Next Article in Journal
A Feature-Augmented Explainable Artificial Intelligence Model for Diagnosing Alzheimer’s Disease from Multimodal Clinical and Neuroimaging Data
Previous Article in Journal
Liquid Biopsy and Single-Cell Technologies in Maternal–Fetal Medicine: A Scoping Review of Non-Invasive Molecular Approaches
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Diagnostics
Volume 15
Issue 16
10.3390/diagnostics15162059
diagnostics-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

Assessment of the Fascial System Thickness in Patients with and Without Low Back Pain: A Narrative Review

by
Lorenza Bonaldi
1,
Alice Berardo
2,3,*,
Antonio Stecco
4,
Carla Stecco
2,5 and
Chiara Giulia Fontanella
2,3
1
Department of Civil, Environmental and Architectural Engineering, University of Padova, 35131 Padova, Italy
2
Centre for Mechanics of Biological Materials, University of Padova, 35131 Padova, Italy
3
Department of Industrial Engineering, University of Padova, 35131 Padova, Italy
4
Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York City, NY 10016, USA
5
Department of Neuroscience, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy
*
Author to whom correspondence should be addressed.
Diagnostics 2025, 15(16), 2059; https://doi.org/10.3390/diagnostics15162059
Submission received: 30 June 2025 / Revised: 6 August 2025 / Accepted: 15 August 2025 / Published: 16 August 2025
(This article belongs to the Special Issue Musculoskeletal Disorders: Diagnosis, Management, and Rehabilitation, 2nd Edition)
Browse Figures
Versions Notes

Abstract

Background and Objectives: The hypothesis that fascial thickness variability may serve as a biomarker for low back pain (LBP) requires a clear understanding of typical thickness values in both LBP and non-LBP populations—an area still lacking in the literature. This narrative review aims to define reference values and patterns of variability for the superficial fascia, deep fascia, and subcutaneous tissue in individuals with and without LBP. Methods: A literature search was conducted in PubMed and ScienceDirect using keywords such as superficial fascia, deep fascia, thoracolumbar, subcutaneous fat, back pain, lumbar, thorax, and thickness. Inclusion criteria focused on human studies with proper identification of the relevant soft tissue structures. A total of 21 studies, published up to February 2024, met the inclusion criteria and were analyzed. Results: The review revealed notable intra- and inter-study variability in the thickness of the investigated structures. In LBP populations, both deep fascia and subcutaneous tissues were generally equal to or thicker than in controls (non-LBP), whereas consistent data on superficial fascia thickness remain limited. Age, sex, and anatomical location were discussed as potential influencing factors. Conclusions: These findings support the establishment of reference thickness values for subcutaneous and fascial tissues and encourage further investigation into their structural and functional roles in LBP. The observed variability may offer a basis for patient- and site-specific assessment and intervention strategies.

1. Introduction

The fascial tissues are part of a system that is a multilayered structure composed of loose (adipose cells, glycosaminoglycans, and hyaluronan) and dense connective tissues (collagen fibers). From the skin to the deepest plane, it comprises the superficial fascia (SF) and the deep fascia (DF) [1,2]. The SF and DF are connected through the superficial and deep retinacula cutis, respectively, which organize the adipose tissue into lobules. Both these fascial tissues have different compositions, structures, and mechanical properties, which vary further depending on the body region. In the thoracolumbar region, the SF appears as a fibroadipose structure composed of interconnected lamellae that lie between the dermis and the DF. The DF, also known as the thoracolumbar fascia (TLF), is an aponeurotic fascia consisting of multiple sublayers. The SF and DF often merge near the spinous processes. The SF and DF are frequently assumed to share similar anatomical and physiological properties, leading to misleading clinical interpretations. This study aims to further investigate the distinct morphology of these two fascial tissues. In the last decades, the fascial tissue has gained increasing interest due to its role in musculoskeletal dysfunctions, such as low back pain (LBP) [3,4,5]. LBP is still the leading cause of disability in the world [6,7], and the importance of investigating the fascia is because fascial tissue, such as the TLF, is assumed to have a direct and significant implication in LBP, even for its treatment [3,4,5]. Indeed, TLF mobility seems to decrease in people with LBP [8]. Quantitatively speaking, Langevin et al. [5] demonstrated that TLF shear strain (i.e., gliding among connective tissue planes) is reduced by approximately 20% in human subjects with LBP. Anatomically, the above-mentioned TLF is a trilaminar structure that connects the trunk with the upper/lower limbs and that separates the paraspinal muscles from the posterior abdominal wall muscles. Indeed, the superficial lamina of the posterior layer is dominated by the aponeuroses of the latissimus dorsi and the serratus posterior inferior, while the deeper lamina encapsulates the paraspinal muscles. Moreover, the TLF is characterized by a nociceptive nature, as evidenced by its sensitivity to stimuli [9,10,11,12,13,14,15]. For example, Schilder et al. [16] showed that the TLF is sensitive to chemical stimulation, making it prone to contribute to non-specific LBP. Additionally, the biomechanics of the TLF are strongly influenced by its direct connection with muscles [15], thus increasing its spectrum as a potential source of pain. According to Creze et al. [17], the TLF, as well as the erector spinae aponeurosis, is fundamental in the biomechanics of the spine and could be a root cause of LBP.
Therefore, both anatomical and functional alterations could have a fundamental impact. In these terms, Brandl et al. [18] affirmed that alterations in posture, kinematics, and movement patterns are commonly associated with LBP patients, and that TLF has a fundamental impact on spinal stability and paraspinal muscle activity. For instance, the authors demonstrated that TLF deformation could be a suitable parameter to distinguish between LBP and healthy individuals during body movement, such as a lifting task. In another study, Brandl et al. [19] reported that in LBP participants, the erector spinae and multifidus muscles’ activity is significantly affected by TLF, and the hypothesized mechanism (as the root cause) behind it is fascia-related disturbances in neuromotor control due to altered muscle spindle functions. Moreover, Kellis et al. [20] demonstrated that TLF stiffness is remotely influenced by hamstring muscle movements. In addition, according to D’Hooge et al. [21], it is hypothesized that degenerated muscles might also compromise spinal stability and lead to further injury/pain. In terms of other factors that could influence LBP, such as fat, Heuch et al. [22] demonstrated that obesity is associated with a high prevalence of LBP. Other authors [23] have affirmed that BMI (as an indicator of obesity, which is a risk factor for LBP) cannot represent the percentage and distribution of body fat. Thus, subcutaneous fat tissue thickness has been demonstrated to be better than BMI in predicting a symptomatic patient with LBP (two times thicker compared to asymptomatic subjects at all lumbar levels). Additionally, Brooks et al. [24] examined the relationship of regional and total body adiposity to pain and disability in an LBP population, concluding that a regional distribution (score: ratio between abdominal and lumbar adiposity) is associated with LBP.
Even if the correlation between musculoskeletal dysfunctions, such as LBP, and fascial system substrate thickness variation (i.e., SF, DF, and subcutaneous tissue) is hypothesized [2], it is not clear whether it could be a consequence or the main cause of the bodily alterations.
Therefore, to evaluate the change in thickness between the LBP and non-LBP groups, a comprehensive evaluation and description of thickness variability within both groups is a key step for further clinical and treatment evaluations.
The hypothesis of a thickness variation in the LBP scenario, and according to variables such as sex, age, and BMI, requires the definition of thickness variability in non-LBP and LBP.
For all of the above-mentioned reasons, the aim of the present work was to comprehensively review the literature to describe and discuss the thicknesses of the fascial layers (i.e., SF and DF) and surrounding structures (i.e., local subcutaneous tissue thickness in the thoracolumbar region) to determine their variability in non-LBP and LBP scenarios.
Given the heterogeneity of the included studies (detailed in the next section) in terms of anatomical definitions, measurement protocols, and reported outcomes, a narrative review format was chosen. This approach allowed for a more comprehensive and integrative analysis of the available literature, with the flexibility to include relevant conceptual insights and observational findings that would be excluded under a more rigid systematic framework.
Comparing literature could be a useful tool for defining, as a future perspective, the implications in LBP. The main expected outcome of this work was to identify consistent anatomical differences or patterns of variability in fascial and subcutaneous tissue thickness associated with LBP. Such findings could have important implications in clinical practice, particularly for improving diagnostic imaging criteria, tailoring treatment strategies based on patient-specific fascia-related parameters, and informing future interventional studies focused on fascial therapy.

