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Fascia:The Tensional Networkof the Human BodyThe science and clinical applications in manualand movement therapy

E d i t e d b y

Robert Schleip PhD, MA

Director Fascia Research Project, Division of Neurophysiology, Ulm University,

Germany; Research Director European Rolfing Association; Vice President Ida P. Rolf

Research Foundation; Certified Rolfing & Feldenkrais Teacher

Thomas W Findley MD, PhD

Director of Research for the Rolf Institute of Structural Integration; Director of the

Center for Healthcare Knowledge Management, VA Medical Center, East Orange NJ;

Professor of Physical Medicine, UMDNJ - New Jersey Medical School, Newark, New

Jersey USA;

Leon Chaitow ND, DO (UK)

Registered Osteopath and Naturopath; Honorary Fellow and Former Senior Lecturer,

School of Life Sciences, University of Westminster, London, UK; Fellow, British

Naturopathic Association

Peter A Huijing PhD

Professor emeritus Functionality of the locomotor system Research Instituut MOVE,

Faculteit Bewegingswetenschappen, Vrije Universiteit, Amsterdam, The Netherlands

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2012

Contents

On-line video resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Color plate

Section I Scientific foundations . . . . . . . . . . . . . . . . . . . . . . . . . . 1Section Editors: Robert Schleip and Peter A Huijing

PART 1 Anatomy of the fascial body

1.1 General anatomy of the muscle fasciae . . . . . . . . . . . . . . . . . . . . . . 5Peter P Purslow and Jean-Paul Delage

1.2 Somatic fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Frank H Willard

1.3 Fascia superficialis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Marwan Abu-Hijleh, Amol Sharad Dharap and Philip F Harris

1.4 Deep fascia of the shoulder and arm . . . . . . . . . . . . . . . . . . . . . . . 25Carla Stecco and Antonio Stecco

1.5 Deep fascia of the lower limbs . . . . . . . . . . . . . . . . . . . . . . . . . . 31Carla Stecco and Antonio Stecco

1.6 The thoracolumbar fascia: An integrated functional view of theanatomy of the TLF and coupled structures . . . . . . . . . . . . . . . . . . . 37Andry Vleeming

1.7 The deeper fasciae of the neck and ventral torso . . . . . . . . . . . . . . . . 45Rainer Breul

1.8 Visceral fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Frank H Willard

1.9 Membranous structures within the cranial bowl and intraspinal space . . . . 57Torsten Liem and Ralf Vogt

1.10 Diaphragmatic structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Serge Paoletti

PART 2 Fascia as an organ of communication

2.1 Fascia as an organ of communication . . . . . . . . . . . . . . . . . . . . . . 77Robert Schleip

2.2 Proprioception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Jaap C van der Wal

2.3 Interoception: A new correlate for intricate connections between fascialreceptors, emotion, and self recognition . . . . . . . . . . . . . . . . . . . . . 89Robert Schleip and Heike Jager

v

2.4 Nociception: The thoracolumbar fascia as a sensory organ . . . . . . . . . . 95Ulrich Hoheisel, Toru Taguchi and Siegfried Mense

2.5 Fascia as a body-wide communication system . . . . . . . . . . . . . . . . 103James L Oschman

PART 3 Fascial force transmission

3.1 Force transmission and muscle mechanics: General principles . . . . . . . 113Peter A Huijing

3.2 Myofascial force transmission: An introduction . . . . . . . . . . . . . . . . 117Peter A Huijing

3.3 Myofascial chains: A review of different models . . . . . . . . . . . . . . . 123Philipp Richter

3.4 Anatomy Trains and force transmission . . . . . . . . . . . . . . . . . . . . 131Thomas Myers

3.5 Biotensegrity: The mechanics of fascia . . . . . . . . . . . . . . . . . . . . 137Stephen M Levin and Daniele-Claude Martin

3.6 The subcutaneous and epitendinous tissue behavior of themultimicrovacuolar sliding system . . . . . . . . . . . . . . . . . . . . . . . 143Jean Claude Guimberteau

PART 4 Physiology of fascial tissues

4.1 The physiology of fascia: An introduction . . . . . . . . . . . . . . . . . . . 149Frans Van den Berg

4.2 Fascia is alive: How cells modulate the tonicity and architecture of fascialtissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157Robert Schleip, Heike Jager and Werner Klingler

4.3 Extracellular matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165Frans Van den Berg

4.4 The influence of pH and other metabolic factors on fascial properties . . . 171Jorg Thomas and Werner Klingler

4.5 Fluid dynamics in fascial tissues . . . . . . . . . . . . . . . . . . . . . . . . 177Guido F Meert

Section II Clinical application . . . . . . . . . . . . . . . . . . . . . . . . . 183Section Editors: Thomas W Findley and Leon Chaitow

