Osteopathy Journals and Research by Darren Chandler

 

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  1. Muscular anatomy of the pes anserine

    The pes anserine is composed of the: 

    • Sartorius.
    • Gracilis.
    • Semitendinosus.

    LaPrade et al (2009) found each individual pes anserine tendon was attached in an almost linear fashion at the lateral edge of the pes anserine bursa. The sartorius tendon attaches more proximally, followed by the gracilis tendon and then the semitendinosus tendon.

    Sartorius

    Origin: ASIS

    Insertion: (1) joins to the pes anserine tendon below the tibial tuberosity. (2) Below and medial to the medial tibial tuberosity. (3) Deep fascia of the crus. (Dziedzic et al 2013).

    Action (Dziedzic et al 2013): 

    • Initialises hip and knee flexion from the phase of full extension. 
    • Weak external rotator and abductor of the hip joint.
    • Rotates the tibia and fibula internally with the knee joint flexed.

    Gracilis

    Origin: pubis, inferior pubic ramus, ischial ramus.

    Insertion: upper part of the medial surface of the tibia.

    Additional attachments: deep fascia of the lower leg and medial head of the gastrocnemius.

    Actions: adducts, flexes and medially rotates the leg. When the foot is fixed the gracilis rotates the femur and pelvis laterally on the tibia.

    Semitendinosus

    Origin: ischial tuberosity, joint tendon of the biceps femoris and an aponeurosis connecting these two muscles.

    Insertion: upper medial surface of the tibia behind the sartorius and distal to the gracilis. At its termination it is united to the gracilis tendon.

    Additional attachments: deep fascia of the leg, gracilis, sartorius (Lee et al 2014), medial head of gastrocnemius and biceps femoris.

    Action:

    • Hip extension.
    • Knee flexion.
    • With the hip extended an internal rotator of the thigh.

    Pes anserine bursa

    The pes anserine bursa is located at the upper medial aspect of the tibia, at the insertion of the conjoined tendon of the pes anserine muscles. LaPrade et al (2009) found each individual pes anserine tendon was attached in an almost linear fashion at the lateral edge of the pes anserine bursa. The sartorius tendon attaches more proximally, followed by the gracilis tendon and then the semitendinosus tendon most distally. They also found attachments of the superficial medial collateral ligament to the pes anserine bursa.

    The bursa separates the pes anserine tendons from the distal portion of the tibial collateral ligament and the bony surface of the medial tibial condyle. It does not communicate with the knee joint.

    The shape of the anserine bursa is of an irregular circular. Lee et al (2014) found its boundaries to be:

    Superior: the proximal line of the tibia (around the level of the tibial plateau), and sometimes above this.

    Medial: follows the line of the sartorius muscle. 

    Inferior: 16mm from the inferomedial point of the tibial tuberosity and in relation to the pes anserine tendon.

    Sometimes the infrapatellar nerve (from the saphenous nerve) lies near the bursa. Hemler et al (1991) presented a case of a patient with symptoms of medial tibial stress syndrome cured by an injection of the pes anserine bursa. They attributed this to an entrapment neuropathy of the saphenous nerve from a pes anserine bursitis.

    Fascial layers of the medial knee 

    Wymenga et al (2006) identified three layers of the fascia in the medial knee:

    Layer I: superficial fascia

    The superficial fascia is subcutaneous. It blends with the pes anserine and tibial periosteum distally, it covers the sartorius and quadriceps proximally, the retinaculum anteriorly, and forms the deep crural fascia posteriorly.

    The superficial portion of layer I adheres to the sartorius. The deep portion of layer I adheres to the gracilis and semitendinosus tendons.

    Layer II: superficial medial collateral ligament

    The superficial medial collateral ligament extends from the femoral epicondyle to the anteromedial tibial crest 5–7 cm below the joint line. LaPrade (2009) found a majority of the distal attachments of the superficial medial collateral ligament to be to the semimembranosus and pes anserine bursa rather than the tibia.

    Posteriorly these fibres are continuous with the oblique fibres of layer III although this was disputed by LaPrade (2009) who found no clear connection.

    Anterior to the femoral attachment these fibres are continuous with the medial patellofemoral ligament.

    Tuncay et al (2007) found the semitendinosus and gastrocnemius tendons to lie between layer I and II.

    Just as the superficial portion of layer I adheres to the sartorius, the deep portion of layer I adheres to the gracilis and semitendinosus tendons. Tuncay et al (2007) found two fascial bands associated with the semitendinosus:

    • Dense 3–4-cm band around the gracilis and semitendinosus tendons approximately 8–10 cm proximal to their tendon insertion.
    • Fascial band originating from the semitendinosus and extending to the gastrocnemius fascia.