2. Materials and Methods

2.1. Research Questions

This review aimed to investigate the thickness variability of fascial tissues in the thoracolumbar region with or without low back pain (LBP vs. non-LBP) by addressing two specific research questions: (1) What are the typical thickness values and their variability for the superficial fascia (SF), deep fascia (DF), and subcutaneous tissues in the thoracolumbar region in asymptomatic individuals? (2) How do these thicknesses differ between individuals with and without LBP, also in association with other factors (e.g., sex, age, and surrounding structures)?
These questions were developed to support a comprehensive review of the literature and to guide a comparative analysis of fascial anatomy in symptomatic and asymptomatic LBP populations.

2.2. Keywords

To answer the identified research questions, the current narrative review examined the literature in the following databases: PubMed and ScienceDirect. The search was conducted before February 2024. Keywords present in the title and abstract included superficial fascia, deep fascia, thoracolumbar, subcutaneous fat, back pain, lumbar, thorax, and thickness. The queries were (i) “superficial fascia” and (“back pain” or trunk or lumbar or thorax) and thickness; (ii) (“deep fascia” or thoracolumbar) and (“back pain” or trunk or lumbar or thorax) and thickness; (iii) “subcutaneous fat” and (“back pain” or trunk or lumbar or thorax) and thickness. Additional articles were added from references or other sources, such as websites.

2.3. Article Inclusion Criteria

Inclusion criteria were (i) human studies (subjects > 18 years old), (ii) presence of quantitative information (e.g., thickness measurement values), and (iii) proper structure identification (i.e., SF). Exclusion criteria also pertained to articles published in languages other than English.
The articles were first screened according to the title and abstract, and secondly, in full text by one of the authors. Since the review has been presented in a narrative form, the screening flowchart with the number of articles according to PRISMA guidelines [25] is not reported. However, for clarity, the rationale is provided, adapted from the PRISMA one (Figure 1). Finally, a total of 21 relevant works presenting clear numerical values were organized into the following table that summarized all the study characteristics (Table 1). An example of the anatomical structures of interest is shown in Figure 2. Other works that presented interesting observations about the topic were included in the text for discussion. Three other experts in the field verified the validity of the analysis and added additional considerations to the review.

3. Results

The articles included in the analysis are reported in Table 1 for comparison purposes. A detailed breakdown of fascial thickness values is presented in Table 2, Table 3 and Table 4. For clarity, key trends are briefly summarized here, while full data are retained in the tables for transparency and future reference.
An overview of the included studies is presented in Table 1, detailing sample size, sex distribution, BMI, age, spinal level examined, and measurement methodology. Among the 21 studies reviewed, 16 employed ultrasound (US) as the primary imaging modality, four were conducted ex vivo, and two used MRI, reflecting a predominant reliance on non-invasive imaging for in vivo assessments. Regarding anatomical focus, the DF was investigated in 19 studies, the SF in two studies, and subcutaneous tissue thickness in eight studies, with some works examining multiple structures concurrently (84% for DF, 50% for SF, and 63% for subcutaneous tissue). The spinal levels most frequently assessed were L2–L5, although a few studies extended the analysis to thoracic regions or the full lumbar spine. Study populations varied widely, including both LBP and non-LBP individuals, with diverse age ranges (from young adults to elderly participants) and BMIs. Sex distribution was mixed in most studies, though a few included only males or females. Detailed characteristics are summarized in Table 1.
Table 1. Study characteristics of the analyzed cohort extracted from the Materials and Methods section of the reported references. Non-LBP groups include subjects without specific evidence of LBP. US: ultrasound; M: male; F: female; BMI: body mass index; SF: superficial fascia; DF; deep fascia; LBP: low back pain s.d.: standard deviation.
Table 1. Study characteristics of the analyzed cohort extracted from the Materials and Methods section of the reported references. Non-LBP groups include subjects without specific evidence of LBP. US: ultrasound; M: male; F: female; BMI: body mass index; SF: superficial fascia; DF; deep fascia; LBP: low back pain s.d.: standard deviation.
StructureReferenceStudy Population (Number)SexBMI (kg/m2)Age
(Mean ± s.d.)		Spinal LevelMethod
SF[26]10M 100%23.06 ± 2.6 30.6 ± 4.99 (non-LBP)Posterior chestUS
[27]6M 50%, F 50%-73–85 (not specified)-Ex vivo
DF[28]18F 100%23 ± 422 ± 1 (non-LBP)L2US
1727 ± 469 ± 4 (non-LBP)
[4]107 (47 non-LBP, 60 LBP)M (43% non-LBP, 42% LBP)
F (57% non-LBP, 58% LBP)		25.9 ± 0.7 (non-LBP)
25.7 ± 0.6 (LBP)		39.3 ± 14.1 (non-LBP)
38.3 ± 13.3 (LBP		L2–L3US
[5]121 (50 non-LBP, 71 LBP)M (24 non-LBP, 38 LBP)
F (26 non-LBP, 33 LBP)		26.1 ± 0.6 (non-LBP)
26 ± 0.5 (LBP)		41.8 ± 2.3 (non-LBP)
44.6 ± 1.8 (LBP)		L2–L3US
[29]48M 50%, F 50%24.537.4 ± 13.3 (LBP)L2–L3US
[30]22-Lower than 28.5 (exclusion criteria)25–65 (LBP)L2–L3US
[31]66M 100%23 ± 1.522.6 ± 3.7 (non-LBP)L2–L3US
[32]50M 58%, F 42%23.91 ± 3.5836 (non-LBP)L3US
[33]92M 49%
F 51%		24.03 ± 6.1 (non-LBP)
23.37 ± 5.22 (LBP)		27.09 ± 12.38 (non-LBP)
28.96 ± 10.54 (LBP)		L3US
[20]14M 100%Mass 78.9 ± 8.02 kg
Height 181 ± 9.71 cm 		23.7 ± 7.31 (non-LBP)L3–L4US
[34]54M (12 non-LBP, 10 LBP)
F (19 non-LBP, 13 LBP)		22.30 ± 2.00
(non-LBP)
22.11 ± 2.84
(LBP)		22.94 ± 5.23 (non-LBP)
25.13 ± 10.04 (LBP)		L4US
[35]30M 100%24.03 ± 2.14 24 ± 5 (non-LBP)
28 ± 10 (LBP)		L4US
[36]63M (15 non-LBP, 15 LBP)
F (15 non-LBP, 18 LBP)		24.4 ± 3.2 M (non-LBP)
23.3 ± 3.6 (F non-LBP)
25.8 ± 3.9 M (LBP)
26.8 ± 3.0 (F LBP)		Non-LBP:
39.3 ± 14.3 (M)
39.8 ± 14.1 (F)
LBP:
44.5 ± 13.9 (M)
47.8 ± 11.9 (F)		L4–L5US
[37]65M (15 non-LBP, 16 LBP)
F (15 non-LBP, 19 LBP)		24.4 ± 3.2 M (non-LBP)
23.3 ± 3.6 (F non-LBP)
25.6 ± 3.8 M (LBP)
26.8 ± 3.0 (F LBP)		Non-LBP:
39.3 ± 14.3 (M)
39.8 ± 13.7 (F)
LBP:
44.1 ± 13.5 (M)
47.8 ± 11.9 (F)		L4–L5US
[38]63M (15 non-LBP, 15 LBP)
F (15 non-LBP, 18 LBP)		24.4 ± 3.2 M (non-LBP)
23.3 ± 3.6 (F non-LBP)
25.8 ± 3.9 M (LBP)
26.8 ± 3.0 (F LBP)		Non-LBP:
39.3 ± 14.3 (M)
39.8 ± 14.1 (F)
LBP:
44.5 ± 13.9 (M)
47.8 ± 11.9 (F)		L4–L5US
[11]20--50–75 (not specified)At different levelEx vivo
[26]Reported above
[39]29F 100%20.4 and 22.4 according to different testing groups22.5 (18–29) (not specified)n/aUS
[17]10M 40%
F 60%		-77 ± 10 (non-LBP)n/aEx vivo
[40]40M 45%
F 55%		-59–84 (non-LBP)n/aEx vivo
Subcutaneous tissue[4]Reported above
[30]Reported above
[32]Reported above
[37]Reported above
[36]Reported above
[41]165M 47%
F 53%		-39.1 (LBP)L3–S1MRI
[23]280M (50 non-LBP, 52 LBP)
F (50 non-LBP, 111 LBP)		24.5 ± 2.7 (non-LBP)
26.7 ± 4.3 (LBP)		32.5 ± 8.1 (non-LBP)
35.8 ± 6.8 (LBP)		L1–S1MRI
[26]Reported above

