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A histological study of the deep fascia of the upper limb

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Post-mortem specimens taken from the antebrachial and brachial fasciae of 20 upper limbs were studied by histological and immunohistochemical staining in order to evaluate collagen fibre bundle arrangement, the presence of elastic fibres, and the density of innervation in deep muscular fascia. The study demonstrated that the fasciae are formed of numerous layers of undulating colla-gen fibre bundles. In each layer, the bundles are parallel to each other, whereas adjacent layers show different orientations. Each layer is separated from the adjacent one by a thin layer of adipose tissue, like plywood. Many elastic fibres and a variety of both free and encapsulated nerve endings, espe-cially Ruffini and Pacini corpuscles, are also present, suggesting a proprioceptive capacity of the deep fascia. Thanks to the undulating collagen fibre bundles and elastic fibres, the fasciae can adapt to stretching, but this is only possible within certain limits, beyond which nerve terminations are acti-vated by stretching. This mechanism allows a sort of "gate control" on the normal activation of in-trafascial receptors. The capacity of the various collagen layers to slide over each other may be al-tered in cases of over-use syndrome, trauma or surgery. In such cases, the amortising mechanism of the fascia on the nervous terminations is lost, causing incorrect paradoxical activation of nerve re-ceptors within the fascia, resulting in the propagation of a nociceptive signal even in situations of normal physiological stretch. At the same time, the layered collagen fibres allow transmission of ten-sion according to the various lines of force. This structure of the muscular fascia guarantees percep-tive and directional continuity along a particular myokinetic chain, acting like a transmission belt be-tween two adjacent joints and also between synergic muscle groups.
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it. j. anat. embryol. Vol. 111, n. 2: 000-000, 2006
A histological study of the deep fascia of the upper limb
Carla Stecco
1,2
M.D., Andrea Porzionato
1
M.D., Veronica Macchi
1
M.D.,
Cesare Tiengo
1
M.D., Anna Parenti
3
M.D., Roberto Aldegheri
2
M.D.,
Vincent Delmas
4
M.D. and Raffaele De Caro
1
M.D.
1
Section of Anatomy, Department of Human Anatomy and Physiology, University of Padova, Italy
2
Section of Orthopedics, Department of Medical Surgical Specialities, University of Padova, Italy
3
Section of Pathologic Anatomy, Department of Oncological and Surgical Sciences, University of
Padova, Italy
4
Normal Anatomy Institute, Rene´Descartes University, Paris
Key words: fascia, collagen, proprioception, myokinetic chain, motor coordination, over-use
syndrome.
SUMMARY
Post-mortem specimens taken from the antebrachial and brachial fasciae of 20 upper limbs
were studied by histological and immunohistochemical staining in order to evaluate collagen fibre
bundle arrangement, the presence of elastic fibres, and the density of innervation in deep muscular
fascia. The study demonstrated that the fasciae are formed of numerous layers of undulating colla-
gen fibre bundles. In each layer, the bundles are parallel to each other, whereas adjacent layers show
different orientations. Each layer is separated from the adjacent one by a thin layer of adipose tissue,
like plywood. Many elastic fibres and a variety of both free and encapsulated nerve endings, espe-
cially Ruffini and Pacini corpuscles, are also present, suggesting a proprioceptive capacity of the
deep fascia.
Thanks to the undulating collagen fibre bundles and elastic fibres, the fasciae can adapt to
stretching, but this is only possible within certain limits, beyond which nerve terminations are acti-
vated by stretching. This mechanism allows a sort of “gate control” on the normal activation of in-
trafascial receptors. The capacity of the various collagen layers to slide over each other may be al-
tered in cases of over-use syndrome, trauma or surgery. In such cases, the amortising mechanism of
the fascia on the nervous terminations is lost, causing incorrect paradoxical activation of nerve re-
ceptors within the fascia, resulting in the propagation of a nociceptive signal even in situations of
normal physiological stretch. At the same time, the layered collagen fibres allow transmission of ten-
sion according to the various lines of force. This structure of the muscular fascia guarantees percep-
tive and directional continuity along a particular myokinetic chain, acting like a transmission belt be-
tween two adjacent joints and also between synergic muscle groups.