PART 5 Fascia-related disorders

5.1 Fascia-related disorders: An introduction . . . . . . . . . . . . . . . . . . . 187Thomas W Findley

5.2 Dupuytren’s disease and other fibrocontractive disorders . . . . . . . . . . 191Ian L Naylor

5.3 “Frozen shoulder” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199Axel Schultheis, Frank Reichwein and Wolfgang Nebelung

Contents

vi

5.4 Spastic paresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207Mick Kreulen, Mark JC Smeulders and Peter A Huijing

5.5 Diabetic foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Sicco A Bus

5.6 Scleroderma and related conditions . . . . . . . . . . . . . . . . . . . . . . 225Tanya M Ball

5.7 Trigger points as a fascia-related disorder . . . . . . . . . . . . . . . . . . . 233Roland U Gautschi

5.8 Fascia-related disorders: Hypermobility . . . . . . . . . . . . . . . . . . . . 245Nicol C Voermans and Peter A Huijing

5.9 Anatomy of the plantar fascia . . . . . . . . . . . . . . . . . . . . . . . . . . 253Scott Wearing

PART 6 Diagnostic procedures for fascial elasticity

6.1 Diagnostic procedures for fascial elasticity: An introduction . . . . . . . . 265Thomas W Findley

6.2 Fascial palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269Leon Chaitow, Patrick Coughlin, Thomas W Findley and Thomas Myers

6.3 Hypermobility and the hypermobility syndrome: Assessment andmanagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279Jane Simmonds

PART 7 Fascia-oriented therapies

7.1 Inclusion criteria and overview . . . . . . . . . . . . . . . . . . . . . . . . . 293Leon Chaitow

7.2 Trigger point therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297Jan Dommerholt

7.3 Rolfing structural integration . . . . . . . . . . . . . . . . . . . . . . . . . . . 303Monica Caspari and Heidi Massa

7.4 Myofascial induction approaches . . . . . . . . . . . . . . . . . . . . . . . . 311Andrzej Pilat

7.5 Osteopathic manipulative therapies and fascia . . . . . . . . . . . . . . . . 319Hollis H King

7.6 Connective tissue manipulation . . . . . . . . . . . . . . . . . . . . . . . . . 327Stephanie A Prendergast and Elizabeth H Rummer

7.7 Fascial manipulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335Carla Stecco and Antonio Stecco

7.8 Managing dysfunctional scar tissue . . . . . . . . . . . . . . . . . . . . . . 343Petra Valouchova and Karel Lewit

7.9 Acupuncture as a fascia-oriented therapy . . . . . . . . . . . . . . . . . . . 349Dominik Irnich and Johannes Fleckenstein

7.10 Gua sha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359Arya Nielsen

Contents

vii

7.11 Prolotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367Manuel F Cusi

7.12 Neural therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375Rainer Wander and Stefan Weinschenk

7.13 Dynamic fascial release – manual and tool assisted vibrationaltherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383Zachary Comeaux

7.14 Graston techniquet: A contemporary instrument assisted mobilizationmethod for the evaluation and treatment of soft tissue lesions . . . . . . . 391Warren I Hammer

7.15 The fascial distortion model . . . . . . . . . . . . . . . . . . . . . . . . . . . 397Georg Harrer

7.16 Frequency-specific microcurrent . . . . . . . . . . . . . . . . . . . . . . . . 405Carolyn McMakin

7.17 Surgery and scarring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411Willem J Fourie

7.18 Temperature effects on fascia . . . . . . . . . . . . . . . . . . . . . . . . . . 421Werner Klingler

7.19 Neurodynamics: Movement for neuropathic pain states . . . . . . . . . . . 425Michel W Coppieters and Robert J Nee

7.20 Stretching and fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433Thomas Myers and Christopher Frederick

7.21 Fascia in yoga therapeutics . . . . . . . . . . . . . . . . . . . . . . . . . . . 441Thomas Myers

7.22 Pilates and fascia: The art of “working in” . . . . . . . . . . . . . . . . . . . 449Marie-Jose Blom

7.23 Nutrition model to reduce inflammation in musculoskeletaland joint diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457Mary T Hankinson and Elizabeth A Hankinson

7.24 Fascial fitness: Suggestions for a fascia-oriented training approachin sports and movement therapies . . . . . . . . . . . . . . . . . . . . . . . 465Divo G Muller and Robert Schleip

Section III Research directions . . . . . . . . . . . . . . . . . . . . . . . . 477Section Editor: Peter A Huijing

PART 8 Fascia research: Methodological challenges and new directions

8.1 Fascia: Clinical and fundamental scientific research: Consideringthe scientific process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481Peter A Huijing

