1 81
2 82
3 83
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5 85
PM R XXX (2015) 1-8
6 www.pmrjournal.org 86
7 87
8 88
Narrative Review
9 89
10 90
11 91
Fascial Disorders: Implications for Treatment
12 92
13 93
14 94
Q16
Antonio Stecco, Robert Stern, Ilaria Fantoni, Raffaele De Caro, Carla Stecco
15 95
Q1
16 96
17 97
18 98
19 99
20 100
Abstract
21 101
22 102
23 103
In the past 15 years, multiple articles have appeared that target fascia as an important component of treatment in the field of
24 104
physical medicine and rehabilitation. To better understand the possible actions of fascial treatments, there is a need to clarify the
25 105
definition of fascia and how it interacts with various other structures: muscles, nerves, vessels, organs. Fascia is a tissue that
26 106
27 occurs throughout the body. However, different kinds of fascia exist. In this narrative review, we demonstrate that symptoms 107
28 108
Q3
related to dysfunction of the lymphatic system, superficial vein system, and thermoregulation are more related to dysfunction
29 109
involving superficial fascia. Dysfunction involving alterations in mechanical coordination, proprioception, balance, myofascial
30 110
pain, and cramps are more related to deep fascia and the epimysium. Superficial fascia is obviously more superficial than the
31 111
32 112
other types and contains more elastic tissue. Consequently, effective treatment can probably be achieved with light massage or
33 113
with treatment modalities that use large surfaces that spread the friction in the first layers of the subcutis. The deep fasciae and
34 114
the epymisium require treatment that generates enough pressure to reach the surface of muscles. For this reason, the use of small
35 115
36 surface tools and manual deep friction with the knuckles or elbows are indicated. Due to different anatomical locations and to the 116
37 117
qualities of the fascial tissue, it is important to recognize that different modalities of approach have to be taken into consid-
38 118
eration when considering treatment options.
39 119
40 120
41 121
42 122
43 123
44 124
45 125
Introduction and the individuals who perform research in fascial
46 126
treatments.
47 127
48 128
In the past 15 years, multiple articles have appeared Fascia is a tissue that occurs throughout the body.
49 129
that target fascia as an important component of treat- However, different kinds of fasciae exist (Table 2). In
50 130
51 131
ment in the field of physical medicine and rehabilitation any general classification system, it is important to
52 132
[1,2]. The current research was performed on PubMed recognize a superficial fascia, a deep (or muscular)
53 133
databases using keywords that contain the word fascia, and a visceral fascia (Figure 1). Numerous au- 134
54
55 135
 fascia related to various noninvasive treatments. The thors [3-5] recognize, in addition, the existence of the
56 136
research included articles published between 2000 and epimysium and perimysium within deep fasciae. Each
57 137
58 138
2015 (Table 1). A total of 79 articles were surveyed. category of fascia has specific anatomical and histo-
59 139
These studies varied immensely in quality. Moreover, logical features that interact with the aforementioned
60 140
61 there were no clear indications for relating symptoms to structures in a very precise manner. These must be 141
62 142
specific fascial treatment modalities. This is a very separated from each other and compared.
63 143
important issue that demands clarification, for the sake
64 144
65 145
of the clinical specialty, for patients, and for Literature Search Strategy
66 146
practitioners.
67 147
68 The purpose of this narrative review is to clarify the The current research was performed by A.S. on arti- 148
69 149
physiology of fascia and its disorders to better correlate cles available only in PubMed databases using keywords
70 150
fascial symptoms with specific therapeutic approaches. that contain the word  fascia. Key words are listed in
71 151
72 152
The review includes articles, found in the PubMed da- Table 1. Articles involved various noninvasive treat-
73 153
tabases in the last decade, with a clear focus in fascial ments with a level of evidence of II-3 or above. The
74 154
75 155
anatomy and pathology. This review will facilitate dis- research included articles published between 2000 and
76
Q4156
cussions between clinicians and also between clinicians 2015 (Table 1). A total of 79 articles were surveyed.