3.1. Deep Fascia Thickness

The DF of the lumbar region is also called the TLF, an aponeurotic fascia made up of multiple sublayers [2]. In the literature, different authors have reported TLF thickness (as a composite or single layer) in LBP and/or non-LBP populations (e.g., from in vivo ultrasound imaging or ex vivo evaluations; Table 2). From the literature analysis, in general, thickness values exhibited a significant variability; for example, those from the LBP group were equal to or higher (not always with statistical significance [5,33]) than the non-LBP ones. In detail, refs. [5,33] reported a significantly higher thickness in LBP subjects with respect to non-LBP ones (even if for the latter only for males). In any case, these authors assessed thickness at different levels and from populations of different ages (even if with potential confounding effects).
Langevin et al. [4] showed a 25% increase in perimuscular thickness in LBP subjects, without a specific correlation of thickness with age, but with BMI. Larivière et al. [38] analyzed the thickness of the posterior layer of the TLF in both LBP and non-LBP populations, also without finding a correlation with demographic data (age and sex). Meanwhile, Wilke et al. [28] investigated only non-LBP subjects reporting higher TLF thickness with increasing age. Loukas et al. [40] investigated the anatomy of the vertebral aponeurosis part of the posterior layer of the TLF (from non-LBP subjects), again without significant variations between sex, age, or body sides. Devantery et al. [29] discussed the perimuscular zone thickness of the TLF in subjects with LBP, also dividing it by body side, but focusing before and after treatment (i.e., myofascial technique). These authors demonstrated that the myofascial technique showed a significant decrease in TLF thickness in subjects with LBP, discussing that the decrement in thickness after treatment could be due to a change in hyaluronan viscosity (e.g., [42]), fluid movement, retinacula cutis, and the autonomic system [29]. To validate the claim that treatments affect tissue thickness in LBP subjects, Sanjana et al. [30] investigated the effect of hands-off, self-treatment (MELT) in reducing connective tissue thickness (thickness calculation based on Langevin et al. [4]). Meanwhile, Yang et al. [31] reported that percussive massage therapy does not change TLF thickness, even if referring to non-LBP male individuals (including the epimysial fascia in the calculation). Venkatesan et al. [43] reported that the effect of yoga on TLF thickness remains unclear, so there is still room for further investigations. On the variation of thickness along body planes, Marpalli et al. [11] measured the thickness of the posterior layer of the fascial tissue in formalin-embalmed human cadavers at different spinal levels, demonstrating that the thickness shows a cranio-caudal increase (but without distinction between LBP and non-LBP). Meanwhile, Creze et al. [17] evaluated the thickness of both the posterior (higher thickness) and middle layers of the TLF from fresh cadavers of a non-LBP population. In contrast, in non-LBP subjects, Hammoudeh et al. [26] compared the DF of different body regions, demonstrating greater thickness in the posterior part of the thorax, followed by the lumbar region. In fact, Hammoudeh et al. [26] investigated not only the DF but also the superficial one at different body sites, concluding that both are thick in the so-called high-tension areas, i.e., the upper trunk.
Table 2. Thickness (mean ± standard deviation) of the DF from the literature—divided between LBP and non-LBP subgroups. Unique cell: not specified or not considered separately between LBP and non-LBP subjects. Gray cells: works that include LBP and non-LBP groups for comparisons. * Mean ± standard error. Standard deviations and subgroup details are reported as presented in the original articles. In cases where such information was not available, missing values in our tables reflect the absence of data in the primary sources.
Table 2. Thickness (mean ± standard deviation) of the DF from the literature—divided between LBP and non-LBP subgroups. Unique cell: not specified or not considered separately between LBP and non-LBP subjects. Gray cells: works that include LBP and non-LBP groups for comparisons. * Mean ± standard error. Standard deviations and subgroup details are reported as presented in the original articles. In cases where such information was not available, missing values in our tables reflect the absence of data in the primary sources.
ReferenceThickness (mm)
Non-LBPLBP
[28]1.33-
2.35
[4]-+25%
[5] *3.70 ± 0.40 (M)
4.10 ± 0.30 (F)		4.90 ± 0.30 (M)
4.10 ± 0.30 (F)
[29]-Before treatment (divided into two populations)
2.00 ± 0.64 and 1.80 ± 0.45 (right)
1.90 ± 0.50 and 1.78 ± 0.42 (left)
[30]-0.36 (left)
0.34 (right)
[31]2.56 ± 0.69 (left)
2.69 ± 0.67 (right)		-
[32]2.8
(median value and referred to by authors as SF)		-
[33]1.75 ± 0.852.11 ± 0.65
[20]<3.00-
[34]1.80 ± 0.601.80 ± 0.60
[35]1.60 ± 0.40 (right)
1.50 ± 0.40 (left)		1.70 ± 0.40 (right)
1.50 ± 0.40 (left)
[36]3.30 ± 0.90 (right)
3.50 ± 1.10 (left)		3.90 ± 1.30 (right)
4.00 ± 1.40 (left)
[37]3.90 (M)
3.20 (F)		4.10 (M)
3.50 (F)
[38]3.70 ± 1.10
[11] *1.93 (thoracic right)
1.82 (thoracic left)
2.44 (lumbar right)
2.42 (lumbar left)
4.29 (sacral right)
4.34 (sacral left)
[26]2.00-
[39] Users and non-users of hormonal contraceptives:
4.20 and 5.60 (1st measurement)
4.00 and 5.40 (2nd measurement)
[17]0.96 ± 0.15 (posterior layer)
0.41 ± 0.05 (middle layer)		-
[40]3.00 ± 0.50-