8.2 Imaging: Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483Helene Langevin and Yasuo Kawakami

8.3 Advanced MRI techniques for in-vivo biomechanical tissue movementanalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489Cengizhan Ozturk, Alper Yaman, Can A Yucesoy and Peter A Huijing

Contents

viii

8.4 Roles of fascia in molecular biology of adaptation of muscle size . . . . . 497Richard T Jaspers, Can A Yucesoy and Peter A Huijing

8.5 Mathematical modeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503Can A Yucesoy and Peter A Huijing

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511Heike Jager

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515

Contents

ix

Contributors

Marwan F Abu-Hijleh MBBCh, PhD, MHPE

Professor & Chairman, Department of Anatomy, College ofMedicine & Medical Sciences, Arabian Gulf University,Bahrain

Tanya M Ball MSc BA BCSI LSSM

Board Certified KMIt Structural Integrator/Sports Massage and Remedial Therapist & Tutor,Basingstoke, UK

Frans van den Berg PT, MT, OMT, BSc

Senior Instructor Orthopaedic Manual Therapy, Zell amMoos, Austria

Marie-Jose BlomMovement educator and Pilates Master Teacher.Founder/President of SmartSpine Works co, LLC andLong Beach Dance Conditioning inc. Internationalpresenter/lecturer, Marina Del Rey, Ca USA

Rainer Breul Dr rer nat med habil, DO h.c.

Professor of Anatomy, Professor of Osteopathy LudwigMaximilian University, Munich, Germany

Sicco A Bus PhD

Senior Investigator and Head Human PerformaceLaboratory, Department of Rehabilitation, AcademicMedical Center, University of Amsterdam, The Netherlands

Monica Caspari BN, RSFaculty member, Rolf Institute of Structural Integration,Boulder CO USA; Certified Advanced Rolfer, RolfMovement Integration Practitioner, Sao Paulo, Brazil

Leon Chaitow ND, DO

Registered Osteopath and Naturopath; Honorary Fellowand Former Senior Lecturer, School of Life Sciences,University of Westminster, London, UK; Fellow, BritishNaturopathic Association

Zachary Comeaux DO (US), FAAO

Professor, Division of Osteopathic Principles and Practice,West Virginia School of Osteopathic Medicine, Lewisburg,WV, USA

Michel W Coppieters PT, PhD

Associate Professor, School of Health and RehabilitationSciences, The University of Queensland, St Lucia, Australia

Manuel F CusiMBBS,CertSpMed(RACGP),FACSP,FFSEM(UK)

Conjoint Lecturer, Faculty of Medicine, University of NewSouth Wales; Sport & Exercise Medicine Physician inprivate practice, Sydney, Australia

Patrick Coughlin PhD

Professor, Dept. of Basic Sciences, The CommonwealthMedical College, Scranton, PA, USA

Jean-Paul Delage PhD

Inserm U 1034 (Adaptation cardiovasculaire a l’ischemie)Universite Victor Segalen, Bordeaux, France

Amol Sharad Dharap MBBS, MS

Assistant Professor of Anatomy, Arabian Gulf University,Bahrain

Jan Dommerholt PT, DPT, MPS

Physical Therapist, Bethesda Physiocare/MyopainSeminars, Bethesda, MD, USA; Adjunct AssociateProfessor, Shenandoah University, Winchester, VA, USA;Associate Professor, Universidad CEU Cardenal Herrera,Valencia, Spain

Thomas W Findley MD, PhD

VA Medical Center, East Orange NJ; Professor of PhysicalMedicine, UMDNJ - New Jersey Medical School, NewarkNJ, USA

Johannes Fleckenstein MD

Registrar in Anaesthesia, Multidisciplinary Pain Centre,Department of Anaesthesiology, University of Munich,Germany

Willem J Fourie PT, MSc

Private practitioner, Johannesburg, South Africa

Chris Frederick PT

Physical Therapist; KMI Certified Structural Integrator;Co-founder Stretch to Win Institute for Fascial StretchTherapy, Tempe, AZ, USA

xi

Roland U Gautschi MA, dipl. PT

Senior-Instructor Triggerpoint-Therapy IMTTt,Baden, Switzerland

Jean Claude Guimberteau MD

Plastic surgeon and Hand surgeon. Scientific DirectorInstitut Aquitain de la Main. Institut Aquitain de la main,Pessac, France

Warren I Hammer DC, MS, DABCO

Doctor of Chiropractic, Norwalk, CT, USA PostgraduateFaculty, New York Chiropractic College

Elizabeth A Hankinson BA

Study Coordinator, Amyloid Treatment and ResearchProgram, Boston University School of Medicine, Boston,Massachussetts, USA

Mary Therese Hankinson MBA, MS, RD, EDAC

Patient Centered Care (Planetree) Coordinator, VA NJHealth Care System, Former Dietetic Internship Director,VA NJ Health Care System, East Orange, NJ USA

