Narrative Review

Fascial Disorders: Implications for Treatment

Q16

Antonio Stecco, Robert Stern, Ilaria Fantoni, Raffaele De Caro, Carla Stecco

Q1

Abstract

In the past 15 years, multiple articles have appeared that target fascia as an important component of treatment in the field of

physical medicine and rehabilitation. To better understand the possible actions of fascial treatments, there is a need to clarify the
definition of fascia and how it interacts with various other structures: muscles, nerves, vessels, organs. Fascia is a tissue that
occurs throughout the body. However, different kinds of fascia exist. In this narrative review, we demonstrate that symptoms
related to dysfunction of the lymphatic system, superficial vein system, and thermoregulation are more related

Q3

to dysfunction

involving superficial fascia. Dysfunction involving alterations in mechanical coordination, proprioception, balance, myofascial
pain, and cramps are more related to deep fascia and the epimysium. Superficial fascia is obviously more superficial than the
other types and contains more elastic tissue. Consequently, effective treatment can probably be achieved with light massage or
with treatment modalities that use large surfaces that spread the friction in the first layers of the subcutis. The deep fasciae and
the epymisium require treatment that generates enough pressure to reach the surface of muscles. For this reason, the use of small
surface tools and manual deep friction with the knuckles or elbows are indicated. Due to different anatomical locations and to the
qualities of the fascial tissue, it is important to recognize that different modalities of approach have to be taken into consid-
eration when considering treatment options.

Introduction

In the past 15 years, multiple articles have appeared

that target fascia as an important component of treat-
ment in the field of physical medicine and rehabilitation

[1,2]

. The current research was performed on PubMed

databases using keywords that contain the word
“fascia” related to various noninvasive treatments. The
research included articles published between 2000 and
2015 (

Table 1

). A total of 79 articles were surveyed.

These studies varied immensely in quality. Moreover,
there were no clear indications for relating symptoms to
specific fascial treatment modalities. This is a very
important issue that demands clarification, for the sake
of

the

clinical

specialty,

for

patients,

and

for

practitioners.

The purpose of this narrative review is to clarify the

physiology of fascia and its disorders to better correlate
fascial symptoms with specific therapeutic approaches.
The review includes articles, found in the PubMed da-
tabases in the last decade, with a clear focus in fascial
anatomy and pathology. This review will facilitate dis-
cussions between clinicians and also between clinicians

and the individuals who perform research in fascial
treatments.

Fascia is a tissue that occurs throughout the body.

However, different kinds of fasciae exist (

Table 2

). In

any general classification system, it is important to
recognize a superficial fascia, a deep (or muscular)
fascia, and a visceral fascia (

Figure 1

). Numerous au-

thors

[3-5]

recognize, in addition, the existence of the

epimysium and perimysium within deep fasciae. Each
category of fascia has specific anatomical and histo-
logical features that interact with the aforementioned
structures in a very precise manner. These must be
separated from each other and compared.

Literature Search Strategy

The current research was performed by A.S. on arti-

cles available only in PubMed databases using keywords
that contain the word “fascia.” Key words are listed in

Table 1

. Articles involved various noninvasive treat-

ments with a level of evidence of II-3 or above. The
research included articles published between 2000 and
2015 (

Table 1

). A total of 79 articles were surveyed

Q4

.

PM R XXX (2015) 1-8

www.pmrjournal.org

REV 5.2.0 DTD
PMRJ1516_proof
1 July 2015
7:41 pm
ce

1934-1482/$ - see front matter

ª 2015 by the American Academy of Physical Medicine and Rehabilitation

http://dx.doi.org/10.1016/j.pmrj.2015.06.006

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

152

153

154

155

156

157

158

159

160

Fascial Anatomy

Superficial Fascia

Q5

According to the Italian and German schools

Q6

, the

“superficial fascia” is a fibrous layer that divides the
subcutis into a superficial and deep, loosely organized
adipose-rich layer. It is formed by loosely packed inter-
woven collagen fibers admixed with abundant elastic
fibers. Superficial fascia is present throughout the body
and, according to Abu-Hijleh et al

[6]

, has arrangements

and thickness that vary according to the region of the
body, to the body surface, and also to differences that
exist between genders. It is thicker in the lower than in
the upper extremities, on the posterior than on the
anterior aspect of the body, and in females compared
with males. Macroscopically, the superficial fascia ap-
pears as a well-defined membrane and can be dissected
with scalpels. Microscopically, its structure is better
described as multi-lamellar, or like a tightly packed
honeycomb. The superficial fascia is tightly connected
with superficial veins and with lymphatic vessels. Inside
the superficial fascia, the subcutaneous plexus is present,
which functions in thermoregulation.

Deep Fascia

The term “deep fascia” refers to all of the well-

organized, dense, fibrous layers that interpenetrate
and surround muscles, bones, nerves and blood vessels,
binding all of these structures together into a firm,
compact, continuous mass. Over bones it is termed the
periosteum; around tendons it forms the paratendon;
and around vessels and nerves it forms the neuro-
vascular sheath. Around joints it strengthens the
capsules and ligaments. So, we can consider the para-
tendon, the neurovascular sheath, and the periosteum
as particular specializations of deep fascia, not only
because they are in continuity with deep fascia but also
because they have the same histological features. It is
possible to distinguish 2 major types of muscular fascia,
according to their thickness and to their relationships
with underlying muscles: the aponeurotic fasciae and
the epimysial fasciae. The aponeurotic fasciae contain
collagen fiber bundles that are aligned all along the
main axis of the limbs. Consequently, in both longitu-
dinal and oblique directions, the deep fasciae function
like a tendon, allowing force transmission along the
limbs. Another important characteristic of the aponeu-
rotic fascia is its ability to adapt to volume variations of
the underlying muscles during contraction. In the
transverse direction, collagen fiber bundles are less
compact and, due to the presence of loose connective
tissue, are easily separated from each other. This
increased motion of the collagen fiber bundles allows
the aponeurotic fasciae to adapt to the volume varia-
tions of the underlying muscles, particularly since they
contain so few elastic fibers.

