Knee Anatomy

A. Bone anatomy (
Figure 1)
1. Tibia
a. The tibia slopes anterior to posterior (7 to 10).
b. It articulates with the femur on the medial plateau (larger and biconcave) and the lateral plateau
(smaller, more circular, convex in sagittal plane, and concave in frontal plane).
c. The medial and lateral plateaus are separated by the intercondylar eminence with the medial and
lateral spinous processes.
d. The tibial tuberosity is the site of attachment of the patellar tendon. It typically is located in the
midline anteriorly but may be slightly lateral.
e. The Gerdy tubercle is the insertion of the iliotibial band and is located 2 to 3 cm lateral to the
tibial tubercle on the proximal tibia.
f. The proximal fibula articulates with a facet of the lateral cortex of the tibia and is not part of the
knee articulation.
2. Femur
a. Medial and lateral condyles
i. Both condyles are convex.
ii. The medial condyle is larger and projects farther posteriorly and distally than the lateral femoral
condyle.
iii. The lateral condyle projects farther anteriorly and has more width in the medial to lateral
direction.
b. Just distal to the intercondylar notch of the lateral femoral condyle is a small ridge called the
sulcus terminalis.
[Figure 1. Radiographs of the knee. A, AP radiograph of knee. FE = femur, PAT = patella, ME =
medial epicondyle, LE = lateral epicondyle, MFC = medial femoral condyle, LFC = lateral
femoral condyle, IE = intercondylar eminence, MTP = medial tibial plateau, LTP = lateral tibial
plateau, FH = fibular head, TI = tibia. B, Lateral radiograph of knee. FE = femur, TG = trochlear
groove, PAT = patella, BL = Blumensaat line, MFC = medial femoral condyle, LFC = lateral
femoral condyle, IE = intercondylar eminence, FH = fibular head, TT = tibial tuberosity, TI =
tibia. C, Sunrise view of knee (patella). LF = lateral facet of patella, MF = medial facet of
patella, TRO = trochlea.]

c. The adductor tubercle is just proximal to the medial epicondyle and is the origin of the medial
collateral ligament (MCL).
d. The intercondylar notch of the femur has a variable width and is the site of attachment of the
cruciate ligaments: the anterior cruciate ligament (ACL) on the lateral wall and the posterior
cruciate ligament (PCL) on the medial wall.
3. Patella
a. The patella is the largest sesamoid bone in the body.
b. The bone averages 2.5 cm in thickness.
c. It has the thickest articular surface in the body (approximately 5 mm in midportion, 2 mm on the
sides).
d. FacetsThe patella has three main facets: lateral (the largest), medial, and odd (smallest and far
medial, articulates with femur in deep flexion). The lateral trochlear facet is longer and taller,
preventing lateral subluxation of the patella.
e. The Wiberg classification defines three types of patellae based on the position of the vertical
ridge:
i. Type I: the medial and lateral facets are roughly equal.
ii. Type II (most common): the medial facet is smaller and is half the size of the lateral facet.
iii. Type III: the medial facet is so far medial that the central ridge is barely noticeable.
B. Vascular anatomy (
Figure 2)
1. The blood supply to the knee is formed from an anastomosis around the knee derived from
several arterial branches:
a. Descending geniculate artery (branch of femoral artery)
b. Medial and lateral superior geniculate arteries (branch of popliteal artery)
c. Medial and lateral inferior geniculate arteries (branch of popliteal artery)
d. Middle geniculate artery (branch of popliteal artery)
e. Anterior tibial recurrent arteries
2. The inferior geniculate arteries pass deep to their respective collateral ligaments.

