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We report a 55-year-old men patient with a primitive central nervous system non-Hodgkin lymphoma B cell (LNH PNSLC), treated with chemotherapy rituximab, methotrexate, and ibrutinib (first treatment) who developed a refractory ventricular arrhythmic storm two hours after the ibrutinib intake. Indeed, ibrutinib could be associated with severe and occasionally fatal cardiac events. The swift emergence of a ventricular electrical storm with cardiac arrest demanded the prompt initiation of veno-arterial extracorporeal membrane oxygenation to effectively navigate this critically ill patient toward recovery. This intervention was deemed imperative, given the absence of any available antidote for the effects of ibrutinib. Veno-arterial extracorporeal membrane oxygenation proved successful in rescuing this patient, resulting in a complete neurological recovery. Consequently, he was able to resume his chemotherapy treatment.

The retinacula of the ankle are specialized anatomical structures characterized by localized thickenings of the crural fascia that envelop the deep components of the lower leg, ankle and foot. The ankle retinacula include the extensor retinacula, the peroneal retinacula and flexor retinaculum. Despite their potential to explain persistent and unexplained pain following an injury, these structures are often overlooked or incorrectly diagnosed. Hence, this comprehensive review was performed aiming to investigate the use and the methodology of US imaging to assess ankle retinacula. The search was performed on PubMed and Web of Science databases from inception to May 2024. The MeSH keywords used were as follows: “Ankle Retinacula”, “Foot Retinacula”, “Superior extensor retinaculum”, “Inferior extensor retinaculum”, “peroneal retinaculum”, “superior peroneal retinaculum”, “inferior peroneal retinaculum”, “flexor retinaculum”, “Ultrasound Imaging”, “Ultrasound”, “Ultrasonography” and “Ultrasound examination”. In total, 257 records underwent screening, resulting in 22 studies meeting the criteria for inclusion after the process of revision. Data heterogeneity prevents synthesis and consistent conclusions. The results showed that advanced US imaging holds promise as a crucial tool to perform an US examination of ankle retinacula, offering static and dynamic insights into ankle retinacula pathology. Understanding normal anatomy and US imaging is essential for accurately identifying injuries. Future research should focus on clinical trials to validate parameters and ensure their reliability in clinical practice.

Background: Lymphedema represents a frequent cause of disability for patients undergoing oncological treatments and, being a chronic, non-reversible pathology, requires targeted and continuous rehabilitation treatments. To date, the studies available on the use of ultrasound in patients with lymphedema mainly report descriptive data; therefore, with this study, we wanted to describe in a more objective way the typical ultrasound alterations found in these patients, measuring the thickness of the different superficial structures, and defining subcutis echogenicity. Methods: 14 patients affected by secondary lymphedema of the upper limbs were enrolled in this cross-sectional observational study (12 had breast cancer and 2 with melanoma as their primary diagnosis). All patients were classified as stage II according to the ISL classification. Patients were examined between March and July 2023 with a clinical and an ultrasound evaluation. Ultrasound evaluation was performed following a protocol and took into consideration thickness of the cutis, subcutis, superficial and deep fascia, and subcutis echogenicity. Results: The cutis of the affected limbs was thicker in the distal anterior region of the arm and throughout the anterior region of the forearm. The subcutaneous tissue was thicker in the posterior region of the distal arm and throughout the forearm, including the dorsum of the hand and excluding only the proximal posterior region of the forearm. Fascial structures did not demonstrate statistically significant differences in thickness between pathological and healthy limbs, despite undergoing significant changes from a qualitative point of view (loss of the trilaminar skin appearance and the development of anechoic areas due to fluid accumulation around the hyperechoic adipose lobule). A statistically significant difference in the echogenicity of subcutaneous tissue was found at the distal anterior region of the arm and at the entire anterior forearm. Conclusions: High-resolution ultrasound has been confirmed to be a tool capable of supporting the diagnosis of lymphedema and identifying the most compromised regions of the limb. A tailored rehabilitation plan can be developed based on the non-uniform alterations in subcutaneous tissue, where some areas are affected earlier than others. This compartmentalization should be considered in lymphedema staging and management. Ultrasound may provide early detection of these changes, guiding a more precise therapeutic approach.

Background/Objectives: Lymphedema, a common source of disability among oncology patients, necessitates continuous targeted rehabilitation. Recent studies have revealed the role of connective tissue in this pathology; however, despite existing research on ultrasound (US) use in lymphedema, no studies have specifically addressed the use of ultrasound to assess fasciae in patients with lymphedema. This study aims to provide a more objective characterization of typical US alterations in these patients by quantifying the thickness of superficial and deep fasciae and comparing them with those of healthy volunteers. Methods: A cross-sectional study was performed using US imaging to measure the thickness of superficial and deep fascia in different regions and levels of the arm and forearm in a sample of 50 subjects: 25 chronic lymphedema patients and 25 healthy participants. Results: No significant difference in fascial thickness was observed between affected and unaffected upper limbs, but patients had notably thinner superficial fascia and deep fascia compared with healthy volunteers. The findings for superficial and deep fascia revealed statistically significant differences (p < 0.0001) in all regions and levels. Conclusions: This study demonstrates the effectiveness of US imaging as a non-invasive tool for detecting subtle fascial changes in chronic lymphedema patients, revealing thinner fasciae compared with those in healthy volunteers. These findings suggest a potential anatomical predisposition to lymphedema, highlighting the importance of incorporating detailed US assessments in diagnosis and management to improve early intervention and patient outcomes. Future studies could, therefore, investigate whether preventive fascia assessment might improve the early identification of individuals at risk.

Lower limb spasticity and clonus are common sequelae after cerebral stroke. An important part of their etiopathogenesis has been related to the peripheral component of spasticity. Rheological properties of the tissues seem to be involved. Several studies highlighted anatomical and functional changes in the connective structures. The fasciae might be implicated in the pathological process. Thus, this study intends to investigate the effect of the Fascial Manipulation (FM) technique on triceps surae in stroke patients through a clinical randomized controlled trial, to provide a reference for clinical treatment of lower limb spasticity and ankle clonus. A total of 40 patients with post-stroke ankle clonus were selected and divided into a control group and an observation group by random number table method, with 20 cases in each group. Both groups received conventional rehabilitation therapy, while the FM group received Fascial Manipulation based on conventional rehabilitation therapy. Before the first treatment and after 3 weeks of treatment, the Comprehensive Spasticity Scale (CSS), the Passive Range Of Motion (PROM), the simplified Fugl-Meyer motor function score (FMA), and the Modified Ashworth Scale (MAS) were used to assess the degree of ankle clonus, ankle passive range of motion, and lower limb motor function of the two groups of patients. Before treatment, there was no statistically significant difference between the control group and the FM group in terms of CSS, PROM, FMA, and MAS of the affected lower limbs (P>0.05). After 3 weeks of treatment, the CSS and MAS of the affected lower limbs in the control group and FM group decreased, while PROM and FMA increased compared to pre-treatment evaluation, with statistically significant differences (P

