Anfis Regio Hip & Knee

2363_Ch18-259-282.
qxd 12/10/10 12:34 PM Page 261
C H A P T E R18
Hip Joint
Joint Structure and Motions The lower extremity includes the pelvis, thigh, leg, and
foot (Fig. 18-1). Bones of the pelvis are the two hip bones
Bones and Landmarks
(os coxae bones), the sacrum, and the coccyx. The hip
Ligaments and Other Structures bone consists of three bones (ilium, ischium, and pubis)
fused together. The thigh contains the femur and the
Muscles of the Hip
patella. The leg includes the tibia and fibula, and
Anatomical Relationships
Common Hip Pathologies
Summary of Muscle Action
Pelvis
Summary of Muscle Innervation
Points to Remember
Review Questions
General Anatomy Questions
Functional Activity Questions
Thigh
Clinical Exercise Questions
Leg
Foot
Figure 18-1. The bones of the lower extremities

(anterior view).
261
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 262
262 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities
the foot includes seven tarsal bones, 5 metatarsals, and

14 phalanges. Table 18-1 summarizes the bones of the
lower extremity.
Joint Structure and Motions

The hip is the most proximal of the lower extremity
joints. It is very important in weight-bearing and walk-
ing activities. Like the shoulder, it is a ball-and-socket
joint. The rounded or convex-shaped femoral head fits
into and articulates with the concave-shaped acetabu-
lum (Fig. 18-2). The convex femoral head slides in the
direction opposite the movement of the thigh. Unlike
the shoulder, the hip is a very stable joint and therefore
sacrifices some range of motion. Conversely, the shoul-
der, which allows a great deal of motion, is not as stable. Figure 18-2. The hip joint (anterior view).
Being a triaxial joint, the hip has motion in all three
planes (Fig. 18-3). Flexion, extension, and hyperexten-
sion occur in the sagittal plane, with approximately
120 degrees of flexion and 15 degrees of hyperexten-
sion. Extension is the return from flexion. Abduction
and adduction occur in the frontal plane, with about
45 degrees of abduction. Adduction is usually thought
of as the return to anatomical position, although there
is approximately an additional 25 degrees of motion
Flexion Extension Hyperextension
possible beyond the anatomical position. In the trans-
verse plane, medial and lateral rotations are sometimes
referred to as internal and external rotation, respectively.
There are approximately 45 degrees of rotation possible
in each direction from the anatomical position.
The two hip bones are connected to each other ante-
riorly and to the sacrum posteriorly. The sacrum is also
Abduction Adduction Lateral Medial

rotation rotation
Table 18-1 Bones of the Lower Extremity Figure 18-3. Motions of the hip.
Region Bones Individual Bones
Pelvis Os coxae Ilium, ischium, pubis
connected distally to the coccyx. These four bones (the
Sacrum
two hip bones, the sacrum, and the coccyx) are collec-
Coccyx
tively known as the pelvis, or pelvic girdle (Fig. 18-4).
Thigh Femur
Note that the pelvis does not include the femur.
Patella
Leg Tibia
Fibula
Foot Tarsals (7) Calcaneus, talus,
Bones and Landmarks
cuboid, navicular,
As mentioned earlier, the hip joint is made up of the hip
cuneiform (3)
bone and the femur. The hip bone, also known as the os
Metatarsals (5) First through fifth
coxae, is irregularly shaped and actually consists of three
Phalanges (14) Proximal (5), middle
bones—the ilium, the ischium, and the pubis (Fig. 18-5).
(4), distal (5)
By adulthood, these bones fuse together.
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 263
CHAPTER 18 Hip Joint 263
Iliac crest
Sacrum
Posterior superior Anterior

Hip Hip superior
iliac spine Ilium iliac spine
Anterior
Posterior inferior inferior
iliac spine iliac spine
Coccyx
Greater sciatic notch
Acetabulum
Ischial spine
Ischium Superior
Lesser sciatic notch ramus
Figure 18-4. The bones of the pelvis (anterior view). Body Pubis
Obturator foramen
Ischial tuberosity Body
The fan-shaped ilium makes up the superior portion
Ramus
of the hip bone. Its significant landmarks are as follows Inferior ramus
(Figs. 18-5 and 18-6): Figure 18-6. Right hip bone (lateral view).
Iliac Fossa
Large, smooth, concave area on the internal surface
fascia latae, sartorius, and inguinal ligament
to which the iliac portion of the iliopsoas muscle
attach here.
attaches
Anterior Inferior Iliac Spine
Iliac Crest
Abbreviated as AIIS. The projection is just inferior
Bony part that your hands rest on when you put
to the ASIS, to which the rectus femoris muscle
your hands on your hips. Its borders are the ante-
attaches.
rior superior iliac spine (ASIS) and the posterior
superior iliac spine (PSIS). Posterior Superior Iliac Spine
Abbreviated as PSIS. It is the posterior projection on
Anterior Superior Iliac Spine
the iliac crest.
Abbreviated as ASIS. The projection on the
anterior end of the iliac crest. The tensor Posterior Inferior Iliac Spine
Abbreviated as PIIS; located just below the PSIS.
The ischium is the posterior inferior portion of the
Iliac fossa
Iliac crest hip bone. Its significant landmarks are as follows (see
Anterior superior Fig. 18-6):
iliac spine
Body
Ilium
Makes up about two-fifths of the acetabulum.
Ramus
Anterior inferior Posterior
superior
Extends medially from the body to connect with
iliac spine
iliac spine the inferior ramus of the pubis. The adductor
Superior Posterior inferior magnus, obturator externus, and obturator
ramus iliac spine internus muscles attach here.
Ischium
Greater sciatic notch
Tubercle Pubis Ischial Tuberosity
Ischial spine
Rough, blunt projection of the inferior part of the
Lesser sciatic notch body, which is weight-bearing when you are sit-
Body
Body
ting. It provides attachment for the hamstring
Ischial tuberosity
Inferior ramus and adductor magnus muscles.
Ramus Obturator foramen
Figure 18-5. Right hip bone (medial view), consists of the Spine
ilium, ischium, and pubis. The greater sciatic notch, acetabu- Located on the posterior portion of the body between
lum, and obturator foramen are formed by different combi- the greater and lesser sciatic notches. It provides
nations of these bones. attachment for the sacrospinous ligament.
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 264
The pubis forms the anterior inferior portion of the

hip. It can be divided into three parts—the body and its Greater Greater
Head
two rami (see Figs. 18-5 and 18-6): trochanter trochanter
Body Neck
Externally forms about one-fifth of the acetabulum Lesser
trochanter
and internally provides attachment for the obtu-
Pectineal
rator internus muscle. line
Superior Ramus
Lies superior between the acetabulum and the body
and provides attachment for the pectineus muscle. Body
Inferior Ramus Linea

Lies posterior, inferior, and lateral to the body. aspera
Provides attachment for the adductor magnus
and brevis and gracilis muscles.
Symphysis Pubis
A cartilaginous joint connecting the bodies of the
two pubic bones at the anterior midline Adductor
tubercle
Lateral Lateral
Pubic Tubercle epicondyle epicondyle
Medial
Projects anteriorly on the superior ramus near the epicondyle
symphysis pubis and provides attachment for the Lateral Medial
inguinal ligament Condyle Patellar Condyle Lateral
surface Condyle
The following are made up of combinations of the
hip bones (see Fig. 18-5): Anterior Posterior
Figure 18-7. Right femur.
Acetabulum
A deep, cup-shaped cavity that articulates with the
femur. It is made up of nearly equal portions of
the ilium, ischium, and pubis.
Greater Trochanter
Obturator Foramen
Large projection located laterally between the neck
A large opening surrounded by the bodies and rami
and the body of the femur, providing attachment
of the ischium and pubis and through which pass
for the gluteus medius and minimus and for most
blood vessels and nerves
deep rotator muscles.
Greater Sciatic Notch
Large notch just below the PIIS that is actually Lesser Trochanter
made into a foramen by the sacrospinous and A smaller projection located medially and posterior-
sacrotuberous ligaments (see Fig. 17-8). The sci- ly just distal to the greater trochanter, providing
atic nerve, piriformis muscle, and other struc- attachment for the iliopsoas muscle.
tures pass through this opening. Body
The femur is the longest, strongest, and heaviest The long, cylindrical portion between the bone
bone in the body. A person’s height can roughly be ends; also called the shaft. It is bowed slightly
estimated to be four times the length of the femur anteriorly.
(Moore, 1985). It articulates with the hip bones to Medial Condyle
form the hip joint and has the following significant Distal medial end.
landmarks (Fig. 18-7):
Lateral Condyle
Head Distal lateral end.
The rounded portion covered with articular cartilage
articulating with the acetabulum. Lateral Epicondyle
Projection proximal to the lateral condyle.
Neck
The narrower portion located between the head and Medial Epicondyle
the trochanters. Projection proximal to the medial condyle.
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 265
Adductor Tubercle Ligaments and Other Structures