3. The blood supply of the patella is derived from the geniculate artery complex with some
contribution from the anterior tibial recurrent artery and primarily comes in the mid- to inferior
portion of the patella.
C. Nerve anatomy (Figure 2)
1. Innervation of the knee is supplied by branches from the femoral nerve (L2, L3, L4), obturator
nerve (L2, L3, L4), and sciatic nerve (L, L5, S1, S2).
2. The largest nerve providing innervation to the intra-articular knee is the posterior articular branch
of the posterior tibial nerve. This nerve supplies the infrapatellar fat pad, the synovial covering
over the cruciate ligaments, and the periphery of the meniscus.
3. The infrapatellar branch of the saphenous nerve arises proximal to the knee joint medially and
crosses distal to the patella to innervate the skin over the anterior knee/tibia region.
D. Ligament anatomy (
Figure 3)
1. Anterior cruciate ligament (ACL)
a. The ACL is composed of 90% type I collagen and 10% type III collagen.
b. The average length is 33 mm; the average width is 11 mm.
c. The femoral attachment is a semicircular area on the posteromedial aspect of the lateral femoral
condyle (20 mm long and 10 mm wide).
d. The tibial attachment is a broad, irregular, oval-shaped area just slightly medial and anterior to
the midline and between the intercondylar eminences of the tibia (10 mm wide and 30 mm long).
e. The middle geniculate artery is the primary blood supply.
f. The posterior articular branch of the posterior tibial nerve provides innervation.
2. Posterior cruciate ligament
a. The average length of the PCL is 38 mm; the average width is 13 mm.
b. The femoral attachment is a broad, crescent-shaped area anterolateral on the medial femoral
condyle (30 mm long and 5 mm wide).
c. The tibial attachment is in a central sulcus on the posterior aspect of the tibia, 10 to 15 mm below
the articular surface.

d. The meniscofemoral ligaments (ligaments of Humphrey and Wrisberg) are present 70% of the
time; they originate from the posterior horn of the lateral meniscus and insert into the substance
of the PCL and the medial femoral condyle.
[Figure 2. Cross section of the knee at the joint level. A, Cross section of the knee at the level of
the menisci. B, Axial MRI scan at the level of the joint. Note relationships of structures,
particularly the popliteal artery and its close proximity to the posterior aspect of the knee joint.]

[Figure 3. Coronal and sagittal MRIs showing the anatomic structures of the knee. A, Coronal
MRI scan at midportion of knee joint. Note the lateral structures, particularly the inferior fascicle
of the lateral meniscus. B, Sagittal MRI scan of knee at area of the notch. Note the transverse
ligament anteriorly, just above the anterior horn of the lateral meniscus.]
i. The ligament of Humphrey is anterior to the PCL.
ii. The ligament of Wrisberg is posterior to the PCL.
e. The innervation and vascularity of the PCL are similar to the ACL but with a more generous
blood supply.
3. Medial collateral ligament
a. The MCL has two main layers, superficial and deep.
i. Superficial layerThe superficial MCL is also known as the tibial collateral ligament and lies
deep to the gracilis and semitendinosis tendons. It originates from the medial femoral epicondyle
and inserts onto the periosteum of the proximal tibia, deep to the pes anserinus, approximately
4.6 cm distal to the joint line. The anterior fibers of the superficial MCL tighten during the first
90 of flexion, whereas the posterior fibers tighten in extension.
ii. Deep layerThe deep portion of the ligament is also referred to as the medial capsular ligament.
It is a capsular thickening that originates from the femur and blends with the superficial fibers
distally. It is intimately associated with the medial meniscus by attachments to the coronary
ligaments.
b. The blood supply to the MCL is from the superomedial and inferomedial geniculate arteries.
4. Posteromedial knee and medial layers
a. The PM corner is comprised of the various insertions of the semimembranosus tendon that
contribute to capsular thickening as well as the oblique popliteal ligament and the posterior
oblique ligament.
b. The oblique popliteal ligament is a thickening of the most posterior aspect of the capsule. It
extends from the inferomedial aspect of the posterior knee at the site of the semimembranosus

