II BOT_Knee Biomechanics and Applied Anatomy_Punita V. Solanki_11.09.2022.pdf

Notes on Knee Biomechanics

1. CourseSyllabus:KeralaUniversityof
HealthSciences(KUHS)BOTProgramme
2020
CourseCode:022
Year:Second(II)BOT
Subject:206:Biomechanics,Applied
AnatomyandAppliedPhysiology
Lecture:ModuleIII:TheKneeComplex
Punita V. Solanki
MSc (OT), Fellow ACOT (AIOTA), ADCR (Mumbai)
Principal (BOT Programme)
Mobile:[phone] (Personal)
Email: [email protected] 2022

2. Table of Contents
Punita V. Solanki
1.The Knee Complex (Tibio-Femoral and Patello-Femoral Joints)
2. Ligaments of The Knee Complex
3. Movements of The Knee Complex
4. Muscles Crossing The Knee Complex
6. Applied Anatomy & Biomechanics
7. Quiz Time
8. References
September 2022

3. Punita V. Solanki
Articular Surfaces of The Knee Complex
Articular Surfaces of Right Knee Complex (Femur, Tibia & Patella)
A: Anterior; P: Posterior; L: Lateral; M: Medial
A
P
ML
September 2022
P
A
ML

4. Punita V. Solanki
Anatomy of The Knee Complex
Anatomy of Right Knee Complex: Anterior View
D: Distal; P: Proximal; L: Lateral; M: Medial
P
September 2022
D
ML

5. Punita V. Solanki
Anatomy of The Knee Complex
Anatomy of Right Knee Complex: Posterior View
D: Distal; P: Proximal; L: Lateral; M: Medial
P
September 2022
D
LM

6. Punita V. Solanki
The Knee Complex
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011. P: Proximal; P: Posterior; A: Anterior; D: Distal
Thekneecomplexiscomposedoftwodistinctarticulations
locatedwithinasinglejointcapsule:
1.Thetibiofemoraljointisthearticulationbetweenthedistalfemur
andtheproximaltibia.
2.Thepatellofemoraljointisthearticulationbetweentheposterior
patellaandtheanteriorfemur.
Thesuperiortibiofibularjointisnotconsideredtobeapartofthe
kneecomplexbecauseitisnotcontainedwithinthekneejoint
capsuleandisfunctionallyrelatedtotheanklejoint.
D
P
AP

7. Punita V. Solanki
The Tibio-Femoral Joint
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Thetibiofemoraljointisthearticulationbetweenthedistalfemur
andtheproximaltibia.
Thetibiofemoralorkneejointisadoublecondyloidjointwith
threedegreesoffreedomofangular(rotary)motion.
Flexionandextensionoccurinthesagittalplanearoundacoronal
axisthroughtheepicondylesofthedistalfemur.
Medial/lateral(internal/external)rotationoccurinthetransverse
planeaboutalongitudinalaxisthroughthelateralsideofthemedial
tibialcondyleand
Abductionandadductionoccurinthefrontalplanearoundan
anteroposterioraxis.
Thedoublecondyloidkneejointisdefinedbyitsmedialandlateral
articularsurfaces,alsoreferredtoasthemedialandlateral
compartmentsoftheknee.

8. Punita V. Solanki
The Femur
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Femur:Theproximalarticularsurfaceofthekneejointiscomposedof
thelargemedialandlateralcondylesofthedistalfemur.
Themedialcondyle:larger,withagreaterradiusofcurvatureand
projectsfurtherthandoesthelateralcondyle.
Medialobliquityoftheshaftofthefemur:thefemoralcondylesdo
notlieimmediatelybelowthefemoralheadbutareslightlymedialtoit
Asaresult,thelateralcondyleliesmoredirectlyinlinewiththeshaft
thandoesthemedialcondyle.
Asthemedialcondyleextendsfurtherdistally,thedistalendofthe
femurremainsessentiallyhorizontaldespitetheangulationofthe
femur’sshaft.
Sagittalplane:thecondyleshaveaconvexshape,withasmaller
radiusofcurvatureposteriorly.Althoughthedistalfemurasawhole
hasverylittlecurvatureinthefrontalplane,boththemedialand
lateralcondylesindividuallyexhibitaslightconvexityinfrontalplane.

9. Punita V. Solanki
The Femur
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Femur:Thelateralfemoralcondyleisshiftedanteriorlyinrelation
tothemedialfemoralcondyle.
Thetibialarticularsurfaceofthelateralfemoralcondyleisshorter
thanthetibialarticularsurfaceofthemedialfemoralcondyle.
Whenthefemurisexaminedfromaninferiorview,thelateralfemoral
condyleappearsatfirstglancetobelonger.However,whenthe
patellofemoralsurfaceisexcluded,wecanobservethatthelateral
tibialsurfaceextendslessanteriorlythanthemedialcondyle.
Thetwocondylesareseparatedinferiorlybytheintercondylar
notchthroughmostoftheirlengthbutarejoinedanteriorlybyan
asymmetrical,shallowgroovecalledthefemoralsulcus,patellar
groove,orpatellarsurfacethatengagespatelladuringearlyflexion.

10. Punita V. Solanki
The Femur
September 2022
A: Anterior; P: Posterior; P: Proximal; D: Distal; L: Lateral; M: Medial
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
D
P
ML
P
A
ML
D
P
PA

11. Punita V. Solanki
The Tibia
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Tibia:Theasymmetricalmedialandlateraltibialcondylesor
plateausconstitutethedistalarticularsurfaceofthekneejoint.
Themedialtibialplateauislongerintheanteroposteriordirection
thanthelateraltibialplateau.
Thelateraltibialarticularcartilageisthickerthanthearticular
cartilageonthemedialside.
Theproximaltibiaislargerthanthetibialshaftand,consequently,
overhangsthetibialshaftposteriorly.
Thetibialplateauslopesposteriorlyapproximately7°to10°
whichisconduciveforflexingthetibiofemoraljoint.
Themedialandlateraltibialcondylesareseparatedbyaroughened
areaandtwobonyspinescalledtheintercondylartubercles.These
tuberclesbecomelodgedintheintercondylarnotchofthefemur
duringkneeextension.

12. Punita V. Solanki
The Tibia
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Tibia:Thetibialplateausarepredominantlyflat,withaslight
convexityattheanteriorandposteriormargins,whichsuggeststhat
thecombinedbonyarchitectureofthesomewhatconvextibial
plateausandconvexfemoralcondylesdoesnotofferjointstability.
Becauseofthislackofbonystability,accessoryjointstructures
(menisci)arenecessarytoimprovejointcongruency.

13. Punita V. Solanki
Tibiofemoral Alignment & Weight-Bearing Forces
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Theanatomical(longitudinal)axisofthefemurisoblique,directed
inferiorlyandmediallyfromitsproximaltodistalend.The
anatomicalaxisofthetibiaisdirectedalmostvertically.
Consequently,thefemoralandtibiallongitudinalaxesnormallyform
ananglemediallyatthekneejointof180°to185°;thatis,thefemuris
angledupto5°offvertical,creatingaslightphysiological(normal)
valgusangleattheknee.

14. Punita V. Solanki
Tibiofemoral Alignment & Weight-Bearing Forces
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
GenuValgum/Valgus(KnockKnees):medialtibiofemoralangleis
greaterthan185°
GenuVarum/Varus(BowLegs):medialtibiofemoralangleis175°or
less.
Eachconditionaltersthecompressiveandtensilestressesonthe
medialandlateralcompartmentsofthekneejoint.

15. Punita V. Solanki
Tibiofemoral Alignment & Weight-Bearing Forces
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Tibiofemoralalignmentisalternativelymeasuredbydrawinga
lineonaradiographfromthecenterofthefemoralheadtothecenter
oftheheadofthetalus.Thislinerepresentsthemechanicalaxisor
weight-bearinglineofthelowerextremityandinanormallyaligned
knee,itwillpassthroughthecenterofthejointbetweenthe
intercondylartubercles.
Theweight-bearinglinecanbeusedasasimplificationofthe
groundreactionforceasittravelsupthelowerextremity.
Inbilateralstance,theweight-bearingstressesontheknee
jointareequallydistributedbetweenthemedialandlateralcondyles
Inunilateralstance(e.g.,duringthestancephaseofgait),orwhen
dynamicforcesareappliedtothejoint,compartmentalloadingis
altered.Weight-bearinglineshiftstowardthemedialcompartmentto
accountforthenowsmallerbaseofsupportbelowthecenterofmass.
Thisshiftincreasesthecompressiveforcesonmedialcompartment.

16. Punita V. Solanki
Tibiofemoral Alignment & Weight-Bearing Forces
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
During dynamic activities, such as gait,
the line of force shifts medially to the
knee joint center. This medial shift
increases the compressive stresses
medially and increases the tensile
stresses laterally.

17. Punita V. Solanki
Tibiofemoral Alignment & Weight-Bearing Forces
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
AppliedAnatomy
Mechanicalloadingacrossthemedialandlateralcompartmentscan
bemeasuredbothdirectly(invivobyinstrumentingtheprostheses
usedfortotalkneearthroplasty)andindirectly(bymeasuringthe
externalforcesthroughthelegfromaforceplateembeddedinawalk
waytomeasuregroundreactionforcesduringactivitiesofdaily
livinge.g.,walking,runningetc.inagait&motionlaboratory).
Mostactivitiesofdailylivingplaceagreaterload(asmeasuredby
kneeadductionmoments)onthemedialcompartmentcomparedto
thelateralcompartment.Highkneeadductionmomentsareassociated
withthedevelopmentofmedialkneeosteoarthritis(OA).
Theassociationbetweenkneemalalignmentandprogressionof
kneeOAhasimplicationsforpatientswhopresentwithabnormal
anatomicalalignment.Treatment:includeslateral/medialheel
wedgesoranunloadingkneebraceorcorrectiveosteotomysurgery.

