Thursday 21 March 2024

Saturday Night Palsy

What is a Saturday Night Palsy?

Saturday Night Palsy
Saturday Night Palsy

Saturday night palsy, a compressive neuropathy of the radial nerve, is caused by an object or surface pressing directly onto the upper medial arm or axilla for an extended length of time.

The posterior segment of the brachial nerve plexus gives rise to the C5 to T1 nerve roots, which make up the radial nerve. Before wrapping down the medial aspect of the humerus and resting in a spiral groove, it runs deep to the axillary artery and then passes inferiorly to the teres minor. A nerve palsy caused by compression of the radial nerve affects motor and sensory function.

"Saturday night palsy" is the name given to the relationship between Saturday night partying and the ensuing drowsiness which can result in an extended period of immobility and nerve compression. This compression leads to Radial nerve palsy that impairs sensory and motor function. Additionally, Saturday night palsy has also been referred to as "honeymoon palsy".

Causes of Saturday Night Palsy

It is possible that drunken individuals become incapable of reflexively readjusting their sleeping positions. A person falling asleep with their arm hanging over a chair or other hard surface is the classic scenario, which compresses the axilla. Similarly, one has "honeymoon palsy" if they fall asleep on someone else's arm and then compress their nerve.

It is crucial to keep in mind that Saturday night palsy can arise from abnormal positioning or use of the limbs that can compress by a similar mechanism, even though these are the more well-known presentations. Examples of this include using crutches incorrectly, wearing tight apparel or accessories, bood cuff, and more.

Epidemiology

It has been estimated that the prevalence of Saturday night palsy is 1.42 per 100,000 women and 2.97 per 100,000 men.

It is the fourth most prevalent mononeuropathy in the United States and is highly prevalent worldwide.

Because of the age-neutral mechanism of the injury, it has been seen in patients of all ages.

History

Patients often describe how excessive alcohol consumption precedes abnormal sleeping positions, which in turn causes their symptoms.

Patients may describe another mechanism by which the upper medial arm or axilla would have been unnaturally compressed if alcohol consumption is absent.

Patients may not recognize this information as the trigger event, so they may withhold it unless asked.

Symptoms of Saturday Night Palsy

It may take a few days after the first injury for symptoms to appear, which could cause a delayed presentation.

Patients may report experiencing pain, tingling, numbness, weakness, or any combination of these symptoms.

A physical examination may show a typical wrist drop due to the preservation of flexor muscle function supplied by other nerves in the hand and arm and the loss of extensor muscle function controlled by the radial nerve branches. This prevents extension of the fingers and wrist at the metacarpophalangeal joints. It becomes challenging to open the hand and grasp objects when the thumb's ability to extend is also lost.

Because the ulnar nerve controls the proximal and distal interphalangeal joints, patients can still extend their fingers at this level. This is something that healthcare providers should be aware of.

Patients may also lose the radial nerve innervation that controls the triceps reflex.

The posterior forearm, posterior hand, and posterolateral aspect of the lateral three and a half digits are frequently affected by sensory deficiencies that first affect the posterior or lateral upper arm.

Diagnosis

Physical Examination

Since Saturday night palsy is primarily diagnosed and evaluated clinically, many patients with a clear medical history and physical examination might not require further diagnostic testing.

However, additional diagnostic techniques might be helpful in evaluating possible side effects and causes in addition to estimating prognosis.

Electromyography and nerve conduction studies can localize lesions anatomically and help separate peripheral neuropathies, brachial plexopathies, and cervical radiculopathies.

A low-risk, low-cost technique that can help visualize the nerve and identify areas of disruption or damage is ultrasound. Additionally, in certain cases, it can be very helpful in expediting early surgical intervention by detecting obvious disruption of the nerve.

In addition to identifying the affected muscles, magnetic resonance imaging (MRI) can provide fine detail that ultrasound is unable to provide. In addition, it can detect tissue masses and screen for neurological conditions and other disease processes.

Bony tumors, fractures, and dislocations that may be the cause of nerve damage can all be found with X-ray imaging.

Treatment of Saturday Night Palsy

Physical rehabilitation is the main focus of Saturday night palsy; a soft wrist splint keeps the wrist extended during treatment. However, during rehabilitation, it is essential to permit passive range of motion of the affected extremity, which can be achieved with a dynamic splint.

The previous measures can be supplemented with supportive care, which includes steroid injections, systemic corticosteroids, NSAIDs, and rest.

One of the latest therapeutic approaches is localized injections administered via ultrasound to speed up healing. Surgery is only recommended in cases of severe damage to the radial nerve or when an intrinsic process, such as a mass, bone, spur, or cyst, is the cause of the compression.

Physiotherapy Treatment

  • Strenthening Exercises of Wrist Muscles
  • Exercises for numbness and tingling in the hands.
  • TENS, or transcutaneous nerve stimulation, is used to treat neuropathic pain locally.
  • Electrical Stimulation (SF or IG) as per RD Test

Differential Diagnosis

One common cause of radial nerve injury is a traumatic fracture of the humerus. Severe blunt trauma, crush injuries, puncture wounds, and stab wounds are other frequent causes.

In patients with physical exam findings consistent with the possibility of a radial nerve injury, anterior glenohumeral shoulder dislocation should be taken into consideration. This condition is rare.

Iatrogenic injury can arise from any surgery or injection involving anatomy related to the radial nerve's path.

Internal compression from cysts, masses, tumors, muscle hypertrophy, and fibrinous tissue can result in nerve palsy.

Neurologic diseases or repetitive overuse can cause isolated palsies. Acute ischemic strokes have also been reported in some patients who initially presented with isolated symptoms.

Prognosis

The extent of the injury, which is established by the force and duration of compression, determines the prognosis for Saturday night palsy.

Neuropraxia, a temporary conduction block that prevents nerve degeneration, is caused by mild damage. A partial recovery is nearly always the outcome of this kind of injury.

Axonotmesis, which is characterized by Wallerian degeneration and axonal damage with partial or delayed recovery, is caused by moderate damage.

Neurotmesis, characterized by complete axon degradation and Schwann cell death, is the result of severe injury and has a low chance of full recovery. Almost invariably, patients with this degree of injury will need surgery.

Only using electromyography to assess the extent of damage can be challenging, and predicting the prognosis early on can be challenging as well.

Even mild cases require at least 2-4 months, and often longer, to recover from.

Complications

Ignoring to take into account a wide range of possible diagnoses may result in issues, like failing to identify a serious illness or disease. Since the course of treatment for radial nerve deficits varies widely from case to case, it is imperative to identify the underlying cause.

The primary complication of true compressive Saturday night palsy is that it may not heal, which might require further investigation through surgery.

Following that, a number of surgical options are available, such as nerve grafting, nerve transfers, tendon or muscle transfers, and other methods. Similar to the majority of surgical operations, a range of complications pertaining to intraoperative problems and post-operative infections are possible.

