Osteopathy Journals and Research by Darren Chandler

 

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  1. Anatomy of the Iliotibial Band

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

    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 two united layers receives fibers from the gluteus maximus and runs down the lateral thigh. As it courses down the lateral thigh Fairclough et al (2006) found the Iliotibial band continuous with the strong lateral intermuscular septum, which was firmly anchored to the linea aspera of the femur. Evans (1979) found fibers from the lateral intermuscular septum form the horizontal fibers of the iliotibial band.

    Distally, after coursing through the Biceps Femoris and Vastus Lateralis Godin et al (2017) found the distal attachments of the Iliotibial band to be: 

    • Proximal bundle: runs nearly transversely from the superficial Iliotibial band to the distal femur. Inserts on the proximal ridge of the distal femoral body, distal to the lateral intermuscular septum 53.6 mm proximal to the lateral epicondyle.
    • Distal bundle: runs from the superficial Iliotibial band from a proximal and lateral to distal and medial direction inserting on to the supracondylar flare.
    • Capsulo-osseous layer: a distinct fascial portion of the deep Iliotibial band. Runs from just proximal to the lateral gastrocnemius tubercle to the lateral tibial tubercle*. Intimately related to the lateral knee capsule and the fascia surrounding the lateral gastrocnemius tendon. Evans (1979) found additional attachments to the lateral meniscus.
    • Gerdy tubercle: the superficial Iliotibial band attaches to the Gerdy tubercle.
    • Iliopatellar Band: attaches to the lateral aspect of the patella and patellar tendon. The distal edge of this portion forms the lateral patellotibial ligament, part of the lateral retinaculum.

    Fairclough et al (2006) found conversely to popular belief no bursa was found between the tendonous fibrous bands of the Iliotibial band and femur just adipose tissue. 

    Wilke et al (2016) found more distally the Iliotibial band connected strongly to the crural fascia which in itself was hardly seperable from the peroneal longus fascia.

    *: anterolateral aspect of the proximal tibia, between the Gerdy tubercle and the fibular head.

    Deep layer: The deep layer of the iliotibial band emerges 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.

    Additional muscular attachments to the Iliotibial band include:

    ·           Vastus Lateralis (Becker et al 2010).

    ·           Biceps Femoris.

    ·           Tensor Fascia Lata.

    ·           Gluteus Maximus.

    Anatomy of the Tensor Fascia Lata

    The Tensor Fascia Lata arises from the anterior part of the outer lip of the iliac crest; from the outer surface of the anterior superior iliac spine, and part of the outer border of the notch below it, between the gluteus medius and sartorius; and from the deep surface of the fascia lata.

    It is inserted between the two layers of the iliotibial band at about the junction of the middle and upper third of the thigh.

    Actions of the Tensor fascia Lata

    Traditionally the Tensor Fascia Lata along with the more vertical anterior and middle fibers of the Gluteus Medius are involved in hip abduction holding the pelvis horizontal during the stance phase of the gait:

    Heel strike: anterior fibers of the Gluteus Medius initiates initial abduction during the heel strike keeping the pelvis horizontal.

    Mid-stance: Tensor Fascia Lata keeps the pelvis horizontal. Anterior rotation of the pelvis is achieved from the anterior fibers of the Gluteus Medius.

    The hip joint is stabilised with the posterior fibers of the Gluteus Medius from heel strike to mid-stance and from the Gluteus Minimus from mid-stance to back stride (Gottschalk et al 1989).

    The other actions of the Tensor Fascia Lata include very weak internal rotation and knee extension (Umehara et al 2015).

    Stretching of the Iliotibial band

    Fredericson et al (2002) found a hip adduction stretch with the subjects arms reaching over head (i.e full shoulder abduction and extension) increased the stretch on the Iliotibial Band. Wilhelm et al (2017) found that a similar stretch to this (without using the added leverage of the shoulder position) didn’t uniformly increase the stretch throughout the iliotibial band but did so most prominently in the proximal portion.

    Evans (1979) found the deep layer of the iliotibial band resisted hip extension.

    Fairclough et al (2006) noted the tension of the distal part of the Iliotibial Band altered at different degrees of knee flexion:

    Initial knee flexion: during initial knee flexion bands of the Iliotibial Band that attach to the patella come under tension as the patella rotates laterally.