18. Punita V. Solanki
Medial and Lateral Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
MedialandLateralMenisci(AccessoryJointStructures)
1.Improvesrelativetibiofemoralincongruencebyconvertingthe
convextibialplateauintoconcavitiesforthefemoralcondyles.
2.Playanimportantroleindistributingweight-bearingforces.
3.Reducesfrictionbetweenthetibiaandthefemurand
4.Servesasshockabsorbers
5.Thearrangementofmeniscalfibersallowsaxialloadstobe
dispersedinaradialdirection,therebyreducingwearonthehyaline
articularcartilage

19. Punita V. Solanki
Medial and Lateral Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
1.ThemedialmeniscusisC-shaped,whereasthelateralmeniscus
formsfourfifthsofacircle.
2.Lyingwithinthetibiofemoraljoint,themenisciarelocatedontopof
thetibialcondyles,coveringonehalftotwothirdsofthearticular
surfaceofthetibialplateau.
3.Bothmenisciareopentowardtheintercondylartubercles,thick
peripherallyandthincentrally.
4.Thelateralmeniscuscoversagreaterpercentageofthesmaller
lateraltibialsurfacethanthesurfacecoveredbythemedialmeniscus.
5.Duetolargerexposedsurface,themedialcondyleismore
Susceptibletoinjuryfromtherelativelygreatercompressiveloads
thatpassthroughthemedialcondyleduringroutinedailyactivities.

20. Punita V. Solanki
Medial and Lateral Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
6.Compressiveforcesinthekneemayreachonetotwotimesbody
weightduringgaitandstairclimbingandthreetofourtimesbody
weightduringrunning,withthemenisciassuming50%to70%of
thisimposedload.
7.Theseloadscanbeinfluencedbythepresenceoffrontalplane
malalignment.Thegreaterthedegreeofgenuvarum,thegreateris
thecompressiononthemedialmeniscus.

21. Punita V. Solanki
Medial and Lateral Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
MeniscalAttachmentsMeniscalmotiononthetibiaislimitedby
multipleattachmentstosurroundingstructures.Themedialmeniscus
hasgreaterligamentousandcapsularrestraints,limitingtranslationto
agreaterextentthanisforthelateralmeniscus.Therelativelackof
mobilityofthemedialmeniscusmaycontributetoitsgreater
incidenceofinjury.
Theopenanteriorandposteriorendsofthemenisciarecalledthe
anteriorandposteriorhorns,eachofwhichisfirmlyattachedtothe
tibiabelow.Anteriorly,themenisciareconnectedtoeachotherbythe
transverseligament.

22. Punita V. Solanki
Medial and Lateral Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
MeniscalAttachments
Common
Attachments
Medial Meniscus
Attachments
Lateral Meniscus
Attachments
Anterior
Transverse Ligament
Patello-meniscal
Ligaments
Coronary Ligaments
Anterior Cruciate
Ligament (ACL)
Posterior
Posterior Cruciate
Ligament (PCL)
Joint Capsule through
Medial Collateral
Ligament (MCL)
Semimembranosus
Muscle
Meniscofemoral
Ligaments
Popliteus muscle

23. Punita V. Solanki
Medial and Lateral Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
RoleoftheMenisci
Strongattachmentsallowsgreatercontactareabetweenthemenisci
andthefemur.
Thecontactareaatthetibiofemoraljointisincreasedandjointstress
(forceperunitarea)isreduced.
Removalofthemeniscinearlydoublesthearticularcartilagestresson
thefemurandmultipliestheforcesbysixorseventimesonthe
tibialplateaucontributingtodegenerativechangeswithinthe
tibiofemoraljoint.

24. Punita V. Solanki
Medial and Lateral Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
MeniscalNutritionandInnervation
Firstyearoflife:bloodvesselsarecontainedthroughoutthemeniscal
body.
Onceweight-bearingisinitiated:vascularitybeginstodiminishuntil
onlytheouter25%to33%isvascularizedbycapillariesfromthejoint
capsuleandthesynovialmembrane.
After50yearsofage:onlytheperipheryofthemeniscalbodyis
vascularized.
Peripheralportion:obtainsitsnutritionthroughbloodvesselsand
Centralportion:relyonthediffusionofsynovialfluid.
Theprocessoffluiddiffusiontosupportnutritionrequires
intermittentloadingofthemeniscusbyeitherweight-bearingor
muscularcontractions.

25. Punita V. Solanki
Medial and Lateral Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
MeniscalNutritionandInnervation
Duringprolongedperiodsofimmobilizationorconditionsofnon-
weightbearing,themeniscusmaynotreceiveappropriatenutrition.
Avascularnatureofthecentralportionofthemeniscusreducesthe
potentialforhealingafteraninjury.Inadults,onlytheperipheral
vascularizedregionofthemeniscusiscapableofinflammation,repair,
andremodelingafteratearinginjury.
Thehornsofthemenisciandtheperipheralvascularizedportionof
themeniscalbodiesarewellinnervatedwithfreenerveendings
(nociceptors)andthreedifferentmechanoreceptors(Ruffini
corpuscles,Paciniancorpuscles,andGolgitendonorgans).
Thepresenceofnociceptorsinthemeniscus:resultsinpainafter
ameniscaltear,atleastfortearslocatedintheperiphery.
Proprioceptivedeficits:occuraftermeniscalinjuryasaresultof
injurytothemechanoreceptorswithinthemeniscus.

26. Punita V. Solanki
Knee Joint Capsule
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Jointcapsulethatenclosesthetibiofemoralandpatellofemoraljointsis
largeandlax.
Itisgrosslycomposedofasuperficialfibrouslayerandathinnerdeep
synovialmembrane.
Theouterfibrousportionofthecapsuleisfirmlyattachedtotheinferior
aspectofthefemurandthesuperiorportionofthetibia.
Posteriorly,thecapsuleisattachedproximallytotheposteriormarginsof
thefemoralcondylesandintercondylarnotchanddistallytotheposterior
tibialcondyle.
Thepatella,thetendonofthequadricepsmusclessuperiorly,andthe
patellartendoninferiorlycompletetheanteriorportionofthejoint
capsule.
Theanteromedialandanterolateralportionsofthecapsuleareoften
separatelyidentifiedasthemedialandlateralpatellarretinaculaeor
togetherastheextensorretinaculum.
Thejointcapsuleisreinforcedmedially,laterally,andposteriorlyby
capsularligaments.

27. Punita V. Solanki
Knee Joint Capsule
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
1.Bonycongruenceandoverallligamenttautnessaremaximalinfull
extensiontheclose-packedpositionofthekneejoint.
2.Inkneeflexion,theperiarticularpassivestructurestendtobe
lax,andtherelativebonyincongruenceofthejointpermitsgreater
anteriorandposteriortranslations,aswellasrotationofthetibia
beneaththefemur.
3.Thekneejointcapsuleanditsassociatedligamentsarecriticalin
restrictingexcessivejointmotionstomaintainjointintegrityand
normalfunction.
4.Thejointcapsuleisstronglyinnervatedbybothnociceptorsas
wellasPacinianandRuffinicorpuscles.Thesemechanoreceptors
maycontributetomuscularstabilizationofthekneejointbyinitiating
reflex-mediatedmuscularresponses.
5.Thejointcapsuleisresponsibleforprovidingatightsealfor
keepingthelubricatingsynovialfluidwithinthejointspace.

28. Punita V. Solanki
Knee Joint Capsule Reinforcements
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edition.
2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th English Edition. 2011.
5. Neumann Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd Edition.
2010.

29. Punita V. Solanki
Synovial Layer of the Knee Joint Capsule
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Thesynovialmembraneformstheinnerlininginmuchoftheknee
jointcapsule.
Therolesofthesynovialtissuearetosecreteandabsorbsynovial
fluidintothejointforlubricationandtoprovidenutritiontoavascular
structures,suchasthemenisci.
Posteriorly,thesynoviumbreaksawayfromtheinnerwallofthe
fibrousjointcapsuleandinvaginatesanteriorlybetweenthefemoral
condyles.Theinvaginatedsynoviumadherestotheanterioraspectand
sidesoftheanteriorcruciateligamentandtheposteriorcruciate
ligament.Therefore,boththeanteriorcruciateligamentandthe
Posteriorcruciateligamentarecontainedwithinthefibrouscapsule
(intracapsular)butlieoutsideofthesynovialsheath(extrasynovial).

30. Punita V. Solanki
Synovial Layer of the Knee Joint Capsule
September 2022
Theintricatefoldsofthesynoviumexcludeseveralfatpadsthatlie
withinthefibrouscapsule,makingthemintracapsularbut
extrasynovial.Theanteriorandposteriorsuprapatellarfatpadslie
posteriortothequadricepstendonandanteriortothedistalfemoral
epiphysis,respectively.Theinfrapatellar(Hoffa’s)fatpadliesdeepto
thepatellartendon.
Thekneehasasmanyas14bursae,whichformatinter-tissue
junctionsthatencounterhighfrictionduringmovement.
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edition.
2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th English Edition. 2011.
5. Neumann Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd Edition.
2010.

