Osteopathy Journals and Research by Darren Chandler

 

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  1. Introduction

    Stecco et al (2009) found the crural fascia composed of three layers of parallel, collagen fibre bundles separated by a thin layer of loose connective tissue. Only a few elastic fibres were found.

    The arrangement of the collagen fibres gives the crural fascia different degrees of strength in different directions and a non-linear elastic behaviour.  

    Boundaries

    • Superiorly: continuous with the fascia lata, patella, ligamentum patella, tibial tuberosities, tibial condyles and head of the fibula.
    • Posteriorly: covers the popiliteal fossa (aka popliteal fascia) and the calf.
    • Anteromedially: blends with the periosteum of the tibia.
    • Anterolaterally: blends with the head of fibula and lateral malleolus.
    • Inferiorly: continuous with the flexor and extensor retinaculum and the Achilles tendon.

    Soft tissue attachments

    Muscular attachments to the crural fascia include:

    • Biceps Femoris.
    • Sartorious, Gracilis, Semitendinosus & Semimembranosus.
    • Tibialis Anterior & Extensor Digitorium Longus.

    The Iliotibial band also strongly attaches to the crural fascia (which intern attaches to the fascia of the peroneal longus) (Wilke et al 2016). The authors found strain to the Iliotibial band caused local movement in the crural fascia and the underlying fascia of the peroneal muscle.

    Stecco et al (2014) found the crural fascia to be a structure that can transmit muscular forces at a distance connecting different segments of the limb.

    Intermuscular septums

    The crural fascia forms the intermuscular septums: 

    • Anterior intermuscular septum: attached to the anterior border of the fibula.
    • Posterior intermuscular septum: attached to the posterior border of the fibula.

    Anatomy of the transverse intermuscular septum

    • Fibrous stratum extending transversely from the medial margin of the tibia to the posterior border of the fibula.
    • Superiorly it is attached to the fascia of the popliteus, which is, in effect, an expansion of the tendon of the semimembranosus.
    • Inferiorly continuous with the flexor and superficial fibula retinacula.

    The transverse  intermuscular septum divides the superficial and deep muscles of the calf.

    Osteofascial compartments 

    Anterior compartment

    Boundaries

    • Superficial: crural fascia.
    • Posteriorly: interosseous surfaces of the tibia and fibula and the interosseous membrane.
    • Laterally: anterior intermuscular septum.

    Muscular contents:

    • Tibialis Anterior.
    • Extensor Digitorium Longus
    • Extensor Hallucis Longus.
    • Peroneal Tertius.
    • Anterior fibulocalcaneus: Lambert and Atsas (2010) identified this anomalous muscle originating from the fibula, anterior intermuscular septum, and the investing fascia of the peroneal tertius to pass anterior to the lateral malleolus and insert on the calcaneus.

    Innervation: deep peroneal nerve

    Stecco et al (2014) found the fascia in the anterior compartment to be stiffer than in the posterior compartment. This can explain why anterior compartment syndrome is more common than posterior compartment syndrome. However stretching the crural fascia for 120 secs decreases the stress of the crural fascia by 40%.

    Lateral compartment

    Boundaries

    • Anteriorly: anterior intermuscular septum.
    • Posteriorly: posterior intermuscular septum.
    • Laterally: crural fascia.
    • Medially: lateral surface of fibula.

    Muscular contents:

    • Peroneal Longus.
    • Peroneal Brevis.

    Innervation: superficial peroneal nerve.

    Posterior compartment

    Boundaries

    • Superficial: crural fascia.
    • Laterally: posterior intermuscular septum.
    • Posteriorly: fibula, tibia and interosseous membrane.
    • Divided into the superficial and deep compartments by the transverse intermuscular septum.

    Muscular contents

    Superficial posterior compartment:

    • Gastrocnemius.
    • Soleus.
    • Plantaris.

