The fascia of the limbs and back--a review

Human shoulder anatomy: new ultrasound, anatomical, and microscopic perspectives

This study aimed to describe the shoulder anatomy, together with the anatomical relationships in adults and early stages of development. The shoulder muscles were studied from ultrasound, anatomical, and microscopic perspectives in a sample of 34 human shoulders. Thickness measurements were taken of the tendons and fasciae of the subscapularis, long head tendon of the biceps brachii, supraspinatus, infraspinatus, and teres minor. Ultrasound and dissection techniques are strongly correlated. However, the measurements obtained from the dissection technique were superior to those obtained from the ultrasound in all cases, except for the thickness of the long head tendon of the biceps brachii, the teres minor tendon, and the fascia thickness of the infraspinatus. In addition, the study of shoulder anatomy revealed no differences between females and males. Relevant findings from dissection included a clear overlap between the infraspinatus and supraspinatus, which shared tendon fibers, and a similar connection between the transverse ligament of the long head tendon of the biceps brachii and the subscapularis, which created a more interconnected shoulder function. The study of the anatomical measurements shows an underestimation of the shoulder measurements in the ultrasound compared with the dissection technique, but a high correlation between the measurements made by the two techniques. We present reference values for the tendon and fascia thicknesses of the rotator cuff, with no differences observed by gender. The relationships between shoulder structures described in the anatomical study imply as well that, in the event of an injury, adjacent tissues may be affected. This extended information may facilitate future optimal clinical explorations.

Fascia Lata Autografts Achieve Interface Healing With the Supraspinatus Muscle Histologically and Mechanically in a Rat Supraspinatus Tendon Reconstruction Model for Massive Irreparable Rotator Cuff Tears

PURPOSE

To evaluate the histologic healing process and mechanical characteristics of the interface between a fascia lata autograft and supraspinatus muscle by establishing a supraspinatus tendon reconstruction model for chronic massive irreparable rotator cuff tears (MIRCTs).

METHODS

A total of 40 rats were studied. Eight rats were killed to establish an intact control group, and the other rats were first established as a chronic MIRCT model and then developed as the supraspinatus tendon reconstruction model. Histology, fatty infiltration, mechanics, and open field test for the interface between the fascia lata autograft and muscle were assessed at 2, 4, 8, and 16 weeks postoperatively.

RESULTS

Histologically, the interface between the fascia lata autograft and muscle gradually regenerated structural characteristics similar to the normal muscle-tendon interface by 16 weeks postoperatively. The amount of collagen I and III increased significantly during the healing time and stabilized at 8 weeks postoperatively. Fatty infiltration was obvious in the supraspinatus muscle 4 weeks after establishing the MIRCT model. However, the degree of fatty infiltration in the supraspinatus muscle gradually decreased after supraspinatus tendon reconstruction and stabilized at 8 weeks postoperatively. The ultimate failure force and ultimate stress gradually increased from 2 to 16 weeks and reached the level of the intact control tendon at 16 weeks postoperatively (P = .086). The movability of the forepaw returned to normal in the open field test (P = .907).

CONCLUSIONS

In this rat supraspinatus tendon reconstruction model, fascia lata autografts showed good interface healing with the supraspinatus muscle, and fatty infiltration in the supraspinatus muscle was histologically decreased. The interface between the fascia lata autograft and muscle showed mechanical strength similar to the anatomic muscle-tendon interface.

CLINICAL RELEVANCE

A supraspinatus tendon reconstruction technique using fascia lata autografts might be a good histologic and biomechanical option for treating MIRCTs.

Effectiveness of ultrasound guided interfascial hydrodissection with the use of saline anesthetic solution for myofascial pain syndrome of the upper trapezius: a single blind randomized controlled trial

Background

Myofascial pain syndrome (MPS) is described as pain that arise from myofascial trigger points (MTrPs) which is a hyperirritable spot within a taut band of skeletal muscle. A newer needling technique called the interfascial hydrodissection (IH), wherein anesthetic saline solution (ASS) is injected between the fascia of the muscles using ultrasound as guide. It is theorized that this technique blocks the nerve branches and improve gliding in between the muscle and fascia.

Objective

To determine the short and long-term effects of interfascial hydrodissection using 2% Lidocaine and saline solution compared to dry needling with MPS of the upper trapezius on pain and quality of life using.

Methods

This study is a single-blind randomized controlled trial where ultrasound guided IH with ASS was compared to dry needling (DN) of the MTrPs. Both groups were taught self-stretch exercises (SSE) to be done everyday after the procedure. Outcome measures were pain using the visual analogue scale (VAS) and quality of life assessment with EQ-5D-5l questionnaire. All participants were assessed by a blinded assessor before the intervention, immediately after, 10 and 30 min, one week, two weeks, four weeks, three months, and six months after the procedure. Data Analysis: Two-way mixed ANOVA and follow-up independent T-test were conducted for the outcome measures across several time points between the 2 groups.

Results

A total of 46 participants with two dropouts were all included during the final analysis. Both groups demonstrated significant differences in VAS scores between baseline and the different time points, the IH + SSE group demonstrated the more significant effect size at as compared to the DN + SSE group. For EQ-5D-5l, no statistical differences were seen in all dimensions but there was a larger effect size for usual activities, pain/discomfort and anxiety/depression.

Conclusion

Interfascial hydrodissection is a technique that can manage both short and long term symptoms of MPS. This could be utilized as an alternative management for those with chronic MPS of the upper trapezius.

Philippine Health Research Registry ID

PHRR221003-005034.

Ultrashort echo time pulse sequences for visualization of deep peripheral fasciae and epimysium in porcine models with histologic correlations

Background

The deep peripheral fascia and epimysium are vital for muscle and tendon support, but their tight proton composition results in hypointense signals in conventional spin echo sequences. Ultrashort echo time (UTE) magnetic resonance imaging (MRI), using microsecond TE values, may visualize these structures. The purpose of this study was to evaluate whether UTE pulse sequence with a three-dimensional cone trajectory (3D UTE), with or without fat suppression (FS), can be used to visualize the fascia and epimysium using porcine lower legs as an example.

Methods

The anterior soft tissues of porcine lower legs were dissected and partially separated into distinct layers to expose the deep peripheral fascia, epimysium, and muscle. Axial 3D UTE and 3D UTE FS imaging using dual-echo acquisition and echo subtraction were performed both before and after dissection. Prior to dissection, the thickness, signal-to-noise ratios (SNRs), and contrast-to-noise ratios (CNRs) of structures believed to be deep peripheral fascia and epimysium were measured in both 3D UTE and 3D UTE FS. Post-dissection images were also analyzed to measure the SNRs and CNRs for the deep peripheral fascia and epimysium. Histological evaluations were carried out to verify the identities of the deep peripheral fascia and epimysium, as well as their thickness, and these measurements were compared to imaging findings.

Results

In pre-dissection images obtained with 3D UTE and 3D UTE FS, both the deep peripheral fascia and epimysium exhibited high signal intensity. In the subtraction images, the mean thickness of the deep fascia was 0.87 mm, and that of the epimysium was 0.80 mm when imaged with 3D UTE. This is compared to measurements of 0.77 and 0.22 mm in 3D UTE FS, respectively. Histological analyses confirmed the thickness of the deep peripheral fascia and epimysium as 0.65 and 0.14 mm, respectively. In the post-dissection images, the deep fascia continued to display high signal intensity when compared with adjacent soft tissues, consistent with the histological findings. Meanwhile, the epimysium showed very low CNRs.

Conclusions

3D UTE and 3D UTE FS can be used to visualize the deep peripheral fascia with high signal intensity and contrast but are insufficient to show signal intensity in the epimysium.

Compartments of the crural fascia: clinically relevant ultrasound, anatomical and histological findings

PURPOSE

Compartment syndrome is a surgical emergency that can occur in any part of the body and can cause cell necrosis when maintained over time. The resulting defects can affect the nerves, muscle cells, bone tissue, and other connective tissues inside the compartment, and fasciotomy has to be performed. The anatomical and histological characteristics of the leg make acute, chronic, and exertional compartment syndrome more likely in this limb. For these reasons, knowledge of the ultrasound, anatomical, and histological features of the crural fascia can help in the treatment of leg compartment syndrome.

METHODS

Twenty-one cryopreserved lower limbs from adult cadavers and from one 29-week-old fetus were obtained from the dissection room. They were examined by ultrasound and a subsequent anatomical dissection and microscopy to study the crural fascia and its relationship with the different muscles. Anthropometric measurements were taken of the distances from the head of the fibula and lateral malleolus to the origin of the tibialis anterior muscle in the crural fascia, the exit of the superficial fibular nerve, and the fascia covering the deep posterior muscles of the leg.

RESULTS

The crural fascia has very important clinical relationships, which can be identified by ultrasound, as the origin of the tibialis anterior muscle at 16.25 cm from the head of the fibula and the exit of the superficial fibular nerve that crosses this fascia at 21.25 cm from the head of the fibula. Furthermore, the presence of a septum that fixes the deep posterior muscles of the leg and the vessels and nerve can be seen by ultrasound and can explain the possible development of a posterior compartmental syndrome of the leg. Awareness of these features will help to keep these structures safe during the surgical treatment of compartment syndrome.

