Osteopathy Journals and Research by Darren Chandler

 

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  1. Introduction

    Entrapment neuropathy of the saphenous nerve in the subsartorial (adductor) canal can account for:

    • Anteromedial thigh and shin symptoms.
    • Knee medial joint line pain.
    • Restless leg syndrome (Lewis 1991).

    Outlined is a review of the anatomy of the subsartorial canal including its associated anatomical structures including:

    • Fascia Lata.
    • Medial Intermuscular septum.
    • Sartorious fascia.
    • Vastofemoral and Vastoadductor membrane.
    • Fascia overlying the Obturator Externus and Adductor Magnus.

    Subsartorial (adductor) canal

    Standring (2015) identified the subsartorial (adductor) canal as a intermuscular tunnel occupying the distal two thirds of the medial aspect of the thigh. 

    Boundaries

    The boundaries of the subsartorial canal include:

    • Proximal: apex of the femoral triangle.
    • Distal: distal attachment of the tendon of the adductor magnus.
    • Roofed: Sartorious muscle and its fascia and the vastoadductor membrane (Oliveira et al 2009).
    • Posterior: (proximal) Adductor Longus and (distal) Adductor Magnus (and its fascia that continues over the Obturator Externus. Kumka, 2010).
    • Anterolateral: Vastus Medialis.

    Contents

    The contents of the subsartorial canal include:

    • Superficial femoral artery.
    • Femoral vein.
    • Femoral nerve (Saphenous nerve and nerve to the Vastus Medialis)

    Oliveira et al (2009) found the connective tissue of the adductor canal continuous with the outer layer of the vessels. They identified this as a cause of inhibiting the vessels from sliding freely during movement and causing a dynamic compression mechanism.

    Soft tissues associated with the subsartorial canal

    The soft tissues associated with the Subsartorial canal are: 

    Fascia Lata

    The deep investing fascia which envelopes the muscles of the thigh is known as the Fascia Lata. It splits into two distinct layers at several locations in the thigh, either to enclose muscles such as Gluteus Maximus and Tensor Fascia Lata, or to create openings such as the saphenous opening for the great saphenous vein.

    Proximally the fascia lata has a complete attachment to the pelvic bone: anteriorly to the pelvic rami and inguinal ligament, laterally to the iliac crest (with a thickening at the iliac tubercle) and posteriorly to the ischial tuberosity, sacrotuberous ligament, sacrum and coccyx (Huang et al 2013)

    Stecco et al (2013) found the fascia lata continuous with the gluteus fascia and the crural fascia. It is thicker laterally and posterolaterally. They found it's not adhered to the muscles of the thigh due to a loose connective tissue between the fascia lata and the muscles. There are three exceptions:

    (1) In the distal thigh the fascia lata gives origin to some fibers of the vastus lateralis and vastus medialis.

    (2) Where the fascia lata gives a myofascial origin to the bicep femoris.

    (3) There is a complete adhesion of the vastus medialis to the fascia lata along its entire course.

    The fascia lata forms intermuscular septum these are:

    (1) Medial intermuscular septum: described below. It seperates the Vastus Medialis from the Adductor Longus and Magnus. It attaches to the linea aspera and medial supracondylar ridge (Burnet et al 2004).

    (2) Lateral intermuscular septum: it seperates the anterior and posterior compartments of the thigh. It lies between the Vastus Lateralis and Bicep Femoris and attaches to the linea aspera of the femur (Fairclough et al 2006). Fibers from the lateral intermuscular septum run from the femur to the iliotibial band. These form the horizontal fibers of the iliotibial band (Evans 1979)

    As well as the vastus lateralis, vastus medialis and the bicep femoris the fascia lata also receives muscular insertions from the gluteus maximus. These muscle fibers attach onto the iliotibial band and the lateral intermuscular septum.

    The iliotibial band is merely a lateral expansion of the fascia lata and made up of three layers: superficial, middle and deep.

    The superficial and middle layer encloses the tensor fascia lata anchoring it to the iliac crest. These layers unite at the distal end of the tensor fascia lata to form a tendon for the muscle. These united two layers receives fibers from the gluteus maximus and run down the lateral thigh. Fairclough et al (2006) found the iliotibial band attached to the region of, or directly to, the lateral epicondyle of the femur by strong fibrous strands before terminally attaching to gerdy's tubercle on the tibia. Evans (1979) found additional attachments to the patella retinaculum and lateral meniscus.

