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2012;8(S2):3945
www. r eumat ol ogi acl i ni ca. or g
Clinical Anatomy of the Knee
Miguel ngel Saavedra
a,b,
, Jos Eduardo Navarro-Zarza
c
, Pablo Villase nor-Ovies
b,d
,
Juan J. Canoso
b,e,f
, Anglica Vargas
b,g
, Karla Chiapas-Gasca
b,h
, Cristina Hernndez-Daz
b,h
,
Robert A. Kalish
b,f,i
a
Rheumatology Department, La Raza National Medical Center, Mexico City, Mexico
b
Mexican Group for the Study of Clinical Anatomy (GMAC), Mexico
c
Rheumatology, Hospital General de Chilpancingo, Dr. Raymundo Abarca Alarcn, Chilpancingo, Guerrero, Mexico
d
Rheumatologist, Tijuana, Mexico
e
ABC Medical Center, Mexico City, Mexico
f
Tufts University School of Medicine, Boston, MA, USA
g
Rheumatology, National Institute of Cardiology, Mexico City, Mexico
h
Musculoskeletal Ultrasonography Laboratory Department, National Institute of Rehabilitation, Mexico City, Mexico
i
Rheumatology Division, Tufts Medical Center, Boston, USA
a r t i c l e i n f o
Article history:
Received 2 October 2012
Accepted 3 October 2012
Available online 6 December 2012
Keywords:
Knee
Bursitis
Regional pain syndrome
Baker cyst
Clinical anatomy
a b s t r a c t
The clinical anatomy of several pain syndromes of the knee is herein discussed. These include the iliotibial
tract syndrome, the anserine syndrome, bursitis of the medial collateral ligament, Bakers cyst, popliteus
tendon tenosynovitis and bursitis of the deep infrapatellar bursa. These syndromes are reviewed in terms
of the structures involved and their role in knee physiology. All of the discussed structures can be iden-
tied in their normal state and more so when they are affected by disease. The wealth of information
gained by cross examination of the medial, lateral, posterior and anterior aspects of the knee brings to
life knowledge acquired at the dissection table, from anatomical drawings and from virtual images.
2012 Elsevier Espaa, S.L. All rights reserved.
Anatoma clnica de la rodilla
Palabras clave:
Rodilla
Bursitis
Sndrome doloroso regional
Quiste de Baker
Anatoma clnica
r e s u m e n
En este artculo se revisa la anatoma clnica de varios sndromes dolorosos de la rodilla. Estos incluyen
el sndrome de la bandeleta iliotibial, el sndrome de la pata de ganso, la bursitis del ligamento colat-
eral medial, el quiste de Baker, la tenosinovitis popltea y la bursitis infrapatelar profunda. El anlisis
anatmico de estos sndromes revela una multiplicidad de estructuras identicables en su estado normal
y ms an en las tendinosis o cuando hay un derrame sinovial. El examen cruzado de las estructuras
mediales, laterales, posteriores y anteriores de la rodilla provee aspectos dinmicos que complementan
su estudio por diseccin, lminas anatmicas e imgenes virtuales.
2012 Elsevier Espaa, S.L. Todos los derechos reservados.
General Considerations
The knee is the largest synovial joint in the body and one of the
most complex biomechanical systems known.
1,2
This joint includes
a condyloid joint between the condyles of the femur and the tibia
and a saddle joint between the posterior surface of the patella and
Corresponding author.
E-mail address: miansaavsa@gmail.com(M.. Saavedra).
thepatellar surfaceof thefemur (Fig. 1). Theupper tibiobular joint,
which is not involved in weight bearing, frequently communicates
with the femorotibial joint.
3
The main movements of the knee are exion between 120
and
150
and 10
.
3
With maximal extension
the knee screws home as the medial femoral condyle slides back
on the medial meniscus and tibia while the lateral femoral condyle
remains inplace, lockingthe joint. This rotationmovement initiates
at 70
.
4
To unlock
the knee, at the very beginning of exion the popliteus muscle (P),
1699-258X/$ see front matter 2012 Elsevier Espaa, S.L. All rights reserved.
http://dx.doi.org/10.1016/j.reuma.2012.10.002
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40 M.. Saavedra et al. / Reumatol Clin. 2012;8(S2):3945
Adductor
tubercle
Medial
condyles
Tibial
tuberosity
Head
neck
and
shaft
of
fibula
Superior
tibiofibular
joint
For iliotibial
tract
Fig. 1. This simple diagram shows 2 most important attachment sites. One is for
iliotibial tract. This site is unnamed in the Terminologia Anatomica but is widely
known by clinicians as lateral tubercle of tibia or Gerdys tubercle. The other site is
the tibial tuberosity where the patellar tendon attaches.
From Passmore R, Robson JS. A companion to medical studies, vol. 1, 2nd ed. Oxford:
Wiley/Blackwell; 1976, p 24.7.
taking hold on the tibia, pulls back fromthe lateral femoral condyle
and causes a reciprocal forward movement of the medial femoral
condyle on the medial meniscus and tibia (Fig. 2), reversing the
lockingof thejoint.
