PM R 8 (2016) 161-168

www.pmrjournal.org

Narrative Review

Fascial Disorders: Implications for Treatment

Antonio Stecco, MD, Robert Stern, MD, Ilaria Fantoni, MD, Raffaele De Caro, MD,
Carla Stecco, MD

Abstract

In the past 15 years, multiple articles have appeared that target fascia as an important component of treatment in the field of
physical medicine and rehabilitation. To better understand the possible actions of fascial treatments, there is a need to clarify the
definition of fascia and how it interacts with various other structures: muscles, nerves, vessels, organs. Fascia is a tissue that
occurs throughout the body. However, different kinds of fascia exist. In this narrative review, we demonstrate that symptoms
related to dysfunction of the lymphatic system, superficial vein system, and thermoregulation are closely related to dysfunction
involving superficial fascia. Dysfunction involving alterations in mechanical coordination, proprioception, balance, myofascial
pain, and cramps are more related to deep fascia and the epimysium. Superficial fascia is obviously more superficial than the
other types and contains more elastic tissue. Consequently, effective treatment can probably be achieved with light massage or
with treatment modalities that use large surfaces that spread the friction in the first layers of the subcutis. The deep fasciae and
the epymisium require treatment that generates enough pressure to reach the surface of muscles. For this reason, the use of small
surface tools and manual deep friction with the knuckles or elbows are indicated. Due to different anatomical locations and to the
qualities of the fascial tissue, it is important to recognize that different modalities of approach have to be taken into consid-
eration when considering treatment options.

Introduction and the individuals who perform research in fascial

In the past 15 years, multiple articles have appeared
that target fascia as an important component of treat-
ment in the field of physical medicine and rehabilitation
[1,2]. The current research was performed on PubMed
databases using keywords that contain the word
fascia related to various noninvasive treatments. The
research included articles published between 2000 and
2015 (Table 1). A total of 79 articles were surveyed.
These studies varied immensely in quality. Moreover,
there were no clear indications for relating symptoms to
specific fascial treatment modalities. This is a very
important issue that demands clarification, for the sake
of the clinical specialty, for patients, and for
practitioners.
The purpose of this narrative review is to clarify the
physiology of fascia and its disorders to better correlate
fascial symptoms with specific therapeutic approaches.
The review includes articles, found in the PubMed da-
tabases in the last decade, with a clear focus in fascial
anatomy and pathology. This review will facilitate dis-
cussions between clinicians and also between clinicians
treatments.
Fascia is a tissue that occurs throughout the body.
However, different kinds of fasciae exist (Table 2). In
any general classification system, it is important to
recognize a superficial fascia, a deep (or muscular)
fascia, and a visceral fascia (Figures 1-3). Numerous
authors [3-5] recognize, in addition, the existence of
the epimysium and perimysium within deep fasciae.
Each category of fascia has specific anatomical and
histological features that interact with the aforemen-
tioned structures in a very precise manner. These must
be separated from each other and compared.
Literature Search Strategy
The current research was performed by A.S. on arti-
cles available only in PubMed databases using keywords
that contain the word fascia. Key words are listed in
Table 1. Articles involved various noninvasive treat-
ments with a level of evidence of II-3 or above. The
research included articles published between 2000 and
2015 (Table 1). A total of 79 articles were surveyed.

1934-1482/$ - see front matter 2016 by the American Academy of Physical Medicine and Rehabilitation
http://dx.doi.org/10.1016/j.pmrj.2015.06.006
162 Fascial Disorders: Implications for Treatment

Table 1 Deep Fascia

Key words used and numbers of PubMed articles surveyed
Key Words
Fascia treatment
Fascial treatment
Fascia therapy
Fascial therapy
Fascia technique
Fascial technique
Fascia method
Fascial method
Fascia manipulation
Fascial manipulation
Fascia relase
Fascial release
Myofascial therapy
Myofascial treatment
Myofascial release
Total
Fascial Anatomy
Superficial Fascia
According to the Italian and German schools of
thought, the superficial fascia is a fibrous layer that
divides the subcutis into a superficial and deep, loosely
organized adipose-rich layer. It is formed by loosely
packed interwoven collagen fibers admixed with abun-
dant elastic fibers. Superficial fascia is present
throughout the body and, according to Abu-Hijleh et al
[6], has arrangements and thickness that vary according
to the region of the body, to the body surface, and also to
differences that exist between genders. It is thicker in the
lower than in the upper extremities, on the posterior than
on the anterior aspect of the body, and in females
compared with males. Macroscopically, the superficial
fascia appears as a well-defined membrane and can be
dissected with scalpels. Microscopically, its structure is
better described as multi-lamellar, or like a tightly
packed honeycomb. The superficial fascia is tightly con-
nected with superficial veins and with lymphatic vessels.
