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Fascial manipulation

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DOI: 10.1016/B978-0-7020-3425-1.00007-6

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Fascial Anatomy in Manual Therapy:
Introducing a New Biomechanical Julie Ann Day, PT
Model
Centro Socio Sanitario dei Colli, Physiotherapy, Padova, Italy

ABSTRACT detailed studies pertaining to specific areas suggested.17 Deep fascia is a well-vascular-
Background and Purpose: Fascial of fascia are important, they do not pro- ized tissue often employed for plastic sur-
anatomy studies are influencing our under- vide a vision of the human fascial system as gery flaps,18 and it responds to mechanical
standing of musculoskeletal dysfunctions. an interrelated, tensional network of con- traction induced by muscular activity in dif-
However, evidenced-based models for nective tissue. A few authors consider its ferent regions.19 It has an ectoskeletal role
manual therapists working with move- 3-dimensional (3D) continuity8-10 but these and can potentially store mechanical energy
ment dysfunction and pain are still devel- holistic models do not always provide spe- and distribute it in a uniform manner for
oping. This review presents a synthesis of cific indications for treatment. A functional harmonious movement. The mechanical
one biomechanical model and discusses model for the entire human fascial system properties of the fascial extracellular matrix
underlying hypotheses in reference to some that correlates dysfunctional movement itself can be altered by external mechanical
current trends in musculoskeletal research. and pain is in its infancy with regards to stimuli that stimulate protein turnover and
Method: The author conducted principally evidence-based investigations and studies. fibroblastic activity.20,21 These characteris-
a search of the health sciences literature This paper will examine a 3D bio- tics and the reported abundant innervation
available on PubMed for the years 1995 to mechanical model for the human fascial of deep fascia indicate that it could have
2011, and consulted published texts con- system that takes into account movement the capacity to perceive mechanosensitive
cerning this model. Findings: Some of the limitation, weakness, and pain distribution signals.22
hypotheses proposed by this model have during the analysis of musculoskeletal dys- The correct embryonic development
been investigated via anatomical dissec- functions. While the interaction between of the musculoskeletal system requires the
tions that have addressed the connections all fascial layers is contemplated within this coordinated morphogenesis of muscle, mus-
between deep fascia and muscles, the his- model, this paper will focus on the part that cular fascia, tendon, and skeleton. In the
tology of deep fascia, and its biomechanical addresses the deep fascia, which appears to embryo, muscle tissue and its fascia form as
characteristics. These dissections have led to be principally implicated in musculoskeletal a differentiation of the paraxial mesoderm
new anatomical findings. This model may activity. that divides into somites on either side of
also present new challenges for research in The model is the result of 35 years of the neural tube and notochord. The carti-
fields such as peripheral motor control and study and clinical practice by Luigi Stecco, lage and bone of the vertebral column and
proprioception. Clinical Relevance: This an Italian physiotherapist.11,12 Developed ribs develops from the ventral part of the
information could introduce new perspec- specifically for manual therapists working somite, the sclerotome, whereas the dorsal
tives for clinicians involved in the manual with movement dysfunction and pain, the part of the somite, the dermomyotome,
treatment of musculoskeletal dysfunctions. chief focus of this model is the relationship gives rise to the overlying dermis of the
between muscles, deep fascia, and its compo- back and to the skeletal muscles of the body
Key Words: deep fascia, fascial anatomy, nents (epimysium, perimysium, and endo- and limbs.23 It is now known that muscu-
manual therapy, myofascial unit mysium). More recently, this work has been lar connective tissue is critical for the form
supported by a series of extensive anatomi- and function of the musculoskeletal system,
INTRODUCTION cal dissections of unembalmed cadavers. muscle development, and muscle regenera-
One tissue gaining increasing attention Histological, biomechanical, and functional tion in general. For example, in mammals,
in manual therapy is the connective tissue studies have also been undertaken to verify fetal connective tissue fibroblasts express the
known as fascia. While there is still on- some of the underlying hypotheses concern- transcription factor Tcf4, which is essential
going discussion about how to categorize ing the architecture of the fascia, its innerva- for proper muscle development. Studies
and name the various fascial layers1 it is, tion, its relationship with muscle fibers, and indicate that Tcf4-expressing cells actually
nevertheless, possible to distinguish 3 differ- the possible mechanisms of action of the establish a pre-pattern in the limb meso-
ent types of human fasciae, namely, superfi- manual technique itself. derm that determines the sites of myogenic
cial, deep, and visceral fascia. Each of these differentiation, thereby shaping the basic
has its own anatomical and biomechanical Deep Muscular Fascia pattern of vertebrate limb muscles.24 Other
characteristics and specific relationships to Studies of deep muscular fascia sup- studies demonstrate that the absence of
surrounding structures. Most studies con- port its role in epimuscular myofascial specific transcription factors in muscle con-
cerning fasciae focus on the anatomy and force transmission13,14 although the degree nective tissue disrupts muscle and tendon
pathology of specific areas, such as the to which it is involved in in-vivo muscle patterning in limbs, and that to understand
thoracolumbar fascia,2 abdominal fascia,3 movements is still not clear.15 Deep fascia the etiology of diseases affecting soft tissue
the Achilles tendon enthesis organ,4 plan- is implicated in deep venous return16 and formation a focus on connective tissue is
tar fascia,5,6 and the iliotibial tract.7 While its possible role in proprioception has been required.25