77 157
78 158
79 159
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation
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http://dx.doi.org/10.1016/j.pmrj.2015.06.006
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2 Fascial Disorders: Implications for Treatment
161 241
Table 1
Deep Fascia
162 242
Key words used and numbers of PubMed articles surveyed
163 243
164 Key Words Articles (n)
The term  deep fascia refers to all of the well- 244
165 245
organized, dense, fibrous layers that interpenetrate
Fascia treatment 2
166 246
Fascial treatment 2 and surround muscles, bones, nerves and blood vessels,
167 247
168 Fascia therapy 7 248
binding all of these structures together into a firm,
169 249
Fascial therapy 2
compact, continuous mass. Over bones it is termed the
170 250
Fascia technique 0
171 251
periosteum; around tendons it forms the paratendon;
Fascial technique 2
172 252
and around vessels and nerves it forms the neuro-
Fascia method 0
173 253
Fascial method 2
174 vascular sheath. Around joints it strengthens the 254
175 Fascia manipulation 2 255
capsules and ligaments. So, we can consider the para-
176 256
Fascial manipulation 3
tendon, the neurovascular sheath, and the periosteum
177 257
Fascia relase 0
178 258
as particular specializations of deep fascia, not only
Fascial release 4
179 259
because they are in continuity with deep fascia but also
Myofascial therapy 18
180 260
181 Myofascial treatment 16
because they have the same histological features. It is 261
182 262
Myofascial release 19
possible to distinguish 2 major types of muscular fascia,
183 263
Total 79
according to their thickness and to their relationships
184 264
185 265
with underlying muscles: the aponeurotic fasciae and
186 266
Fascial Anatomy the epimysial fasciae. The aponeurotic fasciae contain
187 267
188 collagen fiber bundles that are aligned all along the 268
189 269
Q5
Superficial Fascia main axis of the limbs. Consequently, in both longitu-
190 270
dinal and oblique directions, the deep fasciae function
191 271
192 272
Q6
According to the Italian and German schools, the like a tendon, allowing force transmission along the
193 273
 superficial fascia is a fibrous layer that divides the limbs. Another important characteristic of the aponeu-
194 274
195 275
subcutis into a superficial and deep, loosely organized rotic fascia is its ability to adapt to volume variations of
196 276
adipose-rich layer. It is formed by loosely packed inter- the underlying muscles during contraction. In the
197 277
198 woven collagen fibers admixed with abundant elastic transverse direction, collagen fiber bundles are less 278
199 279
fibers. Superficial fascia is present throughout the body compact and, due to the presence of loose connective
200 280
and, according to Abu-Hijleh et al [6], has arrangements tissue, are easily separated from each other. This
201 281
202 282
and thickness that vary according to the region of the increased motion of the collagen fiber bundles allows
203 283
body, to the body surface, and also to differences that the aponeurotic fasciae to adapt to the volume varia-
204 284
205 exist between genders. It is thicker in the lower than in tions of the underlying muscles, particularly since they 285
206 286
the upper extremities, on the posterior than on the contain so few elastic fibers.