Sestrin proteins, conserved family proteins which mainly induced by ROS, DNA damage, inflammation, and other injuries. Growing evidences proved sestrin proteins exert protective functions in cardiovascular diseases, chronic degenerative osteoarthritis, musculoskeletal diseases, aging and others, sestrin proteins exhibit an anti-inflammatory response, improving metabolism and other valuable character. However, there is no comprehensive and detailed summary and literature research on the intervention methods of sestrin proteins at present. As the advance of research during last several years, exercise training and other interventions are considered to be the potential methods to up-regulate expression level of protein. In view of the physiological function of this protein, a review of the main studies on regulating the expression level of this protein can provide a novel approach for the clinical treatment and scientific research. In present study, all related researches about interventions and potential mechanisms were reviewed and the mainstream methodologies were described.

Fractal analysis is a mathematical approach employed to study and describe complex patterns and structures across various disciplines, including mathematics, physics, computer science, biology and finance. Introduced by mathematician Benoit Mandelbrot in the 1970s, fractals are intricate, self-similar patterns that repeat at different scales, exhibiting consistent structures upon magnification or reduction. This analysis involves generating fractals through iterative processes or recursive equations, resulting in highly detailed and complex formations. Fractal analysis enhances medical images by removing noise while preserving details and improving diagnostic quality in magnetic resonance and computed tomography scans. However, there is a lack of comprehensive studies on its application in ultrasound imaging, prompting this narrative review to investigate its use and methodology in this context. Selected papers on the use of fractal analysis in ultrasound imaging were analyzed. Out of 186 records screened, 60 duplicates were removed and 28 were discarded. The text content of 98 potentially eligible papers was checked, with 65 not meeting inclusion criteria. Finally, 33 studies were included in the review. Fractal analysis enhances ultrasound imaging by providing detailed tissue texture characterization, aiding in the diagnosis of conditions like breast and lung cancer, osteoporosis and hypertensive disorders in pregnancy. It quantifies biological structure complexity and improves diagnostic accuracy and reliability. This technique supports clinicians in making informed decisions by offering critical insights into various medical conditions.

Over the past decade, there has been a notable increase in research focused on ultrasound imaging of thoracolumbar fascia (TLF). Nevertheless, published papers’ results about the application of US imaging in TLF examination are still sparse. Background and Objevtives: Hence, this systematic review was performed aiming to firstly investigate the use and the methodology of ultrasound imaging to assess pathologic and healthy TLF. Secondarily, we aim to assess intra- and inter-observer reproducibility of US imaging in TLF assessment. Materials and Methods: The search was done on PubMed and Web of Science database from inception to April 2024. Furthermore, the references of included papers were thoroughly checked to find eligible publications. The MeSH keywords used were: “Thoracolumbar fascia”, “Ultrasound Imaging”, “Ultrasound”, “Ultrasonography”, and “Ultrasound examination”. Results: Studies were aimed primarily at TLF diagnosis, treatment monitoring, or evaluating movement-related changes, underscoring the diverse clinical applications. The US parameters assessed included TLF thickness, echogenicity, stiffness, deformation, shear strain, and displacement, providing comprehensive insights into TLF features. Conclusions: Advanced US imaging holds promise as a reliable tool in musculoskeletal assessment, offering insights into TLF pathology/disfunction, treatment outcomes, and movement dynamics.

The International Symposium on Myofascial Pain, Fibromyalgia, and Fascial Pain Disorders was held at the University of Padua, Padua, Italy in June of 2023. This report presents a summary of the presentations from scientists and clinicians from around the world who presented to the symposium. The purpose of this symposium and resultant paper is improve health professional’s recognition and understanding of the clinical characteristics, co-morbidities, mechanisms, and treatment strategies for these common conditions to better understand and manage their pain, dysfunction, and quality life.

Ultrasound imaging of the musculoskeletal system is paramount for physicians of different specialties. In recent years, its use has become the extension of physical examinations like using a “magnifying glass”. Likewise, the eventual concept has naturally and spontaneously evolved to a “fusion” of classical physical examination and static/dynamic ultrasound imaging of the musculoskeletal system. In this regard, we deem it important to explore the current use/awareness regarding ‘ultrasound examination’, and to better provide insight into understanding future research spots in this field. Accordingly, this study aimed to search the global/research status of ‘ultrasound examination’ of the musculoskeletal system based on bibliometric and visualized analysis.

Background & Aims: Glisson’s capsule is the interstitial connective tissue that surrounds the liver. As part of its normal physiology, it withstands significant daily changes in liver size. The pathophysiology of the capsule in disease is not well understood. The aim of this study was to characterise the changes in capsule matrix, cellular composition, and mechanical properties that occur in liver disease and to determine whether these correlate with disease severity or aetiology. Methods: Samples from ten control patients, and six with steatosis, seven with moderate fibrosis, and 37 with cirrhosis were collected from autopsies, intraoperative biopsies, and liver explants. Matrix proteins and cell markers were assessed by staining and second harmonic generation imaging. Mechanical tensile testing was performed on a test frame. Results: Capsule thickness was significantly increased in cirrhotic samples compared with normal controls irrespective of disease aetiology (70.12 ± 14.16 μm and 231.58 ± 21.82 μm, respectively), whereas steatosis and moderate fibrosis had no effect on thickness (90.91 ± 11.40 μm). Changes in cirrhosis included an increase in cell number (fibroblasts, vascular cells, infiltrating immune cells, and biliary epithelial cells). Key matrix components (collagens 1 and 3, hyaluronan, versican, and elastin) were all deposited in the lower capsule, although only the relative amounts per area of hyaluronan and versican were increased. Organisational features, including crimping and alignment of collagen fibres, were also altered in cirrhosis. Unexpectedly, capsules from cirrhotic livers had decreased resistance to loading compared with controls. Conclusions: The liver capsule, similar to the parenchyma, is an active site of disease, demonstrating changes in matrix and cell composition as well as mechanical properties. Impact and implications: We assessed the changes in composition and response to stretching of the liver outer sheath, the capsule, in human liver disease. We found an increase in key structural components and numbers of cells as well as a change in matrix organisation of the capsule during the later stages of disease. This allows the diseased capsule to stretch more under any given force, suggesting that it is less stiff than healthy tissue.