    The deep layer of the iliotibial band merges just distal to where the superficial and middle layers fuse distal to the tensor fascia lata (Putzer et al 2017). From here it runs deep attaching to the vastus lateralis and rectus femoris fascia. Coursing deeper still it follows the iliofemoral ligament to attach to the supraacetabular fossa between the tendon of the reflected head of the rectus femoris and the hip joint capsule. It resists hip extension.

    With reference to the subsartorial canal the fascia lata's importance lies in its attachments to the Adductor Longus, Adductor Magnus, it's strong attachments to the Vastus Medialis and Medial Intermuscular Septum. The importance of these are discussed below.

    Sartotious fascia

    Burnet et al (2004) describes a fascial envelope around the Sartorius in the upper thigh which in a majority of cases continues distally in the lower part of the muscle.

    Posteriorly this is reinforced by the thick aponeurotic roof of the subsartorial canal: the vastofemoral and vastoadductor membrane.

    Vastofemoral and Vastoadductor membrane

    The Vastofemoral and Vastoadductor membrane are two membranes in the subsartorial canal. They can be continuous with each other or discontinuous. Oliveira et al (2009) describes the Vastoadductor membrane as being the roof of the subsartorial canal.

    (a) Vastofemoral membrane

    Vastofemoral membrane lies proximal in the subsartorial canal. It runs between the Vastus Medialis and femoral artery (Elazab & Elazab 2017).

    (b) Vastoadductor membrane

    Tubbs et al (2007) found the vastoadductor membrane to originate from the medial intermuscular septum. Elazab & Elazab (2017) found the fibers of the vastoadductor membrane to originate from the adductor magnus tendon and the fascia overlying the adductor magnus. This fascia runs continuous proximally over the Obturator Externus (Kumka 2010).

    The vastoadductor membrane lies distally to the Vastofemoral membrane in the subsartorial canal. It bridges from the adductor longus proximally and adductor magnus distally to the vastus medialis (Elazab & Elazab 2017)

    Tubbs et al (2007) measured the vastoadductor membrane 7.6cm long. They measured 28cm from the ASIS to the proximal boarder of the vastoadductor membrane and 10cm from the adductor tubercle to the distal boarder.

    Subsartorial (adductor) canal

    All ready described above this intermuscular canal is bound on all sides by muscular and fascial tissue capable of causing an entrapment neuropathy and vascular claudication.

    Medial Intermuscular Septum

    From superficial to deep the medial intermuscular septum joins the fascia lata superficially before travelling deep through the thigh seperating the Vastus Medialis in the anterior compartment and the Adductor Longus and Magnus in the posterior compartment. Travelling deeper still it attaches to the medial lip of the linea aspera of the femur and its medial supracondylar ridge (Burnet et al 2004).

    Tubbs et al (2007) found the medial intermuscular septum to give origin to the vastoadductor membrane. This membrane bridges across the medial intermuscular septum from the vastus medialis to the adductor longus (proximally) and adductor magnus (distally). In contrast Elazab & Elazab (2017) found the vastoadductor membrane to originate from the adductor magnus tendon and fascia.

    Considerations in the myofascial treatment of the Subsartorial canal

    Obturator Externus & Adductor Magnus

    Elazab & Elazab (2017) found the fascia of the Obturator Externus and the Adductor Magnus gives origin to the Vastoaddutor membrane. The Adductor Magnus also forms a boundary for the Subsartorial canal.

    Obturator Externus

    Origin: the external bony margin of the obturator foramen and a few fibres from the obturator membrane.

    Insertion: Trochanteric fossa with some fibres extending towards the piriformis fossa.

    Action: primary function of external rotation with the hip in flexion.

    With the hip in extension the Obturator Externus does not function as an external rotator. In fact the Obturator Externus stretches slightly when extended and externally rotated (Gudena et al 2015). 

    Stretching the obturator externus

    The mean efficiency of stretching the muscle in internal rotation is (Gudena et al 2015):

    (1)    Most effective in hip extension.

    (2)    Secondly most effective in 90 degrees hip flexion.

    (3)    Thirdly most effective in a neutral hip position.

    Vaarbakken et al (2015) found the most effective way to stretch the Obturator Externus was in extension/abduction/internal rotation.

    Adductor Magnus

    Origin: pubis to the ischium

    Insertion: a point between the greater trochanter and the linea aspera, down the linea aspera to the medial condyle (adductor tubercle) of the femur.

