Download CHAPTER ONE: INTRODUCTION

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CHAPTER ONE:
INTRODUCTION
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1.1
OVERVIEW
Osteopathy is a form of manual medicine and science. It is a philosophy that respects the
inherent healing abilities of the human form. It is a marriage between scientific knowledge and art. It
unites anatomy and physiology with the realm of creativity and individuality. The objective of osteopathy
is to normalize mobility and motility of both individual structures and bodily systems. Restoring the
health, and mobility to each system allows for normal, harmonious inter-system communications to
occur, and the body to function at optimum. Health exists when there is normal anatomical and
physiological communication within all systems in the human organism.
Osteopathy came into existence by a medical doctor who was presently dissatisfied with the
medical profession at the time. Osteopathy was discovered by Dr. Andrew Taylor Still in the year 18741.
Dr. Still lost three children to a meningitis epidemic2. He became disenchanted with the traditional
medical system and the prescription of drugs at the time. After extensive study of anatomy and
physiology, and realization that restoring balance to these two integrative fields of study that the body has
an innate ability to self heal3. Still also realized that structure governs function, the role of the artery is
absolute, and the body functions as a unit4. These are the four basic concepts of osteopathy.
With osteopathy the goal is to search for the causes to the dysfunctions, and to normalize the
inherent movement and mechanics and bring the body back to balance so that it may function as an
integrated unit. If the functioning of tissue is compromised and not reversed, it may cause compensatory
actions and movements. This may have an effect locally and also systemically.
1
(Still, 1987, p. 2)
2
(Webster, 1917, p. 17)
3
(Goetz, 1900, p. 7)
4
(Goetz, 1900, p. 14)
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The osteopath strives to re-establish normal function with manipulative measures that are
designed to help normalize the area or structure in lesion5. The osteopath acts as a mechanic to normalize
and tinker with any abnormalities present in the structure or soft tissue, in order to assist the body to heal
itself. Still recognized that most diseases and conditions are either, caused or maintained by structural
imbalances in the body. These imbalances can directly interfere with normal function 6. That is why it is
paramount to address any structural concerns, in order to facilitate the body to function unhindered and
optimally. Still recognized the relationship of structure and function. He also recognized how important
the role of the artery is.
As a result, every cell and system must be properly nourished. The body compensates and adapts
in order to ensure that the liquid lifeline is maintained. Still recognized that the nerves and all tissues are
bathed in lymph and blood7. He believed that the fluids were a natural healing source in the body. Still
believed that the cure for all diseases, and the innate protection is found in the blood8. He believed that if
you remove the cause that is clogging or blocking the blood flow, the blood has inherent curative
properties, and can heal all diseases.
The osteopath embraces the use of complexity when treating the biomechanics of the body. With
an understanding of the biomechanics of the human body, the osteopath can treat distant from the region
of the patient’s complaints or symptoms. For example, an issue concerning the hip bone and the tensions
of the ligamentous complex in this region, can create problems via fascial chains down to the knee, and
even more distally down to the foot. It is extremely important to see all the connections in a
biomechanical chain and see the complexity of the cause and effect that can continue to distant locations.
5
(Goetz, 1900, p. 15)
6
(Hulett, 1903, p. 25)
7
(Lane, 1918, p. 11)
8
(Lane, 1918, p. 28)
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The paradigm of osteopathy respects the complexity of the human organism. The human body
can be broken down into systems, organs, tissue and cells. Osteopathy respects how all these systems
work independently, but more importantly the inter-relationship between all systems. Other health
professionals specialize and focus on specific regions or systems of the body. This is a very limiting,
short sighted paradigm to work with. In this case the practitioner is limited with their short sightedness.
They see only the individual trees that make up a forest, but they fail to see the whole forest, or the
complexity and relationship that the individual trees have that constitutes the forest as a whole.
Osteopaths see the human organism as a functioning unit. Osteopathy values the continuities, contiguities
and relationships with all structures and functions within the body. Osteopathy is a complex,
comprehensive form of manual medicine formed by principles to assist the body to heal itself.
1.2
BACKGROUND
I have been interested in pursuing a career as a health care professional for quite some time now.
I was exposed to physiotherapy at a young age as a result of playing competitive sports, and sustaining
sports related injuries. The extent of some of these sports related injuries resulted in quite a few
orthopedic surgeries. I spent countless hours in clinics for rehabilitation for injuries and post surgical
orthopedic care. Having been a competitive athlete and experiencing the stress, frustration, identity loss
and disappointment of not being able to participate or contribute to my teams success while recovering
from injuries, I found my calling. I wanted to be involved with an active population, and I wanted to be
able to help people return to their normal activities or sports as efficiently and prudently as possible.
I was fortunate to receive a soccer scholarship to Mercyhurst University in Erie, Pennsylvania
where I received a physiotherapy assistant degree. This was just a taste into the realm of healthcare, and I
wanted to know more. I continued my studies in the United States where I received a Baccalaureate of
Science in Sports Medicine with a concentration in Athletic Therapy. It was there where I was initially
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introduced to osteopathy. Our team Doctor on campus was an Osteopathic Doctor. I was extremely
fascinated with his approach and the amount of manual treatment he did. It was inspiring to see this
doctor really take the time to listen and assess and even treat his patients. I was accustomed to the normal
5-8 minute appointments with regular doctors, who rarely palpated and were just eager to write a
prescription, and see the next person in the waiting room. This to me was fascinating. So I looked into
Osteopathy, and learned that there are major differences in the profession between Canada and the United
States.
Once I graduated and returned to Canada, I studied to be a Registered Massage Therapist. Again,
I was happy to receive more techniques in my repertoire, but I felt that there must be more. I was not
interested in studying Chiropractic or even Physiotherapy. I really wanted to find a curriculum that would
inspire and challenge me, and provide me with a skill set to treat effectively. I decided to give
Osteopathy a try. I had always enjoyed anatomy, and thought I had a good handle on it. I was quickly
humbled when during the first day of my first osteopathy class six years ago, when Guy Voyer was
teaching. I could not believe all the information that was being delivered. I learned very quickly that first
class at Sutherland Academy of Osteopathy that there was a huge arena of anatomy that I did not know
about. All the information I had learned over my years of study seemed rather elementary after that first
class. I felt that my previous curriculums had created such a false sense of knowledge. That is when my
journey to be an Osteopath began. It was a very challenging, humbling, even frustrating journey at times.
It has made me a much better practitioner, and allowed me to grow and still aspire to grow and learn more
in this field.
Osteopathy has a very different approach then traditional therapy. Osteopathy inspires the
practitioner to find the source of the ailment or complaint. It emphasizes the necessity of individualized
treatments. It provides a philosophy of searching out any restriction or lesioned tissue and normalizing all
the links in continuity and contiguity that may be influencing the normal functioning of an area.
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Every Osteopathic school at the moment has their own focal points and approach to their
curriculum. The emphasis at Sutherland Academy of Osteopathy is the complexity of the fascial system
and how it relates to the biomechanics of the human structure. Lesions and imbalances in the fascial web
can influence optimal functioning of soft tissue structures and the normal functioning of osteoarticulations. These fascial imbalances can create chaos at a muscular, oste-oarticular, and neurological
level. At Sutherland we learn a series of fascial chain techniques that focus on balancing any altered or
asymmetrical tensions in biomechanical chains throughout the body.
1.3
METHODOLOGY OF SUTHERLAND ACADEMY
Sutherland Academy strives to ensure the quality of its graduates by emphasizing a strong
foundation in anatomy, and biomechanics. Another important characteristic is that the philosophy of
traditional osteopathy be applied and respected. The teachings at Sutherland provided students with all
the needed tools and skill to treat lesions and ailments. The philosophy that no two treatments are alike
because of the complexity and individuality of each patient is also a strongly emphasized paradigm at
Sutherland.
The theory of complexity is also strongly emphasized. Actively using the complexity model as the style
of teaching at Sutherland, and then encouraging us to continue to use complexity theory in our daily
treatments. The teachers at Sutherland aspired for the students to truly embrace osteopathy in totality,
and did not want the curriculum to just develop highly trained manual practitioners. Appreciating and
understanding all that osteopathy entails, and applying the theory, are fundamentally as important, if not
more important than the execution of the quality of the techniques in treatments. One can easily have a
repertoire of tools, but knowing when and how to use them to treat in an organized manner is an art and
science in itself.
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1.4 ON COMPLEXITY
Complexity is a whole system approach to understanding and describing a system with in depth
knowledge of the inter-connectedness of all the parts of the whole. Blaise Pascal described complexity
paradigm in his book Pensees, “…that it is impossible to understand the whole without understanding the
parts and impossible to understand the part without understanding the whole9.” Osteopathy embraces this
philosophy. Understanding the anatomy, and all the miniscule continuities and contiguities is crucial
when treating an individual. A prudent osteopath needs to understand the macro anatomy and the micro
anatomy of the human machine. Complexity paradigm is present with every single osteopathic
assessment, treatment and palpation. This paradigm must be respected when treating the complex human
organism. It is not enough to be able to visualize the gross anatomy. Looking at the knee, the osteopath
needs to visualize and feel beyond the patellofemoral joint. The osteopath must demonstrate a profound
knowledge of the gross anatomy, the vascular, the neurological, and the interconnectedness of the fascial
web of the entire human being. Complexity is not isolated to visualization of the anatomy.
Complexity also applies to the various fields and planes the osteopath must feel and interpret.
Palpation is both a science and an art. With experience, and patience, the osteopath can feel the density of
the various types of tissue, and the fluid dynamics of a structure. Feeling fluidic blocks, fascial
restrictions, or the direction of ease and resistance is just another way how complexity permeates the
philosophy of osteopathy.
As the osteopath palpates and treats, a dialogue is created between the local tissue, distant tissue,
and with the osteopaths own hands via a phenomenon of thixotropy. This dialogue or communication
travels up and down myofascial chains in the body. Restricted, adhered structures acquire more freedom
to move towards their optimum range. The local and adjacent structures regain their normal mobility and
motility. The rhythm and pressure applied is perceived by mechanoreceptors in the skin and underlying
fascia, and can have a stimulating, normalizing, or inhibiting effect at the nervous system level.
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(Morin, 2008, xvi)
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Complexity uses the reigns of anatomy and physiology; however the osteopath can control these reigns
with observation and palpation.
1.5 METHODOLOGY
By applying the philosophy of Osteopathy and the techniques learned at Sutherland Academy of
Osteopathy, I hope to demonstrate the effectiveness of an osteopathic treatment on patellofemoral pain
syndrome using fascial chains. After an initial assessment, patient history taking to determine etiology,
and reviewing the questionnaires completed by the subjects, the goal of the osteopathic treatments is to
determine and treat structural and soft tissue imbalances with various normalizing techniques. Each
treatment will be individualized to respect the complexity of each subject. After the initial assessment,
and clearing structural imbalances, the next step is to determine which fascial chain needs to be addressed
via induction testing. Once this is established the fascial chain is normalized in its entirety. Addressing
the structural, soft tissue, and fascial chains will have an effect on the biomechanics of the lower
extremity. After each treatment the patient is educated and assigned quadriceps myofascial stretching.
The control group completes the same questionnaires, and assessments. They receive effleurage
treatments to the lower extremity of the affected side.
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CHAPTER TWO:
Background
Information
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2.1
PATELLOFEMORAL PAIN SYNDROME OVERVIEW
The knee is an area that is subject to injury, and patellofemoral pain syndrome is a common
ailment that affects the anterior aspect of the knee. Patellofemoral syndrome, commonly known as
“runners knee”, affects all age groups of various activity levels. Patellofemoral pain syndrome (PFPS) is
one of the most common musculoskeletal complaints of the knee constituting 25% of all identified knee
pathologies10. It is reported to affect 15-33% of the active adult population and 21-45% of adolescents11.
PFPS affects both the athletic and non athletic population and effects the female athletic population more
readily. More specifically, PFPS effects the adolescent female population more readily12. Unfortunately,
this syndrome tends to be more female dominant.
People that have PFPS typically complain of anterior knee pain during activity and is aggravated
with ascending or descending stairs, squatting or hill work. People experiencing PFPS also complain of
pain with prolonged activities or inactivity especially with prolonged sitting. It can be associated with
unilateral or bilateral knees13. This can be a very painful syndrome, especially if associated with both
knees.
2.2
ETIOLOGY
OVER TRAINING
There are many theories on how patellofemoral pain syndrome develops. The general consensus in the
therapeutic world is that PFPS is a multi-factorial pathology. Anterior knee pain develops insidiously,
and is characterized as acute or sharp, or diffuse over the area of the knee14. In addition to a sudden
appearance, PFPS can also result from over training. PFKS can manifest as with an increase in activity, a
10
(Baqquie, 1997, p. 10 ; Taunton, 2002, p. 95)
11
(Lindberg, 1986, p. 20 )
12
(Messier et all, p. 1991)
13
(Juhn, M, 1999, p. 2014)
14
(Goldberg, 1991, p. 187)
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change of training surfaces, and sudden increase in training load. In the latter situation, the theory behind
the development is a result of over-training, and not properly acclimatizing to the change in activity level
or surfaces, resulting in repetitive overloading of the patella-femoral joint15. Repetitive overloading of the
patella-femoral joint can cause an inflammatory condition.
Osteopathy is extremely valuable throughout the process of inflammation. We use fluidic soft tissue
techniques to aid the inflammatory process combined with gentle mobilisation to aid fluid movement and
to reduce stiffness. After the initial acute stage of inflammation, the osteopath can then decide how best
to modify each area within the fascial chain. If the injured area is stiff, or hypermobile, wearing down and
over-used, other areas in the chain may require modification by increasing their function so as to
redistribute forces more evenly. In these cases, it is far easier to increase a small amount of motion in
multiple areas, rather than a lot of motion in one area. Enough small changes will give a greater and safer
benefit without the body facing undue stress. In addition to overloading and over-training, biomechanics
is another theory as to the evolution of this syndrome.
2.2.2
BIOMECHANICAL CONSIDERATIONS
PFPS is theorized to develop as a result of various biomechanical considerations. Some factors
believed to contribute to PFPS is pes planus or excessive foot pronation. Foot pronation is a combination
of eversion, dorsiflexion, and abduction of the foot16. Excessive foot pronation occurs when the medial
arch of the foot is lacking or has been compromised. Excessive foot pronation causes an ascending
biomechanical compensation causing compensatory internal rotation of the tibia, possibly up to the femur.
This compensatory action effects the loading of the patellofemoral joint17. In addition to pes planus, an
individual with the opposite alignment, pes cavus can also experience sign and symptoms of PFPS. As a
15
(Goldberg, 1991, p. 188)
16
(Juhn, 1999, p. 2015)
17
(Juhn, 1999, p. 2016)
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result of a high arch, the cushioning effect is reduced, which can also contribute to additional stress on the
patellofemoral joint during heel strike phase of gait18 Foot morphology affects the biomechanical transfer
of forces and the result of increased tibial-femoral torsion will cause an increase in knee adduction, or
medial collapse of the knee19. In addition to foot morphology, the Quadricep, or ‘Q’ angle is considered
to be a biomechanical factor in PFPS.
Osteopathy looks at the functioning of all the parts of an individual. Osteoarticular pumping and
treatments on fascial chains addresses any biomechanical imbalances that may occur. Depending where
the lesioned tissue is in the chain, this can contribute to either ascending or descending lesions.
Osteopathy helps restore balance in the body by addressing any deviations from normal function.
2.2.3
QUADRICEPS ANGLE
According to the Wheeless’ Textbook of Orthopedics, the quadriceps angle, or ‘Q’ angle is
defined as the the angle formed by a line drawn from the anterior superior iliac spine to central aspect of
the patella and a second line drawn from the center part of the patella to the tibial tubercle20. In the
female population, the Q angle should be less than 22 degrees with the knee in extension and less than 9
degrees with the knee in 90 degrees of flexion21. In men, the Q angle should be less than 18 degrees with
the knee in extension and less than 8 degrees with the knee in 90 degrees of flexion. A typical Q angle is
12 degrees for men and 17 degrees for women22. This angle is significant in determining the tracking of
the patella through the trochlea of the femur. Typically, this angle is higher in females due to the
structural alignment of their pelvis in relationship to their knee. As the angle increases, the chance of
18
(Reid, 1992, p. 348)
19
(Powers, 2003, p. 640)
20
(Wheeless, 1996, online)
21
(Tibero, 1967, p. 162)
22
(Mohammed et all, 2007, p. 24)
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patellar compression problems increases, due to the increase in lateral pull of the patella on the
trochlear23. The patella is positioned in such a way to fit into the sulcus or trochlear on the femur. If this
is compromised as a result of mal-positioning of the patella or soft tissue imbalances, this will jeopardize
the efficiency of the patella-femoral joint. Another theory contributing to PFPS is muscular imbalances.
The osteopath will treat all the structures in tension, or lesion as a result of a quadriceps angle that
is deviant from the norm. Treating the links in the biomechanical chains is beneficial. Providing the
greatest freedom of movement in hypertonic tissue, or contracted tissue will help decrease compensatory
movements.
Figure 1, This diagram illustrates the quadriceps angle between males and females
(http://www.hughston.com/hha/a_14_4_2.htm).
2.2.3
MUSCULAR IMBALANCES
Plenty of theories suggest that muscular imbalances can contribute to the development of PFPS.
The primary imbalances in discussion are between the quadriceps and hamstrings, the tensor fascia lata
and gluteus medius, and between the vastus medialis and lateralis24. Any soft tissue imbalances that exist
23
(Mohammed et all, 2007, p. 25)
24
(Liebenson, 1996, p. 15; Press and Young, 1998, p. 255)
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within or around the structure of the knee can potentiate the manifestation of compromised tracking or
misalignment of the patella. The misalignment or mal-tracking of the patella may lead to cartilaginous
changes in the trochlear or underside of the patella, causing pain to the knee. The tensor fascia lata and
ilio tibial band have been suggested to be prime perpetrators in lateral translation of the patella25.
Muscular imbalances can contribute to the overall functioning of the knee and contribute to
biomechanical compromises at the knee joint.
Osteopathy sees the functioning of the muscular system and the effects it has on the fascial
system. It can contribute to postural issues, and biomechanical compensations. Addressing the
hypertonic tissues to allow optimal freedom within the chains is the goal of the osteopath. Addressing
the nervous system in cases of hypertonicity and hypotonicity addresses the individual in a holistic
encompassing manner. In addition to muscular imbalances, it has been suggested that tissue hypoxia may
contribute to PFPS.
2.2.4
TISSUE HYPOXIA
When an area is deprived of oxygen it is a pathological condition called tissue hypoxia. Tissue
hypoxia serves as a catalyst for the release of neural growth factors and substance P26. These substances
are important in normal body functions and contribute to body’s efforts in maintaining a homeostatic
environment. With the release of neural growth factors hyper-innervation may occur and substance Pcontaining nerves may generate pain27. In 2005, Sanchis-Alfonso et al., established that morphological
and ultra-structural changes affiliated with ischemia including hyper-vascularization and augmented
25
(Hudson, 2009, p. 148)
26
(Hudson, 2009, p. 150)
27
(Liebenson, 1996, p. 16)
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vascular endothelial growth factor were released in the lateral retinacula of painful patellofemoral
misalignment28. In addition to this theory, blunt trauma to the patella is speculated to contribute to PFPS.
Osteopathy has a set of tools that can address concerns like hypoxia. Fluidic and mechanical
osteo-articular pumping have a profound effect with fluidic dynamics. The role of the artery is supreme29.
Osteopathy can contribute significantly to vascular pathologies. Pumping techniques help the body to
remove tissue debris from the area, and bring oxygenated, nourishing blood to the area in question.
Another contributing factor to developing patellofemoral pain syndrome is blunt trauma to the
patella. Blunt trauma can cause an array of anatomical concerns such as cartilage softening, bruising, and
soft tissue splinting to name a few. These injuries can cause a change directly relating to the mechanics
of the knee, or create other lesions that the body may have to compensate for.
Osteopathy facilitates the inflammatory response during a traumatic or injurious event. This is
elaborated further in the section of inflammation.
Tiberio suggests that it is important to exclude any pathology that may mirror patellofemoral
symptoms30. These include, but are not limited to ligamentous injuries, tendinopathy, bursitis, plica
syndrome, and meniscal tears. This is done with thorough examination and assessment of the knee, and a
patient’s history taking. One of the most common denominator in determining if a patient has PFPS is
anterior or retro-patellar pain exacerbated with ascending or descending stairs, squatting, or prolonged
sitting or kneeling. That is determined based on the absence of other detectable pathology.
