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A newly discovered membrane at the origin of the proximal tendinous complex of the rectus femoris

Authors:
  • Hospital Viladecans

Abstract and Figures

Purpose The rectus femoris (RF) forms the anterior portion of the quadriceps muscle group. It has a proximal tendinous complex (PTC) which is constituted by a direct tendon (DT), an indirect tendon (IT), and a variable third head. Direct and indirect tendons finally converge into a common tendon (CT). All the PTC shows a medially sloping in its proximal insertion.We investigated several anatomical specimens and discovered a new component: a membrane connecting the CT with the anterior superior iliac spine. Such membrane constitutes a new origin of the PTC. The aim of this study was to clarify whether this membrane was an anatomical variation of the PTC or a constant structure and to describe its morphology and trajectory. Material and methods We dissected 42 cadaveric lower limbs and examined the architecture of the PTC. We paid special attention to the morphology and interaction patterns between the tendons and the membrane. Results We demonstrated that the membrane is a constant component of the PTC. It has a lateral to medial trajectory and is in relation to the common tendon, the DT, and IT, which present a medial slope. This suggests that the membrane has an stabilizer role for the PTC, acting as a corrector of the inclined vector of the complex. Conclusion The RF injuries are frequent in football. The newly discovered membrane is a constant component of the PTC and its integrity should be included in the algorithm to diagnose injuries.
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Surgical and Radiologic Anatomy
https://doi.org/10.1007/s00276-022-02954-3
ORIGINAL ARTICLE
A newly discovered membrane attheorigin oftheproximal tendinous
complex oftherectus femoris
S.Mechó1,2 · I.Iriarte3· R.Pruna4 · R.Pérez‑Andrés5 · A.Rodríguez‑Baeza6
Received: 27 March 2021 / Accepted: 21 April 2022
© The Author(s) 2022
Abstract
Purpose The rectus femoris (RF) forms the anterior portion of the quadriceps muscle group. It has a proximal tendinous
complex (PTC) which is constituted by a direct tendon (DT), an indirect tendon (IT), and a variable third head. Direct and
indirect tendons finally converge into a common tendon (CT). All the PTC shows a medially sloping in its proximal insertion.
We investigated several anatomical specimens and discovered a new component: a membrane connecting the CT with the
anterior superior iliac spine. Such membrane constitutes a new origin of the PTC. The aim of this study was to clarify whether
this membrane was an anatomical variation of the PTC or a constant structure and to describe its morphology and trajectory.
Material and methods We dissected 42 cadaveric lower limbs and examined the architecture of the PTC. We paid special
attention to the morphology and interaction patterns between the tendons and the membrane.
Results We demonstrated that the membrane is a constant component of the PTC. It has a lateral to medial trajectory and
is in relation to the common tendon, the DT, and IT, which present a medial slope. This suggests that the membrane has an
stabilizer role for the PTC, acting as a corrector of the inclined vector of the complex.
Conclusion The RF injuries are frequent in football. The newly discovered membrane is a constant component of the PTC
and its integrity should be included in the algorithm to diagnose injuries.
Keywords Rectus femoris· Proximal rectus femoris tendon· Thigh· Anterior superior iliac spine· Membrane
Introduction
The rectus femoris (RF) forms the most ventral layer of the
quadriceps. It is the only one of the four muscles of the
quadriceps complex that crosses two joints. Besides being
part of the group of flexor muscles of the hip, it also extends
the knee joint, and stabilizes the pelvis in the standing posi-
tion [6, 1416, 21]. It is a bipennate muscle composed of
fascicles that are pennated obliquely to the central tendon
[14]. Its embryological development starts at the 17th stage
(crown-rump length 11–14mm, 41days post fertilization)
according to O’Rahilly etal. [17]. At this stage, we can iden-
tify mesenchymal condensations of the femur, tibia, fibula,
and premuscle masses. The quadriceps femoris first develops
as a single mass overlying the anterior aspect of the middle
of the femur’s shaft. Then, at the 20th stage (20mm embryo)
according to O’Rahilly, all different heads of the quadriceps
femoris are clearly demarcated and attached to the skeletal
apparatus by distinct tendons [18].