31. Punita V. Solanki
Patellar Plicae
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Formationofthekneejoint’ssynovialmembraneoccursinearly
embryonicdevelopment.Initially,thesynovialmembranemay
separatethemedialandlateralarticularsurfacesintoseparatejoint
cavities.By12weeksofgestation,thesynovialseptaeareresorbedto
somedegree,whichresultsinasinglejointcavitybutwithretention
oftheposteriorinvaginationofthesynoviumthatformssome
separationofthecondyles.Thefailureofthesynovialmembraneto
becomefullyresorbedresultsinpersistentfoldsinspecificregionsof
themembrane.Thesefoldsarecalledpatellarplicae.
Thereare4potentiallocationswherepatellarplicaemaybefound.
Themostfrequentlocationsfortheplicae,indescendingorderof
incidence,areinferior(infrapatellarplica),superior
(suprapatellarplica),andmedial(mediopatellarplica).Thereis
alsothepotentialforalateralplica,althoughtheyarerelativelyrare.
Mostprominentmedialplicaisknownbyabout20names,including
alarligament,synovialispatellaris,intra-articularmedialband
etc.

32. Punita V. Solanki
Patellar Plicae
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Thekneejointmay
containaninferior,
superior,ormedial
patellarplicaora
combinationofthese.
Theseplicaearefolds
withinthesynovial
layerofthejoint
capsule.
Synovialplicae,whentheyexist,aregenerallycomposedofloose,pliant,
andelasticfibrousconnectivetissuethateasilypassesbackandforthover
thefemoralcondylesasthekneeflexesandextends.Aplicamaybecome
irritatedandinflamed,whichleadstopain,effusion,andchangesinjoint
structureandfunctionduetorepetitivetrauma,calledplicasyndrome.

33. Punita V. Solanki
Fibrous Layer of the Knee Joint Capsule
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Thefibrousjointcapsuleliessuperficialtothesynovialliningofthe
kneejointandprovidespassivesupportforthejoint.
Thefibrousjointcapsuleitselfiscomposedoftwoorthreelayers,
dependingonlocation.Additionalstructuralsupporttothe
incongruentkneejointisprovidedbyseveralcapsularthickenings
(orcapsularligaments),aswellasbothintracapsularand
extracapsularligaments.
Theanteriorportionofthekneejointcapsuleiscalledtheextensor
retinaculum.Afasciallayercoversthedistalquadricepsmusclesand
extendsinferiorly.Deeptothislayer,themedialandlateralretinacula
arecomposedofaseriesoftransverseandlongitudinalfibrousbands
connectingthepatellatothesurroundingstructures.

34. Punita V. Solanki
Fibrous Layer of the Knee Joint Capsule
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Medially,thethickestandclinicallymostimportantbandwithinthe
medialretinaculumisthemedialpatellofemoralligament(MPFL).
Itsfibers,orientedinatransversemanner,courseanteriorlyfrom
theadductortubercleofthefemurtoblendwiththedistalfibersofthe
vastusmedialisandeventuallyinsertontothesuperomedialborderof
thepatella.
Thetransverselyorientedfiberswithinthelateralretinaculum,
calledthelateralpatellofemoralligament,travelfromtheiliotibial
(IT)bandtothelateralborderofthepatella.Theremainderofthe
retinacularbandsincludetheobliquelyorientedmedial
patello-meniscalligament,thelateralpatello-meniscalligament,
andthelongitudinallypositionedmedialandlateralpatello-tibial
Ligaments.

35. Punita V. Solanki
Fibrous Layer of the Knee Joint Capsule
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Themedialportionofthejointcapsuleiscomposedofthedeepand
superficialportionsofthemedialcollateralligament.
Themostsuperficiallayerofthejointcapsuleonthemedialsideofthe
kneejointisafasciallayerthatcoversthevastusmedialismuscle
anteriorlyandthesartoriusmuscleposteriorly.
Laterally,thejointcapsuleiscomposedsuperficiallyoftheiliotibial
bandanditsthickfascialata.Thecapsuleisreinforced
postero-laterallybythearcuateligamentandpostero-mediallyby
theposteriorobliqueligament(POL).

36. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
JointLigaments:Thekneejointligamentsarevariouslycreditedwith
resistingorcontrollingthefollowing:
1.Excessivekneeextension.
2.Varusandvalgusstressesattheknee(attemptedadductionor
abductionofthetibia,respectively).
3.Anteriororposteriordisplacementofthetibiabeneaththefemur.
4.Medialorlateralrotationofthetibiabeneaththefemur.
5.Combinationsofanteroposteriordisplacementsandrotationsofthe
tibia,togetherknownasrotarystabilizationofthetibia.

37. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edition.
2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th English Edition. 2011.
5. Neumann Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd Edition.
2010.

38. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
MedialCollateralLigament(MCL):canbedividedintoasuperficial
portionandadeepportionthatareseparatedbyabursa.
ThesuperficialportionoftheMCLarisesproximallyfromthemedial
Femoralepicondyleandtravelsdistallytoinsertintothemedial
aspectoftheproximaltibiadistaltothepesanserinus(gracilis,
sartoriusandsemitendinosus)
ThesuperficialportionoftheMCLattachesanteriortotheoriginof
theposteriorobliqueligament,andjustdistaltothefemoralinsertion
ofthemedialpatellofemoralligament.
ThedeepportionoftheMCLiscontinuouswiththejointcapsule,
originatesfromtheinferioraspectofthemedialfemoralcondyle,and
insertsontheproximalaspectofthemedialtibialplateau.

39. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
MedialCollateralLigament(MCL):specificallythesuperficial
portion,istheprimaryrestrainttoexcessivevalgus(abduction)and
lateraltibialrotationstressesattheknee.
Thekneejointisbetterabletoresistavalgusstressatfullextension
comparedtoapositionofkneeflexionbecausetheMCListautin
extension(e.g.,close-packedposition).Asjointflexionisincreased,
theMCLbecomesmorelaxandgreaterjointspaceopeningispossible
(mediallygapping).
Atfullextension,theMCLaccountedfor57%oftherestraining
forceagainstvalgusopening,butat25°ofkneeflexion,theMCL
accountedfor78%oftheload.
TheMCLalsoresistsanteriortranslationofthetibiaonthefemurin
absenceoftheprimaryrestraintsagainstanteriortibialtranslation.
MCLhealswellonitsownafterruptureordamageduetoitsrich
bloodsupply&theremodelingprocesscantakeuptoayear.

40. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
LateralCollateralLigament(LCL):attachesproximallyfromthe
lateralfemoralcondyleandthentravelsdistallytothefibularhead,
whereitjoinswiththetendonofthebicepsfemorismuscletoformthe
conjoinedtendon.
TheLCLisnotathickeningofthecapsulebutisseparatethroughout
muchofitslengthandisconsideredtobeanextracapsularligament.
TheLCLisprimarilyresponsibleforresistingvarusstressesand
alsolimitsfrontalplanemotioni.e.adductionmostsuccessfullyat
fullextension.
At5°ofkneeflexion,theLCLaccountsfor55%oftherestraining
forceagainstvarusstressandthiscapacityincreasesto69%with
thekneeflexedto25°.
TheLCLalsolimitsexcessivelateralrotationofthetibia.

41. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
LateralCollateralLigament(LCL)

42. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
AnteriorCruciateLigament(ACL):isattacheddistallytothetibiaon
thelateralandanterioraspectofthemedialintercondylartibialspine
anditextendssuperiorly,laterally,andposteriorlytoattachtothe
posteromedialaspectofthelateralfemoralcondyle.
TheACLconsistsoftwoseparatebundlesthatwraparoundeach
otherasthekneeflexesi.e.theantero-medialbundle(AMB)and
postero-lateralbundle(PLB)thatarenamedfortheirtibial
insertionsandhaveslightlydifferentfunctions.
ThemajorbloodsupplytotheACLarisesprimarilyfromthemiddle
genicularartery.
TheACLfunctionsasprimaryrestraintagainstanteriortranslation
(anteriorshear)ofthetibiaonthefemur.Withthekneeclosetofull
extension,thePLBistaut;asthekneeflexesthePLBloosensandthe
AMBbecomestight.
TheACLisalsoresponsibleforresistinghyperextensionoftheknee.

43. Punita V. Solanki
Knee Joint Ligaments
September 2022
AnteriorCruciateLigament(ACL)
TheACLalsoprovidesrotarystabilityofthekneeduringmedial/
lateralrotation,varus/valgusangulations,andcombinationsthereof.
RotationalstabilityisprovidedtoagreaterextentbythePLB.
QuadricepsloadingofanACLdeficientkneeresultsinincreased
medialtibialtranslationcontributingtothedevelopmentof
degenerativechangesinthejoint.
InjurytotheACLoccursmostcommonlywhenthekneeisslightly
flexedandthetibiaisrotatedineitherdirectioninweight-bearing.
TheACListhemostfrequentlytotallyrupturedligamentoftheknee.
ApproximatelyhalfofallACLinjuriesoccurinpersonsbetween15and
25yearsofage,oftenduringhighvelocitysportingactivitiessuchas
Americanfootball,downhillskiing,lacrosse,basketball,andsoccer.
MostACLtearsinvolveatransientsubluxationoftheknee,causing
secondarytraumatobone,articularcartilage,menisci,ortheMCL
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edition.
2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th English Edition. 2011.
5. Neumann Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd Edition.
2010.

