Sonographic measurement of deep fascia parameters - Interrater reliability.

PURPOSE: The deep fascia has recently been a current topic in many medical fields, including rehabilitation. Some research has already focused on assessing deep fascia, however results of individual authors differ in certain aspects. This study focuses on the inter-rater reliability of ultrasound (US) measurement of the thickness of deep fascia and loose connective tissue (LCT). The aim was to define the causes of any discrepancies in measurement that could contribute to the unification of management of evaluating fascia. METHODS: An observational study was performed including 20 healthy individuals in whom fascia lata of the anterior thigh was examined by US imaging and then measured in Image J software. Three raters participated in this study: the first with 6 years of US imaging experience, other two were newly trained. The measurement of fascial parameters was conducted in two phases with special consultation between them resulting in an agreement of the research team on the more precise way of measurement. RESULTS: Results revealed the value of inter-rater reliability ICC3,1 = 0.454 for deep fascia thickness and ICC3,1 = 0.265 for LCT thickness in the first phase and any significant difference in the second phase. This poor inter-rater reliability led to a search for possible causes of discrepancies, which authors subsequently highlighted. CONCLUSION: The findings of the study show the main pitfalls of deep fascia measurement that should contribute to the unification of evaluation.

An anatomical comparison of the fasciae of the thigh: A macroscopic, microscopic and ultrasound imaging study.

Although the number of Ultrasound (US) imaging studies investigating the fascial layers are becoming more numerous, the majority tend to use different reference points and terminology to describe their findings. The current work set out to compare macroscopic and microscopic data of specimens of the fascial layers of the thigh with US imaging findings. Specimens of the different fascial layers of various regions of the thigh were collected for macroscopic and histological analyses from three fresh cadavers and compared with in vivo US images of the thighs of 20 healthy volunteers. The specimens showed that the subcutaneous tissue of the thigh is made up of three layers: a superficial adipose layer, a membranous layer/superficial fascia, and a deep adipose layer. The deep fascia is composed of an aponeurotic fascia, which envelops all the thigh muscles and is laterally reinforced by the iliotibial tract and an epimysial fascia, which is specific for each muscle. The morphometric measurements of the thickness of the superficial fascia were different (anterior: 153.2 ± 39.3 µm; medial: 128.4 ± 24.7 µm; lateral: 154 ± 28.9 µm; and posterior: 148.8 ± 33.2 µm) as were those of the deep fascia (anterior: 556.8 ± 176.2 µm; medial: 820.4 ± 201 µm; lateral: 1112 ± 237.9 µm; and posterior: 730.4 ± 186.5 µm). The US scans showed a clear picture of the superficial adipose tissue, the superficial fascia, and the deep adipose tissue, as well as the deep fasciae. The epimysial and aponeurotic fasciae of only some topographic areas could be independently identified. The US imaging findings confirmed that the superficial and deep fascia have different thicknesses, and they showed that the US measurements were always larger with respect to those produced by histological analysis (p < 0.001) probably due to shrinkage during the processing. The posterior region (level 1) of the superficial fascia had, for example, a mean thickness of 0.56 ± 0.12 mm at US, while the histological analysis showed that it was 148.8 ± 33.2 µm. Showing a similar pattern, the thickness of the deep fascia was as follows: 1.64 ± 0.85 mm versus 730.4 ± 186.5 µm. Study results have confirmed that US can be considered a valid, non-invasive instrument to evaluate the fascial layers. In any event, there is a clear need for a set of standardised protocols since the thickness of the fascial layers of different parts of the human body varies and the data obtained using inaccurate reference points are not reproducible or comparable. Given the inconsistent terminology used to describe the fascial system, it would also be important to standardise the terminology used to define its parts. The difficulty in distinguishing between the epimysial and aponeurotic/deep fascia can also impede data interpretation.

Measurement of iliotibial band diameter in iliotibial band friction syndrome and comparison with an asymptomatic population.