207 287
anterior aspect of the body, and in females compared It is apparent that the adaptability of aponeurotic
208 288
209 289
with males. Macroscopically, the superficial fascia ap- fascia is based on its unique relationship with loose
210 290
pears as a well-defined membrane and can be dissected connective tissue. Several studies demonstrate that the
211 291
212 292
with scalpels. Microscopically, its structure is better aponeurotic fasciae are richly innervated (mean volume
213 293
described as multi-lamellar, or like a tightly packed fraction, 1.2%). Abundant free and encapsulated nerve
214 294
honeycomb. The superficial fascia is tightly connected endings (including Ruffini and Pacinian corpuscles) have
215 295
216 296
with superficial veins and with lymphatic vessels. Inside been found in the thoracolumbar fascia, the bicipital
217 297
the superficial fascia, the subcutaneous plexus is present, aponeurosis, and the various retinacula [7-12]. Nerve
218 298
219 299
which functions in thermoregulation. fibers, particularly numerous around blood vessels, are
220 300
221 301
222 302
Table 2
223 303
Description of different fascia types
224 304
225 Fascia Type Anatomy Neural Properties Depth Load Transmission Treatment Profile 305
226 306
Superficial Loosely packed, interwoven Pacini Rufini corpuscle From a few millimeters Low effect Light massage with a
227 307
collagen fibers admixed and free ending below the skin to the large surface
228 308
229 with abundant elastic fibers nerves middle of the 309
230 310
hypodermal
231 311
Deep Well-organized, dense, Pacini Rufini corpuscle Inferior to the High effect Deep manipulation
232 312
fibrous layers and free ending hypodermal over the with a small surface
233 313
nerves epimysium for a limited amount
234 314
of gliding
235 315
236 316
Epimysial Fibrous laminae composed of Relation with muscle Over the muscles High effect in Deep manipulation
237 317
type I and III collagen fibers spindles combination with with a small surface
238 318
and elastic fibers the adherent for a limit amount of
239 319
muscle gliding
240 320
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A. Stecco et al. / PM R XXX (2015) 1-8 3
321 401
322 402
323 403
324 404
325 405
326 406
327 407
328 408
329 409
330 410
331 411
332 412
333 413
334 414
335 415
336 416
337 417
338 418
339 419
340 420
Figure 3. ---.
341 421
342 422
343 423
Q15
Figure 1. ---.
mainly reflect the progression of muscular fibers, forming
344 424
345 425
a dense lamina that continues into the tendon of the
346 426
distributed throughout the fibrous components of their
muscle. One of the most important features of the epi-
347 427
respective fascia. The capsules of the corpuscles and
348 428
mysial fasciae is their tight adherence to underlying
349 429
free nerve endings (mechanoreceptors) are closely
muscles via multiple fibrous septa that originate from
350 430
connected to the surrounding collagen fibers and fibrous
their inner aspect and penetrate the muscle. For this
351 431
stroma that make up the fascia. Deising et al [13] find a
352 432
reason, it is impossible to separate the functions and
353 433
dense neuronal innervation with nonpeptidergic nerve
features of the epimysial fascia and underlying muscle.
354 434
fiber endings and encapsulated mechano-receptors in
355 435
Various authors [17-19] have demonstrated how 30%-40%
356 436
muscle fascia. Stecco et al [12] have also demonstrated
of the force generated by these muscle is transmitted not
357 437
the presence of autonomic nerve fibers in deep fasciae.
358 along the tendon but, rather, by the connective tissue 438
359 Tesarz et al [14] confirmed the dense sensory innerva- 439
surrounding the muscle.
360 440
tion of the thoracolumbar fascia. For these reason,
The presence of a constant basal tone of these muscle
361 441
authors have considered the thoracolumbar fascia an
362 442
fibers maintains the epimysial fasciae in a state of
363 443
important link in nonspecified low back pain.
permanent more or less increased tension. Many muscle
364 444
365 fibers do not necessarily extend from origin to insertion 445
366 446
(non-spanning muscles) but have tapered ends in the
Epimysial Fascia
367 447
middle of the muscle belly and end within the muscle
368 448
369 449
belly. These muscles can transmit force between adja-
Epimysial fascia comprises fibrous laminae with a
370 450
cent muscle fibers only via their common perimysium,
371 mean thickness of 150 to 200 mm. They are composed of 451
372 452
emphasizing the concept that force transmission can
type I and III collagen fibers [15] as well as many elastic
373 453
occur by pathways other than through myotendinous
fibers (w15%). In fusiform muscles (ie, biceps brachii),
374 454
routes [20]. These extratendinous transmission forces
375 455
the collagen fibers have an angle of incidence of 55 with
376 456
may also be used for stabilization of the joint. The force
respect to the path of the muscle fibers at rest [16]. In
377 457
expressed by a muscle depends not only on its anatomical
378 pennate muscles (ie, rectus femoris) the epimysial fascia 458
379 459
structure but also by the angle at which its fibers are
380 460
attached to the intramuscular connective tissue and their
381 461
382 relation with the epimysium and deep fasciae [21]. 462
383 463
The epimysial fasciae have free nerve endings that
384 464
are neither Pacini nor Ruffini corpuscles. The free nerve
385 465
386 466
endings are particularly numerous surrounding vessels,
387 467
but are also distributed homogeneously throughout their
388 468
389 fibrous components. In addition, the epimysial fasciae 469
390 470
make a connection with another type of nervous
391 471
receptor: the muscle spindles. Indeed, the capsule of
392 472
393 473
the muscle spindles corresponds to the perimysium,
394 474
epimysium, or fascial septae [22,23].