INTRODUCTION
In recent years, the deep muscular fascia has attracted increasing interest and is
currently indicated in the pathogenesis of a wide variety of conditions. Bednar et al.
(1995) found inflammation and micro-calcification of the thoracolumbar fascia in
patients with chronic lumbalgia, suggesting the role of the fascia in the aetiology of
lower back pain. In the transverse fascia of patients with inguinal hernia, Pans et al.
(2001), Rodrigues et al. (2002) and Rosch et al. (2003) verified the presence of a web
of disorganised collagen fibres and an increase in vascularisation in comparison to
healthy control subjects. It has been suggested that the fascia is implicated in the
regulation of posture (Palmieri et al., 1986), muscular biomechanics (Gerlach and
Lierse, 1990), peripheral motor coordination (Stecco, 2004) and proprioception
(Stecco et al., 2006). For some authors (Rolf, 1997; Paoletti, 1998), the fascia has the
capacity to adapt to physical stress, and manual therapies can influence its tone, vis-
cosity or structure.
Despite growing interest in the fascia, a comprehensive anatomical and histo-
logical description of this tissue is still lacking. The deep fascia of muscles is de-
scribed in most texts as a lamina of dense connective tissue surrounding muscles
(e.g. Moore and Agur, 2001), with the sole function of an inert structural support
(Kuslick et al., 1991). Some authors (e.g. Yahia et al., 1993) have expressed the need
for a histological study of the fascia.
Hence, the aim of this study was to clarify the histological structure of the deep
muscular fascia of the upper limb, with particular reference to its content and ar-
rangement of collagen and elastic fibres and types of innervation.
MATERIALS AND METHODS
The study was performed on 20 upper limbs (12 right, 8 left) from 13 subjects
(10 males, 3 females; mean age 79.9 years) on the basis of research approved by the
Normal Anatomy Institute of the Rene´ Descartes University in Paris. No limbs
showed any evidence of traumatic lesions or pathologies, and had not been em-
balmed or frozen prior to examination. For each limb, 4 different samples of the
same size (1 x 1.5 cm) of the middle thirds of the anterior brachial fascia and of the
anterior antebrachial fascia. The samples were mounted on cardboard to avoid de-
formation artefacts.
All specimens were immediately preserved in formaldehyde 4% in phosphate
buffer saline (PBS) 0.1 M, pH 7.0, embedded in paraffin, and then cut into 10-αm
thick sections, which were stained with hematoxylin and eosin (H.E.), azan-Mallory,
Weigert’s Van Gieson stain for elastic fibres and silver impregnation. Anti-S100 im-
munohistochemistry was also performed. The intrafascial vascular network was also
analysed.
2C. Stecco et alii
Immunohistochemical method: Five-αm thick sections were treated with H
2
O
2
0.15% for 15 minutes in order to inhibit endogenous peroxidase activity. After
washing in PBS, the sections were incubated with normal goat serum 1:100 for 30
minutes and then with polyclonal antibodies raised against S100 (DAKO, Italy) for
nervous tissues, diluted 1:500 in PBS at 37°C in a humid chamber for 60 minutes.
Repeated washings were performed and the sections were then incubated with sec-
ondary antibody (goat anti-rabbit IgG peroxidase-coniugated antibodies DAKO)
1:50 for 30 minutes. Lastly, the reaction was enhanced with 3,3’-diaminobenzidine
(DAB substrate tablets, Sigma, 0.1% v/v H
2
O
2
). The preparations, contrasted with
hematoxylin, were dehydrated and mounted on Canadian balsam (BDH, Italy).
Negative controls were obtained by omitting the primary antibody. All preparations
were observed under a Leica DM 4500B microscope.
