the role of connective tissue in the embryology of the musculoskeletal system towards a paradigm shift

This paper presents a review of literature regarding the role of embryological connective tissue in the formation of muscles and the organization of the musculoskeletal system. The intention is to introduce a potential paradigm shift with regards to understanding peripheral coordination of movement and movement patterns. This new perspective could improve comprehension of the normal physiological function of connective tissue and, whenever it is pathological, resultant symptoms. Furthermore, this paper briefly discusses some implications of this paradigm shift in the interpretation of movement patterns, posing further questions for future research

The Fascial Manipulation Technique and Its Biomechanical Model: A Guide to the Human Fascial System

This paper examines the principal characteristics of an innovative biomechanical model for interpreting the human fascial system and discusses the mechanisms that underlie the model in reference to some current trends in musculoskeletal research. The model, developed specifically for manual therapists working with movement dysfunction and pain, is the fruit of thirty-five years of study and physiotherapy clinical practice. It presents a functional interpretation of the relationship between muscles, deep fascia, and its derivatives (epimysium, perimysium, and endomysium). This model guides the clinical reasoning process employed in the manual therapy method known as Fascial Manipulation. Reference is made throughout to recent anatomical dissections designed specifically to examine the connections between deep fascia and muscles, the histological aspects of deep fascia, and its biomechanical characteristics. This knowledge could contribute to clinician\u2019s understanding of the myofascial system and the role that deep fascia may play in musculoskeletal dysfunctions

2019 Ejtm Special on Muscle Fascia

For many years the fasciae have been considered by the anatomists only as a “white envelope for the muscles”, that is generally removed in anatomical tables, to recognize muscle nerves and vessels. This is one of the reasons that different descriptions of the fasciae exist. On the other hand, in the last years the fasciae and their properties are becoming of central importance to clinicians practicing in various conventional and alternative therapies. The results from the worldwide research activities constitute a body of significant and important data, but this clinical interest is not supported by in-depth comprehension to how integrate the new knowledge about fasciae with the classical biomechanical models based on muscles, tendons and bones. To close this gap an Ejtm Special on “Muscle Fascia” will be published September 30, 2019, but the typescripts will be added to the Ejtm Early Release list as soon as all authors will approve their Epub papers. Deadline for original articles and reviews is June 1st, 2019, but the Editors hope that authors submit their typescripts much earlier

A global approach for plantar fasciitis with extracorporeal shockwaves treatment

Extracorporeal Shockwaves Treatment is considered an effective therapeutic option for plantar fasciitis, but the standard application in the medial insertion of the plantar fascia on the calcaneus has provided ambiguous evidences. In this case, a 63-year man with plantar fasciitis was treated in a 3-session program and Foot and Ankle Outcome Scale and Foot Functional Index questionnaires were chosen for the clinical outcome evaluation. The therapy was focused on the active trigger or myofascial points of the leg, thigh and pelvis in order to return the correct equilibrium of the myofascial system of the whole limb. The patient has already reported an improvement after the second session (FAOS: 76 vs 33, FFI: 85%) which was confirmed in the third one and in the 1-month follow up (FAOS: 79, FFI: 6%) Results suggest that plantar fasciitis may be due to proximal rigidity or tension of the fascia and a global approach using ESWT may have a similar or better outcome respect to the standard application

The Fascial Manipulation Technique and Its Biomedical Model: A Guide to the Human Fascial System

This is the expanded abstract of a workshop presented at the Second International Fascia Research Congress; October 27 – 30, 2009; Amsterdam, Netherlands

Analysis of the presence of the hyaluronic acid inside the deep fasciae and in the muscles

Recent works have demonstrated that the deep fascia is a multilayer structure, formed by different layers of collagen fibers and loose connective tissue (LCT). The aim of this work was to study the layers of LCT inside the deep fasciae, and in particular to evaluate the presence of Hyaluronic acid (HA). Three fresh not embalmed cadavers were studied. Samples of the deep fascia together with the underlying muscles were taken from the neck over the SCOM, from the abdomen over the rectus muscle and from the thigh over the sartorius muscle. Samples were stained with hematoxylin-eosin, azan-Mallory, Alcian blue and a biotinylated HA-binding protein that has high specificity for HA. At the microscopic evaluation, the deep fascia was formed of two or three layers of parallel collagen fibre bundles, densely packaged. Each collagen layer presented a mean thickness (± SD) of 277.6 ± 86.1 µm. Between the different layers, a thin layer of loose connective tissue could be recognized, having mean thickness 43 ± 12 µm. Staining with the Alcian Blue and with the highly specific HA-binding peptide documented a layer of hyaluronan between fascia and muscle and inside deep fascia, in particular inside the loose connective tissue separating the fibrous sub-layer of the fascia. In some samples, some fibroblast-like cells that stained very well at the Alcian Blue stain were observed. It was postulated that these were specialized cells for the biosynthesis of the HA-rich matrix, that we’ll call “fasciacyte”. This means that the fascia thus provides an extracellular matrix that is a gliding lubricant over muscle, permitting the free contraction of muscles, but also a unique matrix for its repair and regeneration. Besides, the HA inside the deep fascia facilitates the free sliding of two adjacent fibrous fascial layers, guaranteed the normal functionality of the deep fascia. If the HA assumes a more packed conformation, or more generally if the loose connective tissue inside the fascia alters its density, the behavior of the whole deep fascia and of the underlying muscle could be compromised. This could be at the origin of many myofascial pains