395 475
396 476
Strasmann et al [24], analyzing the septum of the
397 477
supinator muscle, affirm that a great number of muscle
398 478
spindles are inserted directly into the connective tissue
399 479
400 480
Figure 2. ---. of the septum. Also, examining the evolution of the
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4 Fascial Disorders: Implications for Treatment
481 561
locomotor system, it becomes evident that the muscle because of their hyperechogenicity. Furthermore, they
482 562
spindles are firmly connected with the fascia, as has are composed of interwoven connective tissue fibers
483 563
484 been demonstrated in the lamprey [25]. Muscle spindles emerging directly from the saphenous adventitia. The 564
485 565
are sensory receptors within the belly of a muscle that evaluation of serially sectioned specimens reveals that
486 566
primarily detect changes in the length of this muscle. these strands form two continuous laminae. Such a
487 567
488 568
The sensitive fibers of the muscle spindle are stimulated double-laminar ligament can also be demonstrated
489 569
by minimal stretching, the threshold corresponding to a using anatomic or surgical preparations, especially if
490 570
491 571
tension of 3 g. For this reason, the epimysial fascia plays care is taken to preserve the planar arrangement of the
492 572
a fundamental role. The spindles can be shortened, connective framework of the hypodermis.
493 573
494 responding to the gamma stimulus only if the perimy- Schweighofer et al [30] describe the same structure 574
495 575
sium is elastic and adaptable. for the small saphenous vein, and the dissections of
496 576
Stecco et al [31] confirm that all the major superficial
497 577
498 578
Disorders of the Superficial Fascia veins of the inferior limbs are enveloped by a splitting of
499 579
the superficial fascia along their entire length. This
500 580
501 Fasciae and Lymphedema strong anatomic relationship between the saphenous 581
502 582
veins and the superficial fascia may have an important
503 583
Knowing the strong relationships between lymph role both in daily clinical practice and in the patho-
504 584
505 585
vessels and superficial fascia, it can be can postulated physiology of varicose disease. First, the tension of the
506 586
not only that an alteration in the superficial fascia can superficial fascia strongly influences the saphenous vein
507 587
508 cause lymphedema, but also that a patient with lym- caliber and consequently modulates the blood flow 588
509 589
phedema probably has an alteration of the superficial within it. Second, the superficial fascia may prevent the
510 590
fascia. Any treatment that involves superficial fascia saphenous vein from excessive pathological dilatation,
511 591
512 592
should improve the symptoms related to lymphedema. acting as a kind of of mechanical shield. These anatomic
513 593
This hypothesis is supported by a number of studies. findings can also explain why greater dilation and tor-
514 594
515 595
According to Tassenoy et al [26], in the case of lym- tuosity occur in the saphenous tributaries in primary
516 596
phedema, the adipose tissue, inferior to the superficial varicosities. Finally, the superficial fascia could be
517 597
518 fascia, has a honeycomb appearance, as established by considered a major marker for the correct identification 598
519 599
magnetic resonance imaging (MRI). This corresponds to and stripping of the saphenous vein.