BACKGROUND: Iliotibial band friction syndrome (ITBFS) is an overuse injury of the lateral aspect of the knee. This syndrome classically affects the active young population. PURPOSE: To determine the diameter of the ITB using magnetic resonance imaging (MRI) in patients clinically diagnosed with ITBFS, compare the results with asymptomatic patients, and assess the inter-observer agreement between a senior and a junior radiologist with different levels of experience in musculoskeletal imaging. MATERIAL AND METHODS: From April 2014 to October 2019, 78 knee MRI scans of 78 patients were included in the study group who were referred from the orthopedic clinic with a clinical diagnosis of ITBFS. In the control group, there were 114 knee MRI scans of 114 patients who had knee MRI for various reasons and had no radiological abnormality on the performed knee MRI. The ITB diameters, cut-off values, and interclass correlation coefficient (ICC) were calculated. RESULTS: Mean thickness of the ITB was higher in the study group compared to the control group in measurements done by both the senior and junior radiologists and this was statistically significant (P < 0.001). Cut-off values of the diameters of the ITB were calculated as 2.385 for the senior radiologist and 2.420 for the junior radiologist. ICC of 0.80 was determined, which showed excellent agreement among interpreters. CONCLUSION: ITB thickness in the study group was significantly higher than in the control group. There was also excellent agreement among the two observers. Measurement of ITB thickness on axial plane knee MRI is one of the reliable criteria for ITBFS.

A fluoroscopic analysis of the length changes of the capsulo-osseous layer of the distal iliotibial band.

PURPOSE: Previous studies have implicated the iliotibial band and its deeper capsulo-osseous layer as key restraints against internal rotation. However, the kinematic properties of the capsulo-osseous layer, throughout knee range of motion, are not currently known. Therefore, the purpose of this research was to quantify the length changes of this structure through various degrees of knee flexion. METHODS: Ten cadaveric knee specimens were dissected to expose the capsulo-osseous layer of the iliotibial band. Radiopaque beads were embedded, at standardized increments, into the tissue and fluoroscopic images were taken from 0° to 105° of knee flexion in 15° increments. The positions of the beads were identified in each image and the length, width, and area changes of the capsulo-osseous layer were calculated. The data were analyzed as a percent change from 0° and compared across flexion angles using a repeated-measures analysis of variance (α = 0.05). RESULTS: There was a significant increase in the length of the capsulo-osseous layer at flexion angles greater than 30°, with changes occurring primarily at the level of the femoral insertion. Meanwhile, non-homogenous decreases in width and area were found with increasing flexion angle. The distance between the capsulo-osseous layer insertion on the distal femur and proximal tibia significantly increased from 60° to 105°; maximal changes occurred at 105° [9.64 (4.12) %, p = 0.003]. CONCLUSIONS: The capsulo-osseous layer of the iliotibial band behaves in a non-isometric fashion and this work suggests that tensioning and fixation should occur between 75° and 105° of flexion, if repair or reconstruction is indicated.

High-resolution ultrasound of the fascia lata iliac crest attachment: anatomy, pathology, and image-guided treatment.

Pathology of the fascia lata attachment at the iliac crest (FLAIC) is an under-recognized and often misdiagnosed cause of lateral hip pain. The fascia lata has a broad attachment at the lateral iliac crest with contributions from the tensor fascia lata muscle, the iliotibial band, and the gluteal aponeurosis. The FLAIC is susceptible to overuse injuries, acute traumatic injuries, and degeneration. There is a paucity of literature regarding imaging and image-guided treatment of the FLAIC. We review anatomy and pathology of the FLAIC, presenting novel high-resolution (18-24 MHz) ultrasound images including ultrasound guidance for targeted therapeutic treatment.

Influence of female hormones on fascia elasticity: An elastography study.