Small projection proximal to the medial epicondyle
to which a portion of the adductor magnus Like all synovial joints, the hip has a fibrous joint cap-
muscle attaches. sule. It is strong and thick, and it covers the hip joint
Linea Aspera in a cylindrical fashion. It attaches proximally around
Prominent longitudinal ridge or crest running most the lip of the acetabulum and distally to the neck of
of the posterior length. the femur (Fig. 18-9). It forms a cylindrical sleeve that
encloses the joint and most of the femoral neck.
Pectineal Line Three ligaments reinforce the capsule: the iliofemoral,
Runs from below the lesser trochanter diagonally the pubofemoral, and the ischiofemoral ligaments
toward the linea aspera. It provides attachment (Fig. 18-10). The most important of these ligaments is
for the adductor brevis. the iliofemoral ligament. It reinforces the capsule ante-
Patellar Surface riorly by attaching proximally to the anterior inferior
Located between the medial and lateral condyle iliac spine and crossing the joint anteriorly. It splits into
anteriorly. It articulates with the posterior sur- two parts distally to attach to the intertrochanteric line
face of the patella. of the femur. Because it resembles an inverted Y, it is
often referred to as the Y ligament. It is also known as
The tibia will be discussed in more detail in the ligament of Bigelow. Its main function is to limit
Chapter 19, but it is important to identify one land- hyperextension.
mark now (Fig. 18-8): The pubofemoral ligament spans the hip joint
Tibial Tuberosity medially and inferiorly. It attaches from the medial part
Large projection at the proximal end in the midline. of the acetabular rim and superior ramus of the pubis,
It provides attachment for the patellar tendon. and runs down and back to attach on the neck of the
femur. Like the iliofemoral ligament, it limits hyperex-
tension. In addition, it limits abduction.
The ischiofemoral ligament covers the capsule
posteriorly. It attaches on the ischial portion of the
acetabulum, crosses the joint in a lateral and superior
direction, and attaches on the femoral neck. Its fibers
limit hyperextension and medial rotation.
All three of these ligaments attach along the rim of
Tibial the acetabulum and cross the hip joint in a spiral fash-
tuberosity ion to attach on the femoral neck. The combined effect
of this spiral attachment is to limit motion in one direc-
tion (hyperextension) while allowing full motion (flex-
ion) in the other direction. Therefore, these ligaments
are slack in flexion and become taut as the hip moves
into hyperextension. If you thrust your hips forward so
Anterior
Figure 18-8. Right tibia (anterior view). Figure 18-9. The hip joint capsule (anterior view).
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 266
Pubofemoral
Iliofemoral ligament Ischiofemoral
ligament
ligament
Anterior Posterior
Figure 18-10. The hip joint capsule is reinforced by three ligaments: the iliofemoral, the pubofemoral, and the ischiofemoral
ligaments.
that they are in front of the shoulders and knees, you doubtful that it adds significantly to the joint’s
can stand in the upright position without using any strength. Its other feature is that it contains a blood ves-
muscles by essentially resting on the iliofemoral liga- sel that supplies the head of the femur. However, this
ment. This is the basis for the standing posture of an vessel alone cannot supply enough blood to the head to
individual with paralysis following spinal cord injury keep it viable.
(Fig. 18-11). The depth of the acetabulum is increased by the
The ligamentum teres is a small intracapsular liga- fibrocartilaginous acetabular labrum, which is located
ment of debatable importance (Fig. 18-12). It attaches around the rim. The free end of the labrum surrounds
proximally in the acetabulum and distally in the fovea the femoral head and helps to hold the head in the
of the femoral head. Some sources indicate that it acetabulum.
becomes taut during adduction or lateral rotation, Although the inguinal ligament has no function at
when the hip is semiflexed. However, given its size, it is the hip joint, it should be identified because of its pres-
ence. It runs from the anterior superior iliac spine to the
pubic tubercle and is the landmark that separates the
anterior abdominal wall from the thigh (Fig. 18-13).
When the external iliac artery and vein pass under the
inguinal ligament, their names change to the femoral
artery and vein.
The iliotibial band or tract is the very long, tendi-
nous portion of the tensor fascia latae muscle (see
Fig. 18-26). It attaches to the anterior portion of the
iliac crest and runs superficially down the lateral side
of the thigh to attach to the tibia. Both the gluteus
Ligamentum teres
Figure 18-11. The spiral attachment of the hip ligaments

tends to limit hyperextension. Therefore, an individual who is Capsule (cut)
paraplegic can stand in the upright position by thrusting the Figure 18-12. The ligamentum teres. Oblique view with
hips forward of the shoulders and knees. femur laterally rotated and capsule cut away.
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 267
Table 18-2 Muscles of the Hip

Muscle One-Joint Two-Joint
Group Muscles Muscles
Anterior Iliopsoas Rectus femoris
Sartorius
Medial Pectineus Gracilis
Inguinal ligament Adductor magnus
Adductor longus
Adductor brevis
Posterior Gluteus maximus Semimembranosus
Deep rotators (6) Semitendinosus
Biceps femoris
(long head)
Lateral Gluteus medius Tensor fascia latae
Gluteus minimus
Figure 18-13. The inguinal ligament (anterior view).
Iliopsoas Muscle
maximus and tensor fascia latae muscles have fibers O Iliac fossa, anterior and lateral surfaces
attaching to it. of T12 through L5
The end feel of all hip joint motions except flexion is I Lesser trochanter
firm (soft tissue stretch) because of tension in the cap- A Hip flexion
sule, ligaments, and muscles. For hip flexion, the end
feel is soft (soft tissue approximation) because of con- N Iliacus portion: femoral nerve (L2, L3)
tact between the anterior thigh and the abdomen. Psoas major portion: L2 and L3
Muscles of the Hip

There are many similarities between the shoulder and
hip joints. Like the shoulder, the hip has a group of one-
joint muscles that provide most of the control, and it
Psoas major
has a group of longer, two-joint muscles that provide
the range of motion. These muscles can also be grouped
according to their location and somewhat by their func-
tion. For example, the anterior muscles tend to be flex-
ors, lateral muscles tend to be abductors, posterior
muscles tend to be extensors, and medial muscles tend
to be adductors. Table 18-2 classifies the hip muscles by Iliacus
location and function.
The iliopsoas muscle is actually two muscles with
separate proximal attachments and a common distal
attachment (Fig. 18-14). The iliacus muscle portion
arises from the iliac fossa, and the psoas major muscle
portion comes from the transverse processes, bodies,
and intervertebral disks of the T12 through L5 verte-
brae. These muscles blend together to attach on the
lesser trochanter of the femur. The iliopsoas muscle is a
prime mover in hip flexion. Because of its attachment
on the vertebrae, the psoas muscle portion contributes Figure 18-14. The iliopsoas muscle is made up of the
to trunk flexion when the femur is stabilized. psoas major and the iliacus (anterior view).
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 268
The rectus femoris muscle is part of the quadriceps

muscle group and is the only one of that group to cross
the hip (Fig. 18-15). Its proximal attachment is on the
AIIS. It runs almost straight down the thigh, where it is
joined by the three vasti muscles to blend into the
quadriceps tendon (also called the patellar tendon). This
tendon encases the patella, crosses the knee joint, and
attaches to the tibial tuberosity. The rectus femoris mus-
cle is a prime mover in hip flexion and knee extension.
Rectus Femoris Muscle
O Anterior inferior iliac spine
I Tibial tuberosity
A Hip flexion, knee extension
N Femoral nerve (L2, L3, L4)
The sartorius muscle is the longest muscle in the
body (Fig. 18-16). This straplike muscle arises from the
anterior superior iliac spine. It runs diagonally across
the thigh from lateral to medial and proximal to distal
to cross the medial knee joint posteriorly. Because of its
line of pull, it is capable of flexing, abducting, and lat-
erally rotating the hip and flexing the knee. However, it
is not considered a prime mover in any one of these
motions. It is most efficient when doing all four
Figure 18-16. The sartorius muscle (anterior view).
motions at the same time. An example of this motion is
when you cross your legs by putting one foot on the

opposite knee.
Sartorius Muscle
O Anterior superior iliac spine
I Proximal medial aspect of tibia
A Combination of hip flexion, abduction,
lateral rotation, and knee flexion
N Femoral nerve (L2, L3)
Located medial to the iliopsoas muscle and lateral to
the adductor longus muscle is the pectineus muscle. Its
origin is on the superior ramus of the pubis, and its inser-
tion is on the pectineal line of the femur (Fig. 18-17).
Because it spans the hip anteriorly and medially, it pro-
vides hip flexion and adduction.
Pectineus Muscle
O Superior ramus of pubis
I Pectineal line of femur
A Hip flexion and adduction
There are three other one-joint hip adductors, all
Figure 18-15. The rectus femoris muscle (anterior view). with the same first name (Fig. 18-18). The adductor
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 269
longus muscle, the most superficial of the three, orig-

inates from the anterior surface of the pubis near the
tubercle and inserts on the middle third of the linea
aspera of the femur. Because it is superficial, its ten-
don can easily be felt in the anterior-medial groin.
Being able to palpate this tendon is important when
checking for correct fit of the quadrilateral socket of
an above-knee prosthesis. It is a prime mover in hip
adduction.
Adductor Longus Muscle
O Pubis
I Middle third of the linea aspera
A Hip adduction
N Obturator nerve (L3, L4)
The adductor brevis muscle implies by its name
that it is shorter than the other adductor muscles. It
lies deep to the adductor longus muscle but superfi-
cial to the adductor magnus muscle. It arises from
the inferior ramus of the pubis and inserts on the
pectineal line and proximal linea aspera above
Figure 18-17. The pectineus muscle (anterior view). Note the adductor longus muscle. It is a prime mover in
that the distal attachment is on the posterior femur. hip adduction.
Adductor longus Adductor brevis Adductor magnus

Figure 18-18. The three adductor muscles (anterior view). Note that the distal attachments are on the posterior femur.
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 270
Adductor Brevis Muscle

O Pubis
I Pectineal line and proximal linea aspera
A Hip adduction
The largest and deepest of the adductors is the
adductor magnus muscle. It arises from the ischial
tuberosity and ramus of the ischium and inferior ramus
of the pubis. It makes up most of the bulk on the medi-
al thigh. It inserts along the entire linea aspera and
adductor tubercle. There is an interruption, or hiatus,
in the distal attachment between the linea aspera and
adductor tubercle. The femoral artery and vein pass
through this opening. After these structures have
passed through to the posterior surface, their names
become the popliteal artery and vein, respectively. Because
of its size, the adductor magnus muscle is a very strong
hip adductor.
Adductor Magnus Muscle

O Ischium and pubis
I Entire linea aspera and adductor tubercle
A Hip adduction Figure 18-19. The gracilis muscle (anterior view). Note that
N Obturator and sciatic nerve (L3, L4) it passes behind the knee but attaches anteriorly.
The only hip adductor that is a two-joint muscle is

the gracilis muscle (Fig. 18-19). It arises from the sym-
physis and inferior ramus of the pubis and descends the
thigh medially and superficially. It crosses the knee
joint posteriorly and curves around the medial condyle
to attach distally on the anteromedial surface of the
proximal tibia. It assists with knee flexion.
Gracilis Muscle
O Pubis
I Anterior medial surface of proximal end
of tibia
A Hip adduction
The gluteus maximus muscle can be described as a
large, thick, one-joint, quadrilateral muscle located
superficially on the posterior buttock (Fig. 18-20). It
arises from the general area of the posterior sacrum,
coccyx, and ilium, and it runs in a diagonal direction
distally and laterally to the posterior femur, inferior to
the greater trochanter. Some fibers also attach to the ili-
otibial band. Because it spans the hip posteriorly in this
diagonal direction, it is very strong in hip extension, Figure 18-20. The gluteus maximus muscle
hyperextension, and lateral rotation. (posterior view).
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 271
Gluteus Maximus Muscle Deep Rotator Muscles