Moreover, long-term disability can be difficult to achieve, and partial recovery is typical in these situations. Even though consistent, long-term physical therapy is required to restore some functionality, it can be extremely demanding.

Neglecting to take into account a wide range of possible diagnoses may result in issues, like failing to identify a serious illness or disease. Since the course of treatment for radial nerve deficits varies widely from case to case, it is essential to identify the underlying cause.

The primary complication of true compressive Saturday night palsy is that it may not heal, which might require further investigation through surgery.

Following that, a number of surgical options are available, such as nerve grafting, nerve transfers, tendon or muscle transfers, and other methods. Similar to the majority of surgical operations, a range of complications related to intraoperative problems and post-operative infections are possible.

Moreover, long-term disability can be difficult to achieve, and partial recovery is typical in these situations. Even though consistent, long-term physical therapy is required to restore some functionality, it can be very taxing.

Multidisciplinary Team (MDT) Approach

For the treatment of patients with Saturday night palsy, a team-based approach works best.

A patient with Saturday night palsy should be evaluated thoroughly by the initial healthcare provider to rule out other possible causes of a neurological deficit that has just started.

To schedule an electromyogram and other diagnostic or therapeutic procedures, a neurologist should also be appropriately referred.

Physical therapy needs to be suggested as well.

Instruction on supportive measures needs to be given to patients.

In cases where early surgical intervention is considered necessary, a specific timeline should be established to facilitate appropriate surgical follow-up.

Patients should, in any case, be given reasonable expectations about the recovery process, which may not be as easy or convenient as they had intended.

Monday 11 March 2024

Trapezius Muscle Pain

What is a Trapezius Muscle Pain?

Trapezius muscle pain

Trapezius muscle pain can range from mild discomfort to severe, debilitating pain, affecting daily activities and overall quality of life.

One of the main muscles of the back and neck is the trapezius muscle, so named because of its trapezoidal shape. It reaches across the shoulder blades and descends from the base of the skull to the thoracic spine. This large muscle is important for many movements of the upper back, shoulders, and neck, such as pulling, lifting, and rotating the shoulders.

Despite the trapezius muscle's strength and durability, it can become painful or uncomfortable for a variety of reasons, including bad posture, overuse, stress, or injury.

It is essential to understand the causes, signs, and effective treatments of trapezius muscle pain in order to manage this common condition while improving musculoskeletal health. This article discusses the trapezius muscle's anatomy and function, common causes of pain in the area, warning signs, and preventative and therapeutic measures.

Related Anatomy

Trapezius Muscle Anatomy
Trapezius Muscle Anatomy

The trapezius muscle is a large, superficial muscle that covers much of the upper back and neck. It is divided into three distinct regions: the upper (or superior), middle, and lower (or inferior) trapezius.

Upper Trapezius:

Origin: Occipital bone (base of the skull) and the spinous processes of the cervical vertebrae (C1-C4).

Insertion: Clavicle (collarbone) and acromion process of the scapula (shoulder blade).

Function: Elevates and upwardly rotates the scapula. It also assists in neck extension and lateral flexion.

Middle Trapezius:

Origin: Spinous processes of the thoracic vertebrae (T1-T5).

Insertion: Medial aspect of the acromion process and superior lip of the spine of the scapula.

Function: Retracts (adducts) the scapula, pulling it toward the spine.

Lower Trapezius:

Origin: Spinous processes of the thoracic vertebrae (T6-T12).

Insertion: Medial end of the spine of the scapula.

Function: Depresses (pulls downward) and upwardly rotates the scapula. It also assists in scapular retraction.

Nerve Supply:

The trapezius muscle is innervated by the spinal accessory nerve (cranial nerve XI) and branches of the cervical spinal nerves (C3-C4).

Blood Supply:

Blood is supplied to the trapezius muscle primarily by branches of the superficial cervical artery, transverse cervical artery, and dorsal scapular artery.

To understand the function of the trapezius muscle and the possible causes of pain and dysfunction, one must have a thorough understanding of its complex anatomy. Any area of the trapezius muscle that is dysfunctional can cause pain, restricted movement, and poor posture. For this reason, it is critical to properly assess the situation and implement targeted interventions to address problems related to the trapezius muscle.

Trapezius Muscle Pain Causes

Causes of Trapezius Pain are:

Poor Posture:

Extended periods of sitting or standing with bad posture can cause the trapezius muscle to become overworked and strained. Muscle soreness and discomfort can arise from the trapezius becoming overstretched and fatigued from slouching or hunching the shoulders forward.

Muscle Overuse

Overuse of the trapezius muscle can result from repetitive motions or activities involving the arms, shoulders, and neck. This usually happens in jobs or activities where lifting, carrying, or reaching overhead for extended periods of time is required.

Muscle Tension and Stress

People may unintentionally tense their necks and shoulders in response to emotional stress, anxiety, or tension, which can increase the tension in the trapezius muscle. Trigger points and muscle soreness can arise as a result of persistent muscle tension.

Trauma or Injury

Acute pain and inflammation can be brought on by direct trauma to the trapezius muscle, such as a fall or impact, which can result in muscle strains, tears, or contusions. Furthermore, over time, repetitive microtrauma from manual labor or sports-related activities can result in chronic muscle injuries.

Neck and Shoulder Strain

Strains to the muscles, ligaments, or joints of the neck and shoulders can cause pain that refers to the trapezius muscle. Secondary trapezius muscle pain can be caused by diseases like cervical spondylosis, whiplash injuries, or shoulder impingement syndrome.

Poor Ergonomics

Pain in the trapezius muscle can be caused by a poorly designed piece of equipment, incorrect lifting techniques, or an incorrectly set up workstation. It's crucial to maintain good ergonomics to avoid tense and sore muscles when performing daily tasks.

Nerve Compression

Referred pain, tingling, or numbness in the muscle can be caused by compression or irritation of the spinal accessory nerve or cervical spinal nerves, which supply the trapezius muscle.

Postural Imbalances

Unbalances in the muscles that surround the trapezius, like those in the pectoral or rhomboids, can cause compensatory movements and put more strain on the trapezius, making it more vulnerable to pain and dysfunction.

Symptoms of Trapezius Muscle Pain

Other Associated Symptoms are:

Shoulder and Neck Discomfort

Trapezius muscle pain frequently manifests as neck, shoulder, and upper back pain. The pain can be dull, achy, or sharp, and its severity ranges from mild to severe.

Muscle Tenderness

When the trapezius muscle is palpated, certain trigger points or the muscle fibers themselves may be tender or tense in certain places.

Restricted Range of Motion

Pain in the trapezius muscles can restrict shoulder and cervical range of motion, making it challenging to execute actions like raising arms overhead, turning the head, or twisting the neck.

Muscle Stiffness and Tightness

Muscle stiffness and tightness are common symptoms of trapezius muscle pain, especially in the upper back and neck. Feelings of discomfort and decreased flexibility may result from this.