    Layer III: the true capsular layer and mid-third medial capsular ligament (deep medial collateral ligament)

    Layer III thickens and forms the deep medial collateral ligament as a thickening of the medial joint capsule.

    The deep medial collateral ligament (layer III) separates the superficial medial collateral ligament (layer II) from the medial meniscus.

    The deep medial collateral ligament extends from the medial femoral condyle to the meniscus and from the meniscus to the tibia.

    Proximally the deep medial collateral ligament attachment merges into the superficial medial collateral ligament fibres, but sometimes it has a distinct attachment 0.5 cm distally.

    The meniscotibial attachment of the deep medial collateral ligament is clearly separated from the superficial medial collateral ligament but blends with it posteriorly.

    Anterior to the superficial medial collateral ligament layer III is thin and loose blending with layer I into the retinaculum.

    Conjoint attachments of layers II and III

    The conjoined tissue of layers II and III forms the posteromedial capsule

    A condensation of fibres within the posteromedial capsule forms the posterior oblique ligament. This ligament is an important stabiliser of the medial side of the knee.

    The femoral attachment of the posteromedial capsule is located at the adductor tubercle.

    The posteromedial capsule is augmented by:

    • Semimembranosus tendon: inserts into the posteromedial tibia just below the joint line. It has various extensions into the posteromedial capsule and the posterior capsule.
    • Adductor Magnus tendon: LaPrade et al (2009) found the distal-medial aspect of the adductor magnus tendon had a thick fascial expansion, which fanned out posteromedially and attached to the medial gastrocnemius tendon, the capsular arm of the posterior oblique ligament and the posteromedial capsule.
    • Gastrocnemius: as well as a thick fascial attachment to the adductor magnus the medial gastrocnemius has a thin fascial band extending to the capsular arm of the posterior oblique ligament (LaPrade et al 2009).

    References

    The fascial band from semitendinosus to gastrocnemius: the critical point of hamstring harvesting An anatomical study of 23 cadavers (2007) Ibrahim Tuncay, Hudaverdi Kucuker, Ibrahim Uzun and Nazim Karalezl

    The Anatomy of the Medial Part of the Knee (2009). Robert F. LaPrade, Anders Hauge Engebretsen, Thuan V. Ly, Steinar Johansen, Fred A. Wentorf, Lars Engebretsen

    Surgical anatomy of the medial collateral ligament and the posteromedial capsule of the knee (2006) Ate B Wymenga Sint Maartenskliniek, Jan-Jaap Kats, Jan G M Kooloos

    Anatomy and Biomechanics of the Medial Side of the Knee and Their Surgical Implications (2015) Matthew D. LaPrade, Mitchell I. Kennedy, Coen A. Wijdicks, and Robert F. LaPrade

    Anatomy of sartorius muscle (2013). D. Dziedzic, U. Bogacka, B. Ciszek

    Surgical anatomy of the medial collateral ligament and the posteromedial capsule of the knee (2006). A. B. Wymenga J. J. Kats J. Kooloos B. Hillen

    Pes anserinus and anserine bursa: anatomical study (2014). Je-Hun Lee, Kyung-Jin Kim, Young-Gil Jeong, Nam Seob Lee, Seung Yun Han, Chang Gug Lee, Kyung-Yong Kim, and Seung-Ho Han

    Saphenous Nerve Entrapment Caused by Pes Anserine Bursitis Mimicking Stress Fracture of the Tibia (1991) Douglas E. Hemler, Wendy K. Ward, Kent W. Karstetter, Phillip M. Bryant

    The fascial band from semitendinosus to gastrocnemius: the critical point of hamstring harvesting An anatomical study of 23 cadavers (2007). Ibrahim Tuncay, Hudaverdi Kucuker, Ibrahim Uzun & Nazim Karalezli

     
  2. Supraspinous ligament

    The supraspinous ligament forms part of the posterior ligamentous system of the vertebral column. It is a strong fibrous cord that connects the tips of the spinous processes. It extends between C7 and L4 in 73% of adults. Anteriorly, the supraspinous ligament merges with the interspinous ligament. Posteriorly the supraspinous ligament blends with myofascial structures.

    The most superficial fibers extend over three or four vertebrae, the deeper spans two or three vertebrae the deepest connect adjacent spinous processes.

    Within the lumbar spine the supraspinous ligament is most easily distinguishable at L2-L3. It then gradually diminishes below this level.

    The supraspinous ligament in the thoracic region is a thin membranous structure. It's only at the thoracolumbar junction does it become better defined.

