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Lie face down on a bed with your legs out straight and then try lifting your knee off the matress. You probably can’t raise it more than an inch or two; and while attempting to do so, you may feel a pulling sensation in your groin. That’s because you are stretching your iliofemoral ligament. It is named for its attachments on the iliac portion of the pelvis and on the neck of the femur (thigh bone). The ligament forms the shape of an inverted Y, so it is also called the Y ligament. 

The ligament is thick, strong, and able to withstand 750 pounds of stretching without tearing. It stabilizes the hip while standing and thereby spares the muscles from having to perform this task by themselves, which saves energy and limits muscle fatigue. This toughie has some interesting history.    

As far back as 1532, Vesalius, the first modern anatomist and apparently a ballet buff, was impressed. He noted that the iliofemoral ligament was unparalleled in thickness and hardness. He noted that its unusual attachments to the bones, well away from the edges of the joint, allowed the hip great mobility even while supporting body weight. Vesalius marveled at the mobility that this ligament afforded. “It is quite amazing how far forward the head of the femur moves out of the socket … in the position of the feet known in ballet as ‘twice simple’ and denoted in choreography by the mark ʃʃ.’”

The iliofemoral ligament is known today in the United States as the ligament of Bigelow. As with certain diseases, e.g., Parkinsonism, Hodgkin’s, and Alzheimer’s, a person’s name can also become associated with an anatomical structure, typically because that individual “discovered” it or was the first to describe it in detail. Two well-known examples are the Fallopian tubes and Eustachian tubes. These eponyms give credit to the observations of Gabriele Fallopio (1522/23-1562) and Bartolomeo Eustachio (1514-1564). They were contemporaries of Vesalius and joined him in systematically dissecting and describing human anatomy during the Renaissance when every detail was begging for discovery. All the anatomists of that time, however, tended to gloss over ligaments. So it wasn’t until1749 that a French anatomist, Exupère Joseph Bertin (1712-1781), published an anatomy treatise that described the Y ligament; and in France today, it is known as the ligament of Bertin.

How then was a Bostonian, Henry Jacob Bigelow (1818-1890), roughly a century later, lucky enough to have his name attached in perpetuity to the Y ligament in the US? Was there some nationalism at play?

Bigelow was one of those people who seemed to live a charmed existence, always being in the right place at the right time. His father was an esteemed physician, scientist, and Harvard Medical School professor for 50 years. The younger Bigelow’s peers described Henry as thin, athletically gifted, handsome, and charismatic. After graduating from Harvard Medical School, he studied in London and Paris under several of the most eminent medical thinkers of the time.

On return to Boston, he opened his practice; and in January 1846, age 28, he was appointed as a visiting surgeon at Massachusetts General Hospital. Nine months later, Bigelow witnessed the first administration of ether as a general anesthesia for a surgical procedure, and a month after that he published what quickly became a landmark article, “Insensibility During Surgical Operations Produced by Inhalation.” Why Bigelow, rather than the surgeon (John Warren) or especially the administrator of ether (William Morton), authored this seminal paper is unclear, but certainly Bigelow’s name was thereafter in lights. In ensuing years, Bigelow administered most of the ether anesthesia at MGH and became a strong advocate for its use.

When not in the operating room, he continued his interest in pathological anatomy, particularly of the hip joint.  He is credited with detailed dissections and descriptions of the iliofemoral ligament but, to my assessment, Bigelow did not discover any key elements that had been overlooked by earlier anatomists. 

Based on his observations of the Y ligament, Bigelow devised a new method of reseating a dislocated hip. This entailed flexing the hip and relaxing the Y ligament rather than applying traction to the injured limb and stretching the ligament, which had been the practice for millennia. Was it Bigelow’s charisma, serendipitous timing, residence in Boston, or improved method of treating hip dislocations that sealed his name in the pantheon of ligament eponyms?

Ligaments associated with the vocal cords normally grow longer during puberty. This accounts for the voice change, particularly in young men, where the cords lengthen by two thirds compared to only one fourth in women. The change is caused by increasing testosterone levels at puberty. No testosterone surge, no voice change.

Take for example, Carlo Maria Michelangelo Nicola Broschi. He was born in 1705 into an Italian family of musicians. His father, a composer and choir master, died early, and the family’s economic uncertainty may have prompted the decision for young Carlo, an already talented singer, to be castrated. At that time, castration was an accepted treatment for a hernia, but in Carlo’s case the operation was ostensibly necessitated by a fall from a horse, but the subtext was that his vocal ligaments would not lengthen.