    Action:

    The superior fibers that run horizontally to the more proximal part of the linea aspera flex the the thigh

    The fibers that attach to the linea aspera laterally rotates the thigh.

    The fibers that attach distally on the femur at the adductor tubercle medially rotates the thigh (Reimann et al 1996).

    The more vertical fibers that run more distally on the linea aspera and adductor tubercle extend the thigh.

    Vastus Medialis

    As well as forming a boundary for the Subsartorial canal the Vastus Medialis is an attachment for the vastoadductor membrane.

    Origin: femur

    Insertion: patella tendon

    Action: Pulls the patella medially and has a minimal roll in knee extension. Mixed results if the Vastus Medialis activates with joint hip adduction and knee extension.

    The Vastus Medialis muscle fibers run at an almost horizontal angle (50 to 55 degs to the shaft of the femur) giving it a minimal function in knee extension (Miao et al 2015). Studies are mixed supporting the activation of the Vastus Medialis with simultaneous knee extension and hip adduction with Miao et al (2015) finding only in patellofemoral pain did this actively recruit the Vastus Medialis. 

    Adductor Longus

    The Adductor Longus forms a boundary for the Subsartorial canal.

    Origin: ramus superior of the pubic bone and deep portion of the anterior pubic ligament.

    Insertion: linea aspera

    van de Kimmenade et al (2015) found the muscle a relatively thin muscle.

    The adductor longus forms a continuous 'complex' with the abdominal muscles (Schilders et al 2017):

    • Pyramidalis: the Adductor Longus has attachments to the pyramidalis and deep anterior pubic ligament.
    • External oblique and anterior rectus sheath: via the superficial anterior pubic ligament the aponeurosis of the external oblique and anterior rectus sheath connects with the fascia lata over the adductor area. 

    Action: flexion, adduction and internal rotation and external rotation of the femur.

    Flexion and abduction intensifies the lateral rotating function of the Adductor Longus. Extension and adduction intensifies the internal rotating function of the Adductor Longus (Reimann et al 1996).

    Sartorius

    The Sartorius fascia attaches to the Vastoadductor membrane.

    Origin: ASIS

    Insertion: (1) joins to the pes anserine tendon below the tibial tuberosity. (2) Below and medial to the medial 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.

    References

    Tubbs RS, Loukas M, Shoja MM, Apaydin N, Oakes WJ, Salter EG.Anatomy and potential clinical significance of the vastoadductor membrane (2007). 

    Elazab EEB. Morphological study and relations of the fascia vasto-adductoria (2017).

    Flavia de Oliveira, Ricardo Bragança de Vasconcellos Fontes, Josemberg da Silva Baptista, William Paganini Mayer, Silvia de Campos Boldrini, and Edson Aparecido LibertiThe connective tissue of the adductor canal – a morphological study in fetal and adult specimens (2009). 

    Standring S. Gray’s Anatomy 41st edition (2015). 

    NEIL G. BURNET, TOM BENNETT-BRITTON , ANDREW C.F. HOOLE, SARAH J. JEFFERIES & IAN G. PARKINThe anatomy of sartorius muscle and its implications for sarcoma radiotherapy (2004). 

    Eman Elazab Beheiry Elazab. Subsartorial Compartments and Membranes in the Adductor Canal: Morphological, Histological and Immunohistochemical Study (2017) 

    Myroslava Kumka. Critical sites of entrapment of the posterior division of the obturator nerve: anatomical considerations (2010). 

    Lewis F. The role of the saphenous nerve in insomnia: a proposed etiology of restless legs syndrome. (1991). 

    Elazab EEB. Morphological study and relations of the fascia vasto-adductoria (2017). 

    Gudena R, Alzahrani A, Railton P, Powell J, Ganz R.The anatomy and function of the obturator externus (2015). 

    Reimann R, Sodia F, Klug F. Controversal rotation function of certain muscles of the hip (1996). 

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

    Ernest Schilders, Srino Bharam, Elan Golan, Alexandra Dimitrakopoulou, Adam Mitchell, Mattias Spaepen, Clive Beggs, Carlton Cooke, and Per Holmich. The pyramidalis–anterior pubic ligament–adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept (2017). 

