Research Review: Relationship between the Gluteus Maximus & the Fascia Lata (Iliotibial Band)
By Stefanie DiCarrado DPT, PT, NASM CPT & CES
Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
Original Citation: Stecco, A., Gilliar, W., Hill, R., Fullerton, B., Stecco, Carla. (2013). The anatomical and functional relation between gluteus maximus and fascia lata. Journal of Bodywork & Movement Therapies. 17. 512-517 - ABSTRACT
Note the fascial attachment of the gluteus maximus
Why is this relevant?: The gluteus maximus (Gmax) is typically thought of as a muscle acting predominately at the hip and the sacroiliac joint (SIJ). This study supports more recent findings of Gmax influence at the knee via the iliotibial band (ITB) and the possible influence in knee mechanics.
Study Summary
| Study Design | Descriptive Study |
| Level of Evidence | III: Evidence from non experimental descriptive study |
| Subject Demographics |
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| Outcome Measures | Attachment sites |
| Results |
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| Conclusions | The predominate attachment of Gmax fibers into fascia implies this muscle's influence throughout the lower extremity rather than at the hip & SIJ alone. |
| Conclusions of the Researchers | Gmax attaches more to fascia than bone creating an intricate movement and stabilization system affected by all muscles invested by the same fascia. |
The gluteus maximus, through its fascial attachments may exert influence throughout the lower kinetic chain
Review & Commentary:
The authors performed a systematic, layer by layer dissection of the Gmax and the surrounding fascia. First, the skin and subcutaneous layers were removed to reveal the deep fascial overlaying the Gmax . To separate the distal part of the muscle from the proximal insertion, researchers created a vertical incision running from the posterior superior iliac spine (PSIS) to the ischial tuberosity (IT). Researchers evaluated the specific Gmax insertions into the fasica lata, iliotibial tract, lateral intermuscular septum, and linea aspera bony landmark of the femur with careful dissection. Lastly, the authors attempted to separate the fascia into layers without a scalpel to investigate the connectivity between layers.
The fascia lata is a layer of connective tissue covering all muscles in the upper part of the leg. It thickened laterally as the iliotibial band and blended with both inter- and intramuscular septa. The intermuscular septa divides the upper leg into separate compartments and originates from the inner surface of the fascia lata. Posteriorly, the fascia was continuous with the intramuscular septa that divided the quadriceps muscles from the hamstring muscles . The proximal 1/3 of the fascia lata was easily split into two or 3 layers because of the loose connective tissue between the layers which allows them to glide on one another. Distally, that loose connective tissue layer was replaced with dense collagen fibers in a cross hatched design and was more difficult to separate. This may indicate improved tissue mobility of the lateral thigh closer to the hip and a stronger support system as the fascia approaches the knee.
Researchers listed the following muscle attachment sites of the fascia lata found in all cadavers: distal insertion into muscle fibers of the vastus lateralis (VL ) with a mean attachment size of 3cm and the entire surface of the vastus medialis (VM). The fascia gave rise to several strong intermuscular septa that divided the thigh into different compartments. The authors did not state the specific number of cadavers that presented with a fascia lata and biceps femoris (BF) attachment but did note a relationship with a mean attachment size of 4.25cm longitudinally and 2.5cm transversely. This is particularly interesting considering the relationship of the short head of BF in both Lumbo Pelvic Hip Complex Dysfunction (LPHCD) and Lower Leg Dysfunction (LLD).
Previous cadaver dissection of the Gmax confirmed superficial and deep fibers of the Gmax . The superficial fibers were found to insert predominately into the ITB whereas the deep muscles were local to the area of the sacroiliac joint. It would have been beneficial for the authors of this study to specify superficial versus deep when discussing the distal attachments of the Gmax .
The authors describe a cranially directed force to the distal portion of the Gmax after separating it from the proximal insertion. Unfortunately, the authors did not include the effect of the traction within their results, discussion, or conclusion. Such information offers insight into the biomechanical affects of the muscle if the traction is applied within the correct alignment so as to match muscle fiber orientation. Further research should explore this applied traction and record the resultant movements throughout the lower leg.
Why is this study important?
