TYPE Editorial

PUBLISHED 14 August 2024

DOI 10.3389/fmed.2024.1472116

Editorial: Fascia as a
OPEN ACCESS multi-purpose structure of
connective tissue - dysfunction,
EDITED AND REVIEWED BY
Arch Mainous,
University of Florida, United States

*CORRESPONDENCE
Anna Mika
diagnostics and treatment
anna.mika@awf.krakow.pl

RECEIVED 28 July 2024

ACCEPTED 02 August 2024
Anna Mika1*, Łukasz Oleksy2,3,4 , Caterina Fede5 , Carmelo Pirri5
PUBLISHED 14 August 2024 and Carla Stecco5
CITATION
1
Mika A, Oleksy Ł, Fede C, Pirri C and Stecco C Institute of Clinical Rehabilitation, University of Physical Education in Krakow, Kraków, Poland,
2
(2024) Editorial: Fascia as a multi-purpose Faculty of Health Sciences, Department of Physiotherapy, Jagiellonian University Medical College
structure of connective tissue - dysfunction, Krakow, Kraków, Poland, 3 Department of Orthopedics, Traumatology and Hand Surgery, Faculty of
diagnostics and treatment. Medicine, Wrocław Medical University, Wrocław, Poland, 4 Oleksy Medical & Sports Sciences, Rzeszów,
Front. Med. 11:1472116. Poland, 5 Department of Neurosciences, Institute of Human Anatomy, University of Padua, Padua, Italy
doi: 10.3389/fmed.2024.1472116

COPYRIGHT KEYWORDS
© 2024 Mika, Oleksy, Fede, Pirri and Stecco.
This is an open-access article distributed fascia, musculoskeletal system, diagnostic methods, rehabilitation, treatment, fascial
under the terms of the Creative Commons dysfunction
Attribution License (CC BY). The use,
distribution or reproduction in other forums is
permitted, provided the original author(s) and
the copyright owner(s) are credited and that
the original publication in this journal is cited,
in accordance with accepted academic Editorial on the Research Topic
practice. No use, distribution or reproduction Fascia as a multi-purpose structure of connective tissue - dysfunction,
is permitted which does not comply with diagnostics and treatment
these terms.

For many years, the fasciae have been considered only as a “white envelope for the
muscles”, and very little attention has been given to their macroscopic and histological
anatomy. With the last researches it is clear that we can recognized many fasciae, each
one with specific features: the superficial fascia, the muscular fasciae, the visceral fasciae
and the neural fasciae. The superficial fascia is rich in elastic fibers (1), it is adaptable and
strongly connected with the skin (2), it envelops and protect the superficial vessels and
nerves and probably plays a key role in lymphatic drainage (3), and in tissue healing and
regeneration processes (4). The muscular (or deep) fasciae are distinguished in two big
groups: the aponeurotic fasciae, that work as a bridge connecting different muscles, and
the epimysial fasciae, specific for each muscle. The deep fasciae are formed by collagen
fibers organized in layers, and each layer is separated by the closer one by loose connective
tissue, rich in water and hyaluronan (HA) (5). The collagen fibers define the mechanical
behavior of fasciae, the hyaluronan defines the tissue hydration and the ability of glide.
All these elements could be altered by trauma, bad posture, immobilization. The visceral
fasciae envelope the viscera and define their mobility and motility (6). They have a rich
autonomic innervation and connect the organs to the locomotor system in very precise
points. Finally, also the meningeal layers could be considered specialized fasciae.
The fasciae are very well-innerved (more than muscles, tendons, and joints), both with
sensitive an autonomic innervation, so much to be considered a sensory organ (7). We can
distinguished three different type of innervation inside fasciae:

• Free nerve ending forming a network, totally embedded in the fasciae, and able
to perceive every change in the fascial tension. These receptors have a key role in
proprioception and in the perception of the motor directions, but also they could be
able to perceive pain (8).

