The fascial (connective tissue) system

Clinical and symptomatological reflections: the fascial system – J Multidiscip Healthc. 2014 – free full-text PMC article

Every body structure is wrapped in connective tissue, or fascia, creating a structural continuity that gives form and function to every tissue and organ.

Currently, there is still little information on the functions and interactions between the fascial continuum and the body system; unfortunately, in medical literature there are few texts explaining how fascial stasis or altered movement of the various connective layers can generate a clinical problem

Certainly, the fascia plays a significant role in conveying mechanical tension, in order to control an inflammatory environment.  

The fascial continuum is essential for

  1. transmitting muscle force,
  2. correct motor coordination, and
  3. preserving the organs in their site;

the fascia is a vital instrument that enables the individual to communicate and live independently

This article considers what the literature offers on symptoms related to the fascial system, trying to connect the existing information on the continuity of the connective tissue and symptoms that are not always clearly defined.

In our opinion, knowing and understanding this complex system of fascial layers is essential for the clinician and other health practitioners in finding the best treatment strategy for the patient.

Introduction: definition of fascia

The human body must be considered as a functional unit, where every area is in communication with another through the fascial continuum, consequently originating perfect tensegritive equilibrium.5

Medical literature does not suggest a sole definition of fascia, because it varies in terms of thickness, function, composition, and direction depending on its location.

The fascial tissue is equally distributed throughout the entire body, enveloping, interacting with, and permeating

  • blood vessels,
  • nerves,
  • viscera,
  • meninges,
  • bones, and
  • muscles,

creating various layers at different depths, and forming a tridimensional metabolic and mechanical matrix.6,7

The fascia becomes an organ that can affect an individual’s health.8 Awareness of its functions and of the areas it controls becomes significant within a more general perspective concerning the patient’s wellness and health (Figure 1).

Shape and arrangement of the muscles on the ventral (A), dorsal (B), and lateral (C) surface of the human body.

All fascial layers contain a variable amount of fibroblasts with the ability to contract, known as myofibroblasts.

They contain a type of actin similar to the one traceable in the muscles of the digestive system; ie, alpha-smooth muscle actin.6 Scientific research has proven that the fascial continuum is innervated by the autonomic sympathetic system.6

Symptoms: facts and hypotheses

The transmission of the force is ensured by the fascial integrity, which is expressed by the motor activity produced; the tension produced by the sarcomeres results in muscle activity, using the various layers of the contractile districts (epimysium, perimysium, endomysium), with different directions and speed

The connective tissue can control the orientation of the muscle fibers, so as to reflect the vector of the force’s direction, and to render the transition of the tension more fluid and ergonomic.24

The fascial system is rich in proprioceptors, particularly the Ruffini’s and the Pacini’s corpuscles, mostly in the areas of transition between the articulation and the fascia, and between the fascia and the muscular tissue, blending with the receptors of these structures.6,8

The fascial continuum can be considered a sense organ of human mechanics, which affects daily postural patterns.6,8,26

The muscle system is part of the fascial continuum, and when it is affected by pathologies or systemic disorders such as visceral, genetic, vascular, metabolic and alimentary disorders, its function undergoes a nonphysiological alteration; there are many epigenetic processes that can lead to its adjustment as a response to mechanotransductive stimuli, resulting in further decrease of its function and properties.27–37

An increased level of circulating cytokines originating in the connective system, due to systemic pathologies, could develop neuropathic pain.43–46

The connective tissue can directly convey pain signals; in fact, it contains nociceptors that can translate mechanical stimuli into pain information.

Furthermore, if there are nonphysiological mechanical stimuli, the proprioceptors can turn into nociceptors.3,6,7

There are many reasons why the fascial continuum can turn into a source of pain.

This seems to happen in many cases of Ehlers-Danlos Syndrome (EDS).

The nociceptors synthesize some neuropeptides that can alter the surrounding tissue, and generate an inflammatory environment; the epineurium and the perineurium, both belonging to the fascial system, are innervated by the nervi nervorum, which can develop pain sensation creating a vicious circle, when they are in contact with pro-inflammatory molecules.6,47

All the fascial layers need hyaluronic acid to slide over each other; if its quantity decreases or it is not regularly distributed, the local or systemic sliding property of the connective tissue is compromised.12

In fact, the stiffness experienced by some patients when they wake up in the morning could be related not with the joint but with the fascial system: if there is a minor quantity of hyaluronic acid or when it is not equally distributed, the tissue is dehydrated and has less possibility of sliding

The same dehydration prevents the catabolites of cellular metabolism from being properly removed, stimulating the nociceptors; the accumulation of metabolites alters the pH inside the fascia, making a more acid cell environment; this results in dysfunctional physiology of the hyaluronic acid, and complicates the sliding of the different fascial layers, again stimulating the nociceptors.3,12

Clinical scenarios: facts and hypotheses

Research has proven that patients who suffer from chronic lumbar backache present an inflammation of the local fascial area, and experience degenerating variations of collagen fibers and microcalcifications, besides a 25% increase in thickening of the perimuscular fascial tissue if compared with nonsuffering subjects.47

The entire thoracolumbar fascia plays a fundamental role in this pathological condition.66

The absence of sliding of the different layers in the lumbar area and the morphological alteration of the tissue generate a nonphysiological mechanical tension, resulting in lumbar pain symptoms.66 This nonphysiological condition develops a lack of coordination in the activation of the muscles of the thoracolumbar fascia involved, with resultant mechanical instability of the lumbar column and pain.67

Pain symptoms are intensified by stress, as the fascia is innervated by the sympathetic nervous system, especially in the area near the blood vessels; therefore, it is likely to produce vasospasm and ischemic pain.47,68

From the current data in the literature, we can strongly assume that the connective tissue is more responsive than the muscular tissue in the activation of nociceptors, and examination on animals has proven that the medullar neurons receiving fascial nociceptive afferents are activated 4% to 15% more than a noninflamed fascia, with an experimentally-induced inflammation of a low back pain muscle (multifidus).68–70

This explains why connective tissue disorders are so painful.

We can logically hypothesize a problem of instability in the ankle caused by the anatomical connection with the thoracolumbar fascia, because of a proprioceptive alteration of the fascial continuum and of its relevant muscular coordination.

An aching ankle has been proven to cause urogenital and visceral disorders, such as dyspareunia.64 This event can be explained by the muscular connections existing between the pelvic floor and the ankle (rectum abdominis, adductor lungus and triceps surae), producing hypertonus of the pelvic musculature, and by nociceptive information, which at the medullar level can develop a metabolic and electrical antidromic communication, and involve a greater number of neurons of the metameric segment, consequently concerning the viscera (somaticovisceral reflex).64,65,78

The fascial continuum can also develop symptoms in areas which are far from the original dysfunctional point, making it more difficult to diagnose the patient’s clinical scenario. For this reason, a patient must be observed as a sole entity and not as a collection of single body segments.1,65


Currently, there is still little information on the functions and interactions between the fascial continuum and the body system

Certainly, the fascia plays a significant role in conveying mechanical tension, in order to control an inflammatory environment.

The fascia is the philosophy of the body, meaning that each body region is connected to another, whereas osteopathy is the philosophy of medicine, meaning that the entire human body must work in harmony.

Knowing and understanding this complex system of fascial layers is essential for the clinician, and all health practitioners, in finding the best treatment strategy for the patient.  

See also:


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  1. Pingback: Connective Tissue & the Brain | EDS and Chronic Pain News & Info

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