It is apparent that the adaptability of aponeurotic

fascia is based on its unique relationship with loose
connective tissue. Several studies demonstrate that the
aponeurotic fasciae are richly innervated (mean volume
fraction, 1.2%). Abundant free and encapsulated nerve
endings (including Ruffini and Pacinian corpuscles) have
been found in the thoracolumbar fascia, the bicipital
aponeurosis, and the various retinacula

[7-12]

. Nerve

fibers, particularly numerous around blood vessels, are

Table 1
Key words used and numbers of PubMed articles surveyed

Key Words

Articles (n)

Fascia treatment

2

Fascial treatment

2

Fascia therapy

7

Fascial therapy

2

Fascia technique

0

Fascial technique

2

Fascia method

0

Fascial method

2

Fascia manipulation

2

Fascial manipulation

3

Fascia relase

0

Fascial release

4

Myofascial therapy

18

Myofascial treatment

16

Myofascial release

19

Total

79

Table 2
Description of different fascia types

Fascia Type

Anatomy

Neural Properties

Depth

Load Transmission

Treatment Profile

Superficial

Loosely packed, interwoven

collagen fibers admixed
with abundant elastic fibers

Pacini Rufini corpuscle

and free ending
nerves

From a few millimeters

below the skin to the
middle of the
hypodermal

Low effect

Light massage with a

large surface

Deep

Well-organized, dense,

fibrous layers

Pacini Rufini corpuscle

and free ending
nerves

Inferior to the

hypodermal over the
epimysium

High effect

Deep manipulation

with a small surface
for a limited amount
of gliding

Epimysial

Fibrous laminae composed of

type I and III collagen fibers
and elastic fibers

Relation with muscle

spindles

Over the muscles

High effect in

combination with
the adherent
muscle

Deep manipulation

with a small surface
for a limit amount of
gliding

2

Fascial Disorders: Implications for Treatment

REV 5.2.0 DTD
PMRJ1516_proof
1 July 2015
7:41 pm
ce

161

162

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181

182

183

184

185

186

187

188

189

190

191

192

193

194

195

196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

219

220

221

222

223

224

225

226

227

228

229

230

231

232

233

234

235

236

237

238

239

240

241

242

243

244

245

246

247

248

249

250

251

252

253

254

255

256

257

258

259

260

261

262

263

264

265

266

267

268

269

270

271

272

273

274

275

276

277

278

279

280

281

282

283

284

285

286

287

288

289

290

291

292

293

294

295

296

297

298

299

300

301

302

303

304

305

306

307

308

309

310

311

312

313

314

315

316

317

318

319

320

distributed throughout the fibrous components of their
respective fascia. The capsules of the corpuscles and
free nerve endings (mechanoreceptors) are closely
connected to the surrounding collagen fibers and fibrous
stroma that make up the fascia. Deising et al

[13]

find a

dense neuronal innervation with nonpeptidergic nerve
fiber endings and encapsulated mechano-receptors in
muscle fascia. Stecco et al

[12]

have also demonstrated

the presence of autonomic nerve fibers in deep fasciae.
Tesarz et al

[14]

confirmed the dense sensory innerva-

tion of the thoracolumbar fascia. For these reason,
authors have considered the thoracolumbar fascia an
important link in nonspecified low back pain.

Epimysial Fascia

Epimysial fascia comprises fibrous laminae with a

mean thickness of 150 to 200

mm. They are composed of

type I and III collagen fibers

[15]

as well as many elastic

fibers (

w15%). In fusiform muscles (ie, biceps brachii),

the collagen fibers have an angle of incidence of 55

with

respect to the path of the muscle fibers at rest

[16]

. In

pennate muscles (ie, rectus femoris) the epimysial fascia

mainly reflect the progression of muscular fibers, forming
a dense lamina that continues into the tendon of the
muscle. One of the most important features of the epi-
mysial fasciae is their tight adherence to underlying
muscles via multiple fibrous septa that originate from
their inner aspect and penetrate the muscle. For this
reason, it is impossible to separate the functions and
features of the epimysial fascia and underlying muscle.
Various authors

[17-19]

have demonstrated how 30%-40%

of the force generated by these muscle is transmitted not
along the tendon but, rather, by the connective tissue
surrounding the muscle.

The presence of a constant basal tone of these muscle

fibers maintains the epimysial fasciae in a state of
permanent more or less increased tension. Many muscle
fibers do not necessarily extend from origin to insertion
(non-spanning muscles) but have tapered ends in the
middle of the muscle belly and end within the muscle
belly. These muscles can transmit force between adja-
cent muscle fibers only via their common perimysium,
emphasizing the concept that force transmission can
occur by pathways other than through myotendinous
routes

[20]

. These extratendinous transmission forces

may also be used for stabilization of the joint. The force
expressed by a muscle depends not only on its anatomical
structure but also by the angle at which its fibers are
attached to the intramuscular connective tissue and their
relation with the epimysium and deep fasciae

[21]

.

The epimysial fasciae have free nerve endings that

are neither Pacini nor Ruffini corpuscles. The free nerve
endings are particularly numerous surrounding vessels,
but are also distributed homogeneously throughout their
fibrous components. In addition, the epimysial fasciae
make a connection with another type of nervous
receptor: the muscle spindles. Indeed, the capsule of
the muscle spindles corresponds to the perimysium,
epimysium, or fascial septae

[22,23]

.

Strasmann et al

[24]

, analyzing the septum of the

supinator muscle, affirm that a great number of muscle
spindles are inserted directly into the connective tissue
of the septum. Also, examining the evolution of the

Figure 2.

---.

Figure 3.

---.

Figure 1.

