Fascial plane blocks: from microanatomy to clinical applications.

PURPOSE OF REVIEW: In the last 20 years, advancements in the understanding of fasciae have significantly transformed anaesthesia and surgery. Fascial plane blocks (FPBs) have gained popularity due to their validated safety profile and relative ease. They are used in various clinical settings for surgical and nonsurgical indications. Growing evidence suggests a link between the microscopic anatomy of fasciae and their mechanism of action. As a result, knowledge of these aspects is urgently needed to better optimise pain management. The purpose of this review is to summarise the different microscopic aspects of deep/muscular fascia to expand our understanding in the performance of FPBs. RECENT FINDINGS: There is ample evidence to support the role of FPBs in pain management. However, the exact mechanism of action remains unclear. Fasciae are composed of various structural elements and display complex anatomical characteristics at the microscopic level. They include various cell types embedded within an extracellular matrix abundant in collagens and hyaluronan. Increasingly, numerous studies demonstrated their innervation that contributes to their sensory functions and their role in proprioception, motor coordination and pain perception. Lastly, the diversity of the cellular and extracellular matrix, with their viscoelastic properties, is essential to understanding the FPBs' mechanism of action. SUMMARY: Physicians must be aware of the role of fascial microscopic anatomy and better understand their properties to perform FPBs in a conscious manner and enhance pain management.

Ultrasound Imaging of Ankle Retinacula: A Comprehensive Review.

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.

Optimizing healthcare in space: the role of ultrasound imaging in medical conditions.

In the context of long-distance space travel, managing medical conditions presents unique challenges due to communication delays. Consequently, onboard physicians must possess proficiency in diagnostic tools such as ultrasound, which has demonstrated its efficacy in the Space. However, there is a notable lack of comprehensive discussion regarding its effectiveness in handling medical scenarios in the Space. This bibliometric and systematic review aims to provide an updated analysis of the evidence supporting the role of ultrasound imaging in diagnosing medical conditions within microgravity environments.

Ultrasound Imaging of Thoracolumbar Fascia: A Systematic Review.

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.

Chondrotoxicity of Intra-Articular Injection Treatment: A Scoping Review.

The purpose of this scoping review was to identify possible chondrotoxic effects caused by drugs usually used for intra-articular injections. PubMed, Scopus, Web of Science and Cochrane were searched. Inclusion criteria required randomized controlled trials written in English that evaluate the toxic effect that damages the cartilage. The literature search resulted in 185 unique articles. 133 full-text articles were screened for inclusion, of which 65 were included. Corticosteroids, with the exception of triamcinolone, along with local anaesthetics, potentially excluding ropivacaine and liposomal bupivacaine, and nonsteroidal anti-inflammatory drugs, exhibited insufficient safety profiles to warrant casual use in clinical settings. Hyaluronic acid, on the other hand, appears to demonstrate safety while also mitigating risks associated with concurrent compounds, thereby facilitating therapeutic combinations. Additionally, there remains a paucity of data regarding platelet-rich plasma, necessitating further evaluation of its potential efficacy and safety. Overall, it seems that results are significantly influenced by the dosage and frequency of injections administered, observed in both human and animal studies.

Quantity and Distribution of Muscle Spindles in Animal and Human Muscles.

Muscle spindles have unique anatomical characteristics that can be directly affected by the surrounding tissues under physiological and pathological conditions. Understanding their spatial distribution and density in different muscles is imperative to unravel the complexity of motor function. In the present study, the distribution and number/density of muscle spindles in human and animal muscles were reviewed. We identified 56 articles focusing on muscle spindle distribution; 13 articles focused on human muscles and 43 focused on animal muscles. The results demonstrate that spindles are located at the nerve entry points and along distributed vessels and they relate to the intramuscular connective tissue. Muscles' deep layers and middle segments are the main topographic distribution areas. Eleven articles on humans and thirty-three articles on animals (totaling forty-four articles) focusing on muscle spindle quantity and density were identified. Hand and head muscles, such as the pronator teres/medial pterygoid muscle/masseter/flexor digitorum, were most commonly studied in the human studies. For animals, whole-body musculature was studied. The present study summarized the spindle quantity in 77 human and 189 animal muscles. We identified well-studied muscles and any as-yet unfound data. The current data fail to clarify the relationship between quantity/density and muscle characteristics. The intricate distribution of the muscle spindles and their density and quantity throughout the body present some unique patterns or correlations, according to the current data. However, it remains unclear whether muscles with fine motor control have more muscle spindles since the study standards are inconsistent and data on numerous muscles are missing. This study provides a comprehensive and exhaustive approach for clinicians and researchers to determine muscle spindle status.

