Knee Flashcards

1
Q

Why is the knee joint classified as a complex joint?

A

Because it involves more than 2 articular surfaces and it contains intracapsular menisci.

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2
Q

What are the 3 articulations of the knee joints?

A
  • the 2 joints between the femur and tibia are classified as synovial, bi-condylar type;
  • the joint between the femur and patella is classified as a synovial , sellar type.
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3
Q

Classsify the knee joint

A
  • Synovial – possesses a capsule, synovium, hyaline cartilage, etc.
  • Complex (also Compound if PFJ included) – intraarticular structures intervene between the bones
  • Bicondylar – two areas of joint contact
  • Modified Hinge Joint – not just sagittal plane movement
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4
Q

Why is the knee joint described as a ‘modified hinge joint’?

A

Movements are largely restricted to one plane, however some axial rotation is possible.

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5
Q

Where does the knee joint line correspond to?

A

The upper margin of the tibial condyles.

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6
Q

What are the 2 main functions of the knee joint?

A
  • Mobility
  • Weightbearing/stability
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7
Q

The bony architecture of the knee joint makes it
relatively unstable, therefore how is it adapted to its function of weightbearing?

A

Strong collateral ligaments (transverse stability)
Intracapsular ligaments, ie cruciate ligaments (antero-posterior stability)
Strong capsule
Arrangement of the muscles surrounding the joint

Rotational stability is provided by both the cruciate and collateral ligaments

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8
Q

Describe the position of the synovial membrane lining the knee joint

A

It lines the capsule posteriorly and is reflected onto the bone as far as the articular surfaces. At the sides the membrane lines the capsule as far as the attachment of the menisci. Anteriorly, commencing at the upper border of patella, it forms a large pouch (suprapatellar bursa) under the quadriceps tendon over the anterior surface of the femur. Each side of the patella the membrane extends beneath the expansions of the vasti muscles.

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9
Q

Why are numerous bursae associated with the knee joint?

A

-The arrangement of the anterior structures
-The closeness of tendons surrounding the joint.

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10
Q

Define ‘synovium’

A

Complex arrangement of folds and pouches.
Characterised by extensive presence of bursae (bursa) – either communicating or non-communicating with the joint synovium.

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11
Q

What are the main functions of bursae?

A

Bursae minimise friction between moving surfaces (typically tendons and bone)

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12
Q

Give the 4 principle bursae and their respective locations

A
  • Subcutaneous prepatellar bursa [between the lower part of the patella and the skin]
  • Deep infrapatellar bursa [between the upper part of the tibia and the ligamentum patellae]
  • Subcutaneous (superficial) infrapatellar bursa [between the tibial tubercle and the skin]
  • Suprapatellar bursa [extends 6 cm above the base of the patella between the femur and the
    quadriceps femoris]
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13
Q

Describe the location of the subtendinous bursae

A

On the lateral side between the lateral collateral ligament and the tendons of biceps femoris and popliteus muscles.
On the medial side of the joint are a series of bursae separating the medial collateral ligament from
the tendons of the other hamstring muscles and gastrocnemius muscle.

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14
Q

Describe the articular surfaces of the fibrous joint capsule

A
  • “True” capsular fibres of the knee are absent anteriorly
  • Various structures crossing the knee joint blend with/provide expansions of fibrous tissue to form a patchwork of retinaculae
  • Lateral – ITB, LCL
  • Anteriorly – Quadriceps and tendons
  • Medially – MCL, Sartorius, Gracilis
  • Posteriorly – Hamstrings particularly Semimembranosus (OPL), Popliteus
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15
Q

Identify the bones in knee articulation

A

Femur
Tibia
Patella

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16
Q

Describe the shape of the femur

A

Femur: Convex femoral condyles, longer anteroposteriorly than transversely, diverge posteriorly, with the medial condyle being narrower and jutting out more than the lateral. The intercondylar notch continues the groove of the patella surface. Faint grooves separate condylar and patellar surfaces, with the patellar surface divided by a groove into smaller medial and larger lateral parts.

