Chapter 12 / Tensor Fasciae Latae and Sartorius Muscle 233 treated leg against the chest to stabilize places the sartorius in a shortened posi- the pelvis and lumbar spine. As ice or va- tion and is to be avoided. Sitting in this pocoolant is applied from above down- position can generate referred pain when ward over the sartorius muscle, the clini- sartorius TrPs are active. cian moves the thigh to be treated into ad- duction, extension, and medial rotation. Sleeping in the jackknifed position The intermittent cold-with-stretch proce- with the knees and hips flexed places the dure is followed by moist heat and then muscle in a sustained shortened position full active range of motion. and can aggravate its TrPs. Local injection, ischemic compression, When patients with sartorius TrPs lie deep friction massage, or stripping mas- on either side, they find it more comfort- sage may be required. These techniques able to place a pillow or other padding may be the treatment of choice, since between the knees. It hurts to rest one TrPs in this muscle do not usually limit knee against the other because of referred range of motion; instead, the taut bands tenderness to the knee region. Other pa- need to be treated as a local problem. tients sleep on the back for relief, which may not be the best solution. 13A. INJECTION AND STRETCH— Home Therapeutic Program SARTORIUS Some patients may find it convenient to To inject TrPs in the superficial sartorius apply self-ischemic compression or deep muscle it is necessary to angle the needle friction massage to the sartorius TrPs. tangentially, nearly parallel to the surface These techniques, which apply local of the skin. stretch of the taut band, are probably more effective than an overall stretch of Occasionally during injection of a TrP the muscle. in the vastus medialis or rectus femoris muscle, the needle penetrates an overly- The patient may be instructed how to ing sartorius TrP that had escaped notice, use gravity and postisometric relaxation unexpectedly causing a twitch of the (Chapter 2, page 11) to release taut bands muscle and a characteristic pins-and- in this muscle. needles or tingling sensation projected up and down over the sartorius muscle. This To recruit gravity for lengthening the referred pain is not sudden but rather a sartorius muscle, the patient lies on the spreading pain. unaffected side with the buttocks at the end of the bed or examining table and 14A. CORRECTIVE ACTIONS— pulls the thigh of the asymptomatic lower SARTORIUS limb to the chest while allowing the up- permost involved limb to hang down over Systemic perpetuating factors, as de- the end of the bed. Positioning of the scribed in Volume 1, Chapter 4,101 should body should be such that gravity pulls the be identified and resolved. thigh into extension and adduction. The contract-relax phases of postisometric re- Corrective Body Mechanics laxation are then synchronized with slow deep respiration. Since a lower limb-length inequality can perpetuate sartorius TrP activity by caus- References ing increased adduction of the longer limb at the hip during walking58 or addi- 1. Anderson JE: Grant's Atlas of Anatomy, Ed. 8. tional extension during running, the ine- Williams & Wilkins, Baltimore, 1983 (Figs. 4- quality should be corrected (see Chapter 17, 4-20). 4). This asymmetry tends to stretch the deep fascia and nerve at the entrapment 2. Ibid. (Fig. 4-21B). point.58 3. Ibid. (Fig. 4-22). 4. Ibid. (Figs. 4-23, 4-65). Corrective Posture and Activities 5. Ibid. (Fig. 4-26). 6. Ibid. (Fig. 4-28). The lotus position (similar to the tailor's 7. Andriacchi TP, Andersson GBJ, Ortengren R, et position for which the muscle is named) al.: A study of factors influencing muscle activ- ity about the knee joint. J Orthop Res 1:266- 275, 1984.
234 Part 2 / Hip, Thigh, and Knee Pain 34. Ferner H, Staubesand J: Sobotta Atlas of Human Anatomy, Ed. 10, Vol. 2. Urban & Schwarzen- 8. Aquilonius S-M, Askmark H, Gillberg P-G, et berg, Baltimore, 1983 (Figs. 7, 413). al.: Topographical localization of motor end- plates in cryosections of whole human mus- 35. Ibid. (Fig. 380). cles. Muscle Nerve 7:287-293, 1984. 36. Ibid. (Fig. 410). 9. Arcangeli P, Digiesi V, Ronchi O, Dorigo B, 37. Ibid. (Figs. 420, 421). Bartoli V: Mechanisms of ischemic pain in pe- 38. Ferraz de Carvalho CA, Garcia OS, Vitti M, et ripheral occlusive arterial disease. In Advances in Pain Research and Therapy, edited by J.J. Bon- al.: Electromyographic study of the m. tensor ica and D. Albe-Fessard, Vol. I. Raven Press, fascia latae and m. sartorius. Electromyogr Clin New York, 1976 (pp. 965-973, see Fig. 2). Neurophysiol 72:387-400, 1972. 39. Gerwin R: Personal communication, 1990. 10. Baker BA: The muscle trigger: evidence of 40. Ghent WR: Meralgia paraesthetica. Can Med overload injury. J Neurol Orthop Med Surg 7:35- Assoc J 87:631-633, 1959. 44, 1986. 41. Good MG: Diagnosis and treatment of sciatic pain. Lancet 2:597-598, 1942. 11. Bardeen CR: The musculature, Sect. 5. In Mor- 42. Good MG: What is \"fibrositis?\" Rheumatism 5: ris's Human Anatomy, edited by C M . Jackson, 117-123, 1949. Ed. 6. Blakiston's Son & Co., Philadelphia, 43. Gose JC, Schweizer P: Iliotibial band tightness. 1921 (p. 491). J Orthop Sports Phys Therap 70:399-407, 1989. 44. Guo-Xiang J, Wei-Dong X: Meralgia paraesthet- 12. Ibid. (p. 500, Fig. 442). ica of spinal origin: brief report. J Bone Joint 13. Ibid. (p. 502). Surg [Br] 70:843-844, 1988. 14. Basmajian JV, Deluca CJ: Muscles Alive, Ed. 5. 45. Gutstein M: Diagnosis and treatment of muscu- lar rheumatism. Br J Phys Med 7:302-321, 1938 Williams & Wilkins, Baltimore, 1985 (p. 318). (Case IV). 15. Beazell JR: Entrapment neuropathy of the lat- 46. Hope T: Pinpointing entrapment neuropathies in the elderly. Geriatrics 35:79-89, 1980. eral femoral cutaneous nerve: cause of lateral 47. Houtz SJ, Fischer FJ: An analysis of muscle ac- knee pain. J Orthop Sports Phys Therap 70:85- tion and joint excursion during exercise on a 86, 1988. stationary bicycle. J Bone Joint Surg [Am] 41: 16. Brody DM: Running injuries: prevention and 123-131, 1959. management. Clin Symp 39:2-36, 1987 (see pp. 48. Inman VT: Functional aspects of the abductor 19, 22, 23). muscles of the hip. J Bone Joint Surg 29:607- 17. Broer MR, Houtz SJ: Patterns of Muscular Activity 619, 1947. in Selected Sports Skills. Charles C Thomas, 49. Jefferson D, Eames RA: Subclinical entrapment Springfield, 1967. of the lateral femoral cutaneous nerve: an au- 18. Butler ET, Johnson EW, Kaye ZA: Normal con- topsy study. Muscle Nerve 2:145-154, 1979. duction velocity in the lateral femoral cutane- 50. Johnson CE, Basmajian JV, Dasher W: Electro- ous nerve. Arch Phys Med Rehabil 55:31-32, myography of sartorius muscle. Anat Rec 173: 1974. 127-130, 1972. 19. Carter BL, Morehead J, Wolpert S M , et al.: 51. Jull GA, Janda V: Muscles and motor control in Cross-Sectional Anatomy. Appleton-Century- low back pain: assessment and management, Crofts, New York, 1977 (Sects. 37-48). Chapter 10. In Physical Therapy of the Low Back, 20. Ibid. (Sects. 38-48, 64-72). edited by L.T. Twomey, J.R. Taylor. Churchill 21. Christensen E: Topography of terminal motor Livingstone, New York, 1987 (pp. 253-278, see innervation in striated muscles from stillborn pp. 266-267, Fig. 10.4). infants. Am J Phys Med 38:65-78, 1959. 52. Kamon E: Electromyographic kinesiology of 22. Clemente CD: Gray's Anatomy of the Human jumping. Arch Phys Med Rehabil 52:152-157, Body, American Ed. 30. Lea & Febiger, Phila- 1971. delphia, 1985 (pp. 491, 492, Fig. 6-31). 53. Kaplan EB: The iliotibial tract. Clinical and 23. Ibid. (pp. 559, 568). morphological significance. J Bone Joint Surg 24. Ibid. (pp. 561-562). [Ami 40:817-832, 1958. 25. Ibid, (p. 572). 54. Keegan JJ, Holyoke EA: Meralgia paresthetica: 26. Ibid. (pp. 1229-1231). an anatomical and surgical study. J Neurosurg 27. Coers C, Woolf AL: The Innervation of Muscle. 79:341-345, 1962. Blackwell Scientific Publications, Oxford, 55. Kellgren JH: A preliminary account of referred 1959 (pp. 18-20). pains arising from muscle. Br Med J 7:325-327, 28. Deal CL, Canoso JJ: Meralgia paresthetica and 1938 (Case VII). large abdomens [letter]. Ann Intern Med 96:787- 56. Kellgren JH: Observations on referred pain 788, 1982. arising from muscle. Clin Sci 3:175-190, 1938 29. Duchenne GB: Physiology of Motion, translated (Fig. 8). by E.B. Kaplan. J. B. Lippincott, Philadelphia, 57. Kelly M: The relief of facial pain by procaine 1949 (p. 259). (novocaine) injections. J Am GeriatrSoc 77:586- 30. Ecker AD: Diagnosis of meralgia paresthetica. 596, 1963 (Table 1). JAMA 253:976, 1985. 58. Kopell HP, Thompson WAL: Peripheral Entrap- 31. Edelson JG, Nathan H: Meralgia paresthetica: ment Neuropathies. Robert E. Krieger, New an anatomical interpretation. Clin Orthop 122: York, 1976 (pp. 84-88). 255-262, 1977. 32. Eibel P: Sigmund Freud and meralgia paraes- thetica. Orthop Rev 73:118-119, 1984. 33. El-Badawi MG: An anomalous bifurcation of the sartorius muscle. Anat Anz 763:79-82, 1987.
Chapter 12 / Tensor Fasciae Latae and Sartorius Muscle 235 59. Lange M: Die Muskelharten (Myogelosen). J.F. 85. Pare EB, Stem JT Jr, Schwartz JM: Functional Lehmanns, Munchen, 1931 (p. 49, Fig. 13). differentiation within the tensor fasciae latae. J Bone Joint Surg [Am] 63:1457-1471, 1981. 60. Ibid. (pp. 144-145, Fig. 45, Case 27). 86. Perry J: The mechanics of walking. Phys Ther 61. Lewit K: Manipulative Therapy in Rehabilitation of 47:778-801, 1967. the Motor System. Butterworths, London, 1985 (pp. 148-149, Fig. 4.36). 87. Rasch PJ, Burke RK: Kinesiology and Applied Anatomy, Ed. 6. Lea & Febiger, Philadelphia, 62. Ibid. (p. 153, Fig. 4.42). 1978 (p. 282). 63. Ibid. (pp. 170-171, Fig. 4.67). 88. Reynolds MD: Myofascial trigger point syn- 64. Ibid. (p. 315). dromes in the practice of rheumatology. Arch 65. Lockhart RD: Living Anatomy, Ed. 7. Faber & Phys Med Rehabil 62:111-114, 1981. Faber, London, 1974 (pp. 58, 59). 89. Rohen JW, Yokochi C: Color Atlas of Anatomy, 66. Mackova J, Janda V, Macek, et al.: Impaired Ed. 2. Igaku-Shoin, New York, 1988 (p. 416). muscle function in children and adolescents. J 90. Ibid. (p. 419). Man Med 4:157-160, 1989. 67. Macnicol MF, Thompson WJ: Idiopathic mer- 91. Ibid. (p. 422). algia paresthetica. Clin Orthop 254:270-274, 1990. 92. Ibid. (p. 438). 68. Mann RA, Moran GT, Dougherty SE: Compara- 93. Saudek CE: The hip, Chapter 17. In Orthopaedic tive electromyography of the lower extremity in jogging, running, and sprinting. Am J Sports- and Sports Physical Therapy, edited by J.A. med 74:501-510, 1986. Gould III and G.J. Davies, Vol. II. CV Mosby, St. 69. Massey EW: Meralgia paraesthetica. JAMA 237: Louis, 1985 (pp. 365-407, see p. 385). 1125-1126, 1977. 94. Ibid. (pp. 389-390). 70. Meberg A, Skogen P: Three different manifesta- 95. Sola AE: Treatment of myofascial pain syn- tions of congenital muscular aplasia in a fam- dromes. In Recent Advances in the Management ily. Acta Paediatr Scand 76:375-377, 1987. of Pain, edited by Costantino Benedetti, C. 71. Merchant AC: Hip abductor muscle force: an Richard Chapman, Guido Moricca. Raven experimental study of the influence of hip po- Press, New York, 1984, Series title: Advances in sition with special reference to rotation. J Bone Pain Research and Therapy, Vol. 7 (pp. 467-485, Joint Surg [Am] 47:462-476, 1965. see p. 480-481, Fig. 12). 72. Muller-Vahl H: Isolated complete paralysis of 96. Sola AE: Trigger point therapy, Chapter 47. In the tensor fasciae latae muscle. Eur Neurol 24: Clinical Procedures in Emergency Medicine, ed- 289-291, 1985. ited by J.R. Roberts and J.R. Hedges. W.B. 73. Namey TC: Emergency diagnosis and manage- Saunders, Philadelphia, 1985 (pp. 674-686, ment of sciatica: differentiating the non-dis- see pp. 681-683, Fig. 47-9). kogenic causes. Emerg Med 6:101-109, 1985. 97. Sola AE, Williams RL: Myofascial pain syn- 74. Nemeth G, Ekholm J, Arborelius UP: Hip load dromes. Neurology 6:91-95, 1956. moments and muscular activity during lifting. 98. Stookey B: Meralgia paraesthetica. JAMA 90: Scand J Rehabil Med 76:103-111, 1984. 1705-1707, 1928. 99. Stubbs NB, Capen EK, Wilson GL: An electro- 75. Netter FH: The Ciba Collection of Medical Illustra- myographic investigation of the sartorius and tions, Vol. 8, Musculoskeletal System. Part I: tensor fascia latae muscles. Res Q Am Assoc Anatomy, Physiology and Metabolic Disorders. Health Phys Educ 46:358-363, 1975. Ciba-Geigy Corporation, Summit, 1987 (p. 80). 100. Teng P: Meralgia paresthetica. Bull Los Angeles Neurol Soc 37:75-83, 1972. 76. Ibid. (p. 83). 101. Travell JG, Simons DG: Myofascial Pain and Dys- 77. Ibid. (p. 85). function: The Trigger Point Manual. Williams & 78. Ibid. (p. 86). Wilkins, Baltimore, 1983. 102. Warfield CA: Meralgia paresthetica: causes and 79. Ibid. (p. 87). cures. Hosp Pract 21:40A,40C,40I, 1986. 103. Weber EF: Ueber die Langenverhaltnisse der 80. Ibid. (p. 90). Fleischfasern der Muskeln im Allgemeinen. 81. Ibid. (p. 91). Berichte Ciber die Verhandlungen der Kdniglich 82. Ibid. (p. 94). Sachsischen Gesellschaft der Wissenschaften Zu 83. Ober FR: The role of the iliotibial band and fas- Leipzig 3:65, 1851. cia latae as a factor of back disabilities and sci- 104. Winter Z: Referred pain in fibrositis. Med Rec atica. J Bone Joint Surg [Am] 78:65-110, 1936. 84. Orton D: Meralgia paresthetica from a wallet 757:34-37, 1944. [letter]. JAMA 252:3368, 1984.
