Take a Step Back...Have you ever been in a situation where you`re pretty sure you have a case of primary nociceptive pain on your hands, but no matter what you have tried in your tool-kit so far, it hasn`t had the positive effect you`re wanting?

You may also be experiencing situations where patients are complaining of multiple areas of pain that don`t correspond or fit into the paradigms that we are familiar with, even as fully trained manual therapists. Perhaps what you may be missing is the fascial component, an often overlooked tissue category that may contribute to persistent musculoskeletal pain. Fascia is innervated, making it a potential pain generator and has strong mechanical presence that can restrict mobility if not addressed. As such it should be included in every therapist’s assessment and treatment repertoire.

Fascia is innervated making it a potential pain generator. It should be included in every therapist's repertoire.

An Old Concept

The concept of fascia as a contributor to musculoskeletal dysfunction is not new - the osteopathic profession has been talking about fascia for a number of years. However, other professionals are also beginning to explore the world of fascia, as witnessed by the explosion of research in this field and the number of participants from various professions in several International Fascia Research Conferences since 2007. Physiotherapists, with their varied skill-set in manual therapy are poised to "take on" this important tissue.

In my 35 year career I have amassed many wonderful tools in my tool box from multiple post-graduate courses that I have taken over the years. Despite this, I too have experienced my fair share of clinical frustrations and this has led me to explore this fascinating world of fascia. This approach to treatment has brought a deeper level of understanding to seemingly complex cases.

We as physiotherapists like to classify dysfunction as much as possible, thinking along the lines of joint dysfunction vs. muscle flexibility problems vs. recruitment imbalance etc., but the truth is that continuity between tissues does exist. We must be willing to think outside of the box and open up our approach to thinking more globally if we want to move forward with some of our more challenging cases.

The truth is that continuity between tissues does exist. We must be willing to think outside of the box.

A Little About Fascia

The impact of fascia on the motor control system and its neurophysiological implications cannot be overlooked as we consider the overall function of the patient. Fascia is present in epimysial & divisional layers of the musculo-skeletal system as well as in the fascial envelope layers of the organs and the perineural sheets of the nervous system. Improving mobility in one subsystem will affect mobility in other regions. Myofibroblasts are cells found in fascia – they are an intermediary between smooth muscle cells (ex. found in viscera, autonomic nerves) and traditional fibroblasts (cells that primarily build and maintain the collagenous matrix). These cells interpret mechanical signals and set up biochemical responses. What this means for us as physiotherapists is that we must let go of the traditional concept of fascia simply being a passive tension transmitter and embrace the concept that fascia is dynamically adaptable and an important tissue in cell regulation.


Another major concept in fascial anatomy is that the body is set up as a tensegrity system. Because of this, a pull on one corner of the connective tissue framework exerts a pull throughout the structure, affecting muscles, bone, nerve, blood vessels, glands and organs. An increase in tension of one of the members results in increased tension in members throughout the structure, even ones on the opposite side. An injury can arise unsuspectingly from long-term strains in other parts of the body. Small kinks in myofascial force transmission such as those provided by scars or adhesions have surprising functional consequences, often at some distance from the site.

Fascia can be irritated by many factors such as :

  • trauma- past or present (falls, blows)
  • surgery (scarring, adhesions)
  • mechanical stress (posture, repetitive movements)
  • chemical insults
  • endocrine effects
  • emotional stress

These insults may induce biochemical changes in the connective tissue which will, in turn, have effects on its viscoelastic properties. Its density may increase, the collagen fibers will tend to align along the axis of the lines of force and the tissue will lose elasticity.

So What Does Fascial Dysfunction Look Like

Goeffrey Maitland, one of the grandfathers of our profession as manual therapists, had a significant impact globally and one of his most important messages to us was the importance of a good subjective evaluation. This is true for all cases of musculo-skeletal pain but it is particularly important for cases of fascial dysfunction. A patient with this type of problem may present with the following subjective complaints:

  • "I feel tension in my leg overall, as if I am wearing a twisted pair of pantyhose"
  • "I know that other therapists and doctors have told me that my right leg and arm symptoms are separate problems but that`s not how it feels to me"

Other characteristics of myofascial pain include pain that is dull, aching, and often deep. It`s intensity may be low-grade to severe and there are frequently many areas of local tenderness. It does not follow dermatomal, myotomal, or sclerotomal patterns.