44. Punita V. Solanki
Knee Joint Ligaments
September 2022
AnteriorCruciateLigament(ACL):MechanismofInjury
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edition.
2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th English Edition. 2011.
5. Neumann Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd Edition.
2010.

45. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
PosteriorCruciateLigament(PCL):attachesdistallytotheposterior
tibialsurface,betweentheposteriorhornsofthetwomenisciand
travelssuperiorlyandsomewhatanteriorlytoattachtothelateral
aspectofthemedialfemoralcondyle.ThePCLisintracapsularbut
extrasynovial.
ThePCLisdividedintobandsthatarenamedfortheirtibialorigins:
posteromedialbundle(PMB)andtheanterolateralbundle(ALB).
Whenthekneeisclosetofullextension,thelargerandstrongerALB
islax,whereasthePMBbecomestaut.At80°to90°offlexion,the
ALBismaximallytautandthePMBisrelaxed.
ThePCLservesastheprimaryrestrainttoposteriordisplacement,
orposteriorshear,ofthetibiabeneaththefemur.Infullyextended
knee,thePCLwillabsorb93%ofaposteriorlydirectedloadappliedto
thetibia,yieldingonlyminimalposteriordisplacements.ThePCLis
moreadeptatrestrainingposteriortibialmotionwiththekneeflexed.

46. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
PosteriorCruciateLigament(PCL)
ThePCLhasaroleinrestrainingvarusandvalgusstressesatthe
Kneeandplaysaroleinbothrestrainingandguidingrotationof
thetibia.ThePCLresiststibialmedialrotationat90°kneeflexionbut
lesssoinfullextensionanddoesnotresistlateralrotationverywell.
ThepopliteusmusclesharestheroleofthePCLinresistingposteriorly
directedforcesonthetibiaandcancontributetokneestabilitywhen
thePCLisabsent.
Anisolatedhamstringcontractionmightdestabilizethekneejointin
theabsenceofthePCLbecauseofitsposteriorshearonthetibiainthe
flexedknee.Contractionofthegastrocnemiusmusclealso
significantlystrainsthePCLatflexionanglesgreaterthan40°,whereas
quadricepscontractionreducesthestraininthePCLatkneeflexion
anglesbetween20°and60°.

47. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
PosteriorCapsularLigaments
The posteromedial corner of the capsule is reinforced by the
semimembranosus muscle, by its tendinous expansion called the
oblique popliteal ligament, and by the stronger and more superficial
posterior oblique ligament.

48. Punita V. Solanki
Knee Joint Ligaments
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
PosteriorCapsularLigaments
The posterolateral corner of the capsule is reinforced by the arcuate
ligament, the lateral collateral ligament, the iliotibial band, the
posterolateral part of the joint capsule, and the popliteus complex
(popliteus muscle, tendon, and popliteo-fibular ligament).
Both the posterior oblique ligament and the arcuate ligaments
are taut in full extension and assist in checkinghyperextensionof
the knee; the posterior oblique ligament and arcuate ligaments also
check valgus and varus forces, respectively,
The orientation of the lateral branch of the arcuate ligament allows it
to become tight in tibial lateral rotation. After trauma involving the
posterior cruciate ligament and medial collateral ligament, the
posterior oblique ligament and posteromedial capsule become
important stabilizers against posterior tibial translation.

49. Punita V. Solanki
Iliotibial Band
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
IliotibialBand
Theiliotibial(IT)bandortractisformedproximallyfromthefascia
investingthetensorfascialata,thegluteusmaximus,andthegluteus
mediusmuscles.Theiliotibialbandcontinuesdistallytoattachtothe
lateralintermuscularseptumandinsertsintotheanterolateraltibia
(Gerdy’stubercle),reinforcingtheanterolateralaspectoftheknee
joint.
Theiliotibialbandcanbeviewedas
(1)atendinousportionconsistingoftheproximalbandtothelateral
femoralepicondyleattachment,and
(2)aligamentousportionbetweenthelateralfemoralepicondyleand
Gerdy’stubercleonthetibia.
Iliotibialbandremainsconsistentlytaut,regardlessofthepositionof
thehiporknee.Despiteitslaterallocation,theiliotibialbandalone
providesonlyminimalresistancetolateraljointspaceopening.

50. Punita V. Solanki
Iliotibial Band
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
IliotibialBand
Additionalfibrousconnectionsfromtheiliotibialbandtothebiceps
femorisandvastuslateralismusclesformaslingbehindthelateral
femoralcondyle,whichassisttheACLinrestrainingposterior
femoral(oranteriortibial)translationwiththekneenearfull
extension.
Withthekneeflexed,however,thecombinationoftheiliotibial
band,thelateralcollateralligament,andthepoplitealtendoncan
provideevengreaterassistanceinresistinganteriordisplacementof
thetibiaonthefemuraswellasincreasethestabilityofthelateralside
ofthejoint.Theattachmentoftheiliotibialbandtothelateralborder
ofthepatellamayalsoaffectpatellofemoralfunction.

51. Punita V. Solanki
Tibio-Femoral Joint Kinematics
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Theprimaryangular(orrotary)motionofthetibiofemoraljointis
flexion/extension,althoughbothmedial/lateral(internal/external)
rotationandvarus/valgus(adduction/abduction)motionsoccurtoa
lesserextent.
Axis:Transepicondylaraxisrepresentsanaccurateestimateofthe
axisforflexionandextension,itshouldbeappreciatedthatthisaxisis
nottrulyfixedbutrathershiftsthroughouttheROM.
Flexion/Extension
Theinitiationofkneeflexion(0°to25°),occursprimarilyas:
1.Posteriorrollingofthefemoralcondylesonthetibiathatmoves
thecontactofthefemoralcondylesposteriorlyonthetibialplateau.
2.Asflexioncontinues,therollingofthefemoralcondylesis
accompaniedbyasimultaneousanteriorglidethatisjustsufficient
tocreateanearlypurespinofthefemurontheposteriortibia
withlittlelineardisplacementofthefemoralcondylesafter25°of
flexion.

52. Punita V. Solanki
Tibio-Femoral Joint Kinematics
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Extensionofkneefromflexionisessentiallyareversalofthismotion.
1.Tibio-femoralextensionoccursinitiallyasananteriorrollingof
Thefemoralcondylesonthetibialplateau,displacingthe
femoralcondylesbacktoaneutralpositiononthetibialplateau.
2.Aftertheinitialforwardrolling,thefemoralcondylesglide
posteriorlyjustenoughtocontinueextensionofthefemurasan
almostpurespinofthefemoralcondylesonthetibialplateau.

53. Punita V. Solanki
Role of Cruciate Ligaments and Menisci
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
A. In flexion of the femur,
posterior rolling of the
femoral condyles creates
tension in the “rigid” anterior
cruciate ligament (ACL) that
results in an anterior
translational force imposed
by the anterior cruciate
ligament on the femur.
B. In extension of the femur,
anterior rolling of the femoral
condyles creates tension in the
“rigid” posterior cruciate
ligament (PCL) that results in
a posterior translational force
imposed by the posterior
cruciate ligament on the
femur.
The motion (or distortion) of the menisci is
an important component of tibio-femoral
flexion and extension. Failure of the menisci
to distort in the proper direction can result in
limitations of joint motion and/or damage to
the menisci.

54. Punita V. Solanki
Knee ROM
ROM: Range of Motion; PROM: Passive Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
Joints Left Knee Right Knee Norms
Knee PROMEnd
Feel
PROM End
Feel
ROM End
Feel
Extension to
Flexion*
0°-135°¥
to 140°£
Soft
Extension to
Hyperextension
0°-5° Firm
Medial (Internal)
Rotation
$
0°-15° Firm
1
Lateral (External)
Rotation
$
0°-20° Firm
1
*American Academy of Orthopaedic Surgeons; ∞American Medical Association;
¥ Reference No. 4 (Pedretti); £ Reference No. 6 (Norkin) $ at 90°Knee Flexion (Reference No. 1)
September 2022
Knee extension (or hyperextension) up to 5°is considered within
normal limits. Excessive knee hyperextension (e.g., beyond 5°of
hyperextension) is termed genu recurvatum

55. Punita V. Solanki
Knee ROM
ROM: Range of Motion; PROM: Passive Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Knee extension (or hyperextension) up to 5°is considered within
normal limits. Excessive knee hyperextension (e.g., beyond 5°of
hyperextension) is termed genu recurvatum

56. Punita V. Solanki
Knee ROM During ADL
ROM: Range of Motion; ADL: Activities of Daily Living
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeRangeofMotionDuringActivitiesofDailyLiving
1.DeepKneeSquats:160°ofkneeflexion.
2.Normalgaitonlevelground:approximately60°to70°ofkneeflexion.
3.Ascendingstairs:about80°ofkneeflexion.
4.Sittingdownorarisingfromachair:90°ofkneeflexionormore
Passiveinsufficiencyoftherectusfemoriscouldlimitkneeflexionto120°or
lessifthehipjointissimultaneouslyextended.
Whenthelowerextremityisinweight-bearing,ROMlimitationsatotherjoints
suchastheanklemaycauserestrictionsinkneeflexionorextension.

