3/10/2017

Fascia
Fascial
Manipulation
Judy Pun
Physiotherapist (KWH)

What is fascia ? Fascia classification

 Superficial fascia
“Fascia is an uninterrupted, three-
dimensional web of tissue that extends from
head to toe, from front to back, from interior  Deep/muscular
to exterior…Fascia can refer to dense fascia
plantar fascial sheets (such as the fascia
lata) as well as joint capsules, organ
capsules, muscular septa, ligaments,  Visceral fascia
retinacula, aponeuroses, tendons,
myofascia, neurofascia, and other fibrous
collagenous tissues”
First international Fascia Research Congress

Fascia system Fascia system

-Superficial fascia - Deep fascia

Superficial layer Deep fascia

• Retinaculum cutis superficialis

formed by vertical septa,
superficial adipose tissue,
superficial veins , lymphatic
vessels, subcutaneous plexus Aponeurotic Epimysial
fasciae fasciae
Deep layer
• Loose connective tissue, deep
adipose tissue, oblique septa,
Retinaculum cutis profundus Deep fasciae Thoracolumbar Epimysium of
of the limbs fascia/ Rectus muscles/ trunk
sheath

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Deep fascia of the limbs Deep fascia/myofascia

 Multiple layers of undulated collagen
fibre bundles form the deep fascia
 Each layer parallel to each other
 A thin layer of loose connective tissue
separates the different layers (2-3 layers)
 Adjacent layers shows different
orientation strong resistance to traction
 Abundant free and encapsulated nerve
endings (Ruffini and Pacinian corpuscles, Evaluation of rectus femoralis muscle
and fascia lata with ultrasound. It is
autonomic nerve fibers, sensory evident that the three layers of dense
connective tissue forming the fascia
innervation lata, are divided by two layers of loose
connective tissue
 Various in thickness in different body Stecco C et al. (2011)
parts

Histological study of deep Presence of Hyaluranic Acid

fascia in deep fascia

On the left: crural fascia (HE stain), on the right: brachial fascia (Van Gieson stain). Both the fasciae are A. Hyaluronan in loose connective tissue inside and under the deep fascia (Alcian blue 912.5).
formed by two to three layers of collagen fibre bundles separated by a thin layer of loose connective tissue
(LCT) that permits the different layers to slide one on the other B. Hyaluronan (brown color) within the fascia lata as demonstrated with the HA-binding peptide (9400).

Stecco C et al (2008)
Stecco C et al (2011)

Hypothesis- Sliding system Physiological functions of

fascia
 Hyaluronic acid (HA)is a
substance that is present to
lubricate and facilitate the
movements between the 1. Muscular force transmission
muscle fibers 2. Proprioception and nociception
3. Synchronisation of body movement
 HA is localized to the deep or
muscular surface of the deep between body segment
fascia

 The deep fascia produces a

gliding interface in conjunction
with the epimysial of the
muscle and the arelolar tissue
plane

Stecco C et al. (2011)

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Reaction of fascia to stress

inflammation Repeated
inflammation

Can Fascia be a source of repair Collagen fibre

hyperplasia

PAIN ?
Reorganisation Collagen fibre
of collagen fibres dysplasia

healing Ground substance

densification

Etiology of overuse syndrome Manual techniques for myofascial pain

Myofascial Release
technique (Barnes,
1990)- sustained
pressure applied
- Retention of HA to a restricted
tissue barrier 90-
- HA aggregation has
after exercise, in the 120 sec.
been reported—>the
endomysial location
viscoelasticity is
Trauma or surgery dramatically increased Fascial
Acupuncture Janet Travel
fascia adhesion ( many points have manipulation (1940)- identified
the same body (Stecco, 2004) myofascial trigger
landmark) –focus to fascia points (muscle
fibres)
- damage of - movement Needling request - role in MSK sys.
proprioception dysfunction

Soft tissue
modification
- Rolfing (1980)
(stretching /pompage
technique
pain - Cyriax method (1963)