The aim of this study was to examine the influence of hormonal changes during the menstrual cycle on deep fasciae. A total of 29 women, 17 users, and 12 nonusers of hormonal contraceptives were examined clinically and by ultrasound, including shear wave elastography, at two phases of the menstrual cycle. The thickness and elasticity of the fascia lata, thoracolumbar fascia, and plantar fascia were measured, compared between hormonal contraceptive users and nonusers, and correlated with clinical data. There were statistically significant differences between users and nonusers of hormonal contraceptives: the thoracolumbar fascia was thicker in nonusers (P = 0.011), and nonusers had higher maximal and mean stiffnesses of the fascia lata (P = 0.01 and 0.0095, respectively). Generally, nonusers had a higher body mass index (BMI). The elasticity of the thoracolumbar and the plantar fasciae did not differ significantly between the groups. We found no correlation between thickness and elasticity in the fasciae. There were no statistically significant differences in hypermobility, cephalgia, or dysmenorrhea between users and nonusers of hormonal contraceptives. The results of this pilot study suggest that deep fasciae can be evaluated by shear wave elastography. Nonusers of contraceptives had greater stiffness of the fascia lata and higher BMI. Clin. Anat. 32:941-947, 2019. © 2019 Wiley Periodicals, Inc.

Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males.

Incidence of transexualism and request for neophalloplasty is increasing yielding a current prevalence of trans-male in the USA of 1:2500. Surgeons have explored various techniques to improve desirable outcomes of neophallic construction, decrease the length of surgery, and minimize stigmatizing scars. The anterolateral thigh (ALT) flap is an alternative to the traditional radial forearm flap for patients who do not want a forearm scar. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The ALT flap is a skin, fat and fascia flap that is usually supplied by the descending branch of the lateral circumflex femoral vessels and the lateral femoral cutaneous nerve. However, variability in neurovascular supply does exist with important clinical implications. In the pedicled surgical procedure, neurovascular supply is left partly attached to the donor site ("pedicle") and simply transposed to the perineum, keeping the pedicle intact as a conduit to supply the tissue with blood and innervation. ALT flap offers clinical advantages of less obvious donor site concealable with clothing, decreased surgical time, preservation of erogenous sensation and vascular supply of the flap without microsurgical anastomosis of nerves and vessels, and good potential for urethroplasty. This surgery may be difficult in patients with thicker skin and more subcutaneous thigh fat. Clin. Anat, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Morphometric and dynamic measurements of muscular fascia in healthy individuals using ultrasound imaging: a summary of the discrepancies and gaps in the current literature.

PURPOSE: The objectives of this work was to conduct a comprehensive state-of-the art review of the current literature to identify any gaps or discrepancies and summarize the main challenges for obtaining a homogeneous evaluation of muscular fascia in healthy individuals. METHODS: An electronic document search using key words and MeSH terms was performed with various databases. Two independent investigators were tasked with the screening of articles and data extraction. A critical appraisal of what is known was then conducted. RESULTS: The literature search identified 65 articles related to healthy facia in the various databases consulted and 20 articles were kept for the review. The thickest portion of the fascia lata (the iliotibial tract) and the plantar fascia are the most often studied muscular fasciae whereas there is paucity of studies on fascia related to other muscles in the body. CONCLUSION: US imaging is suitable to complement physical examination and for evaluating treatment outcomes. However, the small number of studies and the heterogeneity of the methods did not allow us to establish normal reference values for muscular fascia thickness and to provide strong recommendations about measurement protocols.

Morphometric properties of the tensor fascia lata muscle in human foetuses.

BACKGROUND: In neonatal and early childhood surgeries such as meningomyelocele repairs, closing deep wounds and oncological treatment, tensor fasciae lata (TFL) flaps are used. However, there are not enough data about structural properties of TFL in foetuses, which can be considered as the closest to neonates in terms of sampling. This study's main objective is to gather data about morphological structures of TFL in human foetuses to be used in newborn surgery. MATERIALS AND METHODS: Fifty formalin-fixed foetuses (24 male, 26 female) with gestational age ranging from 18 to 30 weeks (mean 22.94 ± 3.23 weeks) were included in the study. TFL samples were obtained by bilateral dissection and then surface area, width and length parameters were recorded. Digital callipers were used for length and width measurements whereas surface area was calculated using digital image analysis software. RESULTS: No statistically significant differences were found in terms of numerical value of parameters between sides and sexes (p > 0.05). Linear functions for TFL surface area, width, anterior and posterior margin lengths were calculated as y = -225.652 + 14.417 × age (weeks), y = -5.571 + 0.595 × age (weeks), y = -4.276 + 0.909 × age (weeks), and y = -4.468 + 0.779 × age (weeks), respectively. CONCLUSIONS: Linear functions for TFL surface area, width and lengths can be used in designing TFL flap dimensions in newborn surgery. In addition, using those described linear functions can also be beneficial in prediction of TFL flap dimensions in autopsy studies.