520 600
fluid associated with the fibrosis. In particular, the skin
521 601
522 602
septa (or fibrous retinacula cutis) increase their thick- Thermoregulation and Skin Tropism
523 603
ness, the area and perimeter of fat cells is significantly
524 604
525 increased (P < .05), and fluid is associated with or close All the subcutaneous arteries participate in the for- 605
526 606
to the muscle fascia. In addition, Marotel et al [27] find mation of 2 subcutaneous plexi: the subpapillary
527 607
that with CT scans in patients with lymphedema, there plexus, just under the papillaris dermis (top layer of the
528 608
529 609
occurs, in order of frequency skin thickening, increase skin), and the deep plexus, inside the superficial fascia.
530 610
in the subcutaneous tissues area, muscular fascia The 2 plexi freely communicate. Only one-fifth of the
531 611
532 612
thickening, fat infiltration, lines parallel and perpen- capillaries are necessary for skin vascularization,
533 613
dicular to the skin (corresponding to fibrous retinacula whereas all of the others function in thermoregulation.
534 614
cutis), and areas of edema along deep fascia. The arteries of the deep plexus present multiple artero- 615
535
536 616
We suggest that the disposition of the collagen and venous connections. These provide shunts that control
537 617
elastic fibers inside the superficial fascia could guide blood flow to the skin and consequently control body
538 618
539
lymphatic flux in the correct direction. Indeed, Hauck temperature. The dilation and narrowing of the sub- 619
540 620
and Castenholz [28] demonstrate the existence of a cutaneous arteries determines both skin temperature
541 621
542  low-resistance pathway along connective tissue fibers and skin color in the light-skinned races/ethnicities. 622
543 623
for the transinterstitial fluid movement, from the pil- Marked skin pallor of the skin, seen in acute shock,
544 624
laries to the initial lymphatics. If the superficial fascia is results from vasoconstriction in the arterial plexus of
545 625
546 626
altered, the lymphatic drainage becomes compromised. the hypodermis. It is possible for a change in the
547 627
superficial fascia to cause a change in skin color or even
548 628
549 Fasciae and Venous Pathologies chronic ischemia of the skin. We can hypothesize that a 629
550 630
fibrotic superficial fascia can restrict or choke the
551 631
The superficial fascia is strongly associated with the arteries inside it, thereby reducing skin vascularization.
552 632
553 633
superficial veins. In particular, Caggiati [29] shows that If the arterio-venous shunts become deficient, an
554 634
 stereo-microscopy of cross-sectioned specimens dem- alteration of thermoregulation may occur, resulting in
555 635
556 636
onstrates two thick strands originating from the outer sensations of excessively hot or cold skin. According to
557 637
adventitia of the long saphenous vein and anchoring it Distler et al [32], chronic ischemia can result in fibrosis
558 638
to the opposite faces of the compartment. These by creating a pathological path that decreases skin
559 639
560 640
strands are also easily recognized by ultrasonography vascularization.
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A. Stecco et al. / PM R XXX (2015) 1-8 5
641 721
According to Storkebaum and Carmeliet [33], the echogenicity, trunk flexion range of motion, and trunk
642 722
regulation of peripheral resistance arteries is essential extension. This demonstrates the importance of altered
643 723
644 for several physiological processes, including control of sliding of the thoracolumbar fascial layers in low back 724
645 725
blood pressure, thermoregulation, and increase in blood pain.
646 726
flow to the central nervous system and to the heart More recently, Stecco et al [37] documented a corre- 727
647
648 728
under stress conditions, such as occurs in severe hyp- lation between a decrease in range of motion and an in-
649 729
oxia. For these authors, defects in control of peripheral crease in neck deep fasciae thickness. In particular, a
650 730
651 731
resistances lead to disorders such as hypertension, value of 0.15 mm of the sternocleidomastoid fascia is
652 732
orthostatic hypotension, Raynaud phenomenon, defec- proposed as a cut-off value that allows the clinician to
653 733
654 tive thermoregulation, hand-foot syndrome, migraine, make a diagnosis of myofascial disease in subjects with 734
655 735
headaches, and congestive heart failure. chronic neck pain. Apparently, from this study, variations
656 736
of thickness in fascia correlate with increases in quantity
657 737
658 738
Disorders of the Deep Fascia of its loose connective tissue, but not with fibrous tissue.