O Posterior sacrum and ilium O Posterior sacrum, ischium, pubis
I Posterior femur distal to greater I Greater trochanter area
trochanter and to iliotibial band A Hip lateral rotation
A Hip extension, hyperextension, lateral N Numerous (see Table 18-3)
rotation
N Inferior gluteal nerve (L5, S1, S2) Three muscles that are known collectively as the
hamstring muscles cover the posterior thigh. They
There are six small, deep, mostly posterior muscles consist of the semimembranosus, the semitendinosus,
that span the hip joint in a horizontal direction, and and the biceps femoris muscles (Fig. 18-22). They have
they all laterally rotate the hip. Because they all work a common site of origin on the ischial tuberosity.
together to produce the same motion, their individ- The semimembranosus muscle runs down the
ual attachments are not functionally important; medial side of the thigh, deep to the semitendinosus
therefore, they can be grouped together as the deep muscle, and inserts on the posterior surface of the medi-
rotator muscles (Fig. 18-21). However, the piriformis al condyle of the tibia. The semitendinosus muscle has
is the best known of this group, perhaps because of its a much longer and narrower distal tendon that spans the
close relationship to the sciatic nerve. Table 18-3 knee joint posteriorly and then moves anteriorly to
summarizes their attachments and innervation. attach to the anteromedial surface of the tibia with the
gracilis and sartorius muscles. The biceps femoris mus-
cle has two heads and runs down the thigh laterally on
the posterior side. The long head arises with the other
two muscles on the ischial tuberosity, but the short head
arises from the lateral lip of the linea aspera. Both heads
join together, spanning the knee posteriorly to attach lat-
erally on the head of the fibula and, by a small slip, to the
lateral condyle of the tibia. Because they span the knee
posteriorly, they flex the knee. The long head, because it
Obturator externus spans the hip posteriorly, extends the hip.
Semimembranosus Muscle
O Ischial tuberosity
I Posterior surface of medial condyle of tibia
A Extend hip and flex knee
Anterior N Sciatic nerve (L5, S1, S2)
Semitendinosus Muscle
O Ischial tuberosity
I Anteromedial surface of proximal tibia
N Sciatic nerve (L5, S1, S2)
Biceps Femoris Muscle
Piriformis
O Long head: ischial tuberosity
Gemellus superior Short head: lateral lip of linea aspera
Gemellus inferior I Fibular head
Quadratus femoris A Long head: extend hip and flex knee
Obturator internus Short head: flex knee
N Long head: sciatic nerve (S1, S2, S3)
Posterior Short head: common peroneal nerve
Figure 18-21. The deep rotator muscles. (L5, S1, S2)
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 272
Table 18-3 Deep Rotator Muscles

Muscle Proximal Attachment Distal Attachment Innervation
Obturator externus Rami of pubis and ischium Trochanteric fossa Obturator nerve
Obturator internus Rami of pubis and ischium Greater trochanter Nerve to obturator internus
Quadratus femoris Ischial tuberosity Intertrochanteric crest Nerve to quadratus femoris
Piriformis Sacrum Greater trochanter S1, S2 segments
Gemellus superior Ischium Greater trochanter Nerve to obturator internus
Gemellus inferior Ischial tuberosity Greater trochanter Nerve to quadratus femoris
The other two gluteal muscles are more laterally Proximally, the gluteus minimus muscle lies deep
located. The gluteus medius muscle is triangular, much and inferior to the gluteus medius muscle on the later-
like the deltoid muscle of the shoulder (Fig. 18-23). It al ilium (Fig. 18-24). The distal attachment is on the
attaches proximally to the outer surface of the ilium anterior aspect of the greater trochanter. This gives the
and distally to the lateral surface of the greater gluteus minimus muscle a somewhat diagonal line of
trochanter. Because it spans the hip laterally, the glu- pull, making it able to medially rotate the hip. Because
teus medius muscle can abduct the hip. Its anterior it spans the hip laterally, it also abducts the hip.
fibers are able to assist the gluteus minimus muscle in
Gluteus Minimus Muscle
medially rotating the hip.
O Lateral ilium
Gluteus Medius Muscle
I Anterior surface of the greater trochanter
O Outer surface of the ilium
A Hip abduction, medial rotation
I Lateral surface of the greater trochanter
N Superior gluteal nerve (L4, L5, S1)
A Hip abduction
N Superior gluteal nerve (L4, L5, S1) Attaching to the ilium and the femur and span-
ning the hip laterally, these two gluteal muscles have
another very important function. When you stand on
one leg, the distal segment (femur) becomes more sta-
ble than the proximal segment (pelvis); therefore, the
origin moves toward the insertion. Another term for
this change is reversal of muscle function. If these
Semitendinosus
Biceps femoris
Semimembranosus
Figure 18-22. The hamstring muscles (posterior view). Figure 18-23. The gluteus medius muscle (lateral view).
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 273
occurs every time you pick up one leg, as when walk-

ing. Weakness or loss of these muscles results in a
“Trendelenburg gait.” For example, if your right hip
abductors are weak, the left side of your pelvis will
drop significantly when you stand on your right leg
and lift your left leg off the ground.
The tensor fascia latae muscle is a very short mus-
cle with a very long tendinous attachment (Fig. 18-26).
It arises from the ASIS, crosses the hip laterally and
slightly anteriorly, and then attaches to the long fas-
cial band called the iliotibial band, which proceeds
down the lateral thigh and attaches to the lateral
condyle of the tibia. It is a hip abductor, but due to its
slight anterior position, it is perhaps strongest when
performing a combination of flexion and abduction.
Stated another way, it is most efficient when abduct-
ing in a slightly anterior direction.
Figure 18-24. The gluteus minimus muscle (lateral view).
muscles did not contract when you stood on one

leg, the opposite side of your pelvis would drop
(Fig. 18-25). Therefore, the gluteus medius and min-
imus muscles contract to keep the pelvis fairly level
and to prevent the opposite side of the pelvis from
dropping too much when you stand on one leg. This
Iliotibial band
A B
Figure 18-25. Anterior view. (A) In reversal of muscle func-
tion, the right hip abductors contract to keep the pelvis Figure 18-26. The tensor fascia latae muscle (lateral view).
steady when the left leg is lifted. (B) When right hip abduc- The very long, tendinous portion of this muscle is known as
tors are weak, the left side of the pelvis drops. the iliotibial band.
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 274
Tensor Fascia Latae Muscle and slightly lateral, while the sartorius runs down in a
medial direction. Between these two muscles lies the rec-
O Anterior superior iliac spine tus femoris, which runs straight down toward the knee.
I Lateral condyle of tibia Moving medially from the sartorius are the iliopsoas,
A Combined hip flexion and abduction pectineus, adductor longus, and gracilis. Deep to the
N Superior gluteal nerve (L4, L5) adductor longus near the hip is the adductor brevis, and
deep to the adductor brevis is the large, wide adductor
magnus. More distally on the thigh, the adductor mag-
Anatomical Relationships nus lies deep to the adductor longus (Fig. 18-28).
Table 18-2 organizes the hip muscles into four groups Viewing the hip region from the medial side superfi-
based on location. Using this grouping, the anatomical cially, the sartorius, the upper portion of the adductor
relationships of the hip muscles can be easily discussed longus, the gracilis, and the upper half of the adductor
by adding one other factor: superficial muscles versus magnus can be seen from front to back, followed by the
deep muscles. medial hamstrings (Fig. 18-29). From this medial view,
Starting anteriorly, there are two superficial muscles: you can see that most of the adductor longus and much
the tensor fascia latae and the sartorius, which have their of the adductor brevis and adductor magnus lie deep.
origin on the anterior superior iliac spine (Fig. 18-27). On the posterior side, the gluteus maximus covers the
They make an inverted V from their common attach- proximal posterior hip region (Fig. 18-30). Distal to the
ment. The tensor fascia latae runs down toward the knee gluteus maximus, and taking up most of the posterior
Anterior Iliacus
superior
iliac spine Psoas
Pectineus
Inguinal (cut)
ligament
Tensor Adductor
fascia Iliopsoas longus (cut)
latae (cut)
Gracilis
Sartorius
Iliopsoas Pectineus (cut)
(cut)
Pectineus
Obturator
Adductor Adductor externus
longus longus (cut)
Quadratus
Gracilis femoris
Adductor
Vastus brevis
intermedialis
Adductor
magnus
Iliotibial Rectus
band femoris
Rectus
femoris (cut) Gracilis
(cut)
Patella Lateral
Medial
epicondyle
epicondyle
Patella
Tibial
tuberosity Tibial
tuberosity
Figure 18-27. Anterior superficial muscles (right leg). Figure 18-28. Anterior deep muscles (right leg).
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 275
Gluteus
maximus
Inferior Gluteus
pubic Obturator medius
ramus internus
Ischial
Sartorius Tensor
tuberosity
fascia latae
Adductor
longus Adductor magnus
Gluteus
Gracilis Semitendinosus maximus
Rectus
Semimembranosus Adductor
femoris
magnus
Gracilis
Vastus
medialis
(knee Semitendinosus Iliotibial
muscle) band
Semimembranosus Biceps
femoris
(long head)
Pes anserine
Figure 18-29. Medial muscles (right leg).
thigh, are the hamstring muscles. Deep to the gluteus

maximus and slightly more lateral is the gluteus medius, Figure 18-30. Posterior superficial muscles (right leg).
and deeper still is the gluteus minimus (Fig. 18-31). The
deep rotators are the deepest muscles; you can see five of
the six deep rotators in the figure. The hamstring mus- femoral head undergoes necrosis. It is usually seen in
cles are deep to the gluteus maximus at their proximal children between the ages of 5 and 10 years. During the
attachment on the ischial tuberosity. course of the disease, it may take about 2 to 4 years for
Viewing the proximal hip from the lateral side in the head to die, revascularize, and then remodel. Slipped
Figure 18-32, you can see the gluteus maximus posteri- capital femoral epiphysis is seen in children during the
orly, the iliotibial band laterally, and the tensor fascia growth-spurt years. The proximal epiphysis slips from its
latae anteriorly. The gluteus medius lies deep to these normal position on the femoral head.
structures, and the gluteus minimus lies deep to the The angle between the shaft and the neck of the
gluteus medius. femur in the frontal plane is referred to as the angle of
inclination, which normally is 125 degrees. This angle
varies from birth to adulthood. At birth, the angle may
Common Hip Pathologies be as great as 170 degrees, but by adulthood the angle
The hip joint is the site of many orthopedic conditions decreases significantly. However, factors such as con-
that occur throughout life and can affect lower extremity genital deformity, trauma, or disease may affect the
alignment. Congenital hip dislocation, or dysplasia, angle. Coxa valga is characterized by a neck-shaft
occurs when an unusually shallow acetabulum causes angle greater than 125 degrees (Fig. 18-33). Because
the femoral head to slide upward. The joint capsule this angle is “straighter,” it tends to make the limb
remains intact, though stretched. Legg-Calvé-Perthes longer, thus placing the hip in an adducted position
disease, or coxa plana, is a condition in which the during weight-bearing. Coxa vara is a deformity in
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 276
Iliac
Gluteus crest
Minimus Gluteus
Gluteus
medius
medius
(cut)
Gluteus Tensor
maximus fascia
Deep rotators latae
Gluteus Sartorius
maximus
(cut)
Semitendinosus Rectus
(cut) femoris
Biceps femoris
long head (cut)
Iliotibial
Adductor magnus
band
Iliotibial
band
Semimembranosus
Vastus
Gracilis lateralis
Long head
Biceps
femoris Short head
Biceps femoris
short head
Semitendinosus Biceps femoris
(cut) long head (cut)
Sartorius (cut)
Gastrocenemius
Figure 18-31. Posterior deep muscles (right leg). Figure 18-32. Lateral muscles (right leg).
which the neck-shaft angle is less than the normal

