Faculty Bibliography

Recent studies reveal the role of the ankle retinacula in proprioception and functional stability of the ankle, but there is no clear evidence of their role in the outcomes of ankle sprain. 25 patients with outcomes of ankle sprain were evaluated by MRI to analyze possible damage to the ankle retinacula. Patients with damage were subdivided into two groups: group A comprised cases with ankle retinacula damage only, and group B those also with anterior talofibular ligament rupture or bone marrow edema. Both groups were examined by VAS, CRTA and static posturography and underwent three treatments of deep connective tissue massage (Fascial Manipulation technique). All evaluations were repeated after the end of treatment and at 1, 3 and 6 months. At MRI, alteration of at least one of the ankle retinacula was evident in 21 subjects, and a further lesion was also identified in 7 subjects. After treatment, VAS and CRTA evaluations showed a statistically significant decrease in values with respect to those before treatment (p < 0.0001). There were also significant improvements (p < 0.05) in stabilometric platform results. No significant difference was found between groups A and B. The initial benefit was generally maintained at follow-up. The alteration of retinacula at MRI clearly corresponds to the proprioceptive damage revealed by static posturography and clinical examination. Treatment focused on the retinacula may improve clinical outcomes and stabilometric data.

INTRODUCTION: In recent times new surgical approaches have been developed, in which subcutaneous tissue is the primary object, such as flaps and fat removal techniques, but different descriptions and abundance of terminology persist in Literature about this tissue. AIM AND METHODS: In order to investigate the structure of abdominal subcutaneous tissue, macroscopic and microscopic analyses of its layers were performed in 10 fresh cadavers. Results were compared with in vivo CT images of the abdomen of 10 subjects. RESULTS: The subcutaneous tissue of the abdomen comprises three layers: a superficial adipose layer (SAT), a membranous layer, and a deep adipose layer (DAT). The SAT presented fibrous septa that defined polygonal-oval lobes of fat cells with a mean circularity factor of 0.856 +/- 0.113. The membranous layer is a continuous fibrous membrane rich in elastic fibers with a mean thickness of 847.4 +/- 295 mum. In the DAT the fibrous septa were predominantly obliquely-horizontally oriented, defining large, flat, polygonal lobes of fat cells (circularity factor: mean 0.473 +/- 0.07). The CT scans confirm these findings, showing a variation of the thickness of the SAT, DAT and membranous layer according with the subjects and with the regions. DISCUSSION: The distinction of SAT and DAT and their anatomic differences are key elements in modern approaches to liposuction. The membranous layer appears to be also a dissection plane which merits further attention. According with the revision of Literature, the Authors propose that the term "superficial fascia" should only be used as a synonym for the membranous layer.

SUMMARY: The perception of what appears to be connective tissue fibrosis, and its consequent modification during therapy, is a daily experience for most manual therapists. The aim of this study was to evaluate the time required to modify a palpatory sensation of fibrosis of the fascia in correlation with changes in levels of patient discomfort in 40 subjects with low back pain utilizing the Fascial Manipulation technique. This study evidenced, for the first time, that the time required to modify an apparent fascial density differs in accordance with differences in characteristics of the subjects and of the symptoms. In particular, the mean time to halve the pain was 3.24 min; however, in those subjects with symptoms present from less than 3 months (sub-acute) the mean time was lesser (2.58 min) with respect to the chronic patients (3.29 min). Statistically relevant (p < 0.05) differences were also evidenced between the specific points treated.

STUDY DESIGN: Research report. OBJECTIVES: To evaluate the anatomical characteristics of the ankle retinacula and their relationship with the fasciae and muscles in healthy subjects and in patients with ankle sprain outcomes. BACKGROUND: The role of the retinacula in proprioception has begun to emerge, but without clear anatomical bases or descriptions of their possible damage in patients with ankle sprain outcomes. METHODS: Dissection, histological and immunohistochemical analysis of 27 legs. An in vivo radiological study by MRI was also performed on 7 healthy volunteers, 17 patients with outcomes of ankle sprain, and 3 amputated legs. RESULTS: The retinacula are thickenings of the deep fascia presenting bone or muscular connections. They are formed of 2-3 layers of parallel collagen fibre bundles, densely packaged with a little loose connective tissue, without elastic fibres but many nervous fibres and corpuscles. By MRI, the retinacula appeared as low-signal-intensity bands with a mean thickness of 1 mm. In patients with outcomes of ankle sprain, MR findings were abnormal retinacula thickness, signal intensity, and full-thickness gap. DISCUSSION: The retinacula are not static structures for joint stabilisation, like the ligaments, but a specialisation of the fascia for local spatial proprioception of the movements of foot and ankle. Their anatomical variations and accessory bundles may be viewed as morphological evidence of the integrative role of the fascial system in peripheral control of articular motility.

