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Abstract

Background. One of the least researched anatomical structures of the human body is the ligament of head of femur, most often referred to as ligamentum teres. The history of the nomination of this term, medical contexts of its use, the etymology and the first synonyms are not sufficiently understood. Purpose. The purpose of the article is to present the most complete collection of evidence from ancient medical authors about the term ligamentum teres, trace the history of its nomination and analyze the gradual changes in the level of knowledge about the anatomy, mechanical and geometric properties of this structure, its pathology and treatment methods. Methods. The study is based on an interdisciplinary approach, comprising a combination of linguistic and medical analysis of the texts in ancient Greek and Latin, which contain references to ligamentum teres. Results. Text analysis showed that ligamentum teres was known in Palestine at the time of the compilation of the Book of Genesis. In the medical sources written by the Greek physicians, references to it and the description of its properties and role date back to the V-IV cent. BC. The study of textual sources and their medical contexts showed the evolution of the development of this term from the general concept of "sinew" to a narrowly defined "ligament" with detailed qualitative characteristics of the structure and function of this anatomical structure. It has been noted that since ancient times ligamentum teres has been recognized as an important element of biomechanics of hip joint and the action of walking. Conclusions. This work will serve as a basis for further studies and treatment of the interesting and mysterious structure that is ligamentum teres-a true ligamentum incognitum. KEY WORDS Ancient medicine; ancient traumatology; Galen; Hippocrates; hip joint; ligamentum capitis femoris; ligament of head of femur; ligamentum teres. MLTJ, 2020;10 (3):536-546 doi: 10.32098/mltj.03.2020.27
ORIGINAL ARTICLE
Nr 2020;10 (3):536-546
536
CORRESPONDING AUTHOR:
Sergey V. Arkhipov
Laboratory of Clinical Physiology
and Biomechanics
Federal State Budgetary Institution
N.N. Priorov National
Medical Research Center
of Traumatology and Orthopaedics
of the Ministry of Health of the Russion
Federacion
10 Priorova Street, Moscow, Russia, 127299
E-mail: archipovsv@gmail.com
DOI:
10.32098/mltj.03.2020.27
LEVEL OF EVIDENCE: 1A
SUMMARY
Background. One of the least researched anatomical structures of the human body is
the ligament of head of femur, most often referred to as ligamentum teres. The history
of the nomination of this term, medical contexts of its use, the etymology and the first
synonyms are not sufficiently understood.
Purpose. The purpose of the article is to present the most complete collection of
evidence from ancient medical authors about the term ligamentum teres, trace the
history of its nomination and analyze the gradual changes in the level of knowledge
about the anatomy, mechanical and geometric properties of this structure, its patholo-
gy and treatment methods.
Methods. The study is based on an interdisciplinary approach, comprising a combina-
tion of linguistic and medical analysis of the texts in ancient Greek and Latin, which
contain references to ligamentum teres.
Results. Text analysis showed that ligamentum teres was known in Palestine at the time
of the compilation of the Book of Genesis. In the medical sources written by the Greek
physicians, references to it and the description of its properties and role date back to
the V-IV cent. BC. The study of textual sources and their medical contexts showed the
evolution of the development of this term from the general concept of “sinew” to a
narrowly defined “ligament” with detailed qualitative characteristics of the structure
and function of this anatomical structure. It has been noted that since ancient times
ligamentum teres has been recognized as an important element of biomechanics of hip
joint and the action of walking.
Conclusions. This work will serve as a basis for further studies and treatment of the
interesting and mysterious structure that is ligamentum teres – a true ligamentum
incognitum.
KEY WORDS
Ancient medicine; ancient traumatology; Galen; Hippocrates; hip joint; ligamentum
capitis femoris; ligament of head of femur; ligamentum teres.
Ancient Textual Sources on Ligamentum Teres:
Context and Transmission
S.V. Arkhipov1, I.V. Prolygina2
1 Laboratory of Clinical Physiology and Biomechanics, Federal State Budgetary Institution N.N. Priorov
National Medical Research Center of Traumatology and Orthopaedics of the Ministry of Health of the Russion
Federacion, Moscow, Russia
2 A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
INTRODUCTION
Recently, the attention of researchers and clinicians has been
increasingly attracted by the under-investigated anatomical
structure ligamentum teres (LT), which connects the femoral
head and the acetabulum (1,2). Despite the fact that LT has
been known for over three millennia, its anatomy and func-
tion have not been fully studied and continue to be refined
(3-6). For instance, its role in the musculoskeletal system
is still not clear, and opinions on this issue are often very
divided (7-10). Some authors concluded that LT is a rudi-
mentary structure of hip joint (HJ) (11,12). The contem-
porary studies, however, regard it as a fully functional liga-
ment with the strength comparable to that of the anterior
cruciate ligament of the knee joint (8). The recent data show
the importance of LT as an HJ-stabilizing structure, which
is involved in maintaining vertical positions (13-17). LT is
currently recognized as a potential source of pain as well
as mechanical symptoms in HJ, including gait impairment
537
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S.V. ArkhipoV, i.V. prolyginA
(3,18-24). The evasive knowledge about LT is reflected in
dozens of its synonyms, with its original names unknown
not only to laymen, but even to experts (7,23,25). In some
publications, including those claiming to be comprehensive,
the earliest extant evidence regarding LT is, in our opinion,
insufficiently covered (26,27). Therefore, this work attempts
to provide the most complete review of LT-related sources
from ancient authors. We believe that this will make it possi-
ble to clarify the earliest period of studying LT and knowl-
edge about it and will help experts to better understand the
basis of their research.