    Interspinous ligament

    The interspinous ligaments run between, to attach on to, consecutive spinous processes. It attaches to the ligamentum flavum anteriorly and supraspinous ligament posteriorly. The left and right ligaments are seperated by a potential cleft. Only the anterior part of the ligament is truly ligamentous. The posterior part of the ligament is formed from myofascial structures that dip into the interspinous space to attach to the superior edge of the spinous process rather than to its tip.

    Collagen fiber orientation in the interspinous ligaments is:

    Cervical region (Prestar et al 1985):

    • Anterocranial direction: prevents flexion (i.e. the cervical lordosis from diminshing).

    Thoracic region (Prestar et al 1985):

    • Longitudinal bundles of fibres connect the tops of the spinous processes: prevents flexion (i.e. augmentation of the thoracic kyphosis).

    The interspinous ligaments in the thoracic region is a thin membranous structure. It's absent in the upper thoracic spine being replaced by loose connective tissue between the two multifidus muscles. It’s only at the thoracolumbar junction does the interspinous ligament become better defined (Gillian and Zhang 2002).

    Lumbar spine (Prestar et al 1985):

    • L1-5: Heylings (1978) and Scapinelli et al (2006) found the collagen fibers to run in a posterocranial direction. They are divided into the anterior, middle and posterior sections. The anterior section is an extension of the ligamentunm flavum. The middle section has the largest volume and forms a thick italic S-shaped curve, which is believed to be the main component in resisting flexion. The posterior section inserts obliquely backwards blending into the supraspinous ligament.
    • L5-S1: collagen fibers run in a posterocranial and posterocaudal direction. Mahato (2013) found these fibers to run a lot more vertical than those in the upper lumbar spine to resist flexion. These fibers interlace with the thoracolumbar fascia, whose fibres form, below L4, a scissor-latticed structure.

    Changes in the interspinous ligament have been noted at L5-S1 due to the change in contribution from the aponeurosis of the longissimus thoracis in the lower lumbar spine and the supraspinous ligament being absent at this level. Because of this Heylings (1976) found fibres of the right and left lumbodorsal fascia were thickest at this level and decussated across the mid-line. He also found the most medial tendons of the erector spinae aponeurosis crossed the mid-line to gain attachment to the opposite side of the posterior edge of the L5-S1 spinous process.

    The lumbar interspinous ligaments functions in:

    • Resisting flexion: predominately in its middle part (Heyling 1978 and Scapinelli et al 2006).
    • Resisting extension: Prester et al (1985) found the interspinous ligament to limit backwards-shifting of the cranial vertebra in extension.
    • Transmitting tension from the thoracolumbar fascia to the spine (Aspden and Hukins 1987, Yahia et al 1990).

    Characteristics of the supraspinous and interspinous ligaments at different levels

    Johnson and Zhang (2002) analysed the supraspinous ligament at different levels.

    Upper thoracic spine (T1–T5)

    Supraspinous ligament

    The dense connective tissue attaching to the spinous processes in the upper thoracic spine originates mainly from muscles and tendons.

    Tendons of the trapezius and splenius cervicis blend together at the midline creating an impression of a fine ligament running longitudinally over the tips of the spinous processes.

    Dense connective tissue fibers arising from the middle portion of trapezius meet in the midline, decussating prior to attaching to the tips of the T1–T4 spinous processes. They are joined by the tendons of the rhomboid major and splenius cervicis.

    Willard et al (2012) found that although the posterior layer of the thoracolumbar fascia extended up to and fused with the trapezius and rhomboid muscles these muscles are positioned external to it. As such they are enveloped in their own epimysial fascia.

    Standring (2016) found the supraspinous ligament is also formed from the tendonous attachments of the semispinalis thoracis.

    The deep layer of the thoracolumbar fascia - overlying and connecting with the splenius cervicis, longissimus thoracis and iliocostalis - also attaches to the spinous processes.

    Interspinous ligament

    The interspinous ligaments are absent throughout the upper thoracic spine. Instead, the interspinous compartment is occupied by a thin layer of loose connective tissue located between the bilateral multifidus muscles.

    Lower thoracic spine (T6–T12)

    Supraspinous ligament

    At T6 the spinal attachments of the posterior layer of the thoracolumbar fascia becomes evident. This coincides with a marked transition in the midline connective tissue organization and the presence of the decussating fibers of trapezius. 

    This composite of fibers from the posterior layer of the thoracolumbar fascia, dense connective tissue and decussating fibers of trapezius attaches as a single layer of connective tissue directly to the lateral aspect of the T6–T9 spinous processes.