RESULTS
The deep fasciae of the arm and forearm presented analogous histological char-
acteristics. Both fasciae had a mean thickness ranging from 100 to 200 αm, and were
formed of multiple layers of collagen fibre bundles. They were of variable size,
showed an undulating course, and were parallel to each other. Fibroblasts, at times
exhibiting star-shaped cytoplasmic elongations, were arranged between the collagen
fibre bundles and parallel to them. The alignment of the bundles differed from layer
to layer (Fig.1a). Each layer was separated from the adjacent one by a thin layer of
adipocytes. At some points, these laminae were packaged and connected with the
underlying epimysium, without interposing adipose tissue (Fig.1b). Numerous elas-
tic fibres were also evidenced by van Gieson stain. They appeared as short, branched
fibres, not arranged in bundles, arranged between the collagen bundles and the vari-
ous layers in a less orderly manner, to form an irregular mesh (Fig. 1c). Numerous
vessels also followed rather tortuous paths through the collagen layers of the muscu-
lar fascia.
Some small nerve branches were highlighted with silver impregnation, and,
with anti-S100 immunohistochemistry, nerve fibres were found in all specimens of
the deep fascia. Although they were particularly numerous around vessels, they were
also distributed throughout the fibrous components of the fascia. Some nerve fibres
were connected to collagen fibres, others were surrounded by loose connective tis-
sue. In some specimens, Ruffini, Pacini and rare Golgi-Mazzoni corpuscles were
also highlighted (Fig. 1d).
DISCUSSION
From a histological viewpoint, some authors (Geneser, 1986; Standring et al.,
2005) consider the deep muscular fascia as consisting of dense, regular, connective
A histological study of the deep fascia of the upper limb 3
tissue similar to aponeurosis, characterised by extremely well-ordered, parallel bun-
dles of inelastic collagen fibres, although for Standring et al. (2005) the fascia is
sometimes also irregular loose connective tissue. Conversely, Gerlach and Lierse
(1990) described the muscular fascia of the lower limb as composed of intertwined
bundles of collagen fibres. For other authors (Bogduk and Macintosh, 1984; Martini
et al., 2004), it is formed of numerous laminae of dense connective tissue in which
collagen fibres may be aligned in several directions, whereas for yet others (e.g.
Fawcett, 1986), the laminae are difficult to distinguish because the collagen fibres
often pass from one lamina to the adjacent one.
Our results show that the fascia is essentially composed of numerous layers of
parallel, undulating collagen fibre bundles, intermingled with many elastic fibres.
Thin layers of adipocytes separate adjacent layers, allowing single layers to slide over
Fig.1—a)Layered arrangement of deep muscular fascia and its connections with epimysium (azan-
Mallory stain, magnification 5x).
b) Undulating collagen fibres interspersed with fusiform fibrocytes. Layered arrangement is clearly
evident, layers being separated from the next by adipose tissue. In each layer, collagen fibres
are parallel, but their direction varies from one layer to the next. Numerous small vessels are
also visible between bundles of collagen fibres (azan-Mallory stain, magnification 10x).
c) Note numerous fine elastic fibres with differing orientation, interspersed with collagen fibres (van
Geison stain, magnification 20x).
d) Ruffini corpuscle immersed in loose connective tissue, between two bundles of collagen fibres
(anti-S100 stain, magnification 40x).
4C. Stecco et alii
each other. The alignment of the collagen fibres varies from layer to layer. As a
whole, this type of structure may be compared with that of plywood, as in the de-
scriptions by Bogduk and Macintosh (1984) and Martini et al. (2004). Instead, the
significant quantity of elastic fibres found means that the description of Geneser
(1986) is not in agreement with ours. In addition, the deep muscular fascia of the up-
per limb cannot be considered as loose, areolar, connective tissue (Standring et al.,
2005), due to its significant collagen component.