Ultrasound Imaging in Football Players with Previous Multiple Ankle Sprains: Keeping a Close Eye on Superior Ankle Retinaculum.

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.

Ultrasound imaging and Fascial Manipulation®: 'Adding a twist' on the ankle retinacula.

BACKGROUND: Retinacula of the ankle are thickening of the deep fascia of the leg (crural fascia) and foot i.e. inseparable structures. Recent studies report their crucial role in functional stability and proprioception of the ankle. CASE PRESENTATION: A 38-yr-old Caucasian man - with a history of lateral malleolus fracture 12 years ago, obesity and right ankle osteoarthritis - was referred to a physiatrist for a right ankle pain that had significantly worsened over the last year. During walking, the patient experienced stinging pain in the area of tibialis anterior and peroneus tertius muscles, and the superior extensor retinaculum. Magnetic resonance imaging and ultrasonography showed clear thicknening (2.05 mm) of the oblique superomedial band of the inferior extensor retinaculum. Sonopalpation was performed to precisely evaluate/confirm the site of maximum pain. Foot function index (FFI) score was 42. RESULTS: Subsequently, the patient was prescribed fascial manipulation, and he had clinical improvement after the first session (FFI: 21). At 1-month follow-up, the patient was still asymptomatic without any functional limitation (FFI: 24). US imaging confirmed the decreased thickness of the oblique superomedial band of the extensor retinaculum (1.35 mm). CONCLUSION: Fascial Manipulation® appears to be a useful tool to reduce thickness, stiffness, and pain in this case as displayed by the ultrasound Imaging.

Myofascial junction: Emerging insights into the connection between deep/muscular fascia and muscle.

Muscles and fasciae are mutually connected and are influenced by force transmission. However, the anatomical connectivity and histological features of these structures remain unclear. The aim of this study was to assess the evidence for connection between muscles and deep/muscular fasciae. We assessed this relationship in different topographical regions of human cadavers and in mice. The results showed that myofascial junctions (MFJ) were made up of collagen I immune-positive structures occupying an average area of 5.11 ± 0.81 µm2, distributed in discrete regions at the interface between muscle and fascia with an average density of 9.7 ± 2.51 MFJ/mm and an average inclination angle of 35.25 ± 1.52°. These specialized structures also showed collagen III and HA immunopositivity and the presence of elastic fibers. The human myofascial junction can be visualized, opening emerging insights into the connection between deep/muscular fascia and muscle.

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Ankle/Foot.

ABSTRACT: In this dynamic scanning protocol, ultrasound examination of the ankle is described using various maneuvers to assess different conditions. Real-time patient examination and scanning videos are used for better simulation of daily clinical practice. The protocol is prepared by several/international experts in the field of musculoskeletal ultrasound and within the umbrella of European Musculoskeletal Ultrasound Study Group in Physical and Rehabilitation Medicine/Ultrasound Study Group of the International Society of Physical and Rehabilitation Medicine.

The Effect of Mechanical Stress on Hyaluronan Fragments' Inflammatory Cascade: Clinical Implications.

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.

Effectiveness of Deep Cervical Fascial Manipulation® and Sequential Yoga Poses on Pain and Function in Individuals with Mechanical Neck Pain: A Randomised Controlled Trial.