Inside the superficial fascia, the subcutaneous plexus is
present, which functions in thermoregulation.
Articles (n) The term deep fascia refers to all of the well-
2 organized, dense, fibrous layers that interpenetrate
2 and surround muscles, bones, nerves and blood vessels,
7 binding all of these structures together into a firm,
2
compact, continuous mass. Over bones it is termed the
0
2 periosteum; around tendons it forms the paratendon;
0 and around vessels and nerves it forms the neuro-
2 vascular sheath. Around joints it strengthens the
2 capsules and ligaments. So, we can consider the para-
3
tendon, the neurovascular sheath, and the periosteum
0
4 as particular specializations of deep fascia, not only
18 because they are in continuity with deep fascia but also
16 because they have the same histological features. It is
19 possible to distinguish 2 major types of muscular fascia,
79
according to their thickness and to their relationships
with underlying muscles: the aponeurotic fasciae and
the epimysial fasciae. The aponeurotic fasciae contain
collagen fiber bundles that are aligned all along the
main axis of the limbs. Consequently, in both longitu-
dinal and oblique directions, the deep fasciae function
like a tendon, allowing force transmission along the
limbs. Another important characteristic of the aponeu-
rotic fascia is its ability to adapt to volume variations of
the underlying muscles during contraction. In the
transverse direction, collagen fiber bundles are less
compact and, due to the presence of loose connective
tissue, are easily separated from each other. This
increased motion of the collagen fiber bundles allows
the aponeurotic fasciae to adapt to the volume varia-
tions of the underlying muscles, particularly since they
contain so few elastic fibers.
It is apparent that the adaptability of aponeurotic
fascia is based on its unique relationship with loose
connective tissue. Several studies demonstrate that the
aponeurotic fasciae are richly innervated (mean volume
fraction, 1.2%). Abundant free and encapsulated nerve
endings (including Ruffini and Pacinian corpuscles) have
been found in the thoracolumbar fascia, the bicipital
aponeurosis, and the various retinacula [7-12]. Nerve
fibers, particularly numerous around blood vessels, are

Table 2
Description of different fascia types
Fascia Type Anatomy Neural Properties Depth Load Transmission Treatment Profile
Superficial Loosely packed, interwoven Pacini Rufini corpuscle From a few millimeters Low effect Light massage with a
collagen fibers admixed and free ending below the skin to the large surface
with abundant elastic fibers nerves middle of the
hypodermal
Deep Well-organized, dense, Pacini Rufini corpuscle Inferior to the High effect Deep manipulation
fibrous layers and free ending hypodermal over the with a small surface
nerves epimysium for a limited amount
of gliding
Epimysial Fibrous laminae composed of Relation with muscle Over the muscles High effect in Deep manipulation
type I and III collagen fibers spindles combination with with a small surface
and elastic fibers the adherent for a limit amount of
muscle gliding
 A. Stecco et al. / PM R 8 (2016) 161-168
Figure 1. CT scan of the lumbar area.
distributed throughout the fibrous components of their
respective fascia. The capsules of the corpuscles and
free nerve endings (mechanoreceptors) are closely
connected to the surrounding collagen fibers and fibrous
stroma that make up the fascia. Deising et al [13] find a
dense neuronal innervation with nonpeptidergic nerve
fiber endings and encapsulated mechano-receptors in
muscle fascia. Stecco et al [12] have also demonstrated
the presence of autonomic nerve fibers in deep fasciae.
Tesarz et al [14] confirmed the dense sensory innerva-
tion of the thoracolumbar fascia. For these reason,
authors have considered the thoracolumbar fascia an
important link in nonspecified low back pain.