The structural organisation of the fascia allows strong resistance to traction,
even when it is exercised in different directions, due to the differing orientations of
the collagen fibres in the layers. At the same time, the fascia can adapt to stretching,
thanks to the elastic fibres together with the undulating arrangement of the collagen
fibres. Once traction stops the same elastic fibres probably allow the fascia to return
to its resting state.
In 1899, Testut wrote that “although the fasciae are extremely pliable, at the
same time, they are very resistant and almost inextensible”. The histological struc-
ture described in our study represents the anatomical basis of this apparent func-
tional contradiction.
The presence of many free and encapsulated nerve terminations, particularly
Ruffini and Pacini corpuscles, indicates that the deep muscular fascia probably plays
a proprioceptive role. The capsules of these corpuscles are connected to the collagen
fibres that surround them and are therefore probably also subjected to stretching
(Stecco, 2006). Instead, the larger nerve fibres are often surrounded by loose con-
nective tissue, which preserves the nerve from the traction to which the fascia is sub-
jected. Adaptation of the fascia is only possible within certain limits, beyond which
the nerve terminations are activated by stretching. This mechanism allows a sort of
“gate control” on normal activation of the intrafascial receptors. Further studies will
be necessary to reveal the presence of fibres of the autonomic nervous system and to
determine whether such innervation pertains to the vessel walls or if is specifically
related to the muscular fascia.
The capacity of the various collagen layers to slide over each other may be al-
tered in cases of over-use syndrome, trauma or surgery. In such cases, the amortising
mechanism of the fascia on the nervous terminations is lost, causing incorrect para-
doxical activation of nerve receptors within the fascia, resulting in the propagation
of a nociceptive signal even in situations of normal physiological stretch.
Paoletti (2002) and Stecco (2004) hypothesise that the deep fascia between two
joints guarantees perceptive and directional continuity along a specific myokinetic
chain, acting as a transmission belt between two adjacent joints and also between
synergic muscle groups. The layered arrangement of the collagen fibres of the deep
muscular fascia, allowing the transmission of traction, is the anatomical basis to this
hypothesis.
Received 12/05/2006. Accepted 20/05/2006
A histological study of the deep fascia of the upper limb 5
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For correspondence:
Prof. Raffaele De Caro,MD
Section of Anatomy, Department of Human
Anatomy
and Physiology, University of Padova,
Via A Gabelli 65, 35127 Padova, Italy
Tel +39 049 8272327;
Fax +39 049 8272328;
E-mail: rdecaro@unipd.it
6C. Stecco et alii
... 13 Crimp requires more explanation. Crimp is found in collagen fibres, the predominant material in passive tissues: 32,74 it describes a wave-like pattern to the fibres at rest 39 and produces the characteristic toe region in passive tissues, 36 the initial phase of the stress/strain curve that has a high strain at low stress. Through the folding of collagen, crimp allows greater total length but a preservation of tension. ...
... 59 These generalised demands are mirrored by multiple directions of fibre alignment and cell population. 74 The architectural generalisation of fascia prevents it from attaining the mechanical peaks of tendons, but allows it to operate within mechanically diverse environments. Demonstrating the significance mechanical forces have on tissue material and architecture is the gradual progression of tendon into bone. ...
... The retinacula are the most highly innervated fascial tissues. Sanchis- The first in-depth focus on the role of fascia in proprioceptive function came from Stecco et al. (2004Stecco et al. ( , 2006). They, with the cadaveric analysis details, suggested that "the presence of many free and encapsulated nerve terminations indicates that the deep muscular fascia probably plays a proprioceptive role" ( Stecco et al., 2006, p 5). Stecco et al., in 2007(b), published yet another cadaveric analysis study based on specimens taken from the deep fascia from 20 human upper limbs. ...