Proximal origin of RF is made up of two components,
a direct tendon (DT) and an indirect tendon (IT) or reflex
* S. Mechó
mechomeca@gmail.com
1 Department ofMorphological Sciences (Human
Anatomy andEmbriology Unit), Faculty ofMedicine,
Universitat Autònoma de Barcelona, Can Domènech Ave,
08193Bellaterra(Barcelona), Spain
2 Department ofRadiology, Medical Department
ofFutbol Club Barcelona, Hospital ofBarcelona-SCIAS,
Bellaterra(Barcelona), Spain
3 Department ofPhysical Medicine andRehabilitation, Ars
Médica Clinics, Bilbao, Spain
4 Department ofOrthopedics andSports Medicine, ICATME,
Barcelona, Spain
5 Department ofRadiology, Gemans Trias i Pujol Hospital,
Badalona, Barcelona, Spain
6 Department ofMorphological Sciences (Human Anatomy
andEmbriology Unit), Faculty ofMedicine, Universitat
Autònoma de Barcelona, Barcelona, Spain
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Surgical and Radiologic Anatomy
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(Fig.1). The IT has been found to develop prior to the DT;
indeed, until the sixth fetal month, only the IT can be dis-
tinguished [22, 23, 26, 27]. A few centimeters from their
origins (approximately 2cm from the origin of the DT and
5.5cm from the origin of the IT), both tendons converge in
the common tendon (CT), and form the proximal tendinous
complex (PTC), a Y-shaped structure covered by a com-
mon paratendon [1, 3, 5, 6, 8, 10, 14, 16, 19, 20, 22, 23, 26,
27]. The DT originates from the anterior inferior iliac spine
(AIIS) and the underlying rough surface, and it is formed of
fibers with a longitudinal craniocaudal direction [1, 68, 14,
20, 22]. The IT originates from the supraacetabular sulcus
and the lateral aspect of the capsule of the hip joint, and
presents fibers in a transverse direction in the axial plane [1,
68, 14, 20, 22].
The DT is located more ventrally and presents an incli-
nation that is medial to the longitudinal axis of the muscle
(Fig.1a). It has a short course with a very proximal myoten-
dinous junction in the thigh. Moreover, its fascicular tendi-
nous structure is distributed along the anterior surface of the
muscle continuing with the myofascial junction (epimysium,
perimysium, and muscle fiber fascicles) [2, 9, 15, 21]. It is
mainly involved at the beginning of the hip flexion [3].
The IT has a triangular morphology, follows an anteropos-
terior course (Fig.1b), and usually has a medial inclination
with respect to the longitudinal axis of the muscle. It extends
along the anterior midline of the muscle, forming the central
septum. It later thins out and reach the lower third of the
thigh, acquiring a linear shape with a long sagittal axis [6,
9, 14, 15]. The myoconnective junction (MCJ) of the IT
has a greater craniocaudal extension than the one of the DT
[14]. The IT performs its main function as a hip flexor once
flexion has begun.
The RF is the component of the quadriceps that is more
frequently injured in sports [4]. To better understand all the
structures that can be involved in myoconnective injuries, it
is necessary to know in detail the anatomic characteristics
of the rectus femoris. In this study, we found a membrane-
localized anterior to the PTC (Fig.1a), connecting it to the
anterior superior iliac spine (ASIS) that, to our knowledge,
has not been previously described.
Hence, our objective is to introduce the newly-discovered
membranous structure, determine if it is a fixed component
of the PTC, and describe its anatomy and relationship with
the PTC.
Fig. 1 a Anterior overview of a left thigh showing the membrane
(m) that connects the common tendon (CT) to the anterior superior
iliac spine (ASIS). The membrane is opaque. b Illustration of a lat-
eral overview of a left thigh showing the proximal tendinous complex
(PTC). The membrane is localized anterior to it
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Materials andmethods
We studied 42 hemipelvis that included the thigh from bod-
ies donated to the Faculty of Medicine of the Universitat
Autònoma de Barcelona (UAB). The average age of the sub-
jects was 79years (range 54–98). 35.72% of the subjects
were males and 64.28% females; 50% of the limbs were right
and 50% were left.
Body donation at the UAB is regulated by an acceptance
document approved by the Ethics Commission in Animal
and Human Experimentation (file CEEAH 2904 of March
11, 2015). All hemipelvis were preserved by arterial per-
fusion of modified Cambridge solution (phenol, ethanol,
glycerin, and formaldehyde) and maintained at 6–7°C until
their use.