68 Orthopaedic Practice Vol. 23;2:11

 As muscle cells differentiate within Myofascial Unit Center of coordination
the mesoderm, each single muscle fiber is Six myofascial units (MFU) are consid- Within the deep muscular fascia of each
progressively surrounded by endomysium, ered to govern the movement of the body MFU, a specific small area called the center
groups of fibers by perimysium, whole mus- segments on the 3 spatial planes. An MFU of coordination (CC) is identified. A CC is
cles are enclosed by epimysium and deep is described as a functional unit composed defined as a focal point for vectorial forces
fascia encloses groups of muscles. The con- of motor units innervating monoarticular produced by monoarticular and biarticular
nective tissue that accompanies the develop- and biarticular muscle fibers, the joint that muscle fibers of an MFU acting on a body
ment of muscle fibers and nerve components they move in one direction on one plane, segment during a precise movement and are
facilitates the different innervations and the deep fascia that unites these fibers, and often situated within the deep fascia overly-
functions of the muscle fibers within each the nerve components involved in this ing a muscle belly. In reference to the MFU
muscle belly. Furthermore, the fascia unites movement. One example is the MFU for for knee extension mentioned previously,
all of the fibers of a single motor unit that knee extension where fibers from medial the CC is located between the vastus latera-
are often distributed throughout a muscle and lateral vasti are the monoarticular com- lis and rectus femoris, halfway on the thigh
in non-adjacent positions, allowing for syn- ponents and fibers from the rectus femoris (see Figure 2).
ergy between recruited fibers and separation provide the biarticular component (Figure Through clinical observation and stud-
from nonrecruited fibers. Fascia can there- 2). Myofascial units are considered to be the ies comparing acupuncture points, myo-
fore adapt to variations in form and volume functional building blocks of the myofascial fascial trigger points, and the sum of the
of each muscle according to muscular con- system. In this model, it is postulated that vectorial forces involved in the execution
traction and intramuscular modifications deep fascia is a potentially active component of each segmental movement, Stecco12 (pp 325-
induced by joint movement. in movement coordination and peripheral 326)
noted that impeded gliding of the deep
This fascial-based organization allows motor control and that, due to its innerva- fascia commonly occurs at these intersect-
each single muscle fiber to slide somewhat tion, the fascial component of each MFU ing points of tension. The term center of
independently from its adjacent fibers. In is a possible source of directional afferents coordination is used to infer the possible
addition, deep muscular fascia has signifi- that could contribute to proprioceptive involvement of deep fascia in monitoring
cant characteristics that allow it to perceive information. movement of a related segment via its con-
muscle fiber tension. Many muscle fibers nections to muscle spindles, Golgi tendon
attach directly onto fascia,26 and it also con- organs, and other mechanoreceptors.
nects with muscle fibers via intermuscular
septa, fascial compartments, and tendon
sheaths. Histological studies of deep fascia
in the limbs show that it consists of elas-
tic fibers and undulated collagen fibers
arranged in layers. Each collagen layer is
aligned in a different direction and this
permits a certain degree of stretch as well
as a capacity to recoil.27 Fascia can also be
tensioned, as it connects with bone through
periosteum.
Even though this strict relationship
between muscle fibers and their surround-
ing fascia is characteristic of all muscles,
the role of the fascia in musculoskeletal
function has only received attention in the
last decade. In fact, the number of studies
about how muscles work is still significantly
higher than studies investigating the pos-
sible functions of deep muscular fascia.