Headaches

Tension headaches or cervicogenic headaches can result from pain that radiates from the trapezius muscle to the head and temples. The dull, band-like sensation that surrounds the head is a common symptom of these headaches.

Shoulder Blade Pain

Pain may be localized to the area between the shoulder blades (scapulae), particularly when the middle and lower trapezius muscles are involved.

Trapezius Muscle Spasms

In rare cases, involuntary muscle contractions or spasms may accompany pain in the trapezius muscle, making movement more difficult and uncomfortable.

Numbness or Tingling

Numbness, tingling, or pins and needles may be experienced in the affected area due to compression or irritation of the nerves innervating the trapezius muscle.

Postural Changes

 People who experience chronic pain in the trapezius muscle may adopt compensatory postures or movements to ease their discomfort. As a result, there may be more musculoskeletal imbalances and pain throughout time.

Fatigue and Weakness

It may be difficult to carry out daily tasks involving the shoulders and neck when dealing with chronic pain in the trapezius muscle.

Differential Diagnosis

When making a differential diagnosis for pain in the trapezius muscle, other medical conditions that may have similar symptoms are taken into account. Among the possible differential diagnoses are the following:

  • Cervical Radiculopathy: Pain, numbness, or tingling that radiates from the cervical spine and may resemble pain in the trapezius muscle is caused by compression or irritation of the spinal nerves. Cervical radiculopathy can cause weakness or changes in sensation in the upper extremities, and it is frequently accompanied by neck pain.
  • Rotator Cuff Injury: Damage to the rotator cuff's muscles and tendons in the shoulder can result in pain and a restricted range of motion that can be felt in the neck and upper back. People who have experienced shoulder trauma or who perform repetitive overhead activities are more likely to sustain rotator cuff injuries.
  • Cervical Disc Herniation: Herniation of the intervertebral discs in the cervical spine can compress surrounding nerves, causing pain in the neck, shoulders, and arms. Herniated cervical discs can also result in abnormal reflexes, sensory abnormalities, and muscle weakness.
  • Thoracic Outlet Syndrome (TOS): The condition known as Thoracic Outlet Syndrome (TOS) is caused by compression of nerves or blood vessels in the thoracic outlet, which is the area between the collarbone and the first rib. TOS symptoms include arm and shoulder pain, tingling, numbness, and weakness. Certain activities or postures that compress the thoracic outlet can make TOS worse.
  • Fibromyalgia: This is a chronic pain syndrome that is marked by body-wide musculoskeletal pain, fatigue, and tender points. Although fibromyalgia can include pain in the trapezius muscle, the illness usually presents with several tender points and systemic symptoms.
  • Myofascial Pain Syndrome: Referred pain patterns can be caused by the presence of trigger points, which are small, tender, spastic areas of muscle. Although the symptoms of trigger points in the trapezius muscle can resemble those of trapezius muscle pain, they can be distinguished by manual palpation and trigger point identification.
  • Postural Syndromes: Musculoskeletal pain in the upper back, neck, and shoulders can result from long-term poor posture or anatomical abnormalities in the spine or shoulders. Managing postural-related pain requires addressing underlying postural imbalances and ergonomic issues.
  • Shoulder Impingement Syndrome: Shoulder pain and dysfunction that may be referred to the trapezius muscle area can be caused by impingement of the rotator cuff tendons or bursa between the humeral head and the acromion process of the scapula.

Diagnosis

A thorough evaluation by a medical professional is usually necessary to diagnose trapezius muscle pain. This evaluation may consist of the following elements:

Medical History: The healthcare professional will start by getting details regarding the patient's symptoms, such as where, when, and how much pain they are experiencing, along with any triggers or mitigating factors. A thorough medical history aids in determining any possible contributing factors or underlying causes.

Physical Examination: To evaluate the flexibility, strength, and range of motion of the shoulders, neck, and upper back, a comprehensive physical examination is performed. To find trigger points, tight spots, or tender spots in the trapezius muscle, the medical professional may palpate the muscle.

Neurological Examination: To assess nerve function, reflexes, and sensory function in the upper limbs, a neurological examination may be carried out. This aids in the evaluation of any indications of nerve irritation or compression that might be causing the symptoms.

Imaging Studies: X-rays, CT (Computed Tomography) scans, and MRIs (Magnetic Resonance Imaging) may occasionally be requested in order to rule out underlying structural abnormalities or injuries in the neck, shoulders, or spine. These imaging modalities can assist in locating any possible sources of pain or dysfunction as well as provide detailed images of the musculoskeletal structures.

Nerve Conduction Studies and Electromyography (EMG): These tests may be suggested to evaluate the electrical activity and function of the muscles and nerves that supply the trapezius muscle. Neurological disorders and abnormalities of the muscles can be diagnosed with the aid of nerve conduction studies and EMG.

A diagnosis of trapezius muscle pain or another musculoskeletal condition may be made in according to the evaluation's results. The recommended course of treatment will be individualized to target the particular underlying cause and reduce symptoms; this may include a mix of complementary therapies, medication, physical therapy, and lifestyle changes.

Treatment of Trapezius Muscle Pain

A combination of conservative treatments targeted at pain reduction, muscle function enhancement, and addressing underlying contributing factors is usually used to treat trapezius muscle pain. 

Common treatment options are:

Rest and Activity Modification: Reducing activities that aggravate pain in the trapezius muscle or taking a brief break from them can help manage symptoms and stop the muscle from getting worse. It's crucial to stay out of positions or repetitive movements that put strain on the trapezius muscle during the first stages of treatment.

Physical therapy: A customized program for physical therapy can help improve flexibility, strengthen the trapezius muscle, and address postural imbalances. To lessen discomfort and accelerate healing, practitioners can use manual therapy, stretching exercises, therapeutic exercises, and modalities like TENS, IFC Machine, heat or ice therapy.

Pain management: Nonsteroidal anti-inflammatory medications (NSAIDs) available over-the-counter, such as ibuprofen or naproxen, can help lessen pain and inflammation caused by pain in the trapezius muscle. For temporary pain relief, doctors may occasionally prescribe prescription drugs or muscle relaxants.

Trigger Point Therapy: Tightness and tension in the trapezius muscle can be released with the use of manual techniques like trigger point massage, myofascial release, or dry needling. Localized pain relief and improved muscle function can be achieved by focusing on trigger points located within the muscle.

Posture Correction: Preventing recurrent pain in the trapezius muscle requires addressing underlying postural imbalances and ergonomic factors. It might be advised to provide education on good posture for everyday tasks, workplace ergonomics, and ergonomic adjustments.

Stress management: By promoting relaxation and easing muscle tension, stress-reduction methods like yoga, deep breathing exercises, mindfulness meditation, and relaxation exercises can lessen the chance of aggravating trapezius muscle pain.

Therapeutic modalities can be used to relieve pain, lower inflammation, and encourage tissue healing in the trapezius muscle. These include heat therapy, cold therapy, ultrasound, and electrical stimulation.

