JRRD Volume 51, Number 6, 2014

Pages 875–884

Fascia—Current knowledge and future directions in physiatry: Narrative

review

Evan H. Kwong, BSc, MD, MSc;1* Thomas W. Findley, MD, PhD2

1
Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Alberta,
Canada; 2Research Service, Department of Veterans Affairs New Jersey Healthcare System, East Orange, NJ; and
Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers, the State University of 
New Jersey, Newark, NJ

Abstract—Fascia can be considered part of the connective tis- tory, gastrointestinal, musculoskeletal, and neurological
sues that permeate the human body. However, in medical train- systems. Fascia is part of all of these systems and may be
ing, its definition is not clear, and even among specialists, its affected by fibroproliferative diseases with connective
role is not completely understood. Physiatrists have a unique tissue remodeling [1–3]. Fascia has not been studied thor-
opportunity to add to the growing scientific and clinical knowl- oughly as a whole in terms of its purpose and integration
edge about fascia, particularly about how this connective tissue
with the entire body in different organ systems. In mus-
network may apply clinically to musculoskeletal disorders. In
this narrative review, the structure and function of fascia are
culoskeletal medicine, it is important to understand the
discussed from the perspective of physiatry. role of this truly “connective” tissue. The specialty of
physiatry is well-positioned to contribute to the growing
research about fascia and apply new knowledge regard-
Key words: connective tissue, fascia, fascia function, fibro- ing its importance in the musculoskeletal system.
blast, hyaluronic acid, mechanotransduction, musculoskeletal It is important to attempt to define the word fascia, as
disorders, musculoskeletal system, myofibroblast, physiatry. it does not have a clear and concise definition.
Traditionally, fascia has been defined as the “term
applied to masses of connective tissue large enough to be
INTRODUCTION visible to the unaided eye” [4]. In Latin, fascia means
“bundle, bandage, strap, unification, and binding
Physiatrists treat many disorders affecting the mus- together” [5]. The following excerpt from Gray’s Anat-
culoskeletal system, and thus it is important to under- omy summarizes the various roles that it may have:
stand the pathophysiology of these disorders. Fascia, part
of the connective tissues that permeate the human body,
may be the unifying structure and concept that is essen-
tial to elucidate the mechanisms of these dysfunctions. Abbreviations: FCU = flexor carpi ulnaris, VA = Department
of Veterans Affairs.
Once these precise mechanisms are detailed, focused *
Address all correspondence to Evan H. Kwong, BSc, MD,
treatments and prophylactic regimens for musculoskele- MSc; 408–1160 Burrard St, Vancouver, BC, Canada V6Z
tal disorders can be optimized. 2E8; 604-336-3690; fax: 604-336-3691. 
In medical education, trainees are taught about vari- Email: [email protected]
ous organ systems, including the cardiovascular, respira- http://dx.doi.org/10.1682/JRRD.2013.10.0220

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Fascia that is organized into condensations on agreement exists that it is a membranous layer of connec-
the surfaces of muscles—and their epimysial tive tissue inside the subcutaneous tissue found in
sheaths—and other tissues is termed investing between the superficial and deep adipose tissue. The deep
fascia. Between muscles that move extensively, fascia is found beneath these layers and is more of a
it takes the form of loose areolar connective tis- fibrous membrane that surrounds all of the muscles, but
sue and provides a degree of mechanical isola- has varying characteristics depending on its region of the
tion. It constitutes the loose packing of body. The simplest description of deep fascia is dense
connective tissue around peripheral nerves, irregular connective tissue, but more research has shown
blood and lymph vessels as they pass between that it can have a structured organization depending on its
other structures and often links them together as location [8] and may also contain layers of loose connec-
neurovascular bundles. It forms a dense connec- tive tissue [10].
tive tissue layer investing some large vessels. [4] To complicate matters, it may be difficult to distin-
Much of this classical description is valid and impor- guish other various specialized layers, a concept also
tant, yet during anatomical dissections in medical train- mentioned in Gray’s Anatomy: “Deep fascia is also com-
ing, fascia has a history of being less emphasized. Its posed mainly of collagenous fibres, but these are com-
widespread nature makes it difficult to compartmentalize pacted and in many cases arranged so regularly that the
and define. For example, the Federative Committee on deep fascia may be indistinguishable from aponeurotic
Anatomical Terminology defines fascia as “sheaths, sheets tissue” [4].
or other dissectible connective tissue aggregations” [6]. Despite discussion by different international commit-
The following is a proposed definition from the 2007 tees, there is still no consensus on how to define fascia
Fascia Research Congress: “Fascia is the soft tissue com- because many characteristics need to be taken into con-
ponent of the connective tissue system that permeates the sideration [6,8]. Although a single unifying term such as
human body. . . . The scope of our definition of and inter- fascia to describe these various tissues may not be an
est in fascia extends to all fibrous connective tissues, accurate term histologically, it may still be helpful to cli-
including aponeuroses, ligaments, tendons, retinaculae, nicians or scientists. The definition of fascia depends on
joint capsules, organ and vessel tunics, the epineuria, the the intended focus [6]. Much like how the terms “cardio-
meninges, the periostea, and all the endomysial and inter- vascular system” or “nervous system” encompass a vari-
muscular fibers of the myofasciae” [7]. To note, many ety of different cell types, the term “fascial system” may
specialized structures have been included in this defini- provide a conceptual model by which to explain the intri-
tion. There are a variety of fascial structures that exist cate workings of connective tissues surrounding the vas-
with different densities and arrangements of collagen cular, lymphatic, neurological, and musculoskeletal
fibers [6]. These structures are also influenced by the systems, among others. This insightful perspective of
location in the body or by external forces during develop- examining systems of the human body could benefit both
ment [8]. Hence, different fascial structures may serve the scientific and clinical communities.
different functions. Since ligaments and tendons are In this narrative review, the following questions are
highly specialized tissues, clinicians and scientists should addressed: (1) How connective is fascia? (2) How much
be careful about categorizing all of these various connec- of a role does fascia play in force transmission? (3) What
tive tissue types into one term [9]. changes in fascia can occur at the cellular level? (4) Is fas-
Twelve terms encompassing structures often called cia innervated? (5) Can fascia become dysfunctional and
fascia have been proposed [9]: dense connective tissue, result in pain? (6) What does treatment of fascia involve?
areolar connective tissue, deep fascia, superficial fascia,
interosseous membranes, intermuscular septae, epimy-
sium, perimysium, endomysium, periosteum, neurovas- METHODS
cular tract, and intra- and extramuscular aponeuroses.
There are a multitude of different morphologies. The Using MEDLINE and CINAHL, the keyword “fascia”
superficial and deep fascia alone have been studied and was used in combination with the standard operator “and”
reviewed in detail [8]. There is some controversy as to with the following terms: “anatomy,” “force transmission,”
the exact definition of superficial fascia, but a common “mechanotransduction,” “fibroblast,” “myofibroblast,”
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KWONG and FINDLEY. Fascia: Current knowledge, future directions