---

Q15

.

3

A. Stecco et al. / PM R XXX (2015) 1-8

REV 5.2.0 DTD
PMRJ1516_proof
1 July 2015
7:41 pm
ce

321

322

323

324

325

326

327

328

329

330

331

332

333

334

335

336

337

338

339

340

341

342

343

344

345

346

347

348

349

350

351

352

353

354

355

356

357

358

359

360

361

362

363

364

365

366

367

368

369

370

371

372

373

374

375

376

377

378

379

380

381

382

383

384

385

386

387

388

389

390

391

392

393

394

395

396

397

398

399

400

401

402

403

404

405

406

407

408

409

410

411

412

413

414

415

416

417

418

419

420

421

422

423

424

425

426

427

428

429

430

431

432

433

434

435

436

437

438

439

440

441

442

443

444

445

446

447

448

449

450

451

452

453

454

455

456

457

458

459

460

461

462

463

464

465

466

467

468

469

470

471

472

473

474

475

476

477

478

479

480

locomotor system, it becomes evident that the muscle
spindles are firmly connected with the fascia, as has
been demonstrated in the lamprey

[25]

. Muscle spindles

are sensory receptors within the belly of a muscle that
primarily detect changes in the length of this muscle.
The sensitive fibers of the muscle spindle are stimulated
by minimal stretching, the threshold corresponding to a
tension of 3 g. For this reason, the epimysial fascia plays
a fundamental role. The spindles can be shortened,
responding to the gamma stimulus only if the perimy-
sium is elastic and adaptable.

Disorders of the Superficial Fascia

Fasciae and Lymphedema

Knowing the strong relationships between lymph

vessels and superficial fascia, it can be can postulated
not only that an alteration in the superficial fascia can
cause lymphedema, but also that a patient with lym-
phedema probably has an alteration of the superficial
fascia. Any treatment that involves superficial fascia
should improve the symptoms related to lymphedema.
This hypothesis is supported by a number of studies.
According to Tassenoy et al

[26]

, in the case of lym-

phedema, the adipose tissue, inferior to the superficial
fascia, has a honeycomb appearance, as established by
magnetic resonance imaging (MRI). This corresponds to
fluid associated with the fibrosis. In particular, the skin
septa (or fibrous retinacula cutis) increase their thick-
ness, the area and perimeter of fat cells is significantly
increased (P < .05), and fluid is associated with or close
to the muscle fascia. In addition, Marotel et al

[27]

find

that with CT scans in patients with lymphedema, there
occurs, in order of frequency skin thickening, increase
in the subcutaneous tissues area, muscular fascia
thickening, fat infiltration, lines parallel and perpen-
dicular to the skin (corresponding to fibrous retinacula
cutis), and areas of edema along deep fascia.

We suggest that the disposition of the collagen and

elastic fibers inside the superficial fascia could guide
lymphatic flux in the correct direction. Indeed, Hauck
and Castenholz

[28]

demonstrate the existence of a

“low-resistance pathway” along connective tissue fibers
for the transinterstitial fluid movement, from the pil-
laries to the initial lymphatics. If the superficial fascia is
altered, the lymphatic drainage becomes compromised.

Fasciae and Venous Pathologies

The superficial fascia is strongly associated with the

superficial veins. In particular, Caggiati

[29]

shows that

“stereo-microscopy of cross-sectioned specimens dem-
onstrates two thick strands originating from the outer
adventitia of the long saphenous vein and anchoring it
to the opposite faces of the compartment.” These
strands are also easily recognized by ultrasonography

because of their hyperechogenicity. Furthermore, they
are composed of interwoven connective tissue fibers
emerging directly from the saphenous adventitia. The
evaluation of serially sectioned specimens reveals that
these strands form two continuous laminae. Such a
double-laminar ligament can also be demonstrated
using anatomic or surgical preparations, especially if
care is taken to preserve the planar arrangement of the
connective framework of the hypodermis.

Schweighofer et al

[30]

describe the same structure

for the small saphenous vein, and the dissections of
Stecco et al

[31]

confirm that all the major superficial

veins of the inferior limbs are enveloped by a splitting of
the superficial fascia along their entire length. This
strong anatomic relationship between the saphenous
veins and the superficial fascia may have an important
role both in daily clinical practice and in the patho-
physiology of varicose disease. First, the tension of the
superficial fascia strongly influences the saphenous vein
caliber and consequently modulates the blood flow
within it. Second, the superficial fascia may prevent the
saphenous vein from excessive pathological dilatation,
acting as a kind of of mechanical shield. These anatomic
findings can also explain why greater dilation and tor-
tuosity occur in the saphenous tributaries in primary
varicosities. Finally, the superficial fascia could be
considered a major marker for the correct identification
and stripping of the saphenous vein.

Thermoregulation and Skin Tropism

All the subcutaneous arteries participate in the for-

mation of 2 subcutaneous plexi: the subpapillary
plexus, just under the papillaris dermis (top layer of the
skin), and the deep plexus, inside the superficial fascia.
The 2 plexi freely communicate. Only one-fifth of the
capillaries are necessary for skin vascularization,
whereas all of the others function in thermoregulation.
The arteries of the deep plexus present multiple artero-
venous connections. These provide shunts that control
blood flow to the skin and consequently control body
temperature. The dilation and narrowing of the sub-
cutaneous arteries determines both skin temperature
and skin color in the light-skinned races/ethnicities.
Marked skin pallor of the skin, seen in acute shock,
results from vasoconstriction in the arterial plexus of
the hypodermis. It is possible for a change in the
superficial fascia to cause a change in skin color or even
chronic ischemia of the skin. We can hypothesize that a
fibrotic superficial fascia can restrict or choke the
arteries inside it, thereby reducing skin vascularization.
If the arterio-venous shunts become deficient, an
alteration of thermoregulation may occur, resulting in
sensations of excessively hot or cold skin. According to
Distler et al

[32]

, chronic ischemia can result in fibrosis

by creating a pathological path that decreases skin
vascularization.