The iliotibial tract: imaging, anatomy, injuries, and other pathology.

The iliotibial tract, also known as Maissiat's band or the iliotibial band, and its associated muscles function to extend, abduct, and laterally rotate the hip, as well as aid in the stabilization of the knee. A select group of associated injuries and pathologies of the iliotibial tract are seen as sequela of repetitive stress and direct trauma. This article intends to educate the radiologist, orthopedist, and other clinicians about iliotibial tract anatomy and function and the clinical presentation, pathophysiology, and imaging findings of associated pathologies. Specifically, this article will review proximal iliotibial band syndrome, Morel-Lavallée lesions, external snapping hip syndrome, iliotibial band syndrome and bursitis, traumatic tears, iliotibial insertional tendinosis and peritendonitis, avulsion fractures at Gerdy's tubercle, and Segond fractures. The clinical management of these pathologies will also be discussed in brief.

Deep and superficial circumflex iliac arteries and their relationship to the ultrasound-guided femoral nerve block procedure: A cadaver study.

The in-plane lateral to medial approach is a standard technique for ultrasound-guided femoral nerve block (USG-FNB). The first bifurcation of the femoral artery, which consists of the deep artery of the thigh (DAT) or occasionally the lateral circumflex femoral artery (LCFA), is regarded as the distal border for this procedure. We sometimes detect arteries along the estimated needle trajectory for USG-FNB. The superficial (SCIA) and deep (DCIA) circumflex iliac arteries run laterally parallel to the inguinal ligament from the femoral or external iliac artery. The relationship between the SCIA and DCIA and other anatomical structures related to USG-FNB around the femoral triangle region was studied by gross anatomical examination of 100 formalin-fixed adult cadavers. At least one SCIA and one DCIA were identified around each femoral triangle; 81.8% of SCIA and 58% of DCIA originated from the femoral artery. All DCIA coursed between the fascia lata and fascia iliaca and 80% of SCIA penetrated the fascia lata. In 94% of femoral triangles, at least one arterial branch heading towards the lateral part of the thigh originated from the femoral artery from the level of the inguinal ligament to the first bifurcation of the femoral artery. The presence of SCIA and DCIA should be considered during USG-FNB using the in-plane lateral to medial approach to avoid inadvertently injuring them, as they are occasionally located along the presumed needle trajectory superficial to the fascia iliaca. Clin. Anat. 30:413-420, 2017. © 2017 Wiley Periodicals, Inc.

Anatomical study of the morphological continuity between iliotibial tract and the fibularis longus fascia.

PURPOSE: Recent research indicates that the skeletal muscles of the human body do not function as independent actuators. Instead, they seem to be linked by connective tissue forming myofascial chains. While the existence of such meridians has been demonstrated for the ventral and the dorsal side of the body, no data are available for morphological fusion of lateral muscles. This study aimed to provide evidence for the inferior part of the lateral myofascial chain. METHODS: Fourteen legs (7 embalmed cadavers, four ♂, 86 ± 7 years) were dissected to reveal a potential myofascial continuity between the fibularis longus muscle, more detailed, its fascia, and the iliotibial tract (ITT). Three investigators judged the general existence as well as the degree and characteristics of the continuity. If an anatomical continuity was evident, strain was applied to both structures in order to evaluate the tissues' ability for tensile transmission. RESULTS: An indirect connection between the iliotibial tract and the fascia of the fibularis longus muscle was found: in all examined legs, the ITT fused strongly with the crural fascia. The latter was hardly separable from the fibularis longus fascia. Application of strain to the ITT caused local movement in the crural fascia and the underlying fascia of the fibularis muscle. CONCLUSIONS: The iliotibial tract fuses firmly with the crural fascia and the degree of continuity suggests that moderate amounts of strain might be transmitted. However, biomechanical studies precisely quantifying this tensile transmission are warranted in order to estimate the relevance of the linkage for the locomotor system.