“innervation,” “nerve fibres,” “proprioception,” “myo- In fact, fascia is “more evident in living bodies” [11].
fascial pain,” “manual therapy,” “manipulation,” and This concept is important, not only because embalmed
“acupuncture.” Limitations included English language cadaveric tissues for anatomical dissections may change
and years 1987–2013. From the list of references gener- with time or after specimen preparation, but also because
ated, the abstract or introduction of each article was of the fundamental differences in studying structure ver-
reviewed and a selection from this list was identified as sus function. When defining fascial tissue via anatomical
relevant to the questions and sections addressed in this dissections, it may be difficult to define it only structur-
narrative review. Additional articles from the citations of ally, especially if fascial tissue has a dynamic and wide-
the identified articles were obtained if further details of spread role. For example, functions such as force
certain concepts were needed. Information from the transmission and sliding are not easily demonstrated in
selected articles was summarized and used for each sec- static specimens.
tion contained in this narrative review. Certain book
chapters were also included for a general overview. Myofascial Force Transmission
Functional myofascial sequences are directly
involved in the organization of movement and muscular
RESULTS force transmission [12–13]. Dense connective tissues and
tendons are predominantly aligned type I collagen and
Anatomy and Function are more specialized for force transmission [14–15].
With regard to the musculoskeletal system and the Forces exerted by any one muscle are known to transmit
word “fascia,” the medical community may be more longitudinally along the myotendinous junction to exert
familiar with terms such as the plantar fascia, tensor fas- an action across a joint. However, these forces may also
cia lata, and the deep fascial compartments of the lower be transmitted epimuscularly between muscle fibers and
limb. In traditional anatomy textbooks, fascia is usually fascial connective tissues [14–16]. For example, it has
described in relation to various body parts when some been shown that after transecting the flexor carpi ulnaris
clinical or biomechanical importance is known rather (FCU) tendon, a residual wrist flexion force remains
than devoting a separate chapter about fascia. This nam- when the FCU muscle was contracted [17]. This action is
ing suggests a network of disjointed pieces rather than a thought to be mediated by the myofascial connections of
single layer crossing multiple structures. If read carefully, FCU to the other wrist and finger flexors. In fact, up to
these textbooks do allude to the continuity of fascia by 30 percent of muscle tension may be transmitted via
using descriptions such as “blend,” “common lower extramuscular force transmission [18]. Myofascial con-
attachment,” or “surrounding” [11]. nections between muscles are involved in the force trans-
With embalmed cadaveric specimens, the majority of mission of one muscle to a neighboring one, and even to
fascial tissues are either ignored or difficult to discern antagonistic muscles [19–20].
during a dissection. However, if unembalmed cadavers How these findings apply clinically needs further
are dissected using “fascia-sparing” techniques, much investigation. Understanding epimuscular force transmis-
more may be garnered regarding the structure and func- sion may aid in the understanding of pathophysiology of
tion of the musculoskeletal system. The gross anatomy of neurological disorders affecting the musculoskeletal sys-
fascia has been studied via careful dissections, describing tem, such as spasticity [19]. An interesting review of
various myofascial trains and functional sequences [12– myofascial force transmission and how it relates to ten-
13]. For example, there are expansions of pectoralis don transfer surgery in the treatment of spasticity has
major muscle to the brachial fascia, continuing via lacer- been published [21]. This paradigm shift of how we think
tus fibrosus and biceps muscle to the antebrachial fascia about the biomechanics of muscle action has profound
and flexor carpi radialis, then to the flexor retinaculum, implications in helping us obtain a better understanding
and finally to the palmaris longus muscle connecting to of spasticity and other neuromuscular issues.
the fascia of the thenar eminence [13]. These “fascia- Additionally, force transmission from muscles to sur-
sparing” dissections demonstrate functional connections rounding fascia may cause stretching and tension [13]. It
and emphasize the continuity of fascia throughout the is proposed that these fascial expansions allow reciprocal
human body. feedback between fascia and muscles. These physical
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connections also suggest that forces and states of contrac- not a specific structure in itself. These connections were
tion may be transmitted and perceived not only locally also examined using electron microscopy, and multiple
but also at farther distances. polyhedral microvacuoles of different sizes and shapes
were seen. They not only were visualized between the
Mechanotransduction flexor tendons within the carpal tunnel but were also
The mechanical force transmission that occurs at the described in other selected areas of the body, including
macroscopic level may affect tissues at the cellular level. the scalp, neck, scapula, and between rectus abdominus
Fascia contains fibroblasts, which are involved in the muscle and subcutaneous fat.
synthesis of the extracellular matrix. Fibroblasts have This microvacuolar system is thought to be com-
been well studied in the wound healing literature [22– posed primarily of proteoglycans [30]. Proteoglycans,
24]. Fibroblasts can develop into myofibroblasts with specifically glycosaminoglycans, have a high density of
stretching and certain biochemical signaling such as negative charges and can thereby draw in water mole-
transforming growth factor beta-1 and extra domain A cules, forming gels at very low concentrations [31–32].
fibronectin. The myofibroblast expresses more alpha As such, it is proposed that this microvacuolar system
smooth muscle actin and has a phenotype with increased contains water and has viscoelastic properties, behaving
contractile force capacity. like a gel. It likely provides lubrication and absorbs shear
Morphological transformations of fibroblasts have stresses, which results in nearly frictionless musculoten-
been studied in three-dimensional in vitro matrices. It dinous movement. This described sliding system may
was found that at rest, fibroblasts are in a dendritic state actually be equivalent to the loose connective tissue of
[25–26]. When a stretching force was applied to the the extracellular matrix. The extracellular matrix is “a
matrix environment, fibroblasts changed into an system of insoluble protein fibres, adhesive glycoproteins
expanded lamellar morphologic state. Mechanical stimuli and soluble complexes composed of carbohydrate poly-
can modulate cell signaling, gene expression, matrix mers linked to protein molecules [proteoglycans and gly-
adhesion, and connective tissue tension [26–28]. Repetitive cosaminoglycans], which bind water” [4].
mechanical straining of fibroblasts in a two-dimensional A prominent layer of loose connective tissue resides
model induces changes in cellular proliferation as well as between deep fascia and the epimysium of the underlying
secretion of inflammatory mediators [29]. skeletal muscle [10]. There are also similar, less promi-
As summarized earlier, epimuscular force transmis- nent layers within the deep fascia itself. These layers
sion occurs through fascial connective tissues. Local and were found to be rich in hyaluronic acid [10,33], which is
distal fascial expansions in functional sequences can be one of several groups of glycosaminoglycans [31,34].
affected by muscle contractions or stretching. Because of The density of the extracellular matrix may depend on
mechanotransduction, cellular changes of fibroblasts within the concentration of this hyaluronic acid and factors such
fascia may occur in response to these external forces. as temperature or possibly other physical parameters.
Connective tissue remodeling may occur, in turn affecting Based on their observations, Stecco et al. theorized that
function. Thus, the role of fibroblasts in cellular events of this substance, along with water, may create the smooth
tissue remodeling during day-to-day activities, exercise, gliding between the surfaces of fascia and muscle,
injuries, and therapies needs to be further explored. between different fascia sublayers, and also between dif-
ferent motor units [10]. Any alteration of the hyaluronic
Sliding acid can theoretically change the properties of the extra-
Interfaces between fascial layers and other structures cellular matrix, affecting sliding. This may lead to
can allow them to slide upon one another. For example, restrictions in sliding and modification of the receptors
subcutaneous tissue can slide over deep fascia, and mus- within fascia and is also theorized as a potential cause of
cles can slide because of an interface between the deep myofascial pain [35]. There are also ongoing studies
fascia and epimysium [8]. regarding mathematical models to help explain the poten-
The term “microvacuolar system” has been used to tial flow of hyaluronic acid during manual therapy [36–
describe the types of connections between fascial struc- 37]. These theories are important for understanding the
tures visualized using fiberoptic cameras under the der- musculoskeletal system and need further research and
matological layers [30] that may allow sliding, but it is exploration.
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KWONG and FINDLEY. Fascia: Current knowledge, future directions