BACKGROUND: This study aimed to investigate the effect of fascial manipulation (FM) of the deep cervical fascia (DCF) and sequential yoga poses (SYP) on pain and function in individuals with mechanical neck pain (MNP). METHOD: Following the predefined criteria, ninety-nine individuals with MNP were recruited, randomised, and assigned to either the intervention group (IG) (n = 51) or the control group (CG) (n = 48). Individuals in the IG received FM (4 sessions in 4 weeks) and the home-based SYP (4 weeks). The CG participants received their usual care (cervical mobilisation and thoracic manipulation (4 sessions in 4 weeks) along with unsupervised therapeutic exercises (4 weeks). The participants underwent baseline and weekly follow-up measurements of pain using a numerical pain rating scale (NPRS) and elbow extension range of motion (EEROM) during the upper limb neurodynamic test 1 (ULNT1). The baseline and the fourth session follow-up measurements of the patient-specific functional scale (PSFS) and fear-avoidance behavior Questionnaire (FABQ) were also taken. RESULTS: A repeated-measures ANOVA was performed. There were statistically significant differences between the IG and CG on the NPRS third and fourth sessions, with mean differences (MD) of -1.009 (p < 0.05) and -1.701 (p < 0.001), respectively. Regarding EEROM, there was a 20.120° difference (p < 0.001) in the fourth session between the groups. The MD in FABQ was -5.036 (p < 0.001), but there were no significant differences in PSFS between the groups during the follow-up. CONCLUSION: FM and SYP can aid in reducing pain and fear-avoidance behaviour and improve the function and extensibility of the upper quarter region.

A New Player in the Mechanobiology of Deep Fascia: Yes-Associated Protein (YAP).

Recent studies have demonstrated that fascial fibroblasts are susceptible to mechanical stimuli, leading to the remodeling of the extracellular matrix (ECM). Moreover, the extensive literature on Yes-associated protein (YAP) has shown its role in cell mechanics, linking cell properties, such as shape, adhesion, and size, to the expression of specific genes. The aim of this study was to investigate the presence of YAP in deep fascia and its activation after a mechanical stimulus was induced via a focal extracorporeal shockwave (fESW) treatment. Thoracolumbar fascia (TLF) samples were collected from eight patients (age: 30-70 years; four males and four females) who had undergone spine elective surgical procedures at the Orthopedic Clinic of University of Padova. YAP was measured in both tissue and TLF-derived fibroblasts through immunoblotting. COL1A1 and HABP2 gene expression were also evaluated in fibroblasts 2, 24, and 48 h after the fESW treatment. YAP was expressed in all the examined tissues. The ratio between the active/inactive forms (YAP/p-YAP) of the protein significantly increased in fascial fibroblasts after mechanical stimulation compared to untreated cells (p = 0.0022). Furthermore, COL1A1 and HABP2 gene expression levels were increased upon treatment. These findings demonstrate that YAP is expressed in the deep fascia of the thoracolumbar region, suggesting its involvement in fascial mechanotransduction processes, remodeling, regeneration, and fibrogenesis. This study indicates, for the first time, that YAP is a "new player" in the mechanobiology of deep fascia.

Hearing and Seeing Nerve/Tendon Snapping: A Systematic Review on Dynamic Ultrasound Examination.

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 Ground State of Epitaxial Germanene on Ag(111).

Two-dimensional (2D) honeycomb lattices beyond graphene, such as germanene, appear very promising due to their outstanding electronic properties, such as the quantum spin Hall effects. While there have been many claims of germanene monolayers up to now, no experimental evidence of a honeycomb structure has been provided up to now for these grown monolayers. Using scanning tunneling microscopy (STM), surface X-ray diffraction (SXRD), and density functional theory, we have elucidated the Ge-induced (109×109)R±24.5° reconstruction on Ag(111). We demonstrate that a powerful algorithm combining SXRD with STM allows us to solve a giant surface reconstruction with more than a hundred atoms per unit cell. Its extensive unit cell indeed consists of 98 2-fold or 3-fold coordinated Ge atoms, forming a periodic arrangement of pentagons, hexagons, and heptagons, with the inclusion of six dispersed Ag atoms. By analogy, we show that the (77×77)R±19.1° reconstruction obtained by segregation of Ge through an epitaxial Ag/Ge(111) film possesses a similar structure, i.e., Ge pentagons/hexagons/heptagons with a few Ag atoms. Such an organization is more stable than that of pure Ge monolayers and can be assigned to the ground state of epitaxial germanene.

