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Genu Recurvatum Svndrome )anice K. loudon, PhD, PT, SCS, ATC '
Heather 1. Goist, MS, PT2 Karen L. Loudon, MOMT, PT, A T C ~
he purpose of this paper is to review the anatomy and
biomechanics of the knee and to present clin- ical signs/symptoms
and
rehabilitation techniques associated with genu recurvatum. Genu
recurva- tum is a position of the tibiofemoral joint in which the
range of motion occurs beyond neutral or 0" of exten- sion (2).
Genu recurvatum clinically appears to be more common in fe- males
than males and may exist due to postural habit, increased joint
lax- ity, or knee injury. Physical therapist5 may only be called
upon to address this condition following injury or postcerebral
vascular accident when poor muscle control of the knee ex- ists.
However, the question may arise: does genu recurvatum predispose an
individual to knee injury?
Anatomy The posterior structures of the
knee are likely to be stressed in an individual who displays
genu recurva- tum. The following anatomical review is designed to
assist readers in under- standing the effects of genu recurva- tum
on the knee joint complex.
The stability of the posterolateral compartment of the knee is
provided by both capsular and noncapsular soft tissue structures,
including the arcuate complex, posterior capsule, lateral meniscus,
fabellofibular liga- ment, and biceps femoris muscle.
The arcuate complex is com- posed of the arcuate ligament,
lateral collateral ligament, popliteus muscle/ tendon, and the
lateral head of the
Genu recurvatum is a common entity found in the clinic that may
have negativr! consequence to knee structures. The purpose of this
article is to review the anatomy, biomechanics, and clinical
effects associated with genu recurvatum. Genu recurvatum is
operationally defined as knee extension greater than 5'.
Individuals who exhibit genu recurvatum may experience knee pain,
display an extension gait pattern, and have poor proprioceptive
control of terminal knee extension. An evaluative process and
treatment program are discussed that include muscle imbalance
correction, proprioceptive practice, gait, and functional training.
Taping or knee bracing may be used initially to facilitate knee
control. This article is intended to draw attention to patients
with genu recurvatum and presents a suggested treatment
progression. Individuals who are involved in athletic endeavors
should be aware of knee position during activities to help protect
joint structures. Key Words: knee, genu recurvatum, anterior
cruciate ligament, rehabilitation ' Assistant Professor, Department
of Physical Therapy Education, University of Kansas Medical Center,
Kansas City, KS. Address for correspondence: 9848 Outlook, Overland
Park, KS 66207.
Director of Physical Therapy, Sports Medicine Institute,
University of Kansas Medical Center, Kansas City, KS ' Staff
Physical Therapist, Watkins Health Center, University of Kansas,
Lawrence, KS
gastrocnemius. These structures are pictured in Figure 1. The
arcuate ligament consists of a Y-shaped sys- tem of capsular fibers
(14,28) that supports the posterior capsule. The lateral collateral
ligament originates from the lateral epicondyle of the femur and
runs postero-inferiorly to insert on the head of the fibula. It
offers the majority of the varus re- straint at 25" of knee flexion
(4,20).
The popliteus has several attach- ments, including the lateral
aspect of the lateral femoral condyle, the pos- teromedial aspect
of the head of the fibula, and the posterior horn of the lateral
meniscus (29). The larger base of this triangular muscle inserts
obliquely into the posteriosuperior part of the tibia above the
soleal line. This muscle has several important functions, including
reinforcement of the posterior third of the lateral c a p sular
ligament (28), unlocking of the knee during flexion and extension
by
externally rotating the femur on the tibia, preventing
impingement of the posterior horn of the lateral menis- cus by
drawing it posteriorly, and, with the posterior cruciate ligament,
preventing posterior glide of the tibia (2,17,23). Attached to the
popliteus tendon is the popliteofibular liga- ment which forms a
strong attach- ment between the popliteal tendon and the fibula.
This ligament adds to posterolateral stability (19.30-32). The
fourth structure of the arcuate complex is the lateral head of the
gastrocnemius which originates on the posterior a..pect of the
lateral femoral condyle and inserts into the posterior surface of
the calcaneus. The gastrocnemius checks knee ex- tension when the
foot is fixed. Ken- dall et a1 advocates that weakness of the
gastrocnemius causes knee hyper- extension (1 5).
Further support of the posterior knee is given by the posterior
joint
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Plantaris m. Femur7C n / \ I' '/ " Lat. Collateral lig.
Gastrocnemius m.
mimembranosus m.
lique Popliteal lg.
