Hip & Anterior Thigh Pain
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 to reenforce the hip joint capsule 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). The anterosuperior part of the hip joint capsule is also reenforced by the rectus femoris and iliopsoas fascia (and iliocapsularis) (Tsutsumi et al 2019).
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 (or scansorious)
The gluteus quaratus (or 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, greater trochanter and/or vastus lateralis.
Action: hip abduction and internal rotation.
Rectus Femoris
Anterior or straight head: AIIS. Its fascicular tendinous structure is distributed along the anterior surface of the muscle continuing with the myofascial junction (epimysium, perimysium, and muscle fiber fascicles) —> quadricep tendon. Initiates hip flexion (Mecho et al 2022) > knee extension.
Posterior or reflected head: supraacetabular groove and the lateral aspect of the hip joint capsule. It extends along the anterior midline of the muscle, forming the central septum —> quadricep tendon. It function as a hip flexor once flexion has begun (Mecho et al 2022) > knee extension. The anterorsuperior part of the hip joint capsule is also reneforced by the gluteus minimus tendon and fascia, iliopsoas fascia (and iliocapsularis) (Tsutsumi et al 2019)
Third head originates from the posterior or reflected head and is attached to (i) the iliofemoral ligament and (ii) tendon of the gluteus minimus at the anterior aspect of the greater trochanter (Tubbs et al 2006) —=> quadric.
Fourth head “connective tissue component”: ASIS —> middle to distal third of the anterior surface of the common tendon of the rectus femoris (Mecho et al 2022).
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. Xu et al (2020) found multiple transverse or obliquely orientated fascial layers originated from the aponeurotic fibres of the sartorius and rectus femoris.
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.
Ilipsoas fascia.
At the middle third of the inguinal ligament the iliopsoas fascia is strengthened laterally by the peripheral fascicular aponeurotic sheets of the iliacus (Xu et al 2020) and deep and medial surfaces of the rectus femoris (Tsutsumi et al 2019). This portion of the ilipsoas fascia also connects with the pectineus (Stecco 2015) and pectineal ligament (of Cooper) (Steinke et al 2019).
Iliacus minor, ilioinfratrochanteric or iliocapsularis muscle (MacDermott et al 2022).
Iliacus minor: AIIS and strongly attached to the anteromedial hip capsule —> just distal to the lesser trochanter.
It is separated from the iliacus medially and rectus femoris superficially by a connective tissue raphe.
It is innervated by a small branch of the femoral nerve that passes through the iliacus to reach the iliacus minor
Reduces capsular impingement during walking and hip flexion and acts as an important contributor to hip stability, especially in dysplastic hips (Ng et al 2019).
Anterior hip pain: fat pad composed of loose connective tissue from the rectus femoris, gluteus minimus, and iliopsoas
AIIS has shared attachments for:
Rectus femoris.
Iliopsoas (ilio-infratrochanteric muscle, iliocapsularis muscle or iliacus minor).
Iliofemoral ligament which reinforces the hip joint capsule.
Fat pad is located (Tsutsumi et al 2021):
On the AIIS.
Between the proximal rectus femoris and hip joint capsule.
Lateral to the deep portion of the iliopsoas and iliacus minor.
Medial to the gluteus minimus.
Spreads distally deep to the gluteus minimus tendon and superficial to the vastus lateralis (intertrochanteric line), anterior portion of the lateral femoral intermuscular septum and anterior gluteus maximus tendon (gluteal tuberosity).
The fat pad is divided into segments by loose connective tissue septa. These loose connective tissue septa are derived from the deep aponeuroses of the rectus femoris, gluteus minimus, and iliopsoas, and continued with the joint capsule. The function of the loose connective tissue septa may promote the transmission of muscle force dissipating the stress on these muscle attachments (Tsutsumi et al 2021).
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 S, Tisserand P, Brunet C, Müller 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.
Tsutsumi M, Nimura A, Utsunomiya H, Kudo S & Akita K (2021). Spatial distribution of loose connective tissues on the anterior hip joint capsule: a combination of cadaveric and in-vivo study
Mac Dermott KD, Venter RG, Bergsteedt BJ, Pękala PA, Henry BM, Keet K. (2022). Anatomical features of the iliocapsularis muscle: a dissection study.
Mechó S, Iriarte I, Pruna R, Pérez-Andrés R, Rodríguez-Baeza A. (2022). A newly discovered membrane at the origin of the proximal tendinous complex of the rectus femoris.
Xu Z, Mei B, Liu M, Tu L, Zhang H, Zhang M (2020). Fibrous configuration of the fascia iliaca compartment: An epoxy sheet plastination and confocal microscopy study
Stecco C (2015). Functional atlas of the human fascial system
Tsutsumi M, Nimura A, Honda E, Utsunomiya H, Uchida S, Akita K. (2019). An Anatomical Study of the Anterosuperior Capsular Attachment Site on the Acetabulum
Ng KCG, Jeffers JRT, Beaulé PE. (2019). Hip Joint Capsular Anatomy, Mechanics, and Surgical Management
