Clinical Anatomy 32:929–933 (2019)

ORIGINAL COMMUNICATION

Fascial Nomenclature: Update on Related

Consensus Process
ROBERT SCHLEIP ,1,2,3* GIL HEDLEY,4 AND CAN A. YUCESOY5
1
Department of Neuroanesthesiology, Neurosurgical Clinic, Ulm University, Guenzburg, Germany
2
Department of Sports Medicine and Health Promotion, Friedrich Schiller University Jena, Jena, Germany
3
Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany
4
Integral Anatomy Productions LLC, Melbourne, Florida
5
Biomedical Engineering, Bogazici University, Istanbul, Turkey

The term fascia is increasingly used not only by anatomists but also by other pro-
fessionals and authors in different health-oriented fields. This goes along with an
inconsistent usage of the term, in which many different tissues are included by dif-
ferent authors causing an increasing amount of confusion. The Fascia Research
Society acted to address this issue by establishing a Fascia Nomenclature Commit-
tee (FNC) with the purpose of clarifying the terminology relating to fascia. This
committee conducted an elaborate Delphi process to foster a structured consen-
sus debate among different experts in the field. This process led to two distinct
terminology recommendations from the FNC, defining the terms “a fascia” and
“the fascial system.” This article reports on the process behind this proposed ter-
minology as well as the implications for inclusion and exclusion of different tissue
types to these definitions. Clin. Anat. 32:929–933, 2019. © 2019 The Authors. Clinical Anatomy
published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.

Key words: fascia; terminology; Delphi technique; nomenclature; connective

tissue

INTRODUCTION mesentery root—are then excluded. In contrast, more

osteopathic-oriented textbooks put great emphasis on
Hardly any area of anatomical science is character- the visceral fasciae (Paoletti, 2006; Schwind, 2006).
ized by such divergent terminology as is the case in the Similarly, there has been confusion about the question
field of fascia-related connective tissues. For many as to which of the three hierarchical muscular tissue
experts in the field, only dense sheet-like connective tis- containers–epimysium, perimysium, and endomysium–
sues are considered as “fascia,” and only if they express could be included as “fascia.” While most anatomists
more than one dominant fiber direction. Consequently, tend to agree to consider muscular septi and the perimy-
for a connective tissue to be regarded as fascia, its fiber sium to be fascial tissues, there is less consensus on the
arrangement is often considered to be “irregular.” How- endomysium due to its microscopic size and/or a higher
ever, such inference may be incorrect, particularly if, for quantity of collagen types III and IV which are also asso-
example, epimysial envelopes are considered in which ciated with a softer tissue structure. The resultant confu-
tissues, two main fiber directions are present that cross sion in language yields major difficulty in communication
each other in a regular manner at very specific angles
(Benetazzo et al., 2011). *Correspondence to: Robert Schleip, Department of
In contrast, other authors in this field also include Neuroanaesthesiology, Neurosurgical Clinic, Ulm University
very soft layers such as the areolar zones within the Ludwig-Heilmeyer-Str. 2, 89312 Guenzburg, Germany.
E-mail: [email protected]
hypodermis or as is found in the envelopes around tiny
vessels (Guimberteau and Armstrong, 2015). Some Received 24 April 2019; Revised 6 June 2019; Accepted 6
authors restrict the term “fascia” to muscular connec- June 2019
tive tissues (Landers, 2019). Visceral connective Published online 27 June 2019 in Wiley Online Library
tissues—like the mediastinum, the pericardium or the (wileyonlinelibrary.com). DOI: 10.1002/ca.23423

© 2019 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American
Association of Clinical Anatomists.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use,
distribution and reproduction in any medium, provided the original work is properly cited.
930 Schleip et al.

