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1. Why Fascia?
a. Connective tissue continuum throughout the body forming a body-wide cellular
signaling system1
b. Forms a “trideminsional metabolic and mechanical matrix”2
c. Active structures that play key roles in the function of many components of the
body, especially in the musculoskeletal system3
d. High clinical relevance
2. Anatomy and Functions of Fascia4
i. Historically considered as rather inconsequential, a “packaging material”5
b. Expanded Definition of Fascia
i. Includes all fibrous connective tissues
1. Fascia of skin (superficial fascia); deep fascia; special
arrangements in limbs; tendons; ligaments; investing tissue of
muscle and connective tissue within muscle; bone; fascia of major
organs and great body cavities; fascia surrounding blood vessels,
nerves, viscera, and meninges
ii. Creates “structural continuity that gives form and function to every tissue
and organ”2
iii. The “trideminsional metabolic and mechanical matrix”2
iv. Focus of Presentation
1. Fascia of skin (superficial fascia), deep fascia, investing tissue of
muscle and muscle groups, connective tissue components of
muscle
c. General Anatomy of Fascia
i. Superficial and Deep Fascia
1. Superficial Fascia
a. Loose connective tissue
b. Deep to dermis
c. Binds dermis to underlying structures (e.g., deep fascia)
d. Single continuous layer
e. Highly variable amount of adipose tissue
f. Allows gliding between dermis and deeper structures
i. Multiple sheets of collagen
1. Allows for the gliding
2. Elastic fibers (elastin) allows skin to return to
original position
g. Transmits tortuous vessels to & from dermis
2. Deep Fascia
a. Dense regular connective tissue
b. Between superficial fascia and underlying tissue (e.g.,
muscle)
i. Multiple sheets of collagen
1. Collagen fibers parallel within sheet
2. Different orientation of collagen in each
adjacent layer (sheet)
3. Allows tensile strength in many different
directions
c. Continuous throughout body, but named regionally (e.g.,
thoracolumbar fascia)
d. Forms intermuscular septa
ii. Muscle Fascia
1. Epimysium, perimysium, endomysium
a. Epimysium
i. Continuous with epitendineum
ii. Acts as a “surface tendon”
iii. Transmits forces along muscle length
iv. Sometimes continuous with deep fascia, sometimes
separate (e.g., thoracolumbar fascia)
b. Perimysium
i. Surrounds muscle fascicles
ii. Blends with epimysium at muscle surface
iii. Runs entire length of muscle
iv. Continuous with endotendineum
v. “Internal tendon” – transmits forces
c. Endomysium
i. Surrounds individual muscle cells
ii. May also be involved in force transmission
iii. The Fibroblast
1. Predominant cell of fascia
2. Important in mechanotransduction (see below)
iv. Innervation of Fascia
1. Fascia has a rich nerve supply, in fact, the CNS receives the
largest quantity of sensory nerves from myofascial tissues6
a. Free nerve endings
i. Nociception
ii. Exercise-induced delayed onset muscle soreness7
iii. Interstitial receptors
1. Largest group
2. Stimulation affects ANS6
a. May alter local fluid dynamics, including
plasma extravasation
i. Changes viscosity of extracellular
matrix
b. May increase vagal tone
i. Results in “hypothalamic tuning
and “deep and healthy
relaxation”6,8
b. Encapsulated nerve endings (e.g., Pacinian corpuscles,
Ruffini endings)6
1. Proprioception
a. Muscle relaxation
2. Understanding innervation may lead to improved treatments
d. Functions of Fascia
i. Resists/restricts movement (does not stretch)
ii. Contains and separates muscle groups into compartments
1. Osteofascial compartments
2. Along with muscle fascia creates an “ectoskeleton”
a. Osteofascial compartment + Muscle Fascia = Ectoskeleton
i. Osteofascial compartments
1. Intermuscular septa
2. Bony attachments
ii. Muscle fascia
1. Epimysium, perimysium, and endomysium
b. Ectoskeleton + muscle = myofascia
i. Myofascia