The human iliotibial band is specialized for elastic energy storage compared with the chimp fascia lata.

This study examines whether the human iliotibial band (ITB) is specialized for elastic energy storage relative to the chimpanzee fascia lata (FL). To quantify the energy storage potential of these structures, we created computer models of human and chimpanzee lower limbs based on detailed anatomical dissections. We characterized the geometry and force-length properties of the FL, tensor fascia lata (TFL) and gluteus maximus (GMax) in four chimpanzee cadavers based on measurements of muscle architecture and moment arms about the hip and knee. We used the chimp model to estimate the forces and corresponding strains in the chimp FL during bipedal walking, and compared these data with analogous estimates from a model of the human ITB, accounting for differences in body mass and lower extremity posture. We estimate that the human ITB stores 15- to 20-times more elastic energy per unit body mass and stride than the chimp FL during bipedal walking. Because chimps walk with persistent hip flexion, the TFL and portions of GMax that insert on the FL undergo smaller excursions (origin to insertion) than muscles that insert on the human ITB. Also, because a smaller fraction of GMax inserts on the chimp FL than on the human ITB, and thus its mass-normalized physiological cross-sectional area is about three times less in chimps, the chimp FL probably transmits smaller muscle forces. These data provide new evidence that the human ITB is anatomically derived compared with the chimp FL and potentially contributes to locomotor economy during bipedal locomotion.

Iliotibial band syndrome: an examination of the evidence behind a number of treatment options.

Iliotibial band (ITB) syndrome (ITBS) is a common cause of distal lateral thigh pain in athletes. Treatment often focuses on stretching the ITB and treating local inflammation at the lateral femoral condyle (LFC). We examine the area's anatomical and biomechanical properties. Anatomical studies of the ITB of 20 embalmed cadavers. The strain generated in the ITB by three typical stretching maneuvers (Ober test; Hip flexion, adduction and external rotation, with added knee flexion and straight leg raise to 30 degrees ) was measured in five unembalmed cadavers using strain gauges. Displacement of the Tensae Fasciae Latae (TFL)/ITB junction was measured on 20 subjects during isometric hip abduction. The ITB was uniformly a lateral thickening of the circumferential fascia lata, firmly attached along the linea aspera (femur) from greater trochanter up to and including the LFC. The microstrain values [median (IQR)] for the OBER [15.4(5.1-23.3)me], HIP [21.1(15.6-44.6)me] and SLR [9.4(5.1-10.7)me] showed marked disparity in the optimal inter-limb stretching protocol. HIP stretch invoked significantly (Z=2.10, P=0.036) greater strain than the SLR. TFL/ITB junction displacement was 2.0+/-1.6 mm and mean ITB lengthening was <0.5% (effect size=0.04). Our results challenge the reasoning behind a number of accepted means of treating ITBS. Future research must focus on stretching and lengthening the muscular component of the ITB/TFL complex.

Cadaveric fascia lata versus intravaginal slingplasty for the pubovaginal sling: surgical outcome, overall success and patient satisfaction rates.

BACKGROUND: A wide variety of surgical procedures has been used to treat female stress urinary incontinence (SUI). The purpose of this study was to compare cadaveric fascia lata (CFL) sling with intravaginal slingplasty (IVS) in the surgical treatment of SUI. METHODS: One hundred and thirty-nine women with SUI were randomly assigned to either CFL sling (n = 67) or IVS (n = 72). Concomitant urinary urge incontinence was present in 49 patients (73%) in the CFL sling and 44 patients (61%) in the IVS group. Daily mean pad usage was 4.1 +/- 3.5 in the CFL sling and 2.9 +/- 1.7 in the IVS group. The objective cure rate was evaluated by the pad test, and patient satisfaction rate was assessed by a subjective questionnaire. RESULTS: The surgical results of both procedures with a follow-up 12 months were documented. The overall success rate was 79% in the CFL sling and 70.8% in the IVS (p = 0.261). In contrast patient satisfaction rates were 82 and 87.5%, respectively (p = 0.210). Comparison of the CFL sling with IVS showed persistent urinary urge incontinence in 67 and 25% (p = 0.0001) and de novo urinary urge incontinence in 22 and 6.9%, respectively (p = 0.009). The groups did not differ significantly with respect to intraoperative and postoperative complications. CONCLUSIONS: There is no statistical difference in the overall success, satisfaction and complication rates in either group. In our series, both procedures were found to be effective, durable and significantly improved quality of life in patients with SUI but long-term results are awaited.