THE BIOMECHANICAL MODEL

In order to analyze the fascial system
more effectively, Stecco11(p 28) divides the
body into 14 functional segments: head,
neck, thorax, lumbar, pelvis, scapula,
humerus, elbow, carpus, digits, hip, knee,
ankle, and foot (Figure 1). Each functional Figure 1. Fourteen body segments. CP: Caput, CL: Collum, TH: Thorax, LU: Lumbar,
segment is comprised of a combination of PV: Pelvis, SC:Scapula, HU: Humerus, CU: Cubitus, CA: Carpus, DI :Digits, CX:
portions of muscles, their fascia, and the Coxa, GE: Genu, TA: Tarsus, PE: pes. Each segment comprises joint(s), portions of
joint components that move when these muscles that move the joint(s), the fascia surrounding these muscle fibers. Latin terms
muscle fibers contract. are used to distinguish these segments from simple joints.

Orthopaedic Practice Vol. 23;2:11 69

 is important for myofascial force transmis- limb or trunk, yet another part is tensioned
sion and coordinated movement. In almost directly by muscle fibers that insert onto it
every MFU, a number of monoarticular and indirectly by its insertions onto bone.
fibers insert onto the intermuscular septum The combination of the biarticular muscle
that separates two antagonist MFUs on the fibers found in each MFU and so-called
same plane. For example, in the MFU for myotendinous expansions (see Discussion
elbow extension, the monoarticular fibers section) forms the anatomical substratum
are situated in the lateral and medial heads of the myofascial sequences.
of triceps and the anconeus muscle, and they
collaborate with biarticular fibers from the Myofascial Spirals and Centers of Fusion
long head of triceps to move the elbow joint Stecco also identifies small areas located
into extension. The monoarticular compo- principally over the retinacula that might
nents stabilize the joint during movement monitor movements in intermediate direc-
while the biarticular components synchro- tions between two planes, as well as move-
nize movement between adjacent joints. In ments of adjacent segments in different
other words, the short vectors, created by directions.12 (p 208) These small areas are called
the monoarticular fibers, and the long vec- centers of fusion (CF) and combinations of
tors from the biarticular fibers allow for pre- these CF form myofascial spirals.
Figure 2. The MFU (Myofascial Unit) cision and stability of each segment during It is important to note here that studies
for knee extension comprises monoar- movement. The MFU for elbow extension have shown that retinacula are reinforced
ticular components (vastus lateralis VL, has its own antagonist myofascial unit that areas of the deep fascia itself, rather than
medialis: VM, and intermedius), and coordinates elbow flexion. When the elbow separate bands as commonly illustrated in
biarticular components (rectus femoris: extends, the monoarticular fibers from the topographical anatomy texts.28,29 Retinac-
RL). The CC (center of coordination) lateral and medial heads of triceps con- ula actually continue from one joint to the
for this MFU is situated midway on the tract and the intermuscular septum where next via oblique collagen fibers within the
thigh over the deep fascia between vastus they insert will be stretched. The brachialis deep fascia, creating macroscopically visible
lateralis and rectus femoris and the CP muscle inserts on the other side of this same spiral formations. Stecco postulates12 (p 213)
(center of perception) is located in the septum. It is an elbow flexor and the mono- that during complex movements, such as
anterior knee joint. articular component of the MFU for elbow walking or running, these spiral-form col-
flexion. This connection means that during lagen fibers would progressively wind and
Center of perception elbow extension brachialis is stretched a unwind, and the ensuing tensioning of
For each MFU, a circumscribed area little too, causing its stretch receptors to the retinacula could progressively activate,
around the joint is described. This is where fire. Thus, the deep fascia can be envisioned inactivate, and synchronize mechanore-
traction exerted during muscle fiber activ- as a component in agonist and antagonist
ity of this MFU is perceived on the joint activity.
capsule, tendons, and ligaments. This cir-
cumscribed area is called the center of per- Myofascial Sequences
ception (CP); and according to Stecco,11 (p Biarticular muscle fibers (part of each
23)
when any given MFU is malfunctioning, MFU) link unidirectional MFUs positioned
then pain is felt in its corresponding CP. For in a specific direction to form myofascial
example, in the MFU for knee extension the sequences.11 (p 98) This type of organization
CP is located in the anterior knee joint (see is said to guarantee the synchronization of
Figure 2). single MFUs in order to develop forceful
Any impeded gliding between collagen movements and to monitor upright posture
fibers within the deep fascia of an MFU in the 3 spatial planes.
is thought to cause anomalous tension, A single myofascial sequence coordi-
resulting in firing of afferents from embed- nates movement of several segments in
ded mechanoreceptors within the fascial one direction on one plane. Sequences on
component of the MFU. Subsequently, the same spatial plane (sagittal, frontal, or
disturbed motor unit recruitment could horizontal) can be considered as reciprocal
then produce incongruent joint movement, antagonists. This means that areas of altered
resulting in conflict, friction, inflammation fascia can potentially produce recogniz-
of periarticular soft tissues, and sensations able patterns of extended tension that can
of pain or joint instability over time. develop along the same sequence, or be dis-
tributed on the same plane between antago- Figure 3. Myofascial sequences on the
Fascial Mediation of Agonist-antagonist nist sequences (Figure 3). This is thought to sagittal plane (anterior, posterior) in the
Interaction be possible because a part of the deep fascia lower limb. The fibers of the indicated
This model also considers the interaction slides freely over the muscle fibers, thereby biarticular muscles connect adjacent seg-
between agonist and antagonist MFUs that transmitting tension along the length of the ments.