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17
Q

Describe the shape of the tibia

A

Tibia: Flat articular surfaces separated by intercondylar eminence with triangular areas anterior and posterior, the eminence lodging in the intercondylar notch of the femur, The oval concave medial articular surface is larger than the rounded lateral surface, concave transversely but concavo-convex anteroposteriorly.

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18
Q

Describe the shape of the patella

A

Patella: Oval articular surface divided into larger lateral and smaller medial areas by a vertical ridge. Another faint ridge separates a medial perpendicular facet from the main medial area.

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19
Q

Describe the attachments of the fibrous capsule and identify areas where the capsule may be thicker or deficient.

A

The knee is surrounded by a thick ligamentous sheath composed mainly of muscle tendons and their expansions; there’s no complete fibrous capsule.
Anteriorly, the fibrous capsule attachment to the femur is deficient, blending with the quadriceps tendons, its attachment to the tibia is more complete, being deficient only in the tibial tuberosity.
Posteriorly, true capsule fibres pass vertically from above the articular surface to the posterior border of the tibia, being strengthened by the oblique popliteal ligament.
At the sides capsular fibres pass from the femoral to tibial condyles, blending posteriorly with a ligamentous network and anteriorly with tendinous expansion of quadriceps femoris: the lower lateral capsule is strengthened by the arcuate popliteal ligament from the fibular head.

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20
Q

Define Q angle

A

A line representing the resultant line of force of the quadriceps, made by connecting a point near the ASIS to the mid-point of the Patella.
The Q angle can be measured in laying or standing. Standing is usually more suitable, due to the normal weight-bearing forces being applied to the knee joint as occurs during daily activity.

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21
Q

Define ‘Genu Valgus’

A

Decreasing of the femoraltibial angle (less than 170-175). A person with knock knees (genu valgum) has a large gap between their feet when they’re standing with their knees together. Many young children have knock knees, which tend to be most obvious at around the age of 4.

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22
Q

Define ‘Genu Varus’

A

Increasing of the femoraltibial angle (more than 170-175). Bow legs (or genu varum) is when the legs curve outward at the knees while the feet and ankles touch. Infants and toddlers often have bow legs. Sometimes, older kids do too. It’s rarely serious and usually goes away without treatment, often by the time a child is 3–4 years old

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23
Q

What are the 2 ligaments oustide the joint capsule called?

A

Medidal and lateral collateral ligaments.

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24
Q

What are the key roles of the collateral ligaments?

A

Movement
Weight bearing
Strengthens joint
Limits hyperextension of knee
Limit valgus and varus force respectively

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25
Q

Describe the structure of the MCL

A

MCL is broader
Strong band passing downward and forward from the medial epicondyle of femur to the medial condyle and shaft of tibia.
The most superficial fibres extend below the level of the tibial tuberosity, deeper fibres pass from femur to tibia, while the deepest spread out to attach to the head of the medial meniscus.

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26
Q

Describe the structure of the LCL

A

LCL is shorter – a rounded cord – and is independently of the capsule/lateral meniscus
5cm long.
Passes downward and backwards from the lateral epicondyle of the femur to the lateral surface of the fibular head anterior to the apex
Does not blend with the joint capsule

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27
Q

Give the 2 sets of intra-capsule structures found in the knee joint capsule

A

Cruciate ligaments (ACL and PCL)
Menisci (Medial and Lateral)

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28
Q

Describe the attachments of the menisci

A

The deep surface of the capsule is attached to the periphery of each meniscus connecting it to the adjacent margins of the tibia. The medial collateral ligament is blended into the fibrous capsule whereas the lateral ligament is free standing. Through this arrangement, the medial ligament is attached to the medial meniscus, and the 2 structures are often both involved in any injury process.