4

Fascial Disorders: Implications for Treatment

REV 5.2.0 DTD
PMRJ1516_proof
1 July 2015
7:41 pm
ce

481

482

483

484

485

486

487

488

489

490

491

492

493

494

495

496

497

498

499

500

501

502

503

504

505

506

507

508

509

510

511

512

513

514

515

516

517

518

519

520

521

522

523

524

525

526

527

528

529

530

531

532

533

534

535

536

537

538

539

540

541

542

543

544

545

546

547

548

549

550

551

552

553

554

555

556

557

558

559

560

561

562

563

564

565

566

567

568

569

570

571

572

573

574

575

576

577

578

579

580

581

582

583

584

585

586

587

588

589

590

591

592

593

594

595

596

597

598

599

600

601

602

603

604

605

606

607

608

609

610

611

612

613

614

615

616

617

618

619

620

621

622

623

624

625

626

627

628

629

630

631

632

633

634

635

636

637

638

639

640

According to Storkebaum and Carmeliet

[33]

, the

regulation of peripheral resistance arteries is essential
for several physiological processes, including control of
blood pressure, thermoregulation, and increase in blood
flow to the central nervous system and to the heart
under stress conditions, such as occurs in severe hyp-
oxia. For these authors, defects in control of peripheral
resistances lead to disorders such as hypertension,
orthostatic hypotension, Raynaud phenomenon, defec-
tive thermoregulation, hand-foot syndrome, migraine,
headaches, and congestive heart failure.

Disorders of the Deep Fascia

Myofascial Pain

Some recent studies have been published that address

the possible role of the deep fascia in myofascial pain.
Deising et al

[13]

injected nerve growth factor into the

fascia of the erector spinae muscles at the lumbar level
and observed a long-lasting sensitization to mechanical
pressure and to chemical stimulation. Sensitization was
confined to deeper tissues, but did not reach the skin.
This suggests that sensitization of fascial nociceptors to
mechanical and chemical stimuli may contribute to the
pathophysiology

of

chronic

musculoskeletal

pain.

Schilder et al

[34]

have also demonstrated that injections

of hypertonic saline into the thoracolumbar fascia result
in a significantly protracted time of pain intensity,
compared to injections into the subcutis or into muscle.
Also, pain intensity and pain radiation evoked by injec-
tion into fascia was significantly greater compared to
injection into muscle or the subcutis. The description of
pain after fascia injection, as reported by volunteers,
were burning, throbbing, and stinging. This suggests an
innervation by both A- and C-fiber nociceptors. For this
reason the authors support the supposition that the
thoracolumbar fascia is a prime candidate for contribu-
tion to nonspecific lower back pain.

Changes in innervation can also occur pathologically

in fascia. Sanchis-Alfonso and Rosello-Sastre

[11]

report

the ingrowth of nociceptive fibers and an immuno-
reaction to substance P in the lateral knee retinaculum
of patients with patello-femoral alignment problems.
Bednar et al

[35]

found an alteration in both the histo-

logical structure (inflammation and microcalcifications)
and the degree of innervation of the thoracolumbar
fascia in patients with chronic lumbalgia, indicating a
possible role of fascia in lumbar pain. In particular,
these authors noted a loss of nerve fibers in the thoa-
columber fascia of back pain patients.

A recent work by Langevin et al

[36]

focuses attention

on the sliding capability of fascial sublayers. These au-
thors found significant correlations in male participants
with chronic low back pain between shear strain capa-
bility of the thoracolumbar fascia and with the following
variables: perimuscular connective tissue thickness,

echogenicity, trunk flexion range of motion, and trunk
extension. This demonstrates the importance of altered
sliding of the thoracolumbar fascial layers in low back
pain.

More recently, Stecco et al

[37]

documented a corre-

lation between a decrease in range of motion and an in-
crease in neck deep fasciae thickness. In particular, a
value of 0.15 mm of the sternocleidomastoid fascia is
proposed as a cut-off value that allows the clinician to
make a diagnosis of myofascial disease in subjects with
chronic neck pain. Apparently, from this study, variations
of thickness in fascia correlate with increases in quantity
of its loose connective tissue, but not with fibrous tissue.

Alterations in Proprioception

The first to suggest a possible role of the deep fasciae

in proprioception were Viladot et al

[38]

. These authors

affirmed that because the ankle retinacula (which
represent specialization of the deep fascia) are thin and
flexible, they have a modest effect on the mechanical
stability of the joint, whereas they have a far more
important role in proprioception. Pisani

[39]

concludes

that the histological features of the retinacula are more
suggestive of a perceptive function, whereas the tendons
and ligaments are structured for a mechanical role. The
retinacula are the most highly innervated fascial tissues.
They are rich in free nerve endings, Ruffini and Pacini
corpuscles, Golgi-Mazzoni, and rare spherical clubs

[12]

.

The retinacula cannot be considered merely as passive
stabilizers but, rather, as specialized proprioceptive
organs to better perceive joint movements

[40,41]

.

Sanchis-Alfonso and Rosello-Sastre

[11]

demonstrate an

increase in free nerve endings and nerve in-growth in the
shortened compressed lateral retinaculum in patients
with patellofemoral malalignment and anterior knee
pain. Samples of lateral knee retinacula were excised at
the time of proximal realignment or isolated lateral
retinacular release. Stecco et al

[40]

demonstrate, with

MRI and static posturography, damages to ankle reti-
nacula (adherences, formation of new fibrous bundles
into the deep fasciae of the foot, interruption of the
retinacula) in patients with alterations of proprioception
and functional ankle instability after ankle sprain.
Damage to the retinacula and their embedded pro-
prioceptors result in inaccurate proprioceptive affer-
entation. This may result in poorly coordinated joint
movement and eventual inflammation and activation of
nociceptors. A treatment focused on restoring normal
fascial tension may improve the outcome of ankle sprain.