4,5
External andinternal rotations of thetibiarel-
ative the femur are best shownwiththe subject sitting andthe knee
exed90
exion.
28
The popliteal fossa. The popliteal fossa (Fig. 4) has a rhombus
shape that is more clearly gured out in anatomical plates than
in vivo. With the volunteer lying on the examining table, face
down, the popliteal fossa, rather than showing a depression, usu-
ally bulges out. This is caused by subcutaneous fat which varies in
amount according to the persons make up and weight and should
not be mistaken for a Baker cyst. Of the 4 sides of the rhombus the
upper 2 are, medially, the ST tendon that lies on SM (this muscle
remains eshy almost to its insertion which makes it undetectable
on palpation), and laterally, BF. Going up the thigh, particularly in
strong people, SM appears to coalesce with BF without a dividing
line. The distal 2 sides of the rhombus are, medially, the medial
head of G and laterally, the lateral head of G. It should be recalled
that the medial head of G has its origin above the medial femoral
condyle and its lateral head, in the upper part of the lateral femoral
condyle and adjacent supracondylar line. Plantaris (Pla) muscle
shares insertion with the lateral head of G. Contained in the rhom-
bus, from deep to supercial and from medial to lateral lie the
popliteal artery, the popliteal vein and the tibial nerve. The area
that concerns us at this time, however, is the contact area between
SM in his way to the posterior upper tibia and the medial head of
G in his way to its supracondylar origin. At this site, exion move-
ments of the knee separate these muscles and extension brings
themtogether.
29
In addition, at the beginning of exion and at the
end of extension an area of friction is created. A bursa at this site
promotes gliding and allows harmless motion. This is the G-SM
bursa, the anatomical substrate of the Baker cyst. Medial head of
G and SM are placed behind the medial femoral condyle and so
is this bursa. Lindgren, Willen and Rauschning,
30,31
in a series of
landmark anatomical studies determinedthe timing, the frequency
and the nature of this acquired communication. The communica-
tion is absent in the rst decade of life but reaches 10% in the 2nd
decade, 20% in the 3rd decade 30% in the 4th decade, 40% in the
5th decade, reaching a top frequency of 50%60% thereafter. Thus,
once a communication is established, a knee effusion of any nature
will ll the bursa which if large enough will result in a Baker cyst.
Although the sequence of events leading to the acquired commu-
nication are still unknown, based on ndings in the contralateral
knee in unilateral cases, the posterior capsule becomes paper thin
at the bursal site. The gap is an 18(424) mm wide transverse slit
that separates the capsule from G.
31
We have wondered whether
this capsular wear results from the posterior displacement of the
medial femoral condyle every time the knee is locked in extension.
There is quite a difference between a communicating bursa and
a Baker cyst. When uid enters a communicating bursa the lling
occurs in exion when the capsular gap opens and G and SMsep-
arate. As the knee is extended G and SM come together and the
bursa, placed in between, empties its content into the knee and
the capsular gap closes. Thus, normal communicating G-SM bur-
sae should not be detectable in US studies performed in full knee
extension. In a Baker cyst, a larger volume of distention causes part
of the bursa to lie supercial to the muscles and in extension this
portion of the sac, unable to empty, becomes compressed by the
unyielding popliteal fascia. This makes popliteal cysts become soft
andevenundetectable inexionandhardinextension.
29
This nd-
ing on examination is known as the Foucher sign of the Baker cyst.
Solid and true cystic lesions of the popliteal fossa do not soften in
exion, i.e., have a negative Foucher sign. The usefulness of this
sign was evidenced by a recent referral to one of the authors. A
50-year-old male with B-cell lymphoma in remission was sent by
his oncologist for evaluation of a popliteal mass with a presumed
diagnosis of a Baker cyst. He was a strongly built, healthy looking
male with a tennis ball size mass in the right popliteal fossa. There
was no knee effusion. The mass was rm and its consistency was
unchanged by knee exion. Given his background and the nega-
tive Foucher sign he was sent back to his oncologist with a likely
diagnosis of recurrent lymphoma in the supercial popliteal nodes,
which was proven by a PET scan.
Popliteal vein compression causes swelling, pain, and rarely,
venous thromboembolism. Swelling of the leg in Baker cysts may
result fromvenous compression, synovial uid leakage or cyst rup-
ture. The role of lymphatic ectasia in the leg edema caused by
an unruptured popliteal cyst remains to be determined.
32
Baker
cysts may compress the tibial nerve and cause gastrocnemius
muscle atrophy, paresthesias, and pain. Very unusually, isolated
arterial compression may result in intermittent claudication.
33
A
rare complication of a Baker cyst is an acute or chronic com-
partment syndrome.
34
Baker cysts are best shown in US studies
whichare additionallyuseful torule out concurrent or maskerading
phlebitis.
