Research Review: Histological Study of the Deep Fasciae of the Limbs

By William Chancey Sumner, PTA, MS, CES, CAFS, HMS, FRCms, c-PT

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Stecco, C., Porzionato, A., Lancerotto, L., Stecco, A., Macchi, V., Day, J., De Caro, R. (2008). Histological Study of the Deep Fasciae of the Limbs. Journal of Bodywork and Movement Therapies, 12, 225 - 230. ABSTRACT

Introduction:

The number of published research studies and popularity of fascia has increased exponentially in the past decade; however, there are still gaps in our understanding (1-7). New research has implicated that fascia may play a role in force transmission, proprioception and pain (1). This 2008 study by Italian researchers provides foundational information about fascial layers, vascular and neural networks, and organization. This information may aid the human movement professional in the development of fascia specific techniques and interventions.

Bodies World Exhibit - Iliotibial Band invest into the knee and anterior crural fascia (Image: courtesy of www.BrentBrookbush.com)

Study Summary

Study Design	Descriptive study
Level of Evidence	III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies
Participant Characteristics	Demographics Number of participants: 6 cadavers 4 males 2 females Mean age = 69 years old Inclusion Criteria: Medical cadavers without trauma Exclusion Criteria: Traumatic lesions or pathologies of the limbs
Methodology	72 samples of the deep fascia of the limbs were taken during 6 cadaveric dissections. 12 different samples of the same size (1 x 1.5cm) were obtained. Three samples were taken from the following portions of the upper limbs and lower limbs: Brachial fascia Antebrachial fascia Fascia Lata Crural fascia Histological and immunohistochemical stains were performed to aid in analysis of the collagen fiber bundle arrangement, presence of elastic fibers, and type of innervations. Analysis of the interfasical vascular network was completed by recording the type and caliber of the vessels. Deep fascia from the limbs was measured twice to determine fascial thickness.
Data Collection and Analysis	Samples were preserved in 4% formaldehyde in phosphate buffer saline (PBS) 0.1M pH 7.0, subsequently preserved in paraffin and sections were cut into 10-µm thickness. Histological stains - hematoxylin and eosin, Azan-Mallory, van-Gieson, silver impregnation Immunohistochemical stains – antibody anti-S1000 Immunohistochemical method: 5-µm sections treated with 0.15% H2O2 for 15 minutes to decrease endogenous peroxidase activity. Samples were washed in PBS saline and then incubated with normal goat serum 1:100 for 30 minutes. Next, samples were washed with polyclonal antibodies raised against S-100 (DAKO, Italy) for nervous tissues, diluted 1:500 in PBS at 37° C in humid chamber for 60 minutes. Repeated washings were performed and then sections intubated with secondary antibody (Goat anti-rabbit IgG peroxidase-coniugated antibodies DAKO) 1:50 for 30 minutes. Reaction was highlighted with 3,3’-diaminobenzidine (DAB substrate tablets, Sigma, 0.1% v/v H2O The preparations, contrasted with haematoxylin, were dehydrated and mounted with Canadian balsam (BDH, Italy). Negative controls were obtained by omitting the primary antibody. All preparations were observed with a Leica DM 4500B microscope.
Outcome Measures	Structural organization of deep fascia of the limbs Innervation of deep fascia of the limbs
Results	Loose connective tissue between the fascia and muscle allows for the following: Easy identification between the fascia and muscle The ability for muscle to slide under fascia Muscles and fascia are connected in some regions, for example the musculotendinous junction and tendon/periosteum junction, providing attachments for muscle fibers. Fascial thickness varies by region with the following measures: The mean thickness of deep fascia is ~1mm It is thicker than 1mm in the inferior limbs and in the posterior region of all limbs It is thinner than 1mm near the pelvis but thicker near the knee The mean thickness of the brachial fascia is 863µm (micrometers) It is thinner in the anterior region but thicker in the posterior region The mean thickness of the antebrachial fascia is 755µm Mean caliber of the vessels is 102.15 +/- 34.9µm Fascia is reinforced by the following structures: Crural fascia is reinforced by the iliotibial tract The antebrachial fascia is reinforced by the lacertus fibrosus and retinacula of the wrist In one specimen, within the fascia lata, muscle fibers were found. Nerve fibers are present in all specimens of deep fascia and particularly numerous around vessels. Elastic fibers are abundantly found in the upper limbs fascia but only found in loose connective tissue and periphery of the lower limbs.
Our Conclusions	This study aids in understanding the structural organization of fascia. The findings of this study aid in consideration of the role fascia plays in optimal motion and dysfunction. Further, knowledge of fascial sheath structure may inspire the development of fascial specific techniques.
Researchers' Conclusions	Fascia appears to be organized differently in the upper limbs versus lower limbs. Fascia is made of two to three layers of parallel collagen fiber bundles. Loose connective tissue is present between the fascia and underlying muscles. This tissue allows for muscle to glide under the fascia. Nerve fibers are larger within the loose connective tissue and are oriented perpendicularly to the collagen fibers. Therefore, the nerves could be stimulated by stretching of the collagen fibers.

