What can go wrong with the Fascia? (Fascia Facts Part 3)

Movement is life, and this applies to the fascia especially when considering the layers of the deep fascia.  It is essential that separation and lubrication (space and slide) be maintained between these layers if they are going to function properly to govern movement of the neuro-musculo-skeletal system as well as multiple involuntary organ functions.

Studies of anatomy have shown that the loose connective tissue (LCT) found between the fascial layers plays a critical role in maintaining this space and slide.  A key component of the LCT is the biochemical hyaluronan (HA).  Produced naturally in our body and found throughout our connective tissues, HA is a very interesting substance that has, in a way, multiple personalities.  When it’s happy and normally functioning, HA binds with water which keeps the LCT from getting too thick.  This promotes the critical space and slide between the tissue layers.  But when HA is unhappy or stressed, it becomes tangled on itself like my hair after washing it.  It also changes to its other personality (HA, not my hair) and becomes water repelling.  This makes the LCT thicker (like soup that needs more broth), and HA becomes space occupying instead of space creating.  This in turn causes the layers to adhere instead of slide, disrupting movement of bones and bowels depending on where the problem is located.    

The next burning question is “Why does this happen?”  (Or what makes HA unhappy?)  The word that is thought to explain it best is overload.  Overload comes in many forms, but basically boils down to three categories: 

1. Trauma or injury
2. Repetitive movement
3. Immobilization

Let’s take a deeper look at these, because the only way to stay healthy and functioning is to understand what went wrong in the first place.    

Trauma and Injury.  Some cases are obvious, such as a motor vehicle accident, fall on the ice, or collision on the volleyball or basketball court.  Bones can be broken, ligaments torn, and tendons rupture.  These typically get lots of attention and are managed accordingly.  But in the absence of these glaring injuries it’s easy to believe you’re lucky and escaped harm.  Wrong.  Even when things aren’t torn or broken, the connective tissue is still traumatized and altered, resulting in a loss of space and slide in the deep fascia layers.  You guessed it:  the HA is unhappy.  Things heal and soreness improves.  Sometimes the tissue layers are restored to their prior state – namely with space and slide.  But sometimes they are not.  Keep in mind that in the event of bone, ligament, and tendon damage and healing there may still be a loss of slide in the tissue layers which can persist indefinitely – that can mean years.  Surgery is also a trauma as it alters the anatomy and changes how tissues move. 

Some traumas are easy to recall – we wish we could forget them.  Others were so long ago – maybe an ankle sprain in high school track – we don’t even think about them anymore.  It was bad at the time but seemed to heal and is no longer symptomatic.  That doesn’t mean full mobility and function are restored to the tissues.  I like to point out that pregnancy, labor, and delivery are traumas – to the mom and the baby, certainly in varying degrees.  While some women seem to rebound better than others, it’s good to appreciate that things aren’t always what they seem.  Preexisting issues in a woman’s body can predispose her to more struggles.  Talking about the babies, I strongly believe we grossly underestimate the traumas of childhood, possibly beginning at birth with a troubled labor and delivery. As they grow children are repeatedly subject to trauma.  I’m not trying to dramatize every bump or bruise.  But we start falling down from the moment we begin standing up.  Kids fall off their bikes or the swing, cry a bit, then eventually run back out to play while we marvel at their resilience.  I have to wonder if each of those episodes compromises a little bit of tissue slide, accumulates and over time, and eventually becomes the aches and pains of adulthood.  This is my platform for early intervention and not minimizing the complaints of children. 

Repetitive Movement.  All day long, every day, we do the same movements over and over and over.  Open a door, hold a phone, pull a lever, type on a keyboard, carry a toddler (often on the same hip), pitch a ball, etc.  Certainly our dominant side does more work for us and is subject to more use.  This impacts the rest of the body as it postures to support and perform the activity.  The same movement/activity repeated day after day has a tendency to bias the body and work some areas harder than others.  Studies show that even with 30 minutes of computer work or piano playing, we begin to accumulate biochemicals in the upper trapezius muscles and fascia (between the neck and shoulders) that can trigger tightness, pain, and dysfunction.  No wonder so many people are so tight and sore here!  Within reason the body can manage this.  But we are not machines that can keep repeatedly doing an activity.  Even a machine is subject to breakdown, and needs maintenance to overcome wear and tear.  Think about the tires on your car – rotating them is a good practice for avoiding uneven wear arising from the surfaces we drive on, the way we drive, the different demands on the tire according to where it is on the car, and the alignment of the car. Our bodies are subject to similar stresses, but rotating body parts is not quite as simple as tires.  Changing the activity as much and often as possible is a strategy, but may only be feasible to a point. 