CHAPTER 13 Pectineus Muscle \"The Fourth Adductor\" HIGHLIGHTS: REFERRED PAIN projects over tenderness where this muscle lies directly under the pectineus muscle just below the inguinal lig- the skin. Snapping palpation across the muscle ament, extends deep into the groin and perhaps fibers may produce a vigorous local twitch re- the hip joint, and may travel a short distance sponse and evoke referred pain. ASSOCIATED down the anteromedial aspect of the thigh. The TRIGGER POINTS are often found in the ilio- proximal ANATOMICAL ATTACHMENT of this psoas muscle and/or the other adductor mus- muscle is to the pubic bone. Distally, it anchors cles, especially the adductor longus and brevis. to the back of the femur below the attachment of The INTERMITTENT COLD-WITH-STRETCH the iliopsoas muscle. FUNCTION of the pec- procedure entails application of the spray or ice tineus muscle involves a combination of adduc- over the muscle from its proximal to its distal tion and flexion of the thigh at the hip. The pec- end and beyond it a short distance, while the tineus qualifies as the fourth adductor. The main thigh is passively abducted and extended at the SYMPTOM is persistent pain, which often be- hip. This is followed by a moist hot pack and full comes apparent after trigger points (TrPs) in the active range of motion. INJECTION AND other three adductor and/or iliopsoas muscles STRETCH may be required to inactivate TrPs have been inactivated. ACTIVATION OF TRIG- fully in this muscle. The thigh of the supine pa- GER POINTS may result from tripping or falling tient is abducted and laterally rotated and the on a staircase, may follow fracture of the femo- overlying femoral artery is located by its pulsa- ral neck or a total hip replacement, or may occur tion. The TrPs in this muscle are injected in a in a situation that causes strong resistance to medial direction to avoid the femoral artery, adduction of the thigh, such as sexual activity or which is continuously palpated during injection. gymnastic exercises. PERPETUATION OF CORRECTIVE ACTIONS include compensation TRIGGER POINTS may be caused by sus- for a lower limb-length inequality and/or a small tained or repeated hip adduction-flexion, or by hemipelvis; avoidance of prolonged shortening systemic factors. PATIENT EXAMINATION of the muscle, especially while sitting; and reveals little restriction of range of motion. TRIG- avoidance of vigorous activities that suddenly GER POINT EXAMINATION elicits exquisite stretch the muscle beyond its tolerance. 1. REFERRED PAIN where the hip joint is located. The deep (Fig. 13.1) groin pain may also extend medially to the region where the adductor magnus at- Myofascial trigger points (TrPs) in the taches to the pelvis. pectineus muscle produce a deep-seated aching pain in the groin immediately dis- 2. ANATOMICAL ATTACHMENTS AND tal to the inguinal ligament; the pain may CONSIDERATIONS also cover the upper part of the anter- (Fig. 13.2) omedial aspect of the thigh (Fig. 13.1).5 The pain is often described by patients as The pectineus muscle attaches proxi- \"in the groin and in the hip joint,\" but mally to the pecten (crest) of the superior they may have a poor understanding of ramus of the pubic bone lateral to the pu- 236
Chapter 13 / Pectineus Muscle 237 Figure 13.1. Pattern of pain (bright red) referred medial side. The essential referred pain pattern is from a trigger point (X) in the right pectineus muscle solid red, and the occasional spillover pattern is stip- (darker red), seen from in front and slightly from the pled. bic tubercle. This attachment is caudal more diagonally directed fibers, the pec- and deep to the inguinal ligament, which tineus is similar anatomically to the ad- attaches medially to the pubic tubercle ductor brevis. (Figs. 13.2 and 13.4).610 The pectineus muscle exhibits a num- The pectineus muscle comprises most ber of variations. It may be more or less of the medial part of the floor of the femo- completely divided into superficial and ral (Scarpa's) triangle. This triangle is deep, or into medial and lateral parts.6 In bounded by the inguinal ligament above, the latter situation, the lateral portion is by the sartorius muscle laterally, and by supplied by either a branch of the femoral the adductor longus muscle medially. nerve or the accessory obturator nerve, if Medial to the pectineus, the floor of the present, and the medial portion is sup- triangle is completed by the adductor plied by the obturator nerve.10 brevis muscle, and lateral to it, by the iliopsoas muscle.19 The obturator externus muscle lies deep to the pectineus muscle and covers The pectineus muscle attaches distally the obturator foramen of the pelvis.15,17 to the pectineal line on the medial poste- rior aspect of the femur.9 The pectineal Supplemental References line extends distally from the lesser tro- chanter (attachment of the iliopsoas mus- Other authors have illustrated the pectineus mus- cle) to the linea aspera33 (attachment of cle, showing its relationship to surrounding mus- the vastus medialis, adductor longus, and cles from the front v i e w , 2 , 1 4 , 2 4 , 3 1 , 3 4 to major blood adductor magnus muscles). The pec- vessels in the femoral triangle,1,13,26 and its attach- tineus overlies the uppermost fibers of ment to the pecten of the pubic bone.3, 17, 25 They the adductor brevis muscle as they de- show its relation to other muscles in cross section scend to attach to the back of the femur approximately at the middle of the pectineus27 or (see Fig. 13.4).8,34 Except for its usual in- in a series of cross sections throughout the length nervation by the femoral nerve and its of the muscle.6 Its attachment to the femur is best seen from behind.4,16
238 Part 2 / Hip, Thigh, and Knee Pain Figure 13.2. Attachments of the right Anterior Sacrum pectineus muscle (red), seen from in superior (sagittal front and slightly from the medial side. iliac spine section) The muscle attaches proximally and me- dially to the superior ramus of the pubis, Ischial and distally it fastens to the posterior tuberosity surface of the femur medial to its mid- Pubic tubercle line. Lesser trochanter Femur Patella 3. INNERVATION 4. FUNCTION (Fig. 13.3) The pectineus muscle is usually supplied by the femoral nerve via branches of the The pectineus muscle is the one best second to fourth lumbar spinal nerves.10 suited for the combined movements of The branch of the femoral nerve to the adduction and flexion at the hip. It is the pectineus arises immediately below the most proximal adductor muscle. inguinal ligament, passes beneath the femoral sheath and penetrates the ante- There is general agreement that the pec- rior surface of the muscle.11 The muscle tineus is both an adductor and flexor of may also receive a branch from the obtu- the thigh at the h i p . 1 0 , 1 2 , 2 0 , 2 2 , 2 8 , 3 2 It adducts rator nerve. When an accessory obturator more strongly as the thigh is flexed.32 nerve is present (about 29% of speci- Based on his electrical stimulation exper- mens), the muscle is innervated via the iments, Duchenne12 concluded that the accessory obturator from the third and pectineus is such a strong adductor-flexor fourth lumbar nerves. Instead of passing that it and the iliopsoas muscle, function- through the obturator foramen, this acces- ing together, can cross one thigh over the sory nerve crosses over and anterior to the other when an individual is in the seated superior ramus of the pubis to which the position. pectineus attaches.11 T h e muscle's short lever arm and its small angle of pull of about 60° suggest
Chapter 13 / Pectineus Muscle 239 Axis in bone Figure 13.3. Relation of the right pectineus muscle Axis hidder (red) to the axis of rotation (vertical bar) of the femur from view in the neutral position. Within view, the muscle is dark red; behind bone, it is light red. A, side view, B, front Axis in view. Here the muscle passes close to and in front of full sight the axis of rotation; however, it may pass either in front of or behind the axis. Whether this muscle medially or laterally rotates the thigh in this position is highly de- pendent on minor variations in anatomy. Adapted from Kendall and McCreary.22 that its purpose is power rather than and McCreary,22 relates these attachments to the speed. Leverage improves as the thigh mechanical axis of rotation of the thigh. The front moves forward and inward,28 which cor- view (Fig. 13.38) shows how far lateral to this axis relates with the increased electromy- the pectineus attaches on the femur. Both front ographic (EMG) activity observed in the and side views show that, at least sometimes, the muscle at 90° of thigh flexion.32 muscle crosses in front of the axis line. Thus, with its proximal attachment on the pubis being more There has been general indecision6 or anterior than its distal attachment on the femur, disagreement32 as to whether the muscle when the muscle passes anterior to the axis of ro- rotates the thigh medially10 or later- tation, it pulls the thigh toward the body, medi- ally.12,20,31 For passive stretching of the ally rotating it at the hip joint. The one reported pectineus muscle, it is unlikely that rota- EMG study32 showed, in two subjects, no gross tion of the thigh either way produces differences in the intensity of electrical activity much difference in its length in most peo- during adduction, flexion, or medial rotation. ple. However, essentially no electrical activity ap- peared in response to lateral rotation. When one examines its anatomy, the contro- versy is not surprising. The muscle fibers run The second author analyzed hip rotation in 90° from a medial attachment on the pubis to a more of hip flexion on one skeleton and used string to lateral distal attachment behind the femur. At first simulate the muscle line of pull. Remarkably little glance it looks as if the muscle would laterally ro- change of (simulated) muscle length occurred tate the thigh. Figure 13.3, adapted from Kendall with either medial or lateral rotation of the femur.
240 Part 2 / Hip, Thigh, and Knee Pain However, a small change in bony configuration do. Also, examination of the muscle will could easily change this result one way or the reveal taut bands and TrP tenderness only other. Poor leverage may account for the relatively with the myofascial syndrome. large EMG response to active medial rotation.32 An EMG study of a large number of subjects with The pain of pectineus TrPs may also be a diversity of body builds is needed to clarify the suggestive of hip joint disease, which is factors that determine the rotational action of this diagnosed by radiography. muscle. Pubic stress symphysitis, seen in dis- 5. FUNCTIONAL (MYOTATIC) UNIT tance runners30 and persons who compete in contact sports like ice hockey, causes Muscles that function with the pectineus pain in the region of the symphysis pubis. in its thigh adduction-flexion action are The pain is aggravated by sports activity. four adductors—the adductors longus, A TrP in the pectineus can aggravate the brevis, and magnus, and the gracilis—and symphysitis and add confusingly similar one flexor of the thigh, the iliopsoas mus- symptoms. Pectineus TrPs can be identi- cle. The remaining hip flexors, namely, fied by manual examination. The diagno- the tensor fasciae latae, sartorius and rec- sis is reinforced by relief of pain follow- tus femoris muscles, tend to be or clearly ing inactivation of TrPs. are abductors, not adductors. Tenderness at the symphysis pubis is Muscles that are the chief antagonists also common when the patient has an up- to adduction of the thigh by the pectineus slip of the innominate bone. are the gluteus medius, gluteus minimus, and tensor fasciae latae. The gluteus max- 7. ACTIVATION AND PERPETUATION imus and hamstring muscles oppose flex- OF TRIGGER POINTS ion 1 8 , 2 1 , 2 9 Activation 6. SYMPTOMS Pectineus muscle TrPs are likely to result Patients with pectineus TrPs complain of from tripping or falling, or from any other the referred pain, but rarely present with event that causes unexpectedly strong re- pain from this muscle only. Usually, ad- sistance to combined adduction-flexion ditional functionally related muscles are of the thigh at the hip. One patient5 acti- involved. After TrPs in the three other ad- vated his pectineus TrPs while rapidly ductors or the iliopsoas have been inacti- lifting and moving a heavy computer. vated, the pectineus is uncovered as the Some patients have forgotten the initial cause of persistent deep-seated groin incident until specifically queried about pain, especially during weight-bearing ac- the possibility of one. Unaccustomed sex- tivities that cause abduction of the thigh. ual activity that involves vigorous ad- Therefore, the pectineus should be ductor activity can be responsible for acti- checked for TrP tenderness after inacti- vating pectineus TrPs. A sudden, vigor- vating either adductor or iliopsoas TrPs. ous adduction-flexion movement while performing gymnastic exercises may Patients with pectineus TrPs may also overload the muscle, especially when it is be aware of limited abduction at the hip, already fatigued. Another activity that especially when seated in the lotus posi- can stress the muscle is horseback riding, tion (see Section 15, Case Report). A m o n g when the rider uses the thighs, rather the four muscles that act as adductors, than the legs and feet, to grasp the horse. however, TrPs in the pectineus restrict the range of abduction the least. TrPs in this muscle also develop in as- sociation with disease of the hip joint, Differential Diagnosis such as advanced osteoarthritis, or with fracture of the neck of the femur, and after Patients with obturator nerve entrapment surgery on the hip. may present with a pain complaint sug- gestive of pain referred from pectineus Perpetuation TrPs.7 The entrapment causes more pro- nounced sensory changes than the TrPs Repetition of a mechanical stress similar to that which previously activated the pectineus TrPs can perpetuate them. In
Chapter 13 / Pectineus Muscle 241 addition, a lower limb-length inequality The lateral distal part of the pectineus may impose chronic overload on this muscle lies deep to the femoral neurovas- muscle. These TrPs are perpetuated also cular bundle (Fig. 13.4). The artery by a sustained posture that places the courses down the middle of the femoral muscle in a shortened position, such as triangle. Its pulsation is readily palpable sitting cross-legged or with the hips in a in most patients. jackknifed position; an individual with a small hemipelvis often sits cross-legged. The TrPs in the pectineus muscle are located just distal to the superior ramus of 8. PATIENT EXAMINATION the pubis (see Fig. 13.1). These TrPs lie immediately under the palpating finger in Pectineus TrPs primarily cause pain with this subcutaneous muscle. To feel the little weakness or restriction of motion. stringlike taut band in this muscle, the Some patients exhibit an antalgic gait.5 finger palpates in the same proximal loca- Testing the abduction-extension range of tion described above, rubbing across the motion usually produces only mild to fibers of the pectineus muscle parallel to moderate pain at very nearly the full the border of the superior ramus of the range,5 often with no further increase in pubic bone. Pressure may be applied to a pain when the thigh is medially or later- TrP in the pectineus in the manner shown ally rotated in this stretch position. (This in Figure 13.5 to elicit its spot tenderness. finding applies, of course, only after con- Flat palpation of this TrP may induce a current iliopsoas and other adductor mus- clear referral of pain. Snapping palpation cle TrPs have been inactivated.) of the TrP may elicit a visible or palpable twitch of the muscle. When the patient with an active pec- tineus TrP stands on the opposite leg and 10. ENTRAPMENTS then attempts to swing the involved thigh into extreme adduction with flexion at No nerve entrapments are known to be the hip, groin pain occurs at the end of caused by TrPs in the pectineus muscle. the movement. 11. ASSOCIATED TRIGGER POINTS 9. TRIGGER POINT EXAMINATION (Figs. 13.4 and 13.5) The TrPs in the pectineus muscle are fre- quently discovered in association with The pectineus muscle can be located by TrPs in the iliopsoas, the three adductors, first palpating the upper border of the and the gracilis muscle. When these symphysis pubis. Two or three centime- neighboring TrPs have been inactivated, a ters (approximately an inch) lateral to the search for the cause of the residual ten- symphysis is the pubic tubercle (see Fig. derness and deep groin pain reveals the 13.2), to which the medial end of the in- pectineus TrPs. For this reason, it is im- guinal ligament attaches (Fig. 13.4). When portant after eliminating any TrPs in the the thigh is placed in moderate abduction iliopsoas and adductor muscles, always without flexion, the adductor longus to check for residual pain-producing ac- muscle (Fig. 13.4) should be palpable, if tive TrPs in the pectineus. not visible. The adductor longus and brevis muscles lie parallel to, and are im- 12. INTERMITTENT COLD WITH mediately medial and deeper than, the STRETCH pectineus. The pectineus muscle attaches (Fig. 13.6) * to the crest (pecten) of the superior ramus Since the lower, more diagonal fibers of of the pubic bone just inferior to the me- the pectineus muscle give it a major ad- dial portion of the inguinal ligament. By ductor function, it is essential that all the palpating lateral to the pubic tubercle, the other muscles functioning as adductors anterior edge of the superior ramus of the be freed of TrP tightness in order to effec- pubic bone is readily felt. If there is any tively release the pectineus muscle. doubt as to the location of the pubic tu- bercle, one can identify the proximal at- The use of ice for applying intermittent tachment of the adductor longus, which cold with stretch is explained on page 9 of this volume and the use of vapocoolant : is close and medial to the tubercle.