Fascia and Diabetes

Duffin et al

[42]

demonstrate that patients with type I

diabetes have a plantar fascia that is significantly
thicker compared to that of normal controls. Also, Li
et al

[43]

show that collagen cross-linking by advanced

5

A. Stecco et al. / PM R XXX (2015) 1-8

REV 5.2.0 DTD
PMRJ1516_proof
1 July 2015
7:41 pm
ce

641

642

643

644

645

646

647

648

649

650

651

652

653

654

655

656

657

658

659

660

661

662

663

664

665

666

667

668

669

670

671

672

673

674

675

676

677

678

679

680

681

682

683

684

685

686

687

688

689

690

691

692

693

694

695

696

697

698

699

700

701

702

703

704

705

706

707

708

709

710

711

712

713

714

715

716

717

718

719

720

721

722

723

724

725

726

727

728

729

730

731

732

733

734

735

736

737

738

739

740

741

742

743

744

745

746

747

748

749

750

751

752

753

754

755

756

757

758

759

760

761

762

763

764

765

766

767

768

769

770

771

772

773

774

775

776

777

778

779

780

781

782

783

784

785

786

787

788

789

790

791

792

793

794

795

796

797

798

799

800

glycation end-products alters the physical properties of
collagen structures and tissue behavior, reduces tissue
stress relaxation (P < .01), with a concomitant increase
in tissue yield stress (P < .01), and ultimately failure
stress (P ¼ .036). Such collagens are also more suscep-
tible to degradation by collagenases, and the panoply of
other matrix-metalloproteinases.

Epimisyal Fascia and Its Disorders

Fascia and Immobilization

According to studies by Ja

¨rvinen et al

[44]

, immobi-

lization results in a marked increase in the endo- and
perimysial connective tissue. The majority of the
increased endomysial collagen is deposited directly on
the sarcolemma of the muscle cells. Immobilization of
the endomysium also results in a substantial increase in
the number of perpendicularly oriented collagen fibers
that make contact with two adjacent muscle fibers.
Furthermore, immobilization clearly disturbs the normal
structure of the endomysium, making it impossible to
distinguish the various networks of fibers from one
another. In the perimysium, immobilization-induced
changes are similar. The number of longitudinally ori-
ented collagen fibers increases, the connective tissue
becomes very dense, the number of irregularly oriented
collagen fibers is markedly increased, and consequently
the different networks of collagen fibers cannot be
distinguished from each other. Even the crimp angle of
the collagen fibers decreases more than 10% in all
muscles after the immobilizatio period. It is apparent
from the above-described quantitative and qualitative
changes in the intramuscular connective tissue that they
significantly contribute to the decreased function and
diminished biomechanical properties of immobilized
skeletal muscle.

Fascia and Aging

Gao et al

[45]

demonstrate that the epimysial fascia

from old rats is much stiffer than that of young rats. This
increased stiffness cannot be attributed to variations in
the thickness of the epimysial fasciae or in the size of
the collagen fibrils. Microscopic analysis does not show
any change in the arrangement or size of the collagen
fibrils of the epimysial fasciae in older rats

[45]

. It is

probable that the key element explaining this stiffness
is the composition of the extracellular matrix with
respect to the presence of hyaluronan. It is important to
note that the space between the collagen fibers of the
epimysial fasciae is occupied by hyaluronan. This allows
the collagen fibers to slide with less friction during
movement

[46]

. Age-related increase in the stiffness of

the epimysial fasciae could play an important role in the
muscular contraction and in the reduced elasticity that
is often typical in older patients.

Fascia and Peripheral Motor Coordination

The epimysial fasciae have free nerve endings, but

lack Pacini and Ruffini corpuscles. Despite this, the
epimysial fascia play a key role in proprioception and
peripheral motor coordination due to their close rela-
tionship with muscle spindles. Indeed the muscle spin-
dles are localized in the perimysium and their capsule
connects

to

the

epimysium

and

fascial

septae

[23,47,48]

. Strasmann et al

[24]

analyzing the septum of

the supinator muscle find that many muscle spindles are
inserted directly into the connective tissue of the
septum. Von Du

¨ring and Andrei

[25]

Q7

, studying the evo-

lution of the locomotor system, discovered that muscle
spindles are strongly connected to the fascia. Due to
these connections, it is evident that tension developed
inside the deep fascia is also able to lengthen the
muscle spindles connected with it, activating them by
passive stretch. If epimysial fascia is overstretched, it is
possible that the muscle spindles connected to this
portion of the fascia could become chronically stretched
and overactivated. This implies that the associated
muscular fibers will be constantly stimulated to con-
tract. This could explain the increased amount of
acetylcholine found in myofascial pain and, in partic-
ular, in trigger points

[49,50]

. This passive stretch situ-

ation could be responsible for muscular imbalances and
recurrent cramps, and could result in incorrect move-
ment of joints. This may represent a typical case in
which there is limitation of joint range of motion and
associated joint pain. The causation is often found in
the proximal muscles that move the joint. Palpation of
the proximal muscle belly will often reveal an area of a
painful localization of dense tissue. Another problem
connected with the muscle spindles inside the epymisial
fasciae is when the epimysial fascia is too rigid, and
consequently the muscle spindle are not activated
because they are embedded in a rigid structure. This
emphasizes the fact that normal muscular function is
dependent on normal well-hydrated, functioning fascia.
If the epimysial fascia is densified, some parts of a
muscle will not function normally during movement,
causing an unbalanced movement of the joint, with
resulting uncoordinated movement and eventual joint
pain. The epimysial fasciae could be considered as a key
element in peripheral motor coordination.

