- Structures of the Knee
- Bones of the Knee
- Ligaments in the knee
- Tendons in the Knee
- Cartilage of the knee
- Muscles Around the Knee
- The Joint Capsule
- Knee Arteries and Veins
- Knee Function
- Problems in the Knee
- Pathological Conditions and Syndromes in the Knee
- Traumatic Knee Injuries
- Repetitive Knee Injuries
- Types of Knee Surgery
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Our knee is the most complicated and largest joint in our body. It’s also the most vulnerable because it bears enormous weight and pressure loads while providing flexible movement. When we walk, our knees support 1.5 times our body weight; climbing stairs is about 3-4 times our body weight and squatting about 8 times.
The knee joint is a synovial joint which connects the femur, our thigh bone and longest bone in the body, to the tibia, our shinbone and second longest bone. There are two joints in the knee—the tibiofemoral joint, which joins the tibia to the femur and the patellofemoral joint which joins the kneecap to the femur. These two joints work together to form a modified hinge joint that allows the knee to bend and straighten, but also to rotate slightly and from side to side.
The knee is part of a chain that includes the pelvis, hip, and upper leg above, and the lower leg, ankle and foot below. All of these work together and depend on each other for function and movement.
The knee joint bears most of the weight of the body. When we’re sitting, the tibia and femur barely touch; standing they lock together to form a stable unit. Let’s look at a normal knee joint to understand how the parts (anatomy) work together (function) and how knee problems can occur.
Anatomical terms allow us to describe the body clearly and precisely using planes, areas and lines. Instead of your doctor saying “his knee hurts” she can say “his knee hurts in the anterolateral region” and another doctor will know exactly what is meant. Below are some anatomic terms surgeons use as these terms apply to the knee:
- Anterior — if facing the knee, this is the front of the knee
- Posterior — if facing the knee, this is the back of the knee, also used to describe the back of the kneecap, that is the side of the kneecap that is next to the femur
- Medial — the side of the knee that is closest to the other knee, if you put your knees together, the medial side of each knee would touch
- Lateral — the side of the knee that is farthest from the other knee (opposite of the medial side)
Structures often have their anatomical reference as part of their name, such as the medial meniscus or anterior cruciate ligament. The medial meniscus would refer to the meniscus on the inside of the knee, the anterior crucial ligament would be on the anterior side (front) of the knee.
Structures of the Knee
The main parts of the knee joint are bones, ligaments, tendons, cartilages and a joint capsule, all of which are made of collagen. Collagen is a fibrous tissue present throughout our body. As we age, collagen breaks down.
The adult skeleton is mainly made of bone and a little cartilage in places. Bone and cartilage are both connective tissues, with specialized cells called chondrocytes embedded in a gel-like matrix of collagen and elastin fibers. Cartilage can be hyaline, fibrocartilage and elastic and differ based on the proportions of collagen and elastin. Cartilage is a stiff but flexible tissue that is good with weight bearing which is why it is found in our joints. Cartilage has almost no blood vessels and is very bad at repairing itself. Bone is full of blood vessels and is very good at self repair. It is the high water content that makes cartilage flexible.
Bones of the Knee
The bones give strength, stability and flexibility in the knee. Four bones make up the knee (see above image):
- Tibia —commonly called the shin bone, runs from the knee to the ankle. The top of the tibia is made of two plateaus and a knuckle-like protuberance called the tibial tubercle. Attached to the top of the tibia on each side of the tibial plateau are two crescent-shaped shock-absorbing cartilages called menisci which help stabilize the knee.
- Patella—the kneecap is a flat, triangular bone; the patella moves when the leg moves. It’s function is to relieve friction between the bones and muscles when the knee is bent or straightened and to protect the knee joint. The kneecap glides along the bottom front surface of the femur between two protuberances called femoral condyles. These condyles form a groove called the patellofemoral groove.
- Femur—commonly called the thigh bone; it’s the largest, longest and strongest bone in the body. The round knobs at the end of the bone are called condyles.
- Fibula—long, thin bone in the lower leg on the lateral side, and runs along side the tibia from the knee to the ankle.
Ligaments in the knee
The knee works similarly to a rounded surface sitting atop a flat surface. The function of ligaments is to attach bones to bones and give strength and stability to the knee as the knee has very little stability. Ligaments are strong, tough bands that are not particularly flexible. Once stretched, they tend to stay stretched and if stretched too far, they snap.