242 Part 2 / Hip, Thigh, and Knee Pain Psoas minor and major Femoral nerve External iliac vein lliacus External iliac artery Greater trochanter Psoas minor tendon Inguinal ligament of femur Superior ramus of pubis Femoral nerve Femoral artery Femoral vein Vastus lateralis Pectineus Adductor brevis Rectus femoris Adductor longus Adductor magnus Gracilis Sartorius Vastus medialis Lateral patellar Patella retinaculum Medial patellar Patellar ligament retinaculum Tibia Figure 13.4. Anatomical relations of the right pec- riorly, by the sartorius muscle laterally, and the ad- tineus muscle (medium red) to neighboring thigh mus- ductor longus medially. The femoral artery is dark red; cles (light red) and to the femoral (Scarpa's) triangle, the femoral vein has black hatching; and the femoral This triangle is bounded by the inguinal ligament supe- nerve is white. with stretch is detailed on pages 67-74 of with stretch to the adductor magnus mus- Volume l . 3 5 Techniques that augment re- cle in the manner illustrated as the first laxation and stretch are reviewed on page step of the procedure for the hamstring 11 of this volume. Full stretch is avoided muscles, abducting the thigh of the su- across hypermobile joints. Alternate treat- pine patient (see Fig. 16.11A). ment techniques are summarized on page 000 of this volume. Next, intermittent cold with stretch is applied to the adductor longus and brevis To release this entire functional unit, (see Fig. 15.14). During the application of one starts by applying intermittent cold vapocoolant or ice, the operator gently ab-
Chapter 13 / Pectineus Muscle 243 Figure 13.5. Palpation of trigger points in the right the ilium. The pectineus muscle forms the upper me- pectineus muscle (light red). Dark red marks the path dial floor of the femoral triangle. The pillow under the of the palpable (pulsating) femoral artery, which is part thigh elevates the knee slightly to relieve excessive of the neurovascular bundle. The dashed line identi- tension on the pectineus muscle. The rolled towel pro- fies the inguinal ligament. The open circle marks the vides lumbar support for the patient's comfort. The pubic tubercle and the solid circle, the anterior supe- blanket helps to prevent chilling of the patient. rior iliac spine. The solid black line locates the crest of ducts the thigh at the hip, with the foot on ity to help take up the slack that devel- the affected side placed against the mid- ops. Since this position also stretches the dle of the opposite thigh of the supine pa- iliopsoas muscle, before finishing the pro- tient. This position also adds some cedure, downsweeps of vapocoolant or stretch to the pectineus, but is an incom- ice are also applied beside the midline of plete stretch without adding hip exten- the abdomen as illustrated in Figure 5.5. sion. When the limit of this motion is For the final stretch, the patient's hip is reached, medial and then lateral rotation placed close to the edge of the treatment at the hip may be performed. If either table and the leg of the limb being treated movement is found to increase tension on is allowed to hang over the edge. For pro- the pectineus muscle and cause discom- tection of the lumbar region (particularly fort, more sweeps of vapocoolant or ice if there is hypermobility), the pelvis are applied during this additional rotary should be stabilized; either the pelvis can stretch. be strapped down or the patient can hold the opposite thigh close to the abdomen Immediately following intermittent (not pictured). As sweeps of ice or vapo- cold with stretch, the clinician applies a coolant are applied as shown in Figure moist heating pad to the areas of cooled 13.6, the clinician, using the assistance of skin. When the skin has rewarmed, the gravity, gently abducts and extends the patient actively moves the thigh slowly thigh until resistance (a barrier) is and smoothly through full flexion-adduc- reached. To include postisometric relaxa- tion and then extension-abduction sev- tion in each treatment cycle, the patient eral times to reestablish normal active slowly inhales and gently tries to flex and range of motion. adduct the thigh while the clinician re- sists the movement, maintaining the posi- Instead of, or in addition to, intermit- tion. Then, as the patient relaxes and tent cold with stretch, the clinician can slowly exhales, the clinician allows grav- apply ischemic compression and deep massage (see Chapter 2 for details). Full
244 Part 2 / Hip, Thigh, and Knee Pain Figure 13.6. Stretch position and the ice-stroking or grasping the knee instead of the leg would avoid any vapocoolant-spray pattern (thin arrows) for a trigger possible trauma to the knee. At the limit of the range, point (X) in the right pectineus muscle. The doffed line one may add pressure at the distal thigh to test first marks the inguinal ligament and the solid circle, the medial and then lateral passive rotation at the hip, to anterior superior iliac spine. To stretch the pectineus, learn whether either movement increases the tension the thigh is gradually moved outward and downward on the pectineus muscle. (in abduction and extension). Moving the thigh by lengthening of the muscle should follow creases the risk of puncturing the artery. this deep massage. The abducted position also helps to in- crease the tension of the muscle fibers 13. INJECTION AND STRETCH and to make the taut bands more readily (Fig. 13.7) palpable. Before the authors learned to release the The TrP is palpated as described in adductor magnus muscle first, spray and Section 9, Trigger Point Examination. stretch of the pectineus was usually not Two fingers straddle the TrP to localize it effective, and it was necessary to inject for accurate penetration by the probing the TrPs in this muscle to obtain com- needle. The femoral artery is avoided by plete relief of pain. palpating its pulsations and directing the needle away from it. In thin patients, the To inject these TrPs, the thigh of the su- artery is readily palpated laterally in the pine patient is placed in lateral rotation, femoral (Scarpa's) triangle (Fig. 13.4). abduction, and slight flexion (Fig. 13.7). This position shifts the femoral artery to- The basic technique for injection of the ward the lateral margin of the muscle, TrPs with 0.5% procaine solution is de- since the vessel is fixed distally at the ad- scribed and illustrated in Volume 1, ductor hiatus. Injecting this muscle with Chapter 3, Section 13.35 A 37-mm (l1/2-in) the thigh in the anatomical position in- 21-gauge needle is directed medially pre-
Chapter 13 / Pectineus Muscle 245 Figure 13.7. Injection of a trigger point in the right ment; and the open circle, the pubic tubercle. The pectineus muscle (light red). The thigh of the supine femoral artery (dark red) is avoided by palpating its patient is placed in abduction, lateral rotation, and pulsations and directing the needle medially away slight flexion. The solid circle locates the anterior su- from it. perior iliac spine; the dashed line, the inguinal liga- cisely into the TrP and pressure applied such as ilial rotations, have been previ- for hemostasis as the needle is with- ously corrected. The apparent asymmetry drawn. The effectiveness of this approach that is almost always caused by an ilial is illustrated in a case report of Baker5 rotation should be corrected by mobiliza- and in the case report in Section 15 of this tion and restoration of normal pelvic chapter. symmetry, not by a limb-length correc- tion. Injection of a TrP is followed at once by application of intermittent cold with Corrective Posture and Activities stretch, then a moist hot pack, and finally by several cycles of active range of mo- The patient also should avoid sitting with tion, alternating thigh extension-abduc- the knees crossed or the hips flexed tion and thigh flexion-adduction. acutely (in a jackknifed position) because these positions maintain the pectineus 14. CORRECTIVE ACTIONS muscle in a shortened state. When sitting erect in a chair, one's knees should not be In general, activities or positions that higher than the hips. overload the thigh adductors or that im- mobilize the muscle in a shortened posi- Some patients, especially women, may tion should be avoided or modified. perform vigorous adduction of the thighs during sexual intercourse, which can Patients with persistent myofascial overload the adductor muscles including pain syndromes who respond poorly to the pectineus. Alternative positions specific local TrP therapy should be should be explored or adductor-condi- screened carefully for both mechanical tioning exercises gradually instituted af- and systemic perpetuating factors (Vol- ter pain-producing TrPs have been inacti- ume 1, Chapter 4).35 vated. Corrective Body Mechanics When sleeping, if the patient lies on the side opposite to the involved pectineus Any discrepancy in lower limb length or muscle, a pillow should be placed be- any asymmetry in hemipelvis size should tween the knees [see Fig. 4.31) to prevent be corrected. Correction of these body postural aggravation of the pectineus asymmetries is made by supplying a suit- TrPs. able shoe lift or ischial (butt) lift (see Chapter 4), assuming that malalignments,
246 Part 2 / Hip, Thigh, and Knee Pain Home Therapeutic Program metry. Examination of muscles in the hip region revealed palpable tenseness of the entire pec- The patient should be instructed in a self- tineus muscle, a taut band within the muscle, and stretch exercise for the pectineus muscle. exquisite tenderness at one spot along the band. This can be performed using the position Snapping palpation at the tender spot elicited no shown in Figure 13.6. The patient can en- obvious local twitch response and no distinguish- hance muscle lengthening by using post- able radiation of pain. isometric relaxation as described in Sec- tion 12. Looking upward while inhaling Procaine injection of TrPs in the pectineus mus- facilitates contraction of the muscle; look- cle, followed at once by application of vapocool- ing downward while exhaling enhances ant spray and stretch to the other adductors and relaxation of the muscle. Gravity takes up the pectineus muscle, reduced the TrP sensitivity the slack that develops. Instructions to finger pressure approximately 50%. After 2 should also be given in corrective posture weeks of self-administered postisometric relaxa- and activities as described previously. tion23 for gentle adductor stretch in the lotus posi- tion, the patient achieved a comfortable full range 15. CASE REPORT of motion in this position. Adduction of the flexed (Seen by David G. Simons, M.D.) thigh during standing was then painless, and the patient was able to perform both concentric and S.S., a 24-year-old male physical therapist, re- isometric adduction strengthening exercises with- ported that, while fatigued, he had performed re- out discomfort. peated martial art kicks a year earlier. This vigor- ous kicking movement produced marked adduc- Comment: tion of the thigh across the front of the body with partial flexion at the hip. Suddenly, during one of This case is unusual in that it is a single-muscle these movements, he felt a twinge of pain deep in pectineus syndrome. Initial therapy by TrP injec- the right groin, anterior to the hip joint. As he con- tion and stretch was chosen rather than intermit- tinued the exercise, pain intensified. The ensuing tent cold with stretch alone, because it was clearly intense, aching soreness caused him to avoid any a single-muscle myofascial syndrome that had ballistic kicking or sports activity that required been refractory to previous conservative therapy. strong adduction of the thigh. The acute phase lasted several weeks. Ordinary ambulation was The non-progressive nature of the symptoms painless. Conservative therapy with ice, hot and the immediate and lasting response to ther- packs, and ultrasound had no effect. The problem apy made further investigation for systemic per- was aggravated by repeated assumption of the po- petuating factors unnecessary. sition of combined hip flexion, abduction, and lat- eral rotation (lotus position), in an attempt to References work through the pain. 1. Anderson JE: Grant's Atlas of Anatomy, Ed. 8. Wil- The patient previously was treated by two phy- liams & Wilkins, Baltimore, 1983 (Fig. 4-20). sicians and five physical therapists without any improvement. X-rays were unremarkable, re- 2. Ibid. (Fig. 4-22). vealing only minimal sclerosis around the acetab- 3. Ibid. (Fig. 4-39). ulum of the hip joint. 4. Ibid. (Fig. 4-40). 5. Baker BA: Myofascial pain syndromes: ten sin- When first seen, the patient described the pain as annoying and worrisome, but not disabling. It gle muscle cases. J Neurol Orthop Med Surg 10: restricted his recreational gymnastic activities. He 129-131, 1989. had no rest pain and no pain with ordinary activi- 6. Bardeen CR: The musculature, Sect. 5. In Mor- ties. However, when he assumed the lotus posi- ris's Human Anatomy, edited by C M . Jackson, Ed. tion, abduction of the thigh at the hip was re- 6. Blakiston's Son & Co., Philadelphia, 1921 (p. stricted on the right side, and there was aching 504). pain in the groin that increased as abduction was 7. Bowman AJ Jr, Carpenter AA, Iovino J, et al.: In- increased. A more abrupt pain in the same region trapelvic complications of hip surgery: a case re- occurred in the standing position when the right port of obturator nerve entrapment. Orthopedics thigh was crossed over in front of the left, produc- 2:504-506, 1979. ing full adduction combined with some flexion. 8. Carter BL, Morehead J, Wolpert S M , et al.: Cross- Sectional Anatomy. Appleton-Century-Crofts, Examination for a lower limb-length inequality New York, 1977 (Sects. 39-43, 45-48). and for a small hemipelvis showed no body asym- 9. Clemente CD: Gray's Anatomy of the Human Body, American Ed. 30. Lea & Febiger, Philadelphia, 1985 (pp. 278-279). 10. Ibid. (pp. 563-564). 11. Ibid. (pp. 1230-1232). 12. Duchenne GB: Physiology of Motion, translated by E.B. Kaplan. Lippincott, Philadelphia, 1949 (pp. 266, 267).
Chapter 13 / Pectineus Muscle 247 13. Ferner H, Staubesand J: Sobotta Atlas of Human 25. Ibid. (p. 270). Anatomy, Ed. 10, Vol. 2. Urban & Schwarzen‐berg, 26. Ibid. (p. 298). Baltimore, 1983 (Fig. 407). 27. Pernkopf E: Atlas of Topographical and Applied Human 14. Ibid. (Figs. 415, 416). Anatomy, Vol. 2. W.B. Saunders, Philadelphia, 1964 15. Ibid. (Fig. 417). (Fig. 329). 16. Ibid. (Fig. 420). 28. Rasch PJ, Burke RK: Kinesiology and Applied Anatomy, 17. Ibid. (Fig. 421). Ed. 6. Lea & Febiger, Philadelphia, 1978 (p. 272). 18. Hollinshead WH: Functional Anatomy of the Limbs 29. Ibid. (p. 282). 30. Rold JF, Rold BA: Pubic stress symphysitis in a and Back, Ed. 4. W.B. Saunders, Philadelphia, 1976 female distance runner. Phys Sportsmed 74:61‐65, (pp. 271, 300‐302, 304). 1986. 19. Hollingshead WH: Anatomy for Surgeons, Ed. 3., Vol. 31. Spalteholz W: Handatlas der Anatomie des Men-schen, 3, The Back and Limbs. Harper & Row, New York, Ed. 11, Vol. 2. S. Hirzel, Leipzig, 1922 (p. 349, 350). 1982 (pp. 685, 696‐698). 32. Takebe K, Vitti M, Basmajian JV: Electromyography 20. Janda V: Muscle Function Testing. Butterworths, of pectineus muscle. Anat Rec 780:281‐283, 1974. London, 1983 (pp. 161, 169, 176). 33. Toldt C: An Atlas of Human Anatomy, translated by 21. Ibid. (pp. 161, 164, 169, 171). M.E. Paul, Ed. 2, Vol. 1. Macmillan, New York, 1919 22. Kendall FP, McCreary EK: Muscles, Testing and (p. 132, Fig. 320). Function, Ed. 3. Williams & Wilkins, Baltimore, 34. Ibid. (p. 352). 1983 (p. 178). 35. Travell JG, Simons DG: Myofascial Pain and Dys- 23. Lewit K, Simons DG: Myofascial pain: relief by function: The Trigger Point Manual. Williams & post‐isometric relaxation. Arch Phys Med Rehabil Wilkins, Baltimore, 1983. 65:452‐456, 1984. 24. McMinn RMH, Hutchings RT: Color Atlas of Human Anatomy. Year Book Medical Publishers, Chicago, 1977 (p. 244).
