Osteopathy Journals and Research by Darren Chandler

 

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  1. Introduction

    The relations of the gluteus minimus and tensor fascia lata to the rectus femoris can have important clinical applications to patients with hip and anterior thigh pain.

    These relations exist through:

    • Shared tendon attachments of the gluteus minimus and rectus femoris.
    • Dense fascia between the origins of the rectus femoris and tensor fascia lata uniting the deep aspects of their muscular sheaths.
    • Deep layer of the iliotibial band connecting to both the tensor fascia lata and fascia of the rectus femoris.

    Each muscle is discussed intern along with its action and anatomical relations.

    Gluteus Minimus

    Origin

    The tendon originates anteriorly from the ASIS; superiorly from the iliac tubercle; inferiorly along the inferior gluteal line extending posteriorly to the sciatic notch (Flak et al 2012). 

    Insertion

    The tendon inserts anterosuperiorly into the capsule of the hip joint via a tendon made up of the gluteus minimus fascia (Beck et al 2000) and fibrous tracts (Nazarian et al 1987); it then continues to its main insertion on the greater trochanter. 

    Its terminal tendon at the greater trochanter blends with the anterior part of the gluteus medius tendon, superficial tendonous fibers of the anterior part of the vastus lateralis (Nazarian et al 1987) and when present the third head of the rectus femoris (Tubbs et al 2006). Nazarian et al (1987) found the junction of the gluteus minimus, gluteus medius and vastus lateralis closely bound to the greater trochanter.

    The capsular part of the gluteus minimus tendon blends with the piriformis and conjoint (obturator internus-gemelli complex) tendons (Philippon et al 2014).

    Action

    The Gluteus Minimus stretches and contracts with (Beck et al 2000):

    • Hip flexion and abduction: main action of the Gluteus Minimus.
    • External rotation of the extended hip: anterior section elongates, middle section doesn’t change length and the middle to posterior sections shorten.
    • Internal rotation: the entire muscle elongates increasingly from anterior to posterior. This may help prevent impingement of the femoral neck against the superomedial acetabular rim.
    • Internal rotation with hip flexion: anterior to middle sectors shorten and the posterior sector shows no change in length.
    • Hip external rotation: all muscle fibres elongate.
    • Hip abduction: posterior section shows a slight shortening increasing to the anterior section of the muscle.
    • Stabilises the femoral head in the hip joint.

    Gluteus quaratus and scansorious

    The Gluteus quaratus and scansorious is an anomalous muscle of the Gluteus Minimus. It is present as either small fibers or a distinct muscular bundle.

    The attachments of these muscles are variable:

    Origin: AIIS, ASIS and/or deep laminae of the gluteus minimus.

    Insertion: hip joint capsule, anterior intertrochanteric line above the lesser tuberosity, greater trochanter and/or vastus lateralis.

    Action: hip abduction and internal rotation.

    Rectus Femoris

    Origin: AIIS (anterior or straight head) and the superior surface of the acetabulum (posterior or reflected head).

    A third head was found by Tubbs et al (2006). It originated from the posterior head and attached to (i) the iliofemoral ligament and (ii) tendon of the gluteus minimus at the anterior aspect of the greater trochanter. 

    Insertion: quadriceps tendon.

    Action: hip flexion and knee extension.

    Fascial relations of the Rectus Femoris

    As well as sharing a common tendon with the Gluteus Minimus various fascial relations of the rectus femoris exist:

    • Tensor fascia lata and Sartorius.

    Henry (1957) described fascial webs that are found in the layers that occupy “the space between the origins of the rectus femoris and tensor fasciae [lata] muscles, uniting the deep aspects of their sheaths”. Putzer et al (2017) noted these fibers after dissecting the interval between the tensor fascia lata, sartorius, and rectus femoris. They described a strong band of fibers extending from a proximal-lateral to distal-medial direction.

    • Deep layer of the Iliotibial Band.

    The deep layer of the iliotibial band emerges from 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 to attach to the supraacetabular fossa between the hip joint capsule and the tendon of the reflected head of the rectus femoris

    • Fascia lata.

    Fourie (2011) found the rectus femoris could easily be separated and lifted off the underlying vastus lateralis and vastus intermedius muscles by blunt dissection along its full length. The muscle stays free to slide under the fascia lata and over the vasti throughout its entire length from origin to insertion into the quadriceps tendon.

    References

    A STUDY OF THE HUMAN FASCIA LATA AND ITS RELATIONSHIPS TO THE EXTENSOR MECHANISM OF THE KNEE (2011). Willem Jacobus Fourie

    The anatomy and function of the gluteus minimus muscle. (2000). Beck M, Sledge JB, Gautier E, Dora CF, Ganz R

    Does a third head of the rectus femoris muscle exist? (2006) R.S. Tubbs W. Stetler Jr., A.J. Savage, M.M. Shoja, A.B. Shakeri, M. Loukas, E.G. Salter, W.J. 

    Extensile Exposure. 2nd ed. (1957). Henry AK. pp. 209–210.

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

    A Review of the Anatomy of the Hip Abductor Muscles, Gluteus Medius, Gluteus Minimus, and Tensor Fascia Lata (2012). NATASHA AMY MAY SPARKS FLACK, HELEN D. NICHOLSON, STEPHANIE JANE WOODLEY

    Anatomic basis of the transgluteal approach to the hip (1987). Nazarian STisserand PBrunet CMüller ME.

    Surgically Relevant Bony and Soft Tissue Anatomy of the Proximal Femur (2014). Marc J. Philippon, Max P. Michalski, Kevin J. Campbell, Mary T. Goldsmith, Brian M. Devitt, Coen A. Wijdicks, Robert F. LaPrade

  2. Introduction

    It has been reported that 15% to 25% of pain in patients with pain in the posterior iliac crest area results from injury of the posterior ramus of the T12 thoracic nerve due to fracture or degenerative changes and this pain is often confused with back pain originating in the sacral region.

    Maigne (1996) described thoracolumbar junction syndrome as a condition with typical pain on the iliac crest and tenderness on palpation of the thoracolumbar junction, and it is accompanied by lesions in the spine in about 60% of patients. In most cases, symptoms generally appear when there are lesions in T12-L1, which is the thoracolumbar junction

    Symptoms 

    Symptoms of thoracolumbar joint syndrome include:

    • Back pain.
    • Pseudo-visceral pain.
    • Posterior iliac crest pain.
    • Irritable bowel symptoms.

    Clinical signs correlate with spinal nerve root innervations. The posterior ramus supplies subcutaneous tissue of the upper buttocks and lower waste, the anterior ramus supplies the lower abdomen and groin, and the lateral cutaneous branch supplies the trochanter. Therefore, patients may complain of pseudo-visceral pain in the lower abdomen, pseudo-sciatica, pubic tenderness, and irritable bowel symptoms besides low back pain, which can lead to misdiagnosis

    Diagnostic tests

    Diagnostic tests for thoracolumbar joint syndrome include:

    • Pain on applying pressure to the facet joints.
    • Pain on applying pressure to the sides of the spinous processes.

    When examining the thoracolumbar junction, one must always look carefully for tender points upon palpation of spinous processes and facet joints. Looking for the presence of a posterior iliac crestal point tenderness and performing a positive pinch-roll test can also be beneficial.

    References

    Thoracolumbar Junction Syndrome Causing Pain around Posterior Iliac Crest: A Case Report. (2013). Kim SR, Lee MJLee SJSuh YSKim DHHong JH.

    Diagnosis and treatment of pain of vertebral origin: a manual medicine approach. Baltimore: Williams & Wilkins (1996). Maigne R.