The superior extensor ankle retinaculum (SEAR), a transversely fascial thickening positioned above the tibia–talar joint, serves as a crucial anatomical structure in ankle stability. The purpose of this study was to measure and compare by ultrasound (US) imaging the bilateral thickness and echogenicity of SEAR in football players with previous multiple ankle sprains (group 1) and healthy volunteers (group 2). A cross-sectional study was performed using ultrasound imaging to measure longitudinal and transversal axes using a new protocol in a sample of 50 subjects: 25 football players with previous multiple ankle sprains and 25 healthy subjects. The findings for SEAR thickness revealed statistically significant differences for both axes (p = 0.0011 and p = 0.0032) between the healthy side and the previously sprained side, and with the corresponding side of group 2 (p = 0.003 and p = 0.004). Moreover, in group 1, regarding the ROI echogenicity, a statistically significant difference was found between the sides (p = 0.0378). These findings suggest that the football players with previous ankle sprains showed a thicker and inhomogeneous SEAR on the sprain side, unveiling a remodeling of this structure compared to the other side and to the healthy volunteers. In these athletes, during US examination, one needs to keep “a US eye” on side-to-side SEAR comparisons.

Urinary incontinence is still an underestimated problem due to its anatomical complexity and social taboo. Most of the time, it is believed to affect predominantly the elderly female population, and the literature still lacks data on its presence in the younger and male populations. Its relationship with other pelvic floor dysfunctions (PFDs) and sport activity remains an open topic. Thus, the present study surveyed 342 subjects of both genders, ranging from 18 to 39 y/o and with different sport activity levels, to understand the prevalence of PFDs (such as haemorrhoids, anal fissures, involuntary urinary/faecal leakage, and urgency). The results also showed a significative prevalence in younger, sporty, and male people. Approximately one third of the population had urinary incontinence mostly during stress activities (sport activity: 17%, cough/sneeze: 13%). The statistical analysis confirmed a higher prevalence in the cases of a light (32%) and intense (41%) sport activity level and a protective role of sport if practiced between 5 and 10 h/week, with bodybuilding/CrossFit and running seeming to be the riskiest sports. The relationship with the other PFDs showed a statistically significant dependence with most of them, confirming that urinary incontinence cannot be considered a separate problem from the other PFDs.

It is a common experience, reported by patients who have undergone manual therapy that uses deep friction, to perceive soreness in treatment areas; however, it is still not clear what causes it and if it is therapeutically useful or a simple side effect. The purpose of this narrative review is to determine whether manual and physical therapies can catalyze an inflammatory process driven by HA fragments. The literature supports the hypothesis that mechanical stress can depolymerize into small pieces at low molecular weight and have a high inflammatory capacity. Many of these pieces are then further degraded into small oligosaccharides. Recently, it has been demonstrated that oligosaccharides are able to stop this inflammatory process. These data support the hypothesis that manual therapy that uses deep friction could metabolize self-aggregated HA chains responsible for increasing loose connective tissue viscosity, catalyzing a local HA fragment cascade that will generate soreness but, at the same time, facilitate the reconstitution of the physiological loose connective tissue properties. This information can help to explain the meaning of the inflammatory process as well as the requirement for it for the long-lasting resolution of these alterations.

Abstract Painful lesions on the plantar aspect of the first interphalangeal joint (IPJ) of the hallux can be attributed to structures called ossicles, nodules, or sesamoids. The aims of the present study were first to verify that ultrasonography (US) is a high-sensitivity tool for diagnosing an interphalangeal ossicle (IO), and second to prove that US-guided-shaving surgery (“milling”) is a safe and feasible technique for remodeling the IO. The study is divided into three parts. In the first part, the prevalence of IOs was estimated in 12 cadaver feet using US, anatomical dissection, and fluoroscopy. In the second, a detailed US and morphological description of the IO was obtained. In the third, six cadaver feet were subjected to surgical milling. IO prevalence was 41.6% in gross anatomy, 41.6% in US examination and just 16.6% in fluoroscopy. The ossicles had a mean length of 4 mm (± 2 mm) and a width of 7 mm (± 2 mm). The ossicles could be completely shaved in all specimens without injuring important anatomical structures. Our results indicate that US is a more precise tool for diagnosing an IO than X-ray. Moreover, our US-guided mini-invasive surgical technique appears feasible and safe.

The winter of 2022 approaches with the need to finalize our plans for next year. This is urgent for the 2023 Meeting of the Padua Days of Muscle and Mobility Medicine (Pdm3) to be held March 29th to April 1st, 2023 at the Hotel Petrarca in the Thermae of Euganean Hills (Padua), Italy. A preliminary Pdm3 Program is almost ready with sessions, organzers and keynote speakers, but ther is still rooms for many interesting and interested young speakers. Some of the Pdm3 sessions dedicated to molecular and cellular myology are organized by old Pdm3 Friends, but there will also be interesting new entries, including those for Rehabilitation Sessions. No doubt that 2023 Pdm3 will attract old friends, but topics of a few sessions are at the frontiers of Translational Myology and new entries are most warmly acknowledged. This is true for both basic myology research, which include beside traditional MiRNA the new entry of the LNC-RNA and the “dark side of the genome”. As to rehabilitation topics, beside the old friends of the “LBI workshop on muscle rehabilitation - from mouse to elderly”, new entries are sessions on Muscle Fascia, Muscle Rehabilitation in Dentistry (that will organize also a Practical Course) and the session on “European Medical Thermalism and FEMTEC” that will also offer a practical Course. We hope that by January 20th, 2023 many old and new friends will send their abstracts to fill an half-empty program and then by May 1st, 2023 they submit Communications to EJTM that deserve them to increase the 2023 EJTM Impact Factor.

The superficial fascia has only recently been recognized as a specific anatomical structure. Furthermore, whereas it is actually recognized that the innervation of the deep/muscular fascia plays a key role in proprioception and nociception, there are very few studies that have analyzed these characteristics in the superficial fascia. In this work, our group analyzed two different anatomical districts (abdomen and thigh), from volunteer patients, undergoing surgery procedures. Each sample was processed for histological analysis by Hematoxylin&Eosin, and by immunohistochemistry stainings (in 5-micron-paraffin embedded section and in cryosectioned free floating samples), with antibodies specific for nerve fibers: S100 antibody for myelinating and non-myelinating Schwann cells, PGP9.5 antibody as pan-neuronal marker, tyrosine hydroxylase for autonomic innervation. The results revealed a huge innervation: the nervous structures were found above all around blood vessels and close to adipocytes, but they penetrated also in the connective tissue itself and are found in the midst of fibro-adipose tissue. The tissue is pervaded by both thin (mean diameter of 4.8 ± 2.6 μm) and large nerve fiber bundles of greater diameter (21.1 ± 12.2 μm). The ratio S100/TH positivity was equal to 2.96, with a relative percentage of autonomic innervation with of 33.82%. In the light of these findings is evident that the superficial fasciae have a clear and distinct anatomical identity and a specific innervation, which should be considered to better understand their role in thermoregulation, exteroception and pain perception. The knowledge of the superficial fascia may improve grading and developing of different manual approach for treatments of fascial dysfunctions, and the understanding of how some factors like temperature or manual therapies can have an impact on sensitivity of the fascia.