3.2. Superficial Fascia Thickness

Fascial tissue continuity, such as the connectivity among the SF and DF, paves the way to also study the SF in the LBP scenario, since alterations in the SF could have an impact on force transmission along the whole body.
The term “superficial fascia” appeared only at the end of the nineteenth century with studies on the abdomen and pelvis. In 1825, Velpau affirmed that it is present throughout the body, but unfortunately, no one systematically continued its characterization, thus creating difficulties in its identification and nomenclature [44].
Indeed, regarding SF thickness, in the literature, there is a paucity of significant works [26,27], with little to no data in the LBP scenario (due to a lack of data in terms of its correlation; see Table 3). The SF of the thoracolumbar region does not have a proper name like the deep one. It appeared as a fibroadipose structure made up of interconnected lamellae extending between the dermis and the DF [2]. Hammoudeh et al. [26] reported a higher average SF thickness in the posterior part of the thorax (0.6 mm). Abu-Hijleh et al. [27] evaluated the thickness of the membranous layer of the SF from formalin-fixed cadavers (potential bias for comparison with [26]) in different regions of the body, concluding that the arrangement and thickness varied according to body region, surface, and sex. In the posterior/back trunk, female thickness is significantly higher than the male thickness, and for females, the posterior region is thicker than the anterior abdominal wall.
Table 3. Thickness (mean ± standard deviation) of the SF from the literature—divided between LBP and non-LBP subgroups. Unique cell: not specified or not considered separately between LBP and non-LBP subjects. * Mean ± standard error.
Table 3. Thickness (mean ± standard deviation) of the SF from the literature—divided between LBP and non-LBP subgroups. Unique cell: not specified or not considered separately between LBP and non-LBP subjects. * Mean ± standard error.
ReferenceThickness (mm)
Non-LBPLBP
[26]0.600-
[27] *0.145 ± 0.015 (M)
0.165 ± 0.009 (F)

3.3. Subcutaneous Tissue Thickness

Subcutaneous tissues could provide more specific (local) information about fat distribution at a specific site (i.e., lumbar) than global body mass index (BMI). In the literature, different authors have investigated subcutaneous tissue thickness [4,23,26,30,32,36,37,41], even with some methodological differences in tissue localization (i.e., considering the fat component). In Table 4, the literature results on subcutaneous tissue thickness are reported, where an increase can be noted in LBP populations when compared to controls [4,23,36,37]. In addition, in some studies, LBP populations were older than controls. According to some authors [23], the mean subcutaneous fat thickness was thicker in symptomatic women than in men, while there was no significant difference in the asymptomatic groups. For example, refs. [36,37] demonstrated higher thickness in females than in males, in both LBP and non-LBP groups, where the female populations were older. The same authors [23] reported that subcutaneous tissue thickness was better than BMI in predicting symptomatic patients with LBP. For the abdomen (thus for a different region), Kanehisa et al. [45] evidenced that aging was associated with a decrement in muscle thickness and an increment in subcutaneous fat, rather than muscle thickness, which reflected waist circumference, regardless of age and sex. In terms of dysfunctions, Calvo-Lobo et al. [32] demonstrated that lumbar erector spinae contractile properties during tensiomyography assessments may be widely correlated with subcutaneous tissue thickness.
Table 4. Thickness (mean ± standard deviation) of subcutaneous tissue from the literature—divided between LBP and non-LBP subgroups. Unique cell: not specified or not considered separately between LBP and non-LBP subjects. Gray cells: works that include LBP and non-LBP groups for comparisons. * Data derived from Figure 3 of the cited study.
Table 4. Thickness (mean ± standard deviation) of subcutaneous tissue from the literature—divided between LBP and non-LBP subgroups. Unique cell: not specified or not considered separately between LBP and non-LBP subjects. Gray cells: works that include LBP and non-LBP groups for comparisons. * Data derived from Figure 3 of the cited study.
ReferenceThickness (mm)
Non-LBPLBP
[4] *4.8 ± 0.65.3 ± 0.5
[30]-8.32 (left)
[32]3.0 (median)-
[37]5.0 ± 1.9 (M)
7.4 ± 3.3 (F)		5.3 ± 2.9 (M)
11.1 ± 4.7 (F)
[36]6.4 ± 3.0 (right)
6.0 ± 2.8 (left)
5.0 ± 1.9 (M)
7.4 ± 3.3 (F)		8.6 ± 4.8 (right)
8.4 ± 4.7 (left)
5.3 ± 2.9 (M)
11.1 ± 4.7 (F)
[41]-25.4 (L3–L4)
29.1 (L4–L5)
32.2 (L5–S1)
[23]14.2 ± 8.7 (L1–L2)
14.8 ± 8.8 (L2–L3)
18.7 ± 10.4 (L3–L4)
25.6 ± 12.6 (L4–L5)
30.2 ± 13.3 (L5–S1)
10.8 ± 4.522.4 ± 9.7 (F)
17.9 ± 9.7 (M)
[26]<4.0-

4. Discussion

In recent decades, the fascial tissues have been demonstrated to play a key role in a variety of musculoskeletal dysfunctions, due to their force transmission capacity, structural properties to form special compartments (i.e., the SF around the subcutaneous vein, ensuring vessel patency [27]), and free nerve concentration that leads to a sensory organ. Therefore, fascial tissues have a fundamental role in non-specific musculoskeletal disorders (i.e., LBP). The aim of the present work was to investigate the morphology (i.e., thickness) of the soft tissues (i.e., SF, DF, and subcutaneous tissue) by collecting literature works investigating non-LBP and LBP subjects. Thickness values were reported to highlight their variability, also considering the influence of different biases (e.g., sex, age, spinal levels, and methods).

