Analysis of Kneeling by Medical Imaging Shows the Femur Moves Back to the Posterior Rim of the Tibial Plateau, Prompting Review of the Concave-Convex Rule

Phys Ther. 2019 Mar 1;99(3):311-318. doi: 10.1093/ptj/pzy144.


Background: Physical therapists assess joint movement by observation and palpation. New imaging technologies that enable vision of bones and joints during functional activities can be used to analyze joint kinematics and review traditional assumptions.

Purpose: The purpose was to measure relations between flexion, rotation, and translation at the knee and to validate these visually.

Design: This was a prospective, observational study.

Methods: Twenty-five healthy participants aged >45 years (13 males) knelt from upright kneeling to full flexion with the foot free. Fluoroscopy recorded movement at 30 frames per second of x-ray. A computed tomography scan provided 3-dimensional data, which were registered to the fluoroscopy frames to provide a moving model. Motion in 6 degrees of freedom was analyzed for coupling of movements.

Results: Mean (standard deviation) flexion reached by participants was 142 (6)° in kneeling. Posterior femoral translation was coupled to flexion (r = 0.96). From 90° to 150° flexion, the femur translated posteriorly by 36 (3) mm to finish 23 (3) mm posterior to the center of the tibia at 150° flexion. From 90° to 150° flexion, the femur externally rotated from 8 (6)° to 16 (5)°. Flexion was coupled to rotation (r = 0.47). Abduction was <3° and lateral translation was <3 mm. Visually, the femur appeared to translate posteriorly until the femoral condyles rested on the posterior rim of the tibial plateau with concurrent external rotation so that the popliteal fossa aligned with the posterior margin of the medial tibial plateau.

Limitations: A limitation of the study is that knee flexion can include squat and lunge as well as kneeling.

Conclusion: Deep flexion requires femoral posterior translation and external rotation. These findings invite review of the concave-convex rule as it might apply to manual therapy of the knee.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Biomechanical Phenomena
  • Female
  • Femur / physiology*
  • Fluoroscopy
  • Humans
  • Knee Joint / diagnostic imaging*
  • Knee Joint / physiology
  • Male
  • Middle Aged
  • Prospective Studies
  • Range of Motion, Articular*
  • Rotation
  • Tibia / physiology*
  • Tomography, X-Ray Computed

Associated data

  • ISRCTN/ISRCTN75076749