    Whilst the crural fascia does not integrate with the calf muscle it does join with the Achilles paratenon 4cm proximal to its calcaneal attachment (Mattiussi et al 2016). Stecco et al (2014) found the crural fascia divides to envelope the Achilles tendon and give origin to the Achilles paratenon.

    Deep posterior compartment

    • Flexor Hallucis Longus.
    • Flexor Digitorium Longus.
    • Tibialis Posterior.
    • Popliteus.
    • Fibulocalcaneus (peroneocalcaneus) internus (PCI) muscle (of MacAlister): Lambert et al (2011) identified this anomalous muscle arising from the distal third of the fibula, posterior intermuscular septum of the leg, and flexor hallucis longus muscle. This muscle inserted into the inferior surface of the medial calcaneus distal to the coronoid fossa. This insertion differs from the documented insertion of this muscle that attaches to the inferior surface of the sustentaculum tali of the calcaneus or distal to the sustentaculum tali into the medial aspect of the calcaneus. 

    Innervation: tibial nerve

    Stecco et al (2014) examined the macroscopic and microscopic characteristics of the achilles paratendineous tissues (paratenon, epitenon and endotenon) as forming a sheath around the Achilles.

    The crural fascia splits to encircle the Achilles tendon and gives origin to its paratenon. Mattiussi et al (2016) found the crural fascia to join with the Achilles paratenon 4cm proximal to the Achilles tubercle on the calcaneus.

    In patients with tendonitis a substantial increase in the paratenon is present. This could support the relationship of paratendineous tissue and the crural fascia in the aetiology and pathology of tendonitis (Mattiussi et al 2016).

    Neurological relations of the crural fascia

    Anatomy of the Peroneal Nerve

    Common peroneal nerve

    Originates from the dorsal branches of L4-L5 and ventral rami of S1-S2.

    Runs from the lateral popliteal fossa between the tendon of the biceps femoris, to which it is bound by fascia, and the lateral head of the gastrocnemius.

    Passes into the anterolateral compartment of the leg through a tight opening in the thick fascia overlying the tibialis anterior.

    Curves lateral to the neck of the fibula into the fibular tunnel. The floor of the tunnel is formed from the bone and the roof from the musculoaponeurotic arch of the soleus and peroneous longus (Ryan et al 2003). From here the nerve divides into the superficial peroneal and deep peroneal nerve.

    Common peroneal nerve innervates the knee and superior tibiofibular joint. The cutaneous branches (lateral sural and sural communicating branches. Innervates the skin on the anterior, posterior and lateral surfaces of the lateral leg.

    Superficial peroneal nerve

    The nerve runs deep to the the peroneal longus. Sandwiched between this muscle and the peroneal brevis and extensor digitorium longus.

    Pierces the crural fascia anywhere from half way down to the distal third of the leg.

    The nerve the nerve becomes superficial, crossing the distal fibula from posterior to anterior on average 11cm proximal to the tip of the fibula and usually within 6 – 12 cm of the lateral malleolus tip (Asp et al 2014).

    Superficial peroneal nerve innervates: peroneal longus, peroneal brevis and skin of anterolateral leg.

    Asp et al (2014) and Tomaszewski et al (2017) found great anatomical variations in the superficial peroneal nerve.

    Deep peroneal nerve

    The nerve runs deep to the peroneal longus coursing obliquely anteriorly deep to the extensor digitorium longus.

    Runs down the interosseous membrane descending with the anterior tibial artery.

    Deep peroneal nerve innervates: tibialis anterior, extensor hallucis longus, extensor digitorium longus and peroneal tertius. Ankle joint.

    Lateral terminal branch: innervates extensor digitorium brevis. Tarsal and 2-4 Mt-Phl joints

    Medial terminal branches: innervates the cutaneous interosseous area between 1-2 toes and 1 Mt-Phl joint.