In addressing people with PFPS often practitioners develop tunnel vision. They focus largely on
the knee as the focal point of dysfunction. In osteopathy , an important part of the paradigm is looking at
28
(Sanchis-Alfonso et al. 1998, p. 704)
29
(Lane, 1918, p. 28)
30
(Tiberio, 1987, p. 161)
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an issue from all angles. Osteopathy is the philosophy that recognizes that the knee may be the result of
soft tissue and structural imbalances above and below the knee. A recent theory established by Press and
Young, is that an increase in lumbar lordosis combined with subtalar pronation may also contribute to
PFPS. These imbalances may contribute to the lateral translation of the patella. An increase in lumbar
lordosis coupled with subtalar pronation can contribute to lower limb kinematics. If the body is subjected
to these descending and ascending imbalances compensatory movements are inevitable. Unfortunately
one of the joints that maybe be subjected to the compensatory movements is the knee. These alterations
in biomechanics can lead to the patella tracking incorrectly in the trochlear. Once the mal-tracking of the
patella occurs there is additional stresses imparted on the underside of the patella, resulting in pain in this
joint.
Osteopathy provides us with the vision of finding the cause to these compensatory movements.
As opposed to just treating the compensatory mechanics occurring in the knee, an osteopath will fall the
links in tension above and below this joint and treat the entire chain of imbalances. Understanding the
symptomology of patellofemoral pain may help lead to a proper assessment of this condition.
2.3
SIGNS AND SYMPTOMS
People who have patellofemoral pains syndrome can experience a variety of signs and symptoms.
Two of the most common symptoms of PFPS is pain on or behind the patella and instability31. This pain
is often increased with repetitive motions such as ascending or descending stairs, running, jumping or
squatting motions32. Other classic sign of PFPS is pain with prolonged inactivity. Prolonged activities
such as kneeling, standing or sitting are often characteristic complaints of thus suffering from PFPS. Pain
specifically associated with prolonged sitting is termed the ‘theatre sign’33. Other characteristics include
31
(Nijs, 2006, p. 70)
32
(Green, 2003, p. 5)
33
(Green, 2003, p. 5)
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crepitus, pain with full flexion of the knee, and stiffness at the knee 34. McConnell has reported
“buckling” in the knee while walking, catching and locking, instability, and swelling around the knee as
additional symptoms of PFPS35. Since anterior knee pain can is a common pathology, and PFPS is often
indicated when other pathologies have been ruled out.
2.4
CONVENTIONAL TREATMENT
Typically patellofemoral pain syndrome is the result of chronic overload at the patellofemoral
joint. It is not typically cause from trauma. In the atypical occasions where it is caused by trauma,
typical conventional treatments includes rest and elevation and non-steroidal anti-inflammatory drugs for
the first seven days36. Additionally, in this time frame therapeutic modalities such as interferential
current, therapeutic pulsed ultrasound are utilized to manage the inflammatory stage. Avoidance of any
patellar loading exercises are to be avoided during 2.4this initial stage.
After the initial inflammatory stage has subsided, bracing and taping techniques are applied.
McConnell taping is typically applied from a lateral to medial direction to in order to influence patellar
glide, tilt, and rotation37. In addition to using taping during daily activities such as walking, the taping is
also utilized when doing rehabilitative exercises. The idea behind this taping is to influence abnormal
biomechanical movements of the patella.
Stretching and strengthening exercises are prescribed to restore balance in conventional therapy.
Typical stretching and foam rolling of the tensor fascia latae, and the ilio tibial band is a primary focus
34
(Green, 2003, p. 6)
35
(McConnell, 2002, p. 365)
36
( Green, 2003, p. 5)
37
(McConnell, 2002, p. 367)
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and generally prescribed. Strengthening of the vastus medialis and quadriceps, typically accompanied
with McConnell taping to re-establish normal patellar movement during closed kinetic chain exercises are
commonly prescribed.
Another modality used for typical treatment of this syndrome is orthotics. The idea is that the excessive
pronation will contribute to this syndrome, so a rigid orthotic will help counteract this compensatory
movement. These are the typical conventional methods to treating patellofemoral pain syndrome. They
are unfortunately a very linear and limited approach.
The complex approach of osteopathy, with the techniques learned at Sutherland Academy of
Osteopathy allow for treatments of the lower extremity via, structural fascial corrections. These structural
and functional corrections treat the entire lower extremity as a linked chain, and a biomechanical unit.
Conventional therapy tends to focus on one or two links in the chain, but the osteopath sees and treats all
the links and restores balance throughout this chain.
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CHAPTER THREE:
Contextual Information
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3.1
INFLAMMATION PROCESS
Inflammation is an important natural stage in the healing process. The stages of healing are not
independent and separate entities but rather overlap. Inflammation manifests is characterized by five
cardinal signs; redness, swelling, heat, pain, and loss of function38. These five cardinal signs occur in the
first stages of inflammation. Inflammation has been defined as, “the succession of changes which occur
in a living tissue when it is injured, provided that the injury is not of such a degrees to at once destroy its
structure and vitality39.” Inflammation is a natural occurrence in the body. The osteopath is fully able to
treat during the inflammatory stage of healing.
At the moment, various authors describe the inflammatory state as being a multi-staged process.
The number of stages ranges from three main stages all the way up to eight stages, depending on the
author, and their classification of stages. All the stages will be discussed, followed by an osteopathic
discussion of treatments acceptable during the various stages.
The inflammatory process can be triggered by a variety of mechanisms such as introduction of a
pathogen, or mechanical stresses. For the purpose of this paper, mechanical stress or trauma will be
discussed in detail. Trauma is one of the catalyst for the inflammation process. The body must experience
a form of trauma that impairs tissue structure. Trauma can consist of macro trauma, or micro trauma.
Macro trauma is tissue injury received by force or impact on the tissue40. An example of this sort of
injury is a contusion or contact injury sustained in a sporting event, or from a fall. Micro trauma is from
repetitive or over-use, friction like injuries41. In each of these cases the body perceives trauma and the
inflammatory process starts.
38
(Spector, 1963, p. 118)
39
(Sanderson, 1871, p. 34)
40
(Sanderson, 1871, p. 40)
41
(Sanderson, 1871, p. 41)
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The second stage of inflammation occurs at the cellular level and are regulated by a series of
specific cell signals that stimulate a variety of cell types, resulting in a cascade of events42. As a result of
tissue trauma, the membrane of the cell is disrupted. The cell becomes hypoxic as a result of injury and
the sodium pumps fail, causing sodium to increase in the cell43. The cellular membrane is disrupted and
contents of the cell spill into the extracellular spaces. Smooth muscles around larger blood vessels
contract to slow the flow of blood through the capillary beds at the injured site44. This stage is
considered the vasoconstriction process of the vascular phase. This gives more opportunity for
leukocytes to stick to the walls of the capillary and wring out into the surrounding tissue. With the
disturbance of the cell membrane, chemical mediators such as histamine and bradykinin spill out of the
cell45. These chemical mediators act as messengers to the body. The mast cells in the connective tissue
adjacent to blood vessels, in addition to the basophils, neutrophils, and platelets leaving the blood from
the injured capillaries stimulate the synthesis of these vasodilators46. Taber’s Cyclopedia Medical
Dictionary defines basophils as white blood cells that produce and store histamine, and heparin, an
anticoagulant47. The same reference defines neutrophils as the first white blood cell to respond during
soft tissue injury48. They notify the body that cells have been damaged, and direct the body to mobilize its
resources to deal with the situation. Histamines act to increase cellular permeability at this stage49. After
these substances have been released, vasodilation occurs. During this stage the endothelial cells that
42
(Sanderson, 1871, p. 45)
43
(Sanderson, 1871, p. 46)
44
(MacIntyre,1995, p. 24)
45
(MacIntyre,1995, p. 30)
46
(MacIntyre,1995, p. 30)
47
(Clayton, 1997, p. 204)
48
(Clayton, 1997, p. 1297)
49
(MacIntyre,1995, p. 31)
22
make up the wall of the smaller blood vessels contract50. This increases the space between the endothelial
cells resulting in increased capillary permeability. The blood vessels get larger in diameter as a result of
this.
Adhesion molecules are stimulated on the surface of the endothelial cells on the inner wall of the
capillaries51. Corresponding molecules on the surface of leukocytes called integrins attach to these
adhesion molecules52. The integrins cause the leukocytes to flatten and squeeze through the space
between the endothelial cells. This process is called diapedesis or extravasation.
Most leukocyte migration starts in the arterioles, then progresses to post-capillary venules
because hemodynamic shear forces are lower in these venules 53. The traumatic event resulting in the
start of the inflammatory process, causes a release of various mediators, such as the aforementioned
histamine, leukotrienes, and prostaglandins54. According to Sanderson, prostaglandins have a strong
physiological effect as to regulate the contraction and relaxation of smooth muscle tissue. As a result of
the vasodilation, and changes in cellular permeability, the leukocytes migrate from the blood vessels into
the site of injury. Vasodilation allows for increased blood flow, and is manifested as warmth and redness.
This leukocytic migration results in plasma exudate, from the blood, which contains important proteins
such as coagulation, fibrinin, and immunoglobins55. This plasma exudate is in excess at the injury site,
and causes local edema, and stasis as a result of the concentration of this substance.
50
51
(MacIntyre,1995, p. 32)
(Spector, 1963, p. 119)
52
(Spector, 1963, p. 119)
53
( Sanderson, 1871, p. 35)
54
( Sanderson, 1871, p. 36)
55
(Pilon, 2011, p. 2046)
23
The pressure of this additional fluid at the injury site, causes pain due to increased pressure on
nerve endings. The plasma exudate serves an important function by creating a protective perimeter
around the injured tissue. This exudates contains various proteins that result in a cascading even of
healing. This exudate contains fibrinogen, which forms clots and prevents additional loss of blood, and
plasminogen, which degrades the clot in time56. The fibrinogen is an important substance in the clotting
process. Fibrinogen gets converted to fibrin, which combines with platelets to form a net that traps red
blood cells to make a clot57. Once the inflammation has subsided, fibrinolytic process continue. Through
a series of enzymatic processes, the clot is broken down by plasmin58. There is a series of enzymatic
process that occurs in a specific sequence.
The leukocytes migrate to the vascular endothelial lining of the small vessels and create a tightly
packed formation on the endothelium. Normally, healthy endothelium does not bind circulating cells or
impedes their function. Once the leukocytes have migrated, they firmly adhere to the wall of the
endothelium, by means of cell adhesion molecules, and migrate through the wall of the endothelium
(diapedesis), into the interstitial spaces59. Neutrophils, monocytes, lymphocytes, eosinophils, and
basophils also use this same pathway to migrate into the tissue from the blood60. According to Pilon, the
predominating cell during the acute stage of inflammation is the neutrophils during the first six to twentyfour hours of the inflammatory process 61. This process is necessary and results in the slowing of the
blood in the blood stream and allows for chemical mediators and inflammatory cells to collect and
respond accordingly.
56
(MacIntyre, 1995, p. 27)
57
(MacIntyre, 1995, p. 27)
58
(MacIntyre, 1995, p. 27)
59
(MacIntyre, 1995, p. 28)
60
(Talukder, 2005, p.6)
61
(Pilon, 2011, p. 2046)
24
The neutrophils that utilized the same pathway as the leukocytes, migrate to the site of tissue
damage. The neutrophils mature and become phagoctyic cells that serve to engulf and kill bacteria or
tissue debris in the area. All these process occur in the acute stages of inflammation. The second stage of
inflammation is the regeneration and repair phase.
During the second stage of inflammation, which typically occurs from 48 hours from initial injury
and can last up to 4 weeks is the regeneration phase 62. The focus of this stage is to rebuild the site of
injury. The continued recruitment of fibroblasts and their rapid propagation at the site of injury are
responsible for the synthesis of collagens, proteoglycans and other constituents of the extracellular matrix
63
. Initially, these components are randomly placed at the site of injury. Fibroblasts continue to lay down
type III collagen fibers at the site of injury. While this is occurring, capillaries bud and grow in the region
of the tissue damage, and create an extensive vascular network64. This capillary network is important in
bringing nutrition to the area, and removing tissue debris. As this process continues, the number of
fibroblasts diminish as more collagen is being laid down65. This stage overlaps with the acute phase, and
with the major tertiary phase.
The third major stage is the remodeling stage. Type III collagen fibers are converted to type one
collagen at this phase66. The phase is believed to overlap the second stage of inflammation. This phase is
believed to start around weeks the first and second week post trauma67. Fibrin deposits from the
inflammatory stage will gradually be removed by fibrinolytic enzymes and be replaced by granulation
62
(Cameron, 1999, p. 15)
63
(Cameron, 1999, p. 16)
64
(Cameron, 1999, p. 16)
65
(Ryan, 1988, p. 185)
66
(Ryan, 1988, p. 185)
67
(Ryan, 1988, p. 186)
25
tissue, which organizes into scar tissue68. This tissue has a stronger tensile strength than in the second
phase. Collagen fibers are oriented in response to local stress subjected on the tissue.
Inflammation is a natural occurrence in the mechanism of self healing. Uncontrolled
inflammation can have an effect on normal function of an injured area. With the increase of swelling that
occurs, there is also an increase in pain, as a result of the increase pressure on the nerve endings, and
chemical irritants. Increase swelling in the extra cellular matrix, and muscle guarding inhibits normal
function. The additional fluid in the extra cellular matrix as a result of the process of inflammation,
creates a source of friction between adjacent layers of fascia69. In normal healthy tissue, the fascial layers
have an innate mobility. In healthy tissue, the inherent ebb and flow, or primary respiratory movement,
creates a fluidic gliding between fascial layers. If mobility of the fascial system is impaired, and
immobility occurs at this fascial level, long term consequences could result in disease or postural
imbalances70. The adherences, or potential lesions that occur at this tissue level, if not addressed in a
timely fashion, will have effects adjacent to the initial site of injury and at a distant, following direct
continuities and contiguities of the fascial chains in the body.
The inflammation process, if it becomes chronic and not properly intervened by the osteopath at
the correct time, can wreak havoc in the body. Fluid exchange is crucial to normal physiology. All
processes in the body occur because of the fluidic flow. Should the flow become slowed or completely
stagnant, vital processes in the body will be altered, and health will be compromised.
3. 1.2 OSTEOPATHIC CONSIDERATIONS FOR INFLAMMATION
68
(Ryan, 1988, p. 187)
69
(Sanderson, 2007, p. 325)
70
(Sanderson, 2007, p. 325)
26
Osteopathy via palpation and soft tissue techniques addresses pathologies of friction or overuse.
The inflammatory condition is controlled, but not impeded, with fluidic and soft tissue pumping and
techniques in the body. Osteopathy plays an important role with inflammatory conditions and its
potentially adverse reaction on the body if extensive or prolonged. According to the methodology of
Sutherland Academy, applications of various osteopathic techniques are beneficial depending on the stage
of inflammation. Osteopathic pumping techniques are not advised during the stage of vasoconstriction in
the initial vascular phase. Inflammation is a naturally occurring phenomenon in the body, and we are not
to interfere with this stage of the inherent healing process. Shortly after the initial assault on the tissues,
roughly thirty minutes to 5 hours afterwards, osteopathic liquid pumping techniques are beneficial71. This
is the vasodilation stage of the vascular phase. The suggested pumping techniques are fluidic in natural,
and are used to facilitate the extent and volume of the edema during this acute stage of healing. During
the second stage of inflammation, where the focus is to rebuild , remove tissue debris, and foreign
invaders, osteopathic articular pumping are preformed72. According to Mr. Voyer, osteopathic articular
pumpings are necessary to help the movement of the articular fluids. These techniques facilitate the
movement, and thus activity of leukocytic rich fluid at the site of the injury.
Only during the regeneration, or final stage of inflammation are mechanical articular pumpings
recommended73. The body is a very fine tuned machine, however the process of scar tissue organization
is a chaotic unorganized event. Scar tissue is not a very intelligent tissue, and it is the duty of the
Osteopath to influence this aspect of the healing process. Mechanical pumping at this time are crucial for
gently guiding the normal, unorganized basket weave of scar tissue into a more aligned tensile unit.
Osteopaths value the importance of fluidic movement of tissue. Any disturbance or adhesions is
71
(G.Voyer D.O, Osteo-articular pumping course, 1st year, A.S.O.Q, 2006)
72
(G.Voyer D.O, Osteo-articular pumping course, 1st year, A.S.O.Q, 2006)
73
(G.Voyer D.O, Osteo-articular pumping course, 1st year, A.S.O.Q, 2006)
27
disruptive to the normal functioning of healthy tissue. Continuous disturbance or imbalances can
eventually effect the structure, which will impede the function, and create other disturbances in adjacent
tissues. Furthermore, adhesions and lack of mobility creates a stagnant microenvironment. This
microenvironment is like a septic tank, of which only waste products remain, and nutrition, and health are
the hopeless bystanders74. The Osteopath does not stop the innate process of healing, but rather works in
conjunction to limit the potential adverse effects of uncontrolled inflammation.
74
(G.Voyer D.O, Osteo-articular pumping course, 1st year, A.S.O.Q, 2006)
28
3.2
FASCIA
Fascia is a type of connective tissue that creates a three dimensional web extending without
disruption from head to toe. This tissue lines cavities, bones, vessels, and envelops muscles and viscera.
There is even connective tissue components located within each cell. Fascia is composed of fibroblasts,
mast cells, adipose cells, macrophages, plasma cells, leukocytes, collagen, reticular and elastic fibers75.
The fascial system functions to support, protect, stabilize, communicate, and cushion76. Fascia creates
separation between vessels, organs, bones, and muscles. It creates space through which nerves, blood
vessels, and fluids can pass. This tissue is located throughout the body and has various depths.
Connective tissue is made up of hollow collagen microtubules and other fibers intermeshed throughout.
A fluid similar to cerebrospinal fluid is found within these hollow collagen tubules. This fluid has a
cohesive bond. The cohesive bond is through hydrogen bonding, and interactions found between the
triple helix peptides77. The Primary Respiration Mechanism travels inherently through these connective
tissue, and is felt throughout the boy. There is also a serous fluid found between layers of fascial
sheaths78. The superficial fascia is an areolar tissue located under the dermis of the skin79. There is a
significant amount of adipose tissue in the superficial fascia which acts as a heat insulator. Underneath
this tissue lies another fascial layer. This is the fascia profunda which envelops muscles and other
internal structures80. The fascia surrounds individual muscle fibers and groupings of muscular fibers.
75
(Lindsay, 2008, p. 2)
76
(Paoletti, 1998, p. 151)
77
(Sills, 2004, p. 228)
78
(Sills, 2004, p. 227)
79
(Benjamin, 2009, p.1)
80
(Benjamin, 2009, p.18)
29
The importance of this tissue is its continuum throughout the body. Still writes at length of the
omnipresence and universality of fascia throughout the body. He expresses that a profound knowledge of
this tissue is, “...imperative, and is one of the greatest aids to the person who seeks the causes of
disease81.” This tissue is extremely important to the Osteopath, as its continuous web surrounds and
infiltrates all tissues in the body. Therefore, can have an effect on all systems in the body.
Modern anatomy books go into detail of naming fascia regionally, and providing the false notion
that fascia, and its underlying tissues are separate entities. Federic Wood Jones cautions against studying
the separateness of this tissue, and aspires to see fascia as a continuum throughout the entire body82. The
importance of this tissue for the purpose of this thesis is to examine the significance of fascial tensions
and chains and how they can treat biomechanical imbalances. Any tension, imbalance, or abnormal
adhesions in a fascial chain can impair the normal biomechanics, thus resulting in pain and/or
dysfunction. More specifically, improper biomechanics in tissues above or below the knee joint, can
directly influence the mechanics of the knee, and thus impart knee pathologies.
According to Paoletti, when executing a particular set of movement patterns, harmonization and
coordination occurs at the level of fascia 83. Movement patterns as seemingly simple as walking, involves
a series of mechanisms that involve the entire body. The fascial system acts as a series of ropes and
pulleys, that must be coordinated through the harmonization of multiple systems, including the muscles,
nerves, and centers of balance84. Every movement generated is the summation of multiple components,
including flexion, extension, translatory, and rotational movements.
