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Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review
Open accessAbstract
The rectus abdominis muscles are interrupted by tendinous inscriptions, which typically appear as fibrous bands crossing the muscle. The current literature on tendinous inscriptions is scarce; hence, this review will provide a detailed overview of their anatomical description, including their variation, embryology, comparative anatomy, and clinical application. Understanding the anatomy and function of the tendinous inscription assists in providing clinical relevance and in guiding reconstructive surgeons in their surgical planning and design.
Overview
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TL;DR
This comprehensive review synthesizes anatomical, embryological, comparative, and clinical literature on tendinous inscriptions of the rectus abdominis, emphasizing their variable number, shape, thickness, and vascularity. It highlights surgical relevance for TRAM flap planning and other reconstructive procedures, while noting scarce and uncertain evidence on their development.
Key findings
- Anson and McVay examined 162 rectus abdominis muscles in 81 cadaveric specimens: 1.2% (2/162) had one inscription, 5.9% (9/162) two, 58.0% (94/162) three, 35.2% (57/162) four, and 82% of specimens had an equal number bilaterally. The review also states the muscle is usually divided by three to five irregular fibrous bands and typically has three to four paired tendinous inscriptions.
- Among 530 inscriptions, 67% (356/530) extended completely from lateral to medial muscle borders, 24% (128/530) did not extend across more than half the muscle width, and 9% (46/530) were fragments less than half the width. Milloy et al. classified 484 complete or almost complete inscriptions: 109 (22.5%) straight, 57 (12%) biphasic with apices pointing caudally, 186 (38%) biphasic with apices pointing cephalad, and 132 (27.5%) multiphasic.
- Broyles et al. assessed 168 tendinous inscriptions in 32 fresh human cadavers; 18% (30/168) showed full thickness during their anterior–posterior course without intervening neurovascular structures. Among nine hemiabdominal specimens with 55 inscriptions, 42% (23/55) demonstrated at least one full-thickness tendinous inscription.
- Whetzel and Huang dissected 14 cadavers and found the arterial supply arises from transverse arcades from the superior or inferior epigastric arteries, with the greatest number of perforators within the tendinous inscriptions; the periumbilical inferior tendinous inscription region had the highest density (1.47 per sq cm), while the superior periumbilical muscular segment had the highest concentration (0.123 per sq cm). Embryologically, the rectus abdominis lacks tendinous inscriptions until the 17th week of gestation, with inscriptions appearing between the late 17th and 20th weeks; Rizk and Adieb studied 60 rat embryos and 10 postnatal rat specimens and concluded tendinous intersections were only observed postnatally and attached exclusively to the ventral, not dorsal, rectus sheath.
Methods
- Design: comprehensive narrative review of the literature on tendinous inscriptions of the rectus abdominis.
- Data: existing anatomical, embryological, comparative anatomy, and clinical studies, including cadaveric samples such as 81 cadavers/162 muscles, 32 fresh cadavers, 14 cadavers, and 46 cadavers, plus animal embryological work in 60 rat embryos and 10 postnatal rats.
- Analysis: narrative synthesis of anatomical description, variation, embryology, comparative anatomy, and clinical applications; no systematic search strategy or meta-analysis is described.
Limitations
- Stated in the paper: the current literature on tendinous inscriptions is scarce, and the embryological origins of tendinous inscriptions are uncertain.
- Evident from the text: as a narrative review, it does not report a systematic search strategy, inclusion/exclusion criteria, or quality appraisal, and it synthesizes heterogeneous cadaveric, animal, and clinical studies without presenting primary data.
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In the paper
“The tendinous inscriptions may divide the RA into three or four muscular segments: at the opposite free end of the xiphoid process, umbilicus, midway between these two structures, and sporadically below the umbilicus [1,3].”
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
What the sources say
- Not checked yetcites [1] Defining the anatomy of the tendinous intersections of the rectus abdominis muscle and their clinical implications in functional muscle neurotization Ann Plas Surg Broyles JM Schuenke MD Patel SR Vail CM Broyles HV Dellon AL 1 4 0 2017 https://www.ncbi.nlm.nih.gov/pubmed/28671887 28671887
- Not checked yetcites [3] The tendinous intersections of rectus abdominis muscle J MGIMS Meenakshi S Manjunath KY 34 39 13 2008 http://dro.dur.ac.uk/9507/1/9507.pdf?DDD45+zspp51+cqjd36
hedgedstates a possible cause- Asserted: passes — The authors put it forward as true.