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29
Q

Describe the shape of the menisci

A

The menisci are intra-articular crescentic-shaped fibrocartilage structures triangular in cross-section interposed between femoral and tibial condyles. The periphery is attached to the joint capsule and the medial meniscus firmly anchored to medial collateral ligaments. The superior surface is smooth and concave, the inner free border is thin. The medial meniscus is broader posteriorly than anteriorly; the lateral meniscus is of uniform width. Anterior and posterior horns attach the menisci to the intercondylar eminence

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30
Q

Describe the attachments of the menisci

A

Posteriorly the medial meniscus is attached to the oblique popliteal ligament via the joint capsule and the lateral meniscus to the popliteus tendon: the lateral meniscus usually contributes a slip to the PCL (mensicofemoral ligament). From their outer margins thickenings of the joint capsule attach the menisci to the side of the patella (meniscopatellar fibres).

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31
Q

What is the transverse meniscomeniscal ligament?

A

The transverse or meniscomeniscal ligament is a ligament in the knee joint that connects the anterior margin of the lateral meniscus to the anterior end of the medial meniscus .

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32
Q

Identify the key roles of the mensici

A
  • Improve congruence
  • Weight bearing
  • Shock absorption
  • Lubrication
  • Participate in locking mechanism
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33
Q

Describe the position of the Anterior Cruciate Ligament

A

Passes posteriorly, laterally and proximally from the anterior tibial spine to the medial surface of the lateral femoral condyle, spiralling medially through 110* as it does so. The anteromedial band limits flexion and posterolateral band limits extension.
Longer than PCL (5:3)

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34
Q

Describe the position of the Posterior Cruciate Ligament

A

Passes anteriorly, medially and proximally from the posterior intercondylar area of the tibia to the lateral side of the medial femoral condyle, crossing the ACL on its medial aspect. The anterolateral band limits flexion and the postermedial limits extension.

35
Q

Identify the key functions of the cruciate ligaments

A

-Provide resistance to the anterior and posterior displacement of the tibia with respect to the femur.
-Provide medio-lateral stability

36
Q

What are the 4 active movements carried out on the knee?

A

Flexion, extension, medial rotation and
lateral rotation

37
Q

Which active movement has the largest ROM at the knee joint?

A

Flexion

38
Q

Which active movement has the smallest ROM at the knee joint?

A

Extension

39
Q

What are the 2 categories of rotation of the knee joint?

A

Adjunct rotation
Conjunct rotation

40
Q

Define conjunct rotation

A

Otherwise known as automatic rotations, defined as movements that occur at a joint as an inevitable accompaniment of some other main movement and result from the geometry of the articular surfaces.
Essential elements of the locking and unlocking mechanisms of the knee joint.

41
Q

Define a ‘roll’ in the context of the knee joint locking mechanism

A

A roll is a rotary movement, one bone rolling on another.

42
Q

Define a ‘spin’ in the context of the knee joint locking mechanism

A

A spin is a rotary movement, one body spinning on another.

43
Q

Define a ‘slide’ in the context of the knee joint locking mechanism

A

A slide is a translatory movement, sliding of one joint surface over another

44
Q

Define ‘Arthrokinematics’

A

Arthrokinematics describes the movement of joint surfaces in terms of angulation or translation.

45
Q

Briefly describe what the ‘locking mechanism’ is

A
  • A natural phenomenon of the knee joint (and others)
  • Acts to provide stability on the knee in an extended position. Improves efficiency in terms of energy use
  • Occurs due to a combination of factors:
  • Relative mismatch in size between the medial and lateral femoral condyles
  • Ligamentous tension in the extended position (MCL/LCL/ACL/PCL/Posterior capsule)
  • Menisci pushed forwards by the moving femur act as a wedge between the bones
46
Q

Describe the locking mechansim during extension, with the foot ON the ground i.e. weight bearing

