Image Credit: Beth Scupham

Fascia in Primary Care Series

~TS was a bright, unassuming patient in her mid-twenties who was unable to open her jaw after accidentally hitting her chin on a counter.  The trauma had been forceful enough to cause bruising around her temporomandibular joint (TMJ), located in front of the ear.  She had been unable to eat solid food or even talk because of the intense pain with jaw opening and she was requesting an extension on her work excuse.  The pain had not improved with rest since the injury three weeks earlier.  

TMJ pain is included among the Temporomandibular Disorders (TMD), a heterogeneous group of TMJ-related symptoms that ranks second to low back pain as a cause of chronic joint pain and disability.  It affects mostly those younger than 55, and of those, more women (ratio ~5:1).  Treatments range from the psychological to surgical. 

Traditional TMJ treatments target muscles closest to the joint, but, like common protocols for Benign Paroxysmal Positional Vertigo (BPPV) and Plantar Fasciitis (Heel Pain), this straightforward approach often yields incomplete relief, especially for chronic sufferers.  Approaching these conditions as a fascial network problem could offer a new way to “connect the dots” for these common conditions in Primary Care.   

Because anti-inflammatory medication and rest had failed, I offered to try a myofascial approach to her jaw pain.  After three weeks of no improvement, TS was “open to anything.” 

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Luigi Stecco was an Italian physical therapist, researcher, and author who created the Stecco technique of Fascial Manipulation®.  His two children, Dr. Antonio Stecco, MD, PhD (Professor of Physical Medicine and Rehabilitation) and Dr. Carla Stecco, MD (Professor of Orthopedic Surgery) have dedicated their careers to studying fascia.  After dissection of hundreds of unpreserved cadavers, Professor C. Stecco published The Functional Atlas of the Human Fascial System (2015) to document fascia’s role as a unifying entity and organ system.

If you have ever tried to peel the skin off of raw chicken, you may recall seeing silvery, fine fibers between the skin and meat and the surprising amount of force it required to accomplish the task.  In the human body, these retinacular fibers* exist in layers within the Superficial Fascia and act as “structural bridges that mechanically link the skin, subcutaneous layer and deeper muscle layer.” ¹ In normal tissue, this network is a “dynamic anchor of skin to underlying tissues” and connects the layers loosely enough to allow for gliding skin movement without disrupting the deep fascia.” ¹  Over time, however, these stretchy layers of the Superficial Fascia transform “into fibrous tissue that creates a rigid connection between skin and deep fascia.”¹ 

* As mentioned in the Plantar Fasciitis article, other researchers have identified this fibrous network. 

We simplistically attribute movement to our brain and individual muscles, but to execute sophisticated movements, we should be crediting our fascia.  When we use a ten-speed bicycle or a stick-shift car, we manually shift gears to adjust the amount of force needed for a steep hill or to go faster on flat ground.  With far more nuances, the deep fascia functions like an automatic transmission, deploying “belts” and “gear shifters” to maximize the output of the hardware, our bones and muscles.  Without these aponeurotic and epimysial types of deep fascia, ballet or pole-vaulting would be far less graceful and athletic.  

According to Stecco’s Atlas, “the repetitive selective stretching of specific portions of the deep fascia stimulates the alignment of collagen fibers along these lines of force.” ¹  When these Type I collagen fibers misalign from injury or dysfunctional mechanics, they alter normal joint movement, ultimately impacting whole body mechanics.  These collagen fibers are so strong that our upright posture is maintained more by fascia (and ligaments) than by muscles.²

In addition to increasing rigidity with adherent layers, fascia also develops knots called “densities.”²  These densities restrict movement patterns which also in turn affects mechanics.  

Thus, our fascia, from superficial to deep, organizes itself according to movement patterns; as the layers become more fibrous and adherent, the external body begins to reflect the state of the deep fascia.  

Imagine our layered, density-pocked fascia encasing us — like a Spider-man costume made out of an evolving patchwork of flexible fabrics, ranging from lycra to Kevlar.  Over our lifetime, we are slowly being shrink wrapped in a stiffening and scarring fascial sheath, literally of our own making. 

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Although deep muscles such as the masseter, temporalis, and pterygoids directly control the TMJ, I wondered if our “costume” could fit so tightly that these interior muscles were unable to make the jaw open?  Originating at the midline side of the clavicle (collarbone) and traversing the entire neck before inserting onto the mastoid bone behind the ear, the sternocleidomastoid (SCM) muscle seemed well-positioned to play a role in this restriction.  I proposed that we focus on the SCM and adjacent fascia to address TS’ jaw pain. 