Coxa valga
125 degrees. Because it is “more bent,” it tends to make
the involved limb shorter, dropping the pelvis on that
side during weight-bearing.
The angle between the shaft and the neck of the
Angle of inclination
femur in the transverse plane is called the angle of tor-
sion, which normally has the head and neck rotated
outward from the shaft approximately 15 to 25 degrees. Coxa vara
Looking down on the femur (Fig. 18-34A), you can see Neck
the femoral head and neck superimposed on the shaft.
The shaft is best shown here by a line through the
femoral condyles, which attach to the shaft distally. As
the shaft rotates, so do the condyles. An increase in this
angle is called anteversion, which forces the hip joint
Shaft
into a more medially rotated position (Fig. 18-34B).
This causes a person to walk more “toed in.” A decrease
in the angle of torsion is called retroversion.
This forces the hip joint into a more laterally rotated Figure 18-33. Angle of inclination is normally about
position, causing the person to walk more “toed out” 125 degrees. Coxa valga is an angle greater than 125 degrees,
(Fig. 18-34C). and coxa vara is an angle less than 125 degrees.
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 277
neck. These are very common among the elderly,

Patella usually resulting from falls. High-impact trauma such
as motor vehicle accidents may cause hip fractures in
Neck Lateral femoral
Femoral younger individuals.
condyle
condyles Iliotibial band syndrome is an overuse injury caus-
Femoral head ing lateral knee pain. It is commonly seen in runners
and neck
Condyles and bicyclists. This syndrome is believed to result from
repeated friction of the band that slides over the lateral
femoral epicondyle during knee motion. It is caused by
Medial femoral such factors as muscle tightness, worn-down shoes, and
condyle running on uneven surfaces. Because many muscles
Angle of torsion insert at the greater trochanter, there are many bursae
providing a friction-reducing cushion between the mus-
A
cles and bone. Trochanteric bursitis is the result of
either acute trauma or overuse. It can be seen in runners
or bicyclists or in someone with a leg-length discrepan-
cy, or it can be caused by other factors that put repeat-
Neck ed stress on the greater trochanter. A hamstring strain,
also called “pulled hamstring,” is probably the most com-
mon muscle problem in the body. Unfortunately, it is
often recurrent. It may result from an overload of the
muscle or trying to move the muscle too fast. Therefore,
this is a common injury among sprinters and in sports
that require bursts of speed or rapid acceleration, such
Condyles
as soccer, track and field, football, and rugby. Hamstring
strains can occur at one of the attachment sites or at
Anteversion is an increased angle and results in toed-in gait any point along the length of the muscle.
Hip pointer is a misnomer because it occurs at the
B pelvis, not the hip. It is a severe bruise caused by direct
trauma to the iliac crest of the pelvis. It is most com-
monly associated with football but can be seen in
Condyles
almost any contact sport. Spearing the hip/pelvis with a
helmet while tackling may be the most common cause.
Neck

Table 18-4 summarizes the actions of the prime movers
of the hip joint.
Retroversion is a decreased angle and results in toed-out gait

Summary of Muscle Innervation
Generally speaking, the femoral nerve innervates muscles
C
on the anterior surface of the hip and thigh region (hip
Figure 18-34. Superior view. (A) Angle of torsion normally
flexors). The obturator nerve innervates hip adductors
has the head and neck rotated outward from the shaft
approximately 15 to 25 degrees. An increase in this angle is on the medial side. The superior gluteal nerve supplies
called anteversion (B), and a decrease in this angle is called the hip abductors on the lateral side. The hamstring
retroversion (C). muscles, which are hip extensors and are located posteri-
orly, receive innervation from the sciatic nerve.
Osteoarthritis is a degeneration of the articular car- There are, of course, exceptions to all generalizations.
tilage of the joint. It may result from trauma or wear The gluteus maximus, a posterior muscle, receives inner-
and tear, and is typically seen later in life. It is common- vation from the inferior gluteal nerve. The deep rotators
ly treated with a total joint replacement. Hip fractures do not fit neatly into any sort of category; therefore, they
tend to be of two types: intertrochanteric and femoral are included individually in the summary of hip joint
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 278
muscle innervation in Table 18-3 and 18-5 instead of as a

Table 18-4 Action of Hip Prime Movers group. Table 18-6 summarizes the segmental innervation.
Action Muscle As has been stated in previous chapters, there is variation
Combination of Tensor fascia latae among sources regarding some segmental innervation.
flexion and The deep rotators are included here as a group.
abduction
Combination of Sartorius
flexion, abduction,
Points to Remember
● In determining the leverage, the muscle’s
and lateral rotation
point of attachment to the bone is used.
Flexion Rectus femoris, iliopsoas,
● With a second-class lever, resistance is
pectineus
between the axis and the force. With a third-
Extension Gluteus maximus,
class lever, force is in the middle.
semitendinosus,
● End feel is the quality of the feel when apply-
semimembranosus,
ing slight pressure at the end of the joint’s
biceps femoris (long
passive range.
head)
● A closed kinetic chain requires that the distal
Hyperextension Gluteus maximus
segment is fixed and the proximal segment(s)
Abduction Gluteus medius, gluteus
move.
minimus
● To stretch a one-joint muscle, it is necessary
Adduction Pectineus, adductor
to put any two-joint muscles on a slack over
longus, adductor
the joint not crossed by the one-joint muscle.
brevis, adductor
● To contract a two-joint muscle most effectively,
magnus, gracilis
start with it being stretched over both joints.
Medial rotation Gluteus minimus
● When determining whether a concentric or
Lateral rotation Gluteus maximus, deep
eccentric contraction is occurring, decide
rotators
● if the activity is accelerating against gravity
or slowing down gravity, or

● if a weight greater than the pull of gravity is
affecting the activity.
Table 18-5 Innervation of the Muscles of the Hip

Muscle Nerve Spinal Segment
Iliopsoas
Psoas part Anterior rami L2, L3
Iliacus part Femoral L2, L3
Rectus femoris Femoral L2, L3, L4
Sartorius Femoral L2, L3
Pectineus Femoral L2, L3, L4
Gracilis Obturator L2, L3
Adductor longus Obturator L3, L4
Adductor brevis Obturator L3, L4
Adductor magnus Obturator L3, L4
Gluteus maximus Inferior gluteal L5, S1, S2
Gluteus medius Superior gluteal L4, L5, S1
Gluteus minimus Superior gluteal L4, L5, S1
Tensor fascia latae Superior gluteal L4, L5
Semitendinosus Sciatic L5, S1, S2
Semimembranosus Sciatic L5, S1, S2
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 279
Table 18-5 Innervation of the Muscles of the Hip—cont’d

Biceps femoris (long head) Sciatic S1, S2, S3
Obturator externus Obturator L3, L4
Obturator internus Nerve to the obturator internus L5, S1
Gemellus superius Nerve to the obturator internus L5, S1
Quadratus femoris Nerve to the quadratus femoris L5, S1
Gemellus inferior Nerve to the quadratus femoris L5, S1
Piriformis Anterior rami S1, S2
Table 18-6 Segmental Innervation of Hip Muscles

Spinal Cord Level L2 L3 L4 L5 S1 S2 S3
Iliopsoas X X
Sartorius X X
Gracilis X X
Rectus femoris X X X
Pectineus X X X
Adductor longus X X
Adductor brevis X X
Adductor magnus X X
Tensor fascia latae X X
Gluteus medius X X X
Gluteus minimus X X X
Semitendinosus X X X
Semimembranosus X X X
Biceps femoris (long head) X X X
Deep rotators X X X X X
Review Questions
General Anatomy Questions 4. Describe the hip joint:

a. Number of axes:
1. List the bones that make up the
b. Shape of joint:
a. pelvis.
c. Type of motion allowed:
b. hip bone.
c. hip joint. 5. What hip motions occur in
d. acetabulum. a. the transverse plane around the vertical axis?
e. obturator foramen. b. the sagittal plane around the frontal axis?
f. greater sciatic notch. c. the frontal plane around the sagittal axis?
2. If you were handed an unattached hip bone, what 6. What is referred to as the Y ligament? Why?
landmarks would you use to determine if it was a 7. Why is the hip joint not prone to dislocation?
right or left hip bone? 8. What is the direction of the line of attachment of
3. How would you determine if an unattached femur the hip ligaments—vertical, horizontal, or spiral?
is a right or left one? What does this line of attachment allow for?
(continued on next page)
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 280
Review Questions—cont’d
9. Which two-joint hip muscles attach below the knee? together, and hands on her knees, and she pushes
10. Which hip joint muscles are not prime movers in down to assist when standing (Fig. 18-36)?
any single action but are effective in a combination
of movements? List the movements.
11. What muscle(s) keeps your pelvis from dropping
on one side when you lift one foot off the floor?
Describe what happens.
12. Does the femoral head surface glide in the same or
opposite direction as the thigh during hip flexion/
extension?
13. What is the end feel of hip flexion? Hip extension?