Abstract It is recognized that different fasciae have different type of innervation, but actually nothing is known about the specific innervation of the two types of deep fascia, aponeurotic and epymisial fascia. In this work the aponeurotic thoracolumbar fascia and the epymisial gluteal fascia of seven adult C57-BL mice were analysed by Transmission Electron Microscopy and floating immunohistochemistry with the aim to study the organization of nerve fibers, the presence of nerve corpuscles and the amount of autonomic innervation. The antibodies used were Anti-S100, Anti-Tyrosine Hydroxylase and Anti-PGP, specific for the Schwann cells forming myelin, the sympathetic nerve fibers, and the peripheral nerve fibers, respectively. The results showed that the fascial tissue is pervaded by a rhomboid and dense network of nerves. The innervation was statistically significantly lower in the gluteal fascia (2.78 ± 0.6% of positive area, 140.3 ± 31.6/mm2 branching points, nerves with 3.2 ± 0.6 mm length and 4.9 ± 0.2 µm thickness) with respect to the thoracolumbar fascia (9.01 ± 0.98% of innervated area, 500.9 ± 43.1 branching points/mm2, length of 87.1 ± 1.0 mm, thickness of 5.8 ± 0.2 µm). Both fasciae revealed the same density of autonomic nerve fibers (0.08%). Lastly, corpuscles were not found in thoracolumbar fascia. Based on these results, it is suggested that the two fasciae have different roles in proprioception and pain perception: the free nerve endings inside thoracolumbar fascia may function as proprioceptors, regulating the tensions coming from associated muscles and having a role in nonspecific low back pain, whereas the epymisial fasciae works to coordinate the actions of the various motor units of the underlying muscle.

Nerve/tendon snapping can occur due to their sudden displacement during the movement of an adjacent joint, and the clinical condition can really be painful. It can actually be challenging to determine the specific anatomic structure causing the snapping in various body regions. In this sense, ultrasound examination, with all its advantages (especially providing dynamic imaging), appears to be quite promising. To date, there are no comprehensive reviews reporting on the use of dynamic ultrasound examination in the diagnosis of nerve/tendon snapping. Accordingly, this article aims to provide a substantial discussion as to how US examination would contribute to ‘seeing’ and ‘hearing’ these pathologies’ different maneuvers/movements.

The thoracolumbar fascia (TLF) plays an important role in lower back pain (LBP). Recent studies have revealed an association between increases in TLF thickness and reduced TLF gliding in patients with LBP. The purpose of this study was to measure and compare by ultrasound (US) imaging the thickness of the TLF at the bilateral L3 level of the lumbar spine in the longitudinal and transverse axes in chronic non-specific LBP and in healthy subjects. A cross-sectional study was performed using US imaging to measure the longitudinal and transverse axes with a new protocol in a sample of 92 subjects: 46 chronic non-specific LBP patients and 46 healthy participants. The findings for TLF thickness revealed statistically significant differences (p < 0.05) in the longitudinal and transverse axes between the two groups. Moreover, in the healthy group, a statistically significant difference was found between the longitudinal and transverse axes (p = 0.001 for left and p = 0.02 for right), which was not evident in the LBP patients. These findings suggest that the LBP patients lost anisotropy of the TLF, with it becoming homogeneously thicker and losing adaptability in the transversal direction. The US imaging evaluation suggests that TLF thickness behavior points out altered fascial remodelling compared to healthy subjects, a sort of “frozen back”.

Recently, the superficial fascia has been recognized as a specific anatomical structure between the two adipose layers—the superficial adipose tissue (SAT) and the deep adipose tissue (DAT). The evaluation of specific characteristics of cells, fibers, blood circulation, and innervation has shown that the superficial fascia has a clear and distinct anatomical identity, but knowledge about lymphatic vessels in relation to the superficial fascia has not been described. The aim of this study was to evaluate the presence of lymphatic vessels in the hypodermis, with a specific focus on the superficial fascia and in relation to the layered subdivision of the subcutaneous tissue into SAT and DAT. Tissue specimens were harvested from three adult volunteer patients during abdominoplasty and stained with D2-40 antibody for the lymphatic endothelium. In the papillary dermis, a huge presence of lymphatic vessels was highlighted, parallel to the skin surface and embedded in the loose connective tissue. In the superficial adipose tissue, thin lymphatic vessels (mean diameter of 11.6 ± 7.71 µm) were found, close to the fibrous septa connecting the dermis to the deeper layers. The deep adipose tissue showed a comparable overall content of lymphatic vessels with respect to the superficial layer; they followed the blood vessel and had a larger diameter. In the superficial fascia, the lymphatic vessels showed higher density and a larger diameter, in both the longitudinal and transverse directions along the fibers, as well as vessels that intertwined with one another, forming a rich network of vessels. This study demonstrated a different distribution of the lymphatic vessels in the various subcutaneous layers, especially in the superficial fascia, and the demonstration of the variable gauge of the vessels leads us to believe that they play different functional roles in the collection and transport of interstitial fluid—important factors in various surgical and rehabilitation fields.

Human Fascia Lata (FL) is a connective tissue with a multilayered organization also known as aponeurotic fascia. FL biomechanics is influenced by its composite structure formed by fibrous layers (usually two) separated by loose connective tissue. In each layer, most of the collagen fibers run parallel in a distinct direction (with an interlayer angle that usually ranges from 75–80°), mirroring the fascia’s ability to adapt and withstand specific tensile loads. Although FL is a key structure in several musculoskeletal dysfunctions and in tissue engineering, literature still lacks the evidence that proves tissue anisotropy according to predominant collagen fiber directions. For this purpose, this work aims to analyze the biomechanical properties of ex-vivo FL (collected from fresh-frozen human donors) by performing uniaxial tensile tests in order to highlight any differences with respect to loading directions. The experimental outcomes showed a strong anisotropic behavior in accordance with principal collagen fibers directions, which characterize the composite structure. These findings have been implemented to propose a first constitutive model able to mimic the intra- and interlayer interactions. Both approaches could potentially support surgeons in daily practices (such as graft preparation and placement), engineers during in silico simulation, and physiotherapists during musculoskeletal rehabilitation, to customize a medical intervention based on each specific patient and clinical condition.