- Medial Collateral Ligament (tibial collateral ligament) – attaches the medial side of the femur to the medial side of the tibia and limits sideways motion of your knee.
- Lateral Collateral Ligament (fibular collateral ligament) – attaches the lateral side of the femur to the lateral side of the fibula and limits sideways motion of your knee.
- Anterior cruciate ligament – attaches the tibia and the femur in the center of your knee; it’s located deep inside the knee and in front of the posterior cruciate ligament. It limits rotation and forward motion of the tibia.
- Posterior cruciate ligament – is the strongest ligament and attaches the tibia and the femur; it’s also deep inside the knee behind the anterior cruciate ligament. It limits the backwards motion of the knee.
- Patellar ligament – attaches the kneecap to the tibia
The pair of collateral ligaments keep the knee from moving too far side-to-side. The cruciate ligaments crisscross each other in the center of the knee. They allow the tibia to “swing” back and forth under the femur without the tibia sliding too far forward or backward under the femur. Working together, the 4 ligaments are the most important in structures in controlling stability of the knee. There is also a patellar ligament that attaches the kneecap to the tibia and aids in stability. A belt of fascia called the iliotibial band runs along the outside of the leg from the hip down to the knee and helps limit the lateral movement of the knee.
Tendons in the Knee
Tendons are elastic tissues that technically part of the muscle and connect muscles to bones. Many of the tendons serve to stabilize the knee. There are two major tendons in the knee—the quadriceps and patellar. The quadriceps tendon connects the quadriceps muscles of the thigh to the kneecap and provides the power for straightening the knee. It also helps hold the patella in the patellofemoral groove in the femur. The patellar tendon connects the kneecap to the shinbone (tibia)—which means it’s really a ligament.
Cartilage of the knee
The ends of bones that touch other bones—a joint—are covered with articular cartilage. It’s gets its name “articular” because when bones move against each other they are said to “articulate.” Articular cartilage is a white, smooth, fibrous connective tissue that covers the ends of bones and protects the bones as the joint moves. It also allows the bones to move more freely against each other. The articular cartilages of the knee cover the ends of the femur, the top of the tibia and the back of the patella. In the middle of the knee are menisci—disc shaped cushions that act as shock absorbers.
- medial meniscus—made of fibrous, crescent shaped cartilage and attached to the tibia, on the inside of the knee
- lateral meniscus—made of fibrous, crescent shaped cartilage and attached to the tibia, on the outside of the knee
- articular cartilage is on the ends of all bones in any joint—in the knee joint it covers the ends of the femur and tibia and the back of the patella. The articular cartilage is kept slippery by synovial fluid (which looks like egg white) made by the synovial membrane (joint lining). Since the cartilage is smooth and slippery, the bones move against each other easily and without pain.
In a healthy knee, the rubbery meniscus cartilage absorbs shock and the side forces placed on the knee. Together, the menisci sit on top of the tibia and help spread the weight bearing force over a larger area. Because the menisci are shaped like a shallow socket to accommodate the end of the femur, they help the ligaments in making the knee stable. Because the menisci help spread out the weight bearing across the joint, they keep the articular cartilage from wearing away at friction points.
The weight bearing bones in our body are usually protected with articular cartilage, which is a thin, tough, flexible, slippery surface which is lubricated by synovial fluid. The synovial fluid is both viscous and sticky lubricant. Synovial fluid and articular cartilage are a very slippery combination—3 times more slippery than skating on ice, 4 to 10 times more slippery than a metal on plastic knee replacement. Synovial fluid is what allows us to flex our joints under great pressure without wear.
Muscles Around the Knee
The muscles in the leg keep the knee stable, well aligned and moving—the quadriceps (thigh) and hamstrings. There are two main muscle groups—the quadriceps and hamstrings. The quadriceps are a collection of 4 muscles on the front of the thigh and are responsible for straightening the knee by bringing a bent knee to a straight position. The hamstrings is a group of 3 muscles on the back of the thigh and control the knee moving from a straight position to a bent position.
The Joint Capsule
The capsule is a thick, fibrous structure that wraps around the knee joint. Inside the capsule is the synovial membrane which is lined by the synovium, a soft tissue that secretes synovial fluid when it gets inflamed and provides lubrication for the knee.
