Directions: Locate the patella and orient the superior, inferior, medial, and lateral poles while palpating each aspect of this bone.
Structures That Attach Here: Quadriceps tendon/patellar tendon, medial and lateral patellofemoral ligaments
Femur
Medial and Lateral Femoral Condyles
How to Palpate
Position of Partner: Supine, sitting
Directions: Palpate the patella and locate the medial and lateral borders. Palpate immediately to each side of the patella to locate the femoral condyles. You can also gently push the patella laterally to access the anterior aspect of the medial femoral condyle, and vice versa for the lateral femoral condyle. When your partner is positioned with their knee flexed, in either a seated or supine position, you will be able to access more of the distal articulating surfaces given the position of the femur and posterior positioning of the tibia on the condyles.
Muscles That Attach Here: Gastrocnemius (lateral and medial femoral condyles), plantaris (lateral femoral condyle), popliteus (lateral femoral condyle)
Structures That Attach Here: The anterior cruciate ligament attaches to the lateral femoral condyle, and the posterior cruciate ligament attaches to the medial femoral condyle.
Medial and Lateral Femoral Epicondyles
How to Palpate
Position of Partner: Supine, sitting
Directions: Begin by palpating the femoral condyles. Then move transversely to the sides of the knee, either medially, for the medial epicondyle, or laterally, for the lateral epicondyle. The epicondyles will feel like small bumps or protrusions on either side of the distal femur.
Directions: First locate the medial epicondyle as described above. Palpate proximally to this structure, sinking into the soft tissue of the medial compartment of the thigh. Within this tissue the tubercle may be located, which will feel like a depression of the femur as it graduates to the slender shaft of the bone.
Muscles That Attach Here: Adductor magnus (adductor portion)
Tibia
Medial and Lateral Tibial Plateaus
How to Palpate
Position of Partner: Sitting
Directions: Locate the medial aspect of the knee by palpating the patella and/or superior third of the patellar tendon. Palpate medially or laterally to the midline along the anterior aspect of the knee joint line. Palpate into the joint line, which feels like a depression of tissue between the femur and tibia. Attempt to appreciate the very small, accessible flat shelf of the tibial plateau, which is located toward the inferior aspect of the joint line.
Structures That Attach Here: Medial and lateral menisci, coronary ligaments, anterior cruciate ligament, posterior cruciate ligament
Pes Anserine
How to Palpate
Position of Partner: Supine, sitting
Directions: Place your partner in a supine or seated position. Locate the tibial tuberosity and, from there, palpate medially approximately two finger breadths to locate the pes anserine tendon. Alternatively, follow the muscle belly and tendon of the semitendinosus, gracilis, or sartorius muscle to its insertion at the pes anserine. Selective muscle contraction through active range of motion or resistive testing may be performed to appreciate each muscle.
Muscles That Attach Here: Semitendinosus, gracilis, sartorius
Lateral Condyle of the Proximal Tibia (Gerdy’s Tubercle)
How to Palpate
Position of Partner: Supine, sitting
Directions: First, locate the tibial tuberosity. Palpate superolaterally to the tibial tuberosity, approximately halfway between the tibial tuberosity and the anterior aspect of the head of the fibula. Make sure to stay on the tibia and not palpate too far onto the femur. Alternatively, find and follow the iliotibial band to its insertion on this broad, bony aspect of the tubercle.
Structures That Attach Here: Iliotibial band
Tibial Tuberosity
How to Palpate
Position of Partner: Supine, sitting, standing
Directions: Locate the apex of the patella and palpate inferiorly along the patellar tendon to the bony ridge of the tibial tuberosity. Visually, this protrusion may be identified before even palpating the structure.
Muscles That Attach Here: Quadriceps complex via the patellar tendon/ligament
Shaft
How to Palpate
Position of Partner: Supine, sitting, standing
Directions: Locate the tibial tuberosity and palpate inferiorly along the shaft of the tibia along the anterior aspect of the lower shank.
Muscles That Attach Here: The shaft of the tibia serves as a proximal and distal attachment for numerous muscles of the knee, and of the ankle and foot complex. Refer to muscle structures within this chapter and the next for more details.
Fibula
Head of Fibula
How to Palpate
Position of Partner: Supine, sitting
Directions: Locate the tibial tuberosity and then palpate transversely, moving laterally around the tibia until you meet the prominent head of the fibula. Alternatively, you may palpate the distal fibula at the lateral malleolus and follow the fibula proximally until the head of the fibula is appreciated.