Background: Masticatory muscle thickness provides objective measurements of the temporomandibular motor function, which may change in patients with oral myofascial pain. Moreover, they are considered as being part of the craniocervical unit by a crucial relationship with cervical muscles and their fasciae. In this study, we aimed to assess by ultrasound (US) imaging the fasciae of the masseter, temporal, and sternocleidomastoid muscles to understand their mean thickness and eventual variation in relationship with the muscles, sides, and sex.Methods: We studied 16 healthy volunteers without temporomandibular joint dysfunction. Concerning each subject were evaluated the range of motion of the temporomandibular joint and of the neck, the thickness of muscles and their fasciae of both sides, and the delta of muscle thickness.Results: All the motor evaluations of the subjects showed normal ranges. The US results showed that the fasciae have a mean thickness of 0.50 ± 0.1 mm, which did not change during muscle contraction. The evaluated muscles presented a symmetry between right and left (p > 0.05), even if the delta of muscle (US) thickness had a huge range between different subjects, for example in the masseter muscle from 0.7 to 4.2 mm.Conclusions: Ultrasound imaging is a suitable and reliable tool to study the muscles and fasciae of the head and neck region, permitting also the evaluation of the ability of the muscles to contract. Finally, identifying functional asymmetry that could become symptomatic, US imaging could allow an early rehabilitation treatment.

By leveraging the recent development of artificial intelligence algorithms, several medical sectors have benefited from using automatic segmentation tools from bioimaging to segment anatomical structures. Segmentation of the musculoskeletal system is key for studying alterations in anatomical tissue and supporting medical interventions. The clinical use of such tools requires an understanding of the proper method for interpreting data and evaluating their performance. The current systematic review aims to present the common bottlenecks for musculoskeletal structures analysis (e.g., small sample size, data inhomogeneity) and the related strategies utilized by different authors. A search was performed using the PUBMED database with the following keywords: deep learning, musculoskeletal system, segmentation. A total of 140 articles published up until February 2022 were obtained and analyzed according to the PRISMA framework in terms of anatomical structures, bioimaging techniques, pre/post-processing operations, training/validation/testing subset creation, network architecture, loss functions, performance indicators and so on. Several common trends emerged from this survey; however, the different methods need to be compared and discussed based on each specific case study (anatomical region, medical imaging acquisition setting, study population, etc.). These findings can be used to guide clinicians (as end users) to better understand the potential benefits and limitations of these tools.

With an incidence of over 1.5 million worldwide per annum, breast cancer continues to be the most common cancer affecting the female population. The main and most effective treatment in over 40% of these patients is a primary neoplasm resection. General anaesthesia, at times in association with loco-regional anaesthetics, is the most commonly used anaesthesia technique for radical mastectomies. Nausea, vomiting, and considerable postoperative pain, which are commonly experienced side effects and complications of general anaesthesia, tend, however, to augment most patients’ post-surgical morbidity. A growing body of research has shown that loco-regional anaesthesia often used together with and, in some cases, in the substitution of general anaesthesia can be a safe, effective alternative. This work is a case report regarding a 94-year-old elderly patient who was anaesthetised during a left radical mastectomy using exclusively combined interpectoral and pectoserratus plane blocks.

# Background Because of their importance in core stability, training the deep abdominal muscles, fascial structures and particularly the transversus abdominis, is a key component of many sport and physical therapy programs. However, there are gaps in knowledge about age-related changes in the structure and activation capacity of these muscles. # Hypothesis/Purpose This study investigated the association between deep abdominal muscles and fascial structures and transversus abdominis activation with age in healthy adults. # Study design A cross-sectional study. # Methods Eighty-six adults aged 18 to 77 participated in this study. An ultrasound image of their transversus abdominis, internal oblique, external oblique and associated fasciae was first captured at rest, then during a contraction of the transversus abdominis. Bivariate correlation analyses and hierarchical analyses were performed (significance level: *p* \< 0.05). # Results The thickness of these three muscles decreases with age ($\rho$ = -0.66 for external oblique, -0.51 for internal oblique and -0.58 for transversus abdominis), whereas the thickness of their fasciae increases ($\rho$ = 0.39 for the fascia of external oblique, 0.54 for the fascia between internal oblique and external oblique, and 0.74 for the fascia between internal oblique and transversus abdominis). Transversus abdominis activation decreases with age (*r* =-0.44). Age accounts for 19.5% of the variance in transversus abdominis activation. # Conclusion These results demonstrate that normal aging is associated with changes in deep abdominal myofascial structures and transversus abdominis activation. Assessment of these metrics can provide valuable baseline information for physical therapists involved in rehabilitation and strengthening programs targeting older individuals. # Level of evidence Level 2

Recent studies have shown that fascial fibroblasts are sensitive to different stimuli (biochemical or biophysical), promoting extracellular matrix remodeling, as well as synthetic activity. Moreover, the extensive literature on the renin–angiotensin system (RAS) reported its involvement in tissue remodeling. This study aimed to investigate the presence of RAS components in the deep fascia. Thoracolumbar fascia specimens were collected from 13 patients (age range: 25–75 years; seven males and five females) who had undergone elective spinal surgical procedures at the Orthopedic Clinic of the University of Padova. Gene expression analysis was performed to investigate the expression of Ang II type 1 receptor (AT1R), Ang II type 2 receptor (AT2R), MAS receptor (MasR), angiotensinogen, angiotensin-converting enzyme 2 (ACE2) and angiotensin-converting enzyme 1 (ACE1). AT1R and ACE2 were also measured with immunoblot. AT1R was the most expressed angiotensin receptor subtype (300.2 ± 317 copies/25 ng of mRNA), followed by MasR (37.1 ± 39.56 copies/25 ng of mRNA) and AT2R (147 ± 122 copies/25 ng of mRNA). The amounts of angiotensinogen, ACE1 and ACE2 were hardly detectable. These findings demonstrate that RAS system receptors are present in the deep fascia, with a greater expression of AT1R, suggesting their involvement in fascial remodeling and fibrogenesis.