Fabellof ibular ~op~iteus m.
7 Poptiteus bursa
FIGURE 1. Anatomy of the posterolateral comer of the knee.
capsule. The capsule forms two pouches that extend over the
articu- lar surface of the femoral condyle and tibial plateaus
(29). The capsule is thin over the posterior aspect of the femoral
condyles but is s u p ported by the two heads of the gas-
trocnemius and reinforced by the oblique popliteal ligament. The c
a p sule is also reinforced by the arcuate ligament laterally.
Stability is further enhanced in- ternally by the lateral
meniscus, which forms a concave articular sur- face for
articulation with the convex lateral femoral condyle (13). The
periphery of the lateral meniscus at- taches to the tibia, the
capsule, and coronary ligament but not the lateral collateral
ligament. Posteriorly, the lateral meniscus is separated from the
joint by the popliteus tendon (Figure 2). The mensicofemoral liga-
ments of Humphrey and Wrisberg also attach to the lateral meniscus
(13) (Figure 2). The Ligament of Humphrey runs anteriorly from the
lateral meniscus to the posterior cru- ciate ligament. The Ligament
of Wrisberg extends from the medial femoral condyle and attaches to
the
posterior horn of the lateral menis- cus, posterior to the
posterior cruci- ate ligament (33). Gray describes these structures
as giving support to the capsule during rotational move- ment of
the tibia and stabilization of the meniscus (6).
A fabella is an accessory sesamoid bone located in the
posterolateral corner of the knee. It may be osseous or
cartilagenous in makeup and is
Popliteus
absent in 15-20% of the population (26). When the fabella is
present, there is a fabellofibular ligament which courses
superiorly and obliquely from the latelal head of the gastrocnemius
to the fibular styloid (14). The fabelle fibular ligament helps
prevent exces- sive internal rotation of the tibia and adds further
ligamentous support on the lateral and posterolateral aspects of
the knee (34). Seebacher et al found through dissection that the
arcuate ligament was quite large in the absence of a fabella
(26).
The biceps femoris muscle has two heads that originate from the
inferomedial facet of the ischial tu- berosity (long head) and from
the lateral lip of the linea aspera of the femur (short head). The
muscle in- serts on the lateral condyle of the tibia and the head
of the fibula. The superficial layer of the common ten- don has
been identified as the major force creating external tibial
rotation (5). The biceps' pull on the tibia re- tracts the joint
capsule and pulls the iliotibial tract posteriorly, keeping it taut
throughout flexion. The tendon is also important in controlling
inter- nal rotation of the femur.
The stability of the posteromedial portion of the knee is
provided by the oblique popliteal ligament, semi- membranosus
tendon, and medial
FIGURE 2. Anatomy of the posterior knee.
/ Post. Cruciate lig. Ant. Cruciate lig.
Lig. of Humphrey and Wrisberg
Lat. Meniscal Attachment
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collateral ligament. The oblique p o p liteal ligament is a
dense thickening in the posterior capsule made up of a continuation
of the popliteal tendon and part of the insertion of the semi-
membranosus (7). It arises posterior to the medial condyle of the
tibia and extends superiomedially to at- tach to the posterior
fibrous capsule. The oblique popliteal ligament pro- vides
reinforcement to the lateral capsule and limits anteromedial rota-
tion of the tibia.
The semimembranosus muscle stems from the lateral facet of the
ischial tuberosity and receives slips from the ischial ramus. This
muscle inserts on the posterior medial aspect of the medial condyle
of the tibia and has an important expansion that reinforces the
posteromedial comer of the knee capsule. The semimem- branosus
pulls the meniscus posteri- orly and internally rotates the tibia
on the femur during knee flexion.
The medial collateral ligament is divided into a superficial and
a deep layer. The deep layer (medial capsu- lar ligament) is a
continuation of the capsule and blends with the medial meniscus and
consists of the upper meniscofemoral portion and a lower
meniscotibial portion. The superficial band is a thick, flat band.
It has an arc-like attachment proximally on the medial femoral
condyle just distal to the adductor tubercle and extends to the
medial surface of the tibia a p proximately 6 cm below the joint
line where it covers the medial inferior genicular artery and nerve
(6). The supeficial band blends with the pos- terior capsule and is
separated from the deep medial collateral ligament by a bursa. Most
of the posterior ob- lique fibers of the superficial medial
collateral ligament blend with the posteromedial comer of the
capsule and, when combined, are referred to as the posterior
oblique ligament (9).