Lifestyle Changes: Adopting healthful routines like consistent exercise, enough sleep, a balanced diet, and adequate hydration can promote general musculoskeletal health and lower the incidence of pain and dysfunction in the muscles.

Ergonomic Modifications: Changing the way that workstations, chairs, computers are set up, and lifting is done can help lessen the strain that regular activities place on the trapezius muscle and lower the chance of developing muscle soreness.

Injections: For localized pain relief and to reduce inflammation in the trapezius muscle, corticosteroid injections or trigger point injections may be considered in certain situations.

Physiotherapy Treatment of Trapezius Muscle Pain

Physiotherapy is essential for treating pain in the trapezius muscle because it corrects muscle imbalances, restores mobility, increases strength, and encourages good posture. 

The following elements of a physiotherapy treatment plan for pain in the trapezius muscle may be available:

Manual Therapy Techniques:

  • Soft tissue mobilization: A massage technique used to ease the trapezius muscle's tightness and tension.
  • Joint mobilization: Mild manual techniques to ease shoulder and neck stiffness and increase joint mobility.

Therapeutic Exercises:

  • Stretching exercises: Focused stretches to increase flexibility and decrease muscle tension in the trapezius muscle.
  • Strengthening exercises: Postural muscles are the emphasis of these progressive resistance workouts, which aim to strengthen the trapezius and surrounding muscles and support good alignment and stability.
  • Scapular stabilization exercises: These exercises help to prevent shoulder impingement and lessen strain on the trapezius muscle by enhancing scapular control and muscle balance.

Postural Correction:

Instruction on ergonomic adjustments, daily activities, and work tasks that promote good posture to avoid straining the trapezius muscle.

exercises for postural retraining to enhance awareness and alignment of the head, shoulders, and spine.

Modalities:

Applying heat packs or warm compresses to the trapezius muscle to improve blood flow, ease tension, and reduce pain is known as heat therapy.

Cold therapy: Applying ice or cold packs to the trapezius muscle to relieve pain and reduce inflammation.

Electrical stimulation: To reduce pain and encourage muscle relaxation, neuromuscular electrical stimulation (NMES) or transcutaneous electrical nerve stimulation (TENS) may be utilized.

Trigger Point Treatment:

By deactivating trigger points in the trapezius muscle, trigger point release techniques—such as manual pressure, ischemic compression, or dry needling—can lessen referred pain patterns.

Learning and Self-Control:

Patient education regarding ergonomics, good body mechanics, and ways to avoid straining muscles and having trapezius muscle pain recurrence.

guidance on self-care practices, stretching regimens, and at-home workouts to speed up recovery and preserve musculoskeletal health.

Gradual Rehabilitative Intervention:

Progressive increase in activities and exercises as function improves and pain subsides, emphasizing everyday living activities and functional movements.

Monitoring development and modifying the treatment plan in accordance with each patient's needs and preferences.

An comprehensive physiotherapy strategy catered to the requirements and objectives of the patient can successfully treat pain in the trapezius muscle, restore function, and enhance quality of life. To maximize results and achieve long-term musculoskeletal health, the patient and physiotherapist must collaborate and communicate on a regular basis.

Exercises for Trapezius Muscle Pain

The goals of exercises for pain in the trapezius muscle are to reduce stress, enhance muscle strength and flexibility, and encourage good posture.

Upper Trapezius Stretch
Upper Trapezius Stretch

The following efficient exercises can help reduce pain in the trapezius muscle:

Upper Trapezius Stretch:

  • Keep your back straight and sit or stand tall.
  • Till you feel a stretch along the side of your neck, gently tilt your head to one side and bring your ear towards your shoulder.
  • After holding the stretch for 15 to 30 seconds, move on to the opposite side.
  • Two to three repetitions per side.

Levator Scapulae Stretch:

  • Take a tall stance or sit upright, then slowly turn your head to the side and look over your shoulder.
  • Place your hand on the top of your head and apply gentle pressure to increase the stretch.
  • Hold the stretch for 15-30 seconds, then switch to the other side.
  • Repeat 2-3 times on each side.

Scapular Retraction:

  • Stand with your back against a wall or in a neutral position.
  • As though you were attempting to hold a pencil between your shoulder blades, squeeze them together.
  • Hold the squeeze for 5-10 seconds, then relax.
  • Repeat for 10-15 repetitions.

Shoulder Shrugs:

  • Stand or sit with your arms at your sides.
  • Shrug your shoulders upwards towards your ears as high as possible.
  • Hold for 1-2 seconds, then lower your shoulders back down.
  • Repeat for 10-15 repetitions.

Trapezius Strengthening with Resistance Bands:

  • A stable object at waist height should be used to fasten one end of a resistance band.
  • Hold the other end of the band in one hand and stand with your side facing the anchor point.
  • Keep your arm straight and pull the band diagonally across your body, engaging the trapezius muscle.
  • Slowly return to the starting position.
  • Perform 10-15 repetitions on each side.

Neck Retraction Exercise:

  • Maintain a neutral head posture while sitting or standing.
  • Gently tuck your chin towards your neck, creating a double chin.
  • Hold for a few seconds, then release.
  • Repeat for 10-15 repetitions.

Wall Angels:

  • Stand with your back against a wall and your arms bent at 90 degrees with your elbows and wrists touching the wall.
  • Slowly slide your arms upwards along the wall while keeping your elbows and wrists in contact with the wall.
  • Squeeze your shoulder blades together the entire time you perform the movement.
  • Return your arms to the starting position by sliding them down.
  • Repeat for 10-15 repetitions.

Thoracic Extension Stretch:

  • Sit on the floor with a foam roller positioned horizontally under your upper back.
  • Support your head with your hands, keeping your elbows bent.
  • Slowly lean back over the foam roller, arching your upper back and extending your thoracic spine.
  • After holding the stretch for 15 to 30 seconds, go back to your starting posture.
  • Repeat 2-3 times.

Regularly perform these exercises, paying attention to your form and deliberate movements. Stretch lightly at first, then progressively increase the resistance and intensity as tolerated. Before beginning any new exercise program, especially if you have pre-existing health conditions or concerns, get advice from a medical professional or physical therapist.

Keeping a healthy lifestyle, practicing proper posture, and putting ergonomic techniques into practice can all help prevent pain in the trapezius muscle. 

The following advice can help avoid pain in the trapezius muscle:

Maintain Proper Posture:

Maintain a straight back, relaxed shoulders, and a head that is in line with your spine when you sit or stand.

Stay away from hunching forward or slouching as these postures can strain the trapezius muscle and cause imbalances in the muscles.

Take Regular Breaks:

Take frequent breaks to stand up, stretch, and move around if your job requires you to sit at a desk for extended periods of time or if it's sedentary.

Throughout the day, gently stretch your shoulders and neck to release tension and avoid stiffness.