With rigorous training, which for some castrati lasted 10 years, Carlo’s singing prowess soared, not only from talent and training, but also from the increased lung capacity and the enlarged resonating chambers of a growing adolescent. His first performance was at age 15. Using the stage name of Farinelli, he performed widely across Europe and became quite wealthy and popular–a rock star of his time. For instance, his brother composed a piece to showcase Farinelli’s virtuosity and his angelic, supernatural voice. When Farinelli performed, the audience responded with tears of ecstasy and a standing ovation for five minutes. He made regular court appearances for royalty, including nightly recitals for nine years for King Philip V of Spain. Farinelli, the most famous of the castrati singers of his time, died in 1782 at age 77.

The stimulus to produce castrati and the unbroken male voice into adult life occurred in the late 16^th century in order to provide singers who could manage the growing complexity of church music. At the beginning of the 17^th century, opera became popular in Italy, which increased the demand in castrati singers.

By the end of the next century, however, opera fashion had changed, so the remaining demand for castrati was for the Sistine Chapel Choir, where they sang until 1903. This terminated when the newly elected pope, Pius X, decreed, “Whenever … it is desirable to employ the high voices of sopranos and contraltos, these parts must be taken by boys, according to the most ancient usage of the Church.”

In addition to the effects of testosterone on vocalization, its absence also allows bones, including the ribs, to grow unnaturally long. This provided the castrati singers supernatural lung capacity and breathing power. For instance, listen to Alessandro Moreschi, the last surviving castrato singer. He made several solo recordings in the early 1900s, You can hear why this famous singer was called the Angel of Rome.

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Don’t miss this heart-warming video. (4 minutes)

And this canine swimming and diving Olympian (10 seconds).

Found on the internet: a wide array of bone gifts for your favorite canine companion.

Jazzy suggests that you let your dog sleep on your feet while you read …

Articles touting the benefits of supplementing one’s diet with creatine have appeared recently in journals as wide ranging as Scientific American and The Economist. What’s the buzz?

A French chemist, Michel Chevreul (1786-1889), discovered creatine in an extract of skeletal muscle in 1832. He named it creatine after the Greek word for meat κρέας (kreas). It is a fairly simple molecule consisting of two amino acids. Our kidneys, liver, and pancreas make creatine, about half of what we need. The rest comes from dietary sources, principally from fish, pork, beef, and chicken. Vegan and vegetarian diets are inadequate sources of creatine, so supplementation, especially for diet-restricted athletes, is highly important. Creatine circulates via the blood stream before 95% of it is stored in muscles, 5% in the brain. Once inside the cells, a phosphorous atom is added, making phosphocreatine.

What do creatine and its intracellular offspring, phosphocreatine, do? The energy-producing molecules (think tiny batteries) in each of our thirty trillion cells are adenosine triphosphate (ATP).

When one of the three phosphates breaks off, the molecule becomes adenosine diphosphate (ADP), and energy is released, which makes muscles contract, and away we go.

There are several ways that the stores of ATP can be replenished (like recharging a battery). By far the fastest is when phosphocreatine yields its “phospho.” (An analogy would be an electric car, which can be slowly recharged overnight; but a hybrid vehicle can call on its gasoline-assist motor should an immediate energy boost be needed to accelerate while going uphill.)   

Athletes have known about taking extra creatine for decades, and creatine supplementation is safe and entirely legal. Excellent research has shown that for explosive, demanding movements, weightlifting for instance, adding creatine can increase maximum performance by up to 15%. It may also help with recovery, injury prevention, and rehabilitation should an injury occur.

What about for the rest of us who have given up on our Olympic weight-lifting and 100-meter sprint aspirations?

Beginning at about age 30, we lose about 10% of our muscle mass per decade, which can be reduced by about half with regular resistance exercise. Recent research shows that creatine supplementation helps slow the loss, especially when it is combined with weight lifting. And minimizing muscle loss in aging adults is extremely important for longevity. For one thing, strong muscles improve balance and preserve bone health. Together that minimizes the risk of fragility fractures, which can be lethal.

Studies on tissues other than muscle are less conclusive. Creatine may also aid brain function, especially under conditions of stress, such as sleep deprivation, as well as for cognitively impaired individuals. These benefits seem to be most pronounced in older adults.

What about side effects from creatine supplementation? Water retention in the muscles may cause weight gain. Some people note mild digestive symptoms, which are usually transient. Reports of associated muscle cramping rattle around on social media, but a compilation of 685 clinical trials that included 26,000 people found no significant increase in cramping related to creatine supplementation.

