LUIGI STECCO - CARLA STECCO

FASCIAL
MANIPULATION
PRACTICAL PART
Foreword by
ROBERT SCHLEIP

PICCIN
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 GENERAL INDEX

Foreword V Mf units of the upper limb 82

Example of treatment 90
Abbreviations VIII
Preface .............................. IX Chapter 5 - Mf Sequence of mediomotion . . 91
Acknowledgements XI Mf units of the trunk 92
Introduction .......................... 1
Mf units of the lower limb ..... ..... 102
Mf units of the upper limb 109
3 Example of treatment 117
Basic Principles
Superficial fascia 5
Deep fascia 7 Chapter 6 - Mf Sequence of lateromotion ... 119
Epimysial fascia 12
Physiology of the fasciae 13 Mf units of the trunk 120
Mf units of the lower limb 130
Mf units of the upper limb 137
Part I: The centres of coordination
Example of treatment 145
Chapter 1 - Fascial Manipulation 19
A - Fascial control of segmental movement 19 Chapter 7 - Mf Sequence of intrarotation ... 147
The myofascial unit 19
Mf units of the trunk 148
-
B Fascial control of posture 25
Mf units of the lower limb 158
The myofascial sequence 25
Mf units of the upper limb 1 65
Example of treatment 173
-
Chapter 2 Treatment of the CC 31
A - Compilation of an assessment chart
for segmental treatments 31
-
Chapter 8 Mf Sequence of extrarotation ... 175

B - Compilation of an assessment chart for Mf units of the trunk 176

global treatments 35 Mf units of the lower limb 186
Fascial manipulation - Indications and Mf units of the upper limb 193
Contraindications 37 Example of treatment 201

Chapter 3 - Mf Sequence of antemotion .... 39 Parte II: The centres of fusion

Mf units of the trunk 40 Chapter 9 - Fascial Mobilisation 205
Mf units of the lower limb . . . - . 50
Mf units of the upper limb 56 -
A Fascial control of segmental motor
Example of treatment 64 schemes ........................... 205
The centre of fusion 208
Chapter 4 - Mf Sequence of retromotion .... 65 B - Fascial control of global complex
movements 210
Mf units of the trunk
Mf units of the lower limb
—76
66 The myofascial diagonals
The myofascial spirals
211
213
 GENERAL INDEX XI

Chapter 10 - Treatment of the CF 221 CF of the lower limb 293

Example of treatment 299
A - Assessment chart compilation for
segmental treatments of CF 221
B - Assessment chart compilation for Chapter 14 - Ante-medio centres of fusion . . 301
global treatments of CF 223
CF of the upper limb 303
CF of the trunk 310
Chapter 11 - Retro- latero centres of fusion . . 229 CF of the lower limb 317
231
Example of treatment 323
CF of the upper limb
CF of the trunk 238
CF of the lower limb 245 Chapter 15 - Synoptic tables 325
Example of treatment 251
CF and CC 327
Chapter 12 - Retro-medio centres of fusion . 253
Comparative movement verifications .... 339
Parallelism with acupuncture 355
CF of the upper limb 256
CF of the trunk 262 Conclusion 359
CF of the lower limb 269
Example of treatment 275 Bibliography 361

Chapter 1 3 - Ante-latero centres of fusion .. 227 Alphabetical index of centres of coordination

and centres of fusion 363
CF of the upper limb 279
CF of the trunk 286 Alphabetical index of anatomical photographs 365

ACKNOWLEDGEMENTS
This manual has been realised thanks to the con¬ We would like to express our gratitude to Prof.
tribution of Dr. Antonio Stecco, M.D., resident at Ivano Colombo, who was the first to be interested
the Department of Physical Medicine and Rehabili¬ in this method and to Prof. Raffaele De Caro, Direc¬
tation of Padova University. tor of the Institute of Human Anatomy of Padova
University, for his ongoing collaboration.
The anatomical photographs were taken at the
Normal Anatomy Institute of the “Rene Descartes**
University in Paris in collaboration with Prof. Vin¬
cent Delmas and Prof. Oliver Gagey.
This method is known in Italy and other coun¬
We would like to thank the editor. Dr. Massimo tries thanks to the teachers: Mirco Branchini, An¬
Piccin, who has always valued the advantages of, drea Turrina. Ercole Borgini, Luca Ramilli, Giorgio
and the ideas behind, this method, diffusing it not Rucli, Lorenzo Copctti, and Julie Ann Day. We
only in Italy but also in other countries with the would like to acknowledge all of them, also on be¬
publication of the English edition. half of their students.
 INTRODUCTION

The intention of this manual is to provide a prac¬ coordinate two or three mf units. Centres of Fusion
tical tool for therapists, or fascial therapists, who (CF) generally extend over a wider area than the
utilise fascia] manipulation in the treatment of CC(s), so they are often composed of two or three
myofascial (mf) pain. sub-units that have proven to be of significant ther¬
Divided into two parts, the first section of this apeutic effect. To facilitate fascial therapists, these
book examines the treatment of the Centres of sub-units are numbered accordingly: 1, 2, or 3. Reti¬
Coordination (CC) of each mf unit, and the second nacula consist in the fusion of numerous layers of
section deals with the treatment of the Centres of collagen fibres, therefore these points necessitate a
Fusion (CF). "mobilisation" of the collagen layers rather than a
An introductory chapter illustrates the basic deep, penetrating manipulation.
principles of anatomy and histology of the fasciae Segmental CC(s) arc united in myofascial
(superficial, deep and epimysial). A clear under¬ sequences or myokinetic chains. Likewise, the
standing of the composition and the localisation of CF(s) are united in myofascial diagonals and spirals.
these tissues is essential in order to be able to treat Anatomical photographs of the fasciae introduce
them effectively. each mf sequence and mf diagonal. While photo¬
The first section of this book presents the mf graphs of the fasciae are apparently less precise
units, which move the various body segments in the than anatomical drawings of each muscle, fascial
three spatial planes. Six mf units coordinate each therapists need to focus their attention on this less¬
articulation: namely, the mf units of antemotion, er known tissue rather than on muscles. In effect,
retromotion, lateromotion, mediomotion, intrarota¬ each mf unit consists of muscle fibres located with¬
tion, and extrarotation. Each mf unit has a Centre of in several different muscles and the fascia that
Perception (CP), which corresponds to the area unites them together.
where a patient feels, or perceives, their pain and a Synoptic tables that summarise all of the points
Centre of Coordination (CC), which corresponds to and all the movement verifications can be found in
the origin of the dysfunction. the final part of this book.
The site of pain, or CP. is normally located
around an articulation. Each mf unit governs a par¬
ticular area of an articulation, therefore, accurate
movement verifications can identify the mf unit
responsible for any given joint pain, or dysfunction.
These movement verifications are not individual
muscle tests. They evaluate the overall performance
of the bone-nerve-myofascial complex, or myofascial
unit, as it moves a segment in a specific direction.
After experiencing Fascial Manipulation, many
patients remark, “this is not a massage!" In effect, it
involves deep pressure over specific areas (CC),
necessary for identifying fascial alterations. Having
isolated a fascial alteration, manipulation is per¬
formed for several minutes until the pain disap¬
pears. Each CC is located at a distance from its rel¬
ative CP and is painful only on palpation.
The second section of this book examines motor
schemes comprised within complex movements. In
this case. Centres of Fusion (CF) located within the
retinacula, fascial structures surrounding the joints, The Fascial Manipulation Logo
 BASIC PRINCIPLES

The term "fascia” is often used for connective tis¬ FASCIAE OF THE TRUNK
sue formations that are structurally quite different
from one another, with significant functional diversi¬ Epidermis, dermis
ties. We therefore need to define our understanding of
superficial fascia, deep fascia, and epimysial fascia. loose connective layer
Hypodermis membranous layer
These connective tissue formations are arranged loose connective layer
in layers (Fig. 1 ). If wc examine them layer by lay¬
er. from the external to the internal layer in the external layer
s_perf.
trunk region, we find: lamina
muscle (pect. major)
internal layer
I . the skin, formed by the epidermis and dermis;
Deep
2. the superficial layer of the hypodermis, con¬ Fascia external layer
sisting in loose connective tissue, rich in adi¬ medial muscle ([Link])
lamina internal iayer
pose cells, and intersected by the superficial
retinaculum cutis; deep lamina . ...
3. the superficial fascia (membranous layer),
formed by collagen and elastic fibres;
FASCIAE OF THE LIMBS
4. the deep layer of the hypodermis, consisting
in loose connective tissue and the deep reti¬ Epidermis, dermis
naculum cutis;
5. the deep fascia, that envelops the large mus¬
cles of the trunk and the aponeurotic fibres of
the limbs;
( looseconnective layer
membranous layer
loose connective layer

6. the epimysial fascia, which lies beneath the undulated collagen fibres
deep fascia in the limbs; Deep aponeurotic collagen fibres
Fascia undulated collagen fibres
7 . the rib cage, the pelvis and. within them, their
respective visceral fasciae.
As we will sec further on, the organisation of the undulated collagen fibres
Epimysial muscle fibres
deep fascia in (he limbs is quite different from that Fascia penostium
of the trunk.
Prior to examining the superficial fascia in detail, Fig. 1. Macroscopic subdivision of the fasciae.
the different biological tissues with which one inter¬
acts during Fascial Manipulation are now considered.
connective tissue, rich in adipose cells) and in the
The tissues spaces between muscles. It also forms the lamina
propria, sustaining the epithelium of the mucosa
True connective tissue comprises so-called and the membranes that line the hollow organs.
loose and dense connective tissue. Dense connective tissues can be divided into
Loose connective tissue is found in abundance regular or irregular, according to the arrangement of
beneath the skin layer (hypodermis or subcutaneous their collagen fibres'. In the first case, the collagen

1
Connective tissue consists of three types: dense regular, dense irregular, and loose irregular. Dense irregular is found in fascial sheaths, apo¬
neuroses etc; loose irregular is found in the superficial and deep fascia, in the endomysium, in muscular sheaths etc Loose connective tissue mo¬
stly forms the tech. iHenlmg D. 2005)
4 FASCIAL MANIPULATION

Fig. 2. Collagen fibres of the lacertus fibrosus <50x. Azan- Fig. 4. Connective tissue skeleton of all muscles.
Mallory).

fibre bundles are parallel, close packed and inexten¬ the epimysial fasciae of the trunk and the
sible. Their function, as seen in tendons and limbs: their undulating conformation allows
aponeuroses, is to transmit muscular force (Fig. 2). them to be lengthened, activating embedded
In the second case, the collagen fibre bundles neuroreceptors.
have a less orderly arrangement. Two particular
types are identifiable: Muscular tissue is responsible for voluntary and
- multilayer, parallel collagen fibres; in each involuntary movements of organs and the various
layer fibres arc aligned in different directions, apparatuses. There arc three categories of muscle
as found in retinacula and within deep fascia tissue: striated skeletal, striated cardiac and smooth
of the limbs. muscle (issue. Bundles of associated muscle fibres,
undulated collagen fibres (Fig. 3). as found in united by connective tissue2, form all skeletal mus¬
cles. providing muscle with a connective tissue
skeleton (Fig. 4). Via this "skeleton", the muscular
fibres transmit their contractile force to bone.
In fact, in each muscle we find collagen fibres in
parallel with muscle fibres (epimysial fascia, per¬
imysium. and endomysium), as well as collagen fi¬
bres in scries with muscle fibres (epitendon and
tendinous fibres). The epitendon is the continuation
of the epimysial fascia; the tendinous fibres arc the
transformation of the undulated collagen fibres of
the perimysium into parallel, inextensible collagen
fibres.
Nervous tissue is formed by (wo types of cells:
neurones, cells specialised in receiving and trans¬
mitting nerve impulses, and neuroglia or glial cells.
The latter provide important functional support for
Fig. 3. Undulated fascial fibres between adipose cells and neurones. There is also a connective tissue stroma,
muscular fibres of quadriceps <25x, Hematoxylin-Eosin). essential for nervous tissue survival’.

: A dense connective tissue sheath, the epimysium. surrounds each muscle in the body. This sheath inserts onto bone via the tendon, with which
it is continuous. Septa of interstitial connective tissue extend from the epimydum and surround muscle fibre bundles forming the perimysium. La¬
stly, Ilie endomysium, consisting in a basal membrane and a thin web of reticular fibres, surrounds each single muscle fibre. < Adamo S, 2006)
A nene is an anatomical structure encased in a dense connective tissue sheath lepincurium) from which connective tissue offshoots (perineu¬
rium) extend, dividing the interna) pan of the nerve into compartments. Laminae of reticular connective tissue extend from the perineurium to sur¬
round each single nerve fibre (endoneuriumi. (Adamo S.. 20061
 BASIC PRINCIPLES 5

layer, arc aligned parallel to the skin, such as to

form a true lamellar fascia (superficial fascia).
The deep layer of the hypodermis is very thin
and consists of loose connective tissue. Also at this
level, connective tissue septa connect the superfi¬
cial fascia to the deep fascia, forming the retinacu¬
lum cutis profundus. Here the sparsely distributed
septa are thinner and more oblique as compared to
those of the retinaculum cutis superficial is.
In some particular regions of the body (e.g. crani¬
um, neck), striated muscle fibres have developed
within split layers of superficial fascia itself (super¬
ficial musculoaponeurotic system or panniculus
camosus). Double or split layers of superficial fascia
also enclose subcutaneous vessels and many nerves.
Fig. 5. A nerve within the fascia (250x. immunohistochemi*
cal S100). For some authors (Marquart C.,Varnaison E.
2001), the hypodermis5 and the superficial fascia
arc to be considered as an integral part of the skin.
The histological specimen in Fig. 5 demonstrates These authors remark that, by pinching the skin, it
a sectioned nerve as it passes through the brachial is evident that the hypodermis is continuous with
fascia; the fascia forms an insulating sheath, pro¬ the dermis and that it slides over the muscular fas¬
tecting the nerve from any deformation. However, cia thanks to a thin, deeper layer.
when the nerve terminates at its designated recep¬ Other authors describe yet different versions of
tor, numerous fascial collagen fibres unite with ei¬ the superficial fascia of the face (parotid gland re¬
ther the nerve capsule or the free nerve ending, de¬ gion. temporal region6, etc).
pending on the type of receptor. This ensures During dissections, once the skin is removed, we
stretch of the receptor during movement. find the subcutaneous tissue, rich in adipose cells
(Fig. 8). Histological studies of the subcutaneous
Superficial fascia loose connective tissue7 evidence nerve fibres, nu-

We will now present the description of the su¬

perficial fascia as proposed by the majority of
anatomists (including Fazzari,Testut, and Gray).
The subcutaneous layer, or hypodermis, can be
divided into three layers (Fig. 6): superficial, inter¬
mediate or superficial fascia, and deep. In the super¬
ficial layer, bundles of collagen fibres, also known
as cutaneous ligaments, extend from the dermis to
the intermediate layer. These transverse septa shape
cavities containing adipose lobules (panniculus adi-
posus). Together these ligaments, or transverse sep¬
ta. form the retinaculum cutis superficial is4. Fig. 6. Diagram of the subcutaneous loose connective tis¬
The fibres of the intermediate, or membranous sue, transverse section.