AIM: Analysis of the pectoral fascia from a macroscopic and histological point of view. RESULTS: The pectoral fascia appears as a thin collagen layer (mean thickness of 297 microm) formed by undulated collagen fibres and many elastic fibres, within which small nerves are highlighted. Numerous septa detach from its internal surface, creating an intimate connection between the fascia and the pectoralis major muscle. DISCUSSION: The pectoral fascia and the pectoralis major muscle should be considered together, given that the anatomical base is effectively a myofascial unit, term that defines the muscles and the fascia of a specific region that have a precise functional organization. The capacity of force transmission between the inferior and superior limbs needs to be attributed to this entire myofascial complex. We hypothesize that the superficial, large muscles of the trunk developed inside the superficial layer of the deep fascia to enhance modulation of tension transmission between the different segments of the body.

Classical anatomy still relegates muscular fascia to a role of contention. Nonetheless, different hypotheses concerning the function of this resilient tissue have led to the formulation of numerous soft tissue techniques for the treatment of musculoskeletal pain. This paper presents a pilot study concerning the application of one such manual technique, Fascial Manipulation, in 28 subjects suffering from chronic posterior brachial pain. This method involves a deep kneading of muscular fascia at specific points, termed centres of coordination (cc) and centres of fusion (cf), along myofascial sequences, diagonals, and spirals. Visual Analogue Scale (VAS) measurement of pain administered prior to the first session, and after the third session was compared with a follow-up evaluation at 3 months. Results suggest that the application of Fascial Manipulation technique may be effective in reducing pain in chronic shoulder dysfunctions. The anatomical substratum of the myofascial continuity has been documented by dissections and the biomechanical model is discussed.

Fifteen unembalmed cadavers were dissected in order to study the "anatomical continuity" between the various muscles involved in the movement of flexion of the upper limb. This study demonstrated the existence of specific myofascial expansions, with a nearly constant pattern, which originate from the flexor muscles and extend to the overlying fascia. The clavicular part of the pectoralis major sends a myofascial expansion, with a mean length of 3.6cm, to the anterior region of the brachial fascia, and the costal part sends one to the medial region of the brachial fascia (mean length: 6.8cm). The biceps brachii presents two expansions: the lacertus fibrosus, oriented medially, with a mean height of 4.7cm and a base of 1.9cm, and a second, less evident, longitudinal expansion (mean length: 4.5cm, mean width: 0.7cm). Lastly, the palmaris longus sends an expansion to the fascia overlying the thenar muscles (mean length: 1.6cm, mean width: 0.5cm). During flexion, as these muscles contract, the anterior portion of the brachial and antebrachial fascia is subject to tension. As the fascia is rich in proprioceptive nerve endings, it is hypothesized that this tension activates a specific pattern of receptors, contributing to perception of motor direction. If the muscular fascia is in a non-physiological state, these mechanisms are altered, and the proprioceptors in the fascia may be incorrectly activated, thus giving rise to many types of extra-articular pain.

The aim of this study is to analyse the deep fasciae of limbs in order to evaluate the collagen and elastic fibre arrangement and the types of innervation. Histological and immunohistochemical stains were performed in 72 specimens. The deep fascia of the limbs is a sheath presenting a mean thickness of 1mm, formed by two to three layers of parallel collagen fibre bundles. In the adjacent layers, they show different orientations. Each layer is separated from the adjacent one by loose connective tissue, permitting the sliding of the collagen layers. Nerve fibres were found in all specimens, while muscular fibres were evidenced only in one specimen. The described structure permits the fasciae of the limbs to have a strong resistance to traction, even when exercised in different directions. The capacity of the different collagen layers to glide one on the other could be altered in cases of overuse syndrome, trauma, or surgery.

BACKGROUND/AIMS: The aim of this study was to analyse the relationships between the expansions of the pectoral girdle muscles, i.e. pectoralis major, latissimus dorsi and deltoid, and the brachial fascia. METHODS: Thirty shoulder specimens from 15 unembalmed adult cadavers were studied by dissection and in vivo radiological studies were performed in 20 patients using magnetic resonance (MR) imaging. RESULTS: The clavicular part of the pectoralis major muscle sent a fibrous expansion onto the anterior portion of the brachial fascia, its costal part onto the medial portion and medial intermuscular septum. The latissimus dorsi muscle showed a triangular fibrous expansion onto the posterior portion of the brachial fascia. The posterior part of the deltoid muscle inserted muscular fibres directly onto the posterior portion of the brachial fascia, its lateral part onto the lateral portion and the lateral intermuscular septum. In MR images, the brachial fascia appeared as a low-signal-intensity sinuous line of connective tissue, sharply delineated in T(1)-weighted sequences. CONCLUSION: The expansions of the pectoral girdle muscles onto the brachial fascia were present in all the subjects and showed a quite constant course with a specific spatial organization. During the various movements of the arm, these expansions stretch selective portions of the brachial fascia, with possible activation of specific patterns of fascial proprioceptors.