    Further knee flexion: as the knee is further flexed tension shifts from the anterior to posterior bundles of the Iliotibial Band possibly due to the attachments of the Biceps Femoris. 

    As the tibia moves posteriorly the capsulo-osseous layer of the iliotibial band comes under tension. Fairclough et al (2006) gave the impression this posterior movement was on progressive knee flexion not a posterior shunt of the tibia from knee extension.

    Femoral attachments anchoring the Iliotibial band to the distal femur contributes to restraining tibial internal rotation (Godin et al 2017). Kittl et al (2016) reported that the distal Iliotibial band is the primary restraint to internal rotation between 30 and 90 of knee flexion.

    Stretching of the Tensor Fascia Lata

    Traditionally the Tensor Fascia Lata has been stretched using hip adduction/extension/external rotation.

    Umehara et al (2015) found that hip adduction/extension with added knee flexion at >90 degs stretched the Tensor Facsia Lata more than adding hip external rotation. This was because the Tensor Fascia Lata very minimally if not at all was used for hip internal rotation.

    This may explain why using knee flexion reduced the range of motion in hip adduction when performing Ober’s test (Gajdosik 2003)

    References

    Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches (2002). Fredericson M, White JJ, Macmahon JM, Andriacchi TP.

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

    DEFORMATION RESPONSE OF THE ILIOTIBIAL BAND-TENSOR FASCIA LATA COMPLEX TO CLINICAL-GRADE LONGITUDINAL TENSION LOADING IN-VITRO (2017). Mark Wilhelm, Omer Matthijs, Kevin Browne, Gesine Seeber, Anja Matthijs, Phillip S. Sizer, Jean-Michel Brismée, C. Roger James, Kerry K. Gilbert.

    The functional anatomy of tensor fasciae latae and gluteus medius and minimus (1989). FRANK GOTTSCHALK, SOHRAB KOUROSH AND BARNEY LEVEAU.

    Effect of hip and knee position on tensor fasciae latae elongation during stretching: An ultrasonic shear wave elastography study (2015). Umehara JIkezoe TNishishita SNakamura MUmegaki HKobayashi TFujita KIchihashi N

    The vastus lateralis muscle: an anatomical investigation (2010). Becker IBaxter GDWoodley SJ.

    Influence of knee positions and gender on the Ober test for length of the iliotibial band (2003). Gajdosik RLSandler MMMarr HL.

    Anatomical study of the morphological continuity between iliotibial tract and the fibularis longus fascia (2016). Wilke JEngeroff TNürnberger FVogt LBanzer W.

    A Comprehensive Reanalysis of the Distal Iliotibial Band Quantitative Anatomy, Radiographic Markers, and Biomechanical Properties (2017). Jonathan A. Godin Jorge Chahla, Gilbert Moatshe, Bradley M. Kruckeberg, Kyle J. Muckenhirn, Alexander R. Vap, Andrew G. Geeslin, Robert F. LaPrade

    The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACLdeficient knee: response (2016). Kittl C, El-Daou H, Athwal KK, Gupte CM, Weiler A, Williams A, Amis AA.

    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

  2. Anatomy

    Muscular anatomy (Saiko & Stuber, 2009)

    The Psoas has fibrous attachments to the anterior aspect of L1-5 transverse processes and to the anteromedial aspect of L1-5 discs (except L5/S1) and vertebral bodies. 

    The fascicles that attach to the vertebrae and discs are oriented inferolaterally. They come together as a common tendon which descends over the pelvic brim. It shares a common insertion with the iliacus muscle on the lesser trochanter of the femur.

    The psoas major is the largest muscle in cross section at the lower levels of the lumbar spine

    Fascial relations of the Psoas (Saiko & Stuber (2009)

    The fascial relations of the Psoas are:

    • Medial arcuate ligament: this is a tendonous continuation of the superior psoas fascia.  The medial arcuate ligament continues superiorly to the diaphragm to attach on to the transverse processes of L1 and L2 (Cai et al 2013) and in some cases L3 (Deviri et al 1988).
    • Right and left crus of the diaphragm: the crura constitute the spinal attachments of the diaphragm. They attach to the anterolateral component of the L1-3 vertebral bodies and anterior longitudinal ligament. The crura and their fascia overlap the psoas major and appear to be continuous with this muscle until they come more anterior and blend with the anterior longitudinal ligament.
    • Pelvic floor fascia, conjoint tendon, transverse abdominis and internal oblique: as the psoas descends, its inferomedial fascia becomes thick at its inferior portion and is continuous with the pelvic floor fascia. This forms a link with the conjoint tendon, transverse abdominis, and the internal oblique.  As the psoas major courses over the pelvic brim, the fascia of the fascicles from the transverse processes attach firmly to the pelvic brim.