1. Allows force transmission not only to tendons
but also CT structures associated with muscles
and groups of muscles
2. Individual muscles do not act alone and should
not be considered separately9
3. Even agonists and antagonists may be coupled
4. Effects biomechanical interactions of
musculoskeletal structures10,11
5. Coordination of Muscle Activity
a. Example – Thoracolumbar Fascia
i. Integrates muscles of upper and
lower limbs, pelvis, and spine
ii. Coordinates pendulum-like
movements of walking and
swimming
iii. Link between transversus
abdominis muscle and control of
segmental motion
iv. Importance of “the core” to
improve altered intersegmental
motion (spinal instability) in LBP
b. Key text resource: Anatomy Trains
(Myers, 2020, Fourth ed.)12
3. Helene Langevin and the Fascia Renaissance
a. Current Director of National Center for Complementary and Integrative Health
b. Described fascia as connective tissue continuum throughout the body
c. May form a body-wide cellular signaling system1
d. Theory of Mechanotransduction
4. Mechanotransduction
a. Convert physiologic mechanical stimuli into biochemical responses
b. Three processes: mechanocoupling, cell-cell communication, effector cell
response
c. Mechanocoupling
i. Physical load can trigger changes to cytoskeleton
ii. Thought to be important in effects of manual & mechanotherapies
1. E.g., massage, manipulation (including fascial manipulation),
acupuncture, exercise, yoga
d. Cell-cell communication
i. Via gap junctions
ii. Stimulus in one location to elicit changes in distant cells
e. Effector cell response
i. Mechanical loading can lead to changes in protein synthesis
ii. Can lead to remodeling of extracellular matrix13,14
5. Clinical Relevance
a. Enthesopathy-type injuries
i. Where intermuscular septa attach to bone
b. Overuse injuries, especially lower (pelvic) and upper (pectoral) extremities15
c. Myofascial pain syndromes (MFP) – important
i. Fascia can become rigid and fibrotic due to inflammation16
ii. Multiple facial layers affected (superficial, deep, muscle)17
1. Affects biomechanical interactions10
iii. Causes loss of efficient gliding among fascial layers18
1. Can result in increased tissue thickness, found in chronic low back
and neck pain19,20
2. Can result in persistent pain and loss of mobility6,21-23
6. Fascia and Manual Therapy (MT)
a. Manual therapy (MT) commonly used to treat connective tissues, including
fascia16
b. Myofacial pain syndromes (MFP) commonly treated with MT
i. Effects of MT on MFP
1. MT has initial localized inflammatory reaction on fascia24
2. MT has long-term anti-inflammatory effect on fascia16
3. MT decreases stiffness within fascia25
4. Multiple layers of fascia affected17
a. Deep fascia – 73%, Superficial fascia – 55%, Muscle – 43%
b. Deep fascia alone – 23%, Deep & Superficial – 22%, Deep &
Muscle – 18%
c. Average = 3.0 +1.2 layers
5. Facial Manipulation approach developed by Stecco10,26,27
a. Treat areas of “densification” to allow fascial layers to glide
more smoothly over one another
b. Decreases concentration of unbound water toward normal
inside deep fascia as seen on MRI28
c. Clinical trials showing effectiveness, e.g., in low back
pain29,30
d. Each point should be treated as distinct pathologic entity17
c. Avoid therapeutic overreach
i. “Fascia Distortion Model” as a treatment was developed in the 1990s. The
theory states that all musculoskeletal complaints can be traced back to
three-dimensional deformations/distortions of the fascia. There is no
empirical evidence to support this theory that all musculoskeletal pain is
related to fascia.31
7. Primary Resources
a. Chapter 14 in spinal anatomy textbook (Cramer and Bakkum, 2014)4
b. Fascia Research Society:32 Home - Fascia Research Society
i. International conferences: Sixth International Fascia Research Congress,
September 10-14, 2022, Montreal, Canada.
c. Textbook: Anatomy Trains (Myers, 2020, Fourth ed.)12