between different professionals in the field. Additionally, While such differentiation is easily possible in areas such
the lack of clarity in the terminology detracts from speci- as the human lower back (Benjamin, 2009; Willard et al.,
fying, scientifically/clinically addressing and communica- 2012), it becomes very cumbersome in other parts of the
tion of functionally important aspects of fasciae. For body, which express various transitions between unidirec-
example, muscular connective tissues have been shown tional and multidirectional textures, which is very often
to affect muscle function (Wilke et al., 2018) which indi- the case in the vicinity of major joints. In fact, as shown
cates several clinical implications (Yucesoy and Huijing, by the work of van der Wal (2009), tendons and apo-
2007) and endomysium, as an integral part of this sys- neuroses often do not insert directly into the skeleton;
tem plays a central role determining the muscle’s contri- instead, they tend to blend and connect with capsular and
bution to joint movement (Huijing, 1999). ligamentous tissues close to their attachments.
Several attempts have already been made by Figure 1A illustrates a description of the iliotibial band
respected international institutions to respond to this in which the respective authors attempted to apply proper
challenging situation. The International Anatomical terminology (in their case with multiple references to
Nomenclature Committee (1983) confirmed the usage Gray’s Anatomy) and to use the term “aponeurosis”—as
of previous nomenclature committees and used the term distinguished from other dense connective tissue bands
“fascia superficialis” for the entire loose layer of subcuta- and sheets–for dense connective tissue sheets which can
neous tissue lying superficial to the denser layer of “fascia be seen as direct extensions of skeletal muscle fibers
profunda.” While most medical authors in English- (Benjamin et al., 2008). In congruence with this clear ter-
speaking countries followed that terminology, authors in minological distinction, the authors went ahead and
other countries did not congruently adopt it. For example, excluded (and even excerpted) one of the sturdiest pieces
many Italian authors excluded the panniculus adiposus in their otherwise exemplary analysis of the iliotibial band
situated within this tissue layer, and most French authors because it did not fit their nomenclature. However, as can
continued to exclude both the panniculus adiposus and be seen on a novel anatomical dissection of the same
the textus connectivus laxus beneath the stratum structure shown in Figure 1B, the tissue portion excerpted
membranosum (Wendell-Smith, 1997). by the previous investigation constitutes one of the stur-
The subsequent international nomenclature, proposed diest elements of the upper leg and obviously plays a
by the Federative Committee on Anatomical Terminology major role in the tensional force-transmitting function of
(1998), therefore attempted to lead toward a more uni- the iliotibial band. It seems likely that any subsequent
form international language (Wendell-Smith, 1997). It analysis of the biomechanical function of the iliotibial tract
defined fascia as “sheaths, sheets or other dissectible con- will tend to be misleading if this important element is
nective tissue aggregations.” This includes “investments excluded. In fact, it seems that while using their scalpel
of viscera and dissectible structures related to them.” This in perfect adherence to the terminological distinctions
highly esteemed group of anatomical experts suggested of Terminologia Anatomica and Gray’s Anatomy, the
that future authors should no longer use the term “fascia” authors discarded one of the most important force-
for loose connective tissue layers and should instead apply transmitting elements from this structure.
the term “fascia” only to denser connective tissue aggre- Based on this and many similar points of critique on the
gations. Accordingly, they recommended against the use existing situation and on the increasing confusion of terms
of the old term “superficial fascia” as such (and to substi- (Stecco, 2014), the creation of a task force was suggested
tute “tela subcutanea” or “subcutaneous tissue”). Con- as a useful step toward building a consensus (Langevin,
gruent with this decision, this most recent international 2014). The proposed steps include the following:
Terminologia Anatomica even suggested excluding some
of the most frequently used “fascia” names in anatomy 1. “diverse points of view need to be heard. This
from their proposed definition. For example, they rec- means that the task force should include repre-
ommended that the commonly used term “Camper’s fas- sentatives from major stakeholders
cia” should be abandoned and be replaced by the term (i.e., individuals and groups who have already
“panniculus adiposus abdominis” (FCAT, 1998). published in this area)
This elegant attempt for the most part failed (Huijing 2. individuals who are not part of the task force need
and Langevin, 2009). Many English textbooks continued to have the opportunity to voice their opinions …
to use the terms “superficial fascia” or “Camper’s fascia” 3. consensus needs to be reached within the task
(Platzer, 2008; Netter, 2011; Tank, 2012). This included force
the 39th edition of Gray’s Anatomy (Standring, 2008), 4. recommendations need to be clear and published
while the following 40th edition started to follow the in such a way that people who are new to the
fascia-related recommendations of the Terminologia field can easily find them…” (Langevin, 2014).
Anatomica (Standring, 2015). In contrast, the rec-
ommended terminologies in the publications around the The Fascia Research Society acted to address this issue
Fascia Research Congress lineage (Findley and Schleip, by establishing a Fascia Nomenclature Committee (FNC)
2007; Huijing et al., 2009; Chaitow et al., 2012; Wearing in mid-2014. This article reports the activities and resul-
et al., 2015) do include tissues such as joint capsules, tant terminological recommendation from this group.
loose connective tissues, ligaments, and aponeuroses.
The critique of the latter group of authors has been well MATERIALS AND METHODS
formulated regarding the proposed distinction (in the
Terminologia Anatomica as well as Gray’s Anatomy) This group quickly reached out to all authors known to
between fasciae and aponeuroses (Schleip et al., 2012). them who had published on this topic in the English
 Fascial Nomenclature 931