A
  • The femur simultaneously rolls forwards, slides backwards and spins medially on the tibial
    plateau.
  • Because the medial condyle of the femur is longer the movement of the lateral condyle ends
    before extension is completed.
  • The movement of the medial femoral condyle continues and as a result the last 300 of
    extension is associated with some conjunct medial rotation of the femur. This occurs about a
    vertical axis and ‘locks’ the knee joint into full extension. This close pack position provides
    maximum congruency, compression, contact and thus stability.
  • During extension the menisci are pushed forwards by the femoral condyles to increase the
    area of contact between the 2 bones.
    MCL, LCL, ACL, PCL, Oblique popliteal ligaments all taut
    Patella moves proximally on femur
47
Q

Describe the locking mechansim during extension, with the foot OFF the ground i.e. non-weight bearing:

A
  • The tibia simultaneously rolls and slides forwards with lateral spin of the femoral condyles.
  • The continued movement of the medial condyles will be accompanied by conjunct lateral
    rotation of the tibia on the femur to ‘lock’ the joint.
  • During extension the menisci are pushed forwards by the femoral condyles to increase the
    area of contact between the 2 bones
    MCL, LCL, ACL, PCL, Oblique popliteal ligaments all taut
    Patella moves proximally on femur
48
Q

Describe the unlocking mechansim during
flexion, with the foot ON the ground i.e. weight bearing

A

Femur laterally rotates on the tibia to unlock the knee.
Femoral condyles roll backwards and slide forwards to maintain contact with the tibial plateau.
Lateral tibial condyle is smaller than the medial tibial condyle, so the femur laterally rotates on the tibia
Menisci drawn backwards on femoral condyles.
Ligaments relax
Patella moves distally on femur, held by quadreceps firmly

49
Q

Describe the unlocking mechansim during
flexion, with the foot OFF the ground i.e. non weight bearing

A

The first few degrees of flexion are associated with meidal rotation of the tibia on the femur which unlocls the knee before it can fully flex.

50
Q

Describe the close pack position of the knee joint

A

The “close-pack” position of the knee joint is full extension. This is where the collateral
ligaments are taut, the menisci are pushed forwards and the femur has undergone medial
rotation on the tibia creating the “locking” mechanism of the knee.

51
Q

Describe the loose pack position of the knee joint

A

The “loose-pack” position of the knee joint is a position of flexion of roughly 70-90 degrees
where ligaments are most lax and rotation/varus and valgus movement are most evident.

52
Q

Which is the muscle group which contributes to fibres of the knee joint capsule?

A

Quadriceps

53
Q

Give the major divisions of the knee muscles?

A
  1. Posterior femoral group = Hamstrings (3 muscles);
  2. Anterior femoral group = Quadriceps (4 muscles);
  3. Muscles of the medial thigh which act on the knee = Sartorius and Gracilis (note – not part
    of the adductor compartment of the thigh); and
  4. Muscles of the Deep Posterior Compartment of the Lower Leg = Popliteus
54
Q

Give the action and function of the quadriceps femoris muscle group?

A
  • Action(s) Leg extension at knee joint
  • Function(s) Powerful extensor of knee, but frequently works eccentrically to control flexion produced by gravity, e.g. sitting, sitting down, squats.
55
Q

Give the 4 muscles of the quadreceps muslce group

A

Rectus femoris
Vastus lateralis
Vastus medius
Vastus intermedius

56
Q

Fully classify the rectus femoris

A
  • Shape/Position/Special Features: Bipennate
  • Origin: Straight head- from anterior inferior ileac spine, reflected head- from above acetabulum
  • Insertion: base of patella
  • Nerve Supply and Root Value: Femoral Nerve (L2-4)
57
Q

Fully classify the vastus lateralis

A
  • Shape/Position/Special Features The largest and most powerful part of the quadriceps femoris
  • Origin: Upper part of intertrochanteric line, lower border greater trochanter, lateral side gluteal tuberosity, upper half lateral lip linea aspera, lateral intermuscular septum
  • Insertion: Base and lateral border patella
  • Nerve Supply and Root Value Femoral nerve (L2-4)
58
Q