CONCLUSION

The ultrasound study allows identification of anatomical structures in the leg and, thus, avoids damage to them during surgery for compartmental syndromes.

Examination of the effect of fascial therapy on some physical fitness parameters in taekwondo athletes

One of the objectives of this study is to determine the effect of the eight-week fascial therapy program on flexibility, vertical jump, standing long jump, speed and anaerobic strength parameters in taekwondo athletes. Another aim of the research is to create a therapy protocol that can be used in athletes related to performance development through the relaxation of the fascial system, which is considered an indicator of physical fitness and has numerous functions in the body. This study included 32 taekwondo players who were licensed, actively attending taekwondo training. In the study, two groups were formed as fascial therapy group (FTG) (n ​= ​16) and control group (CG) (n ​= ​16). After the groups were randomized, fascial relaxation techniques were applied to the fascial therapy group for eight weeks, up to twice a week, and for 30 ​min. According to the findings obtained as a result of the research, FTG ([-0.36 ​± ​0.17] seconds [s]) for the 20 ​m (m) Sprint (T2-T1) had a lower mean time than CG (0.00 ​± ​0.07) s, FTG (0.06 ​± ​1.95) for the Flamingo Balance Test (T2-T1) had a lower mean fall than CG (1.25 ​± ​1.13), FTG ([3.56 ​± ​2.37] centimeters [cm]) for the Sit & Reach Test (T2-T1) had a lower mean fall than CG ([-0.19 ​± ​1.28] cm), FTG ([5.75 ​± ​2.54] cm) had a higher jump distance than CG ([1.88 ​± ​8.11] cm) according to the results of Vertical Jump Test (T2-T1) and finally FTG ([9.13 ​± ​5.56] cm) had a longer distance than CG ([-0.31 ​± ​1.85] cm) according to the results of Standing Long Jump Test (T2-T1). The result of our study has shown that fascial techniques can be used safely by experienced physiotherapists and can be included in the training program. It is recommended that coaches of sports disciplines work with experienced physiotherapists on this subject and include fascial methods in their training programs.

A New Player in the Mechanobiology of Deep Fascia: Yes-Associated Protein (YAP)

Recent studies have demonstrated that fascial fibroblasts are susceptible to mechanical stimuli, leading to the remodeling of the extracellular matrix (ECM). Moreover, the extensive literature on Yes-associated protein (YAP) has shown its role in cell mechanics, linking cell properties, such as shape, adhesion, and size, to the expression of specific genes. The aim of this study was to investigate the presence of YAP in deep fascia and its activation after a mechanical stimulus was induced via a focal extracorporeal shockwave (fESW) treatment. Thoracolumbar fascia (TLF) samples were collected from eight patients (age: 30-70 years; four males and four females) who had undergone spine elective surgical procedures at the Orthopedic Clinic of University of Padova. YAP was measured in both tissue and TLF-derived fibroblasts through immunoblotting. COL1A1 and HABP2 gene expression were also evaluated in fibroblasts 2, 24, and 48 h after the fESW treatment. YAP was expressed in all the examined tissues. The ratio between the active/inactive forms (YAP/p-YAP) of the protein significantly increased in fascial fibroblasts after mechanical stimulation compared to untreated cells (p = 0.0022). Furthermore, COL1A1 and HABP2 gene expression levels were increased upon treatment. These findings demonstrate that YAP is expressed in the deep fascia of the thoracolumbar region, suggesting its involvement in fascial mechanotransduction processes, remodeling, regeneration, and fibrogenesis. This study indicates, for the first time, that YAP is a "new player" in the mechanobiology of deep fascia.

Static Injection, Migration, and Equalization (SIME): A New Paradigm for Safe Ultrasound-Guided Brazilian Butt Lift: Safer, Faster, Better

BACKGROUND

Although the Brazilian butt lift (BBL) is one of the most popular procedures in body contouring, it has been associated with the risk of pulmonary fat embolism when fat graft is injected into the gluteal muscles. The subcutaneous plane has been identified as a safe site for fat graft injection, but deaths from fat embolism continue to occur because there is no mechanism to confirm consistent subcutaneous placement.

OBJECTIVES

The aim of this paper was to determine if real-time intraoperative ultrasound could accurately identify the subcutaneous gluteal anatomic landmarks and permit a single surgeon to consistently target fat graft placement in the subcutaneous space.

METHODS

In total, 4150 BBLs were performed with real-time intraoperative ultrasound being used to confirm the subcutaneous position of a static cannula during fat graft injection. Serial deposits of fat graft were performed in each buttock. Ultrasound confirmed that fat graft consistently remained above the deep gluteal fascia and migrated through the deep subcutaneous space. These fat graft deposits were then equalized with a moving cannula to correct any contour deformities. Operative times were recorded and compared with BBL performed by expansion vibration lipofilling without ultrasound.

RESULTS

Real-time intraoperative ultrasound allowed for the visual confirmation of consistent subcutaneous fat graft deposition and the targeting of fat graft into specific gluteal subcutaneous compartments.

CONCLUSIONS

Real-time intraoperative ultrasound allows the surgeon to confirm a subcutaneous-only fat graft injection, target specific gluteal subcutaneous compartments, and take advantage of the unique architecture of the deep subcutaneous space to create gluteal projection and correct contour deformities.

A model for personalized diagnostics for non-specific low back pain: the role of the myofascial unit

Low back pain (LBP) is the leading cause of disability worldwide. Most LBP is non-specific or idiopathic, which is defined as symptoms of unknown origin without a clear specific cause or pathology. Current guidelines for clinical evaluation are based on ruling out underlying serious medical conditions, but not on addressing underlying potential contributors to pain. Although efforts have been made to identify subgroups within this population based on response to treatment, a comprehensive framework to guide assessment is still lacking. In this paper, we propose a model for a personalized mechanism-based assessment based on the available evidence that seeks to identify the underlying pathologies that may initiate and perpetuate central sensitization associated with chronic non-specific low back pain (nsLBP). We propose that central sensitization can have downstream effects on the "myofascial unit", defined as an integrated anatomical and functional structure that includes muscle fibers, fascia (including endomysium, perimysium and epimysium) and its associated innervations (free nerve endings, muscle spindles), lymphatics, and blood vessels. The tissue-level abnormalities can be perpetuated through a vicious cycle of neurogenic inflammation, impaired fascial gliding, and interstitial inflammatory stasis that manifest as the clinical findings for nsLBP. We postulate that our proposed model offers biological plausibility for the complex spectrum of clinical findings, including tissue-level abnormalities, biomechanical dysfunction and postural asymmetry, ecological and psychosocial factors, associated with nsLBP. The model suggests a multi-domain evaluation that is personalized, feasible and helps rule out specific causes for back pain guiding clinically relevant management. It may also provide a roadmap for future research to elucidate mechanisms underlying this ubiquitous and complex problem.

Acute effects of thoracolumbar fascia release techniques on range of motion, proprioception, and muscular endurance in healthy young adults

PURPOSE

This study investigates the acute effects of Graston and myofascial release on thoracolumbar fascia (TLF) on lumbar range of motion (ROM), lumbar and cervical proprioception, and trunk muscle endurance in healthy young adults.

METHOD

Twenty-four healthy young individuals were included in the study. Individuals were randomly divided into two groups as Graston technique (GT) (n = 12) and myofascial release (MFR) (n = 12). GT group received a fascial treatment with a graston instrument and the MFR group (n = 12) received manual myofascial treatment. Both techniques were applied for 10 min and as a single session. Lumbar ROM (goniometer), lumbar proprioception (digital inclinometer), cervical proprioception (CROM device), and trunk muscle endurance (with McGill Endurance Test) were evaluated before and after treatment.

RESULTS

Age, gender and body mass index of individuals in both groups were similar (p > 0.05). In both GT and MFR groups, an increase in ROM in the flexion direction (p < 0.05) and a decrease in the angle of deviation in proprioception in the flexion direction were determined (p < 0.05). Neither technique had a significant effect on cervical proprioception and trunk muscle endurance (p > 0.05). In addition, no difference was found between the effectiveness of Graston and myofascial release (p > 0.05).

CONCLUSION

This study showed that Graston and myofascial release applied to TLF in healthy young adults effectively improve lumbar ROM and proprioception in the acute period. Considering these results, both Graston and myofascial release can be used to provide elasticity of TLF and improve proprioceptive return.