70 Orthopaedic Practice Vol. 23;2:11

ceptors located within these periarticular introduces a new paradigm to the current described in various regions such as the tho-
structures. understanding of musculoskeletal function. racolumbar fascia,40 the brachial fascia,41
It does find some resonance in studies fascia lata, crural fascia, and various retinac-
MANUAL METHOD BASED ON that examine motor unit activity, which are ula.42 While some of the nerve fibers found
THIS MODEL providing new understandings of move- in fascia are probably involved in local
A manual approach for treating the ment33 and muscle fatigue.34 Motor unit blood flow control due to their adrenergic
human fascial system, called the Fascial activity determines movement and differ- nature,43 others do appear to be propriocep-
Manipulation method, is based on the ent movements require varying degrees of tors. Encapsulated mechanoreceptors and
model described above. Once the initial contractile force. This force depends on the proprioceptors such as Pacini and Ruffini
obstacle of the new terminology is overcome, number of motor units recruited, muscle corpuscles and Golgi tendon organs are
and the main principles are understood, cli- fiber types, and motor neuron firing rates.35 embedded in deep muscular fascia, with
nicians apply this biomechanical model to (p 20)
While humans appear to have an infi- their connective tissue capsules in direct
interpret the spread of tensional compensa- nite number of combinations of motor-unit continuity with endomysium and perimy-
tions from one segment to another, and to recruitment and discharge rates that can be sium.44 This means that whenever a muscle
trace back to initial disturbances. A funda- used to vary muscle force, control strategies fiber contracts, it inevitably stretches the
mental concept for clinicians is the indica- have reduced these options substantially. fascia enclosing it and this may stimulate
tion to go beyond treating the site of pain These strategies include definite patterns in nearby embedded receptors.
(CP) and to trace back to its fascial origin the recruitment order of motor units and Interestingly, as mentioned before, the
in corresponding key areas (CC and/or CF). the use of discharge rate to grade muscle histological studies have shown that colla-
As treatment is usually at a distance from force, although motor-unit properties can gen fiber distribution within deep fascia is
the site of pain, or the inflamed area, this apparently adapt within limited ranges well organized and not irregular, as gener-
technique can be applied during the acute when challenged. Motor unit recruitment ally reported, and it does correspond to
phase of a dysfunction. is related to the mechanical function of precise motor directions. More specifically,
A systematic evaluative process of move- the muscles, although many factors such as in the limbs, two to 3 layers of parallel col-
ment using codified movement and palpa- mechanics, sensory feedback, and central lagen fiber bundles form the deep fascia
tory tests guides therapists in selecting the control can influence recruitment patterns.36 and adjacent layers are oriented in different
combination of fascial alterations to be The possible relationship between directions.45 The angle between the fibers of
treated. Changes in range of movement, alterations in fascia, pain, and motor unit adjacent layers of the crural fascia has been
pain, and/or muscle recruitment are veri- recruitment clearly warrants further stud- measured and was found to be approxi-
fied after treatment of each point.30 In other ies. Findings from studies of pain and mately 78.46 Loose connective tissue sepa-
words, therapists identify which CC and/ motor unit recruitment do suggest that rates each layer permitting the collagen
or CF are involved in any given dysfunc- pain induces reorganization in motor unit fiber layers to slide and to respond to ten-
tion of one or more MFUs. This method is recruitment. One study showed how injec- sion (Figure 4). The deep fascia of the trunk
applied in a wide variety of musculoskeletal tions of a saline solution into the infrapa- has quite a different histological structure,
dysfunctions, and treatment of segmental tellar pad caused anterior knee pain that as compared to limb fascia, as it is formed
or multisegmental problems is approached reduced the coordination of motor units of a single layer of undulated collagen fibers
through the analysis of chronological events between the medial and lateral vasti muscles adhering to the underlying muscles.47 One
involved in each individual case. as compared to subjects without knee pain.37 study of the pectoral fascia indicates how
The manual technique itself is directed In another study, the authors indicate how tensioning of a particular area of this fascia
towards the deep muscular fascia. Therapists pain induces a reorganization of motor unit
use their elbow, knuckle, or fingertips over recruitment strategy, involving changes in
the CC and/or CF, creating localized hyper- recruitment order and changes in the popu-
emia through deep friction. Deep friction lation of units recruited, favoring those
can apparently alter the ground substance with a slightly different force direction.38
of the deep fascia via mechanotransduction Furthermore, injections of inflammatory
mechanisms31 and this could restore glid- agents (Freund Adjuvans solution) into rat
ing between collagen fibers. According to lumbar muscles have evidenced an increase
the Stecco model, it is important to apply in the proportion of dorsal horn neurons
friction precisely over the small areas where with input from the posterior lumbar fascia,
tension produced by muscle fiber contrac- demonstrating a correlation between deep
tion apparently converges.32 muscles and areas of deep fascia at a dis-
tance.39 (p 251)
DISCUSSION Steccos hypothesis of deep fascias role in
This biomechanical model shifts empha- proprioception and motor coordination12 (p
sis from muscles with origins and tendinous 15,16)
definitely pivots on demonstrating the
insertions moving bones, to motor units afferent innervation of deep fascia. Differ- Figure 4. Layers of collagen fibers within
activating groups of muscle fibers united ent studies do suggest that fascia is richly deep fascia have different orientations.
by fascia that bring about movement. innervated. The presence of abundant free Note: Mechanoreceptors are embedded
Interpreting movement in terms of MFUs and encapsulated nerve endings have been within these layers.