The Fascial Manipulation Technique and Its Biomedical Model: A Guide to the Human Fascial System

This is the expanded abstract of a workshop presented at the Second International Fascia Research Congress; October 27 – 30, 2009; Amsterdam, Netherlands

The possible use of ultrasonography for the diagnosis of myofascial neck pain

A definitive diagnosis of chronic neck pain (CNP) is sometimes not possible. The aim of this study was to understand the possible role of the deep fasciae in CNP and the utility of the ultrasonography in the diagnosis of myofascial neck pain. The morphometric and clinical data of 25 healthy subjects and 28 patients with CNP were compared. For all subjects, the active and passive cervical Range Of Motion (ROM) was analysed and the Neck Pain Disability Questionnaire (NDPQ) was administered. The fascial thickness of the sternal ending of the sternocleidomastoid and medial scalene muscles was also analysed by ultrasonography. There were significant differences between healthy subjects in the thickness of the upper side of the sternocleidomastoid fascia and the lower and upper sides of the right scalene fascia. Analysis of the thickness of the sub-layers showed a significant increase of the loose connective tissue inside the fascia, rather than of the fibrous sublayers. The data support the hypothesis that the loose connective tissue inside the fasciae plays a significant role in the pathogenesis of CNP. In particular, the value of 0.15 cm of the SCM fascia was considered as a cut-off value which allows the clinician to make a diagnosis of myofascial disease in a subject with CNP. The variation of thickness of the fascia correlated with the increase in quantity of the loose connective tissue but not with dense connective tissue, and probably more specifically with hyaluronan

Echographic study of the muscular fasciae

Today there is a great interest about the muscular fasciae and their possible role in myofascialpain, but it is still unclear what are their main features in living. For example the thickness of the thoracolumbar fascia, that is probably the most studied fascia, varies from 0.37 mm [1] to 0.68 mm [2]. The lack of a standard value for the fascial thickness has a great clinical relevance, indeed it seems that their increased thickness could be related to myofascial pain or reduction of the range of motion. Therefore, the definition of standard values of fascial thickness is the first step to investigate fascial alterations that may play a role in myofascial pain. The fascial thickness was evaluated in 24 subjects with a mean age of 30.46 years (SD ± 9.241).The mean BMI was of 22.08 (SD ± 3.696),in particular women with an BMI of 20.30 and 25.08 for men. The measurement was performed with the portable ultrasound system of SonoSite®, linear probe of 15 Hz. For each subject 13 deep fasciae were analyzed, both in the trunk, superior and inferior limbs. The collected data showed that the average thickness of the fasciae ranges from 0.71 ± 0.15 mm (deep fascia of the anterior region of the arm) and 1.62 ± 0.39 mm (plantar fascia). The fasciae of the anterior compartments are thinner respect to the fasciae of the posterior ones (p valu

Role of fasciae in Civinini-Morton’s neuroma

Civinini-Morton’s metatarsalgia is characterized by a swelling, known as “neuroma”, of the common digital plantar nerve (CDPN), which may cause extreme pain and disability. Microscopically, the affected nerve presents extensive concentric perineural fibrosis. It is considered an entrapment syndrome, due to the impingement of CDNP against the stiff deep transverse metatarsal ligament (DMTL). According to this hypothesis, some surgeons suggest neurolysis, by cutting the DMTL1, as a treatment, instead of generally performed neurectomy. Also some rehabilitation techniques affirm that modifying perineural connective tissue improves patients’ symptoms2. To better study the relationships of the nerve with DTML and deep fasciae of the foot we dissected 15 feet and analyzed 30 MRI. Data from dissections confirm that CDPN’s bifurcation in the second and third webspace is always distal to DTML. Proximal to the metatarsal heads, the nerve is encased by a sheath made by concentric sleeves of fibrous and loose connective tissue continuous with vascular sheaths and deep fasciae of the foot: this arrangement, similar to a “telescope”, may provide a channel to allow the nerve to move independently from surrounding structures, being protected against traction during walking. In the intermetatarsal space, fascial septa connect DMTL, tendon sheaths and plantar fascia, and bound lobules of adipose tissue, more abundant on plantar aspect of the neurovascular bundle: these, along with adipocytes contained between concentric layers of neural sheath, could cushion compressive stresses. Distally to DMTL this protective system is less represented. MRI shows marked inter-individual morphologic variation of the intermetatarsal channel: its size varies from 16.22 mm2 to 64.43 mm2, with a mean value of 37.34 mm2. Its shape ranges from oval or rounded (with a big distance between DMTL and plantar fascia) to roughly rectangular (with a narrow distance); in some people the channel is filled with adipose tissue, while in others fibrous tissue prevails. Fascial septa also vary among people, ranging from barely discernible to 1.2 mm thick, while DMTL is relatively constant (from 0.5 mm to 1.0 mm thick). Plantar fascia varies from 0.6 to 1.1 mm. People who lack an efficient “sliding and cushioning system” could tolerate less mechanical stresses during walking and thus be at increased risk of Civinini-Morton’s syndrome. Perineural scarring (which forms the neuroma) consequent to nerve impingement could, by destroying neural sheath’s structure, further impair nerve protection and worsen symptoms