The hemipelvis were dissected and examined using a
standardized protocol, by planes from the anterior aspect
of the proximal thigh. The skin and subcutaneous cellular
tissue were lifted to identify the sartorius muscle (S) and the
femoral (Scarpa’s) and quadriceps triangles. The superficial
fascia of the S and the vascular and nerve contents of the
femoral triangle were also removed to expose the iliopsoas
muscle (IP). Afterwards, the IP was dissected from the pel-
vic brim to its extra-pelvic portion in the proximal thigh, and
the inguinal ligament (IL) was sectioned, keeping its inser-
tion in the anterosuperior iliac spine undamaged. The origin
of the tensor fasciae latae muscle (TFL) in the quadriceps
triangle was identified and the connective tissue anterior to
the RF was dissected, between the S and TFL muscles. Then,
the S was distally sectioned and moved away respecting its
iliac origin, and below, the membrane or fibrous lamina,
which is the target of this study appears.
We analyzed different morphological aspects of the mem-
brane: wideness, thickness, and distal insertion in the antero-
medial aspect of the CT. The wideness was assessed as the
extension in the anteroposterior plane of the membrane with
respect to the anterior margin of the ASIS: we considered a
membrane short when its anterior margin was deeper than
the anterior aspect of the ASIS; and medium or long, when
its anterior margin was at the same level or more anterior
than the ASIS (Fig.2). The thickness was assessed accord-
ing to the opacity of the membrane (opaque or transparent)
(Figs.1a, 2b). Finally, the distal insertion on the anterome-
dial aspect of the CT was evaluated by dividing the CT into
proximal, middle, and distal thirds (Fig.3).
Data analysis
The categorical variables were described as absolute fre-
quencies and percentages. The correlations between mor-
phological categories and demographic variables were
evaluated using pearson Chi-Square Test. The level of statis-
tical significance was set at P < 0.05. The statistical software
Fig. 2 a Lateral overview of the PTC of the right rectus femoris mus-
cle (RF). The membrane (arrowhead) shows a deeper anterior margin
than the anterior margin of the ASIS. Short and opaque membrane. b
Lateral overview of the PTC of the left RF. The membrane (arrow-
head) shows its anterior margin at the same level than the anterior
margin of the ASIS. Medium and transparent membrane. c Anterior
overview of the PTC of the right RF. The membrane (arrowhead)
shows its anterior margin in a more anterior position than the anterior
margin of the ASIS. Long and transparent membrane
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Surgical and Radiologic Anatomy
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StatPlus: Mac Pro Version v7 (AnalySoft Inc) was used for
data analysis.
Results
Underneath the S, a fibrous membrane was clearly identified,
separating this muscle from the IP (Fig.4a). The membrane
had an oblique course, from lateral to medial, and a medial
concavity to accommodate the IP (Fig.4b). It extended from
the distal third (40/42 cases) or the middle third (2/42 cases)
of the anterior surface of the CT of the RF to the lower part
of the ASIS. It was located deep to the iliac origin of the S
and the iliac insertion of the IL. The DT had a medial slop-
ing trajectory to reach its origin in the AIIS; therefore, it was
positioned medially to the membrane. In many cases, the IT
also had a medial sloping trajectory. Hence, the PTC usually
had a medial slope and the membrane a lateral slope (Fig.5).
The membrane was constantly present in all the samples
studied. In 23/42 cases it was wide (medium and long mem-
brane), and in 23/42 cases it was slightly thick (opaque).
Finally, only in one case presented a canal containing the
muscular origin of the S (Fig.6).
In Table1, we show the distribution of the different mor-
phological category according to gender and side. In gen-
eral, there was a greater number of wide (medium and long)
membranes and opaque membranes for both genders. How-
ever, in the case of the left side, there were more transparent
membranes (52.4%). In general, the majority of the mem-
branes show distal insertion in the CT. Finally, there were
no significant differences between gender and side (Table2).