Orthopaedic Practice Vol. 23;2:11 71

could activate specific patterns of proprio- ers in position and movement sense.50 There pectoralis major, palmaris longus, latissimus
ceptors, potentially providing directional is evidence that muscle spindles contrib- dorsi, deltoid, triceps brachialis, and exten-
and spatial afferent information.48 ute to both the sense of limb position and sor carpi ulnaris all present myotendinous
While the Stecco model focuses on the limb movement, and that there is continu- expansions of their deep fascia. A study of
role that deep fascia could play in peripheral ous interaction between the contraction of the functional relationship between shoul-
motor control, collaboration and integra- limb muscles and centrally generated motor der stabilizers and hand-grip suggests that,
tion with the central nervous system is duly command signals; however, the role of the in agreement with the Stecco model, this
recognized.11 (p 164) Nevertheless, the inter- fascia in this interplay does require further myofascial organization could be a means
relationship that exists between muscle fiber studies. for transmission of tension along a myofas-
contractions, mechanoreceptors embed- The Stecco model also suggests that if cial sequence, permitting the coordination
ded in deep muscular fascia and peripheral the fascia is in a physiologic state, sliding between stabilization of a proximal joint
motor control is a rather controversial aspect and tending appropriately, it could con- or joints while distal joints are involved in
of this model. Muscle spindles lie in paral- tribute to simultaneous adaptation between forceful movement.56
lel to muscle fibers and they do have a thin agonist and antagonist according to the Fascial anatomy studies have also added
connective tissue capsule that is continuous inclination of the muscle fibers and the seg- to the growing consensus among anatomists
with either the endomysium or the peri- ment involved. Studies of myofascial force that retinacula, in particular the ankle reti-
mysium of the surrounding muscle fibers. transmission mechanisms51,52 do suggest nacula, may play an important role in pro-
Stecco proposes12 (p 20) that when gamma some evidence for this hypothesis of deep prioception and should not be considered
fiber stimulation causes intrafusal spindle fascias role in agonist and antagonist inter- merely as passive elements of stabilization,
fibers to contract a minimal stretch could action but this is another area requiring fur- but a type of specialization of the fasciae for
be propagated throughout the entire fascial ther investigation. movement perception.57 Ankle retinacula
continuum, including tensioning the deep As part of the fascial anatomy studies are thickenings of the deep fascia formed
fascia at the CC. If this fascial continuum carried out on unembalmed human cadav- by 2 to 3 layers of parallel collagen fiber
is elastic, then it could adapt to this stretch ers, numerous myotendinous expansions bundles, densely packed with a little loose
permitting muscle spindles to contract nor- linking adjacent body segments have been connective tissue, and they present virtually
mally with subsequent correct activation of identified.53 These myotendinous expan- no elastic fibers but many nerve fibers and
alpha motor fibers and muscular contrac- sions are well documented in anatomical corpuscles. In fact, the histological features
tion. On the other hand, if there is excessive texts, yet no clear functional significance of retinacula appear to be more suggestive of