    At T9 the lower portion of trapezius gives rise to a tendinous aponeurosis which spans the lower thoracic and upper lumbar spinous processes.

    T9 also marks the commencement of fiber decussation of the thoracolumbar fascia. These fibers form small fibrous compartments around individual fibers running longitudinally within the lower tendinous portion of trapezius.

    Interspinous ligament

    The interspinous ligament commences at T6 as an anterior extension of the thoracolumbar fascia. It forms a single sheet of dense connective tissue running between the spinous processes of adjacent vertebrae.

    The posterior layer of the thoracolumbar fascia becomes progressively thicker below T10 and, correspondingly, the interspinous tissue becomes better defined and bilaminar in form.

    Lumbar spine (L1–L5)

    Supraspinous ligament

    The principal connective tissue components of the supraspinous ligament in the lumbar spine is the midline attachments of the:

    • Posterior layer of the thoracolumbar fascia: distinct bands of dense connective tissue fibers from the thoracolumbar fascia cross the midline to merge with the contralateral fibers to contribute to both the supraspinous and interspinous ligament. In the upper lumbar spine the tendonous aponeurosis from the trapezius intertwines with the midline attachments of the thoracolumbar fascia.
    • Longissimus thoracis: with the multifidus contributes to supraspinous ligament formation in the mid and lower lumbar spine.
    • Multifidus: Creze et al (2018) found the multifidus to be strongly attached to the erector spinae aponeurosis close to the midline. The multifidus with the longissimus thoracis contributes to the supraspinous ligament in the mid and lower lumbar spine.

    At L5, the dense connective tissue becomes further modified to create a horizontal T-bar formation as the posterior layer of the thoracocolumbar fascia joins with the common erector spinae aponeurosis to attach onto the L5 spinous process.

    Heylings (1976) found beyond the lower limit of the supraspinous ligament at L5-S1 fibres of the right and left lumbodorsal fascia were thickest and decussated across the mid-line.

    Where the supraspinous ligament was present Heylibngs (1976) found the tendons of the erector spinae aponeurosis gained attachment to the lateral part of the posterior edge of the spinous process. At L5-S1, caudal to the termination of the ligament, the most medial tendons crossed the midline to gain attachment to the opposite side of the posterior edge of the L5-S1 spinous processes. More laterally placed tendons at this level remained attached to their own side of these spinous processes.

    The absence of a supraspinous ligament at L5-S1 can be associated with the greater range of flexion in this region.

    Interspinous ligament

    Connective tissue contributions to the interspinous ligament are from:

    • Thoracolumbar fascia: distinct bands of dense connective tissue fibers from the thoracolumbar fascia cross the midline to merge with the contralateral fibers to contribute to both the interspinous and supraspinous ligaments.
    • Longissimus thoracis aponeurosis.
    • Multifidus tendons.

    The interspinous ligament merges anteriorly with the posterior capsule of the zygoapophyseal joints.

    Sacrum (S1–S5)

    The tendinous origins of the multifidus and erector spinae aponeurosis contribute to the midline dense connective tissue arrangement at this level. Caudal to S3, there is no contribution from the surrounding musculature and the fascia gradually diminishes at the level of the coccyx.

    References

    The thoracolumbar fascia: anatomy, function and clinical considerations (2012). F H Willard, A Vleeming, M D Schuenke, L Danneels and R Schleip

    Regional differences within the human supraspinous and interspinous ligaments: a sheet plastination study (2002). Gillian M. Johnson Ming Zhang

    Supraspinous and interspinous ligaments of the human lumbar spine (1976). D. J. A. HEYLINGS 

    Organization of the fascia and aponeurosis in the lumbar paraspinal compartment (2018). Creze M, Soubeyrand M, Nyangoh Timoh K, Ggey O 

    The lumbar interspinous ligaments in humans: anatomical study and review of the literature. (2006). Scapinelli RStecco CPozzuoli APorzionato AMacchi VDe Caro R.

    Ligamentous connections of the spinal processes (1985). Prestar FJFrick HPutz R.

    Anatomy of Lumbar Interspinous Ligaments: Attachment, Thickness, Fibre Orientation and Biomechanical Importance (2013). MAHATO, N. K.

    Structure-function relationship of human spinal ligaments (1990). Yahia HDrouin GNewman N.

    Collagen organisation in the interspinous ligament and its relationship to tissue function (1987).  R. M. ASPDEN, N. H. BORNSTEIN AND D. W. L. HUKINS

    Gray's Anatomy. The anatomical basis of clinical practice. 41st editon. (2016). Standring S