Fascial Manipulation® and other myofascial release therapies open scarred areas and layers.  As the tissue is freed, it lengthens again, like stretching out tape that has folded and stuck to itself.  Theoretically, even joint space could gradually be restored by these methods, as long as the biomechanics are corrected as well.     

Fascia is the largest sensory organ of the body, with more pain receptors than even our skin.  Increased pressure or tensional forces on fascia is thought to be the actual source of pain that we feel in our joints or disc spaces, etc.   

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With the release of her SCM and contiguous fascia, the relief of pain for TS was dramatic and immediate.  TS was able to open her jaw with less pain for the first time since the injury.  Just as for Mr. Thomas, we repeated the release work with more confidence and achieved more pain relief.  I improvised a home-treatment program and sent her back to follow-up with her primary care provider.  

To my surprise, TS appeared on my schedule a few weeks later.  She had been able to return to work a couple of weeks after I had seen her; but because of our success, she was interested in more treatment with me.  It turns out that she had been living with chronic bilateral TMJ pain and clicking for 10 years.  

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In training, we are taught to examine patients undressed-with-gowns for better visibility of the symptomatic area (Fig. 1a).  With my growing appreciation of fascia’s contribution to patient’s symptoms, however, I stopped examining patients in gowns and began surveying their clothing for clues. 

I found that certain patterns and wrinkles in the material accentuated asymmetries especially with the side-view (Fig. 1b).  (I will even turn their front-facing image upside-down to look for misalignments below the knee, since the brain has a well-known weakness for filling in the mental image with what it “expects” to see.) 

Fortunately, our trunk and neck are not rigid structures. Imagine if our upper body behaved like a mast and the boat were our pelvis. With a neutral pelvis, our body would resemble Fig. 2a. When our pelvis tilts forward and down (anterior pelvic rotation), our “mast” would tip (Fig. 2b) and these people would look bent over! (The mechanics of posterior pelvic rotation requires its own article.)

Because of our many vertebrae, our muscles can bend our “human mast” to adapt to an imbalanced pelvis. This enables us to “right” our torso, which is effective in the short term (Fig. 2c).

This boat analogy helps us see what is happening when the pelvis is not well-balanced on the thigh bone.  With knee hypermobility, the knee is pushed backwards, which causes the thigh bone to orient diagonally.  In this individual, the front of the pelvis rotates downward (anterior pelvic rotation) and the upper body tips forward.  To maintain balance and erect posture, the back (and neck) arches more sharply, with some slight loss in height and forward displacement (Fig. 3b and 3c). 

Knee Hyperextension (Genu Recurvatum) occurs when the knee joint extends beyond 180 degrees.  It affects more females than males, and many physical therapy and orthopedic journal articles document its association with knee pain and athletic injuries.  The dysfunctional mechanics of the knees result in shortened and stiff quadriceps muscles, a significant restriction that affects gait and consequently, other joints such as the hip, knee, and ankle.  For nonsurgical cases, therapies are aimed at knee proprioception education, gait retraining, leg exercises, and postural awareness.  

Genu Recurvatum’s effect on the knees, hips, and ankles is a straightforward concept — after all, these are three contiguous joints.  But if these patients have stiff quadriceps muscles, then fascia research suggests that they would have inflexible, adherent thigh tissue, all the way to the deep fascia.  If we follow this logic, then Genu Recurvatum patients may be susceptible to other conditions that have their root in disrupted fascial mechanics.

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In the neck, the overlap of muscle and fascial layers is complex. The challenges in mapping parts of the fascial network are akin to those found in mapping high-density communities. In a large swath of torso, the superficial fascia can be easily dissected away from the other layers, but in the neck, the compressed geography requires precision, and slows research progress.

The neck has a layer of superficial fascia (SF) and three layers of deep fascia; these three deep layers are called the superficial, middle and deep laminae (SL, ML, DL respectively).  In 2014, Stecco et al found that “the [SL] surrounds the neck like a collar . . . (it) becomes thicker over the upper part of the SCM where it adheres to the [SF] and tendon of the SCM. . . Superiorly, this [SL] partially attaches to the lower border of the mandible, the mastoid process, the superior nuchal line, and the external occipital protuberance.” ¹

The SCM, mastoid, posterior skull (occiput) . . . these were the same areas that relieved TS’ jaw pain when released.