CHAPTER 14 Quadriceps Femoris Group Rectus Femoris, Vastus Medialis, Vastus Intermedius, and Vastus Lateralis \"Four-Faced Trouble Maker\" HIGHLIGHTS: REFERRED PAIN patterns of The role of the oblique (distal, diagonal) fibers of myofascial trigger points (TrPs) in the quadri- the vastus medialis is to counter the lateral pull ceps femoris muscle group can appear on the of the vastus lateralis on the patella, a critically medial, anterior, or lateral aspects of the thigh important function. When the foot is free, the and in the knee. The common TrP in the rectus quadriceps femoris acts primarily to extend the femoris occurs at the upper end of the muscle leg at the knee (all four heads) and to assist flex- and refers to the lower anterior thigh and ante- ion of the thigh at the hip (rectus femoris only). rior knee regions. The TrPs in the vastus medi- The rectus femoris forms a FUNCTIONAL UNIT alis refer pain to the knee anteromedially and for flexion at the hip primarily with the iliopsoas upward along the anteromedial aspect of the and pectineus muscles, which are opposed by thigh. The vastus intermedius pain pattern hits the gluteus maximus and hamstring muscles. All the middle portion of the anterior thigh, and the heads of the quadriceps femoris contribute to vastus lateralis has at least five TrP sites that knee extension and are opposed primarily by can cause misery along the lateral thigh from the hamstring muscles. SYMPTOMS of quadri- the pelvis and greater trochanter to the lateral ceps femoris TrPs are chiefly pain and weak- side of the knee. ANATOMICAL ATTACH- ness. Since the quadriceps femoris is the only MENTS of the rectus femoris are such that it strong extensor at the knee, any TrP in that crosses both the hip and the knee joints, unlike muscle group compromises knee extension. A the three vasti of the quadriceps femoris, which buckling knee can be caused by TrPs in the vas- cross only the knee joint. Proximally, the rectus tus medialis and reportedly from the vastus femoris is anchored to the pelvis in the region of lateralis. TrPs in either of these muscles can dis- the anterior inferior iliac spine. The vastus in- tort patellar balance. The TrPs in the rectus fem- termedius that lies deep to it attaches to a large oris, vastus medialis, and vastus lateralis are area of the anterolateral surface of the femur. likely to disturb sleep. Vastus lateralis TrPs can Both the vastus medialis and vastus lateralis at- cause lateral thigh pain and/or locking of the pa- tach on their respective sides to the posterior tella with the knee in the extended position. Dif- aspect of the femur along the length of its shaft. ferential diagnosis of knee pain should consider Tendons of all four heads of the quadriceps fem- other causes of patellofemoral dysfunction, in- oris unite to form a strong tendon, which at- cluding tendinitis of the quadriceps or patellar taches distally to the base of the patella. The pa- tendons, as well as knee joint dysfunction and tella is anchored to the tibial tuberosity by the pathology. ACTIVATION OF TRIGGER POINTS patellar ligament. Quadriceps FUNCTION fre- in the quadriceps femoris often occurs during a quently involves the exertion of force on the fall, misstep, or trauma to the muscle, and due thigh (reverse action), and it often involves to injection of irritant medication into the muscle. lengthening contractions to control knee flexion. Quadriceps femoris TrPs often are perpetuated Function is easily inhibited by disturbance of by tightness of the hamstrings, which hinders full knee mechanics including effusion into the joint. extension at the knee and thus imposes an ex- 248
Chapter 14 / Quadriceps Femoris Group 249 cessive load on the quadriceps femoris group of lateralis. The adductor longus and brevis are muscles. Deep knee bends readily overload this generally treated by intermittent cold with pas- muscle. PATIENT EXAMINATION starts with sive stretch prior to stretch of the vastus medi- evaluation of gait for asymmetries, deviations, alis. The cooled skin is promptly rewarmed with and malalignment of lower limb segments. a moist heating pad, and the patient performs Strength and range of motion are tested sepa- slowly executed full active range of motion rately for the rectus femoris and for the three through several cycles. With a few exceptions, vasti. Loss of patellar mobility reveals informa- INJECTION of quadriceps femoris TrPs pre- tion about the relative tightness of individual sents no special difficulties. Caution must be ex- heads of the muscle. TRIGGER POINT EXAMI- ercised with vastus medialis TrP2 along the me- NATION of the rectus femoris by flat palpation dial margin of the muscle close to the femoral locates TrPs near its proximal attachment. The artery, vein, and nerve. The vastus intermedius TrP that commonly causes buckling of the knee and vastus lateralis TrPs located deep at the is found in the medial border of the vastus medi- midthigh level appear deceptively non-tender to alis near the transition to oblique fibers. The flat palpation and are hard to localize for injec- vastus intermedius harbors multiple deep TrPs tion, but pose no particular hazard. In order to that are often difficult to localize by palpation. locate TrPs and inject the distal vastus lateralis The TrP in the distal vastus lateralis that causes TrP1 that is responsible for the locked patella, a locked patella is superficial, but can be located the patella must be moved distally. CORREC- only if the patella is moved distally to uncover TIVE ACTIONS include avoiding overload of the the TrP for flat palpation. The clusters of deep quadriceps femoris by lifting an object from TrPs in the middle two-fourths of the vastus ground level in a safe manner that does not lateralis are usually multiple and require deep strain either the thigh or back muscles, and by palpation for their discovery, but they are difficult avoiding deep knee bends. Patients with a buck- to localize. INTERMITTENT COLD WITH ling knee TrP in the vastus medialis muscle STRETCH for the rectus femoris requires simul- should have an appropriate shoe insert added if taneous hip extension and knee flexion during their second metatarsal is longer than the first and after application of ice or vapocoolant over metatarsal or if they have a hyperpronated foot. all of the muscle and all of its referred pain pat- Prolonged immobility should be avoided. A tern. Lengthening the remaining three heads of home self-stretch exercise program helps en- the quadriceps femoris requires only knee flex- sure continued relief. Lying with the vastus later- ion. The patient should be in somewhat different alis TrPs on a tennis ball augments their inacti- positions for lengthening each of the heads, with vation by self-massage. Strengthening exer- cold application patterns tailored to cover each cises should begin with unweighted slow muscle and its referred pain pattern. The patella lengthening contractions; weighted shortening is depressed distally while fully flexing the knee contractions should start only after the related when releasing the most distal TrP in the vastus muscle TrPs have been inactivated. 1. REFERRED PAIN Rectus Femoris (two-jointed puzzler) (Figs. 14.1-14.5) (Fig. 14.1) The trigger points (TrPs) in all four The TrPs in the rectus femoris muscle, heads of the quadriceps femoris muscle like those in the long head of the triceps refer pain to the thigh and knee region. brachii of the upper limb, are extremely Only the rectus femoris and vastus common and frequently overlooked. medialis TrPs produce anterior knee Neither of these two-joint muscles usu- pain. Those in the vastus lateralis cause ally undergoes full stretch in daily activi- posterolateral knee pain. The referred ties. Seldom is either examined to deter- pain from the rectus femoris TrPs is mine if it restricts range of motion. The more likely to be felt deep in the knee rectus femoris is a two-joint puzzler be- joint than is the knee pain referred from cause the usual location of its TrP is at the vastus medialis or the vastus later- hip level, high on the thigh just below the alis. anterior inferior iliac spine, but the pain is felt at the knee in and around the pa-
250 Part 2 / Hip, Thigh, and Knee Pain Figure 1 4 . 1 . Pain pattern (bright red) referred from the usual trigger point (X) in the right rectus femoris muscle (dark red). Other parts of the quadriceps fem- oris are light red. Solid bright red de- notes the essential pattern of pain expe- rienced by nearly everyone with this trig- ger point. Red stippling indicates the occasional extension of its essential re- ferred pain pattern. tella (Fig. 14.1), and sometimes deep in only minimally restrict the range of mo- the knee joint. Patients with these TrPs tion of the knee and because the TrP may often have severe deep aching pain at not produce pain, but only dysfunction. night over the lower thigh above the knee The vastus medialis is often a \"quitter.\" anteriorly. They are unable to find a posi- After several weeks or months, the initial tion or movement that provides relief un- pain phase of its TrPs changes to an inhi- til they learn how to stretch this muscle bition phase. The pain is replaced by un- fully. Occasionally, a rectus femoris TrP expected episodes of quadriceps weak- occurs in the lower end of the muscle just ness that produce buckling of the knee. above the knee near the patella and is This sudden weakness may cause the in- likely to refer pain deep into the knee dividual to fall, inflicting injury. joint. In children, the vastus medialis was the Vastus Medialis (buckling knee muscle) second most frequently seen location for (Fig. 14.2) TrPs (11%) among 85 cases of myofascial pain.19 The most common pain pattern re- The vastus medialis TrP1, which is the ferred from this muscle in children was more common of the two TrP locations in comparable to that of TrP1 in adults. this muscle, refers pain to the front of the knee (Fig. 14.2A), as previously illus- Vastus Intermedius (frustrator) t r a t e d . 1 0 1 , 1 0 2 , 1 1 3 The more proximal TrP2 re- (Fig. 14.3) fers aching pain in a linear distribution over the anteromedial aspect of the knee The vastus intermedius muscle is a \"frus- and lower thigh (Fig. 14.26). trator\" because it develops many TrPs that cannot be palpated directly; they are The TrPs in this muscle are easily over- hidden beneath the rectus femoris mus- looked because the taut muscle fibers cle. The pain pattern from these TrPs ex-
Chapter 14 / Quadriceps Femoris Group 251 Figure 14.2. Pain patterns (dark red) referred from and removed. Solid dark red depicts the essential pat- trigger points (Xs) in the right vastus medialis muscle tern of pain experienced by nearly everyone with (medium red). The remaining parts of the quadriceps these trigger points. Red stippling indicates the occa- femoris, which are retained for orientation, are light sional extension of the essential referred pain pattern. red; the rectus femoris (also light red) has been cut A, distal TrP1 B, proximal TrP2. tends over the front of the thigh nearly to length of the thigh laterally and to the the knee, but is most intense at midthigh outer side of the knee. Occasionally, the (Fig. 14.3). TrPs at multiple locations in lateral thigh pain extends as high as the the vastus intermedius may refer pain pelvic crest. When its TrPs are in the and tenderness that extend over the up- more superficial layers of the muscle, per thigh anterolaterally. The TrPs in this they are more likely to have a local pat- muscle are usually multiple, rarely soli- tern, whereas TrPs located deep in the tary. muscle usually produce pain that ex- plodes up and down the thigh. When vas- Kellgren reported that 0.1 mL of 6% hy- tus lateralis TrPs refer pain and tender- pertonic saline solution injected into the ness to the proximal thigh region, the pa- vastus intermedius muscle caused pain in tient may be unable to lie on that side, the knee.60 disturbing sleep at night. Good48 also found that myalgic spots (probably TrPs) Vastus Lateralis (stuck patella muscle) in the lateral edge of the vastus lateralis (Fig. 14.4) referred pain to the knee. The vastus lateralis characteristically de- A distinctive feature of TrP1 in the vas- velops multiple TrPs along the lateral as- tus lateralis is a \"stuck patella,\" in addi- pect of the thigh. This muscle has the tion to pain around the lateral border of largest bulk of the four heads of the quad- the patella that sometimes extends up- riceps femoris. Its five TrP locations (Fig. ward over the lateral region of the thigh 14.4) can refer pain throughout the full
252 Part 2 / Hip, Thigh, and Knee Pain Figure 14.3. Pain pattern (dark red) referred from the common trigger point location (X) in the right vastus in- termedius muscle (medium red). Other parts of the quadriceps femoris are light red. The rectus femoris has been cut and removed. Dark solid red denotes the essential pattern of pain felt by nearly everyone with this trigger point. Red stippling indicates occasional ex- tension of the essential referred pain pattern. Additional trigger points may oc- cur more distally in the muscle. (Fig. 14.4). This pattern has been de- referred from the TrP4 region of the vastus scribed in a case report by Nielsen,87 and lateralis swings anteriorly around the lat- has been illustrated.103,113 Pain from this eral border of the patella rather than pos- TrP1 may extend into and through the teriorly to the popliteal space. TrP5, in the knee, and sometimes toward the back of proximal end of the vastus lateralis mus- the knee, as illustrated for children.19 The cle, refers pain and tenderness only to its more posteriorly located TrP2 also causes immediate vicinity (Fig. 14.4). A compos- pain lateral to the patella, but refers pain ite pattern of TrP4 and TrP5 has been pre- more extensively up the lateral aspect of sented as the anterior vastus lateralis re- the thigh and sometimes down the lateral ferred pain pattern.101,102 aspect of the leg farther distally than the pattern of TrP1. The TrP3 location postero- Vastus lateralis TrPs apparently are laterally at midthigh level refers pain that common in children. They were the TrPs travels the entire length of the postero- most frequently found (35%) in a study of lateral region of the thigh and includes 85 children with myofascial pain syn- the lateral half of the popliteal space. It is dromes.19 the one quadriceps TrP area that pro- duces posterior knee pain. Ligamentous Trigger Point (Fig. 14.5) A more anteriorly placed \"hornets' nest\" of TrPs at midthigh level in the TrP4 The fibular (lateral) collateral ligament region is not uncommon and is likely to may harbor a ligamentous TrP that refers cause severe pain over the entire length of pain proximally to the lateral side of the the lateral thigh, slightly anterior to the knee (Fig. 14.5). This location of the pain pain of TrP3, and extending upward al- may suggest that it arises from distal TrPs most to the pelvic crest. Distally, the pain in the vastus lateralis muscle.
Figure 14.4. Pain patterns (bright red) referred from cates the occasional extension (spillover) of the es- trigger points (Xs) in the right vastus lateralis muscle sential referred pain pattern. TrP, restricts patellar mo- (dark red). The rectus femoris is light red. Solid bright bility. TrP4 is close to the fascia lata and produces a red denotes the basic pain experienced by nearly \"bolt of lightning\" pain that prevents sleeping on the everyone with these trigger points. Red stippling indi- affected side.
254 Part 2 / Hip, Thigh, and Knee Pain Figure 14.5. Pain pattern (solid red and red stippling) referred from a liga- mentous trigger point (X) in the fibular collateral ligament of the right knee (lat- eral view). 2. ANATOMICAL ATTACHMENTS AND spine and the other to a groove above the CONSIDERATIONS posterior brim of the acetabulum.3, 29 Dis- (Figs. 14.6-14.9) tally, the muscle attaches to the proximal border of the patella and, through the pa- All four muscles of the quadriceps fem- tellar ligament, to the tuberosity of the oris group attach by a common tendon to tibia (Fig. 14.6). The rectus femoris ex- the patella which, in turn, is attached to tends the length of the thigh in front. the tibial tuberosity by the patellar liga- Proximally, it is covered by the sartorius ment (Fig. 14.6). The patella is a sesamoid muscle at and just below the attachment bone in the tendon of the quadriceps fem- to the anterior inferior iliac spine; more oris.29 The three vasti muscles cross only distally, the sartorius crosses diagonally the knee joint, since they attach proxi- to lie along the medial border of the rec- mally to the femur and distally through tus femoris,27 covering the adductor canal the patella and patellar ligament to the that contains the femoral nerve and blood tibia. The rectus femoris, however, vessels. crosses both the knee and the hip joints; it alone of the quadriceps group attaches The superficial fibers of the rectus femoris form proximally to the pelvis. It joins the vasti a bipennate inverted \" V \" pattern,96, 97 while the to attach distally to the patella and, deep fibers course directly down to the deep apo- through the patellar ligament, to the tibial neurosis.29 Together, the directions of the vastus tuberosity.10,29 medialis and vastus lateralis lower fibers form a diagonal pattern opposite to that of the upper fi- The quadriceps femoris is the largest bers of the rectus femoris (Fig. 14.6).96 (heaviest) muscle in the body. It may weigh 50% more (1271 gm) than the next Anatomical variations of the quadriceps femoris heaviest muscle, the gluteus maximus are rare. The rectus femoris rarely may anchor to (814 g m ) . 1 1 8 the pelvis by only one tendon. That tendon may attach either to the anterior inferior iliac spine or Rectus Femoris to the rim of the acetabulum.11 (Fig. 14.6) Vastus Medialis The two-joint rectus femoris muscle lies (Fig. 14.7) between the vastus medialis and vastus lateralis, and covers the vastus inter- T h e vastus medialis attaches proximally medius (Figs. 14.6 and 14.7). along the entire length of the poster- omedial aspect of the shaft of the fe- Proximally, the rectus femoris is mur,3 to the lower half of the inter- anchored to the pelvis by two tendons, trochanteric line, the medial lip of the one attached to the anterior inferior iliac
Anterior Chapter 14 / Quadriceps Femoris Group 255 inferior iliac spine Figure 14.6. Attachments (front view) of the right rectus femoris muscle (dark red) in relation to the vastus lateralis and vastus medialis muscles (light red). Fig- ure 14.8 shows the cross section of the thigh at the level indicated here. Level of Rectus cross femoris section Vastus Vastus medialis lateralis Patella Lateral Medial patellar patellar retinaculum retinaculum Tibial Patellar tuberosity ligament Tibia linea aspera, the upper part of the me- T h e vastus medialis attaches distally dial supracondylar line, the tendons of not only to the medial border of the pa- the adductor longus and adductor mag- tella and through the patellar ligament nus, and to the medial intermuscular to the tibial tuberosity, but also, by a septum.29 Anteriorly, the vastus medialis slip of muscle to the medial patellar reti- attaches to the aponeurosis of the quad- naculum. The distal fibers of the vastus riceps femoris tendon together with the medialis are markedly angulated as they vastus intermedius muscle, and its fibers attach in the region of the patella (Fig. wrap around the femur angling down- 14.7) and can be clearly separated from ward from its posterior attachments (Fig. the rest of the vastus medialis by fiber 14.7). Thus, when the muscle is freed direction and by a fascial plane. These anteriorly and pulled aside, one sees a distal angulated fibers often attach prox- considerable area of bare bone between imally not to the femur, but chiefly to it and the vastus intermedius. This con- the adductor magnus, partly to the ad- trasts with the extensive lateral attach- ductor longus, and to the medial in- ment of the vastus intermedius to the termuscular septum. The latter obliquely anterior femur that underlies much of oriented fibers have been designated the the vastus lateralis.3,42 vastus medialis oblique.23, 70
256 Part 2 / Hip, Thigh, and Knee Pain Vastus Intermedius the knee by the small articularis genu muscle that lies deep to the distal end of the vastus in- (Fig. 14.8) termedius muscle.7 The smaller deep infrapatellar bursa lies between the patellar ligament and the The vastus intermedius is at least as large upper part of the tibia. The fourth bursa is the as the rectus femoris and lies deep to it small subcutaneous infrapatellar bursa.11,28 and also partly deep to the vastus lateralis (Figs. 14.7 and 14.8). Supplemental References It attaches proximally to the anterior All four heads of the quadriceps femoris muscle and lateral surfaces of the upper two- are illustrated from in front without associated thirds of the shaft of the femur; it attaches nerves or vessels,6,84 and with nerves.83 A similar distally to the patella a n d , through the picture that omits the vastus intermedius is ac- patellar ligament, to the tibial tuberos- companied by another that portrays accurately the ity.29 As noted previously, the vastus in- relation of the quadriceps femoris to the sartorius termedius is clearly separated on its me- muscle.96 All heads are presented from the anter- dial side from the vastus medialis, but lat- omedial view without associated nerves or ves- erally the vastus intermedius fibers merge sels,39 and with the vastus intermedius omitted.97 with those of the vastus lateralis, as seen in cross section (Fig. 14.8). The vastus medialis is shown from the front view with the limb rotated laterally, and in rela- Vastus Lateralis tion to the saphenous nerve and femoral vessels in the adductor canal.4 (Fig. 14.9) The vastus lateralis is portrayed from behind76 The vastus lateralis, the largest compo- and from the lateral side.41,44 The vastus medi- nent of the quadriceps femoris, is a much alis43,77 and the rectus femoris77 are seen from the bigger, heavier muscle than is generally medial side. appreciated. Seen from in front (Fig. 14.7), it is not impressive; however, when All four heads of the quadriceps femoris appear seen from the lateral side (Fig. 14.9), its in a cross section high in the thigh at the level of large extent becomes apparent. Its large the distal attachment of the gluteus maximus5 and size is also apparent in a cross section of in a series of cross sections every 2 cm throughout the thigh (Fig. 14.8); at a higher level it the length of the quadriceps femoris.27 The rela- surrounds nearly half the circumference tionships of the four heads are revealed in a series of the femur. of three cross sections.40, 86 Proximally, it is anchored to the lateral The skeletal attachments of both ends of the side of the posterior aspect of the upper quadriceps femoris muscle are marked on the three-fourths of the femur3 by an aponeu- bones.3,42,.75,85 rosis that covers the inner part of the muscle.29 The aponeurosis deep to the The articularis genu muscle is seen with its at- m u s c l e attaches distally to the lateral bor- tachments.7 der of the patella and via the patellar liga- ment crosses the knee. A few fibers of the The surface appearance of all heads except the muscle attach to the lateral patellar reti- vastus intermedius is revealed photographically naculum. as the quadriceps femoris is held in strong con- traction.38,72 Bursae The relations of the suprapatellar bursa, subcu- Four bursae are associated with the quadriceps taneous prepatellar bursa, and the deep infrapatel- muscle and the patella at the knee.28 The large lar bursa to the patella and associated tendons of subcutaneous prepatellar bursa, (shown elsewhere the quadriceps femoris are shown in sagittal sec- in cross section27 and in sagittal section28) sepa- tion.29 The suprapatellar bursa is seen from the rates the patella from its overlying skin. The lateral view29 and also appears in cross section at suprapatellar bursa (also shown in cross section27) a level through the quadriceps femoris tendon is actually an extension of the synovial cavity of proximal to the patella.40 the knee joint; it lies between the femur and the portion of the quadriceps femoris tendon just 3. INNERVATION above the patella. It extends deep to the aponeuro- ses of the vasti muscles, especially that of the vas- All four heads of the quadriceps femoris tus medialis, and is retracted during extension of and the articularis genu muscle are sup- plied by branches of the femoral nerve composed of fibers from the second, third, and fourth lumbar spinal nerves.29
