Myofascia of the Knee
Lateral knee fascia
The lateral compartment has three-layers:
Superficial lateral of the retinaculum : continuation of the fascia lata enveloping the vastus lateralis. Laterally and distally from the insertion of the vastus lateralis on the patellar proximal-lateral angle it becomes gradually thicker and adherent as it covers and partly joins the fibrous thickening of the iliotibial tract. Interdigitations between the fascia lata and iliotibial tract, as well as myofascial expansions from the vastus lateralis form the lateral retinaculum: a crisscross of longitudinal fibers (attaching to Gerdy tubercle to join the crural fascia), and oblique fibres (that run anteriorly to attach to the patella and patellar ligament and fascial fibres) (Biz et al 2022).
Intermediate layer of the retinaclum: lateral patellofemoral ligament (refer ‘anterior knee fascia’; ‘patella retinaculum’; ‘lateral retinaculum’). Whilst not part of the retinaculum the lateral collateral ligament is at this level.
Deep layer: joint capsule and lateral patellomeniscal ligament (refer ‘anterior knee fascia’; ‘patella retinaculum’; ‘lateral retinaculum’).
Iliotibial band
The iliotibial band is merely a lateral expansion of the fascia lata. It is a consolidation of the tensor fascia latae anteriorly, gluteal aponeurotic fascia centrally, and gluteus maximus posteriorly. The proximal iliotibial band is divided into three layers: superficial, middle and deep.
Superficial and middle layer: encloses the tensor fascia lata anchoring it to the iliac crest. The superficial layer originates from the iliac crest anterior to the gluteal aponeurotic fascia origin, and the intermediate layer arises from the ilium just below the tensor fascia lata origin. These layers unite at the distal end of the tensor fascia lata to form a tendon for the muscle. These two united layers receives fibers from the gluteus maximus and gluteal aponeurotic fascia to run down the lateral thigh. As it courses down the lateral thigh Fairclough et al (2006) found the iliotibial band continuous with the strong lateral intermuscular septum, which was firmly anchored to the linea aspera of the femur. Evans (1979) found fibers from the lateral intermuscular septum form the horizontal fibers of the iliotibial band.
Distally, after coursing through the biceps femoris and vastus lateralis Godin et al (2017) found the distal attachments of the iliotibial band to be:
Proximal bundle: runs nearly transversely from the superficial iliotibial band to the distal femur. Inserts on the proximal ridge of the distal femoral body, distal to the lateral intermuscular septum 53.6 mm proximal to the lateral epicondyle.
Distal bundle: runs from the superficial iliotibial band from a proximal and lateral to distal and medial direction inserting on to the supracondylar flare. This could be Kaplan fibers mentioned below under 'lateral femoral condyle and epicondyle'.
Lateral femoral condyle and epicondyle: Herbst et al (2017) found transverse fibers from the deep layer of the iliotibial band (Kaplan fibers) connect the superficial iliotibial band to the distal femoral metaphysis and condyle. These authors also found accessory insertions of the deep iliotibial band located proximal and anterior to the lateral femoral epicondyle. Fairclough et al (2006) described the attachment of the iliotibial band to the region of, or directly to, the lateral epicondyle as strong fibrous ‘tendinous’ strands and then more ‘ligamentous’ strands between the lateral epicondyle of the femur and Gerdy's tubercle on the tibia. Variable and indistinct insertions from the capsulo-osseous layer are also attached to the lateral epicondyle.
Capsulo-osseous layer: a distinct fascial portion of the deep iliotibial band. Runs from just proximal to the lateral gastrocnemius tubercle to the lateral tibial tubercle*. Herbst et al (2017) found variable and indistinct attachments from this layer around the lateral femoral epicondyle. The capsulo-osseous layer is intimately related to the lateral knee capsule and the fascia surrounding the lateral gastrocnemius tendon and biceps femoris (Herbst et al 2017). Evans (1979) found additional attachments to the lateral meniscus.
Gerdy’s tubercle: the superficial iliotibial band attaches on to a wide area from Gerdy tubercle anteriorly to the anterolateral and lateral tibia posteriorly. Deep fibers of the iliotibial band attach slightly posterior to Gerdy’s tubercle (Herbst et al 2017).