Epimysial Fascia
Epimysial fascia comprises fibrous laminae with a
mean thickness of 150 to 200 mm. They are composed of
type I and III collagen fibers [15] as well as many elastic
fibers (w15%). In fusiform muscles (ie, biceps brachii),
the collagen fibers have an angle of incidence of 55
with
respect to the path of the muscle fibers at rest [16]. In
pennate muscles (ie, rectus femoris) the epimysial fascia
Figure 2. MRI of the lumbar area.
163
Figure 3. Ultrasonography of the lumbar area.
mainly reflect the progression of muscular fibers, forming
a dense lamina that continues into the tendon of the
muscle. One of the most important features of the epi-
mysial fasciae is their tight adherence to underlying
muscles via multiple fibrous septa that originate from
their inner aspect and penetrate the muscle. For this
reason, it is impossible to separate the functions and
features of the epimysial fascia and underlying muscle.
Various authors [17-19] have demonstrated how 30%-40%
of the force generated by these muscle is transmitted not
along the tendon but, rather, by the connective tissue
surrounding the muscle.
The presence of a constant basal tone of these muscle
fibers maintains the epimysial fasciae in a state of
permanent more or less increased tension. Many muscle
fibers do not necessarily extend from origin to insertion
(non-spanning muscles) but have tapered ends in the
middle of the muscle belly and end within the muscle
belly. These muscles can transmit force between adja-
cent muscle fibers only via their common perimysium,
emphasizing the concept that force transmission can
occur by pathways other than through myotendinous
routes [20]. These extratendinous transmission forces
may also be used for stabilization of the joint. The force
expressed by a muscle depends not only on its anatomical
structure but also by the angle at which its fibers are
attached to the intramuscular connective tissue and their
relation with the epimysium and deep fasciae [21].
The epimysial fasciae have free nerve endings that
are neither Pacini nor Ruffini corpuscles. The free nerve
endings are particularly numerous surrounding vessels,
but are also distributed homogeneously throughout their
fibrous components. In addition, the epimysial fasciae
make a connection with another type of nervous
receptor: the muscle spindles. Indeed, the capsule of
the muscle spindles corresponds to the perimysium,
epimysium, or fascial septae [22,23].
Strasmann et al [24], analyzing the septum of the
supinator muscle, affirm that a great number of muscle
spindles are inserted directly into the connective tissue
of the septum. Also, examining the evolution of the
164 Fascial Disorders: Implications for Treatment
locomotor system, it becomes evident that the muscle
spindles are firmly connected with the fascia, as has
been demonstrated in the lamprey [25]. Muscle spindles
are sensory receptors within the belly of a muscle that
primarily detect changes in the length of this muscle.
The sensitive fibers of the muscle spindle are stimulated
by minimal stretching, the threshold corresponding to a
tension of 3 g. For this reason, the epimysial fascia plays
a fundamental role. The spindles can be shortened,
responding to the gamma stimulus only if the perimy-
sium is elastic and adaptable.
Disorders of the Superficial Fascia
Fasciae and Lymphedema
Knowing the strong relationships between lymph
vessels and superficial fascia, it can be can postulated
not only that an alteration in the superficial fascia can
cause lymphedema, but also that a patient with lym-
phedema probably has an alteration of the superficial
fascia. Any treatment that involves superficial fascia
should improve the symptoms related to lymphedema.
This hypothesis is supported by a number of studies.
According to Tassenoy et al [26], in the case of lym-
phedema, the adipose tissue, inferior to the superficial
fascia, has a honeycomb appearance, as established by
magnetic resonance imaging (MRI). This corresponds
to fluid associated with the fibrosis. In particular, the
skin septa (or fibrous retinacula cutis) increase their
thickness, the area and perimeter of fat cells is signifi-
cantly increased (P < .05), and fluid is associated with or
close to the muscle fascia. In addition, Marotel et al [27]
find that with CT scans in patients with lymphedema,
there occurs, in order of frequency skin thickening, in-
crease in the subcutaneous tissues area, muscular fascia
thickening, fat infiltration, lines parallel and perpen-
dicular to the skin (corresponding to fibrous retinacula
cutis), and areas of edema along deep fascia.