Stability of the knee is also pro- vided by the cruciate
ligaments shown in Figure 3. The posterior cru- ciate ligament is
attached to the pos- terior part of the posterior intercon-
ACL PCL
FIGURE 3. Anterior cruciate ligament (ACl) and pos- terior
cruciate ligament (PC[).
dylar fossa of the tibia, overlapping the posterior rim of the
upper sur- face of the tibia, attaching posteriorly to the
insertion of the posterior horns of the lateral and medial me-
nisci on the tibia (22). The posterior cruciate ligament travels
obliquely medially, anteriorly and superiorly, attaching to the
lateral surface of the medial femoral condyle. The majority of the
ligament is taut in flexion and prevents anterior displacement of
the femur on the tibia.
The anterior cruciate ligament (ACL) is attached to the anterior
in- tercondylar fossa of the tibia along the edge of the medial
condyle and between the insertion of the anterior horn of the
medial meniscus anteri- orly and the lateral meniscus posteri- orly
(3). The ACL travels obliquely superiorly and laterally and
attaches to the posterior medial side of the lateral condyle of the
femur. Distinct portions of the ACL are taut throughout the range
of knee motion (3). The ACL guides the anterior gliding movements
of the femoral condyles on the menisci and tibial plateaus and
prevents ante- rior tibial displacement. During inter- nal rotation
of the tibia, the cn~ciates tighten around themselves and provide
stability (23).
Biomechanics Movement at either the hip or
ankle joint will influence knee joint mechanics. Normal
arthrokinematics
of the weight-bearing knee, moving from flexion to extension,
consist of the femur rolling anteriorly and glid- ing posteriorly
on the fixed tibia (12). A relative internal rotation of the femur
on the tibia occurs near terminal extension due to the contin- ued
anterior rolling of the lateral femoral condyle. With knee hyperex-
tension, the femur does not continue to roll anteriorly but tilts
forward, creating anterior compression be- tween the femur and
tibia (1 5). Two radiographs are shown in Figure 4, displaying
normal knee alignment and a hyperextended position. A hy-
perextended position in conjunction with the normal femoral
internal ro- tation results in tension on the ACL and posterior
structures of the knee (2), which is shown in Figure 5.
In the normal knee, bony contact does not limit hyperextension
as it does at the elbow. Rather, hyperex- tension is checked by the
soft tissue structures. In the relaxed standing position with the
knee straight or slightly flexed, the vector force is be- hind the
knee so there is a tendency for further knee flexion unless the
quadriceps contracts (13). When the knee hyperextends, the axis of
the thigh runs obliquely inferiorly and posteriorly, which tends to
place the ground reaction force anterior to the knee. In this
position, the posterior structures are placed in tension, which
helps to stabilize the knee joint, and no quadriceps muscle activ-
ity is necessary. This can be seen in individuals following a
cerebral vascu- lar accident who lose motor control of the
quadriceps and are still able to stand.
Gait can also be affected by genu recurvatum. During the loading
re- sponse in gait, an individual with genu recurvatum transfers
body weight directly from the femur to the tibia without the usual
muscle energy absorption and cushioning a flexed knee provides.
This may lead to pain in the medial tibiofemoral joint
(compression) and posterolateral lig- amentous structures
(tensile). In indi-
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FIGURE 4. A) Radiograph ofpatient with normal knee alignment. BJ
Radiograph ofpatient with genu recurvatum. Notice the tilt o i the
femur on the tibia.
viduals with quadriceps weakness, compensation may occur by
hyperex- tending the knee to provide greater knee stability.
Clinical Implications According to Kendall et al, "pos-
tural faults that persist can give rise to discomfort, pain, or
disability" (15). If a patient presents with a for- ward head
posture and cervical pain, part of the physical therapist's treat-
ment will be to focus on improving the patient's posture. The same
should apply to the hyperextended knee. The therapist should not
only strengthen muscles about the knee if weak but also address
knee posture. Loudon et al found a positive corre- lation between
genu recumtum and ACL injury in female athletes (16). Hutchison and
Ireland contributed the recurvatum posture and laxity in the
posterior capsule to habitual pos- ture that may lead to injury (1
1).
From the anatomical and biome- chanical review, it appears that
the pos-
sible consequence of genu recunatum in the active individual may
be stress placed on the ACL, anterior joint, or posterolateral
comer of the knee.
Evaluation Individuals with genu recumtum
may present with one of a variety of lower extremity diagnoses.