... Sanchis- The first in-depth focus on the role of fascia in proprioceptive function came from Stecco et al. (2004Stecco et al. ( , 2006). They, with the cadaveric analysis details, suggested that "the presence of many free and encapsulated nerve terminations indicates that the deep muscular fascia probably plays a proprioceptive role" ( Stecco et al., 2006, p 5). Stecco et al., in 2007(b), published yet another cadaveric analysis study based on specimens taken from the deep fascia from 20 human upper limbs. The main aim was to find out type of nerve fibres and endings in the deep muscular fascia. ...
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Introduction: Myofascial release (MFR) is a form of manual therapy that involves the application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain, and improve function. MFR is being used to treat patients with a wide variety of conditions, but there is a scarcity of evidence to support its efficacy. Studies are emerging in this field with varying results and conclusions. Analysis of the recent research trials and reviews will be a better way to appraise the quality and reliability of such works. Objective: This work attempts to analyse and summarise the evidence from three randomised controlled trials (RCTs) and one systematic review of the effectiveness of MFR on various neuromuscular conditions and pain. Methodology: Effectiveness of MFR on tension type headache, lateral epicondylitis and chronic low back pain were the RCTs identified for the analysis. The systematic review selected analysed the published RCTs on MFR till 2014. The methodological qualities of the studies were assessed using the PEDro, Centre for Evidence-Based Medicine's (CEBM) Level of Evidence Scale, Risk of Bias (RoB) Analysis Tool and AMSTAR 2. Results: The RCTs analysed in this study were of moderate to high methodological quality (PEDro scale), with higher level of evidence (CEBM scale) and less bias (RoB). The effectiveness of MFR on tension type headache (TTH) was the first among the studies with a moderate methodological quality (6/10 in PEDro), with a 2b level of evidence on the CEBM scale. The study proved that direct technique or indirect technique MFR was more effective than the control intervention for TTH. The second RCT studied MFR for lateral epicondylitis (LE). The study was of a moderately high quality on the PEDro scale (7/10) with a 1b- level in CEBM. The MFR was found more effective than a control intervention for LE in computer professionals. The RCT on chronic low back pain (CLBP) also scored 7/10 in the PEDro scale and 1b in the CEBM scale. This study confirmed that MFR is a useful adjunct to specific back exercises and more helpful than a control intervention for CLBP. All three RCTs stated the usage of self-report measures and underpowered sample size as the major limitations along with a performance bias reported in the TTH trial. The systematic review demonstrated moderate methodological quality as per the AMSTAR 2 tool which analysed 19 RCTs for a result. The literature regarding the effectiveness of MFR was mixed in both quality and results. Omission of a risk of bias analysis was the major limitation of this review. The authors quoted that “MFR may be useful as either a unique therapy or as an adjunct therapy to other established therapies for a variety of conditions”. Conclusion: Critical appraisal is an important element of evidence-based medicine to carefully and systematically examine research to judge its trustworthiness, its value and relevance in a particular context. This review concludes that the three RCTs and the systematic review analysed were completed with moderate to good quality as per various quality measures, but with reported methodological flaws and interpretation biases. These studies with the critical appraisal can act as ‘pavements’ on which high quality future MFR trials and evidence can be built on. KEY WORDS: myofascial release, myofascial release therapy
... Important features of deep muscular fascia and its components indicate its potential role in normal musculoskeletal activity. It connects with muscle fibres via intermuscular septa, fascial compartments, tendon sheaths, and with bone through periosteum and numerous muscle fibres attach directly onto this fascial layer (Stecco et al., 2006). It is densely innervated and van der Wal (2009) includes fasciae as part of connective tissue structures that have a possible role in proprioception and nociception. ...
... Indeed just like recent research 18 highlights the importance of fascia as a connective tissue supporting the skeleton (Stecco et al., 2006;Schleip et al., 2005), focus on business model research should not only study the bones --the components -of the business model (Osterwalder & Pigneur, 2010), or the subconstructs of business model innovation (Clauss 2017) -but the connective tissue joining all the different parts together. To make a risky analogy with medicine, just like fascia is an entire system and a newly defined organ that merits study, similarly more research would be welcome on the connections between business model components and their relationships to one another. ...