Immobilization.  Research shows that when tissues remain in a position too long they are subject to physiologic processes that change their nature.  There is an accumulation of biochemicals including HA, which leads to crowding (loss of space) and binding (loss of slide) between layers.  Perhaps this accounts for at least part of the morning stiffness attributed to conditions like arthritis and plantar fasciitis.  As with trauma, some forms of immobilization are obvious:  a cast, splint, or bed rest.  Often immobilization follows a trauma, which is a double whammy compromising function of the connective tissues.  Time and immobilization typically heal traumatized tissues and diminish pain (hopefully).  But complete healing requires restoration of the tissue layer space and slide.  

Similarly, sitting – especially for extended periods of time – promotes this accumulation and binding of HA in the tissues.  No, I am not saying that “sitting is the new smoking.”  That’s a bit dramatic (see my video on this subject). But it does harbor issues and is a form of immobilization.  Symptoms may not be apparent while sitting, but with coming to standing, pain and stiffness in the low back, hips, knees, and perhaps feet may be pronounced for at least the first few steps.  Once the tissues are lengthened and shortened a few times with walking then they are primed to move a little better.  Fascial layers with healthy space and slide can accommodate the lack of movement associated with sitting, and meet the demand to rise and walk without difficulty.  But tissues that are already harboring dysfunction will exhibit more difficulty accomplishing this seemingly simple task.  We typically attribute this to old age and arthritis, but seeing this improve quickly with restoration of tissue slide belies the arthritis explanation.    

What can be done to fix it? 

LOTS!  It’s far from all bad news!  The characteristic of the tissue that gets it into trouble (modification in response to overload or stress) is the same quality that can be accessed to reverse it from dysfunction back to function.  So not all stress and overload are bad; they just have to be applied in an appropriate dose and location.  I am a big believer in the manual therapies especially those, as you might imagine, that target the connective tissues like fascia.  There is a smorgasbord of different soft tissue techniques as well as certifications out there, and I won’t even try to name them all.  Some clinicians pull a bit from each for their treatment plate, and some fill their plate with one particular approach – usually whichever one they have found to work the best and they feel most proficient using.  Many techniques have studies that show they are beneficial. The truth is for many manual therapy interventions, including joint mobilization/manipulation, and even dry needling, the exact mechanism of change is not precisely understood.  But that doesn’t mean we shouldn’t utilize them in the meantime.  Whatever helps people reduce pain, return to moving and functioning, minimize/eliminate medications, and avoid surgery is worthwhile to utilize.   

Since graduating PT school in 1984 I have pursued and enjoyed attending many courses from many different perspectives (Fascial Manipulation-Stecco®, John Barne’s Myofascial Release, Stanley Paris, Myopain Seminars, Institute of Physical Art, MSU College of Osteopathic Medicine, Postural Restoration Institute®, and many more) always looking for better ways to address problems and help patients (myself included). While many of these have added to my current knowledge base and practice approach, the one that I have found to work the most consistently and impressively for me has been the Fascial Manipulation-Stecco® method (FM).  The motto of the Fascial Manipulation Association, “A Knowledgeable Hand is Potent,” is so true.

  Knowledgeable hands do not necessarily go with lots of letters after one’s name, nor do knowledgeable hands always accompany a particular health care field or license.  To my way of thinking, knowledgeable hands are developed by a person who: 

• Uses their hands regularly and frequently for palpation in assessment and treatment
• Is open-minded and seeking, even when it means they need to revise their paradigm, which is very demanding
• Embraces a life-long path of learning
• Is willing to give all they can to each patient, and is also passionate about helping people recover and thrive

So I celebrate anyone who does all this, regardless of their professional silo or which approach(es) they utilize.  Having said that, this is my blog so I’m going to focus on the interventions I have found to work best in practice!  These will be addressed on separate pages. 

Resources:

• Stecco A.  Fascial entrapment neuropathy.  Clinical Anatomy 32:883–890 (2019).
• Stecco C.  Function atlas of the human fascial system.  Churchill Livingstone Elsevier, 2015. 
• Stecco C, et al.  The fascia:  the forgotten structure.  IJAE, Vol . 116, n. 3: 127-138, 2011.
• Stecco L. 
• Macchi V, et al.  Musculocutaneous Nerve: Histotopographic Study and Clinical Implications.  Clinical Anatomy 20:400–406, 2007. 
• Pavan P, et al.  Painful connections: densification versus fibrosis of fascia.  Curr Pain Headache Rep (2014) 18:441
• van der Wal J.  The architecture of the connective tissue in the musculoskeletal system—an often overlooked functional parameter as to proprioception in the locomotor apparatus.  International Journal of Therapeutic Massage and Bodywork, Volume 2, Number 4, December 2009. 

This post is part of a series explaining fascia. Read the rest of the series here: What is Fascia? and Where is Fascia found? The posts are combined on the page Fascia Facts.