57. Punita V. Solanki
Knee ROM
ROM: Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeMedial(Internal)andLateral(External)Rotation

58. Punita V. Solanki
Knee ROM
ROM: Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeMedial(Internal)andLateral(External)Rotation
Theserotationsofthekneejointoccuraboutalongitudinalaxisthat
runsthroughorclosetothemedialtibialintercondylartubercle.Axial
rotationispermittedbyarticularincongruenceandligamentouslaxity.
Therefore,therangeofkneejointrotationdependsonthe
flexion/extensionpositionoftheknee.
Whenthekneeisinfullextension,theligamentsaretaut,thetibial
tuberclesarelodgedintheintercondylarnotch,andthemenisciare
tightlyinterposedbetweenthearticulatingsurfaces;consequently,
verylittleaxialrotationispossible.Asthekneeflexestoward90°
capsularandligamentouslaxityincrease,thetibialtuberclesareno
longerintheintercondylarnotch,andthecondylesofthetibiaand
femurarefreetomoveoneachother.At90°thetotalmedial/lateral
rotationavailableisapproximately35°,withtherangeforlateral
rotationbeingslightlygreater(0°-20°)thantherangeformedial
rotation(0°-15°).

59. Punita V. Solanki
Knee ROM
ROM: Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeValgus(Abduction)/Varus(Adduction)
Frontalplanemotionattheknee,althoughminimal,doesexistandcan
contributetonormalfunctioningofthetibio-femoraljoint.
FrontalplaneROMistypicallyonly8°atfullextension,and13°with
20°ofkneeflexion.
Excessivefrontalplanemotioncouldindicateligamentous
insufficiency.

60. Punita V. Solanki
Knee Coupled Motion
ROM: Range of Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Flexionisconsideredtobecoupledtoavarusmotion,while
extensioniscoupledwithvalgusmotion.
AutomaticorLockingMechanismoftheKnee
Thereisanobligatorylateralrotationofthetibiathataccompaniesthe
finalstagesofkneeextensionthatisnotvoluntaryorproducedby
muscularforces.Thiscoupledmotion(lateralrotationwithextension)
isreferredtoasautomaticorterminalrotation.
Duringthelast30°ofnon-weightbearingkneeextension(30°to0°),
theshorterlateraltibialplateau/femoralcondylepaircompletesits
rolling-glidingmotionbeforethelongermedialarticularsurfacesdo.
Asextensioncontinues,thelongermedialplateaucontinuestorolland
toglideanteriorlyafterthelateralsideoftheplateauhashalted.This
continuedanteriormotionofthemedialtibialcondyleresultsinlateral
rotationofthetibiaonthefemur,withthemotionmostevidentinthe
final5°ofextension.

61. Punita V. Solanki
Knee Coupled Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Increasingtensioninthekneejointligamentsasthekneeapproaches
fullextensionmayalsocontributetotheobligatoryrotationalmotion,
bringingthekneejointintoitsclose-packedorlockedposition.The
tibialtubercleshavenowbecomelodgedintheintercondylarnotch,
themenisciaretightlyinterposedbetweenthetibialandfemoral
condyles,andtheligamentsaretaut.Consequently,automaticrotation
isalsoknownasthelockingorscrewhomemechanismoftheknee.
Toinitiatekneeflexionfromfullextension,thekneemustfirstbe
“unlocked”;thatis,thelaterallyrotatedtibiacannotsimplyflexbut
mustmediallyrotateconcomitantlyasflexionisinitiated.
Thisautomaticrotationorlockingofthekneeoccursinbothweight-
bearingandnon-weightbearingkneejointfunction.Inweight-bearing,
thefreelymovingfemurmediallyrotatesontherelativelyfixedtibia
duringthelast30°ofextension.Unlocking,consequently,isbrought
aboutbylateralrotationofthefemuronthetibiabeforeflexioncan
proceed.

62. Punita V. Solanki
Knee Coupled Motion
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022

63. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
September 2022
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edition.
2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th English Edition. 2011.
5. Neumann Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd Edition.
2010.

64. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
September 2022
KneeFlexorGroup
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. 5th Edition.
2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th English Edition. 2011.
5. Neumann Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd Edition.
2010.

65. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeFlexorGroup
Therearesevenmusclesthatcrossthekneejointposteriorlyandthus
havetheabilitytoflextheknee.Thesearethesemimembranosus,
semitendinosus,bicepsfemoris(longandshortheads),sartorius,
gracilis,popliteus,andgastrocnemiusmuscles.Theplantarismuscle
maybeconsideredaneighthkneeflexor,butitiscommonlyabsent.
Exceptshortheadofthebicepsfemorisandthepopliteus,allofthe
kneeflexorsaretwo-jointmuscles.
Fiveoftheflexors(popliteus,gracilis,sartorius,semimembranosus
andsemitendinosusmuscles)mediallyrotatethetibiaonafixedfemur
whereasthebicepsfemorislaterallyrotatethetibia.
Thelateralmuscles(bicepsfemoris,lateralheadofthegastrocnemius,
andthepopliteus)producevalgusmomentsattheknee,whereas
thoseonthemedialsideofthejoint(semimembranosus,
semitendinosus,medialheadofthegastrocnemius,sartorius,and
gracilis)cangeneratevarusmoments.

66. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Semitendinosus,semimembranosus,andthelongandshortheadsof
thebicepsfemorismusclesarecollectivelyknownasthehamstrings.
Thesemuscleseachattachproximallytotheischialtuberosityofthe
pelvis,excepttheshortheadofthebiceps,whichhasaproximal
attachmentontheposteriorfemur.
Thesemitendinosusmuscleattachesdistallytotheanteromedial
aspectofthetibiabywayofacommontendonwiththesartoriusand
thegracilismuscles.Thecommontendoniscalledthepesanserinus
becauseofitsshape(pesanserinusmeans“goose’sfoot”)
Thesemimembranosusmuscleinsertspostero-mediallyonthetibia
(and,asnotedearlier,hasfibersthatattachtothemedialmeniscus
thatcanfacilitateposteriordistortionofthemedialmeniscusduring
kneeflexion).
Bothheadsofthebicepsfemorismuscleattachdistallytotheheadof
thefibula,withasliptothelateraltibia.

67. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Theshortheadofthebicepsfemorismuscledoesnotcrossthehip
jointandactsuniquelyatthekneejoint.Therestofthehamstring
musclescrossboththehip(asextensors)andtheknee(asflexors);
therefore,theirforceproducingcapabilityatthekneeisdictatedby
theangleofthehipjoint.Greaterhamstringforceisproducedwiththe
hipflexedbecausethehamstringsarelengthenedacrossthehip.
Whenthetwo-jointhamstringsarerequiredtocontractwiththehip
extendedandthekneeflexedto90°ormore,thehamstringsare
shortenedacrossboththehipandtheknee.Thehamstringsproduce
lessforceaskneeflexionapproachesthehamstring’smaximal
shortenedposition(activeinsufficiency)andthehamstringsmust
overcometheincreasingtensioninthelengthenedrectusfemoris
muscle(passiveinsufficiency).
Innon-weightbearingactivities,thehamstringsgenerateaposterior
shearingforceofthetibiaonthefemurthatincreasesaskneeflexion
increases,peakingbetween75°and90°ofkneeflexion.

68. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Thegastrocnemiusmuscle(capableofgeneratingalargeplantar
flexortorqueattheankle)makesarelativelysmallcontributionto
kneeflexion,producingthegreatestkneeflexiontorquewhentheknee
isinfullextension.Attheknee,thegastrocnemiusmuscleappearsto
belessofamobilitymusclethanitisadynamicstabilizer.
Thesartoriusmusclefunctionsasaflexorandmedialrotatorofthe
tibia.Duringgait,thesartoriusmuscleistypicallyactiveonlyduring
theswingphase.
Thegracilismusclefunctionsprimarilyasahipjointflexorand
adductor,aswellashavingthecapabilitytoflexthekneejointand
produceslightmedialrotationofthetibia.
Thethreemusclesofthepesanserinusappeartofunctioneffectively
asagrouptoresistvalgusforcesandprovidedynamicstabilitytothe
anteromedialaspectofthekneejoint.

69. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Theprimaryfunctionofthepopliteusmuscleisasamedialrotatorof
thetibiaonthefemur.Unlockingthekneeisbythepopliteusmuscle.
Thesoleusandgluteusmaximusmusclesdonotcrossthekneejoint.
But,withthefootfixedonthegroundduringweight-bearing,asoleus
musclecontractioncanassistwithkneeextensionbypullingthetibia
posteriorly.Thegluteusmaximusmuscle,likethesoleusmuscle,is
capableofassistingwithkneeextensioninaweight-bearingposition.

70. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeExtensorGroup

71. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeExtensorGroup
Thefourextensorsoftheknee(rectusfemoris,vastuslateralis,vastus
medialis,vastusintermedius)areknowncollectivelyasthe
quadricepsfemorismuscle.Theonlyportionofthequadricepsthat
crossestwojointsistherectusfemorismuscle,whichcrossesthehip
andkneefromitsattachmentontheanteriorinferioriliacspine.
Thevastusintermedius,vastuslateralis,andvastusmedialismuscles
originateonthefemurandmergewiththerectusfemorismuscleinto
acommontendon,calledthequadricepstendon.Thequadriceps
tendoninsertsintotheproximalaspectofthepatellaandthen
continuesdistallypastthepatella,whereitisknownasthepatellar
tendon(orpatellarligament).
Thefourcomponentsofthequadricepsfemorismusclefunction
toextendtheknee.

72. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeExtensorGroup
Upperfibersofvastusmedialisarereferredtoasthevastusmedialis
longus(VML)andlowerfibersarereferredtoasthevastusmedialis
oblique(VMO).
Thecompressiveforcefromquadricepsmusclesispresentthroughout
theROMbutisminimizedatfullextensionandincreasesasknee
flexioncontinues.
PatellarInfluenceonQuadricepsMuscleFunction
Thepatellalengthensthemomentarmofthequadricepsby
increasingthedistanceofthequadricepstendonandpatellartendon
fromtheaxisofthekneejoint.Thepatella,asananatomicalpulley,
deflectstheactionlineofthequadricepsfemorismuscleawayfrom
thejointcenter,increasingtheangleofpullonthetibiatoenhancethe
abilityofthequadricepstogenerateextensiontorque.

73. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
KneeExtensorGroup
Peaktorquesareoftenobservedatapproximately45°to60°ofknee
flexion,aregioninwhichboththemomentarmandthelength-tension
relationshipofthemusclearemaximized.
QuadricepsLag
Ifthereissubstantialquadricepsweaknessorifthepatellahasbeen
removedbecauseoftrauma(aprocedureknownasapatellectomy),
thequadricepsmaynotbeabletoproduceadequatetorqueto
completethelast15°ofnonweightbearingkneeextension.Thiscan
beseenclinicallyinapatientwhodemonstratesa“quadricepslag”
or“extensionlag.”
Althoughthekneecanbefullyextended
passively,effortsatactiveextensiontypically
failtoproducethelast15°to20°ofextension.
Clinically,thischaracteristicdemonstration
ofquadricepsweaknessisreferredtoasan
“extensorlag.”

74. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Thequadriceps,notonlyproducesanextensiontorquebutalso
createsananteriorshearofthetibiaonthefemur.Thisanterior
translationalforcemustberesistedbyactiveorpassiveforcescapable
ofeitherproducingaposteriortibialtranslationorpassively
resistingtheanteriortibialtranslationimposedbythequadriceps.The
anteriorcruciateligamentrepresentsthemostprominentpassive
restrainttotheimposedanteriortibialtranslationofthequadriceps.
Thestrainonbothbundlesoftheanteriorcruciateligamentordinarily
increasesasthekneejointapproachesfullextension.

75. Punita V. Solanki
Muscles Acting At Knee Joint (Arthro-Kinetics)
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
QuadricepsStrengthening:Weight-BearingVersusNon-
Weightbearing
Theweight-bearingquadricepsexercisesofasquatandlegpress
resultedinaposteriortibialshearforceatthekneethroughoutthe
entireROM,peakingbetween83°and105°ofkneeflexion.The
posteriorshearwouldpresumablystresstheposteriorcruciate
ligament.Incontrast,therewasananteriorshearforceina
non-weightbearingkneeextensionexercisewhenthequadriceps
activelyextendedthekneefrom40°to10°,withthemaximalanterior
shearoccurringbetween20°and10°.
Aposteriorshearforcewasalsofoundduringnon-weightbearing
exercise,butthisforcewaspresentonlybetween60°and101°of
flexion.Thisstudydemonstratedthatthestressontheposterior
cruciateligamentthatispresentduringsometypesofweight-bearing
exercisesmayactuallybedetrimentaltothehealingprocess
ifthisligamentisdamaged.

76. Punita V. Solanki
Knee Joint Stabilizers
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022

77. Punita V. Solanki
Knee Joint Stabilizers
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022

78. Punita V. Solanki
Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Embeddedwithinthequadricepsmuscle,theflat,triangularly
shapedpatellaisthelargestsesamoidboneinthebody.Thepatellais
aninvertedtrianglewithitsapexdirectedinferiorly.
Theposteriorsurfaceisdividedbyaverticalridgeandcoveredby
articularcartilage.Thisridgeissituatedapproximatelyinthecenterof
thepatella,dividingthearticularsurfaceintoapproximatelyequally
sizedmedialandlateralfacets.
Boththemedialandlateralfacetsareflattoslightlyconvexsidetoside
andtoptobottom.Mostpatellaealsohaveasecondverticalridge
towardthemedialborderthatseparatesthemedialfacetfroman
extrememedialedge,knownastheoddfacetofthepatella.The
posteriorsurfaceofthepatellaintheextendedkneesitsonthe
femoralsulcus(orpatellarsurface)oftheanterioraspectofthedistal
femur.

79. Punita V. Solanki
Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Thefemoralsulcushasagroovethatcorrespondstotheridgeonthe
posteriorpatellaanddividesthesulcusintomedialandlateralfacets.
Thelateralfacetofthefemoralsulcusisslightlymoreconvexthanthe
medialfacetandhasamorehighlydevelopedlipthandoesthemedial
surface.Thepatellaisattachedtothetibialtuberositybythepatellar
tendon.
Thepatellofemoraljointisoneofthemostincongruentjointsinthe
body.

80. Punita V. Solanki
Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Thepatellafunctionsprimarilyasananatomicalpulleyforthe
quadricepsmuscle.
Interposingthepatellabetweenthequadricepstendonandthe
femoralcondylesalsoreducesfrictionasthefemoralcondylescontact
thehyalinecartilage–coveredposteriorsurfaceofthepatellarather
Thanthequadricepstendon.
Theabilityofthepatellatoperformitsfunctionswithoutrestricting
kneemotiondependsonitsmobility.Becauseoftheincongruenceof
thepatellofemoraljoint,however,thepatellaisdependentonstatic
anddynamicstructuresforitsstability.

81. Punita V. Solanki
Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
PatellofemoralArticularSurfacesandJointCongruence
Inthefullyextendedknee,thepatellaliesonthefemoralsulcus.
Becausethepatellahasnotyetenteredtheintercondylargroove,joint
congruencyinthispositionisminimal,whichsuggeststhatthereis
greaterpotentialforpatellarinstabilitywiththekneenearfull
extension.Stabilityofthepatellaisaffectedbytheverticalpositionof
thepatellainthefemoralsulcus,becausethesuperioraspectofthe
femoralsulcusisshallowerthantheinferioraspect.Thevertical
positionofthepatella,inturn,isrelatedtothelengthofthepatellar
tendon.Ordinarily,theratioofthelengthofthepatellartendontothe
lengthofthepatellaisapproximately1:1andisreferredtoasthe
Insall-Salvatiindex
Amarkedlylongtendonproducesanabnormallyhighpositionofthe
patellaonthefemoralsulcusknownasPatellaAlta,whichincreases
theriskforpatellarinstability.PatellaBaja,alsoknownaspatella
infera,isanabnormallylowlyingpatella,associatedwithrestricted
rangeofmotion,crepitations,andretropatellarpain&extensor
dysfunction.Itmaybeduetoashortenedpatellartendon.

82. Punita V. Solanki
Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Whenthepatellasitsinthefemoralsulcusintheextendedknee,only
theinferiorpoleofthepatellaismakingcontactwiththefemur.Asthe
kneebeginstoflex,thepatellaslidesdownthefemur,increasingthe
surfacecontactarea.Inthismanner,thefirstconsistentcontact
betweenthepatellaandthefemuroccursalongtheinferiormarginof
boththemedialandlateralfacetsofthepatellaat10°to20°ofknee
flexion.
Atfullflexion,thepatellaislodgedintheintercondylargroove,and
contactisonthelateralandoddfacets,withthemedialfacet
completelyoutofcontact

83. Punita V. Solanki
Motions of Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022

84. Punita V. Solanki
Motions of Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Asthecontactbetweenthepatellaandthefemurchangeswithknee
Jointmotion,thepatellasimultaneouslytranslatesandrotates
onthefemoralcondyles.
Whenthefemurisfixedwhilethekneeisflexing,thepatella(fixedto
thetibialtuberosityviathepatellartendon)ispulleddown,gliding
Inferiorlyandrotatingonthefemoralcondyleswiththedistalapex
ofthepatellamovingposteriorly.Thissagittalplanerotationofthe
patellaasthepatellatravels(or“tracks”)downtheintercondylar
grooveofthefemuristermedpatellarflexion.
Kneeextensionbringsthepatellabacktoitsoriginalpositioninthe
femoralsulcus,withtheapexofthepatellapointinginferiorlyatthe
endofthenormalROM.Thispatellarmotionofglidingsuperiorly
whilerotatingupandaroundthefemoralcondylesisreferredtoas
patellarextension.

85. Punita V. Solanki
Motions of Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Inadditiontopatellarflexionandextension,thepatellatiltsarounda
longitudinalaxis(proximaltodistalthroughthepatella),shifts
mediallyandlaterallyinthefrontalplane,andspinsorrotatesaround
ananteroposterioraxis(perpendiculartothepatella).Tiltingabout
thelongitudinalaxisistermedlateral/medialpatellartiltandis
namedforthedirectioninwhichtheanteriorsurfaceofthepatellais
movingrelativetofemoralcondyles.
Lateralpatellatiltoccurswhenthelateraledgeofthepatella
approximatesthesurfaceofthelateralfemoralcondyleandmedial
patellatiltoccurswhenthemedialedgeofthepatellamovestoward
themedialfemoralcondyle.
Thepatellatranslatessuperiorlyandinferiorlywithkneeextension
andflexion,respectively.