Rectus Lesser Chapter 14 / Quadriceps Femoris Group 257 femoris trochanter (cut end) Figure 14.7. Attachments (front view) Greater of femur of the right vastus medialis (light red), trochanter vastus intermedius (dark red), and vas- of femur tus lateralis (light red) muscles of the quadriceps femoris group. The bulk of Hook the overlying rectus femoris muscle has been cut and removed. Part of the ante- Vastus rior attachment of the vastus medialis to lateralis the aponeurosis of the quadriceps ten- don along the medial edge of the vastus Vastus intermedius has been cut and pulled intermedius aside by the lower hook. This reveals the deeper fibers of the vastus medialis as Lateral they disappear to attach behind the fe- patellar mur and it exposes the bare bone deep retinaculum to the fibers anteriorly. The upper hook Patellar pulls the vastus lateralis aside to show ligament the underlying portion of the vastus in- termedius. Tibia Hook Vastus medialis Rectus femoris tendon (cut end) Patella Medial patellar retinaculum Tibial tuberosity The femoral nerve passes deep to the sors of the leg at the knee. The rectus fem- sartorius muscle and then travels in the ad- oris also either flexes the thigh at the hip ductor canal along the medial edge of the or flexes the pelvis on the thigh, depend- vastus medialis, which is supplied directly ing on which segment is fixed.12,29 The by branches from this nerve. The branches three vasti respond simultaneously to vig- to the remaining three heads of the quadri- orous effort. Participation of the rectus ceps femoris muscle pass between the rec- femoris also depends on demands at the tus femoris and the vastus intermedius to hip joint. The four heads trade off among their destinations (as illustrated).83 A fila- themselves in variable ways during slow ment from one of the femoral nerve's increase of knee extension to maximum branches to the vastus intermedius pene- effort. Balanced tension on the patella be- trates that muscle to supply the articularis tween the vastus medialis and vastus genu muscle and the knee joint.30 lateralis maintains normal positioning and tracking of the patella. 4. FUNCTION For upright activities with the foot When the leg and foot are free to move, fixed on a supporting surface, the quadri- the four heads of the quadriceps femoris ceps muscle group exerts its pull proxi- muscle act together as the prime exten- mally rather than distally. These muscles
258 Part 2 / Hip, Thigh, and Knee Pain Semitendinosus Sciatic nerve Semimembranosus Biceps femoris Adductor magnus Gracilis Perforating vessels Vastus lateralis Adductor longus Femur Sartorius Femoral vessels Vastus intermedius Vastus medialis Rectus femoris Deep femoral vessels Figure 14.8. Cross sectional anatomy of the right medium red. All other muscles including the adductor thigh at the level indicated in Figure 14.6 and also in group and hamstrings are light red. See also a cross Figure 14.13, looking down from above. The blood section at a higher level, Figure 16.5. vessels are dark red and the quadriceps muscles are frequently undergo lengthening contrac- dle of the downstroke during ergometer tions to control or decelerate movement cycling. caused by body weight. There is no consistent major difference The quadriceps femoris functions to in the proportion of fiber types among the control movements of bending backward, four heads of the quadriceps femoris. The squatting, sitting down from the standing numbers of slow-twitch (type 1) and fast- position, and descending stairs, but is not twitch (type 2) fibers are consistently active in quiet standing. During walking, nearly equal. it is active immediately after heel-strike to control knee flexion and at toe-off to Actions stabilize the knee in extension. It is not active during the period that the knee is In stimulation studies, as would be expected from extending during stance. Stance phase the attachments, the rectus femoris pulled the pa- quadriceps activity is either prolonged or tella in a purely proximal direction, the vastus increased (or both) under certain circum- medialis pulled it proximally and medially, and stances, such as when there is significant the vastus lateralis pulled it proximally and later- loss of function in the plantar flexors, ally.34 Only the isolated contraction of the vastus when heavy loads are carried on the back, lateralis could cause luxation of the patella (al- when walking speed is increased, and ways laterally).34 The balanced tension on the pa- when one wears high heels. The quadri- tella provided by the diagonal vectors of the vas- ceps femoris is not active in extension of tus medialis and the vastus lateralis is important the leg during the early swing phase, but to normal tracking of the patella (and normal it is active in the last part of swing, in quadriceps function).92 preparation for weight bearing. The quad- riceps femoris also serves an important The rectus femoris can assist in abduction of the function (shortening) during rising from thigh in supine subjects, but showed little activity sitting and in ascending stairs, and it during rotation of the leg at the knee.8,15,92 functions in many sports activities. A strong peak of activity appears in the mid- Electromyographically, the four heads can trade off among themselves in variable ways during a slow increase toward a maximal effort to extend the knee.16,32 When rising from the sitting to the
Chapter 14 / Quadriceps Femoris Group 259 Figure 14.9. Attachments (lateral view) of the right vastus lateralis muscle (dark red) in relation to the rectus femoris muscle (light red). Greater Rectus trochanter femoris of femur Vastus lateralis Lateral Rectus patellar femoris retinaculum tendon Patella Patellar ligament Tibia standing position and vice versa, there is no fixed primary function of these diagonal fibers is to sta- sequence of relative recruitment among the four bilize the patella and prevent its lateral disloca- heads of the quadriceps femoris muscle.16 tion. 23,59,94 Maximum effort to extend the knee isometri- Functions cally at eight positions between 0° and 90° pro- duced similar EMG activity among the four heads Standing and Positioning of the quadriceps femoris at each position. The vastus medialis oblique produced twice the action During balanced standing, the quadriceps femoris potential count of any other part of the quadriceps is almost completely inactive, whether a load is at all angles.71 placed in front of the thighs or strapped to the back.14 Orthopaedic texts have commonly attributed the last 15° of extension at the knee to the action Duarte et al.33 confirmed and extended an earlier of the distal diagonal fibers of the vastus medialis study by Basmajian and associates,18 which estab- (vastus medialis oblique) described previously lished when the various heads of the quadriceps under Anatomical Attachments. Several studies femoris muscle were active in common postures have presented convincing evidence that this is and during movements. Using fine-wire elec- not the case;70,71,81 investigators concluded that the trodes, they33 found that electromyographically the three vasti acted simultaneously, and that the
260 Part 2 / Hip, Thigh, and Knee Pain phase when walking in high heels, as compared to flat heels.57 most active were the vastus medialis and vastus intermedius. Late activation of the rectus femoris In gait studies on five normal adults before and occurred during hip flexion, bending backwards, after tibial nerve block, Sutherland and associates squatting, and sitting down. The vasti took the found that, after the nerve block, quadriceps activ- brunt of the load when arising from a squat posi- ity during stance was prolonged to compensate for tion. Rectus femoris EMG activity was more prom- loss of the normal contribution of the ankle plan- inent in high speed movement, whereas the vasti tar flexors to knee stability.107 were active in opposing fixed resistance. Lifting The quadriceps femoris works in close coordi- nation with the rectus abdominis when fast vol- When an individual lifts a load with the trunk untary trunk movements are performed during erect and the knees bent, a significant part of the standing.89 load usually carried by the paraspinal muscles is borne by the quadriceps femoris group of muscles. Walking With knees straight and hips flexed, the quadri- ceps group is inactive,47,82 but as the knees are In normal walking, activity of the quadriceps fem- flexed to assume the crouched position, the rectus oris group is biphasic.17,110 Electrical activity femoris in one study,47 and also the vastus medi- reaches a peak after heel-strike, but before foot alis and vastus lateralis in another,90 showed in- flat, to control the knee flexion that occurs in creased electrical activity with increased knee early stance.55 The second peak of activity appears flexion. When a load was then lifted from this at toe-off to stabilize the knee in extension. Sur- crouched position, the electrical activity of the prisingly, the quadriceps was found to be silent rectus femoris was more than doubled when the during the early phase of knee extension during load was held out in front, away from the body, as the swing phase. Thus, extension of the leg at the compared to the activity when the load was held knee probably occurs as the result of passive close to the body. swing.17 Sports and Jumping Yang and Winter121 found, in 11 healthy sub- jects, that the second peak of electrical activity During right-handed throwing and hitting in was most prominent at higher walking speeds and sports, the greatest electrical activity among the much more marked in the rectus femoris than in rectus femoris, vastus medialis, and vastus later- the vastus lateralis. Another study79 reported a alis muscles consistently appeared in the left rec- sudden increase in the rate of electrical activity tus femoris. The vigorous jumping effort of a one- with increasing walking speed at speeds between foot jump volleyball spike and of a basketball 0.9 and 1.2 m/sec (3 and 4 ft/sec). EMG activity of layup strongly activated all of these three heads the vastus lateralis was increasingly prolonged in bilaterally.25 Vigorous activity of the rectus fem- the stance phase with increasingly heavy loads, oris was observed during the take-off and landing up to 50% of body weight, carried on the back.46 phases in a detailed study of jumping.58 During stair climbing, rectus femoris EMG ac- The quadriceps femoris provides an important tivity appeared at the beginning of stance phase braking action (serving as a checkrein on knee until the second period of double support, when flexion) on landing after jumping. It provides a the contralateral foot is placed on the step above. similar shock-absorbing effect during running. During descent of stairs, the rectus femoris was Such vigorous lengthening contractions can cause usually active through most of the stance phase, postexercise muscular soreness (see Appendix). but most vigorously at the beginning and end of stance.110 Ergometer Cycling Among 19 subjects, 12 of whom were trained During cycling, the vastus medialis and vastus athletes, some remarkable intersubject variability lateralis were active throughout the downstroke of was observed in the timing of EMG activity among the bicycle pedal, reaching a peak of nearly 50% the rectus femoris, medial hamstrings, tibialis an- of maximum voluntary EMG activity shortly terior, and gastrocnemius muscles during level before the middle of the downstroke. The rectus walking and during ascending and descending femoris reached a lower peak of 12% of maximum stairs. The contraction pattern of the rectus fem- voluntary EMG activity shortly after the beginning oris was clearly the most constant among these of the downstroke and started to increase activity muscles.110 gradually halfway through the upstroke.37 The re- duced activity of the rectus femoris during down- Six young women showed a marked increase in stroke reflects the fact that this hip flexor and quadriceps femoris EMG activity during stance knee extensor is inhibited from contributing to
Chapter 14 / Quadriceps Femoris Group 261 knee extension when the thigh is being extended of slow-twitch (type 1) fibers in the vastus later- at the hip. During standardized ergometer cycling, alis varied from 25 to 90%.50 In most studies, the the knee extensors performed 39% of the positive percent of slow-twitch fibers in the vastus later- mechanical work, and the hip flexors only 4%.36 alis has been near 50%.35,45,49-51,54,68,69 88 One study68 reported the distribution of fiber types throughout Vecchiet and associates116 injected hypertonic the entire vastus lateralis muscle in six previously saline solution to test the vastus lateralis for sensi- healthy men who suffered sudden accidental tivity to the production of referred pain following death. Each sample represented the distribution 30 minutes of cycling at 70% of maximum capac- in 1 sq mm of tissue. The proportion of type 1 fi- ity. Injection of 10% saline solution into the mus- bers increased primarily as the samples were cle was significantly more painful immediately af- taken from greater depth (for example, 40—60% ter and 60 minutes following the exercise than it depth in one muscle). It was not unusual for indi- was prior to the exercise. vidual values within one muscle to range from 33 to 65% type 1 fibers. This study warns us that Interactions studies that did not control for depth of the sam- ples must be interpreted with caution. The effect of contraction of the two-joint rectus femoris is never limited to only one joint. The ac- With increasing age, quadriceps femoris tion of this muscle in motion at the knee alone is strength decreased in both males and females be- closely coordinated with that of the vasti muscles; tween the ages of 20 and 70 years. This could be in biarticular motions it has complex relation- accounted for partly by a loss of motor units ships. As would be expected, a movement that si- through loss of innervation.106 A study of just the multaneously shortens the muscle at both joints, vastus lateralis99 in 45 healthy, sedentary men and such as kicking a football, strongly activates it. women 65-89 years of age also presented evi- Conversely, a movement that elongates the muscle dence of partial denervation, decrease in percent- simultaneously across both joints inhibits its con- age of and atrophy of type 2 fibers, streaming of Z traction. Moreover, elongating the muscle at one lines with rod formation, dilatation of sarcoplas- joint inhibits its activity for shortening at the mic reticulum, and increase in intracellular lipid other. The rectus femoris is inactive when hip droplets. The Z line changes are similar to those flexion is accompanied by knee flexion, even described in the repair stage following postex- though it is active in hip flexion alone. Similarly, ercise stiffness (see Appendix), and the increase the muscle is electrically inactive when hip exten- in intracellular lipid droplets suggests impaired sion accompanies knee extension, whereas it is aerobic energy metabolism. active in knee extension alone.12 Painless infusion of as little as 10 mL of sterile The vastus lateralis component of the quadri- isotonic saline into normal knee joints caused ceps femoris was monitored in a study of postural some reduction of maximum strength of the quad- adjustments to a fast trunk flexion movement dur- riceps. Larger quantities strongly inhibited the ing standing.89 When the subject activated the tibi- quadriceps, reducing its contraction by more than alis anterior to help provide forward momentum, 50%.122 Aspiration of chronic knee effusion did the resultant knee flexion was controlled by a not immediately reduce inhibition of the quadri- lengthening contraction of the vastus lateralis. ceps.56 Inhibition of quadriceps strength is related more closely to effusion in the knee joint than to When the foot excessively pronates (due to a the painfulness of contraction.56, 122 Selective Morton foot structure, a hypermobile midfoot, an- weakness and wasting of the quadriceps femoris kle equinus, muscular imbalance, or some other develop following meniscal and ligamentous inju- cause), the leg and thigh deviate inward, the Q an- ries of the knee.122 Fourteen meniscectomy pa- gle increases, and the vastus medialis muscle can tients at 34 days postoperatively still experienced become overloaded. The muscle may serve a role severe inhibition of contraction of the quadriceps in controlling the knee angulation, protecting the muscle, but had little or no pain. Inhibition was medial ligaments of the knee in the process. greater when the knee was extended than when it was flexed.100 Quadriceps function can be inhib- Fiber Types and Performance ited by non-painful sensory input, such as pres- sure from the knee joint.13 In a therapy program, No consistent major difference in the proportion this inhibition of concentric contraction may be of fiber types was observed among the four heads largely overcome by first facilitating eccentric of the quadriceps femoris. contractions.2 The vastus lateralis has been the most popular of the four heads for biopsy. Individual studies found considerable variation in fiber type distri- bution both within and between subjects. In one study of elite female track athletes, the proportion
262 Part 2 / Hip, Thigh, and Knee Pain Surgical excision of one, two, or three heads of of the vastus lateralis. A third exception, the quadriceps femoris reduced isometric strength the buckling hip syndrome, may occa- 22%, 33%, and 55%, respectively, and reduced sionally be seen when TrPs are present isokinetic strength somewhat more. Usually only both at their usual location in the rectus slight impairment of function was observed with femoris (just below the anterior inferior less than 50% loss of strength.74 Another study81 iliac spine) and high in the vastus in- reported the effects of excision of all of the vastus termedius. Hip buckling occurs when the lateralis and 75% of the vastus intermedius; ex- weight-bearing patient extends the knee tensor torque was reduced 60% on the operated and the hip simultaneously. side. Although this patient had a normal vastus medialis, he still had an extensor lag. Patients who complain of weakness of knee extension often have rectus femoris, A study of low-level static contraction of the vastus medialis, and/or vastus interme- quadriceps femoris required holding one leg in dius TrPs, active or latent. The vastus in- extension at 5% of maximum voluntary contrac- termedius is likely to cause more trouble tion for 1 hour. Results demonstrated that the going up stairs, and the rectus femoris, muscle was able to maintain homeostasis with re- going down stairs. spect to energy turnover, but not with respect to intra/extracellular potassium concentration.105 Rectus Femoris Sustained contraction, even at this low level, dis- turbs muscle function. When patients are awakened at night by pain in front of the knee cap and just Assuming that during compression blood flow above it on the anterior thigh, TrPs in the in the muscle stops when intramuscular pressure rectus femoris muscle should be sus- exceeds systolic pressure, onset of ischemia pected. This is especially true if, on awak- would occur during brief static contractions at ening in a side-lying position, the knee is 50% of maximum voluntary contraction for the extended and the hip is flexed, an unu- rectus femoris.98 This clearly becomes an increas- sual position that fully shortens the rec- ingly limiting factor to sustained contraction at tus femoris. Patients rarely discover for about this level of effort. themselves the combined position of hip extension and knee flexion that is re- 5. FUNCTIONAL (MYOTATIC) UNIT quired to stretch the rectus femoris fully in order to obtain relief. Together, the four heads of the quadri- ceps femoris group compose the prime Patients who have knee pain and a extensor of the knee. The three vasti nor- sense of weakness when going down mally work closely together. E M G activity stairs should be checked for rectus fem- of the rectus femoris may vary from that oris TrPs. of the other three heads because of its ad- ditional action as a hip flexor. The pri- Vastus Medialis mary antagonists to extension at the knee are the three hamstring muscles, which Distal TrPs in the vastus medialis initially are assisted by the gastrocnemius, pop- produce a toothache-like pain deep in the liteus, gracilis, and sartorius muscles.92 knee joint, which often interrupts the pa- tient's sleep. It may be misinterpreted as For hip flexion, the rectus femoris acts being due to inflammation of the knee with the iliopsoas, pectineus, tensor fas- joint.95 The myofascial pain usually fades ciae latae, and adductors—depending on in a few weeks or months and is replaced the degree of hip flexion. The primary an- by episodic inhibition of quadriceps fem- tagonists to hip flexion are the gluteus oris function that causes unexpected maximus, three hamstring muscles, and buckling (weakness) of the knee during the adductor magnus.92 walking.9,111 Buckling usually occurs dur- ing walking on rough ground when sud- 6. SYMPTOMS den medial rotation of the knee places an unexpected load on the vastus medialis Referred pain is commonly the presenting as the muscle lengthens during knee flex- symptom with two main exceptions, the ion. This buckling response may cause buckling knee syndrome of the vastus the individual to fall. medialis and the locked patella syndrome