1. A right-handed tennis player strikes a ball with a
forehand swing and follows through. The left hip
is moving into what positions (Fig. 18-35)?
Figure 18-36. Position of hips when beginning to stand.
3. Standing in anatomical position and keeping your

pelvis fairly level, shift your weight to your right
foot.
a. What hip joint motion has occurred at your
right hip?
b. What muscle group initiates this action?
c. Is this an open- or closed-chain activity?
4. While weight-bearing on the left leg, note the
motions of your right hip as you swing your right
leg in the following activities:
a. Walking
b. Stepping up onto a curb
c. Getting into a car
d. Getting on what is commonly called a boy’s
bicycle (bar between handlebars and seat)
5. Lie supine on a table with knees bent and your
feet flat. Note the position of your pelvis and
determine if you can put your hand on the small
of your back.
Figure 18-35. Position of tennis player when hitting a fore- a. If you cannot, what is the position of your
hand swing. pelvis?
b. If you can, what is the position of your pelvis
2. a. How is hip flexion affected by sitting on a low and lumbar spine?
surface versus a higher one (e.g., a regular versus 6. From the position described in question 5, slowly
a raised toilet seat)? slide your feet down the table until your hips and
b. What accompanying hip motions or positions knees are extended. Again, note the position of
may occur if a person has her feet apart, knees your pelvis and determine if you can put your hand
2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 281
on the small of your back. Repeat this again, keep-

ing your right knee and hip flexed with your foot
flat, while you move your left foot down until your
left hip and knee are extended.
a. What is accomplished at the pelvis by keeping
your right hip and knee flexed?
b. What can be said about left hip muscle length if
you cannot rest your left thigh completely on
the table? In other words, why wouldn’t you be
able to extend your left hip?
c. What is the one-joint hip muscle attaching on
the pelvis and lumbar spine that may be respon-
sible for this limitation?
d. What difference does the position of the pelvis
have on anterior hip muscle length?
Figure 18-37. Starting position.
7. Pretend that you cannot completely extend your
hip due to tight hip flexors. How might you com-
pensate for this when standing?
8. You are seated at a table. Stand up while turning to
the right. Stop halfway through this motion without moving your right foot. Describe what has
(before you move your feet). occurred at the left hip in terms of
a. The right hip is in what positions? (1) flexed/ a. joint motion.
extended, (2) abducted/adducted, or (3) medially b. whether stretching or strengthening is
rotated/laterally rotated occurring.
b. The left hip is in what positions? (1) flexed/ c. muscle(s) involved.
extended, (2) abducted/adducted, or (3) medially 3. If the position in Figure 18-37 was changed by
rotated/laterally rotated holding the left knee in more flexion (difficult to
9. When a tennis player hits the ball (see Fig. 18-35), achieve comfortably, but pretend), do you think
what type of kinetic chain activity is occurring at this a good position in which to stretch the rectus
the hip? At the shoulder? femoris? Why?
4. Lying on your right side with your left hip and
knee in extension, raise your left leg toward the
ceiling about 2 feet. Describe what has occurred
1. While lying prone with your right knee flexed, raise in terms of
your right leg straight up, keeping your pelvis flat a. joint motion.
on the table. Describe what has occurred in terms of b. whether stretching or strengthening is
a. hip joint motion. occurring.
b. whether stretching or strengthening is c. muscle(s) involved.
occurring. 5. Repeat the exercise in question 4 with your left hip
c. muscle(s) involved. in approximately 30 degrees of flexion. Describe
2. In the position shown in Figure 18-37, move your what has occurred in terms of
right leg forward until your right knee is directly a. joint motion.
over your right ankle. Your left hip is hyperextended b. whether stretching or strengthening is
and your left knee is flexed and resting on the floor. occurring.
Rock your weight forward onto the front (right) leg c. muscle(s) involved.

2363_Ch18-259-282.qxd 12/10/10 12:34 PM Page 282
6. Lie on your back with your hips and knees in 9. Figure 18-38 shows an individual doing hip flexion
extension. Raise your right leg toward the ceiling. exercises two different ways. The starting position in
a. Is a concentric or eccentric contraction both exercises is hip extension and knee extension. In
occurring at the hip? exercise A, the person flexes the hips with the knees
b. The hip flexors are demonstrating what class of flexed. In exercise B, the person performs the same
lever? hip flexion motion but with the knees extended.
7. While lying prone with your left knee flexed, raise a. Which exercise is more difficult?
your left leg straight up, keeping your pelvis flat on b. Why?
the table. 10. Starting in a supine position with the knees flexed,
a. Are the hamstrings contracting at their strongest? move into the position shown in Figure 18-39.
b. Why? a. What type of kinetic chain activity is this?
8. Sitting on the floor with your legs far apart, lean b. What hip motion is occurring?
forward from the hips while keeping your back c. What type of contraction is occurring?
straight. Describe what has occurred in terms of d. What hip muscle group is the agonist?
a. hip joint motion. e. If this motion could not be completed because a
b. whether stretching or strengthening is occurring. muscle was passively insufficient, what muscle
c. muscle(s) involved. would that be?
A B
Figure 18-38. Hip flexion exercise.
Figure 18-39. Ending position.

2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 283
C H A P T E R 19
Knee Joint
Joint Structure and Motions Joint Structure and Motions
Bones and Landmarks
At first glance, the knee joint appears to be relatively
Ligaments and Other Structures simple. However, it is one of the more complex joints in
the body. The knee is supported and maintained entirely
Muscles of the Knee
by muscles and ligaments with no bony stability, and it
Anterior Muscles frequently is exposed to severe stresses and strains.
Therefore, it should be no surprise that it is one of the
Posterior Muscles
most frequently injured joints in the body.
Anatomical Relationships The knee joint is the largest joint in the body, and it is
classified as a synovial hinge joint (Fig. 19-1). The
motions possible at the knee are flexion and extension
Summary of Muscle Innervation (Fig. 19-2). From 0 degrees of extension, there are approx-
imately 120 to 135 degrees of flexion. Due to some liga-
Common Knee Pathologies
ment laxity, the knee may have a few degrees of hyperex-
Points to Remember tension beyond 0; beyond 5 degrees of hyperextension is
considered genu recurvatum. Unlike the elbow, the
Review Questions
knee joint is not a true hinge, because it has a rotation-
General Anatomy Questions al component. This rotation is not a free motion but
rather an accessory motion that accompanies flexion
and extension.
Figure 19-1. The knee joint (lateral view).
283
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 284
All three types of arthrokinematic motion are used

during knee flexion and extension. The convex femoral
condyles move on the concave tibial condyles or vice
versa, depending upon whether it is an open- or closed-
chain activity. The articular surface of the femoral Spin
condyles is much greater than that of the tibial
condyles. If the femur rolled on the tibia from flexion to Roll
extension, the femur would roll off the tibia before the
motion was complete (Fig. 19-3A). Therefore, the femur Glide
must glide posteriorly on the tibia as it rolls into exten-
sion (Fig. 19-3B). It should also be noted that the artic-
ular surface of the femoral medial condyle is longer
than that of the lateral condyle (Fig. 19-4A). As exten-
sion occurs, the articular surface of the femoral lateral
condyle is used up while some articular surface remains
on the medial condyle (Fig. 19-4B). Therefore, the A B
medial condyle of the femur must also glide posteriorly Figure 19-3. Arthrokinematic movements of the knee joint
to use its entire articular surface (Fig. 19-4C). It is this surfaces in a closed-chain activity of knee extension in which
posterior gliding of the medial condyle during the last the femur moves on the tibia (medial view). (A) Pure rolling
few degrees of weight-bearing extension (closed-chain of the femur would cause it to roll off the tibia as the knee
action) that causes the femur to spin (rotate medially) extends. (B) Normal motion of the knee demonstrates a
on the tibia (see Fig. 19-3B). combination of rolling, gliding (posteriorly), and spinning
Looking at the same spin, or rotational, movement (medially) in the last 20 degrees of extension.
during non-weight-bearing extension (open-chain
action), note that the tibia rotates laterally on the femur
(see Fig. 19-4). These last few degrees of motion lock the
knee in extension; this is sometimes called the screw-
home mechanism of the knee. With the knee fully
extended, an individual can stand for a long time with- Medial
out using muscles. For knee flexion to occur, the knee condyle
must be “unlocked” by laterally rotating the femur on
the tibia. This small amount of rotation of the femur on
the tibia, or vice versa, keeps the knee from being a true
hinge joint. Because this rotation is not an independent
motion, it will not be considered a knee motion.
A B
C
Figure 19-4. The screw-home motion of the left knee. In
the weight-bearing position (closed-chain activity), the femur
Flexion Extension rotates medially on the tibia as the knee moves into the last
Figure 19-2. Knee motions (lateral view). few degrees of extension.
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 285
CHAPTER 19 Knee Joint 285
Articulation between the femur and patella is

referred to as the patellofemoral joint (Fig. 19-5). The
smooth, posterior surface of the patella glides over the
patellar surface of the femur. The main functions of
the patella involve increasing the mechanical advantage
of the quadriceps muscle and protecting the knee joint.
An increased mechanical advantage is achieved by
lengthening the quadricaps moment arm. As discussed
in Chapter 8 (in the “Torque” section), moment arm is
the perpendicular distance between the muscle’s line of
action and the center of the joint (axis). By placing the
patella between the quadriceps, or patellar tendon, and
the femur, the action line of the quadriceps muscles is
farther away (Fig. 19-6). Hence, the moment arm
lengthens, allowing the muscle to have greater angular
force. Without the patella, the moment arm would be
shorter and much of the muscle’s force would be a sta-
bilizing force directed back into the joint. A B
The Q angle, or patellofemoral angle, is the angle Figure 19-6. Moment arm of the quadriceps muscles is
greater with a patella (A), than without a patella (B) (side view).
between the quadriceps muscle (primarily the rectus
femoris muscle) and the patellar tendon. It is determined
by drawing a line from the anterior superior iliac spine
(ASIS) to the midpoint of the patella, and from the tibial
tuberosity to the midpoint of the patella. Although the
rectus femoris attaches to the anterior inferior iliac spine
(AIIS), the ASIS lies just above the AIIS and is easier to
palpate. The angle formed by the intersection of these
lines represents the Q angle (Fig. 19-7). In knee extension,
this angle ranges from 13 to 19 degrees in normal indi- ASIS
viduals. The angle tends to be greater in females, because
the pelvis is generally wider in women. Many different
knee and patellar problems, such as patellofemoral pain
syndrome, are associated with Q angles greater or
smaller than this range.
Quadriceps
line of pull
Q angle
Midpoint of patella
Tibial tuberosity
Figure 19-5. The patellofemoral joint (lateral view). Figure 19-7. The Q angle of the knee (anterior view).
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 286
Bones and Landmarks Body

The long, cylindrical portion between the bone ends;
The knee is composed of the distal end of the femur also called the shaft. It is bowed slightly anteriorly.
articulating with the proximal end of the tibia. The Medial Condyle
landmarks of the femur significant to the knee are the Distal medial end.
following (see Figs. 18-7 and 19-8):
Lateral Condyle
Head Distal lateral end.
The rounded portion covered articulating with the
acetabulum. Lateral Epicondyle
Projection proximal to the lateral condyle.
Neck
The narrower portion located between the head and Medial Epicondyle
the trochanters. Projection proximal to the medial condyle.
Greater Trochanter Adductor Tubercle