Georg Harrer MD

Anesthesiologist Rudolfstiftung Community Hospital,Vienna, Austria; FDM Instructor; Past President ofEuropean Fascial Distortion Model Association,Vienna, Austria

Philip F Harris MD, MSc, MB,ChB

Professor Emeritus of Anatomy, University ofManchester, UK

Ulrich Hoheisel Dr. rer. nat.Medical Faculty Mannheim, University of Heidelberg,Heidelberg, Germany

Peter Huijing PhD

Professor Emeritus Functionality of the locomotorsystem, Research Instituut MOVE, FaculteitBewegingswetenschappen, Vrije Universiteit,Amsterdam, The Netherlands

Dominik Irnich PD, Dr. Med

Head of the Multidisciplinary Pain Centre, Department ofAnesthesiology, University of Munich, Germany

Heike Jager PhDDivision of Neurophysiology – Fascia Research, Universityof Ulm, Germany

Richard Jaspers PhD

Assistant Professor, Research Institute MOVE, FaculteitBewegingswetenschappen, Vrije Universiteit, Amsterdam,The Netherlands

Yasuo Kawakami PhDProfessor, Faculty of Sport Sciences, Waseda University,Tokyo, Japan

Hollis H. King DO, PhD

Professor & OPP Program DirectorUniversity of Wisconsin Department of Family MedicineMadison, WI, USA

Werner Klingler MD, PhD

Division of Neurophysiology, Ulm University, GermanyNeuroanesthesia, Neurosurgical University Hospital,Ulm-Guenzburg, Germany

Mick Kreulen MD, PhD

Plastic surgeon, Department of Plastic, European boardcertified handsurgeon, Reconstructive and Hand Surgery,Academic Medical Centre, University of Amsterdam, TheNetherlands

Helene M. Langevin MD

Professor, Department of Neurology, University ofVermont, Burlington, USA

Stephen M. Levin MD, FACS

Director, Ezekiel Biomechanics Group, McLean, VA, USA

Karel Lewit MD, DSc

Professor of Medicine, Charles University, Prague,Czech Republic

Torsten Liem DO, MSc Ost, MSc paed Ost

Vice-principal, German School of Osteopathy/OsteopathieSchule Deutschland, Hamburg, Germany

Carolyn McMakin MA, DC

Clinical Director, Fibromyalgia and Myofascial Pain Clinic ofPortland, Oregon; President, Frequency SpecificSeminars, Washington, USA

Daniele-Claude Martin PhD

Movement researcher and trainer, Munich, Germany

Heidi Massa BA, JD

Certified Advanced Rolfer, Rolf Movement, IntegrationPractitioner, Chicago, IL, USA

Guido F Meert PT, DOAcademic principal and lecturer, DeutschesFortbildungszentrum fur Osteopathie (GermanOsteopathic Skill Centre), Neutraubling-Regensburg,Germany

Siegfried Mense MD

Senior Professor of Anatomy, Medical Faculty Mannheim,University of Heidelberg, Germany

Contributors

xii

Divo Gitta Muller HPContinuumMovement teacher, reg. naturopath, Director ofBodybliss, Munich, Germany.

Thomas Myers LMT

Director, Kinesis Incorporated, ME, USA

Ian L Naylor BPharm, MSc, PhD

Senior Lecturer, School of Pharmacy, Universityof Bradford, UK

Wolfgang Nebelung PD, Dr. Med

Arthroscopy Department – Sports Orthopaedics,Marienkrankenhaus Kaiserswerth, Dusseldorf, Germany

Robert J. Nee PT, MAppSc

PhD Candidate, Division of Physiotherapy, School ofHealth and Rehabilitation Sciences, The University ofQueensland, St Lucia, Australia

Arya Nielsen PhD

Professor of East Asian Medicine; Faculty Beth IsraelMedical Center, New York, USA

James L. Oschman PhD

President, Nature’s Own Research Association, Dover,NH, USA

Cengizhan Ozturk MD, PhD

Professor, Institute of Biomedical Engineering, BogaziciUniversity, Istanbul, Turkey

Serge Paoletti DO, MROF

Osteopath, Chambery, France; Postgraduate teacher,Osteopathic school, University of Saint Petersburg,St Petersburg, Russia

Andrzej Pilat PTDirector Myofascial Therapy School “Tupimek”, Madrid,Spain; Postgraduate Program Physiotherapy SchoolONCE, Universiad Autonoma, Madrid, Spain

Stephanie A Prendergast MPT

Physical Therapist, Co-owner, Pelvic Health andRehabilitation Center, San Francisco, CA, USA

Peter P Purslow BSc, PhD

Professor of Food Science, University of Guelph, Guelph,Ontario, Canada

Frank Reichwein Dr. med.

