You have probably heard bits of the old song, “the leg bone connected to the thigh bone…” Well, they really are connected – via fascia.

What is Fascia?

Fascia in Muscle Magnified

It’s the white stuff that you see when you cut into a piece of meat. We humans have it, too, and it’s everywhere in the body. It surrounds your organs, your muscles, and your bones, it’s also within all the muscles.  In fact, if you took away everything else in the body and left only the fascia, it would still look like a human body.  Fascia is ubiquitous in the body.

According to Tom Myers, the author of Anatomy Trains, fascia connects one muscle to another, even across bones. The anatomy books often show the muscles as if one ends, then there is a little gap, then another muscle begins. In reality, they are connected with fascia that runs from one muscle to the next. Our feet really are connected to our heads.

In his introduction to The Extracellular Matrix and Ground Regulation by Alfred Pischinger, James Oschman notes that, “The matrix is not an inert filler substance or filter, but is instead a body-wide communication and support system, vital to all functions. Pischinger further indicates “The fascia forms the largest system in the body as it is the system that touches all the other systems.”

Fascia is a matrix that is composed of tiny fibers and a mucus-like substance. It has a lattice structure that you can see in the photo above. It also has semi-conducting properties that provide communication throughout the body.  It is possible that acupuncture works via the fascial system.

What Does Fascia Have to do with my Pain?

The fascial system is constantly altering itself to support the structural needs of the body. One function of fascia is to provide stability and support for your habitual postures and movements. For example, if you like to sit at your desk leaning to your left, resting on your left elbow while you work, your body will help you to do that comfortably by laying down extra fascia in certain locations in your body. This fascia is aligned in the directions necessary to support that posture.

The problem is that after years of this process, this fascia ends up restricting normal movement and you can no longer straighten out completely. It feels as if your muscles are stiff, but it’s not the muscles – it’s the fascia that won’t allow the muscles to release. There is a fine line between a little bit of extra stability and immobility.

As a bonus, this fascia over time can cause twists, pulls and drags on all the other soft tissues and even on the bones and internal organs. These eventually cause pain and restriction far from where the original problem is.

So try this: if you’re wearing a tee shirt or other shirt with some stretch, tug on it at the hem on the right side at your waist. Look at what happens to the material at the left shoulder or the right shoulder or the neck, depending on the angle of your tug. See the ripples that travel all the way up to the neck? Fascia does exactly the same thing in the body. A restriction in the tissue at the ankle can cause a tug that travels all the way up the legs and through the hips to the back. It can cause twists and restrictions in muscles that then cause your pain, all far away from the actual problem.

Now Let’s Talk about Bones

Fascia also surrounds the bones – it’s called the periosteum. The tendons and ligaments that we think of as attaching to the bones actually attach to the periosteum. One colleague of mine, who is a massage teacher, illustrates the periosteum by wrapping dryer sheets around the bones of the class skeleton.  The periosteum can get twisted and restricted just like fascia elsewhere in the body. It can eventually cause twists in the bone tissue itself.

Bone Structure Magnified

And speaking of bones – we think of bones as solid dense structures. In fact, bone tissue consists of the same fascial matrix as soft tissue, but with calcium crystals in it that make it harder. It’s also a lattice structure – not completely solid, as you can see in the picture above. Bone tissue can become twisted (albeit only slightly) just like other tissue, depending on our postures and activities. Twists in bones can also be the reason for knots in your muscles.

My own experience is a perfect example of a twist in bone tissue that caused a restriction in the muscle. I had a knot in my inner thigh muscle at about mid-thigh that no amount of bodywork would correct. I and several colleagues worked and worked on this muscle over the course of a couple of years with no lasting results. I went for a treatment from my teacher who developed the Spontaneous Muscle Release Technique (SMRT). She found that I had a twist in the femur (thigh) bone right at the spot where that muscle was bunched up. She applied SMRT for 20 seconds on the bone that released the twist and the muscle relaxed immediately. That knot has never returned. After some discussion about other issues she was seeing in my body, I realized that the twist was a result of how I liked to sit in my car while driving – for the previous nine years!

The Movement Connection

One of my teachers says that when clients come to her with low back pain, the key to resolving the pain long-term for more than half of them is addressing and treating issues in the feet.