659 739
660 740
661 Myofascial Pain Alterations in Proprioception 741
662 742
663 743
Some recent studies have been published that address The first to suggest a possible role of the deep fasciae
664 744
665 745
the possible role of the deep fascia in myofascial pain. in proprioception were Viladot et al [38]. These authors
666 746
Deising et al [13] injected nerve growth factor into the affirmed that because the ankle retinacula (which
667 747
668 748
fascia of the erector spinae muscles at the lumbar level represent specialization of the deep fascia) are thin and
669 749
and observed a long-lasting sensitization to mechanical flexible, they have a modest effect on the mechanical
670 750
pressure and to chemical stimulation. Sensitization was stability of the joint, whereas they have a far more
671 751
672 752
confined to deeper tissues, but did not reach the skin. important role in proprioception. Pisani [39] concludes
673 753
This suggests that sensitization of fascial nociceptors to that the histological features of the retinacula are more
674 754
675 755
mechanical and chemical stimuli may contribute to the suggestive of a perceptive function, whereas the tendons
676 756
pathophysiology of chronic musculoskeletal pain. and ligaments are structured for a mechanical role. The
677 757
678 Schilder et al [34] have also demonstrated that injections retinacula are the most highly innervated fascial tissues. 758
679 759
of hypertonic saline into the thoracolumbar fascia result They are rich in free nerve endings, Ruffini and Pacini
680 760
in a significantly protracted time of pain intensity, corpuscles, Golgi-Mazzoni, and rare spherical clubs [12].
681 761
682 762
compared to injections into the subcutis or into muscle. The retinacula cannot be considered merely as passive
683 763
Also, pain intensity and pain radiation evoked by injec- stabilizers but, rather, as specialized proprioceptive
684 764
685 tion into fascia was significantly greater compared to organs to better perceive joint movements [40,41]. 765
686 766
injection into muscle or the subcutis. The description of Sanchis-Alfonso and Rosello-Sastre [11] demonstrate an
687 767
pain after fascia injection, as reported by volunteers, increase in free nerve endings and nerve in-growth in the
688 768
689 769
were burning, throbbing, and stinging. This suggests an shortened compressed lateral retinaculum in patients
690 770
innervation by both A- and C-fiber nociceptors. For this with patellofemoral malalignment and anterior knee
691 771
692 772
reason the authors support the supposition that the pain. Samples of lateral knee retinacula were excised at
693 773
thoracolumbar fascia is a prime candidate for contribu- the time of proximal realignment or isolated lateral
694 774
tion to nonspecific lower back pain. retinacular release. Stecco et al [40] demonstrate, with
695 775
696 776
Changes in innervation can also occur pathologically MRI and static posturography, damages to ankle reti-
697 777
in fascia. Sanchis-Alfonso and Rosello-Sastre [11] report nacula (adherences, formation of new fibrous bundles
698 778
699 779
the ingrowth of nociceptive fibers and an immuno- into the deep fasciae of the foot, interruption of the
700 780
reaction to substance P in the lateral knee retinaculum retinacula) in patients with alterations of proprioception
701 781
702 of patients with patello-femoral alignment problems. and functional ankle instability after ankle sprain. 782
703 783
Bednar et al [35] found an alteration in both the histo- Damage to the retinacula and their embedded pro-
704 784
logical structure (inflammation and microcalcifications) prioceptors result in inaccurate proprioceptive affer-
705 785
706 786
and the degree of innervation of the thoracolumbar entation. This may result in poorly coordinated joint
707 787
fascia in patients with chronic lumbalgia, indicating a movement and eventual inflammation and activation of
708 788
709 possible role of fascia in lumbar pain. In particular, nociceptors. A treatment focused on restoring normal 789
710 790
these authors noted a loss of nerve fibers in the thoa- fascial tension may improve the outcome of ankle sprain.
711 791
columber fascia of back pain patients.