Is iliotibial band syndrome really a friction syndrome?

Iliotibial band (ITB) syndrome is regarded as an overuse injury, common in runners and cyclists. It is believed to be associated with excessive friction between the tract and the lateral femoral epicondyle-friction which 'inflames' the tract or a bursa. This article highlights evidence which challenges these views. Basic anatomical principles of the ITB have been overlooked: (a) it is not a discrete structure, but a thickened part of the fascia lata which envelops the thigh, (b) it is connected to the linea aspera by an intermuscular septum and to the supracondylar region of the femur (including the epicondyle) by coarse, fibrous bands (which are not pathological adhesions) that are clearly visible by dissection or MRI and (c) a bursa is rarely present-but may be mistaken for the lateral recess of the knee. We would thus suggest that the ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee. The perception of movement of the ITB across the epicondyle is an illusion because of changing tension in its anterior and posterior fibres. Nevertheless, slight medial-lateral movement is possible and we propose that ITB syndrome is caused by increased compression of a highly vascularised and innervated layer of fat and loose connective tissue that separates the ITB from the epicondyle. Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed.

Morphological and histomorphometric evaluation of the ventral rectus sheath of the rectus abdominis muscle, fascia lata and pectoral fascia. The beginning of a morphological information bank of human fascias.

The aim of this study was to characterize and compare the morphological and histomorphometric characteristics of the pectoral fascia, fascia lata and ventral rectus sheath. Twenty cadaveric samples of these fascias were analyzed and stained with hematoxylin and eosin, orcein, Van Gieson, Masson's trichrome and Verhoeff¨s stain (1200 slides in total). Morphological evaluation, semiquantitative, morphometric and microdensitometric analysis of elastic fibers present in each of the tissues and a morphometrical analysis of tissue thickness were performed. The mean value of the pectoral fascia thickness was 612±68.13 µm; 84±246 µm for the fascia lata and 584±92 µm for the ventral rectus sheath. The area occupied by the elastic fibers in the pectoral fascia was 12.24±5.84%; 6,54±3.85% for the fascia lata and 11.11±5.26% for the ventral rectus sheath. There were no statistically significant differences when comparing the mean values between the pectoral fascia and the ventral rectus sheath (p=0.07). There were statistically significant differences when comparing the fascia lata to the pectoral fascia and the ventral rectus sheath (p≤0.001). This study reports other morphological characteristics not described in previous histological studies of the analyzed tissues. The results of the morphometric and densitometric analysis in this study reveal that the fascia lata has the fewest elastic fibers of all the tissues analyzed, and the pectoral fascia has the most. These results will be useful for the beginning of a morphological information bank of human fascias.

Structural Properties of the Anterolateral Capsule and Iliotibial Band of the Knee.