* The cutaneous ligaments (retinacula cutis) anchor the skin to the deep fascia. They are abundant in the face, palms of d»c hand, soles of the fe¬
et and in breast tissue. INash LG 2004)
' The skin comprises the epidermis, the dermis, and the hypodermis; the hypodermis cannot be considered us a separate subcutaneous tissue. In
tlsc deeper put t of the hy podermis, an apparently lamellar area, in continuity with the interlobular septa, is often present and it is difficult to separa¬
te from the hypodermis. This region corresponds to a plane of gliding, as do all layers of loose connective tissue. The lamellar layer of the hypoder¬
mis was initially named "superficial fascia", but anatomists have now excluded this termfMarquart-Elabz. 2001 )
* On the basis of our observations on the parotid gland, no parotid fascia as such seems to be present, hut rather a superficial thickening of the
connective tissue with muscle fibres, which can be identified as the superficial fascia together with the platysma This implies abandoning the ex¬
pression introduced by Mitz who defines this structure as representing a "superficial musculoaponeurotic system" (SMAS).which. in fact, can be
considered Io correspond Io the superficial fascia. (Zigmlti O.L.. IW| )
'
The subcutaneous connective tissue was observed to be composed of multiple layers of thin collagen sheets containing elastic fibers. Those
piled up collagen sheets were kumcly interconnected with each other, while ouler and inner sheets were respectively anchored to the dermis and
epimysium by elastic fibers. (Kawamata S.J003)
6 FASCIAL MANIPULATION

mcrous adipose cells (Fig. 7} and a mesh of colla¬

gen and elastic fibres. This tissue presents a differ¬
ent thickness in the various regions of the body, and
this thickness also varies considerably from one
subject to another. This loose connective tissue lay¬
er is only present in animals that have developed
thermoregulation (homeothermy). Furthermore, in
furry animals (e.g. rabbits), it is particularly thin,
whereas in animals with very little fur (e.g. pigs) it
is more than abundant.
In humans, this adipose layer is absent in the
lips, eyelids, penis and scrotum.
Having removed the adipose tissue by dissec¬
tion. the superficial fascia is then visible (Fig. 9). It
Fig. 7. Superficial fascia of the forearm (50x, immunohisto¬ presents as an extremely elastic membrane, rich in
chemical S100).
blood vessels.
Within certain limits, this membranous layer
glides over the deep fascia. Two specific factors en¬
hance this ability to glide: a thin, intervening layer of
loose connective tissue and the oblique alignment of
the fibrous septa of the retinaculum cutis profundus.
Along the linea alba, the supraspinous liga¬
ments. and the inguinal ligament, the deep cuta¬
neous retinaculum unites the superficial to the deep
fascia in a robust manner.
According to the various body regions, superfi¬
cial fascia has different regional characteristics:
• in the abdomen it is bilaminated, taking the
name of Camper’s fascia (more superficial
and loose) and Scarpa’s fascia (deeper and
more membranous);
• in the pelvis it forms the superficial fascia of
the perineum (Colles’ fascia) that attaches to
the borders of the urogenital diaphragm;
• in the cranium, it forms the galea aponeuroti-
ca, stretched between the frontalis and occipi¬
talis portions of the occipitofrontalis muscle
and the superficial musculoaponeurotic sys¬
tem (SMAS);
• in the palms of the hands and soles of the feet,
the collagen fibres connecting the skin to
deep fascia are more numerous, in order to
impede gliding. This allows for a solid grip or
foothold.
We find the same arrangement of tissue layers
mirrored in the internal wall of the trunk’: the
serous membrane is in contact with the visceral or¬
gans (parietal peritoneum). In the next layer, we
find the subserosal connective tissue, and in the last
Fig. 8. Subcutaneous tissue of the posterior region of the layer, the transversalis fascia, and the internal inter¬
lower leg. rich in adipose cells. costal muscle.

K
lw a fuller understanding of the fascial relationships of the visceral organs and therr vessels, a general scheme is prevented: in the abdomen,
the internal layers consist of the peritoneum, the deep layer of the subperitoncal fascia. the superficial layer of the subpentoneal fascia and the
tnmsversalis fascia. The external layers comprise die skin, the superficial layer of the suticutancouv fascia, the deep layer of the subcutaneous fas¬
cia and the investing layer of the abdominal fascia. (Sato T., 19X4 >
 BASIC PRINCIPLES 7

Deep fascia of the trunk

Comparative anatomy texts describe how the ex¬
trinsic muscles of the trunk originate from the fas¬
cia that covers the cpiaxial myomeres (Kent G.
1997). For this reason, the large muscles of the
trunk (latissimus dorsi. pectoralis major, gluteus
maximus etc.) have developed within a doubled or
bilaminated layer of the deep fascia. Consequently,
in the trunk, these deep fascia laminae are insepara¬
ble from the epimysium9 of the individual muscles.
Testut, Chiarugi, and Gray describe the large
tnmk muscles as being comprised within a doubled
layer of fascia"*.
Therefore, we can say that the deep fascia of the
trunk is subdivided into three laminae (Fig. 10) and
that each lamina is. in turn, bilaminated in order to
accommodate the various muscles:
- superficial lamina: in the neck, the superficial
lamina encloses sternocleidomastoid and
trapezius; it then forms the pectoralis fascia,
the latissimus dorsi fascia, and gluteus max¬
imus fascia:
- middle lamina: the middle lamina of the cer¬
vical fascia encloses the omohyoid muscle,
and then forms the serrati fascia, and the fas¬
cia of the oblique muscles;
- deep lamina: the deep lamina of the cervical
fascia encloses prcvertcbral and paravertebral
Fig. 9. Superficial fascia of the lower leg (with adipose cells muscles, to then form the fascia of the erector
removed), sectioned, and retracted, to highlight underlying spinae. the rectus abdominis fascia, and the il¬
deep fascia.
iopsoas fascia.
In humans, there are no muscles w ithin the superfi¬
The subserosal membrane is absent between the cial lamina of the abdominal deep fascia" because
internal intercostal muscle and the parietal pleura, during the evolutionaiy process they have atrophied12.
whereas it duplicates in the retroperitoneal region to
surround the kidneys, the ureters and the bladder.
Layers of acinose
tissue for gliding
Deep fascia
The deep fascia lies beneath the superficial fas¬
cia. Its external surface extends throughout the
whole body in a uniform manner, while its internal
surface connects to underlying muscles. This inti¬
mate connection between deep fascia and muscles
differs considerably between the trunk and the limbs Fig. 10. Subdivision of the deep fascia of the trunk.

" Wrc assert that transvcrsalis fascia is the inner epimysium of transvenus abdominis muscle; no separate deep investing fascia exists. (Skanda*
lakis P.N.2006)
The deep fascia corresponds Io the epimysium of some muscles. (Gray H.. 1993)
.
The pectoralis fascia is a thin lamina that covers the pectoralis major ami extends septa between its muscular bundles. Inferiorly it continues
with the shoulder, axilla, and thorax fasciae. It is very thin over the pectoralis major hut it thickens in the space between this muscle and latissimus
durst, crossing over this latter muscle as die axillary fascia; the axillary fascia doubles itself into two lamina at tl»e lateral margin of latissimus dor
si to include this muscle, (Gray H. 1993)
" Rizk noted that the external oblique is bi-laminar. with an external layer and a deep layer. The deep layer is continuous w ith the fibre bundles
of the contralateral internal oblique's aponeurosis: the superficial layer lias S- shaped fibres that insert into the abdominal fascia. (Gray H., 1993>
In ammolcs. lateral musculature (obliquev-lransvcrsus) of the thoracic region is complicated by the presence of the ribs (absent in amphi¬
“
bians), w hereas it is present in tire abdomen The external oblique is bi- laminated into a superficial and a deep layer. The superficial layer of the ex¬
ternal obliques becomes Ute internal intercostal muscles and the deep layer the external intercostal muscles. (Stefanclli A. 196K)

Copy ixjhlnd nia® sal

8 FASCIAL MANIPULATION

A thin layer of connective adipose separates the

various laminae of the trunk's deep fascia from one
another, allowing for gliding to occur between lay¬
ers. Some authors have inappropriately called these
thin adipose layers, "thin fascia”1'. Numerous septa
unite the trunk fasciae to the underlying muscles’4.
When these muscles contract they tension the fasci¬
ae, activating the neuroreceptors embedded within
the fascia. This could be the basis of proprioception.
The fasciae of the large muscles of the trunk en¬
close the aponeuroses in the same way that the epi-
tendon encloses the tendons of the limbs15.
During anatomical dissections, we found a thin
lamina of connective tissue lay ing over live latissimus
dorsi and continuing over the aponeurosis (Fig. 1 1).
In effect, the collagen fibres of the latissimus dorsi’s
aponeurosis are clearly visible beneath this layer.
These aponeurotic fibres arc parallel, inextensible, Fig. 11. Detail of thoracolumbar fascia over the latissimus
and ipsidirectional, just like the fibres of other ten¬ dorsi; note the aponeurotic fibres arranged according to the
dons designated to the transmission of force. Histo¬ directions of traction.
logical studies16 also confirm that the thoracolumbar
fascia has a layered formation; the more superficial
layer, or the external lamina of the latissimus dorsi,
lies over the aponeurosis of the same muscle.
The so-called thoracolumbar fascia is actually a
system of fasciae and aponeuroses (Fig. 12). It is
comprised of numerous layers of aponeuroses and
fasciae, originating from several different muscles.
Starting from the more external layer, we find the
epimysial fascia of latissimus dorsi. which. once the
muscle fibres terminate, continues with the same
muscle’s aponeurotic collagen fibres. In part, these
collagen fibres insert onto the spinous processes of
the lumbar vertebrae. In part, they cross to the op¬
posite side of the body, providing insertions for nu¬
merous gluteus maximus’ muscle fibres. In the next Fig. 12. Diagram illustrating conformation of thoracolumbar
layer, we find that the epimysial fascia of the inter¬ fascia.
nal oblique muscle continues with the aponeurosis
of this same muscle, terminating where internal rosis. the erector spinac fuses with the previous two
oblique inserts onto the spinous process. Longitudi¬ only at the sacrum level. The fascia-aponeurosis of
nally. within this compartment formed by these two the transversus abdominis muscle inserts onto the
fasciae-aponeurotic structures, lies the muscle transverse processes. forming the inferior boundary
group of erector spinac. Via its own fascia-aponcu- of the erector spinae compartment.

The external oblique muscle of tl»e abdomen is coveted by both subcutaneous tissue am! thin fascia or investing aponeurosis that continues
°
onto its inscnional aponeurosis, or laminar tendon. A second connective tissue lamina lies between the external oblique and the internal oblique
muscles. A third connective tissue lamina is found between the internal oblique muscle and the transversus muscle. Ail of these fasciae an? extre¬
mely thin and of little importance (Chianigi G.)
The nerves and vessels pass beneath the gluteus maximus within the deep gluteal fascia, an intermuscular plane, rich in adipose tissue and
structured in such a way that its external surface is mure rigid titan its internal surface. (Lang J. 19WI)
Tlx intimate relationship between trapezius and its investing fascia is rarely considered, In fact, many fibres of the muscle itself insert onto
the internal surface of the deep fascia of trapezius. (Bertling D.. 2005 >
.
'* The penlendom, which contains elastic ami collagen fibres, continues, superficially with the surrounding connective tissue and, deeply, with
the endotendon that occupies the spaces between the tendinous bundles. (Gray H.. 1993)
"■
The superficial lamina of tlx posterior layer of tlx thoracolumbar fascia continues with tlx latissimus dorsi, gluteus maximus and, partially,
with the external oblique muscle and trapezius. At the 1.5 level and at the sacrum a strong connection exists between the superficial and deep lami
nae of the thoracolumbar fascia The tranversus abdommus and the internal oblique muscles arc indirectly attached to the thoracolumbar fascia via
a raphe funned from tlx fusion of the middle layer to the deep layer of the sanx fascia. i Vlecimng A.. 1995)
 BASIC PRINCIPLES 9

The fact that part of the latissimus dorsi collagen ccptors. Only these extensible structures can ensure
fibres do not insert onto the spinous processes is ex¬ activation of neuroreceptors.
tremely important. As already mentioned, they con¬ For example, two layers of the deep fascia
tinue into the opposite side of the body, providing (cpimysium) of gluteus maximus. gluteus medius,
insertions for some gluteus maximus muscle fibres. and tensor fascia latae muscles (Fig. 14), form the
This collagen fibre “bridge", between latissimus fascia lata.
dorsi on one side and gluteus maximus on the oppo¬ Furthermore, between these two layers of the fascia
site side, coordinates motor activity between an up¬ lata extend collagen fibres that originate from the
per limb and its contralateral lower limb17. While aponeuroses of these abovementioned muscles. The
these collagen fibres do not transmit muscular con¬ distal tendon, or distal aponeurosis, of gluteus max¬
tractile force to bone, as most tendons do, their role imus. for example, splits in two. one part inserting on¬
is to synchronise the activity of two synergic mus¬ to the femur and the other terminating within the fascia
cles. This activity of peripheral motor coordination lata itself30 (an aponeurosis with a fascial insertion).
is typical of the fascia. Hence, various muscles contribute to the forma¬
Hence, the term “muscular fascia" comprises tion of the fascia lata in the posterior region of the
not only the thin, epimysial fascia layer, but also thigh (Fig. 15). Collagen fibres originating from glu¬
those aponeurotic portions that unite different mus¬ teus medius and minimus are on a more superficial
cles together and do not insert onto bone plane and they project medially, contributing to the
In the trunk, collagen fibre bridges between syn¬ “cavezza” or halter-like formation known as the sus¬
ergic muscles often constitute a definite continuity. pensory retinaculum of gluteus maximus21. The glu-
The aponeurotic continuity between external
oblique on one side and the contralateral internal
oblique in the abdomen is one example, as are the A B C
right and left portions of the trapezius muscle in the
cervicodorsal region.