4.1. Answer to Research Question 1: Typical Thickness Values and Variability for SF, DF, and Subcutaneous Tissue in the Thoracolumbar Region in Asymptomatic Individuals

Table 2, Table 3 and Table 4 highlight the variability between different works and data reported. In healthy individuals, the DF showed cranio-caudal variability likely associated with the vertebral level, while the available data on SF in asymptomatic populations remain sparse, often limited to just two reported studies involving ultrasound (US) assessments, one of which was ex vivo. However, differences according to body regions have been reported by authors. The subcutaneous tissue has been extensively studied, particularly through US and MRI, showing variability along the cranio-caudal direction (caudal thicker). In general, further stratification according to factors such as age, sex, and BMI is needed to better define normal reference values.

4.2. Answer to Research Question 2: Thickness Variability in Relation to Factors Such as Clinical Conditions (i.e., Non-LBP vs. LBP Individuals), Age, Sex, and Surrounding Structures

In subjects with LBP, an equal or greater thickness of the TLF was found (i.e., US or ex vivo assessments); however, this result could have been influenced by biases, as in most cases, the subjects with LBP were older than the control groups. This aspect still has gaps that need deeper investigation to assess if LBP is strongly correlated with aging. Regardless, even if the sensitivity of the DF to hormonal changes was demonstrated by [39], a specific correlation between its thickness and age or sex is controversial.
Moreover, some authors have reported the impact of treatments on the change (e.g., reduction) in connective tissue thickness, but further considerations must be made on a case-by-case basis, considering both the specific treatment and the initial population (i.e., LBP or non-LBP). The paraspinal muscles (such as multifidus and erector spinae) are enveloped in fascial structures, thus becoming interesting targets in LBP investigation, as well as for statistical correlations with TLF thickness.
Regarding functional relationships, as an example, some authors [35] investigated the differences in TLF and multifidus between athletes with and without chronic LBP—also finding that chronic LBP subjects exhibited a greater disorganization of the TLF morphology in comparison to healthy athletes. Specifically, the same authors compared a cross-sectional area at resting and during muscle contraction, finding a reduced difference of multifidus cross-sectional area between the two scenarios when compared to a healthy control group. Therefore, in subjects with LBP, during muscle contraction, the tissue deformation is different compared to those without LBP, probably due to differences in the fasciae surrounding them (again, to report the continuity and influences among structures).
In the literature, there is a much larger number of studies (than for SF) regarding the thickness of the subcutaneous tissue (i.e., from US and MRI assessments). The results showed a thickening in subjects with LBP compared to controls, and in women compared to men (in LBP). In general, further research should be conducted on age- and sex-balanced cohorts to identify potential correlations with these variables and relative root causes. Furthermore, a correlation between the thickness of the subcutaneous tissue and the functionality of the muscles could be analyzed. In the literature, there are a variety of works that have discussed the quantity of paraspinal intramuscular fat infiltrations (e.g., MRI or magnetic resonance spectroscopy [46,47,48]) to analyze the implications of muscular tissue substitution with adipose tissue in case of dysfunctions. For example, Venkatesan et al. [43] affirmed that an increase in fat infiltration of paraspinal muscle, a decrease in the cross-sectional area of the lumbar multifidus, and an increase in TLF thickness characterize the degeneration of lumbar muscle in chronic LBP. Goubert et al. [49] demonstrated differences in muscle structure and muscle function between different LBP populations [41].

4.3. Sex and Age Differences

Although some studies have reported greater subcutaneous fat thickness in women and age-related muscle changes, the data are generally inconsistent due to unbalanced cohort designs. The DF may respond to hormonal changes [39], but its exact behavior across sex and age remains controversial.
Bhadresha et al. [41] observed that muscular content declines with age, and individuals with LBP showed more subcutaneous fat infiltration than controls. This aligns with the hypothesis that age, sex, and LBP interact in complex ways that influence the morphology of soft tissues in the thoracolumbar region.
To clarify these relationships, future studies should include age- and sex-balanced cohorts, with appropriate stratification and statistical analyses.

4.4. Clinical Relevance and Functional Implications

Fascial tissues, particularly the TLF, act in spinal stability and muscle function. Their thickening and disorganization in individuals with chronic LBP, as observed in athletes [35], suggest that these structural changes may contribute to dysfunctional movement patterns or persistent pain.
Specifically, reduced deformation of the multifidus during muscle contraction in LBP subjects implies altered mechanical interactions with the surrounding fascia. This further supports the concept of the fascia as a dynamic, responsive tissue, integral to musculoskeletal health.
The presence of increased subcutaneous fat, intramuscular fat infiltration, and fascial thickening in LBP cohorts could serve as potential biomarkers for dysfunction severity. Dynamic imaging tools, such as ultrasound, may enhance the clinical relevance of these markers by providing real-time insights into tissue behavior during movement or contraction.

4.5. Limitations and Future Developments

A limitation of this study is the fact that a meta-analysis was not conducted in terms of data correlations (thickness) with other variables such as age, BMI, sex, methods, spinal levels (only presented in a narrative form), and previous medical records. Moreover, from a methodological point of view, this review could be further extended in a systematic form and include additional reviewers for article screening and databases (i.e., Scopus).
Based on the thickness variation along the cranio-caudal direction, the differences reported in the DF could be correlated with the spinal level in future work.
This work also analyzed the SF as part of the fascia system, due to its proximity to the subcutaneous tissue and direct relationship with the DF through retinacula cutis [2]. Regarding the SF, only two results reported values from US and ex vivo assessments, reflecting the recent interest in this structure compared to others. However, a variation in terms of arrangement and thickness according to body regions, body surface area, and sex has been reported. However, this review highlights the limited knowledge currently available about this tissue.
Indeed, in addition to paraspinal muscle cross-sectional areas, intramuscular fat fraction was hypothesized to be a predictive biomarker for dysfunctions (e.g., pain and disability) and relative severity. This fat could be better investigated in relation to LBP (i.e., recurrence), aging, BMI, and TLF thickness. To investigate all of these properties and correlations, further studies could be conducted in the future, for example, through ultrasound dynamic evaluations.
Finally, a limitation of the present review is the restricted database search (PubMed and ScienceDirect), which may have led to the exclusion of relevant studies indexed in other databases such as Scopus or Embase. Future studies could expand the search strategy to enhance comprehensiveness.

5. Conclusions

The strength of this study is that it offers, for the first time, a comprehensive review of fascial tissue thickness (also in relation to subcutaneous tissue) in a non-LBP scenario, as well as a comparison (when data are available) with LBP groups.
The collected data show significant variability in the description of soft tissue properties and, consequently, a lack of standard references.
To conclude, morphological information of the fascia in LBP patient assessment/prevention/treatment, tissue engineering (e.g., [50]), and similar must be guided by the knowledge of their anatomical characteristics and variability, as well as the ones of the surrounding structure, in the LBP scenario. For example, in clinical practice, structures could be identified and interventions managed based on their properties, where thickness may be considered as a biomarker for musculoskeletal dysfunction through a classification approach. Indeed, the values collected in this review could be useful for the validation of automatic techniques that identify, segment, and classify these structures from bioimages. Finally, a practical implication is the possibility of targeting the treatment (e.g., physical therapy) on that specific fascial layer, and then monitoring the patient in the follow-up. In the future, a dynamic evaluation of fascial thickness can provide further insights about its deformability and, therefore, extend the knowledge to functional implications and rehabilitation. Indeed, fascial anatomy reveals a strong mechanical relationship between muscles and the deep fascia, both of which contribute to active movement and respond to passive motion. In contrast, the superficial fascia and retinacula cutis appear to be less directly involved in movement; however, their higher density of free nerve endings compared to deeper structures suggests a prominent role in peripheral sensory input, particularly in response to superficial pressure or subcutaneous alterations.
Thus, all of these findings highlight the role of fascial tissue variability as a potential hub to define corrective and preventive actions for patient- and site-specific evaluations and care.