Ultrasound (US) imaging is increasingly the most used tool to measure the thickness of superficial and deep fasciae, but there are still some doubts about its reliability in this type of measurement. The current study sets out to assess the inter-rater and intra-rater reliability of US measurements of superficial and deep fasciae thicknesses in the arm and forearm. The study involved two raters: the first (R1) is an expert in skeletal–muscle US imaging and, in particular, the US assessment of fasciae; the second (R2) is a radiologist resident with 1 year’s experience in skeletal–muscle US imaging. R2, not having specific competence in the US imaging of fasciae, was trained by R1. R1 took US images following the protocol by Pirri et al. 2021, and the US-recorded images were analyzed separately by the two raters in different sessions. Each rater measured both types of fasciae at different regions and levels of the arm and forearm. Intra- and inter-rater reliability was excellent for the deep fascia and good and excellent for the superficial fascia according to the different regions/levels (for example for the anterior region of the arm: deep fascia: Ant 1: ICC2,2 = 0.95; 95% CI = 0.81–0.98; superficial fascia: Ant 1: ICC2,2 = 0.85, 95% CI = 0.79–0.88). These findings confirm that US imaging is a reliable and cost-effective tool for evaluating both fasciae, superficial and deep.

The superficial fascia has received much attention in recent years due to its important role of compartmentalizing the subcutaneous tissue. Ultrasound (US) imaging, owing to its high definition, provides the possibility of better visualizing and measuring its thickness. The aim of this study was to measure and compare, with US imaging, the thickness of superficial fascia in the arm and forearm in different regions/levels. An observational study has been performed using US imaging to measure superficial fascia thickness in the anterior and posterior regions at different levels in a sample of 30 healthy volunteers. The results for superficial fascia thickness revealed statistically significant differences (p < 0.0001) in the arm between the anterior and posterior regions; in terms of forearm, some statistically significant differences were found between regions/levels. However, in the posterior region/levels of the arm, the superficial fascia was thicker (0.53 ± 0.10 mm) than in the forearm (0.41 ± 0.10 mm); regarding the anterior regions/levels, the superficial fascia of the arm (0.40 ± 0.10 mm) was not statistically different than the forearm (0.40 ± 0.12 mm). In addition, the intra-rater reliability was good (ICC2,k: 0.88). US helps to visualize and assess the superficial fascia inside the subcutaneous tissue, improving the diagnosis of fascial dysfunction, and one of the Us parameters to reliably assess is the thickness in different regions and levels.

Anatomical education and surgical training with cadavers are usually considered an appropriate method of teaching, above all for all surgeons at various levels. Indeed, in such a way they put into practice and exercise a procedure before performing it live, reducing the learning curve in a safe environment and the risks for the patients. Really, up to now it is not clear if the nonuse of the cadavers for anatomical education and surgical training can have also forensic implications. A substantial literature research was used for this review, based on PubMed and Web of Science database. From this review, it is clear that the cadaveric training could be considered mandatory, both for surgeons and for medical students, leading to a series of questions with forensic implications. Indeed, there are many evidences that a cadaver lab can improve the learning curve of a surgeon, above all in the first part of the curve, in which frequent and severe complications are possible. Consequently, a medical responsibility for residents and surgeons which perform a procedure without adequate training could be advised, but also for hospital, that has to guarantee a sufficient training for its surgeons and other specialists through cadaver labs. Surely, this type of training could help to improve the practical skills of surgeons working in small hospitals, where some procedures are rare. Cadaver studies can permit a better evaluation of safety and efficacy of new surgical devices by surgeons, avoiding using patients as ≪guinea pigs≫. Indeed, a legal responsibility for a surgeon and other specialists could exist in the use of a new device without an apparent regulatory oversight. For a good medical practice, the surgeons should communicate to the patient the unsure procedural risks, making sure the patients' full understanding about the novelty of the procedure and that they have used this technique on few, if any, patients before. Cadaver training could represent a shortcut in the standard training process, increasing both the surgeon learning curve and patient confidence. Forensic clinical anatomy can supervise and support all these aspects of the formation and of the use of cadaver training.

Extracorporeal shock waves (ESWs) are used in the treatment of soft tissue injuries, but their role in the treatment of myofascial pain has not yet been demonstrated. The aim of this study was to investigate changes in cell biology of fibroblasts derived from deep/muscular fascia following treatment with ESWs. Primary fascial fibroblasts were collected from small samples of human fascia lata of the thigh of three volunteer patients (two men, one woman) during orthopedic surgery, and put in culture. These cells were exposed to 100 impulses of 0.05 mJ/mm2 with a frequency of 2.5 Hz, using 3D-printed support. This study demonstrated for the first time that ESWs can lead to in vitro production of hyaluronan-rich vesicles immediately after the treatment. At 1, 4, and 24 h after treatment, Alcian blue and Toluidine blue staining; immunocytochemistry to detect hyaluronic acid binding protein (HABP), collagen I, and collagen III; and transmission electron microscopy demonstrated that these vesicles are rich in hyaluronan and collagen I and III. The diameter of these vesicles was assessed, highlighting a small size at 1 h after ESW treatment, whereas at 4 and 24 h, they had an increase in the size. Particularly evident was the release of hyaluronan-rich vesicles, collagen-I, and collagen-III starting at 1 h, with an increase at 4 h and maintenance by 24 h. These in vitro data indicate that fascial cells respond to ESW treatment by regulating and remodeling the formation of extracellular matrix.

Fasciae have received much attention in recent years due to their important role in proprioception and muscular force transmission, but few studies have focused on fetal fasciae development and there is no study on the retinacula. The latter are fascial reinforcements that play a key role in proprioception and motor coordination. Furthermore, it is still unclear if they are genetically determined or if they are defined by movements, and if they are present during gestation or if they appear only later in the childhood. We aim to identify their structural organization by qualitative and quantitative assessments to establish their role the myofascial development, highlighting their appearance and organization. Samples from the wrist retinacula, posterior forearm, ankle retinacula, anterior leg, iliotibial tract and anterior thigh of six fetus body donors (from 24th to 40th week of gestation) and histological sections were obtained and a gross anatomy dissection was performed. Sections were stained with hematoxylin-eosin to observe their overall structure and measure their thicknesses. Using Weigert Van Gieson, Alcian blue and immunostaining to detect Hyaluronic Acid Binding Protein (HABP), Collagens I and III (Col I and III) were realized to assess the presence of elastic fibers and hyaluronan. This study confirms that the deep fasciae initially do not have organized layers and it is not possible to highlight any reinforcement. The fascial development is different according to the various area: while the deep fascia and the iliotibial tract is already evident by the 27th week, the retinacula begin to be defined only at the end of pregnancy, and their complete maturation will probably be reached only after birth. These findings suggest that the movement models the retinacula, structuring the fascial system, in particular at the end of pregnancy and in the first months of life. The fasciae can be imagined, initially, as “white tablets” composed of few elastic fibers, abundant collagens and HA, on which various forces, u movements, loads and gravity, “write their history”.