MATERIALS AND METHODS
This study is based on an interdisciplinary approach involv-
ing a combination of linguistic and medical knowledge.
The original fragments of ancient physicians on LT, written
in ancient Greek and Latin, as preserved in the electronic
platform Thesaurus Linguae Graecae (University of Califor-
nia, Irvine, CA, USA), were investigated in relation to the
modern views on normal and pathological anatomy of this
anatomical element, its role in the musculoskeletal system,
its mechanical and geometric properties. The pathology
treatment methods are also considered.
This work submits to the ethical standards of the Muscles,
Ligaments and Tendons Journal (28).
RESULTS
Biblical tradition: Genesis 32:32
Perhaps the earliest known mention of LT is found in the
Book of Genesis. The period of the compilation of the Penta-
teuch, which includes the Book of Genesis, can be approx-
imated only with a very relative accuracy. Given the peri-
od of codification and the long oral tradition of its sources,
it can be dated to the period of the XIV-VI centuries BC
(29-31). In this ancient written source, LT is mentioned in
the context of the narrative of the Patriarch Jacob wres-
tling with God and acquiring the name of Israel. Genesis
32:32 says:
«That is why to this day the Israelites do not eat the thigh
sinew which is at the hip socket: because he had struck Jacob
at the hip socket on the thigh sinew».
NJB.
In the Masoretic text of the Biblia Hebraica, the expres-
sionגִּיד הַנָּשֶׁה אֲשֶׁר עַל כַּף הַיָּרֵךְ is used. It can literally be
translated as “the thigh sinew, which [is located] in the
socket of the hip joint”. The etymology of the term הַנָּשֶׁה
(hannasheh) is unclear, and the term גִּיד (gid) is translated
as “sinew” (32).
The authors of the Septuagint (LXX), the Greek translation
of the Old Testament (III-I cent. BC in Alexandria) from a
pre-masoretic version of the Hebrew text, rendered this text
as: «
», that is, “the sinew which shrank, which is upon
the hollow of the thigh” (KJV). The translators, apparent-
ly, linked the word hannasheh (LXX: ) with
the root nashah, interpreting it as “to dislocate”, “become
weak”. From the point of view of modern medicine, it can
be assumed that in this case we are talking about damage to
acetabulum.
The Latin translation of the Bible, the so-called Vulgate,
was completed in the IV century AD by St. Jerome, who
translated the Bible directly from Hebrew, but was also very
familiar with the Greek text of the Septuagint. This frag-
ment described above is conveyed there as follows: nervum
qui emarcuit in femore Iacob, “sinew, which weakened in
Jacob’s thigh”. The Hebrew, the Greek and the Latin texts
formed the basis for all the subsequent translations into
other ancient and modern languages, as well as for patristic,
Jewish and modern biblical comments.
Most biblical commentators agree that Genesis 32:32
mentions the sciatic nerve (nervus ischiadicus), the large
nerve trunk of the femoral region, which the Greeks called
the Achilles tendon (33-35). Other commentators argue
that this word refers to the tendon which holds the head of
the femur in the acetabulum, along with the surrounding
muscles (36). However, neither in the Pentateuch nor in the
other Old Testament books there is any further mention of
the anatomical structure of HJ, so it is difficult to establish
the exact meaning. In our opinion, consistent with the point
of view of some other authors (37), this “sinew” is LT, since
no muscle tendons are attached in acetabulum and no large
nerve trunks are present. Moreover, the transverse section
of the proximal end of LT reveals an approximately cylindri-
cal shape, resembling a tendon or a nerve fragment.
The quote from Genesis 32:32 has an important historical
and medical implication for anatomy, traumatology, and
biomechanics of HJ. This fragment is one of the earliest
mentions of HJ and, possibly, the first written reference in
the history of mankind to a special anatomical element in it,
that is, LT. It can be assumed that in Palestine of the bibli-
cal times it was known that LT could be damaged by an
indirect trauma mechanism, for example, by a forced hip
rotation, its subluxation and dislocation. This is also the
first known description of one of the earliest visual symp-
toms of LT injury, that is, lameness. In addition, Genesis
provides perhaps the first “medical history” of HJ and LT
injury. As befits the modern medical record, the patient’s
538 Muscles, Ligaments and Tendons Journal 2020;10 (3)
Ancient Textual Sources on Ligamentum Teres: Context and Transmission
name, marital status, personal characteristics, approximate
age and working conditions are described, as well as the
circumstances, time and location of the injury, localization
of the damage, its mechanism, consequences and pathomo-
rphology. From further narration (Genesis 50:2), we learn
that the Patriarch Jacob was posthumously embalmed by
Egyptian physicians, first mentioned in Genesis as repre-
sentatives of a specific and separate profession (25). This
allows us to conclude that the diagnosis of LT injury could
be morphologically verified by means of some prototype of
pathological study. From the biblical text it follows that the
resulting biomechanical ambulation disorder turned out to
be persistent, and the cause of it was damage to HJ, or, more
precisely, LT.
Paradoxical as it may seem, an analysis of this ancient, not at
all medical source, allows us to make a significant assump-
tion for modern science: LT is an important functional rela-
tion of HJ, and only with it intact, normal-walking can be
achieved, making LT a part in the organization of this type
of human locomotion.