insertion on the tibia and travels superolaterally, inserting into the capsule behind the lateral
femoral condyle.
c. The posterior oblique ligament originates from the medial surface of the femur distal to the
adductor tubercle and posterior to the origin of the superficial MCL, and inserts at the posterior
medial corner of the tibia. It plays a role, in conjunction with the coronary ligaments, in
stabilizing the medial meniscus. It might also play a role in PM rotatory stability.
d. The medial side of the knee has three layers, with the MCL involved with the deep two layers.
i. Layer I: deep fascia overlying the vastus medialis and the MCL and extending to the sartorius
ii. Layer II: superficial MCL and the structures anterior to it, and the posterior oblique ligament
iii. Layer III: the capsule, including the deep MCL and the coronary ligaments
iv. The semitendinosus and gracilis tendons are located between layers I and II.
5. Lateral collateral ligament (LCL)
a. The LCL is also known as the fibular collateral ligament.
b. It is tubular in shape, with a diameter of 3 to 4 mm and length of 66 mm.
c. The LCL originates 1.4 mm proximal and 3.4 mm posterior to the ridge of the lateral femoral
epicondyle and is posterior and superior to the insertion of the popliteus tendon. It inserts on the
lateral aspect of the fibular head.
d. The blood supply is from the superolateral and inferolateral geniculate arteries.
6. Posterolateral corner
a. The PL corner consists of superficial and deep layers.
i. The superficial layer is comprised of the biceps femoris tendon and the iliotibial band.
ii. The deep layer is comprised of the LCL, the capsule, the popliteus tendon, the arcuate ligament,
the popliteofibular ligament, and the fabellofibular ligament.
b. The lateral capsule extends from the anterior border of the popliteus tendon's insertion on the
femur to the lateral gastrocnemius attachment.
i. The mid-third lateral capsular ligament is a thickening of the lateral capsule of the knee and is
divided into two components: the meniscofemoral and meniscotibial components.

ii. A Segond fracture, which is pathognomonic of an ACL injury, is a result of an avulsion injury of
the meniscotibial component.
c. The popliteus originates on the back of the tibia and inserts medial, anterior, and distal to the
LCL, approximately 18 mm away.
i. The popliteus is intracapsular, becoming intra-articular as it passes through a hiatus in the
peripheral attachment of the meniscus.
ii. As it courses intra-articularly, it gives off three branches that contribute to the dynamic stability
of the lateral meniscus. These are known as the popliteomeniscal fascicles.
d. The arcuate ligament is Y-shaped. It arises from the styloid process of the fibula, advancing to be
contiguous with the oblique popliteal ligament posteriorly.
e. The popliteofibular ligament runs from the musculotendinous junction of the popliteus to the
posterosuperior prominence of the fibular head adjacent to the insertion of the LCL.
f. The fabellofibular ligament originates from the fabella and inserts on the fibular head.
7. Other ligaments and structures
a. Anterior
i. The quadriceps mechanism involves four muscles: the rectus femoris, the vastus medialis, the
vastus lateralis, and the vastus intermedius.
ii. The medial and lateral retinacula are extensions of the quadriceps tendon.
iii. The patellofemoral ligaments are discrete thickenings in the retinaculum. The medial
patellofemoral ligament, which originates from the adductor tubercle and inserts onto the medial
border of the patella, is the key restraint in preventing lateral displacement of the patella.
iv. The patellar tendon extends from distal pole of the patella, inserting onto the tibial tubercle. The
patellar tendon is from 3.0 to 3.5 mm in width.
b. Posterior
i. The popliteal fossa contains the popliteal neurovascular structures and is formed proximally by
the biceps femoris laterally and the semimembranosus and pes anserinus medially.
ii. The fossa is formed distally by the two heads of the gastrocnemius.
c. Plica

i. Synovial plica are variable-appearing folds of tissue in the knee thought to represent embryologic
remnants.
ii. The plica may be medial (most common), lateral, suprapatellar, and/or infrapatellar.
iii. The medial plica originates superior laterally to the patella in the synovium and inserts into the
anterior fat pad.
E. Meniscus anatomy
1. Menisci are crescent-shaped fibrocartilaginous structures with a triangular cross section.
2. Menisci are composed of primarily type I collagen with fibers arranged obliquely, radially, and
vertically.
3. The vascular supply to both menisci arises mainly from the lateral and medial geniculate arteries.
Vascular penetration is 20% to 30% of the width of the medial meniscus and 10% to 25% of the
lateral meniscus.
4. The menisci are connected anteriorly by the transverse (intermeniscal) ligament and peripherally
via the coronary ligaments.
5. The medial meniscus is C-shaped, with an average width of 9 to 10 mm and an average thickness
of 3 to 5 mm. The peripheral attachments are more rigid than the lateral meniscus.
6. The lateral meniscus is circular and covers a larger portion of the articular surface than the
medial meniscus. The average width is 10 to 12 mm, and the average thickness is 4 to 5 mm.
7. The anterior and posterior horn attachments of the lateral meniscus are close to each other and
near the ACL (just posterior and just anterior), whereas the medial horns are separated and far
from the ACL (posterior is along the posterior tibial eminence, and anterior is anterior to the
ACL and the eminence).
F. Arthroscopic and portal anatomy (
Figure 4)
1. Arthroscopic examination reveals the normal and pathologic intra-articular anatomy. Most
structures are evident upon evaluation arthroscopically.
2. Standard working arthroscopic portals include an AL and AM portal just inferior to the patella.
a. Other portals are the superomedial and superolateral portals, often used for inflow.
b. Less-used portals are the midpatellar tendon portal and the PM and PL portals.
3. Structures potentially at risk