This is partially because of the direct fascial connection between the feet and the low back. However, there is also a movement connection. If there is a problem with your foot and you adjust your gait (walking pattern) to compensate for the foot problem, you will likely use muscles in your hips and low back to lift your leg up to walk instead of pushing off from the ball of your foot. These muscles weren’t designed to be used that way, so a common consequence years later is a chronic muscle imbalance that either causes pain or sets the stage for an injury.

This kind of adjustment often happens subconsciously. The body’s ability to adapt is amazing, but it is also a double-edged sword because it adapts without you being conscious of the change. If you’re not aware of how you are compensating, then you’re probably not going to be aware of the changes that occur in your body because of the compensation. Then twenty years later you have back pain, or you strain your back with a simple movement like opening the shower curtain, and don’t understand why.

How my Treatments can Help

I recently treated a 39-year-old woman who is a professional dancer. She has been dancing since she was seven years old. She started with ballet and then branched out into a variety of types of dancing. Her movements are incredibly graceful. However, she complained of hip and low back pain, as well as stiffness and pain in her feet.

Palpation of her hips and legs revealed that all the tissue on the inside of her legs was pulled up toward her hips, while the tissue on the outside of her legs was pulled down toward her feet. The tissue in her inner thighs was twisted toward the front and around to the outside of her body on both legs. Of course, her feet were stuck in plantar flexion (pointed) from years of dancing on her toes, and her midfoot lacked mobility on both sides. SMRT treatment of these issues provided a lot of relief for her after only one treatment.

SMRT is the perfect technique to address these restrictions in fascial and bone tissue, as well as muscles, tendons and ligaments.  It is gentle, almost painless, and it works with the nervous system so the treatment is incredibly relaxing while achieving lasting results.

Thanks for reading!
Dr. Carol

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Tissue damage is neither sufficient nor necessary to cause pain. – Lorimer Moseley

I just watched multiple videos of Lorimer Moseley talking about the information gained from the years of pain research conducted by him and his team. This information is very interesting and provides some food for thought on some aspects of pain that may be new to many people.

When something (pretty much anything!) happens to the body, the brain must try to work out what is going on, is it dangerous, and what should be done about it. If the brain determines that the situation is dangerous, it will send pain signals as a protection mechanism to that part of the body that experienced the event. Pain is an output of the brain that is designed to protect you. The tissue damage itself, if any, is not the true source of the pain. For example, if you sprain an ankle, the pain is not coming from the torn tissue in the ankle even though you feel it there. The pain sensation comes from the brain.

In determining whether to send a pain signal, the brain takes many things into account from many sources – verbal inputs, visual inputs, memories, etc. Research has shown that it is possible to cause a person to “feel” pain in a plastic prosthetic limb (similar to phantom pain in an amputee), and to cause a person to “feel” pain in another person’s arm by tricking the brain with mirrors and special goggles.

This may partially explain how viewing a diagnostic report or film such as an x-ray and having someone with authority communicate a “diagnosis” to us can potentially exacerbate a pain issue. These are additional inputs that the brain will draw on to determine whether the situation calls for a pain signal.

There are many, many examples of people with very mild structural or tissue changes who experience significant pain and people with multiple severe structural issues who have no pain. Studies have been done on people without pain and they have been found to have the same exact structural variations in the same percentages as those with pain.

Could the verbal input of a diagnosis or visual input of an x-ray film be influencing the brain’s decision as to whether a situation warrants a pain signal? Pain is all about protecting the tissues, not measuring the status of the tissues. The pain is very real; it’s just not necessarily correlated with the tissue trauma. Anything that suggests you need protecting takes pain levels up and anything that suggests you are safe brings pain levels down.

This means that anything that changes your brain’s evaluation of danger will change your pain.

When pain duration continues and becomes long-term, the problem is that the neurons that keep producing the pain become better at producing the pain from smaller and smaller inputs. This basically means that the nervous system is somewhat in overdrive – overreacting to inputs that shouldn’t result in pain signals. Also, the neural networks over time lose their capacity for precision, so the pain spreads and becomes more generalized. Furthermore, stress alone causes increased resting nerve impulses, and what person in pain doesn’t have stress? This is how chronic pain evolves from a symptom that might indicate a tissue injury to becoming the disease itself.

Some questions to think about: what in my life, my thoughts, my beliefs, my behaviors, my diet, my relationships, etc. implies threat? Then think about the same questions with regard to safety. The goal is to reduce the threat associated with any answers to the first part and increase the safety associated with any answers to the second part. The body and brain are adaptable and they will change if you train them. Respondents who eat inappropriate food, smoke, consume alcohol and have sedentary jobs not balanced by other physical activity, experience a higher level of pain.