Deep fascia of the limbs

Rather than enveloping muscles that have devel¬
oped within its split layers, deep fascia in limbs, as
compared to that of the trunk, glides over muscles.
In fact, limb fascia is the continuation of (he bilam¬
inated epimysial fascia of large trunk muscles.
Collagen fibre bridges, which in the trunk unite
synergic muscles, in the limbs extend within the
deep fascia itself.
On histological analysis (Fig. 13), limb fascia
appears to be formed by a series of parallel and in¬
extensible collagen fibres that transmit muscular
Fig. 13. Antebrachial fascia (100x, Azan-Mallory); A, undulat¬
force l9. as well as undulated collagen fibres that are ed collagen fibres; B. adipose layer for gliding; C. inextensi¬
sensitive to stretch and can activate embedded re- ble collagen fibres

,T Histological examination of the posterior layer of the thoracolumbar fascia demonstrates that the number of hminae varies according to the

spinal levcliat LI level there arc two laminae, three at L3-5 level and five laminae at the sacrum level. The latissimus dorsi aponeurosis is the chief
component of this fascial layer. The fibres of the superficial lamina crossover the mid-line, joining with the lamina on the opposite side. At L4-L5
level, the supraspinous ligament is absent, The posterior layer of the thoracolumbar fascia supports movements on the sagittal plane, whereas the
middle layer contributes to stability on the coronal and sagittal planes. iTesh K.M., 1986)
•* Other authors have described the dorsolumbar muscles as being covered by two layers of fascia. The external layer has been named the dor¬
sal layer of the himbodorsal fascia or superficial himbodorsal fascia (Crouch). In the cat. this fascia fuses with the aponeurosis of the erector spinac
at the sacrum level and. near the iliac crest, gives attachment to part of the sartorius muscle. The aponeurosis of the erector spinac lies beneath this
layer of fascia. Reighaul named this the <leep layer of the himbodorsal fascia. Even though this layer, in part, glides freely muscles like a fascia, we
consider it is an aponeurosis due to the fact that it gives insertions to many muscles. (Bogduk N 1998 >
•• Surprisingly, most material parameters tor the two layers of the fascia lata did not differ significantly from corresponding values lor the iso¬
lated tendons ansi tendon-bone preparations. (Butler D.L., 1984)
31
The fascia luta. or femoral, is reinforced laterally by a certain number of aponeurotic expansions from the gluteus maximus fascia and the ten¬
sor fascia lata muscles. (Teslul L. 19X7 )
21 The halter system Distally, from the line that connects the ischial tuberosity to the apex of the greater trochanter, the transverse bundles of

the fascia lata project towards the skin and the undeiiy ing musculoskeletal plane. Thanks to the presence of a rigid system of “retinacula" these
bundles limit the subcutaneous connective tissue. circumscribing the distal margin of the gluteus maximus in a halter-like formation. (Lang J, 19X8 1
10 FASCIAL MANIPULATION

Fig. 15. Arrangement of endofascial collagen fibres in deep

layer of the upper thigh: A, collagen fibres originating from
gluteus maximus. Distally they pass beneath those of the
gluteus medius; B. collagen fibres from the gluteus medius;
C, collagen fibres from the tensor fascia lata and gluteus mi¬
nimus.

Fig. 14. Connection of the deep fascia of gluteus medius and

maximus to the fascia lata. Removal of the superficial fascia
in the trunk reveals the epimysial fascia of gluteus maximus,
whereas in the lower limb the deep fascia (fascia lata) is vis¬
ible.

teus maximus’ aponeurosis extends laterally, be¬

neath this connective tissue lamina, to join with the
longitudinal aponeurosis of the tensor fasciae latac.
This web of endofascial collagen fibres transmits in¬
formation concerning contraction of one muscle to
another synergic muscle in a more distal segment. As
we have already seen, the large trunk muscles uni¬
form their activity with the contralateral muscles via
their aponeurotic-fascial continuity. For example, if
Fig. 16. Diagram of the fascia lata illustrating the conforma¬
a person is carrying an object in both arms, then the tion of the deep fascia in the limbs (longitudinal section).
right pectoralis major muscle must develop the same
force as the left pectoralis major. The pectoralis ma¬
jor fascia, which crosses over the sternum (Fig. 21 ), change of information. The aponeurotic expansion
synchronises these two muscles, activating their re¬ of gluteus maximus onto the iliotibial tract (Fig,
spective muscle spindles in a uniform manner. 14), for example, can synchronise hip movements
In the limbs. endofascial collagen fibres from the with movements of the knee (Fig. 16).
aponeurotic expansions guarantee this type of ex¬ In anatomy, while great importance is given to

opynghlad mstefal
 BASIC PRINCIPLES 11

Fig. 18. Diagram Illustrating myofascial insertions along the

femoral and crural fasciae (longitudinal section).

order to synchronise activity between the two

segments.
Traction, in a proximal-distal direction, helps to
coordinate and to adapt static muscle contractions
in the lower limb to any postural variations of the
trunk (Fig. 1 8). Distal to proximal traction helps to
synchronise proximal muscle tension with motor
variations in the extremities. When, for example,
we arc out walking and suddenly we hit our fool
against an obstacle, then the entire lower limb and
the trunk quickly adapt, even before we have time
to realise what has happened. The cndofascial col¬
lagen fibres are an essential source of information
Fig. 17. Distal Insertion of semitendinosus (detached proxi¬
mally) onto the medial crural fascia. for the CNS during such a rapid and complex pos¬
tural adjustment.
All of the muscles surrounded by the fascia lata
the insertions of muscles onto bone, the insertions and the crural fasciae send tendinous expansions
of muscles onto fascia are basically ignored. Forex- onto these same fasciae --.creating a type of retinac¬
ample. the semitendinosus muscle (Fig. 17) glides ulum (Fig. I9).
under the fascia lata enclosed by its own epimysial The same happens in the upper limb: the latis¬
fascia. Prior to its insertion onto the tibia, it sends simus dorsi, pectoralis major2', and deltoid muscles
tendinous expansions to (he crural fascia; thereby all send tendinous expansions onto the brachial fas¬
forming, within the crural fascia itself, collagen fi¬ cia before inserting onto the humerus. The two lay¬
bres aligned according to traction produced by this ers of epimysial fascia (hat accompany these expan¬
same muscle (Fig. 18). sions continue on, contributing to the brachial fascia.
This tendinous expansion of semitendinosus has Within the extracellular matrix of the deep fascia
a double function: there are also elastic fibres. These fibres allow the
- to traction the crural fascia proximally, in¬ fascia to adapt to any stretch from the previously
forming the lower leg muscles about the state mentioned aponeuroses, and to return to its physio¬
of contraction of the thigh muscles; logical length afterwards.
- to receive traction from lower leg muscles, in If endofascial collagen fibres served only for the

a The popliteal fascia comprises two layers of collagen fibres that cross over each other. The superficial fibres are orientated transversally and
they continue with the media) intermuscular septa; the deep fibres continue with the lateral septa, and are tensioned by the same muscles they she¬
ath I Lang J. I988)
" Sappey has quite rightly indicated that the latissimus dorsi and pectoralis major muscles both send a large expansion onto die brachial fascia.
(Tcstut L. 1 987)
12 FASCIAL MANIPULATION

reinforcement of the fascia, then there would be no

need for the thin layers of loose connective tissue
that facilitate gliding between one connective tissue
lamina and the next24 (Fig. 20).

Epimysial fascia
The deep fascia of the trunk often fuses with the
epimysial fascia25. Hence, having removed the su¬
perficial fascia, wc find that only a thin, connective
tissue layer, acting as both deep fascia and
epimysial fascia, encloses the large trunk muscles.
In the table regarding the deep fascia of the trunk
(Fig. 1). we can see that beneath the hypodermis
lies the external layer of the deep fascia's superfi¬
cial lamina. These collagen fibres arc inseparable
from the epimysial fascia and are connected to the
muscle fibres via numerous septa. Being undulated,
they adapt to variations in muscle length, and. at the
same time, they can effectively stretch the receptors
that arc embedded between them.
The large muscles of the trunk all terminate in
Fig. 19. Deep crural fascia, posterior region: reti¬ aponeuroses (flat tendons). As already mentioned,
naculum-like formation of collagen fibres.
via their deeper portion, these aponeuroses insert
onto bone, whereas via their superficial collagen fi¬
bres they join with the aponeuroses of muscles on
the opposite side of the body. Wc have seen that
part of the latissimus dorsi’s aponeurosis on one
side continues writh the aponeurosis of the contralat¬
eral gluteus maximus. Likewise, the pcctoralis ma¬
jor aponeurosis on one side continues with that of
the contralateral pectoralis major (Fig. 21); the
trapezius aponeurosis on the right continues with
that on the left (Fig. 22); and the external oblique
aponeurosis continues with the aponeurosis of the
contralateral internal oblique, and so forth. All of
these aponeurotic connections function in a proxi¬
mal-distal as well as a distal-proximal direction,
synchronising the activity of the two muscles. This
feedback mechanism plays a similar role to that al¬
ready described for the collagen fibres in the
femoral and crural fasciae.
The deep fascia of the limbs has the following
conformation (sec Fig. 1):
- externally, immediately beneath the hypoder¬
mis. we find the undulated collagen fibres of
Fig. 20. Antebrachial fascia (250x. Van the deep fascia:
Gieson); A, undulated collagen fibres; B. adi¬ - within the split layer of the deep fascia we
pose layer, for gliding; C. parallel collagen fi¬
bres; D, adipose layer (for gliding) between find aponeurotic-type collagen fibres;
two aponeurotic laminae. - beneath the deep fascia there is a thin layer of
* For rl»c ir asy nchronv . the collagen fibre bundles must glide freely between one another in order to balance the tissue structure against any ex¬
ternal leruiona) forces. (Threlkeld AJ, 1992)
We assert that transvcrsalis fascia is the inner cpimvsium of tninssersus abdominis muscle; no separate deep investing fascia exists. (Skan-
dalakis P.N.. 2006)
 BASIC PRINCIPLES 13

Fig, 21. Aponeurosis and fascia (superficial layer) of the

right-sided pec tor a Us major passing over the sternum to
continue with the aponeurosis and fascia of the contralater¬
al pectoralis major.

Fig. 23. Epimysial fascia or epimysium of the triceps surae

muscle.

Fig. 22. The aponeurotic fibres of the trapezius on one side The proximal aponeurosis inserts onto the
continue with those on the contralateral side and are visible
beneath the superficial fascia of the dorsum.
popliteal fascia and is formed by the perimysium of
only a few muscle fibres. On the contrary', the distal
tendon is the continuation of the perimysium of
loose connective tissue, which allows for in¬ all the muscle fibres of the triceps surae.
ter-fascial gliding; The collagen fibres in the epimysial fascia have
- next we find the epimysial fascia that is cont¬ a fine, undulated and web-like conformation, as
inuous with the perimysium and the en- these fibres must respond to muscle as it shortens or
domysial fascia of the muscle. lengthens, as well as to stretch of the endomysium
In this photograph of the triceps surae (Fig. 23.). and the muscle spindles (Fig. 24).
we can see that the epimysial fascia continues with The epimysial fascia generally slides beneath the
two tendinous formations: deep fascia27, with the exception of those points
- that of the proximal part of the gastrocnemius, where the muscles insert onto the fascia.
similar to the flat aponeuroses of the trunk When a muscle is subjected to continuous ten¬
muscles; sion (overuse, prolonged static postures), the undu¬
- that of the distal part of gastrocnemius, typi¬ lated collagen fibres within its fascia tend to adopt
cal of the fusiform muscles of the limbs. the inextensible conformation typical of tendon fi-

* Epimysium and perimysium coalesce to form tendons. These data showed that epimysium incorporation into sutunng improve* capacity to
bear forces compared with perimysium incorporation. (Kragh J J-., 2005)
n The deep fascia is a simple structure of densely-packed collagen bundles and elastic fibres, and has hyaluronic acid concentrated on its inner
surface, which is in contact with the underlying muscle. The post- surgical specimens demonstrated preservation of die structure of the interface
between fascia and muscle, including Ilie retention ol the hyaluronic acid lining, if Ilie epimysium was intact. However, if the epimysium was di¬
srupted. the structure of the interface was obliterated. (McCombe D.. 2001 )

Copy rghlnd ma®rsal

14 FASCIAL MANIPULATION

• longitudinal, fibres that transmit tension

along the motor trajectories of the spatial
planes. These trajectories are comparable to
the myokinetic chains or sequences. These
longitudinal, myofascial “bridges" coordinate
muscles moving different body segments
along a specific trajectory', particularly in
virtue of the fact that they have a strong resist¬
ance to traction. In fact, we have used dy¬
namometers to measure their resistance to
traction, and all are capable of sustaining sev¬
eral kilograms of traction.
• oblique, these fibres transmit tension devel¬
oped by the oblique muscle fibres, those that
generally intervene in complex, dynamic, spi¬
24. Continuity of muscular fibres with ondomysium and ral-form motor gestures.
epimysial fascia (200x. Azan-Mallory). These longitudinal and oblique fibre bundles are
located within the deep fascia of rhe limbs, whereas
in the trunk they are found within the connective
brcsM. This transformation of the connective tissue tissue skeleton of the muscles.
structure determines motor incoordination and re¬ Two fundamental functions are attributed to the
sultant non-physiological tension is transmitted to fascia:
misalignment and pain.
(he articulation, causing joint - the perception of movement in the three spa¬
tial dimensions (mf sequences) and during the
motor schemes (mf spirals)
Physiology of the Fasciae - the motor coordination between static postur¬
The physiology of the fasciae is virtually incom¬ al muscles (mf sequences) and between mus¬
prehensible unless it is examined together with cles involved in dynamic gestures (mf spirals)
muscle.
Motor perception is determined by ncuro-reccp-
The superficial fascia provides for:
tors such as Ruffini corpuscles, Pacini corpuscles,
a) muscles to slide beneath the skin as they con¬
Golgi corpuscles, and free nerve endings (Fig. 25).
tract. Whenever, scars or burns cause skin to
adhere to muscular fascia then movement is
compromised;
b) the separation of the cutaneous perception
(exteroception) from that of the deep muscu¬
lar fascia (proprioception).
The deep fascia synchronises:
c) the activity of those motor units aligned in
parallel that actuate the same movement
(myofascial unit);
d) the activity of several muscles aligned in se¬
ries that actuate the movement of a segment
in the same direction (mf sequence).
Synchronous motor activity of muscles located
in different segments are regulated by their own in¬
sertions onto the deep fascia2’.
Collagen fibre bundles with two fundamental
Fig. 25. Section of crural fascia (400 x. S10O) highlighting
orientations form the tendinous expansions of mus¬ free nerve endings (brown) aligned with undulating collagen
cles onto the fascia: fibres.