Innervation and corpuscles within ankle retinacula [44]. Although

Traditionally, fascia is associated with various pain- they were distributed homogeneously throughout the
ful disorders such as plantar fasciitis, exertional compart- fibrous components of fascia, they were also found to be
ment syndrome, or myofascial trigger points. However, more prominent around vessels. Interestingly, the intra-
fascia may be implicated in other aspects of musculoskele- fascial nerves were often oriented perpendicular to the
tal disorders, including not only pain but also propriocep- collagen fibers, which suggests that they could be stimu-
tive dysfunction. lated by stretching of the collagen fibers. Besides free
Studies have shown that intense local and referred nerve endings, various fascial expansions have been
pain occurs with injection of hypertonic saline into the shown to have encapsulated receptors such as Ruffini and
tendons and fascia [38–39]. Injections into tendon and Pacini corpuscles, suggesting a static and dynamic pro-
tendon-bone junction sites were found to be more sensi- prioceptive function [44–45]. Furthermore, muscle spin-
tive than injections into the muscle belly [38]. Sensitivity dles tend to be located in areas of the muscle where the
to pain was not found to be a strictly volume-driven pro- architecture suggests lateral myofascial force transmis-
cess because ultrasound-guided injections of isotonic sion, indicating there is no clear division between “mus-
saline into fascia resulted in less pain than hypertonic cle” and “ligamentous or fascial” nerve endings [46].
saline injections even though both fluids distended the If the periarticular regular dense connective tissue is
fascia [39]. The innervation profile of fascia may par- thought of in series with the periarticular muscle, colla-
tially explain why these injections result in pain. gen fibers within fascial tissue around joints may be
For example, thoracolumbar fascia plays a role in stretched with movement [46]. Any contraction of the
low back pain [40], with current literature providing fur- muscles results in a simultaneous stretch of the fascial
ther supportive findings. The thoracolumbar fascia of tissue. If these tissues contain free nerve endings and
subjects with low back pain had degenerative changes mechanoreceptors, then any dysfunction of fascial struc-
and also contained regions of increased peripheral nerve tures may potentially play a large role in pain or influ-
endings [41]. Histological changes were present that ence proprioception.
were similar to those of ischemic and inflammatory con-
ditions. Although Bednar et al. found that thoracolumbar Injury
fascia was deficiently innervated [41], Yahia et al. There are multiple theories as to how myofascial tis-
reported free nerve endings and mechanoreceptors [42]. sue is altered after trauma or overuse. One component of
Tesarz et al. found that the thoracolumbar fascia and the fascial dysfunction in fibromyalgia could be chronic ten-
overlying subcutaneous tissue are densely innervated, sion in fascia and an impaired fascial healing response
including nociceptive and sympathetic fibers [43]. There [47]. Additionally, in musculoskeletal injury with dam-
were also specific differences between the three layers of age to proprioception, there may be alteration of collagen
the thoracolumbar fascia. Nerve fibers were present in fiber composition, transformation of fibroblasts into
high densities in the outer and subcutaneous tissue layers, myofibroblasts, or changes in ground substance [44].
but not so in the middle layer. Nerve fibers consistent After an injury, inflammation may occur, which
with postganglionic sympathetic fibers were also found could have a role in altering fascia. As mentioned previ-
close to blood vessels, which again suggests a vascular ously, repetitive mechanical straining of fibroblasts has
component leading to ischemic pain. The presence of been shown to result in secretion of inflammatory media-
sensory fibers in the superficial layers may contribute to tors [29]. The biochemical milieu of myofascial trigger
painful sensations experienced during manual therapies points has been shown to contain many substances both
for back pain, which are directed toward these fascial lay- locally and remotely, including substance P, calcitonin
ers. Further histological studies of fascia to determine gene-related peptide, bradykinin, 5-HT, norepinephrine,
nociceptor and sympathetic fiber distribution throughout tumor necrosis factor alpha, and interleukin 1-beta [48–
different regions of the body may help explain various 49]. These inflammatory substances may result in activa-
pain disorders with local and/or referred symptoms. tion of fibroblasts into myofibroblasts when combined
However, fascial innervation may not only be with a tensioned environment [22]. This, in turn, may
restricted to nociceptive fibers. Immunohistochemical lead to alterations in gene expression [26–28], causing
staining of ankle retinacula revealed small nerve fibers changes in the extracellular matrix including altered
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JRRD, Volume 51, Number 6, 2014

hyaluronic acid production. This may result in restriction induce remodeling of the extracellular matrix [59]. Tar-
in fascia, leading to altered lines of force with muscle geted remodeling may counteract any dysfunction in fas-
contraction [35,50]. These processes may contribute to cia. Further research is needed to identify how
the decreased movement between fascial layers, which acupuncture helps treat myofascial pain at sites distant
has been shown to occur in thoracolumbar fascia layers from the needle insertion.
in those with chronic back pain, for example [51]. Over Further research is also needed about how fascia may
time, these biomechanical changes from restricted fascia be affected by other current treatment regimens, such as
could lead to decreased strength and coordination, and therapeutic modalities, exercise, medications, interven-
ultimately pain and dysfunction [35,52]. tional injections, and surgery.