Author Contributions

Conceptualization, L.B. and A.B.; data curation, formal analysis, investigation, methodology, and writing—original draft preparation, L.B.; project administration, resources, supervision, and visualization, C.G.F., A.B., and C.S.; writing—review and editing, C.G.F., A.B., C.S., L.B. and A.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
LBPLow back pain
BMIBody mass index
DFDeep fascia
TLFThoracolumbar fascia
SFSuperficial fascia
MRIMagnetic resonance imaging
USUltrasonography

References

  1. Bonaldi, L.; Berardo, A.; Fontanella, C.G. The Mechanical Behavior of the Fascial System. In Fascia, Function, and Medical Applications; CRC Press: Boca Raton, FL, USA, 2024; pp. 107–116. [Google Scholar]
  2. Stecco, C.; Hammer, W.; Vleeming, A.; De Caro, R. Functional Atlas of the Human Fascial System; Livingstone, C., Ed.; Elsevier Ltd.: Amsterdam, The Netherlands, 2015; ISBN 9780702044304. [Google Scholar]
  3. Langevin, H.M.; Sherman, K.J. Pathophysiological Model for Chronic Low Back Pain Integrating Connective Tissue and Nervous System Mechanisms. Med. Hypotheses 2007, 68, 74–80. [Google Scholar] [CrossRef] [PubMed]
  4. Langevin, H.M.; Stevens-Tuttle, D.; Fox, J.R.; Badger, G.J.; Bouffard, N.A.; Krag, M.H.; Wu, J.; Henry, S.M. Ultrasound Evidence of Altered Lumbar Connective Tissue Structure in Human Subjects with Chronic Low Back Pain. BMC Musculoskelet. Disord. 2009, 10, 151. [Google Scholar] [CrossRef]
  5. Langevin, H.M.; Fox, J.R.; Koptiuch, C.; Badger, G.J.; Greenan- Naumann, A.C.; Bouffard, N.A.; Konofagou, E.E.; Lee, W.N.; Triano, J.J.; Henry, S.M. Reduced Thoracolumbar Fascia Shear Strain in Human Chronic Low Back Pain. BMC Musculoskelet. Disord. 2011, 12, 203. [Google Scholar] [CrossRef]
  6. Ferreira, M.L.; de Luca, K.; Haile, L.M.; Steinmetz, J.D.; Culbreth, G.T.; Cross, M.; Kopec, J.A.; Ferreira, P.H.; Blyth, F.M.; Buchbinder, R.; et al. Global, Regional, and National Burden of Low Back Pain, 1990–2020, Its Attributable Risk Factors, and Projections to 2050: A Systematic Analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023, 5, e316–e329. [Google Scholar] [CrossRef]
  7. Buchbinder, R.; Underwood, M.; Hartvigsen, J.; Maher, C.G. The Lancet Series Call to Action to Reduce Low Value Care for Low Back Pain: An Update. Pain 2020, 161, S57–S64. [Google Scholar] [CrossRef]
  8. Vining, R.; Onifer, S.M.; Twist, E.; Ziegler, A.M.; Corber, L.; Long, C.R. Thoracolumbar Fascia Mobility and Chronic Low Back Pain: Phase 2 of a Pilot and Feasibility Study Including Multimodal Chiropractic Care. Chiropr. Man. Ther. 2022, 30, 46. [Google Scholar] [CrossRef]
  9. Simons, K.; Rapp, A.; Yilmaz, E.; Halalmeh, D.R.; Moisi, M.D. Innervation of the Thoracolumbar Fascia and Its Relationship to Lower Back Pain. Spine Sch. 2018, 2, 19–21. [Google Scholar] [CrossRef]
  10. Platzer, W. Color Atlas of Human Anatomy—Locomotor System, 6th ed.; Thieme Publishing Group: Stuttgart, Germany, 2014; Volume 1. [Google Scholar]
  11. Marpalli, S.; Mohandas Rao, K.G.; Venkatesan, P.; George, B.M. The Morphological and Microscopical Characteristics of Posterior Layer of Human Thoracolumbar Fascia; A Potential Source of Low Back Pain. Morphologie 2021, 105, 308–315. [Google Scholar] [CrossRef] [PubMed]
  12. Wilke, J.; Schleip, R.; Klingler, W.; Stecco, C. The Lumbodorsal Fascia as a Potential Source of Low Back Pain: A Narrative Review. BioMed Res. Int. 2017, 2017, 5349620. [Google Scholar] [CrossRef] [PubMed]
  13. Kondrup, F.; Gaudreault, N.; Venne, G. The Deep Fascia and Its Role in Chronic Pain and Pathological Conditions: A Review. Clin. Anat. 2022, 35, 649–659. [Google Scholar] [CrossRef]
  14. Willard, F.H.; Vleeming, A.; Schuenke, M.D.; Danneels, L.; Schleip, R. The Thoracolumbar Fascia: Anatomy, Function and Clinical Considerations. J. Anat. 2012, 221, 507–536. [Google Scholar] [CrossRef]
  15. Gatton, M.L.; Pearcy, M.J.; Pettet, G.J.; Evans, J.H. A Three-Dimensional Mathematical Model of the Thoracolumbar Fascia and an Estimate of Its Biomechanical Effect. J. Biomech. 2010, 43, 2792–2797. [Google Scholar] [CrossRef]
  16. Schilder, A.; Hoheisel, U.; Magerl, W.; Benrath, J.; Klein, T.; Treede, R.D. Sensory Findings after Stimulation of the Thoracolumbar Fascia with Hypertonic Saline Suggest Its Contribution to Low Back Pain. Pain 2014, 155, 222–231. [Google Scholar] [CrossRef]
  17. Creze, M.; Soubeyrand, M.; Nyangoh Timoh, K.; Gagey, O. Organization of the Fascia and Aponeurosis in the Lumbar Paraspinal Compartment. Surg. Radiol. Anat. 2018, 40, 1231–1242. [Google Scholar] [CrossRef] [PubMed]
  18. Brandl, A.; Wilke, J.; Egner, C.; Reer, R.; Schmidt, T.; Schleip, R. Thoracolumbar Fascia Deformation during Deadlifting and Trunk Extension in Individuals with and without Back Pain. Front. Med. 2023, 10, 1177146. [Google Scholar] [CrossRef] [PubMed]
  19. Brandl, A.; Egner, C.; Reer, R.; Schmidt, T.; Schleip, R. Associations between Deformation of the Thoracolumbar Fascia and Activation of the Erector Spinae and Multifidus Muscle in Patients with Acute Low Back Pain and Healthy Controls: A Matched Pair Case-Control Study. Life 2022, 12, 1735. [Google Scholar] [CrossRef]
  20. Kellis, E.; Kekelekis, A.; Drakonaki, E.E. Is Thoracolumbar Fascia Shear-Wave Modulus Affected by Active and Passive Knee Flexion? J. Anat. 2023, 244, 438–447. [Google Scholar] [CrossRef] [PubMed]