Large projection located laterally between the neck Small projection proximal to the medial epicondyle to
and the body of the femur, providing attachment which a portion of the adductor magnus muscle
for the gluteus medius and minimus and for most attaches.
deep rotator muscles. Linea Aspera
Lesser Trochanter Prominent longitudinal ridge or crest running most
A smaller projection located medially and posterior- of the posterior length.
ly, just distal to the greater trochanter; it provides Pectineal Line
attachment for the iliopsoas muscle. Runs from below the lesser trochanter diagonally
toward the linea aspera. It provides attachment
for the adductor brevis.
Patellar Surface
Located between the medial and lateral condyle
Greater Greater anteriorly. It articulates with the posterior surface
trochanter trochanter of the patella.
The landmarks of the tibia significant to the knee are
as follows (Fig. 19-9):
Intercondylar Eminence
A double-pointed prominence on the proximal sur-
face at about the midpoint, which extends up
Body
into the intercondylar fossa of the femur.
Linea
Medial Condyle
aspera The proximal medial end.
Lateral Condyle
The proximal lateral end.
Plateau
Adductor The enlarged proximal end, including the medial and
Lateral
tubercle
Lateral
lateral condyles and the intercondylar eminence.
epicondyle Medial epicondyle
Tibial Tuberosity
epicondyle
Large projection at the proximal end on the anterior
Lateral Medial
Condyle surface in the midline.
Patellar condyle Lateral
surface condyle The fibula is lateral to, and smaller than, the tibia. It
Anterior Posterior is set back from the anterior surface of the tibia, allow-
Figure 19-8. Right femur. ing a large space for muscle attachment (Fig. 19-10).
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 287
Lateral condyle Intercondylar eminence

Superior
Tibial plateau Tibial plateau
Medial condyle Inferior

Tibial tuberosity
Anterior Surface Posterior Surface
Figure 19-11. The patella.
Crest
This feature gives the lower leg its rounded circumfer-
ence. The fibula is not part of the knee joint, because it
does not articulate with the femur. Although it provides
a point of attachment for some of the knee structures,
it has a larger role at the ankle.
The patella is a triangular sesamoid bone within the
quadriceps muscle tendon (Fig. 19-11). It has a broad,
superior border and a somewhat pointed distal portion.
The calcaneus (see Fig. 19-10) is the most posterior
of the tarsal bones and is commonly known as the heel.
It is identified here because it provides attachment for
the gastrocnemius muscle.
Medial malleolus
Figure 19-9. Right tibia (anterior view).

Ligaments and Other Structures
As stated earlier, the knee is held together not by its
bony structure but by ligaments and muscles. The cru-
ciate and collateral ligaments are the two main sets of
ligaments for this task (Fig. 19-12). The cruciates are
located within the joint capsule and are therefore
called intracapsular ligaments. Situated between the
Lateral
condyle of
the femur Posterior
Patella
cruciate
ligament
Fibular head
Medial
Anterior
condyle of
Tibia cruciate
the femur
ligament
Medial
collateral
Fibula Lateral
ligament
collateral
ligament Medial
Lateral meniscus
meniscus Medial condyle
Lateral malleolus of the tibia
Lateral
condyle Transverse
Calcaneus ligament
of the tibia
Tibial
Head of tuberosity
the fibula
Figure 19-10. Right leg (lateral view). Figure 19-12. The right knee in flexion (anterior view).
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 288
medial and lateral condyles, the cruciates cross each attaching to the medial condyles of the femur and
other obliquely (cruciate means “resembling a cross” in tibia. Fibers of the medial meniscus are attached to this
Latin). They are named for their attachment on the ligament, which contributes to frequent tearing of the
tibia (Fig. 19-13). The anterior cruciate ligament medial meniscus during excessive stress to the medial
attaches to the anterior surface of the tibia in the inter- collateral ligament. On the lateral side is the lateral
condylar area just medial to the medial meniscus. It collateral ligament, or fibular collateral ligament.
spans the knee laterally to the posterior cruciate liga- This round, cordlike ligament attaches to the lateral
ment, and it runs in a superior and posterior direction condyle of the femur and runs down to the head of the
to attach posteriorly on the lateral condyle of the fibula, independent of any attachment to the lateral
femur. The posterior cruciate ligament attaches to meniscus. It protects the joint from stresses to the
the posterior tibia in the intercondylar area, and it runs medial side of the knee. It is quite strong and not com-
in a superior and anterior direction on the medial side monly injured.
of the anterior cruciate ligament. It attaches to the The collateral ligaments supply stability in the
anterior femur on the medial condyle. In summary, frontal plane. The medial collateral ligament provides
the anterior cruciate runs from the anterior tibia to the medial stability and prevents excessive motion if there is
posterior femur, and the posterior cruciate runs from a blow to the lateral side of the knee. The lateral collat-
the posterior tibia to the anterior femur. eral ligament provides stability to the medial side.
The cruciates provide stability in the sagittal plane. Because their attachments are offset posteriorly and
The anterior cruciate ligament keeps the femur from superiorly to the axis of flexion, the collateral ligaments
being displaced posteriorly on the tibia. Conversely, it tighten during extension, contributing to the stability
keeps the tibia from being displaced anteriorly on the of the knee, and slacken during flexion.
femur. It tightens during extension, preventing exces- Located on the superior surface of the tibia, the
sive hyperextension of the knee. When the knee is medial and lateral menisci (plural of meniscus) are two
partly flexed, the anterior cruciate keeps the tibia half-moon, wedge-shaped fibrocartilage disks. They are
from moving anteriorly. Conversely, the posterior designed to absorb shock (Fig. 19-14). Because they are
cruciate ligament keeps the femur from displacing thicker laterally than medially and because the proxi-
anteriorly on the tibia or the tibia from displacing mal surfaces are concave, the menisci deepen the rela-
posteriorly on the femur. It tightens during flexion tively flat joint surface of the tibia. Perhaps because of
and is injured much less frequently than the anterior its attachment to the medial collateral ligament, the
cruciate ligament. medial meniscus is torn more frequently.
Located on the sides of the knee are the collateral lig- There are two types of end feel at the knee joint. With
aments (see Fig. 19-12). The medial collateral ligament, knee flexion, the end feel is soft (soft tissue approxima-
or tibial collateral ligament is a flat, broad ligament tion) due to the contact between the muscle bellies of
the thigh and leg. With knee extension, the end feel is
firm (soft tissue stretch) due to tension of the joint cap-
sule and ligaments.
The purpose of a bursa is to reduce friction, and
approximately 13 of them are located at the knee joint.
They are needed because the many tendons located
Posterior cruciate Quadriceps tendon

ligament
Anterior cruciate Transverse ligament
ligament Medial Anterior cruciate
meniscus ligament
Articular Lateral
surface of meniscus
the tibia
Articular surface
of the tibia
Posterior cruciate
ligament
Figure 19-13. Cruciate ligaments are named for their
attachment on the tibia (side view). Figure 19-14. Right knee (superior view).
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 289
around the knee have a relatively vertical line of pull

against bony areas or other tendons. Figure 19-15 Semimembranosus
illustrates many of the bursae around the knee as and semitendinosus Biceps
muscles femoris
viewed from the medial side. Table 19-1 summarizes muscle
the most commonly discussed bursae. Common
Tibial nerve
The popliteal space is the area behind the knee, peroneal
and it contains important nerves (tibial and common Popliteal nerve
artery and vein
peroneal) and blood vessels (popliteal artery and vein). Popliteal
This diamond-shaped fossa is bound superiorly on the space
Medial head of
medial side by the semitendinosus and semimembra- gastrocenmius
nosus muscles and by the biceps femoris muscle on muscle
the lateral side (Fig. 19-16). The inferior boundaries
Lateral head of
are the medial and lateral heads of the gastrocnemius gastrocenmius
muscle. muscle
The pes anserine (Latin for “goose foot”) muscle
group is made up of the sartorius, gracilis, and Figure 19-16. The muscular boundaries of the right
semitendinosus (Fig. 19-17) muscles. Each muscle popliteal space (posterior view).
has a different proximal attachment. The sartorius
muscle arises anteriorly from the iliac spine, the
gracilis muscle arises medially from the pubis, and
the semitendinosus muscle arises posteriorly from
the ischial tuberosity. They all cross the knee posteri-
orly and medially, then join together to attach
distally on the anterior medial surface of the
proximal tibia. This arrangement can also be seen in Sartorius
Gracilis
Semitendinosus
Quadriceps
Semimembranosus
Suprapatellar b.
Prepatellar b.
Gastrocnemius
b. Figure 19-17. The three muscle attachments of pes anser-
Patella ine (medial view).
Femur
Semimembranosus b.
Anserine b.
Deep infrapatellar b.
Superficial Figure 18-29. Orthopedic surgeons sometimes alter
infrapatellar b. Tibia this common attachment to provide medial stability
to the knee.
Sartorius Muscles of the Knee

Gracilis Gastrocnemius Many of the two-joint muscles of the knee were dis-
cussed with the hip. However, further clarification of
Semitendinosus
these muscles does need to be made. Table 19-2 shows
Medial View the muscles that cross the knee, although not all have a
Figure 19-15. Bursae around the knee joint (side view). major function.
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 290
Table 19-1 Bursae of the Knee

Name Location
Anterior
Prepatellar Between the patella and skin
Deep infrapatellar Between proximal tibia and patellar ligament
Infrapatellar Between tibial tuberosity and skin
Suprapatellar* Between distal femur and quadriceps tendon
Posterior
Gastrocnemius* Between lateral head of gastrocnemius muscle and capsule
Biceps Between fibular collateral ligament and biceps tendon
Popliteal* Between popliteus tendon and lateral femoral condyle
Gastrocnemius* Between medial head of gastrocnemius muscle and capsule
Semimembranosus Between tendon of semimembranosus muscle and tibia
Lateral
Iliotibial Deep to the iliotibial band at its distal attachment
Fibular collateral ligament Deep to the fibular collateral ligament next to the bone
Medial
Anserine Deep to sartorius, gracilis, and semitendinosus tendons
*Communicates with knee joint.
Anterior Muscles
The quadriceps muscles are comprised of four muscles
that cross the anterior surface of the knee (Fig. 19-18).
The rectus femoris muscle is the only one of this
group to cross the hip. Its proximal attachment is on the
AIIS. It runs almost straight down the thigh, where it is
joined by the three vasti muscles and blends into the
quadriceps tendon (also called the patellar tendon). This
tendon encases the patella, crosses the knee joint, and Rectus femoris
attaches to the tibial tuberosity. The rectus femoris mus-
cle is a prime mover in hip flexion and knee extension.
Vastus lateralis
Table 19-2 Muscles of the Knee Vastus intermedialis

