EXERCISE AND QUALITY OF LIFE
Review article
Volume 6, No. 1, 2014, 31-42
UDC 611.74/612.75/616.75
FASCIA - THE FORGOTTEN TISSUE
Dušica Marić*, Mirela Erić, Bojana Krstonošić and Dragana Smiljenić
Department of Anatomy, School of Medicine, University of Novi Sad, Serbia
Corresponding author: Department of Anatomy, Medical Faculty, University of Novi Sad
Abstract
Fascia is an important component of connective tissue that surrounds bones, muscles, blood
vessels, nerve and organs of the body. The fibrous fascia creates a web that wraps around struc-
tures of the body, providing a continuum that unites the entire human body from head to toe with-
out interruption. The term myofascial refers to the unit comprised of muscle and connective tis-
sue. A myofascial meridian can be defined as a linear series of muscles units interconnected with-
in the fascial webbing of the body. A myofascial meridian transfers tension sequentially from one
myofascial unit of the meridian to the next. Understanding the role of fascia in postural distortion
is of vital importance to movement therapists. Poor posture deforms the fascia and stress the mus-
cles, resulting in pain and weakness. Correction is possible, but both muscles and fascia need to
be taken into account.
Key words: Fascia; Myofascia; Connective tissue
Myofascial antomy
Fascia is a amazing event of bioengineering whose importance is now being realized. In re-
cent years fascia has accelerated to the leading position of rehabilitation science. Recommended
terminology generated after Ist International Fascia Research Congress in 2007 states that fascia is
a soft tissue component of connective tissue system, and it’s an uninterrupted, three-dimensional
web of tissue that extends from head to toe, from front to back, from interior to exterior, and sur-
rounds muscles, bones, organs, nerves, blood vessels and other structures.
The complexity of fascial tissue can be simplified into three parts: superficial, middle and
deep layers. The musculo-skeletal system is double bagged structure (Myers, 2009). The bones,
cartilage, periosteum and ligaments forming the inner bag, and the muscles are in the outer bag.
The outer bag makes the structures called fascia, intermuscular septa, and myofascia. Looking at
the body from this fascial perspective, we can see that fascia provides the context for all other tis-
* Corresponding author. Medical Faculty, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia, e-mail:
maricduska@gmail.com
© 2014 Faculty of Sport and Physical Education, University of Novi Sad, Serbia
Dušica Marić, Mirela Erić, Bojana Krstonošić and Dragana Smiljenić
sues to form. If bone cells lay down bone matrix within a fascial sleeve, a bone is formed within
fascial periosteum. If nerve cells are formed within fascial sleeving, the brain and spinal cord are
formed within meninges, and peripheral nerves are formed within sleeves of endoneurium, peri-
neurium, and epineurium (Myers, 2009).
The classic anatomical studies start with human dissection in the 17th century and explain-
ing the body as a series of isolated parts. The classic representation of muscles is that they have
discrete attachment on bones. By this model, each of the muscles is independent of one another
(a single muscle theory). We have convenient mechanical picture that a muscle ‘begins’ here and
‘ends’ there. According to new myofascial theory we have in body only one muscle; it just hangs
around in 600 or more fascial pockets (Myers, 2009). We need to remind ourselves that muscle
never attaches to bone. Muscle cells float within the fascial net like fish within fishing net (Myers,
2009). Their movement pulls on the fascia, the fascia is attached to the periosteum, and the peri-
osteum pulls on the bone. Far more often, even though some of the fascial tendinous fibers of the
muscle do attach into and end at the attachment bone, other fascial tendinous fibers go beyond the
bony attachment site and are continuous with the fascial tendinous fibers of the adjacent muscle.