This study tested the hypothesis that pectoralis II (PECS II) + serratus plane blocks would reduce opioid consumption and improve outcomes compared with standard practice in minimally invasive cardiac surgery. A retrospective and observational study was realized in the intensive care unit (ICU) setting of “ICLAS GVM, Istitituto Clinico Ligure Alta Specialità, (Rapallo, Italy)”, including adult patients who underwent right minithoracotomy for replacement/plastic aortic, mitral and tricuspid valve or atrial myxoma resection in cardiac surgery. Seventy-eight patients were extracted by the database and divided into two groups. Group 1 (41 patients) received ultrasound-guided PECS II + serratus plane blocks with Ropivacaine 0.25% 10 mL + 20 mL + 30 mL. Group 2 (37 patients) received intravenous opioids analgesia with morphine 20–25 mg/day or tramadol 200–300 mg/day. The primary outcomes were: the pain perceived: Critical-Care Pain Observation Tool (CPOT) score; the opioids consumption: mg morphine or tramadol, or µg sufentanyl administered; and mg paracetamol, toradol, tramadol or morphine administered as a rescue. The secondary outcomes were the hours of orotracheal intubation and of stay in ICU, and the number of episodes of nausea, vomiting, delayed awakening and respiratory depression. Group 1 vs. Group 2 consumed less opioids (Sufentanyl p < 0.0001; Morphine p < 0.0001), had a lower pain perceived (p = 0.002 at 6 h, p = 0.0088 at 12 h, p < 0.0001 at 24 h), need for rescue analgesia (p = 0.0005), episodes of nausea and vomiting (p = 0.0237) and intubation time and ICU stay (p = 0.0147 time of IOT, p < 0.0001 stay in ICU). Ultrasound-guided PECS II + serratus plane blocks demonstrated better than intravenous opioids analgesia in patients undergoing minimally invasive cardiac surgery.

Persistent scar pain associated with healed surgical incisions after a trauma is a common and potentially debilitating type of fascial pain. At present, there is no universally effective treatment for persistent surgical or post-trauma scar pain. Herein we describe the successful objective diagnosis of debilitating scar pain by Ultrasound (US) imaging. The sonopalpation of the fasciae and subcutaneous tissues seems to be relevant to diagnose the real cause of the pain and why not to monitor the treatment.

Knowledge about fasciae has become increasingly relevant in connection to regional anesthesiology, given the growing interest in fascial plane, interfascial, and nerve blocks. Ultrasound (US) imaging, thanks to high definition, provides the possibility to visualize and measure their thickness. The purpose of this study was to measure and compare, by US imaging, the thickness of deep/muscular fasciae in different points of the arm and forearm. An observational study has been performed using US imaging to measure brachial and antebrachial fasciae thickness at anterior and posterior regions, respectively, of the arm and forearm at different levels with a new protocol in a sample of 25 healthy volunteers. Results of fascial thickness revealed statistically significant differences (p < 0.0001) in the brachial fascia between the anterior and the posterior regions; in terms of the antebrachial fascia, no statistically significant difference was present (p > 0.05) between the regions/levels. Moreover, regarding the posterior region/levels, the brachial fascia had a greater thickness (mean 0.81 ± 0.20 mm) than the antebrachial fascia (mean 0.71 ± 0.20 mm); regarding the anterior region/levels, the antebrachial fascia was thicker (mean 0.70 ± 0.2 mm) than the brachial fascia (mean 0.61 ± 0.11 mm). In addition, the intra-rater reliability reported good reliability (ICC2,k: 0.88). US imaging helps to improve grading of fascial dysfunction or disease by revealing subclinical lesions, clinically invisible fascial changes, and one of the US parameters to reliably evaluate is the thickness in the different regions and levels.

The present study compares the structure and composition of fascia lata in healthy subjects and in patients with hip osteoarthritis (OA), to evaluate any differences in the amount of Collagen type I, Collagen type III, and Hyaluronan. Fascia lata samples from voluntary healthy subjects and patients with OA were harvested during surgery. Collagen type I (COL I), III (COL III) antibody, and biotinylated hyaluronan binding protein (HABP) immunohistochemistry stainings were used to evaluate fascial morphology and COL I, COL III, and Hyaluronan (HA) content in both groups. Ten samples from healthy subjects and 11 samples from OA patients were collected. COL I was significantly more abundant in the OA group (p = 0.0015), with a median percentage positivity of 75.2 (IQR 13.11)%, while representing only 67 (IQR: 8.71)% in control cases. COL III, with median values of 9.5 (IQR 3.63)% (OA group) and 17.10 (IQR 11)% (control cases), respectively, showed significant reduction in OA patients (p = 0.002). HA showed a median value of 10.01 (IQR 8.11)% in OA patients, denoting significant decrease (p < 0.0001) with respect to the control group median 39.31 (IQR 5.62)%. The observed differences suggest a relationship between fascial pathology and hip OA. The observed increase in COL I in OA patients, along with the reduction of COL III and HA, could lead to fascial stiffening, which could alter fascial mechanics and be linked to the development and symptoms of OA.

Wound healing is an intricate, dynamic process, in which various elements such as hyperglycemia, neuropathy, blood supply, matrix turnover, wound contraction, and the microbiome all have a role in this “out of tune” diabetic complex symphony, particularly noticeable in the complications of diabetic foot. Recently it was demonstrated that the fasciae have a crucial role in proprioception, muscular force transmission, skin vascularization and tropism, and wound healing. Indeed, the fasciae are a dynamic multifaceted meshwork of connective tissue comprised of diverse cells settled down in the extracellular matrix and nervous fibers; each constituent plays a particular role in the fasciae adapting in various ways to the diverse stimuli. This review intends to deepen the discussion on the possible fascial role in diabetic wounds. In diabetes, the thickening of collagen, the fragmentation of elastic fibers, and the changes in glycosaminoglycans, in particular hyaluronan, leads to changes in the stiffness, gliding, and the distribution of force transmission in the fasciae, with cascading repercussions at the cellular and molecular levels, consequently feeding a vicious pathophysiological circle. A clear scientific perception of fascial role from microscopic and macroscopic points of view can facilitate the identification of appropriate treatment strategies for wounds in diabetes and create new perspectives of treatment.

Extracorporeal Shockwaves Treatment is considered an effective therapeutic option for plantar fasciitis, but the standard application in the medial insertion of the plantar fascia on the calcaneus has provided ambiguous evidences. In this case, a 63-year man with plantar fasciitis was treated in a 3-session program and Foot and Ankle Outcome Scale and Foot Functional Index questionnaires were chosen for the clinical outcome evaluation. The therapy was focused on the active trigger or myofascial points of the leg, thigh and pelvis in order to return the correct equilibrium of the myofascial system of the whole limb. The patient has already reported an improvement after the second session (FAOS: 76 vs 33, FFI: 85%) which was confirmed in the third one and in the 1-month follow up (FAOS: 79, FFI: 6%) Results suggest that plantar fasciitis may be due to proximal rigidity or tension of the fascia and a global approach using ESWT may have a similar or better outcome respect to the standard application.