Treatment
Treatment of disorders depends on the diagnosis and DISCUSSION AND CONCLUSIONS
pathophysiology. Since the mechanisms of the proposed
fascial dysfunction are not clearly elucidated yet, it may In physiatry, it is important to have an objective sci-
be difficult to outline focused treatment methods. How- entific basis for diagnoses and treatments. The medical
ever, anecdotal successes such as manual therapy tech- model is focused on evidence-based practice. Thus, fur-
niques or acupuncture have led to further research into ther research is needed to complement the anecdotal
possible mechanisms, which in return may lead to more experiences of clinicians treating musculoskeletal disorders.
information about pathophysiology. This narrative review summarized several aspects of
Since alterations in fascia due to trauma or overuse the structure and function of fascia from the gross ana-
may be potential causes of pain and dysfunction, one tomical level to the cellular level. Fascia is continuous
hypothesis of how manual therapy works is the restora- throughout the body, supporting various functions [8,12–
tion of the normal physiological state of fascia [52]. 13]. Its continuity aids in force transmission both longitu-
Manual therapy theoretically restores mobility by reopti- dinally and epimuscularly [14–16]. Through mechano-
mizing the distribution of lines of force within fascia transduction, these forces may be transmitted at a cellular
[35,52–53]. Simulated myofascial release on in vitro level, altering gene expression of fibroblasts and thereby
fibroblasts originally injured by repetitive motion strain changing the extracellular matrix composition [26–28].
results in normalization of cell morphology and attenua- Repetitive mechanical straining of fibroblasts can also
tion of inflammatory responses [50]. There appears to be result in secretion of inflammatory mediators [29]. All of
an important balance between the amount and type of these changes could affect the normal functions of force
strain resulting in cellular destruction and apoptosis ver- transmission or sliding in the musculoskeletal system.
sus cellular proliferation [29,50]. Simmonds et al. pub- This dysfunction could lead to pain or proprioceptive
lished an interesting review of the role of fascia in issues, considering that fascia has been shown to be
various manual therapy techniques [54]. Chaudhry et al. innervated [41–44]. Thus, treatment of disorders affect-
have summarized a model based on considering hyal- ing the musculoskeletal system may need to be focused
uronic acid as a non-Newtonian fluid, suggesting that on this fascial network.
manual therapy improves sliding by generating fluid Studying fascia objectively at the basic science and
pressure [36]. Recent studies have started to document clinical levels will provide important information that
immediate and delayed changes at the cellular level to may change clinical practice. Once the structure and
manual treatments in vivo [55]. functions of fascia in the musculoskeletal system are further
Additionally, there have been theories regarding the elucidated, the pathophysiology of many disorders and
myofascial connective tissue planes and acupuncture their consequences may be better explained. Many neuro-
meridians [56]. Acupuncture needles, with rotation, muscular and musculoskeletal disorders can be addition-
induce winding of connective tissue around the needle ally served by research with a fascial perspective in order
point [57]. In vitro models may be able to elucidate the to optimize treatment strategies.
response of acupuncture depending on the mechanostruc- Physiatry, a holistic specialty, needs to consider the
tural characteristics such as collagen concentration and ubiquitous nature of fascia. Fascia is not only a structure
formation [58]. Mechanical stimuli by acupuncture may but also a concept that can change one’s perspective of
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KWONG and FINDLEY. Fascia: Current knowledge, future directions

how the musculoskeletal system functions. Different Medicine and Rehabilitation, University of British Columbia, Vancouver,
medical and surgical specialists focus on different organ British Columbia, Canada.
systems of the human body. The specialty of physiatry Disclaimers: The views expressed in this article are those of the
