Forces Maintaining Alignment
In addition to the boney restraints of the
trochlear groove (femoral sulcus), the patella is
stabilized by passive and dynamic (muscular)
restraints. The superficial portion of the
extensor retinaculum, to which the
vastusmedialis and vastuslateralis muscles have
an attachment, provides dynamic stability in
the transverse plane. The medial and lateral
patellofemoral ligaments, which attach to the
adductor tubercle medially and iliotibial band
laterally provide passive restraints to the patella
in the transverse plane.105 Longitudinally, the
medial and lateral patellotibial ligaments and
patellar tendon fixate the patella inferiorly
against the active pull of the quadriceps muscle
superiorly (Fig. 21.4).
Patellar Malalignment and Tracking Problems
Malalignment and tracking problems of the
patella may be caused by several factors that
may or may not be interrelated.97
Increased Q-angle.With an increased Q-angle,
there may be increased pressure of the lateral
facet against the lateral femoral condyle when
the knee flexes during weight bearing.
Structurally, an increased Q-angle occurs with
a wide pelvis, femoral anteversion, coxavara,
genu valgum, and laterally displaced tibial
tuberosity. Lower extremity motions in the
transverse plane that may increase the Q-angle
are external tibial rotation, internal femoral
rotation, and a pronated subtalar joint.
Dynamic knee valgus (see Fig. 21.9), where the
knee joint center moves medially relative to the
foot during weight-bearing activities, also
increases the Q-angle.227,228
FOCUS ON EVIDENCE
A recent weight-bearing MRI study270 that
compared femoral rotation, lateral patellar
displacement, lateral patellar tilt, and
patellar rotation in females with patellofemoral
pain (n=15) to pain-free individuals (n=15) at
45, 30, 15, and 0 knee
flexion, showed a significant group-by-angle
interaction for femoral medial rotation
(p=0.037), lateral patellar displacement
(p=0.011), and patellar tilt (p=0.03) in the
subjects with patellofemoral pain than those in
the control group. The largest difference
among groups was at 0 knee flexion for each
of these three measures. There was no
significant change in patellar rotation.
Muscle and fascial tightness.A tight iliotibial
(IT) band and lateral retinaculum prevent
medial gliding of the patella. Tight ankle
plantarflexors result in pronation of the foot
when the ankle dorsiflexes, causing medial
torsion of the tibia
and functional lateral displacement of the tibial
tuberosity in relationship to the patella.159
Tight rectus femoris and hamstring muscles
may affect the mechanics of the knee, leading
to compensations.166
Hip muscle weakness. Weakness of the hip
abductors and external rotators may result in
adduction of the femur and valgus at the knee
and contribute to increased medial rotation of
the femur observed under loaded weight
bearing in subjects with patellofemoral pain
syndrome.121,189
Lax medial capsular retinaculum or an
insufficient VMO muscle.The
vastusmedialisobliquus (VMO) muscle may
be weak from disuse or inhibited because of
joint swelling or pain, leading to poor medial
stability.272 Poor timing of its
contraction, which alters the ratio of firing
between the VMO and vastuslateralis (VL)
muscle, may lead to an imbalance of
forces.245,292 It has been suggested that
weakness or poor timing of VMO contractions
increases the lateral drifting of
the patella. However, a recent systematic
review and metaanalysisindicated that,
although there is a trend demonstrating delayed
onset of VMO relative to VL contractions in
subjects with patellofemoral pain, evidence
supporting this idea is difficult to access due to
unexplained heterogeneity in the studies
reviewed.42
Patellar Compression
Patellar contact.The posterior surface of the
patella has several facets. It is not completely
congruent as it articulates with
the trochlear groove on the femur. When the
knee is in completeextension (0), the patella is
superior to the trochleargroove. By 15 of
flexion, the inferior border of the patella begins
to articulate with the superior aspect of the
groove. As
the knee flexes, the patella slides distally in the
groove, and more surface area comes in
contact. Beyond 60 there is controversy as to
whether the contact area continues to increase,
levels off, or decreases.96,97 In addition, as the
knee flexes past 90, the quadriceps tendon
comes in contact with the trochlear groove as
the patella slides inferiorly.
Compression forces.In full extension, because
there is minimal to no contact of the patella
with the trochlear groove, there is no
compression of the articular surfaces.
Furthermore, because the femur and tibia are
almost parallel, the line of pull of the
quadriceps muscle and patellar tendon causes a
very small resultant compressive load. The
resultant force of the quadriceps and patellar
tendon forces rises as the knee flexes, but there
is also greater surface area of the patella in
contact with the groove to dissipate this force.
The joint reaction force on the articular surface
rises rapidly between 30 and 60. There is
controversy as to the extent of joint reaction
forces in greater degrees of flexion.
During squatting, the joint reaction force
continues to rise until 90 and then levels off or
decreases because the quadriceps tendon
begins making contact with the trochlear
groove and therefore dissipates some of the
force.96
In an open-chain, nonweight-bearing
exercise with a free weight on the distal leg, the
greatest joint reaction force in the
patellofemoral articulation occurs at around
30 of flexion.96This is more likely due to the
changing moment arm of the weight rather than
the resultant force of the quadriceps and
patellar tendons. In an open-chain with variable
resistance, the peak stress is at 60 and peak
compression is at 75.67
An increased Q-angle causes increased
lateral facet pressure as the knee flexes.228
Muscle Function
Knee Extensor Muscle Function
The quadriceps femorismuscle group is the
only muscle crossing anterior to the axis of the
knee and is the prime
mover for knee extension. Other muscles that
can act to extend the knee require the foot to be
fixated, creating a closed chain. In this
situation, the hamstrings and the soleus
muscles can cause or control knee extension by
pulling the tibia posteriorly.