Area One-Joint Muscle Two-Joint Muscle Vastus medialis
Anterior Vastus lateralis Rectus femoris
Vastus medialis
Vastus intermedialis
Posterior Biceps femoris Biceps femoris
(short) (long)
Popliteus Semimembranosus
Semitendinosus
Sartorius Figure 19-18. The quadriceps muscle group (anterior
Gracilis view). The three vasti muscles lie deep to the rectus femoris.
Gastrocnemius The vastus medialis and lateralis attach proximally on the
posterior femur but join the other two muscles to cross the
Lateral Tensor fascia latae
knee anteriorly.
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 291
The vastus lateralis muscle is located lateral to the rec-

tus femoris muscle. It originates from the linea aspera
of the femur and spans the thigh laterally to join the
other quadriceps muscles at the patella. The vastus
medialis muscle also comes from the linea aspera, but
it spans the thigh medially. Located deep to the rectus
femoris muscle is the vastus intermedialis muscle. It
arises from the anterior surface of the femur and spans
the thigh anteriorly. It blends together with the other
vasti muscles along its length. All four quadriceps mus-
cles attach to the base of the patella and the tibial
tuberosity via the patellar tendon. Because all four mus-
cles span the knee anteriorly, they all extend the knee.
Because the rectus femoris muscle also spans the hip
anteriorly, it flexes the hip. Semitendinosus
Rectus Femoris Muscle Semimembranosus
O AIIS Biceps femoris,

long head
I Tibial tuberosity via patellar tendon
Biceps femoris,
A Hip flexion, knee extension short head
Vastus Lateralis Muscle
O Linea aspera
I Tibial tuberosity via patellar tendon
A Knee extension Figure 19-19. The hamstring muscle group
N Femoral nerve (L2, L3, L4) (posterior view).
Vastus Medialis Muscle

condyle of the tibia. The semitendinosus muscle has a
O Linea aspera
much longer and narrower distal tendon that moves
I Tibial tuberosity via patellar tendon anteriorly after spanning the knee joint posteriorly. It
A Knee extension attaches to the anteromedial surface of the tibia with the
N Femoral nerve (L2, L3, L4) gracilis and sartorius muscles. The biceps femoris mus-
cle has two heads and runs laterally down the thigh on
Vastus Intermedialis Muscle the posterior side. The long head arises with the other
O Anterior femur two muscles on the ischial tuberosity, but the short head
arises from the lateral lip of the linea aspera. Both heads
I Tibial tuberosity via patellar tendon join together, spanning the knee posteriorly to attach lat-
A Knee extension erally on the head of the fibula and, by a small slip, to the
N Femoral nerve (L2, L3, L4) lateral condyle of the tibia. The short head of the biceps
femoris is the only part of the hamstring muscle group
that has a function only at the knee. The other parts have
Posterior Muscles a function at both the hip and the knee.
Three muscles that are known collectively as the ham-
Semimembranosus Muscle
string muscles cover the posterior thigh. They consist of
the semimembranosus, the semitendinosus, and the O Ischial tuberosity
biceps femoris muscles (Fig. 19-19). They have a com- I Posterior surface of medial condyle of
mon site of origin on the ischial tuberosity. tibia
The semimembranosus muscle runs down the
medial side of the thigh deep to the semitendinosus mus-
cle and inserts on the posterior surface of the medial N Sciatic nerve (L5, S1, S2)
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 292
Semitendinosus Muscle The gastrocnemius muscle is a two-joint muscle

that crosses the knee and the ankle (Fig. 19-21). It is an
O Ischial tuberosity extremely strong ankle plantar flexor but also has a sig-
I Anteromedial surface of proximal tibia nificant role at the knee. It attaches by two heads to the
A Extend hip and flex knee posterior surface of the medial and lateral condyles of
N Sciatic nerve (L5, S1, S2) the femur. After descending the posterior leg superfi-
cially, it forms a common Achilles tendon (often called
Biceps Femoris Muscle the heel cord by laymen) with the soleus muscle and
O Long head: ischial tuberosity attaches to the posterior surface of the calcaneus.
Short head: lateral lip of linea aspera Although its major function is at the ankle, it does span
the knee posteriorly, has a good angle of pull, and is a
I Fibular head large muscle. Therefore, its contribution as a knee
A Long head: extend hip and flex knee flexor cannot be overlooked. In addition, its unusual
Short head: flex knee contribution to knee extension has been demonstrated
N Long head: sciatic nerve (S1, S2, S3) in individuals with no quadriceps muscle function
Short head: common peroneal nerve (Fig. 19-22). In a closed kinetic chain action with the
(L5, S1, S2) foot planted on the ground so that the distal segment
(leg) is stationary, the proximal segment (thigh)
The popliteus muscle is a one-joint muscle located becomes the movable part. This is also a reversal of
posteriorly at the knee in the popliteal space, deep to the muscle action in which the femur is pulled posteriorly,
two heads of the gastrocnemius muscles (Fig. 19-20). It or into knee extension. This feature of the gastrocne-
originates on the lateral side of the lateral condyle of the mius muscle makes it possible for a person to stand
femur and crosses the knee posteriorly at an oblique upright without the use of quadriceps muscles.
angle to insert medially on the posterior proximal tibia.
Because it spans the knee posteriorly, it flexes the knee. It
is credited with “unlocking” the knee, as it initiates knee
flexion.
Popliteus Muscle
O Lateral condyle of femur
I Posterior medial condyle of tibia
A Initiates knee flexion
N Tibial nerve (L4, L5, S1)
Figure 19-20. The popliteus muscle (posterior view). Figure 19-21. The gastrocnemius muscle (posterior view).
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 293
medially, contributing greatly to medial stability. The

gastrocnemius and hamstring muscles provide posteri-
or stability both medially and laterally, and the quadri-
ceps muscles provide anterior stability.
Anatomical Relationships
Gluteus maximus Muscles cross the knee either anteriorly or posteriorly.
The rectus femoris is the most superficial muscle of the
Paralyzed
quadriceps
anterior group. At the mid- and lower thigh, the vastus
lateralis and the vastus medialis are superficial on
either side of the rectus femoris (Fig. 19-23). Deep to
the rectus femoris and between the two vasti muscles is
Soleus
the vastus intermedialis (Fig. 19-24).
The hamstring muscles are on the posterior thigh.
Gastrocnemius Superficially, the biceps femoris (long head) is on the lat-
eral side, and the semitendinosus is on the medial side.
Deep to these muscles is the short head of the biceps
Foot anchored
femoris (laterally) and the semimembranosus (medially).
on floor
Dorsi- Plantar The deepest muscle at the distal end of the thigh is the
flexion flexion
Body weight Body weight
A B
Inguinal
Figure 19-22. Side view. (A) With a paralyzed quadriceps ligament
unable to pull the knee into extension, the body weight line Tensor
fascia
falls behind the knee, causing flexion. However, in a com-
latae
bined reversal of muscle action of the gluteus maximus and
gastrocnemius muscles, knee extension during stance is possi-
ble. (B) In the closed-chain position, they pull the knee into
Sartorius
extension. The soleus assists by plantar flexing the dorsiflexed
ankle into a neutral ankle position. This puts the body weight
line in front of the knee and ankle axes and allows the knee
to remain extended.
Vastus Gracilis
lateralis
Gastrocnemius Muscle Rectus
femoris
O Medial and lateral condyles of femur
I Posterior calcaneus Vastus
medialis
A Knee flexion, ankle plantar flexion
N Tibial nerve (S1, S2) Iliotibial
band
The gracilis, sartorius, and tensor fascia latae muscles Patella
span the knee joint posteriorly, but because of their
angle of pull, their size in relation to other muscles, and
Patellar
other such factors, they do not have a prime mover func- tendon
tion. However, they do provide stability to the joint.
The tensor fascia latae muscle spans the knee later- Tibial
ally, essentially in the middle of the joint axis for flexion tuberosity
and extension. It contributes greatly to lateral stability.
The gracilis and sartorius muscles span the knee Figure 19-23. Anterior knee muscles (superficial view).
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 294
Anterior
superior Table 19-3 Prime Movers of the Knee
iliac spine
Action Muscle
Anterior
Rectus femoris
inferior
Extension Quadriceps group
(cut) Rectus femoris
iliac spine
Vastus medialis
Greater
trochanter Vastus intermedialis
Vastus lateralis
Flexion Hamstring group
Semimembranosus
Semitendinosus
Vastus lateralis Biceps femoris
Gracilis Popliteus
Vastus intermedialis Gastrocnemius
Vastus medialis
The other two knee flexors, the popliteus and gastroc-

nemius muscles, receive innervation from the tibial
nerve. (Not included in this discussion or in Table 19-4
Iliotibial band
(cut) are the two-joint hip muscles that span the knee but do
not act as prime movers at the knee—the sartorius, gra-
Patella cilis, and tensor fascia latae muscles.) The knee extensors
receive innervation from the femoral nerve, which comes
Head of fibula off the spinal cord at a higher level than does innervation
of the knee flexors. This is significant when dealing with
Tibial tuberosity
individuals with spinal cord injuries. Tables 19-4 and
19-5 summarize the innervation to the knee. It should be
Figure 19-24. Anterior knee muscles (deep view). noted that there is some discrepancy among various
sources regarding spinal cord level of innervation.
Common Knee Pathologies

popliteus. It lies deep to the proximal heads of the gas- Genu valgum, also called “knock knees,” is an align-
trocnemius. ment of the lower extremity in which the distal segments
The sartorius crosses the knee on the medial side, (ankles) are positioned more laterally than normal. The
anterior to the gracilis, followed more posteriorly by the knees tend to touch while the ankles are apart. Genu
semitendinosus (pes anserine; see Fig. 18-29). The ten- varum (bowlegs) is the opposite alignment problem in
sor fascia latae crosses the knee joint laterally by way of which the distal segments are positioned more medially
the iliotibial band. than normal. The ankles tend to touch while the knees
are apart. Malalignment at one joint often affects align-
ment at an adjacent joint. Therefore, coxa varus is seen
Summary of Muscle Action in conjunction with genu valgus, while coxa valgus may
Table 19-3 summarizes the actions of the prime movers be seen in conjunction with genu varus. Genu recurva-
of the knee. tum, also called, “back knees” is the positioning of the
tibiofemoral joint in which range of motion goes
beyond 0 degrees of extension.
Summary of Muscle Innervation Patellar tendonitis, or jumper’s knee, is character-
The femoral and sciatic nerves play a major part in the ized by tenderness at the patellar tendon and results
innervation of the knee joint. The femoral nerve inner- from the overuse stress or sudden impact overloading
vates the quadriceps muscle group, and the sciatic nerve associated with jumping. It is commonly seen in
innervates the hamstring muscle group. basketball players, high jumpers, and hurdlers.
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 295
Table 19-4 Innervation of the Muscles of the Knee