86. Punita V. Solanki
Motions of Patello-Femoral Joint
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Lateralandmedialpatellashiftsaretranslations(gliding)thatoccur
inaplaneofmotion,ratherthanrotationaroundanaxis.Alateral
patellashiftisdefinedasthepatellamovingtowardthelateralfemora
lcondyleinthefrontalplanealongthemedial-lateralaxis.Alateral
patellashiftiscommonlyusedduringthepatellaapprehensiontestto
evaluatethestabilityofthepatellawithinthefemoralgroove.
Rotationofthepatellaaboutananteroposterioraxis(termedmedial/
lateralrotationofthepatella)isreferencedbythemovementofthe
distalapexofthepatella.Medialrotationoccurswhenthepatella
spinsaroundthisperpendicularaxiswiththeapexofthepatella
Pointingtowardthemedialfemoralcondyleandthebaseofthe
patellamovingclosertothelateralfemoralcondyle.Whenthekneeis
insomeflexionandthereismedialrotationofthetibiaonthefixed
femur,theinferiorpoleofthepatellawillpointMediallyasthepatella
mediallyrotates.Asthetibiarotateslaterally,thepatellawillrotate
laterallytokeeptheapexalignedwiththetibialtuberosity.

87. Punita V. Solanki
Patello-Femoral Joint Reaction Force / Stress
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
The patellofemoral joint can undergo very high stresses during
typical activities of daily living. Joint stress (force per unit area) can
be influenced by altering either joint forces and/or joint surface
contact areas. The patellofemoral joint reaction (contact) force is
influenced by both the force generated by the quadriceps and the knee
angle.
As the knee flexes and extends, the patella is pulled superiorly by the
quadriceps tendon, with the pull resisted inferiorly by the patella
tendon. The combination of these pulls produces a posterior
compressive force of the patella on the femur that varies with the
amount of knee flexion.
TwoInterrelatedFactorsAssociatedwith
JointCompressionForceonthe
PatellofemoralJoint
1.Forcewithinthequadricepsmuscle
2.Kneeflexionangle

88. Punita V. Solanki
Patello-Femoral Joint Reaction Force / Stress
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Thepatellofemoraljointstress
1.FullKneeExtension:thereissmallcontactareathatthepatellahas
withthefemur,theminimalposteriorcompressivevectorofthevastus
lateralisandvastusmedialismusclesmaintainslowjointstressat
fullextension.Thisistherationalefortheuseofstraightleg
raisingexercisesasawayofimprovingquadricepsmusclestrength
withoutcreatingorexacerbatingpatellofemoralpain.
2.KneeFlexionat20°:duringthestancephaseofwalking,the
patellofemoralcompressiveforceisapproximately25%to50%of
bodyweight.
3.Greaterkneeflexionandgreaterquadricepsactivity:asduring
running,patellofemoralcompressiveforceshavebeenestimatedto
reachbetweenfiveandsixtimesbodyweight.
Normalpatellofemoraljoint:medialfacetbearsthemajorityofthe
compressiveforce.From30°to70°offlexion,magnitudeofcontact
forceishigheratthickcartilageofmedialfacetnearcentralridge.

89. Punita V. Solanki
Patello-Femoral Joint Reaction Force / Stress
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Thepatellofemoraljointstress
Theverticalpositionofthepatellacanalsosignificantlyinfluence
patellofemoralstress.
PatellaAlta:theonsetofcontactbetweenthequadricepstendonand
femoralcondylesisdelayed.Asflexionincreases,patellofemoral
compressiveforceswillthereforecontinuetorise.
PatellaBaja:thecontactbetweenthequadricepstendonandthe
femoralcondylesoccursearlierintherange,resultinginaconcomitant
reductioninthemagnitudeofthepatellofemoralcontactforce.

90. Punita V. Solanki
Patello-Femoral Joint Stability
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Duetophysiologicalvalgusthatnormallyexistsbetweenthetibiaand
femur,theactionlinesofthequadricepsandthepatellartendondonot
coincide.Instead,thepatellaispulledslightlylaterallybythetwo
forces.Thepresenceofaresultantlateralpullonthepatellain
extension,wherebonystabilityisreduced,suggeststhatsofttissue
stabilizersmustassumemoreresponsibilityformedial-lateralstability
Oncekneeflexionisinitiatedandthepatellabeginstoslidedowninto
thefemoralsulcus(atabout20°offlexion),medial-lateralstabilityis
increasedbytheadditionofthebonystability.
LongitudinalStabilizersofthePatello-FemoralJoint:
1.Patellartendoninferiorly
2.Quadricepstendonsuperiorly
3.Patello-tibialligaments(partofextensorretinaculum)
Longitudinalstabilizersprovidepassiveincreasesinpatellofemoral
compressionwhichinturnhelpstostabilizepatellainmedial-lateral
direction.

91. Punita V. Solanki
Patello-Femoral Joint Stability
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
TransverseStabilizersofthePatello-FemoralJoint:
1.Superficialportionofextensorretinaculum
2.Medialandlateralpatellofemoralligaments
3.Iliotibialbandlaterally
4.Anteriorlyprotrudinglaterallipofthefemoralsulcus
Asthethickestportionofthemedialretinaculum,themedial
patellofemoralligamentaloneprovidesapproximately60%ofthe
passiverestrainingforceagainstlateraltranslation(lateralshift)ofthe
patella.
Boththetransverseandthelongitudinalstructurescanthusinfluence
themedial-lateralpositioningofthepatellawithinthefemoral
sulcus,aswellasinfluencepatellartrackingasthepatellaslides
downthefemoralcondylesandintotheintercondylargroove.
Thepresenceofhyper-mobilitymayresultinpatellarsubluxations
ordislocations,whereashypo-mobilitymayyieldgreater
patellofemoralstresses.

92. Punita V. Solanki
Patello-Femoral Joint Stability
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Theforceonthepatellaisdeterminedbytheresultantpullofthefour
musclesthatconstitutethequadricepsandbythepullofthe
patellartendon.Eachofthesegmentsofthequadricepscancontribute
tofrontalplanemobilityandstability.Thepullofthevastuslateralis
muscleisnormally35°lateraltothelongaxisofthefemur,whereas
thepulloftheproximalportionofthevastusmedialismuscle(vastus
medialislongus)isapproximately15°to18°medialtothe
femoralshaftwiththedistalfibers(vastusmedialisoblique)oriented
50°to55°medially.
Relativeweaknessofthevastusmedialismusclemaysubstantially
increasetheresultantlateralforcesonthepatella.Anatomical
variationsmaycontributetoasymmetricalpullsonthepatella.
Quadricepsmuscleasawholedoesappeartobesusceptibletothe
Inhibitoryeffectsofacutejointeffusionscausedbyinjury.This
inhibitionofthequadricepscanresultinhypotoniaandatrophy,
minimizingthecompressiveroleofthequadricepsandalteringthe
resultantpullonthepatella.

93. Punita V. Solanki
Asymmetry of Patellofemoral Stabilization
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Theneteffectofthepullofthe
quadricepsandthepatellarligamentcan
beassessedclinicallyusinga
measurementcalledtheQ-angle
(quadricepsangle).
TheQ-angleistheanglebetweenaline
connectingtheanteriorsuperioriliac
spinetothemidpointofthepatellaand
theextensionofalineconnectingthe
tibialtubercleandthemidpointofthe
patella.
AQ-angleof10°to15°measuredwith
thekneeeitherinfullextensionor
slightlyflexedisconsiderednormal.

94. Punita V. Solanki
Asymmetry of Patellofemoral Stabilization
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
AnyalterationinalignmentthatincreasestheQ-angleisthoughtto
increasethelateralforceonthepatella.Anincreaseinthislateralforce
mayincreasethecompressionofthelateralpatellarfacetagainstthe
laterallipofthefemoralsulcus.Inthepresenceofalargeenough
lateralforce,thepatellamayactuallysubluxordislocateoverthe
femoralsulcuswhenthequadricepsmuscleisactivatedwithan
extendedkneeandmaypredisposethepatellatopathologicalchanges.
WomenhaveaslightlygreaterQ-anglethandomenbecauseofthe
presenceofawiderpelvis,increasedfemoralanteversion,anda
relativekneevalgusangle.
Severalabnormalitiesmayincreaselateralforcesonthepatellaother
thanQ-angleincreasee.g.,imbalancebetweenthevastuslateralisand
vastusmedialismuscles;kneepain;patellarmalalignment;tight
iliotibialband;tibio-femoraljointmalalignmentsuchasgenuvalgum
&genuvarum;medialfemoraltorsion(femoralanteversion)&lateral
tibialtorsion;excessiveorprolongedpronationinthefootetc.

95. Punita V. Solanki
Applied Anatomy: Patello-Femoral Joint Pain
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Weight-BearingVersusNon-WeightBearingExercisesWith
PatellofemoralPain
Effectivequadricepsstrengtheninginapatientwithpainmustbe
performedinapain-freerange.
Innon-weightbearingextensionexercises,suchastheseatedknee
extension,thequadricepsmustproducemoretorqueasextension
progresses(quadricepsforceincreaseswithdecreasingkneeflexion
angle)Thegreatercompressiveforcegeneratedbytheincreased
quadricepscontractioncanbedetrimentalforanindividualwith
patellofemoralpain,especiallyifthedegenerationislocatedonthe
inferioraspectofthepatellathatisincontactwiththefemurnear
extension.
Inweight-bearingexerciserequiresgreaterquadricepsactivitywith
greaterkneeflexion(e.g.,atthebottomofasquat)astheresistance
momentarmincreases.

96. Punita V. Solanki
Applied Anatomy: Patello-Femoral Joint Pain
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
Weight-BearingVersusNon-WeightBearingExercisesWith
PatellofemoralPain
Duringweight-bearingexercises,greaterkneeflexionwilltherefore
increasethecompressiveforceacrossthepatellofemoraljointboth
becauseofincreasedforcedemandsonthequadricepsmuscleand
becauseoftheincreasedpatellofemoralcompressionthatoccurseven
withpassivekneeflexion.
Sotherecommendationforthosewithpatellofemoralpainis:
1.Avoiddeepflexionwhiledoingweight-bearingextension
exercises.
2.Avoidthefinal30°ofextensionduringnon-weightbearingknee
extensionexercises.