* The first phenomena,of both hysteresis and stress-relaxation,demonstrated an increased stiffness of the thoracolumbar fascia when it is stret¬
ched in succession. When the fascia is stretched in succession, it diminishes its capacity for deformation tYahia L.H.. 1993 )
* In hand recon-struetive surgery . the palmaris longus muscle is one of rise most utilized doner sites fur tendon reconstruction procedures. Even
in cases of an accessory palmaris longus it has been noted that it always inserts onto the deep fascia (Tiengo C„ 2006)
 BASIC PRINCIPLES 15

As these ncurorcccptors arc activated by stretch,

they can only function correctly if they arc embed¬
ded in a tissue that is capable of lengthening. Re¬
gardless of which part of the body they are located,
they always transmit the same type of nerve im¬
pulse to the brain. In order that this information has
a directional significance, these receptors must be
situated within a structure that has a precise, topo¬
graphical orientation. The body’s fascial compart¬
ments. together with its intermuscular septa, form
just that sort of structure because it corresponds to
the three spatial dimensions.
in the anterior region of the limbs, fascial com¬
partments enclosing muscles that move all body
segments forward, or anteriorly, have formed. In
the posterior region of the limbs, another sequence Fig. 26. Neuroreceptor: Pacini corpuscle (100x, immunohis-
to-chemicalSIQO).
of fascial compartments encloses the extensor mus¬
cles. In the lateral and medial regions of the limbs,
we find the intermuscular septa, which are stretched
by the abductor and adductor muscles. These same it cannot adapt to the stretch of a single muscle
sequences are found in the trunk, but with the fol¬ spindle, and the enlargement of the central part of
lowing variations. The paravertebral muscles are the spindle w ith the subsequent firing of the annu¬
distributed in two compartments (the right and the lospiral fibres does not take place. Golgi tendon or¬
left erector spinae). The rectus abdominis is com¬ gans also have a web of collagen fibres surrounding
prised within two fascial compartments, divided by their axons; these fibres wind up or unwind, accord¬
the linca alba. Two ipsilateral forces (iliocostalis ing to the direction of stretch to which they are sub¬
and obliques) actuate lateral flexion of the trunk. jected. such that the inhibitory nerve impulse may
The contraction of these muscles also stretches their or may not be activated.
surrounding fascia, consequently activating recep¬ Innervation of the fascia varies according to the
tors. In fact, when we bend sideways we tend to
function of the fascia itself:
perceive movement at the level of the trunk wall
rather than from the periarticular receptors of the
• in the superficial fascia we find thermorecep¬
tors and pressure sensitive receptors such as
vertebrae.
Pacini corpuscles (Fig. 26). A concentric
Fascia intervenes in motor coordination '.
Muscle spindles and Golgi tendon organs are the
lamellar structure contributes to the activation
nerve terminations that regulate muscular contrac¬ of these receptors’ nerve impulses and, be¬
tion. Muscle spindles are embedded in the endomy- cause they are activated by pressure, then the
sium, in parallel with the muscle fibres. The Golgi subcutaneous, loose connective tissue is their
tendon organs are embedded in the myotendinous most suitable tissue environment.
junctions, in series with the muscle fibres. The con¬ • we find different receptors in the deep fascia:
tinuity of the endomysium with the connective tis¬ - in the retinacula there arc various types of
sue skeleton ensures transmission of spindle con¬ receptors, all suited to interpreting the mul¬
traction to the entire fascia. Obviously, this continu¬ tiple functions of this structure;
ity can operate in the opposite sense, so that passive - in the epimysial fascia and the endomysium
stretch of a muscle can activate even a single mus¬ there are the muscle spindles;
cle spindle. In fact, spindles can be stimulated ac¬ - in the passage from muscle to tendon there
tively, via the gamma fibre circuit, or passively, by are the myotendinous organs of Golgi;
stretch of their muscle. However, these mechanisms - along the fascial compartments there are
can only be activated correctly if the fascia main¬ mostly free nerve endings, activated by
tains its physiological elasticity. If fascia is too rigid muscular stretch.

*' The rectovaginal septum is formed by a web of collagen and elastic fibres, and smooth muscle cells with nene fibres that emerge from the
hypogastric plexus. With variations in the endorectal pressure, this septum pays an active role in modulating the muscle tone of the pelvic walls.
(SteccoC.. 2005»
16 FASCIAL MANIPULATION

As already mentioned, both undulated and paral¬ role in tension transmission and. subsequently, co¬
lel collagen fibres are found within the fascia. ordination.
When the undulated fibres lengthen, they can The receptors of the deep fascia are all proprio¬
stretch the free nerve endings, whereas parallel col¬ ceptors that are capable of acting as nociceptors
lagen fibres transmit tension from one muscle to an¬ whenever they are stretched beyond their normal
other in an adjacent segment. physiological limit.
Hence, the extensible fibres are necessary for Cutaneous receptors are all exleroreceptors. In
motor perception and the parallel fibres for motor the galea aponeurotica, the palms of the hand and
coordination between the various muscles. If fascia the soles of the feet, many collagen fibres unite skin
comprised only undulating collagen fibres, then it to deep fascia: hence, the receptors in these regions
would only have a perceptive role; if fascia com¬ have both a proprioceptive and an exteroreceptive
prised only parallel fibres, then it could only have a role.
 Part I
The Centres of Coordination
 1
FASCIAL MANIPULATION

Two fundamental aspects of the fascia form the According to Bernstein (1967), the contribution
bases of the method presented in this book: of reflexes could not resolve the problem of coordi¬
- recent research indicating that fascia could nation entirely. Bonds, possibly formed through
play an important role in coordination and learning processes, were then hypothesised.
proprioception (Huijing P. 2001 ) and. conse¬ Reflexes plus learnt bonds could explain unvar¬
quently, in the control of posture and complex ied, or standardised, motor patterns but are inade¬
movements; quate in explaining the adaptability of our gestures
- the remarkable plasticity of fascial tissue1 (if to sudden, unpredictable variations within any giv¬
over stimulated it modifies its texture) as well en situation.
as its malleability*, (manipulation can restore Schmicd (1993) showed that synchronisation of
its physiological elasticity). motor units modifies in the presence of visual and
In this chapter, we will analyse the role of fascia auditory' feedback.
in the motor control of a single segment (A) and in Bennett (1994) demonstrated that neuronal facil¬
the control of posture (B). itation of hand muscles by the motor cortex varies
In the following chapter, we will examine how during precision grip tasks, thereby adapting mus¬
manipulation can exploit fascial malleability in the cular activity to a specific task.
treatment of myofascial pain. We attribute fascia with an active role in these
peripheral mechanisms controlling muscular syner¬
gies. We hypothesise that the myofascial unit, the
A - Fascial control of segmental myofascial sequence, and the myofascial spiral
movement manage this task -dependent recruitment.
Whilst the intent of this text is to provide practi¬
Exactly how the nervous system controls the cal clinical indications, further research is clearly
enormous quantity of independent variables simul¬ necessary to clarify these underlying physiological
taneously present within any given movement is mechanisms.
one of the key problems faced by Neuroscience to¬ Nevertheless, results obtained through applica¬
day. These variables include: tion of this method demonstrate that a hypothesis of
- kinematic variables: available joint range, ve¬ fascial involvement in peripheral motor coordina¬
locity, acceleration: tion is worth consideration.
- dynamic variables: muscular force, torques,
and power;
The myofascial unit
- neuronal variables: temporal and spatial pa¬
rameters for recruitment of single motor units Recent experiments (Smeulders M, 2005)
(Rulli M, 2005). demonstrate that 37% of muscular force is transmit¬
Sherrington attempted to explain muscular re¬ ted not only to tendon insertions but also to adjacent
cruitment synergies via peripheral neuronal mecha¬ structures. Given that muscular insertions onto sep¬
nisms (reflexes). ta and fascia develop a considerably minor force as

1
Poorly functioning fascia (inflammation, adherence*. postural stress) causes cross-linking between fibre collagen molecule*, with consequent
.
adhesions and reduced mobility The extracellular matrix becomes dense or viscous, interfering with normal catabolism and anabolism. (Hcrtling
D., 200S)
2 Connective tissue is a colloidal substance
in which the ground substance can be influenced by the application of energy (heal or mechanical
pressure) to change its aggregate form from a more dense ‘gef slate to a more fluid 'sof slate (thixotropy). (Schleip R.. 20031
20 FASCIAL MANIPULATION

connective tissue, such as to be capable of force

transmission".
Fascia does not only connect these muscular fi¬
bres passively. It is also directly involved in muscle
spindle activity. In fact, whenever a muscle length¬
ens its spindles arc passively stretched because they
are inserted within the endomysium of that muscle.
Whenever firing of gamma nerve fibres causes con¬
traction of intrafusal muscle fibres, spindles actively
traction the endomysium. (Baldissera F. 1996).
This type of adaptability requires an elastic fas¬
cial system, capable of responding to spindle
stretch by shortening and closing-off the alpha¬
gamma circuit.

Physiology of the myofascial unit

Whenever a nerve impulse activates a motor unit
then all of the muscle fibres within that unit w ill con¬
tract. However, these fibres do not all contract simul¬
taneously (jack knife effect). The exact position of
the joint on which they act determines w hich fibres
contract. It has been demonstrated 4 (Ninos J., 1997,
Sheehy P„ 1998), that during knee extension the
thousands of knee extensor fibres are not all activat¬
ed simultaneously. They intervene according to the
Fig. 1.1. Having sectioned and hooked back the fascia lata of degree of knee joint position. This infers a continu¬
the anterior region of the thigh, numerous adherences to the ous feedback /feedforward mechanism within each
epimysial fasciae are visible. myofascial unit. Fascia is subject to different tension
according to changes in the degree of joint move¬
compared to insertions onto bone, the question aris¬ ment. This determines variations in the adaptation of
es as to why the body “needlessly** disperses such a fascia to muscle spindle stretch, with consequent
significant quantity of energy. Fascial structures variations in recruitment of relative muscle fibres.
arc. in fact, partially elastic, therefore they adapt to Logically, in order to synchronise all muscle fi¬
muscle contraction. bres that move a joint in one direction, a single
Analysts of the myofascial unit provides an¬ point of reference is also fundamental. For all mus¬
swers to this apparent illogicality: fascia connects cle spindles connected to a specific sector of fascia
all of the motor units that act on a single joint in this reference point is called the vectorial centre, or
parallel L In our dissections, we have seen that centre of coordination (CC). For example, contrac¬
anatomical reality is quite different from illustra¬ tion of latissimus dorsi. teres major, infraspinatus
tions found in some anatomical atlases. In the above and the spinal (scapular) part of deltoid results in
specimen (Fig. 1.1), all of the collagen fibre con¬ retromotion of the humerus. /Xnatomy texts often il¬
nections or "bridges** between the fasciae of adja¬ lustrate these muscles as isolated entities but a se¬
cent muscles have been left intact. ries of fascial "bridges" (Fig. 1 .2) actually unite
Numerous septa originating from the internal sur¬ them, focusing their contractile force towards a sin¬
face of the deep fascia connect with the epimysial gle vectorial centre, or centre of coordination, for
fascia. Epimysial fascia is continuous with perimy¬ retromotion of the humerus.
sium and this, in turn, with endomysium. Huijing In summary, those motor units involved in mov¬
(2001 ) also affirms: "Extra-muscular connective tis¬ ing a segment in a specific direction, together with
sue has an intimate connection with intra-muscular their accompanying fascia, form a myofascial unit

muscle, surrounded by Areolar and dense connective tissue, form an inseparable unit known as myofascia. (Herding D . 2005)
’' Striated
Surface electromyography and motor analysts were recorded simultaneously dunng knee flexion between 10° to 60° degrees. Significant
change* in the muscular activity of vastus lateralis and medialis were recorded during the varying degrees of knee flexion whereas no changes in
biceps femoris were recorded eiectromyographically. (Ninos J.. 1997)
 FASCIAL MANIPULATION 21

Anatomy of the myofascial unit

Monoarticular and Particular muscle fibres form
each mf unit (Stccco L. 2002):
- monoarticular fibres comprised within a mf
unit intervene only in movements actuated by
that specific mf unit:
- Particular fibres function both within a single
mf unit, as well as on proximal or distal mf
units. For example, monoarticular fibres
(soleus) and Particular fibres (gastrocnemius)
form the mf unit of retro-talus. Soleus acts on¬
ly during rctromotion of the talus while gas¬
trocnemius is also involved in retromotion
genu (knee) and pes (foot).
Hence. Particular fibres provide fascial continu¬
ity along a sequence. This explains w hy treatment of
a single segmental cc, at times, benefits all of the mf
sequence and not only the pertinent cp of the specific
mf unit being manipulated. These positive effects are
assured when. during compression over a cc. referred
pain extends in a proximal and/or distal direction.
Biarticular fibres intervene on the proximal or
distal segment according to the selected or pro¬
grammed movement. For example, many muscles
involved in movement of the pelvis are also in¬
Fig.1.2. Dissection of the scapular region highights collagen volved in movement of the thigh. Their selective re¬
fibres that extend from latissimus dorsl to the Infraspinatus cruitment will depend on:
fascia, and atso the deltoid fascia (below). - for the pelvis, if closed chain movements are
required (i.e. during weightbearing)
(mf). Within the overlying fascia, which is always - for the hip, if open chain movements are re¬
continuous with the muscle fibres of every myofas¬ quired (i.e. when the thigh is free to move,
cial unit, we can identify a specific centre of coordi¬ such as the swing phase of gait, kicking etc.).
nation (cc). We can also identify a so-called centre
of perception (cp) in the fascia that extends over the
The body segments
moving joint.
Every centre of coordination has a precise Each mf unit comprises a joint, the accompany¬
anatomical location within the fascia. These points ing fascia, the bones, and the various muscle fibres
are situated where traction, resulting from motor that move thisjoint. Therefore. a myofascial unit ex¬
unit activity involved in a specific movement, con¬ tends well beyond the usual confines of bones or
verges. joints. The term shoulder, for example, necessarily
The centre of perception (CP or cp) is located in includes the scapulo-thoracic articulation, the gleno¬
the joint, which is moved by the relative myofascial humeral and the acromio-clavicular articulations.
unit. The term “glenohumeral” defines the articulation
Any consolidated alteration (or fibrosis) of the without considering all of the muscles that move this
fascia comprising the centre of coordination results joint. In Italian, the term “humerus" indicates the
in incoordinate movement, with consequent irrita¬ bone, whereas in Latin and Spanish it means “shoul¬
tion of articular nociceptors (cp or area of referred der". For these reasons, when referring to mf units,
pain). In (his case, the altered cc becomes the cause we have decided to adopt a new terminology for the
of pain and the joint (cp) is where pain manifests (ef¬ body segments (Fig. 1.3). utilising terms derived
fect). Even when there is only an atypical fascia) ten¬ from Latin and used internationally (Tab. 1.1).
sion. the cp can be the site of pain. In this case, pain Whilst primitive fish have single segment Pxlies
can be more diffuse: it may invest the entire joint or that move as a single myofascial unit, humans have
manifest itself in the antagonist mf unit or. some¬ numerous segments that move independently from
times. it extends along all of the myokinetic chain. one another.
22 FASCIAL MANIPULATION