Directions: Appreciate the superficial soft tissue contours of the medial and lateral heads of the gastrocnemius and palpate from the posterior aspect of the knee joint inferiorly along each muscle belly. Continue to palpate inferiorly along the Achilles tendon to the muscle insertion at the heel.
Soleus
Origin(s): Posterior head and superior aspect of the fibula, soleal line, and middle third of tibia
Insertion(s): Calcaneus
Action(s): Ankle plantarflexion
Innervation(s): Tibial nerve
How to Palpate
Position of Partner: Prone
Directions: Begin by appreciating the muscle contour and bellies of the gastrocnemius and its medial and lateral heads as described above. Palpate the medial aspect of the soleus by sliding medially from the bottom third of the tibia toward the posterior shank. Palpate the lateral aspect of the soleus by sliding laterally from the bottom third of the tibia posteriorly, appreciating the change in muscle bulk and contour between the gastrocnemius and soleus. You may position the knee in flexion and ask your partner to plantarflex. In this position, the soleus becomes a more effective plantar flexor than the gastrocnemius.
Plantaris
Origin(s): Lateral condyle of femur
Insertion(s): Calcaneus
Action(s): Ankle plantarflexion
Innervation(s): Tibial nerve
How to Palpate
Position of Partner: Prone
Directions: Locate the intersection of the lateral head of the gastrocnemius and the medial aspect of the biceps femoris tendon. Palpate superomedially within the popliteal space, aiming for the posterior aspect of the lateral condyle of the femur. Palpate deep within the tissue until you appreciate the small muscle belly of the plantaris. This muscle can be difficult to palpate given the required depth of palpation through superficial tissues, as well as variation in the actual size of the muscle belly itself.
Popliteus
Origin(s): Lateral aspect of the lateral femoral condyle
Insertion(s): Posterior aspect of tibia superior to soleal line
Directions: Locate the medial knee joint line on the medial aspect of the leg and move posteriorly and inferiorly until you palpate the proximal posterior tibia. Palpate deep to the superficial tissue (i.e., medial head of the gastrocnemius) to press into the tissue of the popliteus. Given the anatomical position of this muscle, and degree of overlying muscle tissue, the specificity of palpating this structure is poor. You may consider sliding the soft tissue of the gastroc-soleus complex to improve your access on the posterior shank.
Fibularis Longus
Origin(s): Head and superior two-thirds of the fibula
Insertion(s): Base of 1st metatarsal, medial cuneiform
Action(s): Ankle eversion, plantarflexion
Innervation(s): Superficial fibular nerve
How to Palpate
Position of Partner: Sitting, supine, side-lying
Directions: Acknowledge the origin of the muscle by palpating the lateral aspect of the fibular head. Follow the muscle belly to its tendon along the lateral aspect of the distal shank and posterior to the lateral malleolus. Instruct your partner to evert the foot against resistance to appreciate the muscle belly and its tendon as it wraps around the plantar surface of the foot. As the tendon wraps around the plantar surface of the foot on the way to its insertion, it is likely you will lose the ability to accurately palpate it due to approximation with other tissue structures.
Fibularis Brevis
Origin(s): Inferior two-thirds of fibula
Insertion(s): Lateral base of 5th metatarsal
Action(s): Ankle eversion, plantarflexion
Innervation(s): Superficial fibular nerve
How to Palpate
Position of Partner: Sitting, supine, side-lying
Directions: Appreciate the origin of the muscle by palpating the lateral aspect of the fibular head. Follow the muscle belly to its tendon along the lateral aspect of the distal shank and posterior to the lateral malleolus. Instruct your partner to evert the foot against resistance to appreciate the muscle belly and its tendon as it descends around the fibular tubercle/trochlea on its way to the lateral base of the 5th metatarsal.
Fibularis Tertius
Origin(s): Inferior fibula, interosseous membrane
Insertion(s): Dorsal base of the 5th metatarsal
Action(s): Ankle dorsiflexion, eversion
Innervation(s): Deep fibular nerve
How to Palpate
Position of Partner: Sitting, supine, side-lying
Directions: Locate the insertion point of the fibularis tertius at the dorsal base of the 5th metatarsal. Instruct your partner to evert and dorsiflex their foot. Identify the tendon on the lateral side of the foot, lateral to the tendons of the extensor digitorum muscle. Follow the tendon proximally along the dorsum of the foot toward the anterolateral aspect of the distal shank, at the inferior aspect of the fibula, to palpate the muscle belly.