Practice Ergonomic Work Habits:

To encourage neutral posture and reduce strain on the trapezius muscle, rearrange your workspace.

In order to lessen neck strain, place your computer monitor at eye level and use an ergonomic chair with adequate lumbar support.

Benefit from ergonomic add-ons like supportive cushions, adjustable desks, and ergonomic keyboards.

Use Proper Lifting Techniques:

Use your leg muscles to lift heavy objects instead of your back and shoulders by bending your knees and maintaining a straight back.

When lifting, keep the object close to your body and try not to twist or reach awkwardly.

Stay Active and Exercise Regularly:

Exercise on a regular basis to build strength in the muscles of your neck, shoulders, and upper back, especially the trapezius muscle.

Include activities that help you maintain good posture, like core and back strengthening exercises.

Practice exercises that promote flexibility and mobility, like yoga, Pilates, or swimming.

Manage Stress and Tension:

To release tension in your shoulders and neck, try stress-reduction methods like deep breathing, meditation, or mindfulness.

Throughout the day, take breaks to unwind and reduce stress, particularly if you're dealing with a heavy workload or emotional strain.

Drink plenty of water and eat a balanced diet:

In order to keep muscles hydrated and avoid dehydration, which can exacerbate tension and cramping in the muscles, drink lots of water throughout the day.

To enhance overall muscle health and function, maintain a well-balanced diet high in vitamins, minerals, and nutrients.

Get Adequate Sleep:

Make sure you are getting enough restorative sleep every night by making quality sleep a priority.

Invest in pillows and a supportive mattress to help maintain healthy spinal alignment and lessen shoulder and neck strain when you sleep.

These preventive steps can help lower your chance of experiencing pain in your trapezius muscles and improve your overall musculoskeletal health.

Summary

In summary, pain in the trapezius muscle is a common condition that can greatly affect everyday activities and quality of life. Effective management and prevention of trapezius muscle pain require an understanding of its anatomy, causes, symptoms, and available treatments. The most common causes of pain in the trapezius muscle are injury, stress, poor posture, and overuse of the muscles.

Physiotherapy is essential for reducing pain in the trapezius muscle and enhancing muscle function and mobility. It includes manual therapy techniques, therapeutic exercises, and modalities. Furthermore, preventing trapezius muscle pain can be achieved by putting preventive measures into practice, such as maintaining good posture, adopting ergonomic work habits, being active, controlling stress, and getting enough sleep.

Through the implementation of focused interventions and a comprehensive approach to musculoskeletal health, people can effectively manage pain in the trapezius muscle, enhance their general quality of life, and avoid further episodes of pain. For a customized assessment and treatment recommendations, it's crucial to consult a healthcare provider if you suffer from severe or chronic muscle pain. People may achieve optimal musculoskeletal health and long-term relief through preventive care and lifestyle adjustments.

Wednesday 6 March 2024

Bicipital Groove

Bicipital Groove
Bicipital Groove

The humerus bone of the upper arm contains an anatomical feature called the Bicipital Groove, which is also referred to as the intertubercular groove or the sulcus. The long head of the biceps brachii muscle tendon, which extends from the shoulder to the elbow, is accommodated and protected by the bicipital groove, which is located on the anterior (front) aspect of the bone.

It permits the long tendon of the biceps brachii muscle to pass through. This unique groove facilitates the smooth movement of the arm and efficient transfer of muscular forces by supporting the stability and healthy operation of the biceps tendon.

Studying human anatomy requires an understanding of the structure and function of the bicipital groove, especially in order to understand upper limb mechanics and the relationships between bones, muscles, and tendons.

The bicipital groove splits the greater and smaller tubercles. Adults are about 8 cm long, 4–6 mm deep, and 1 cm wide on average. The long biceps brachii tendon lodges between the pectoralis major tendons on the lateral lip and the teres major tendons on the medial lip. An additional branch of the anterior humeral circumflex artery originates at the shoulder joint.

The latissimus dorsi muscle inserts into the bicipital groove floor. The teres major muscle inserts into the groove on the medial lip.

It ends near the location where the top part of the bone joins the middle third, curving downward.  It is the axilla's lateral wall.

Attachments of Bicipital Groove

Musculotendinous

Three tendons attach to the bicipital groove are:

  • lateral lip: pectoralis major
  • floor: latissimus dorsi
  • medial lip: teres major

Relations and/or Boundaries

The bicipital groove is located on the anterior surface of the proximal humerus and has the following boundaries:

  • Superiorly: transverse humeral ligament
  • Laterally: greater tuberosity of the humerus
  • Medially: lesser tuberosity of the humerus

Function

The long tendon of the biceps brachii muscle can pass through the bicipital groove.

The transverse humeral ligament and the muscle fibers that extend from it stabilize and facilitate the tendon of the long head of the biceps brachi muscle in this groove, preventing subluxation during multidirectional biomechanical movements of the arms. Furthermore, the main biomechanical actions of the biceps brachi muscle, whose tendon is situated in the bicipital groove, are supination, flexion, and screwing.

Clinical Importance

  • Long head of biceps tendon dislocation
  • Bicipital Tendinitis
  • Pectoralis major tear
  • Latissimus dorsi tear

Friday 16 February 2024

Subscapularis Muscle

What is the Subscapularis Muscle?

Subscapularis Muscle
Subscapularis Muscle

The subscapularis is a broad, triangular muscle that inserts into the front of the shoulder-joint capsule, the lesser tubercle of the humerus, and the subscapular fossa.

It is one of the four rotator cuff muscles, along with the teres minor, infraspinatus, and supraspinatus. The biggest and strongest rotator cuff muscle is the subscapularis.

Weakness in internal rotation results from function loss caused by injury to the muscle or tendon. The preferred course of therapy for tendinopathies and partial tears is non-operative care.

If conservative therapy is unsuccessful, (1) surgical surgery may be necessary; (2) based on the individual’s activity level or occupation (athletes, for example); and (3) in the event of full-thickness rips.

Structure

A thick fascia covering the subscapularis joins to the scapula at the borders of the attachment (origin) of the subscapularis.

The fibers of the muscle merge into an insertion tendon after passing laterally from the muscle’s origin. The glenohumeral (shoulder) joint capsule and the tendon are intermingled.

A bursa sits between the tendon and a bare spot at the lateral angle of the scapula the neck of the scapula. It is connected to the cavity of the shoulder joint by an opening in the joint capsule. The serratus anterior and subscapularis are divided by the subscapularis (supra serratus) bursa.

Origin of Subscapularis muscle

It originates from the bottom two-thirds of the groove on the axillary border (subscapular fossa) of the scapula, the intermuscular septa (which form ridges on the scapula), and the medial two-thirds of the scapula's costal surface.

Aponeurosis, which divides the muscle from the teres major and the long head of the triceps brachii, is the source of some fibers. Tendinous laminae, which cross the muscle and are linked to ridges on the bone, are the source of other fibers.