The supplements come in various forms. Creatine monohydrate is the most studied and affordable form. Other forms are touted to hasten absorption, improve digestibility, and reduce bloating, but they are less studied. The monohydrate form is the gold standard, and because it is derived entirely from non-animal sources, it is suitable for vegans and vegetarians. Mixed in water, the crystal has a faintly bitter taste. Mixed in breakfast cereal or a smoothie, it disappears.

Back to Michel Chevreul, who discovered creatine. He had a stellar career as a scientist, and his work with animal fats revolutionized soap and candle making. Also, he was the first to recognize that patients with diabetes excrete sugar in their urine.

Perhaps most remarkably, Chevreul wrote extensively on the perception of color, noting that when two colors are juxtaposed, each appear to shift in hue and darkness to their complementary color (halfway around the color wheel). This may sound trite, but it has proved to be a comprehensive theory for all the visual arts and underpins design principles for nearly every decorative art and especially Impressionist paintings. Van Gogh wrote to his brother, “If the complementary colors are taken at equal value, that is to say, at the same degree of brightness and light, their juxtaposition will raise both the one and the other to an intensity so violent that human eyes will scarcely be able to bear to look at it.” Georges Seurat and Paul Signac in particular took advantage of this phenomenon when juxtaposing tiny specks of complementary colors. 

In later life Chevreul began studying the effects of aging, a topic he knew something about because he lived to be 102. We cannot attribute his longevity to creatine supplementation, however, because the concentration of ingested creatine in muscle was not discovered until 1912.

Chevreul is among the 72 French engineers, mathematicians and scientists whose names are engraved on the Eiffel Tower. That’s lot to think about while pumping iron with creatine aiding your prowess.   

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Book Report

Ligaments launched on May 5 and became, at least momentarily, the Amazon #1 Best Seller in Musculoskeletal Diseases. It joins Bones and Muscle to form The Musculoskeletal Trilogy. Enjoy all three.

The Book Soup store at the Bradley International Terminal at Los Angeles International Airport recently hosted a signing event for Walking the Line, Discoveries Along the Los Angeles City Limits. With the upcoming Super Bowl (2027), and Olympics (2028) in Los Angeles, more visitors and residents will likely be interested. Avoid the rush, buy now.

Launching May 5 after three years in the making, Ligaments joins Dr. Meals’ musculoskeletal series for general readers.

Learn about these critical binders. Come to appreciate these unsung, essential elements of our musculoskeletal system.

Order now and receive Ligaments on launch date, May 5, 2026. (Pre-launch sales count toward day-of-launch numbers and contribute to “best seller” status.)

Praise for Ligaments:

“As only Dr. Roy Meals can do, he takes what might appear to be a tedious read and makes it both entertaining and broadly accessible.” Stacy Hite, Certified Hand Therapist

“You do not need to have majored in biology or be an orthopedic surgeon to enjoy this book.” Marc Safran, MD

Last month’s post regarding the shape of handles on baseball bats contributing to a particular type of wrist bone fractures drew comments from several readers. Here is an update.

Roger Maris broke Babe Ruth’s longstanding record for the most home runs in a season (61) in 1961. Fans of the Bambino objected, however, because the season in 1961 was longer than in Ruth’s day, so Maris had more opportunities to swing for the fences than did Ruth. Thus Maris’s record is marked with an asterisk. Over the next season, Maris developed pain in his hand, was determined to have a hook of hamate fracture, and had the fracture fragment removed. His batting prowess never returned to its pre-fracture level.

Recognizing that the traditional knob on the baseball bat’s handle is a cause of hamate hook fractures, innovators have come up with alternatives, which do not subject the hamate hook to undue pressure. One sports a gentle taper. The other is shaped like an axe handle. Both are legal and favored by some sluggers. Time will tell whether a redesign of the traditional knob becomes the norm.

Opening day for another season of baseball is just weeks away, yet several Major Leaguers have already been sidelined by a unique musculoskeletal injury. These are not the elbow ligament tears that plague fire balling pitchers (see post from July 23, 2025). Rather they are fractures of a tiny bone in the hand that steal power from sluggers swinging for the outfield bleachers. So far this spring, Corbin Carroll (Arizona Diamondbacks), Francisco Lindor (NY Mets), and Jackson Holliday (Baltimore Orioles) have been sidelined with hook of hamate fractures.

Here is a little anatomical background. To aid recall, medical students have mnemonics for lots of lists, including the eight wrist bones, which link the hand to the forearm. One of the cleaner mnemonics is “She Love To Please The Tall Campus Hero,” which stands in for Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, and Hamate. Hamus in Latin means hook, and the hamate has a “peninsula” that juts into the palm similar to the way that Cape Cod hooks into the Atlantic Ocean.