These myofascial units are linked to each other. Examining the fascial connections between mus-
cles allows us to discern specific lines of linkage that travel throughout the body. These lines are
called myofascial meridians. Each myofascial meridian is a somewhat discrete aspect of the fas-
cial web that travels and connects far reaches of the body (Myers, 2009). In the single muscle the-
ory, the biceps gets defined as a radio-ulnar supinator, an elbow flexor, and a weak flexor of the
shoulder. In the Anatomy Trains view the biceps brachii is an element in a continous fascial plane
or myofascial meridian which runs from the outside of the thumb to the 4th rib and beyond. The
second fact does not negate the first, but adds a contex for understanding the biceps role in stabi-
lizing the thumb and keeping the chest open and breath full (Myers, 2009).
Myofascial meridians
The Anatomy Trains model identifies a set of myofascial meridians as the major continu-
al tension bands along which this tensile strain runs through the outer myofasciae from bone to
bone (Myers, 2009). Muscle attachments (stations in Anatomy Trains) are where the continuous
tensile net attaches to the relatively isolated, outwardly-pushing compressive struts. Thomas My-
ers describes myofascial meridians as a map of global lines of tension that traverse the entire mus-
cular surface of the human body acting to keep the skeleton in shape. Myofascial meridians in the
human body include: the superficial front line, the superficial back line, the lateral lines (2 sides),
the spiral line, the arm lines (2 front and 2 back), the functional lines (2 front and 2 back), and the
deep front line (Myers, 2009).
The superficial back line runs from the underside of the foot up the back of the leg to the sa-
crum, and up the back to the skull, and over the skull to the forehead. The superficial front line runs
from the toes up the front of the leg and up the torso to the top of the sternum, and passes along
the side of neck to the back of the skull. The lateral line runs from the underside of the foot up the
side of the leg and trunk, under the shoulder complex to the side of the neck and skull. Arms line:
deep front arm line runs from the ribs down the front of the arm to the thumb. The superficial front
arm line runs from the sternum and ribs down the inside of the arm to the palm of the hand. The
deep back arm line runs from the spinous processes through the scapula to the back of the arm and
little finger. The superficial back arm line runs from the spinous processes over the shoulder and
outside the arm to the back of the hand. The spiral line runs from the side of the skull across the
neck to the opposite shoulder and ribs, and back across the belly to the front of the hip, the outside
32
Fascia - the forgotten tissue
of the knee, the inside of the ankle, and under the arch of the foot and back up the leg and back to
the skull. The functional line: the back functional line runs from one shoulder across the back to
the opposite leg. The front functional line runs from one shoulder across the front of the belly to
the opposite leg. The deep front line is a core line that begins deep on the sole of the foot and runs
up of the leg to the front of the hip joint and across the pelvis to the front of the spine and on up
through the thoracic cavity to the jaw and the skull (Myers, 2009)..
Fascia takes responsibility for maintaining structural integrity, for providing support and
protection, and acts as shock absorber. Fascia has an essential role in hemodynamic and biochem-
ical process and provides the matrix that allows for intercellular communication (LeMoon, 2008).
Chaitow (Chaitow et al., 2006) adds that fascia extends to all dense fibrous connective tissues, in-
cluding aponeuroses, ligaments, tendons, retinaculae, joint capsules, organ and vessel tunics, the
epineurium, the meninges, the periostea, and all the endomysial and intermuscular fibers of the
myofasciae.
Fascia are controls the posture and regulate movements (Myers, 2009). The spinal mobili-
ty is limited by the lumbar fascia and the stability of foot is reachable thanks to the stiffness of the
plantar fascia (Grant & Riggs, 2008, Schleip, 2005), knee is supported by iliotibial tract along the
lateral thigh (Grant & Riggs, 2008). Retinacula are not static structures for joint stabilisation as
the ligaments, but specialized fasciae for local spatial proprioception of the foot and ankle move-
ments, and play integrative role of the fascial system in peripheral control of articular motility
(Stecco, 2010).