Anatomical considerations and clinical implications of bicipital aponeurosis: A magnetic resonance imaging study

The bicipital aponeurosis (BA) is the distal aponeurosis of the biceps brachii which usually covers the median nerve (MN), and the brachial artery (BrA) and sometimes causes compression of these structures. Since these situations are rarely reported in the literature, BA frequently does not come to mind as a cause of such compression. Therefore, the diagnosis may be delayed. In this study, we aimed to investigate the morphometry of BA and its relationship with the surrounding neurovascular structures and to draw attention to BA as a structure that can cause entrapment of the MN and rarely, the BrA. We examined the MRIs of the elbow of 279 patients (107 women, 172 men) aged between 18 and 72 years. We measured the thickness, length and width of BA, and investigated the anatomical relationship between BA, BrA, and MN. The respective median thickness, width, and length of BA were 0.7 (0.4-1.8 mm), 18.0 (6.0-34.0 mm), and 32.0 (18.0-50.0 mm), respectively. In all sections examined, the BA covered the BrA and MN, and was located immediately anterior to the BrA. In 225 (80.6%) of 279 MRIs, the BrA was located anterior to the MN and posterior to the BA. In the remaining 54 (19.4%) MRIs, the MN was located anterior to the BrA and posterior to the BA. The respective median thickness, width, and length of the BA were 0.7 mm, 18.0 mm, and 32.0 mm, respectively. It covered the BrA and MN and was located immediately anterior to the BrA. The BA sometimes causes compression syndromes of these structures, therefore, for physicians, it is important to understand the anatomy of the BA.

The effect of deep tissue massage on respiratory parameters in healthy subjects—A non-randomised pilot study

Background

Deep tissue massage (DTM), based on deep palpation and elimination of fascia restrictions, can reduce symptoms resulting from fascial disorders. The goal of this study was the analysis of the DTM effect on respiratory parameters in healthy people.

Material and methods

The study involved a group of 40 people divided into two subgroups. The experimental group underwent a single DTM session. Classic massage was performed in the control group. Before and after treatment the chest circumference and oxygen saturation were measured and a spirometry test was performed.

Results

The chest expandability significantly increased in both groups with greater effect in DTM group. Vital capacity and saturation, significantly increased in the experimental group. No significant changes in dynamic parameters were noticed in the control group, while FVC slightly decreased in the experimental group.

Conclusions

In this study, deep tissue massage appeared to improve chest expendability and vital capacity with simultaneous decrease of FVC in healthy subjects. Further studies are needed to specify the effect of DTM on the respiratory system.

Thoracolumbar fascia mobility and chronic low back pain: Phase 1 of a pilot and feasibility study assessing repeated measures and the influence of paraspinal muscle contraction

BACKGROUND

Differential movement, or shear strain (SS), between layers of thoracolumbar fascia is reduced with chronic low back pain. To provide a foundation for clinical research involving SS, this study assessed temporal stability and the effect of paraspinal muscle contraction on SS in persons with chronic low back pain.

METHODS

We used ultrasound imaging to measure SS in adults self-reporting low back pain ≥1 year. Images were obtained by placing a transducer 2-3 cm lateral to L2-3 with participants lying prone and relaxed on a table moving the lower extremities downward 15°, for 5 cycles at 0.5 Hz. To assess paraspinal muscle contraction effects, participants raised the head slightly from the table. SS was calculated using 2 computational methods. Method 1 averaged the maximum SS from each side during the third cycle. Method 2 used the maximum SS from any cycle (2-4) on each side, prior to averaging. SS was also assessed after a 4-week no manual therapy period.

RESULTS

Of 30 participants (n = 14 female), mean age was 40 years; mean BMI 30.1. Mean (SE) SS in females with paraspinal muscle contraction was 66% (7.4) (method 1) and 78% (7.8) (method 2); 54% (6.9) (method 1) and 67% (7.3) (method 2) in males. With muscles relaxed, mean SS in females was 77% (7.6) (method 1) or 87% (6.8) (method 2); 63% (7.1) (method 1) and 78% (6.4) (method 2) in males. Mean SS decreased 8-13% in females and 7-13% in males after 4-weeks CONCLUSION: Mean SS in females was higher than males at each timepoint. Paraspinal muscle contraction temporarily reduced SS. Over a 4-week no-treatment period, mean SS (with paraspinal muscles relaxed) decreased. Methods less likely to induce muscle guarding and enabling assessment with broader populations are needed.

Mechanical effects of needle texture on acupoint tissue

OBJECTIVE

This study aims to clarify how the stimulation of acupuncture points is achieved by needles with different surface texture during acupuncture; it also seeks to lessen injury at the insertion site and increase the therapeutic efficacy of acupuncture, by simulating the mechanical effects of various needle surface patterns on Zusanli (ST36) without changing the radius of acupuncture needles.

METHODS

Five acupuncture needle models with different surface patterns, including the smooth needle, the lined needle, the ringed needle, the left-hand threaded needle and the right-hand threaded needle, and a layered model of the Zusanli acupoint were used to investigate how to reduce tissue damage and increase stimulation during acupuncture treatment. Puncturing of the skin as well as lifting-inserting and twisting needle manipulations were simulated using these models, and the degree of damage and force of stimulation caused by the acupuncture needles with different surface patterns during acupuncture were compared.

RESULTS

The smooth needle and the lined needle caused the least tissue damage during insertion, while the left-hand threaded and the right-hand threaded needles caused the most damage. The ringed needle, the left-hand threaded needle and the right-hand threaded needle stimulated the acupoint tissue more during lifting-inserting manipulations, while the lined needle and the smooth needle produced less stimulation. The stimulation of the lined needle on the acupoint tissue was the largest during twisting manipulation, whereas the left-hand threaded needle and the right-hand threaded needle had smaller effects. In lifting-inserting and twisting manipulations, both the left-hand threaded needle and right-hand threaded needle provided more stimulation, but the torsion direction in which they produced better stimulation was the opposite.

CONCLUSION

According to the simulation results, the ringed pattern enhances stimulation best in the lifting-inserting manipulation, whereas the lined pattern enhances stimulation best in the twisting manipulation. Both the right-hand and left-hand thread patterns have certain enhancing effects in these two operations. Taking the geometric properties of the pattern into account, the left-hand thread pattern and the right-hand thread pattern have the geometric characteristics of both the lined pattern and the ringed pattern. To conclude, a pattern perpendicular to the movement direction during the acupuncture manipulation creates more stimulation. These results have significance for future needle design. Please cite this article as: Sun MZ, Wang X, Li YC, Yao W, Gu W. Mechanical effects of needle texture on acupoint tissue. J Integr Med. 2023; Epub ahead of print.

Are fascial strains involved in chronic pelvic pain syndrome? An exploratory matched case-control study

BACKGROUND

Chronic pelvic pain (CPP) and chronic pelvic pain syndrome (CPPS) do not have a definite cause, even if their impact on quality of life was demonstrated. Furthermore, there is evidence of myofascial dysfunctions in a large number of CPP/CPPS, so that the role of fascia can be hypothesized.

METHODS

The aim of this exploratory matched case-control study was to assess whether fascial strains (FS) represent a factor associated with CPP/CPPS. The study followed the "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) statement. We collected data from 189 subjects (cases: 58; controls: 131) who attended the clinic. The participants were managed through a 2:1 enrollment ratio. A standardized booklet requested for clinical information, previous FS and the following questionnaires: "National Institutes of Health Chronic Prostatitis Symptom Index" (NIH-CPSI), "Hospital Anxiety and Depression Scale" (HADS), "Fear Avoidance Belief Questionnaire" (FABQ). Each subject underwent a palpatory assessment to detect abnormal palpatory findings in the pelvic area.

RESULTS

The analyses showed that episiotomy, genito-urinary infections and surgery had a significantly increased odds ratio (OR) of 4.13, 3.1 and 3.08, respectively. FS as a whole had a significantly raised OR: 2.22 (1.14 to 4.33). The analysis was adjusted for physical activity and for type of job and OR decreased to 1.94 (0.82 to 4.61), losing its significance (p = 0.129). A strong correlation between symptoms' impact and CPP/CPPS was detected (rpbs = 0.710; p < 0.001) and a moderate one (0.3 < rpbs < 0.7; p < 0.001) was found considering anxiety, depression and abnormal palpatory findings.

CONCLUSION

This exploratory study suggests that FS could represent an etiological factor for developing CPP/CPPS. However, further research on fascial dysfunctions and relative implications in CPP/CPPS is needed for confirmation.

Effect of lacertus fibrosus release on perineural pressure of the median nerve at the elbow: a cadaveric study

PURPOSE

The lacertus fibrosus (or bicipital aponeurosis) is a potential site of proximal median neuropathy at the elbow. Lacertus syndrome with motor and/or sensory symptoms has been addressed with a minimally invasive surgical lacertus release. This study evaluates if a lacertus release alters the maximal perineural pressure (Pmax) of the median nerve at the level of the lacertus fibrosus during elbow flexion.

METHODS

Seven upper limbs from four fresh cadavers were included. Perineural pressure of the median nerve at the level of the lacertus fibrosus was measured continuously during automated elbow flexions by the biceps brachii muscle.

RESULTS

The mean Pmax before the lacertus release was significantly different than the mean Pmax after the lacertus release (669.15 mmHg vs 77.01 mmHg, p = 0.0180). The mean Pmax after the lacertus release decreased with an average 81.41%.