The terms /nervus: classical tradition
Ancient authors of the Classical period did not initially
distinguish between such anatomical structures as tendon,
ligament and nerve neither in terminology, nor, apparent-
ly, in practice, as indicated by the absence of special names
for each one of them. There was a single term ,
to which the multivalent term “sinew” corresponds most
closely. It can mean “tendon”, “ligament”, “nerve”, as well
as “vein” and “artery”. The Latin term nervus has the same
root as the Greek   and generally has the same
initial meanings as “string”, “thread”, “fiber”, from which,
by metaphorical transfer, they acquired the medical meaning
of “white fibrous threads that support the muscles, connect
the joints and transmit nerve or motor impulses” (38). The
term , in the meaning of “sinew”, which can mean
“tendons”, “ligaments”, and “muscles”, and possibly “large
nerves” and “blood vessels”), is found in Homer’s Iliad:
«[…] Phylides, taking note / That bold Amphiclus bent at
him, prevented him, and smote / His thigh’s extreme part,
where of man his fattest muscle lies, / The nerves torn with
his lance’s pile, and darkness clos’d his eyes».
Iliad XVI: 313-316.
Hippocrates (born 460 BC), expounding in the treatise Plac-
es in Man on certain types of sinews, mentions those that
are “connected with joints,” meaning tendons, and “hollow
veins”, that is, blood vessels, lymphatic vessels, various
ducts and bronchi (De loc. in hom., 5) (39).
Apparently, it is about the articular ligaments connecting
two, and in some cases more, bone organs, that Aristotle (IV
cent. BC) writes in the History of Animals, mentioning that:
«They aid in the support of the body <...> The sinews around
the joints have not received any name, for all the bones
where they are contiguous are bound together by the sinew
(). And there are many sinews round all the bones».
Hist. anim. III, V, 50 (515b 11).
The distinction between nerves, muscles, tendons and liga-
ments first appears only in the anatomy of the first Alexan-
drian school (III cent. BC). Herophilus (IV-III cent. BC)
did not yet have a clear distinction between nerves and
muscles, since he recognized both muscles and nerves as
organs of voluntary movement (40). The idea of the phys-
iology of muscle contraction first appears in Erasistratus
(IV-III cent. BC). He believed that muscle contracted under
the influence of the pneuma that is contained within, and
the nerves were deprived of any function in voluntary move-
ment (Gal. De loc. aff.) (41,42). In terminology, Erasistra-
tus distinguished between sensory () and motor
nerves (, ).
Apparently, it was Pliny the Elder (1st cent. AD) that
used the Latin term nervus as applied to tendons in Natu-
ral History. When speaking about the Achilles tendon, he
calls it a “sinew” (nervus), which is defined as “flat” (platys)
(Hist. nat. 26, 90). He uses the same term with reference to
ligaments:
«In all animals they (nervi) are fastened to the lubricous
surface of the bones, and so serve to fasten those knots in the
body which are known as articulations or joints, sometimes
lying between them, sometimes surrounding them, and some-
times running from one to the another; in one place the are
long, and in another broad, according as the necessity of each
case may demand».
Hist. nat. 11, 217.
Here we have one of the first classifications of ligaments and
the first use of the concept of “round” (lat. teres, rotundum)
used to describe ligaments in general. As for the nerves,
since they do resemble thin tendons, the ancient anatomists
thought that they served for flexion and extension of various
parts of the body.
Aulus Cornelius Celsus (25 BC – 50 AD) writes about a
pathology of HJ ligaments, called “sinews” (nervis), which
are damaged and stretched when hip is dislocated:
«When the bone is replaced nothing further need be done,
but the patient must be kept in bed for a rather long time or
539
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S.V. ArkhipoV, i.V. prolyginA
the thigh may become displaced again on moving while the
sinews (nervis) are still relaxed».
De med. VIII, 20, 8.
Galen of Pergamon (II-III cent. AD) provides a more clear
systematization of various kinds of sinews. He often accom-
panies the term  with clarifying definitions or gives
one-word synonyms. In the treatise On Bones for Beginners
Galen describes three types of sinews: those originating in
the brain and spinal cord -  , “sinews
responsible for voluntary movements”; originating in bones
  , “connecting sinews” or ,
“ligaments”; and originating in the muscles - ,
“tendons” (De oss. ad tir., 24) (41). Speaking in the treatise
On Movement of Muscles on the origin of this term, he associ-
ates it with the verb , “bow one’s head, nod” (De motu
musc. 1, 1) (41).
13 centuries later, the etymology and medical ambiguity
of the term nervus would be discussed by Andreas Vesa-
lius (1514–1564) in his anatomical atlas On the Fabric of
the Human Body (1543), in which he’d accept and repeat
the definitions of Galen (De humani fabr. corp. IV, 1). The
modern etymological dictionaries consider this interpreta-
tion to be a paretymology and correlate the term 
with the verb , “spin” (43), implying the pulling and
twisting of yarn from a tuft of wool.
In a later treatise, On the Usefulness of Parts of the Body,
Galen already clearly differentiates both the terms and the
functions of ligaments and nerves:
«Where a member needs only a connection, there is only
a ligament (), and where it needs only a sensa-
tion, there is only a nerve (). On the contrary, in
organs that could benefit from having voluntary movement,
you can see them together: a nerve that transmits an order
received from the center of thought and determines the prin-
ciple of movement, and a ligament that provides the nerve
with its power to maintain the joints brought into a state of
movement».
De usu part. XII, 3, 7 (41)
Ancient medical authors (prior to Galen) about
ligamentum teres
In the history of ancient medicine, LT and its topographic
anatomy were first mentioned in the treatise Instruments of
Redactions by Hippocrates:
«The femur itself bends outward and forward; its head
is a round epiphysis which gives origin to ligament
() inserted in the acetabulum of the hip-joint. This
bone is articulated somewhat obliquely, but less so than
the humerus».