language in academic journals to invite them for active

participation. In addition, the group decided to apply the
Delphi method as a structured and transparent commu-
nication process for fostering a statement of consensus
among a wide array of experts in a specific field (Adler
and Ziglio, 1996; von der Gracht, 2012). The process
included three written communication rounds, each of
which consisting of a questionnaire being distributed to
the experts, collecting and summarizing their responses,
and communicating this back to the same group. The
participants were always allowed to comment on the
responses of others, as well as on the proposed summa-
ries from the facilitators. A total of 21 experts partici-
pated in the three rounds of this process.
During the first two rounds, it became clear that,
given the wide range and disparity of perspectives
and linguistic traditions among the different profes-
sionals involved, it would not be possible, even with
multiple additional rounds of communication, to reach
a shared consensus about a single recommended
usage of the term “fascia.” The ongoing process,
therefore, aimed at a possible consensus regarding
several different and alternate definitions instead.
The third round of the Delphi process was already
structured as a preparation of a personal committee
meeting, being held in association with the 4th Fascia
Research Congress, Washington, 2015. Fifteen of the
previously participating experts, as well as four nonvoting
external guests, attended this meeting. As a major new
step toward achieving a comprehensive and practical ter-
minology, it was decided to establish two different fascia-
related definitions. One of those was proposed toward
detailed and distinction-oriented histological descrip-
tions, whereas the other definition aims to emphasize the
Fig. 1. (A) Example of a fascia dissection based on med- uniting character of the fascial net by recognizing the
ically “precise” terminology. This dissection image was used multijoint functional capacities of this body-wide continu-
in an otherwise excellent treatise on the iliotibial tract (ITT). ous network. A clear formulation for the former definition
Following the proposal of Gray’s Anatomy (Standring, 2008) was already achieved at this face-to-face meeting. A spe-
to distinguish between aponeuroses and fasciae, the authors cial task force was created at the same meeting with the
chose to describe this tissue as an aponeurosis and therefore aim of elaborating on the formulation of the later defini-
excluded all tissue portions with a non-aponeurotic character. tion with continuing input from the larger group of
Unfortunately, this included one of the sturdiest portions of experts. This report covers the final consensus of the
this structure: the connection to the lateral iliac crest, poste- FNC regarding both of the proposed definitions.
rior of the anterior superior iliac spine. Notice the common
thickening of the iliac crest at the former attachment of this RESULTS
ligamentous portion (located at a straight force transmission
line from the knee over the greater trochanter), reflecting The FNC delivered two different terminologies based
the very strong pull of this “ligamentous portion” of the ITT on different classifications. The first one—centered
on the pelvis. TFL, tensor fasciae latae. (B) Dissection of the around the term “a fascia”—is recommended for commu-
same structure based on the functional term “the fascial sys- nication of histological and topographical aspects on a
tem.” The strong densification of the “ligamentous portion” mesoscopic and microscopic scale. In contrast, the sec-
of the ITT on this preparation can be easily recognized, indi- ond terminology—using the term “the fascial system”—is
cated by the arrowhead. In addition, note the continuous recommended for the description of functional properties
transitions on the ITT between regions with a unidirectional on a macroscopic scale. Such functional properties
and others with a multidirectional fiber orientation. The spec- include force transmission, sensory functions (proprio-
imen is one of the first samples of the Fascial Net Plastination ception, interoception, and nociception), fluid transmis-
Projection of the Fascia Research Society, in which a three- sion, as well as the regulation of wound healing and
dimensional plastinated demonstration of “the fascial net” of fibrotic pathological processes (Tables 1 and 2).
the human body is attempted. (A) Illustration taken with
permission from Benjamin et al. (2008). (B) Illustration DISCUSSION
©FasciaResearchSociety.org/plastination, with support from
Gubener Plastinate GmbH. [Color figure can be viewed at While the recommended terms “a fascia” and “the
wileyonlinelibrary.com] fascial system” may not always fit well into the syntax
932 Schleip et al.