ly primates have developed independent

movements of the fingers and toes.
Specific muscles, connected together by precise
fasciae, move the joints of the limbs and the trunk.
A brief definition of the anatomical boundaries
of each mf unit (Fig. 1 3) is as follows:
The digiti segment (DI) includes the distal row
of carpal bones, all the mctacarpals. and all the pha¬
langes of the fingers. The single fingers of the hand
arc indicated with Roman numbers (1° for the
thumb; II for the index finger. 111° for the middle
finger, etc).
The segment of the carpus (CA) comprises the
proximal row of carpal bones and the distal two
thirds of the forearm.
The cubitus segment (CU) comprises the proxi¬
mal third of the forearm and the distal two thirds of
the upper arm. This division respects the distribu¬
tion of those muscular fibres (of biceps brachii. bra-
chioradialis, and triceps) that move the elbow joint.
The humerus segment (HU) includes the gleno¬
humeral joint and those muscular fibres of deltoid,
biceps brachii, and triceps that intervene in shoul¬
derjoint movements.
The segment of the scapula (SC) comprises
Fig.1.3. Anatomical boundaries of the myofascial units.
bones and muscles of the shoulder girdle,excluding
those of the above mentioned humerus segment.
The caput segment (CP) comprises the head, and
Tab. 1.1. Terms used to indicate body segments and their abbre¬ includes three subunits: the eyes, mandible, and ears.
viations The abbreviation cpl indicates the subunit of the eyes,
Abbr. Termini latini English cp 2 that of the mandible, and cp 3 that of the ears.
The collum (CL) extends from the first to the
di Digiti fingers seventh cervical vertebra.
ca Carpus wrist
cu Cubitus elbow Tire thorax segment (TH) comprises the rib cage
hu Humerus shoulder with the twelve thoracic vertebrae.
sc Scapula scapula
cp Caput head
Tire lumbi (LU) comprises the lumbar vertebrae
cl Collum neck and the portion of the abdomen above the umbilicis.
th Thorax 1borax The pelvis segment (PV) comprises pan of the
lu Lumbi lumbar
pv Pelvi pelvis ischium, the crest of the ilium, the sacrum and. an¬
ex Coxa thigh teriorly, the pubic symphysis.
g* Genu knee
The coxa segment (CX) comprises the hip joint
la Talus ankle
pc Pes foot (acetabulum, femur head and neck), the proximal
half of the thigh, and the sacrotuberous and
sacropsinous ligaments.
The genu (GE) extends from halfway on the
For example, lateral neck flexion can occur thigh to. anteriorly, the tibial tuberosity and. poste¬
while the thorax remains stable or. likewise, lumbar riorly, to the proximal third of triceps surae.
rotation in one direction with pelvis rotation in the The talus (TA) comprises those muscle fibres in
opposite direction. the lower leg that move the talus in the three spatial
Apart from the trunk, quadrupeds also have four planes.
limbs (hat comprise four main articulations The pes (PE) comprises a part of the calcaneus, a
- coxa-femoral and glenohumeral joints, part of the tarsus and all of the metatarsal-pha¬
- elbow or cubitus and knee joints. langeal bones. Each toe is numbered in a similar
- tibiotarsal and radio-carpal joints, manner to the fingers (1° for the hallux. 11° for the
- the joints of the hands and the feet. In fact, on¬ second toe etc.).
 FASCIAL MANIPULATION 23

Fig.1.4. In an aquatic setting, lateromotion produces for*

ward movement.

These boundaries are not absolute. For example, in

the leg we find muscles that move the tarsus as well
as the toes. The same is true of the catpus and the fin¬
gers in the hand. When applying this method it is use¬
ful to remember this "merging" of some segments.
However, in general, the above outline aids in
comprehension of mf unit function, as well as how
to define the precise localisation of pain.

Tab. 1.2. Old and new terminology describing movement on the

three spatial planes and the abbreviations

Frontal plane

Lateromotion Mediomotion
LA ME
Abduction Adduction

Sagittal plane

Antemotion Retromotion
AN RE We have chosen to use directional terms to de¬
Flexion Extension scribe the movements of the body segments rather
Horizontal plane than using conventional terms, which are some¬
times contradictory. For example, forward move¬
Intrarotation Extrarotation
IR ER ment of the hip is called flexion, whereas a back¬
Pronation Supination ward movement of the knee is also called flexion.
The term flexion refers to the closure of a joint
without respecting the exact direction of the move¬
Body movements ment. We prefer to use terms such as latero-medio,
ante-retro, and intra-extra (Fig. 15) because the
In fish, movements on the frontal plane dominate motor cortex actually programs movement accord¬
as they advance in the aquatic environment using ing to spatial directions and not according to die
lateral motion of their entire body (Fig. 1 .4). opening or closing of joints (Kandel ER. 1994).
In a terrestrial environment the trunk can flex to Given that each body segment moves on the
the left and right (lateromotion), it bends forwards three spatial planes then, for each segment, there
and backwards (ante and retromotion), and it rotates arc six myofascial units; for example, in the coxa
externally and internally (extra and intrarotation). segment we find:
Movements of lateromotion occur on a frontal
plane, those of ante and retromotion on a sagittal
- the myofascial unit of ante-coxa (an-cx) that
moves the hip forwards,
plane whereas rotation occurs on a horizontal plane - the mf unit di retro-coxa (re-cx) that moves
(Tab. 1.2). the hip backwards.
24 FASCIAL MANIPULATION

Stimulus over CC
lor trigger point

CP or area
Referred pain ol referred
area pain

Fig.1.6. Relationship between trigger point and referred pain Fig.1.7. Compression of a CC causes pain with consequent
pattern, according to Travel!. antalgic contracture and activation of articular nerve termi¬
nations (afferences) due to overstretch.

- the mf unit of latero-coxa (la-ex) that moves Whilst extended research into the explanation of
the hip laterally, trigger points has taken into consideration myofib¬
- the mf unit of medio-coxa ( me-cx) that moves rils*. skin, vessels, and nerve reflexes’, fascia itself
the hip medially, to the median line. has been somewhat ignored.
-the mf unit of intra-coxa (ir-cx) that rotates
the hip inwardly.
According to Travel!, trigger points refer my¬
ofascial pain over a specific topographical distribu¬
- the mf unit of extra-coxa (er-cx) that rotates tion, characteristic to each muscle. Direct compres¬
the hip outwardly. sion. acute stress, chronic fatigue, trauma, and cold
The three posterior mf units (re. la. er) arc antag¬ can activate trigger points (TP), as well as visceral
onists to the three anterior mf units (an. me, ir). disease and emotional disturbances.
Therefore, we consider agonist and antagonist mf To explain the relationship between a trigger
units, rather than agonist and antagonist muscles. point and its referred pain pattern (Fig. 1 .6), Travel!
refers to the spinal reflex arcs; that is. hoth the TP’s
Referred pain and Centre of Perception (CP) nociceptive afferent and the feedback from the re-
ilex pain area converge to the same destination.
For thousands of years it has been common This would result in a constant referred pain pat¬
knowledge that compression of precise points on the tern but, actually, this pattern is variable (Hwang
body can provoke specific, referred pain patterns'. M. 2005): at times, pain can extend to the nearby
These points have a precise location in all individu¬ joint and, at times, along an entire limb. For exam¬
als6; however, referred pain varies from individual to ple. pressure over the paravertebral muscles of a
individual7; it docs not follow nerve pathways lumbalgic patient causes referred pain to extend to¬
.
(Hwang M 2005) or single muscle conformation. wards the lumbosacral joint (Fig. 1 .7). However,

5
. .
Myofascial trigger point diagnostic criteria are: I a tender spot in a tmit band of skeletal muscle; 2 a local-twitch response of some muscular
fibres in response to stimulus of a TP; 3. predicted pain referral pattern, in response to medianical stimulus of a TP. (Travell e Simons)
• A IT provokes a typical dettromiographical signal, while adjacent parts ol the same muscle are silent. It could he that muscle spindles have
an important role in the pathophysiology of a myofascial TP. < Hubbard e Berkoff. 1993 1
Multiple stimulation of a specific TP in tire same individual riproduces the exact area of referred pain more precisely than stimulation of the
same TP in different individuals. Referred pain, other than that from muscular sources, can have origin from other structures, namely, skin, joint fa¬
cets. and internal organs. tGrobli C.. 2003)
’ Up until today . there is no significant proof to support the hypothesis of histological changes in TPs in humans. In 1951 Glogowsky and Wal
Intff were able to establish myofibril distraction in myogelosis. Nearly 20 years later Fassbender, during electromicroscopic analysis of myogelo¬
sis. found degeneration of band 1 myofilaments. Finally. Pongrau and Spath observed degeneration of muscle fibres in the presence of edematous
.
reactions, (Grobli C 2003)
’ It is probable that the observed phenomena concerning intemcuroncs in the dorsal hont could be considered as the origin of TP referred pain.
IGrobli C^2OO3)

Copy iqt itrtd m aK-t ml

 FASCIAL MANIPULATION 25

pressure over the same muscles in a patient with bursitis, followed by a MRI to examine possible ro¬
sciatic-type pain, can cause pain to extend down the tator cuff lesions. In absence of any positivity, bone
entire lowrer limb. Pressure applied posteriorly, to¬ densitometry for decalcification may follow whilst,
wards the tendinous insertions onto the vertebrae or simultaneously, blood tests are usually ordered to
ribs can propagate referred pain anteriorly, towards exclude infection or malignous processes... mean¬
the abdomen or the inguinal region. while the person continues to suffer. Instead, an im¬
We have acertained that these three patterns of mediate application of fascial manipulation may re¬
referred pain correspond to certain conformations solve their pain, confirming a diagnosis of myofas¬
of the fascia: namely, the mf unit, the mf sequence, cial pain. Clearly, if after two or three treatment
and the mf spiral. sessions symptoms remain unvaried, a therapist
The pattern of referred pain within a mf unit can should refer the person to other specialists for fur¬
be explained as follows: compression of an active ther investigations.
trigger point, or centre of coordination (cc), deter¬
mines a nociceptive signal, which causes contrac¬
tion of the specific muscular chain coordinated by -
B Fascial control of posture
that cc (Fig. 1.7). An active cc implies that the fas¬
cia is already in an altered state. Therefore, this an¬
Fascia extends throughout the body and it unites
all body segments. In some ways, this reflects the
talgic, reflex contraction is poorly coordinated, re¬
definition that Guidetti gives to posture: “We can
sulting in an incongruous effect on the pertinent
define Posture as all those positions assumed by the
joint. Non-physiological stretch of the periarticular
body in which a particular relationship between the
receptors produces yet another nociceptive signal.
diverse body segments is emphasized" (Guidetti G..
Afferent nerves will convey the pain sensation to a
1997).
spinal segment related to the joint being moved in
Basal fascial tension stimulates the receptors
an anomolous manner (cp). rather than to the seg¬
embedded within the fascia and the resulting affer¬
ment connected to the [Link] trigger point. In fact, if
ent impulses, conveyed to the central nervous sys¬
the fascia where the cc is located is in a normal,
tem. contribute to postural control. These afferent
elastic state, then its compression produces a local,
impulses are effectively the same from all of the
tactile sensation without determining pain and an¬ body; they only acquire a directional and positional
talgic contractions.
significance if mapped out within the context of a
We will now examine the practical application
precise fascial architecture.
of this antalgic mechanism. When a joint is painful, In fact, the fascia is divided into specific com¬
it is not the painful joint (area of referred pain) that
partments for each myokinetic chain:
requires treatment, but the motor source (muscle¬
fascia surrounding thecc). More precisely, if a joint
- myofascial sequences that move the body for¬
wards and backwards (sagittal plane);
pain manifests itself anteriorly (an) then, presum¬ - myofascial sequences that move the body lat¬
ably, it is the mf unit of antemotion that is acting in¬ erally and towards the median line (frontal
congruously. Hence, from the site of pain we can plane);
deduce which cc is dysfunctional. Joint pain in the
- myofascial sequences that move the various
posterior region (re) implicates the mf unit of retro- segments into intrarotation and extrarotation
motion. If joint pain is in the lateral region (la) wre (horizontal plane).
can hypothesise a compromised mf unit of latero- Fascia not only provides a directional signifi¬
motion. Similarly, a medial site of pain (me) can in¬ cance to afferent nerve impulses. Via its endofascial
dicate the mf unit of mediomotion. In this text, for collagen fibres, it also intervenes in the active man¬
each mf unit, we will describe the anatomical loca¬ agement of movement.
tion where pain may manifest and the exact locat¬
ion of the corresponding centre of coordination.
The myofascial sequence
Myofascial pain is one of the most frequent af¬
flictions of the locomotor system. Nonetheless, it is The mf units that move body segments in the
often overlooked in the medical field and patients same direction on one plane form each sequence.
suffering pain are often subjected to a scries of in¬ Muscular insertions onto the overlying fascia syn¬
strumental tests that can prove to be superfluous. chronise the activity of these mf units.
For example, a patient presenting with a painful For example, in the anterior region of the upper
shoulder is often subjected to X-rays, to exclude limb we find a fascial compartment surrounding the
micro-fractures; then an ultrasound scan to exclude mf unit of ante-cubitus in the upper arm and ante-car-
26 FASCIAL MANIPULATION

Fig.1.9. Antebrachial fascia sectioned and stretched back to

highlight origin of flexor carpi radialis fibres.

Fig.1.8. The lacertus fibrosus of biceps brachii acts as a

bridge between the mf unit of ante*cubitus and that of ante*
carpus. chains of flexion, extension, adduction, abduction,
intra and extrarotation, but they also introduce the
concept of fascial coordination between the single
pus in the forearm. The fascial “bridge" of lacertus mf units. This coordination between individual mf
fibrosus unites these two mf units (Fig. 1 .8). units could be actuated via feedback between fascia
When biceps brachii and brachialis contract (an- and the muscle spindles. Spindles are activated in
cu) lacertus fibrosus traction draws the antebrachial two ways: or via direct stimulation from the central
fascia in a proximal direction. When flexor radialis nervous system or via passive stretch.
carpi contracts, the point where the lacertus fibro¬ • Direct stimulation of muscle spindles by gam¬
sus inserts onto the antebrachial fascia is pulled in a ma efferent fibres causes contraction of intra¬
distal direction. fusal muscle fibres. Spindles do insert onto
This traction is possible because some muscle fi¬ the cndomysium-pcrimysium. hence, any
bres of flexor carpi radialis originate from the over- contraction stretches this connective tissue
lying antebrachial fascia (Fig. 1.9). Thus, it is the surround. Contraction of numerous spindles
continuity of the collagen fibres of the fascia that conveys tension to the deep cpimysial fascia
synchronises the flexor muscles or mf units of ante¬ from various angles, forming vectors that
motion during forward (antemotion) movement of converge towards the centre of coordination
the upper limb. of the single mf units. If this cc is elastic then
these spindles can shorten in length, dilating
their median receptor portion, resulting in
Physiology of the mf sequence
correct propagation of la afferent impulses,
Mf sequences are named with the same direc¬ with subsequent activation of alpha efferent
tional terminology as the mf units: ante, retro, latcro fibre impulses. These alpha fibre impulses
etc. Mf sequences do correspond to the myokinetic produce contraction of the extrafusal muscle

Copy nqhtHd nia®r»j|

 FASCIAL MANIPULATION 27

MYOFASCIAL CHAIN ALONG cle is fusiform in shape then we find a

THE ANTE SEQUENCE fusiform aponeurosis; where the muscle is
quadrate, with an ample extension of its my¬
ofascial insertion, then the aponeurosis is
thinner and wider.