Chapter 14 / Quadriceps Femoris Group 263 Baker9 cites the case of an incapacitated 12- slight flexion. The patient cannot walk, year-old athlete with the buckling knee syndrome can hardly crawl, and is uncomfortable in who was completely relieved by inactivation of a wheelchair if the chair has no elevating the vastus medialis TrP. leg rests and the knee must be bent close to 90°. With surface electrodes over the vastus medialis of a patient with active TrPs in Troedsson115 found each of 35 patients the muscle and disabling knee pain, the with trick knees to have a tender indu- senior author observed reduced E M G ac- rated area along the lower medial border tivity when the seated patient lifted the of the vastus lateralis muscle in the symp- foot and unsuccessfully attempted full tomatic limb. Twenty-four of the 25 pa- knee extension. Following inactivation of tients who were treated with physical the TrPs in the vastus medialis by local therapy directed to the vastus lateralis procaine injection, the muscle at once were relieved of the knee instability. (Our showed a marked increase in the surface experience has been that the lower me- EMG activity when the patient again ex- dial border of the vastus medialis is a more erted a maximum effort to extend the probable location of TrPs responsible for knee. The full range of knee extension re- a buckling knee.) turned; the weakness had disappeared. Differential Diagnosis Vastus Intermedius Unexplained thigh and knee pain in chil- Patients with TrPs in the vastus in- dren, even in infants, is more frequently termedius have difficulty fully straighten- due to quadriceps femoris TrPs than is ing the knee, especially after it has been generally realized.19,20 These youngsters immobile for some time during sitting. with thigh and knee pain should be exam- They cannot step up onto the next stair ined for TrPs. step and then straighten the knee, or walk without a limp after arising from a chair. Knee pain in patients with disease of Their pain occurs during knee movement, the hip joint, or who have had a surgical rarely at rest. Driving a car is usually not a procedure on the hip joint, is often as- problem, since no vigorous extension at sumed to originate in the hip; however, it the knee is required. can also arise from quadriceps femoris TrPs. (Posterior knee pain may also be The buckling knee syndrome also can due to TrPs in the hamstring muscles.) result from the combination of vastus in- termedius TrPs and TrPs in the two heads The lateral thigh pain characteristic of of the gastrocnemius muscle near their proximal vastus lateralis TrPs is com- femoral attachments. monly misdiagnosed as trochanteric bur- sitis because of referred pain and referred Vastus Lateralis tenderness in the area of the greater tro- chanter. A similar pain pattern may also When the patient complains that it hurts be caused by TrPs in the anterior part of to walk, and the pain distribution is along the gluteus minimus muscle or by TrPs in the lateral aspect of the thigh including the tensor fasciae latae muscle. Similarly, the knee, TrPs in the vastus lateralis mus- anterior knee and thigh pain characteris- cle may be responsible. Patients with tic of TrPs in the rectus femoris may actu- TrPs in the vastus lateralis also complain ally be referred from adductor longus that it hurts to lie on the involved side and/or brevis TrPs, and medial thigh pain and that the pain disturbs their sleep. suggestive of vastus medialis TrPs may arise from TrPs in the gracilis muscle. Myofascial TrPs in the distal end of the vastus lateralis (and sometimes in the Phantom limb pain may be induced by vastus intermedius also) can immobilize residual quadriceps femoris TrPs remain- the patella. Partial loss of normal patellar ing in the stump of an above-knee ampu- movement causes difficulty in straighten- tee. Also, when a flap of quadriceps mus- ing or bending the knee after getting up cle that contains TrPs is used to cover the from a chair. A completely locked patella end of the bone, the patient may have dif- immobilizes the knee joint, usually in ficulty ambulating on it until its TrPs are inactivated.
264 Part 2 / Hip, Thigh, and Knee Pain A so-called trick knee (one that sud- measured as the Q angle, the angle be- denly buckles and gives way without tween a line passing through the center of warning) may be caused by anterior sub- the patella to the anterior superior iliac luxation of the lateral tibial plateau, spine and a line through the center of the which usually requires surgical correc- patella to the tibial tubercle. The angle tion.73 Probably, a more common source should not exceed 14° in males and 17° in of this symptom is the presence of TrPs in females.108 Valgus deformity of the knee the vastus medialis. and underdevelopment of the distal vas- tus medialis are commonly associated Knee Pain with lateral patellar subluxation.84,91 In- creased tension and shortening of the vas- Pain in the region of the knee can arise tus lateralis caused by TrPs aggravate this from articular dysfunction including liga- condition. mentous strain and tears, from a torn me- niscus, from tendinitis, bursitis, myofas- Medial subluxation of the patella is cial problems, or compromise of nerves. rare, but when it is diagnosed, it may be a Radin91 lists 16 non-myofascial causes of complication of a lateral retinacular re- anterior knee pain. When considering lease operation that severs the vastus knee pain from the point of view of the lateralis tendon. Over half of the patients quadriceps femoris, the patella is of spe- with this subluxation problem are re- cial importance. ported to have had immediate relief of the knee pain for which the procedure was Chondromalacia patellae usually fol- done. However, the subsequent medial lows dislocation of the patella with chon- patellar subluxation from release of the dral or osteochondral fracture, or direct vastus lateralis tendon often becomes dis- trauma to the patella. It is a common abling.53 cause of knee pain in runners.64 Findings in chondromalacia that help distinguish Pain in the medial side of the knee and it from myofascial knee pain include: proximal calf may be caused by saphe- subpatellar tenderness, which is elicited nous nerve entrapment.120 by displacing the patella medially or lat- erally and palpating the underside of its Lateral knee pain may be caused by en- edges; tenderness to compression of the trapment of the lateral femoral cutaneous patella against the femur; effusion within nerve.21 Lateral knee pain may also re- the knee joint; quadriceps femoris muscle sult from an iliotibial tract friction syn- atrophy; and crepitus or grating during drome,24 as described in Chapter 12. active extension of the knee.31 Quadriceps tendinitis is characterized Patellofemoral dysfunction is defined by pain at the upper pole of the patella, as anterior knee pain coming from the more common laterally than medially.64 patellofemoral articulation without any There is a relatively high probability that gross abnormality of the articular carti- this symptom is actually caused by vastus lage of the patella. The pain is attributed lateralis TrPs. to abnormal tracking of, or pressure on, the patella.108 Abnormal size or placement Tendinitis of the patellar ligament, of the patella may be the cause of knee \"jumper's knee,\" is particularly common dysfunction and pain.119 in basketball players, high jumpers, and hurdlers.22,64 The pain and the tenderness Normal functioning of the patellofem- at the attachment of the patellar ligament oral joint depends largely on the dynamic to the lower pole of the patella are not balance between the medial and lateral likely to be myofascial in origin, unless a forces exerted by the vastus medialis and major portion of the quadriceps muscle vastus lateralis muscles. Lateral subluxa- group harbors TrPs. tion is more common than medial dis- placement of the patella, since the line of Taylor109 reported two cases of deep infrapatel- pull of the quadriceps musculature is lat- eral to the alignment of the patellar liga- lar bursitis, one caused by Staphylococcus aureus ment that connects the patella to the tibial tubercle. This deviation is commonly infection, and the other caused by deposition of uric acid crystals of gout. Brucini and co-workers26 examined the EMG ac- tivity of the vastus medialis in 18 patients with osteoarthritis of the knee and in eight healthy con-
Chapter 14 / Quadriceps Femoris Group 265 trols. The controls showed no EMG activity at the result of tightness caused by TrPs in the antagonistic hamstring muscles. The rest, supine, or as a rule during quiet standing on quadriceps cannot recover until the ham- string tightness is released. The patient, only one leg or on both legs. In 14 of the 18 pa- however, complains of pain referred from the quadriceps femoris TrPs, not from the tients, low-level involuntary EMG activity ap- hamstring TrPs, which are the perpetuat- ing factor. Quadriceps femoris TrPs are peared at rest in the supine position with the knee also perpetuated by overload resulting from active TrPs in the soleus muscle. straight, but was eliminated in every case by some Soleus TrPs restrict ankle dorsiflexion, and this can overload the quadriceps es- form of active or passive lower limb movement. pecially when lifting \"correctly\" with the knees bent and torso erect. Also, the vastus medialis muscle showed electri- Placing any muscle in a fixed position cal activity in proportion to the amount of weight for long periods tends to aggravate its TrPs. Immobilization is often an integral placed on the painful knee. Before treatment, a part of therapy for orthopaedic problems of the lower limb. Patients should be voluntary contraction of the quadriceps femoris checked for TrPs before and after immobi- lization, especially if they are experienc- group of muscles, which was sustained for a few ing unexpected pain afterward. seconds, resulted in EMG activity that persisted Some people habitually sit for long pe- riods with one foot tucked under the but- for 2-30 seconds after the patient tried to relax. tock (often subconsciously to correct a small hemipelvis). This habit can be the Following injection of tender areas [that had TrP critical perpetuating factor that prevents recovery from the pain of quadriceps characteristics] in the periarticular muscles, EMG TrPs. activity ceased immediately on termination of vol- Rectus Femoris untary contraction. Myofascial TrPs are activated in the rec- tus femoris muscle, as in other muscles of 7. ACTIVATION AND PERPETUATION the quadriceps femoris group, by a fall or OF TRIGGER POINTS accident that produces a suddenly over- loaded lengthening contraction, such as a Many patients with diabetes are taught to high velocity skiing accident. inject insulin into the lateral aspect or midline of the thigh, and several patients Sitting for a long time with a heavy have developed TrPs in the rectus femoris weight on the lap (e.g., holding a heavy or vastus lateralis muscle where they in- child on the lap during a long car trip) jected themselves. Injection of insulin or can activate TrPs in this muscle. TrPs in other drugs112 in the region of a latent TrP the rectus femoris tend to persist because can activate it. Quadriceps myofibrosis the muscle does not ordinarily undergo can result from repeated intramuscular full stretch in the course of daily activi- injections.1 ties. Full stretch requires, simultane- ously, complete flexion at the knee and The quadriceps group is susceptible to nearly complete extension at the hip. activation of TrPs by an acute overload from a sudden vigorous eccentric (length- The rectus femoris may develop an ac- ening) contraction. Such a vigorous con- tive TrP during recovery from hip fracture traction can result from a misstep into a and hip surgery. hole, stepping off the curb, or from stum- bling. Direct trauma by impact against the Lange63 associated degenerative joint femur can activate TrPs in any head of the disease of the hip with myogelosis [TrPs] quadriceps, but least likely in the vastus in the rectus femoris and vastus lateralis intermedius. muscles. We see rectus femoris TrPs de- velop as the result of overload caused by Acute or chronic overload can occur in an exercise program that includes deep knee bends. This exercise perpetuates quadriceps femoris TrPs, especially those in the vastus intermedius. Another exer- cise that is likely to perpetuate TrPs in the quadriceps is an attempt to strengthen the muscle harboring active TrPs by ex- tending the knee in a concentric contrac- tion with a weight placed near the ankle. A slow eccentric contraction is tolerated much better. Quadriceps femoris TrPs are commonly perpetuated by sustained overload that is
266 Part 2 / Hip, Thigh, and Knee Pain abnormal hip joint mechanics, and then protecting TrPs in the other quadriceps vastus lateralis TrPs develop because that femoris muscles, which are members of muscle attempts to compensate for the the same functional unit. compromised rectus femoris. Vastus Lateralis Vastus Medialis Vastus lateralis TrPs are activated by sud- Excessive pronation of the foot from vari- den overload of the muscle, particularly ous causes (a hypermobile midfoot, ankle during lengthening contractions, e.g., in equinus, muscular imbalance) can perpet- skiing accidents. In addition, because of uate TrPs in the vastus medialis. This the muscle's size and exposed location, member of the quadriceps femoris group TrPs may be activated in the vastus later- often develops TrPs also because of the alis by direct trauma, e.g., as the result of Morton foot structure (relatively long sec- a fall sideways against the edge of a step ond, short first metatarsal). This structure, or a piece of furniture, during lurching if uncorrected, results in excessive medio- movements in sports, or from a bullet lateral \"rocking\" of the foot. See Chapter wound in the thigh. 20, Peroneal Muscles, for the diagnosis and management of this condition. With chro- Vastus lateralis TrPs are perpetuated nicity, these vastus medialis TrPs are likely when the muscle is immobilized in a to cause a buckling knee. The question of- shortened position for a long period, as ten arises as to why the patient has vastus when sitting with the knee fully ex- medialis TrPs in only one limb when both tended. feet have relatively short first and long sec- ond metatarsals. Further examination often 8. PATIENT EXAMINATION reveals that the limb on the side of the in- (Figs. 14.10-14.12) volved knee is shorter, and it is the shorter limb that sustains greater impact and push- The patient's gait is analyzed first. A pa- off forces during ambulation. tient with a \"stuck patella\" from a vastus lateralis TrP will walk stiff-legged with- Lange62 associated the development of out bending one knee normally, and so myogelosis in the vastus medialis with tends to drag that foot. The inability both flat feet, which is accompanied by prona- to extend fully and flex the knee freely re- tion of the foot. sults in a limp. The patient cannot rise from a chair while keeping the back In addition, this muscle is likely to de- straight, and must pitch the torso forward velop TrPs as the result of strenuous ath- to lighten the load on the thigh muscles. letic activity, such as jogging, skiing, foot- The limp can be improved and hip buck- ball, basketball, and soccer. Vastus medi- ling can be avoided if the patient walks alis TrPs are also activated by falls and on tiptoe on the disabled side, avoiding direct trauma to the knee joint and/or the the need to extend the knee fully; how- muscle (such as dashboard trauma from a ever, this compensation leads to other motor vehicle accident when a seat belt is problems. not worn.) Activation of TrPs in it is a common sports injury and the TrPs are While walking, if the patient toes out generally quite responsive to specific TrP treatment, provided that perpetuating fac- and complains of medial thigh pain or tors are corrected. perhaps of a buckling knee, vastus medi- Vastus medialis TrPs may be perpetu- ated by prolonged kneeling on a hard sur- alis TrPs associated with a Morton foot face, e.g., kneeling on the ground while gardening or beside the bathtub while structure should be suspected (see Fig. bathing a baby. 8.3 for an illustration of this stance). Pa- Vastus Intermedius tients with vastus medialis TrPs evidence This muscle is rarely the first quadriceps muscle to develop TrPs; it develops them minimal restriction of knee flexion. secondarily as a result of overload from TrPs in the vastus intermedius muscle may be responsible, if, while walking, the patient has difficulty bending the knee to lift the foot off the ground and instead hikes the hip (pelvis) on that side to clear the foot from the floor, and if he or she has trouble climbing stairs. |
Chapter 14 / Quadriceps Femoris Group 267 While palpating the quadriceps femoris neously extend the hip and flex the knee. for taut bands and TrPs, one may encoun- As illustrated in Figure 14.11, motion at ter a fibrotic mass produced by an earlier one joint increases at the expense of the tear of the muscle. Surgical extirpation of other joint when the muscle is tight. At the fibrotic tissue resulted in good return the full range of motion, the heel should of quadriceps femoris function in all of touch the buttock with the hip near full three such cases.93 extension. Restriction of this normal range by latent TrPs in the rectus femoris Examination of the Patella occurs commonly. A tight iliopsoas mus- cle restricts extension at the hip, but does For the examination of the patella, the not affect flexion at the knee. knee should be straight and the quadri- ceps femoris must be completely relaxed. It is informative to test the knee jerk re- Quadriceps tension can restrict passive sponse, which can be inhibited by TrPs in movement of the patella. Before examin- the rectus femoris muscle. In this case, ing for patellar mobility, the clinician the tendon reflex returns after inactiva- should observe and palpate the patella for tion of these TrPs. subluxation at rest, which nearly always occurs in the lateral direction.78 It is im- Three Vasti portant to test patellar mobility (Fig. 14.10) whenever quadriceps femoris TrPs In the mobility test for the three vasti are suspected. TrP tension in the vastus muscles (Fig. 14.12), the operator exam- medialis restricts normal lateral mobility ines the supine patient for range of knee of the patella (Fig. 14.10E) but does not flexion with the thigh flexed at the hip. cause a locked patella. TrPs in the vastus intermedius signifi- cantly restrict flexion at the knee. The With a \"stuck patella\" caused by a TrP heel does not reach the buttock by several fingerbreadths. However, TrPs in the vas- in the distal vastus lateralis, the patella tus lateralis cause this restriction only if the patella is displaced or locked. TrPs in loses all passive movement, including its the vastus medialis cause, at most, only minor restriction of knee flexion. Large normal downward range of motion (Fig. calf muscles or fat calves rarely restrict full knee flexion. 14.10C) of at least 1 cm (about /1 in) that 2 While conducting the test for range of motion, one should also test for weakness occurs during knee flexion. A patient by comparing the involved and unin- volved sides. Myofascial TrPs induce an with a \"stuck patella\" is unable to extend inconsistent, ratchety weakness without atrophy (except perhaps for a small the knee fully and may be unable to flex it amount that may be caused by disuse).87 Marked quadriceps femoris atrophy is more than about 5°. Attempts to move the usually associated with disease of the knee joint.122 The size of the quadriceps patella passively may produce grating femoris muscle in children is measurable directly by ultrasound imaging.52 sounds, which may indicate abnormal 9. TRIGGER POINT EXAMINATION pressure against the femur or damaged (Figs. 14.13-14.17) chondral surfaces. Less severe vastus As seen in Figure 14.13, the front of the thigh is covered mainly by the quadri- lateralis tension from TrPs restricts only ceps femoris muscles, except its proxi- mal medial region that is occupied by medial mobility of the patella (Fig. the hip adductors. These two groups of muscles are separated superficially by 14.10D). the sartorius muscle, which has been cut and reflected in this figure. The Increased tension due to vastus in- termedius TrPs restricts rotation of the patella in either direction (Fig. 14.10F and G). In addition, tension from the vas- tus lateralis restricts normal medial rota- tion (with reference to the upper pole) of the patella (Fig. 14.10F). Tension from the vastus medialis restricts corresponding lateral rotation of the patella in the frontal plane around the center of the patella (Fig. 14.10G). Rectus Femoris To test the stretch range of motion of the rectus femoris, the operator must simulta-
268 Part 2 / Hip, Thigh, and Knee Pain Figure 14.10. Examination of left patellar mobility, medial displacement. E, lateral displacement. F, me- normal subject. A, resting position of the patella. B, dial rotation (with reference to the upper pole of the upward displacement. C, downward displacement. D, patella). G, lateral rotation. groove between the sartorius and the der of the quadriceps femoris through- adductor longus, the adductor canal, is out most of its length. The vastus later- generally readily identifiable by deep alis covers nearly all of the lateral palpation. It delineates the medial bor- thigh, as seen in Figure 14.9.