authors and do not necessarily reflect the position or policy of the VA
has an opportunity to focus on studying the fascial sys- or U.S. Government.
tem with the goal of contributing to the growing research
and clinical cases about fascia and the musculoskeletal
system. More than 100 years ago, A. T. Still, MD, was an REFERENCES
acute observer of the body, particularly the fascial sys-
tem, and founded the practice of osteopathic medicine. 1. Wynn TA. Common and unique mechanisms regulate
Many of his observations hold true today [60] and can fibrosis in various fibroproliferative diseases. J Clin Invest.
guide the incorporation of fascial concepts into the prac- 2007;117(3):524–29. [PMID:17332879] 
tice of physiatry. http://dx.doi.org/10.1172/JCI31487
The fascia gives one of, if not the greatest prob- 2. Hinz B, Gabbiani G. Fibrosis: Recent advances in myofi-
lems to solve as to the part it takes in life and broblast biology and new therapeutic perspectives. F1000
death. It belts each muscle, vein, nerve, and all Biol Rep. 2010;2:78. [PMID:21170369]
organs of the body. It is almost a network of 3. Hinz B, Phan SH, Thannickal VJ, Prunotto M, Desmoul-
nerves, cells and tubes, running to and from it; it ière A, Varga J, De Wever O, Mareel M, Gabbiani G.
Recent developments in myofibroblast biology: Paradigms
is crossed and filled with, no doubt, millions of
for connective tissue remodeling. Am J Pathol. 2012;180(4):
nerve centers and fibers to carry on the work of 1340–55. [PMID:22387320] 
secreting and excreting fluid vital and destruc- http://dx.doi.org/10.1016/j.ajpath.2012.02.004
tive. By its action we live, and by its failure we 4. Standring S, editor. Gray’s anatomy: The anatomical basis
shrink, or swell, and die. Each muscle plays its of clinical practice. 40th ed. Edinburgh (UK): Churchill
part in active life. Each fiber of all muscles owes Livingstone; 2008.
its pliability to that yielding septum-washer, that 5. Findley T. Fascia research II: Second International Fascia
gives all muscles help to glide over and around Research Congress. Int J Ther Massage Bodywork. 2009;
all adjacent muscles and ligaments, without fric- 2(3):4–9. [PMID:21589733]
tion or jar. It not only lubricates the fibers but 6. Schleip R, Jäger H, Klingler W. What is ‘fascia’? A review
gives nourishment to all parts of the body. Its of different nomenclatures. J Bodyw Mov Ther. 2012;16(4):
nerves are so abundant that no atom of flesh fails 496–502. [PMID:23036881] 
to get nerve and fluid supply therefrom. [61] http://dx.doi.org/10.1016/j.jbmt.2012.08.001
7. Findley T. Second International Fascia Research Congress.
Int J Ther Massage Bodywork. 2009;2(2):1–6.
[PMID:21589727]
ACKNOWLEDGMENTS
8. Stecco C, Macchi V, Porzionato A, Duparc F, De Caro R.
The fascia: The forgotten structure. Ital J Anat Embryol.
Author Contributions:
2011;116(3):127–38. [PMID:22852442]
Concept of manuscript: E. H. Kwong, T. W. Findley.
Interpretation of literature: E. H. Kwong, T. W. Findley. 9. Langevin HM, Huijing PA. Communicating about fascia:
Drafting of manuscript: E. H. Kwong. history, pitfalls, and recommendations. Int J Ther Massage
Revision of manuscript for important intellectual content:  Bodywork. 2009;2(4):3–8. [PMID:21589739]
E. H. Kwong, T. W. Findley. 10. Stecco C, Stern R, Porzionato A, Macchi V, Masiero S,
Providing final approval of version to be published: E. H. Kwong,  Stecco A, De Caro R. Hyaluronan within fascia in the etiology
T. W. Findley. of myofascial pain. Surg Radiol Anat. 2011;33(10):891–96.
Financial Disclosures: The authors have declared that no competing [PMID:21964857] 
interests exist. http://dx.doi.org/10.1007/s00276-011-0876-9
Funding/Support: This material is based on work supported with
11. Thompson JS, Akesson EJ, Loeb JA, Wilson-Pauwels L,
resources and the use of facilities at the Department of Veterans
Affairs (VA) New Jersey Healthcare System, East Orange, New Jersey.
editors. Thompson’s core textbook of anatomy. 2nd ed.
Additional Contributions: The authors thank Ms. Laurie Dabaghian, Philadelphia (PA): Lippincott; 1990.
who assisted in the proofreading of the manuscript. Dr. Kwong is now 12. Myers TW. Anatomy trains: Myofascial meridians for
with the Division of Physical Medicine and Rehabilitation, Department manual and movement therapists. 2nd ed. Edinburgh (UK):
of Medicine, Providence Health Care and the Division of Physical Churchill Livingstone; 2009.
882