More and more evidences show how the thoracolumbar fascia is involved with nonspecific low back pain. Additionally, recent studies about anatomy have shown the presence of a continuity between the thoracolumbar fascia and the deep fascia of the limbs; but actually, a dysfunction of just the thoracolumbar fascia or of the tightly contiguous myofascial tissue is generally recognized as possible cause of nonspecific low back pain. Five patients among those affected by nonspecific low back pain were manipulated just on those fascial spots that were painful, when palpated, and located in other areas of the body than the low back one. Each patient reported a clinically significant reduction of the painful symptoms (a Pain Numerical Rating Scale score difference ≥ 2) straight after the manipulation. A dysfunction of the myofascial tissue that is not tightly contiguous with the symptomatic area is then suggested to be taken into consideration among the causes of nonspecific low back-pain.

The aim of this study was to characterize the microscopic structure and sensory nerve endings of the crural interosseous membrane (IM). 13 IMs from 7 cadavers were used to analyze the organization of the collagen fibers, IM’s thickness, distribution of elastic fibers and nerve elements. The IM is mainly a two-layer collagen fascicle structure with the collagen fibers of adjacent layers orientated along different directions, forming angles of 30.5 +/- 1.7° at proximal and 26.6 +/- 2.1° at distal part (P>0.05). The percentage of elastic fibers between the two layers and inside the collagen fascicle layer is 10.1 +/- 0.5% and 2.2 +/- 0.1% (P

For many years the fasciae have been considered by the anatomists only as a “white envelope for the muscles”, that is generally removed in anatomical tables, to recognize muscle nerves and vessels. This is one of the reasons that different descriptions of the fasciae exist. On the other hand, in the last years the fasciae and their properties are becoming of central importance to clinicians practicing in various conventional and alternative therapies. The results from the worldwide research activities constitute a body of significant and important data, but this clinical interest is not supported by in-depth comprehension to how integrate the new knowledge about fasciae with the classical biomechanical models based on muscles, tendons and bones. To close this gap an Ejtm Special on “Muscle Fascia” will be published September 30, 2019, but the typescripts will be added to the Ejtm Early Release list as soon as all authors will approve their Epub papers. Deadline for original articles and reviews is June 1st, 2019, but the Editors hope that authors submit their typescripts much earlier.

Background and Objectives: Sacroiliac joint dysfunction (SIJD) generally refers to pain in the lower back due to abnormal sacroiliac joint movement, either from hypomobility or hypermobility. It is considered to be the principal cause in up to 40% of low back pain cases. In literature, it emerges that the “fascia”, by its anatomical continuity, if altered or densified in different regions of the body with respect to the sacroiliac joint and its surroundings, may have a fundamental role in the genesis of SIJD and low back pain. The purpose of the present study is to evaluate the effectiveness of incorporating a single session of Fascial Manipulation®-Stecco method®, treating the muscular fasciae at distance from the painful region. Materials and Methods: Twenty patients with acute and chronic sacroiliac joint dysfunction (SIJD) were recruited (16 males and 4 females, mean age of 46.6 ± 12.98 years). Patients underwent a predefined assessment protocol, followed by an evaluation of myofascial pain and subsequent manipulation of the fascia at points at least 20 cm away from the posterior inferior iliac spines (PIIS). Each patient underwent three pain evaluations: pre-treatment (t0), post-treatment (t1), and at a 1-month follow-up (t2). For the evaluation in t0, t1 the numerical rating scale (NRS) for the intensity of pain and the algometer for the pain threshold at the PIIS were used; in t2 only the NRS scale. Results: The results obtained by comparing the algometer measurements with the NRS values between t0 and t1 were in both cases statistically significant (p < 0.0001), whereas the comparison between the NRS values at t1 and at t2 was not statistically significant (p > 0.05). Conclusions: A single Fascial Manipulation treatment, even when applied at least 20 cm from the PIIS, can potentially decrease pain around the SIJ. The inclusion of this type of approach in SIJD can allow for improved patient management, better tolerance for other treatments and a more rapid application of pain-free exercise programs.

Background: Fascial layers may play an important role in locomotor mechanics. Recent researches have revealed an association between increases of fascia thickness and reduced joint flexibility in patients with chronic pain. The purpose of this study was to measure and compare, through the use of ultrasound imaging, the thickness of the deep/crural fascia in different points of the leg as well as the epimysial fascia thickness at level 2 of anterior compartment of leg, in male basketball players with history of recurrent ankle sprain and in healthy participants. Methods: A cross-sectional study has been performed using ultrasound imaging to measure deep/crural fascia thickness of anterior, lateral and posterior compartment of the leg at different levels with a new protocol in a sample of 30 subjects, 15 basketball players and 15 healthy participants. Results: Findings of fascial thickness revealed statistically significant differences (p < 0.01) in epimysial fascia thickness and in deep/crural fascia thickness between levels/compartments of the same group and between two groups. Moreover, Post 3 deep/crural fascia thicknesses (p < 0.001) were decreased showing statistically significant difference for the basketball players group respect the healthy participants group. Conclusions: These findings suggested that the posterior compartment was thicker than anterior compartment, probably due to a postural reason in both groups. Moreover, they showed an increase of thickness of the epimysial fascia in basketball players with previous ankle sprains. This variability underlines the importance to assess the fasciae and to make results comparable.

Stretching exercises are integral part of the rehabilitation and sport. Despite this, the mechanism behind its proposed effect remains ambiguous. It is assumed that flexibility increases, e.g., action on muscle and tendon, respectively, but this is not always present in the stretching protocol of the exercises used. Recently, the fasciae have increased popularity and seems that they can have a role to define the flexibility and the perception of the limitation of the maximal range of motion (ROM). Deep fascia is also considered a key element to transmit load in parallel bypassing the joints, transmitting around 30% of the force generated during a muscular contraction. So, it seems impossible dividing the action of the muscles from the fasciae, but they have to be considered as a “myofascial unit”. The purpose of this manuscript is to evaluate the mechanical behavior of muscles, tendons, and fasciae to better understand how they can interact during passive stretching. Stress-strain values of muscle, tendon and fascia demonstrate that during passive stretching, the fascia is the first tissue that limit the elongation, suggesting that fascial tissue is probably the major target of static stretching. A better understanding of myofascial force transmission, and the study of the biomechanical behavior of fasciae, with also the thixotropic effect, can help to design a correct plan of stretching.