712 792
713 793
A recent work by Langevin et al [36] focuses attention Fascia and Diabetes
714 794
on the sliding capability of fascial sublayers. These au-
715 795
716 796
thors found significant correlations in male participants Duffin et al [42] demonstrate that patients with type I
717 797
with chronic low back pain between shear strain capa- diabetes have a plantar fascia that is significantly
718 798
bility of the thoracolumbar fascia and with the following thicker compared to that of normal controls. Also, Li
719 799
720 800
variables: perimuscular connective tissue thickness, et al [43] show that collagen cross-linking by advanced
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6 Fascial Disorders: Implications for Treatment
801 881
glycation end-products alters the physical properties of Fascia and Peripheral Motor Coordination
802 882
collagen structures and tissue behavior, reduces tissue
803 883
804 stress relaxation (P < .01), with a concomitant increase The epimysial fasciae have free nerve endings, but 884
805 885
in tissue yield stress (P < .01), and ultimately failure lack Pacini and Ruffini corpuscles. Despite this, the
806 886
stress (P ź .036). Such collagens are also more suscep- epimysial fascia play a key role in proprioception and
807 887
808 888
tible to degradation by collagenases, and the panoply of peripheral motor coordination due to their close rela-
809 889
other matrix-metalloproteinases. tionship with muscle spindles. Indeed the muscle spin-
810 890
811 891
dles are localized in the perimysium and their capsule
812 892
Epimisyal Fascia and Its Disorders connects to the epimysium and fascial septae
813 893
814 [23,47,48]. Strasmann et al [24] analyzing the septum of 894
815 895
Fascia and Immobilization the supinator muscle find that many muscle spindles are
816 896
inserted directly into the connective tissue of the
817 897
818 Q7
898
According to studies by Järvinen et al [44], immobi- septum. Von Düring and Andrei [25], studying the evo-
819 899
lization results in a marked increase in the endo- and lution of the locomotor system, discovered that muscle
820 900
821 perimysial connective tissue. The majority of the spindles are strongly connected to the fascia. Due to 901
822 902
increased endomysial collagen is deposited directly on these connections, it is evident that tension developed
823 903
the sarcolemma of the muscle cells. Immobilization of inside the deep fascia is also able to lengthen the
824 904
825 905
the endomysium also results in a substantial increase in muscle spindles connected with it, activating them by
826 906
the number of perpendicularly oriented collagen fibers passive stretch. If epimysial fascia is overstretched, it is
827 907
828 that make contact with two adjacent muscle fibers. possible that the muscle spindles connected to this 908
829 909
Furthermore, immobilization clearly disturbs the normal portion of the fascia could become chronically stretched
830 910
structure of the endomysium, making it impossible to and overactivated. This implies that the associated
831 911
832 912
distinguish the various networks of fibers from one muscular fibers will be constantly stimulated to con-
833 913
another. In the perimysium, immobilization-induced tract. This could explain the increased amount of
834 914
835
changes are similar. The number of longitudinally ori- acetylcholine found in myofascial pain and, in partic- 915
836 916
ented collagen fibers increases, the connective tissue ular, in trigger points [49,50]. This passive stretch situ-
837 917
838 becomes very dense, the number of irregularly oriented ation could be responsible for muscular imbalances and 918
839 919
collagen fibers is markedly increased, and consequently recurrent cramps, and could result in incorrect move-
840 920
the different networks of collagen fibers cannot be ment of joints. This may represent a typical case in
841 921
842 922
distinguished from each other. Even the crimp angle of which there is limitation of joint range of motion and
843 923
the collagen fibers decreases more than 10% in all associated joint pain. The causation is often found in
844 924
845 muscles after the immobilizatio period. It is apparent the proximal muscles that move the joint. Palpation of 925
846 926
from the above-described quantitative and qualitative the proximal muscle belly will often reveal an area of a
847 927
changes in the intramuscular connective tissue that they painful localization of dense tissue. Another problem
848 928
849 929
significantly contribute to the decreased function and connected with the muscle spindles inside the epymisial
850 930
diminished biomechanical properties of immobilized fasciae is when the epimysial fascia is too rigid, and
851 931
852 932
skeletal muscle. consequently the muscle spindle are not activated
853 933
because they are embedded in a rigid structure. This
854 934
Fascia and Aging emphasizes the fact that normal muscular function is
855 935
856 936
dependent on normal well-hydrated, functioning fascia.