Pectoralls major Anatomy of the mf sequence

exerts traction
on the brachial The myofascial insertions along the antemotion
fascia in a proximal
direction sequence will now be examined. The mf unit of
ante-humerus (an-hu) is composed of Particular
(clavicular part of deltoid and pectoralis major) and
Brachialis exerts monoarticular muscles (coracobrachialis). Pec¬
traction on the
same fascia in a toralis major extends a tendinous expansion onto
distal direction the anterior brachial fascia, and coracobrachialis in¬
serts, in part, onto the medial intermuscular septum.
When these muscles contract, the brachial fasci¬
Blceps-lacertus ae tense slightly (note arrow pointing in a proximal
exerts traction on
the antebrachial direction. Fig. [Link]); this delicate stretch of the
fascia in a brachial fascia is sufficient to activate, or better still,
proximal direction
synchronise the muscle spindles of the brachialis
muscle. Many fibres of the brachialis muscle origi¬
nate from the lateral and medial intermuscular sep¬
Flexor mm exert
traction on the ta; its contraction stretches the brachial fascia in a
same fascia distal direction (note four oblique arrows. Fig.
distally
[Link]). This guarantees a continuous feedback be¬
tween the mf units of ante-humerus and ante-cubi-
tus. During elbow flexion, not only brachialis is ac¬
Palmaris longus tive, but also biceps brachii. Via the lacertus fibro-
exerts traction on sus, contraction of biceps brachii stretches the ante¬
the palmar fascia In rior region of the antebrachial fascia. This deter¬
a proximal direction
mines a passive stretch to the muscle spindles of the
mf unit of ante-carpus. Contraction of those mus¬
Thenar and hypothenar cles governing antemotion of the carpus (flexor
mm. traction the same carpi radialis and palmaris longus), stretches the
fasoa distally
thenar and hypothenar eminence fasciae, which take
origin from the palmaris longus itself. This anatom¬
Fig.1.10. Mf sequence of antemotion in the upper limb. ical continuum demonstrates just how important it
is that the fascia always maintains its basal elastici¬
ty in perfect shape. If trauma or overuse alters its ex¬
tracellular matrix, its ability to adapt correctly to
fibres. For the most part, the force of contrac¬ these delicate stretches is reduced, resulting in inac¬
tion is transmitted to the tendon or bony inser¬ curate activation of muscle spindles and, subse¬
tions bringing about movement, however, a quently. of the periarticular nociceptors.
part of this force is transmitted to the many Tcnsional compensation for a densified cc com¬
small myotendons that insert onto the fascia. monly extends along a mf sequence. It is. therefore,
• Passive stretch of muscle spindles occcurs via imperative to investigate previous and concomitant
the myotendinous insertions that numerous pain during our anamnesis in order to understand if
muscles extend onto the fascia. This type of a specific sequence is involved.
spindle activation could synchronise the ac¬ This text describes the unidirectional sequences
tion of two adjacent, unidirectional mf units. of the upper and lower limbs, and the trunk, in a se¬
In fact, in every mf unit we can find these quential manner in order to facilitate comprehen¬
tendinous expansions that insert onto the fas¬ sion of this concept of continuity.
cia of adjoining mf units. Wherever the mus¬ The sequence of retromotion (Fig. 1.13). situated
28 FASCIAL MANIPULATION

in the posterior region of the trunk and limbs, is the

antagonist to the antemotion sequence. This associ¬
ation is useful for focusing our attention on the spa¬
tial planes. These two sequences form the agonist¬
antagonist mf forces that, together, control body
posture on the sagittal plane.
An excessive tension in an ante mf unit often
causes a counter-tension in a retro mf unit; this neu¬
tralises forces that could cause misalignment of the
body segment.
Muscles comprising the retro sequence also ex¬
tend tendinous expansions onto their overlying fas¬
cia. Anatomical texts describe these expansions
without attributing them any physiological signifi¬
cance .

MYOFASCIAL CHAIN ALONG

THE RETRO SEQUENCE

latissimus dorsi
exerts traction on
the brachial fascia
in a proximal
direction
Fig.1.11. Tendinous expansion of latissimus dorsi onto pos¬
terior region of the brachial fascia.

triceps brachii
exerts traction on
the same fascia in
a distal direction

tnceps exerts
traction on the
antebrachial fascia
in a proximal
direction
extensor mm.
exert traction on
the same fascia in
a distal direction

extensor carpi
ulnaris exerts
traction on the
hypothenar fascia in
a proximal direction

hypolhenar eminence
mm. exert traction on
the same fas&a in a
distal direction
Fig.1.12. Antebrachial fascia, sectioned and stretched back
to highlight origin of the extensor carpi ulnaris from the
same fascia. Fig.1.13. Mf sequence of retromotion in the upper limb.

Copyrghlad material
 FASCIAL MANIPULATION 29

For example, latissimus dorsi extends a tendi¬ the fascia in a proximal and a distal direction. The
nous expansion onto the posterior brachial fascia wide variety of limb movements has created a web
(Fig.1.11); this expansion stretches the two inter¬ of collagen fibres within the deep fascia:
muscular septa in a proximal direction. Both the - horizontal fibres, formed in response to trac¬
medial and lateral heads of triceps brachii take ori¬ tion exerted by segmental muscular fibres (mf
gin from these septa. unit);
Contraction of triceps brachii causes simultane¬ - longitudinal fibres, formed in response to
ous elbow extension, via its tendon inserted onto traction between diverse myofascial units (mf
the olecranon, and stretch of the posterior ante¬ sequence):
brachial fascia, via a tendinous expansion onto this - oblique fibres, formed in response to traction
same fascia caused by complex or global movements (mf
Many muscular fibres of extensor carpi ulnaris spirals).
take origin from the posterior antebrachial fascia The deep fascia of the trunk doubles to surround
(Fig. 1.12). Passive stretch of the muscle spindles the diverse myofascial sequences:
can activate these fibres. This reciprocal, tcnsional - two longitudinal compartments comprise the
interplay between unidirectional mf units could jus¬ ante sequence (rectus abdominal muscles)
tify the presence of muscle spindles. In fact, carti¬ and the retro sequence (paravertebral mus¬
laginous fish have absolutely no spindles, yet, all cles);
the same, their musclescontract. The muscles of the - the lateromotion sequence on one side is an¬
various metameres in these fish insert onto myosep- tagonist to the contralateral sequence; the
la (fascia), ensuring their synchronisation by unit¬ medio sequence has only a perceptive role;
ing them into a single mf unit of lateromotion. - the rotation sequences are united by the fasci¬
The latero and medio sequences in the limbs al¬ ae of the serrati and the obliques; the spirals
so have muscular fibres that insert onto the fascia. are connected via the large, superficial mus¬
Similar to the sagittal plane, these fibres can tension cles.
32 FASCIAL MANIPULATION

(humerus: hu. cubitus: cu. carpus: ca etc) and. sub¬

sequently. for the mf units (an-hu. rc-ca, etc). We
recommend using these abbreviations as it can fa¬
cilitate the identification of the mf unit requiring
treatment.
The exact location (loc) of the joint pain is de¬
fined: in the lateral part (la), anterior part (an), pos¬
terior part (re), or medial part (me) etc. It is then in¬
dicated if the pain is in the right (rt) or left (It)
limb/trunk or bilaterally (bi). Often the localisation
of pain (la, an, re...etc.) can correspond to the
painful movement (PaMo).
The chronicity (chron). or length of time the
problem has been present, is then recorded. Pain
present only for a few days (d), two or three weeks
(w) or a less than 3 months (m). is considered as
acute. If it has been present for more than 3 months
or for years (y) then it is considered chronic. Chron¬
ic pain often presents a recurrent pattern (rec), with
periods of remission and exacerbation. In the case
of recurrent pain, it is useful to record the frequen¬
cy: once a week (Ixw), twice a month (2xm). three
times a year Oxy). This data is helpful because re¬
duction in frequency can signify an improvement.
For example, if after treatment, the patient refers
that their cephalalgia, previously occurring twice a
week (2xw), presents itself only once in a month Fig. 2. 2. Example of compilation of an assessment chart for
(Ixm), then this is an indication that treatment has Isolated hip pain (segmental disturbance).
been effectuated in the correct point.
The last section of data, referring to the intensity
of the pain (int), is quantified using asterisks: * 3. cysts: these often develop over a specific ten¬
slight pain arising during heavy work strain or don to compensate for incongruous muscu¬
sport; ** strong pain that does not. however, inter¬ lar activity:
rupt daily activity; *♦* very strong pain that does 4. hypertonicity: hypertonicity and hypertrophy
not allow normal daily activities (Fig. 2.2). may develop to compensate a fascial altera¬
Having completed this part of the subjective ex¬ tion;
amination. any known movement that aggravates 5. hypotonicity: often hypotonicity and hypo¬
the pain (PaMo) is also recorded. Patient's rarely trophy in muscles are consequences of nerve
report unidirectional movements as their major pain irritation:
source, but commonly indicate complex move¬ 6. clicks: clicks, for example in the TMJ or
ments or gestures. Subsequent movement verifica¬ knee joint during movement, indicate a ten-
tions will identify individual, exacerbating move¬ sional imbalance;
ments. Even if the patient reports a complex move¬ 7. partial dislocation: small subluxations during
ment, it can still be useful, in association with other movement can indicate an alteration in a mf
data, in identifying a dysfunctional mf unit. unit;
At times, there is no painful movement or, on 8. paraesthesia: anomalous sensation in a cuta¬
the contrary, all movements are painful. In these neous area due to a ncuro-fascial compres¬
cases, instead of the painful movement (PaMo), we sion;
can record any evident, symptomatic alterations re¬ 9. posture (ptr): misalignment of the body can
ported by the patient or observed by the therapist, indicate a compensation for a disturbed mf
such as: unit;
I. inflammation: this normally localises in the 10. deformation: every chronic misalignment
site of pain, that is, around the joint; that causes bony deformation indicates an
2. oedema: quantifiable by measuring circum¬ adaptation of the bone to a persistent trac¬
ference of the joint tion.
 TREATMENT OF THE CC 33

This information is necessary to quantify the re¬ .

Tab. 2.1 Grid for movement verification of a single segment
sults. which arc not always immediately evident but
can consolidate after one week. Frontal Plane Sagittal Plane Horizontal Plane
me-cx an-cx ir-cx*

Hypothesis la-cx re-cx er-cx*”

Prior to commencing, we need to establish a

therapeutic plan based on the anamnesis and the ted movement (joint range can be measured
subjective examination. with a goniometer before and after treatment);
The recorded data can indicate two possible hy¬
potheses:
- actively: the patient moves the implicated
segment or segments in the three planes and
- segmental: in this case, pain is localised in a refers which direction aggravates the pain
single segment, and so. from the site of pain (pain can be measured using an algometric or
and the painful movement, we can deduce the Vas scale);
potentially dysfunctional mf unit. We can - against resistance: the fascial therapist applies
then distinguish the exact altered centre of co¬ resistance as the patient executes the previous
ordination by palpation. movements. Where possible, apply resistance
- global: in this case, pain is located in nume¬ comparatively to two limbs to test any diffe¬
rous segments, and so, we can hypothesise the rences (force can be measured using a dyna¬
involvement of a spatial plane on which the mometer before and after treatment).
different compensations have developed. Initially, it is best to record movements on a grid,
In both cases, before commencing treatment wre facilitating comparison of impaired movements
will need to confirm our hypothesis via the move¬ (Tab. 2.1). With acquired experience, this step can
ment verification (MoVe) and the palpation verifi¬
be done mentally.
cation (PaVe).
For the segmental movement verification, the
mobility of only one segment is examined in all of
Verification the three planes. The painful direction is noted us¬
ing from one to three asterisks, according to the de¬
Movement verifications or tests are proposed for gree of pain, limited movement, or weakness. The
each mf unit. These arc not the same as single mus¬ unimpeded, non-painful directions can be annotated
cle tests. All of our muscles participate in a wide either without adding any asterisks, or else, not not¬
variety of movements, whereas a mf unit is respon¬ ed at all and then it is implied that they have been
sible for the execution of a single movement of a tested and were insignificant. For example, the
single joint in a specific direction. A mf unit utilises movement verification for the coxa segment (ex)
monoarticular and biarticular fibres situated in dif¬ may evidence aggravation of pain on the horizontal
ferent muscles and is never composed of just one plane (er-cx ♦♦♦, ir-cx *). In the following grid, it
muscle. can be deduced that the cc that requires careful at¬
Each joint is governed by: tention during palpation verification is that of extra-
- six segmental myofascial units: two for the coxa
sagittal plane (ante-retro), two for the frontal The palpation verification should be carried
plane ( medio- latero) and two for the horizon¬ out, in a comparative manner, over the cc of those
tal plane (intra-extra) (see summary tables); mf units that were highlighted during the movement
- four mf units of fusion, involved in interme¬ verification. In the aforementioned case, palpation
of the cc of er-cx and ir-cx is indicated. Often only
diate movements: ante-latero, ante-medio, re-
tro-latero. and retro-medio (these mf units of one of the two will present a definite alteration of
fusion are discussed in the second part of this the fascial tissue (Tab. 22).
text)
The movement verification is designed to high¬
light the compromised mf unit. It is therefore neces¬ Tab. 2.2. Grid for the segmental palpation verification
sary to examine the movements of the ailing joint in
the three spatial planes Frontal Plane Sagittal Plane Horizontal Plane
The movement verification can be carried out: me-cx an-cx ir-cx
- passively: the therapist moves the joint passi¬ la-cx re-cx er-cx”
vely in the three planes noting the most limi-
34 FASCIAL MANIPULATION