a. The infrapatellar branch of the saphenous nerve is at risk with any of the anterior portals inferior
to the patella.
b. The saphenous nerve is at risk with the PM portal.
c. The peroneal nerve is at risk with the superolateral portal.
II. Knee Biomechanics
A. Gait in reference to the knee
1. Normal gait (walking)The gait cycle has two phases:
a. Swing phase (40%)Initial swing, midswing, and terminal swing.
b. Stance phase (60%)Initial contact, loading response, midstance, terminal stance, and preswing.
2. Three essential actions occur at the knee.
a. Flexion to decrease the impact of initial contact
b. Extension for weight-bearing stability
c. Flexion for toe clearance during swing
3. Patients with ACL-deficient knees demonstrate the avoidance of quadriceps contraction during
activities when the knee is near full extension.
4. Loss of knee extension can occur following ACL reconstruction or other surgery. This will
interfere
[Figure 4. Arthroscopic views of the knee. A, Arthroscopic photograph of lateral gutter. POP =
popliteus tendon, LFC = lateral femoral condyle, LM = lateral meniscus. B, Arthroscopic
photograph of lateral compartment. LFC = lateral femoral condyle, POP = popliteus, LM =
lateral meniscus, LTP = lateral tibial plateau. C, Arthroscopic photograph of patellofemoral
compartment. P = patella, TRO = trochlea. D, Arthroscopic phototograph of medial plica. P =
patella, MT = medial trochlea, PL = plica. E, Arthroscopic photograph of notch. LFC = lateral
femoral condyle, ACL = anterior cruciate ligament, PCL = posterior cruciate ligament. F,
Arthroscopic photograph of medial compartment. MFC = medial femoral condyle, MM = medial
meniscus. G, Arthroscopic photograph of medial compartment. MFC = medial femoral condyle,
MTP = medial tibial plateau, MM = medial meniscus.]
with limb advancement because the knee is flexed and the limb does not easily reach the ground.
It will also result in increased contralateral hip and knee flexion so that there is limb clearance
during swing phase.

B. Muscle, ligament, and joint forces

1. Estimation of muscle forces on the knee with walking: The mean maximum muscle forces are
741 N in the quadriceps, 1,199 N in the hamstrings, and 1,039 N in the gastrocnemius.
2. Estimation of forces on ligaments with various activities
a. Normal walkingThe mean maximum forces are 329 N in the PCL, 154 N in the ACL, 62 N in
the MCL, and 235 N in the LCL.
b. Squat, leg press, knee extensionPeak tibiofemoral compressive forces: 3,134 N during squat,
3,155 N during leg press, 3,285 N during knee extension. Peak PCL tensions: 1,868 N during
squat, 1,866 N during leg press, 959 N for seated knee extension. There is no anterior ACL
tension during leg press and squat. Peak ACL tension is 142 N during seated knee extension.
[
Figure 5. A human knee with the lateral femoral condyle removed, exposing the cruciate
ligaments. Superimposed is a diagram of a 4-bar linkage comprising the ACL (AB), the PCL
(CD), the femoral link CB joining the ligament attachment points on the femur, and the tibial
link AD joining the attachment points on the tibia]
c. Isokinetic/isometric extension
i. Peak ACL forces, occurring at knee angles of 35 to 40, may reach 0.55 times body weight.
ii. Peak PCL forces are lower and occur around 90.
d. Isokinetic/isometric flexion
i. Peak PCL forces, which occur around 90, may exceed 4 times body weight; the ACL is not
loaded.
ii. Peak PCL forces occur near the lowest point of the squat and may reach 3.5 times body weight
or about 2,500 N during a full squat for a 73-kg person.
3. Joint reaction force is the combination of forces acting on a joint with various activities. In the
knee, this is the result of the ground reaction force as well as the forces of muscle contraction.
a. Tibiofemoral jointMaximum knee joint force is approximately 3 times body weight with
normal walking and 4 times body weight with stairs.
b. Patellofemoral jointNormal walking produces compressive forces that are approximately one
half body weight. This increases to 3 times body weight with stairs and 7 times body weight with
deep knee bends.
C. Ligament kinematics