Insertion of Subscapularis muscle

It attaches to the anterior portion of the shoulder joint capsule as well as the smaller tubercle of the humerus. Tendinous fibers penetrate the bicipital groove and extend to the larger tubercle.

Nerve Supply

The posterior cord of the brachial plexus (C5 to C7) contains branches that give rise to the subscapular nerve, which trifurcates into the upper, middle, and lower subscapular nerves. Both the upper and lower subscapular nerves supply the subscapularis.

The cranial half of the muscle is innervated by the upper subscapular nerve, whereas the caudal half of the muscle is innervated by the lower subscapular nerve, which bifurcates into two branches.

The latissimus dorsi muscle is innervated by the middle scapular nerve, also referred to as the thoracodorsal nerve, whereas the teres major is innervated by the inferior branch of the lower subscapular nerve.

Blood Supply and Lymphatics

The main blood supply to the subscapularis muscle is provided by the subscapular artery, which is a branch of the axillary artery. The lymph nodes in the axilla receive lymph drainage.

Course of the Muscles

The subscapularis muscle enters into the humerus’s lesser tubercle after starting at the subscapular fossa. The muscle adducts the humerus and spins it inside out. In the bicipital groove, the bicep tendon is located beneath the subscapularis tendon.

Innervation

The upper and lower subscapular nerves (C5–C6), which are branches of the posterior chord of the brachial plexus, supply the subscapularis.

Actions/movements

The humerus’s internal rotation is its primary function. In specific postures, it aids with shoulder adduction and extension.

The actions of this muscle are significantly influenced by the position of the arm: when the arm is raised, the subscapularis pulls the humerus forward and downward; when the humerus is fixed, the insertion of the subscapularis can act as an origin and cause the inferior border of the scapula to abduct.

Function of Subscapularis muscle

As the proximal humerus is fixed during elbow, wrist, and hand motions, the subscapularis helps to stabilize the shoulder joint. It is an effective barrier that keeps the humerus’ head from moving forward in front of the shoulder joint.

Surgical Considerations

Partial tears do not require surgery for treatment. When a patient fails conservative care and there is a full-thickness tear, a surgical examination may be necessary, depending on the patient’s activity level and job.

Either an open method or an arthroscopy is used to do surgery. Pathology of the biceps often co-occurs and may need tenotomy or tenodesis.

Clinical significance

The subscapularis etiology of shoulder pain can be caused by tears, tendinopathy, and tendonitis. The most common cause of tendonitis in the subscapularis is overuse from throwing or overhead sports putting the tendon in touch with the coracoid process.

When the symptoms worsen over time and tendon remodeling starts tendinopathy results. Acute rotator cuff tears in athletes who use overhead motion are more common than chronic degenerative injuries from overhead usage.

Subscapularis tears occur less frequently than tears in other rotator cuff tendons. When tears do occur, they are usually caused by a lesser tubercle avulsion, an anterior shoulder dislocation, falling on the outstretched arm during shoulder abduction, or rotator cuff tears.

To Know Shoulder Impingement Click Here

Examination

There is no reliable test for the subscapularis, making isolating its activity from other shoulder joint medial rotators challenging. 

The approved clinical test for evaluating the subscapularis is the Gerber Lift-off test. The sensitivity of the bear hug test for subscapularis muscle injuries is great. Significant subscapularis tearing is indicated by positive bear-hug and belly press tests.

Imaging

A gratifying and thorough subscapularis evaluation cannot be obtained with a single imaging tool or method; instead, a combination of the axial MRI / long-axis US and sagittal oblique MRI / short-axis US planes appears to produce meaningful findings.

Furthermore, subscapularis tendon rips have been linked to smaller tuberosity bone alterations. Cyst-related observations appear to be more sensitive when paired with findings related to cortical abnormalities.

Fatty infiltration of the superior sections of the subscapularis muscle, while sparing the inferior regions, is another characteristic that is commonly observed.

It is simple to identify between the supraspinatus and subscapularis tendon because the long biceps tendon disappears from the shoulder joint through the rotator cuff interval. The interval sling is made up of those two tendons.

Ultrasonography

Mack and colleagues devised an ultrasonographic technique that allows for the exploration of nearly the whole rotator cuff in six phases. It makes the whole region visible, from the sub-edge of the subscapularis tendon to the point where the musculus teres minor and the infraspinatus tendon meet.

The subscapularis tendon is the subject of one of the six stages. Initially, the examiner directs the applicator to the proximal humerus in a direction that is as close to the sulcus intertubercularis as feasible. Gliding now to the medial side reveals the subscapularis tendon’s insertion

Longitudinal plane of the musculus subscapularis and its tendon

The subscapularis tendon is 3-5 centimeters below the surface. It is worth attempting to display using a very penetrating 5 MHz linear applicator since it is quite deep for ultrasonography. As it turned out, it made a thorough examination of the muscle that immediately borders the scapula easier.

Nevertheless, the requisite level of mapping is not achieved for the major interest tendon. According to anatomical study, the ventral portion of the joint socket and its labrum can only be seen by external rotation. When the tuberculum minus is in the neutral position, it blocks the vision.

Tissue harmonic imaging

Tissue harmonic imaging, or THI, is increasingly recognized and employed in addition to traditional ultrasonography, primarily in abdominal imaging.

THI uses harmonic frequencies that are not in the incident beam and that come from within the tissue as a result of nonlinear.

Wavefront propagation. Higher contrast resolution may result from these harmonic signals since they may emerge differentially at anatomic locations with comparable impedances.” In comparison to the traditional US, it offers a much lower inter- and intraobserver variability, an elevated signal-to-noise ratio, and greater contrast resolution.

Furthermore, common US artifacts including side-lobe, near-field, and reverberation artifacts may be all but eliminated. As previously indicated, THI has already improved cardiac, vascular, breast, and abdominal sonography.

THI has not been used extensively for musculoskeletal issues, despite the method’s potential benefits. For instance, the still difficult distinction between partial- and full-thickness rotator cuff tears depends on the existence of a hypoechoic defect and/or the loss of the outer tendon convexity/non-visualization of the tendon.

Strobel K. et al. have concluded that using THI can lead to generally better visibility of joint and tendon surfaces, notably superior for subscapularis tendon anomalies, as compared to a standard MR Arthrography.

Pathologies

There are three trigger sites in the subscapularis; the two most prevalent ones are located close to the muscle’s outer border. Fortunately, the inside edge of the muscle trigger point is far less frequent because it is almost tough to manually release and palpate.

Pain referred from subscapularis trigger points is mostly felt in the posterior shoulder area, extending down the back of the upper arm and into the shoulder blade region. There may also be a distinct “band” of transferred pain that surrounds the wrist. The client usually knows that they have wrist discomfort, but they do not believe that it is connected to their shoulder ache.

Throwers often cause injuries to it. Applying pressure to the tendon insertion on the inside of the upper arm will cause discomfort and tenderness. Pain when moving the shoulder, particularly when the arm is elevated above the shoulders, is one indication of subscapularis tendinitis.