stiffness within the system, then particular has ever been assigned to these structures. a perceptive function, whereas tendons and
small areas on the deep fascia (the CC/ Some authors have suggested these expan- ligaments mainly play a mechanical role.
CF) will not be elastic and muscle spindle sions have a role in stabilizing tendons,54 Dissections have shown that the retinacula
contraction could be less than perfect, dis- and the term tensegrity has been used to have specific muscular and bone connec-
torting afferent information to the central describe this type of connection existing tions that allow them to be sensitive to
nervous system and thereby interfering with between body segments.55 These expan- the tonus of the muscles. Given their con-
correct motor unit activation (Figure 5). sions extend well beyond any bony inser- tinuity with deep fascia, and the fact that
Incongruent motor unit activation could tion of the muscle, forming a continuum tendons typically pass beneath retinacula,
then result in uncoordinated movement, with the deep fascia in adjacent segments. any impediment in gliding of the retinac-
producing joint instability or pain.49 For example, in the upper limb, the lacer- ula would interfere with correct function-
Studies addressing sensory processing do tus fibrosus of biceps brachialis can be con- ing of the tendons themselves. This could
point to the muscle spindles as prime play- sidered as a myotendinous expansion, yet potentially lead to problems such as teno-
synovitis, or dysfunction of the associated
muscles, as well as altering the function of
adjacent segments via disturbed propriocep-
tive afferents.

CONCLUSION
The architecture of deep muscular fascia
and its precise relationship to the muscles it
surrounds forms the basis of an innovative
biomechanical model for the human myo-
fascial system. It suggests that deep muscular
fascia could act as a coordinating compo-
nent for motor units grouped together into
functional units and that this connective
tissue layer unites these functional units
to form myofascial sequences. This holistic
vision of the human fascial system is par-
Figure 5. Schematic diagram illustrating possible mechanism of interaction between tially supported by ongoing evidence-based
spindles, fascia, and CNS as suggested by Stecco. research into fascial anatomy. Clinically it is

72 Orthopaedic Practice Vol. 23;2:11

common to find patients with regional pain
syndromes and some of the aspects pre-
sented in this biomechanical model could
provide indications for comprehending the
possible connection between different areas
of pain. The Stecco model does employ an
unusual terminology and numerous new
abbreviations that can present an initial
obstacle to comprehension. Nonetheless, 13. Huijing PA, Baan GC. Myofascial force positive mesodermal population provides
this model introduces interesting perspec- transmission via extramuscular pathways a prepattern for vertebrate limb muscle
tives for clinicians involved in the manual occurs between antagonistic muscles. Cells patterning. Dev Cell. 2003;5(6):937-944.
treatment of musculoskeletal dysfunctions Tissues Organs. 2008;188(4):400-414. 25. Hasson P, DeLaurier A, Bennett M, et
but further well-conducted clinical studies 14. Yucesoy CA, Baan G, Huijing PA. al. Tbx4 and tbx5 acting in connec-
to test its validity are necessary. Epimuscular myofascial force trans- tive tissue are required for limb muscle
mission occurs in the rat between the and tendon patterning. Dev Cell.
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