Antonio Stecco

Histological study of the deep fasciae of the limbs

The aim of this study is to analyse the deep fasciae of limbs in order to evaluate the collagen and elastic fibre arrangement and the types of innervation. Histological and immunohistochemical stains were performed in 72 specimens. The deep fascia of the limbs is a sheath presenting a mean thickness of 1mm, formed by two to three layers of parallel collagen fibre bundles. In the adjacent layers, they show different orientations. Each layer is separated from the adjacent one by loose connective tissue, permitting the sliding of the collagen layers. Nerve fibres were found in all specimens, while muscular fibres were evidenced only in one specimen. The described structure permits the fasciae of the limbs to have a strong resistance to traction, even when exercised in different directions. The capacity of the different collagen layers to glide one on the other could be altered in cases of overuse syndrome, trauma, or surgery.

Fascial Components of the Myofascial Pain Syndrome

Myofascial pain syndrome (MPS) is described as the muscle, sensory, motor, and autonomic nervous system symptoms caused by stimulation of myofascial trigger points (MTP). The participation of fascia in this syndrome has often been neglected. Several manual and physical approaches have been proposed to improve myofascial function after traumatic injuries, but the processes that induce pathological modifications of myofascial tissue after trauma remain unclear. Alterations in collagen fiber composition, in fibroblasts or in extracellular matrix composition have been postulated. We summarize here recent developments in the biology of fascia, and in particular, its associated hyaluronan (HA)-rich matrix that address the issue of MPS.

Pectoral and femoral fasciae: common aspects and regional specializations

The aim of this study was to analyse the organization of the deep fascia of the pectoral region and of the thigh. Six unembalmed cadavers (four men, two women, age range 48–93 years old) were studied by dissection and by histological (HE, van Gieson and azan-Mallory) and immunohistochemical (anti S-100) stains; morphometric studies were also performed in order to evaluate the thickness of the deep fascia in the different regions. The pectoral fascia is a thin lamina (mean thickness ± SD: 297 ± 37 μm), adherent to the pectoralis major muscle via numerous intramuscular fibrous septa that detach from its inner surface. Many muscular fibres are inserted into both sides of the septa and into the fascia. The histological study demonstrates that the pectoral fascia is formed by a single layer of undulated collagen fibres, intermixed with many elastic fibres. In the thigh, the deep fascia (fascia lata) is independent from the underlying muscle, separated by the epimysium and a layer of loose connective tissue. The fascia lata presents a mean thickness of 944 μm (±102 μm) and it is formed by bundles of collagen fibres, arranged in two to three layers. In each layer, the fibres are parallel to each other, whereas the orientation of the fibres varies from one layer to the adjacent one. The van Gieson elastic fibres stain highlights the presence of elastic fibres only in the more external layer of the fascia lata. In the thigh the epimysium is easily recognizable under the deep fascia and presents a mean thickness of 48 μm. Both the fascia lata and pectoral fascia result innerved, no specific differences in density or type of innervations is highlighted. The deep fascia of the pectoral region is morphologically and functionally different from that of the thigh: the fascia lata is a relatively autonomous structure with respect to the underlying muscular plane, while the pectoralis fascia acts as an additional insertion for the pectoralis major muscle. Different portions of the pectoralis major muscle are activated according to the glenohumeral joint movements and, consequently, selective portions of the pectoral fascia are stretched, activating specific patterns of proprioceptors. So, the pectoralis muscle has to be considered together with its fascia, and so as a myofascial unit, acting as an integrated control motor system.

Application of Fascial Manipulation© technique in chronic shoulder pain—Anatomical basis and clinical implications

Classical anatomy still relegates muscular fascia to a role of contention. Nonetheless, different hypotheses concerning the function of this resilient tissue have led to the formulation of numerous soft tissue techniques for the treatment of musculoskeletal pain. This paper presents a pilot study concerning the application of one such manual technique, Fascial Manipulation, in 28 subjects suffering from chronic posterior brachial pain. This method involves a deep kneading of muscular fascia at specific points, termed centres of coordination (cc) and centres of fusion (cf), along myofascial sequences, diagonals, and spirals. Visual Analogue Scale (VAS) measurement of pain administered prior to the first session, and after the third session was compared with a follow-up evaluation at 3 months. Results suggest that the application of Fascial Manipulation technique may be effective in reducing pain in chronic shoulder dysfunctions. The anatomical substratum of the myofascial continuity has been documented by dissections and the biomechanical model is discussed.

The Ankle Retinacula: Morphological Evidence of the Proprioceptive Role of the Fascial System

Study Design: Research report. Objectives: To evaluate the anatomical characteristics of the ankle retinacula and their relationship with the fasciae and muscles in healthy subjects and in patients with ankle sprain outcomes. Background: The role of the retinacula in proprioception has begun to emerge, but without clear anatomical bases or descriptions of their possible damage in patients with ankle sprain outcomes. Methods: Dissection, histological and immunohistochemical analysis of 27 legs. An in vivo radiological study by MRI was also performed on 7 healthy volunteers, 17 patients with outcomes of ankle sprain, and 3 amputated legs. Results: The retinacula are thickenings of the deep fascia presenting bone or muscular connections. They are formed of 2–3 layers of parallel collagen fibre bundles, densely packaged with a little loose connective tissue, without elastic fibres but many nervous fibres and corpuscles. By MRI, the retinacula appeared as low-signal-intensity bands with a mean thickness of 1 mm. In patients with outcomes of ankle sprain, MR findings were abnormal retinacula thickness, signal intensity, and full-thickness gap. Discussion: The retinacula are not static structures for joint stabilisation, like the ligaments, but a specialisation of the fascia for local spatial proprioception of the movements of foot and ankle. Their anatomical variations and accessory bundles may be viewed as morphological evidence of the integrative role of the fascial system in peripheral control of articular motility.