There are up to 13 bursa of various sizes in and around the knee. These fluid filled sacs cushion the joint and reduce friction between muscles, bones, tendons and ligaments. There are bursa located underneath the tendons and ligaments on both the lateral and medial sides of the knee. The prepatellar bursa is one of the most significant bursa and is located on the front of the knee just under the skin. It protects the kneecap. In addition to bursae, there is a infra patellar fat pad that helps cushion the kneecap.
Knee Arteries and Veins
So now we have all the parts, let’s see how the knee moves (articulates)—which is how we walk, stoop, jump, etc. The knee has limited movement and is designed to move like a hinge.
The Quadriceps Mechanism is made up of the patella (kneecap), patellar tendon, and the quadriceps muscles (thigh) on the front of the upper leg. The patella fits into the patellofemoral groove on the front of the femur and acts like a fulcrum to give the leg its power. The patella slides up an down the groove as the knee bends. When the quadriceps muscles contract they cause the knee to straighten. When they relax, the knee bends.
Problems in the Knee
The knee doesn’t have much protection from trauma or stress (pressure or force). In addition to wear and tear on the knee, sports injuries are the source of many knee problems.
Knee symptoms come in many varieties. Pain can be dull, sharp, constant or off-and-on. Pain can also be mild to agonizing. The range of motion in the knee can be too much or too little. You may hear grinding or popping, the muscles may feel weak or the knee can lock. Some knee problems only need rest and ice, others need physical therapy (knee rehab exercises) or even surgery.
- Swelling: One of the most common symptoms is local swelling. There are two types of swelling. One is caused by the knee producing too much synovial fluid and the other is caused by bleeding into the joint (hemarthrosis). Swelling within the first hour of an injury is usually from bleeding. Swelling from 2-24 hours is more likely to be from the joint producing large amounts of synovial fluid trying to lubricate an abnormality inside the knee. The best home treatment for swelling is R.I.C.E. therapy. Chronic swelling can distend the knee, prohibit full range of motion and the muscles can atrophy from non-use. Also, if the cause of the swelling is blood, the blood can be destructive to the joint.
- Locking. Locking is when something is keeping the knee from fully straightening out. This is usually a loose body in the knee. The loose body can be as small as a grain of sand or as big as a quarter. The best treatment is removal of the loose body by arthroscopy. Another type of locking is when the knee hurts so bad that you just won’t use it. The best treatment here is rest and maybe some ice; swelling is not usually present.
- Giving Way. If your kneecap slips out of is groove for an instant, it causes your thigh muscles to loose control causing the feeling of instability—that is, you don’t feel like your knee is stable, won’t support your weight—and you usually try to grab hold of something for support. Giving way can also be caused by weak leg muscles or an old ligament injury.
- Snaps, Crackles and Pops. Noises coming from your knee without pain are likely nothing to worry about. Sometimes the noise is caused by loose bodies that just float around and are not causing pain or injury to the knee. However, If you have pain, swelling or loss of knee function, you should see an orthopedist. The most common cause—chondromalacia patella—is caused by an injury. Another common cause is a dislocating kneecap—that is, a kneecap that keeps slipping out of its groove. Pops without trauma (injury) are not worrisome, pops with trauma can mean ligament tears. Crackling, grinding or grating (crepitus) means there is a roughness to the bone surfaces and likely from degenerative disease or wear-and-tear arthritis (osteoarthritis).
- Pain and Tenderness. Where and how bad the pain is will help find the underlying cause. It also helps to know what caused it and what makes it hurt. Pain that gets worse with activity is often tendinitis or stress fractures. Pain and tenderness accompanied by swelling can be more serious such as a tear or sprain. Some pain can be caused by muscles spasms associated with trauma.
Pathological Conditions and Syndromes in the Knee
- Osteochondritis Dissecans
- Osteoarthritis (Degenerative Arthritis)
- Infectious Arthritis
- Chondromalacia Patellae
- Plica Syndrome
- Rheumatoid Arthritis
Traumatic Knee Injuries
- Anterior cruciate ligament (ACL) Injury
- Meniscus tear
- Lateral and Medial Collateral Ligament Injury
- Posterior Cruciate Ligament (PCL) Injury
- Patellar Injuries
- Dislocation of the Patella
- Rupture of the Patellar Tendon
- Fracture and Stress Fracture
Repetitive Knee Injuries
- Patellofemoral Syndrome (Runner’s Knee)
- Bursitis (Housemaid’s Knee)
- Illiotibial Band Syndrome
- Osgood-Schlatter Disease