Until recently, fascia – connective tissue that surrounds and runs through muscles, joints, organs, blood vessels, and nerves has been of minimal interest to health professionals and sports people. The traditional view has been that fascia in the human body was passive, with its’ function to only “hold things together” and transmit mechanical force. This concept is now outdated, and recent studies have been investigating how fascia contributes to movement awareness, biomechanics, injuries, and pain. Fascia is an amazing anatomical system of high importance to human movement.
Fascia can broadly be divided into two layers, superficial and deep. The superficial layer of fascia lies just beneath the skin and is connected to the skin via skin ligaments. If you move the skin, you move the fascia too and I’ll get to the importance of this later. The second layer is the deep layer, an intricate network which separates and envelopes muscles, forms sheaths for blood vessels and nerves, and strengthens ligaments around joints. The deep fascia is largely made up of collagen (stiff connective tissue) with some elastin fibers (stretchable connective tissue).
Picture: Subcutaneous tissue (Stecco et al, 2011)
Both layers of fascia are richly supplied with free nerve endings, particularly Pacinian corpuscles and Ruffini endings – mechanoreceptors that detect and respond to mechanical forces. When the fascia is stretched, the nerve endings are stretched too, providing the body with sensory feedback that feeds into our ability to detect and coordinate movement. The deep fascia probably plays the most important role here as the stretch and pull generally comes from muscle action, whereas stretching of the skin will stimulate the superficial fascia (one explanation of how taping “works”).
The fascia is also a potential source of pain. A recent study (1) investigated how lower back pain originating from the thoracolumbar fascia is expressed differently from pain originating from the muscles and skin. In this study, the researchers injected a bolus of saline under ultrasound guidance into the fascia or underlying muscles. After injection into the fascia, participants described the injection as “torturous”, “exhausting”, and “agonizing”. In contrast, injection into the muscle was described as “stinging”, “numbness”, and “throbbing”.
Picture: Thoracolumbar fascia
Injury or dysfunction to fascial tissue has clinical implications. Fascia can be torn in an acute injury such as an ankle sprain, kneecap dislocation, or muscle strain, however stiffness and thickening of fascia with overuse or disease can give rise to chronic inflammation of the tissue and ongoing pain. The most well-known example of this is plantar fasciitis (base of foot), however stiffness and pain arising from the fascia can arise from many areas of the body.
Tightness and restriction of fascial tissue comes from adhesions and fibrosis between fascial layers. Fascia usually slides and glides as we move, however when the tissue becomes tight and fibrotic the ability to move freely and pain-free is reduced.
Fascia doesn’t really respond to traditional stretching, as the tissue usually becomes irritated when it is stretched too much. Manual myofascial therapies (massage) may be able to improve the remodeling of the tissues and improve mobility between the fascial layers. A 2012 study (2) reported a reduction in postsurgical intraabdominal adhesions following a course of myofascial abdominal massage in rats.
Picture: Myofascial massage
Whilst evidence into myofascial therapies is in the very early stages, I use and recommend massage/myofascial therapy as the first port of call in combination with an appropriate exercise/rehabilitation program for people with myofascial pain or dysfunction.
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