The fascia: the forgotten structure.

Nyeste oppdateringen om bindevet her, som gir en klar definisjon av hva det faktisk er. Nevner forholdet mellom superficial og deep facia.

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In 1987, Myers wrote: “the traditional approach that studies the muscles as inde- pendent units, has been a barrier to understand the bigger picture of fascial func- tion”. Indeed, the whole musculoskeletal system is usually studied only with respect to its bone and muscle components, the fasciae being traditionally relegated to the role of deftly holding ‘parts’ together.

It is increasingly evident that the fasciae may play important roles in venous return (Caggiati, 2000), dissipation of tensional stress concentrated at the sites of entheses (Benjiamin et al., 2008), etiology of pain (Langevin et al., 2001; Langevin, 2006), interactions among limb muscles (Huijing et al., 1998; Huijing, 1999; Huijing and Baan, 2001a,b; Yucesoy et al., 2006) and movement perception and coordina- tion (Vleeming et al., 1995, 1996; Stecco L., 1996, 2004; Stecco L. and Stecco C., 2009), due to their unique mechanical properties and rich innervation. Huijing et al. (2003) showed that only 70% of muscle tension transmission is directed through tendons, which thus definitely play a mechanical role, but 30% of muscle force is transmitted to the connective tissue surrounding muscles, highlighting the role of the deep fasciae in the peripheral coordination of agonist, antagonist and synergic muscles. The many functions of the fasciae include the roles of the ectoskeleton for muscle attachments and protective sheets for underlying structures (Wood Jones, 1944; Benjiamin, 2009). Lastly, recent studies have emphasized the continuity of the fascial system between regions, leading to presume its role as a body-wide proprioceptive/communicating organ (Langevin, 2006; Langevin et al., 2006; Lindsay, 2008; Kassolik et al., 2009).

This ample list of functions partly also derives from the fact that the term ‘fas- cia’ has been applied to a large number of very different tissues, ranging from well- defined anatomical structures, such as the fascia lata, thoracolumbar fascia, plantar and palmar fasciae, and cervical and clavipectoral fasciae, to the loose packing tissues which surround all the moving structures within the body. In fact, according to the American Heritage Stedman’s Medical Dictionary (2007), a fascia is “a sheet or band of fibrous connective tissue enveloping, separating, or binding together muscles, organs, and other soft structures of the body”, so that only the well-defined fibrous connective tissue layers may appropriately be called “fascia”, and it is consequently incorrect to use this term to mean all the connective tissue of the body.

Functionally, the superficial fascia may play a role in the integrity of the skin and support for subcutaneous structures, particularly veins, by ensuring their patency.

The deep fascia is a fibrous membrane forming an intricate network which envel- ops and separates muscles, forms sheaths for nerves and vessels, strengthens liga- ments around joints, and binds all the structures together into a firm compact mass. The deep fasciae envelop all the muscles of the body, but have different features according to region.

Under the deep fascia, the muscles are free to slide because of their epimysium. Loose connective tissue rich in hyaluronic acid lies between the epimysium and the deep fasciae (McCombe et al., 2001).

In the last few years, several studies have demonstrated the presence of many free, encapsulated nerve endings, particularly Ruffini and Pacini corpuscles, inside the deep fasciae (Stilwell, 1957; Yahia et al., 1992; Stecco C. et al., 2007), although dif- ferences exist according to the different regions; retinacula seem to be the most highly innervated structures. Analysis of the relationship between these nerve endings and the surrounding fibrous tissue shows that the corpuscle capsules and free nerve end- ings are closely connected to the surrounding collagen fibers, indicating that these nerve endings may be stretched, and thus activated, every time the surrounding deep fascia is stretched.

Some recent studies have reported possi- ble alterations of the retinacula (Demondion et al., 2010), particularly in ankle sprain outcomes (Stecco A. et al., 2011), in that they sometimes show more intense signal ascribable to local edema and inflammation; in patellofemoral malalignment, the medial and lateral retinacula of the knee show different thicknesses and/or degrees of tension. Despite these data, the fascial system is usually not analysed, by either radiologists or surgeons, and only a few papers report the visualization of possible alterations of the fasciae.

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