In the hand, several key ligaments and muscles attach to the hook’s tip. An important nerve and artery pass along one side, while the tendons that close the fingers (and grip baseball bats) fit snuggly on the other.

The good news is that the hook of the hamate is well protected by fat and thick skin in the palm and further by an athletic glove. The bad news is that it is fragile and subject to injury from direct blows, either singular or, perhaps more likely, cumulative. These injuries are notoriously sustained from baseball bats and also on golf clubs when the golfer’s swing is suddenly halted by a tree root. The hook, which is just a little larger than a smashed raisin, snaps off at its base. Pain and weakened grip ensue. The fracture rarely heals without surgery, and although attempts have been made to stabilize the fracture with a tiny screw, the standard treatment is to remove the hook. Batters are out for at least eight weeks and may never fully recover their pre-injury power.

Why the current epidemic? It stems from the way a power hitter holds the bat. Ty Cobb, among others, sometimes held the bat with a gap between his hands, which gave him the ability to direct the ball as he wished. Subsequently, batters may choke up on the bat to provide the same sense of control. By contrast, power hitters, in quest of increased bat speed, hold the bat with their little finger wrapped around the knob, or sadly for the hamate, with their little finger entirely off the bat. Now the hamate’s hook is directly under the knob and subject to its withering force.  “Hooked on baseball” takes on a new meaning.

Play ball! (And Go Dodgers!)

Tommy John was an extremely successful Major League pitcher whose career spanned from 1963 to 1989. He was a four-time MLB All Star; and among baseball’s all-time leaders, he is 8^th in games started and 26^th in both wins and shutouts.

Yet after his stats and awards are eclipsed and forgotten, his name will live on because of what happened to his pitching elbow and the treatment he received. It changed the entire game. To my knowledge, Tommy John is the only patient to have a surgical procedure named after him—a form of immortality, I suppose, at least in the baseball world. (Another baseball great, Lou Gehrig, famously developed a deadly disease, which carries his name.)  

About 11 years into John’s Major League career, John ripped his elbow’s supporting (collateral) ligament on the side closest to his trunk. This is the ”ulnar side” in ortho speak. He said that it felt like his throwing arm was flying out over second base as the rest of his body continued its momentum toward the plate.

After a month of rest and rehab, he still couldn’t pitch effectively and so underwent an entirely untested ulnar collateral ligament reconstruction. His surgeon gave him a one-in-a-hundred chance that he would ever pitch again. Those were terrible odds, but the only alternative was to quit baseball.

His surgeon took a tendon from John’s opposite forearm, the one that 15% of people are naturally missing. The surgeon drilled bone holes on both sides of John’s elbow and laced the graft in figure-of-eight fashion to substitute for the failed ligament. John rehabbed for over a year and then returned to the Dodger’s starting lineup and pitched multiple shutouts and 20-game winning seasons over the rest of his career.

Aware of the success of John’s surgery, pitchers started gripping the ball tighter to make it spin faster and throwing harder over more innings with fewer rest days. They knew that if they tore their elbow ligament, they could have the “Tommy John procedure.” For MLB pitchers active in 2023, over a third of them had received this procedure at some time in their career. Some experts speculate that the recently instituted pitch clock, designed to speed up a baseball game, allows less recovery between pitches and contributes to the problem. If so, we are going to see more elbow injuries.

These are not sudden injuries to strong, healthy ligaments like what can happen to ones in fingers and ankles. Rather they are wear-and-tear issues that finally surface with a pop, like ACL tears. And they are not restricted solely to the pros.

Little Leaguers and high school pitchers are playing year-round; and naturally they emulate the Major Leaguers by trying to put more spin and more heat on their throws. For training, weighted baseballs ranging up to 70 ounces (half the weight of a woman’s shot put) are readily available on the internet, whereas a regulation baseball weights about five ounces. Additionally, dads may be behind home plate with radar guns hoping that a future Major League contract will put the whole family on easy street. Finally, the progressively overwhelmed ligament snaps. On examination, the joint may not gap open perceptibly when moderately stressed by an examiner, but it apparently opens up sufficiently while accelerating a baseball to 90 or 100 miles an hour to cause pain and momentary instability.