Arthroscopy Department – Sports Orthopaedics,Marienkrankenhaus Kaiserswerth, Dusseldorf, Germany

Philipp Richter DO

Osteopath, Burg Reuland, Belgium

Elizabeth H Rummer MSPT

Physical Therapist, Co-owner, Pelvic Health andRehabilitation Center, San Francisco, CA, USA

Robert Schleip PhD, MA

Director Fascia Research Project, Division ofNeurophysiology, Ulm University, Germany; ResearchDirector European Rolfing Association;Vice President Ida P. Rolf Research Foundation;Certified Rolfing & Feldenkrais Teacher

Axel Schultheis Dr. med.

Arthroscopy Department – Sports Orthopaedics,Marienkrankenhaus Kaiserswerth, Dusseldorf, Germany

Jane Simmonds PD, MA, BAppSc (Physio), BPE

Medical advisor HMSA and UK EDS support groupProgramme Lead – MSc Sport and Exercise RehabilitationUniversity of Hertfordshire, UK

Mark J C Smeulders MD, PhD

Research director, Department of Plastic, Reconstructiveand Hand Surgery, Academic Medical Centre, University ofAmsterdam, The Netherlands

Antonio Stecco MD

Physical Medicine and Rehabilitation specialist, Universityof Padova, Padua, Italy

Carla Stecco MD

Research Fellow and Orthopaedic surgeon, University ofPadova, Padua, Italy

Toru Taguchi DScAssistant Professor of Neuroscience, Research Institute ofEnvironmental Medicine, Nagoya University, Nagoya, Japan

Jorg Thomas MD

Doctor of medicine, Department of Anesthesiology,University of Ulm, Ulm, Germany

Petra Valouchova PhD, PT

Lecturer, School of Medicine, Charles University, Prague,Czech Republic

Andry Vleeming PhD

Prof. at Department of Rehabilitation, Medical UniversityGhent Belgium, Department of Anatomy, MedicalUniversity of New England, Maine, USA

Nicol Voermans MD, PhD

Neurologist, RadboudUniversity NijmegenMedical Centre,Nijmegen, The Netherlands

Contributors

xiii

Ralf Vogt DOOsteopath, Dietenheim, Germany

Jaap C van der Wal MD, PhD

Senior Lecturer in Anatomy and Embryology (retired),University of Maastricht, Maastricht, The Netherlands

Rainer Wander Dr. med.

President DGfAN [German Society for Acupuncture andNeural therapy], Elsterberg, Germany

Scott Wearing PhD

Research Program Leader (Injury Management), Centreof Excellence for Applied Sport Science Research,Queensland Academy of Sport, Brisbane, AustraliaAssociate Professor and Smart Futures Fellow, Facultyof Health Sciences and Medicine, Bond University, GoldCoast, Australia

Stefan Weinschenk Dr. med.

Ambulanz fur Naturheilkunde und integrativeMedizin, Universitatsfrauenklinik Heidelberg,Germany

Frank Willard PhD

Professor of Anatomy, University of New England, Collegeof Osteopathic Medicine, Biddeford, USA

Alper Yaman PhD

PhD candidate, Institute of Biomedical Engineering,Bogazici University, Istanbul, Turkey

Can A Yucesoy PhD

Associate Professor of Biomedical Engineering,Institute of Biomedical Engineering, Bogazici University,Istanbul, Turkey

Contributors

xiv

Introduction

Welcome to the world of fascia!

Thisbook is the first comprehensive text in anewfieldin musculoskeletal therapy and research: the fasci-nating world of fascia. Fascia forms a continuous ten-sional network throughout the human body, coveringand connecting every single organ, every muscle, andeveneverynerveor tinymuscle fiber.After several de-cades of severe neglect, this “Cinderella of orthopedicscience” is developing its own identitywithinmedicalresearch. The number of research papers on fascia inpeer-reviewed journals has shown a steady rise. Thefirst International Fascia Research Congress, held atthe Conference Center, Harvard Medical SchoolinOctober 2007was followed by a second in Amster-dam in 2009 and there will shortly be a third inVancouver in 2012. Similar to the rapidly growingfieldof glia research inneurology, thisunderestimatedcontextual tissue, fascia, is being found to play animportant role in health and pathology.