81
(Still, 1987, p.29)
82
(Benjamin, 2009, p. 11)
83
84
( Paoletti, 1998, p. 185)
( Paoletti, 1998, p. 186)
30
3.2.2
FASCIA AND ITS INNATE NERVOUS SYSTEM
Fascia is such an interesting tissue. According to Schleip, fascia is highly innervated by
mechanoreceptors that react to manual pressure85. Andrew Taylor still recognized the importance of this
tissue in the body. Still recognized that fascia contained “...a network of nerves, cells, and tubes running
to and from it; filled with millions of nerve-centres86. Because of the abundance of sensory receptors in
this tissue, it intelligently communicates with the nervous system. The fascia consists of a variety of
receptors. Golgi receptors, Ruffini, and Pacini corpuscles are found throughout fascial tissue in varying
concentrations87. These receptors are laced throughout. Schleip describes the Golgi receptors as being
adaptive anti-gravity balancing receptors in the bi-ped88. He discusses how the Pacini bodies respond to
rapid changes in pressure and vibration, and respond to high velocity thrust and vibration techniques. The
Ruffini endings respond to long-term pressure, transverse stretching, and if stimulated can result in the
lowering of the sympathetic nervous system89. This theory can explain the melting away or release
sensation experienced with soft tissue manipulation.
Schleip provides the example of working on the connective tissue of the lateral ankle, an area that
contains no striated muscle fibers. The manual touch of the Osteopath stimulates the Ruffini endings,
which in turn, prompts the central nervous system to alter the tonus of some motor units in the muscle
tissue under the Osteopaths hand90. In addition to these more commonly known receptors, Schleip
discusses two other receptors that are not traditionally mentioned. He states that a typical motor nerve in
85
(Schleip, 2003, p. 11)
86
(Still, 1987, p. 29)
87
(Schleip, 2003, p. 14)
88
(Schleip, 2003, p. 14)
89
(Schleip, 2003, p. 15)
90
(Schleip, 2003, p. 15)
31
a nerve fiber has a vasomotor function, but there is a larger distribution of sensory fibers91. These sensory
fibers consist of a mere 20% belong to the type I and type II nerves which originate in the muscle
spindles, Golgi organs, Pacini corpuscles and Ruffini endings92. There is an additional group of sensory
fibers located in the muscle nerve.
Figure 2, A typical muscle nerve depicting three times as many sensory neurons than motor neurons.
Figure by Twyla Weixl, (Schleip, 2003, p. 16).
According to Schleip there are an additional type of fibers found in the fascia. These fibers are
called interstitial muscle receptors and are found abundantly in fascia93. These receptors are
mechanoreceptor and pain receptors, and have also shown to have autonomic functions such as affecting
the nervous systems regulation of blood flow according to Schleip94. Understanding the four types of
sensory fibers allows for an understanding as to the way osteopathic palpation can influence tissues at the
local and systemic level via palpation. This insight explains the profound effects of both fluidic and
mechanical osteopathic pumpings on the entire system. This is yet another example of complexity
manifesting at cellular level of the amazing machinery of the human body.
91
(Schleip, 2003, p. 16)
92
(Schleip, 2003, p. 16)
93
(Schleip, 2003, p. 17)
94
(Schleip, 2003, p. 17)
32
3.2.3
FASCIA CHAINS
Fascial chains are biomechanical slings that consist of muscles and their investing fascia. They
are a continuous system from the cranium to the feet, and work harmoniously to transmit, and coordinate
movement and transmit forces throughout the body95. Fascial chains are lines of communication located
in the body. These chains are present throughout the entire body. They create chains of transmission from
one end of the body to the other. In addition to transmitting forces linearly, depending on the thickness of
the fibers, the orientation of the fibers, their collagen makeup, transmission of force can be from
superficial to deep, or obliquely linking the body from one side to the other96. These chains are important
channels of communication throughout the body. Each link in the chain communicates to the adjacent
link via fascial continuities and contiguities. Communication via the fascial chains is integral at
maintaining harmony and balance.
Unfortunately due to trauma, stress, age, scars, infection, inflammation, and postural habits, these
chains have the potential to communicate disharmony throughout the chain. Fascial chains can be
perturbed and restrictions can be created along the entirety of the chain. A lesional chain can initiate in
any part of the body and spread either in an ascending or descending fashion97. A lesion is a pathological
entity. John Martin Littlejohn states that a lesion is something that is physiological and not an anatomical
condition98. He explains how a lesion creates modification in normal movements patterns. According to
Paoletti, ascending chains are more common as a result of the interaction between the ground forces, and
95
(Paoletti, 1998, p. 184)
96
(Paoletti, 1998, p. 187)
97
(Paoletti, 1998, p. 200)
98
(Littlejohn, 1980, p. 1)
33
the constant pressure of our distal segment, and the constant battle with gravity99. Addressing fascial
chains in their entirety is imperative during an osteopathic treatment.
For the purpose of this study, three major chains of the lower extremity will be discussed. These
three chains were selected because of their significance in treating the biomechanical disturbances
associated with patellofemoral pain syndrome. The fascial chains are taught in F1 at Sutherland Academy
and consist of; the iscio-gluteal chain (posterior-medial), the ischio-cuatneous chain of Luschka (lateralposterior), and the inguinal chain(anterior).
The idea of fascial chains is not a new concept. One of the pioneers of this concept was a Belgian
physiotherapist with osteopathic training. Godelieve Struyf-Denys adapted the principle of muscular
chains from Kabat, and the principle of stretching from Meziere100. Struyf describes ten muscular chains,
five located on the anterior, and five in each half of the body. Struyf believed that there was a dominant
chain in each individual, and felt that it was impossible to completely neutralize this chain101. Struyf
believed that these chains represented the personality of the individual. The idea was to restore balance
amongst the chains to decrease dysfunction. Struyf believe that there were three major contributors to
imbalanced chains.
99
(Paoletti, 1998, p. 200)
100
(Richter, 2007, p. 11)
101
(Richter, 2007, p. 12)
34
A)Antero-lateral chain
D) Postero median.
B) Postero lateral
C) Antero median
E) Postero anterior-Antero posterior.
Figure 3, This diagram displays the five different muscular chains of Godelieve Struyf Denys
(http://www.ceramontreal.ca/g-d-s-method-en/course-outline/).
The first one is as a result of the patients psyche, their posture and morphology102. She takes into
account an emotional aspect in her chains. The second is related to their lifestyle, work habits, sports or
lack of movement103. She believes that lifestyles can make an imprint in the body via fascial chains. The
final contributor is emotional factors such as stress, anger and sorrow104. The emotional aspect can have a
strong influence on how a person holds themselves. Her system involved three vertical chains, and two
horizontal chains. The five major chains display the attitudinal manifestations in anatomical muscular
102
(Richter, 2007, p. 12)
103
(Richter, 2007, p. 12)
104
(Richter, 2007, p. 13)
35
chains. In the antero lateral dominant chain the body is introverted and withdrawn105. Struyf explains that
the posture exhibits narrow shoulders, and timidity. This attitude favors a relational reserved, quiet
method but very virtuous106. According to Struyf, this individual has a tendency to allergies, and to the
colds.
In the postero lateral chain the body is arched, positioned with wide shoulders and good, solid
musculature. According to Struyf, this open stance favors the communication of extroverted, go-getter
individuals but they have a tendency for impatience107. The typical tendency is muscular cramps and
migraines.
In the antero median dominant chain the body is rounded and slumped, leaning in a more
posterior fashion. These individuals tend to be more reflective, tend to take care of the others without
needing recognition108. Struyf explains that the typical tendency is water retention in the lower
extremities.
The postero median dominant chain presents with the body in an anterior pitched posture.
Individuals with this dominant chain tend to be lanky, and have a desire to control and exhibit signs of
independence109. Struyf states that the typical tendency for this individual is rheumatism and lombalgia.
Lastly, the posterior anterio-anterior posterior dominant chain demonstrates three major attitudes;
impulsiveness, receptiveness, and emotional. Struyf suggests that these individual have a strong desire to
105
(Richter, 2007, p. 13)
106
(Richter, 2007, p. 13)
107
(Richter, 2007, p. 14)
108
(Richter, 2007, p. 15)
109
(Richter, 2007, p. 14)
36
be spiritual connected, and strive for the ideals and are highly morals individuals in all situation110.
Unfortunately, according to Struyf, these people have a tendency towards insomnia, anxiety and to the
nervous exhaustion.
Two French osteopaths by the names of Paul Chauffour, and Leopold Busquet have also
demonstrated other models of chains in the body. Chauffour and Busquet describe similar chains and
their association between cranial, visceral and muscular chains111. They both discuss the parallels of
cranial and visceral dysfunction and postural mal position. In addition to these systems of fascial chains,
Paoletti describes a similar system with internal, and external chains that transmit forces throughout the
body.
Like other like minded individuals, we are taught the importance of treating the fascial chains at
Sutherland Academy. The methodology of the treatment of a chain is based on normalization of the soft
tissue, combined with osteo-articular pumping. The ischio-gluteal chain starts at the lisfranc junction and
terminates at the deltoid of Farabeuf. This chain travels from the lisfranc junction, to the dorsal pedis and
superficial plantar fascia, and continues to the peieux and middle plantar fascia. From here, this chain
continues to the navicular, cuboid, talus and calcaneus, and tibio tarsal joint. It continues from the
intermalloelar fascia, Achilles tendon, and cruris fascia. Continuing up the leg on the medial aspect via
the medial gastrocnemius fascia, popliteal fascia, and expansion of the semi-membranosus, to the
popliteal/crural fascia, and travelling up to the femoralis fascia. From here, the chain continues up the
semi-membranosus fascia, the pes anserine bursa, then to the semi-tendinosus fascia to the posterior
ischio-coccygeal fascia, and terminates at the deltoid of Farabeuf.
The second fascial chain of the lower extremity is the ischio- cutaneous chain of Luscka. This
chain follows a posterior lateral mapping. It starts with the metatarsal, cuboid, dorsal pedis, superficial
110
(Richter, 2007, p. 14)
111
(Richter, 2007, p. 18)
37
plantar, and middle plantar fascia. It continues to the ligament of Henle, the lateral annular ligament and
the crural fascia. It continues cephalically with Barkow’s ligament, and the tibial expansion of the biceps
femoris. It continues with the head of the fibula, the fibula-fabellar ligament, the anterior cruciate and
posterior cruciate ligaments of the knee. It then goes up to the femoralis fascia of the long and short head
of the biceps, and continues along the biceps femoris. From here it continues to the ischio tendinous band
of Luschka and finishes at the coxo-femoral joints. There are additional chains, but for the relevance of
this thesis, only three of the eight learned will be discussed.
The last fascial chain of relevance is the inguinal chain. This chain is an anteriorly situated chain.
It commences at the intermetatarsal joints, the dorsal and superficial plantar fascial and the navicular.
From here it continues with the lacinatum ligament, the sinus tarsi, and the crural fascia. Proceeding to
the periosteal fascia, the tibial and patellar expansion of the tensor fascia lata, and then the lateral alar
ligament of the knee. From here, the chain continues with the lateral Pauzat ligament the medial alar and
Pauzat ligaments of the knee followed by the pes anserine bursa. The trochlear patellar joint is next,
followed by the sartorial, femoralis, and Hunter’s canal fascia. Then the actual Hunter’s canal and the
fasica adductionata. Continuing cephalically, the fossa ovalis, the cribiformis and pectineal fascia into
Scarpa’s triangle. From here, into the fascia iliaca the lacunar and Gimbernaut’s ligament, the
interfoveolar and hasselbacks fascia. Finally, Cooper’s ligament, the inguinal ligament, the ilio-pectineal
band and terminating at the pubis symphysis. These are the fascial chain taught at Sutherland academy.
They are not as linear as other models of fascial chains previously discussed, however they are thorough
in their approach.
3.2.4
FASCIAL INVESTIGATIONS
The fascia of the body is envelopes, intersects, and communicates throughout the entire body.
Understanding the intricacies of the fascial system, and how it is woven throughout the body provides a
38
plethora of knowledge of the interconnectedness and complexity of the human organism. Discussion of
the fascia of the lower leg is most important for this study.
Beginning with the most external layer, the superficial fascia will be discussed. This fascia
envelopes the entire thigh and is situated between the adipose layer of the dermis and subcutaneous
cellular tissue112. This fascia can be separated into layers. In between the layers of the superficial fascia
are the superficial vessels and nerves113. A vascular network is found in between the layers of the fascia.
The most superficial layer of this tissue is an extension of the superficial fascia of the abdomen and
thoracolumbar fascia114. This superficial fascia continues down the entire length of the leg and concludes
at the foot. Another layer to this fascia is the deep layer of the superficial fascia. This layer is a very
thin, and located on the inner side of the long saphenous vein, beneath the Poupart ligament115.
According to Gray, this fascia adheres to the fascia lata, and continues its journey where it becomes the
cribiformis fascia medially. This fascia is perforated like a sieve, by numerous blood and lymphatic
vessels, hence the term cribiformis.
Travelling to the next layer in the body, the deep fascia of the thigh is apparent with the removal
of the superficial fascia. This deep fascia, varies in thickness throughout the leg. It is named fascia lata,
which means side band in Latin, and attaches to the pubic bone anteriorly, and is continuous with the
gluteal aponeurosis posteriorly116. The fascia lata has numerous attachments. It attaches above and
behind the sacrum and coccyx, the iliac crest and the sacro-tuberous ligament where it continues to the
112
(Paoletti, 1998, p. 23)
113
(Gray, 1901, p. 418)
114
(Gray, 1901, p. 418)
115
(Gray, 1901, p. 418)
116
(Gray, 1901, p. 419)
39
ramus and body of the iscium, and the sacro-sciatic ligament117. At the area of the iliac crest the thick
fascia lata travels caudally down the lateral aspect of the thigh, where it sandwiches the tensor fascia
femoris superficially above and below this muscle118 . Gray remarks that the layers reunite at the caudal
end of the tensor fascia femoris, and converge into the thick strong fascia known as the iliotibial band.
The iliotibial band travels distally and attaches on the condyles of the femur, the tuberosity of the tibia,
until it reaches the head of the fibula 119. The deep fascia, once in the location of the gluteal region, is
called the gluteal fascia. The gluteal fascia continues anterior and distally, where it is called the fascia
femoris and attaches anteriorly to Pouparts’ ligament the pubic bone beneath120. As it continues down the
anterior and medial aspect of the leg it is called the cribiformis fascia. This fascia continues down the
posterior aspect of the leg where it is called the crural fascia. Once it reaches the area of the foot it is
called the pedis fascia121. AS the fascia travels to different regions on the body it adapts that name.
3.2.4.2
FASCIA LATA
The fascia latae is thickest in the upper lateral regions, and it receives expansions of the gluteus
maximus muscle, and the tensor fascia femoris is situated between its layers according to Gray. As this
tissue continues caudally it covers the gluteus medius, where is divides superficially coming over the
gluteus maximus, and beneath it. The deeper layer of the fascia latae forms the medial, lateral and
intermuscular septums of the thigh and the crural intermuscular septum of the posterior and anterior
117
(Gray, 1901, p. 419)
118
(Gray, 1901, p. 420)
119
(Gray, 1901, p. 420)
120
(Paoletti, 1998, p. 44)
121
(Paoleti, 1998, p. 44)
40
aspect in the lower leg122. The naming of the fascia influenced by the region it is located. There is one
seamless web of fascia that travels, envelopes, and creates compartments throughout the entire body.
Figure 4, Cross-section through the middle of the thigh. (Anterior compartment is at upper left; medial at
center right; posterior at center bottom. (http://www.ask.com/wiki/Fascial_compartments_of_thigh).
3.2.4.3 FASCIA ILIACA
Another fascia that will be discussed in detail is the fascia iliac. The fascia iliaca is a large aponeurotic
sheath. It covers the back part of the abdominal cavity, the psoas, and iliacus in their entirety123. This
fascia is proximally thinner, and it gradually thickens as it advances to the crural arch. The fascial part
122
(Gray, 1901, p. 419)
123
(Grays, 1901, p. 416)
41
that covers the psoas is attached cephalically to the ligamentum arcuatum internum, and the quadrates
lumborum arcade. It attaches to the vertebral bodies of the lumbar spine, to the anterior longitudinal
ligaments, and is in relation to pillars of the thoracic diaphragm. It attaches posteriorly to the anterior
fascia of the quadrates lumborum, and the spinal muscles. It has attachments to the upper portion of the
sacrum and externally above the crest of the ilium. It is continuous to the lumbar fascia124. There is a
portion of this fascia that connects with the iliacus muscle. It is connected to the entire length of the inner
aspect of the iliac crest, the brim of the true pelvis where it merges with the periosteum125. This fascia
continues down to Poupart’s ligament. It is intimately connected to the posterior aspect of Poupart’s
ligament, and is in continuity with the fascia transversalis126. There is a significant amount of vessels and
nerves that this fascia is in relation with. Some of these include the lumbar sympathetic plexus, nerves in
the femoral region, splanchnic nerves, ilio lumbar nerves, genitor-femoral nerves and lymphatic
vessels127. This fascia creates a compartmental division as it travels inferior to Poupart’s ligament as the
ilio-pectineal band. This band separates the femoral vessels and the psoas muscle. As it descends it forms
the posterior wall of the femoral sheath128. This fascia is in connection with numerous structures. The
external iliac vessels lie anterior to this portion, while lumbar plexus lies posterior. The fascia iliaca due
to its approximation with viscera will have an effect on the visceral system.
The fascia iliaca is connected to the visceral system. On the anterior aspect of the fascia iliaca it
is in relation with the renal pedicals, the kidneys, fascia of the kidneys and the ovaries129. Other
relationships exist with other structures and viscera. There is a relation with the renal arteries, ovaries,
124
(Grays, 1901, p. 416)
125
(Grays, 1901, p. 416)
126
(Grays, 1901, p. 416)
127
(Voyer, 1992, p 4-7)
128
(Grays, 1901, p. 416)
129
(Voyer, 1992, p. 4)
42
uterus and the pancreas130. In addition to theses relations there are more relations with the intestines. This
fascia is related to the ileum, root of the mesentery the appendix, the cecum on the right and the sigmoid
colon, and corresponding vessels on the left. The fascia iliac has numerous anatomical investigations.
This fascia is in relation to the rectus femoris, which is in relation to the patella.
The endless web of fascia is the communication link throughout the entire body. When we work
on one part, as small as this part may seem, based on the fascial connections we work on all the systems
of the body. The Osteopath treats the entire functioning organism by treating the links in the fascial
system.
3.3
ANATOMICAL DISCUSSION
The study of anatomy is a vitally important field of science in order to understand the complexity
of the human body. Anatomy is the study of the structure of living things. Studying anatomy gives us a
greater appreciation for the location and shape of structures in the human body. Anatomy and physiology
when studied together provides us with a magnitude of information. The two disciplines complement
each other nicely. While anatomy focuses on the structure and location, physiology focuses on the
biological processes that occur in and around the structures. Additionally, for the purpose of this study,
anatomy of the lower leg will focused in this section. The following discussion will include the
classification of joints, important musculature, and additional soft tissue structures such as ligaments and
tendons. A discussion of the fascial system and the important fascial links will also be discussed in detail.
Understanding the joints involved in the lower leg is important from a treatment perspective, and also for
further biomechanical understanding.
130
(Voyer, 1992, p. 4)
43
3.3.1
JOINT ANATOMY
The most proximal joint of the lower extremity is the coxofemoral joint. This joint is a
diarthrodial ball and socket joint and has three axes of movement and a large freedom of movement.
Although it is a ball and socket joint similar to that of the shoulder, the major difference is that there is
substantially more stability since it is a weight bearing joint. The articulating surface, the acetabulum is
created by the union of three bones: the ilium, ischium and the pubis. The orientation of this cup like
depression is downward, outward and forward. The acetabulum is deepened by a ring of fibrocartilage
called a labrum131. This fibrocartilaginous ring is thicker in the lateral region than the medial and central
aspect. The central aspect of the acetabulum is non-articular, and contains a fat pad covered with
synovial fluid. The acetabulum articulates with the femoral head.
The femoral head varies in shape depending on the individual. The head of the femur is covered
entirely with articular cartilage132. The femoral head continues into the femoral neck. The distal aspect of
the neck projects anteriorly, medially and superiorly between the greater and lesser trochanters. There are
two major angulations of the femur that will be discussed which can affect the distribution of the forces
and function of the joint. One angulation occurs in the frontal plane between the femoral neck and the
axis of the femoral condyles, and the other occurs in the transverse plane between the axis of the femoral
neck and the axis of the femoral condyles133. These angulations develop in utero. Initially the femoral
shaft is abducted, flexed and laterally rotated relative to the neck and the head of the femur134. The
femoral shaft gradually adducts, rotates medially, and then extends, however the femoral head and neck
remain in the origin position. The medial rotation that occurs in utero brings the femoral condyles where
they face anteriorly.