Fascial manipulation (FM)- a Stecco’s Fascial manipulation-

new biomechanical model Biomechanical Model
14 body segments.
 Fascial manipulation (FM) is a Each segment
manual therapy, developed by served by six
myofascial units (mf
Italian physiotherapist Luigi units).
Stecco.
 Over 40 yrs of clinical practice
with vas caseload of MS problems
 focuses on the myofascial
system , in particular the deep CF
muscular fascia, including the
epimysium and the retinacula

CP= centre of perception, where pain is felt

Day J A, 2011

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Each body segment has 6 myofascial Stecco’s Fascial manipulation-

units coordinating its movement Biomechanical Model
14 body segments.
Each segment
 78 mf units- trunk and served by six
limbs myofascial units (mf
units).
 18 subunits- head
 Total of 14 body
Mf unit = monoarticular
segments that move and biarticular
in 6 directions(an-re, unidirectional muscle
fibres, their deep fascia CF
la-me, ir-er) on 3 and the joint they move
in one direction on one
planes plane.

CP= centre of perception, where pain is felt

Day J A, 2011

Stecco’s Fascial manipulation-

The Myofascial (MF) unit Biomechanical Model
 A MF unit is composed of: 14 body segments.
Centre of
Coordination = point
Each segment
1. Motor units, innervating fibres in served by six
on deep fascia
where unidirectional
monoarticular and biarticular myofascial units (mf
muscular forces
units).
muscles, to move a body segment in converge

a specific direction
Mf unit = monoarticular
2. The joint that is moved and biarticular
unidirectional muscle Centre of fusion
3. Nerve and vascular components fibres, their deep fascia CF
= points where
vectors from 2
4. The fascia that connects these and the joint they move
in one direction on one adjacent mf units
elements together plane. converge.

CP= centre of perception, where pain is felt

Day J A, 2011

Characteristic of densified point

(CCs) Dysfunction
 Over mm belly, Increase of the viscosity of HA in the centre of
where traction of coordination

unidirectional Decrease of the sliding system in the CC

fibres converge
Improper recruitment of muscle fibres
 1 CC for each
mfu The resultant vector become faulty
 Referred pain
Ultrasonography of the deep fascia of the neck over the Mechanical incoordination in the articulation
 Prolong, deep sternocleidomastoid muscle. The deep fascia is
highlighted with a red arrow.
A. Normal fascia, the two fibrous layers (white layers)
 Area is densified, and the loose connective tissue (in black) in the
middle are visible.
Phase of compensation

feels stratified B. Densification of the same fascia: the loose

connective tissue is increased, the fibrous layers
are normal. The total thickness of the deep fascia is Symptoms in the Center of perception
increased.

Pavan PG et al 2014

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Anatomical study of myofascial continuity

in the anterior region of the upper limb From MF unit to Myofascial
- The pectoral and clavicular part of
sequences…
the pectoral major muscle
continues laterally to join the
brachial fascia anteriorly.  Biarticular muscle fibres
and myotendinous
- The biceps brachii has an expansion to the deep
fascia of the forearm: the lacerus fibrosus or bicipital expansions form an
aponeurosis
- Originate from the biceps tendon, distal to its
anatomical continuity
musculotendinous juncture, inserted into the proximal
portion of the antebrachial fascia.
between body segments-
- The main group was inserted in an oblique direction, transmission of force and
downwards and medially, and then merges with the
forearm fascia. tension

- At the wrist, many collagen fibre bundles forming

the flexor retinaculum reinforced the antebrachial  Activation of embedded
fascia.
receptors- specific
- Distally continued with the palmar tissue reinforced
the aponeurosis of the palmaris longus. directional feedback that
- The palmaris longus sent some myofascial
expansions to the flexor retinaculum and to the integrates with other
fascia overlying the thenar muscles.
Stecco C 2009 afferents.