  21. D’Hooge, R.; Cagnie, B.; Crombez, G.; Vanderstraeten, G.; Dolphens, M.; Danneels, L. Increased Intramuscular Fatty Infiltration without Differences in Lumbar Muscle Cross-Sectional Area during Remission of Unilateral Recurrent Low Back Pain. Man. Ther. 2012, 17, 584–588. [Google Scholar] [CrossRef]
  22. Heuch, I.; Hagen, K.; Heuch, I.; Nygaard, Ø.; Zwart, J.-A. The Impact of Body Mass Index on the Prevalence of Low Back Pain The HUNT Study. Spine 2010, 35, 764–768. [Google Scholar] [CrossRef]
  23. Özcan-Ekşi, E.E.; Kara, M.; Berikol, G.; Orhun, Ö.; Turgut, V.U.; Ekşi, M.Ş. A New Radiological Index for the Assessment of Higher Body Fat Status and Lumbar Spine Degeneration. Skelet. Radiol. 2022, 51, 1261–1271. [Google Scholar] [CrossRef]
  24. Brooks, C.; Siegler, J.C.; Marshall, P.W.M. Relative Abdominal Adiposity Is Associated with Chronic Low Back Pain: A Preliminary Explorative Study. BMC Public Health 2016, 16, 700. [Google Scholar] [CrossRef]
  25. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews. BMJ 2021, 372, n71. [Google Scholar] [CrossRef] [PubMed]
  26. Hammoudeh, D.S.N.; Dohi, T.; Cho, H.; Ogawa, R. In Vivo Analysis of the Superficial and Deep Fascia. Plast. Reconstr. Surg. 2022, 150, 1035–1044. [Google Scholar] [CrossRef] [PubMed]
  27. Abu-Hijleh, M.F.; Roshier, A.L.; Al-Shboul, Q.; Dharap, A.S.; Harris, P.F. The Membranous Layer of Superficial Fascia: Evidence for Its Widespread Distribution in the Body. Surg. Radiol. Anat. 2006, 28, 606–619. [Google Scholar] [CrossRef]
  28. Wilke, J.; Macchi, V.; De Caro, R.; Stecco, C. Fascia Thickness, Aging and Flexibility: Is There an Association? J. Anat. 2019, 234, 43–49. [Google Scholar] [CrossRef]
  29. Devantéry, K.; Morin, M.; Grimard, J.; Gaudreault, N. Effects of a Myofascial Technique on the Stiffness and Thickness of the Thoracolumbar Fascia and Lumbar Erector Spinae Muscles in Adults with Chronic Low Back Pain: A Randomized before-and-after Experimental Study. Bioengineering 2023, 10, 332. [Google Scholar] [CrossRef] [PubMed]
  30. Sanjana, F.; Chaudhry, H.; Findley, T. Effect of MELT Method on Thoracolumbar Connective Tissue: The Full Study. J. Bodyw. Mov. Ther. 2017, 21, 179–185. [Google Scholar] [CrossRef]
  31. Yang, C.; Huang, X.; Li, Y.; Sucharit, W.; Sirasaporn, P.; Eungpinichpong, W. Acute Effects of Percussive Massage Therapy on Thoracolumbar Fascia Thickness and Ultrasound Echo Intensity in Healthy Male Individuals: A Randomized Controlled Trial. Int. J. Environ. Res. Public Health 2023, 20, 1073. [Google Scholar] [CrossRef]
  32. Calvo-Lobo, C.; Díez-Vega, I.; García-Mateos, M.; Molina-Martín, J.J.; Díaz-Ureña, G.; Rodríguez-Sanz, D. Relationship of the Skin and Subcutaneous Tissue Thickness in the Tensiomyography Response: A Novel Ultrasound Observational Study. Rev. Assoc. Med. Bras. 2018, 64, 549–553. [Google Scholar] [CrossRef]
  33. Pirri, C.; Pirri, N.; Guidolin, D.; Macchi, V.; Porzionato, A.; De Caro, R.; Stecco, C. Ultrasound Imaging of Thoracolumbar Fascia Thickness: Chronic Non-Specific Lower Back Pain versus Healthy Subjects; A Sign of a “Frozen Back”? Diagnostics 2023, 13, 1436. [Google Scholar] [CrossRef]
  34. Perez, A.M.; Fernández-Carnero, S.; Sicilia-Gomez-de-Parada, C.; Cuenca-Zaldívar, N.; Naranjo-Cinto, F.; Pecos-Martín, D.; Gallego-Izquierdo, T.; Nuñez-Nagy, S. Diaphragmatic Activation Correlated with Lumbar Multifidus Muscles and Thoracolumbar Fascia by B-Mode and M-Mode Ultrasonography in Subjects with and without Non-Specific Low Back Pain: A Pilot Study. Medicina 2023, 59, 315. [Google Scholar] [CrossRef]
  35. Almazán-Polo, J.; López-López, D.; Romero-Morales, C.; Rodríguez-Sanz, D.; Becerro-De-bengoa-vallejo, R.; Losa-Iglesias, M.E.; Bravo-Aguilar, M.; Calvo-Lobo, C. Quantitative Ultrasound Imaging Differences in Multifidus and Thoracolumbar Fasciae between Athletes with and without Chronic Lumbopelvic Pain: A Case-Control Study. J. Clin. Med. 2020, 9, 2647. [Google Scholar] [CrossRef] [PubMed]
  36. Larivière, C.; Gagnon, D.H.; Preuss, R. Structural Remodeling of the Lumbar Multifidus, Thoracolumbar Fascia and Lateral Abdominal Wall Perimuscular Connective Tissues: Medium-Term Test-Retest Reliability of Ultrasound Measures. J. Bodyw. Mov. Ther. 2021, 27, 265–273. [Google Scholar] [CrossRef]
  37. Larivière, C.; Preuss, R.; Gagnon, D.H.; Mecheri, H.; Henry, S.M. Structural Remodelling of the Lumbar Multifidus, Thoracolumbar Fascia and Lateral Abdominal Wall Perimuscular Connective Tissues: A Cross-Sectional and Comparative Ultrasound Study. J. Bodyw. Mov. Ther. 2020, 24, 293–302. [Google Scholar] [CrossRef]
  38. Larivière, C.; Henry, S.M.; Preuss, R. Structural Remodeling of the Lumbar Multifidus, Thoracolumbar Fascia and Lateral Abdominal Wall Perimuscular Connective Tissues: A Search for Its Potential Determinants. J. Anat. 2021, 238, 536–550. [Google Scholar] [CrossRef]
  39. Vita, M.; Sedlackova, Z.; Herman, M.; Furst, T.; Smekal, D.; Cech, Z. Influence of Female Hormones on Fascia Elasticity: An Elastography Study. Clin. Anat. 2019, 32, 941–947. [Google Scholar] [CrossRef]
  40. Loukas, M.; Shoja, M.M.; Thurston, T.; Jones, V.L.; Linganna, S.; Tubbs, R.S. Anatomy and Biomechanics of the Vertebral Aponeurosis Part of the Posterior Layer of the Thoracolumbar Fascia. Surg. Radiol. Anat. 2008, 30, 125–129. [Google Scholar] [CrossRef] [PubMed]
  41. Bhadresha, A.; Lawrence, O.J.; McCarthy, M.J.H. A Comparison of Magnetic Resonance Imaging Muscle Fat Content in the Lumbar Paraspinal Muscles with Patient-Reported Outcome Measures in Patients with Lumbar Degenerative Disk Disease and Focal Disk Prolapse. Glob. Spine J. 2016, 6, 401–410. [Google Scholar] [CrossRef]