    Points of entrapment

    • Sural nerve: perforates the popliteal fascia.
    • Common peroneal nerve: Jaeyeon et al (2016) identified the main sites of entrapment of the common peroneal nerve as: between the two heads of the peroneus longus, between the peroneus longus and the posterior intermuscular septum, between the peroneal and tibialis anterior muscles in the anterior intermuscular septum, in the thick tendinous fascia superficial to the soleus and between the origin of the soleus and peroneus longus as an anatomical anomaly.
    • Common and superficial peroneal nerve: Hiramatsu et al (2016) identified the peroneal longus as a source of entrapment after an inversion strain. The authors identified the peroneal longus as a source of entrapment at the fibula tunnel and as the superficial peroneal nerve ran behind the peroneous longus. 
    • Superficial peroneal nerve: Tzika et al (2015) found an entrapment site of the superficial peroneal nerve due to mechanical compression of the nerve at its exit from the crural fascia.
    • Accessory superficial peroneal nerve: Paraskevas et al (2014) found the superficial peroneal nerve presents great anatomic variability. They reported a case where an accessory superficial peroneal sensory nerve was encountered. The nerve originated from the main superficial peroneal nerve trunk, proximal to the superficial peroneal nerve emergence from the crural fascia, and followed a subfascial course. After fascial penetration the nerve was distributed to the skin of the proximal dorsum of the foot and lateral malleolar area. A potential entrapment site of the nerve was observed as the accessory nerve travelled through a fascial tunnel at the lateral malleoli area while perforating the crural fascia.

    References

    Investigation of the mechanical properties of the human crural fascia and their possible clinical implications. (2014). Stecco C, Pavan PPachera PDe Caro RNatali A.

    Mechanics of crural fascia: from anatomy to constitutive modelling. (2009). Stecco C, Pavan PGPorzionato AMacchi VLancerotto LCarniel ELNatali ANDe Caro R.

    Anatomical study of the morphological continuity between iliotibial tract and the fibularis longus fascia. (2016). Wilke J, Engeroff T, Nürnberger F, Vogt L, Banzer W.

    Entrapment of the superficial peroneal nerve: an anatomical insight. (2015). Tzika MParaskevas GNatsis K.

    Potential entrapment of an accessory superficial peroneal sensory nerve at the lateral malleolus: a cadaveric case report and review of the literature. (2014). Paraskevas GK, Natsis K, Tzika M, Ioannidis O

    An anterior fibulocalcaneus muscle: An anomalous muscle discovered in the anterior compartment of the leg. (2010). Lambert HW, Atsas S.

    The fibulocalcaneus (peroneocalcaneus) internus muscle of MacAlister: Clinical and surgical implications. (2011). Lambert HW, Atsas SFox JN.

    Anatomical basis for pressure on the common peroneal nerve. (1999). Ihunwo AO, Dimitrov ND.

    Deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tear: a report of two cases and a review of the literature. (2016). Hiramatsu KYonetani YKinugasa KNakamura NYamamoto KYoshikawa HHamada M

    Acute Achilles Paratendinopathy following Major Injury of the Crural Fascia in a Professional Soccer Player: A Possible Correlation? (2016). Gabriele MattiussiMichele TurloniPietro Tobia Baldassi, and Carlos Moreno 

    Common peroneal nerve palsy due to deep tendinous fascia superficial to the soleous muscle: a case report (2018) Jaeyeon Kim, Hak-Cheol Ko, Byung-Chul Son

    The paratendineous tissues: an anatomical study of their role in the pathogenesis of tendinopathy. (2014). Stecco C, Cappellari A, Macchi V, Porzionato A, Morra A, Berizzi A, De Caro R.

    The superficial peroneal nerve: A review of its anatomy and surgical relevance (2014). A Asp, D Marsland, R Elliot

    Superficial fibular nerve variations of fascial piercing: A meta-analysis and clinical consideration. (2017). Tomaszewski KA, Graves MJ, Vikse J, PÄ™kala PA, Sanna B, Henry BM, Tubbs RS, Walocha JA.

    Relationship of the common peroneal nerve and its branches to the head and neck of the fibula. (2003). Ryan W, Mahony N, Delaney M, O'Brien M, Murray P.

  2. 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