The palpation verification is carried out over the transform friction into heat, modifying the consis¬
centre of coordination (cc) of each inf unit, consid¬ tency of the fascia's extracellular matrix, which is
ered the origin of the symptoms. This point does not heat sensitive. In fact, any given pressure has a
normally manifest spontaneous pain itself. It is only deeper, more intense action when the area of ma¬
painful when it is compressed. Hence, in order to be nipulation is reduced. The direction of manipula¬
able to verify any alterations in the tissue, it is im¬ tion is also important. It is regulated by the need to
portant to knowr the precise location of each differ¬ create the maximum friction against the fascia to
ent cc. Patients are often surprised when the thera¬ develop the maximum heat in the minimum amount
pist is interested in palpating a point at quite a dis¬ of time. Between two to ten minutes of manipula¬
tance from w here they arc feeling their pain (cp). At tion are required to develop the necessary degree of
times, it can be useful to palpate the centre of per¬ heat. This variability in time depends on the
ception, if only to be able to quantify any changes chronicity of the fascial fibrosis and its consistency.
in local sensitivity before and after treatment. Fascial manipulation acts on different tissues:
Palpation of an active cc usually highlights two - it mobilises the hypodermis or the subcutane¬
types of tissue alteration: ous loose connective tissue:
- a sense of "roughness" in the connective tis¬ - it modifies the consistency of the deep fa¬
sue (fascia); scia’s extracellular matrix;
- the presence of tight or contracted muscle fi¬ - it restores gliding between the endofascial
bres. collagen fibres;
This alteration or "roughness" of the fascia - it ruptures adhesions between the layers of
forms due to trauma, overuse (postural or occupa¬ deep fascia in the trunk;
tional). over-stretch, and strains; the muscular con¬
traction forms due to changes in the alpha-gamma
- it recreates elasticity of the connective tissue
skeleton (epimysium, endomysium)
circuit. In the acute phase, for example during an at¬ In this book, all of the photographs that depict
tack of acute lumbago, muscular contracture is treatment demonstrate the suggested treatment po¬
more evident, whereas in the chronic phase, fascial
sition for both the patient and the therapist.
alteration is more evident. Whenever a cc presents In these photographs, treatment is often shown
muscle contracture and fascial alterations, the aim
as performed with the knuckles, in order to high¬
of treatment is always to liquefy the fascia, rather
than to release the contracture. Once the fascial af- light the exact localisation of each point. In order to
ferents are normal, that is, no longer nociceptive, complete a lengthy manipulation without tiring
then muscle tone normalises itself. oneself we suggest using one's elbow whenever
During palpation verification, we consider one possible.
objective factor, as perceived by the therapist, and When necessary, the suggested patient position
three subjective factors, as referred to by the pa¬ is adapted to an individual patient's situation (e.g.
tient. In the first case, the therapist searches the area pregnancy or any particular difficulty in assuming
for an alteration in the tissue. This manifests itself the position). The fascial therapist should always
as granular tissue, perhaps producing a “creaking" assume the most comfortable working position pos¬
sensation, and it resists tissue mobilization like a sible, partially distributing weight onto the non¬
taut cord (Hammer Wl. 2005). Instead, the patient working arm, and dosing the amount of pressure ap¬
is asked to refer: plied to the treated point during manipulation.
1. when palpation has centred the point of maxi¬
mum sensitivity. In practice, this is actually
the simplest way to define the point to be trea¬ Results
ted. jump sign is often absent and so we re¬
ly on the patient's sensations to guide us; After every treatment, record each cc manipulat¬
2. when palpation triggers a needle-type sensa¬ ed and the outcome; for example, if the cc of extra¬
tion; this is preferable to a sensation of only coxa rt has been treated in one session with an im¬
pain or strong pressure; mediate, positive outcome in terms of symptoms,
3. when palpation provokes a referred pain; ge¬ then it is recorded on the assessment chart as fol¬
nerally. this does not manifest immediately, lows: er-cx rt ++; if latero-coxa was treated in the
but after a few minutes of manipulation. same session without producing any results it is still
recorded on the assessment chart to avoid repeating
Treatment treatment of this point in subsequent sessions. If,
for example, treatment of latero-coxa had actually
Treatment is always aimed at precise points of worsened the patient's symptoms then an asterisk is
the fascia. Only manipulation of a limited area will added to indicate this, whereas if its treatment had
 TREATMENT OF THE CC 35

produced no change then (he cc alone is recorded fore a more lasting improvement consolidates
(Fig. 2.2). (*++).
This immediate post-treatment evaluation, as If a patient refers that their symptoms have re¬
well as that effectuated after one week, will influ¬ mained unchanged (+♦), then we need to doubt our
ence the choice of points to treat in the subsequent treatment choices, repeating the anamnesis and the
sessions. verifications more accurately.
It is always wise to attend one week before mak¬ Small hematomas limited to specific areas may
ing a second treatment. This allows the tissues develop in subjects with particularly fragile capil¬
enough time to respond and adjust to the manipula¬ laries. These tend to reabsorb spontaneously within
tive stimuli. a few days.
On the patient's return, we enquire about their Small, superficial skin abrasions can occur if,
reaction to the manipulation and record the out¬ during treatment, the fascial therapist slides over
come on the assessment chart, once again using the patient's skin instead of adhering to it correct¬
symbols (Tab. 2.3); in the section “results lw“, wre ly-
record one, two or three plus signs if the outcome is
positive(+++)- If the benefit was immediate but it
lasted only one day. the problem then returning as B - Compilation of an assessment chart for
before, we record (+*). In the first case, the global treatments
etiopathogenesis of the pain had been correctly ap¬
proached. In the second case, treatment had been By practicing segmental manipulation for a cer¬
directed only to the antalgic contracture and not to tain period, the more experienced fascial therapist
the cause, that is, the fascial alteration. will notice that pain is often present simultaneously
in more than one area, and that its distribution is not
altogether casual. It often extends along precise mf
sequences or is distributed over one plane.
Tab. 2.3. Symbols used to quantity results

Sym Meaning Indications

Data
++ Immediately better, al¬ Continue to treat oc’s on
so in following days the same plane Record the different pathologies and muscu¬
•++ Immediately worse, Post treatment inflamma¬ loskeletal dysfunctions, which patients report dur¬
then much better tion eccessive ing the anamnesis, in a concise and chronological
Slightly better, less than Segmental treatment but order. This helps to formulate connections between
50% not global what, at first, can appear to be apparently discon¬
nected events. This is an essential ingredient for the
Immediately better, but Only release of muscular
then returned the same contraction elaboration of a successful treatment plan.
Firstly, we need to determine if the concomitant
?? Pain location has Treatment has created a pain (PaConc) and the maximum pain (PaMax) are
changed compensation rather than
a balance distributed on the same plane.
By means of an attentive analysis of the chronol¬
Symptoms worse than Maybe treated only con¬ ogy of the different disturbances, we can elaborate
before treatment sequence, not cause
the route that the various compensatory' tensions
may have developed over time.
Lastly, we consider any paraesthesia present in
Problems that may arise after treatment the hands, feet, or head, because fascial limitations
often find their final compensation in the extremi¬
The patient must feel better immediately after ties.
treatment. If not. then either the wrong point has
been treated or the point “responsible" for the dys¬
function has not been manipulated sufficiently. Site of Pain (SiPa)
Within a few minutes after treatment, an inflamma¬
tory reaction develops in and around the treated Under the section “SiPa". we record the current
point. This is a necessary reaction, both for the me¬ reason for w hich the patient is seeking treatment or.
tabolism of the manipulated tissues and for an opti¬ in other words, the maximum pain (PaMax). This is
mal repair of the fascia. At times, this inflamma¬ the same praxis already described in the compila¬
tion accentuates symptoms for about two days be¬ tion of a segmental assessment chart (Fig. 23),
38 FASCIAL MANIPULATION

together with lumbar pain, due to incoordination tary muscles (Schleip R. 2006). it is not efficient in
between the forces of extrarotation lumbi to the the case of structural alteration or permanent dam¬
right and intrarotation lurnbi to the left. age. This does not mean that fascial manipulation
Reciprocal tensional equilibrium between ago¬ constitutes a palliative treatment. On the contrary, it
nist and antagonist muscles is fundamental on all is valid for many pain syndromes that would other¬
planes. For example, rectus abdominis (an-lu) must wise be treated only with analgesics. Pain is the
be in tcnsional balance not only with the paraverte¬ body’s way of communicating that a part is not
bral muscles (rc-lu), but also with rectus femoris functioning. If we do not intervene in this initial
(an-gc) and this, in turn, with the hamstrings (re-ta). phase then the incorrect use of a joint, or an organ,
Excessive tension in rectus femoris inclines the evolves towards arthritis or tissue fibroses with
pelvis anteriorly on the sagittal plane, resulting in a damage that can then only be repaired surgically.
hyperlordosis and contraction of the paravertebral The principal contraindication for fascial ma¬
muscles (re-lu). nipulation is the insufficient preparation of the fas¬
cial therapist. If therapists are knowledgeable
about anatomy then they know where and how to
Fascial Manipulation: indications apply pressure appropriately to avoid injuring
and contraindications nerves and vessels. When an inexperienced fascial
therapist first approaches this type of treatment, as
Medical practitioners and patients alike often en¬ with any manual therapy, their tactile sensitivity is
quire about the indications or contraindications of poorly developed and they tend to apply more pres¬
fascial manipulation concerning a whole variety of sure than is necessary. With practice it becomes
disturbances. clear that excessive pressure does not reduce treat¬
In fact, the indications for this method range ment time. Once the correct point has been located,
from locomotor apparatus' dysfunctions to visceral it is sufficient to apply the least amount of force
dysfunctions. The term “dysfunction" is to be em¬ necessary to engage the deep fascia, and to attend
phasised here because, while the fascia intervenes patiently for the sudden modification of the fascial
in the motor activity of both voluntary and involun¬ tissue.
 3
MYOFASCIAL SEQUENCE
OF ANTEMOTION

SAGITTAL PLANE

This mf sequence moves body segments forward

and comprises the following mf units:

Trunk
ante-caput 1.2,3 an-cp 1,2.3
ante-collum an-cl
ante-thorax an-th
ante-lumbi an-lu
ante-pelvis an-pv

Upper limb
ante-scapula an-sc
ante-humerus an-hu
ante-cubitus an-cu
ante-carpus an-ca
ante-digiti an-di

Lower limb
ante-coxa an-cx
ante-genu an-ge
ante-talus an-ta
ante-pes an-pc

Fig. 3.1. CC of the antemotion sequence.

40 FASCIAL MANIPULATION

CC of antemotion of the caput

An-cp 2 An-ep 1 Temporal fascia, Galea aponeurotica or

Over the Inferior border of the or deep fascia superficial fascia
zygomaticus muscle orbital fossa

Fig. 3.2. Lateral view of the head, after having retracted the skin inferiorly and the scalp superiorly.

The connective tissue structure is different in the various regions of the head: in the parotid region and the
cheek, the superficial musculoaponeurotic system (SMAS or superficial fascia) is comprised between two
layers of adipose tissue. Around the lips and the eyes, the superficial fascia unites with the deep muscular
fascia. In the temple region, the superficial fascia (galea aponeurotica) is comprised between two layers of
adipose tissue (innominate fascia), separating it from the overlying scalp and from the underlying temporal
fascia.

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 41

CC of antemotion of the trunk

an-th
insertion of rectus abdominis
onto VI°. VII° rib.

an-lu
against border of rectus abdominis
to the side of the umbilicus

an-pv
— medially to the iliac spine
over the iliacus muscle

Collagen fibre bundles of external

oblique's aponeurosis, passing down
over the spermatic cord

Fig. 3.3. Deep abdominal fascia united to the aponeurosis of the external
oblique muscle

The external oblique muscle presents as a uniform muscle, whereas fibre bundles with diverse orientations
and separated by septa form the internal oblique and the transversus abdominis. Based on these morpholog¬
ical differences it is reasonable to hypothesise functional diversities.
NOTE: All of the anatomical photographs in this text arc of cadavers that had not been embalmed or frozen
prior to dissection.

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42 FASCIAL MANIPULATION

CP and sites of pain of antemotion sequence in the head and trunk

Fig. 3.4. Distribution of referred pain from antemotion cc(s).

The red stars indicate the centres of perception which, in case of dysfunction of a mf unit, correspond to the
area where pain of the various segments (cp, cl. th. lu. pv) commonly manifests. The centres of perception
of the trunk are near the centres of coordination. The red line follows the distribution of referred pain. Al
times, when treating the neck segment. the patient may feel pain refer to the mandible and the eye; at other
times, w hen treating the cc of an-pv. the patient may feel referred pain extending towards the neck like a
“tight cord”.
In the sections regarding each single segment, relevant pathologies arc reported in detail.

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 45

Mf unit of ante-caput 3 an-cp 3

Fig. 3.11. Site of pain and Its origin.

Site of pain or CP:

in the temporomandibular joint. Can be
pain, or only click, on opening mouth.

Origin of dysfunction or CC:

lack of coordination between masseter
and digastric muscles due to fascial al¬
teration or rigidity.

Fig. 3.12. Movement verification.

Ask patient to open their mouth and

note any deviations of the mandible.
There can be limited jaw opening due
to rigidity of the masseter muscle or
deficit of digastric muscle

Fig. 3.13. Treatment.

Patient supine; therapist uses fingertips

of index and middle fingers over ante¬
rior portion of digastric muscle, below
inferior border of the body of the man¬
dible.

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46 FASCIAL MANIPULATION

Mf unit of ante-collum an-cl

Fig. 3.14. Site of pain and Its origin.

Site of pain or CP'.

patient complains of pain in anterior
neck region (agonist muscles) or in
posterior region (antagonist mf unit).

Origin of dysfunction or CC:

as the vertebrae are the only fulcrum
on which all muscles of the neck act,
then an anterior fascial alteration can
cause pain in the posterior neck region.

Fig. 3.15. Movement verification.

Pain accentuates when the patient lifts

their head from supine position. In
standing, patient may have difficulty
looking downwards or bending neck
forward c.g. chin to sternum.

Fig. 3.16. Treatment

Patient supine; therapist palpates fascia

over anterior border of sternocleido¬
mastoid muscle at the level of the thy¬
roid cartilage. Having identified the
densified area treatment is carried out
with knuckle or fingertip.

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 47

Mf unit of ante-thorax an-th

Fig. 3.17. Site of pain and its origin.

Site of pain or CP’.

sense of oppression in the anterior
chest, respiratory problems, anxiety.

Origin of dysfunction or CC :
in the point of the thoracic fascia
where some pectoralis major fibres
unite with the rectus abdominis sheath.

Fig. 3.18. Movement verification.

Patient supine, hands behind head, lifts

shoulders from table, to test thoracic
insertion of rectus abdominis.

Fig. 3.19. Treatment.

Therapist uses knuckles of index and

middle fingers against lower border of
rib cage in the lateral region of rectus
abdominis. In robust patients, it is pos¬
sible to use the elbow for this CC.

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48 FASCIAL MANIPULATION

Mf unit of ante-lumbl an-lu

Fig. 3.20. Site of pain and its origin.

Site of pain or CP:

anterior abdominal wall along rectus
abdominis sheath; pain is related to ex¬
cessive muscular stress. An anterior al¬
teration may involve the vertebral col¬
umn. causing posterior pain.

Origin or centre of coordination:

if the abdominal fascia is subjected to
intense training it becomes less elastic,
with repercussions to the muscular fi¬
bres.

Fig. 3.21. Movement verification.

Patient supine, attempts to raise head,

thorax and legs simultaneously; it is
difficult to test this mf unit in the
standing position.

Fig. 3.22. Treatment

According to patient's physique, the

therapist uses knuckle or elbow against
the rectus sheath, at the umbilicus lev¬
el; referred pain may extend towards
the pubis or towards the xyphoid
process.

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 49

Mf unit of ante-pelvis an-pv

Fig. 3.23. Site of pain and its origin.

Site of pain or CP .
bilateral or unilateral sense of heavi¬
ness in the iliac fossa; pain may also
refer to the anterior thigh or the sacrum
region.

Origin or centre of coordination:

monoarticular fibres (iliacus) and biar-
ticular fibres (psoas) unite in the iliac
fossa.

Fig. 3.24. Movement verification.