Hypotheses which accord myofascia a central rolein the mechanisms of therapies have been advancedfor some time in the fields of acupuncture, massage,structural integration, chiropractic and osteopathy.Practitioners in these disciplines, especially thosewhich do not have the longevity of osteopathy or chi-ropractic, are generally unaware of the scientific basisfor evaluating such hypotheses. Many practitionersare unaware of the sophistication of current labora-tory research equipment and methods. Laboratoryresearchers, in turn, may be unaware of the clinicalphenomena which suggest avenues of exploration.Thirty years ago the study of physical medicine andrehabilitation included muscle strengthening, anat-omy, exercise physiology, and other aspects of ther-apeutic modalities. What was notably less presentin the scientific and medical literature was how tounderstand and treat disorders of the fascia and con-nective tissues. Since then much additional infor-mation has been developed, particularly since 2005(see Fig. 0.1).

The purpose of this book is to organize relevant in-formation for scientists involved in the research ofthe body’s connective tissue matrix (fascia) as well

as for professionals involved in the therapeutic ma-nipulation of this body wide structural fabric. Whileit grew out of materials presented at the First and theSecond International Fascia Research Congresses in2007 and 2009 (www.fasciacongress.org), it reflectsthe efforts of almost 100 scientists and clinicians.

Not only a packing organ

As every medical student knows and every doctorstill remembers, fascia is introduced in anatomy dis-section courses as the white packing stuff that onefirst needs to clean off, in order “to see something”.Similarly, anatomy books have been competing witheach other, in how clean and orderly they present thelocomotor system, by cutting away the whitish orsemitranslucent fascia as completely and skillfullyas possible. Students appreciate these appealinggraphic simplifications, with shiny red muscles, eachattaching to specific skeletal points. However, thesesimplified maps do not fully describe how the realbody feels and behaves, be it in medical surgery orduring therapeutic palpation.

To give an example: in real bodies, muscles hardlyever transmit their full force directly via tendons intothe skeleton, as is usually suggested by our textbookdrawings. They rather distribute a large portionof their contractile or tensional forces onto fascialsheets. These sheets transmit these forces to syner-gistic as well as antagonistic muscles. Thereby theystiffen not only the respective joint, but may even af-fect regions several joints further away. The simplequestions discussed in musculoskeletal textbooks“which muscles” are participating in a particularmovement thus become almost obsolete. Musclesare not functional units, no matter how commonthis misconception may be. Rather, most muscularmovements are generated by many individual motorunits, which are distributed over some portions ofone muscle, plus other portions of other muscles.The tensional forces of these motor units are thentransmitted to a complex network of fascial sheets,bags, and strings that convert them into the final bodymovement.

xv

Similarly, it has been shown that fascial stiffnessand elasticity play a significant role in many ballisticmovements of the human body. First discovered bystudies of the calf tissues of kangaroos, antelopes,and later by horses, modern ultrasound studies haverevealed that fascial recoil plays in fact a similarly im-pressive role inmany of our humanmovements. Howfar you can throwa stone, howhighyou can jump, howlong you can run, depends not only on the contractionof yourmuscle fibers; it also depends to a large degreeonhowwell the elastic recoil properties of your fascialnetwork are supporting these movements.

If the architecture of our fascial network is indeedsuch an important factor in musculoskeletal behavior,whyhas this tissuebeenoverlookedfor sucha long time?There are several answers to this question.Thedevelop-ment of new imaging and research tools now allow us tostudythis tissue invivo.Another reason is that this tissueresists the classical method of anatomical research: thatof splitting something into separate parts that can becounted and named. You can reasonably estimate thenumber of bones or muscles; yet any attempt to countthe number of fasciae in the bodywill be futile. The fas-cial body is one large networking organ, withmany bagsandhundredsof rope-like localdensifications, and thou-sands of pockets within pockets, all interconnected bysturdy septa aswell as by looser connective tissue layers.

What is fascia?

This varied nature of fascia is reflected in the manydifferent definitions of which exact tissue types areincluded under the term “fascia”. The International

Anatomical Nomenclature Committee (1983) con-firmed the usage of previous nomenclature com-mittees and used the term “fascia superficialis” forthe loose layer of subcutaneous tissue lying superfi-cial to the denser layer of “fascia profunda.” Whilemost medical authors in English-speaking countriesfollowed that terminology, it was not congruentlyadopted by authors in other countries. The nomencla-ture proposed by the Federative Committee on Ana-tomical Terminology (1998), therefore attemptedto lead towards amore uniform international language(Wendell-Smith 1997). It suggested that authorsshould no longer use the term fascia for loose connec-tive tissue layers, such as the former “superficialfascia”, and to apply it only for denser connective tis-sue aggregations. However, this attempt failed signif-icantly (Huijing & Langevin 2009). Most Englishtextbook authorities continued to use the term “su-perficial fascia” to describe subcutaneous tissues(Standring 2008). In addition an increasing numberof non-English authors – following the commonAnglo-Saxon trend in international medicine – havestarted to adopt the same terminology as theseAmerican or British colleagues.