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In the paper
“24% (128/530) did not completely extend across more than half the width of the muscle”
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
What the sources say
- Not checked yetcites [2] Abdominal Wall. In Surgical Anatomy Anson BJ McVay CB Philadelphia WB Saunders Co 1 1971
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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In the paper
“The rectus abdominis muscles are interrupted by tendinous inscriptions, which typically appear as fibrous bands crossing the muscle.”
- Also stated in: § Review · plain
“The RA is divided, in part, by tendinous inscriptions that are usually three to five irregular fibrous bands (Figures 1-2) that cross the RA and adhere mainly to the anterior surface of the sheath [2].”
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Abstract
What the sources say
- Not checked yetcites [2] Abdominal Wall. In Surgical Anatomy Anson BJ McVay CB Philadelphia WB Saunders Co 1 1971
A check is scheduled.
plain- Asserted: passes — The authors put it forward as true.
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- Also stated in: § Review · plain
In the paper
“Anson and McVay [2] found that out of the 530 inscriptions studied, only 67% (356/530) completely extended without interruption from the lateral to the medial muscle borders”
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
What the sources say
- Not checked yetcites [2] Abdominal Wall. In Surgical Anatomy Anson BJ McVay CB Philadelphia WB Saunders Co 1 1971
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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None of the sources cited for this claim have been checked yet.
In the paper
“The tendinous inscriptions limit fluid collection beneath the anterior rectus sheath, prevent muscle rupture, and aid in the biomechanics of the RA [1-2].”
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
What the sources say
- Not checked yetcites [1] Defining the anatomy of the tendinous intersections of the rectus abdominis muscle and their clinical implications in functional muscle neurotization Ann Plas Surg Broyles JM Schuenke MD Patel SR Vail CM Broyles HV Dellon AL 1 4 0 2017 https://www.ncbi.nlm.nih.gov/pubmed/28671887 28671887
- Not checked yetcites [2] Abdominal Wall. In Surgical Anatomy Anson BJ McVay CB Philadelphia WB Saunders Co 1 1971
plainstates a cause- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
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Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
“5.9% (9/162) two inscriptions”
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
Reported 5.9 · recomputed 5.555556
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
“which are only present on the anterior surface of the RA and fuse with the anterior layer of the rectus sheath.”
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
“18% (30/168) of these inscriptions showed full thickness during their anterior–posterior course”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
“the absence of the tendinous inscriptions as reported in a case by Ikiz et al. [13] may contribute to resisting abdominal wall herniation”
§ Tendinous Inscriptions of the Rectus Abdominis: A Comprehensive Review > Review
“the absence of these inscriptions may weaken the anterior abdominal wall.”
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Metadata
- Authors
- Rai, R., Azih, L. C., Iwanaga, J., Loukas, M., Mortazavi, M., Oskouian, R. J., & Tubbs, R. S.
- Affiliations
- St. George's University (GD)
- Corresponding author
- Iwanaga, Joe
- Venue
- Cureus
- Published
- 2018-08-04
- Volume
- 10
- Issue
- 8
- Pages
- e3100-e3100
- ISSN
- 2168-8184 (ISSN-L)
- PMC
- PMC6173272
- OpenAlex
- W2886318833
- Cited by
- 12
- References
- 29
- Citations by year
- 2025: 2 · 2024: 1 · 2023: 1 · 2022: 3 · 2021: 3 · 2020: 2
- FWCI
- 3.45
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- cc-by
- Locations
- Cureus (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed (publishedVersion)
- PubMed Central (publishedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Anatomy › Classical Anatomy and Histology
- Health Sciences › Medicine › Surgery › Reconstructive Surgery and Microvascular Techniques
- Health Sciences › Medicine › Surgery › Hernia repair and management
- Keywords
- rectus abdominis, abdominal wall anatomy, anatomical variation, embryology, comparative anatomy, reconstructive surgery, surgical planning
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