    Neurological relations

    The nerves travelling through the Psoas are:

    • Femoral nerve
    • Lateral femoral cutaneous nerve.
    • Obturator nerve.
    • Superior Cluneal nerve (Tubbs et al 2010).
    • Lumbosacral plexus: lies in the Psoas Major between the transverse process and vertebral body exiting it distally along the medial edge of the muscle (Benglis et al 2009)

    Function of the Psoas

    Hip

    Skyryme et al (1999) found the main function of the Psoas as a hip flexor with other movements dependent upon the position of the subject:

    • Anatomical position: hip flexion with no rotation.
    • Hip abduction: hip flexion, adduction, and external rotation of the hip.
    • Hip adduction: hip flexion with no rotation.
    • Maximal hip flexion: hip adduction.

    Yoshio et al (2002) found the Psoas Major works phasically at different degrees of hip flexion producing predominately:

    • 0-15 degs of hip flexion: stabilizer of the femoral head in the acetabulum. Erects the lumbar spine.
    • 15-45 degs of hip flexion: still as an erector of the Lumbar spine!
    • 45 to 60 degs of hip flexion: hip flexor.

    Lumbar spine

    • Ipsilaterally sidebends the lumbar spine (Kim et al 2013).
    • Lordoses and compresses the Lumbar spine: L1/2 and L2/3: extension. L3-5 pulls the lumbar spine downwards into compression. L5/S1: flexion (Penning 2000).
    • Ipsilateral rotation: Jeon et al (2016) found that during SLRT there is an ipsilateral rotation of the lumbar spine e.g left SLRT produces rotation of the Lumbar spine to the left. This rotation was counterbalanced by the contralateral Psoas producing ipsilateral rotation in the opposite direction of the SLRT e.g. the right Psoas would produce rotation of the Lumbar spine to the right. Andersson et al (2002) also found the Psoas as an ipsilateral rotator.

    References

    Psoas Major: a case report and review of its anatomy, biomechanics, and clinical implications (2009). Sandy Sajko &  Kent Stuber.

     Anatomy and landmarks for the superior and middle cluneal nerves: application to posterior iliac crest harvest and entrapment syndromes (2010). Tubbs RSLevin MRLoukas MPotts EACohen-Gadol AA.

    Psoas muscle and lumbar spine stability: a concept uniting existing controversies Critical review and hypothesis (2000). L Penning

    An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine (2009). Benglis DMVanni SLevi AD.

    Psoas major and its controversial rotational action (1999). Skyrme ADCahill DJMarsh HPEllis H.

    The function of the psoas major muscle: passive kinetics and morphological studies using donated cadavers. (2002). Yoshio MMurakami GSato TSato SNoriyasu S.

    Asymmetry of the cross-sectional area of paravertebral and psoas muscle in patients with degenerative scoliosis (2013). Hyoungmin KimChoon-Ki LeeJin S. YeomJae Hyup LeeJae Hwan ChoSang Ik ShinHui-Jong Lee, andBong-Soon Chang

    Diverging intramuscular activity patterns in back and abdominal muscles during trunk rotation. (2002). Andersson EA, Grundström H, Thorstensson A. 

    Comparison of psoas major muscle thickness measured by sonography during active straight leg raising in subjects with and without uncontrolled lumbopelvic rotation (2016) In-cheol Jeon, Oh-yun Kwon, Jong-hyuck Weon, Sung-dae Choung, Ui-jae Hwang

    Medial arcuate ligament: a new anatomic landmark facilitates the location of the renal artery in retroperitoneal laparoscopic renal surgery (2013). Cai WLi HZZhang XSong YMa XDong JChen WChen GFXu YLu JSWang BJShi TP.

    Medial and lateral arcuate ligaments of the diaphragm: attachment to the transverse process. Deviri ENathan HLuchansky E.