Tibialis Anterior
Origin(s): Lateral condyle of tibia, superior half of tibia, interosseous membrane
Insertion(s): Medial cuneiform, base of 1st metatarsal
Action(s): Ankle dorsiflexion, inversion
Innervation(s): Deep fibular nerve
How to Palpate
Position of Partner: Sitting
Directions: Instruct your partner to dorsiflex their foot and appreciate the thick, cord-like tendon that is visible at the anterior talocrural joint line and runs medially to the plantar aspect of the foot toward its insertion points. Palpate the length of the tendon, and move proximally to the muscle belly, located just lateral to the anterior aspect of the tibia.
Extensor Digitorum Longus
Origin(s): Lateral condyle of tibia, superior three-fourths of fibula, interosseous membrane
Insertion(s): Middle and distal phalanx of 2–5
Action(s): Digit extension, ankle dorsiflexion
Innervation(s): Deep fibular nerve
How to Palpate
Position of Partner: Sitting
Directions: Palpate along the dorsal aspects of the 2nd–5th digits with one hand and instruct your partner to extend their toes against resistance. Appreciate the tendons of the extensor digitorum longus along the dorsal aspect of the foot, up to the muscle belly in the anterior compartment of the lower leg.
Extensor Hallucis Longus
Origin(s): Interosseous membrane, fibula
Insertion(s): Distal phalanx of 1st digit
Action(s): Great toe extension, ankle dorsiflexion
Innervation(s): Deep fibular nerve
How to Palpate
Position of Partner: Sitting
Directions: Palpate along the dorsal aspects of the 1st digit with one hand and instruct your partner to extend their toe against resistance. Appreciate the tendon of the extensor hallucis longus, running from the distal great toe along the dorsal aspect of the foot, up to its muscle belly in the anterior compartment of the lower leg.
Tibialis Posterior
Origin(s): Interosseous membrane, tibia
Insertion(s): Navicular tuberosity, cuneiform, cuboid, sustentaculum tali, base of 2nd–4th metatarsals
Directions: Palpate along the flexor retinaculum, posterior to the medial malleolus. Instruct your partner to plantarflex and invert the foot. With these motions you may see the tendon of this muscle moving slightly over the posterior aspect of the medial malleolus. Continue to palpate the tibialis posterior tendon just posterior to the medial malleolus and follow the tendon up to the muscle belly located on the posterior aspect of the distal shank. Due to the girth of the gastrocnemius-soleus complex, and comparatively thin muscle belly of the tibialis posterior, the specificity of the palpation is likely challenging. It may be more prudent to leverage knowledge of the origin of the muscle tissue rather than relying on specific palpation strategies for this muscle.
Flexor Digitorum Longus
Origin(s): Tibia
Insertion(s): Base of distal phalanges of digits 2–5
Directions: Instruct your partner to plantarflex the 2nd–5th digits against resistance to help make the distal tendons of this muscle more prominent. Palpate and follow the tendons along the plantar aspect of the foot to the medial malleolus, where the muscle then ascends the posterior aspect of the distal shank. Like the tibialis posterior muscle, this muscle will be difficult to palpate toward its origin because of its location deep to the superficial posterior muscles of the lower leg.
Flexor Hallucis Longus
Origin(s): Inferior two-thirds of fibula, interosseous membrane
Directions: Have your partner plantarflex their 1st digit against your resistance to help make this muscle’s distal tendon more prominent. Then follow the tendon toward the medial malleolus and up to the muscle belly, which is located on the posterior aspect of the distal shank. Along with the other muscles of the deep compartment of the posterior lower leg, this muscle will be difficult to palpate toward its proximal end.
Directions: You may begin by palpating the apex of the patella or by palpating the tibial tuberosity. If beginning at the apex of the patella, palpate inferiorly along the patellar tendon, appreciating its proximal and distal attachments and borders. If beginning at the tibial tuberosity, palpate superiorly along the tendon, appreciating its attachments and borders.
Medial Collateral Ligament
How to Palpate
Position of Partner: Supine, sitting
Directions: Begin by locating the medial epicondyle of the femur, one of its attachment points. Palpate from this area, moving distally to the medial aspect of the proximal tibia, its other attachment site. Palpate over the medial aspect of the joint line, strumming over the broad, thin tissue crossing the joint surface medially and appreciating the anatomical boundaries of this medial stabilizer of the knee joint.
Lateral Collateral Ligament
How to Palpate
Position of Partner: Supine, sitting
Directions: First, have your partner flex their knee of interest and cross that leg over their other leg into a figure four position. Palpate along the lateral aspect of the knee from its proximal attachment at the lateral femoral epicondyle to its distal attachment at the head of the fibula, strumming over the thick, cylindrical tissue. With your partner in the figure four position, this ligament should be pronounced, making it easy to differentiate from surrounding structures.