Quadriceps
Rectus femoris Femoral L2, L3, L4
Vastus lateralis Femoral L2, L3, L4
Vastus intermedialis Femoral L2, L3, L4
Vastus medialis Femoral L2, L3, L4
Hamstrings
Semimembranosus Sciatic L5, S1, S2
Semitendinosus Sciatic L5, S1, S2
Biceps femoris—long head Sciatic L5, S1, S2
Biceps femoris—short head Common peroneal L5, S1, S2
Others
Popliteus Tibial L4, L5, S1
Gastrocnemius Tibial S1, S2
Osgood-Schlatter disease is a common overuse weakness or tightness, weakness of hip lateral rotators,
injury among adolescents. It involves the traction- and excessive foot pronation. Chondromalacia patella
type epiphysis on the tibial tuberosity of growing is the softening and degeneration of the cartilage on the
bone where the tendon of the quadriceps muscle posterior aspect of the patella, causing anterior knee
attaches. Popliteal cyst, or Baker’s cyst, is actually pain. Abnormal tracking of the patella within the
misnamed as a “cyst.” This general term refers to any patellofemoral groove causes the patellar articular carti-
synovial hernia or bursitis involving the posterior lage to become inflamed, leading to its degeneration.
aspect of the knee. Prepatellar bursitis (housemaid’s knee) occurs when
Although there is no universal agreement on termi- there is constant pressure between the skin and the
nology and causation, patellofemoral pain syndrome patella. It is commonly seen in carpet layers and is the
generally refers to a common problem causing diffuse result of repeated direct blows or sheering stresses on
anterior knee pain. It is generally considered the result the knee.
of a variety of alignment factors, such as increased Terrible triad is a knee injury caused by a single
Q angle, patella alta (high-riding patella), quadriceps blow to the knee and involves tears to the anterior
Table 19-5 Segmental Innervation of the Knee

Spinal Cord Level L2 L3 L4 L5 S1 S2
Knee Extensors
Rectus femoris X X X
Vastus lateralis X X X
Vastus intermedialis X X X
Vastus medialis X X X
Knee Flexors
Popliteus X X X
Semitendinosus X X X
Semimembranosus X X X
Biceps femoris X X X
Gastrocnemius X X
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 296
cruciate ligament, the medial collateral ligament, ● End feel is the quality of the feel when slight
and the medial meniscus. Miserable malalignment
pressure is applied at the end of the joint’s
syndrome is an alignment problem of the lower
passive range.
extremity involving increased anteversion of the ● An open kinetic chain requires that the distal
femoral head and is associated with genu valgus,
segment is free to move and the proximal
increased tibial torsion, and a pronated flat foot.
segment(s) remain stationary.
● To stretch a one-joint muscle, it is necessary
to put any two-joint muscles on a slack over

Points to Remember the joint not crossed by the one-joint muscle.
● The body commonly experiences forces such ● To contract a two-joint muscle most effectively,
as traction, approximation, shear, bending, start with it being stretched over both joints.
and rotation. These forces also have other ● A muscle becomes actively insufficient when it
names. contracts over all its joints as the same time.

● The muscle’s point of attachment to the ● When determining whether a concentric or
bone is used to determine leverage. With a eccentric contraction is occurring, decide

second-class lever, resistance occurs between ● if the activity is accelerating against gravity
the axis and the force. With a third-class or slowing down gravity, or
lever, force is in the middle. ● if a weight greater than the pull of gravity is
● The longer the force arm, the easier it is to affecting the activity.
move the part. Conversely, the longer the resist- ● Reversal of muscle action occurs when the
ance arm, the harder it is to move the part. origin moves toward the insertion.
Review Questions
General Anatomy Questions 8. In Figure 19-22:

a. What type of kinetic chain activity is demon-
1. Describe the knee joints: strated?
a. Number of axes: b. Is it possible for the muscles to perform this
Knee _________________ function in either an open or closed kinetic
Patellofemoral _________________ chain?
b. Shape of joint: c. Is either the gastrocnemius or gluteus maximus
Knee _________________ muscle working in a reversal of muscle action
Patellofemoral _________________ role?
c. Type of motion allowed:
Knee _________________ 9. A snowboarder catches an edge and falls. His board
Patellofemoral _________________ twists in one direction as his body twists in the
opposite direction. What is the most likely type of
2. Describe knee joint motion in terms of planes and force experienced at the knee?
axes.
10. When assessing the knee collateral ligaments, the
3. What is the “Q angle”? Why is it important? examiner pulls laterally on your ankle while push-
4. Which bones make up the knee joint? ing medially on your knee.
5. Why is the action of the popliteus muscle often a. What type of load is placed on your lower
described as “unlocking” the joint? extremity?
6. What is the pes anserine? b. Which side of your knee undergoes a tensile
stress?
7. An individual with a spinal cord injury at L3 would c. Which side of your knee undergoes a compres-
be expected to have what knee motion? sive stress?
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 297
1. Analyze the person’s position lying on the two
benches illustrated in Figure 19-25 to determine if
one is more advantageous than the other for
strengthening the hamstrings by doing leg curls.
Note that the knees remain extended in both
positions.
a. What is the hamstring action at the hip and at
the knee?
b. What is the position of the hips in Figure 19-25A?
c. What is the position of the hips in Figure 19-25B?
d. In what position would the hamstrings be
actively insufficient? A
e. Which person’s position on the bench will more
effectively work the hamstrings?
f. Why?
B
A
Figure 19-26. Starting positions for knee extension exercise.
the knee extensors. Knee extension is the motion

being performed.
a. What are the hip positions in Figures 19-26A
and 19-26B?
b. What are the names of the one-joint muscles
performing the knee extension?
c. What is the name of the two-joint muscle, and
B
what hip and knee motions does it perform?
Figure 19-25. Bench positions for hamstring curl exercise. d. Describe the length-tension effect on these mus-
cles in each position.
e. Which person’s position will more effectively
2. Analyze the person’s sitting positions illustrated work the rectus femoris?
in Figure 19-26 to determine if one is more f. Which person’s position will more effectively
advantageous than the other for strengthening work the vasti muscles?
2363_Ch19-283-300.qxd 12/10/10 12:37 PM Page 298
3. What is the sequence of right-knee motions when 2. Sit on the edge of a table with your right leg rest-
stepping up onto a curb leading with the right ing on the table and your left leg over the side with
foot, starting with the right knee extended? your left foot on the floor. Keeping the back and
a. Placing right foot up on curb: right leg straight, lean forward at the right hip. See
b. Bringing left foot up on curb: Figure 19-27 for the starting position.
4. Identify the sequence of knee motions (starting a. What are the right hip and knee motions?
with the knee in extension) for kicking a ball and b. Is stretching or strengthening occurring?
identify the activity of the rectus femoris during c. What muscles are involved?
each phase.
a. What is the knee motion when preparing to kick?
b. Over what joints is the rectus femoris being
elongated?
c. What is the knee motion when making ball
contact?
d. What is happening to the rectus femoris at the
knee during ball contact?
e. What is the knee motion during follow-through?
f. What is happening to the rectus femoris during
follow-through?
5. What compensatory motions may occur when step-
ping up onto a curb if your right leg were in a long
leg cast?
a. Which would be the leading leg?
b. What pelvic motion would assist in getting the
right leg up on the curb?

1. What types of exercises are occurring during a “wall Figure 19-27. Starting position.
sit”? Keeping the head, shoulders, and back against
the wall with your feet shoulder-width apart, slowly 3. Lying supine, raise your right leg up toward the
slide down the wall until the thighs are almost par- ceiling about 24 inches, keeping your right knee
allel to the floor. Hold that position for the count straight.
of five. Return to the starting position. a. What are the right hip and knee motions?
During the slide-down phase: b. Is stretching or strengthening occurring?
a. What is the knee motion? c. What muscles are involved?
b. What type of contraction (isometric, concentric, d. Is this an open- or closed-chain activity?
or eccentric) is occurring?
c. What muscles are performing this action? 4. Standing on your left leg and holding on to some-
d. Is this an open- or closed-chain activity? thing for balance, bend your right knee and grasp
During the holding phase: your right foot. Slowly pull your right heel toward
a. What type of contraction (isometric, concentric, your right buttock.
or eccentric) is occurring? a. What are the right hip and knee motions?
b. What muscles are performing this action? b. Is stretching or strengthening occurring?
During the return phase: c. What muscles are involved?
a. What is the knee motion? 5. When performing passive range of motion (PROM)
b. What type of contraction (isometric, concentric, on an individual’s knee, the end feel for flexion
or eccentric) is occurring? should be ____________________ and
c. What muscles are performing this action? _____________________ for extension.

Anfis Regio Hip & Knee

Uploaded by

Copyright:

Available Formats

Anfis Regio Hip & Knee

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Anfis Regio Hip & Knee

Uploaded by

Copyright:

Available Formats

2363_Ch18-259-282.

qxd 12/10/10 12:34 PM Page 261

Figure 18-1. The bones of the lower extremities

262 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

the foot includes seven tarsal bones, 5 metatarsals, and

Joint Structure and Motions

Abduction Adduction Lateral Medial

CHAPTER 18 Hip Joint 263

Posterior superior Anterior

264 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

The pubis forms the anterior inferior portion of the

Inferior Ramus Linea

CHAPTER 18 Hip Joint 265

Adductor Tubercle Ligaments and Other Structures

266 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

Figure 18-11. The spiral attachment of the hip ligaments

CHAPTER 18 Hip Joint 267

Table 18-2 Muscles of the Hip

Muscles of the Hip

268 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

The rectus femoris muscle is part of the quadriceps

when you cross your legs by putting one foot on the

CHAPTER 18 Hip Joint 269

longus muscle, the most superficial of the three, orig-

Adductor longus Adductor brevis Adductor magnus

270 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

Adductor Brevis Muscle

Adductor Magnus Muscle

The only hip adductor that is a two-joint muscle is

CHAPTER 18 Hip Joint 271

Gluteus Maximus Muscle Deep Rotator Muscles

272 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

Table 18-3 Deep Rotator Muscles

CHAPTER 18 Hip Joint 273

occurs every time you pick up one leg, as when walk-

muscles did not contract when you stood on one

274 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

CHAPTER 18 Hip Joint 275

Figure 18-29. Medial muscles (right leg).

thigh, are the hamstring muscles. Deep to the gluteus

276 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

which the neck-shaft angle is less than the normal

CHAPTER 18 Hip Joint 277

neck. These are very common among the elderly,

Summary of Muscle Action

Retroversion is a decreased angle and results in toed-out gait

278 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

muscle innervation in Table 18-3 and 18-5 instead of as a

or slowing down gravity, or

affecting the activity.

Table 18-5 Innervation of the Muscles of the Hip

CHAPTER 18 Hip Joint 279

Table 18-5 Innervation of the Muscles of the Hip—cont’d

Table 18-6 Segmental Innervation of Hip Muscles

General Anatomy Questions 4. Describe the hip joint:

280 PART IV Clinical Kinesiology and Anatomy of the Lower Extremities

Functional Activity Questions

3. Standing in anatomical position and keeping your

CHAPTER 18 Hip Joint 281