We also need to stop correlating our pain with our diagnoses. Who cares if you have stenosis or a bulging disc or facet joint arthritis or a meniscus tear if you have no symptoms? As noted above, many people live normal, pain-free lives even with these issues. The goal is to be pain-free and functional in spite of the pathologies that appear on an x-ray or MRI.

Yet with regard to treatment, thirteen years of experience as a D.O.M. and manual therapist, has clearly shown me that attention to structural issues such as muscle tension, fascial restrictions, tendon and ligament strains, joint capsule adhesions and joint malalignments has a significant positive effect on pain levels. So if pain is purely an output of the brain as a protection mechanism, it is likely that input from the proprioceptors in the tissues are one piece of how the brain is determining the danger level which then determines the pain level. It seems that sometimes there is a vicious cycle going on whereby the proprioceptors in the tissues communicate to the brain that something is wrong, the brain determines there is potential danger and causes pain, the tissues restrict further in response to the pain, which then communicates more negative input to the brain.

According to Moseley, movement is the key to retraining the brain. It gradually suppresses the pain signal, helps you learn, protects your body against other problems, and is the best way to recover. However, the movement itself must not be painful or it will simply exacerbate the danger signals. Even imagining movement is helpful and may be one way to begin retraining when actual movement is too painful.

Acupuncture and manual therapy are uniquely capable of addressing both the tissue dysfunctions that started the process as well as the nervous system itself. Acupuncture in particular can help calm the nervous system and restore constitutional balance. Treating the structural issues at the same time can help the patient regain some range of pain-free motion so that the brain can trust that there is no danger in the movements. Then the movement therapy can effectively do the job of retraining the brain.

~Carol McGlauchlin, DOM

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Pressure is the force used by the massage therapist on the client’s body. Light pressure is usually calming and relaxing but doesn’t always affect the actual tissue being treated. Medium, firm pressure allows for overall relaxation but also provides enough force on the muscle tissue to encourage tissue release. It also conveys a feeling the therapist is completely present with the client. Deep pressure is the use of fairly heavy force in a massage or manual therapy treatment. It may be used to access the deeper tissues, but it is not the only way to achieve this goal. Deep pressure, especially if the client’s muscles are shortened and rigid, is often painful to the client, additionally it is taxing on the therapist’s body.

Deep tissue techniques, on the other hand, have the goal of releasing and realigning the muscles and connective tissues that are closer to the bones. The therapist may use deep pressure to access these tissues, but there are other effective techniques that don’t require deep pressure. Spontaneous Muscle Release Technique (SMRT) and Muscle Energy Techniques (MET) are two such techniques.

Spontaneous Muscle Release Technique (SMRT) is a positional release modality used by the therapist to naturally prompt the client’s body to regain homeostasis. SMRT uses gentle, passive contraction of muscles, tendons, ligaments and connective tissues to speak directly to the proprioceptors within these structures. (Proprioceptors are special cells that tell the brain where all the body parts are in space, as well as information about their status and how they are moving.) The passive contraction creates a mild slackening of the target tissue. The proprioceptors then communicate to the brain that “all is well,” and the brain and nervous system respond by releasing the targeted structures. The passive contraction is achieved via a direct line of very gentle compression through the bones and soft tissue. Any tissue may be targeted, no matter whether surface or deep, depending on the direction of the line of compression. No deep pressure is required or desired.

Muscle Energy Techniques (MET) is a modality where the client gently engages a muscle or group of muscles against a resistance provided by the therapist for a few seconds. This modality takes advantage of how the nervous system and muscles work together to prompt the nervous system to allow release and lengthening in a target muscle. It works on all skeletal muscles, both surface and deep. No deep pressure is required or desired.

In general, I would argue that while mild discomfort is normal, any significant pain produced because of a manual therapy technique conflicts with the goal of the treatment. Pain activates the sympathetic nervous system and produces a stress response in the body. In addition to the typical stress response of increased heart rate and blood pressure, the physiologic result in the musculoskeletal system is increased muscle tone and muscle guarding. None of these responses is consistent with the goals of manual therapy, even if the treatment is therapeutic and focused on a pathological issue. Although sometimes the sensation from a technique can be a “good hurt,” such a technique should be limited and temporary. I prefer to use more uncomfortable techniques only when other modalities have not achieved the desired results. Pain should definitely not be the basis of the entire treatment!

~Carol McGlauchlin, DOM

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