The easy answer is everywhere! No, it’s not to the ends of your hair but your hair follicles are embedded in tissue layers that exchange nutrients which must pass through the fascia. Your fingernails and toenails, embedded in a soft tissue matrix, also rely on the health of the underlying fascia to allow nutrients in and waste products out. The same holds true for your teeth and the gums – the fascia plays into oral health. Most conversations about fascia associate it with muscles, which indeed have a very intimate relationship with the fascia. Certainly big, powerful muscles like the latissimus dorsi (lat) or hamstrings (hams) relate to the fascia, but so do the tiny muscles that rule eye movements. Joints also have specialized fascia surrounding them (often called retinacula) to provide stability, which is why the fascia in these areas is thicker and less flexible. This fascia at the joints is often inseparable from and continuous with the joint ligaments, even though most anatomy texts illustrate them as isolated bands.
Fascia surrounds all the organs in the body, holding them in place so they don’t get tossed around when we turn a cartwheel or roll over in bed. Not only does fascia encase each organ, but it also penetrates into the organs with nerves that orchestrate organ function. Fascia lines our tendons, aiding glide with every muscle contraction. Similarly, fascia can be found surrounding nerves to cushion, protect, and promote glide with every movement. In a nutshell, fascia communicates with every muscle, nerve, vessel (artery, vein, lymphatic), organ (intestines, stomach, bladder, ovaries, prostate, lungs, etc.) in the body. It’s one of the only structures that somehow touches every other anatomical structure and bodily function.
Because it’s so pervasive, I like to point out that fascia is no respecter of the specialties we create in healthcare: gastroenterology, obstetrics, gynecology, orthopedics, dermatology, nephrology, ophthalmology, endocrinology, neurology, and whatever else I might have missed. Similarly we have specialties in physical therapy that also artificially compartmentalize the body: orthopedics, women’s / men’s pelvic health, vestibular, temporomandibular, neurology, geriatrics, foot/ankle, hand, integumentary (skin), pediatrics, etc. It’s not to say these specialties don’t have a role to play in treating disease and dysfunction: they do, and there are cases that merit the focused training these specialists offer. But caution is warranted so we don’t get too myopic in our perspective and lose sight of the relationships between body regions and structures. Fascia crosses over all these specialties impacting each and every aspect of the anatomy. So when a body has multiple problems in multiple areas prompting consults with multiple specialists, it’s worthwhile to consider that the fascia might be the common element especially when problems persist, recur (heal but then return), or do not respond to appropriate care.
What does Fascia do?
Way back when I was in physical therapy school I remember learning little to nothing about fascia. I didn’t say they didn’t teach it, I’m just saying I don’t recall learning much about it. In gross anatomy lab where we dissected cadavers all I remember about fascia is that it was in the way of the “important stuff” we had to learn about, like muscles, joints, tendons, nerves, bursa, etc. Our goal was not to understand fascia, it was to get it out of the way. Too bad, we missed a lot. Fascia is also very different in an embalmed (preserved) cadaver as opposed to an un-embalmed or even a live subject. The embalming chemicals as well as exposure to air completely change the properties and behavior of the tissue. So what the majority of us in healthcare see of the fascia during our training is not very realistic in terms of connective tissue, especially fascia. No wonder so many of us emerge from school with practically no appreciation or understanding of fascia or connective tissue.
For years many have mistakenly relegated fascia to be like Tupperware® containers for compartmentalizing and organizing structures throughout the body. It’s true that fascia helps to maintain the form of the body providing order and support for muscles, tendons, nerves, blood vessels, and organs. But if this was all it did, there would be no need for it to be so richly innervated. There would also be no need for the layered formation – one layer would hold things in place just fine, like a twisty tie, rubber band, or duct tape.
Many great minds have contributed to the growing body of literature which upholds the fascia as a key player in governing movement. I like the word govern used in this sense because it implies allow, guide, restrict, but also prevent or impede. When considering the musculoskeletal system (neck, low back, hip, shoulder, etc.), multiple theories exist as to how movement occurs. Classical models have typically upheld that the brain stimulates a muscle contraction which pulls on a bone causing movement at a joint. Yet there are multiple problems with this model:
- Movement may involve only part of one muscle and part of another, according to the direction of movement;
- Movement is not robotic with only one joint moving at a time, but a complex series of activities that involve many joints and multiple muscles turning on and off in a very complicated and coordinated pattern as needed;
- Muscles and tendons often don’t fully attach to bones – they also connect to fascia;
- Coordination of movement has to be very adaptable and dynamic, capable of modifying in a split second according to the demand on the body. While the brain is amazing, it can’t possibly orchestrate every single element of all movements we make in multiple body regions 24/7. There has to be a peripheral mechanism assisting in this. The fascia, by virtue of its close relationship with the nervous system as well as its pervasive nature throughout the body, is perfectly positioned to play a key role in governing movement.
We give joints far too much focus in health care. Maybe that’s because they are easy to see on imaging (X-ray, MRI) and erroneously assumed to be the source of most pain. But joints don’t just move themselves, they are moved by connective tissue. We also give muscles too much credit for ruling musculoskeletal movement; muscles follow orders, and only turn on and off in response to orders and ability. While the brain certainly stimulates a voluntary muscle contraction, it can’t execute all aspects of the movement from initiation to completion and assure it happens in a smooth, coordinated manner. There is mounting evidence for the perspective that the fascia is the peripheral mechanism assisting the brain in accomplishing movement. It makes sense if you recall that the fascia surrounds every nerve, joint, muscle, and tendon, and also has multiple routes of communication with the nervous system.
But movement applies to more than just our neuro-musculo-skeletal system. It is also crucial to bodily functions such as digestion, urination, reproduction, circulation, and respiration. Disruption of movement in any of these entities interferes with function and ultimately the health of the organism. I like to compare movement to a symphony or a choreographed dance: timing is everything. Each performer has a part to be executed at a precise time in a specific manner. When one performer is off, it can disrupt the whole show. Take, for example, digestion. It can be said to begin in the head with the sight, smell, or even thought of food. Chewing stimulates the stomach to begin preparation for digesting food. We swallow and food moves smoothly and easily (or it’s supposed to) down our esophagus into our stomach, where it then moves into different parts of the stomach as the food breaks down. Next in the performance is the role of the intestines as food moves along this pathway, stimulated by precisely timed involuntary contractions called peristalsis. While the brain certainly has a part in all this, the fact that peristalsis continues even after the severance of the brain from the spinal cord testifies to the presence of a peripheral mechanism playing into this activity. The fascia, lining the organs and richly supplied with nerves capable of stimulating peristalsis along its path, is ideally suited to coordinate this activity. Disruption of any player in the show may lead to dysfunctions like constipation, diarrhea, ulcers, flatus (gas), food intolerances, reflux/GERD, and irritable bowel syndrome (IBS). Running tests on the organs for many of these conditions (like colonoscopy or endoscopy) typically does not reveal the source of the problem. This is because the problem frequently isn’t the organ itself – the problem is the dysfunctional fascial environment in which the organ is trying to exist and function.
This post is part of a series explaining fascia. Read the rest of the series here: What is Fascia? and What can go wrong with the Fascia? The posts are combined on the page Fascia Facts.