New terminology of FM- Head New terminology- Upper limb

and Trunk segments
Segment Latin Abbreviation Segment Latin Abbreviation

•Head Caput CP •Scapula Scapula •SC

(3 subunits: eye, ear/TMJ, occiput/C1)
•Neck Collum •CL •Humerus Humerus •HU

•Thorax Thorax •TH •Elbow Cubitus •CU

•Lumbar Lumbi •LU •Wrist Carpus •CA

•Pelvis Pelvi •PV •fingers digiti •DI

New terminology- Lower Limb Movement

Segments definition/directions
 Sagittal plane
Segment Latin Abbreviation Flexion-Antemotion (AN)
Extension-Retromotion (RE)
•Hip Coxa •CX
 Frontal plane
•Knee Genu •GE Abduction-Lateromotion
(LA)
•Ankle Talus •TA Adduction-Mediomotion
(ME)
•Foot Pes •PE
 Horizontal plane
Internal rotation-
Intrarotation (IR)
External rotation-
Extrarotation (ER)

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Antemotion (AN)

 Forward movement of a
body part on the sagittal
plane

Elbow flexion

Neck flexion Hip flexion

Retromotion (RE)
 Backwards movement
of a body part on the
sagittal plane

Neck extension

Knee flexion Shoulder extension

Extrarotation (ER) Intrarotation (IR)

 Rotation from a
neutral position  Return to a neutral
outwards right or left position from
on the horizontal intrarotation
plane
Neck rotation
Trunk rotation

Wrist supination Hip external rotation Hip internal rotation Neck rotation

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Lateromotion (LA)

 Movement of a
segment on the frontal
plane, from the median
line outwards
Trunk sideflexion

Hip abduction Shoulder abduction

Mediomotion (ME) Manual technique

 Medially directed Centre of
movements on the  Area of treatment: coordination
frontal plane
 Instrument:  Small 1-2cm2
 elbow (70%),
Trunk sideflexion knuckle(28%)
 Target tissue: fingertips (2%)
 Movement:  Deep fascia,
epimysium
 Type of pain:  80% compression,
20% sliding
 Intense, needle-like,
Scapula adduction (> can refer elswhere
Adduction of knee
90 degrees)

Principle of Therapy Contraindications

 HA aggregation chain to Absolute Relative
be reversibly contraindications
disaggregated by an contraindications
increase temperature or  Edema/acute tendinitis
by alkalinzation  Fever
 Lymphedema (III
 Skin lesion stage or more)
 Break down
progressively when the  Recent thrombosis  Non-cooperative
temperature was patient
increased to over ~
 Severe
40oC immunodepression  Recent trauma without
diagnosis-red flags?
 Alter the ground  Oncological patient
substance of the deep
fasciaRestore gliding  Severe bleeding
between collagen fibers disorder
 Corticosteroid therapy

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REFERENCES:
1. Day J A. Fascial Anatomy in Manual Therapy: Introducing a New Biomechanical Model.
Books:
Orthopaedic Practice, 2011, Vol. 23;2:11.
2. Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, De Caro R. The pectoral fascia: - Stecco L, Fascial Manipulation for Musculoskeletal Pain, Nuova Piccin,
anatomicaland histological study. J Bodyw Mov Ther. 2009 Jul;13(3):255-61. 2004
3. Day JA, Stecco C, Stecco A. Application of Fascial Manipulation technique in chronic
shoulder pain--anatomical basis and clinical implications. J Bodyw Mov Ther. 2009
- SteccoL, Stecco C. Fascial Manipulation: Practical Part. Nuova Piccin,
Apr;13(2):128-35. Epub 2008 Jun 24. 2009
4. Stecco A, Macchi V, S, Porzionato A, Tiengo C, Stecco C, Delmas V, De Caro R. Pectoral and
femoral fasciae: common aspects and regional specializations. Surg Radiol Anat. 2009
Jan;31(1):35-42. Epub 2008 Jul 29.
5. Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, De Caro R. The pectoral fascia:
anatomical and histological study. J Bodyw Mov Ther. 2009 Jul;13(3):255-61.
6. Stecco C, Porzionato A, Lancerotto L, Stecco A, Macchi V, Day JA, De Caro R: Histological
study of the deep fasciae of the limbs. J Bodyw Mov Ther. 2008 Jul;12(3):225-30. Epub 2008
Jun 13.
7. Stecco A, Macchi V, Stecco C, Porzionato A, Ann Day J, Delmas V, De Caro R. Anatomical
study of myofascial continuity in the anterior region of the upper limb. J Bodyw Mov Ther. 2009
Jan;13(1):53-62.
8. Stecco A, Macchi V, Stecco C, Porzionato A, Ann Day J, Delmas V, De Caro R. Anatomical
study of myofascial continuity in the anterior region of the upper limb. J Bodyw Mov Ther.
2009 Jan;13(1):53-62. Epub 2007 Jun 28.
9. Stecco C, Masiero Sstern R, Porzionato A, Macchi V, Masiero Stecco A, De Caro R.
Hyaluronan within fascia in the etiology of myofascial pain. Surg Radio; Anat. 2011 Oct. doi:
10.1007/s00276-011-0876-9 ·
10. Pavan PG, Stecco A & Stern R: painful connections: densification versus fibrosis of fascia.
Curr Pain Headache Rep (2014) 18:441
11. Pedrelli A, Stecco C, Day JA. Treating patellar tendinopathy with Fascial Mnaipulation. J
Bodyw Mov Ther 2009; 13(1): 73-80