1. Knee joint motion in the sagittal plane is best described by a four-bar linkage (Figure 5).
a. This allows the femur to roll and slide on the tibia.
b. Posterior rollback facilitates knee flexion.
2. Function of the ligaments (including mechanical properties)
a. Anterior cruciate ligament
i. The ACL is composed of the AM and PL bundles.
ii. It is the primary restraint to anterior tibial translation and is a secondary restraint to varus and
valgus angulation.
iii. The AM bundle is the stronger and stiffer component and tightens with knee flexion.
iv. The PL bundle tightens with knee extension.
v. The ultimate tensile load of the native human ACL is approximately 2,000 N.
vi. The normal ACL is not isometric; in fact, tension increases with knee extension.
vii. Ultimate tensile strength of grafts commonly used for ACL reconstruction: quadruple-looped
hamstring tendon4,000 N; double-looped tibialis tendon4,000 N; bone-patellar tendon-bone
2,900 N; double-looped hamstring tendon2,000 N
b. Posterior cruciate ligament
i. The PCL is comprised of the AL and PM bundles.
ii. It is the primary restraint to posterior tibial translation and is a secondary restraint to varus and
valgus angulation.
iii. The AL bundle is the stronger and stiffer component and tightens with knee flexion.
iv. The PM bundle tightens with knee extension.
c. Medial collateral ligament
i. The MCL is the primary restraint to valgus angulation.
ii. It is a secondary restraint to anterior and posterior tibial translation.
d. Lateral collateral ligament/posterolateral corner

i. The LCL/PL corner is the primary restraint to varus angulation and also resists external rotation.
ii. It is a secondary restraint to anterior and posterior translation.
D. Meniscus
1. The tensile properties of the menisci are nonlinear, anisotropic, and vary by region of the
meniscus.
2. The primary mechanical function of the menisci is to distribute loads across the knee joint.
a. Approximately 50% of the compressive load of the knee joint is transmitted through the menisci
in extension, which increases to 85% at 90 of flexion.
b. The menisci also enhance the shock-absorbing capacity of the knee.
c. The medial meniscus has some role as a secondary restraint to anterior tibial translation in the
ACL-deficient knee.
3. Partial meniscectomy results in increased articular cartilage contact pressure, which is
proportional to the amount of meniscus excised.
4. Total meniscectomy results in a 200% to 300% increase in mean peak articular cartilage contact
pressures.
5. Size-matched allograft meniscus transplantation results in a 56% to 60% decrease in mean peak
articular cartilage contact pressures, although these values are still 36% to 86% higher than
normal.
6. As the knee is moved from 0 to 120 of flexion (motion), mean AP displacement of the medial
meniscus is 5.1 mm, whereas displacement of the lateral meniscus is 11.2 mm. This is likely due
to better bony conformity in the medial compartment and the fact that the medial meniscus is
well fixed to the capsule, whereas the lateral meniscus is less well constrained.
E. Articular cartilage
1. Normal articular cartilage is soft, porous, and permeable.
a. Water, which is responsible for 65% to 80% of the total weight of articular cartilage, resides in
the pores of articular cartilage and may flow out as a result of pressure.
b. Thus, articular cartilage is best viewed as a biphasic material, composed of a solid phase and a
fluid phase.

