Corticosteroid injections (CSIs) are widely used in Physical and Rehabilitation Medicine, but their safety profile is strongly influenced by the formulation-specific chemical structure and physicochemical properties of each molecule, as well as by injection technique and dosing strategy. Particulate corticosteroids such as triamcinolone acetonide and methylprednisolone acetate exhibit low aqueous solubility, microcrystal formation, and prolonged intra-articular residence, which translate into sustained anti-inflammatory effects but also higher risks of chondrotoxicity, calcifications, tendinopathy, cutaneous and muscular atrophy, osteonecrosis, nerve injury, infection, and post-injection flare, especially with repeated or high-dose use. In contrast, more soluble preparations like betamethasone and dexamethasone sodium phosphate provide rapid onset and shorter duration of action, with reduced local depot-related complications but a greater propensity for transient systemic effects such as glycemic spikes. Across adverse events, less soluble, longer-acting formulations and inaccurate extra-articular delivery consistently emerge as key drivers of local tissue damage. Ultrasound guidance significantly improves injection accuracy, optimizes drug deposition of both particulate and non-particulate agents, and may enhance clinical outcomes while limiting complications, thereby representing a relevant component of CSI practice. In conclusion, this narrative review proposes a formulation-oriented framework for corticosteroid selection, integrating pharmaceutical formulation, physicochemical properties, imaging guidance, and individualized rehabilitation strategies to optimize molecule selection, minimize adverse effects, and advance a precision rehabilitation paradigm.

IntroductionMuscle hypertonia is a common symptom in patients with upper motor neuron disorders. To date, the role of intramuscular connective tissue (IMCT) alterations in hypertonic muscle has not been fully explored. This review aimed to identify and characterize alterations in IMCT components in hypertonic muscle in central neurological disorders.MethodsThis scoping review included studies investigating IMCT alterations in hypertonic muscles resulting from central neurological disorders. Four electronic databases, including PubMed/Medline, CINAHL, Web of Science, and Scopus, were searched to identify relevant studies published prior to 20 July 2025. The review followed the Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. The risk of bias was evaluated using ROBINS-E. Data were extracted and narratively synthesized according to IMCT categories.ResultsTwelve studies were included. Among the included studies, increased collagen, glycosaminoglycan content, fascia thickness, and fibroblasts, as well as altered IMCT structural properties, were found in hypertonic muscles. The collagen content was found to be positively correlated with spasticity and stiffness. A key limitation of these studies is that all participants were in the chronic stage of the neurological disease.ConclusionThis scoping review provides evidence that alterations in IMCT components in muscle with hypertonia occur across different neurological conditions. Targeting these changes may provide a new intervention strategy to reduce muscle stiffness and improve the muscle function of patients with hypertonia secondary to neurological disease.

Background: Wound healing contributes to restoring skin integrity. However, scars affect soft tissue in all its layers, including the superficial and deep fascia; moreover, it has been demonstrated that the fibroblasts leading the scarring process develop from progenitors located in the superficial fascia. In the past, research into scar etiology has focused primarily on the dermal and epidermal layers, leaving the role of the fasciae largely overlooked. Many patients presenting with surgical or traumatic scars complain of the increased stiffness and thickness of the scar, reduced extensibility of the area surrounding it, and chronic pain persisting even after the healing process has been completed. The purpose of this systematic review is to investigate the non-invasive tools and methods employed for the objective evaluation of scars that involve fascial layers. Methods: A systematic literature search was conducted on PubMed and WOS. Registration DOI: 10.17605/OSF.IO/SDR3Q. Results: A total of 11 articles were selected; the etiologies of scars were surgical, traumatic, and other (keloids). The investigations were conducted using ultrasound, magnetic resonance imaging, strain elastography, and shear wave elastography on the visceral fasciae, superficial fascia, hypodermis, and musculoskeletal fasciae. Sliding of fasciae was assessed by ultrasound; thickness of fasciae was assessed by ultrasound and magnetic resonance imaging; stiffness was assessed by shear wave elastography and strain elastography; and the qualitative assessment was performed via ultrasound. Conclusions: Our literature review showed that ultrasound, magnetic resonance imaging, strain elastography, and shear wave elastography are currently adopted for investigating the sliding, thickness, stiffness, and qualitative features of scars involving fascial layers. Moreover, our research showed the existence of a gap in the scientific literature on this topic.