This study is important because it provides cadaver based data on the fascial attachments of the Gmax . Knowledge of muscle fiber orientation and attachment enhances our understanding of structure, which may provide further evidence to support ideas on movement and compensation, new thoughts on the function of this muscle at the hip and knee, and possibly inspire new interventions (see the Brookbush Institutes Rules of Human Movement Science ).
How does it affect practice?
This study provides evidence that much of the force created by the glute max is imparted on the ITB, with less force imparted directly on the femur. This implies careful balance in tension is created between the GMax and TFL on the iliotibial band, which may have an affect on various structures crossing the hip and knee via the complex proximal and distal attachments of the ITB. Although the Gmax is generally considered a hip extensor and external rotator with a direct mechanical impact only on hip function, this study is evidence that the Gmax has a direct mechanical impact on the knee.
- Note: previous cadaver studies have also implicated the GMax in having a direct role on lumbar spine mechanics via the thoracolumbar fascia, and a direct role on sacroiliac joint stability via deep fibers (Gibbons, 2004 & Barker, Hapuarachchi, Ross, Sambaiew, Ranger and Briggs ).
Typically the Gmax is thought to be inhibited and weak, and the TFL synergistically dominant. Several studies have demonstrated a relative decrease in activity and latent firing of the Gmax in the presence of sacroiliac joint pain, knee valgus, and an anterior pelvic tilt (Hungerford, Gilleard, Hodges (2003) & Padua, Bell & Clark (2012) & Tateuchi, Taniguchi, Mori, Ichihashi, (2013) ) and dominance/over-activity of the TFL (Padua et. al. (2012) & Tateuchi et. al (2013) ). Two studies have attempted to better activate the GMax while reducing activity of over-active synergists (biceps femoris and TFL ) (Selkowitz, Beneck, & Powers. (2013) & Kan, Jeon, Kwon, Cynn, Choi (2013) ).
Given the evidence above and the information in this study, it may be wise to consider gluteus maximus activation when attempting to improve knee mechanics.
Further Consideration:
The information presented here does indicate a need to consider this muscle, or at least the superficial fibers of this muscle, as overactive in rare situations. For example, if iliotibial band friction syndrome (runner's knee) is thought to be the result of increased tension in the ITB, could the Gmax be contributing to the increased tension? A human movement professional should consider evaluating for hypertonicity and trigger points in addition to under-activty of the Gmax in instances of Lumbo Pelvic Hip Complex Dysfunction (LPHCD) and Lower Leg Dysfunction (LLD) . Over-activity does not imply strength, but instead an increase in neural activity that must be lowered to an optimal level before optimal movement patterns can be attained. Clinically, the author's have never evaluated a GMax that was thought to be tight/shortened, but occasionally have noted the presence of trigger points just inferior to the posterior iliac crest along the upper most (superficial) fibers of the glute max. Additionally, full examination of the BF must be performed as it shares a relationship with the fascia latae.
How does it relate to Brookbush Institute Content?
The Brookbush Institute's predictive model of LPHCD, Sacroiliac Joint Dysfunctio (SIJD) , and LLD include activation and integration of the Gmax due to the tendency toward latent firing, inhibition and weakness. This study provides evidence of a link between optimal function of the Gmax and the knee, potentially a link between Gmax dysfunction and knee pathology, and further knee pathology and LPHCD.
Further consideration will need to be given to a variation on these predictive models of dysfunction that may include GMax over-activity, and/or a model that includes separate intervention for the superficial and deep fibers of the Gmax.
In the search for congruence , it is essential to assimilate this data into the big picture. The model implemented by the Brookbush Institute is based on observable movement dysfunction and corresponding muscular, articular, fascial and neural compensation. A human movement professional must perform careful evaluation of each client to ensure proper exercise selection for the specific dysfunction presented.
The following exercises are examples of a sample routine that may normalize activity and length of the Gmax and TFL , improving the balance of force on the iliotibial band.
TFL SA Static Release
Iliotibial Band (ITB) SA Myofascial Creep
Kneeling Hip Flexor Stretch
Gluteus Maximus Activation
Static Lunge to Row (Posterior Oblique Subsystem Integration Progressions)
Bibliography:
© 2014 Brent Brookbush
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