Fasciacurrentknowledge
Fasciacurrentknowledge
Fasciacurrentknowledge
Pages 875–884
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
875
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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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“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
878
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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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
881
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
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ACKNOWLEDGMENTS
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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
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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
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