After a year of rehab, the surgery returns most pitchers to the mound, but some hurlers reinjure their elbow and require a second operation. There are even several who have had three reconstructions. At some point, they will run out of donor tendons to use for graft material. In anticipation of such a shortage, some surgeons are now reinforcing the reconstructions with strong, nonabsorbable suture material. As with other ligament reconstructions, doing so makes the reconstruction stronger early after surgery, but it may shield the transferred cells from performing at their best and strengthening the stabilization on their own. Time will tell.

Can you imagine that if this trend continues, a baseball rule change would be in order? “Any pitch over 88 MPH is called a ball whether or not it is in the strike zone.” It could be called the Tommy John rule.

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My previous two blog posts (Part 1, Part 2) describe vexatious tears of the anterior cruciate ligaments in athletes, but humans are not alone in sustaining injuries to this critical knee ligament.

The knees of dogs, horses, cattle, and other quadrupeds are called stifles. To add to terminology confusion, our ACL is their cranial cruciate ligament. Regardless of the name, the CCL can tear in quadrupeds just as the ACL can in bipedal humans. We don’t think about cattle running and jumping much, but bulls risk the integrity of their CCLs when servicing cows, and cows in heat risk theirs the same way when riding other cattle. A bovine slipping sideways while standing on its hind legs immensely stresses its stifle, which can cause the CCL to tear. (Gary Larson’s cattle and deer are always standing up. No telling how many of them have CCL injuries.)  

A CCL tear is the most common cause of lameness in dogs and, left unattended, results in the joint not tracking properly, thereby grinding the cartilage off the bone surfaces and leading to osteoarthritis. Large breeds are particularly susceptible, as are overweight and older dogs of any size. In younger ones, an acute injury from suddenly changing direction or jumping down from an elevation can be causative, which puts agility and disc competitors at particular risk.

For older canines, CCL tears more often result from accumulated degeneration. Dogs of any age are susceptible to the “weekend warrior syndrome,” where their muscles and ligaments become deconditioned while their owners are working and then overstressed when their owners finally have time to play.

A tear causes the dog to avoid weight bearing on that leg. Nonoperative management depends on the owner’s preference and the pet’s age, activity level, and general health.

In general, dogs undergoing surgical correction and followed by weight loss if necessary, nonsteroidal anti-inflammatory medications, and a specific rehabilitation protocol do better. Compared to humans, however, dogs are disinclined to use crutches or perform hamstring and core strengthening exercises, so the surgery must provide a limb that is immediately stable for weight bearing. Hence, there are work arounds to substitute for the function of the CCL rather than replacing it.

Barclay Slocum, a veterinarian in Oregon, developed the tibial plateau leveling osteotomy (osteo = bone, otomy = cut). The TPLO rotates the tibia’s joint surface so that it is nearly perpendicular to the bone’s shaft. This shift prevents the femur from sliding forward on the tibia, which provides the same function as an intact CCL. Slocum fixed the cut in the bone securely with a steel plate and screws.

This allowed the dog to begin weight bearing immediately, which minimized deconditioning of all its muscles and ligaments. When Slocum saw that his technically demanding procedure was successful, he did something unusual in veterinary and medical practice. He patented the procedure, and his reports at meetings and in journal publications were short on technical details. Rather he taught the procedure out of his veterinary practice and required signed contracts from his learners that they would not teach the surgical details to others. This approach did not sit well with many veterinarians, but Slocum had a point. Whereas he was achieving excellent results, inexperienced and headstrong surgeons might struggle with the operation, not attend to details, have unsatisfactory outcomes, and give the TPLO a bad name.

An alternative procedure to the TPLO is the tibial tubercle advancement procedure. If you feel your kneecap and begin sliding your fingers toward your ankle, you first encounter the tough, springy patellar ligament and then an inch farther on the hard prominence where it attaches. That bump on the shin bone is your tibial tuberosity, and the TTA moves it forward, which changes the quadriceps’ direction of pull and prevents the tibia from sliding forward on the femur, even in face of a deficient CCL. (The three Swiss orthopedic veterinarians who developed the procedure may have done so in response to Slocum’s closely held TPLO.)

 The TTA moves the tibial tubercle away from the tibia except at the bottom edge, where the tubercle is hinged forward and a titanium wedge and fixation hardware secure its new position. As with the TPLO, the TTA allows for some early, limited weight bearing.

Neither the TPLO nor the TTA has distinct outcome advantages over the other, and the choice of procedure may depend on the veterinarian’s personal experience. Both procedures benefit from a graded post-operative rehabilitation program, which can include underwater walking on a treadmill. There are some endearing videoclips on YouTube of contented pooches striding along chest deep in a tub of water. Who supervises such therapy? Either a vet, nurse, or technician who is certified in canine rehabilitation.

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