You can feel as though you are unable to raise your arm due to an overused subscapularis muscle. It may even be the cause of your frozen shoulder.

Tests For Subscapularis

Lift-Off Test

The lift-off test, often known as “Gerber’s Test,” was first explained by Gerber and Krushell in 1991.

When examining a standing patient, the patient is requested to place their hand behind their back such that the dorsum rests on the area of the mid-lumbar spine. By extending at the shoulder and maintaining or increasing internal rotation of the humerus, the dorsum of the hand is elevated off the back.

A typical lift-off test consists of the ability to actively raise the hand’s dorsum off the back. When the dorsum cannot be moved off the back, the lift-off test is abnormal and suggests a ruptured or dysfunctional subscapularis.

Bear Hug Test

The patient is instructed to do the Bear Hug Test by placing the palm of their afflicted arm on the shoulder of the person opposite them, with their elbow at the maximum anterior translation position in front of their torso.

The doctor places an external rotational force on the patient’s forearm and instructs the patient to hold that posture.

If the patient is unable to hold his arm in place or exhibits weakness in internal rotation as compared to the opposite side, the test is positive and suggests a tear or dysfunction in the subscapularis muscle.

Belly Press Test

The affected arm is positioned on its side, the shoulder flexed to a 90-degree angle, and the palm rests on the patient’s abdomen to perform the belly press test. The patient is directed to do an internal rotation by pressing the palm of his hand against his abdomen.

If the patient’s internal rotation was weaker on one side while it was stronger on the other, or if the internal rotation was absent when the patient was squeezed, the test was considered successful.

Treatment of Subscapularis Tendonitis

Conservative treatment is used for tendinopathy and subscapularis tendonitis. This often entails rest, changing one’s activities to stop the offending behavior, using cold packs, analgesics such as acetaminophen and NSAIDs, and physical therapy.

For most people, this means that their symptoms will go away. Instances of resistance can suggest that corticosteroid injections are necessary.

Subscapularis tendon tears are frequently misdiagnosed, thus a physician must have a high degree of suspicion. NSAIDs and physical therapy can be used to treat elderly people with a partial tear without surgery for a period of six to twelve weeks.

Pain relief and functional improvement may be achieved with a brief intra-articular injection. The patient ought to be sent to an orthopedist for a surgical examination if conservative treatment is not improving the situation.

A surgical examination is necessary for athletes, younger people, and anybody with a full-thickness tear. Either an open approach or an arthroscopic procedure is used for surgery. Pathology of the biceps often co-occurs and may need tenotomy or tenodesis.

Use the thumb method to massage the subscapularis muscle. First, feel the muscle contract; then, release the tension and begin rubbing. Be careful not to massage your nerves along with the muscle. If not, you might have discomfort for several days as you would have strained the nerves in your armpit rather than the muscle.

Exercise of Subscapularis Muscle

Stretching Exercise

Cross Body Arm Raise

A quick and efficient stretch for the subscapularis is the Cross Body Arm Raise.

Starting from a standing position with your feet shoulder-width apart, extend your arm forward on the side of the targeted muscle.

Grip your lifted arm slightly above the elbow with your opposite arm from behind, then gently draw it towards your body.

A comfortable stretch over the Subscapularis should feel good. Hold this posture for approximately 30 seconds, then release it gradually.

During this stretch, pay close attention to any feelings you have and get familiar with what feels comfortable. If you experience any unexpected pain or discomfort, stop right away.

If preferred, you may also execute this stretch while lying prone.

Cross Chest Stretch

Targeting the subscapularis muscle effectively involves stretching the chest muscles.

Start by either sitting up straight with your spine straight or standing with your feet shoulder-width apart.

Place the other hand next to the elbow and extend one arm across your chest.

When you feel a comfortable stretch in the front of your shoulder, slowly bring your arm closer to your body.

Hold this posture for 15 to 30 seconds, then release it and repeat on the other side.

Towel Stretch

An excellent and rather easy exercise for lengthening the Subscapularis muscle is the towel stretch.

Start by sitting or lying down on the ground, depending on how comfortable it is for you, and hold a towel firmly in both hands.

Bend the towel end to a 90-degree angle and wrap it over your forearm, just below your elbow.

Draw yourself as far away from it as you can by holding onto the other end of the towel. You should feel a steady, gentle stretch throughout your shoulder area.

The benefits of the stretch will become apparent to you right away. These benefits include improved range of motion, lessened localized pain and discomfort, and increased mobility. After maintaining this position for 15 to 30 seconds, switch to the other arm.

Internal rotation with abduction

To tie off one end of the resistance band right above your head, take a tall posture with your back to the stationary object.

Your hand reaches for another end.

With your arm out to the side, make a 90-degree angle movement.

To begin, rotate your arm downward against a band’s resistance until your palm is level with your hip.

Return to the starting position slowly, then repeat with the opposite hand.

Internal rotation stretch

Maintain a straight posture. For stretching, you’ll need a resistance band.

Tie one end of the resistance band around a stationary object and hold the other end in your hand.

Next, place your arm by your side with your elbow bent.

With your arm rotating across your abdomen, press it up against the resistance band.

Always keep your elbows close to your sides.

Hold it for 30 seconds when you start to feel stretched.

Proceed to perform on the opposite side.

Strengthening Exercises

Cable Standing Shoulder Internal Rotation

Positioned towards an elbow-height locking cable pulley, take a sideways position. As an alternative, apply a fitness band.

Using the arm nearest to the cable machine, grasp the cable handle. Keep your elbow tucked in at a 90-degree angle and locked against your side.

Pull the wire towards your body while internally rotating your shoulder until your forearm is crossed across your abdomen. Throughout the whole exercise, make sure to maintain a constant position with your elbow pushed against your side.

Once you’ve completed the required number of repetitions, go back to the beginning.

Repeat with your arms switched to the opposite.

Dumbbell Shoulder Internal Rotation

With a dumbbell in your right hand, lie on your right side on the floor. Keep your upper arm near your torso.

Hold the dumbbell straight above your elbow while bending your elbow 90 degrees. If needed, you can sag back a little to accommodate your whole range of motion.

Keeping the elbow at a 90-degree angle, lower the dumbbell towards the floor.

Your shoulder should feel stretched. For further support, you might grip your elbow with the hand on the other side.

Raise the dumbbell in the direction of your body while turning your shoulder inside out to make your forearm straight.

Continue till the desired number of times.

Turn over, then repeat with the other arm.

Monday 11 December 2023

Tensor Fasciae Latae Muscle

Introduction

Tensor Fasciae Latae Muscle
Tensor Fasciae Latae Muscle

The muscle of the proximal anterolateral thigh located between the superficial and deep fibers of the iliotibial (IT) band is called the tensor fasciae latae (TFL). Although there is a lot of variation in the length of the muscle belly, the TFL muscle belly stops before the greater trochanter of the femur in the majority of patients.