Discussion

Only a better comprehension of the anatomy and

physiology of fasciae will permit us to answer common
questions such as the following: Is it the superficial or
deep fascia that generates these symptoms? What
particular fascial treatment is useful for lymphedema?
What is the best approach for changes in proprioception?

From this review, it is possible to conclude that

symptoms related to dysfunction of the lymphatic

6

Fascial Disorders: Implications for Treatment

REV 5.2.0 DTD
PMRJ1516_proof
1 July 2015
7:41 pm
ce

801

802

803

804

805

806

807

808

809

810

811

812

813

814

815

816

817

818

819

820

821

822

823

824

825

826

827

828

829

830

831

832

833

834

835

836

837

838

839

840

841

842

843

844

845

846

847

848

849

850

851

852

853

854

855

856

857

858

859

860

861

862

863

864

865

866

867

868

869

870

871

872

873

874

875

876

877

878

879

880

881

882

883

884

885

886

887

888

889

890

891

892

893

894

895

896

897

898

899

900

901

902

903

904

905

906

907

908

909

910

911

912

913

914

915

916

917

918

919

920

921

922

923

924

925

926

927

928

929

930

931

932

933

934

935

936

937

938

939

940

941

942

943

944

945

946

947

948

949

950

951

952

953

954

955

956

957

958

959

960

system, superficial vein system, and thermoregulatory
system are more related to disorders of the superficial
fascia. Dysfunction such as alteration in mechanical
coordination, proprioception, balance, myofascial pain,
and cramps are more related to the deep fascia and
epimysium (

Table 2

).

Superficial fascia is obviously more superficial than

the other types and contains more elastic tissue.
Consequently, effective treatment can probably be
achieved with treatment modalities that use a large
surface and a small amount of pressure that will reach
the first layers of the subcutis. The deep fasciae and the
epymisium require treatment that generates enough
pressure to reach the surface of muscles. For this
reason, the use of small surface tools or manual deep
friction with elbows or knuckles is preferred.

To effect changes in the physical characteristics of

deep fascia without damaging the superficial fascia and
the skin, treatment should be applied in multiple spots,
rather than gliding over a large skin surface area. Skin
and superficial fascia must be stretched within a specific
range of elongation to avoid swelling, hematomas,
petechiae, and ecchymoses. For this purpose, it is sug-
gested that the clinician test the ability of the skin to
glide in each specific region of the body, before initi-
ating treatment of the deep fascia and the epimysium.
It is contraindicated to generate any kind of edema that
may catalyze fibrosis. This may subsequently affect the
elasticity and sliding ability of the subcutis tissues [51]

Q8

.

Conclusions and Clinical Implications

Fascia (as generalized connective tissue including the

epi- and perimysium) is a plausible source of proprio-
ception and nociception. From this review, it is possible
to conclude that symptoms related to dysfunction of the
lymphatic system, superficial vein system, or thermo-
regulation are more related to disorders of the superfi-
cial fascia. Dysfunction symptoms such as alteration of
the mechanical coordination, proprioception, balance,
myofascial pain, and cramps are more related to the
deep fascia and epimysium.

Because of differences in anatomical location and

quality of the fascial tissue, it is important to recognize
that different treatment modalities are necessary.
Furthermore, a clear description of the symptoms that
will help to define the type of tissue involved

Q9

is funda-

mental to prescribing correct treatments. Careful his-
tory and meticulous clinical evaluation, such as
assessment of movement and palpation, are the first
steps toward improving the specificity of diagnosis in
patients with fascial alterations. Correct diagnoses
should facilitate more specific and more effective
therapies that may ultimately decrease costs and hasten
positive outcomes.

Manual and physical therapies soften the fascia in its

various forms and at varying depths of tissue. These

must be applied in relation to the types of fasciae that
are involved

Q10

.

This review is not designed to evaluate the literature

on the treatment of fascial disorders. Other studies will
be required to better understand the efficacy and
specificity of the different modalities of treatment for
specific fascial disorders.

Uncited Figures

Figures 2-3

.

References

1. Simmonds N, Miller P, Gemmell H. A theoretical framework for the

role of fascia in manual therapy. J Bodyw Mov Ther 2012;16:83-93.

2. Roman M, Chaudhry H, Bukiet B, Stecco A, Findley TW. Mathe-

matical analysis of the flow of hyaluronic acid around fascia during
manual therapy motions. J Am Osteopath Assoc 2013;113:600-610.

3. Stecco C. Functional Atlas of the Human Fascial System. 1st ed.

Churchill Livingstone; 2015.

Q11

4. De Bruin M, Smeulders MJ, Kreulen M, Huijing PA, Jaspers RT.

Intramuscular connective tissue differences in spastic and control
muscle: A mechanical and histological study. PLoS One 2014;9:
e101038.

5. Schleip R, Naylor IL, Ursu D, et al. Passive muscle stiffness may be

influenced by active contractility of intramuscular connective
tissue. Med Hypotheses 2006;66:66-71.

6. Abu-Hijleh MF, Roshier AL, Al-Shboul Q, Dharap AS, Harris PF. The

membranous layer of superficial fascia: Evidence for its wide-
spread distribution in the body. Surg Radiol Anat 2006;28:606-619.

7. Stilwell DL Jr. Regional variations in the innervation of deep

fasciae and aponeuroses. Anat Rec 1957;127:635-653.

8. Tanaka S, Ito T. Histochemical demonstration of adrenergic fibers

in the fascia periosteum and retinaculum. Clin Orthop Relat Res
1977;126:276-281.

9. Palmieri G, Panu R, Asole A. Macroscopic organization and sensi-

tive innervation of the tendinous intersection and the lacertus
fibrosus of the biceps brachii muscle in the ass end of a horse. Arch
Anat Histol Embryol 1986;69:73-82.

10. Yahia L, Rhalmi S, Newman N, Isler M. Sensory innervation of

human thoracolumbar fascia. An immunohistochemical study. Acta
Orthop Scand 1992;63:195-197.