131
(Norkin, 1983, p. 258)
132
(Norkin, 1983, p. 258)
133
(Norkin, 1983, p. 259)
134
(Norkin, 1983, p. 259)
44
Another angle of importance to discuss is the angle of inclination. This angle is found in the
frontal plane, and occurs between the femoral neck and femoral shaft. The normal range for this angle in
an adult is 125 degrees135. This angle varies from male to females as a result of the greater width of the
female pelvis. In females typically the angle of inclination is smaller than males. Another angle that
occurs in this proximal joint is the angle of torsion. This angle is formed between the femoral condyles
and the axis of the femoral neck. This angle can vary between 8 and 25 degrees, however normally is
around 12 degrees136. There is also an internal infrastructure that needs to be discussed in relationship to
the femur. This internal architecture is the trabecular system.
This trabecular system has adapted to accommodate the mechanical stresses and strains created
by transmission of forces between the femur and the pelvis. There are two major trabecular systems, the
medial and the lateral, and two accessory systems137. The first system to be discussed is the medial
system, or as Kapandji refers to it as the arcuate bundle of Gallois and Bosquette138. This system arises
from the medial cortex of the upper femoral shaft and radiates outward toward the cortical bone of the
superior aspect of the femoral head. This system develops in order to resist the joint reaction forces
during single limb support139. The lateral trabecular system or supporting bundle arises from the lateral
cortex of the upper femoral shaft and after intersecting the medial system terminates on the cortical bone
on the inferior aspect of the head of the femur140. This system is believed to have developed in response to
the forces created during contraction of the abductor muscles and to tensile stresses experienced by the
135
(Norkin, 1983, p. 261)
136
(Norkin, 1983, p. 262)
137
(Norkin, 1983, p. 263)
138
(Kapandji, 1987, p. 20)
139
(Kapandji, 1987, p. 20)
140
(Kapandji, 1987, p. 20)
45
gravitational moment of force on the upper end of the femur 141. In addition to these main trabecular
systems, the accessory systems are confined to the area of the neck of the femur and the trochanteric area.
One system arises from the medial aspect of the upper femoral shaft and the other system arises laterally.
The lateral system runs parallel to the greater trochanter while the medial system crosses the lateral
system and radiates out into the region of the greater trochanter. Like the femur the pelvis also develops a
trabecular system.
There are two major trabecular systems in the pelvis. These are the sacro-acetabular trabecular system
and the sacro-ischial trabecular system. The sacro-trabecular system transmits forces from the sacroiliac
joints to the head of the femur142. According to Norkin, the sacro-ischial trabecular system transmits
forces from the sacroiliac to the Ischia. Both femoral and pelvic trabecular systems help to provide
stability at the hip by reinforcing the boney structure in the areas of concentrated stress. The following
joint distal to the coxofemoral joint is the patellofemoral joint.
The patellofemoral joint consists of the sulcus on the femur and the articulating surface of the
patella. The normal angle of the sulcus where the patella sits is normally 137 degrees with a variation of
eight degrees143. The patella main function is to improve the efficiency of the quadriceps by increasing
the lever arm of the extensor mechanism. It aids knee extension by producing anterior displacement of the
quadriceps tendon throughout the entire range of motion. The greatest contact force between the patella
and the femur occur between 30 to 70 degrees of flexion144. It also functions as an osseous shield for
both the trochlear and the femoral condyles. When the knee is flexed five degrees the patella forms an
angle between the patellar tendon and the quadriceps tendon of thirty five degrees145. The proximal
141
(Norkin, 1983, p. 263)
142
(Norkin, 1983, p. 265)
143
(Scuderi, 1995, p. 16)
144
(Richter, 2007, p. 31)
145
(Norkin, 1983, p. 192)
46
sulcus of the femur is shaped flatter than the distal aspect of the sulcus. The lateral condyle of the femur
is higher and more prominent then the medial, and this acts to prevent lateral displacement of the patella.
The patella is considered a sesamoid bone and consists of patellar facets. The seven facets
consist of three medial, three laterals and one non-articulating facet on the medial side. This odd facet is
none articulating, except in deep flexion146. Scuderi explains that the medial facets are smaller and more
convex in shape then the lateral ones. These facets and the patellofemoral ligaments assist in maintaining
a central position in the sulcus147. The contact area between the patella and the sulcus change consistently
throughout the range of flexion. In full extension the distal pole of the patella contact the proximal
femoral sulcus in the midline. As the flexion commences, the contact areas shift to the medial and lateral
sides, and continue proximally on the patella and distally on the femur148. The greater range of flexion
increases the stability of the patella due to the increased congruency of the patella and femur. In addition
to the patellofemoral joint, the knee complex is comprised of a distal joint, the tibio-femoral joint.
The knee complex consists of two distinct articulations all found within a common joint capsule;
the tibio-femoral joint and the patellofemoral joint. The tibio-femoral joint is the articulation that exists
between the distal femur and the proximal tibia. This joint is commonly classified as a modified hinge
joint. Characteristic of a hinge joint, there are one to two degrees of freedom of motion. Motions that
occur at this joint are flexion and extension in the sagital plane and rotation in the transverse plane, with a
slight degree of abduction and adduction149. The articulating surfaces of the distal femur are convex,
asymmetrical medial and lateral condyles. The medial condyle is longer than the lateral condyle.
146
147
(Scuderi, 1995, p. 16)
(Scuderi, 1995, p. 19)
148
(Scuderi, 1995, p. 19)
149
(Scuderi, 1995, p. 20)
47
Situated between the condyles is an asymmetric saddle shaped groove called the patellar surface. The
condyles are separated posteriorly by a deep U-shaped notch termed the intercondylar fossa150.
Conversely the proximal tibial condyles are two concave asymmetric plateaus. The medial tibial plateau
is fifty percent larger than the lateral and the articulating cartilage is also thicker on this side compared to
the lateral151. Separating the two plateaus are two boney projections called the intercondylar tubercles.
During knee extension these tubercles become lodged in the intercondylar fossa of the femur.
3.3.2
MENISCI
Important wedge shaped structures are located between the femur and the tibia. These structures
are two asymmetrical fibrocartilaginous discs called menisci. The role of the menisci is to transmit any
compressive forces between the femur and the tibia. The medial meniscus is semi lunar in shape, concave
superiorly, with an anterior and posterior horn where the cartilage terminates152. The medial meniscus is
firmly attached to the joint capsule, the medial collateral ligament via its deep fibers, and to the
semimembranosus muscle posteriorly, and a few fibers of the anterior cruciate ligament via the anterior
horn153. The menisci are attached to the tibia plateau via coronary ligaments. The two anterior horns of the
medial and lateral menisci are in contiguity via a transverse ligament154. This ligament is further attached
to the patella by fibers of the infrapatellar tendon. The lateral meniscus is shaped more circular than the
medial. The lateral meniscus does not have an attachment on the lateral collateral ligament as it is
separated by the popliteus muscle, according to Kapandji. The popliteus has a fibrous expansion to the
posterior aspect of the lateral meniscus. The lateral meniscus contains fibrous expansions of the posterior
cruciate via the posterior horn of the lateral meniscus. This expansion is called the menisco-femoral
150
(Norkin, 1983, p. 295)
151
(Norkin, 1983, p. 295)
152
(Kapandji, 1987, p. 92)
153
(Kapandji, 1987, p. 92)
154
(Kapandji, 1987, p. 92)
48
ligament. Both menisci have lateral attachments from the patella, and these are called mensico-patellar
fibers155. The menisci have a certain amount of movement.
The menisci have a certain amount of movement during flexion and extension of the knee. The
reason for this is that they only have two fixed points at the anterior and posterior horn, and the rest of the
structure is able to move freely156. The meniscus is not adhered entirely to the tibial plateau. During
flexion the menisci move more posteriorly, while during extension the menisci move anteriorly157. Due to
the difference in shape and size, the menisci vary in movement. In flexion the lateral menisci move more
posteriorly than the medial menisci by 6mm158. Furthermore, soft tissue attachments on the menisci have
an influence on the movement during active flexion and extension. During active flexion the medial
meniscus is directed posteriorly because of the attachment of the semimembranosus expansion at the
posterior aspect, and the anterior horn is drawn by fibers of the anterior cruciate ligament. At the same
time, according to Kapandji, the lateral meniscus is directed posterior by the popliteal expansion159. With
active extension both menisci are drawn forward by the menisco-patellar fibers and the posterior horn of
the lateral meniscus is pulled in an anterior direction as a result of increased tension in the meniscofemoral ligament160. The menisci are moveable structures that adapt to the articulating bones they attach
to. The next joint distal to the patella-femoral joint is the proximal tibio-fibular joint,
The proximal tibia articulates with the proximal fibula. It is considered a regular synovial joint.
There is a fibrous joint capsule, with a synovial membrane surrounding this articulation which is
155
(Kapandji, 1987, p. 92)
156
(Kapandji, 1987, p. 94)
157
(Kapandji, 1987, p. 94)
158
(Kapandji, 1987, p. 94)
159
(Kapandji, 1987, p. 94)
160
(Kapandji, 1987, p. 94)
49
strengthened by the anterior and posterior ligaments of the head of the fibula161. According to Callaghan,
the proximal tibio-fibular joint has three major roles. The first is to dissipate torsional stresses at the
ankle, the second is to dissipate lateral tibial bending moments, and to provide tensile as opposed to
compressive weight bearing162. This non weight bearing bone acts as a force dissipater. The fibular
collateral ligament serves to maintain stability at this articulation especially in extension as the fibula is
held tightly in its place163. The next major joint articulation in the lower extremity is the distal tibiofibular joint
This joint is a syndesmotic joint between the distal ends of the tibia and fibula. In between these
two bones is a sheath of tissue called the interosseus or syndesmotic membrane. This joint is
strengthened by anterior and posterior tibio-fibular ligaments. Slight movement exists at this joint to
accommodate the talus during dorsiflexion of the foot164 (35). Distal to this joint is the tibio-talar joint
This joint is a synovial hinge joint that connects the distal aspect of the tibia and fibula with the
proximal surface of the talus. This joint has one degree of freedom and allows for dorsiflexion and
plantar flexion of the foot at the ankle. The lateral malleoli is larger and extends further then the medial
malleoli. The stability of this joint is created with a number of ligaments on both the medial and lateral
aspects. The lateral aspect consists of three lateral collateral ligaments. The anterior talofibular ligament,
the calcaneofibular ligament and the posterior talofibular ligament165. The medial aspect of this
articulation consists of fan-like ligamentous architecture. The medial collateral ligaments consist of a
superficial and deep ligament arrangement. The superficial fibers are triangular in shape, hence the name
deltoid ligament. The deep fibers consist of the anterior talotibial ligament and the posterior talotibial
161
(Kapandji, 1987, p. 98)
162
(Callaghan, 2010, p. 51)
163
(Callaghan, 2010, p. 52)
164
(Callaghan, 2010, p. 53)
165
(Kapandji, 1987, p. 156)
50
ligament. During dorsiflexion the fibula moves superiorly and medially, and during planter flexion the
fibula descends and moves laterally166. The last joint to be discussed is the talocalcaneal or subtalar joint.
The subtalar joint consists of the distal aspect of the talus and the proximal aspect of the
calcaneus. This joint allows for inversion and eversion of the foot. It is considered a plane synovial joint,
and is also referred to as a uniaxial hinge joint167. Some interesting points of the talus bone are
that it has no muscular attachments, and it does not have its own blood supply168. It relies on the
vasculature of its ligamentous system. The main ligament between the talus and the calcaneus is the
interosseous talocalcanean ligament consisting of an anterior and posterior band169. Other ligament in this
structure is the lateral taolcalcaneal ligament, and the posterior talocalcaneal ligament. These are the
major ligaments at this joint.
Following this joint, discussion on the anatomy of the arches of the foot is
next.
3.3.3
ARCHES OF THE FOOT
The architecture of the foot consists of the metatarsal and tarsal bones and is reinforced with
muscles and ligaments. The foot consists of five major arches. These are the anterior, lateral, medial and
the transverse arch. The anterior arch is the shortest arch in length and also the lowest of the arches in the
foot170 . The anterior arch is comprised of the first metatarsal head, and extends to the head of the fifth
metatarsal according to Kapandji. Like all arches, there is a keystone in this arch. The keystone for this
166
(Kapandji, 1987, p. 164)
167
(Callaghan, 2010, p. 53)
168
(Kapandji, 1987, p. 174)
169
170
(Kapandji, 1987, p. 177)
(Kapandji, 1987, p. 218)
51
particular arch is the head of the second metatarsal171. This is a low arch in the foot and it is in contact
with the ground by means of soft tissue structures. This arch has only one major muscular component.
The one muscle that spans across this arch is the transverse head of the adductor hallucis172. The next
arch to be discussed is the next larger arch of the foot.
The second arch is the lateral arch of the foot. This arch consists of three bones and three major
muscles that act to make this arch taut. The bones of this arch are the fifth metatarsal, the cuboid, and the
calcaneus173. The lateral arch is considered to be a more rigid arch because of the strong long plantar
ligament as per Kapandji. This rigidity allows for the triceps surae to transmit a propelling force174. This
arch also contains a keystone. The keystone for this arch is the anterior process of the calcaneus175. The
soft tissue components of this arch consist of three major muscles. These muscles act to tighten the
lateral arch. The muscles are the peroneus brevis and longus, and the abductor digit mini which spans the
entire length of the arch176. The next arch to be discussed is the medial arch.
The medial arch of the foot is the most important arch of the foot. It is the longest and the highest
arch. The medial arch is comprised of a boney, muscular and ligamentous infrastructure. The five bones
of this arch are the first metatarsal, the medial cuneiform, the navicular, the talus and the calcaneus177.
The bones of this arch are supported by numerous ligamentous structures. The cuneometatarsal,
cuneonavicular, the plantar calcaneonavicular, and the talocalcanean ligament resist short lived stresses in
171
(Kapandji, 1987, p. 224)
172
(Kapandji, 1987, p. 224)
173
(Kapandji, 1987, p. 222)
174
(Kapandji, 1987, p. 222)
175
(Kapandji, 1987, p. 222)
176
(Kapandji, 1987, p. 222)
177
(Kapandji, 1987, p. 220)
52
the foot178. This arch also contains a keystone. The keystone for this arch is the navicular bone according
to Kapandji. This arch is supported by muscular components as well. These muscles are the tibialis
posterior, the peroneus longus, the flexor hallucis longus, and abductor hallucis longus and flexor
digitorum longus179. The muscles contribute to its shape and stability. It helps draw the navicular
inferiorly and posteriorly below the head of the talus180. The next two muscles have a common function.
The peroneus longus, flexor hallucis longus, and the abductor hallucis longus are strong contributors to
the shape or curvature of the arch according to Kapandji. The flexor hallucis longus has another function
besides contributing to the curvature of this arch. This muscle acts to thwart the talus from receding when
it is being pushed by the navicular bone. The ext arch of the foot to be discussed is the transverse arch.
The transverse arch of the foot spans the entire length of the foot. It runs in a medial-lateral
direction. It is more proximal than the anterior arch of the foot. It consists of the row of cuneiforms and
the cuboid bone at this location in the foot181. At this part of the arch the keystone bone is intermediate
cuneiform as per Kapandji. More posteriorly, the transverse arch is made up of the navicular and cuboid,
resting mainly the lateral aspect of the cuboid182. The arch is supported with soft tissue structures. The
main muscles are the adductor hallucis, the peroneus longus, and the plantar expansions of the tibialis
posterior183. The last arch of the foot is the longitudinal arch.
The longitudinal curve runs also the length of the foot. It consists of the abductor hallucis on the
medial side, the flexor hallucis longus, and the abductor digiti minimi laterally184. The longitudinal arch
178
(Kapandji, 1987, p. 220)
179
(Kapandji, 1987, p. 220)
180
(Kapandji, 1987, p. 222)
181
(Kapandji, 1987, p. 224)
182
(Kapandji, 1987, p. 224)
183
(Kapandji, 1987, p. 224)
184
(Kapandji, 1987, p. 224)
53
is not as much as an arch like the aforementioned arches, but more of a curvature with medial aspect
being more pronounced then the lateral aspect.
3.4
SOFT TISSUES DISCUSSION
In order to be able to discuss the biomechanical principles, a thorough understanding of the
anatomy is paramount. In order to understand the function, the osteopath needs a clear mental picture of
the structures in the body. Discussion of the anatomy for the purpose of this study will start in the pelvic
region and continue distally to the foot.
The coxofemoral joint is a ball and socket joint with a strong, dense capsule. This capsule
contains a synovial membrane, and is comprised of four distinctive sets of fibrous tissue. The capsule
encases the head of the femur. It attaches medially at the acetabular rim, transverse ligament, and part of
the labrum185. Medially the labrum is intimately connected with other another structure. This structure is
the tendon of the rectus femoris186. The straight head of the rectus femoris muscle originates at the
anterior inferior iliac spine. The reflected head which comes from the groove located above the
acetabular rim187. According to Kapandji these straight head and the reflected head fibers unite prior to
travelling between the two portions of the capsular insertion. The reflected fibers of the rectus arise from
just above the rim of the acetabulum. The third head of the rectus femoris, the recurrent head is an
expansion off the reflective head, and continues in an arch like fashion, and is situated medial to the
greater trochanter188. Intimately connected to this structure is the aponeurotic expansion of the gluteus
minimus.
185
(Kapandji, 1987, p. 24)
186
(Kapandji, 1987, p. 24)
187
(Kapandji, 1987, p. 24)
188
(Paturet, 1951, p. 599)
54
3.4.1
JOINT CAPSULE
The capsule surrounds the neck of the femur where it attaches to the anterior trochanteric line, and
posteriorly at the lateral and middle thirds of the femoral neck above the groove of the obterator
externus189. The capsule is comprised of longitudinal, oblique, arcuate, and circular fibers.
Figure 5, Illustration of a right rectus femoris with the three origins. Direct tendon(tendon directe),
reflective head( tendon reflechi, and reflective head( tendon recurrent) (Weinstabl, 1989, p. 20).
The longitudinal fibers run in a parallel fashion and help to unite the two articulations of the hip
joint. Another set of fibers that have a similar function to the longitudinal ligament are the oblique fibers.
This fiber travels in a more spiraling direction than the longitudinal fibers190. There are a set of fibers that
attach only to the hip bone. These fibers are the arcuate fibers. The arcuate fibers go from one end of the
acetabular ring to the other, in a cris-crossed arched path191. They serve as a stabilizing factor and
according to Kapandji help to maintain the femoral head within the labrum. Having no direct attachment
to any bone are the circular fibers, or zona orbicularis. These fibers are most abundant in the central
189
(Kapandji, 1987, p. 24)
190
(Kapandji, 1987, p. 24)
191
(Kapandji, 1987, p. 24)
55
aspect of the capsule, around the neck of the femur where they create a tightening or collar in this area.
Gray describes the circular fibers as being more abundant posteriorly, and anteriorly having an attachment
with the deep surface of the ilio-femoral ligament192. The capsule of the hip is strengthened by a series of
ligaments.
These ligaments are located on the anterior and posterior surface of the capsule. There are two
ligaments located anteriorly; the iliofemoral ligament and the pubofemoral ligament193. The iliofemoral
ligament travels obliquely in front of the joint. This ligament is runs from the anterior inferior iliac spine
and inserts on the entire trochanteric line194. This ligament is commonly referred to as the ‘Y’ ligament of
Bigelow at the hip. This is because this band has two bands. The superior band (iliotrochanteric
ligament), the strongest of the ligaments, is attached the upper aspect of the trochanteric line, and the
inferior band inserts at the lower aspect of the intertrochanteric line195. There is a thin layer of capsular
tissue that sits between these two bands, and often contains a bursa for the iliopsoas tendon. The
pubofemoral ligament is located distal and medial to this band.
The pubofemoral ligament is another ligament on the anterior aspect of this capsule. This
ligament attaches medially on the iliopubic eminence, and the superior ramus of the pubis along with the
obterator crest, and inserts on the anterior surface of the trochanteric fossa196. These two anterior
ligaments create a zig zag appearance, or the letter ‘Z’. These ligaments help to strengthen the anterior
192
(Gray, 1901, p. 269)
193
(Kapandji, 1987, p. 26)
194
(Kapandji, 1987, p. 26)
195
(Kapandji, 1987, p. 26)
196
(Kapandji, 1987, p. 26)
56
capsule, and are the main contributors of maintaining an erect posture without fatiguing the muscular
system197. On the posterior aspect of the capsule is another ligament.