JRRD, Volume 51, Number 6, 2014

13. Stecco A, Macchi V, Stecco C, Porzionato A, Ann Day J, [PMID:12845617] 

Delmas V, De Caro R. Anatomical study of myofascial http://dx.doi.org/10.1002/path.1427
continuity in the anterior region of the upper limb. J Bodyw 24. Desmoulière A, Chaponnier C, Gabbiani G. Tissue repair,
Mov Ther. 2009;13(1):53–62. [PMID:19118793]  contraction, and the myofibroblast. Wound Repair Regen.
http://dx.doi.org/10.1016/j.jbmt.2007.04.009 2005;13(1):7–12. [PMID:15659031] 
14. Huijing PA. Epimuscular myofascial force transmission: A http://dx.doi.org/10.1111/j.1067-1927.2005.130102.x
historical review and implications for new research. Inter- 25. Grinnell F. Fibroblast mechanics in three-dimensional col-
national Society of Biomechanics Muybridge Award Lec- lagen matrices. J Bodyw Mov Ther. 2008;12(3):191–93.
ture, Taipei, 2007. J Biomech. 2009;42(1):9–21. [PMID:19083673] 
[PMID:19041975]  http://dx.doi.org/10.1016/j.jbmt.2008.03.005
http://dx.doi.org/10.1016/j.jbiomech.2008.09.027 26. Chiquet M, Gelman L, Lutz R, Maier S. From mechano-
15. Maas H, Sandercock TG. Force transmission between syn- transduction to extracellular matrix gene expression in
ergistic skeletal muscles through connective tissue link- fibroblasts. Biochim Biophys Acta. 2009;1793(5):911–20.
ages. J Biomed Biotechnol. 2010;2010:1. [PMID:19339214] 
[PMID:20396618]  http://dx.doi.org/10.1016/j.bbamcr.2009.01.012
http://dx.doi.org/10.1155/2010/575672 27. Wang JH, Thampatty BP, Lin JS, Im HJ. Mechanoregula-
16. Yucesoy CA. Epimuscular myofascial force transmission tion of gene expression in fibroblasts. Gene. 2007;391(1–
implies novel principles for muscular mechanics. Exerc 2):1–15. [PMID:17331678] 
Sport Sci Rev. 2010;38(3):128–34. [PMID:20577061] http://dx.doi.org/10.1016/j.gene.2007.01.014
http://dx.doi.org/10.1097/JES.0b013e3181e372ef 28. Langevin HM, Storch KN, Snapp RR, Bouffard NA, Bad-
17. Kreulen M, Smeulders MJ, Hage JJ, Huijing PA. Biome- ger GJ, Howe AK, Taatjes DJ. Tissue stretch induces
chanical effects of dissecting flexor carpi ulnaris. J Bone nuclear remodeling in connective tissue fibroblasts. Histo-
Joint Surg Br. 2003;85(6):856–59. [PMID:12931805] chem Cell Biol. 2010;133(4):405–15. [PMID:20237796] 
18. Huijing PA, Maas H, Baan GC. Compartmental fasciotomy http://dx.doi.org/10.1007/s00418-010-0680-3
and isolating a muscle from neighboring muscles interfere 29. Dodd JG, Good MM, Nguyen TL, Grigg AI, Batia LM,
with myofascial force transmission within the rat anterior Standley PR. In vitro biophysical strain model for under-
crural compartment. J Morphol. 2003;256(3):306–21. standing mechanisms of osteopathic manipulative treat-
[PMID:12655613]  ment. J Am Osteopath Assoc. 2006;106(3):157–66.
http://dx.doi.org/10.1002/jmor.10097 [PMID:16585384]
19. Huijing PA. Epimuscular myofascial force transmission 30. Guimberteau JC, Delage JP, McGrouther DA, Wong JK.
between antagonistic and synergistic muscles can explain The microvacuolar system: How connective tissue sliding
movement limitation in spastic paresis. J Electromyogr works. J Hand Surg Eur Vol. 2010;35(8):614–22.
Kinesiol. 2007;17(6):708–24. [PMID:17383897]  [PMID:20571142] 
http://dx.doi.org/10.1016/j.jelekin.2007.02.003 http://dx.doi.org/10.1177/1753193410374412
20. Meijer HJ, Rijkelijkhuizen JM, Huijing PA. Myofascial 31. Alberts B, Johnson A, Lewis J, Raff M, Roberts K, Walter
force transmission between antagonistic rat lower limb P. Molecular biology of the cell. 4th edition. New York
muscles: Effects of single muscle or muscle group length- (NY): Garland Science; 2002.
ening. J Electromyogr Kinesiol. 2007;17(6):698–707. 32. Chaudhry H, Bukiet B, Ji Z, Stecco A, Findley T. The
[PMID:17382560]  deformations experienced in the human skin, adipose tis-
http://dx.doi.org/10.1016/j.jelekin.2007.02.006 sues and fascia in manual medicine. J Am Osteopath
21. Smeulders MJ, Kreulen M. Myofascial force transmission Assoc. 2014. In press.
and tendon transfer for patients suffering from spastic pare- 33. McCombe D, Brown T, Slavin J, Morrison WA. The histo-
sis: A review and some new observations. J Electromyogr chemical structure of the deep fascia and its structural
Kinesiol. 2007;17(6):644–56. [PMID:17369052]  response to surgery. J Hand Surg [Br]. 2001;26(2):89–97.
http://dx.doi.org/10.1016/j.jelekin.2007.02.002 [PMID:11281657] 
22. Tomasek JJ, Gabbiani G, Hinz B, Chaponnier C, Brown http://dx.doi.org/10.1054/jhsb.2000.0546
RA. Myofibroblasts and mechano-regulation of connective 34. Fraser JR, Laurent TC, Laurent UB. Hyaluronan: Its
tissue remodelling. Nat Rev Mol Cell Biol. 2002;3(5):349–63. nature, distribution, functions and turnover. J Intern Med.
[PMID:11988769]  1997;242(1):27–33. [PMID:9260563] 
http://dx.doi.org/10.1038/nrm809 http://dx.doi.org/10.1046/j.1365-2796.1997.00170.x
23. Gabbiani G. The myofibroblast in wound healing and fibro- 35. Stecco A, Gesi M, Stecco C, Stern R. Fascial components
contractive diseases. J Pathol. 2003;200(4):500–3. of the myofascial pain syndrome. Curr Pain Headache Rep.
 883