c. The proteoglycans form a strong, durable matrix with mechanical properties that allow it to
withstand repetitive high stresses and strains encountered with normal use.
2. Joint motion and loading are required to maintain normal articular cartilage structure and
function. Increased joint loading as the result of injury or excessive loading may result in
catabolism of articular cartilage with resultant loss of mechanical properties.
3. Prolonged decreased joint use as the result of injury or surgery can lead to alterations in matrix
composition and eventual loss of mechanical properties.
F. Anatomic axis and mechanical axis
1. The anatomic axis of the knee is measured by drawing lines down the center of the tibia and
femur on radiographs. The angle formed by the intersection of these two lines defines the
anatomic axis.
2. The mechanical axis of the lower extremity is determined by drawing a line from the center of
the femoral head to the center of the ankle on a radiograph. This axis usually passes through the
medial part of the femoral notch or lateral part of the medial compartment.
G. Biomechanical basis for physical examination tests
1. The Lachman test is the most sensitive test for diagnosing ACL injuries.
2. The anterior drawer test is useful but has a high false-negative rate.
3. The posterior drawer test is the most accurate physical examination maneuver for diagnosing
PCL injuries.
a. In addition to laxity testing, the step-off between the medial tibial plateau (MTP) and the medial
femoral condyle (MFC) can be determined.
b. With no force applied, the MTP is usually about 1 cm anterior to the MFC.
c. A posteriorly directed force is applied to the proximal tibia, and posterior translation of the tibia
is quantified.
4. Other tests that can be useful in evaluating for abnormal posterior laxity include the posterior sag
test and the quadriceps active test.
5. Varus and valgus stress testing is used to assess the integrity of the MCL and LCL at 0 and 30
of knee flexion.
a. Isolated collateral ligament injuries will have increased laxity at 30 of flexion but not at 0.

b. Increased laxity at 0 of knee flexion usually signifies a high-grade collateral ligament injury,
usually combined with an ACL and/or PCL injury.
6. The "dial test" can be performed with the patient supine or prone.
a. The tibia is passively externally rotated on the femur.
b. A side-to-side difference of 10 constitutes a positive test.
c. Increased external rotation at 30 but not 90 of flexion is indicative of an isolated PL corner
injury, whereas increases at both 30 and 90 suggest injury to both the PL corner and the PCL.
7. The pivot-shift test can be elicited with a combination of forces applied to the proximal tibia
including valgus stress, internal rotation, and axial loading as the knee is taken from a position of
extension to flexion.
a. With the knee in extension, the lateral tibial plateau is subluxated in the ACL-deficient knee.
b. A positive test ("clunk") is appreciated by reduction of the tibia on the femur at around 30 of
knee flexion. A positive test correlates well with patient symptoms of "giving way."
Top Testing Facts
Anatomy
1. The vascular supply for the cruciate ligaments is the middle geniculate artery.
2. The largest nerve providing innervation to the intraarticular knee is the posterior articular branch
of the posterior tibial nerve.
3. The ACL has an anteromedial (AM) bundle and a posterolateral (PL) bundle. The AM bundle is
tight in flexion, and the PL bundle is tight in extension.
4. The middle geniculate artery is the primary blood supply for the ACL.
5. The PCL has two bundles: the anterolateral bundle, which is tight in flexion, and the
posteromedial bundle, which is tight in extension.
6. The meniscofemoral ligament of Humphrey is anterior to the PCL, and the ligament of Wrisberg
is posterior to the PCL.
7. The structure just posterior to the PCL insertion is the posterior tibial artery.
8. The vascular supply to both menisci arises mainly from the lateral and medial geniculate arteries.

9. Structures at risk with inside-out lateral meniscus repair are the lateral inferior geniculate artery
and peroneal nerve.
Biomechanics
1. Peak PCL forces occur near the lowest point of the squat and may reach 3.5 times body weight.
2. Sagittal plane knee motion can best be described by a four-bar linkage.
3. Commonly used grafts for ACL reconstruction (bone-patellar tendon-bone, quadrupled
hamstring, and doubled posterior tibialis tendons) have a higher ultimate tensile load than the
native ACL.
4. The Lachman test is the most sensitive physical examination maneuver for diagnosing an ACL
injury.
5. Increased external rotation at 30 but not 90 of flexion is indicative of an isolated PL corner
injury, whereas increases at both 30 and 90 suggest injury to both the PL corner and the PCL.