BACKGROUND: The role of the anterolateral capsule in knee stability has recently been advocated by studies reporting that a distinct ligament exists in this area. Defining the structural properties of the anterolateral capsule can provide insight into its contribution to joint stability. The structural properties of the iliotibial band also need to be determined, as it is a common graft used for extra-articular tenodesis. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the structural properties of the anterolateral capsule and iliotibial band. The hypothesis was that the iliotibial band will have comparable structural properties to the anterolateral capsule because it is generally an accepted graft for extra-articular reconstruction surgeries. STUDY DESIGN: Controlled laboratory study. METHODS: Nine human cadaveric knees (average age, 57 ± 10 years) were dissected to assess the presence of a discrete capsular thickness originating from the lateral femoral epicondyle to the lateral tibial plateau between the Gerdy tubercle and the fibular head. For each knee, 2 constructs were prepared: (1) a bone-anterolateral capsule-bone specimen and (2) a strip of iliotibial band attached to the Gerdy tubercle. Structural properties, including ultimate load, ultimate elongation, and stiffness, were determined for the anterolateral capsule and the iliotibial band. After tensile testing, plain radiographs were obtained for evaluation of the Segond fracture. A paired t test was used to compare the structural properties of the anterolateral capsule with the iliotibial band. Significance was set at P < .05. RESULTS: Two of the 9 specimens were found to have a discrete thickening of the anterolateral capsule. The iliotibial band had almost 50% higher ultimate load and nearly 3 times higher stiffness (487.9 ± 156.9 N and 73.2 ± 24.1 N/mm, respectively) compared with the anterolateral capsule (319.7 ± 212.6 N and 26.0 ± 11.5 N/mm, respectively) (P < .05 for both). The anterolateral capsule had about double the ultimate elongation compared with the iliotibial band (15.5 ± 7.3 and 8.6 ± 1.4 mm, respectively; P < .05). CONCLUSION: The anterolateral capsule demonstrated significantly reduced structural properties compared with the iliotibial band. The anterolateral capsule did not have a higher ultimate load compared with the posteromedial capsule as reported in the literature. CLINICAL RELEVANCE: The decision to perform an extra-articular reconstruction using an iliotibial band graft should be considered carefully. Unnecessary reconstructions using soft tissue grafts with structural properties that far exceed that of the anterolateral capsule may result in overconstraint of the ACL-reconstructed knee.

Iliotibial band syndrome in runners: innovations in treatment.

Iliotibial band syndrome (ITBS) is the most common cause of lateral knee pain in runners. It is an overuse injury that results from repetitive friction of the iliotibial band (ITB) over the lateral femoral epicondyle, with biomechanical studies demonstrating a maximal zone of impingement at approximately 30 degrees of knee flexion. Training factors related to this injury include excessive running in the same direction on a track, greater-than-normal weekly mileage and downhill running. Studies have also demonstrated that weakness or inhibition of the lateral gluteal muscles is a causative factor in this injury. When these muscles do not fire properly throughout the support phase of the running cycle, there is a decreased ability to stabilise the pelvis and eccentrically control femoral abduction. As a result, other muscles must compensate, often leading to excessive soft tissue tightness and myofascial restrictions. Initial treatment should focus on activity modification, therapeutic modalities to decrease local inflammation, nonsteroidal anti-inflammatory medication, and in severe cases, a corticosteroid injection. Stretching exercises can be started once acute inflammation is under control. Identifying and eliminating myofascial restrictions complement the therapy programme and should precede strengthening and muscle re-education. Strengthening exercises should emphasise eccentric muscle contractions, triplanar motions and integrated movement patterns. With this comprehensive treatment approach, most patients will fully recover by 6 weeks. Interestingly, biomechanical studies have shown that faster-paced running is less likely to aggravate ITBS and faster strides are initially recommended over a slower jogging pace. Over time, gradual increases in distance and frequency are permitted. In the rare refractory case, surgery may be required. The most common procedure is releasing or lengthening the posterior aspect of the ITB at the location of peak tension over the lateral femoral condyle.

Obtaining fascia lata.

The surgical procedure for obtaining fascia lata can be easily carried out by the ophthalmic surgeon. However, anatomy related to obtaining the tissue, as outlined in standard surgical textbooks, is not entirely accurate and should be clarified. The tissue necessary for strong frontalis slings should come from a thick band of fascia lata referred to as the "iliotibial tract." If one attempts to obtain fascia lata by directing a fascia stripper along an imaginary line directed from the head of the fibula to the anterior iliac spine, as suggested in most textbooks, an inadequate specimen may be obtained. The iliotibial tract of fascia lata actually runs from the lateral tibial condyle to the iliac crest. The fascia stripper, therefore, needs to be directed along an imaginary line from the lateral tibial condyle to the iliac crest to obtain the strongest fascia lata and avoid transecting the longitudinal fibers.