    R. J. L. L. van de Kimmenade, C. J. A. van Bergen, P. J. E. van Deurzen and R. A. W. Verhagen. A Rare Case of Adductor Longus Muscle Rupture (2015)

    Miao P, Xu Y, Pan C, Liu H, Wang C. Vastus medialis oblique and vastus lateralis activity during a double-leg semisquat with or without hip adduction in patients with patellofemoral pain syndrome (2015). 

    Vaarbakken K, Steen H, Samuelson G, Dahl HA, Leergaard IB, Stuge B. Primary function of the quadratus femoris and obturator externus muscles indicated from lengths and moment arms measured in mobilized cadavers (2015). 

    Stecco A, Gilliar W, Hill R, Fullerton B, Stecco C. The anatomical and functional relation between gluteus maximus and fascia lata. (2013)

    John Fairclough, Koji Hayashi, Hechmi Toumi, Kathleen Lyons, Graeme Bydder, Nicola Phillips, Thomas M Best and Mike Benjamin. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome (2006)

    David Putzer, Matthias Haselbacher, Romed Hörmann, Günter Klima, and Michael Nogler. The deep layer of the tractus iliotibialis and its relevance when using the direct anterior approach in total hip arthroplasty: a cadaver study (2017)

    Philip Evans. The postural function of the iliotibial tract (1979)

    Brady K. Huang, Juliana C. Campos, Philippe Ghobrial, Michael Peschka, Michael L. Pretterklieber, Abdalla Y. Skaf, Christine B. Chung, Mini N. Pathria.  Injury of the gluteal aponeurotic fascia and proximal iliotibial band: anatomy, pathologic conditions, and MR imaging (2013).

  2. Anatomy of the Iliolumbar Ligaments

    The iliolumbar ligament is generally documented as being split into anterior and posterior bands extending from the L5 transverse process to the ilium (Rucco et al 1996).

    However Kelihues et al (2001) found in only three out of thirty cadavers was the ligament made up of clearly identifiable bands. In a majority of cases, the ligament appeared as a spreading, connective tissue complex, which could be differentiated into two (9/30), three (14/30) or four (4/30) main bands.

    The Iliolumbar ligaments blends with the posterior retinaculum sheat (Willard et al 2012) and the anterior sacroiliac ligaments (Vleeming et al 2012) 

    Back to the traditional description Rucco et al (1996) found the Iliolumbar ligament split into anterior and posterior components:

    Anterior band: the anterior band of the iliolumbar ligament is broad and flat. It has two types (Rucco et al 1996):

    Type 1 originates from the anterior aspect of the inferolateral portion of the L5 transverse process and fans out widely before inserting on the anterior portion of the iliac tuberosity.

    Type 2 originates anteriorly, laterally, and posteriorly from inferolateral aspect of the L5 transverse process and fans out before inserting on the anterior portion of the iliac tuberosity

    The anterior band inserts on the anterior part of the iliac tuberosity below the posterior band (Basadonna et al 1996).

    Posterior band: the posterior band of the iliolumbar ligament is thinner than the anterior section. It originates from the apex of the L5 transverse process and inserts on the iliac crest above the anterior band (Basadonna et al 1996).

    Rucco et al (1996) found in the coronal plane, the spatial disposition of the iliolumbar ligament varies greatly with the size of the L5 vertebra and its position in the pelvis:

    • When L5 is situated low in the pelvis, the bands of the iliolumbar ligament are longer and oblique.

    • When L5 is situated high in the pelvis, the bands of the iliolumbar ligament are shorter and horizontal.

    Anatomical variations 

    More uncommon variations in the attachment of the iliolumbar ligament are mainly on its vertebral attachments. These include (Kelihues et al (2001):

    • Lateral surface of the L5 vertebral body.
    • Lateral surface of the L4 vertebral body and transverse process.
    • Lateral surface of the L3 vertebral body and transverse process.
    • Lateral surface of the S1 body.

    Biomechanics of the Iliolumbar ligament

    Viehofer et al (2015) found fibrocartilaginous connective tissue between the Iliolumbar ligament and its bony attachment. This suggests the insertion sites of the ligament are subject to both tensile and compressive loading. This is probably because of the insertional angle changes between the ligament and bone during loading. This supports the suggestion that the iliolumbar ligament might play an important role in the stabilization of the lumbosacral junction. 

    Pool-Goudzwaard et (2003) concluded the iliolumbar ligaments restrict sacroiliac joint sagittal mobility (they didn't specify nutation or counternutation) and it's the anterior band of the iliolumbar ligament that mainly contributes to this restriction.