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... This confirms the hypothesis that dysfunctions in the fascial system can lead to discomfort and pain. Moreover, fascias represent an important human sensory organ as the numerous mechanoreceptors play a crucial role in proprioception (Stecco et al., 2006(Stecco et al., , 2008. ...
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... In addition, deep muscular fascia has significant characteristics that allow it to perceive muscle fiber tension. Many muscle fibers attach directly onto fascia, 26 and it also connects with muscle fibers via intermuscular septa, fascial compartments, and tendon sheaths. Histological studies of deep fascia in the limbs show that it consists of elastic fibers and undulated collagen fibers arranged in layers. ...
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PURPOSE: Self-myofascial release (SMR) using a foam roller is a popular intervention used to improve flexibility and restore skeletal muscles, fascia, tendons, ligaments and soft-tissue extensibility. However, the mechanism about the effects of SMR on flexibility, delayed onset of muscle soreness and arterial stiffness has not been elucidated. The purpose of this review is to provide basic knowledge for the mechanism about the effects of SMR from a functional and anatomical perspective.METHODS: In this review, we summarized previous studies investigating the effects of SMR which were associated with the human fascial system on flexibility, delayed onset of muscle soreness, arterial stiffness and autonomic nervous system (ANS).RESULTS: SMR with a foam roller can improve flexibility by increasing blood flow and circulation to the soft tissues. Foam rollingrelated mechanisms to increase range of motion or reduce pain include the activation of cutaneous and fascial mechanoreceptors and interstitial afferent nerves that modulate sympathetic/parasympathetic activation as well as the activation of global pain modulatory systems and reflex-induced reductions in muscle and myofascial tone. In addition, SMR with a foam roller may improve arterial stiffness, which was associated with increased circulating level of nitric oxide induced by elevated shear stress on the walls of the blood vessel.CONCLUSIONS: SMR using a foam roller improves flexibility by relaxing tension in skeletal muscles or fascia and may help to improve arterial stiffness and the function of the ANS. We suggest that SMR using a foam roller may help to reduce the risks of cardiovascular disease as a new alternative method.
Thesis
Medial tibial stress syndrome (MTSS), also known as shin splints, is one of the most common sports injuries. Although 20% of the jumping and running athletes have MTSS at some point while engaging in sporting activities, we know little about it. There is a lack of knowledge regarding making the diagnosis, how to treat it effectively and how to best measure outcomes that are relevant to the patient. The diagnosis MTSS is commonly made using history and physical examination. This seems the logical diagnostic approach because MTSS is a pain syndrome without an established tissue pathology. Whether this approach is reliable between different clinicians is unknown. A number of interventions have been studied in randomised controlled trials over the past 40 years. These include shockwave therapy, lower leg braces, dry needling, lower leg stockings, strengthening exercises, a graded running rehabilitation program and ice massage. Which intervention is most effective, however, has remained unclear. Measuring outcomes that matter to the patient are highly important. These so-called patient-reported outcome measures (PROMs) are considered the cornerstone for outcome assessment and measuring treatment success in medicine. There was no PROM for athletes with MTSS prior to this thesis’ commencement, which prevented the standardised measurement of outcomes in athletes with MTSS. A number of studies, described in this thesis, sought to fill these important gaps in the field. This thesis reports that making the diagnosis MTSS based on history and physical examination has almost perfect reliability among clinicians: k = 0.89 (95% CI 0.74 to 1.00), p<0.000001. This supports making the diagnosis of MTSS clinically, without using additional and expensive imaging. A systematic review showed that the research previously performed on the treatment of MTSS is at such a high risk of bias, it’s impossible to recommend any particular choice for use in clinical practice. At this point in time, the most logical treatment is load management, increasing loading capacity through gradual load exposure and strengthening the calf muscles. Lastly, this thesis describes the development and validation of a new PROM: the MTSS score. Items for this outcome measure were developed together with researchers, clinicians and patients. The items and scale were tested for their validity, reliability and responsiveness in a large population of 133 athletes with MTSS recruited from 15 sports medicine, military medicine and physiotherapy practices in The Netherlands. This study showed that the MTSS score is a valid, reliable and responsive 4-item scale that can be used to assess outcomes relevant to the athlete with MTSS.
