OTHER SOFT TISSUE DISORDERS
Biomechanical Properties of Fascial Tissues and Their Role
as Pain Generators
ABSTRACT. Objectives: While fasciae have virtually been treated as the “Cinderella tissue of
orthopedic research” during recent decades, new methodological ﬁndings and hypotheses suggest
that the body-wide fascial network may play a more important role in musculoskeletal medicine
than assumed ordinarily. However, there is a great diversity in literature, as to which tissues
are included under the term “fascia,” be it the superﬁcial fascia, the endomysium, perineurium,
visceral membranes, aponeuroses, retinaculae, or joint/organ capsules. Following the proposed
comprehensive terminology of the 1st Fascia Research Congress, this brief review considers all
collagenous connective tissues as “fascial tissues” whose morphology is dominantly shaped by
tensional loading and can be seen to be a part of an interconnected tensional network throughout
the whole body (1). While morphological differences between aponeuroses and lattice-like or
irregular fasciae can still be properly described with this terminology, it allows one to see tissue
speciﬁcations, such as septae, capsules, or ligaments, as local adaptations of this ubiquitous network
based on speciﬁc loading histories.
What are the biomechanical functions of this fascial network, and what role do they play
in musculoskeletal dysfunctions? This brief review will highlight the load-bearing function of
different fascial tissues and also their proneness to microtearing during physiological or excessive
loading. It will review histological studies, indicating a proprioceptive as well as nociceptive
innervation of fascia. Finally, the potential role of injury, inﬂammation, and/or neural sensitization
of the posterior layer of the human lumbar fascia in nonspeciﬁc low back pain will be explored.
Findings: While the tensional load-bearing function of tendons and ligaments has never been
disputed, recent publication o Huijing (2) has revealed that muscles also transmit a signiﬁcant
portion of their force via their epimysia to laterally positioned tissues, such as synergistic or
antagonistic muscles. The reported contribution of M. transversus abdominis to dynamic lumbar
spinal stability has been associated with the load- bearing function of lumbar fasciae’s middle
layer in humans (3). Similarly, electromyography-based measurements of the “ﬂexion–relaxation
phenomenon” suggest a strong tensional load-bearing function of dorsal fascial tissues during
Robert Schleip and Adjo Zorn, Fascia Research Project, Institute of Applied Physiology, Ulm University, Ulm,
Werner Klingler, Department of Anesthesiology, Ulm University, Germany.
Journal of Musculoskeletal Pain, Vol. 18(4), 2010
Available online at www.informaworld.com/MUP
©2010 Informa Healthcare USA, Inc. All rights reserved.
doi: 10.3109/10582452.2010.502628 393
394 JOURNAL OF MUSCULOSKELETAL PAIN
healthy forward bending of the human trunk [with a reported absence of such load shifting in low
back pain patients] (4).
Recent ultrasound-based measurements indicate that fascial tissues are commonly used as elastic
springs [catapult action] during oscillatory movements, such as walking, hopping, or running, in
which the supporting skeletal muscles contract rather isometrically (5).
Fascial tissues are prone to viscoelastic deformations, such as creep, hysteresis, and relaxation.
Such temporary deformations alter fascial stiffness, which may take several hours for complete
recovery. Load-bearing tests also reveal the existence of a gradual transition zone between re-
versible viscoelastic deformation and complete tissue tearing. Various degrees of microtearing of
collagenous ﬁbers and their interconnections have been documented to occur within this zone (6).
Fascia is densely innervated by myelinated nerve endings that are assumed to serve a propri-
oceptive function. These include Pacini’s [and paciniform] corpuscles, Golgi tendon organs, and
Rufﬁni endings (7). In addition, they are innervated by free endings. Newer histological examina-
tions have shown that at least some of these free nerve endings are substance P-containing receptors
that are commonly assumed to be nociceptive (8). Delayed onset muscle soreness can be induced
by repetitive eccentric contraction. A recent experimental study suggests that the epimysial fascia
plays a major role in the generation of related pain symptoms (9).
Panjabi’s (10) new explanatory model of low back pain injuries suggests that single trauma or
cumulative microtrauma causes subfailure injuries of dorsal fascial tissues and their embedded
mechanoreceptors, thereby leading to corrupted mechanoreceptor feedback and further resulting
in connective tissue alterations and neural adaptations. Langevin (11) reports that the posterior
layer of lumbar fascia tends to be thicker in chronic low back pain patients and also expresses
less shear motion during passive trunk ﬂexion. In addition, our group has shown a high density
of myoﬁbroblasts, whose existence is usually associated with excessive loading or injury repair in
the same fascial layer (12). Surgical examinations by Bednar et al. (13) and Dittrich (14) report
frequent signs of injury and inﬂammation of the lumbar fascia in low back pain patients. Finally,
injection of an inﬂammatory agent into the rat’s lumbar back muscles resulted in a dramatic
increase of the proportion of dorsal horn neurons with input from the superﬁcial lumbar fascia
Conclusions: Fascial tissues serve important load-bearing functions. Severe tensional loading
can induce temporary viscoelastic deformation and even microtearing. The innervation of fascia
indicates a potential nociceptive function. Microtearing and/or inﬂammation of fascia can be a
direct source of musculoskeletal pain. In addition, fascia may be an indirect source of back pain due
to sensitization of fascial nerve endings associated with inﬂammatory processes in other tissues
within the same segment.
KEYWORDS. Myoﬁbroblasts, fascial tonicity, delayed onset muscle soreness [DOMS], fascial
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Submitted: April 10, 2010
Revision Accepted: April 13, 2010