It is doubtful, however, that their primary diagnosis is genu
recurvatum. Syrnp toms attributable to genu recumtum include
anteromedial joint pain or posterolateral knee pain. The antero-
medial pain is due to the compressive forces at the medial
tibiofemoral compartment and is accentuated if a varus alignment is
present. The pos- terior pain is due to the tension placed on the
posterior structures and is aggravated by stepping or forceful knee
extension in weight bearing (IS). The patient may also complain of
knee instability during activities of daily living.
Patients may have a history of an injury that forced them into
hyperex-
tension. Examples include landing from a jump on an extended
knee, a blow to the anteromedial aspect of the proximal tibia
forcing the knee into hyperextension, or a noncontact external
rotation hyperextension in- jury. Noyes et al have described pos-
terolateral syndrome as an injury to the posterolateral structures
in con- junction with a tom ACL (21). The unsuspecting individual
with postero- lateral syndrome may have no history of injury but
has developed knee pain over a period of time. A thor- ough
subjective examination will guide the clinician to suspect genu
recurvatum as a contributing factor.
Objectively, individuals with genu recumtum will be easily
spotted in static standing. The sagittal view best demonstrates
this posture and is demonstrated by the subject in Fig- ure 6.
Individuals may also present with excessive femoral internal rota-
tion, genu varum or valgum, tibia1 varum, or excessive subtalar
joint pro- nation, which is more noticeable in the frontal plane.
Figure 7 depicts the same individual in Figure 6 in the frontal
view.
During gait, there may be an ob- vious varus-extension thrust
that, ac- cording to Noyes et al, is characteris- tic of chronic
injuries to the
FIGURE 5. Hyperextension and anterior cmciate liga- ment (ACL)
stress.
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FIGURE 8. Varus-extension thrust gait (right leg).
FIGURE 6. Genu recurvaturn in standing.
posterolateral structures of the knee (21). An example of a
varus thrust in gait is depicted in Figure 8. As in standing,
excessive femoral internal rotation past the midstance of gait will
accentuate genu recurvatum as seen in Figure 9.
Individuals with genu recurvatum may have a functional strength
deficit in the quadriceps muscle or gastroc- nemius that allows
knee hyperexten-
sion (27). When performing activities such as step-ups, patients
will use m e mentum to straighten the lower ex- tremity and they
will be unable to control weight-bearing terminal knee extension.
Kendall et al report that the hyperextension posture of the knee is
caused from weakness in the gastrocnemius (1 5). The gamocne- mius
controls knee extension in weight bearing.
Proprioception in individuals with genu recurvatum may be
defi-
FIGURE 7. Excessive iernoral internal rotation in standing.
FIGURE 9. Excessive internal rotation of the left leg during
stance.
cient near the end range of exten- sion. A pilot study done by
the au- thors demonstrated that individuals who stood in
hyperextension and without knee injury were unable to reproduce
knee joint angles in the last 15" of extension compared with other
knee angles of 45 and 60" on a leg press machine. Individuals may
perceive the hyperextended knee po- sition as "normal" and, when
intro- duced to more vigorous activity, they may have a tendency to
stay in hyper- extension, putting their knee at risk for injury
(11.16).
Special tests that should be per- formed during the knee
examination should focus on identifjmg postero- lateral
instability. The external rota- tion recurvatum test provides a
tool to assess posterolateral instability. There will be an
external rotatory subluxation in which the tibia rotates around an
axis in the intact posterior cn~ciate ligament. Posterior subluxa-
tion of the lateral tibial plateau is first reduced as the knee
extends but then, as the knee hyperextends, sub- luxation recurs
and the tibia again rotates externally. As the subluxation occurs,
the tibia can be seen to rotate externally and the lateral tibial
pla- teau can be felt to become promi- nent posteriorly (1). Other
tests that may be clinically significant are the posterolateral
drawer and the varus stress test at 30".
Treatment Progression Rehabilitation of the individual
with knee problems and genu recur- vatum should focus on
biomechanical correction, proprioception training, muscle control,
gait training, and functional activities (24). The treat- ment
progression is displayed in the Table. The rehabilitation process
log- ically builds on the results found in the evaluation. The
following section illustrates a progressive treatment plan for the
individual with genu re- curvatum.
A thorough biomechanical evalu- ation of the lower extremity
chain
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L I T E R A T U R E R E V I E W - - - - - - - - .-.... - . - .
.-- - - - . - .