Myofascial Pain of the Jaw Muscles: Comparison of Short-Term Effectiveness of Botulinum Toxin Injections and Fascial Manipulation Technique

Abstract A randomized controlled trial was performed to compare the short-term effectiveness of botulinum toxin injections and physiatric treatment provided by means of Fascial Manipulation techniques in the management of myofascial pain of jaw muscles. Thirty patients with a Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnosis of myofascial pain were randomized to receive either single-session botulinum toxin injections (Group A) or multiple-session Fascial Manipulation (Group B). Maximum pain levels (VAS ratings) and jaw range of motion in millimeters (maximum mouth opening, protrusion, right and left laterotrusion) were assessed at baseline, at the end of treatment, and at a three-month follow-up. Both treatment protocols provided significant improvement over time for pain symptoms. The two treatments seem to be almost equally effective, Fascial Manipulation being slightly superior to reduce subjective pain perception, and botulinum toxin injections being slightly superior to increase jaw range of motion. Differences between the two treatment protocols as to changes in the outcome parameters at the three-months follow-up were not relevant clinically. Findings from the present investigation are in line with literature data supporting the effectiveness of a wide spectrum of conservative treatment approaches to myofascial pain of the jaw muscles. Future studies on larger samples over a longer follow-up span are needed on the way to identify tailored treatment strategies.

The pectoral fascia: Anatomical and histological study

AIM Analysis of the pectoral fascia from a macroscopic and histological point of view. RESULTS The pectoral fascia appears as a thin collagen layer (mean thickness of 297 microm) formed by undulated collagen fibres and many elastic fibres, within which small nerves are highlighted. Numerous septa detach from its internal surface, creating an intimate connection between the fascia and the pectoralis major muscle. DISCUSSION The pectoral fascia and the pectoralis major muscle should be considered together, given that the anatomical base is effectively a myofascial unit, term that defines the muscles and the fascia of a specific region that have a precise functional organization. The capacity of force transmission between the inferior and superior limbs needs to be attributed to this entire myofascial complex. We hypothesize that the superficial, large muscles of the trunk developed inside the superficial layer of the deep fascia to enhance modulation of tension transmission between the different segments of the body.

Fascia research – A narrative review

This article reviews fascia research from our laboratory and puts this in the context of recent progress in fascia research which has greatly expanded during the past seven or eight years. Some readers may not be familiar with the terminology used in fascia research articles and are referred to LeMoon (2008) for a glossary of terms used in fascia-related articles.

Fascia redefined: anatomical features and technical relevance in fascial flap surgery.

Fascia has traditionally been thought of as a passive structure that envelops muscles, and the term “fascia” was misused and confusing. However, it is now evident that fascia is a dynamic tissue with complex vasculature and innervation. A definition of fascia as an integral tissue has been provided here, highlighting the main features of the superficial and deep fasciae. Wide anatomic variations and site-specific differences in fascial structure are described, coupled with results of our extensive investigations of fascial anatomy. This will enable surgeons to make better decisions on selecting the appropriate fascia in the construction of fascial flaps. The use of the superficial or deep fasciae in the creation of a fascial flap cannot be selected at random, but must be guided by the anatomical features of the different types of fasciae. In particular, we suggest the use of the superficial fascia, such as the parascapular fascio-cutaneous free flap or any cutaneous flap, when a well-vascularized elastic flap, with the capacity to adhere to underlying tissues, is required, and a fascio-cutaneous flap formed by aponeurotic fascia to resurface any tendon or joints exposures. Moreover, the aponeurotic fascia, such as the fascia lata, can be used as a surgical patch if the plastic surgeon requires strong resistance to stress and/or the capacity to glide freely. Finally, the epimysial fascia, such as in the latissimus dorsi flap, can be used with success when used together with the underlying muscles. Clearly, extensive clinical experience and judgment are necessary for assessment of their potential use.

The Expansions of the Pectoral Girdle Muscles onto the Brachial Fascia: Morphological Aspects and Spatial Disposition

Background/Aims: The aim of this study was to analyse the relationships between the expansions of the pectoral girdle muscles, i.e. pectoralis major, latissimus dorsi and deltoid, and the brachial fascia. Methods: Thirty shoulder specimens from 15 unembalmed adult cadavers were studied by dissection and in vivo radiological studies were performed in 20 patients using magnetic resonance (MR) imaging. Results: The clavicular part of the pectoralis major muscle sent a fibrous expansion onto the anterior portion of the brachial fascia, its costal part onto the medial portion and medial intermuscular septum. The latissimus dorsi muscle showed a triangular fibrous expansion onto the posterior portion of the brachial fascia. The posterior part of the deltoid muscle inserted muscular fibres directly onto the posterior portion of the brachial fascia, its lateral part onto the lateral portion and the lateral intermuscular septum. In MR images, the brachial fascia appeared as a low-signal-intensity sinuous line of connective tissue, sharply delineated in T1-weighted sequences. Conclusion: The expansions of the pectoral girdle muscles onto the brachial fascia were present in all the subjects and showed a quite constant course with a specific spatial organization. During the various movements of the arm, these expansions stretch selective portions of the brachial fascia, with possible activation of specific patterns of fascial proprioceptors.