Vectiar. 1 (39).
Indeed, LT attaches to the bottom of acetabular fossa at an
acute angle, and its counterpart in the shoulder joint is at a
right angle. This so-called “ligamentum teres in the shoulder
joint” is clearly visible in certain animal species and is other-
wise called ligamentum gleno-humerale (syn. lig. interarticu-
lare humeri) (44,45). Its counterpart in humans is not very
prominent and is called ligamentum glenohumerale superius
(46,47). This fragment indirectly indicates that Hippocrates
studied the anatomy primarily by dissecting animal bodies.
It should be noted that Hippocrates describes LT as an
already well-known element, noting its location and attach-
ment to the bone of HJ. How could Hippocrates, who did
not dissect humans, observe LT? It is likely that he could
have seen this anatomical element when examining a patient
with an open hip dislocation. This pathology is a rare type
of trauma that currently occurs with high energy trauma as
a result of a car accident and fall (48,49). Similar high-ener-
gy traumas could be observed in the time of Hippocrates,
for example, when one fell from height, was hit by a large
animal or by a heavy part of rigging of a ship.
In Galen’s IV commentary on Hippocrates’ book On Joints,
a fragment of the treatise On External Treatment by the
Greek physician Heraclides of Tarentum (III-II cent. BC)
was preserved (50). Speaking about the reduction of a dislo-
cated hip, he gives the earliest description of the pathology
of LT resulting from this injury:
«Those who believe that the hip does not remain set because
the ligament () connecting the femur to the acetabu-
lum is torn, do not know things of general knowledge, when
expressing their negation. For neither Hippocrates nor Diocles
would have described the reductions, and neither would
Phylotimus, Evenor, Nileus, Molpis, Nymphodorus and some
others. And we have achieved this goal [reduction] in two
children, although in adults the joint is dislocated again more
often. This case should be judged not from hearsay, but since
the thigh sometimes remains [set], it must be assumed that
this ligament does not always rupture, but that it stretches and
contracts again [...]» In Hipp. de artic. IV, 40 (41).
From this fragment we learn that in the days of Heraclides
of Tarentum physicians already knew not only about LT,
its attachment to the hip and the acetabulum, as well as its
connecting function, but also about its injury incurred by a
traumatic hip dislocation. It is safe to assume that the author
personally performed anatomical studies of both normal
and pathologically altered HJ. He also opined that LT could
540 Muscles, Ligaments and Tendons Journal 2020;10 (3)
Ancient Textual Sources on Ligamentum Teres: Context and Transmission
stretch and contract, thus remaining intact after hip disloca-
tion. A few modern studies partly confirm the Heraclides of
Tarentum’s guess and indicate the possibility of LT recovery
after hip dislocation (18,51,52).
There is an extant fragment of the text by another Greek
surgeon, Hegetor, a native of Alexandria (II century BC).
The Apollonius of Citium’s (90-15 BC) commentary on the
Hippocrates’ book On Joints provides an excerpt from it:
«In the bookOn Causes”, Hegetor mentioned hip disloca-
tion in the following passage:Why don’t those who rely only
on experience seek to find any other [way] of reduction the
femoral head for those who have it dislocated, in such a way
that every time it dislocates, it can be reset? After all, we can
observe that the lower jaw, and the humeral head, the elbow,
and the knee, and each finger, and the majority of joints that
may dislocate, can be reset in a similar way. For, not being
able to understand why this joint only, after dislocation and
repeated reduction, won’t remain in its place, and seeing what
often happens with other joints, they will probably come to
the conclusion that there might be a better way of reduction,
after which the joint will stay [set]. If they only thought about
the reason from the point of view of anatomy, - because the
femoral head is a foundation for the ligament () [of
femoral head], which grows into the middle of acetabulum;
and when it remains [intact], the femur cannot dislocate,
but when it ruptures, the hip cannot provide a firm connec-
tion; and when there is a lack of connection, the joint cannot
remain in place. Since the reason has been clarified, one can
refrain altogether from a reduction of a dislocated femur and
not make attempts doomed to failure».
In Hipp. de art. (53).
Hegetor repeats the previously known information about
LT about the areas of its attachment and its anchoring role,
but, unlike Heraclides of Tarentum, he is somewhat pessi-
mistic about the possibility of reduction of hip dislocation.
Perhaps the author in his practice encountered cases of
complicated dislocation accompanied by a fracture of the
wall of acetabulum or femoral head, or perhaps he was not
able to differentiate the dislocation from the femoral neck
fracture. For these reasons, his attempts to “set it” were
not successful, which served as the basis for therapeutic
pessimism.
Further, Apollonius of Citium expresses its own opinion on
this issue:
«If the dislocated and displaced hip could not remain in place,
then the physician [Hippocrates] would have clearly indi-
cated the incurability of this case, so that we would not be
led astray. Don’t those who hold the opposite opinion know
about the nature of joints, ligaments and the teachings about
these things in general? After all, the physician considered
the cause of the mild or, on the contrary, complex displace-
ment and reduction of the joints to lie in the natural struc-
ture, condition, and strength or stretching of the ligaments
(), associated with fluid, so that, with respect to femur
dislocation, if it does not remain [in place], this happens not
because the ligament () [of the femoral head] is torn,
but because of the natural weakening or stretching of the liga-
ments (), just as he says about the bulls that their
joints are mobile by nature». In Hipp. de art. (53).