Treahnent Area Goal Treatment Examples Biomechanical To improve
biomechanical faults In-shoe orthotics
evaluation to alleviate tissue stress Correct muscle imbalances
Proprioception To teach the patient how to
identify good knee alignment in static and dynamic postures
Muscle control Improve absolute quadriceps strength; improve
synchrony of lower extremity muscles
Gait To teach the patient of knee awareness during gait
Functional activities To carry over good knee alignment to
function
Terminal extension holds Posterior knee taping
Theraband terminal knee extension Single leg balance Mini-dips
Squats Step-ups (front, lateral, back) Lunges (forward, side,
backward) Jump landings Minor walking with bent knee Heel lift
Stair climbing lump landing Sports-specific skills
TABLE. Treatment considerations ior individuals with genu
recurvatum.
should be performed first. If the pa- tient presents with
unilateral hyperex- tension, assess the lumbar spine and pelvis for
obliquity or muscle imbal- ance. The hip should be evaluated for
excessive internal rotation which contributes to genu recurvatum in
stance. At the foot, the subtalar and midfoot joints should be
checked for excessive pronation, which allows ex- cessive internal
rotation of the tibia. Prefabricated shells, such as AliMed's BFO,
can be used initially to improve foot position.
Next, proprioceptive awareness of knee terminal extension should
be mastered. Patients need to learn that 0" of knee extension is
normal knee
position. Verbal cueing is helpful but other strategies, such as
the use of posterior knee taping, can give the patient direct
sensory feedback. Fig- ure 10 presents the proper taping technique
to prevent hyperextension. These devices need to be used only
temporarily until the patient recog- nizes neutral knee position.
This neu- tral position should then be carried over to dynamic
strengthening exer- cises.
Muscle strengthening exercises are performed with good knee
posi- tion, and muscle balance is stressed rather than absolute
strength. Muscle sequencing is the key with the ham- strings and
firing in coniunction with the quadriceps to
'I"T guide the knee into extension rather than using the passive
force of gravity 4 (10). The knee is kept in the same
plane as the foot and never allowed to hyperextend as
demonstrated in
b , Figure 1 1. Patients should progress through weight-bearing
exercises. such as resistive terminal extension, single leg
balance, minidips, squats,
L forward and backward step-ups. lung- es, and jump landings.
These exer-
n cises require sequential use of eccen- tric and concentric
control of the lower extremity. Knee control during gait can be ..
..
FIGURE 10. Posteriorkneeshapping toprevent hyper- taught in
conjunction with the previ- extension. ouslv mentioned exercises.
Noyes et
FIGURE 11. Subject performing mini-dip with good knee alignment.
The towel under the medial border of the foot is used to limit
subtalar joint pronation.
al recommend that the patient main- tain knee flexion of 5"
throughout the stance phase of gait (21). Initial- ly, walking
speed will be very slow and deliberate. A mirror can be used to
give visual feedback to the patient to maintain the flexed knee
posture. The use of a 1- to 2-inch elevated heel may be used in the
initial train- ing to create a flexion moment at the knee. The
trunk should be rnain- tained in an upright position vs. a forward
lean or flexed hip during midstance to avoid an anterior shift of
body weight (21.25). Excessive in- ternal femoral rotation should
also be controlled during this phase of gait (21).
Continued training of the patient with genu recurvatum should
focus on more functional tasks such as stair climbing. During the
pull-up phase of stair climbing, patients should be trained to
refrain from thrusting into knee extension. Individuals may have a
tendency to hyperextend their knees with other daily activities,
such as bending forward to brush their teeth. Individuals should be
trained to avoid this knee position during trunk forward
bending.
The last phase of rehabilitation focuses on more complex
activities
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and sports-specific skills. For athletes involved in jumping and
cutting sports, it is important that they mas- ter a bent knee
position. Henning et al suggested that extreme loads are placed on
the ACL when the knee is straight or near straight during plant-
ing and cutting, landing from jumps, and sudden stops while running
(8). Emphasis should be placed on bend- ing the knee during these
sports ac- tivities to prevent injuries to the ante- rior cruciate
ligament.
SUMMARY This paper discusses a common
finding in athletes with knee pathol- ogy. Genu recurvatum or
knee joint hyperextension is a malposition be- tween the femur and
tibia and should be considered a postural fault. Treatment of this
fault will take time and involves repetitive training of the
athlete to reestablish a more ideal femorotibial alignment.
JOSPT
ACKNOWLEDGMENTS We thank Lisa Stehno-Rittel for
the graphic art work used in this manuscript.
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JOSPT Volume 27 Number .5 May IN8
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