We suggest that the disposition of the collagen and
elastic fibers inside the superficial fascia could guide
lymphatic flux in the correct direction. Indeed, Hauck
and Castenholz [28] demonstrate the existence of a
low-resistance pathway along connective tissue fibers
for the transinterstitial fluid movement, from the pil-
laries to the initial lymphatics. If the superficial fascia is
altered, the lymphatic drainage becomes compromised.
Fasciae and Venous Pathologies
The superficial fascia is strongly associated with the
superficial veins. In particular, Caggiati [29] shows that
stereo-microscopy of cross-sectioned specimens dem-
onstrates two thick strands originating from the outer
adventitia of the long saphenous vein and anchoring it
to the opposite faces of the compartment. These
strands are also easily recognized by ultrasonography
because of their hyperechogenicity. Furthermore, they
are composed of interwoven connective tissue fibers
emerging directly from the saphenous adventitia. The
evaluation of serially sectioned specimens reveals that
these strands form two continuous laminae. Such a
double-laminar ligament can also be demonstrated
using anatomic or surgical preparations, especially if
care is taken to preserve the planar arrangement of the
connective framework of the hypodermis.
Schweighofer et al [30] describe the same structure
for the small saphenous vein, and the dissections of
Stecco et al [31] confirm that all the major superficial
veins of the inferior limbs are enveloped by a splitting of
the superficial fascia along their entire length. This
strong anatomic relationship between the saphenous
veins and the superficial fascia may have an important
role both in daily clinical practice and in the patho-
physiology of varicose disease. First, the tension of the
superficial fascia strongly influences the saphenous vein
caliber and consequently modulates the blood flow
within it. Second, the superficial fascia may prevent the
saphenous vein from excessive pathological dilatation,
acting as a kind of of mechanical shield. These anatomic
findings can also explain why greater dilation and tor-
tuosity occur in the saphenous tributaries in primary
varicosities. Finally, the superficial fascia could be
considered a major marker for the correct identification
and stripping of the saphenous vein.
Thermoregulation and Skin Tropism
All the subcutaneous arteries participate in the for-
mation of 2 subcutaneous plexi: the subpapillary
plexus, just under the papillaris dermis (top layer of the
skin), and the deep plexus, inside the superficial fascia.
The 2 plexi freely communicate. Only one-fifth of the
capillaries are necessary for skin vascularization,
whereas all of the others function in thermoregulation.
The arteries of the deep plexus present multiple artero-
venous connections. These provide shunts that control
blood flow to the skin and consequently control body
temperature. The dilation and narrowing of the sub-
cutaneous arteries determines both skin temperature
and skin color in the light-skinned races/ethnicities.
Marked skin pallor of the skin, seen in acute shock,
results from vasoconstriction in the arterial plexus of
the hypodermis. It is possible for a change in the
superficial fascia to cause a change in skin color or even
chronic ischemia of the skin. We can hypothesize that a
fibrotic superficial fascia can restrict or choke the
arteries inside it, thereby reducing skin vascularization.
If the arterio-venous shunts become deficient, an
alteration of thermoregulation may occur, resulting in
sensations of excessively hot or cold skin. According to
Distler et al [32], chronic ischemia can result in fibrosis
by creating a pathological path that decreases skin
vascularization.
 A. Stecco et al. / PM R 8 (2016) 161-168
According to Storkebaum and Carmeliet [33], the
regulation of peripheral resistance arteries is essential
for several physiological processes, including control of
blood pressure, thermoregulation, and increase in blood
flow to the central nervous system and to the heart
under stress conditions, such as occurs in severe hyp-
oxia. For these authors, defects in control of peripheral
resistances lead to disorders such as hypertension,
orthostatic hypotension, Raynaud phenomenon, defec-
tive thermoregulation, hand-foot syndrome, migraine,
headaches, and congestive heart failure.
Disorders of the Deep Fascia
Myofascial Pain
Some recent studies have been published that address
the possible role of the deep fascia in myofascial pain.
Deising et al [13] injected nerve growth factor into the
fascia of the erector spinae muscles at the lumbar level
and observed a long-lasting sensitization to mechanical
pressure and to chemical stimulation. Sensitization was
confined to deeper tissues, but did not reach the skin.