In classic anatomy illustrations, the head and neck are shown in perfect alignment and the SCM is on a diagonal, but a quick look around you will confirm that many people actually have Forward Head Posture (FHP).  Exactly as it sounds, Forward Head Posture (FHP), means that the head is positioned more “forward” relative to the torso than in “normal” patients.  Not surprisingly, especially if we consider the force vectors at work, many head and neck symptoms correlate with the presence and severity of FHP.  Most therapies are aimed at strengthening the upper back and neck muscles to “hoist” the skull up and backwards into proper position.  In FHP, the SCM muscle is more vertically, rather than diagonally, oriented.    

As a new student of fascia, I found myself people-watching (much to the chagrin of my children) in stores, restaurants, and even while watching TV/movies.  My favorite game evolved into predicting stance after noting the seated posture.  Of course, we associate FHP with age, just watch any entertainer impersonating the elderly.  But, intriguingly, I noticed that many young people with FHP also had Genu Recurvatum.  In my clinical practice, the most severe Genu Recurvatum patients with FHP not only had stiff quadriceps, but stiff SCM muscles as well, often correlating with the more hypermobile knee.  

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In her Atlas, Prof. C. Stecco states, “the superficial fascia of the neck continues into the superficial fascia of the thorax.” ¹  In addition, “the Superficial Fascia can be followed . . . from the thorax . . .  [and] appears to have total continuity with the Superficial Fascia of the thigh.”¹

To assimilate all of this information, I found it helpful to approach this clinical puzzle like a geometry proof.  

1. Deep Fascia is responsible for transmitting force over a distance (GIVEN) 
2. The Skin and Superficial Fascial layers can become adherent all the way to the Deep Fascia (ATLAS)
3. Genu Recurvatum patients have stiff quadriceps (GIVEN)
4. Genu Recurvatum patients likely have stiff, adherent fascial layers (per #2)
5. The Superficial Fascia is anatomically continuous from the neck to the thigh (ATLAS)
6. Superficial Lamina (first layer of Deep Fascia in the neck) encircles the neck and adheres to the Superficial Fascia, the upper SCM, and posterior skull (ATLAS)

.˙.  By virtue of adherent fascial layers, the Deep Fascia of the thigh in Genu Recurvatum patients likely has a connection to the Deep Fascia of the neck via the intervening continuous Superficial Fascia.  

This Thigh-Neck relationship could offer insights as to why head and neck conditions are often so chronic and resistant to therapies aimed at only the neck and upper body.  As Genu Recurvatum patients continue to move and stand, they would drive more tension into their thigh fascia, which could transmit to the neck again, like a perpetual motion machine.   

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Thomas Myers, a myofascial researcher, clinician, and instructor, proposed a groundbreaking concept of functional fascial relationships with the publication of Anatomy Trains in 2001.  Over his long career, he has studied with famous innovators: Buckminster Fuller, who coined the term “tensegrity” to describe the efficiency of tensional forces in a structure; Ida Rolf, biochemist and founder of the Structural Integration® method of bodywork; and Moshe Feldenkrais, physicist and pioneer in brain plasticity work (Awareness Through Movement®).   

Myers illustrates thirteen Myofascial Meridians to describe how “lines” of muscles and fascia are functionally integrated from head to toe.  His diagram of the  Superficial Front Line (SFL) places the SCM muscle and posterior skull fascia in the same “train” as the anterior thigh.  Anatomists are seeking concrete evidence of these Meridians, so far with incomplete results.   

Many years ago, I saw Itzhak Perlman, the famous classical violinist who played the soulful melody on the Schindler’s List soundtrack.  He was touring with a Klezmer group, and it was a mesmerizing performance of virtuosity and playful energy.  Warm and personable, he would stop and talk to the audience; and, after one especially impressive piece performed at lightning speed, he showed us the sheet music — the page looked almost empty.  Novice musicians could never have translated those notes into that robust performance.  

In medicine, an electrocardiogram (EKG) is frequently used to assess our heart’s activity.  Although we refer to it as “a muscle about the size of our fist,” the heart functions more like a team of muscles — moving the atria, ventricles, and valves in perfect sequence and intensity.  The EKG has twelve leads to record the electrical activity simultaneously in different axial orientations.  From these tracings mapped onto a single page, we can infer chamber size, muscle tone, conductivity, etc.  