  42. Stecco, A.; Bonaldi, L.; Fontanella, C.G.; Stecco, C.; Pirri, C. The Effect of Mechanical Stress on Hyaluronan Fragments’ Inflammatory Cascade: Clinical Implications. Life 2023, 13, 2277. [Google Scholar] [CrossRef] [PubMed]
  43. Venkatesan, P.; Soundararajan, K.; Kishen, T.J.; Janardhan, S.; Kumar CR, S. Comparison of Yoga and Dynamic Neuromuscular Stabilization Exercise in Chronic Low Back Pain on Magnetic Resonance Imaging of Lumbar Multifidus—Protocol for a Randomized Controlled Trial. Contemp. Clin. Trials Commun. 2022, 28, 100937. [Google Scholar] [CrossRef]
  44. Berardo, A.; Bonaldi, L.; Stecco, C.; Fontanella, C.G. Biomechanical Properties of the Human Superficial Fascia: Site-Specific Variability and Anisotropy of Abdominal and Thoracic Regions. J. Mech. Behav. Biomed. Mater. 2024, 157, 106637. [Google Scholar] [CrossRef] [PubMed]
  45. Kanehisa, H.; Miyatani, M.; Azuma, K.; Kuno, S.; Fukunaga, T. Influences of Age and Sex on Abdominal Muscle and Subcutaneous Fat Thickness. Eur. J. Appl. Physiol. 2004, 91, 534–537. [Google Scholar] [CrossRef] [PubMed]
  46. Rummens, S.; Bosch, S.; Dierckx, S.; Vanmechelen, A.; Peeters, R.; Brumagne, S.; Desloovere, K.; Peers, K. Reliability and Agreement of Lumbar Multifidus Volume and Fat Fraction Quantification Using Magnetic Resonance Imaging. Musculoskelet. Sci. Pract. 2022, 59, 102532. [Google Scholar] [CrossRef]
  47. Crook, J.; Masi, S.; Naghdi, N.; Roussac, A.; Rye, M.; Rosenstein, B.; Rivaz, H.; Boily, M.; Weber, M.H.; Fortin, M. Comparison of Multifidus Muscle Intramuscular Fat by Ultrasound Echo Intensity and Fat-Water Based MR Images in Individuals with Chronic Low Back Pain. Musculoskelet. Sci. Pract. 2023, 63, 102717. [Google Scholar] [CrossRef]
  48. Ogon, I.; Takebayashi, T.; Takashima, H.; Morita, T.; Yoshimoto, M.; Terashima, Y.; Yamashita, T. Quantitative Analysis Concerning Atrophy and Fat Infiltration of the Multifidus Muscle with Magnetic Resonance Spectroscopy in Chronic Low Back Pain. Spine Surg. Relat. Res. 2019, 3, 163–170. [Google Scholar] [CrossRef]
  49. Goubert, D.; De Pauw, R.; Meeus, M.; Willems, T.; Cagnie, B.; Schouppe, S.; Van Oosterwijck, J.; Dhondt, E.; Danneels, L. Lumbar Muscle Structure and Function in Chronic versus Recurrent Low Back Pain: A Cross-Sectional Study. Spine J. 2017, 17, 1285–1296. [Google Scholar] [CrossRef]
  50. Bonaldi, L.; Fontanella, C.G.; Stecco, C.; Berardo, A. Design, Implementation and Effectiveness of Human Fascia Lata Biomechanics for Tissue Engineering. J. Biomech. 2024, 176, 112369. [Google Scholar] [CrossRef] [PubMed]
Diagnostics 15 02059 g001
Figure 1. Flow diagram of the study selection process adapted for this narrative review. A total of 388 records were identified through database searches, and 16 through other sources. After removing 105 duplicates and 193 non-pertinent works, 106 records were screened by title and abstract. Of the 51 full-text articles assessed, 21 met the inclusion criteria and reported pertinent results regarding the research questions of this review; thus, they were included. Exclusion reasons included non-human studies, absence of quantitative data, or improper anatomical structure identification.
Figure 1. Flow diagram of the study selection process adapted for this narrative review. A total of 388 records were identified through database searches, and 16 through other sources. After removing 105 duplicates and 193 non-pertinent works, 106 records were screened by title and abstract. Of the 51 full-text articles assessed, 21 met the inclusion criteria and reported pertinent results regarding the research questions of this review; thus, they were included. Exclusion reasons included non-human studies, absence of quantitative data, or improper anatomical structure identification.
Diagnostics 15 02059 g001
Diagnostics 15 02059 g002
Figure 2. Example MRI (axial, T2-weighted) with the relative anatomical structures (created in BioRender. Bonaldi, L. (2025) https://BioRender.com/n2jgy4l).
Figure 2. Example MRI (axial, T2-weighted) with the relative anatomical structures (created in BioRender. Bonaldi, L. (2025) https://BioRender.com/n2jgy4l).
Diagnostics 15 02059 g002
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Bonaldi, L.; Berardo, A.; Stecco, A.; Stecco, C.; Fontanella, C.G. Assessment of the Fascial System Thickness in Patients with and Without Low Back Pain: A Narrative Review. Diagnostics 2025, 15, 2059. https://doi.org/10.3390/diagnostics15162059

AMA Style

Bonaldi L, Berardo A, Stecco A, Stecco C, Fontanella CG. Assessment of the Fascial System Thickness in Patients with and Without Low Back Pain: A Narrative Review. Diagnostics. 2025; 15(16):2059. https://doi.org/10.3390/diagnostics15162059

Chicago/Turabian Style

Bonaldi, Lorenza, Alice Berardo, Antonio Stecco, Carla Stecco, and Chiara Giulia Fontanella. 2025. "Assessment of the Fascial System Thickness in Patients with and Without Low Back Pain: A Narrative Review" Diagnostics 15, no. 16: 2059. https://doi.org/10.3390/diagnostics15162059

APA Style

Bonaldi, L., Berardo, A., Stecco, A., Stecco, C., & Fontanella, C. G. (2025). Assessment of the Fascial System Thickness in Patients with and Without Low Back Pain: A Narrative Review. Diagnostics, 15(16), 2059. https://doi.org/10.3390/diagnostics15162059

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop