Life | Special Issue : Fasciae from a Molecular and Biomechanical Perspective

Research

11 pages, 1607 KiB

Open AccessArticle

Dose-Dependent Pain and Pain Radiation after Chemical Stimulation of the Thoracolumbar Fascia and Multifidus Muscle: A Single-Blinded, Cross-Over Study Revealing a Higher Impact of Fascia Stimulation

by Simon Vogel, Walter Magerl, Rolf-Detlef Treede and Andreas Schilder

Life 2022, 12(3), 340; https://doi.org/10.3390/life12030340 - 25 Feb 2022

Cited by 5 | Viewed by 2990

Abstract

Acute low back pain can be experimentally induced by injections of hypertonic saline into deep tissues of the back, such as fascia and muscle. The current study investigated the dose-dependency of peak-pain and spatial extent of concomitant radiating pain following 50, 200 and [...] Read more.

Acute low back pain can be experimentally induced by injections of hypertonic saline into deep tissues of the back, such as fascia and muscle. The current study investigated the dose-dependency of peak-pain and spatial extent of concomitant radiating pain following 50, 200 and 800 μL bolus injections of hypertonic saline (5.8%) into the thoracolumbar fascia and multifidus muscle, since data on dose-dependency is lacking in humans. Sixteen healthy subjects rated (11 female, 5 male; 23.3 ± 3.1 years, mean ± SD) intensity and spatial extent of pain. Injections into the fascia resulted in significantly higher peak-pain (+86%, p < 0.001), longer pain durations (p < 0.05), and larger pain areas (+65%, p < 0.02) and were less variable than intramuscular injections. Peak-pain ratings and pain areas were 2–3-fold higher/larger for 200 μL vs. 50 μL. In contrast, peak pain increased only marginally at 800 μL by additional 20%, while pain areas did not increase further at all in both, fascia and muscle. Thus, higher injection volumes did also not compensate the lower sensitivity of muscle. Peak-pain ratings and pain areas correlated between fascia and muscle (r = 0.530, p < 0.001 and r = 0.337, p < 0.02, respectively). Peak-pain ratings and pain areas correlated overall (r = 0.490, p < 0.0001), but a weak correlation remained when the impact of between-tissue differences and different injection volumes were singled out (partial r = 0.261, p < 0.01). This study shows dose-dependent pain responses of deep tissues where an injection volume of 200 μL of hypertonic saline is deemed an adequate stimulus for tissue differentiation. We suggest that pain radiation is not simply an effect of increased peripheral input but may afford an individual disposition for the pain radiation response. Substantially higher pain-sensitivity and wider pain areas support fascia as an important contributor to non-specific low back pain. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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10 pages, 1817 KiB

Open AccessArticle

Fascia Lata Alterations in Hip Osteoarthritis: An Observational Cross-Sectional Study

by Ilaria Fantoni, Carlo Biz, Chenglei Fan, Carmelo Pirri, Caterina Fede, Lucia Petrelli, Pietro Ruggieri, Raffaele De Caro and Carla Stecco

Life 2021, 11(11), 1136; https://doi.org/10.3390/life11111136 - 25 Oct 2021

Cited by 12 | Viewed by 3311

Abstract

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 [...] Read more.

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. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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11 pages, 22070 KiB

Open AccessArticle

Immediate Effects of Myofascial Release on the Thoracolumbar Fascia and Osteopathic Treatment for Acute Low Back Pain on Spine Shape Parameters: A Randomized, Placebo-Controlled Trial

by Andreas Brandl, Christoph Egner and Robert Schleip

Life 2021, 11(8), 845; https://doi.org/10.3390/life11080845 - 18 Aug 2021

Cited by 12 | Viewed by 10661

Abstract

Background: Spine shape parameters, such as leg length and kyphotic or lordotic angle, are influenced by low back pain. There is also evidence that the thoracolumbar fascia plays a role in such pathologies. This study examined the immediate effects of a myofascial release [...] Read more.

Background: Spine shape parameters, such as leg length and kyphotic or lordotic angle, are influenced by low back pain. There is also evidence that the thoracolumbar fascia plays a role in such pathologies. This study examined the immediate effects of a myofascial release (MFR) technique on the thoracolumbar fascia and of an osteopathic treatment (OMT) on postural parameters in patients with acute low back pain (aLBP). Methods: This study was a single-blind randomized placebo-controlled trial. Seventy-one subjects (43.8 ± 10.5 years) suffering from aLBP were randomly and blindedly assigned to three groups to be treated with MFR, OMT, or a placebo intervention. Spinal shape parameters (functional leg length discrepancy (fLLD), kyphotic angle, and lordotic angle) were measured before and after the intervention using video raster stereography. Results: Within the MFR group, fLLD reduced by 5.2 mm, p < 0.001 and kyphotic angle by 8.2 degrees, p < 0.001. Within the OMT group, fLLD reduced by 4.5 mm, p < 0.001, and kyphotic angle by 8.4°, p = 0.007. Conclusion: MFR and OMT have an influence on fLLD and the kyphotic angle in aLBP patients. The interventions could have a regulating effect on the impaired neuromotor control of the lumbar muscles. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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9 pages, 1850 KiB

Open AccessArticle

Investigation of Reaction Forces in the Thoracolumbar Fascia during Different Activities: A Mechanistic Numerical Study

by Khaled El-Monajjed and Mark Driscoll

Life 2021, 11(8), 779; https://doi.org/10.3390/life11080779 - 1 Aug 2021

Cited by 7 | Viewed by 3079

Abstract

Spinal instability remains a complex phenomenon to study while the cause of low back pain continues to challenge researchers. The role of fascia in biomechanics adds to the complexity of spine biomechanics but offers a new window from which to investigate our spines. [...] Read more.

Spinal instability remains a complex phenomenon to study while the cause of low back pain continues to challenge researchers. The role of fascia in biomechanics adds to the complexity of spine biomechanics but offers a new window from which to investigate our spines. Specifically, the thoracolumbar fascia may have an important role in spine biomechanics, and thus the purpose of this study was to access the mechanical influence of the thoracolumbar fascia on spine biomechanics during different simulated activities. A numerical finite element model of the lumbar spine inclusive of the intra-abdominal and intra-muscular regions as well as the thoracolumbar fascia was constructed and validated. Four different loading scenarios were simulated while deformation, stress, pressure, and reaction forces between the thoracolumbar fascia and spine were measured. Model validation was accomplished through comparison to in vivo and ex vivo published studies. Force transmission between the thoracolumbar fascia and the spine increased 40% comparing kyphotic and squatting lifting patterns. Further, the importance of reciprocating paraspinal and intra-abdominal pressures was demonstrated. It was also found that tension in the thoracolumbar fascia remains even in a simulated prone position. This numerical analysis allowed for an objective interpretation of the loads conveyed through the thoracolumbar fascia in different positional or lifting scenarios. Based on validation studies, it would appear to be a viable experimental platform from which insight can be derived. The loads in the thoracolumbar fascia vary considerably based on simulated tasks and are linked to the pressures in the paraspinal and intra-abdominal regions. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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16 pages, 3341 KiB

Open AccessArticle

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 Kazuyuki Sugawara, Mitsuhiro Aoki and Masahiro Yamane

Life 2021, 11(7), 688; https://doi.org/10.3390/life11070688 - 14 Jul 2021

Cited by 1 | Viewed by 9758

Abstract

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 [...] Read more.

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. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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16 pages, 3908 KiB

Open AccessArticle

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

by Walter Magerl, Emanuela Thalacker, Simon Vogel, Robert Schleip, Thomas Klein, Rolf-Detlef Treede and Andreas Schilder

Life 2021, 11(5), 370; https://doi.org/10.3390/life11050370 - 21 Apr 2021

Cited by 5 | Viewed by 2606

Abstract

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 [...] Read more.

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. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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8 pages, 1855 KiB

Open AccessArticle

Use of Reflective Tape to Detect Ultrasound Transducer Movement: A Validation Study

by Lisa Mohr, Lutz Vogt and Jan Wilke

Life 2021, 11(2), 104; https://doi.org/10.3390/life11020104 - 30 Jan 2021

Cited by 5 | Viewed by 2527

Abstract

During dynamic ultrasound assessments, unintended transducer movement over the skin needs to be prevented as it may bias the results. The present study investigated the validity of two methods quantifying transducer motion. An ultrasound transducer was moved on a pre-specified 3 cm distance [...] Read more.

During dynamic ultrasound assessments, unintended transducer movement over the skin needs to be prevented as it may bias the results. The present study investigated the validity of two methods quantifying transducer motion. An ultrasound transducer was moved on a pre-specified 3 cm distance over the semitendinosus muscle of eleven adults (35.8 ± 9.8 years), stopping briefly at intervals of 0.5 cm. Transducer motion was quantified (1) measuring the 2-D displacement of the shadow produced by reflective tape (RT) attached to the skin and (2) using a marker-based, three-dimensional movement analysis system (MAS). Differences between methods were detected with Wilcoxon tests; associations were checked by means of intraclass correlation coefficients (ICC 3.1) and Bland–Altman plots. Values for RT (r = 0.57, p < 0.001) and MAS (r = 0.19, p = 0.002) were significantly higher than true distances (TD). Strong correlations were found between RT and TD (ICC: 0.98, p < 0.001), MAS and TD (ICC: 0.95, p < 0.001), and MAS and RT (ICC: 0.97, p < 0.001). Bland–Altman plots showed narrow limits of agreement for both RT (−0.49 to 0.13 cm) and MAS (−0.49 to 0.34 cm) versus TD. RT and MAS are valid methods to quantify US transducer movement. In view of its low costs and complexity, RT can particularly be recommended for application in research and clinical practice. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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10 pages, 807 KiB

Open AccessArticle

Flexor Digitorum Brevis Muscle Dry Needling Changes Surface and Plantar Pressures: A Pre-Post Study

by Eva María Martínez-Jiménez, Marta Elena Losa-Iglesias, Marta San Antolín-Gil, Daniel López-López, Carlos Romero-Morales, María Benito-de-Pedro, César Calvo-Lobo and Ricardo Becerro-de-Bengoa-Vallejo

Life 2021, 11(1), 48; https://doi.org/10.3390/life11010048 - 13 Jan 2021

Cited by 6 | Viewed by 3498

Abstract

Background: The effects of the dry needling technique and pain reduction have been demonstrated in numerous quality studies. However, the mechanical effects of dry needling are largely unknown. Methods: A total of 18 subjects with flexor digitorum brevis muscle myofascial trigger point were [...] Read more.

Background: The effects of the dry needling technique and pain reduction have been demonstrated in numerous quality studies. However, the mechanical effects of dry needling are largely unknown. Methods: A total of 18 subjects with flexor digitorum brevis muscle myofascial trigger point were evaluated pre- and post-deep dry needling. We measured static footprint variables in a pre–post study. Main findings: We found differences in rearfoot maximum pressure (119.22–111.63 KPa; p = 0.025), midfoot maximum pressure (13.68–17.26 KPa; p = 0.077), midfoot medium pressure (4.75–6.24 KPa; p = 0.035) and forefoot surface (86.58–81.75 cm²; p = 0.020). All variables with significant differences decrease, with the exception of forefoot surface which showed an increase. Conclusions: After flexor digitorum brevis muscle dry needling, midfoot plantar pressures (maximum and medium) and forefoot surface were increased, and rearfoot maximum pressure was decreased. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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Review

Jump to: Research, Other

19 pages, 3705 KiB

Open AccessReview

Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors

by Larisa Ryskalin, Gabriele Morucci, Gianfranco Natale, Paola Soldani and Marco Gesi

Life 2022, 12(5), 743; https://doi.org/10.3390/life12050743 - 17 May 2022

Cited by 23 | Viewed by 6828

Abstract

In recent years, extracorporeal shock wave therapy (ESWT) has received increasing attention for its potential beneficial effects on various bone and soft-tissue pathologies, yielding promising outcomes for pain relief and functional recovery. In fact, ESWT has emerged as an alternative, non-invasive, and safe [...] Read more.

In recent years, extracorporeal shock wave therapy (ESWT) has received increasing attention for its potential beneficial effects on various bone and soft-tissue pathologies, yielding promising outcomes for pain relief and functional recovery. In fact, ESWT has emerged as an alternative, non-invasive, and safe treatment for the management of numerous musculoskeletal disorders, including myofascial pain syndrome (MPS). In particular, MPS is a common chronic painful condition, accounting for the largest proportion of patients affected by musculoskeletal problems. Remarkably, sensory innervation and nociceptors of the fascial system are emerging to play a pivotal role as pain generators in MPS. At the same time, increasing evidence demonstrates that application of ESWT results in selective loss of sensory unmyelinated nerve fibers, thereby inducing long-lasting analgesia. The findings discussed in the present review are supposed to add novel viewpoints that may further enrich our knowledge on the complex interactions occurring between disorders of the deep fascia including changes in innervation, sensitization of fascial nociceptors, the pathophysiology of chronic musculoskeletal pain of MPS, and EWST-induced analgesia. Moreover, gaining mechanistic insights into the molecular mechanisms of pain-alleviating effects of ESWT may broaden the fields of shock waves clinical practice far beyond the musculoskeletal system or its original application for lithotripsy. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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13 pages, 425 KiB

Open AccessReview

A Role for Superficial Heat Therapy in the Management of Non-Specific, Mild-to-Moderate Low Back Pain in Current Clinical Practice: A Narrative Review

by Jürgen Freiwald, Alberto Magni, Pablo Fanlo-Mazas, Ema Paulino, Luís Sequeira de Medeiros, Biagio Moretti, Robert Schleip and Giuseppe Solarino

Life 2021, 11(8), 780; https://doi.org/10.3390/life11080780 - 2 Aug 2021

Cited by 17 | Viewed by 16050

Abstract

Low back pain (LBP) is a leading cause of disability. It significantly impacts the patient’s quality of life, limits their daily living activities, and reduces their work productivity. To reduce the burden of LBP, several pharmacological and non-pharmacological treatment options are available. This [...] Read more.