This suggests that sensitization of fascial nociceptors to
mechanical and chemical stimuli may contribute to the
pathophysiology of chronic musculoskeletal pain.
Schilder et al [34] have also demonstrated that injections
of hypertonic saline into the thoracolumbar fascia result
in a significantly protracted time of pain intensity,
compared to injections into the subcutis or into muscle.
Also, pain intensity and pain radiation evoked by injec-
tion into fascia was significantly greater compared to
injection into muscle or the subcutis. The description of
pain after fascia injection, as reported by volunteers,
were burning, throbbing, and stinging. This suggests an
innervation by both A- and C-fiber nociceptors. For this
reason the authors support the supposition that the
thoracolumbar fascia is a prime candidate for contribu-
tion to nonspecific lower back pain.
Changes in innervation can also occur pathologically
in fascia. Sanchis-Alfonso and Rosello-Sastre [11] report
the ingrowth of nociceptive fibers and an immuno-
reaction to substance P in the lateral knee retinaculum
of patients with patello-femoral alignment problems.
Bednar et al [35] found an alteration in both the histo-
logical structure (inflammation and microcalcifications)
and the degree of innervation of the thoracolumbar
fascia in patients with chronic lumbalgia, indicating a
possible role of fascia in lumbar pain. In particular,
these authors noted a loss of nerve fibers in the thoa-
columber fascia of back pain patients.
A recent work by Langevin et al [36] focuses attention
on the sliding capability of fascial sublayers. These au-
thors found significant correlations in male participants
with chronic low back pain between shear strain capa-
bility of the thoracolumbar fascia and with the following
variables: perimuscular connective tissue thickness,
165
echogenicity, trunk flexion range of motion, and trunk
extension. This demonstrates the importance of altered
sliding of the thoracolumbar fascial layers in low back
pain.
More recently, Stecco et al [37] documented a corre-
lation between a decrease in range of motion and an in-
crease in neck deep fasciae thickness. In particular, a
value of 0.15 mm of the sternocleidomastoid fascia is
proposed as a cut-off value that allows the clinician to
make a diagnosis of myofascial disease in subjects with
chronic neck pain. Apparently, from this study, variations
of thickness in fascia correlate with increases in quantity
of its loose connective tissue, but not with fibrous tissue.
Alterations in Proprioception
The first to suggest a possible role of the deep fasciae
in proprioception were Viladot et al [38]. These authors
affirmed that because the ankle retinacula (which
represent specialization of the deep fascia) are thin and
flexible, they have a modest effect on the mechanical
stability of the joint, whereas they have a far more
important role in proprioception. Pisani [39] concludes
that the histological features of the retinacula are more
suggestive of a perceptive function, whereas the tendons
and ligaments are structured for a mechanical role. The
retinacula are the most highly innervated fascial tissues.
They are rich in free nerve endings, Ruffini and Pacini
corpuscles, Golgi-Mazzoni, and rare spherical clubs [12].
The retinacula cannot be considered merely as passive
stabilizers but, rather, as specialized proprioceptive
organs to better perceive joint movements [40,41].
Sanchis-Alfonso and Rosello-Sastre [11] demonstrate an
increase in free nerve endings and nerve in-growth in the
shortened compressed lateral retinaculum in patients
with patellofemoral malalignment and anterior knee
pain. Samples of lateral knee retinacula were excised at
the time of proximal realignment or isolated lateral
retinacular release. Stecco et al [40] demonstrate, with
MRI and static posturography, damages to ankle reti-
nacula (adherences, formation of new fibrous bundles
into the deep fasciae of the foot, interruption of the
retinacula) in patients with alterations of proprioception
and functional ankle instability after ankle sprain.
Damage to the retinacula and their embedded pro-
prioceptors result in inaccurate proprioceptive affer-
entation. This may result in poorly coordinated joint
movement and eventual inflammation and activation of
nociceptors. A treatment focused on restoring normal
fascial tension may improve the outcome of ankle sprain.