Fascial inerevation and response to tension
Fascia is densely innervated with mechanoreceptors and nociceptors (Langevin, 2006,
Schleip, 2003a, Schleip, 2003b). The mechanoreceptors, such as Pacini corpucles, Ruffini organs
and free-nerve endings, maintain muscular coordination via the constant feedback from ligaments.
Diversity in location of them suggest different functions, hence, retinaculum plays more percep-
tive function, while tendinous expansions are responsible for mechanical transmission of tension.
Various types of receptors capable of monitoring tension, elongation, pressure, velocity, pain are
located in fascial tissues and create a neurological feedback mechanism by which reflexive interac-
tion with muscles is provided to maintain joint stability and safety as well as coordination of move-
ment. Disruption of the fascia due to injury or overuse also results in corrupted feedback signals
and neurological disorders that are exposing the tissue to additional potential for injury or move-
ment disorders.
Bones, cartilage, ligaments, and tendons are built of varying degrees of the same substance
- collagen - so this unity is more than a structural connection. It is well known that all these things
are malleable, that is, they will transform and change shape and structure when stressed. Over time
the body becomes deformed, the legs bowed, the back bowed, the shoulders hunched, etc. Fascia
pulled continually out of alignment will eventually stay there. Poor posture and bad habits grad-
ually deform the fascia and stress the muscles, resulting in pain and weakness. Correction is pos-
sible, but both muscles and fascia need to be taken into account. The entire supporting structure
needs to be rebuilt.
33
Dušica Marić, Mirela Erić, Bojana Krstonošić and Dragana Smiljenić
Myofascial pain syndrome
Fascia is being recognized in etiology of pain and proprioception (Stecco et al., 2008).
Tightening of myofascia may occur as a response to trauma, overuse syndrome, repetitive stress
injuries, strain, stress, infection, poor posture, and chronic non-physiological tension in the fascia
or surgical scaring. Restricted fascia may compress and put extra stress on the linked soft tissue
structures, resulting in dysfunction and pain (LeBauer et al., 2008). According to Schleip, when
fascia increases its stiffness for a fairly short whereas constantly raised tension may consequently
have metabolic and physiological disadvantages leading to pathological contractures such as Du-
putryen disease, plantar fibromatosis, club foot or frozen shoulder. On the contrary, loss of fas-
cial tone may result in hypermobility of a joint, as in the example of sacroiliac pain (Schleip et al.,
2005). There is an accepted concept that unresolved trauma and/or frozen emotions can be ‘stored’
within the connective tissue in the form of pathology (Minasny, 2009).
The fascia of active people has more strength and springiness to it than that of inactive peo-
ple (Schleip, et al, 2005). Even strenuous activity has shown to strengthen and improve facial re-
sponse. In other words training can cause fascia to improve its function. This discovery can prove
why many players see increased velocity and arm strength after starting a long toss program. The
arms of those who long toss may have more ‘elastic’ storage capacity which can help with rapid
acceleration (Schleip, et al, 2005). By throwing longer and more often you can condition the fas-
cia in the arm. Training the myofascial system is one way that may be accomplished. Those who
adhere to a shorter throwing program or throw infrequently may never reach the level required to
train the myofascial system (Schleip, et al, 2005).
Myofascial pain syndrome is a chronic musculoskeletal pain disorder associated with lo-
cal or referred pain, decreased range of motion, autonomic phenomena, local twitch response in
the affected muscle and muscle weakness without an atrophy (LeMoon, 2008). The term “myofas-
cial pain syndrome” is used synonymously with “regional myofascial pain” and “myofascial trig-
ger point pain syndrome” (Cummings & Baldry, 2007). Myofascial trigger points can be located
in fascia, ligaments, muscles and tendons (Fernandez-de-las-Penas et al., 2005). Trauma, stress,
muscle wasting or ischaemia, visceral pain referral may aggravate the development of this criti-
cal point (Fernandez de las Penas et al., 2005, Fryer & Hodgson, 2005, Grieve, 2006). Myofas-
cial trigger points are considered to be one of the most common cause of musculoskeletal pain and
dysfunction (Cummings & Baldry 2007, Fernandez-de-las-Penas et al., 2005, Fryer & Hodgson,
2005, Simons, 2002). Trigger points are recognized as main cause of headache and neck pain (Fer-
nandez-de-las-Penas et al., 2005). They can be a reason to conditions like frozen shoulder, epicon-
dylitis, carpal tunnel syndrome, atypical angina pectoris or lower back pain (Simons, 2002).