CONCLUSION

A simple surgical release of the lacertus fibrosus significantly decreases the maximal perineural pressure of the median nerve at the level of the lacertus fibrosus during elbow flexion.

From Muscle to the Myofascial Unit: Current Evidence and Future Perspectives

The "motor unit" or the "muscle" has long been considered the quantal element in the control of movement. However, in recent years new research has proved the strong interaction between muscle fibers and intramuscular connective tissue, and between muscles and fasciae, suggesting that the muscles can no longer be considered the only elements that organize movement. In addition, innervation and vascularization of muscle is strongly connected with intramuscular connective tissue. This awareness induced Luigi Stecco, in 2002, to create a new term, the "myofascial unit", to describe the bilateral dependent relationship, both anatomical and functional, that occurs between fascia, muscle and accessory elements. The aim of this narrative review is to understand the scientific support for this new term, and whether it is actually correct to consider the myofascial unit the physiological basic element for peripheral motor control.

Behavior of medial gastrocnemius muscle beneath kinesio taping during isometric contraction and badminton lunge performance after fatigue induction

Kinesio taping (KT) is widely used in sports for performance improvement and injury prevention. However, little is known of the behavior of the muscle region beneath the KT with movement, particularly when the muscle is fatigued. Accordingly, this study investigated the changes in the medial gastrocnemius muscle architecture and fascia thickness when using KT during maximum isometric plantar flexion (MVIC) and badminton lunges following heel rise exercises performed to exhaustion. Eleven healthy collegiate badminton players (4 males and 7 females) were recruited. All of the participants performed two tasks (MVIC and badminton lunge) with a randomized sequence of no taping, KT and sham taping and repeated following exhaustive repetitive heel rise exercise. In the MVIC task, the fascia thickness with the medial gastrocnemius muscle at rest significantly decreased following fatigue induction both without taping and with KT and sham taping (p = 0.036, p = 0.028 and p = 0.025, respectively). In the lunge task, the fascia thickness reduced after fatigue induction in the no taping and sham taping trials; however, no significant change in the fascia thickness occurred in the KT trials. Overall, the results indicate that KT provides a better effect during dynamic movement than in isometric contraction.

Acute Effects of Percussive Massage Therapy on Thoracolumbar Fascia Thickness and Ultrasound Echo Intensity in Healthy Male Individuals: A Randomized Controlled Trial

Percussive massage therapy (PT) has been widely used by therapists and the fitness population to treat myofascial-related conditions. However, there is no evidence to confirm the effects of PT on the fascia. This study aimed to investigate the effects of PT on thoracolumbar fascia (TLF) morphology and other related outcomes.

METHODS

Sixty-six healthy males participated and were randomly allocated into a percussive massage group (PT group) and a control group. The PT group received 15 min of back percussion massage, while the control group rested prone lying in the same environment for 15 min. Thoracolumbar fascia (TLF) thickness and echo intensity, perceived stiffness, lumbar flexibility, and skin temperature were measured in both groups before and immediately after the intervention.

RESULT

TLF thickness and lumbar flexibility did not change when compared in the two groups. However, the echo intensity (left side, difference -3.36, 95% CI -5.1 to -1.6; right side, difference -4.39, 95% CI -6.1 to -2.7) and perceived stiffness (difference, -1.18, 95% CI -1.84 to -0.52) in the TLF region were significantly lower in the PT group than in the control group and were accompanied by increased skin temperature (difference 0.29, 95% CI 0.11 to 0.48).

CONCLUSION

We suggest that a 15 min PT with 30 Hz on the back region could reduce TLF echo intensity and perceived stiffness and increase skin temperature in healthy men individual.

Thoracolumbar fascia mobility and chronic low back pain: Phase 2 of a pilot and feasibility study including multimodal chiropractic care

BACKGROUND

Thoracolumbar fascia mobility observed with ultrasound imaging and calculated as shear strain is lower in persons with chronic low back pain. This pilot and feasibility trial assessed thoracolumbar shear strain in persons with chronic low back pain following spinal manipulation and over an 8-week course of multimodal chiropractic care.

METHODS

Adults self-reporting chronic low back pain ≥ 1 year participated between September 2019 and April 2021 in a trial using ultrasound imaging to measure thoracolumbar shear strain. Ultrasound imaging occurred 2-3 cm lateral to L2-3 while participants relaxed prone on an automated table moving the lower extremities downward 15 degrees, for 5 cycles at 0.5 Hz. Pain intensity on an 11-point numerical rating scale, disability, pain interference, and global improvement were also collected. Participants received 8-weeks of twice-weekly chiropractic care including spinal manipulation, education, exercise, self-management advice and myofascial therapies. Shear strain was computed using 2 methods. The highest shear strain from movement cycles 2, 3, or 4 was averaged over right and left sides for each participant. Alternately, the highest shear strain from movement cycle 3 was used. All data were analyzed over time using mixed-effects models. Estimated mean changes are reported.

RESULTS

Of 20 participants completing 8-weeks of chiropractic care (female n = 11), mean (SD) age was 41 years (12.6); mean BMI was 28.5 (6.2). All clinical outcomes improved at 8-weeks. Mean (95% confidence interval) pain intensity decreased 2.7 points (- 4.1 to - 1.4) for females and 2.1 points (- 3.7 to 0.4) for males. Mean Roland-Morris disability score decreased by 5 points (- 7.2 to - 2.8) for females, 2.3 points (- 4.9 to 0.2) for males. Mean PROMIS pain interference T-score decreased by 8.7 points (- 11.8 to - 5.5) for females, 5.6 points (- 9.5 to - 1.6) for males. Mean shear strain at 8-weeks increased in females 5.4% (- 9.9 to 20.8) or 15% (- 0.5 to 30.6), decreasing in males 6.0% (- 24.2 to 12.2) or 2% (- 21.0 to 16.8) depending on computational method.

CONCLUSION

Spinal manipulation does not likely disrupt adhesions or relax paraspinal muscles enough to immediately affect shear strain. Clinical outcomes improved in both groups, however, shear strain only increased in females following 8-weeks of multimodal chiropractic care. Trial registration ClinicalTrials.gov registration is NCT03916705.

Exercise Selection and Common Injuries in Fitness Centers: A Systematic Integrative Review and Practical Recommendations

Weight resistance training (RT) is an essential component of physical conditioning programs to improve the quality of life and physical fitness in different ages and populations. This integrative review aimed to analyze the scientific evidence on the relationship between exercise selection and the appearance of musculoskeletal injuries in physical fitness centers (PFC). The PubMed or Medline, EMBASE or Science Direct, Google Scholar and PEDro databases were selected to examine the available literature using a Boolean algorithm with search terms. The review process was performed using the five-stage approach for an integrative review and it was reported according to the PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSiST) guidelines. A total of 39 peer-reviewed articles (Price index = 71.7%) met the inclusion criteria and evaluated the link between exercise selection and the incidence of injuries in exercisers who regularly attend PFC. Most injuries occur to the shoulders, elbows, vertebrae of the spine, and knees. Although the injury etiologies are multifactorial, the findings of the reviewed articles include the impacts of overuse, short post-exercise recovery periods, poor conditioning in the exercised body areas, frequent use of heavy loads, improper technique in certain exercises, and the abuse of performance- and image-enhancing drugs. Practical recommendations addressed to clinical exercise physiologists, exercise professionals, and health professionals are given in this paper. The exercise selection in RT programs requires professional supervision and adhering to proper lifting techniques and training habits that consider the anatomical and biomechanical patterns of the musculoskeletal structures, as well as genetic, pedagogical, and methodological aspects directly related to the stimulus-response process to mitigate the occurrence of RT-related injuries in PFC.

Effects of Maximal Eccentric Exercise on Deep Fascia Stiffness of the Knee Flexors: A Pilot Study using Shear-Wave Elastography

The deep fascia is intimately linked to skeletal muscle and may be involved in delayed onset muscle soreness (DOMS). The present study therefore explored the effect of eccentric exercise on fascia stiffness and its relation with DOMS. Healthy active male adults (n = 19, 27 ± 4 years) performed 6 x 10 maximal eccentric knee flexions using an isokinetic dynamometer. Before (baseline) as well as immediately (T0), 1 hour (T1), and each day up to 72 hours (T24 to T72) afterwards, shear wave elastography was used to measure the mechanical stiffness of the biceps femoris muscle and the overlying fascia. As a surrogate of DOMS, pain upon palpation was captured by means of a 100mm visual analogue scale. While muscle stiffness remained unchanged (p > 0.05), deep fascia stiffness increased from baseline to T24 (median: 18 kPa to 21.12 kPa, p = 0.017) and T72 (median: 18 kPa to 21.3 kPa, p = 0.001) post-exercise. Linear regression showed an association of stiffness changes at T24 and pressure pain at T72 (r² = 0.22, p < 0.05). Maximal eccentric exercise leads to a stiffening of the fascia, which, in turn, is related to the magnitude of future DOMS. Upcoming research should therefore gauge the effectiveness of interventions modifying the mechanical properties of the connective tissue in order to accelerate recovery.