Similarly there has been confusion on the questionwhich of the three hierarchical muscular tissue bags –epi-, peri- and endomysium – could be included asfascia. While most authors would agree to consideras fascial tissues, muscular septi and the perimysium(which is often quite dense, particularly in tonicmus-cles) there is less consensus on the endomysial enve-lopes around single muscle fibers, based on theirmuch looser density and higher quantity of collagentypes III and IV. However, almost all authors empha-size the important continuity of these intramuscularconnective tissues, and this continuity was shownextending even within the muscle cell (Purslow2009). So where does fascia stop?

Another area , still to be resolved, are the visceralconnective tissues. For some authors the term fasciais restricted to muscular connective tissues. Visceralconnective tissues – no matter whether they are ofloose composition like the major omentum or moreligamentous like the mediastinum – are often ex-cluded. In contrast, more clinically oriented bookshave placed a lot of emphasis on the visceral fasciae(Paoletti 2006, Schwind 2006).

As valuable as these proposed anatomical dis-tinctions within soft connective tissues are, their verydetail may lead to unwitting exclusion of importanttissue continuities which are only perceived on thelarger scale. For example, the clinical significance

Publication on fascia1200

1000

800

600

400

200

01960 1970 1980 1990 2000 2010 2020

Year

OVIDSCOPUS

Fig. 0.1 • Number of peer reviewed scientific paperson fascia • Papers on fascia indexed in Ovid Medline orScopus have grown from 200 per year in the 1970s and1980s to almost 1000 in 2010.

Introduction

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of the continuity of the fascia of the scalene musclesof the neck with the pericardium and mediastinuminside the thorax is often surprising in our discussionswith orthopedic surgeons, although less so to osteo-paths or general surgeons. Figure 0.2 shows anotherexample of perceptual tissue exclusion, based onterminological distinction. Here one of the sturdiestportions of the iliotibial tract has been excludedfrom this important tissue band, since it did not fitthe distinct nomenclature defined by the authorsof this paper.

Based on this background a more encompassingdefinition of the term fascia was recently proposedas a basis for the first Fascia Research Congress(Findley & Schleip 2007) and was further developed(Huijing & Langevin 2009) for the following con-gresses. The term fascia here describes the ‘softtissue component of the connective tissue systemthat permeates the human body’. One could alsodescribe these as fibrous collagenous tissues whichare part of a bodywide tensional force transmissionsystem. This view of an interconnected tensional net-work is partly inspired by the tensegrity concept, as

described in Chapter 3.5. The complete fascial netthen includes not only dense planar tissue sheets (likesepta, joint capsules, aponeuroses, organ capsules, orretinacula), which may also be called “proper fascia”,but it also encompasses local densifications of thisnetwork in the form of ligaments and tendons. Addi-tionally it includes softer collagenous connective tis-sues like the superficial fascia or the innermostintramuscular layer of the endomysium. The cutis,a derivative of the ectoderm, as well as cartilageand bones are not included as parts of the fascialtensional network. However, the term fascia now in-cludes the dura mater, the periosteum, perineurium,the fibrous capsular layer of vertebral discs, organcapsules as well as bronchial connective tissue andthe mesentery of the abdomen (Fig. 0.3).

This more encompassing terminology offers manyimportant advantages for the field. Rather than hav-ing to draw most often arbitrary demarcation linesbetween joint capsules and their intimately involvedligaments and tendons (as well as interconnected

Fig. 0.2 • Example of a fascia dissection based onspecific terminology • This dissection was used in anotherwise excellent treatise on the iliotibial tract (ITT).Following the proposal of the Federative Committee onAnatomical Terminology (1998) to distinguish betweenaponeuroses and fasciae, the authors chose to describethis tissue as an aponeurosis. Congruently with thisdecision, their dissection and illustration therefore excludedall tissue portions with a non aponeurotic character.Unfortunately this included one of themost dense andmostimportant portions of the iliotibial tract: the connection to thelateral iliac crest, posterior of the anterior superior iliac spine.Notice the common thickening of the iliac crest at the formerattachment of this ligamentous portion (located at a straightforce transmission line from the knee over the greatertrochanter), reflecting the very strong pull of this tissueportion on the pelvis. (TFL: tensor fascia lata.) Illustration takenwith permission from Benjamin et al 2008)

Irregular

Superficialfascia

Dens

eLo

ose

RegularRegularity

Density

Superficialfascia

Visceral fascia

Proper fascia Aponeuroses Ligaments Tendons

Visceral fascia

Intramuscularfascia

Fig. 0.3 • Different connective tissues consideredhere as fascial tissues • Fascial tissues differ in terms oftheir density and directional alignment of collagen fibers. Forexample, superficial fascia is characterizedby a loose densityand a mostly multidirectional or irregular fiber alignment;whereas in the denser tendons or ligaments the fibers aremostly unidirectional. Note that the intramuscular fasciae –septi, perimysium and endomysium – may express varyingdegrees of directionality and density. The same is true –although to a much larger degree – for the visceral fasciae(including soft tissues like the omentum majus and toughersheets like the pericardium). Depending on local loadinghistory, proper fasciae can express a two-directional ormultidirectional arrangement.Not shownhereare retinaculaeand joint capsules, whose local propertiesmay vary betweenthose of ligaments, aponeuroses and proper fasciae.