In this fragment, the author agrees with the views of Hera-
clides and Hippocrates, noting the possibility of lengthen-
ing, weakening of strength and elasticity of LT. Apollonius
of Citium talks (already with confidence) about the possibil-
ity of pathological changes in LT and transformation of its
geometric and mechanical properties. These changes, regis-
tered over 2000 years ago, are still the cause of differences
in the description of normal LT. It should also be noted that
Apollonius of Citium says, like Hippocrates, that ligaments,
and hence LT, are present in animals (cf. De artic. 8, 14-15;
52; Vectiar. 5, 5-6) (39).
Another mention of LT is found in the Roman anatomist
and physician Rufus of Ephesus (I-II cent. AD). Speaking
about the names of different body parts in the treatise De
appellationibus partium corporis humani, he writes:
«The name of pelvis () [is given to] the ligament
() that attaches to acetabulum and secures the entire
joint» (54).
The statement by Rufus suggests that the author was aware
of the existence of LT, its attachment to acetabulum and its
connective function.
Galen and the Byzantine authors
Galen, who, along with Hippocrates, had remained the main
authority in the field of anatomy until the time of Andreas
Vesalius, mentions LT in a number of his treatises. In one of
his early essays, On Bones for Beginners, written for those
who are just beginning to study anatomy, Galen, explaining
the structure of HJ, says:
«There is a socket of large size in each of the ischia, attached by
a very stout ligament () to the head of the femur».
De oss. ad tir. XX, 2 (41).
This quote is interesting in that Galen notes, like the previ-
ous authors, that LT is attached directly to the bones that
form HJ, and not to its capsule or transverse acetabular liga-
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S.V. ArkhipoV, i.V. prolyginA
ment. He also specifically mentions the considerable strength
of LT, which was not pointed out by his predecessors. This
can be explained by the fact that this anatomical element was
personally studied by Galen in somatically healthy young
people who died in battle, i.e. physically well-developed
warriors and gladiators (which is currently impossible for
ethical reasons). The latest information on the low mechani-
cal strength of LT, refers, as a rule, to senior persons (55-58).
In his main work on anatomy, On Anatomical Procedures,
Galen gives a more detailed description of the structure of
HJ and LT yet:
«As with the arm you examined the ligaments of the bones,
so now examine those of all the exposed joints and first of
the hip. This has one ligament ) embracing it
[capsular ligament], as with all joints. A second, hidden in
the depths of the joint [ligamentum teres], ties the head of
the femur to the hollow in the hip-bone [acetabulum]. It is
so tough () that it could be called a cartilaginous
sinew ()».
De anat. adm. II, 10 (41,59).
By the “ligament embracing the hip” Galen clearly
means the HJ capsule (capsula articularis) with the exter-
nal ligaments woven into it. The word “tough” describes
the tension and high elastic modulus of LT (57). In the
described specimen, Galen encountered LT of the “carti-
lage consistence”. Modern histological studies have estab-
lished that “near their attachments the structure of liga-
ments undergoes a transition into fibrocartilage […] and
the fibroblasts become encapsulated and resembled chon-
drocytes” (60).
Galen provides a detailed description of LT in his work on
physiology On the Usefulness of the Parts of the Body:
«In the femoral joint Nature created a ligament (),
which is round, very strong, extending from the femoral head
and connecting in the middle with the acetabulum, but did
not create this in the shoulder joint, arranging it so that it
could perform various movements».
De usu part. XII, 5, 17 (41).
This quotation from Galen echoes the statement made by
Hippocrates in the treatise Instruments of Redactions (§ 1),
where he also compares the anatomical features of HJ and
the shoulder joint. Galen was undoubtedly familiar with
this treatise by Hippocrates, although he left no comment
on this work. Calling the ligament “round” ()
(lat. teres, rotundum), Galen must have meant not only the
cross-sectional shape of LT, but also the interweaving of
thin fibers, the fibrils of its stroma, since the Greek verb
 also means “to twist, rotate”. These thin fibers
or, more precisely, bundles of fibers, were observed by
Galen in ligaments and nerves.
Two more references to LT are found in Galenic Commen-
tary on Hippocrates’ On Joints, considered as one of the
earlier works compiled between 177 and 180 AD. In the
third chapter of the first Galen’s comment we read:
«The femur has a small head and an elongated neck. It
is located in the acetabulum, which is [quite] deep and
surrounded by protruding edges; and at the top of its head
[there is] a strongest ligament ()
connecting with the acetabulum in the deepest place. That is
why the femur is rarely dislocated as opposed to the shoul-
der that has no ligament () and does not enter a
deep cavity».
In Hipp. de art. I, 3 (41).
This passage, as the ones before it, refers to the writings of
Hippocrates, namely, to the treatise On Joints (De artic., 79)
and Instruments of Redactions (Vectiar., 42), in which the
articular cavity of the shoulder joint is compared to the one
of the HJ (39). The above quote shows that Galen had a
good idea of the structure of HJ and distinguished acetab-
ular labrum as well as its “deepest place” – acetabular fossa.
He also notes the strength of LT and one of its functions, the
retention of femoral head in acetabulum.
In the fourth Galenic Commentary on Hippocrates’ On
Joints, § 40, entitled “How to correct hip dislocation when
it is dislocated inward,” the author writes this about HJ:
«In this joint, the ligament [of the femoral head] is extremely
strong, rounded and hidden in it, connecting the top of the
femoral head with the deepest inner part of the acetabulum.