Synotic tables of centres of

coordiantion (CCs)

Practical part

Name Address Date of Birth

Occupation
segm
Sport
locat exacerbate durat intens
Diagnosis
re-co
Assessment Procedure
SiPa PaMo
 MoVe (movement  PaVe (palpatory verification)
PaConc PaMo
PaPrev Examinations, Xrays, verification)
Trauma: • Actively
Paraesthesia cp di pe * densified tissue
• Passively
* painful tissue
Segmen Sagittal Plane Frontal Plane Horizontal Plane CF • Stretch
t * referred pain/symptoms
ante retro medio latero intra extra An-la Re-la Re- An- • Against resistance
me me during palpation
Mo
Ve

Ｐａｉｎ •Having chosen the plane,segment(s) and

Reduced ＲＯＭ MFu(s) : palpate CC of agonist Mfu
Ｗｅａｋｎｅｓs
•no alteration is found? : palpate CC of the
Pa
Ve antagonist Mfu (same plane)
*slight pain and/or deficit
** medium pain and/or deficit • Nothing significant? : palpate other CC(s)
*** very strong pain along agonist sequence
(or blocked movement)
Treatment Results after 1 week •Then palpate the other CC(s) of the
1° 1° segment (change plane?)

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Rx logistics: Demonstration…
From data to
hypothesis 1. Neck pain: an-cl, re-cl, me-cl,
la-cl, er-cl, ir-cl
2. Elbow pain: an-cu, re-cu,
MoVe altered only MoVe altered in MoVe aspecific-
in one plane 2 or 3 planes Generalized unease
me-cu, la-cu, er-cu, ir-cu
3. Back pain: an-lu, re-lu, me-lu,
la-lu, er-lu, ir-lu
4. Knee pain: an-ge, re-ge, me-
Segmental CCs Combination of Diagnostic
On one plane CC and Cf Centres of fusion
ge, la-ge, er-ge, ir-ge

CCs of Lu (back) Movement tests of LU (lumbar)

an-lu
ir-lu me-lu
an-lu la-lu ir-lu er-lu

re-lu me-lu
re-lu er-lu la-lu

Movement tests of GE
CCs of Ge (knee)
(knee)

an-ge
an-ge la-ge ir-ge er-ge ir-ge la-ge

er-ge me-ge
re-ge me-ge re-ge

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CCs of CL (Neck) Movement tests of CL (neck)

IRCL
ir-cl me-cl
an-cl

ir-cl er-cl
an-cl me-cl
RECL
re-cl
er-cl la-cl

re-cl la-cl

CCs of Cu (elbow) Movement tests of CU (elbow)

ir-cu er-cu an-cu ir-cu me-cu

an-cu me-cu

la-cu re-cu re-cu la-cu

re-cu

Thank you

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