Sonographic guide for botulinum toxin injections for chronic migraine headache: EURO-MUSCULUS/USPRM approach.

Application of botulinum toxin A (BoNT-A) into the muscles of the head and neck area has become a widespread and reliable treatment modality for chronic migraine. The mechanism of action for BoNT-A is the inhibition of acetylcholine and local nociceptive peptide release at the terminal nerve endings. Cranial sutures have the highest concentration of nociceptive structures; therefore BoNT-A injection into the suture lines - as opposed to head and neck muscles - has been proposed for the treatment of chronic migraine. Nerve endings in sutures rapidly absorb BoNT-A and transfer it across the afferent nerve fibers in dura mater via orthodromic and antidromic transmission. In this article, ultrasound-guided BoNT-A application around the cranial sutures will be illustrated. It is noteworthy that suture injections would be safer and more efficient when applied with such guidance.

Crural and Plantar Fasciae Changes in Chronic Charcot Diabetic Foot: A Cross-Sectional Ultrasound Imaging Study-An Evidence of Fascial Continuity.

Crural fascia (CF) and plantar fascia (PF) are biomechanically crucial in the gait and in the proprioception, particularly in the propulsion phase of the foot during the gait cycle and in the dissipation of forces during weight-bearing activities. Recent studies have revealed an association between increases in PF thickness and diabetes. The purpose of this study was to measure and compare by ultrasound (US) imaging the thickness of the CF and PF at different regions/levels in chronic Charcot diabetic foot patients (group 1) and in healthy volunteers (group 2). A cross-sectional study was performed using US imaging to measure the CF with Pirri et al.'s protocol and PF with a new protocol in a sample of 31 subjects (15 patients and 16 healthy participants). The findings for CF and PF revealed statistically significant differences in the poster region of CF (Post 1: group 1 vs. group 2: p = 0.03; Post 2: group 1 vs. group 2: p = 0.03) and in PF at two different levels (PF level 1: group 1 vs. group 2: p < 0.0001; PF level 2: group 1 vs. group 2: p < 0.0001). These findings suggest that chronic Charcot diabetic foot patients have CF and PF thicker compared to healthy volunteers. The US examination suggests that fascial thicknesses behavior in these patients points out altered fascial remodeling due to diabetes pathology and biomechanical changes.

Detection of Mast Cells in Human Superficial Fascia.

The recent findings showed that the superficial fascia is a fibrous layer in the middle of hypodermis, richly innervated and vascularized, and more complex than so far demonstrated. This study showed the presence of mast cells in the superficial fascia of the human abdomen wall of three adult volunteer patients (mean age 42 ± 4 years; 2 females, 1 male), by Toluidine Blue and Safranin-O stains and Transmission Electron Microscopy. Mast cells are distributed among the collagen bundles and the elastic fibers, near the vessels and close to the nerves supplying the tissue, with an average density of 20.4 ± 9.4/mm2. The demonstration of the presence of mast cells in the human superficial fascia highlights the possible involvement of the tissue in the inflammatory process, and in tissue healing and regeneration processes. A clear knowledge of this anatomical structure of the hypodermis is fundamental for a good comprehension of some fascial dysfunctions and for a better-targeted clinical practice.

Sono-palpation and sono-Tinel in musculoskeletal ultrasound examination: use all "sono-senses". A systematic review.

Flexibility and dynamic perspective of ultrasound imaging allow for a targeted/focused examination, yielding extra find-ings. Sonopalpation - also referred as sono-Tinel for nerves - is one of those particular features of ultrasound examination whereby the ultrasound probe is actively 'manipulated'. It is paramount to ascertain the painful structure/pathology during the evaluation of a patient and it is not possible with other imaging techniques other than ultrasonography. In this aspect, the cur-rent review aims to provide an analysis of the literature regarding the use of sonopalpation for clinical and research purposes respectively.