Article
Background: The reparation of abdominal wall hernias is one of the most frequently performed operations in surgery worldwide. Besides primary hernias, recurrent and incisional hernias are of particular interest in abdominal surgery. Knowledge about the pathogenesis and successful treatment of abdominal wall hernias are of major socioeconomic importance. Various risk factors for hernia formation have been proposed in the past. In recent years, turnover of connective tissue, particularly collagen, in hernia patients has been the focus of research. Methods: This article reviews the findings concerning collagen metabolism and expression in patients with (recurrent) inguinal and incisional hernia. Results: A disorder of the collagen metabolism is supposed to play a pivotal role in the pathogenesis of primary or recurrent inguinal and incisional hernias. Conclusions: Further research on collagen metabolism in these patients should be transposed into optimized surgical repair procedures.
Article
An electron microscopic study of the elastic fibre and elastic related fibres of the fascia transversalis of the human inguinal triangle was performed in 20 male patients aged 13 to 81 a with right indirect inguinal hernia submitted to surgical repair. The 3 fibre types comprising the elastic system (oxytalan, elaunin, and elastic fibres) tend to be ordered in a precise manner and sequence among the fibrils, fibres, and collagen fibre bundles, respectively. The present findings show that with aging, there is a decrease in the oxytalan fibres and an increase in the amorphous substance of the elastic fibres. The authors concluded that the decrease in oxytalan fibres as a function of age may be responsible for alteration in the resistance of the transversalis fascia.
Article
The muscular system, the connective tissue and the bones are the components of a biomechanical pelvis-lower extremity model. The occasional electrical events in the muscles were not taken into account, as they can only be measured by physiological methods. In this publication, the connective tissue of the lower extremities is examined. The connective tissue system of the thigh and leg was prepared; after removal of the muscles the so-called 'hollow' lower extremity could be studied. A topographical documentation followed, and the structure and directions of the fibers were observed with polarized light. The connective tissue systems of the lower extremities and bones form a biomechanical, effective and functional system, the bone-fascia-tendon system. The components of the connective tissue in such a system are the fascia lata, the crural fascia, the iliotibial tract, the femoral and crural intermuscular septa, and the membrana interossea. The iliotibial tract is not the sole part of this system having a tension band effect, other components--above all the lateral femoral intermuscular septum--also reduce the forces acting on the bones. Therefore, the tensile strength of the iliotibial tract has to be considered lower as supposed. The iliotibial tract is not a part of the fascia lata; it is an independent, vertically tightened tendon of the 'pelvic deltoid muscle' (gluteus maximus, tensor fasciae latae). The iliotibial tract passes over the greater trochanter like on a roller bearing. It is not attached directly to the greater trochanter and to the lateral femoral condyle, so that previous models have to be modified. The iliotibial tract glides in a fascia bag which is composed of oblique and horizontal fibers of the broad fascia. The iliotibial tract, as tendon of the pelvic deltoid muscle, continues in a lateral location into the leg where it is fixed to the lateral malleolus. The present report provides a new description of the structure of the connective tissue system of the lower extremities. The model reported complies with the laws of similarity mechanics by describing exactly the geometric, physical and functional conditions. This representation could facilitate the construction of a computer-aided, efficient, biomechanical model of the pelvis-lower extremity region considering also the complex functional circumstances, in contrast to previous models. In order to construct such a model, the data obtained by the examination of the connective tissue of the lower extremities have to be given into a data bank, which, however, has to be built up.