Soleus muscle and Achilles tendon compressive stiffness is related to knee and ankle positioning

Changes in fascicle length and tension of the soleus (SOL) muscle have been observed in humans using B-mode ultrasound to examine the knee from different angles. An alternative technique of assessing muscle and tendon stiffness is myometry, which is non-invasive, accessible, and easy to use. This study aimed to estimate the compressive stiffness of the distal SOL and Achilles tendon (AT) using myometry in various knee and ankle joint positions. Twenty-six healthy young males were recruited. The Myoton-PRO device was used to measure the compressive stiffness of the distal SOL and AT in the dominant leg. The knee was measured in two positions (90° of flexion and 0° of flexion) and the ankle joint in three positions (10° of dorsiflexion, neutral position, and 30° of plantar flexion) in random order. A three-way repeated-measures ANOVA test was performed. Significant interactions were found for structure × ankle position, structure × knee position, and structure × ankle position × knee position (p < 0.05). The AT and SOL showed significant increases in compressive stiffness with knee extension over knee flexion for all tested ankle positions (p < 0.05). Changes in stiffness relating to knee positioning were larger in the SOL than in the AT (p < 0.05). These results indicate that knee extension increases the compressive stiffness of the distal SOL and AT under various ankle joint positions, with a greater degree of change observed for the SOL. This study highlights the relevance of knee position in passive stiffness of the SOL and AT.

Immediate effect of stair exercise on stiffness, tone, and pressure pain threshold of thoracolumbar fascia in individuals with lower limb amputation: a preliminary report

BACKGROUND

Adaptations to the use of prosthesis in individuals with a lower limb amputation may cause changes in lumbopelvic region structures during daily life activities.

OBJECTIVE

To investigate the effect of stair exercise on the stiffness, tone, and pressure pain threshold (PPT) of the thoracolumbar fascia (TLF) in individuals with unilateral lower limb amputation.

DESIGN

This is a prospective preliminary study.

METHODS

The study was conducted in Prosthetic Orthotic Centers in Istanbul. Syrian individuals with unilateral transtibial (n = 17) and transfemoral (n = 15) amputation who received prosthesis and rehabilitation services at the centers between February 2020 and December 2020 were included in the study. The subjects were instructed to ascend and descend a nine-step stair one at a time at their maximum possible speed. Measurements were made before and immediately after the stair exercise. Tone and stiffness of TLF was measured using myometer. PPT was measured using algometer. Low back pain was evaluated using numerical pain rating scale.

RESULTS

In the transfemoral amputation group, PPT measurements taken immediately after stair exercise were significantly decreased in both the amputated ( P = 0.001) and intact ( P = 0.021) sides, whereas significant reduction in stiffness when compared with the prestair levels was observed only at the intact side ( P = 0.019). The change in PPT values on the amputated side was significantly higher in individuals with transfemoral amputation than those in individuals with transtibial amputation ( P = 0.011).

CONCLUSION

The decrease in PPT values of TLF in the transfemoral amputation group was considered as a precursor sign for low back pain development. Thus, exercises and preventive rehabilitation programs targeting TLF may be needed, especially in this group.

The effect of ageing on fat infiltration of thigh and paraspinal muscles in men

Background

Myosteatosis, skeletal muscle fat infiltration, is associated with inflammation and fibrosis. The age-related increase of myosteatosis is an important characteristic of sarcopenia and contributes to fragility.

Aims

To investigate the impact of healthy aging on intermuscular adipose tissue (IMAT) and muscle fat fraction (FF) in the thigh and the paraspinal muscles in males.

Methods

In 54 healthy males (age 20–70), all active hobby golfers, magnetic resonance imaging was performed to determine volume of IMAT, volume of muscle tissue (MT) and of percentage of FF.

Results

Between ages 20–70, at the thigh, IMAT/MT volume and MT FF increased annually by 2.9% and 1.3%, respectively. At the psoas IMAT/Psoas volume did not change with age. MT FF increased by 1.5% annually. At the erector spinae IMAT/Erector volume decreased by 0.3% and MT FF increased by 2.8% annually.

Discussion

With increasing age, in males, thigh muscle atrophied, muscle tissue was partly replaced by adipose tissue and remaining muscle tissue also contained more fat. Similar effects were observed in the erector spinae. The psoas muscle did not atrophy, although MT FF also increased with age. Overall correlations with age were weak to moderate with higher correlations observed in the paraspinal muscles.

Conclusions

Age-related increases of muscle fat infiltration were observed in the thigh and in the spine. Muscle atrophy did not occur in the psoas. In cross-sectional studies, an adjustment of volumetric parameters by muscle volume is advisable when comparing age-dependent results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-022-02149-1.

A myogenic niche with a proper mechanical stress environment improves abdominal wall muscle repair by modulating immunity and preventing fibrosis

Volumetric muscle loss (VML) healing is often complicated by fibrosis, which impairs muscle regeneration and function. Adjusting mechanical stress in the repair environment may modulate immunity and reduce fibrosis. In this study, we aimed to create a biomaterial with suitable tension conditions and bidirectional tissue-inducing abilities to prevent fibrosis thus promote muscle regeneration and induce aponeurosis-like structures to restore muscle force transmission. A protocol was developed to manufacture decellularized muscle aponeurosis (D-MA) patches with an intact extracellular matrix (ECM) and low cytotoxicity. D-MA optimized the mechanical stress distribution in muscle injury sites and decreased the number of proinflammatory macrophages and myofibroblasts, thereby attenuating muscle fibrosis. Muscle and aponeurosis ECM environments had different microstructures and mechanical properties, which specifically enhanced stem cell differentiation into muscle-like cells on muscle ECM and tenocyte-like cells on aponeurosis ECM in vitro. Four weeks after orthotopic implantation, the biphasic muscle-aponeurosis-like tissue was successfully regenerated by the D-MA scaffold. The regenerated muscle fibers in D-MA were more abundant than those in the fibrotic decellularized muscle (D-M) scaffold. D-MA can be used to repair abdominal defects, which significantly improves the repair outcomes. Our results suggest D-MA as a promising material for VML repair.

The impact of Fascial Distortion Model on shoulder girdle dysfunction

Introduction: Shoulder girdle as highly specialized set of structures is particularly susceptible to overloading and injuries. In current literature USG and MRI results shows poor correlation with the function, which lead to some problems in correct diagnosis. The structure contributing to this issue might be fascia. One of the methods examination and treatment is very poorly known Fascial Distortion Model. The aim of our research was to assess the impact of the Fascial Distortion Model on shoulder girdle dysfunction. Materials and methods: The subject of research were 78 patients with shoulder dysfunction. Experimental group of 50 patients underwent six 30-minutes FDM treatments, performed every second day. The control group of 28 patients were subjected standard physiotherapy. Measurement of mobility and pain was done by: functional tests, DASH questionnaire, modified CONSTANT scale and VAS scale. Results: The experimental group obtained better results than control group. This was due to less pain (M = 0.56, SD = 1.03) vs (M = 6.71, SD = 1.88) and a greater limb function (M = 3.46, SD = 7.80) vs (M = 42.72, SD = 16.52). Participants treated with FDM improved in ROM, DASH score and VAS at the significance level (p = .000). Conclusions: 1. Fascial distortions may contribute to dysfunction of the shoulder complex. 2. Connective tissue problems can limit the range of movement 3. Fascia disorders may contribute pain.

Anatomical study of paratenons and fascia lata connections in the posteromedial knee region

INTRODUCTION

In the last decade, fascia research increased significantly in various aspects such as anatomical and biomechanical features related to epimuscular force transmission.

METHODS

The present anatomic study focuses on macroscopic observations of the potential gracilis and semitendinosus paratenons, as well as fascial surroundings connections in the posteromedial knee region on 17 lower-limbs dissections.

RESULTS

The gracilis and semitendinosus expansions and paratenons were observed in all specimen and further connections with the fascia lata and crural fascia were demonstrated. Contrary to the previously described expansions connected to the tendons, we observed that the expansions were the edges of the paratenon tunnel and that the paratenon structure surrounded the overall muscle. Both paratenons of gracilis and semitendinosus were connected to the crural fascia and, respectively, to the sartorius fascia (part of the fascia lata), to the semimembranosus and the fascia lata. Furthermore, numerous connections between the fascia lata and the neighboring structures in the posteromedial knee region are described.

DISCUSSION-CONCLUSION

The present study describes for the first time gracilis and semitendinosus paratenons and other surrounding fascial connections. Such macroscopic observations may represent a new basis for further characterization of the myofascial pathway of epimuscular force transmission in the knee region.

Myofascial points treatment with focused extracorporeal shock wave therapy (f-ESWT) for plantar fasciitis: an open label randomized clinical trial

BACKGROUND

Plantar fasciitis (PF) is a common cause of heel pain. Among the several conservative treatment options, extracorporeal shock wave therapy (ESWT) is considered the standard treatment. However, recent studies suggest that PF may be sustained by a myofascial impairment proximal to the pain area with a biomechanical disequilibrium of the entire limb and pelvis.

AIM

By combining the concepts of fascial manipulation and ESWT, the purpose of this study was to evaluate the effectiveness of the ESWT on myofascial points in a sample of subjects with PF.

DESIGN

Open label randomized controlled clinical trial.

SETTING

Outpatient clinic.

POPULATION

Patients with PF were randomly assigned to an experimental treatment group (EG), treated with focused ESWT on myofascial points, and a control group (CG), treated with the focused ESWT traditional approach on the medial calcaneal tubercle.

METHODS

Every patient underwent a 3-session program and follow-up after 1 and 4 months. Outcome measures included the Foot and Ankle Outcome Score (FAOS) and the Italian Foot Functional Index (17-iFFI).

RESULTS

Thirty patients were enrolled in the study. Four patients of the CG dropped out the study, therefore twenty-six patients were included in the final analysis. Improvement in 17-iFFI and FAOS scores was observed in both groups starting from the third treatment and confirmed at the 1-month and 4-month follow-ups, with earlier improvement in the score values observed in the EG.

CONCLUSIONS

Treatment of the myofascial points with ESWT in subjects suffering from plantar fasciitis could be an effective treatment option. It fosters the hypothesis that a global biomechanical re-equilibrium of the body would be necessary to completely solve the pathology.

CLINICAL REHABILITATION IMPACT

ESWT on myofascial points could provide an interesting alternative with better outcomes in terms of time needed for recovery compared to traditional ESWT for the conservative management of PF.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Erector Spinae Plane Block. A narrative review

The erector spinae plane (ESP) block is an interfascial block described in 2016 by Forero and collaborators, with wide clinical uses and benefits when it comes to analgesic control in different surgeries. This block consists of the application of local anesthetic (LA) in a deep plane over the transverse process, anterior to the erector spinae muscle in the anatomical site where dorsal and ventral branches of the spinal nerve roots are located. This review will cover its clinical uses according to different surgical models, the existing evidence and complications described to date.

Ultrasound-Guided Erector Spinae Plane Block and Trapezius Muscle Injection for Myofascial Pain Syndrome

OBJECTIVE

There were two goals to this study: the first goal was to research the analgesic effectiveness of erector spinae plane block (ESPB) added to the treatment after trapezius muscle injection (TMI) and the second was to investigate whether repeated TMI increases the analgesic effect in myofascial pain syndrome (MPS).

METHODS

Sixty patients with a diagnosis of MPS were randomized into two groups. The TMI group (n = 30) received ultrasound-guided (USG) TMI with 5 mL of 0.25% bupivacaine two times, with a 1-week interval in between. The ESPB group (n = 30) received USG TMI with 5 mL of 0.25% bupivacaine in the first week and USG ESPB with 20 mL of 0.125% bupivacaine in the second week. The pain severity of the patients was evaluated using the visual analog scale (VAS). The data obtained before (week 0) and after (weeks 1, 2, 3, and 4) the injections were statistically compared between the groups.

RESULTS

In both groups, the mean VAS score decreased in the first week compared to the mean pretreatment score (p < .001). When the VAS scores were compared between the first and second weeks, a decrease was observed in both groups (p < .001), but it was more evident in the ESPB group. Compared to previous weeks, there was no significant difference in VAS scores at the third and fourth weeks.

CONCLUSIONS

The analgesic effect of repeated TMI for MPS was superior to a single injection, but ESPB combined with TMI provided more effective analgesia than repeated TMI.

The characteristics of oro-cervical necrotizing fasciitis-Comparison with severe cellulitis of oro-cervical region and necrotizing fasciitis of other body regions

Background

Necrotizing fasciitis (NF) is an acute and life-threatening soft-tissue infection however rarely seen in oro-cervical region. Therefore, the details of oro-cervical NF (OCNF) are not well known. The purpose of this study was to investigate the characteristics of OCNF by comparing it with severe cellulitis of oro-cervical region (OCSC) or NF of other body regions (e.g., limb, perineum, and trunk) (BNF), respectively.

Materials and methods

At first, various risk factors for OCNF in oro-cervical severe infection (OCSI; composed of OCNF and OCSC), including neutrophil-to-lymphocyte ratio (NLR) and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, were investigated by univariate and multivariate analyses. Next, the differences between OCNF and BNF, including inflammatory markers and mortality, were investigated.

Results

In the present study, 14 out of 231 OCSI patients had OCNF. Multivariate analyses of OCSI patients showed that NLR ≥15.3 and LRINEC score ≥6 points were significantly related to OCNF. During the same period, 17 patients had BNF. The OCNF group had significantly higher inflammatory markers than the BNF group when diagnosis, but significantly lower clinical stages at the time and mortality as outcomes.

Conclusion

We found that compared to BNF, OCNF can be detected at lower clinical stage by using indexes, such as NLR and LRINEC score, besides clinical findings, which may help contributing to patient’s relief.

Qualitative and Quantitative Analyses of Donor Site Morbidity Following a Graft of the Acellular Dermal Matrix Versus Primary Fascial Repair After ALT Flap Harvesting

Background

The anterolateral thigh (ALT) flap is one of the most useful flaps in reconstruction because of its reliability, large skin flap territory, and versatility. The relatively small number of side effects is a common reason for preferring this flap. Primary repair is usually performed at the donor site closure; however, this requires substantial tension and causes many donor site morbidities, including pain. We attempted to use acellular dermal matrix graft to overcome these problems.

Methods

We analyzed a total of 41 cases (41 flaps) in this study. Among these flaps, we conducted donor fascia suture with artificial dermis in 20 cases (study group) and primary fascial suture in 21cases (control group). Post-operative ambulation recovery times, pain scores, drainage removals, and wound problems of the donor site were recorded.

Results

There were no serious complications, including infection, at the donor sites of all 41 cases. Of 20 cases using the acellular dermal matrix, seroma occurred in 2 cases and partial skin necrosis occurred in 2 cases. In 1 case of skin necrosis, the acellular dermal matrix was removed. However, in comparison to the control group, the group using the artificial dermis recovered ambulatory ability 3.9 days earlier and had a 1.8-point lower visual analogue scale score 5 days post-operatively.

Conclusions

Our study suggested that, if used selectively, the acellular dermal matrix may play an effective role in donor site closure in cases with procedures involving the ALT flap.

Osteopathic model of the development and prevention of occupational musculoskeletal disorders

Context

The direct and indirect costs of work-related musculoskeletal disorders are significant. Prevention is the most effective way to control these costs. To do that, we must understand how these disorders develop.

Objectives

To use the five models of osteopathic care to illustrate how cellular processes and neural reflexes interact to create work-related musculoskeletal pathology and to provide evidence-informed musculoskeletal injury and disability prevention recommendations.

Methods

A literature review of electronic databases (Google Scholar, PubMed, OVID, Cochrane Central Register of Controlled Trials, PEDro, and OSTMED.DR) from inception to October 16, 2019 and hand-search of publication references was performed for systematic reviews, cohort studies, case-control studies, and randomized controlled trials. The search terms reflected topics related to occupational injury and injury prevention, and included supplementary laboratory studies and narrative reviews related to the biological aspects of musculoskeletal injury. The eligible studies contained the following criteria: (1) the population of working age; (2) exposures to known risk factors, musculoskeletal disorders, and psychosocial factors; (3) written in English; (4) full text papers published in peer-reviewed journals; and (5) systematic review, cohort study, case-control study, and randomized controlled trial methodology. Studies were excluded if they included outcomes of productivity and costs only or outcomes that were assessed through qualitative methods only.

Results

The literature search resulted in 1,074 citations; 26 clinical studies and 14 systematic reviews were used in this review. A comprehensive workplace musculoskeletal disorder prevention program should match demands to capacity, correct dysfunctional movement patterns, and limit tissue vulnerability (biomechanical-structural model); restore alpha-gamma balance, tonic-phasic synergistic function, and autonomic balance (neurological model); maximize physiologic reserve (metabolic-energy model) component of a prevention program; optimize respiration and circulation (respiratory-circulatory model); and address cognitive distortions (behavioral-biopsychosocial model).

Conclusions

The presented osteopathic model of the development and prevention of work-related musculoskeletal disorders suggests that a combination of preventive interventions will be more effective than any single preventive intervention.

A comparative study for tension-reducing effect of Type I and Type II keystone perforator island flap in the human back

The keystone perforator island flap (KPIF) is popular in reconstructive surgery. However, despite its versatility, its biomechanical effectiveness is unclear. We present our experience of KPIF reconstruction in the human back and evaluate the tension-reducing effect of the KPIF. Between September 2019 and August 2020, 17 patients (51.82 ± 14.72 years) underwent KPIF reconstruction for back defects. In all cases, we measured wound tension at the defect and donor sites before and after KPIF reconstruction using a tensiometer. All defects occurred after complete excision of complicated epidermoid cysts and debridement of surrounding tissues. The defects were successfully covered with Type IIA KPIFs. All flaps survived, and there were no significant postoperative complications. The mean “tension change at the defect after Type I KPIF” and “tension change at the defect after Type II KPIF” were − 2.97 ± 0.22 N and − 5.59 ± 0.41 N, respectively, (P < 0.001). The mean “rate of tension change at the defect after Type I KPIF” and “rate of tension change at the defect after Type II KPIF” were − 36.54 ± 1.89% and − 67.98 ± 1.63%, respectively, (P < 0.001). Our findings confirm the stepwise tension-reducing effect of KPIF and clarify the biomechanics of this flap.

Silicone Implants Immobilized with Interleukin-4 Promote the M2 Polarization of Macrophages and Inhibit the Formation of Fibrous Capsules

Breast augmentations with silicone implants can have adverse effects on tissues that, in turn, lead to capsular contracture (CC). One of the potential ways of overcoming CC is to control the implant/host interaction using immunomodulatory agents. Recently, a high ratio of anti-inflammatory (M2) macrophages to pro-inflammatory (M1) macrophages has been reported to be an effective tissue regeneration approach at the implant site. In this study, a biofunctionalized implant was coated with interleukin (IL)-4 to inhibit an adverse immune reaction and promoted tissue regeneration by promoting polarization of macrophages into the M2 pro-healing phenotype in the long term. Surface wettability, nitrogen content, and atomic force microscopy data clearly showed the successful immobilization of IL-4 on the silicone implant. Furthermore, in vitro results revealed that IL-4-coated implants were able to decrease the secretion of inflammatory cytokines (IL-6 and tumor necrosis factor-α) and induced the production of IL-10 and the upregulation of arginase-1 (mannose receptor expressed by M2 macrophage). The efficacy of this immunomodulatory implant was further demonstrated in an in vivo rat model. The animal study showed that the presence of IL-4 diminished the capsule thickness, the amount of collagen, tissue inflammation, and the infiltration of fibroblasts and myofibroblasts. These results suggest that macrophage phenotype modulation can effectively reduce inflammation and fibrous CC on a silicone implant conjugated with IL-4.

Quantitative Evaluation of the Movement Distance of Deep Fascia and Change of Muscle Shape Related to Chain Response in Fascia Tissue of Lower Limb

By using ultrasonography, we measured the longitudinal movement distance of the deep fascia (LMDDF), change of the pennation angle (PA) and muscle thickness (MT) in both the tensor fasciae latae muscle (TFL) and the gluteus medius muscle (G-Med) during passive movement of the toes/ankle joints. 21 right lower limbs of 21 healthy males were evaluated in this study. We measured the LMDDF of the TFL and G-Med by measuring distance between the designated landmark on skin and the intersection of the major deep-fascia (D-fascia) and the fascial bundle. We also measured change of the PA and MT of both muscles. Additionally, we also measured the reliability of the measurement and the measurement error. The measurement was performed during three manual positions on the toes/ankle; manual holding of the toes and ankle joint in neutral, toes flexion and ankle plantar flexion/inversion position, toes extension and ankle extension/valgus position. The existence of muscle contraction of both the muscles during passive motion was monitored by active surface electrodes. This study confirmed mobility of the D-fascia in which the TFL's D-fascia moves and change of muscle shape in the distal direction during no muscle contraction due to passive movement. This fact suggests the possibility that passive tension on fascia tissue of the ankle extends to the proximal part of the limb, i.e., to the D-fascia of the TFL.

Investigation of the association between human fascia lata thickness and its neighboring tissues' morphology and function using B-mode ultrasonography

The fascia lata is a membrane tissue which envelopes all thigh muscles and connects with the subcutaneous adipose tissues through loose connective tissues. It is presumable that the morphology of the fascia lata is strongly affected by the unique properties of underlying thigh muscles and subcutaneous adipose tissues. We aimed to investigate the relationships between characteristics of the fascia lata and adjoining adipose tissues and underlying muscles. Twenty healthy people were recruited (25 ± 3 years, 167.1 ± 8.5 cm, 62.5 ± 13.2 kg). The thickness of the skeletal muscles (rectus femoris, vastus lateralis, biceps femoris, and semitendinosus), and their overlying fascia lata and subcutaneous adipose tissues were measured by B‐mode ultrasonography. Isometric knee extension and flexion torque during maximal voluntary contraction were also tested. The fascia lata thickness demonstrated site‐dependent differences (vastus lateralis: 0.91 ± 0.20 mm > rectus femoris, biceps femoris, and semitendinosus: 0.56–0.69 mm, p < 0.01). Furthermore, there were large individual variations in the fascia lata thickness even in the same region of the thigh. The fascia lata showed positive simple correlations with height (rectus femoris: r = 0.39 p = 0.01, semitendinosus: r = 0.37 p < 0.05), body mass (rectus femoris: r = 0.59, p < 0.01, vastus lateralis: r = 0.47, p < 0.01, semitendinosus: r = 0.55, p < 0.01), corresponding muscle thickness (rectus femoris: r = 0.39, p < 0.05, semitendinosus: r = 0.74, p < 0.01) and knee extension (rectus femoris: r = 0.52, p < 0.01, vastus lateralis: r = 0.40, p < 0.01) and flexion (semitendinosus: r = 0.41, p < 0.01) torques. After adjusting for the influence of height and/or body mass, the fascia lata thickness showed a partial correlation only with the skeletal muscle thickness at the semitendinosus (r = 0.61, p < 0.01). The present study revealed that the fascia lata has site‐specific differences of the thickness, which positively correlates with the underlying muscle thickness and corresponding joint torque. Furthermore, the fascia lata over the semitendinosus is associated with the underlying muscle characteristics independent of the physical constitution. It is assumed that the fascia lata has the plasticity and changes its thickness, which likely corresponds to the morphology of the neighboring tissues and underlying muscle function.

The fascia lata showed individual differences of its thickness which was positively correlated with its underlying muscle thickness and/or strength. Especially, the fascia lata over the ST reflects the underlying muscle characteristics regardless of the physical constitution.

Hyaluronan and the Fascial Frontier

The buzz about hyaluronan (HA) is real. Whether found in face cream to increase water volume loss and viscoelasticity or injected into the knee to restore the properties of synovial fluid, the impact of HA can be recognized in many disciplines from dermatology to orthopedics. HA is the most abundant polysaccharide of the extracellular matrix of connective tissues. HA can impact cell behavior in specific ways by binding cellular HA receptors, which can influence signals that facilitate cell survival, proliferation, adhesion, as well as migration. Characteristics of HA, such as its abundance in a variety of tissues and its responsiveness to chemical, mechanical and hormonal modifications, has made HA an attractive molecule for a wide range of applications. Despite being discovered over 80 years ago, its properties within the world of fascia have only recently received attention. Our fascial system penetrates and envelopes all organs, muscles, bones and nerve fibers, providing the body with a functional structure and an environment that enables all bodily systems to operate in an integrated manner. Recognized interactions between cells and their HA-rich extracellular microenvironment support the importance of studying the relationship between HA and the body’s fascial system. From fasciacytes to chronic pain, this review aims to highlight the connections between HA and fascial health.

The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function

Purpose

There is growing evidence that vertebral column function and dysfunction play a vital role in neuromuscular control. This invited review summarises the evidence about how vertebral column dysfunction, known as a central segmental motor control (CSMC) problem, alters neuromuscular function and how spinal adjustments (high-velocity, low-amplitude or HVLA thrusts directed at a CSMC problem) and spinal manipulation (HVLA thrusts directed at segments of the vertebral column that may not have clinical indicators of a CSMC problem) alters neuromuscular function.

Methods

The current review elucidates the peripheral mechanisms by which CSMC problems, the spinal adjustment or spinal manipulation alter the afferent input from the paravertebral tissues. It summarises the contemporary model that provides a biologically plausible explanation for CSMC problems, the manipulable spinal lesion. This review also summarises the contemporary, biologically plausible understanding about how spinal adjustments enable more efficient production of muscular force. The evidence showing how spinal dysfunction, spinal manipulation and spinal adjustments alter central multimodal integration and motor control centres will be covered in a second invited review.

Results

Many studies have shown spinal adjustments increase voluntary force and prevent fatigue, which mainly occurs due to altered supraspinal excitability and multimodal integration. The literature suggests physical injury, pain, inflammation, and acute or chronic physiological or psychological stress can alter the vertebral column’s central neural motor control, leading to a CSMC problem. The many gaps in the literature have been identified, along with suggestions for future studies.

Conclusion

Spinal adjustments of CSMC problems impact motor control in a variety of ways. These include increasing muscle force and preventing fatigue. These changes in neuromuscular function most likely occur due to changes in supraspinal excitability. The current contemporary model of the CSMC problem, and our understanding of the mechanisms of spinal adjustments, provide a biologically plausible explanation for how the vertebral column’s central neural motor control can dysfunction, can lead to a self-perpetuating central segmental motor control problem, and how HVLA spinal adjustments can improve neuromuscular function.

The equine navicular apparatus as a premier enthesis organ: Functional implications

Navicular syndrome has been traditionally characterized by progressive lameness with chronic degeneration of the navicular bone. Advances in imaging techniques have revealed that its associated soft tissue structures are also affected. This distribution of lesions is explained by conceptualizing the equine navicular apparatus as an enthesis organ that facilitates the dissemination of mechanical stress throughout the tissues of the foot. The navicular apparatus has the same structural adaptations to mechanical stress as the human Achilles tendon complex. These adaptations efficiently dissipate mechanical force away from the tendon's bony attachment site, thereby protecting it from failure. The comparison of these two anatomically distinct structural systems demonstrates their similar adaptations to mechanical forces, and illustrates that important functional insights can be gained from studying anatomic convergences and cross-species comparisons of function. Such a functional conceptualization of the equine navicular apparatus resolves confusion about the diagnosis of navicular syndrome and offers insights for the development of mechanically based therapies. Through comparison with the human Achilles complex, this review (1) re-conceptualizes the equine navicular apparatus as an enthesis organ in which mechanical forces are distributed throughout the structures of the organ; (2) describes the relationship between failure of the navicular enthesis organ and lesions of navicular syndrome; (3) considers the therapeutic implications of navicular enthesis organ degeneration as a form of chronic osteoarthritis; and based upon these implications (4) proposes a focus on whole body posture/motion for the development of prehabilitative and rehabilitative therapies similar to those that have already proven effective in humans.

Tenderness of the Skin after Chemical Stimulation of Underlying Temporal and Thoracolumbar Fasciae Reveals Somatosensory Crosstalk between Superficial and Deep Tissues

Musculoskeletal pain is often associated with pain referred to adjacent areas or skin. So far, no study has analyzed the somatosensory changes of the skin after the stimulation of different underlying fasciae. The current study aimed to investigate heterotopic somatosensory crosstalk between deep tissue (muscle or fascia) and superficial tissue (skin) using two established models of deep tissue pain (namely focal high frequency electrical stimulation (HFS) (100 pulses of constant current electrical stimulation at 10× detection threshold) or the injection of hypertonic saline in stimulus locations as verified using ultrasound). In a methodological pilot experiment in the TLF, different injection volumes of hypertonic saline (50–800 µL) revealed that small injection volumes were most suitable, as they elicited sufficient pain but avoided the complication of the numbing pinprick sensitivity encountered after the injection of a very large volume (800 µL), particularly following muscle injections. The testing of fascia at different body sites revealed that 100 µL of hypertonic saline in the temporal fascia and TLF elicited significant pinprick hyperalgesia in the overlying skin (–26.2% and –23.5% adjusted threshold reduction, p < 0.001 and p < 0.05, respectively), but not the trapezius fascia or iliotibial band. Notably, both estimates of hyperalgesia were significantly correlated (r = 0.61, p < 0.005). Comprehensive somatosensory testing (DFNS standard) revealed that no test parameter was changed significantly following electrical HFS. The experiments demonstrated that fascia stimulation at a sufficient stimulus intensity elicited significant across-tissue facilitation to pinprick stimulation (referred hyperalgesia), a hallmark sign of nociceptive central sensitization.

Compartments of the antebrachial fascia of the forearm: clinically relevant ultrasound, anatomical and histological findings

PURPOSE

Acute compartment syndrome is defined as a limb-threatening condition caused by bleeding or oedema in a closed muscle compartment surrounded by fascia or bone. It is most commonly encountered in the forearm, which has three compartments: posterior, anterior and lateral. These are surrounded and closed in by the antebrachial fascia, formed by dense connective tissue that facilities their study on ultrasound and is key to fasciotomy treatment. The purpose of this study was to broaden existing ultrasound, anatomical and histological knowledge of the fascia of the forearm to facilitate their identification on ultrasound, with possible clinical and therapeutic applications.

METHODS

The study was performed in 50 cryopreserved upper limbs from adult cadavers from the dissection room of the Faculty of Medicine and Health Sciences. They were examined on ultrasound and subsequent anatomical dissection and microscopy to study the fascia and its relationship with different muscles of the forearm compartments.

RESULTS

Distinct anatomical relationships were observed on ultrasound and dissection between the fascia and the extensor carpi ulnaris, extensor digiti minimi, and anconeus muscle in the posterior compartment, and the flexor carpi radialis and flexor carpi ulnaris in the anterior compartment. They were isolated by the antebrachial fascia and had distinct relationships with the neurovascular structures.

CONCLUSION

These results demonstrate that high-definition ultrasound enables us to locate the antebrachial fascia and particular muscles with a distinct relationship with neurovascular structures. This helps better identify these structures, facilitating diagnosis of any pathology in the area, with potential therapeutic and clinical applications.

The biomechanical role of the lacertus fibrosus of the biceps brachii Muscle

PURPOSE

The lacertus fibrosus (LF) is involved in various surgeries. However, the biomechanical contribution of the LF remains unclear. The aim of this study was to determine the role of the lacertus fibrosus on the elbow and forearm kinematics and on the biceps brachii muscle lever arms.

METHODS

This biomechanical study was performed on seven fresh-frozen upper limbs of cadavers. Elbow flexion, forearm supination, and biceps brachii muscle lever arms were analyzed in the intact conditions (I) and after superficial (R) and deep part (R2) of the lacertus fibrosus release, respectively.

RESULTS

Elbow flexion shows a significant difference (p < 0.0001) between I, R, R2. Abduction/adduction shows a significant difference between I-R (p < 0.0001) and I-R2 (p < 0.0001). Supination does not show a significant difference in mean maximum amplitude, but between 40 and 70%, there are significant differences. There is a significant mean decrease of lever arm in flexion (28%) and supination (50%) after superficial and deep part of the lacertus fibrosus release.

CONCLUSION

The results of this study show that the lacertus fibrosus increases the lever arm during flexion and supination. It limits the flexion and abduction of the elbow and supination of the forearm. Lacertus fibrosus maintains the rhythmicity between the elbow flexion and supination of the forearm.

LEVEL OF EVIDENCE

Basic science study, biomechanics.

Equine Cervical Pain and Dysfunction: Pathology, Diagnosis and Treatment

Simple Summary

Neck pain and dysfunction in the horse is becoming an increasingly important topic among riders, trainers and veterinarians. Some horses may present for a subtle performance decline, while others may show dramatic, dangerous behavior. It is important to recognize how to carefully evaluate the horse in an effort to understand the different types of pain that may be contributing to the different behaviors. The musculoskeletal and nervous systems may both play a role in the development of clinical signs. Recognizing that there are many diagnostic options as well as several treatments choices is important. This synopsis covers the disease processes that may contribute to the development of neck pain and dysfunction in the horse, as well as several possible diagnostic and treatment options.

Abstract

Interest in the cervical spine as a cause of pain or dysfunction is increasingly becoming the focus of many equine practitioners. Many affected horses are presented for poor performance, while others will present with dramatic, sometimes dangerous behavior. Understanding and distinguishing the different types of neck pain is a starting point to comprehending how the clinical presentations can vary so greatly. There are many steps needed to systematically evaluate the various tissues of the cervical spine to determine which components are contributing to cervical pain and dysfunction. Osseous structures, soft tissues and the central and the peripheral nervous system may all play a role in these various clinical presentations. After completing the clinical evaluation, several imaging modalities may be implemented to help determine the underlying pathologic processes. There are multiple treatment options available and each must be carefully chosen for an individual horse. Provided is a synopsis of the current knowledge as to different disease processes that can result in cervical pain and dysfunction, diagnostic approaches and treatment strategies. Improving the knowledge in these areas will ideally help to return horses to a state of well-being that can be maintained over time and through the rigors of their job or athletic endeavors.

Relationship between lamellar sensory corpuscles distributed along the upper arm's deep arteries and pulsating sensation of blood vessels

Vibration is detected by mechanoreceptors, including Pacinian corpuscles (PCs), which are widely distributed in the human body including the adventitia of large blood vessels. Although the distribution of PCs around large limb vessels has been previously reported, there remains no consensus on their distribution in the adventitia of the human deep blood vessels in the upper arm. In addition, the physiological functions of PCs located around the deep limb blood vessels remain largely unknown. This study aimed to elucidate detailed anatomical features and physiological function of lamellar sensory corpuscles structurally identified as PCs using the immunohistochemical methods around the deep vessels in the upper arm. We identified PCs in the connective tissue adjacent to the deep vessels in the upper arm using histological analysis and confirmed that PCs are located in the vascular sheath of the artery and its accompanying vein as well as in the connective tissue surrounding the vascular sheath and nerves. PCs were densely distributed on the distal side of deep vessels near the elbow. We also examined the relationship between vascular sound and pulsating sensation to evaluate the PCs functions around deep arteries and veins and found that the vascular sound made by pressing the brachial arteries in the upper arm was associated with the pulsating sensation of the examinee. Our results suggest that PCs, around deep vessels, function as bathyesthesia sensors by detecting vibration from blood vessels.