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# Biomechanical Properties of Fascial Tissues and Their Role as Pain Generators

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## Abstract

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.
OTHER SOFT TISSUE DISORDERS
Biomechanical Properties of Fascial Tissues and Their Role
as Pain Generators
Robert Schleip
Werner Klingler
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
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,
Germany.
Werner Klingler, Department of Anesthesiology, Ulm University, Germany.
Journal of Musculoskeletal Pain, Vol. 18(4), 2010
Available online at www.informaworld.com/MUP
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
(15).
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
innervation, microtearing
REFERENCES
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Submitted: April 10, 2010
Revision Accepted: April 13, 2010
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Dense connective tissue sheets, commonly known as fascia, play an important role as force transmitters in human posture and movement regulation. Fascia is usually seen as having a passive role, transmitting mechanical tension which is generated by muscle activity or external forces. However, there is some evidence to suggest that fascia may be able to actively contract in a smooth muscle-like manner and consequently influence musculoskeletal dynamics. General support for this hypothesis came with the discovery of contractile cells in fascia, from theoretical reflections on the biological advantages of such a capacity, and from the existence of pathological fascial contractures. Further evidence to support this hypothesis is offered by in vitro studies with fascia which have been reported in the literature: the biomechanical demonstration of an autonomous contraction of the human lumbar fascia, and the pharmacological induction of temporary contractions in normal fascia from rats. If verified by future research, the existence of an active fascial contractility could have interesting implications for the understanding of musculoskeletal pathologies with an increased or decreased myofascial tonus. It may also offer new insights and a deeper understanding of treatments directed at fascia, such as manual myofascial release therapies or acupuncture. Further research to test this hypothesis is suggested.
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Elements of what we call myofascial force transmission today have been on peoples mind for a long time, usually implicitly, sometimes quite explicitly. A lot is there to be learned from the history of our knowledge on muscle and movement. There is little doubt about the presence and effectiveness of the mechanism and pathways of epimuscular myofascial force transmission. However, we should learn much more about the exact conditions at which such transmission is not only of fundamental biomechanical interest, but also quantitatively so important that it has to be considered for its effects in health and disease. Even if the quantitative effects in terms of force would prove small, one should realize that this mechanism will change the principles of muscular function drastically. A new vision on functional anatomy, as well as the application of imaging techniques and 3-D reconstruction of in vivo muscle, will aid that process of increased quantitative understanding, despite usual limitations regarding the mechanics in such experiments. I expect it is fair to say that without understanding myofascial force transmission we will never be able to understand muscular function completely.
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Human tissue specimens were examined for the presence of neural end-organs under light and electron microscopy. To define the innervation of the thoracolumbar fascia in problem back pain patients who have articular abnormality defined through pain-provocation discography or facet blocks. Previous investigators have defined the presence of innervation in control (no back pain) tissue specimens. Tissue specimens were harvested during surgery from 24 back pain patients who had not undergone previous lumbar surgery. Specimens were fixed immediately in the operating room and later processed and studied under light and electron microscopy. Structural and ultrastructural studies failed to identify specific neural end-organs in any of the specimens. Serendipidously, microscopic changes suggestive of ischemia or inflammation in this tissue were found. These findings suggest that the thoracolumbar fascia may be deficiently innervated in problem back pain patients.
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At a certain position of trunk flexion, there is a sudden onset of electrical silence in back muscles. This is called "flexion-relaxation (F-R) phenomenon." The goals of this study were (1) to evaluate the relationship between flexion angle and activity of back muscles during flexion movement and (2) to determine what the difference is between healthy subjects and patients with chronic low back pain (CLBP). Twenty-five healthy subjects (13 males and 12 females; average age, 28.3 yr) and 20 patients with CLBP (12 males and 8 females; average age, 34.1 yr) volunteered for this study. The subjects were asked to flex forward maximally from the erect position and to maintain full flexion, followed by returning to the initial upright position. Flexion angle of trunk and hip was measured during the examination. Electromyographic activity of erector spinae was also monitored simultaneously. F-R phenomenon was observed in all healthy subjects before reaching the maximum flexion. Electrical silence continued even after extending the trunk began. In contrast, no patients with CLBP demonstrated F-R phenomenon. A significant difference in muscular activities of erector spinae between the groups was obtained when returning to the erect position from the maximum flexion. Moreover, time lag between trunk and hip movement was much greater in patients than in healthy subjects. This study demonstrated that neuromuscular coordination between trunk and hip could be abnormal in patients with CLBP.
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FUKUNAGA, T., Y. KAWAKAMI, K. KUBO, and H. KANEHISA. Muscle and tendon interactions during human movements. Exerc. Sport Sci. Rev., Vol. 30, No. 3, pp. 106–110, 2002. Muscle and tendon interaction was estimated in vivo by real-time ultrasonography. Differences between muscles in internal muscle-fiber shortening during isometric actions are due to the elastic properties of tendon. Compliant human tendons allow muscles to contract isometrically during many human movements for efficient force generation.