Objectively, we may find the following;

  • Difficulty maintaining effects of treatment despite good results obtained during treatment and despite the patient being faithful to whatever flexibility, postural or stabilization exercise you have shown him/her
  • Testing of individual joint mobility or muscle length is within normal limits but you note restriction with combined, functional movements.
  • The patients joints may even have a tendency to be hypermobile but they still present with ↓ ROM
  • Recurring dysfunction in a joint; for example, A/P mobs of the cervical spine chronically stiff

In this case we may then ask ourselves if this dysfunction is perhaps connected elsewhere along a fascial line, which may be a contributing factor to its recurrence. Tom Myers, a Structural Integrator from Maine, has written a fascinating book for therapists called "Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists”. This book has helped me understand the multiple ways muscles link and connect to transfer forces and support the body.

If we look at this example of the Deep Front Line of Fascia (Tom Myers; see chart to right) we note the continuity of fascia of the scalene muscles of the neck with the pericardium and mediastinum inside the thorax as well as the adductors of the thigh and the Tibialis Posterior which wraps under the foot. So with this concept in mind, we may choose, for example, to treat this recurring restriction by using A/P`s of the cervical spine in combination with DF/Eversion of the ankles which pre-tenses this line of fascia.

Clinical Treatment Example

Another example of using this concept in treatment is the following case:

I recently treated a middle-aged active woman with complaints of right low back pain (LBP). She had a history of previous LBP, successfully treated with a combination of mobilisations, IMS and stabilization exercises, but this time she just wasn`t responding to treatment. She also had a right fibular fracture 6 months prior and had recovered well from this injury. Her right Quadratus Lumborum was particularly painful, which she described as ``her pain``. Thinking more broadly, I knew that Quadratus Lumborum was part of Tom Myer`s lateral line of fascia (connecting QL with the ITB and lateral intercostals for example) but I did not find any such restriction in this patient. However, QL is also considered part of the Deep Front Line of Fascia which connects it to Tib Posterior (see diagram above). Here was the "AHA moment" I was looking for. 

Although her right foot mechanics were good, stretching her Tib Posterior in prone with DF/Eversion, I could feel a definite connection of a shortened fascial line with her right QL. This was felt through palpation - there was an immediate increase in tension of the right QL as soon as I began to DF/Evert her right foot. I released this tight fascial line in the same position as the test, using DF/Ev of the right foot in an oscillatory fashion while maintaining a constant pressure on the QL. I also made sure to release other aspects of this same fascial line, for example, releasing the iliacus fascia with DF/Ev of the foot, as this muscle is also fascially connected to the QL. Two treatments later, she was pain-free and once again enjoying her sporting activities.

This concept of myofascial continuities has become a framework for understanding not only static postural support but dynamic and optimal movement. Knowledge of fascial connections helps us understand how to direct our approach at the source of the problem (the criminal) and not merely the painful tissue (the victim). To quote Robert Schleip, a prominent researcher and author in the field of fascia, ``After several decades of severe neglect, this "Cinderella of orthopaedic science" is developing its own identity within medical research".

Welcome to the world of fascia!

Resources:

  • Tom Myers, ``Anatomy Trains, second edition``, Churchill Livingstone, 2009
  • Schleip, Robert, ``Fascia is able to contract in a smooth muscle-like manner and therby influence musculoskeletal mechanics`` 6th Interdisciplinary World Congress on Low Back & Pelvic Pain, Nov 2007
  • Schleip, R., Finfley, T., Chaitow, L., Huijing,P. ``Fascia: The Tensional Network of the Human Body``, Churchill Livingstone, Elsevier, 2012