KWONG and FINDLEY. Fascia: Current knowledge, future directions

2013;17(8):352–63. [PMID:23801005]  Int J Ther Massage Bodywork. 2009;2(4):9–23.

http://dx.doi.org/10.1007/s11916-013-0352-9 [PMID:21589740]
36. Chaudhry H, Bukiet B, Roman M, Stecco A, Findley T. 47. Liptan GL. Fascia: A missing link in our understanding of
Squeeze film lubrication for non-Newtonian fluids with the pathology of fibromyalgia. J Bodyw Mov Ther.
application to manual medicine. Biorheology. 2013;50(3– 2010;14(1):3–12. [PMID:20006283] 
4):191–202. [PMID:23863283] http://dx.doi.org/10.1016/j.jbmt.2009.08.003
37. Roman M, Chaudhry H, Bukiet B, Stecco A, Findley TW. 48. Shah JP, Gilliams EA. Uncovering the biochemical milieu
Mathematical analysis of the flow of hyaluronic acid of myofascial trigger points using in vivo microdialysis:
around fascia during manual therapy motions. J Am Osteo- An application of muscle pain concepts to myofascial pain
path Assoc. 2013;113(8):600–10. [PMID:23918911]  syndrome. J Bodyw Mov Ther. 2008;12(4):371–84.
http://dx.doi.org/10.7556/jaoa.2013.021 [PMID:19083696] 
38. Gibson W, Arendt-Nielsen L, Graven-Nielsen T. Referred http://dx.doi.org/10.1016/j.jbmt.2008.06.006
pain and hyperalgesia in human tendon and muscle belly 49. Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY,
tissue. Pain. 2006;120(1–2):113–23. [PMID:16359798]  Phillips TM, Gerber LH. Biochemicals associated with
http://dx.doi.org/10.1016/j.pain.2005.10.023 pain and inflammation are elevated in sites near to and
39. Schilder A, Hoheisel U, Magerl W, Benrath J, Klein T, remote from active myofascial trigger points. Arch Phys
Treede RD. Sensory findings after stimulation of the thora- Med Rehabil. 2008;89(1):16–23. [PMID:18164325] 
columbar fascia with hypertonic saline suggest its contribu- http://dx.doi.org/10.1016/j.apmr.2007.10.018
tion to low back pain. Pain. 2014;155(2):222–31. 50. Meltzer KR, Cao TV, Schad JF, King H, Stoll ST, Standley
[PMID:24076047]  PR. In vitro modeling of repetitive motion injury and myo-
http://dx.doi.org/10.1016/j.pain.2013.09.025 fascial release. J Bodyw Mov Ther. 2010;14(2):162–71.
40. Cailliet R. Low back pain syndrome. 4th ed. Philadelphia [PMID:20226363] 
(PA): F. A. Davis; 1991. http://dx.doi.org/10.1016/j.jbmt.2010.01.002
41. Bednar DA, Orr FW, Simon GT. Observations on the 51. Langevin HM, Fox JR, Koptiuch C, Badger GJ, Greenan-
pathomorphology of the thoracolumbar fascia in chronic Naumann AC, Bouffard NA, Konofagou EE, Lee WN, Tri-
mechanical back pain. A microscopic study. Spine. 1995; ano JJ, Henry SM. Reduced thoracolumbar fascia shear
20(10):1161–64. [PMID:7638659]  strain in human chronic low back pain. BMC Musculoske-
http://dx.doi.org/10.1097/00007632-199505150-00010 let Disord. 2011;12:203–13. [PMID:21929806] 
42. Yahia L, Rhalmi S, Newman N, Isler M. Sensory innerva- http://dx.doi.org/10.1186/1471-2474-12-203
tion of human thoracolumbar fascia. An immunohisto- 52. Ercole B, Antonio S, Julie Ann D, Stecco C. How much
chemical study. Acta Orthop Scand. 1992;63(2):195–97. time is required to modify a fascial fibrosis? J Bodyw Mov
[PMID:1590057]  Ther. 2010;14(4):318–25. [PMID:20850038] 
http://dx.doi.org/10.3109/17453679209154822 http://dx.doi.org/10.1016/j.jbmt.2010.04.006