Fig. 3 a Lateral overview of the PTC of the left RF. The distal mar-
gin of the membrane (m) is marked by a dash line at the distal por-
tion of the CT. In this case, we found an independent tendon attached
to the IT. b Illustration of a lateral overview of the PTC. The distal
margin of the membrane (m) is marked by a dash line at the distal
portion of the CT. c Lateral overview of the PTC of the left RF. The
distal margin of the membrane (m) is marked by a dash line at the
middle portion of the CT. The anterior aspect of the direct tendon
(DT) is behind the membrane. Indirect tendon (IT). d Illustration of a
lateral overview of the PTC. The distal margin of the membrane (m)
is marked by a dash line at the middle portion of the CT
Fig. 4 a Anterior overview of a left thigh. We can identify the sec-
tioned inguinal ligament (IL) with its insertion in the ASIS. The sar-
torius muscle (S) was sectioned and removed, the lateral part of the
iliopsoas muscle (IP) was sectioned and reclined medially. There is
an adipose tissue between the RF and the tensor fasciae latae (TFL)
muscle and a longitudinal thickening in the TFL’s fascia. The mem-
brane (m) separates the iliopsoas and sartorius muscles. b Anterior
overview of the PTC of the left RF. Note the lateral-to-medial-trajec-
tory of the membrane (m) and its medial concavity to accommodate
the IP removed
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Discussion
The new membrane that we describe is part of the PTC and
is similar to a membrane that has been cited as an anatomi-
cal variant of the RF by Macalister in 1875 [13, 2527].
However, we demonstrated that it is not a variant since it
was detected in all the hemipelvis that we studied. It con-
sists of connective tissue belonging to “the fascial system”
according to the Fascia Nomenclature Committee [24]. This
membrane connects the RF CT to the ASIS, representing
an additional origin of the PTC. It is a thin band with a
lateral-to-medial trajectory, an inverted triangle shape from
distal to proximal, and a variable antero-posterior extension.
In this study, we demonstrated that there are no significant
differences in the morphological characteristics (thickness,
wideness, distal insertion level) of the membrane between
Fig. 5 Illustration of an anteromedial overview of a left thigh show-
ing the PTC. The red arrow represents the medial inclination of the
PTC with respect to the longitudinal axis of the RF and the blue
arrow represents the lateral trajectory of the membrane (colour figure
online) Fig. 6 Anterior overview of a left thigh showing a splitting mem-
brane (m)
Table 1 Morphological
characteristics of the
membranes according to gender
and side. Number of cases
in each category (absolute
frequencies and percentages)
Wideness Thickness Distal insertion
Short Medium Large Transparent Opaque Distal Middle
Female 12 (44.5%) 10 (37%) 5 (18.5%) 12 (44.5%) 15 (55.5%) 25 (92.6%) 2 (7.4%)
Male 7 (46.7%) 6 (40%) 2 (13.3%) 7 (46.7%) 8 (53.3%) 15 (100%) 0
Left 10 (47.6%) 9
(42.9%)
2 (9.5%) 11 (52.4%) 10 (47.6%) 19 (90.5%) 2 (9.5%)
Right 9 (42.9%) 7
(33.3%)
5 (23.8%) 8 (38.1%) 13 (61.9%) 21 (100%) 0
Table 2 Statistical results of Pearson Chi-Square test between the dif-
ferent morphological categories, gender and side
Wideness Thickness Distal insertion
Gender p value 0.9 p value 0.8 p value 0.3
Side p value 0.4 p value 0.3 p value 0.1
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gender and side. The membrane thinness, its close relation
with the intermuscular fatty planes, and its adjacent position
to the epimysium of the IP make it difficult to visualize it by
ultrasound. However, using high spatial resolution magnetic
resonance imaging (MRI), in the axial and coronal views of
the hemipelvis, we can visualize the membrane as a very
thin hypointense band in all the sequences (anatomical and
fluid sensitive sequences) (Fig.7).
Muscle lesions are the most common injuries in athletes
and they represent more than 30% of the injuries in soccer
players [4, 9]. In female professional players, the incidence
of muscle injuries is similar to that in males, and the most
affected muscle groups are the same (hamstrings, adductors,
RF and soleus). However, one study identified in females a
predominance of injuries in the quadriceps group (two times
more frequent than in men) over the hamstrings [11]. The RF
is the component of the quadriceps that is more frequently
injured in sports that require repetitive kicking and sprinting,
such as soccer and its different variants around the world
[14, 15, 22, 28]. The MCJ of the central septum is the most
common site of RF injured in soccer. This MCJ depends
on the IT of the PTC [14, 15]. Different studies monitored
these lesions in Australian footballers and showed that they
are associated with a long time to rehabilitate (especially if
proximal) and delayed return-to-play [15]. Therefore, from
a clinical point of view, we are interested in studying all
the elements of the RF and the relationships between them.