Closed-chain function.During standing and the
stance phase of gait, the knee is an intermediate
joint in a closed chain. The quadriceps muscle
controls the amount of flexion at the knee and
also causes knee extension through reverse
muscle pull on the femur. In the erect posture,
when the knee is locked, the quadriceps need
not function when the gravity line falls anterior
to the axis of motion. In this case, tension in
the hamstring and gastrocnemius tendons
supports the posterior capsule.
Patella.The patella improves the moment arm
of the extensor force by increasing the distance
of the quadriceps tendon from the knee joint
axis. Its greatest effect on the leverage of the
quadriceps is during extension of the knee from
60 to 30 and rapidly diminishes from 15 to
0 of extension.99,105
Torque.The peak torque of the quadriceps
muscle occurs between 70 and 50.34 The
physiological advantage of the quadriceps
rapidly decreases during the last 15 of knee
extension because of its shortened length. This,
combined with its decreased moment arm in
the last 15, requires the muscle to significantly
increase its contractile force when large
demands are placed on the muscle during
terminal extension.99
During standing, assistance for extension
comes from the hamstring and soleus muscles
as well as from the mechanical locking
mechanism of the knee. In addition, the
anterior cruciate ligament and the pull of the
hamstring muscle group counter the anterior
translation force of the quadriceps
muscle.76,164
During open-chain knee extension exercises
in the sitting or supine position, when the
resistive force is maximum in
terminal extension because of the moment arm
of the resistance, a relatively strong contraction
of the quadriceps muscle is required to
overcome the physiological and mechanical
disadvantages of the muscle to complete the
final 15 of motion.99 However, it is worth
mentioning that the compressive loads on the
patella also decrease in terminal extension
because of its superior location with respect to
the trochlear groove and the resultant force of
the line of pull of the quadriceps and patellar
tendon.
The therapist needs to be aware of the effect
of the resistance and where in the range of
motion the muscle is being challenged. During
open-chain, nonweight-bearing exercises with
fixed resistance, when the resistance torque
challenges the quadriceps in terminal
extension, there is little challenge midrange
where the muscle is capable of generating
greater tension.
Knee Flexor Muscle Function
The hamstring muscles are the primary knee
flexors and also influence rotation of the tibia
on the femur. Because the hamstrings are two-
joint muscles, they contract more efficiently
when they are simultaneously lengthened over
the hip (during hip flexion) as they flex the
knee. During closed-chain, weight-bearing
activities, the hamstring muscles can assist
with knee extension by pulling on the tibia.
The gastrocnemius muscle also can function
as a knee flexor, but its prime function at the
knee during weight bearing is to support the
posterior capsule against hyperextension
forces.
Thepopliteus muscle supports the posterior
capsule and acts to unlock the knee.
Thepesanserinus muscle group (sartorius,
gracilis, semitendinosus) provides medial
stability to the knee and affects rotation of the
tibia in a closed chain.
Dynamic Stability of the Knee
Because of the incongruity of the femoral
condyles and tibialplateaus, there is little
stability from the boney architecture.
The cruciate and collateral ligaments provide
significant passive stability in the various
ranges of joint motion. Dynamic stability is the
ability of a joint to remain stable in the
presence of rapidly shifting loads during
motion.118 Dynamic stability involves motor
control of the neuromuscular system to
coordinate muscle activity around the joint.
The complex feedforward and feedback
responses mediated by the central nervous
system modulate muscle stiffness and are
important for providing dynamic knee stability
under varying loads and stresses imposed on
the joint structures.304 As summarized in a
clinical commentary by Williams,304 clinical
and scientific evidence is accumulating to
substantiate exercise programs designed for the
purpose of developing dynamic stability of the
kneethat is, to improve control of the knee
via neuromuscular responses in order to reduce
knee ligament stress and the risk of injury
during high-intensity activities.
The Knee and Gait
During the normal gait cycle, the knee goes
through a rangeof 60 (0 extension at initial
contact or heel strike to 60 atthe end of initial
swing). There is some medial rotation of
thefemur as the knee extends at initial contact
and just prior to
heel-off.105,207,222
Muscle Control of the Knee During Gait
Stability during the gait cycle is efficiently
controlled by thenormal function of the
muscles that attach at the knee.207,222
Quadriceps.The quadriceps muscle controls the
amount of knee flexion during initial contact
(loading response) and then extends the knee
toward midstance. It again controls the amount
of flexion during preswing (heel-off to toe-off)
and prevents excessive heel rise during initial
swing. With loss of quadriceps function, the
patient lurches the trunk anteriorly during
initial contact to move the center of gravity
anterior to the knee so it is stable or rotates the
extremity outward to lock the knee.276 With
fast walking, there may be excessive heel rise
during initial swing.
Hamstrings.The hamstring muscles primarily
control the forward swing of the leg during
terminal swing. Loss of function may result in
the knee snapping into extension during this
period. The hamstrings also provide posterior
support to the knee capsule when the knee is
extended during stance. Loss of function
results in progressive genu recurvatum.276
Soleus.The unijoint ankle plantarflexor muscles
(primarily the soleus) help control the amount
of knee flexion during
preswing by controlling the forward movement
of the tibia. Loss of function results in
hyperextension of the knee during
preswing (also loss of heel rise at the ankle and
thus a lag or slight dropping of the pelvis on
that side during the preswing phase).
Gastrocnemius.The gastrocnemius muscle
provides tension posterior to the knee when it
is in extension (end of loading
response or foot flat and just prior to preswing
or heel-off). Loss of function results in
hyperextension of the knee during
these periods as well as loss ofplantarflexion
during preswingor push-off.