35
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M.. Saavedra et al. / Reumatol Clin. 2012;8(S2):3945 43
In children, since the capsular opening that allows the lling of
the bursa has not yet formed, popliteal cysts have long been held to
be the result of direct trauma that causes irritation of the bursa and
a loculated effusion. While this concept is true in a normal school
populationit is not trueinpatients withinammatoryarthritis such
as rheumatoid arthritis. In contrast to what should be expected, the
rate of bursal communication in these children is 50% or more. This
nding, initially shown by Szer in 1992 was conrmed in a recent
series.
36,37
It could be concluded that in RA the damage inicted
by inammation adds to the normal wear of the capsule, causes an
early communication and sets the conditions to develop a pediatric
communicating Baker cyst.
Patient 5. Popliteal tenosynovitis.
A 61 year-old woman consulted with right posterior upper leg
pain. Pain was absent while lying in bed, appeared upon raising
and went away after taking a few steps. On examination there
was a small knee joint effusion and tenderness at the postero-
lateral joint line as well as posteriorly on the upper tibia. An MRI
showed a small joint effusion and uid in the synovial sheath of
popliteus tendon. Symptoms went away 24hours after a steroid
injection in the joint cavity.
Relevant Anatomy Amenable to Self- and Cross-recognition
Although we have no direct proof that the pain originated in the
popliteus sheath in this patient, there are three lines of evidence
pointing to this diagnosis. First, pain occurred concurrent with the
posterior sliding of the medial femoral condyle upon full exten-
sion which is the position in which popliteus muscle, which spans
the lateral femoral condyle and the upper posterior tibia, would be
maximally stretched. Secondly, there was tenderness at the both
the origin and the insertion of popliteus. Third, an MRI showed
uid accumulation at the popliteus synovial investment.
Popliteus has an intraarticular, tendinous origin in the lateral
femoral condyle below the attachment of the bular collateral
Pop - O
1
Pop - O
2
Soleal
line
Pop -I
Fig. 5. Popliteus muscle. Two insertions are shown, in the lateral femoral condyle
below the epicondyle and in the back of the lateral meniscus. Its insertion is in the
posterior surface of tibia above soleal line.
From Passmore R, Robson JS. A companion to medical studies, vol. 1, 2nd ed. Oxford:
Wiley/Blackwell; 1976, p 24.14.
Fig. 6. Swelling of the deep infrapatellar bursa. The patients foot is to the right. The
slight depression proximal to the bursal swelling corresponds to the patella and the
slight swelling proximal to the patella is caused by uid in the suprapatellar bursa
or recess.
ligament (Fig. 5). Additional attachments include the posterior horn
of the lateral meniscus and the bula. The tendon is invested for
some distance by knee synovium(the popliteus bursa) as a superior
and an inferior recess or as a complete investment by coalescence
between the two leaving the tendon free in the lumen.
1,38,39
The
popliteus tendon has a downward and medial course, and emerges
in the popliteal fossa from under the arquate ligament where it
takes an additional eshy insertion. Now muscle, it takes a broad
eshy insertion in the back of the tibia above the soleus.
Case 6. Infrapatelar entheseal organ inammation.
A 14 year-old boy with spondyloarthritis diagnosed at age 12
is seen because of pain and swelling in both knees
Relevant Anatomy Amenable to Self- and Cross-recognition
Deep infrapatellar bursa. This bursa, which is wedged between
the patellar tendon and the tibia exhibits homology with the
retrocalcaneal bursa.
40
Although less well-dened than in the
retrocalcaneal bursa, there is sesamoid brocartilage in the back of
thepatellar tendon, periosteal brocartilageinfront of thetibia, and
anapronor wedge of synovium-coveredfat that hangs fromHoffas
infrapatellar fat pad on the top. The deep infrapatellar bursa, the
adjacent patellar tendon enthesis, the fat pad and the subperiosteal
boneareall components of theinfrapatellar enthesis organ.
19
Inour
Fig. 7. The distended infrapatellar bursa is seen between the upper tibia and the
patellar tendon that appears black. The bursal uid is intense white. A hanging
portion of the fat pad is seen in black on the top.
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44 M.. Saavedra et al. / Reumatol Clin. 2012;8(S2):3945
patient there was a marked swelling of the knee predominantly in
the infrapatellar region where bulging was seen (Figs. 6 and 7). An
MRI study revealed uid not only in the infrapatellar bursa but also
in the synovial cavity of the knee and the soft tissues anterior to the
patella.
Practical Reviewof the Knee and Related Anatomical
Structures
Anterior Aspect
Patellar tendon
Tibial plateaus
Patellar tendon
Hoffas fat pad, changes in the insertional angle with knee exion
Hoffas fat body apron or wedge that tops the deep infrapatellar
bursa
Tibial tuberosity
Sartorius
Gracilis
Semitendinosus
Pes anserinus
Anserine bursae
Medial plica
Insertions of semimembranosus
Lateral Aspect
Iliotibial tract
Biceps femoris
Popliteal fossa
Subcutaneous fat
Biceps femoris
Medial gastrocnemius
Lateral gastrocnemius
Plantaris