This ligament is the ischiofemoral ligament, and it is located on the posterior aspect of the
acetabular rim and labrum198. These posterior fibers traverse the neck of the femur and insert on the inner
aspect of the greater trochanter, and the tendon of the obterator externus according to Kapandji. The later
ligament has a winding course from its proximal attachment to its distal attachment.
The evolution of man from a quadruped posture, to the biped we know today created adaptation
to the capsular ligaments. The upright posture resulted in the winding of the capsular ligaments in a
clockwise direction around the neck of the femur199. This winding, and therefore tension is increased
with hip flexion, and decreased with hip flexion. Movements of the coxofemoral joint increase and
decrease tension in the ligaments depending on the direction of movement.
In addition to the ligaments becoming taut during extension, they are also tightened during other
motions. The motion of lateral femoral rotation increases the tension in the anterior ligaments of the
capsule, with exception to the ischiofemoral ligament200. This is especially true to the more horizontally
orientated ligaments; the superior iliofemoral band, and the pubofemoral ligament. During the opposite
movement of medial rotation the ligaments become approximated towards their sites of origins, and all
the anterior ligaments become slackened201. The motions of adduction and abduction can affect tension
changes on the capsular ligaments.
197
(Gray, 1901, p. 272)
198
(Kapandji, 1987, p. 26)
199
(Kapandji, 1987, p. 26)
200
(Kapandji, 1987, p. 30)
201
(Kapandji, 1987, p.30)
57
3.4.1.2 JOINT MOTIONS
With the motion of abduction the superior two ligaments of the iliofemoral bands relax, and the
pubofemoral band is under tension202. During adduction, the opposite occurs. The superior iliofemoral
band, and to a lesser extent the inferior iliofemoral bands are tensed during this action and the
pubofemoral band is relaxed203. As a result of the zig sagging orientation the ligaments are under varying
degrees of tension depending on the movement being preformed. The capsular structure of the hip plays a
crucial role in assisting both stability and mobility in the hip.
The muscles and soft tissue of the hip will be discussed in detail. The most important flexor
muscles of the thigh are the psoas, iliacus, sartorius, the rectus femoris and tensor fascia latae204. The
iliopsoas muscle is one of the strongest hip flexor muscles. It arises from the transverse process of all the
lumbar vertebrae, and inserts into the lesser trochanter. Due to the crossing of this muscle at the anterior
aspect of the hip joint, it forms a protective barrier to the head of the femur, and promotes a retropelvic
positioning205. This muscle also contributes to lateral rotation. The next muscle is the longest muscle in
the body. This muscle is the sartorius. It arises from the anterior superior iliac spine, and inserts onto the
medial aspect of the tibia. In addition to flexion it produces abduction and lateral rotation of the femur,
and flexion and medial rotation at the knee206. This long muscle is mainly a hip flexor. The next flexor
muscle is the rectus femoris. The rectus femoris has three origins. The first is the commonly known
anterior inferior iliac spine, the reflective and recurrent head. They have a common insertion on the
patella. This is a powerful hip flexor, dependent on the degree of flexion at the knee. This muscles more
202
(Kapandji, 1987, p. 32)
203
(Kapandji, 1987, p. 32)
204
(Kapandji, 1987, p. 40)
205
(Dufour, 2006, p. 135)
206
(Kapandji, 1987, p. 40)
58
efficient with a greater increase in knee flexion according to Kapandji. These muscles are the main
contributors to hip flexion, although there are others that contribute as well. The smaller contributors are
the pectineus, the adductor longus, and the gracilis207. Another major muscle that will be discussed in
significantly greater detail is the tensor fascia latae and its surrounding tissue, the iliotibial band. This
muscle is an important component of the leg. It has numerous attachments, and therefore plays a
significant role in the discussion of patellofemoral pain syndrome.
3.4.2
ILIOTIBIAL BAND
The tensor fascia latae is a muscle located on the lateral aspect of the hip and thigh. This muscle
has an elongated fascial sheath that descends the length of the femur and inserts around the knee joint. It
is a large connective tissue that serves as this continuous sheath of tissue is commonly referred to as the
iliotibial band or IT band. It is an incredibly long connective tissue that crosses two joints.
The tensor fasciae late is a relatively small vertical muscle located on the anterior lateral aspect of the hip.
It has a long tendinous attachment called the ilio-tibial band. The anatomy of the tensor fascia latae and
the ilio-tibial band will both be discussed. According to Gray’s Anatomy the tensor fascia late originates
from the anterior part of the outer lip of the iliac crest. It also has attachment on the outer surface of the
anterior superior iliac spine, and is situated between the gluteus medius and lateral to the sartorius. There
is also an attachment from the deep surface of the fascia latae and the deep surface of the gluteal fascia.
Kaplan also states that there is an attachment on the antero-lateral surface of the iliac fossa, with a
merging of fibers with the gluteus minimus208. Kaplan describes this muscle as being roughly fifteen
centimetres in length and four centimetres wide. This muscle is relatively small in comparison to the
ilio-tibial tract.
207
(Kapandji, 1987, p. 40)
208
(Kaplan, n.d, p. 10)
59
Wheeless textbook of Orthopaedics describes the insertion of the tensor fascia onto the proximal
1/3 of anterior-lateral aspect of the thigh. The iliotibial band continues down to the lateral epicondyle of
the femur, Gerdy’s tubercle, and head of the fibula. Lateral intermuscular septum, and lateral and
transverse retinaculum of the patella209. Gray’s anatomy states that the insertion of the tensor fascia latae
is “between the two layers of the iliotibial band of the fascia latae about the junction of the middle and
upper thirds of the thigh210. There are numerous attachments of this tissue.
Birnbaums anatomical investigations revealed that the anterior aspect of the iliotibial band splits
into a superficial and deep portion that covers the tensor fascia latae211. Furthermore, the deep portion of
the iliotibial band is attached to the femoral joint capsule. This fascia layer is deep to the superficial
fascia and in this area there is another fascia that is connected to the superficial fascia and the tensor
fascia latae. The cribiformis fascia, which is part of the superficial fascia, connects to both of these
structures212. This fascia has numerous perforations to allow numerous blood and lymphatic vessels to
travel through it.
The iliotibial band has a strong connection with the lateral intermuscular septum. This septum is
located between the vastus lateralis and the biceps femoris. More proximally on the hip area the tensor
fascia latae is in connection with the gluteus minimus and the deep surface of the gluteal fascia213. The
tensor fascia latae and the iliotibial band are both structures that have numerous attachments and investing
fibers, and thus must be discussed together.
209
(Kaplan, n.d, p. 8)
210
(Gray, 1901, p. 420)
211
(Birnbaum, 2004, p. 1)
212
(Gray, 1901, p 418)
213
(Kaplan, n.d, p. 10)
60
Frederic Wood Jones remarked that the gluteus maximus and the tensor fascia invest in the deep
fascia rather than to the bones214. Benjamin mentions that the tensor fascia is the deep fascia of the leg.
Understanding the anatomy in depth will help the Osteopath to treat this tissue and all its investing
tissues. This will provide a more thorough and comprehensive treatment, and thus a more rapid recovery.
3.4.3 DELTOID OF THE HIP
Like the deltoid in the shoulder region, there is a ‘deltoid of the hip’. This deltoid of the hip
(Farabeuf) is a fan shaped structure and consists of the tensor fascia latae anteriorly, and the superficial
fibers of the gluteus maximus215. These two muscles create the triangular deltoid of the hip joint. The
gluteus maximus radiates into the iliotibial band. Kaplan’s anatomical investigations revealed that the
iliotibial (IT) band splits into a superficial and a deep portion which wraps the tensor fascia latae216.
There has been some debate as to the actual function of the tensor fascia latae.
Figure 6, This schema shows the comparison of the deltoid of the upper extremity, and the lower
extremity (http://www.allthingshealing.com).
Duchenne, a French Neurologist based his interpretation of the firing of the muscle with slight
electrical stimulation. He noted that with strong stimulation of this muscle the thigh flexed and rotated
214
(Benjamin, 2009, p. 8)
215
(Kapandji, 1987, p. 46)
216
(Kaplan, n.d, p.1)
61
medially217. These two movements were the primary actions achieved through various levels of
stimulation. He noted that there was no abduction of the thigh or extension of the knee218. Similarly there
have been various attempts at exploring the action of this muscle. Other anatomist such as Henle and
Sappey came to the same conclusion as Duchenne. Braus contended that in addition to flexion and
internal rotation of the thigh, this muscle pulls the pelvis towards the thigh in standing219. More recent
descriptions include other muscular actions. Grant states that the action of this muscle is a flexor,
abductor, and medial rotator of the thigh in an open chain position. However, in a closed chain position
the muscle acts on the pelvis, producing flexion, abduction and lateral rotation220. Some anatomists
believe that the tensor fascia latae, via the iliotibial band has an action on the knee as a result of the
insertion on Gerdy’s tubercle.
Kaplan credits Hamilton and Appleton as having the most accurate description of the function of
the tensor fascia latae. Hamilton and Appleton recognize the attachment at Gerdy’s tubercle, but state,
The tensor fascia latae appears to play no direct part in controlling the knee joint movements; it
contributes, however, to the stability of the knee joint. The tensor fascia latae acts principally as a flexor
and medial rotator of the thigh…when the knee is extended; the contraction of the muscle exerts pressure
on the subjacent vastus lateralis and assists thereby in ensuring the stability of the knee221.” After reading
various articles one can see that anatomist from the mid 1800’s to early 1900’s believe the tensor fascia
latae to be a primary hip flexor and internal rotator. More recent textbooks consider the tensor fascia
latae to have the above mentioned movements and the ability to abduct the femur as well.
217
( Kaplan, n.d, p. 2)
218
(Kaplan, n.d, p. 2)
219
(Kaplan, n.d, p. 3)
220
(Kaplan, n.d, p. 2)
221
(Kaplan, n.d, p. 4)
62
It is important to discuss the extensor muscles and adductor muscles of the thigh. The extensor
muscles of the thigh lie posterior to the frontal plane. The gluteus maximus is the most powerful of the
body. It is the most superficial in the gluteal region. It arises from the posterior gluteal line on the ilium,
the iliac crest, and the posterior surface of the sacrum and coccyx, the aponeurosis of the erector spinae
group, and the sacro sciatic ligament222. It inserts on the fascia latae. In addition to this massive muscle,
the gluteus medius and minimus assist this muscle. These muscles contribute a well to lateral rotation of
the femur223. In addition to the gluteal muscles, the hamstring group contributes to the extensor
mechanism.
The biceps femoris muscle is a large muscle on the posterior aspect of the thigh. The long head
arises from the posterior aspect of the ischial tuberosity, and from the distal aspect of the sacro-sciatic
ligament224. The short head arises from the outer aspect of the linea aspera, and the external muscular
septum according to Gray. The insertion is the same, at the head of the fibula, and the lateral aspect of the
tibial tuberosity. The semimembranosis and semitendonosis on the medial aspect of the femur contribute
to hip extension. They also have an effect at the knee, and act as adductors in addition to extensors225.
After discussing the extensor anatomy of the hip, the next group of muscles to discuss is the adductors.
The major adductor of the thigh is the adductor magnus. This muscle arises from the ramus of
the pubis and the ramus of the ischium, and insert on the linea aspera. This muscle is the major adductor
of the thigh. It is assisted by the gracilis, semimembranosus, semitendonosis and biceps femoris according
to Kapandji226. The discussion of the anatomy is somewhat simplified with exception of the tensor fascia
222
(Gray, 1901, p. 472)
223
(Kapandji, 1987, 42)
224
(Gray, 1901, p. 432)
225
IKapandji, 1987, p. 42)
226
(Kapandji, 1987, p. 50)
63
latae. The next region to be discussed is the region of the knee. The focus will be the important
structures as they relate to this thesis.
3.5
KNEE
The ilio-tibial band is long, thick fascial structure on the lateral aspect of the femur. The proximal
attachment has already been discussed in the hip region. At its lower limit the iliotibial tract is attached to
the lateral condyle of the tibia, but in this situation it is intimately combined with an aponeurotic
expansion from the vastus lateralis. Below, the fascia latae is attached to all the prominent points around
the knee-joint, via the condyles of the femur and tibia, the lateral tibial tubercle (Gerdy) and the head of
the fibula227. There is a curved path of the iliotibial band as it attaches onto the lateral aspect of the
patella. It also attaches on the anterior fibers of the biceps femoris distal attachment228. On each side of
the patella it is strengthened by transverse fibers from the lower parts of the vasti lateralis and medialis; of
these fibers the lateral are the stronger and are continuous with the iliotibial tract.
Interesting to note, Glenn Terry, described two functional components of the ilio-tibial band. He
described that distally there are two bands, the iliotibial and the iliopatellar band229. The iliopatellar band
and iliotibial tract can be divided anatomically by an aponeurosis, a superficial, middle, deep, and
capsule-osseous layer230 (40). The aponeurotic layer is the most superficial layer and consists of arciform
fibers according to Terry. These fibers cross the anterior patella and patellar tendon and merge with the
sartorius on the medial aspect. This creates rein-like reinforcements on the lateral and medial side of the
knee joint.
227
(Kaplan, n.d, p. 11)
228
(Kaplan, n.d, p. 11)
229
(Terry et al, 1986, p. 39)
230
(Terry et al, 1986, p. 40)
64
Figure 7, This diagram illustrates the iliotibial band (2), the connection with the arciform fibers (3), and the
continuation with the sartorius(4).(Dufour, 2002, p. 156).
The superficial layer is made up of the vastus lateralis, the iliopatellar band, the lateral
patellotibial ligament, the ilio-tibial tract and the biceps femoris231. The next layer is deep to this layer; it
is the middle layer of the iliotibial tract. This middle layer is apparent with dissection of the superficial
layer. The fibers of this layer are oriented in a different fashion than the superficial layer. Terry believed
that the different orientation of the fibers creates a stronger mesh, and provides greater stability. The next
layer is the deeper layer.
This layer is deeper than the middle layer. It merges on the lateral aspect with the superficial
layer of the iliotibial tract and travels down and merges with the iliopatellar band of the iliotibial band232.
The last player to be discussed is the capsule-osseous layer.
This layer is seen when the superficial and deep layers are dissected. It extends more anterior and
acts as an antero lateral ligament of the knee233. This fascia becomes more superficial as it travels to the
231
(Terry et al, 1986, p. 40)
232
(Terry et al, 1986, p. 41)
65
posterior aspect. It forms a superficial arc that is continuous with the fascia covering the lateral gastroc
and plantaris muscle according to Terry234. This structure inserts on to the fibula, where the short head of
the biceps merges with this structure.
The second part of the iliotibial band is the iliopatellar band. This band connects the anterior
aspect of the iliotibial band and femur to the patella235. The superficial part of the iliopatellar band is not
in plain sight, and is obscured by the aponeurotic and arciform layer. It is believed that the iliopatellar
band helps with deceleration236. As previously mentioned, the superficial layer and the deep layer
adjacent to the patella are inseparable.
Another ligament to note is the distal portion of the iliotibial band. The patellotibial ligament
arises from the inferior aspect of the iliopatellar band, and it inserts anterior on Gerdy’s tubercle237. This
band connects the iliopatellar band to the iliotibial tract. It forms the anterior border of the superficial
layer of the iliotibial band according to Terry. The distal aspect of the iliotibial tract is more than double
the thickness of the proximal portion of the tract. This being said, Kaplan believed that this additional
thickness in the distal aspect of the iliotibial tract demonstrated an anterior lateral stabilizing mechanism
to the tibia238. These anatomical considerations are not typically discussed in popular anatomy books.
The osteopath can appreciate the complexity of the iliotibial band and all its attachments. Understanding
the magnitude of the attachments, and thus the entire structure of the iliotibial band, helps to treat the
function, and the biomechanical relationships in patellofemoral pain syndrome.
233
(Terry et al, 1986, p. 42)
234
(Terry et al, 1986, p. 42)
235
(Terry et al, 1986, p. 43)
236
(Weinstabl et al, 1989, p. 21)
237
(Terry et al, 1986, p. 44)
238
(Terry et al, 1986, p. 44)
66
The next structures to be discussed in the knee are the anatomy of the vastus muscles. The
quadriceps are typically discussed as the extensor mechanism of the knee. The gross anatomy is
discussed primarily with the vastus group only consisting of the vastus lateralis, vastus medialis, and
vastus intermedius. In fact, there are two portions of the vastus lateralis and two portions of the vastus
medialis. The vastus medialis longus inserts at the base of the patella, and the vastus medialis obliquus
inserts at the quadriceps tendon, the superior medial margin of the patella, and the anterior medial
capsule239. The vastus lateralis has a long head and an oblique insertion as well. The vastus lateralis long
head inserts at the lateral third of the base of the patella, and the obliquus inserts into the lateral margin of
the patella240. The oblique portions of both of these muscles have a different function then typically
discussed in anatomy books.
Figure 8, Illustrates the directions of pull of the vasti muscles in relation to the ‘Q’ angle.
(Weinstabl, 1989, p. 20).
239
(Weinstabl et al, 1989, p. 17)
240
(Weinstabl et al, 1989, p. 17)
67
The orientations of the obliquus portion in both the lateral and medial vasti are in oblique, as
opposed to the longus portion of the muscles. This changes the influence on the patella. The longus of
each muscle are primarily extensors, but the oblique fibers of the vastus medialis obliquus have an
antagonistic role to the effects of the vastus lateralis longus, and the vastus lateralis obliquus muscle241.
Weinstabl believed that the role of both vastus medialis obliquus and vastus lateralis obliquus facilitate
the movement of the patella in the patellofemoral joint during extension. The vastus medialis obliquus, in
conjunction with the medial patellofemoral and patellotibial ligaments resist the lateral subluxation of the
patella.
The longitudinal fibres of the quadriceps aponeurosis travel distally alongside the lateral and
medial border of the patella and the patellar tendon. They insert to the lateral and medial tibial condyle242.
This layer also merges anteriorly with the deeper joint capsule, adjacent to and along the length of the
patellar tendon. The tissues which restrain the patella from its lateral aspect have been shown to include
the deep fascia in the most superficial layer, the quadriceps aponeurosis and iliotibial band in the
intermediate layer and the joint capsule in the deepest layer.
Figure 9, Illustrates the longitudinal fibers and the aponeurotic expansion of the quadriceps tissue. (Bouchet, 2002,
p.1526).
241
(Weinstabl, et al, 1989, p. 18)
242
(Weinstabl, et al, 1989, p. 21)
68
The last structures of the knee to be discussed are the patellofemoral ligaments and
meniscofemoral ligaments. The patellofemoral ligaments are transverse capsular thickenings. The lateral
patellofemoral ligament is attached to the lateral patella and inserts on the lateral femoral epicondyle243.
There is a similar transverse structure on the medial aspect of the knee. The medial patellofemoral
ligament originates on the medial femoral epicondyle and the medial collateral ligament, and runs deep to
the vastus medialis obliquus and inserts on the superomedial aspect of the patella244. Similar to these
thickenings on the superior aspect, there are parallel thickenings inferior to this. There is a condensation
of tissue, the lateral meniscopatellar ligament, arise from the inferolateral aspect of the patella to the
anterolateral aspect of the lateral meniscus245. There is a matching ligament, on the other side of the
patella, the medial meniscopatellar ligament. It attaches to the medial surface of the patella and inserts on
the medial femoral epicondyle.
Understanding the role and fiber orientation of the muscles and ligaments is important in treating
the function of the muscles. Anatomy requires a thorough investigation and cannot be overly simplified.
Over simplification could decrease the success in treating all the links in a chain.
Figure 10, This schema illustrates the medial and lateral patella femoral ligaments (3, 15), and the
meniscopatellar ligaments (5, 13). (Bouchet, 2002, p. 1526).
243
(Normura, 2005, p. 511)
244
(Normura, 2005, p. 513)
245
(Normura, 2005, p. 513)
69
In order to understand how the body works, and how the body moves, and how the body
compensates, we need to understand the model of tensegrity. Tensegrity is a merging of the words
tension and integrity. The model of tensegrity and how it applies to osteopathy was developed by
Buckminister Fuller246. The idea behind this model is that if our body is in harmony, and our posture is in
balance, all parts of the body are moving optimally, then fluid circulation should not be obstructed in any
way. Tensegrity is a morphing of tension and integrity.
All structures in the universe are supported by a balance between tension and compression.
Tensegrity structures distribute strain throughout the entire structure. The integrity of the structure is
based on the tension between the soft tissue structures and the hard, solid parts247. When one part moves,
the other part moves as well and therefore the entire structure moves as one. This explains how the
fascial effects are felt far removed from the site of application. Tensegrity structures enable movement,
with the minimum amount of energy expended, and without losing stiffness or stability248. Movement
passes through all tissues. All tissues from the gross anatomical structures to the structures at the cellular
level act as a component in the tensegrity system. On the macroscopic level the bones from the
compressive units which slant towards gravity, and are steadied by the tensions in the muscles, tendons
and ligaments. This structural continuity consists of the extracellular matrix and the cytoskeleton249.
This body wide communication system is paramount in all living structures. It communicates with the
extracellular sugar-proteins biopolymers, or ground substance, the collagens, water molecules, as well as
246
( Ingber, 2003, p.1397)
247
( Ingber, 2003, p. 1397)
248
( Ingber, 2003, 1398)
249
( Stone, 1999, p. 48)
70
the basement membranes, cytoskeletons, nuclear matrices, and genetic material250. The internal structures
of cells are intimately connected to the surrounding connective tissues. From the extracellular matrix,
through all the soft tissue layers, and in between all components of the body, all cells work in harmony
because they are physically connected to each other. Mechanical stability of structures does not depend
on the strength of individual parts but on how the whole structure distributes and balances mechanical
strain.
3.6
EXTRACELLULAR MATRIX
The extracellular matrix is often another term used for connective tissue. It is composed primarily of
three types of biomolecules; structural proteins like collagen and elastin, specialized proteins like fibrillin,
and proteoglycans251. The extracellular matrix includes the interstitial matrix and the basement
membrane. Every process and every function in the body involves the extracellular matrix in one way or
another252. This is because every cell in the body is bathed and nourished in this matrix. All cellular
metabolism waste products must pass through the ground substance, which is the actual medium.
Tensions in this matrix regulate metabolic reactions in the cytoplasm and nuclei of cells253. The
extracellular matrix is a meshwork of ground substance proteoglycan gel and with a strong collagenous
web embedded in it.
The extracellular matrix has numerous roles. It helps to provide cell motility and angiogenesis, physical
support of cells, tensile strength for tissue, cellular communication via integrins, communication to the
outside world, and regulatory roles of cells254. The roles and functions of the extracellular matrix are so
250
(Oschman, 2009, p. 219)
251
(Stone, 1999, p. 49)
252
(Pischinger, 2007, p. 3)
253
( Ingber, 2003, p. 1399)
254
(Stone, 1999, p. 57)
71
diverse, yet this gel like substance is integral in all bodily functions. The web like connection infiltrates
all tissues and thus all systems in the body. If there is stasis, or stagnation of this matrix, there is dis-ease
in the body. Osteopathic techniques are paramount in influencing and directing this important fluid,
throughout tissues, and structural blockages. Osteopathic techniques are especially important in
influencing the movement of fluid through the tubular lumens of the fascia255. Working on the fascial
system influences the movement of the extracellular matrix, and health of the entire system.
Osteopathic techniques that use a fluidic, lemniscate approaches can affect the fluids in areas of
the fascia located throughout the body256. This healthy, innate lemniscate movement of the fascia, or the
Primary Respiratory Mechanism, if altered or hindered can affect systemic health. The goal of the fascial
techniques is to restore the normal ebb and flow of the extracellular fluid. To help restore the regular
flow of fluid in an area of stasis or diminished flow is the goal of the fascial techniques taught at
Sutherland Academy.
3.7
PRIMARY RESPIRATORY MECHANISM
The Primary Respiratory Mechanism is an involuntary movement throughout the entire body.
The Primary Respiratory Mechanism in an inherent physiological process that arises from the central
nervous system and adjacent structures. Sutherland described five phenomena that occur during Primary
Respiratory Mechanism257;
-
The inherent motility of the brain and the spinal cord;
-
Fluctuation of the cerebral spinal fluid;
-
Motility of the intracranial and intraspinal membranes;
-
Articular mobility of the bones of the cranium; and
255
(Sanderson, 2007, p. 85)
256
(Sanderson, 2007, p. 86)
257
( Stone, 1999, p. 260)
72
-
Involuntary mobility of the sacrum between the ilia
This motion occurs in the cranium and travels down to the sacrum. There is a unit of function between
the cranial bones and the dural membrane. This functioning system is called the reciprocal tension
membrane. This motion is transferred throughout the entire system of the body. This membrane system
is composed of the falx cerebri and cerebelli and the tentorium cerebelli258. This system is perceived to
have two phases; an inhalation/flexion phase, and an exhalation/extension phase. These movements
travel throughout the human organism.
3.7.1
FROM PRIMARY RESPIRATION TO FASCIAL BIODYNAMICS
The primary respiratory movement oscillates throughout the entire human organism. This
mechanism is an innate rhythm of the body that is transmitted through the fascia. The cranial vault and
facial structures expand and shorten in response to the fluctuation of the cerebral spinal fluid pressure. In
cranial flexion the skull widens and shortens. In cranial extension the skull lengthens and narrows.
During cranial flexion;
- the occiput goes into extension
- the unpaired organs like the heart, stomach and bladder move into flexion (along
a horizontal respiratory axis)
-the paired organs like the lungs and kidneys go into external rotation like rhythm
- the sacrum goes into counter-nutation;
- this creates an anteriorization of the ilium, there is an inherent shortening, but not a
mechanical contraction of the hamstrings;
- the coxo-femoral joint goes into external rotation; slackens the iliopsoas, and the
inguinal ligament
- there is a reduction/shortening on the anterior aspect of the iliotibial band, causes the fibular
head to move cephalically and into external rotation.
258
(Stone, 1999, p. 260)
73
- dorsiflexion occurs (not mechanical dorsiflexion), as a result of the shortening/reduction phase
of cranial flexion,
- as a result of the reduction phase with dorsiflexion, the cuboid does an internal rotation like
rhythm, and navicular goes into external rotation like rhythm.
-So the sensation of the fascia is in a shortening, cephalic rhythm.
During cranial extension;
- the occiput is in flexion,
- the unpaired organs like the heart, stomach and bladder move into an expansion like
extension (along a horizontal respiratory axis)
-the paired organs like the lungs and kidneys go internal rotation like rhythm
- the sacrum goes into nutation;
- this creates a posteriorization of the ilium, there is an inherent lengthening, not a
mechanical lengthening;
- the coxo-femoral joint goes into internal rotation like rhythm; the iliopsoas expands, and
increases a volumetric like sensation in the inguinal ligament
- this expansion, creates a rhythmic lengthening on the anterior aspect of the iliotibial band, and
inherent shortening like sensation on the posterior aspect of the ilio tibial band, causing the caudal
lengthening sensation of the fibular head and into internal rotation.
- the tibia feels like it expands into internal rotation
- plantarflexion is perceived as the expansion continues distally, and the cuboid does an
external rotation like rhythm, and navicular does an internal rotation like rhythm.
-So the sensation of the fascia is and expansion in a caudal manner.
These are the optimal biomechanics, or biodynamics, as it relates to the Primary Respiratory Mechanism.
It is not to be mistaken for mechanical movements and actions. The sensation of reduction and expansion
is a result of a physiological process. Cranial flexion or extension is a process that involves the systemic
circulation and intracranial blood pressure259. These inherent movements of cranial flexion and extension
259
(Sanderson, 2007, p. 237)
74
are a result of pressure differentials in the system resulting in a wave like flow felt throughout the body.
The sensation that is perceived in cranial flexion is a welling up, and a transverse widening. With cranial
extension, there is more of a receding sensation, a lengthening sensation. One senses a whole body
rhythm of fluid interaction.
Restrictions in the cranio sacral movements, as a result of their fluidic-fascial connections
throughout the body, can influence the functioning of numerous physiological processes elsewhere. The
body functions as an integrated system, with all structures working in relationship to each other. The
osteopath is able through palpation to determine areas of tension in the body by listening to the Primary
Respiratory Mechanism. The continuity of the fascial network enables the osteopath to feel the innate
rhythm of the body. If there are no restrictions or imbalances in this rhythm, then health can be restored.
The Osteopath understands that the inherent Primary Respiration mechanism is the innate blueprint of
healthy motion in the body. The fluidic rhythm of this motion knows no barriers, and passes through all
tissues- be it osseous, muscle, organ, membrane, of fluid.
3.8
POLYGONS OF FORCE
John Martin Littlejohn was a renowned Osteopath. He was one of the first graduates from Andrew Taylor
Still’s school of osteopathy260. Littlejohn had a fascination with physiology and developed an entire
biomechanical model that suggested movement and postural imbalances can create normal function or
dysfunctional processes in the body261. Movement and posture are intimately connected. One’s posture
will directly influence how one moves. Posture is related to soft tissue and its influence on the skeletal
framework. Imbalances in tensions can influence the pattern of movement in various locations of the
body. Littlejohn considered the center line of gravity to be located anterior to the third lumbar
260
(Stone, 1999, p. 127)
261
(Stone, 1999, p. 127)
75
vertebrae262. He considered the spine a series of links in a curved chain, with changing vertebral shape.
Traditionally vertebras are classified according to their location in the spine.
Typically when discussing the spine, the general consensus is that there are seven cervical
vertebrae, twelve thoracic vertebrae and 5 lumbar vertebrae. Littlejohn was more interested in the
shifting of the vertebral shape along the spine. He considered the second cervical vertebrae structurally
similar down to fourth thoracic vertebra, and the thoracic ally similar vertebrae were the fourth thoracic to
the ninth thoracic263. Changes towards a more lumbar shaped vertebra became apparent at the tenth
thoracic down to the sacrum with exception of two transitional vertebrae located at the tenth thoracic
vertebra and eleventh264. Littlejohn also takes into account the angle of the facet joints, and the tendency
to favor specific movements as a result. As a result of the orientation of the articular facets, above the
fifth cervical vertebrae, with exception to first cervical vertebrae, they favor one direction, and below C5,
they favor the other direction265. The change in facet angle also occurs in the thoracic spine.
Depending on the location of the vertebra, they tend to favor a movement. The eleventh and
twelfth thoracic vertebrae prefer extension, while the lower thoracic vertebrae sitting above this level
prefer a side-bending and flexion266. The same applies to the lumbar region, starting below the tenth and
eleventh thoracic vertebrae and extending to the fourth lumbar vertebra. Another exception, applies to the
fifth lumbar vertebra, like the first cervical vertebra, forms a junction with the adjacent non spinal bone267.
Coupled with this structural aspect of this model is the soft tissue system.
262
(Stone, 1999, p. 128)
263
(Stone, 1999, p. 129)
264
(Stone, 1999, p. 129)
265
(Stone, 1999, p. 129)
266
(Stone, 1999, p. 129)
267
(Stone, 1999, p. 129)
76
The soft tissue system creates altering changes of force. Depending on the area of the spine in
discussion, and the anterior, posterior and lateral attachment of the musculature in this area, instability or
hinging in the spine can occur268 . Another aspect to consider is the force of gravity. With the force of
gravity and the weight transmission of the head on the spinal column, a polygon of forces is created269.
The line of force created from the anterior aspect of the skull and the posterior aspect of the skull down to
the pelvis creates two triangles that pivot in front of the third and fourth thoracic vertebrae270. These
triangles are referred to as the upper and the lower triangles. The anterior posterior gravity line goes from
the anterior aspect of the foramen magnum down to the coccyx and the posterior anterior gravity line goes
from the posterior aspect of the foramen magnum to the most anterior aspect of the spine, located at the
second and third lumbar vertebrae.
Figure 11, This diagram shows the anterior-posterior gravity line, the two triangles of Littlejohn in
the middle schema, and the posterior anterior gravity line.
(http://www.johnwernhamclassicalosteopathy.com/bookshop/mechanics-charts/)
268
(Stone, 1999, p. 132)
269
(Stone, 1999, p. 132)
270
(Stone, 1999, p. 132)
77
Certain areas in the spine acquire more tension then other areas. The weight of the head
accumulates tension around the fourth thoracic vertebrae, and with the weight of the body on the pelvis
tension is accumulated at the level of the third lumbar vertebra271. The entire area of the body above the
third lumbar vertebra is supported on this vertebra, and the rest of the body below this vertebra is
supported from this point. In architecture, just like in the body, a central point in an arch is considered a
keystone. Littlejohn considered the ninth thoracic vertebra to be this keystone in the body272. Depending
on the dominance of a specific chain, or line of gravity, a person will adapt a postural manifestation.
3.8.1
ANTERIOR AND POSTERIOR POSTURE
Someone with a posterior posture type presents with an extended occiput, neck tilting downward,
exaggerated thoracic and lumbar curve, and sagging posture, shortened hamstrings, contracted
quadriceps, flexed knees, and their weight is on their heels273. The line of gravity is located posterior to
the normal line of gravity. The line of gravity is posterior to the external auditory meatus, the acromion is
posterior, and there is kyphosis of the thoracic spine. The line of gravity is posterior to the ilium,
coxofemoral joint and the malleolus. An individual who presents with an anterior posture will have
different areas of tension and compensation patterns than someone who demonstrates a posterior posture
The individual that presents with an anterior type posture has an upward pointing chin, an
increased cervical curve, anterior rotated pelvis, contracted quadriceps, hyperextended knees, tight calves,
and their weight is distributed on the balls of their feet274. The line of gravity is anterior to the
coxofemoral joint, the knee, and the lateral maleolus. These postures have different forces of tensions
throughout their body. As a result of the disturbances and imbalances, soft tissue structure, visceral
271
(Stone, 1999, p. 133)
272
(Stone, 1999, p. 133)
273
(Richter, 2007, p. 60)
274
(Richter, 2007, p. 60)
78
structures and ultimately movement patterns and biomechanics will also experience ramifications. The
altered tensions created in the soft tissue system, can eventually affect movement patterns, and ultimately
the optimal functioning of the organism.
Figure 12, From left to right, the posterior dominant posture, normal posture, and the anterior
dominant posture. (http://www.johnwernhamclassicalosteopathy.com/bookshop/mechanicscharts/)
3.5 BIOMECHANICAL CONSIDERATIONS
Osteopaths have a profound interest in movement patterns and movement mechanics of the body.
Structure and function are intimately related. Trauma, stress, posture, surgical procedures, repetitive
movements all can have an effect on the body and its systems. These contributing factors can affect the
tone and the tensions of the structures in the body. It can affect the alignment of a structure and
eventually the function of that structure. Osteopathy strives to bring the body back into structural
79
harmony to create an optimal environment for the body to heal itself. Anatomy is such an important
aspect of Osteopathy. The osteopath sees the connections, and links in the anatomic system, and treats
not just locally but systemically.
The structure of the body is intimately connected. If there is a mal-alignment of one of the links
in the chain it will affect the entire chain, and could lead to problems more distant in the body. If we are
to observe what can happen when one link in the lower extremity is slightly mal positioned, we can see
the domino affect elsewhere in the body.
We will take the example of the cuboid, and follow the compensations all the way through the system. If
the cuboid is positioned or ‘stuck’ in external rotation, it will create an ascending lesion. This will cause
the calcaneus to go into inversion, and will influence the talus to go anteriorly. This in turn will cause the
fibula to move caudally via its ligamentous attachments on the talus. As the talus moves anteriorly, this
widens the mortise joint. This widening of the mortis joint creates instability at this joint. As the fibular is
being pulled anterior and caudally it puts tension on the interosseous membrane and Barkow’s ligament.
The fibers of the iliotibial band will be put under tension along with the rectus femoris, and will continue
this tension all the way up to the anterior superior iliac spine. This will cause an anteriorization of the
ilium. If there is no lesion in the sacral iliac joint on this side, in a stationary posture the sacrum will
follow the ilium and go into a nutation. This nutation affects the pubo-vesico-utero-rectal-sacral
ligament. There is less tension in this ligament on the side of the anterior ilium. There is now a structural
imbalance of the pelvic viscera. A contralateral rotation of the viscera is likely to occur. This can cause
numerous physiological problems if not addressed sooner than later. Going back to the anteriorized
ilium, this causes the head of the femur to move caudally, presenting with a false long leg on this side.
The psoas is under tension as a result. This tension travels up to coxofemoral joint, and into the inguinal
ligament. Prolonged tension in the inguinal region can affect the femoral nerve and the various femoral
vessels in this area. This tension continues cephalically where it can affect the digestive organs on its
80
respective side of the lesion. This tension continues to travel to the lumbar vertebrae where it travels
cephalically with the relationship of the pillars of the diaphragm.
The psoas puts tension on the lumbar vertebrae and increases the lordosis. The diaphragm is under
tension, which means any organ in continuity or contiguity with it is under tension. The liver is drawn
cephalically and posteriorly via the triangular ligaments. The mobility of the diaphragm is restricted due
to this tension in the psoas. This tension can continue cephalically via the central chain of the body. In
addition to this there is tension on the anterior longitudinal ligament from the tension on the psoas. This
tension travels all the way to the anterior arch of the first cervical vertebrae. This can cause a slight
rotation at this level. This demonstrates the chain of events that can occur in an ascending lesion starting
with the cuboid.
Figure 13, Illustrates the attachment of the psoas #26, to the lumbar spine and its relation to the kidney. (Bouchet,
2002, p.2132).
81
Figure 14, Illustrates the relationship of the psoas to the left iliopelvic and sigmoid mesocolon (Bouchet, 2002,
p.2133).
A lesion in the navicular will put create tension in the cuneiforms. This tension will travel up the
peroneals, and continue up the lateral chain. In addition, if the navicular bone is in lesion it will also
cause the posterior tibialis to be under tension. This will put tension on the interosseous membrane; this
tension will travel up the poster chain via the gastroc heads, up the hamstrings, and into the sacrotuberous
ligaments. This ligament will put tension posteriorly on the ilium. This will create tension in the
quadrates lumborum and the lumbosacral fascia. The natural lordotic curve will be decreased. This can
create tension up the diaphragm via the pillars. The thoracolumbar fascia will be under tension and the
latissimus dorsi. This tension will travel up the spine, and into the humeral attachment. The humerus will
be in internal rotation. This can affect the vasculature and brachial plexus, and cause neurological issues.
A descending lesion may exist and also affect the biomechanics of the lower limb. The person
can have a seemingly insidious onset of knee pain. However, the Osteopath knows that there is a cause
for this knee pain. The foot and knee can be biomechanically sound, however if the person is
experiencing digestive issues, or has significant abdominal inflammation, this can cause knee pain. The
fascial is a web of communication. It has a micro tubule architecture that is a highway for fluids. The
82
accumulation of inflammation in this system, can travel down the fascia iliaca, down the rectus femoris,
and into the knee joint. The Osteopath can solve the mystery of the insidious onset of knee pain.
Biomechanics is a very broad topic. It does not simply refer to the osteo-articulations; it refers to the
tensegrity of the entire system. The skeletal structure, the soft tissue interwoven fabric, the visceral,
neural, and circulatory systems are all components to be considered in the subject of biomechanics.
The osteopath is the Sherlock Holmes of the body. We see the clues our body presents, and we
sleuth our way to the cause!
3.6
EMBRYOLOGY
To facilitate learning about the human body as a holistic functioning machine, it is beneficial to
understand and appreciate the evolutionary intricacies that occur from the moment of conception, and the
evolution of the human embryo. Embryology is the biological study of development of the human being
from the point of conception, the developing fetus up to the point of birth. Leslie Brainerd Arey remarks
on the value of studying embryology from numerous perspectives, including a general, philosophical, and
medical275. From a general perspective, the value of studying embryology is to gain appreciation of
existence from a single celled organism. From a philosophical approach, embryology provides the key to
understanding genetic, hereditary, and determination of gender. And lastly, embryology to the medical
student enriches the student’s anatomical vernacular and appreciation of anatomical relationships.
Folding of the embryo gives rise to the foregut, the hindgut, and what will be the future heart.
Neural crest cells, which were originally located on the lateral aspects of the notochord, detach
themselves prior to the folding of the tube. These structures give rise to the dorsal root, cranial, autonomic
275
(Arey, 1946, p. 15)
83
and enteric ganglia276. In the ectodermal tissue lying above the notochord, the neural plate forms. This
structure goes through a series of folding, and invaginations eventually leading to the formation of the
neural tube, which is the rudimentary central nervous system. Differentiation continues in a cephalocaudal direction with the lateral mesodermal tissue located on either side of the neural tube277. These 4244 paired blocks of tissue called somites, give rise to the formation of the spinal column, and connective
and muscular tissue. Each somite yields a muscle segment, and each somite pair contributes to the
formation of a vertebra.
Somites form from the paired mesodermal tissues along the lateral aspect of the neural plate. The
first pair develops in the cervical region. By the end of the fifth week there can be around 42-44 pairs of
somites present. These somites arrange in a cephalo-caudal manner with 4 occipital, 8 cervical, 12
thoracic, 5 lumbar and 5 sacral and somewhere between 8-10 coccygeal somites278. With the regression
of the primitive streak these masses of tissue separate into blocks of tissues termed somites279. They are
typically square in shape and will develop into three major types of tissues; the sclerotomes, myotomes,
and dermatomes.
276
(Mitchell, 2004, p. 5)
277
(Mitchell, 2004, p. 6)
278
(Langman, 1967, p.64)
279
(Larsen, 2009, p. 43)
84
Figure 15, Shows the development of the somites (Humphrey, 1971, p.1428).
The sclerotomes of the somites will develop into the vertebral column and ribs. Mesodermal cells
of the somites evolve into future muscles of the face and body. The dermatomes will develop into the
future dermis of the skin280. The origin of the tissues for the craniofacial muscles derived from the seven
somitomeres and the seven most cephalic somites, gaining their cranial innervations sequentially281.
The myotomes of the first four cephalic somites infest the fourth, fifth, and sixth pharyngeal
arches, carrying the vagus (tenth cranial) and spinal accessory (eleventh cranial) nerves to provide the
extrinsic and intrinsic laryngeal muscles282. By looking at embryology and nerve distribution one can
understand the trace the origin of a muscle. The muscles as we see them may not be where they
originated from. They can migrate to different areas of the body, and typically bring their original
innervations with them.
There is some overlap with the somites, especially concerning innervations. As the somites
segment travels caudally, as does the derivative of that somite. Around days 20-30 a total of 38 paired
somites have developed. Somites continue their paired arrangements until a total of 42-44 paired somites
280
(Rana, 1998, p. 5)
281
(Rana, 1998, p. 43)
282
(Rana, 1998, p. 50)
85
are present283. The length of the embryo at this stage is roughly 4mm. The limb buds initially appear as
bilateral elevations from the ectodermal ring of the lateral body wall284. The upper limb buds develop
first around day 26 -27, and are followed by the development of the lower limb buds at approximately day
28. Even with this minor delay in the development of the lower limb bud, but for the most part there is a
proximodistal sequence of development. The limb buds start off as ectodermal elevations called skin
folds285. These folds migrate ventrally off the posterior aspect of the embryo. Initially the four limbs are
very similar, and their longitudinal axes are both parallel in nature286. The upper limb buds appear low on
the embryo due to the dominant development of the head and neck. The upper limb buds form opposite
the distal cervical segments and lower limb buds form opposite the lumbar and upper sacral segments.
The limb buds of the upper extremity develop from somites 7 through 12, and the lower limb buds
develop from somites 25 through 29287.
283
(O'Rahilly, 1996, p. 258)
284
(Langman’s, 1967, p. 151)
285
(Blechschmidt, 1994, p.153)
286
(O’Rahilly, 1996, p.245)
287
(Rana, 1998, p. 48)
86
Figure 16, This figure shows the typical level of the upper and lower limb buds in respect to the paired
somites. (Humphrey, 1971, p.1430).
The limb buds arise from the somites and consist of a core or mesenchymal tissue that is covered
by ectodermal tissue288. As mentioned previously the somites arise from the mesodermal germ layer.
This mass of tissue is covered with a ring like layer of ectodermal tissue. This tissue is restricted in its
surface growth and as a result thickens into apical ridges, termed the limb placode289. This apically shaped
ectodermal tissue promotes growth of the limb in a proximal distal relationship. As a result of the density
of the ectodermal tissue this area flattens and becomes the highly innervated most distal segment of the
limbs290. These highly innervated areas become the plantar and palmar aspects of the feet and hands.
288
(Langman’s, 1967, p. 139)
289
(Blechschmidt, 1994, p.153)
290
(Blechschmidt, 1994, p.152)
87
An important stage of rotation needs to occur in order for the lower limb to be oriented so that the
plantar aspect of the foot is inferior and caudally. Rotation occurs during the 6th week in utero. Initially
the lower limb buds are situated so that the future big toe is positioned laterally, with the soles of the feet
pointing towards the head of the fetus291. The lower limbs experience medial or internal rotation bringing
the great toe to the midline, while the upper limbs undergo adduction or lateral rotation292. The fetal knee
is now positioned cranially and ventrally.
By the 6th week the limb buds elongate and have changed shape from their original bud-like
formation. They have flattened and become more paddle shaped as they migrate in direction of the
abdomen293. At the same time as the limb is elongating into the forearm and eventual hand, an internal
condensation of the tissue begins. The condensation of the mesenchyme into hyaline cartilage is a
precursor to ossification of the bones in the extremities294. Scuderi states that chondrification of the
femur, tibia, and patella and early differentiation of the patella and patellar ligament start around day 37
of embryological development. Around day 45 chondrification of the patella begins, in addition to the
differentiation of the cruciate and menisci295. Blechschmidt explains that initially the humerus forms,
followed by the two lower bones of the forearm, and the bones of the wrist and fingers. At this stage of
development Blechschmidt explains that the aspect of the arm closest to the abdomen is densely
innervated and can be distinguished as the flexor side of the limb. The extensor side of the limb is the
outer surface of the limb. It should be noted that initially what later becomes the plantar side of the feet,
are directed cranially. The hands are directed medially as well. The upper limb buds are located above
the midline and on the lateral aspect of the embryo. The lower limb buds are located more caudally.
291
(O’Rahilly, 1996, p.350)
292
(O’Rahilly, 1996, p 350)
293
(Langman’s, 1967, p. 140)
294
(Langman’s, 1967, p. 140)
295
(Langman’s, 1967, p. 11)
88
More specifically, the upper limb buds are associated with the lower five cervical and upper two thoracic
segments. The lower limb buds lie opposite the lower four lumbar and upper two sacral segments296. As
these limb buds continue to grow the nerves from these areas continue to migrate with them.
Figure 17, This schema demonstrates the upper and lower limb positions. (O’Rahilly, 1996, p.148).
The future skeletal system starts to form heralded by the development of vascular growths in
week five297. Bernhardt explains that this vascularisation occurs in this sequence; talus, calcaneus,
navicular, cuboid, cuneiforms, metatarsals, and phalanges. By the middle of the sixth week, a
cartilaginous model of the future skeleton is formed. Bernhardt suggests that this cartilage model grows in
a particular sequence starting with the tarsus, first metatarsal, second to fourth metatarsals, the cuboid, the
fifth metatarsal, navicular and digits one to five298. At this stage, the mesenchymal core is differentiating
into lower limb musculature in a proximal-distal sequence. The limbs are now more paddle shaped, and
are starting to become less webbed, segmenting from direction of the hallux to little toe299. By the eighth
296
(Langman’s, 1967, p. 150)
297
(Bernhardt, 1998, p. 2)
298
(Bernhardt, 1998, p. 3)
299
(Bernhardt, 1998, p. 2)
89
week, prominent notches or grooves for the toes have started to develop. By the ninth week the digits are
separated and well developed, and the transverse arch of the foot starts to form 300(3). Bernhardt states
that the transverse arch is formed by the dropping of the first and fifth metatarsal heads in a plantar
direction.
Vascular growths from the heart continue to migrate into these growing limbs. These first
vascular networks of the developing limb play an important part in the shaping of the limb. The growth of
the vascular network and nervous system creates more tension along the medial aspect of the arm, thus
creating the limb to grow in a direction of flexion301. Blechschmidt explains that these vessels are
necessary for transporting raw materials into the limb, and removing any waste products. He discusses
further that these vessels play an important part in removing by-products such as water way from the
inner tissue of the limb. This process causes dehydration and thus cellular consolidation in the stroma of
the limb, resulting in the pre-cartlaginous skeleton of the fetus302. The cartilaginous substance becomes
the precursor to the formation of the skeleton. The large vessel in the limb, the precursor to the femoral
artery plays, an important role in the overall shape of the lower limb. The vessel grows in and inferior
lateral (oblique) direction. This directional growth influences the femur bone to grow in a medial rotated
manner303. The musculature of the lower limb grows around the axis of the femoral artery.
Simultaneously the adductors and gluteal muscles form initially, and then the extensors and flexors of the
thigh follow304. The muscles of the limbs grow in from a proximal origin distally. They grow in length
and are often overlapping like shingles on a rooftop. The musculature of the upper and lower limbs
300
(Bernhardt, 1998, p. 3)
301
(Blechschmidt, 1994, p.158)
302
(Blechschmidt, 1994, p.157)
303
(Blechschmidt, 1994, p.161)
304
(Blechschmidt, 1994, p.161)
90
occurs simultaneously. By the seventh week in utero, the first densification of the mesenchymal cells is
noted at the base of the limb bud.
The lower limb musculature will be the primary focus of discussion. The musculature system is
derived from the mesodermal germ layer. After the somites have differentiated into sclerotomes and
dermomyotomes, the myotomes cells split off and become elongated and spindle shaped305. The muscle
cells, also known as myoblasts blend together and form multi-nucleated muscle fibers. This elongation of
the muscle fibers contributes into two main types of muscular actions. Some fibers elongate into flexor
components and other fibers elongate into extensor components on the arm306. As soon as the limb buds
are formed, the nerves penetrate into the mesenchyme of the buds. These nerves are located bilaterally
where the limb bud arises. The upper limb, which is located at the lower cervical and upper two thoracic
somites receive these associated nerves in the future upper limb. The same applies to the lower limb, with
the associated four lumbar and twos sacral segments. Once the nerves have entered the limb buds this
facilitated further functional differentiation307. The mesodermal cells and the neural tissue develop in
close approximation and at fairly similar time frames.
Another interesting point to be discussed is the segmenting at the joints that occurs in the limbs
prior to the formation of the skeletal system. Blechschmidt explains how segmenting exists even prior to
musculo-skeletal development. Natural bending occurs where the elbows, wrists, knees and ankles
eventually form308. These spaces become more prominent as the embryo develops. Between the 11th and
20th week of gestation a suprapatellar plica forms in about one third of fetuses309. Scuderi states that this
305
(Langman’s, 1967, p. 148)
306
(Langman’s, 1967, p. 150)
307
(Langman’s, 1967, p. 151)
308
(Langman’s, 1967, p. 154)
309
(Scuderi, 1995, p.12)
91
plica can develop into four variants in the adult knee. These four variants are a full septum, a fenestrated
septum, a medial shelf, or a fully involuted structure310. The medial synovial plica which is present in one
third of fetuses and occurs during the same gestational time and lastly the infrapatellar plica develops in
fifty percent of the population. By day forty five, chondrification of the patella commences in
conjunction with the differentiation of the cruciate ligaments and the menisci311. The patellar ossification
center is typically a single entity312. The importance in discussing the embryological development of the
patella is that this structure in the adult can mimic symptoms of PFPS.
A joint capsule develops around theses spaces and is fluid filled313. The foetus continues to
develop throughout the entire pregnancy. After discussion of the embryological development, further
discourse in the anatomy of the lower leg will follow.
310
(Scuderi, 1995, p.12)
311
(Tria, 1995, p. 12)
312
(Tria, 1995, p. 14)
313
(Scuderi, 1995, p.165)
92
4
CHAPTER
FOUR:
Osteopathic
Considerations
93
The Osteopathic philosophy of Sutherland Academy recognizes and implements the complexity of the
human being. Sutherland Academy recognizes the inter connectedness between the anatomy and between
the various systems of the body via the fascial network. This meshwork of tissue communicates
important information throughout the entire system. The micro tubule network is constantly flowing with
fluidic information. This relay network plays an important part in the inflammatory process. The fascia
and the extracellular matrix react and adapt to inflammation, and transmission can be seen in distant
structures following fascial chains.
Inflammation can travel distant to the source or cause in the body. Osteopathy is particularly interested in
the inflammatory process. Uncontrolled or chronic inflammation can spread like wild fire throughout the
system via fascial connections if not mediated accordingly. Understanding the anatomical pathways,
physiology, and biomechanics help the osteopath find the source of the inflammation. Insidious onset of
pain, or pain of unknown etiology can be explained with the philosophy of Osteopathy. For example,
pain and inflammation in the digestive system, can create pain or inflammation distally, like in the knee,
via the transmission down the fascia iliaca and psoas. If one only treats the knee, as a lot of conventional
therapy would, there would be some relief. There may even be a disappearance of pain for a duration of
time. However the inflammation persists in the digestive system, and eventually the knee pain, or other
distal pain appears. Once again the area in pain is treated, and temporary results are achieved. This is an
unjust and unethical way of treating. It may be good for business, but the patient is experiencing a
temporary band-aid approach to health. The philosophy of Osteopathy treats the complexity of the
system, and will find the cause or source of inflammation and help bring the body back to a state of
health.
Understanding and treating the biomechanics with an Osteopathic philosophy will help to address
and postural imbalance. Addressing the osteo-articulations and the soft tissue links will help to eradicate
any lesions and postural compensations. When a structure is in lesion, there is compensation throughout
the entire chain. This was described in the biomechanical section, with the example of the cuboid in
94
external rotation. The Osteopathy has an affinity for biomechanics. Patellofemoral pain syndrome has
many contributing factors; over-training, foot morphology, muscular imbalances, quadriceps angle to
mention a few. Osteopathy treats over-training and the inflammatory condition it produces. Osteopathy
can address the foot mechanics. If the structures are under tension, hypo or hyper mobile, or mal
positioned, the osteopath will treat all the links of the foot, and all the links to the foot to address and
normalize this. The osteopath will address the muscular imbalances that present via soft tissue
manipulation and fascial considerations. The quadriceps angle, will create varying pulls of tension
throughout the entire body. Osteopathy looks at the relationship of the structural components affected by
the quadriceps angle and address all the links in tension or lesion. Osteopathy has a global approach
when treating. The concept of complexity is applied during all treatments. Treating the intricacies and
micro systems in each individual and how these micro systems interact is how Osteopathy is different
from other manual therapies. It is the attention to treating the links in a chain, treating entire chains and
their intra and inter system connections that make Osteopathy a successful philosophy of treatment.
95
5
CHAPTER
FIVE:
Methodology
96
This study on the effectiveness of osteopathy on patellofemoral pain syndrome is a within study
design. The study consists of male and female volunteers from 18 to 60 years of age. The subjects for
this study came from recruitment advertisements posted on the internet via social media networks,
recruitment posters located in highly trafficked areas, such as bus stations, train stations and fitness
venues. Some subjects were informed of this study via word of mouth from health care practitioners such
as osteopaths, physiotherapists and personal trainers in the greater Toronto area. An initial interview with
each individual subject was performed to ensure that the interested volunteer met the criteria to be a
subject in this thesis. The inclusion factors for this study are volunteers, male or female, between the ages
of 18 and 60. Pain located on or behind the patella. Patellofemoral pain experienced with ascending
and/or descending stairs, running, jogging, jumping and/or squatting exercises. Pain in the same area
with prolonged sitting with knees flexed. Pain characteristic of patellofemoral pain syndrome that have
lasted from 1 month to 6 months.
Exclusion criteria were also discussed in the interview with the potential candidates. The criteria
that excluded any volunteers from the study were individuals under the age of 18. Another criterion is
any disabling general illness. Any previous knee surgery to the affected side. Any existing tendon,
ligamentous, or meniscal injuries to the affected side. Physician diagnosed osteoarthritis. A history of
patellar dislocations. If the subject had experienced physiotherapy or chiropractic therapy for
patellofemoral pain syndrome within the last 4 weeks. Other knee pathologies that have been clinically
diagnosed, such as bursitis, osteochondritis dissecans, etc. The female patient that is pregnant was
excluded from this study as well.
According to the study protocol, of the initial 46 applicants, only 36 subjects met the inclusion criteria in
the initial interview selection process. These 36 applicants gave their preliminary consent to participate in
this study and proceeded to the secondary stage of the study. Unfortunately, due to individual
circumstances, such as residential relocation, sickness, personal issues, an additional 6 people did not
complete the study requirements.
97
The secondary stage included a questionnaire and a clinical assessment. The questionnaire was
created using questions from the Anterior Knee Pain Scale, also known as the Kujala knee pain scale.
This original scale was a thirteen item questionnaire including different items on pain and related to
functioning and activities. The scale was condensed to eight questions. Each question had a scoring of 110. Ten being the highest and the most painful on the scale. The items within each category are then
scored to provide a possible overall index record of 1 to 80.
The Anterior Knee Pain Scale was chosen based on the prevalence in journals, as well, that it was proven
by other investigators to be a reliable, measureable, and responsive outcome measure for patellofemoral
pain syndrome314. This questionnaire was modified to use the Visual Analogue Scale for each question,
as opposed to the original weighted multiple choice questions. This modification was suggested by Greg
McIntosh, the statistician used for this study. It was suggested to use the Visual Analogue Scale, utilizing
numbers in combination with facial expressions for clarity and simplicity. This scale also appealed to
those individuals who are numerically and visually oriented.
The initial assessment included review of the questionnaire filled out in advance to the assessment to
insure accuracy, and completion of the questionnaire. Once this was established, the initial assessment
was done. The initial assessment consisted of postural assessment using a grided plumb line.
Observation was made in the anterior, posterior and lateral planes. Depending on visual inspection,
postural tendencies/type was determined. Three main possible postural types were posterior type, normal
and anterior type. Posterior type was determined if the occiput was in extension, neck tilted downward, if
there was an exaggerated dorsal curve, exaggerated lumbar curve, and knee flexion. If the center line of
gravity in the lateral posture falls posterior to the selected reference points this is considered the posterior
type. The anatomical landmarks included the external auditory meatus, the odontoid process, the cervical
vertebral bodies, the sacral promontory, slightly posterior the hip joint, slightly anterior to the center of
314
(Doral, 2011, p.158)
98
knee joint and the lateral malleolus, and through the calcaneocuboid joint. The surface landmarks
included; the external auditory meatus, through the acromion process, approximately midway between the
anterior and posterior aspect of the trunk, midway between the abdomen and back, the greater trochanter,
and slightly anterior to the midline of the knees and lateral malleolus315. In correct posture, the gravity
line passes through the axes of all joints, with the body segments aligned vertically. The gravity line is
characterized by a vertical line drawn through the body’s center of gravity, located at the second sacral
vertebra. The gravity line is an ever-changing reference line that reacts to the constantly altering body
position during upright posture. Although the gravity line typically does not pass through all joint axes of
the human body, people with excellent posture may come close to fulfilling that criterion. Therefore, the
closer a person’s postural alignment lies to the center of all joint axes; the less gravitational stress is
placed on the soft tissue components of the supporting system.
Additionally, during the assessment of the plumb line in lateral posture, if there was an increased cervical
curve, and upward positioned chin, anterior thoracic spine displacement, anterior rotated pelvis, and
hyperextension at the knees, this corresponds with an anterior type.
Upon examination of the subjects with plumb line postural orientation, the postural attitude was recorded
as posterior, normal, or anterior type.
After this postural assessment, orientation of the pelvis was assessed via the pelvic tests taught at
Sutherland Academy of Osteopathy. The pelvis was assessed for anterior-posterior, oblique, vertical,
nutcracker (hemi, cephalo, and caudal nutcracker) lesions. If any lesions or biomechanical asymmetries
were found these were recorded for each subject. After pelvic testing was completed the patient was
asked to lie supine on the treatment table. Any pelvic parasites were cleared by passive internal rotation
and adduction, followed by passive external rotation and abduction of the coxofemoral joint of each leg
performed by myself. Once this had been performed leg length was measured bilaterally with a tape
315
(Moffat, 2006, p. 23)
99
measure. The landmarks used were anterior superior iliac spine to the most proximal aspect of the medial
malleolus. This number was recorded bilaterally.
The quadriceps angle was measured in the same supine position. This involved an extra long
goniometer with an extended arm to measure from the anterior superior iliac spine, through the center of
the patella to the tibial tubercle. The center of the patella was determined by taking measurements of the
base of the patella horizontally to determine the central point. The patella was then measure from the
base to the pole, and divided to determine equal halves. Where this point intersected with the initial
length of the patella, this was marked and determined to be the centre part of the patella. The most
prominent aspect of the tibial tubercle was marked as well for reference points. The quadriceps angle was
measured three times, the average was calculated and this score was recorded bilaterally.
Following this, girth measurements of the thigh were taken. This involved taking measurements
from the base of the patella. This was considered the starting point. Measurements were marked at 1
inch, 3 inch, 5 inch, and 7 inches bilaterally on the subject’s thigh. Taking a girth measurement at 1 inch
was selected in order to help quantify any supra patellar inflammation indicative of inflammation in the
joint capsule.