Therefore, without even seeing the ligament itself, but based
only on this reasoning, we can understand that it is short:
since the hip always rotates - as Hippocrates said: it rotates
in the pelvic bone - and never leaves the acetabulum, the
ligament ought to be very short. And so, it is the ligament
that prevents the hip from being dislocated, at least while it
is in its natural state. And not only can the ligament rupture,
but also, due to the abundance of fluid that has unnaturally
accumulated in the cavity [joint], become so stretched that
it sometimes allows the femur to dislocate from its natural
place. And if, due to a rupture of the ligament, the hip is
dislocated, then even with immediate reduction it will not
be able to remain in its place. <...> This is how the nature of
things teaches us that with a torn ligament, the reduction of
femur cannot remain in its place. It should also be added that
on the outside of the knee joint there are several tendinous
ligaments and in the hip joint there is only this ligament,
since neither anything of this kind, nor any muscles support
542 Muscles, Ligaments and Tendons Journal 2020;10 (3)
Ancient Textual Sources on Ligamentum Teres: Context and Transmission
the joint from the outside. <...> And Hippocrates himself
said at the beginning of this book that even in bulls it is the
hip that get dislocated when they grow old and lose weight,
because when the ligament of the hip is torn, the thigh joint
cannot remain in its place even after reduction, the thing that
especially applies to the emaciated [animals].
Next, let’s look at what can happen if the ligament, weakened
due to the abundance of fluid [in the joint], allows the hip to
dislocate, but then is reset. It seems to me that it is quite obvi-
ous that in the presence of fluid the joint will dislocate again,
and when it dries up, it will regain its natural strength. And
the fact that dislocation of the hip can happen due to the fluid
can be learned from Hippocrates himself, who writes in the
Aphorismsthus:Whoever, due to the chronic sciatica, has
the femoral head dislocated and reset again, will have an accu-
mulation of mucus formed there. And when mucus builds
up in the joint, then the ligament softens and weakens as a
result. And it does not matter whether you call it a ligament
() or a connecting sinew ( ).
For those ligaments that have a rounded shape like tendons are
usually called connecting sinews by anatomists. And we have
already cured this kind of hip dislocation twice, and it did not
dislocate again. Drying medications should be applied over the
joint for a long time until the connective sinew is dry enough
to stop stretching together with the femur extending beyond
the edge of the acetabulum and keep it in its natural position».
In Hipp. de art. IV, 40 (41).
Such an extensive quotation is provided in view of its
exceptional significance. Here Galen describes in detail the
geometric and mechanical properties of LT, its topograph-
ic anatomy and function. Regarding the attachment areas,
the author notes that LT connects with the bones, that is,
with the femoral head and the inside of the acetabulum (In
Hipp. de art. IV, 40; cf. ibid. I, 3) (41), undoubtedly mean-
ing acetabular fossa (lat. fossa acetabuli). Perhaps it is from
this treatise that the term “round ligament” (lat. ligamen-
tum teres, ligamentum rotundum) first entered the academic
vocabulary and is still very much in use.
The author also dwelled on the pathology, that is, a rupture
resulting from a traumatic hip dislocation and its “weak-
ening” due to accumulation of pathological fluid, possibly
implying synovitis. Galen also informs us of his own success-
ful experience in treating a (presumably) recurring hip dislo-
cation in children. Here we find, for the first time in history
of medicine, a description of the conservative treatment of
LT pathology. Galen in this case used some “drying medi-
cations”, possibly in the form of compresses or ointment
dressings, which, according to his clinical plan, “dried” the
LT, eliminating its hyperelasticity, and was conducive to its
contracting.
Galen’s texts were well known to the Byzantine medi-
cal authors, who composed various kinds of encyclope-
dic codices and compendia containing extracts from the
writings of ancient physicians, mainly Hippocrates and
Galen. So, for example, Oribasius (IV-V cent.), when
describing the structure of the femur in his essay “Medi-
cal Collections” (Coll. Med. XXV, 19) gives an exact quote
from the aforementioned Galen’s treatise On Bones for
Beginners (41).
Important refinements in the description of the structure of
LT are also found in the Pseudo-Galen’s treatise Introduc-
tion, or the Physician:
«The hip has one bone. And its head, somewhat curved,
enters the deep acetabulum of the pelvis; and it is connected
by a sinew (), growing from the middle of this cavity
and growing into the middle of the femoral head».
Introd. s. Med. XII (41,61,62).
It should be noted that in this case, Pseudo-Galen, in
reference to LT, uses not the word , which is
more characteristic of Galen, but the old term ,
which was employed by his predecessors Hippocrates,
Heraclides of Tarentum, Hegetor, Apollonius of Citium
and Rufus of Ephesus. Apparently, Pseudo-Galen was
well versed in the normal anatomy of HJ, as he correct-
ly describes the significant depth of acetabulum and the
attachment of LT to its middle, that is, to the bottom of
acetabular fossa. The latter circumstance is extremely
important for biomechanics of HJ, since only with this
type of connection can LT fully perform its important
functions: limiting movements, supporting the pelvis,
the hip abductor muscle group and the upper part of the
femoral head (15,17,23).
Another description of LT, similar to Galen’s, is found in
the works of Byzantine physician Theophilus Protospathar-
ius (circa VII cent.), who, in book V of the treatise On the
Construction of the Human Being, wrote:
«For the sake of this, the kindness and creation of God grew
from the bottom of the acetabulum a round sinew (),
a cartilaginous ligament ( ), grow-
ing into the head of the femur and holding it there to avoid
dislocation».
De corp. hum. fabr. XIII, 204.
In the above passage, Theophilus Protospatharius does not
provide any new information, but, undoubtedly under the
influence of Galen, uses the epithet “round” and “cartilag-
inous”, describing the beginning of LT from the bottom of
acetabulum, and also agreeing with its role of holding the
femoral head and preventing dislocation.