Severe accidental hypothermia represents a unique and potentially reversible cause of cardiac arrest in which prolonged resuscitation may still result in favorable neurological recovery. Unlike normothermic cardiac arrest, hypothermic cardiac arrest (HCA) is characterized by profound metabolic suppression and temperature-mediated myocardial instability, requiring a fundamentally different therapeutic paradigm. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) provides not only circulatory support but also controlled reperfusion and rewarming, positioning it as the cornerstone of modern management. Recent international guidelines have clarified indications for extracorporeal life support (ECLS) in HCA and have contributed to improved standardization of care. Building upon these recommendations, this narrative review focuses on physiological principles underlying extracorporeal rewarming and their implications for bedside management. We examine mechanisms of ischemia-reperfusion injury, rewarming-associated hemodynamic instability and myocardial stunning, discuss dynamic risk assessment beyond statistical thresholds such as the HOPE score and summarize practical considerations regarding cannulation strategies, differential hypoxia, left ventricular unloading and neurologic evaluation. By integrating current evidence with pathophysiological insight and organizational considerations, this review proposes a clinically oriented framework to support decision-making in hypothermic cardiac arrest and to optimize meaningful neurological recovery.

The deep fascia plays a crucial role in musculoskeletal function, yet little is known about its characteristics in children. The current literature lacks reference values for deep fascia thickness in healthy pediatric populations, making assessing alterations in pediatric disorders difficult. This study aims to provide baseline measurements of deep fascia thickness in the lower limbs of healthy pediatric subjects using ultrasound and establish pilot reference data for future clinical applications. This cross-sectional study included 21 healthy children aged 3–9 years. Ultrasound imaging was performed using a 17 MHz linear probe at two standardized locations on fascia lata and crural fascia. A modified imaging protocol ensured feasibility for pediatric subjects. Measurements were analysed using ImageJ, with inter-rater reliability assessed via the Intra-Class Correlation Coefficient (ICC). Statistical analyses, including correlations with age and BMI, were conducted using Jamovi software (p < 0.05). The mean fascia lata thickness was 0.802 ± 0.140 mm (anterior) and 1.34 ± 0.251 mm (lateral). The mean crural fascia thickness was 0.629 ± 0.084 mm (anterior) and 0.644 ± 0.076 mm (lateral). A statistically significant correlation was found only between BMI and lateral crural fascia thickness, whereas no significant correlations with age were observed. Inter-rater reliability was good (ICC 0.893, 95

This narrative review synthesizes evidence from 108 studies to provide the first comprehensive overview of extracorporeal shockwave therapy (ESWT) for plantar fasciitis across three key domains. First, assessment methodologies were evaluated, identifying 36 distinct tools classified into six categories, including pain (with the Visual Analog Scale being the most frequently used), function (most commonly the Foot Function Index), plantar fascia thickness, and other measures. Second, treatment protocols were analyzed, revealing commonly applied parameters of 2000 impulses per session and an energy flux density of 0.2 mJ/mm2 or 3.0 bar. Third, the comparative status of ESWT relative to other interventions was examined. Across 18 alternative treatments, corticosteroid injections, platelet-rich plasma (PRP), dextrose prolotherapy, laser therapy, and ultrasound were the most frequently compared modalities. ESWT and comparator interventions demonstrated differential advantages across specific outcomes; however, these findings cannot be directly translated into clinical recommendations, due to the limitations of the available evidence. By consolidating fragmented data, the present review clarifies the current research landscape and provides a foundational reference to support outcome evaluation and individualized treatment selection.

The deep fascia of the upper limb represents a pivotal anatomical structure essential for effective force transmission, dynamic compartmentalization and musculoskeletal stability. Its composition (rich in type I collagen fibers) enables both mechanical resilience and functional adaptability, crucial for the upper limb's complex movements. Recent advancements in high-resolution ultrasonography, complemented by anatomical/histological studies, have provided unprecedented insights into the fascia's microarchitecture and clinical significance. This paper delivers a simple and systematic guide as regards the sono-anatomy of deep fasciae in the upper limbs, including brachial, antebrachial and palmar fasciae as well as their continuity with adjacent structures. Integrating anatomical, histological and sonographic evidence, this article sheds light on the clinical relevance of fascia-centric approaches applied in rehabilitative and surgical treatments.