857 937
Gao et al [45] demonstrate that the epimysial fascia If the epimysial fascia is densified, some parts of a
858 938
859 939
from old rats is much stiffer than that of young rats. This muscle will not function normally during movement,
860 940
increased stiffness cannot be attributed to variations in causing an unbalanced movement of the joint, with
861 941
862 the thickness of the epimysial fasciae or in the size of resulting uncoordinated movement and eventual joint 942
863 943
the collagen fibrils. Microscopic analysis does not show pain. The epimysial fasciae could be considered as a key
864 944
any change in the arrangement or size of the collagen element in peripheral motor coordination.
865 945
866 946
fibrils of the epimysial fasciae in older rats [45]. It is
867 947
probable that the key element explaining this stiffness Discussion
868 948
869 is the composition of the extracellular matrix with 949
870 950
respect to the presence of hyaluronan. It is important to Only a better comprehension of the anatomy and
871 951
note that the space between the collagen fibers of the physiology of fasciae will permit us to answer common
872 952
873 953
epimysial fasciae is occupied by hyaluronan. This allows questions such as the following: Is it the superficial or
874 954
the collagen fibers to slide with less friction during deep fascia that generates these symptoms? What
875 955
876 956
movement [46]. Age-related increase in the stiffness of particular fascial treatment is useful for lymphedema?
877 957
the epimysial fasciae could play an important role in the What is the best approach for changes in proprioception?
878 958
muscular contraction and in the reduced elasticity that From this review, it is possible to conclude that
879 959
880 960
is often typical in older patients. symptoms related to dysfunction of the lymphatic
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A. Stecco et al. / PM R XXX (2015) 1-8 7
961 1041
system, superficial vein system, and thermoregulatory must be applied in relation to the types of fasciae that
962 1042
Q10
system are more related to disorders of the superficial are involved.
963 1043
964 fascia. Dysfunction such as alteration in mechanical This review is not designed to evaluate the literature 1044
965 1045
coordination, proprioception, balance, myofascial pain, on the treatment of fascial disorders. Other studies will
966 1046
and cramps are more related to the deep fascia and be required to better understand the efficacy and
967 1047
968 1048
epimysium (Table 2). specificity of the different modalities of treatment for
969 1049
Superficial fascia is obviously more superficial than specific fascial disorders.
970 1050
971 1051
the other types and contains more elastic tissue.
972 1052
Consequently, effective treatment can probably be
Uncited Figures
973 1053
974 achieved with treatment modalities that use a large 1054
975 1055
surface and a small amount of pressure that will reach
Figures 2-3.
976 1056
the first layers of the subcutis. The deep fasciae and the
977 1057
978 1058
epymisium require treatment that generates enough
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979 1059
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980 1060
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1187 Disclosure 1272
1188 1273
1189 1274
1190 A.S. Sport Medicine Unit, Internal Medicine Department, University of Padova, R.D.C. Molecular Medicine Department, University of Padova, Padova, Italy 1275
1191 Padova, Italy. Address correspondence to: A.S.; Via Giustiniani 2, 35127 Padova, Disclosure: nothing to disclose 1276
1192 1277
Italy; e-mail: [e-mail]
1193 1278
Disclosure: nothing to disclose
C.S. Molecular Medicine Department, University of Padova, Padova, Italy
1194 1279
Disclosure: nothing to disclose
1195 1280
R.S. Division of Basic Biomedical Sciences, Touro College of Osteopathic Medi-
1196 1281
Submitted for publication January 6, 2015; accepted June 7, 2015.
Q2
cine, New York, NY
1197 1282
1198 Disclosure: nothing to disclose 1283
1199 1284
1200 1285
I.F. Molecular Medicine Department, University of Padova, Padova, Italy
1201 1286
Disclosure: nothing to disclose
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