Tensor Fascia Latae Self-Administered Release (Image: courtesy of www.BrentBrookbush.com)

How this study contributes to the body of research:

This study provides descriptive information about the structure and organization of fascia. In both the upper and lower extremity, fascial sheaths were comprised of loose connective tissue layers between two or three layers of dense connective tissue. This may imply that loose connective tissue accommodates sliding between dense layers, as well as over the underlying muscles. A research study by Levangin et al. on the thoracolumbar fascia demonstrated a decrease in motion between layers in those with a history of low back pain (8); further research is needed to determine if dysfunction may cause the same tissue changes in the fascia of the extremities. This study also described a complex network of vessels and nerves present in all fascia, implying adaptation and sensation are a major function of fascial tissue. This descriptive data may aid human movement professionals and future researchers in determining the role fascia plays in motion and how to address tissue dysfunction.

How the Findings Apply to Practice:

Understanding the structure of fascia may aid in understanding the function and role fascia plays in motion and dysfunction. Additional studies are needed to support suggestions for practical application, but the findings in this study demonstrate layers of fascia that may glide over one another, a dense network of nerves and receptors, and a significant vascular network that may aid in adaptation. Human movement professionals should consider how fascia may contribute to assessment findings, and what techniques may initiate fascial change.

This study had many methodical strengths, including:

This study fills a gap in the research by providing evidence on the organization and presence of a complex neural and vascular network within the fascia of the upper and lower-extremities.
Careful attention was paid to methodology to ensure that consistent samples were obtained without damage.
Various regions of fascia were sampled to reduce the chance that anomalies skewed data, or result in descriptions that could not be applied to the entirety of the extremity.

Weaknesses and limitations that should be noted prior to clinical integration of the findings include:

Although it should be mentioned that sampling like this would not be permissible on living participants, the use of cadavers may have altered some of the measurements recorded.
The average age of the cadavers was 69 years old which may limit generalizability to younger populations.
Consideration of range of motion and/or restrictions may have added additional information regarding changes in tissue and the contribution of fascia.

How the study relates to Brookbush Institute Content?

The Brookbush Institute (BI) views human movement as the outcome of a holistic system, and is dedicated to developing education for each component of that system and practical applications for each component. For example, the predictive models of postural dysfunction are based on evidence of common tissue changes including muscle, joint, nerve and fascia. This study has been integrated into fascia specific content, and will influence the techniques adopted or developed to address fascial dysfunction. The BI will continues to pursue optimal practice by aggregating of all available evidence with a focus on practical application.

The following videos illustrate techniques with intent of affecting fascia:

Instrument Assisted Soft Tissue Mobilization (IASTM) Brachial and Forearm Fascia

IASTM Fascia Latae

IASTM Crural Fascia

Bibliography:

Bibliography:
1. Stecco, C., Pavan, P., Porzionato, A., Macchi, V., Lancerotto, L., Carniel, E., Natali, A., De Caro, R. (2009). Mechanics of crural fascia: from anatomy to constitutive modelling, Surg Radiol Anat, 31, 523 – 529
2. Bednar, D., Orr, F., Simon, G. (1995). Observations on the pathomorphology of the thoracolumbar fascia in chronic mechanical back pain. Spine, 20, 1161 - 1164
3. Standring, S., Ellis, H., Healy, J., Johnston, D., Williams, A. (2005). Gray’s Anatomy 39th Churchill Livingstone; London, England
4. Stecco, C., Porzionato, A., Macchi, V., Tiengo, C., Parenti, A., Aldegheri, R. Delmas, V., De Caro, R. (2006). Histological characteristics of the deep fascia of the upper limb. Italian Journal of Anatomy and Embrology, 111, 105-110
5. Rosch, R., Junge, K., Lynen, P., Mertens, P., Klinge, U., Schumpelick, V. (2003). Hernia – a collagen disease? European Surgery, 35, 11 – 15
6. Paoletti, S., (2002). The Fascia – Role of Tissue in Human Mechanics. Vannes, Sully
7. Erdemir, A., Piazza, S. (2004). Changes in foot loading following flantar fasciotomy: a computer modeling study. Journal of Biomechanical Engineering, 126(2), 237 – 243
8. Langevin, H., Fox, R., Koptiuch, C., Badger, G., Greenan-Nauman, A., Bouffard, N., Konofagou, E., Lee, W., Triano, J., Henry, S. (2011) Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskeletal Disorders. 12: 203.

Questions, comments, and criticisms are welcomed and encouraged -

Histological Study of the Deep Fasciae of the Limbs

Research Review: Histological Study of the Deep Fasciae of the Limbs

Bibliography:

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