97. Punita V. Solanki
Applied Anatomy: Effects of Injury and Disease
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
1.Meniscalinjuriesarecommonandusuallyoccurasaresultof
suddenrotationofthefemuronthefixedtibiawhenthekneeisin
flexion.
2.Ligamentousinjuriesmayoccurasaresultofaforcethatcausesth
ejointtoexceeditsnormalROM.Lower-levelforcesmaysimilarlycaus
edisruptioninligamentsweakenedbyaging,disease,immobilization,
steroids,orvascularinsufficiency.
3.Rehabilitationofarepairedorreconstructedligamentisabalance
inavoidingeithertoomuchortoolittleappliedstress.
4.Bonyandcartilaginousstructuresofthetibio-femoraljointmay
beinjuredeitherbytheapplicationofalargedirectforce,suchas
duringatwistorfall,orbyforcesexertedbyabnormalligamentous
andmuscularforces.
5.Tibialplateaufracturescanoccurwhenlargemagnitudesofforce
areappliedthroughthejoint.

98. Punita V. Solanki
Applied Anatomy: Effects of Injury and Disease
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
6.Kneeosteoarthritisisoftenseeninolderadultsandisparticularly
commoninwomen.Thisprogressiveerosionofarticularcartilagemay
beinitiatedbyaprevioustraumaticjointinjury,obesity,malalignment,
instability,orquadricepsmuscleweaknessetc.
7.Kneejointinstability,asfrequentlyseeninthekneeafteranterior
cruciateligamentinjury,canleadtoprogressivechangesinthe
articularcartilage,inthemenisci,andintheotherligaments
attemptingtorestraintheincreasedjointmobility.
8.Bursitisiscommonaftereitherblunttraumaorrepetitivelow-level
compressions,whichcanirritatethetissue.Thepre-patellarbursa,the
superficialinfrapatellarbursa(knownashousemaid’skneewhenit
isinflamed),andthebursabeneaththepesanserinusarecommon
locationsforinjury.
9.Tendinitisresultsfromrepetitivelow-levelstressestothetissuesof
thetendon.Frequentlythisiscausedbyoveruseoftheaffectedmuscle
andcanoccurinresponsetoapreviousligamentousinjury.

99. Punita V. Solanki
Applied Anatomy: Effects of Injury and Disease
References: 1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis.
5th Edition. 2011. 2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6th
English Edition. 2011.
September 2022
10.Patellarplicasyndrome:classicsymptomsincludepainwith
prolongedsitting,withstairclimbing,andduringresistedextension
exercises.Inflexion,themedialpatellarplicaisdrawnoverthemedial
femoralcondyleandcanbecomecompressedbeneaththepatella
causinginflammation.Iftheinflamedplicabecomesfibrotic,itmay
createasecondarysynovitisaroundthefemoralcondyle,and
deteriorationofthecondylarcartilagemayoccur.Athickenedor
Inflamedsuperiorplicamayerodethesuperioraspectofthemedial
facetofthepatella.
11.Chondromalaciapatella:cartilaginouschangesseenonlateral
patellarfacetdiagnosticofpatellofemoraldysfunction(softeningofthe
cartilage)wasassignedinthepast.Assimilarcartilaginouschanges
canbefoundinasymptomatickneesandthatthemedialpatellarfacet
canshowgreaterchangewithoutsymptomsorprogressivecartilage
deterioration,moregeneraldiagnoseshavebeenused,including
patellofemoralarthralgiaorpatellofemoralpainsyndrome.

100. Punita V. Solanki
Home Work (Peer Group Teaching)
1.Nervesupplytothebonesandjointsofthekneecomplex
2.Bloodsupplytothebonesandjointsofthekneecomplex
3.Listallactivitiesofdailyliving(ADL)requiringfunctionalpositionof
thekneecomplex
4.Listcommondeformitiesofthekneecomplex
September 2022

101. Quiz Time
Punita V. Solanki
Say True or False
Circumductionispossibleatkneecomplex.
Answer:False
Therearethreedegreesoffreedomofmotionatkneecomplex.
Answer:True
Tibio-femoraljointisadoublecondyloidjoint.
Answer:True
Thepatellofemoraljointisoneofthemostincongruentjointsinthe
body.
Answer:True
Thetwofemoralcondylesareseparatedinferiorlybythe
intercondylarnotch.
Answer:True
September 2022

102. Quiz Time
Punita V. Solanki
Say True or False
Thelateraltibialarticularcartilageisthickerthanthearticular
cartilageonthemedialside.
Answer:True
Themedialtibialplateauislongerintheanteroposteriordirection
thanthelateraltibialplateau.
Answer:True
Kneedeformityiscalledgenuvalgum/valgus(knockknees)when
medialtibio-femoralangleisgreaterthan185°
Answer:True
Kneedeformityiscalledgenuvarum/varus(bowlegs)whenmedial
tibio-femoralangleis175°orless.
Answer:True
September 2022

103. Quiz Time
Punita V. Solanki
Say True or False
AQ-angleof10°to15°measuredwiththekneeeitherinfull
extensionorslightlyflexedisconsiderednormal.
Answer:True
Thepatello-femoraljointstressincreasestofiveandsixtimesbody
weightwithgreaterkneeflexionandgreaterquadricepsactivity
Answer:True
PesAnserinusisthecommontendinousinsertionofgracilis,
sartoriusandsemimembranosus
Answer:False
Theobligatorylateralrotationofthetibiathataccompanies
thefinalstagesofkneeextensionthatisnotvoluntaryorproducedby
muscularforcesisreferredtoasautomaticorterminalrotationor
lockingofkneeorscrewhomemechanism.
Answer:TrueSeptember 2022

104. Quiz Time
Punita V. Solanki
Select the Best Option (Multiple Choice Question)
1. An accessory joint structure that enhances congruence of
the articular surfaces of the tibia in the tibio-femoral joint is
a. Bursa.
b. Meniscus.
c. Synovial plica.
d. Articular Cartilage.
Answer Key: b
2. The anteromedial portion of the capsule of the knee
joint is also known as
a. Extensor Retinaculum.
b. Medial Patellar Retinaculum.
c. Both of the above.
d. Flexor Retinaculum.
Answer Key: c
September 2022

105. Quiz Time
Punita V. Solanki
Select the Best Option (Multiple Choice Question)
3. Both medial and lateral collateral ligaments of knee joint are
taut in
a. Full Extension.
b. Full Flexion.
c. Mid Flexion.
d. Hyperextension.
Answer Key: a
4. During extension of knee joint, the iliotibial band assists the
anterior cruciate ligament in preventing.
a. Anterior displacement of femur with fixed tibia.
b. Posterior displacement of femur with fixed tibia.
c. Anterior displacement of tibia with fixed femur.
d. Posterior displacement of tibia with fixed femur.
Answer Key: b
September 2022

106. Quiz Time
Punita V. Solanki
Select the Best Option (Multiple Choice Question)
5. The motions of the patella on the femur during knee
movements are described as
a. Sliding.
b. Tilting.
c. Rotation.
d. All of the above.
Answer Key: d
6. All of the following are dynamic stabilizers of the knee joint
except
a. Quadriceps Femoris.
b. Popliteus.
c. Muscles Inserted At Pes Anserinus.
d. IT Band.
Answer Key: d
September 2022

107. Quiz Time
Punita V. Solanki
Select the Best Option (Multiple Choice Question)
7. The patellofemoral joint stress is lowest with knee in
a. Extension
b. Flexion at 20°
c. Flexion at 90°
d. Flexion at 135°
Answer Key: a
8. All of the following are common malalignments of the knee
complex except
a. Genu Valgum.
b. Patella Alta.
c. Patella Baja.
d. Plica Syndrome.
Answer Key: d
September 2022

108. Recommended Reading & References
Punita V. Solanki
1.Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive
Analysis. 5
th
Edition. 2011. [Section 4. Chapter 11. The Knee. Pages: 395-439.]
2. Kapandji IA. The Physiology of Joints. Volume Two: The Lower Limb. 6
th
English Edition. 2011. [Chapter 2. The Knee. Pages: 66-155.]
3. Radomski MV, Trombly Latham CA. Occupational Therapy for Physical
Dysfunction. 7
th
Edition. 2014. Lippincott Williams & Wilkins, a Wolters
Kluwer Business. [Section II. Chapter 7: Assessing Abilities and Capacities:
Range of Motion, Strength, and Endurance. Pages: 144-241.]
4. Pendleton HM, Schultz-KrohnW. Pedretti’s Occupational Therapy:
Practice Skills for Physical Dysfunction. 8
th
Edition. 2018. Elsevier.
[Part IV: Chapter 21. Joint Range of Motion. & Chapter 22. Evaluation of
Muscle Strength.]
5. Neumann Donald A. Kinesiology of the Musculoskeletal System:
Foundations for Rehabilitation. 2
nd
Edition. 2010. [Section IV Lower Extremity
Chapter 13. Knee. Pages: 520-572.]
6. Norkin CC, White DJ. Measurement of Joint Motion: A Guide to
Goniometry. 5th Edition. 2016. F. A. Davis Company. [Part III. Lower
Extremity Testing. Chapter 9. The Knee. Pages: 315-344.]
September 2022

109. September 2022