    Sims and Moorman (1996) found the iliolumbar ligament the greatest resister of sacral flexion (nutation) although no reference was cited in their study. Snijders et al (2008) found contrary to this finding the iliolumbar ligament stretched in counternutation of the pelvis and flexion of the lumbar spine (and Miyasaka et al 2000).

    Yamamoto et al (1990) found the iliolumbar ligament resists lumbar spine movement predominately in contralateral lateral bending, then flexion (& Miyasaka et al 2000, Snijders et al 2000), then extension and lastly axial rotation.

    Innervation of the Iliolumbar ligament

    Kiter et al (2010) showed the iliolumbar ligament to be richly innervated. As well as the biomechanical function suggested by authors such as Viehofer et al (2015) this also suggests the Iliolumbar ligament has an important proprioceptive coordination role in the lumbosacral region and can be a source of pain.

    Palpation of the iliolumbar ligament

    Maigne and Maigne (1991) claimed the iliolumbar ligament was inaccessible to palpation. They found the insertion of the iliolumbar ligament to the pelvis was shielded by the iliac crest. They believed the area tender to palpation was in fact the dorsal rami of the L1 or L2 nerve roots not the iliolumbar ligament attachment. These nerves cross the iliac crest 7 cm from the midline as they course through the fibroosseous tunnel.

    However other authors such as Harmon and Alexiev (2011), Sipko et al (2010) and Rucco et al (1996) found painful palpation of the iliolumbar ligament at the iliac crest indicative of iliolumbar ligament pathology. 

    Iliolumbar ligament injury

    Posterior bands of the iliolumbar ligament are more prone to injury due to their weaker structure (Basadonna et al 1996 and Rucco et al 1996).

    Sims and Moorman (1996) identified the Iliolumbar ligament as the weakest component of the multifidus triangle which along with its angulated attachment they hypothesised lends it prone to injury.

    Interestingly it is the insertional angle that changes during loading that Viehofer et al (2015) found subjected the ligament to both tensile and compressive loading. 

    Snijders (2004, 2008) found slouching to elongate and place excessive strain on the iliolumbar ligament.

    References

    Iliolumbar ligament insertions. In vivo anatomic study (1996). Basadonna PT, Gasparini D, Rucco V.

    Anatomy of the iliolumbar ligament: a review of its anatomy and a magnetic resonance study. (1996). Rucco V, Basadonna PT, Gasparini D.

    The molecular composition of the extracellular matrix of the human iliolumbar ligament. (2015). Viehöfer AF, Shinohara Y, Sprecher CM, Boszczyk BM, Buettner A, Benjamin M, Milz S.

    Immunohistochemical demonstration of nerve endings in iliolumbar ligament. (2010).  Kiter E, Karaboyun T, Tufan AC, Acar K.

    The occurrence of strain symptoms in the lumbosacral region and pelvis during pregnancy and after childbirth. (2010). Sipko T, Grygier D, Barczyk K, Eliasz G.

    The iliolumbar ligament: its influence on stability of the sacroiliac joint. (2003). Pool-Goudzwaard A, Hoek van Dijke G, Mulder P, Spoor C, Snijders C, Stoeckart R.

    Trigger point of the posterior iliac crest: painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study. (1991). Maigne JYMaigne R.

    The role of the iliolumbar ligament in the lumbosacral junction. (1990). Yamamoto IPanjabi MMOxland TRCrisco JJ.

    Description of the iliolumbar ligament for computer-assisted reconstruction. (2010). Hammer NSteinke HBöhme JStadler JJosten CSpanel-Borowski K.

    Sonoanatomy and Injection Technique of the Iliolumbar Ligament (2011)  Harmon D and. Alexiev V

    The role of the iliolumbar ligament in low back pain. (1996). Sims JAMoorman SJ.

    The influence of slouching and lumbar support on iliolumbar ligaments, intervertebral discs and sacroiliac joints. (2004). Snijders CJHermans PFNiesing RSpoor CWStoeckart R.

    Radiographic analysis of lumbar motion in relation to lumbosacral stability. Investigation of moderate and maximum motion. (2000). Miyasaka KOhmori KSuzuki KInoue H

    Topographic relations between the neural and ligamentous structures of the lumbosacral junction: in-vitro investigation (2001). H. KleihuesS. Albrecht, and W. Noack

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

    The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Vleeming ASchuenke MDMasi ATCarreiro JEDanneels LWillard FH.