11. Sanchis-Alfonso V, Rosello

´-Sastre E. Immunohistochemical analysis

for neural markers of the lateral retinaculum in patients with
isolated symptomatic patellofemoral malalignment. A neuroana-
tomic basis for anterior knee pain in the active young patient. Am
J Sports Med 2000;28:725-731.

12. Stecco C, Gagey O, Belloni A, et al. Anatomy of the deep fascia of

the upper limb. Second part: study of innervation. Morphologie
2007;91:38-43.

13. Deising S, Weinkauf B, Blunk J, Obreja O, Schmelz M, Rukwied R.

NGF-evoked sensitization of muscle fascia nociceptors in humans.
Pain 2012;153:1673-1679.

Q12

14. Tesarz J, Hoheisel U, Wiedenho

¨fer B, Mense S. Sensory innervation

of the thoracolumbar fascia in rats and humans. Neuroscience
2011;194:302-308.

15. Sakamoto Y. Histological features of endomysium, perimysium and

epimysium in rat lateral pterygoid muscle. J Morphol 1996;227:
113-119.

16. Purslow PP. Muscle fascia and force transmission [Review].

J Bodyw Mov Ther 2010;14:411-417.

17. Yucesoy CA, Koopman BH, Grootenboer HJ, Huijing PA. Finite

element modeling of aponeurotomy: Altered intramuscular myo-
fascial force transmission yields complex sarcomere length

7

A. Stecco et al. / PM R XXX (2015) 1-8

REV 5.2.0 DTD
PMRJ1516_proof
1 July 2015
7:41 pm
ce

961

962

963

964

965

966

967

968

969

970

971

972

973

974

975

976

977

978

979

980

981

982

983

984

985

986

987

988

989

990

991

992

993

994

995

996

997

998

999

1000

1001

1002

1003

1004

1005

1006

1007

1008

1009

1010

1011

1012

1013

1014

1015

1016

1017

1018

1019

1020

1021

1022

1023

1024

1025

1026

1027

1028

1029

1030

1031

1032

1033

1034

1035

1036

1037

1038

1039

1040

1041

1042

1043

1044

1045

1046

1047

1048

1049

1050

1051

1052

1053

1054

1055

1056

1057

1058

1059

1060

1061

1062

1063

1064

1065

1066

1067

1068

1069

1070

1071

1072

1073

1074

1075

1076

1077

1078

1079

1080

1081

1082

1083

1084

1085

1086

1087

1088

1089

1090

1091

1092

1093

1094

1095

1096

1097

1098

1099

1100

1101

1102

1103

1104

1105

1106

1107

1108

1109

1110

1111

1112

1113

1114

1115

1116

1117

1118

1119

1120

distributions determining acute effects. Biomech Model Mecha-
nobiol 2007;6:227-243.

18. Yucesoy CA, Koopman BH, Baan GC, Grootenboer HJ, Huijing PA.

Effects of inter- and extramuscular myofascial force transmission
on adjacent synergistic muscles: Assessment by experiments and
finite-element modeling. J Biomech 2003;36:1797-1811.

19. Brunner R, Jaspers RT, Pel JJ, Huijing PA. Acute and long-term

effects on muscle force after intramuscular aponeurotic length-
ening. Clin Orthop Relat Res 2000:264-273.

Q13

20. Huijing PA, Baan GC. Myofascial force transmission causes inter-

action between adjacent muscles and connective tissue: Effects of
blunt dissection and compartmental fasciotomy on length force
characteristics of rat extensor digitorum longus muscle. Arch
Physiol Biochem 2001;109:97-109.

21. Turrina A, Martı´nez-Gonza

´lez MA, Stecco C. The muscular force

transmission system: Role of the intramuscular connective tissue.
J Bodyw Mov Ther 2013;17:95-102.

22. Boyd-Clark LC, Briggs CA, Galea MP. Muscle spindle distribution,

morphology, and density in longus colli and multifidus muscles of
the cervical spine. Spine 2002;27:694-701.

23. Maier A. Proportions of slow myosin heavy chain-positive fibers in

muscle spindles and adjoining extrafusal fascicles, and the posi-
tioning of spindles relative to these fascicles. J Morphol 1999;242:
157-165.

24. Strasmann T, van der Wal JC, Halata Z, Drukker J. Functional

topography and ultrastructure of periarticular mechanoreceptors
in the lateral elbow region of the rat. Acta Anat 1990;138:1-14.

25. Von Du

¨ring M, Andres KH. Topography and fine structure of pro-

prioceptors in the hagfish. Myxine glutinosa. Eur J Morphol 1994;
32:248-256.

26. Tassenoy A, De Mey J, Stadnik T, et al. Histological findings

compared with magnetic resonance and ultrasonographic imaging
in irreversible postmastectomy lymphedema: A case study. Lym-
phat Res Biol 2009;7:145-151.

27. Marotel M, Cluzan R, Ghabboun S, Pascot M, Alliot F, Lasry JL.

Transaxial computer tomography of lower extremity. Lymphology
1998;31:180-185.

28. Hauck G, Castenholz A. Contribution of prelymphatic structures to

lymph drainage [article in German]. Z Lymphol 1992;16:6-9.

29. Caggiati A. The saphenous venous compartments. Surg Radiol Anat

1999;21:29-34.

30. Schweighofer G, Mu

¨hlberger D, Brenner E. The anatomy of the

small saphenous vein: Fascial and neural relations, saphenofe-
moral junction, and valves. J Vasc Surg 2010;51:982-989.

31. Stecco C, Tiengo C, Stecco A, et al. Fascia redefined: Anatomical

features and technical relevance in fascial flap surgery. Surg
Radiol Anat 2013;35:369-376.