Since the EKG captures only 2.5-10 seconds of activity, more types of studies were developed:  the Holter monitor (to record hours of electrical activity), echocardiogram (ultrasound to study wall movement),  nuclear studies (to detect metabolic changes with exertion), and catheterization (to image the blood vessels serving the heart).  With time, however, the heart began to be appreciated as more than just a circulatory engine for the body.  Research has proven the heart’s diverse ways of communicating with the brain and our nervous system; and Heart Rate Variability (HRV) has been found to correlate with improved health, even with cancer recovery.  

Fascia is also wired to the autonomic nervous system via fascial mechanoreceptors, which instantly transmit signals about changes in tension and pressure.  With its layered and extensive network, fascia’s role as an extension of the nervous system is a logical research question.  Perhaps one day, we will be able to detect Fascial Tone Variability (FTV) as a measure of health.

Similar to the heart, fascia seems to have capabilities that extend beyond its muscular mechanics, but its vast nature makes it a challenge to study, especially if we focus mostly on dissected anatomy and discrete orthopedic problems.   

In studying fascia, we may have a lot in common with beginner musicians looking at Perlman’s sheet music.  The information is there, but as yet, we lack the skills and sophistication to appreciate it.   

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TS reported that the most relief she ever experienced over the years was with complementary therapy.  At most, it reduced her pain to 1-2 out of 10 on the Pain Scale, but the pain always returned between visits.  Interestingly, TS had moderate Genu Recurvatum and significant FHP.  Based on my working understanding of the Thigh-Neck relationship, I decided to address her thigh fascia and knee mechanics as the root cause of her TMD.

To our delight and amazement, TS felt instant reduction in her TMJ pain with the very first release of her thigh fascia.  During the myofascial release work, her jaw would pop and open wider with less discomfort.  Based on this experience and the logic of force vector lines, TS was quite motivated to work on changing her knee biomechanics.  

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Fascial Histodynamics

Dr. Alf Breig was a Swedish neurosurgeon and researcher, who published many articles and authored two books: Biomechanics of the Central Nervous System (1960) and Adverse Mechanical Tension in the Central Nervous System (1978).  His books were written at a time when fascia was dissected away in order to reach the “important” tissue.  Almost unbelievably, he writes descriptively and extensively without ever mentioning the word fascia.  

 “The emphasis throughout this book is on the pathogenetic significance of tension . . . it is the effects of this raised tension that appear to be of primary neurophysiological significance . . . I have found that many neurological disorders in which no mechanical component has ever been suspected do in fact have their origin in tension in the nervous tissue; we are at present only just beginning to recognize the histological and neurophysiological sequelae of this tension.”³

Twenty-five years later in 2003, Dr. Donald Ingber, a physician, pathologist, and bioengineer published Tensegrity I and Tensegrity II, describing how structural tension at the cellular level governs cell division, differentiation, death, etc.  His experiments elucidated how cytoskeleton tension is the foundation of the dynamic and adaptive nature of the fascia that we observe at the macro level.  

Without the benefit of Dr. Ingber’s work, Dr. Breig wrote, 

“ . . . the effect of dynamic forces on the tissue elements is so fundamental and so comprehensive in its implications that it would appear justified to regard the relating field as a specified entity in medicine.

“The term that would seem to suggest itself to designate this field is histodynamics.  It may be defined thus:  A branch of medicine dealing with the effects produced on cell elements by the action of dynamic forces.” ³

In my Plantar Fasciitis and TMJ patients with Genu Recurvatum, addressing the fascial tension of the thigh and the mechanics that perpetuated it, resulted in treatment breakthroughs.  Although seemingly unrelated, these conditions, as well as other primary care problems, appear to share the same root cause fascial histodynamics.   

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Within a few visits, our sessions and TS’ diligence was paying off.  She was experiencing some pain-free days and her jaw clicking was reduced as well.  During this time, the chronic low back that had begun in her middle school years also improved.  After several appointments, she recalled that her TMJ pain had started after beginning ballet classes at age 14; she had been encouraged to “hyperextend her knees” to achieve better dance form.  ~

References:

¹ Stecco, C., 2015, Functional Atlas of the Human Fascial System, Elsevier, United Kingdom, p. 23-24, 27, 44, 67, 131, 141.

² Stecco, L. and Stecco, A., 2017, Fascial Manipulation for Musculoskeletal Pain:  Theoretical Part, 2nd Ed, Piccin, Padova, p.68, 108.

³ Breig, A., 1978, Adverse Mechanical Tension in the Central Nervous System:  An analysis of Cause and Effect, Relief by Functional Neurosurgery, Almqvist & Wiksell International (John Wiley & Sons, Inc.), Stockholm and New York City, 264 p.