significant
compression & shear forces during
rotation while flexing or extending
during quick directional changes in
running
The Knee Joint
10-12
Joints
• Anterior & posterior cruciate ligaments
– cross within knee between tibia & femur
– vital in respectively maintaining anterior &
posterior stability, as well as rotatory stability
• 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
The Knee Joint
10-13
Joints
• Posterior cruciate
ligament (PCL) injuries
– not often injured
– mechanism of direct
contact with an opponent
or playing surface
• Fibular (lateral)
collateral ligament (LCL)
– infrequently injured
The Knee Joint
10-14
Joints
• Tibial (medial) collateral ligament (MCL)
– 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
The Knee Joint
10-15
Joints
• Synovial cavity
– supplies knee with synovial fluid
– lies under patella and between surfaces of tibia &
femur
– "capsule of the knee”
• 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
The Knee Joint
10-16
Joints
• Bursae
– more than 10
bursae in &
around knee
– some are
connected to
synovial cavity
– they absorb
shock or prevent
friction
The Knee Joint
10-17
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 >
– internal rotation 30 degrees occurs
– external rotation 45 degrees occurs
The Knee Joint
10-18
Joints
• 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
The Knee Joint
10-19
Movements
• Flexion
– bending or decreasing
angle between femur &
leg, characterized by heel
moving toward buttocks
• Extension
– straightening or
increasing angle between
femur & lower leg
The Knee Joint
10-20
Movements
• External rotation
– 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 >
The Knee Joint
10-21
Muscles
• Quadriceps muscle group
– extends knee
– located in anterior
compartment of thigh
– consists of 4 muscles
•
•
•
•
rectus femoris
vastus lateralis
vastus intermedius
vastus medialis
The Knee Joint
10-22
Muscles
• 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
The Knee Joint
10-23
Muscles
• Q angle
– 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
The Knee Joint
10-24
Muscles
• Hamstring muscle group
– responsible for knee flexion
– located in posterior compartment of thigh
– consists of 3 muscles
• semitendinosus - medial, internal rotator
• semimembranosus - medial, internal rotator
• biceps femoris - lateral, external rotator
• Popliteus assist medial hamstrings in
knee internal rotation
The Knee Joint
10-25
Muscles
• Two-joint 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
The Knee Joint
10-26
Muscles
• Ex. sartorius muscle
– increases its total length & becomes a
better flexor at knee when pelvis is rotated
posteriorly & stabilized by abdominal
muscles
• exemplified by trying to flex knee & cross the
legs in the sitting position
• one usually leans backward to flex legs at
knees
– Football kicker invariably leans well
backward to raise & fix the rectus femoris
origin to make it more effective as a knee
extensor
The Knee Joint
10-27
Muscles
• Gracilis, sartorius, & semitendinosus join
together distally to form pes anserinus
– 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
• Medial & lateral gastrocnemius heads attach
posteriorly on medial & lateral femoral
condyles
– assist with knee flexion
The Knee Joint
10-28
Muscles
Knee joint muscles location
• Anterior - primarily knee
extension
–
–
–
–
Rectus femoris
Vastus medialis
Vastus intermedius
Vastus lateralis
The Knee Joint
10-29
Muscles
Knee joint muscles location
• Posterior - primarily knee flexion
– Biceps femoris
– Semimembranosus
– Semitendinosus
•
•
•
•
Sartorius
Gracilis
Popliteus
Gastrocnemius
The Knee Joint
10-30
Nerves
• Femoral nerves
innervates the knee
extensors (quadriceps)
–
–
–
–
rectus femoris
vastus medialis
vastus intermedius
vastus lateralis
The Knee Joint
10-31
Nerves
• Sciatic nerve
– tibial division
• semitendinosus,
semimembranosus,
biceps femoris (long
head)
– common peroneal
(fibular) division
• biceps femoris (short
head)
The Knee Joint
10-32
Quadriceps Muscles
• Quadriceps muscles - vital in jumping
– functions as a decelerator
• 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
The Knee Joint
10-33
Quadriceps Muscles
• Rectus femoris (two-joint), vastus medialis,
vastus intermedius, vastus lateralis (largest)
• 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
The Knee Joint
10-34
Quadriceps Muscles
• 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
The Knee Joint
10-35
Rectus Femoris Muscle
Flexion of hip
Extension of
knee
Anterior pelvic
rotation
The Knee Joint
10-36
Vastus Lateralis Muscle
Extension of
knee
The Knee Joint
10-37
Vastus Intermedius Muscle
Extension of
knee
The Knee Joint
10-38
Vastus Medialis Muscle
Extension of
knee
The Knee Joint
10-39
Hamstring Muscles
• Hamstring muscle group
– Semitendinosus
– Biceps femoris
– Semimembranosus
The Knee Joint
10-40
Hamstring Muscles
•
•
•
•
•
•
•
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
The Knee Joint
10-41
Semitendinosus Muscle
Flexion of knee
Extension of hip
Internal
rotation of
hip
Internal
rotation of
flexed knee
Posterior pelvic
rotation
The Knee Joint
10-42
Semimembranosus Muscle
Flexion of knee
Extension of hip
Internal rotation
of hip
Internal rotation
of flexed
knee
Posterior pelvic
rotation
The Knee Joint
10-43
Biceps Femoris Muscle
Flexion of knee
Extension
of hip
External
rotation
of hip
External
rotation
of flexed
knee
Posterior pelvic
rotation
The Knee Joint
10-44
Popliteus Muscle
Flexion of knee
Internal
rotation of
flexed knee
The Knee Joint
10-45
Knee Extension
• Agonists
– Rectus Femoris
– Vastus Lateralis
– Vastus Intermedius
– Vastus Medialis
The Knee Joint
10-46
Knee Flexion
• Agonists
– Biceps Femoris
(Long & Short
Head)
– Semitendinosus
– Semimembranosus
The Knee Joint
10-47
Knee Internal Rotation
• Agonists
– Semitendinosus
– Semimembranosus
– Popliteus
The Knee Joint
10-48
Knee External Rotation
• Agonists
– Biceps Femoris
The Knee Joint
10-49
Web Sites
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
Arthroscopy.com
www.arthroscopy.com/sports.htm
– Patient information on various musculoskeletal problems of
the lower extremity
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.
The Knee Joint
10-50
Web Sites
Human Anatomy Online
www.innerbody.com/image/musc08.html
– Interactive musculoskeletal anatomy
American Academy of Orthopaedic Surgeons
http://orthoinfo.aaos.org/category.cfm?topcategory=Knee
– Patient education library on the knee
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
Virtual Hospital
www.vh.org
– Numerous slides, patient information, etc.
The Knee Joint
10-51
Web Sites
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
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
The Knee Joint
10-52
Web Sites
Smart Play: The Knee
www.smartplay.net/ouch/bodybits/b_bitsknee.html
– Anatomy, functions, injuries, etc. of the knee
Chiroweb.com
www.chiroweb.com/archives/21/24/03.html
– Abnormal Q Angle and Orthotic Support
The Knee Joint
10-53
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