Background and Objectives: The thoracolumbar fascia (TLF) has been implicated in low back pain, but imaging-based characterization in degenerative lumbar disorders, particularly in surgical cohorts, remains limited. To describe MRI-derived and US-derived TLF thickness estimates in a heterogeneous degenerative lumbar surgical cohort and explore preliminary imaging patterns and associations with selected clinical variables. Materials and Methods: In this prospective single-center cohort, adults scheduled for elective lumbar surgery underwent preoperative US (short- and long-axis at L3) and review of routine lumbar MRI (axial and sagittal T1-weighted measurements at L3) using standardized protocols. Twenty-six patients were included (15 with lumbar spinal stenosis, five with lumbar disc herniation, four with spondylolisthesis, and two with scoliosis). Disability was assessed using the Oswestry Disability Index (ODI). Exploratory subgroup comparisons, correlation analyses, and Bland–Altman agreement analysis were used to examine subgroup patterns, patient–factor associations, and MRI–US agreement. Results: Interpretable data were available for 19 axial MRI, 18 sagittal MRI, 19 short-axis US, 15 long-axis US, and 19 ODI assessments; paired MRI–US measurements were available in 11 cases for sagittal/long-axis analysis and 12 for axial/short-axis analysis. Mean TLF thickness was 0.89 ± 0.33 mm on axial MRI, 1.16 ± 0.48 mm on sagittal MRI, 2.53 ± 1.44 mm on short-axis US, and 2.49 ± 1.14 mm on long-axis US. Exploratory subgroup analyses showed a between-diagnosis difference only for axial-MRI-derived TLF thickness (p = 0.007), with lower thickness in disc herniation than in stenosis (p = 0.008), while sagittal MRI and US thickness measures did not differ between groups (p ≥ 0.301). ODI was not consistently associated with TLF thickness on MRI or US. Conclusions: In this exploratory surgical cohort, US-derived TLF thickness values were higher than those previously reported in the literature, suggesting possible fascial alteration in degenerative lumbar disease. However, TLF thickness was not consistently associated with disability, and MRI- and US-derived measurements should be interpreted as modality-specific estimates rather than interchangeable values. Given the small heterogeneous cohort and measurement constraints, these findings are descriptive and preliminary, but they provide an imaging framework to guide future standardized studies.

Background: Definitive quantification of fluid spread within the paraneural sheath (PNS) but external to the epineurium during hydrorelease (HR)-like procedures is lacking. We aimed to investigate the spread of low-volume HR within the intra-PNS surrounding the sciatic, tibial, and common peroneal nerves using human cadaveric specimens. Methods: HR with 2.5 mL of dye-mixed saline was performed under ultrasound guidance into the intra-PNS of seven lower limbs from four fresh-frozen cadavers. Dye spread was quantified by measuring longitudinal distance and circumferential dispersion, followed by anatomical dissection within 1 min of injection. Results: All injections demonstrated consistent longitudinal spread along the intra-PNS layer without intraneural infiltration. The mean spread distances were 10.63 ± 3.66, 9.97 ± 3.60, and 8.36 ± 3.04 cm in the sciatic, tibial, and common peroneal nerves, respectively, indicating no significant differences. An opposite-side circumferential spread was observed in all cases, with mean scores indicating mild-to-moderate extension. Conclusions: Low-volume HR selectively spreads within the intra-PNS layer, suggesting that this anatomical layer is a structurally valid and reproducible target for perineural injection techniques.

The evolution of regional anesthesia techniques has markedly influenced the management of postoperative pain, particularly in thoracic surgery. As part of a multimodal analgesic approach, fascial plane blocks have gained prominence due to their efficacy in providing targeted analgesia with minimal systemic side effects. Among these, the superficial intercostal plane (SPIP) block and deep parasternal intercostal plane (DPIP) block are of notable interest. The aim of this study was to investigate the dye spread to the anterior chest wall space and its spread pathway through anatomical morphometric analyses on cadavers for single-injection and double-injection SPIP blocks versus DPIP blocks. In both qualitative and quantitative evaluations, the single-injection SPIP block with 10 mL of dye demonstrated a broader and more extensive spread compared to the double-injection SPIP block, which used 5 mL of dye per injection site (p < 0.05), and the DPIP block with 10 mL of dye (p < 0.05). All the blocks had a positive correlation between the distances from the sternum border and the area of dye spread, suggesting that the crucial role of volume in fascial blocks is that it significantly affects the opening of the fascial compartment, enabling optimal spread of the anesthetic. Adequate volume facilitates proper spread and diffusion across the fascial plane, ensuring more comprehensive fascia coverage and thus enhancing the block’s effectiveness. Finally, precise volume management is key to maximizing both efficacy and safety.