TABLE 1. Proposed histological/anatomical

definition, suggested by the FNC (Stecco and
Schleip, 2016; Stecco et al., 2018)

A fascia is a sheath, a sheet, or any other dissectible

aggregations of connective tissue that forms beneath
the skin to attach, enclose, and separate muscles and
other internal organs.

of a given specific linguistic context, the more con-

ventional terms “proper fascia” and “fascial tissues” Fig. 2. The nomenclature recommendations of the
may sometimes serve as useful replacements. FNC are based on the understanding that the wider and
The definition “a fascia” is very closely oriented on more functional term “the fascial net” (which some
the most recent fascia definition of the Terminologia authors replace by “fascial tissues”) describes a subset
Anatomica. Here, only planar tissues that can be dis- of tissues belonging to the connective tissue system of
sected with a conventional scalpel are included. In the body. Similarly, the term “a fascia” (also called
contrast, tissues like the endomysium or tendons, “proper fascia” by some authors) describes a subset of
which do not fulfill this criterion, are excluded. tissues within the larger category of “the fascial system.”
The second term “the fascial system” acknowl-
edges the increasingly popular concept of fascia as a
body-wide interconnected and prestretched fibrous The FNC considers this process to be an ongoing
network that is characterized—at least to some task. New anatomical research findings or novel deci-
degree—by the expression of tensegrity properties sions by other appointed medical nomenclature
(Findley, 2011). Here, all fibrous connective tissues groups, such as the Federative Committee on Anatom-
are included, which can be seen as elements of a ical Terminology, will conceivably constitute sufficient
body-wide tensional force-transmission system also reason for conducting subsequent Delphi process
including ligaments, tendons, joint capsules, and rounds among the available experts and for discussing
intramuscular connective tissues. It could be argued possible future amendments. As always have been,
that the term “the fascial system” may then be synon- contributions from additional experts in the field will be
ymous to the term “connective tissue.” However, welcome at any point of time during this process.
the newly proposed term differentiates from the
established medical terminology, in which, the term
“connective tissue” clearly includes bones, cartilage, ACKNOWLEDGMENTS
and even blood as former mesenchymal tissues.
The first term “a fascia,” therefore, describes a The above-described two definitions of “a fascia”
subset of dense planar tissues within the larger tissue and “the fascial system”—as described in the two
group described as “the fascial system,” which again tables of the Results section of this report—reflect the
can be understood as a subset within the even larger official recommendations of the FNC. All other remarks
group of tissues that are described as “connective tis- reflect the personal understanding of the authors
sues” in medicine (Fig. 2). based on their active participation in this committee
and should therefore not be misinterpreted as official
declarations of this committee.
The authors thank Carla Stecco and Sue Adstrum for
TABLE 2. Proposed functional definition, suggested their continued engagement in the FNC of the Fascia
by the FNC (Adstrum et al., 2017) Research Association. The same applies to Paulo Tozzi
for his past participation and most valuable contribu-
The fascial system consists of the three-dimensional tions to this group. The Fascia Research Society needs
continuum of soft, collagen containing, loose and to be acknowledged for financial support in conducting
dense fibrous connective tissues that permeate the the personal meeting of the FNC. In addition, the fol-
body. lowing experts need to be acknowledged for their active
It incorporates elements such as adipose tissue, participation in the FNC meeting at the Fascia Research
adventitiae and neurovascular sheaths, aponeuroses, Congress 2015 in addition to their participation in the
deep and superficial fasciae, epineurium, joint
previous Delphi process rounds: Sue Adstrum, Thomas
capsules, ligaments, membranes, meninges,
myofascial expansions, periostea, retinacula, septa, Findley, Jean-Claude Guimberteau, Thomas Hausner,
tendons, visceral fasciae, and all the intramuscular and Werner Klinger, Thomas Myers, Robert Schleip, Antonio
intermuscular connective tissues including Stecco, Carla Stecco, Can A. Yucesoy, Jaap van der Wal,
endomysium/perimysium/epimysium. Andry Vleeming, Scott Waring and Paolo Tozzi. Addi-
The fascial system surrounds, interweaves between, and tional input was contributed to the FNC by Wolfgang
interpenetrates all organs, muscles, bones, and nerve Bauermeister, Leon Chaitow, Markus Friedlin, Marco
fibers, endowing the body with a functional structure, Gesi and colleagues, Gil Hedley, Myroslava Kumka,
and providing an environment that enables all body Helene Langevin, Hanno Milesi, Sue Mirkin, Robert
systems to operate in an integrated manner.
Schmidhammer, John Sharkey and Graham Scarr.
 Fascial Nomenclature 933

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