Circumferential girth marks were taken at the above four mentioned measurements and recorded
bilaterally. A measuring tape was utilized for this procedure. The measuring tape was pulled snuggly to
the patient’s skin, without causing any indentation with the tape in the flesh.
The knee was thoroughly assessed in order to rule out any pathological findings in the knee that could
simulate patellofemoral pain. McMurray’s test was performed bilaterally to rule out any meniscal
pathologies. The anterior and posterior drawer test and Lachman’s test were utilized to rule out any laxity
or pain of the anterior and posterior cruciate ligament. Medial and lateral collateral ligaments were tested
using the varus and valgus stress application tests. The passive extension-flexion sign test was performed
in the supine position on the examination table. This test was utilized to rule out patellar tendonitis. The
100
Bassett sign was utilized as well to rule out this condition. This was done in the supine position on the
examination table with the knee in full extension, and palpation at the inferior pole of the patella. Visual
inspection and palpation for superficial swelling of the pre-patellar bursa was utilized to rule out prepatellar bursitis condition.
Waldron’s test and Clarkes sign were both selected to be used in this study to determine patellofemoral
Pain syndrome. To execute the Waldron’s test, the patient was positioned in supine with the knee fully
extended and applied a compressive force on the patella. Passively flex the knee while maintaining the
compressive force. A positive test is pain or crepitus during passive flexion. The second part of the test
was performed in standing, and again a compressive force is applied to the patella. The patient was asked
to bend slowly at the knee while maintaining the compressive force. Again, a positive test is pain or
crepitus during the active knee flexion.
The Clarke’s sign was applied in the supine position. The patient laid in a relaxed position with the knee
extended and tenses the quadriceps muscle as the examiner presses the patella into the trochlear. Using
the visual analogue scale, the patient reported the intensity of their pain, and this number was recorded.
After the assessment of the knee was completed, the sit to stand navicular drop test was
performed. Measurements of the navicular height in standing and sitting were obtained, and the
difference in navicular height was calculated and recorded for each foot. The procedure for measuring
navicular height was as follows. The skin was marked with a pen over the most prominent point of the
navicular tubercle. Navicular height was measured by marking separate blank papers securely affixed to a
triangular ruler, stabilized at a right angle to the floor, at the level of the navicular tubercle mark. To
reduce measurement bias that can occur when plain rulers are used or when 2 marks are made on the
same paper as has been used in other studies, separate papers were used each time a measure was made. A
straight edge ruler was then used to measure the distance on the blank papers from the mark to the edge.
The seated navicular height was measured in sitting with neutral ankle, and foot flat. Neutral angle is
101
defined by zero degrees of ankle dorsiflexion. This measurement was taken for biomechanical
considerations and possible determination of fascial chains to be utilized in the treatments.
All data was recorded for each subject for the assessment. If all inclusion and exclusion criteria were met
during the physical assessment, the patient was notified if they qualified for the study. Of the 36
participants that qualified for admission into the second stage of assessment, only 32 were deemed
appropriate to proceed to the next stage.
The next step consisted of random assignment into one of two groups; the study group and the control
group. This process was achieved by placing the names of all the participants into a container and sixteen
names were selected by a non partial individual. It was ensured that none of the names were visible in the
container, by the individual assigned this task. The patients were then notified and scheduled for their
follow up appointments. The individuals were instructed that they would be receiving treatments, and
which group they were assigned to was kept confidential. Perchance the subjects knew each other, it was
asked that they kept the details of their treatments confidential until the study was completed.
The control group received two sixty minute treatments of effleurage massage therapy treatments to the
entire undraped leg, from the anterior superior iliac spine down to the plantar fascia. Pressure was
previously determined based on a visual analogue scale. The patient was asked to keep the pressure at a
level of three on the visual analogue scale, which was deemed mild pressure, with no discomfort.
Effleurage principles were applied in a proximal to distal fashion, and with consistent checking in of the
subject to ensure that the pressure stayed as consistent as possible. The patient’s modesty was respected
and the patient was properly draped for no accidental or indecent exposure. The effleurage was
performed by myself, during each treatment using an organic ultra glide lotion. The treatments were
provided once a week. Upon completion of the two sixty minute treatments, the patient was asked to fill
out the same pain questionnaire of the initial assessment. The responses to the questionnaire were
recorded to document any changes in the subjects’ pain rating scale from initial assessment to present.
102
During the first treatment of the study group, the initial treatment consisted of normalizing any
lesions found in the sacral iliac joints. These lesions were documented during the initial assessment and
re-assessed during each treatment. The idea behind the initial treatment was to clear any obvious pelvic
lesions found in the patient using the techniques used at Sutherland Academy of Osteopathy. Depending
on the lesion found with each individual, various techniques were applied to normalize the sacral iliac
joints. These included preparatory work such as transverse muscular stretching, and transverse tendinous
ligamentous stretching to the lumbar and pelvic areas. Osteo-articular pumping of the affected areas on
the sacral-iliac joints was performed. If the lesion had not normalized with these techniques, then
structural normalizations were applied.
The second treatment was performed between 7- 10 days after the first treatment depending on patient
availability. The pelvis was once again assessed to determine if there were any lesions. Once the pelvis
was cleared, selection of the fascial chain to be used was determined. During this second treatment the
fascial chain was selected through methods of induction in supine and seated. With the patient seated,
facing away from the practitioner, one hand was placed on the ilium of the affected side and the other
hand was placed on one of three places. The other hand was placed on the inguinal ligament, gluteus
maximus, and bicep femoris separately. This was repeated in a supine position. Depending what was
found at each structure, the respective chains were chosen; the inguinal ligament chain, the ischio-gluteal
chain, or the ischio-cutaneous chain of Luschka.
Depending on the findings of this induction test, the techniques of the specific chain were applied
for the rest of the treatment. The patient was instructed the quadriceps myofascial stretching, and asked
to perform it 30 seconds three times a day.
The patient came to their third treatment 7 – 10 days after the second treatment. Same process that was
applied for the second treatment day was applied to the third treatment with one exception. The induction
test was performed on the sacral iliac joint and tested with one hand on the ilio-tibial band and then on the
103
sartorius to determine which chain to address in that treatment. Depending on the findings, either the
tractus ilio-tibialis chain or the sartorius chain were selected then applied for the remainder of the third
treatment.
After the third treatment the patient was asked to fill out the same questionnaire they filled out
initially. This questionnaire was to be completed and returned within seven days of the last treatment.
Once this information was collected from the subjects, the data was compiled and submitted to a
statistician. The information was formatted into graphic representations.
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6
CHAPTER SIX:
Results and Conclusion
105
6.1
OVERVIEW
The results of this thesis were noteworthy on a statistical level or quantitative level. The statistics revealed
an improvement in function and symptoms associated with patellofemoral pain syndrome. The study
group demonstrated a statistically significant outcome with the provided Osteopathic philosophy of
treatment compared with the effleurage control group. Moreover it became evident during the
experimental process, on an observational level, as well as the qualitative reports by the subjects in the
study group, that the results were significant. The statistics were compiled and analyzed by Mr. Greg
McIntosh, a statistician and epidemiologist who also gave guidance as to the significance of the data
analyzed and the results.
106
6.2
QUANTITATIVE RESULTS AND STATISTICAL
The mean age of the cohort was 34.16 years (standard deviation 11.93, range 20-60) with 78.1%
females. Besides having the criteria needed to enter the study, all the subjects stated that they were in
good health, and not seeking medical consult on any ailment. None of the subjects had experienced
Osteopathy in the past. In fact, this was the first time the subjects had even encountered the term
Osteopath.
The study group had 15 subjects and there were 15 in the control group. There was no statistically
significant difference in baseline characteristics between the average age, gender, pre-testing quadriceps
strength, and pre-testing hamstring strength in the treatment group of in the study group. The average age
for the study group was 32.7 years, and the average age for the control group was 35.6. The groups then
could be assumed to represent an average healthy population and lend statistical significance to the
sample results. The study group demonstrated statistically significantly higher pre-treatment questionnaire
scores than the control group. The study group showed a mean average of 54% (standard deviation of
5.48), and the control group showed a mean average of 48% (standard deviation of 6.23) in the pretreatment questionnaire scores.
107
The subjects presented with different postures. There was an average anterior posture of 46.9%, an
average of 31.3% posterior posture, and 21.9% posture amongst the subjects in the experiment.
50.0%
Percent
40.0%
30.0%
20.0%
10.0%
0.0%
anterior
posterior
normal
posture
Figure 18, Reveals 46.9% with anterior posture (posterior=31.3%, normal=21.9%).
Independent sample t-tests showed that there was no statistically significant difference in mean
quadriceps strength( study group 3.53, and control group 3.72) and hamstring strength (study group 3.63,
and control group 3.75) between the groups. There was no statistically significant difference in mean pre
to post thigh circumference within groups and between groups.
There was a statistically significant difference between the mean individual post-treatment questionnaire
scores between the study groups. The study group demonstrated a significant decrease in their post
treatment questionnaire scores 15.25, compared with their pre treatment scores of 54.19. The control
groups pre-testing score was 47.63, and their post treatment questionnaire scores were 43.81.
108
QscorPre
QscorPost
60
50
Mean
40
30
20
10
0
study
control
group
Figure 19, Shows that the study group’s pre-treatment questionnaire score was statistically significantly higher than
the control group (study=54.19, SD=5.48, control=47.63, SD=6.217) and there was a statistically significant
difference in mean post questionnaire scores between groups (study=15.25, SD=8.054, control=43.81, SD=6.853,
p<0.001).
There was a statistically significant difference in mean individual post-treatment scores between the
groups and all eight questions (p<0.001).
There were four questions that were considered highly significant in diagnosing patellofemoral pain
syndrome. These were the first four questions in the questionnaire. There was a large difference in the
first four questions of the pre testing scores and the post testing scores in the study group. This was not
demonstrated with the control group.
109
q1pre
q1post
q2pre
q2post
q3pre
q3post
q4pre
q4post
8
Mean
6
4
2
0
study
control
group
Figure 20, Provides a visual representation of how questions 1 to 4 changed in the study group (large
difference in bar height) but not in the control group (all bars approximately the same height).
Pain is considered a subjective matter. It is hard to achieve a balance, and healthy state, if pain prevents
or limits an individual’s functionality. Decreasing the cause of a person’s pain can help to bring their
body back into balance on a physical, physiological, emotional and mental level. Pain is a consideration
to the osteopath, but removing the cause of the pain is more important.
The results of this study are a confirmation of the effectiveness of osteopathic treatment for the
general population, and as an alternative to conventional treatments. This study showed the efficacy of
treating the fascial chains taught at Sutherland Academy to address postural and biomechanical
compensations of an individual. The fascial chains are a communication continuum throughout the entire
system. Treating these communication chains in the system helped addressed dysfunctions that could
create lesions in the system which could contribute to patellofemoral pain syndrome. Addressing the
110
fascial chains early, after injury, or trauma, or during the acute phase of this syndrome will help to
minimize further compensatory issues in the system. The longer one waits to address a lesion, or trauma,
or injury, the more complications can arise, and affect the physiology of other systems.
111
6.3 SUGGESTIONS AND IMPROVEMENTS FOR FUTURE STUDY
The method used in this study was the fascial system of the lower extremity. Another avenue to
treating this syndrome would be to treat the visceral system and the thoracic diaphragm. Treating the
thoracic diaphragm and its relationship with the psoas would be an interesting adaptation to this study.
Another adaptation to this study could be focusing on the pelvic viscera and sacral iliac joints in order to
influence a change in posture to affect this syndrome.
Taking anthropometric measures to determine the exact morphology of the subjects and seeing if there is
a prevalence with lesions or dominance in specific fascial chains, or with posture would be an interesting
continuation on this study.
Working with other health care professionals, such as a surgeon to see how
the fascia responds to the operating process, and see the fascial adaptations in the system would be an
interesting inter-disciplinary experiment. This would create communication and public awareness across
the disciplines on how Osteopathy can facilitate the individual’s recovery process. Another suggestion
would be to treat using a Biodynamic approach and treating with what Sutherland calls, “the Breath of
Life.” Bringing the body back into harmony using the Primary Respiratory Mechanism, with no
structural adjustments to see how micro-tensegrity can affect the macro-tensegrity.
Shortcomings
Some of the shortfalls of this study would be not having the resources available for decreasing
any potential error of the tester. Having access to an exercise physiology lab would increase the
reliability of quantitative measurements. Measurements such as quadriceps and hamstring strength
testing could be influenced by the fatigue of the tester, the angle of the joint between subjects, and the
perceived effort of the subject. This measurement would be interesting to consider if after the treatments
proper biomechanics were re-established, and the nervous system was able to contract the muscle more
efficiently. To increase objectivity of the study, measuring the amplitude of knee flexion and lumbar
112
flexion to determine if there were any structural changes pre and post treatment. Even simply using a
goniometer, or inclinometer to see what changes occurred after treating the fascial chains.
Time of day for assessments may be something to consider for patients that may have any
circulatory or lymphatic issues. Having a consistent time of day for measurements is something to
consider. There were no subjects that expressed any circulatory issues in this study. If radiographic
imaging was more accessible, it would be interesting to see the alignment of the patella in various
position pre and post treatment. Working with another therapist to create a double blind study would
increase the objectivity to when working with the control group. Effleurage is variable from one therapist
to another. Another treatment for the control group could have been a stretching program or conventional
McConnell taping, as opposed to the effleurage.
A bigger population size would be more statistically significant if the time, subjects, and resources were
more readily available. Another short coming of this experiment is not testing the fascial tensions directly
in standing. They were tested in seated and supine, but not standing.
113
7
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APPENDICES
118
APPENDIX A: RECRUITMENT LETTER
119
Oakville Osteopath
PARTICIPANTS NEEDED FOR RESEARCH
IN Patellofemoral Syndrome (Anterior Knee Pain)
I am looking for volunteers to take part in a study of
Patellofemoral Syndrome/Anterior Knee Pain.
As a participant in this study, you will:
 be asked to fill out health history forms, questionnaires, and to provide
follow-up feedback,
 be interviewed to determine if you fit description of thesis requirements,
 receive osteopathic treatments in a pre-determined time frame with followup assessment.
Your participation would involve 3 osteopathic sessions,
each of which is approximately 60 minutes (value of $300).
For more information about this study, or to volunteer for this study,
please contact:
Lucia Orsini, Patello-femoral
Syndrome study
905 466 6310
[email protected]
Lucia Orsini, Patello-femoral
Syndrome study
905 466 6310
[email protected]
Lucia Orsini, Patello-femoral
Syndrome study
905 466 6310
[email protected]
Lucia Orsini, Patello-femoral
Syndrome study
905 466 6310
[email protected]
femoral Syndrome study
Orsini,
Lucia
6310Patello-femoral
905 466
study
Syndrome
[email protected]
905 466 6310
[email protected]
Lucia Orsini, Patello-femoral
Syndrome study
905 466 6310
[email protected]
Lucia Orsini, Patello-femoral
Syndrome study
905 466 6310
[email protected]
Lucia Orsini, Patello-femoral
Syndrome study
905 466 6310
[email protected]
Lucia Orsini, Patello-femoral
Syndrome study
905 466 6310
[email protected]
Lucia Orsini, Registered Massage Therapist, Certified Athletic
Trainer, Osteopath(Candidate)
at
905-466-6310
Email: [email protected]
120
APPENDIX B: CONSENT FORM
121
INFORMED CONSENT FORM FOR PATELLOFEMORAL PAIN SYNDROME THESIS
Date:
Study Title or Topic: Patellofemoral Pain Syndrome
Researcher: Lucia Orsini, Osteopathy Candidate, Diploma of Osteopathic Manual Practitioner,
Sutherland Academy of Osteopathy
Purpose of the Research: Effectiveness of Osteopathy on Patellofemoral Pain Syndrome
What You Will Be Asked to Do in the Research:
Risks and Discomforts: I do not foresee any risks or injury from your participation in the research. All of
the techniques utilized in this study are applied in a safe and controlled environment.
Voluntary Participation: Your participation in the study is completely voluntary and you may refuse to
answer any question or choose to stop participating at any time. Your decision not to volunteer will not
influence the [treatment you may be receiving] [nature of the ongoing relationship you may have with the
researcher] nature of your relationship with Sutherland Academy either now, or in the future.
Withdrawal from the Study: You can stop participating in the study at any time, for any reason, if you
so decide. Your decision to stop participating, or to refuse to answer particular questions, will not affect
your relationship with the researcher or Sutherland Academy. Should you decide to withdraw from the
study, all data generated as a consequence of your participation will be destroyed.
Confidentiality: All information you supply during the research will be held in confidence and, unless
you specifically indicate your consent, your name will not appear in any report or publication of the
research. Your data will be safely stored in a locked facility and only the researcher will have access to
this information. Confidentiality will be provided to the fullest extent possible by law.
Questions about the Research: If you have questions about the research in general or about your role in
the study, please feel free to contact Lucia Orsini, Osteopath Candidate, by email,
[email protected], telephone (905) 466-6310. This research has been reviewed and approved for
compliance with research ethics protocols by the Sutherland Academy of Osteopathy.
Legal Rights and Signatures:
I,________________________________, consent to participate in The Patellofemoral Pain Syndrome
Study conducted by Lucia Orsini. I have understood the nature of this project and wish to participate. I am
not waiving any of my legal rights by signing this form. My signature below indicates my consent.
Signature (Participant)
Date
Signature (Researcher)
Date
122
APPENDIX C: KNEE PAIN QUESTIONNAIRE
123
For each question, please use this visual analogue pain scale as a reference when answering questionnaire.
For each question, circle the number that best describes your level of pain.
1. Do you have pain going UP stairs? Yes/ No(circle one)? How often do you experience pain? □every
time you go up stairs? □ Sometimes? □ No pain going up stairs?
Please circle the number that best indicates how much pain you have when you go up stairs.
2. Do you have pain going DOWN stairs? Yes/ No(circle one)? How often do you experience pain?
□every time you go down stairs? □ Sometimes? □ No pain going down stairs?
Please circle the number that best indicates how much pain you have when going down stairs.
3. Do you have pain with prolonged standing? Yes/No(circle one) □ 0-30 mins after standing □ 30-60
mins, □ 60 mins +, □ No pain?
Please circle the number that best indicates how much pain you have with prolonged standing.
124
4. Do you have pain with prolonged sitting with knees flexed/bent? Yes/No(circle one) □ 0-30mins after
sitting, □ 30-60 mins, □ 60 mins +,□ no pain after prolonged sitting?
Please circle the number that best indicates how much pain you have with prolonged standing.
5. Do you have pain with prolonged running or jogging? Yes/No(circle one), □ 0-0.5 kilometers, □ 0.5 -1
km, □ 1-3kms, □ 5kms +□ No pain after running?
If you are presently not running, what is stopping you?(e.g. pain in
knee?)_________________________________________________
Please circle the number that best indicates how much pain you have with running or jogging.
6. Do you have pain with jumping? Yes/No(circle one) □ immediately, □ after 30 secs, □ after 60
seconds, □ no pain after jumping?
Please circle the number that best indicates how much pain you have with jumping.
7. Do you have pain with squatting exercises? Yes/No(circle one) □ immediately, □ after 30 secs, □ after
60 seconds, □ No pain after squatting exercises?
Please circle the number that best indicates how much pain you have with squatting exercises.
8. How would you rate your pain in the past week? □ Constant, □ Once a day, □ Periodic during the day,
□ 3-5 times a week, □ Every day □ No pain?
Please circle the number that best indicates how much pain you have experienced on average in the past
week.
Thank you for your time and participation.
125
APPENDIX D: LETTER FROM STATISTICIAN
126
May, 2012
Sutherland Academy of Osteopathy
760 Rue Saint Zotique Est
Montréal, QC H S 1M5
(514) 523-0314
To whom it may concern:
Thesis candidate, Lucia Orsini hired me as the statistical consultant to analyse the data he
collected as part of his research thesis. I completed my Masters in Epidemiology from the
University of Toronto’s Faculty of Medicine in 1999. In addition to my full time occupation as an
Epidemiologist, I have worked part time as a statistical analysis consultant for 11 years and have
consulted on the thesis analysis for several students at the Canadian College of Osteopathy.
In Lucia’s study, she made measures on subjects pre and post osteopathy treatment. Lucia’s
main analysis focused on between subject differences. With this type of research design,
independent samples t-tests are an appropriate and valid analytical technique and is the
statistical method I utilized.
Sincerely,
Greg McIntosh, BHK, MSc
Epidemiologist
Oakville, Ontario