Article
The most developed and organized lamina running trough the biceps brachii muscle belly forms a well-marked tendinous intersection connecting the proximal tendon with the distal one. Moreover, the lacertus fibrosus arises from this lamina close to the distal tendon and blends with the fascia of the forearm and joins the extensor carpi radialis muscle. The nerve supply for the biceps tendinous intersection arises from the intramuscular rami of the musculo-cutaneous nerve, whereas the lacertus fibrosus is provided with some cutaneous rami of the same nerve. The biceps brachii tendinous intersection and lacertus fibrosus are provided with free and encapsulated nervous endings. The encapsulated corpuscles are represented by rare Pacini, Pacini-like and Ruffini receptors and by numerous Golgi tendon-organs. All these receptors have been studied by a topographical point of view and the role played by the proprioceptors in synchronizing shoulder, elbow and carpal joint movements both in the flexion and the extension of the limb, has been hypothesized.
Article
The thoracolumbar fascia was studied by dissection in ten adult human cadavers. The posterior layer of this fascia was found to consist of two laminae. The superficial lamina is formed by the aponeurosis of latissimus dorsi. The deep lamina consists of bands of fibers passing caudolaterally from the midline. Both laminae form a retinaculum over the back muscles, and the deep lamina constitutes a series of accessory posterior ligaments that anchor the L2 to L5 spinous processes to the ilium and resist flexion of the lumbar spine. The function of these ligaments is enhanced by the contraction of the back muscles and the action of certain, restricted portions of the abdominal muscles.
Article
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.
Article
The purpose of this study is to provide better understanding of the mechanical response of the lumbodorsal fascia to dynamic and static traction loadings. Since the fascia shows a viscoelastic behaviour, tests in which time is a variable were used, namely hysteresis and stress relaxation. Load-strain and load-time curves obtained from the hysteresis and stress-relaxation tests point out three different phenomena. First, an increase in stiffness is noticed when ligaments are successively stretched, i.e. strains produced by successive and identical loads decrease. Second, if a sufficient resting period is allowed between loadings, stiffening is reversed and strains tend to recover initial values. The third phenomenon, observed in stress-relaxation tests as time progresses, is ligament contraction in stretched and isometrically held samples. This third phenomenon may be explained by the possibility that muscle fibres capable of contracting spontaneously could be present in lumbodorsal fascia ligaments.
Article
Background: Previous works have suggested that a defect in collagen fiber structure may play a role in inguinal hernia formation. These studies focused mainly on the rectus sheath or the skin, while only few reports dealt with the transversalis fascia. According to these findings and to our previous biomechanical and histological studies suggesting that a connective tissue pathology could play a role in the genesis of groin hernias, we performed a biochemical investigation of the collagen in the transversalis fascia and rectus sheath. Materials and methods: The samples were collected from 40 adult patients with uni- or bilateral hernias and from 20 control subjects without hernia (autopsies and organ donors). A constant area of tissue was taken by using a calibrator. The wet and dry weights per 100 mm(2) were determined and the total collagen concentration as well as its sequential extractibility in NaCl, acetic acid, and pepsin was measured. The ratios of alpha(1)/alpha(2) chains (I) and of type I/III collagen were assessed by polyacrylamide gel electrophoresis. Results: Samples collected in the control and patient sheaths showed an increased wet weight per 100 mm(2) in the patients. The wet and dry weights per unit area were increased in the patient fascias. The collagen concentration was increased in the indirect hernias. The fascias from the direct hernias (DH) presented a significantly increased collagen extractibility after pepsin digestion (5.6%), when compared to the control fascias (2.6%). The extractibility was 3.4% in the nonherniated (NH) sides. The qualitative study (ratios alpha(1)/alpha(2) (I) and I/III collagen) showed no difference between the fascia groups. Conclusions: The significant increase of collagen extractibility with pepsin in the DH fascias and at a lesser degree in the NH fascias suggests that molecular alterations of collagen could be involved in the genesis of groin hernias. This connective tissue pathology would express preferentially its effects in the inguinal region, since we have observed no major difference between the rectus sheaths of controls and those of patients.