543
Muscles, Ligaments and Tendons Journal 2020;10 (3)
S.V. ArkhipoV, i.V. prolyginA
CONCLUSIONS
Ancient physicians wrote predominantly in Greek, with
medical literature in Latin being presented but scarcely,
and terminology developed poorly (63). The term ligamen-
tum in the anatomical meaning of “ligament” did not yet
exist Latin literature. The word nervus, “sinew”, was used
to denote ligaments in Latin. By the end of the V centu-
ry the four basic terms for LT that Galen mentions had
already been known:  (sinew),  (liga-
ment),   (connecting sinew) and 
 (cartilaginous sinew).
The physicians of the Classical period clearly established
that LT was present in both humans and animals, chart-
ed its topographic anatomy, as well as established its main
mechanical and geometric properties. In particular, they
noted that it “is located in the acetabulum”, and is “deep-
ly hidden in the joint”, for some authors it “grows from
the femoral head”, for others it “starts from the middle
of the acetabulum”. These physicians also drew attention
to its mechanical properties, that is, very high strength,
resilience, consistence (cartilage density) and, at the same
time, flexibility, allowing movements of the femoral head.
The geometric features were also indicated, in particular,
that LT has a short length, and in shape it is “round”. The
latter characteristic described by Galen subsequently led
to the emergence of the well-known Latin term for LT, i.e.
“round ligament”, which is still applied. Regarding the
role of LT, it was noted that it connects the acetabulum
with the femoral head and prevents its dislocation, that is,
limits rotational and forward movements in HJ.
In Palestine of the biblical times, it was believed that LT
provided a normal gait, participating in the organization of
this type of human locomotion, and an injury to it caused
lameness. Ancient medical authors also knew about its
traumatic rupture, and identified other types of LT pathol-
ogy, in particular, “soaking”, weakening (possibly a dystro-
phic change), stretching (that is, lengthening), suggested
the possibility of its constriction (in other words, short-
ening) and drying (dehydration with increasing elastici-
ty). The factors leading to pathological changes in LT were
identified as trauma, namely hip dislocation, exhaustion,
advanced age, and an excessive accumulation of “fluid”
in HJ. For the treatment of LT pathology, the application
of drying compresses was used. An injury to LT was seen
as the cause of recurring hip dislocation. It was regarding
this issue that the first correspondence discussion on LT
took place, lasting five centuries and involving Heraclides
of Tarentum, Hegetor, Apollonius of Citium and Galen
of Pergamon.
STRENGTHS & WEAKNESSES
Strengths
Our work based on an interdisciplinary approach, allowing
us to propose a combination of linguistic and medical anal-
ysis of various Greek and Latin texts containing references
to ligamentum teres. A linguistic analysis has enabled us to
trace the transformation of the term from 5 cent. BC to 3
cent. AD, as well as the history of the term, medical contexts
of its usage, its etymology and its early synonyms. Due to
descriptive study of different sources we have created a new
field of researching and new questions to acquire a better
understanding of how ancient authors considered normal
and pathological anatomy of the ligamentum teres, its physi-
cal and geometric features to make possible a description of
the conservative treatment of its pathology.
Weaknesses
Works of some ancient authors (Heraclides of Tarentum,
Hegetor), which we have considered as genuine, preserved
only in short fragments and quotations by the later writers,
so that the genuineness of these works and our conclusions
are still in question, and the information we have extracted
from them is often suggestive rather than definitive. Not
all of the passages we quoted (such as Galenus In Hipp.
De art. IV, 40, ed. Kuhn XVIII A: 731-736) have been
published in modern critical editions; an English transla-
tion of these passages are our own. Some authors reiter-
ate or rethink the concepts of their predecessors, but we
considered it necessary to present a complete collection of
the quotations, providing them with comments.
CONFLICT OF INTERESTS
The authors declare that they have no conflict of interests.
LIST OF ABBREVIATIONS
Apollonius:
In Hipp. de art. – In Hippocratis de articulis commentarius
Aristoteles:
Hist. anim. – Historia animalium
Celsus:
De med. – De medicina
Galenus
De anat. adm. – De anatomicis administrationibus
De loc. aff. – De locis affectis
De motu musc. – De motu musculorum
544 Muscles, Ligaments and Tendons Journal 2020;10 (3)
Ancient Textual Sources on Ligamentum Teres: Context and Transmission
De usu part. – De usu partium
In Hipp. de art. In Hippocratis librum de articulis et Galeni
in eum commentarii IV
Hippocrates:
De artic. – De articulis
De loc. in hom. – De locis in homine
Vectiar. – Vectiarius
Oribasius:
Coll. med. – Collectiones medicae
Plinius Major:
Hist. nat. – Historia naturalis
Ps.-Galenus:
Introd. s. Med. – Introductio seu Medicus
Theophilus Protospatharius:
De corp. hum. fabr. – De corporis humani fabrica
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The ligamentum teres (LT) has attracted much greater interest over recent years due to the increased use of hip arthroscopy. There have been advancements in our understanding of the LT’s biomechanical function and its role in hip and groin pain. Our ability to suspect LT tears by clinical examination and imaging has improved. Publications by many authors concerning LT tear treatment and outcomes continue to increase. This manuscript is a review of the function, mechanism of injury, clinical assessment, imaging, arthroscopic assessment, treatment, outcomes, reconstruction, and unusual conditions of the LT.