Iliopatellar Band: attaches to the lateral aspect of the patella and patellar tendon. The distal edge of this portion forms the lateral patellotibial ligament, part of the lateral retinaculum. Merican et al (2009) found these fibers resist knee flexion and medial patella deviation.
*: The lateral tibial tubercle is located on the anterolateral aspect of the proximal tibia, between the Gerdy’s tubercle and the fibular head (Godin et al 2017).
Herbst et al (2017) failed to the find the anterior lateral ligament on dissection. These authors found the capsulo-osseous layer of the ITB and the mid-third capsular ligament both occupied anatomic locations that are similar to that of the anterior lateral ligament. This ligament is documented as resisting internal rotation of the tibia.
Fairclough et al (2006) found conversely to popular belief no bursa was found between the tendinous fibrous bands of the iliotibial band and femur just adipose tissue.
Wilke et al (2016) found more distally the iliotibial band connected strongly to the crural fascia which in itself was hardly separable from the peroneal longus fascia.
Deep layer: The deep layer of the iliotibial band emerges where the superficial and middle layers fuse distal to the tensor fascia lata (Putzer et al 2017). From here it runs superiorly coursing deep attaching to the vastus lateralis and rectus femoris fascia. Coursing deeper still it follows the iliofemoral ligament to attach to the supraacetabular fossa between the tendon of the reflected head of the rectus femoris and the hip joint capsule. It resists hip extension.
Williams (1879) gives a description of the attachment of the deep layer of the iliotibial band to the rectus femoris. He describes at a short distance below the insertion of the tensor fascia lata into the deep layer of the iliotibial band a strong process of fascia lata arising from the iliotibial band passing obliquely upwards and inwards to join the tendon of the rectus femoris at the junction of its two heads. It also spreads backwards over the outer surface enclosing the reflected head of the rectus femoris, to which it is very firmly adherent, being fixed above to the inferior gluteal line, anterior inferior iliac spine and below blending with the capsule of the joint. This band of fascia binds down the tendon of the reflected head of the rectus femoris and connects the two heads.
Additional muscular attachments to the iliotibial band include:
Vastus lateralis (Becker et al 2010). The fascia lata enveloping the vastus lateralis becomes gradually thicker and adherent as it descends laterally and distally from the insertion of the vastus lateralis on the patella as it covers and partly joins the fibrous thickening of the iliotibial tract (Biz et al 2022).
Biceps femoris.
Tensor fascia lata.
Gluteus maximus.
Biceps femoris (Terry & LaPrade 1996)
The fascia covering the posterior aspect of the biceps femoris is continuous with the:
Superficial layer of the iliotibial tract.
Distally the fascia of the lateral compartment of the leg.
Distally and posterolaterally this fascia covers the peroneal nerve.
Long Head of the Biceps Femoris Muscle
The long head of the biceps femoris tendon forms proximal to the knee. At the knee, this tendon divides into two tendinous components: a direct arm (inserts on the fibular head) and an anterior arm (inserts on the fibular head).
The tenson of the long head of biceps femoris also has three fascial components: a reflected arm (inserts on the posterior edge of the iliotibial tract), a lateral arm and an anterior aponeurosis. The lateral side of the anterior arm of the biceps femoris tendon terminates as the anterior aponeurosis that covers the anterior compartment of the leg, whereas the anterior edge of the anterior arm provides an attachment for a lateral aponeurotic expansion and has many fibrous attachments to the lateral collateral ligament.
Short Head of the Biceps Femoris Muscle
The short head of the biceps femoris muscle originates just medial to the linea aspera of the distal femur and has two insertions: a direct arm that attaches on to the fibular head, and an anterior arm that partially blends with the anterior tibiofibular ligament, and inserts on the lateral tibial tuberosity. Throughout its course, the anterior edge of the anterior arm is inseparable from the lateral aponeurosis of the short head of biceps femoris.
It has a proximal muscular attachment to the anterior and medial side of the tendon of the long head of the biceps femoris, a capsular arm that attaches to the posterolateral joint capsule, the capsuloosseous layer that attaches to the iliotibial tract (biceps-capsuloosseous iliotibial tract confluens) and a lateral aponeurosis (inserts on to the lateral collateral ligament).