43. Tesarz J, Hoheisel U, Wiedenhöfer B, Mense S. Sensory 53. Day JA, Stecco C, Stecco A. Application of fascial manip-
innervation of the thoracolumbar fascia in rats and humans. ulation technique in chronic shoulder pain—anatomical
Neuroscience. 2011;194:302–8. [PMID:21839150]  basis and clinical implications. J Bodyw Mov Ther. 2009;
http://dx.doi.org/10.1016/j.neuroscience.2011.07.066 13(2):128–35. [PMID:19329049] 
44. Stecco C, Macchi V, Porzionato A, Morra A, Parenti A, http://dx.doi.org/10.1016/j.jbmt.2008.04.044
Stecco A, Delmas V, De Caro R. The ankle retinacula: 54. Simmonds N, Miller P, Gemmell H. A theoretical frame-
Morphological evidence of the proprioceptive role of the work for the role of fascia in manual therapy. J Bodyw Mov
fascial system. Cells Tissues Organs. 2010;192(3):200–10. Ther. 2012;16(1):83–93. [PMID:22196432] 
[PMID:20197652]  http://dx.doi.org/10.1016/j.jbmt.2010.08.001
http://dx.doi.org/10.1159/000290225 55. Crane JD, Ogborn DI, Cupido C, Melov S, Hubbard A,
45. Stecco C, Gagey O, Belloni A, Pozzuoli A, Porzionato A, Bourgeois JM, Tarnopolsky MA. Massage therapy attenu-
Macchi V, Aldegheri R, De Caro R, Delmas V. Anatomy of ates inflammatory signaling after exercise-induced muscle
the deep fascia of the upper limb. Second part: Study of damage. Sci Transl Med. 2012;4(119):119ra13.
innervation. Morphologie. 2007;91(292):38–43. [PMID:22301554] 
[PMID:17574469]  http://dx.doi.org/10.1126/scitranslmed.3002882
http://dx.doi.org/10.1016/j.morpho.2007.05.002 56. Langevin HM, Yandow JA. Relationship of acupuncture
46. van der Wal J. The architecture of the connective tissue in points and meridians to connective tissue planes. Anat Rec.
the musculoskeletal system-an often overlooked functional 2002;269(6):257–65. [PMID:12467083] 
parameter as to proprioception in the locomotor apparatus. http://dx.doi.org/10.1002/ar.10185
884

JRRD, Volume 51, Number 6, 2014

57. Langevin HM, Churchill DL, Wu J, Badger GJ, Yandow [PMID:23768282] 

JA, Fox JR, Krag MH. Evidence of connective tissue http://dx.doi.org/10.1016/j.jbmt.2013.05.015
involvement in acupuncture. FASEB J. 2002;16(8):872–74. 61. Still AT. Osteopathy research and practice. Kirksville
[PMID:11967233] (MO): Published by the author; 1910.
58. Julias M, Edgar LT, Buettner HM, Shreiber DI. An in vitro
assay of collagen fiber alignment by acupuncture needle Submitted for publication October 16, 2013. Accepted in
rotation. Biomed Eng Online. 2008;7:19–31. revised form March 13, 2014.
[PMID:18606012] 
http://dx.doi.org/10.1186/1475-925X-7-19 This article and any supplementary material should be
59. Langevin HM, Bouffard NA, Badger GJ, Churchill DL, cited as follows:
Howe AK. Subcutaneous tissue fibroblast cytoskeletal Kwong EH, Findley TW. Fascia—Current knowledge
remodeling induced by acupuncture: Evidence for a mech- and future directions in physiatry: Narrative review. J Reha-
anotransduction-based mechanism. J Cell Physiol. 2006; bil Res Dev. 2014;51(6):875–84.
207(3):767–74. [PMID:16511830]  http://dx.doi.org/10.1682/JRRD.2013.10.0220
http://dx.doi.org/10.1002/jcp.20623
60. Findley TW, Shalwala M. Fascia Research Congress evi-
dence from the 100 year perspective of Andrew Taylor
Still. J Bodyw Mov Ther. 2013;17(3):356–64.