References
Ist International Fascia Research Congress. 2007. (htpp://www.fasciacongress.org/2007/).
Myers, T. (2009). Anatomy trains, Myofascial meridians for manual and movement therapies. 2nd
edition, China: Churchill Livingstone.
LeMoon, K. (2008). Terminology used in Fascia Research. Journal of Bodywork and Movement
Therapies 12, 204-212
34
Fascia - the forgotten tissue
Chaitow L., Bradley D., & Gilbert C. (2002). Multidisciplinary Approaches to Breathing Pattern
Disorders. Churchill Livingstone, Edinburgh.
Grant, K. E., & Riggs, A. (2008). Chapter 9: Myofascial Release. 149-166 (Stillerman, E. 2008.
Modalities for Massage and Bodywork. USA: Elsevier Health Sciences).
Schleip, R., Klingier, W. & Lehmann-Horn, F. (2005). Active fascial contractility: Fascia may be
able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dy-
namics. Medical Hypothesis 65, 273-277.
Stecco C, Macchi V, Porzionato A, Morra A, Parenti A, Stecco A, Delmas V & De Caro R. (2010).
The ankle retinacula: morphological evidence of the proprioceptive role of the fascial sys-
tem. Cell Tissue Organs 192(3), 200-210.
Langevin, H.M. (2006). Connective tissue: a body-wide signaling network? Medical Hypotheses
66,1074-1077.
Schleip, R. (2003a). Fascial plasticity - a new neurobiological explanation: part 1. Journal of
Bodywork and Movement Therapies 7(1), 11-19.
Schleip, R. (2003b). Fascial plasticity - a new neurobiological explanation: part 2. Journal of
Bodywork and Movement Therapies 7(2), 104-116.
Stecco, C., Porzionato, A., Lancerotto, L., Stecco, A, Macchi, V., Ann Day, J. & De Caro, R. 2008.
Histological study of the deep fasciae of the limbs. Journal of Bodywork and Movement
Therapies 12, 225-230.
LeBauer, A., Brtalik, R. & Stowe, K. (2008). The effect of myofascial release (MFR) on an adult
with idiopathic scoliosis. Journal of Bodywork and Movement Therapies 12, 356-363.
Minasny, B. (2009). Understanding the Process of Fascial Unwinding. International Journal of
Therapeutic Massage and Bodywork 2 (3), 10-16.
LeMoon, K. (2008). Terminology used in Fascia Research. Journal of Bodywork and Movement
Therapies 12, 204-212.
Cummings, M. & Baldry, P. (2007). Regional myofascial pain: diagnosis and menagment. Best
Practice & Research Clinical Rheumatology 21(2), 367-387.
Fernandez de las Penas, C., Sohrbeck Campo, M., Carnero, J. & Page, J. (2005). Manual therapies
in the myofascial trigger point treatment: A systematic review Journal of Bodywork and
Movement Therapies 9, 27-34.
Fryer, G. & Hodgson, L. (2005). The effect of manual pressure release on myofascial trigger points
in the upper trapezius muscle. Journal of Bodywork and Movement Therapies 9, 248-255.
Grieve, R. (2006). Proximal hamstrings rupture, restoration of function without surgical interven-
tion: A case study of myofascial trigger point pressure release. Journal of Bodywork and
Movement Therapies 10, 99-104.
Simons, D. (2002). Understanding effective treatment of myofascial trigger points. Journal of
Bodywork and Movement Therapies 6(2), 81-88.
35