Fully classify the vastus lateralis

A
  • Shape/Position/Special Features: The largest and most powerful part of the quadriceps femoris
  • Origin: Upper part of intertrochanteric line, lower border trochanter, lateral side gluteal tuberosity, upper half lateral lip linea aspera, lateral intermuscular septum
  • Insertion: Base and lateral border patella
  • Nerve Supply and Root Value: Femoral nerve (L2-4)
59
Q

Fully classify the vastus medialis

A
  • Shape/Position/Special Features: Horizontal fibres to prevent lateral dislocation of the patella and oblique fibres to extend the knee
  • Origin: Lower part of the intertrochanteric line, spiral line, medial lip linea aspera, upper part medial supracondylar line, medial intermuscular septum.
  • Insertion: Medial border patella
  • Nerve Supply and Root Value: Femoral nerve (L2-4)
60
Q

Fully classify the Vastus Intermedius?

A
  • Origin: Upper two-thirds anterior and lateral surfaces of femur
  • Insertion: Base of patella with rectus femoris
  • Nerve Supply and Root Value Femoral nerve (L2-4)
61
Q

Quadriceps Femoris form a communal tendon called…

A

Quadriceps tendon

62
Q

Describe the formation of the ligamentum patellae

A

All 4 heads of quadriceps contribute to the formation of the ligamentum patellae, running from apex of patella to tibial tuberosity, acting as tendon of insertion of quadriceps.

63
Q

Describe the location of the Articularis Genus

A

Attaches from distal end of femur, and into suprapatella bursa.

64
Q

What is the role of the Articularis Genus

A

As quads extend knee, grabs onto top of suprapatella bursa to move it out the way. Physios can manipulate knee joint cavity by contracting quads to move around synovial fluid.

65
Q

Give the action of the hamstrings

A

Extend hip, flex knee

66
Q

Give the function of the hamstrings

A
  • Balancing the pelvis on the trunk
  • Returning the upper body/flexed trunk to upright from a bent forwards position
  • Deceleration of the tibia in gait and running, preventing the knee snapping into extention.
67
Q

Fully classify the semitendinosis

A

Origin: Lower medial facet on ischial tuberosity
Insertion: Medial surface upper part of tibia (behind Sartorius and gracillis)
Nerve supply: Sciatic nerve (L5-S2)

68
Q

Fully classify the semimembranosis

A

Origin: upper lateral facet on ischial tuberosity
Insertion: Posteromedial surface of meidal tibial condyle
Nerve supply: Sciatic nerve (L5-S2)

69
Q

Fully classify the biceps femoris

A

Origin: Long head- lower medial facet on ischial tuberosity; Short head- lower half lateral lip linea aspera of femur
Insertion: Head of fibula
Nerve supply: Sciatic nerve (L5-S2)

70
Q

Describe the Pes Anserinus and give the muscles that its composed of

A

Muscles of the Medial Thigh which act upon the knee:
Anatomical region on the upper medial shaft of the tibia

(Think Sergeant – SGT)
* Sartorius
* Gracilis
* Tendinosus

71
Q

Why is the Pes Anserinus clinically significant?

A
  • Clinically important because of the bursae which separate the tendons.
  • Pes Anserine Bursitis is a clinical condition resulting in pain and loss of function at the knee
72
Q

Fully classify the sartorius

A
  • Shape/Position/Special Features: Strap muscle with longest muscle fibres in the body, called ‘tailors muscle’ as combined action at hip and knee places heel on opposite thigh in sitting.
  • Origin: Anterior superior iliac spine
  • Insertion Upper medial part of shaft of tibia in front of semitendinous and gracilis
  • Nerve Supply and Root Value: Femoral nerve (L2-3)
  • Action(s) Flexes, laterally rotates and abducts hip, flexes knee
  • Function(s) Sitting, running, squatting
73
Q