Ehlers–Danlos Syndromes (EDS) are a group of connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. The co-ocurrence of spondyloarthritis (SpA), an inflammatory arthritis in individuals with EDS, presents unique diagnostic and therapeutic challenges due to overlapping clinical features. This study aimed to investigate the connective tissue characteristics in patients with both EDS and SpA. Twenty-three participants with EDS and co-occurring SpA (SpA + EDS), and fourteen participants with EDS without SpA (EDS-only) were evaluated using ultrasound imaging and strain elastography to assess the thickness and stiffness of the sternocleidomastoid muscle and thoracolumbar fascia. Data were analyzed using descriptive and inferential statistical methods. A statistically significant increase in thoracolumbar fascia thickness was observed in the SpA + EDS group compared to the EDS-only group (p = 0.002). The median thickness in the SpA + EDS group was 5.6 mm (IQR: 2.0 mm), versus 4.4 mm (IQR: 1.7 mm) in the EDS-only. Co-occurring SpA poses diagnostic challenges due to its clinical overlap with EDS. The increased thoracolumbar fascia thickness observed in SpA + EDS patients, while also present to a lesser degree in EDS-only participants, suggests that fascial remodeling may reflect overlapping inflammatory and mechanical processes. Ultrasonography may thus serve as a complementary tool to monitor connective tissue changes in this population.

We demonstrate that the strong N2 bond can be efficiently dissociated at low pressure and ambient temperature on a Si(111)-7x7 surface. The reaction was experimentally investigated by scanning tunnelling microscopy and X-ray photoemission spectroscopy. Experimental and density functional theory results suggest that relatively low thermal energy collision of N2 with the surface can facilitate electron transfer from the Si(111)-7x7 surface to the p*-antibonding orbitals of N2 that significantly weaken the N2 bond. This facile N2 triple bond dissociation on the surface leads to the formation of a Si3N interface.

Complex Regional Pain Syndrome (CRPS) is a debilitating pain disorder involving chronic inflammation, neural sensitization and autonomic dysfunction. Fascia, a highly innervated connective tissue, is increasingly recognized for its role in pain modulation, yet its contribution to CRPS remains underexplored. This narrative review synthesizes the current evidence on fascia's involvement in CRPS pathophysiology and potential therapeutic strategies. A literature search was conducted in PubMed, Scopus and Web of Science, selecting studies on fascia, CRPS, inflammation, oxidative stress and autonomic dysfunction, with emphasis on recent experimental, anatomical and clinical research. Fascia contributes to CRPS through neuroinflammation, fibrosis and autonomic dysregulation. Its rich innervation facilitates peripheral and central sensitization, while inflammatory mediators drive fibrosis, reducing elasticity and exacerbating pain. Autonomic dysfunction worsens hypoxia and oxidative stress, fueling chronic dysfunction. Advances in sonoelastography provide new insights, while fascial manipulation and targeted therapies show promise in early studies. Fascia plays a key role in CRPS pathophysiology, yet its clinical relevance remains underexplored. Future research integrating imaging, molecular profiling and clinical trials is needed to develop evidence-based fascia-targeted interventions, potentially improving CRPS diagnosis and treatment.

BACKGROUND:Only in recent years it has been demonstrated that the thoracolumbar fascia is involved in low back pain (LBP), thus highlighting its implications for treatments. Furthermore, an easily accessible and non-invasive way to investigate the fascia in real time is the ultrasound examination, which to be reliable as is, it must overcome the challenges related to the configuration of the machine and the experience of the operator. Therefore, the lack of a clear understanding of the fascial system combined with the penalty related to the setting of the ultrasound acquisition has generated a gap that makes its effective evaluation difficult during clinical routine. The aim of the present work is to fill this gap by investigating the effectiveness of using a deep learning approach to segment the thoracolumbar fascia from ultrasound imaging. METHODS:A total of 538 ultrasound images of the thoracolumbar fascia of LBP subjects were finally used to train and test a deep learning network. An additional test set (so-called Test set 2) was collected from another center, operator, machine manufacturer, patient cohort, and protocol to improve the generalizability of the study. RESULTS:A U-Net-based architecture was demonstrated to be able to segment these structures with a final training accuracy of 0.99 and a validation accuracy of 0.91. The accuracy of the prediction computed on a test set (87 images not included in the training set) reached the 0.94, with a mean intersection over union index of 0.82 and a Dice-score of 0.76. These latter metrics were outperformed by those in Test set 2. The validity of the predictions was also verified and confirmed by two expert clinicians. CONCLUSIONS:Automatic identification of the thoracolumbar fascia has shown promising results to thoroughly investigate its alteration and target a personalized rehabilitation intervention based on each patient-specific scenario.