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The design, implementation, evaluation, interpretation and report of research is a key important for the science. The research required minimize the uncertainty, therefore we encourage all authors of respect how much can possible the contents in this official editorial also in order to stimulate interest and debate about constructive change in the use of statistics in our disciplines1,2. Authors are required to confirm that these standards and laws have been adhered to by formally citing this editorial within the methods section of their own manuscript.
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Intriguing anatomists and surgeons for centuries, the exact function and biomechanical significance of the ligamentum teres (LT) remains incompletely understood. The LT, also described as the ligamentum femoris capitis, is an intra-articular extrasynovial ligament extending from the cotyloid fossa of the acetabulum to the fovea on the femoral head. Some studies have described it as a vestigial structure in the adult hip. More recent biomechanical studies, however, along with histological and anatomical studies, have suggested the LT to have an important function in proprioception, nociception, and as a secondary stabilizer of the hip joint. The advent and increased utilization of hip arthroscopy to treat hip pathology over the past two decades has ignited a renewed interest in the role of the LT, as well as techniques and indications for management of pathology. In the constellation of intra-articular pain generators of the hip, LT injuries have historically been difficult to diagnose through physical examination or advanced imaging. Numerous classification systems have been proposed based on arthroscopic appearance, and for most cases, conservative management is adequate. In patients undergoing hip arthroscopy, LT débridement usually suffices, although in cases of persistent pain and severe instability, reconstruction of the ligament may be indicated. Multiple methods for reconstruction have been described, with the greatest variation in the method of acetabular fixation of the graft. Future research should focus on clarifying the role of the LT, appropriate surgical indications for reconstruction, and optimization of graft fixation within the acetabulum.
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The anatomic and histological characteristics of the ligamentum teres and its vascular contributions to the femoral head have been well described. The function of the ligamentum teres remains poorly understood. Although excision is the current standard in treating complete developmental hip dysplasia, we developed an interest in maintaining, shortening, and reattaching the ligament to assure early postoperative stability in developmental hip dysplasia. To analyze its potential for providing hip joint stability, we investigated the biomechanical properties of the ligamentum teres in an in vitro porcine model. Six immature porcine hips were dissected, with the proximal femur and acetabular anatomy kept intact, isolating the ligamentum teres. Specimens were loaded in tension using custom fixation rigs at 0.5 mm/s in line with the fibers. Data for displacement and force were collected and sampled at 10 Hz for duration of each test. The ligamentum teres failed in a stepwise fashion. The mean ultimate load to failure was 882 +/- 168 N. Mean stiffness and failure stress were calculated as 86 +/- 25 N/mm and 10 +/- 2 MPa, respectively. The biomechanical function of the ligamentum teres is not inconsequential. We found the ultimate load of the ligamentum teres in the porcine model to be similar to those reported for the human anterior cruciate ligament. The strength of the ligamentum teres may confirm its potential for providing early stability in childhood hip reconstructions. In the setting of dysplasia, the preservation and the transfer of the ligamentum teres to augment stability should be considered as an adjunct to open reduction.
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Background: The functional significance of the ligament of the head of femur (LHF), or ligamentum teres has often been debated. Having gained recent attention in clinical practice, it is suggested to partly provide some mechanical stability to the hip joint. However, the anatomy of this ligament is not well studied. This paper systematically reviews the anatomy of the LHF with the aim of exploring our current understanding of this structure and identifying any gaps in knowledge regarding its morphology and function. Methods: A systematic search of Medline, Embase, ProQuest, Web of Science and Scopus databases was undertaken and relevant data extracted, analyzed. Results: A total of 69 references were obtained, that included 53 full text articles, three published abstracts, and 13 textbooks. Many publications related to clinical studies (n=11) rather than gross anatomy (n=7), with one report on variation of the LHF. Considerable inconsistency in the naming and description of the LHF morphology was observed. Variable attachment sites were reported except for the acetabular notch, transverse acetabular ligament and the femoral fovea. Presence and patency of the ligamental arteries supplying the head of the femur and their exact location were variably described and were often incomplete. The LHF is believed to be taut in extreme hip adduction but there is little evidence to support this. Conclusions: Further investigation of the anatomy of the LHF is recommended, particularly to clarify its mechanical role, innervation and vascular contribution to the developing and adult femur, so to better inform clinical practice. This article is protected by copyright. All rights reserved.
Article
Purpose The purpose of this cadaveric study was to evaluate the function of the ligamentum teres (LT) in limiting hip rotation in 18 distinct hip positions while preserving the capsular ligaments. Methods Twelve hips in 6 fresh-frozen pelvis-to-toes cadaveric specimens were skeletonized from the lumbar spine to the distal femur, preserving only the hip ligaments. Hip joints were arthroscopically accessed through a portal located between the pubofemoral and iliofemoral ligaments to confirm the integrity of the LT. Three independent measurements of hip internal and external rotation range of motion (ROM) were performed in 18 defined hip positions of combined extension-flexion and abduction-adduction. The LT was then arthroscopically sectioned and rotation ROM reassessed in the same positions. A paired sample t test was used to compare the average internal and external hip rotation ROM values in the intact LT versus resected conditions in each of the 18 positions. P < .0014 was considered significant. Results A statistically significant influence of the LT on internal or external rotation was found in 8 of the 18 hip positions tested (P < .0014). The major increases in internal and external rotation ROM occurred when the hip was in 90° or 120° of flexion. Conclusions The major function of the LT is controlling hip rotation. The LT functions as an end-range stabilizer to hip rotation dominantly at 90° or greater of hip flexion, confirming its contribution to hip stability. Clinical Relevance Ruptures of the LT contribute to hip instability dominantly in flexed hip positions.