For flexion, abduction, and internal rotation of the hip, the TFL collaborates with the gluteus maximus, gluteus medius, and gluteus minimus. This muscle helps in knee flexion and lateral rotation by acting through the tibia's connection to the iliotibial (IT) band. Clinically speaking, the TFL is particularly crucial for supporting pelvic stability during standing and walking.

Tensor fasciae latae muscle Anatomy

Origin and insertion

The muscle arises from the anterior iliac crest’s outer lip and the anterior superior iliac spine. Its fibres connect proximally to the fascia lata, a deep tissue that surrounds the whole thigh muscles.

The iliotibial tract is a horizontal reinforcement formed by the tensor fasciae latae, gluteus maximus fibres, and gluteus medius aponeurosis. This connective tissue band travels laterally across the knee joint, inserting at the lateral condyle of the tibia and the lateral patellar retinaculum.

Nerve Supply

The superior gluteal nerve, L4, L5, and S1 innervate the Tensor fasciae latae muscle (TFL). Originating from the anterior rami of L4-S1, the superior gluteal nerve goes parallel to the superior gluteal artery and vein. It passes superior to the piriformis and emerges from the pelvis via the larger sciatic foramen. The gluteus minimus and TFL muscles are where this nerve ends after running anterior to the gluteus maximus muscle.

Blood Supply and Lymphatics

The superior gluteal artery's deep branch supplies blood to the Tensor fasciae latae muscle (TFL). The greatest branch of the internal iliac artery’s posterior division, the superior gluteal artery passes between the first sacral nerve root and the lumbosacral trunk posteriorly. The greater sciatic foramen serves as the superior gluteal artery’s egress from the pelvis, where it splits into superficial and deep branches. To nourish the gluteus medius and minimus as well as the TFL, the deep branch passes between them.

Structure and Function

The TFL descends between and is linked to the deep fascia and the superficial fascia of the IT band. It starts at the anterior superior iliac spine (ASIS) and the anterior side of the iliac crest. The TFL runs superficially to the greater trochanter of the femur as it descends on the anterolateral side of the thigh. The fascial aponeurosis of the gluteus maximus and the tensor fascia latae make up the IT track/band, where the TFL inserts distally. After there, the IT band continues down the lateral part of the thigh to the Gerdy tubercle, which is the lateral condyle of the tibia.

Despite its little size, the TFL collaborates with other muscle groups to support hip and knee mobility and stabilisation.

This muscle works in tandem with the gluteus medius and minimus as well as the gluteus maximus via the IT band to abduct and internally rotate the hip.

Through the IT band’s connection to the lateral tibia’s Gerdy tubercle, the TFL performs its effect on the tibia. Although it is only visible when the knee is flexed over 30 degrees, the TFL is a supporting knee flexor. Moreover, the TFL and IT band collaborate to stabilize the knee during full extension. The lateral rotation of the tibia is also influenced by the TFL through the IT band. As is evident when kicking a football, this lateral rotation may be executed with the hip in the abduction and medial rotation positions.

In terms of clinical use, the TFL’s main purpose is to facilitate walking. The contralateral hip rises as a result of the TFL pulling the ilium inferiorly on the weight-bearing side. During the swing phase of the stride, the leg can swing through without touching the ground thanks to the elevation in the non-weight-bearing hip.

Embryology

One skeletal muscle is the TFL. Skeletal muscle is formed by the paraxial mesoderm, which also forms somitomeres in the head and somites from the occipital to the sacral regions. The progenitor cells known as myoblasts fuse together to form long multinucleated muscle fibres during embryonic development. Myofibrils are seen in the cytoplasm, and by the third month’s end, cross-striations are seen. Tendon is produced by sclerotome cells that are positioned next to myotomes at the boundaries of somites (both anterior and posterior), and it will eventually connect the TFL to the Gerdy tubercle of the tibia.

One kind of transcription factor that controls tendon growth is SCLERAXIS. Together with WNT proteins from nearby ectoderm, lateral plate mesodermal fibroblast growth factors and bone morphogenetic protein 4 (BMP4) instruct the dermomyotome VLL cells to produce the muscle-specific gene MyoD. WNT protein synthesis is stimulated by BMP4 through the dorsal neural tube. In the meanwhile, the dermomyotome DML cells are exposed to the low osmolarity of sonic hedgehog (SHH) proteins, which are released by the neural tube’s floor plate and the notochord. The induction of MYF5 and MyoD endocytosically is caused by these expressions. Myogenic regulatory factors (MRFs) are transcription factors that activate TFL and other pathways involved in muscle development. MyoD and MYF5 belong to this family.

Clinical Significance

When there is tension, friction across or between bony prominences, or when the TFL is attached to the IT band, it can become clinically relevant. Particularly when there is a protracted shortening, such while sitting, the TFL may get constricted. An anterior pelvic tilt and/or medial femur rotation might result from a shortened TFL.

Patients with external snapping hip syndrome describe a perceptible snap that happens with different motions on the lateral part of their hip. Although there are several possible causes of this illness, the IT band shifting across the greater trochanter is the most frequent cause. The posterior band of the IT fascia is assumed to have thickened as a result of this. Even while people with this illness frequently do not complain of discomfort, it might eventually become uncomfortable. Physical therapy along with oral NSAIDs is the usual conservative treatment approach.

A frequent overuse ailment seen in cyclists and runners is IT band syndrome. Patients complain of knee discomfort on the lateral side. Although the exact cause of IT band syndrome is unknown, most experts concur that it falls into one of three primary categories:

Deep to the ITB, compression of the fat and connective tissue

Prolonged inflammation of the bursa in the IT band

Physiologic Variants

While the TFL usually ends before the greater trochanter, it can continue distally to the trochanter in around one-third of cases. This is important from a clinical standpoint since in certain cases, a lateral approach to the proximal femur requires splitting the TFL fibres.

Surgical Considerations

The anterior, anterolateral, posterior, and medial surgical methods are the four fundamental hip joint surgical techniques used in orthopaedics. Surgical landmarks such as the TFL are employed in anterior and anterolateral approaches. The internervous plane between the sartorius (femoral nerve) and the TFL (superior gluteal nerve) is used for the anterior approach to the hip. The intermuscular plane between the TFL and gluteus medius is used in the anterolateral approach to the hip. This method lacks a real internervous plane since the superior gluteal nerve innervates both the gluteus medius and the TFL. But very near to its origin at the iliac crest, the superior gluteal nerve enters the TFL.

The TFL can be utilised to cover soft tissue in reconstructive surgery. There have been documented cases of the TFL being used for free, regional, and local flaps. The TFL is not usually the first option for free flaps because of its modest size, although there have been case reports of TFL free flaps being used in the absence of latissimus dorsi and rectus abdominis flaps. By using the lateral circumflex system of the femoral vasculature, the TFL can be utilised in combination with an anterolateral thigh flap when a significant region has to be covered.