Low back pain (LBP) is a leading cause of disability. It significantly impacts the patient’s quality of life, limits their daily living activities, and reduces their work productivity. To reduce the burden of LBP, several pharmacological and non-pharmacological treatment options are available. This review summarizes the role of superficial heat therapy in the management of non-specific mild-to-moderate LBP. First, we outline the common causes of LBP, then discuss the general mechanisms of heat therapy on (LBP), and finally review the published evidence regarding the impact of superficial heat therapy in patients with acute or chronic non-specific LBP. This review demonstrates that continuous, low-level heat therapy provides pain relief, improves muscular strength, and increases flexibility. Therefore, this effective, safe, easy-to-use, and cost-effective non-pharmacological pain relief option is relevant for the management of non-specific mild or moderate low back pain in current clinical practice. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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13 pages, 616 KiB

Open AccessReview

Does the Calcaneus Serve as Hypomochlion within the Lower Limb by a Myofascial Connection?—A Systematic Review

by Luise Weinrich, Melissa Paraskevaidis, Robert Schleip, Alison N. Agres and Serafeim Tsitsilonis

Life 2021, 11(8), 745; https://doi.org/10.3390/life11080745 - 26 Jul 2021

Viewed by 2420

Abstract

(1) Background: Clinical approaches have depicted interconnectivity between the Achilles tendon and the plantar fascia. This concept has been applied in rehabilitation, prevention, and in conservative management plans, yet potential anatomical and histological connection is not fully understood. (2) Objective: To explore the [...] Read more.

(1) Background: Clinical approaches have depicted interconnectivity between the Achilles tendon and the plantar fascia. This concept has been applied in rehabilitation, prevention, and in conservative management plans, yet potential anatomical and histological connection is not fully understood. (2) Objective: To explore the possible explanation that the calcaneus acts as a hypomochlion. (3) Methods: 2 databases (Pubmed and Livivo) were searched and studies, including those that examined the relationship of the calcaneus to the Achilles tendon and plantar fascia and its biomechanical role. The included studies highlighted either the anatomical, histological, or biomechanical aspect of the lower limb. (4) Results: Seventeen studies were included. Some studies depicted an anatomical connection that slowly declines with age. Others mention a histological similarity and continuity via the paratenon, while a few papers have brought forward mechanical reasoning. (5) Conclusion: The concept of the calcaneus acting as a fulcrum in the lower limb can partially be supported by anatomical, histological, and biomechanical concepts. Despite the plethora of research, a comprehensive understanding is yet to be investigated. Further research exploring the precise interaction is necessary. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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11 pages, 1396 KiB

Open AccessReview

Fascia Mobility, Proprioception, and Myofascial Pain

by Helene M. Langevin

Life 2021, 11(7), 668; https://doi.org/10.3390/life11070668 - 8 Jul 2021

Cited by 42 | Viewed by 15539

Abstract

The network of fasciae is an important part of the musculoskeletal system that is often overlooked. Fascia mobility, especially along shear planes separating muscles, is critical for musculoskeletal function and may play an important, but little studied, role in proprioception. Fasciae, especially the [...] Read more.

The network of fasciae is an important part of the musculoskeletal system that is often overlooked. Fascia mobility, especially along shear planes separating muscles, is critical for musculoskeletal function and may play an important, but little studied, role in proprioception. Fasciae, especially the deep epimysium and aponeuroses, have recently been recognized as highly innervated with small diameter fibers that can transmit nociceptive signals, especially in the presence of inflammation. Patients with connective tissue hyper- and hypo-mobility disorders suffer in large number from musculoskeletal pain, and many have abnormal proprioception. The relationships among fascia mobility, proprioception, and myofascial pain are largely unstudied, but a better understanding of these areas could result in improved care for many patients with musculoskeletal pain. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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Other

Jump to: Research, Review

41 pages, 2755 KiB

Open AccessSystematic Review

The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review

by Mélanie Roch, Nathaly Gaudreault, Marie-Pierre Cyr, Gabriel Venne, Nathalie J. Bureau and Mélanie Morin

Life 2021, 11(9), 900; https://doi.org/10.3390/life11090900 - 30 Aug 2021

Cited by 20 | Viewed by 11614

Abstract

The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize [...] Read more.

The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae. Full article

(This article belongs to the Special Issue Fasciae from a Molecular and Biomechanical Perspective)

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