Fascia and Diabetes
Duffin et al [42] demonstrate that patients with type I
diabetes have a plantar fascia that is significantly
thicker compared to that of normal controls. Also, Li
et al [43] show that collagen cross-linking by advanced
166 Fascial Disorders: Implications for Treatment
glycation end-products alters the physical properties of
collagen structures and tissue behavior, reduces tissue
stress relaxation (P < .01), with a concomitant increase
in tissue yield stress (P < .01), and ultimately failure
stress (P .036). Such collagens are also more suscep-
tible to degradation by collagenases, and the panoply of
other matrix-metalloproteinases.
Epimysial Fascia and Its Disorders
Fascia and Immobilization
According to studies by Jarvinen et al [44], immobi-
lization results in a marked increase in the endo- and
perimysial connective tissue. The majority of the
increased endomysial collagen is deposited directly on
the sarcolemma of the muscle cells. Immobilization
of the endomysium also results in a substantial increase
in the number of perpendicularly oriented collagen fi-
bers that make contact with two adjacent muscle fibers.
Furthermore, immobilization clearly disturbs the normal
structure of the endomysium, making it impossible to
distinguish the various networks of fibers from one
another. In the perimysium, immobilization-induced
changes are similar. The number of longitudinally ori-
ented collagen fibers increases, the connective tissue
becomes very dense, the number of irregularly oriented
collagen fibers is markedly increased, and consequently
the different networks of collagen fibers cannot be
distinguished from each other. Even the crimp angle of
the collagen fibers decreases more than 10% in all
muscles after the immobilizatio period. It is apparent
from the above-described quantitative and qualitative
changes in the intramuscular connective tissue that they
significantly contribute to the decreased function and
diminished biomechanical properties of immobilized
skeletal muscle.
Fascia and Aging
Gao et al [45] demonstrate that the epimysial fascia
from old rats is much stiffer than that of young rats. This
increased stiffness cannot be attributed to variations in
the thickness of the epimysial fasciae or in the size of
the collagen fibrils. Microscopic analysis does not show
any change in the arrangement or size of the collagen
fibrils of the epimysial fasciae in older rats [45]. It is
probable that the key element explaining this stiffness
is the composition of the extracellular matrix with
respect to the presence of hyaluronan. It is important to
note that the space between the collagen fibers of the
epimysial fasciae is occupied by hyaluronan. This allows
the collagen fibers to slide with less friction during
movement [46]. Age-related increase in the stiffness of
the epimysial fasciae could play an important role in the
muscular contraction and in the reduced elasticity that
is often typical in older patients.
Fascia and Peripheral Motor Coordination
The epimysial fasciae have free nerve endings, but
lack Pacini and Ruffini corpuscles. Despite this, the
epimysial fascia play a key role in proprioception and
peripheral motor coordination due to their close rela-
tionship with muscle spindles. Indeed the muscle spin-
dles are localized in the perimysium and their capsule
connects to the epimysium and fascial septae
[23,47,48]. Strasmann et al [24] analyzing the septum of
the supinator muscle find that many muscle spindles are
inserted directly into the connective tissue of the
septum. Von During and Andrei [25], studying the evo-
lution of the locomotor system, discovered that muscle
spindles are strongly connected to the fascia. Due to
these connections, it is evident that tension developed
inside the deep fascia is also able to lengthen the
muscle spindles connected with it, activating them by
passive stretch. If epimysial fascia is overstretched, it is
possible that the muscle spindles connected to this
portion of the fascia could become chronically stretched
and overactivated. This implies that the associated
muscular fibers will be constantly stimulated to con-
tract. This could explain the increased amount of
acetylcholine found in myofascial pain and, in partic-
ular, in trigger points [49,50]. This passive stretch situ-
ation could be responsible for muscular imbalances and
recurrent cramps, and could result in incorrect move-
ment of joints. This may represent a typical case in
which there is limitation of joint range of motion and
associated joint pain. The causation is often found in
the proximal muscles that move the joint. Palpation of
the proximal muscle belly will often reveal an area of a
painful localization of dense tissue. Another problem
connected with the muscle spindles inside the epymisial
fasciae is when the epimysial fascia is too rigid, and
consequently the muscle spindle are not activated
because they are embedded in a rigid structure. This
emphasizes the fact that normal muscular function is
dependent on normal well-hydrated, functioning fascia.