Introduction

aponeuroses, retinacula and intramuscular fasciae),fascial tissues are seen as one interconnected ten-sional network that adapts its fiber arrangementand density according to local tensional demands.This terminology fits nicely to the Latin root ofthe term “fascia” (bundle, strap, bandage, bindingtogether). It is also synonymous with the non-professional’s understanding of the term “connectivetissue”. “Connective tissue research” is too broad aterm, as this includes bones, cartilage and even bloodor lymph, all of which are derivatives of the embry-ologic mesenchyme. In addition, the contemporaryfield of ‘connective tissue research’ has shifted itsprimary focus to tiny molecular dynamics from themacroscopic considerations of several decades ago.The newly forming field of fascia research requiresboth macroscopic and microscopic investigations.This text has undertaken the task of serving bothareas. Even if sometimes microscopic details of col-lagenous tissues are explored, an effort will be madeto always relate these findings to the body as a whole.

While we see great advantages in our wider defi-nition of fascial tissues, we acknowledge that moretraditionally oriented authors will continue to re-strict the term fascia to dense planar layers of “irreg-ular” connective tissues, in distinction from moreregular oriented tissues like aponeuroses or liga-ments. In some areas such a distinction is indeed pos-sible and may be clinically useful (e.g. at the fasciaeand aponeuroses of the lumbar region). We thereforesuggest including twelve additional specifying terms

wherever possible, into the detailed description ofa fascial tissue. These specifying terms were pro-posed by Huijing & Langevin (2009): dense connec-tive tissue, areolar connective tissue, superficialfascia, deep fascia, intermuscular septa, interossealmembrane, periost, neurovascular tract, epimysium,intra- and extramuscular aponeurosis, endomysium.However, we also note that many important areasof the body are characterized by gradual transitionsbetween such morphological categories, and a moregeometrical description of local collagen architecture(in terms of dominant fiber directions, tissue thick-ness and density) may then be more useful to under-standing specific tissue properties (see Fig. 0.2).

This textbook, as have the fascia congresses, hastaken the difficult role of being oriented toward boththe scientist and the clinician. Material presentedspans anatomy and physiology of fascia in Part 1,through clinical conditions and therapies in Part 2,to recently developed research techniques in Part 3.We have pointed out the definitional struggles the re-searcher faces surrounding fascia: Which tissue?What fiber directions? What is connected to what?These research tools will allow the extension of thisdebate to more clinical areas as well, to help definewhich tissues are affected and what directions forcesare applied in the clinical therapies. It is our hopethat clinicians and scientists, both together and sep-arately, will rise to these challenges to advance ourbasic understanding and our clinical treatment offascia.

References

Benjamin, M., Kaiser, E., Milz, S., 2008.Structure–function relationshipsin tendons: a review. J. Anat.212, 211–228.

Federative Committee on AnatomicalTerminology, 1998. TerminologiaAnatomica. Thieme, Stuttgart.

Findley, T.W., Schleip, R., 2007. Fasciaresearch: basic science andimplications for conventional andcomplementary health care.Elsevier Urban & Fischer,Munich.

Huijing, P.D., Langevin, H.M., 2009.Communicating about fascia: history,pitfalls and recommendations.

International Journal ofTherapeutic Massage and Bodywork2 (4), 3–8.

International Anatomical NomenclatureCommittee, 1983. NominaAnatomica, fifth ed. Williams &Wilkins, Baltimore.

Paoletti, S., 2006. The fasciae: anatomy,dysfunction and treatment. EastlandPress, Seattle.

Purslow, P., 2009. The structure andfunctional significance of variations inthe connective tissue within muscle.In: Huijing, P.A., Hollander P.,Findley, T.W., Schleip, R., Fasciaresearch II: basic science and

implications for conventional andcomplimentary health care. ElsevierUrban & Fischer, Munich.

Schwind, P., 2006. Fascial andmembranetechnique: a manual forcomprehensive treatment of theconnective tissue system. Elsevier,Edinburgh.

Standring, S. (Ed.), 2008.Gray’s anatomy –the anatomical basis of clinicalpractice, fortieth ed. Elsevier,Edinburgh.

Wendell-Smith, C.P., 1997. Fascia: anillustrative problem in internationalterminology. Surg. Radiol. Anat.19, 273–277.

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