Medial knee fascia
Wymenga et al (2006) identified three layers of the fascia in the medial knee:
Layer I: superficial fascia
The superficial fascia is fascia lata and deep crural fascia.It blends with the pes anserine and tibial periosteum. The superficial portion of layer I adheres to the sartorius. The deep portion of layer I adheres to the gracilis and semitendinosus tendons (Wymenga et al 2006).
In the patellar region, the fascia lata’s interdigitations with the periosteum, peritenon, quadriceps aponeurosis and capsular structures of the deep layers make it difficult to separate the fascia lata from the deep structures i.e. deep medial collateral ligament as a thickening of the medial joint capsule (refer to layer III) (Biz et al 2022) as they blend into one and join the medial retinaculum (Wymenga et al 2006).
The fascia lata envelopes the vastus medialis and sartorius being thinner in this medial region as muscle fibres from the vastus medialis insert into its inner side. Running distal to the insertion of the vastus medialis on the proximal-medial corner of the patella, this fascia becomes wider and assumes a crisscrossed texture due to fibres joining it from the posterior fascia of the sartorius. This wider, crisscrossed part of the fascia, which is adherent to the quadriceps aponeurosis, is the medial retinaculum. The medial retinaculum continues on the medial leg surface, becoming thicker due to the deep interdigitations with the distal insertion of the sartorius muscle and fibres coming from the posterior region of the leg and adhering to the hamstring tendons and fascia. At the pes anserinus level, the fascia is quite adherent, less elastic and fixed to the tendons’ insertions of the pes anserinus (Biz et al 2022).
Layer II: superficial medial collateral ligament
The superficial medial collateral ligament extends from just proximal and posterior to the medial femoral epicondyle to the anteromedial tibial crest 5–7 cm below the joint line. LaPrade (2009) found a majority of the distal attachments of the superficial medial collateral ligament to be to the semimembranosus and pes anserine bursa rather than the tibia. But Biz et al (2022) found it to attach slightly posterior to the insertion of the pes anserinus to which it was connected by fibrous bundles.
Posteriorly these fibres are continuous with the oblique fibres of layer III although this was disputed by LaPrade (2009) who found no clear connection. Anterior to the femoral attachment the superficial medial collateral ligament is continuous with the medial patellofemoral ligament (medial femoral epicondyle —> medial patella). As well as being attached to the superficial medial collateral ligament the medial patellofemoral ligament also receives fibrous expansions from the distal tendinous insertion of the vastus medialis (Biz et al 2022).
Tuncay et al (2007) found the semitendinosus and gastrocnemius tendons to lie between layer I and II.
Just as the superficial portion of layer I adheres to the sartorius, the deep portion of layer I adheres to the gracilis and semitendinosus tendons. Tuncay et al (2007) found two fascial bands associated with the semitendinosus:
Dense 3–4-cm band around the gracilis and semitendinosus tendons approximately 8–10 cm proximal to their tendon insertion.
Fascial band originating from the semitendinosus and extending to the gastrocnemius fascia.
The superficial (and deep) medial collateral ligament resists valgus strain and internal rotation between 0-90º flexion < 30º. The superficial medial collateral ligament also resists external rotation at 0-90º flexion (Requicha & Comley 2021).
Layer III: the true capsular layer and mid-third medial capsular ligament (deep medial collateral ligament)
Layer III thickens and forms the deep medial collateral ligament as a thickening of the medial joint capsule.
The deep medial collateral ligament (layer III) separates the superficial medial collateral ligament (layer II) from the medial meniscus.
The deep medial collateral ligament extends from just distal and posterior to the medial femoral condyle to the meniscus (meniscofemoral fibers); and from the meniscus to a fan-wide tibial attachment (meniscotibial fibers). It’s adherent to the articular capsule (Requicha & Comley 2021).
Proximally the deep medial collateral ligament attachment merges into the superficial medial collateral ligament fibres, but sometimes it has a distinct attachment 0.5 cm distally.
The meniscotibial attachment of the deep medial collateral ligament is clearly separated from the superficial medial collateral ligament but blends with it posteriorly.
Anterior to the superficial medial collateral ligament layer III is thin and loose blending with layer I (fascia lata attachments from the vastus medialis and fibers from the posterior fascia of the sartorius) into the retinaculum.
Conjoint attachments of layers II and III
The conjoined tissue of layers II and III forms the posteromedial capsule. The posteromedial capsule is composed of (Ramos et al 2021):
Posterior oblique ligament.
Posterior horn of the medial meniscus.
Capsular joint.
Semimembranosus tendon insertion. The posteromedial capsule is also known as the ‘semimembranosus corner’ since all the structures in this region are directly related to it.
A condensation of fibres within the posteromedial capsule forms the posterior oblique ligament. This ligament extends from the semimembranosus tendon being orientated obliquely to blend with the posterior margin of the superficial medial collateral ligament and attaches to the posterior-medial surface of the proximal tibia. It posteriorly reinforces the articular capsule. It is an important stabiliser of the medial side of the knee < extension with internal rotation and external rotation at 0-30º of flexion (Requicha & Comley 2021).
The femoral attachment of the posteromedial capsule is located at the adductor tubercle. It attaches to the posterior horn of the medial meniscus and tibia tightening in extension to contribute to the control of posterior tibial translation (Requicha & Comley 2021).
The posteromedial capsule is augmented by:
Semimembranosus tendon: inserts into the medial and posteromedial tibia just below the joint line and creates an “octopus-like weave” with several expansions to the posteromedial capsule and posterior medial meniscus (along with the deep medial collateral ligament). This enables it to function as a dynamic stabiliser against external rotation and anterior translation of the tibia (Requicha & Comley 2021) and valgus strain (Ramos et al 2021).
Adductor magnus tendon: LaPrade et al (2009) found the distal-medial aspect of the adductor magnus tendon had a thick fascial expansion, which fanned out posteromedially and attached to the medial gastrocnemius tendon, the capsular arm of the posterior oblique ligament and the posteromedial capsule.
Gastrocnemius: as well as a thick fascial attachment to the adductor magnus the medial gastrocnemius has a thin fascial band extending to the capsular arm of the posterior oblique ligament (LaPrade et al 2009).
Fascia of the sartorius, gracilis & semitendinosus (Stecco 2015 pg 335)
Medially the myofascial expansions of the sartorius, gracilis and semitendinosus form the pes anserinus superficialis. The myofascial expansion of the semimembranosus form the pes anserine profundis.
Tendons of the gracilis and semitendinosus have longitudinal fascial expansions that fuses with the crural fascia. The semimembranosus has myofascial expansions that attach on to the crural fascia covering the medial head of the gastrocnemius.
Due to the considerable tension from the sartorius, semitendinosus, semimembranosus and gastrocnemius these myofascial expansions may act as fascial tensors stabilising the medial knee when weight bearing.
Fibers from the posterior fascia of the sartorius form the retinaculum, along with the vastus medialis fibers insertion on to the fascia lata (Biz et al 2022) and medial joint capsule (and deep medial collateral ligament) (refer layer III) (Wymenga et al 2006).
Posterior knee fascia
Popliteal fascia
Satoh et al (2016) found the popliteal fascia a single aponeurotic sheet acting as a three-layered retinaculum:
Layer one. The superficial layer of the popliteal fascia. Strongly interwoven with the epimysium of biceps femoris along its lateral aspect and with that of the semimembranosus along its medial aspect. This ensures that the flexor muscles remained in their correct positions.
Layer two. The intermediate layer: arose from the medial side of biceps femoris and merged medially with the superficial layer.
Layer three. The deep layer: stretched transversely between the biceps femoris and the semimembranosus.
These authors found this fascia was innervated by the posterior femoral cutaneous or saphenous nerve. These nerves are closely related and distributed to densely packed collagen fibers in layer one (superficial layer) as free or encapsulated nerve endings. Therefore this fascia could be a source of pain in the upper region of the popliteal fossa.
Stecco (2015 pg 334-335) identified fascial re-enforcements in the posterior aspect of the knee formed by myofascial expansions of the:
Sartorius.
Popliteus. Posteromedial tibia (forming the floor of the popliteal fossa) —> popliteal hiatus (roof formed by the superior popliteomeniscal fascicle, the floor formed from the inferior popliteomeniscal fascicle and attaches the popliteus to the lateral meniscus) —> enters the knee beneath the lateral collateral ligament and the biceps femoris tendon —> outer side of the lateral condyle of the femur. Blends with the joint capsule. The popliteofibular ligament: popliteus myotendinous junction —> fibular head. It is one of the strongest lateral stabilizers in the knee (Siddharth et al 2014).