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Mika et al. 10.3389/fmed.2024.1472116

• Autonomic fibers, they are around 35% in the superficial to the subcutaneous layers. These alterations were observed
fascia, a little less in the deep fasciae, much more in the visceral separately or in association. In a recent review, Pirri et al. (14)
ones. They are present above all around the main vessels, listed all the Ultrasound (US) parameters that can be altered
and consequently they are responsible of the regulation of the in the fasciae and that can allow to do a diagnosis of fascial
blood flow inside the fasciae, but also in the middle of the pathology: thickness, echogenicity, stiffness, deformation,
connective tissue, and consequently they could be involved in shear strain, and displacement.
the fibrotic process of fascial tissue (9). • The fascia can be altered in their molecular components, such
• The muscle spindles. They are a specific innervation of as the amount of collagen and elastic fibers, or of hyaluronan,
the epimysial fasciae. Indeed these corpuscles are totally or in the density of innervation and vascularization. In this
embedded in the perimysium, and their capsule is nothing case, the imaging evaluations show a standard macroscopic
more than a doubling of the perimysium around the intrafusal organization of the fasciae, and only the biopsy can highlight
fibers. Muscle spindles inform the Central Nervous System the alteration. In the last years Fede et al. (15) demonstrated
(CNS) of the continually changing status of muscle tone, as the quantity of elastic and collagen fibers vary with aging,
movement, loss of normal elasticity, position of body parts, as happens in all the subcutaneous tissues. It was recently
absolute length of muscle and rate of change (velocity) of demonstrated that different levels of estrogenic hormones can
the length of the muscle. In order for a muscle spindle to modulate the production of collagen I, collagen III and fibrillin
function it must be able to lengthen, shorten and glide to allow (16). It seems that post-menopausal fasciae have more collagen
its annulospiral and flower spray organs to be stretched to type I (8.4 vs. 5.2% in control) and less collagen III (1.5 vs.
report accurate information to the CNS (10), and this is made 2.4%), explaining why the fasciae become more rigid with
possible by the epimysial fascia. aging. On the contrary, fasciae become more elastic during
pregnancy, with increased amounts of collagen-III (6.7%)
So, fasciae could be considered a key element in peripheral and fibrillin (3.6%, compared to 0.5% of the control) and
motor coordination and proprioception, but also of interoception. a corresponding decrease of collagen I (1.9%). Mechanical
At the same time, altered (restricted, densified) fasciae are inputs, such as extracorporeal shock wave, also seems to
responsible for chronic stiffness, decreased strength and abnormal change the fiber composition in fasciae, activating gene
movement patterns (loss of motor direction of bodily segments), expression for transforming growth factor β1 and collagen
bad motility of the internal organs, altered lymphatic drainage (11). types I and III (17, 18). With diabetes there are chronic
Besides, the fasciae could be subjected to different types alterations of the connective tissue, with a thickening of the
of alterations, some are clearly visible with standard imaging collagen fibers and a fragmentation of the elastic fibers, leading
evaluations, other need a biopsy to be understood. In a schematic to fascial stiffness (19, 20). The synthesis of the collagen type
way, we can distinguish three different conditions (Figure 1): III fibers increases in diabetic subjects, whereas the synthesis
of collagen type I fibers decreases. Furthermore, Extracellular
• The fascia has only an anomalous tension, due to the Matrix (ECM) turnover in diabetes patients is affected by
overstretching due to the underlying muscles that insert into chronic hyperglycemia, determining the accumulation of
it or to postural alteration. In this case the fascia is healthy, larger quantities of collagen, resulting in ECM thickening.
but the nerve receptors inside are constantly triggered. Wilke Fantoni et al. observed (21) a relationship between fascial
et al. (12) demonstrated the strain transfer along fasciae. In pathology and hip osteoarthritis (OA): in OA patients Authors
particular, the Authors checked the range of motion of the demonstrated an increase in Collagen I (COL I), along with the
neck in 26 healthy participants before and after the stretching reduction of Collagen III (COL III) and HA, leading to fascial
of the inferior limbs. After stretching, the cervical Range of stiffening, which could alter fascial mechanics and be linked to
Motion (ROM) was improved, demonstrating the anatomical the development and symptoms of OA.
continuity of the fasciae of inferior limbs and neck. From a
clinical point of view, it means that a trauma or a tension in the Another element that can alter the microanatomy of fasciae are
inferior limbs can affect the neck mobility, and consequently the myofibroblasts. According to Schleip et al. (22), myofibroblasts
some patients maybe don’t answer to our treatments because are present in all fasciae, but cell density increases in many
they are addressed at the wrong area. Further, it means that it pathological conditions, such as palmar fibromatosis, Morbus
is important to assess in a global way a patient with myofascial Ledderhose, hypertrophic scars, and similar fascial fibrotic
pain, because the fascial alteration could be far away from the conditions, but also in chronic low back pain, where myofibroblasts
site of pain. are associated with an augmented occurrence of (micro-) injuries
• The fascia has macroscopic alterations, such as a scar after and related cellular repair processes. It seems that fascial alteration
surgery or trauma. These alterations could be seen with could be a trigger for the transformation of fibroblasts into
the standard ultrasound evaluation, but also with Magnetic myofibroblasts but, due to their contractile activity, myofibroblasts
Resonance Imaging (MRI) and TC. Stecco et al. (13) further increase fascial tension creating a loop that progressively
evaluated 25 subjects with chronic ankle instability with aggravates the problem. Fasciae express also cannabinoid receptors
MRI, demonstrating in 21 patients specific alterations of [both Cannabinoid 1 and 2 (CB1 and CB2)] and their stimulation
the ankle retinacula (that are fascial thickenings), such as seems to induces the production of hyaluronan-rich vesicles,
edema, interruption of continuity, thickening or adhesion leading to greater tissue fluidity (23, 24).

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Mika et al. 10.3389/fmed.2024.1472116

FIGURE 1
Fascia could cause pain in different modalities, and they required different types of treatment and different way to make diagnosis. One of the most
common cause of fascial pain is an alteration of the fascial tension, that cause a deformation of the fascial free nerve ending.

To conclude, we think that it is time that fasciae will be draft, Writing – review & editing. CS: Writing – original draft,
considered in the clinical setting because there are many evidences Writing – review & editing.
that they can be a source of pain. The various aspects of
diagnosing fascia disorders and the effectiveness of the applied
therapy methods have been confirmed in studies published in Funding
this Research Topic, for the treatment of allergies (Liu et al.),
joint pain and joint disorders (Liu and Wang; Rogers et al.) The author(s) declare that no financial support was received for
and the most common back pain (Brandl et al.), highlighting the research, authorship, and/or publication of this article.
that the fascia should be considered for diagnosis and treatment
in heterogeneous and diverse clinical pictures. However, it is
important to consider that, to understand the fascial alteration and Conflict of interest
how improve a fascial alteration, it is important to consider that
fasciae form a three dimensional network and consequently the The authors declare that the research was conducted in the
point at which the patient feels pain often does not correspond absence of any commercial or financial relationships that could be
at the origin of the fascial problem. This implies that if we construed as a potential conflict of interest.
evaluate with ultrasound, MRI or other instruments the fascia The author(s) declared that they were an editorial
where the patient feels pain, probably we are not able to board member of Frontiers, at the time of submission.
see any alteration, but this does not automatically mean that This had no impact on the peer review process and the
this is not a fascial problem. Besides, the assessment of a final decision.
patient with fascial problems required always a global analysis,
considering previous trauma and previous unbalance conditions of
the fasciae.
Publisher’s note
All claims expressed in this article are solely those of the
Author contributions authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
AM: Writing – original draft, Writing – review & editing. ŁO: reviewers. Any product that may be evaluated in this article, or
Writing – original draft, Writing – review & editing. CF: Writing – claim that may be made by its manufacturer, is not guaranteed or
original draft, Writing – review & editing. CP: Writing – original endorsed by the publisher.

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