Medial and Lateral Meniscus
How to Palpate
Position of Partner: Sitting
Directions: Locate the plateaus of the tibia and palpate along these areas to appreciate the anterior aspects of the menisci. Given the anatomical location of these structures, the specificity of palpation is poor; however, palpation of the medial and lateral joint lines is often performed as part of the physical examination of a suspected meniscus injury.
Medial Patellofemoral Ligament
How to Palpate
Position of Partner: Supine
Directions: Locate the two bony attachments of the ligament at the superomedial aspect of the patella and medial condyle of the femur. Begin by palpating along the superomedial aspect of the patella while moving toward the femur to appreciate this structure.
Iliotibial Band (IT Band/Tract)
How to Palpate
Position of Partner: Side-lying
Directions: Locate the distal attachment of the iliotibial band at the lateral condyle of the proximal tibia (Gerdy’s tubercle), and palpate superiorly along the iliotibial band tissue at the level of the lateral femoral condyle. Along the distal aspect of the lateral thigh, the iliotibial band can be appreciated. Often this structure feels very hard in comparison to the soft tissue that surrounds it. Make sure to differentiate between the vastus lateralis tissue and biceps femoris tendon.
For passive and resistive range of motion assessments, have your partner lie prone to access the largest possible range. To truly appreciate the end range of extension, it may be necessary to have them lie supine with a bolster behind their knee. When the person extends their knee, you’ll then be able to appreciate the end range of their ability to extend their knee.
Background: An unhappy triad injury describes a traumatic injury of the knee involving the anterior cruciate ligament, medial collateral ligament, and medial meniscus. This injury is often the result of an abduction-external rotation force at the knee joint. For example, a lateral blow to the knee while the foot is planting to pivot can cause this injury to occur.
Anterior Knee Pain (Patellofemoral Pain Syndrome, Iliotibial Band Syndrome, and Patellar Tendinopathy)
Background: Three common overuse injuries of the knee are patellofemoral pain syndrome, iliotibial band syndrome, and patellar tendinopathy. Healthcare professionals will often combine a subjective history and physical examination to differentially diagnose the source of knee pain. Pain with palpation of the patella, iliotibial band, or patellar tendon may implicate patellofemoral pain syndrome, iliotibial band syndrome, and/or patellar tendinopathy, respectively.
Ottawa Knee Rules
Background: The Ottawa Knee Rules are a highly sensitive clinical screening tool to determine the need for radiographic imaging for a suspected knee fracture. A healthcare provider will refer a patient to an emergency department for radiographic imaging if any of the following are present during a physical examination with a history of trauma: 1) age fifty-five or older, 2) tenderness to palpation of the fibular head, 3) isolated tenderness of the patella, 4) inability to flex the knee to 90 degrees, 5) inability to bear weight for four steps at time of injury and in the emergency department.
Review Questions: Skeletal Landmarks of the Knee and Lower Leg
The apex of the patella is (superior / inferior) to the base.
The distal attachment of the iliotibial band is (tibial tuberosity / lateral condyle) of the proximal tibia (Gerdy’s tubercle / fibular head).
The (long head / short head) of the biceps femoris originates from the ischial tuberosity, and the (long head / short head) of the biceps femoris originates from the linea aspera.
The is the distal attachment of the adductor magnus muscle.
The medial and lateral menisci are anchored upon the (tibial plateau / tibial tuberosity / femoral condyles).
The quadriceps tendon inserts on the (base of patella / tibial tuberosity / medial epicondyle).
What are the proximal and distal attachments of the medial collateral ligament?
The head of the fibula is located (distally / proximally) along the length of the fibula.
The medial meniscus is located on top of what skeletal landmark of the tibia?
The anterior inferior iliac spine is the proximal attachment of (rectus femoris / vastus intermedius / vastus medialis/ vastus lateralis).
Review Questions: Musculature of the Knee and Lower Leg
Name the muscles that comprise the quadriceps muscle group.
The rectus femoris acts as a (flexor / extensor) at the hip, and a (flexor / extensor) at the knee.
What are the two actions of the biceps femoris?
The vastus intermedius is (superficial / deep) to the rectus femoris.
Identify the three muscles that insert at the pes anserine.
The semitendinosus acts as a (flexor / extensor) at the hip, and a (flexor / extensor) at the knee.
A traumatic injury affecting the function of the femoral nerve would result in muscle weakness or the inability to perform what motion?
Which two nerves innervate the biceps femoris?
What are the actions of the gastrocnemius muscle?
The gastrocnemius and soleus muscle share what muscle action?