Chapter 14 / Quadriceps Femoris Group 269 Figure 14.11. Effects of a tight right rectus femoris the patient's knee (fully rendered limb). The outlined muscle. The open circle identifies the anterior superior limb portrays an equally taut rectus femoris muscle iliac spine. The X locates the usual location of trigger but with increased knee flexion (thin arrow, dotted points in this muscle, which crosses both the hip and line) as compared to that in the fully rendered limb. knee joints. The hand of the operator presses the leg This increased knee flexion is achieved at the ex- upward in the direction of the thick arrow to determine pense of extension at the hip. For a clinical test of the available flexion at the knee throughout an increasing stretch range of this muscle, the opposite thigh should range of hip extension. In this illustration, the tight right be maintained in flexion to stabilize the pelvis and lum- rectus femoris produces a pull on the pelvis that bar spine (see Fig. 14.18). arches the back when the examiner attempts to flex Rectus Femoris cles, only the rectus femoris extends the (Fig. 14.14) leg at the knee. The sartorius arises from the anterior superior iliac spine, above In most individuals, a cleft is palpable be- the attachment of the rectus femoris (Fig. tween the vastus medialis and the medial 14.13) and covers its uppermost end. Lo- border of the rectus femoris (and the un- cal twitch responses can often be elicited derlying vastus intermedius). The lateral from these proximal rectus femoris TrPs border of the rectus femoris is usually as well as from sartorius TrPs. palpable along the length of the anterolat- eral thigh, but there is no palpable dis- Rarely, one encounters a TrP in the dis- tinction between the vastus intermedius tal part of the rectus femoris muscle about and the vastus lateralis. 10 cm (4 in) above the upper border of the patella. The TrP lies at the lateral border The TrPs of the rectus femoris are com- of the rectus femoris and is relatively su- monly located high (proximally) in the perficial. It is not found in isolation, but muscle close to the anterior inferior iliac only in conjunction with deeper TrPs spine and are found by flat palpation (Fig. clearly located in the vastus lateralis. 14.14). Lange61 illustrated this examina- tion using the fingertips. Vastus Medialis (Fig. 14.15) The rectus femoris can be distinguished from the sartorius muscle by having the For examination of the vastus medialis, patient perform isometric knee extension the patient should lie supine with the (without hip flexion). Of these two mus- thigh on the symptomatic side placed in
270 Part 2 / Hip, Thigh, and Knee Pain Figure 14.12. Heel-to-buttock test for flexibility of the knee feels more secure to the patient and vastus medialis, vastus intermedius, and vastus later- does not tend to buckle. alis muscles of the right quadriceps femoris group. The patient should place the hand between the heel The more proximal TrP2 (area being and buttock to become aware of the degree of restric- palpated in Fig. 14.15A) is likely to tion. The fully rendered position depicts a moderately evoke only referred pain and not buck- restricted range of knee flexion, which often is due to ling. It is found at about midthigh near trigger points in the vastus intermedius. Lesser de- the medial border of the vastus medialis grees of limitation are more likely to be caused by trig- next to the adductor muscles (see Fig. ger points in the other two vasti. The operator's test 14.13). Occasionally, the taut band can pressure is applied gently against the leg just above be palpated close to the linea aspera the ankle. The outlined leg showing full knee flexion where the adductor magnus also at- (heel against buttock) confirms full normal length for taches. The clinician presses straight to- all three vasti. Flexion of the thigh at the hip avoids ward the femur to locate TrP spot ten- stretching of the rectus femoris muscle. A dry heating derness and to evoke its pattern of re- pad is placed on the abdomen to maintain body ferred pain. This proximal TrP2 is rarely warmth. present in the absence of vastus medi- alis TrPi. Local twitch responses are of- moderate abduction and the knee sup- ten apparent. ported at about 9 0 ° of flexion (Fig. 14.15). A pad or pillow under the knee Vastus Intermedius improves the patient's comfort. Flat pal- (Fig. 14.16) pation is used and most of the TrPs are usually found close to the medial bor- The reason for the \"frustrator\" nick- der of the muscle (Fig. 14.2). The distal name of the vastus intermedius is the TrP1 (Fig. 14.15B) is the most trouble- inability to palpate directly the multi- some and the one most likely to cause a ple TrPs that can develop along its buckling knee. A cluster of TrPs also length deep to the rectus femoris. may be located along the medial border Rarely is it possible to feel the taut of the muscle about where the transi- bands of TrPs in this deep muscle mass. tion to oblique fibers would be ex- The entire muscle feels tense. When it pected. The adductor muscles are com- is possible to palpate its TrPs, they are monly involved when these distal TrPs found by first locating the upper lateral in the vastus medialis muscle are ac- border of the rectus femoris and follow- tive. ing it a short distance distally until the fingers feel a space that permits palpa- If the patient with vastus medialis TrPs tion very deep, close to the femur. Only has a buckling knee syndrome, a roll of here (Fig. 14.16) is digital pressure skin over the TrP should be grasped and likely to elicit the referred pain pattern held firmly while the patient takes a few of strongly active vastus intermedius steps; during this compression test, the TrPs. The TrPs of the vastus inter- medius are found distal to the usual lo- cation of those in the rectus femoris (compare Fig. 14.1 with Fig. 14.3). Usually, digital pressure on the muscle does not reproduce the TrP referred pain pattern, whereas needle penetration of the TrP does reproduce it. Therefore, the role of these TrPs is easily underesti- mated. Because of the overlying fascia and muscle, what appear to be TrPs of only slight or moderate tenderness on palpation often prove explosively painful when penetrated by a needle. When both the rectus femoris and vas- tus intermedius contain TrPs, inactivat- ing those in the rectus femoris makes it
Chapter 14 / Quadriceps Femoris Group 271 Sartorius Pectineus Figure 14.13. Regional anatomy (front (cut and view) of the right quadriceps femoris reflected) muscle (dark red); the vastus in- Anterior termedius is not visible. The overlying inferior sartorius muscle (light red) has been cut iliac spine and reflected to more clearly reveal the Greater relationship of the quadriceps to the ad- trochanter ductor group, and to the pectineus and of femur gracilis muscles (also light red). Vastus Pubis lateralis Adductor Rectus brevis femoris Adductor Patellar longus ligament Level of cross section Adductor magnus Gracilis Vastus medialis Sartorius (cut and reflected) Patella Tibial tuberosity Tibia easier to locate those in the vastus in- rectly against the underlying bone (Fig. termedius. The vastus intermedius is 14.17). As one can see in this figure, and more likely than the rectus femoris to har- in that showing the referred pain patterns bor TrPs located in the distal part of the of the vastus lateralis (Fig. 14.4), TrPs muscle. may occur throughout most of the length of this muscle. This extensive distribu- Vastus Lateralis tion presents both diagnostic and thera- (Fig. 14.17) peutic difficulties. Deep in the anterolat- eral part of the midthigh, where the mus- The vastus lateralis sometimes develops a cle is thickest and its fibers fuse with myofascial syndrome alone without in- those of the vastus intermedius (Fig. volvement of other parts of the quadri- 14.8), the TrP spot tenderness cannot be ceps femoris. This lateral thigh muscle, clearly localized by palpation from the like the vastus intermedius, usually has surface; rather, one detects a more diffuse multiple TrPs and many of them lie deep tenderness. It is a challenging area be- in the muscle. The taut bands of these cause specific TrP spot tenderness is so TrPs can be located only with difficulty, hard to localize for injection. if at all, and only by flat palpation di-
272 Part 2 / Hip, Thigh, and Knee Pain Figure 14.14. Palpation for tenderness of trigger attachment of the rectus femoris onto the anterior in- points in the right rectus femoris muscle using thumb ferior iliac spine of the pelvis. The solid line locates pressure. The open circle marks the readily palpable the crest of the ilium. Note how high proximally in the anterior superior iliac spine, which is just above the muscle this trigger point area is located. The most distal TrP responsible for a Rectus Femoris locked patella often is found only by hav- ing the patient lie relaxed with the knee Muscles likely to develop TrPs in associa- extended while the operator depresses tion with TrPs in the rectus femoris in- the patella inferiorly and medialward to clude the three vasti and the iliopsoas palpate the vastus lateralis in line with muscle. The intermedius is the vastus and close to the lateral border of the pa- muscle most likely to be involved also; tella, in an area that the patella had cov- the vastus medialis is the least likely. ered before it was depressed. This TrP of- Proximal TrPs in the sartorius muscle ten feels like an exquisitely tender hard may also appear. The relatively rare TrP knot, and has been described and illus- at the distal part of the rectus femoris is trated in a case report.87 found in association with deeper underly- ing TrPs in the vastus lateralis. 10. ENTRAPMENTS Vastus Medialis None of the quadricep femoris group is The vastus medialis is the member of the known to cause nerve entrapments asso- quadriceps femoris group that is most ciated with TrP tension of those muscles. likely to develop TrPs in the absence of TrPs in the other three heads. Such TrPs 11. ASSOCIATED TRIGGER POINTS are often associated with a Morton foot structure. Also frequently associated with Limitation of knee flexion due to TrPs in that foot structure are TrPs in the per- any one vastus muscle encourages the de- oneus longus and gluteus medius mus- velopment of TrPs in the other two vasti cles. and in the rectus femoris. Shortening of the hamstrings due to TrPs, especially in The distal vastus medialis TrP (TrP1 in the biceps femoris, overloads the antago- Fig. 14.2) is often associated with TrPs in nistic quadriceps femoris; when the ham- the hip adductor muscles. This is the only strings have TrPs, usually at least part of part of the quadriceps femoris muscle the quadriceps group does too. group that frequently develops TrPs sec- ondary to adductor TrPs.
Chapter 14 / Quadriceps Femoris Group 273 Figure 14.15. Palpation of common locations of trig- palpation of the proximal trigger point (TrP2) location, ger points (Xs) in the right vastus medialis muscle. A, B, examination of the distal TrP1 region. Figure 14.16. Examination of a trigger point high in the right vastus in- termedius, deep to the rectus femoris muscle. The (Xs) show common sites of proximal trigger points in the vastus in- termedius muscle. The open circle lo- cates the anterior inferior iliac spine. The arrow indicates the downward (poste- rior) direction of strong pressure exerted by the operator. TrPs in the vastus medialis can also be fasciae latae muscle. These other TrPs must aggravated by active TrPs in the proximal be inactivated before the vastus medialis end of the rectus femoris or in the tensor TrPs can be permanently eliminated.