AimEhlers-Danlos syndromes (EDS) are connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. When spondyloarthritis (SpA), an inflammatory arthritis, co-occurs with EDS, overlapping symptoms of joint pain may arise, making diagnosis and management challenging. The aim of this study was to investigate enthesopathic differences in the patellar tendon between patients with EDS and those with co-occurring SpA.Material and methodsTwenty-three participants with EDS and co-occurring SpA (SpA + EDS) and 14 participants with EDS without SpA (EDS-only) underwent ultrasound examination. Assessments were conducted at the inferior patellar pole, mid-patellar tendon, and tibial tuberosity to evaluate enthesopathic changes, including calcifications, enthesophytes, and tendon thickness. Statistical analyses were performed to identify significant differences between groups.ResultsThe most common tendon pathology was hypoechoic change at the level proximal to the tibial tuberosity and the inferior pole of the patella. Compared with the EDS-only group, tendon thickness at the patellar pole was significantly greater in the SpA + EDS group (p = 0.002).ConclusionsThe presence of increased patellar tendon thickness in the SpA + EDS group suggests structural adaptations consistent with enthesopathic change in the context of coexisting inflammatory and connective tissue disorders. These findings highlight the potential role of ultrasound in the evaluation of tendon alterations in hypermobile patients, underscoring the need for longitudinal, multimodal studies to clarify the clinical relevance of these sonographic differences.

BACKGROUND:The relationship between human anatomy on ultrasonography (US) and dissection is unclear.Therefore, we investigated the precise location of a solution injected into eight legs from five fresh-frozen specimens between the fascial layers of two aponeurotic fascial (APF) regions using US. METHODS:The US-guided injection target points were the fascial lata-distal, crural fascia-proximal, and crural fascia-distal. The operator searched the optimal visualization area of two close fascial layers of the two APF regions; 2.5 mL of 0.9% saline was injected through US guidance. The layers with the solution were categorized as above the APF (between the superficial fascia and APF), intra-APF, between the APF and epimysium (EPI), or intra-muscle (under the EPI). RESULTS:A small amount of solution was identified within the intra-APF region, whereas a substantial amount was observed above the APF, between the APF and EPI, and intramuscularly. Regarding the fascia lata-distal and crural fascia-distal, a substantial volume of solution was observed between the APF and EPI in all cases. For the crural fascia-proximal, the solution was observed above the APF in 25% of cases and intramuscularly in 75% of cases. CONCLUSIONS:Solution distribution may be associated with whether the muscle fibers are directly inserted into the APF and the absence of EPI in each area.

Intraoperative ultrasound (IOUS) has developed from a rudimentary adjunct into a versatile modality that now plays a crucial role in neurosurgery. Offering real-time, radiation-free and repeatable imaging at the surgical site, it provides distinct advantages over intraoperative magnetic resonance (MRI) and computed tomography (CT) in terms of accessibility, workflow integration and cost. The clinical spectrum of IOUS is broad: in cranial surgery it enhances the extent of resection of gliomas and metastases, supports dissection in meningiomas and enables localization of MRI-negative pituitary adenomas; in spinal surgery, it guides resection of intradural and intramedullary tumors, assists in myelotomy planning and confirms decompression in degenerative conditions such as cervical myelopathy and ossification of the posterior longitudinal ligament. IOUS also offers unique insights into cerebrospinal fluid disorders, including arachnoid webs, cysts, syringomyelia and Chiari malformation, where it visualizes cord compression and CSF flow restoration. In trauma and oncological emergencies, it provides immediate confirmation of decompression, directly influencing surgical decisions. Recent innovations, including contrast-enhanced ultrasound, elastography, three-dimensional navigated systems and experimental integration with artificial intelligence and robotics, are extending its functional scope. Despite heterogeneity of evidence and operator dependence, IOUS is steadily transitioning from an adjunctive tool to a cornerstone of multimodal intraoperative imaging, bridging precision, accessibility and innovation in contemporary neurosurgical practice.