Fully classify the tensor fascia lata

A
  • Shape/Position/Special Features: Lies next to gluteus medius and minimus, shares same nerve supply.
  • Origin: Anterior superior iliac spine and adjacent iliac crest
  • Insertion: Between 2 layers of iliotibial tract which attaches to the lateral tibial condyle
  • Nerve Supply and Root Value: Superior gluteal nerve
  • Action(s) Abducts and medially rotates hip, extends knee
  • Function(s) sitting, sitting down, squats.
74
Q

Fully classify the popliteus

A
  • Shape/Position/Special Features: Deeply posterior to knee joint, Short, triangular muscle. Tendon is intra-capsular but extra-synovial
  • Origin: Outer surface lateral condyle of femur
  • Insertion: Posterior surface of tibia above soleal line
  • Nerve Supply and Root Value: Tibial nerve (L5)
  • Action(s) Weakly fexes knee and medially rotates tibia
  • Function(s) Role depends on the position of the lower limb. Laterally rotates femur on tibia to unlock knee when foot is fixed, also pulls lateral meniscus backwards to prevent entrapment
75
Q

Give the closed chain position when the tibia is fixed (on the floor)

A
  • Knee extended
  • Femur has medially rotated on the tibia in the “screw home” mechanism
  • Femur is the moving bone, tibia is the fixed bone
  • Popliteus working with a reverse origin-insertion relationship lateral femoral rotation “unlocks” the knee, enabling it to flex
75
Q

Give the closed chain position of knee extension when the tibia is fixed (on the floor)

A
  • Knee extended
  • Femur has medially rotated on the tibia in the “screw home” mechanism
  • Femur is the moving bone, tibia is the fixed bone
  • Popliteus working with a reverse origin-insertion relationship lateral femoral rotation “unlocks” the knee, enabling it to flex
    Patella moves up
76
Q

Give the open chain position of knee extension when the tibia is free (off the floor)

A
  • Knee extended
  • Femur has medially rotated on the tibia in the “screw home” mechanism
  • Tibia is the moving bone, femur is the fixed bone
  • Popliteus medial tibial rotation, enabling extension.
    Patella moves down
77
Q

Fully classify the gracililis

A
  • Position/Shape/Special features: Anterior medial thigh, thin and flattened, broad above, narrow and tapering below.
  • Origin: Body and inferior pubic ramus
  • Insertion: Medial surface shaft of tibia between Sartorius and semitendinosus
  • Nerve supply and root value: Obturator nerve (L2-3)
  • Action(s): Adducts hip and flexes knee
  • Function(s): Adductors work with other muscles during gait, e.g. adductors on left side contract to move body weight over the left foot, allowing right leg to step forward. Maintain level pelvis during gait. Well developed in speed skaters and horse riders for adduction (bringing the lower extremity toward the midline).
78
Q

Give the attachments of the popliteal fossa

A

Innominate Bone
Boundaries formed by muscles.

79
Q

What is the popluteal fossa?

A

The popliteal fossa is a shallow depression located at the back of the knee joint.

80
Q

What type of lever is the quadriceps acting on the knee?

A

Type 3

81
Q

What is a key role of the patella in relation to the quads?

A

The patella can change the angle of pull of the quadriceps

82
Q

Why does the knee joint have static stability?

A

Ligamentous support is the main static stabilising factor of the knee joint.
Collateral ligaments resist varus and valgus forces, whilst also limiting hyperextension.
Cruciate ligaments resist anterior and posterior translation of one bone on another, and also limit
rotational movements of the bones.

83
Q

Why does the knee joint have dynamic stability?

A

Muscles of the knee act to brace the joint and stabilise the two bones of the tibia and femur (the patella is inherently stable, being ensheathed within the tendon of the quadriceps, however it does benefit from medial and lateral stabilisation from Vastus Medialis and Vastus Lateralis).
Muscles of the posterior aspect of the joint – particularly the hamstrings and gastrocnemius –
act to prevent hyperextension of the knee, with some such as Semimembranosus reinforcing the
posterior capsule itself.