If the epimysial fascia is densified, some parts of a
muscle will not function normally during movement,
causing an unbalanced movement of the joint, with
resulting uncoordinated movement and eventual joint
pain. The epimysial fasciae could be considered as a key
element in peripheral motor coordination.
Discussion
Only a better comprehension of the anatomy and
physiology of fasciae will permit us to answer common
questions such as the following: Is it the superficial or
deep fascia that generates these symptoms? What
particular fascial treatment is useful for lymphedema?
What is the best approach for changes in proprioception?
From this review, it is possible to conclude that
symptoms related to dysfunction of the lymphatic
 A. Stecco et al. / PM R 8 (2016) 161-168
system, superficial vein system, and thermoregulatory
system are more related to disorders of the superficial
fascia. Dysfunction such as alteration in mechanical
coordination, proprioception, balance, myofascial pain,
and cramps are more related to the deep fascia and
epimysium (Table 2).
Superficial fascia is obviously more superficial than
the other types and contains more elastic tissue.
Consequently, effective treatment can probably be
achieved with treatment modalities that use a large
surface and a small amount of pressure that will reach
the first layers of the subcutis. The deep fasciae and the
epymisium require treatment that generates enough
pressure to reach the surface of muscles. For this
reason, the use of small surface tools or manual deep
friction with elbows or knuckles is preferred.
To effect changes in the physical characteristics of
deep fascia without damaging the superficial fascia and
the skin, treatment should be applied in multiple spots,
rather than gliding over a large skin surface area. Skin
and superficial fascia must be stretched within a specific
range of elongation to avoid swelling, hematomas,
petechiae, and ecchymoses. For this purpose, it is sug-
gested that the clinician test the ability of the skin to
glide in each specific region of the body, before initi-
ating treatment of the deep fascia and the epimysium.
It is contraindicated to generate any kind of edema that
may catalyze fibrosis. This may subsequently affect the
elasticity and sliding ability of the subcutis tissues.
Conclusions and Clinical Implications
Fascia (as generalized connective tissue including the
epi- and perimysium) is a plausible source of proprio-
ception and nociception. From this review, it is possible
to conclude that symptoms related to dysfunction of the
lymphatic system, superficial vein system, or thermo-
regulation are more related to disorders of the superfi-
cial fascia. Dysfunction symptoms such as alteration of
the mechanical coordination, proprioception, balance,
myofascial pain, and cramps are more related to the
deep fascia and epimysium.
Because of differences in anatomical location and
quality of the fascial tissue, it is important to recognize
that different treatment modalities are necessary.
Furthermore, a clear description of the symptoms that
will help to define the type of tissue involved is funda-
mental to prescribing correct treatments. Careful his-
tory and meticulous clinical evaluation, such as
assessment of movement and palpation, are the first
steps toward improving the specificity of diagnosis in
patients with fascial alterations. Correct diagnoses
should facilitate more specific and more effective
therapies that may ultimately decrease costs and hasten
positive outcomes.
Manual and physical therapies soften the fascia in its
various forms and at varying depths of tissue. These
167
must be applied in relation to the types of fasciae that
are involved.
This review is not designed to evaluate the literature
on the treatment of fascial disorders. Other studies will
be required to better understand the efficacy and
specificity of the different modalities of treatment for
specific fascial disorders.
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Disclosure
A.S. Sport Medicine Unit, Internal Medicine Department, University of Padova,
Padova, Italy. Address correspondence to: A.S.; Via Giustiniani 2, 35127 Padova,
Italy; e-mail: antonio.stecco@gmail.com
Disclosure: nothing to disclose
R.S. Division of Basic Biomedical Sciences, Touro College of Osteopathic Medi-
cine, New York, NY
Disclosure: nothing to disclose
I.F. Molecular Medicine Department, University of Padova, Padova, Italy
Disclosure: nothing to disclose
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R.D.C. Molecular Medicine Department, University of Padova, Padova, Italy
Disclosure: nothing to disclose
C.S. Molecular Medicine Department, University of Padova, Padova, Italy
Disclosure: nothing to disclose
Submitted for publication January 6, 2015; accepted June 7, 2015.