32. Distler JH, Ju

¨ngel A, Pileckyte M, et al. Hypoxia-induced increase

in the production of extracellular matrix proteins in systemic
sclerosis. Arthritis Rheum 2007;56:4203-4215.

33. Storkebaum E, Carmeliet P. Paracrine control of vascular inner-

vation in health and disease. Acta Physiol (Oxf) 2011;203:61-86.

34. Schilder A, Hoheisel U, Magerl W, Benrath J, Klein T, Treede RD.

Sensory findings after stimulation of the thoracolumbar fascia with
hypertonic saline suggest its contribution to low back pain. Pain
2014;155:222-231.

35. Bednar DA, Orr FW, Simon GT. Observations on the pathomor-

phology of the thoracolumbar fascia in chronic mechanical back
pain. A microscopic study. Spine 1995;20:1161-1164.

36. Langevin HM, Fox JR, Koptiuch C, et al. Reduced thoracolumbar

fascia shear strain in human chronic low back pain. BMC Muscu-
loskelet Disord 2011;12:203.

37. Stecco A, Meneghini A, Stern R, Stecco C, Imamura M. Ultraso-

nography in myofascial neck pain: Randomized clinical trial for
diagnosis and follow-up. Surg Radiol Anat 2014;36:243-253.

38. Viladot A, Lorenzo JC, Salazar J, Rodrı´guez A. The subtalar joint:

Embryology and morphology. Foot Ankle 1984;5:54-66.

39. Pisani G. Trattato di Chirurgia del Piede [in Italian]. Torino, Italy:

Minerva Medica; 2004.

Q14

40. Stecco A, Stecco C, Macchi V, et al. RMI study and clinical corre-

lations of ankle retinacula damage and outcomes of ankle sprain.
Surg Radiol Anat 2011;33:881-890.

41. Stecco C, Macchi V, Porzionato A, et al. The ankle retinacula:

Morphological evidence of the proprioceptive role of the fascial
system. Cells Tissues Organs 2010;192:200-210.

42. Duffin AC, Lam A, Kidd R, Chan AK, Donaghue KC. Ultrasonography

of plantar soft tissues thickness in young people with diabetes.
Diabet Med 2002;19:1009-1013.

43. Li Y, Fessel G, Georgiadis M, Snedeker JG. Advanced glycation end-

products diminish tendon collagen fiber sliding. Matrix Biol 2013;
32:169-177.

44. Ja

¨rvinen TA, Jo

´zsa L, Kannus P, Ja

¨rvinen TL, Ja

¨rvinen M. Organi-

zation and distribution of intramuscular connective tissue in
normal and immobilized skeletal muscles. An immunohistochem-
ical, polarization and scanning electron microscopic study.
J Muscle Res Cell Motil 2002;23:245-254.

45. Gao Y, Kostrominova TY, Faulkner JA, Wineman AS. Agerelated

changes in the mechanical properties of the epimysium in skeletal
muscles of rats. J Biomech 2008;41:465-469.

46. McCombe D, Brown T, Slavin J, Morrison WA. The histochemical

structure of the deep fascia and its structural response to surgery.
J Hand Surg (Br) 2001;26:89-97.

47. Cooper S, Daniel PM. Human muscle spindles. J Physiol 1956;133:1-3.
48. Sherrington CS. Further experimental note on the correlation of

action of antagonistic muscles. Br Med J 1893;1:1218.

49. Hubbard DR,

Berkoff

GM.

Myofascial

trigger

points

show

spontaneous needle EMG activity. Spine (Phila Pa 1976) 1993;18:
1803-1807.

50. McPartland JM. Travell trigger points: Molecular and osteopathic

perspectives. J Am Osteopath Assoc 2004;104:244-249.

Disclosure

A.S. Sport Medicine Unit, Internal Medicine Department, University of Padova,
Padova, Italy. Address correspondence to: A.S.; Via Giustiniani 2, 35127 Padova,
Italy; e-mail:

[e-mail]

Disclosure: nothing to disclose

R.S. Division of Basic Biomedical Sciences, Touro College of Osteopathic Medi-
cine, New York, NY

Q2

Disclosure: nothing to disclose

I.F. Molecular Medicine Department, University of Padova, Padova, Italy
Disclosure: nothing to disclose

R.D.C. Molecular Medicine Department, University of Padova, Padova, Italy
Disclosure: nothing to disclose

C.S. Molecular Medicine Department, University of Padova, Padova, Italy
Disclosure: nothing to disclose

Submitted for publication January 6, 2015; accepted June 7, 2015.

8

Fascial Disorders: Implications for Treatment

REV 5.2.0 DTD
PMRJ1516_proof
1 July 2015
7:41 pm
ce

1121

1122

1123

1124

1125

1126

1127

1128

1129

1130

1131

1132

1133

1134

1135

1136

1137

1138

1139

1140

1141

1142

1143

1144

1145

1146

1147

1148

1149

1150

1151

1152

1153

1154

1155

1156

1157

1158

1159

1160

1161

1162

1163

1164

1165

1166

1167

1168

1169

1170

1171

1172

1173

1174

1175

1176

1177

1178

1179

1180

1181

1182

1183

1184

1185

1186

1187

1188

1189

1190

1191

1192

1193

1194

1195

1196

1197

1198

1199

1200

1201

1202

1203

1204

1205

1206

1207

1208

1209

1210

1211

1212

1213

1214

1215

1216

1217

1218

1219

1220

1221

1222

1223

1224

1225

1226

1227

1228

1229

1230

1231

1232

1233

1234

1235

1236

1237

1238

1239

1240

1241

1242

1243

1244

1245

1246

1247

1248

1249

1250

1251

1252

1253

1254

1255

1256

1257

1258

1259

1260

1261

1262

1263

1264

1265

1266

1267

1268

1269

1270

1271

1272

1273

1274

1275

1276

1277

1278

1279

1280

1281

1282

1283

1284

1285

1286

1287

1288

1289

1290