Semimembranosus.
Biceps femoris: attaches on to the lateral condyle of the femur, head of fibula, tibia, crural fascia, popliteus tendon and arcuate popliteal ligament. Therefore, it possibly has an important in knee stability having a synergistic effect between the biceps femoris and the popliteus muscles (Tubbs et al 2006)
Anterior knee fascia
Fibrous layers that cover the knee anteriorly consist of:
Superficial aponeurotic layer is a continuation of the fascia lata proximally and the crural fascia distally.
Intermediate layer: is subdivided into the deep and superficial midline layers.
i. Superficial midline layer: laterally is a thick extension of the ITB. Medially is a thin expansion from the sartorius that connects to the fascia lata.
ii. Deep midline layer: fibers creating the quadriceps and patellar tendons and the crossed fibers of the vastus medialis and vastus lateralis traveling to the tibial condyles of the opposite side.
Deep layer: fibrous layer. Medial and lateral to the patella. Comprises the patellofemoral and meniscopatellar ligaments of the patella retinaculum.
Patella retinaculum
Patella retinaculum is made of (Stecco 2015 pg 328-334):
Fibers passing from the iliotibial band in front of the patella and continue to the crural fascia.
Expansion of the vastus lateralis and medialis.
Expansions of the rectus femoris and vastus intermedius attaching to the patella and crural fascia.
Superficial portion of the medial collateral ligament.
Lateral capsular ligament.
Medial patella retinaculum
The medial patella retinaculum is made up of:
Medial patello-femoral ligament (MPFL).
Medial quadriceps tendon–femoral ligament (MQTFL).
Medial patello-tibial ligament (MPTL).
Medial patello-meniscal ligament (MPML)
Medial patello-femoral ligament (MPFL)
The MPFL is an hourglass-shaped structure. Femur: adductor tubercle, medial femoral epicondyle and gastrocnemius tubercle --> patella: superomedial aspect (Aframian et al 2017). The patella attachments occur mainly through the aponeurosis of the vastus medialis and vastus intermedialis (Placella et al 2014).
Wymenga et al (2006) found attachments of the superficial medial collateral ligament (femoral epicondyle --> anteromedial tibial crest) to the MPFL. Waligora et al (2009) found the MPFL (as well as the LPFL) fused with the fibrous layer of the joint capsule.
These authors also found attachment of the posteromedial joint capsule to the MPFL attachment to the adductor tubercle.
Tanaka (2016) found variations in these attachment finding all MPFL fibers can either attach to the patella or quadriceps tendon.
Medial quadriceps tendon–femoral ligament (MQTFL)
Medial aspect of the distal quadriceps tendon --> femur: adductor tubercle region.
Medial patello-tibial ligament (MPTL)
Patella: medial to the inferior pole* --> tibia: anteromedial tibia (Kruckeberg et al 2019).
Medial patello-meniscal ligament (MPML)
Patella: medial to the inferior pole* --> medial meniscus (Hinckel et al 2019).
*: MPTL and MPML share a common insertion.
Mechanics of the medial patella ligaments
Tanaka et al (2019) found the MPFL accounts for only half of the total restraint to lateral patellar displacement.
These authors found the remaining contributions to patellar stability are derived from the combination of the MPTL and MPML, which function primarily in greater degrees of knee flexion.
In contrast Decante et al (2019) found during knee flexion, the upper bands (upper patella --> femur) stretched while the lower bands (lower patella --> femur) shortened.
The lateral patella retinaculum is made up of:
Iliopatellar band of the ITB (ITB-P).
Lateral patellofemoral ligament (LPFL).
Lateral patellomeniscal ligament (LPML).
Fibers from the vastus lateralis form part of the lateral patella retinaculum (Waligora et al (2009).
Lateral patella retinaculum
In the lateral region, the fascia lata envelopes the vastus lateralis up to the insertion on the patellar proximal-lateral angle. It then becomes gradually thicker and more adherent laterally and distally where it covers and partly joins the fibrous thickening of the iliotibial tract. Interdigitations between the fascia lata and iliotibial tract, as well as myofascial expansions from the vastus lateralis form a crisscross of longitudinal fibers (attaching to Gerdy tubercle to join the crural fascia), and oblique fibres (that run anteriorly to attach to the patella and patellar ligament and fascial fibres). This mesh of fibers is called the lateral retinaculum and fuses with the joint capsule (Biz et al 2022).