We consider the newly discovered membrane as an addi-
tional origin of the PTC. Considering the divergence of the
DT and the IT, and their medial inclination with respect to
the longitudinal axis of the RF, this membrane seems to act
as a lateral stabilizer correcting this medial deviation; there-
fore, it should be included in the radiological algorithm to
monitor the PTC of the RF in the presence of a proximal ten-
don injury. Finally, the assessment of the membrane integ-
rity could help to decide the type of treatment to follow. In
cases where both the direct and indirect tendons are injured,
Lempainen demonstrated that athletes highly benefit from
reattaching the proximal RF [12]. However, in cases of par-
tial injuries, there are different options for the treatment, and
it could be important to consider the integrity of the newly
discovered membrane within the therapeutic algorithm.
The present anatomical study describes a new component
of the PTC of the RF. The PTC shows a medial slope and the
membrane has a lateral trajectory to the ASIS; therefore, we
could suspect that it has a stabilizing function for the PTC.
Future studies could combine these anatomical findings with
advanced imaging techniques with two major aims: (1) con-
firm the possible stabilizing role of the newly discovered
PTC membrane; and (2) study the importance to assess the
Fig. 7 a Axial T1 weighted magnetic resonance (MR) image of the
left pelvis. We can see the membrane (arrowhead) a thin hypointense
band lateral to the iliac muscle (IL) and its relation with the proximal
portion of the CT. IT; S; TFL; gluteus minimus (Gm); gluteus mag-
nus (GM). b Coronal T1 weighted MR image of the left pelvis. We
can see a thicker hypointense membrane (arrow) lateral to the IL and
its distal insertion to the distal portion of the CT. Its heterogeneous
signal could be secondary to the presence of fat tissue within the con-
nective tissue. RF; S; TFL; Gm
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integrity of the membrane to finally choose the most appro-
priate treatment for proximal RF lesions.
Acknowledgements The authors sincerely thank those who donated
their bodies to science so that anatomical research could be performed.
Results from such research can potentially increase mankind's overall
knowledge that can then improve patient care. Therefore, these donors
and their families deserve our highest gratitude.The authors also thank
Jordi Morillas Pérez who performed the data analysis.
Author contributions All authors contributed to the study conception
and design. Material preparation, data collection and analysis were
performed by SM and AR. The first draft of the manuscript was written
by SMand AR and all authors commented on previous versions of the
manuscript. All authors read and approved the final manuscript. Íñigo
Iriarte was the author of the illustrations.
Funding Open Access Funding provided by Universitat Autonoma de
Barcelona. The authors did not receive support from any organization
for the submitted work.
Declarations
Conflict of interest The authors have no relevant financial or non-fi-
nancial interests to disclose.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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The rectus femoris is the most commonly injured muscle of the anterior thigh among athletes, especially soccer players. Although the injury pattern of the muscle belly is well documented, less is known about the anatomy and specific lesions of the proximal tendons. For each head, three distinctive patterns may be encountered according to the location of the injury, which can be at the enthesis, within the tendon, or at the musculotendinous junction. In children, injuries correspond most commonly to avulsion of the anteroinferior iliac spine from the direct head and can lead to subspine impingement. Calcific tendinitis and traumatic tears may be encountered in adults. Recent studies have shown that traumatic injuries of the indirect head may be underdiagnosed and that injuries of both heads may have a surgical issue. Finally, in the case of tears, functional outcome and treatment may vary if the rupture involves one or both tendons and if the tear is partial or complete. Thus, it is mandatory for the radiologist to know the different ultrasound and magnetic resonance imaging (MRI) patterns of these lesions in order to provide accurate diagnosis and treatment. The purpose of this article is to recall the anatomy of the two heads of rectus femoris, describe a reliable method of assessment with ultrasound and MRI and know the main injury patterns, through our own experience and literature review.