Fascial tissue and osteoarthritis: from biology to clinical implications

Abstract

Background: Fascia (FA) is a type of connective tissue that forms a network throughout the body which provides mechanical support and transmits forces across the entire body. Emerging research shows that fascia has a significant impact on pain and neuromuscular function in individuals with osteoarthritis (OA). Altered fascial stiffness can contribute to joint dysfunction, reduced mobility, and increased pain levels. The literature has been reviewed regarding myofascial pain in OA and how connective tissues respond to immobilization. However, there does not appear to be an integrated review synthesizing what we know about the biological mechanisms of fascia, including mechano-transduction processes during immobilization, as well as its application to clinical practice for individuals suffering from OA. Materials and methods: A non-systematic literature search was performed in PubMed according to the SANRA framework. The search terms included fascia, extracellular matrix, connective tissue, innervation, mechanical properties, immobilization, and osteoarthritis. The search results comprised publications written in English from approximately 2009 to 2025, which were subjected to qualitative analysis. Results: The data indicate that the fascia demonstrates viscoelastic characteristics in response to mechanical loading. Cell–matrix mechanical coupling is further transduced into transcriptional programs through mechanosensitive pathways, including integrins, YAP/TAZ, and Piezo channels. In contrast to this viscoelastic nature, immobilization elicits both qualitative and quantitative changes to connective tissue, namely collagen disorganization and hyaluronic acid aggregation, along with decreased sliding potential and impaired innervation, contributing to an increase in stiffness and decrease in range of motion (ROM). Studies utilizing imaging modalities in patients diagnosed with osteoarthritis have shown evidence of increased stiffness of the iliotibial tract on shear wave elastography and thickening of the plantar fascia. There is heterogeneity among patients diagnosed with Osteoarthritis based on the involvement of the fascia, with varying degrees of phenotypic expression. Studies examining the use of manual myofascial therapies have demonstrated a reduction in stiffness and improvement in ROM, with numerous studies reporting short-term benefits. However, these studies also highlight the limitations of their methodology. Conclusions: The currently available evidence provides preliminary support for the inclusion of interventions targeting the fascia as part of a multifaceted approach to treating OA. The existing body of evidence related to the efficacy of treatments targeting the fascia in the treatment of OA is variable and methodologically limited. Therefore, adequately powered randomized controlled trials involving standardized protocols for assessment, imaging-based assessment of fascial properties, and categorization by osteoarthritis phenotype are required to determine whether treatments directed towards the fascia can provide clinically relevant efficacy in addition to providing information regarding long-term effects.