Iliopatellar Band of ITB (ITB-P)
The ITB attaches to the lateral aspect of the patella and patellar tendon. The distal edge of this portion forms the ITB-P.
These fibres criss-cross in a predominantly transverse orientation. They are easily separated from the underlying joint capsule (Merican et al 2009).
These fibers are by far the strongest and stiffest structure in the lateral retinaculum. Being more transverse in orientation and densely arranged they resist medial displacement forces that pull the patella away from the ITB.
These fibers move anteriorly when the knee is extending knee slackening the ITB-P and is conversely pulled tight when the knee is flexed. Therefore these fibers are most tightly stretched in knee flexion and medial patella deviation.
Lateral patellofemoral ligament (LPFL) and lateral patellomeniscal ligament (LPML)
These capsulo-ligamentous bands are thickened bands of the lateral joint capsule. They are not always present as distinct fibre bands,
Lateral patellofemoral ligament (LPFL): patella (middle third) --> femur (distal and anterior to lateral epicondyle) (Shah et al 2017). The vastus intermedialis reinforces the LPFL (Waligora et al 2009). This ligament is separate from the capsular layer (Biz et al 2022).
Lateral patellomeniscal ligament (LPML): lateral border of the patella --> anterior aspect of the lateral meniscus.
Myofascial relations of the quadricep tendon (Waligora et al 2009)
Traditionally the quadriceps femoris insertion into the patella as a common tendon has been described as a three-layered arrangement:
Superficial layer: rectus femoris.
Middle layer: vastus lateralis (including vastus lateralis obliquus) and vastus medialis (including vastus medialis obliquus).
Deep layer: vastus intermedialis.
The strict segregation of these layers can be misleading on dissection.
Superficial layer: rectus femoris
The rectus femoris inserts on to the anterior portion of the patella tendon. Some fibers continue on to the ligamentum patella.
The thickening of the deep fascia posterior to the rectus femoris contribute to the quadricep tendon.
Middle layer: vastus lateralis and vastus medialis
The vastus lateralis and vastus medialis unite to form a continuous aponeurosis that inserts onto the patella posterior to the rectus femoris and continues laterally and medially inserting into the sides of the patella. This aponeurosis is indistinguishable from the fascia lata and retinacula (Biz et al 2022). A thickening of the fascia posterior to the vastus medialis and vastus lateralis also contributes to the quadricep tendon.
Vastus lateralis (& vastus lateralis obliquus)
From the vastus lateralis fibers cross superficial to the patella to the medial condyle of the tibia.
Other fibers blends with the capsule of the knee and form part of the the lateral patellar retinaculum
The vastus lateralis obliquus is a distinct group of vastus lateralis fibers. They are separated from the main belly of the vastus lateralis. Much like the vastus medialis obliquus they can be classified as the more distal oblique fibers of the vastus lateralis.
This vastus lateralis obliquus can originate from the lateral intermuscular septum or ITB and attach on to the superolateral part of the quadriceps tendon.
These fibers provide a more direct lateral pull on the quadriceps tendon due to their lateral insertion on the quadriceps tendon.
Vastus medialis (& vastus medialis obliquus)
Most fibers of the vastus medialis end in an aponeurosis that blends with the medial side of the suprapatellar tendon or the rectus femoris tendon.
More distal fibers form a tendinous expansion attaching to the medial side of the patella. Deep fibers from this expansion reinforce the joint capsule as part of the medial patellar retinaculum.
Obliquely oriented fibers from the vastus medialis obliquus (with the vastus intermedialis) attach the MPFL to the patella (Placella et al 2014).
As with the vastus lateralis tendinous fibers from the vastus medialis obliquus pass across the patella to attach to the lateral tibial condyle.
Deep layer: vastus intermedialis
The vastus intermedialis inserts through a broad, thin tendon into the base of the patella.
Medially and laterally it reinforces the MPFL and LPFL.
Thickening of the deep fascia anterior to the vastus intermedialis contributes to the quadricep tendon.
References
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