274 Part 2 / Hip, Thigh, and Knee Pain Figure 14.17. Examination by flat palpation for trig- rections of pressure being applied. The open circle ger points in the right vastus lateralis muscle. The leg marks the anterior superior iliac spine. A, anterior por- is slightly flexed at the knee, a position provided here tion of the vastus lateralis; B, posterior portion of the by the blanket. The Xs indicate locations of the many muscle. trigger points in this muscle. The arrows show the di- Vastus Intermedius and superior tibiofibular articulations should be evaluated and released from The rectus femoris and vastus lateralis any restriction by gentle mobilization, if muscles of the quadriceps group are the ag- possible. Normal mobility of the patella is onists most likely also to be involved when important. the vastus intermedius develops TrPs. Whenever intermittent cold with stretch Vastus Lateralis is applied to one of the vasti, one must be sure that TrPs in the other two vasti are not TrPs in the anterior part of the gluteus min- blocking the range of knee motion. imus tend to activate satellite TrPs in the vastus lateralis muscle, which lies within The use of ice for applying intermittent the former muscle's pain reference zone. cold with passive stretch is explained on page 9 of this volume and the use of va- 12. INTERMITTENT COLD WITH pocoolant spray with stretch is detailed STRETCH on pages 67-74 of Volume I.114 Tech- (Figs. 14.18-14.22) niques that augment relaxation and stretch are reviewed on page 11 of this When treating the quadriceps femoris volume and other techniques are also muscle, the tibiofemoral, patellofemoral, noted elsewhere.104 Avoid stretching of hypermobile joints to their full range of
Chapter 14 / Quadriceps Femoris Group 275 motion. Alternative treatment methods posite side (Fig. 14.18A) or lying supine are reviewed on pages 9-11 of this vol- with the thigh hanging over the edge of ume. the treatment table (Fig. 14.18B). The un- involved thigh should be flexed to stabi- When treating the quadriceps femoris lize the pelvis and lumbar spine, particu- muscle group for TrPs, it is important to larly if any lumbar hypermobility is pres- apply intermittent cold and stretch to the ent. Before treatment, the patient reaches hamstring muscles also. Whenever any down and feels the distance between the part of the quadriceps femoris harbors ac- heel and buttock to measure how far apart tive TrPs, the hamstrings usually have at they are. Parallel unidirectional slow least latent TrPs that restrict movement. sweeps of cold are applied from the iliac Application of intermittent cold with crest downward over the front and sides stretch of the quadriceps femoris causes of the thigh and knee to cover all of the unaccustomed sudden shortening of the muscle and its referred pain pattern. With hamstring muscles that can activate their the patient in the side-lying position, the latent TrPs, producing severe cramping operator pulls the ankle toward the but- pain. Should such a reactive cramp, or tock to take up slack while applying par- \"kickback,\" of the hamstrings (or any allel sweeps of cold, as described previ- other antagonistic muscle in a com- ously. The patient may assist by also pull- parable situation) occur, the antagonist ing on the ankle, thus learning how to should be lengthened immediately by perform the stretch as part of a home-ex- application of intermittent cold with ercise program (Fig. 14.29). When the stretch. This reaction can be avoided by procedure is finished, the patient tests first releasing hamstring tightness at least how close the heel now approaches the partially before proceeding to full release buttock and, in this way, becomes aware of the quadriceps femoris. of the progress made. It is valuable for patients to experience A moist heating pad or hot pack the improvement that is achieved by hav- rewarms the cooled skin (Fig. 14.19). ing them note the increased range of knee motion after, as compared with before, Following these procedures, the patient treatment. slowly exercises the rectus femoris ac- tively through its fully lengthened and Muscles may respond poorly to inter- shortened ranges of motion, from hip ex- mittent cold with stretch if the patient be- tension combined with knee flexion to comes chilled. A dry heating pad on the hip flexion with knee extension. abdomen, as shown in Figures 14.22 and 14.26, effectively replaces heat lost to the The location for application of the intermittent cold and reflexly increases moist heating pad (Fig. 14.19) should be blood flow to the limbs. One can feel how based not on where it hurts but on where far distally the warmth of this reflex heat- the active TrPs are located. A l t h o u g h the ing has progressed, monitoring it until the pain is rarely felt at the upper end of the feet are warm. This feeling of comfortable rectus femoris, its common TrP site, that warmth helps the patient relax more is where the moist heat must be applied. fully. The replacement of body heat is es- The greater the extent of coverage of the pecially important in a cool or drafty entire muscle by the moist heat, the better treatment room. is the result. Rectus Femoris Generally, TrPs in the rectus femoris (Figs. 14.18 and 14.19) muscle respond well to intermittent cold with stretch when this myofascial TrP Prior to treating the rectus femoris for therapy is properly administered and myofascial TrPs, it is important to iden- when any perpetuating factors are man- tify and correct any coexisting lumbar aged. spine or hip articular dysfunction. Vastus Medialis To stretch the two-joint rectus femoris (Fig. 14.20) muscle passively, the hip must be ex- tended while the knee is flexed. This may Of the four heads of the quadriceps fem- be done with the patient lying on the op- oris, the vastus medialis most dependably
276 Part 2 / Hip, Thigh, and Knee Pain Figure 14.18. Passive stretch posi- tions and partial intermittent cold pattern (thin arrows) for the right rectus femoris muscle. The parallel sweeps of ice or other coolant also extend over the front of the thigh more medially than shown here in order to cover all of the muscle and its entire referred pain pattern. The black X shows the usual location of this muscle's trigger points. The open circle marks the anterior superior iliac spine, which is above the attachment of this muscle on the anterior inferior iliac spine of the pelvis. A, side-lying position. The operator passively lengthens the rectus femoris by simultaneously ex- tending the thigh at the hip and flexing the leg at the knee (thick arrow). B, su- pine position. The operator is again flex- ing the leg at the knee (thick arrow) to lengthen the muscle while the hip is ex- tended. This two-joint stretch contrasts with the one-joint stretch of the three vasti (see Fig. 14.21). The patient's left hand holds the uninvolved thigh in flex- ion to stabilize the pelvis and prevent ex- cessive extension of the spine. responds to intermittent cold with stretch massage, ultrasound, or TrP injection, to that incorporates postisometric relaxa- inactivate any remaining TrPs. Because of tion. However, complete TrP inactivation the attachment of the vastus medialis to may not be obtained by this procedure in fascia of the adductor longus and ad- stubborn chronic myofascial syndromes ductor magnus, release of tension in those of this muscle or when restriction in the muscles is often necessary to achieve full range of knee flexion is a minimal compo- release of the vastus medialis. nent. The latter is not uncommon. When complete relief is not achieved, it be- To apply intermittent cold with stretch comes necessary to use other modalities, to the vastus medialis, the patient lies su- such as ischemic compression, stripping pine with the thigh abducted and the knee flexed on the affected side, as illus-
Chapter 14 / Quadriceps Femoris Group 277 Figure 14.19. Application of a moist wet-proof heat- the three vasti heads of the muscle slightly while ap- ing pad to the left quadriceps femoris muscle following plying the moist heat. Feet are supported in a neutral intermittent cold with stretch or trigger-point injection. position. The blanket over the exposed skin not in the A rolled towel is placed under the knees to lengthen treatment area helps to preserve body warmth. Figure 14.20. Stretch position and intermittent cold taken up in the direction shown by the thick arrow. pattern (thin arrows) for trigger points (Xs) in the right Following inactivation of the vastus medialis trigger vastus medialis muscle. This position simultaneously points, the heel reaches the buttock (outlined leg and stretches the adductors, which therefore must also be foot). covered by sweeps of ice or vapocoolant. Slack is trated in Figure 14.20. Parallel sweeps of well (see Figs. 15.1 and 15.2). It may be ice or vapocoolant spray are directed over necessary to inactivate adductor TrPs in the muscle and distally over the referred order to release the vastus medialis mus- pain pattern, and then the knee is increas- cle fully. ingly flexed as intermittent cooling is continued briefly. The application of cold The patient should palpate the distance should cover the adductors, since they between heel and buttock before and after also are stretched in this position. When the procedure to monitor progress. Full the adductor longus and/or magnus also range of motion should bring the heel up harbor active TrPs, the ice or vapocoolant against the buttock. should be directed so as to include all of the composite adductor pain pattern as The procedure is followed by the appli- cation of a moist heating pad over the muscle with the patient placed in a com-
278 Part 2 / Hip, Thigh, and Knee Pain Figure 14.21. Stretch position and in- termittent cold pattern (thin arrows) for trigger points (Xs) in the right vastus in- termedius muscle in the supine patient. The thick arrow shows the direction of pressure to lengthen the vastus in- termedius passively by flexing the knee. Positioning at the hip joint does not influ- ence the stretch on this muscle, which crosses only the knee joint. This con- trasts with the rectus femoris muscle (see Fig. 14.18B). fortable position, supine with a small pil- this initial rectus femoris release, the op- low under the knee (Fig. 14.19). After sev- posite thigh is flexed to stabilize the pelvis eral minutes of moist heat application, and lumbar spine.) During application of the recumbent patient reestablishes full intermittent cold, the muscle is placed on functional range of motion by slowly al- just enough gentle stretch to take up the ternating between the treatment position slack. The ice or vapocoolant spray is ap- of a fully lengthened vastus medialis to a plied in parallel sweeps as illustrated, and fully shortened muscle. then slack is taken up by further flexing the knee (Fig. 14.21). Vastus Intermedius (Fig. 14.21) Intermittent cold with stretch can be combined effectively with the Lewit tech- The TrPs in the vastus intermedius are nique of postisometric relaxation.66,67 To difficult to inactivate by intermittent cold combine them, the relaxed patient gently with stretch because there may be so extends the knee isometrically against op- many of them and because they tend to erator resistance for at least 3 seconds and become fibrotic, similar to those in the then relaxes. The operator applies inter- subscapularis muscle in the condition mittent cold and again passively length- \"frozen shoulder\" (see Chapter 26, Vol- ens the muscle to take up the slack that ume l 1 1 4 ) . For both of these muscles, it developed following isometric contrac- may be necessary to resort to injection of tion. The addition of the Lewit technique, the TrPs to inactivate them, after adminis- which is a form of contract-relax at maxi- tration of an antifibrotic agent, such as the mal available muscle length,117 facilitates potassium salt of p-aminobenzoic acid, release of tension and inactivation of TrPs sold under the name Potaba. These TrPs in any head of the quadriceps femoris. A are not readily accessible to manual pres- study of the effectiveness of this tech- sure therapy. nique on the quadriceps femoris in eight normal asymptomatic men showed that To apply intermittent cold with passive knee flexion increased 4 ± 1% and that stretch to the vastus intermedius muscle, the increase persisted for 90 minutes.80 the patient lies supine on the treatment ta- ble, as illustrated in Figure 14.21. Move- The intermittent cold-with-stretch pro- ment at the hip does not affect stretch of cedure is followed by application of a this muscle, but an initial stretch proce- moist heating pad over the vastus in- dure including some knee flexion together termedius and then by several cycles of with hip extension ensures release of the slow active movement through its fully rectus femoris so that its tense fibers do lengthened range and fully shortened not block full stretch of the vasti. (During range.
Chapter 14 / Quadriceps Femoris Group 279 Figure 14.22. Stretch position and in- termittent cold pattern for the right vas- tus lateralis. The Xs mark common loca- tions of trigger points in this member of the quadriceps femoris muscle group. The open circle identifies the greater tro- chanter; the solid circle, the anterior su- perior iliac spine; and the heavy solid line, the crest of the ilium. The fully ren- dered right lower limb is shown in the position reached after partial release of muscle tension. The outlined leg and foot have reached the position of full vastus lateralis length with the heel against the buttock. The large arrow shows the direction of gentle pressure applied to take up slack. The vastus in- termedius and the vastus medialis are also being stretched during this proce- dure, and the intermittent cold applica- tion should also include those muscles if they harbor TrPs. The dry heating pad on the abdomen provides reflex circula- tion to the limbs that compensates for heat lost to the cold application and con- siderable exposure of bare skin. Vastus Lateralis The solution preferred for injection of (Fig. 14.22) TrPs is 0.5% procaine in isotonic saline. This may be prepared in the syringe by di- To apply intermittent cold with passive luting one part of 2% procaine solution stretch to the vastus lateralis, the patient with three parts of isotonic saline. The lies supine with the hip flexed to approxi- precise localization of the TrPs is de- mately 90°, as illustrated in Figure 14.22. scribed in detail for each of the four heads The figure shows a dry heating pad placed of the quadriceps femoris in the preceding on the abdomen for reflex heating in a Section 9, Examination of Trigger Points. cold room. Slack is taken up in the vastus lateralis as the intermittent cold is applied Injection of TrPs in any of the four in parallel sweeps distally over the muscle heads, as described later in the subsequent and over its referred pain pattern (Fig. paragraphs, is followed promptly by brief 14.22). Then, after a pause for the patient intermittent cold with stretch and then the to breathe deeply, gentle pressure is ap- application of a moist heating pad. Finally, plied on the leg to increase the passive full active movement of the muscle is per- stretch while a second set of parallel formed slowly and completely through sweeps of ice or vapocoolant is completed. several cycles, from the fully shortened When the distal suprapatellar TrP is of range to the fully lengthened range. concern, one must manually depress the patella, as illustrated in Figure 14.10C and Rectus Femoris as described in a case report,87 to obtain (Fig. 14.23) complete stretch of the vastus lateralis. For injection of the TrPs in the rectus fem- 13. INJECTION AND STRETCH oris muscle, the patient lies supine, the (Figs. 14.23-14.27) thigh is extended slightly, and the knee is bent slightly to eliminate excessive slack A full description of the procedure for in- in the muscle (Fig. 14.23). The taut band is jection and stretch of any muscle appears palpated and the TrP spot tenderness lo- in Volume 1, pages 74-86.114 calized for precise infiltration. All TrPs present in this muscle should be treated. If
280 Part 2 / Hip, Thigh, and Knee Pain Figure 14.23. Injection of the usual trigger point high is more proximal than that of the proximal trigger in the right rectus femoris muscle. The open circle lo- points in the vastus intermedius (see Fig. 14.25). Usu- cates the anterior superior iliac spine. The solid line ally, the patient would be covered with a blanket to marks the iliac crest. The location of this trigger point prevent chilling of the body. the involved muscle has been confirmed Vastus Intermedius to be the rectus femoris and not the sarto- (Fig. 14.25) rius, there should be little likelihood of penetrating the femoral artery or nerve Inactivating the TrPs in this muscle re- with the needle. quires much persistence and can be frus- trating because their true severity is easily Vastus Medialis underestimated. Figure 14.25 shows the (Fig. 14.24) position of the patient for injecting some TrPs in the vastus intermedius muscle. Lo- For injection of vastus medialis TrPs, the calizing these TrPs for injection is difficult patient is positioned with the thigh flexed because they are so deep, within 3 mm (1/8 and abducted and the knee flexed to 90°, in) of the bone. If the needle is inserted far as illustrated in Figure 14.24, to make all into the muscle, it contacts bone. When its TrP areas accessible. The more distal one encounters these TrPs with the needle TrP1 region includes multiple TrPs that deep in the vastus intermedius, they usu- may cause either knee pain or buckling of ally cause an explosion of referred pain. the knee. They are explored with the nee- Before withdrawing the needle through dle as illustrated in Figure 14.24A. the skin, it is important to slide the skin aside and to palpate deeply, checking that Injection of the more proximal TrP2 all TrP tenderness has been eliminated by area is shown in Figure 14.24B. If TrPs re- the probing injection. quiring injection are found toward the medial border of the proximal TrP2 area, As shown in cross section in Figure one must remember that the femoral ar- 14.8, anatomically there is no clear de- tery courses along that border. Then the lineation between the deep lateral fibers needle should be angled laterally, away of the vastus intermedius and the deep from the sartorius muscle and the artery. medial fibers of the vastus lateralis. They commonly are involved together. Many of If, after injection, the vastus medialis the difficulties experienced when inject- TrPs are still tender, the physician should ing TrPs in one muscle apply to the other. examine the upper end of the rectus fem- When one finds TrPs that need injection oris, the tensor fasciae latae, and the ad- in either of these heads of the quadriceps ductor longus and magnus muscles for as- femoris, it is prudent to explore for TrPs sociated TrPs that may perpetuate the in the other head. Some patients have vastus medialis TrPs.
Chapter 14 / Quadriceps Femoris Group 281 Figure 14.24. Injection of vastus medi- alis trigger points. A, broken-line syr- inges portray various probing angles for injection of the distal (TrP1) group of trig- ger points shown as Xs in B. These dis- tal trigger points often cause buckling of the knee. B, injection of the proximal trig- ger point area along the medial border of the muscle, located at the X in A. Figure 14.25. Injection of a trigger point (X) in the right vastus intermedius muscle. The open circle locates the an- terior superior iliac spine. This trigger point area is located more distally and deeper than that in the rectus femoris muscle shown in Figure 14.23. The nee- dle is directed straight downward (poste- riorly) toward the underlying femur, nearly perpendicular to the skin surface. limited tolerance for the autonomic dis- activation of multiple TrPs (Fig. 14.26). ruption caused by the explosive impact of One must identify the spots of TrP tender- injecting these TrPs. This is one region for ness by deep palpation against the femur which analgesic premedication of appre- to localize them for injection. In average hensive patients may be indicated. sized individuals, one may need a 63-mm (21/2-in) needle to reach the deepest T r P 3 , Vastus Lateralis TrP4) and TrP5 locations (Fig. 14.4). It is (Figs. 14.26 and 14.27) often necessary to push the biceps fem- oris aside to reach vastus lateralis TrP3 Effective injection of vastus lateralis TrPs (Fig. 14.4), which is located posteriorly usually requires the identification and in-
282 Part 2 / Hip, Thigh, and Knee Pain Figure 14.26. Injection of trigger points (Xs) in the taut band, if palpable, is pinned down by the fingers of right vastus lateralis muscle. This muscle usually ex- the opposite hand. A blanket covers the untreated hibits multiple trigger points that are difficult to localize lower limb to help keep the patient warm. A dry heat- by palpation. The needle is directed toward a trigger ing pad is applied to the abdomen as a convenient point in the posterior cluster of trigger points while the way to replace heat lost from the exposed lower limb. Figure 14.27. Injection of the most dis tal trigger point (TrP1) in the right vastus lateralis muscle. The dashed line around the patella emphasizes the fact that the patella is being pushed downward to un- cover the trigger point. Tension due to a trigger point in this lowest part of the muscle consistently locks the patella up- ward and thus painfully blocks both flex- ion and extension of the knee. The mid- dle finger of the palpating hand presses the patella downward and pins down the palpable band in the muscle, while the other hand proceeds with the injection. against the back of the femur. The needle the patella. A short needle, 25 mm (1 in) must be slanted anteriorly to stay in the long, may be sufficient for injection. TrPi vastus lateralis and not enter the adja- is injected as illustrated and described in cent hamstring muscle. When penetrated, Figure 14.27. It is necessary to push the these TrPs are likely to refer pain to the patella distally to make the TrP accessible back of the knee. This is a region where during injection. When this TrP has been the needle may have to substitute for the responsible for limited movement at the palpating finger to find the TrPs. knee, full knee function and patient mo- bility return immediately when it is inac- Locating all of the vastus lateralis TrPs tivated, an unforgettably dramatic experi- and injecting them specifically can be te- ence for the patient and the clinician. dious, but becomes necessary when other methods of therapy fail to inactivate them 14. CORRECTIVE ACTIONS fully. (Figs. 14.28-14.31) Cryptic TrP1 is found only by pressing The buckling knee caused by vastus the patella downward as far as it will go medialis (or possibly vastus lateralis) while palpating for a taut band and TrP tenderness just above the lateral border of
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