Patient supine, legs flexed, raises one

leg at a time. If no pain then raise both
legs simultaneously, bringing knees up
toward chest. Pain may manifest in the
inguinal or the sacral region.

Fig. 3.25. Treatment.

Therapist places elbow or knuckle

against medial part of the iliacus fas¬
cia, waiting for the abdominal wall to
relax before beginning to manipulate
deeply.

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52 FASCIAL MANIPULATION

Mf unit of ante-coxa an-cx

Fig. 3.29. Site of pain and Its origin.

Site of pain or CP:

pain in anterior thigh region (hat ac¬
centuates when lifting the leg. as in go¬
ing up a step.

Origin or centre of coordination :

in the iliopectineus fascia that unites
monoarticular (pectineus) and biarticu-
lar fibres (iliopsoas, sartorius).

Fig. 3.30. Movement verification.

Patient standing, vigorously swings leg

forwards and backwards; pain may ac¬
centuate either during stretch of the
muscular fibres (backwards move¬
ment) or on shortening (forwards).

Fig. 3.31. Treatment

Patient supine, leg extended; therapist

places knuckle medially to sartorius’
sheath, below the inguinal ligament,
creating friction against the iliopsoas
fascia. Given the presence of lymphatic
nodules and vessels in this region, do
not protract treatment excessively.

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 53

Mf unit of ante-genu an-ge

Fig. 3.32. Site of pain and its origin.

Site of pain or CP:

pain in anterior part of the knee (tend¬
initis. bursitis, chondromalacia patel¬
lae) that accentuates descending stairs
or mountain; pain may be post-fracture
or post-joint surgery.

Origin or centre of coordination :

even though pain is localised in the
knee we need to refer to those muscles
that move this joint forwards (ante).

Fig. 3.33. Movement verification.

Patient places full weight on one leg

and. by bending the same knee (lunge),
contracts the mf unit of ante-genu. Pain
manifests in the patellar tendon (cp)
but the origin lies in the fascia over the
quadriceps (cc).

Fig. 3.34. Treatment.

The therapist places knuckle or elbow

over the fascia lata, halfway between
the patella and the inguinal ligament,
lateral to the rectus femoris. Palpate for
fascial alteration and the point that
refers pain to the knee.

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54 FASCIAL MANIPULATION

Mf unit of ante-talus an-ta

Fig. 3.35. Site of pain and Ha origin.

Site of pain or CP:

in the anterior region of the ankle (ten¬
dinitis of tibialis anterior or extensor
digitorum). sprains or tibiotarsal joint
fractures.

Origin or centre of coordination :

the extensor tensors become inflamed
when the altered, overlying mf unit
causes them to work in a non-physio-
logical manner.

Fig. 3.36. Movement verification.

Ask patient to walk on tiptoes and then

on their heels to verify if pain accentu¬
ates during active contraction (shorten¬
ing) or stretch of the mf unit.

Fig. 3.37. Treatment

Patient supine, leg extended; the thera¬

pist places their knuckle or elbow
against the summit of the extensor
compartment, halfway on the lower leg
Pain often refers immediately to the
symptomatic area (anterior ankle).

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 55

Mf unit of ante-pes an-pe

Fig. 3.38. Site of pain and its origin.

Site of pain or CP:

in the metatarsophalangeal and inter-
phalangeal joints of the first toe (hal¬
lux); possible tendinitis of the extensor
hallucis longus or brevis.

Origin or centre of coordination :

in the dorsal fascia of the fool that
unites die monoarticular (extensor bre¬
vis) and biarticular (extensor hallucis
longus) muscle fibres.

Fig. 3.39. Movement verification.

Test simultaneously resisted extension

of the two halluxes; sometimes pain is
present, or weakness, or limited ROM.
or paraesthesia.

Fig. 3.40. Treatment.

If weakness is prevalent, then treat¬

ment can extend to the lumbar region;
if only local pain is present, then ma¬
nipulation of the extensor brevis fascia
of the 1° toe, using the knuckle, can be
sufficient.

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56 FASCIAL MANIPULATION

CC of antemotion of the upper limb

an-sc
below coracoid process,
over the pectoralis major
and minor fascia.

an-hu
over the fascia uniting the
clavicular part of deltoid and
pectoralis major, two muscles that
move the shoulder forward.

Fibrous bridge between

pectoralis and brachial fasciae

an-cu
over lateral part of biceps
muscle belly.

Brachial fascia, which forms

the elbow flexor muscles’
compartment

Fig. 3.41. Anterior brachial fascia united to deltoid fascia by a collagen fibre
bridge, which corresponds to the point of insertion of pectoralis ma|or onto the
brachial fascia.

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 59

Mf unit of ante-scapula an-sc

Fig. 3.44. Site of pain and Its origin.

Site of pain or CP:

trauma or sprain in acromioclavicular
joint; pectoralis minor syndrome, with
brachial plexus irritation.

Origin of dysfunction or CC:

in the clavi-coraco-axillary fascia, that
unites the monoarticular (pectoralis
minor) and biarticular (pectoralis ma¬
jor) muscle fibres.

Fig. 3.45. Movement verification.

Ask patient to bring both shoulders for¬

ward and note any lack of symmetry
between the two sides; alternatively,
ask patient to push table forward with
both arms (isometric shoulder flexion).

Fig. 3.46. Treatment.

Therapist uses knuckle or elbow to

penetrate the sub-coracoid sulcus, ma¬
nipulating the point of fascial alter¬
ation that refers pain.

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60 FASCIAL MANIPULATION

Mf unit of ante-humerus an-hu

Fig. 3.47. Site of pain and Its origin.

Site of pain or CP:

pain in the anterior region of the shoul¬
der that accentuates during antemotion
of the shoulder. A diagnosis of capsuli¬
tis is common in these cases.

Origin of dysfunction or CC:

due to lack of coordination of the mf
unit, the huments and scapula move¬
ments arc asynchronous.

Fig. 3.4a. Movement verification.

Ask patient to bring arm forward as in

shaking hands. At times this is so
painful the patient has to use the other
hand to help with the movement.

Fig. 3.49. Treatment.

Patient supine, arm along side, the ther¬

apist uses their knuckle over anterior
part of upper deltoid, searching for the
most significant fascial alteration that
refers pain.

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 61

Mf unit of ante-cubitus an-cu

Fig. 3.50. Site of pain and its origin.

Site of pain or CP:

limited ROM of the elbow, often pain¬
less. can occur following fractures or
dislocation of the radial head.

Origin of dysfunction or CC:

in the densified brachial fascia that
cannot synchronise the monoarticular
(brachialis) and biarticular (biceps and
brachioradialis) muscle fibres.

Fig. 3.51. Movement verification.

Either test comparatively resisted el¬

bow flexion (bilaterally) or compare
elbow flexion ROM by asking patient
to touch both shoulders; measurement
of the distance between the middle fin¬
gertip and the acromion, before and af¬
ter treatment, can be useful.

Hg. 3.52. Treatment.

The therapist initially uses their knuck¬

le to explore the brachial fascia over
the biceps, at the level of the distal ten¬
don of deltoid, then manipulates w ith
the elbow. Often patients understand
why manipulation is applied to an area
distant from their symptoms only when
they feel pain referring to their elbow.

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62 FASCIAL MANIPULATION

Mf unit of ante-carpus an-ca

Fig. 3.53. Site of pain and its origin.

Site of pain or CP:

Along the flexor carpi radialis tendon -
compensatory cysts may form here due
to anomalous muscle tension; some¬
times the patient complains of thumb
pain, similar to writer’s cramp.
Origin or centre of coordination:
in the antebrachial fascia, in the point
where the monoarticular (flexor carpi
radialis) and biarticular (flexor pollicis
longus) muscle fibres unite.

Fig. 3.54. Movement verification.

Test force of flexor carpi radialis

against resistance. Alternatively, ask
patient to place both hands palms
down on the table and then to push
down forcefully patient is asked to
then indicate the most painful area
(flexor carpi radialis tendon).

Fig. 3.55. Treatment.

Patient supine, therapist places knuck¬

le, or elbow, over muscle belly of flex¬
or carpi radialis to manipulate the ante¬
brachial fascia. Here the fascial alter¬
ation is often chronic, requiring more
time to dissolve; hence, use of the el¬
bow is advisable.

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 MYOFASCIAL SEQUENCE OF ANTEMOTION 63

Mf unit of ante-digiti an-di

Fig. 3.56. Site of pain and its origin.

SSite of pain or CP:

the thenar eminence dysfunction mani¬
fests mostly in the first metacarpopha¬
langeal joint but. due to fascial conti¬
nuity. it may also involve the other
metacarpophalangeal joints.

Origin or centre of coordination:

in the area of densified fascia that
unites the monoarticular (flexor polli-
cis brevis) to the biarticular (flexor pol-
licis longus) muscle fibres.

Fig. 3.57. Movement verification.

Passive stretch of the thenar eminence

provokes pain - often the patient inad¬
vertently avoids this movement during
daily living activities.

Fig. 3.58. Treatment.

Having identified the most densified

point of the thenar eminence, the thera¬
pist uses the knuckle to manipulate this
point until tissue fluidity is restored.

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66 FASCIAL MANIPULATION

CC of retromotlon of the head and neck

re-cp 2
summit of the forehead over the
frontalis muscle

Cranial superficial fascia

f Galea aponeurotical

re-cp 1
over superior medial border
of orbital margin

re-cp 3
below inferior border
of occipital protuberance

Superficial fascia (SMAS) of the face.

re-cl
lateral to sixth cervical vertebra

Fig. 4.2. Lateral part of head with the galea aponeurotica and the occipitalis
muscle.

A layer of adipose tissue lies below the skin of the cranium and the neck. This facilitates gliding between
.
the skin and the superficial fascia. In this photograph the adipose layer has been removed together with the
scalp. The occipitalis muscle, comprised within the superficial fascia, is visible in the occipital region.

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 MYOFASCIAL SEQUENCE OF RETROMOTION 67

CC of retromotion of the trunk

re-th
over the muscle belly of the
erector spinac at IV0 dorsal level

Intermuscular septum separating

iongissimus (re) from iliocostalis (la)

rc-lu
over muscle belly of erector
spinac at the 1° lumbar level

Right thoracolumbar fascia, intact.

re-pv
over iliolumbar ligament at the 1°
sacral vertebra level

Fig. 4.3. Erector spinae muscles, left-side, after removal of thoracolumbar

fascia, trapezius, rhomboids, and latissimus dorsl.

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68 FASCIAL MANIPULATION

CP and sites of pain of retromotion sequence of head and trunk

Fig, 4.4. Distribution of referred pain of retromotion cc(s).

The red stars indicate the more frequent sites of pain along the retromotion sequence. Even in presence of
a diffuse pain along the entire back area, as indicated by the red line, the most painful areas arc the ccrvi-
codorsal and lumbosacral junctions.

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 MYOFASCIAL SEQUENCE OF RETROMOTION 69

Mf unit of retro-caput 1 re-cp 1

Fig. 4.5. Site of pain and Its origin.

Site of pain or CP:

in the upper eyelid and the rectus
superior muscle of the eye.

Origin of dysfunction or CC:

in the fascia bulbi or Tenon's capsule
that unites the muscle fibres of rectus
superior to the fibres of the upper
eyelid and orbicularis oculi.

Fig. 4.6. Movement verification.

Ask patient to gaze upwards and verify

any lack of symmetry between the two
eyes or if any eyelid deficit accentu¬
ates.

Fig. 4.7. Treatment.

Patent supine, therapist places both in¬

dex fingertips over internal border of
eyebrows in order to palpate the two
cc(s) comparatively. Treat only the
densified cc that refers pain.

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70 FASCIAL MANIPULATION

Mf unit of retro-caput 2 re-cp 2

Fig. 4.8. Site of pain and its origin.

Site of pain or CP:

pain in frontal sinuses or more often
the patient complains of having the
sensation of a blocked nose.

Origin of dysfunction or CC:

in the forehead fascia that descends
over the nose and connects to the cra¬
nial periosteum via numerous collagen
fibres.

Fig. 4.9. Movement verification

Ask patient to wrinkle forehead to test

tone of frontal muscles. Note any diff¬
erence between the left and right sides.

Fig. 4.10. Treatment

Patient supine, therapist treats the mf

unit of rc-cp 2 on the side that results
more densified and painful, until
symptoms abate.

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 MYOFASCIAL SEQUENCE OF RETROMOTION 73

Mf unit of retro-thorax re-th

Fig. 4.17. Site of pain and its origin.

Site of pain or CP:

the patient complains of painful shoul¬
ders but when asked to indicate the ex¬
act localisation of their pain it is actual¬
ly in the upper thoracic vertebrae.

Origin of dysfunction or CC:

fascial alteration of the thoracic fascia
at the fourth thoracic vertebra level is
often the cause of upper thoracic verte¬
bral conflict.

Fig. 4.18. Movement verification.

Ask the patient to hyperextend the dor¬

sal region; often the rigidity of these
vertebrae is such that moving the
scapula closer together is the only
movement possible, and the thoracic
kyphosis is inalterable

Fig. 4.19. Treatment.

Patient in prone lying; the therapist us¬

es elbow over the erector spinae mus¬
cle bulk at the level of the fourth tho¬
racic vertebra, shifting the pressure
slowly to identify the point that refers
pain to the lumbar or nuchal regions.

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74 FASCIAL MANIPULATION

Mf unit of retro-lumbi re-lu

Fig. 4.20. Site of pain and Its origin.

Site of pain or CP:

Acute or chronic lumbalgia with pain
distributed in lumbosacral region, that
is, in the region where the fascial im¬
balance manifests principally.

Origin of dysfunction or CC:

At (he first lumbar level, where the
erector spinae muscles are well devel¬
oped.

Fig. 4.21. Movement verification.

Ask the patient to contract the erector

spinae cither by arching the back or by
bending forwards. The arthro-myo-fas-
cial imbalance can manifest itself ci¬
ther during concentric or eccentric
muscle contraction.

Fig. 4.22. Treatment.

Patient prone, the therapist uses elbow

over the erector spinae muscle mass at
the first lumbar level, shifting pressure
to find the point that refers pain to the
sacral region. Palpate the opposite side
to compare painfulncss/altcration. If
the fascial alteration is unilateral then
treat only on that side.

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 MYOFASCIAL SEQUENCE OF RETROMOTION 75

Mf unit of retro-pelvis re-pv

Fig. 4.23. Site of pain and its origin.

Site of pain or CP:

if subjected to unbalanced strain the
sacroiliac region may become inflamed
on one or both sides, with local and/or
referred pain.

Origin of dysfunction or CC:

this type of imbalance is mostly due to
fibrosis of the iliolumbar ligament
(CC). between the fifth lumbar verte¬
bra and the posterior superior iliac
spine.

Fig. 4.24. Movement verification.

This test is similar to that for the lum¬

bar region but here sacroiliac mobility
is accentuated by asking the patient to
push their pelvis forwards with their
hands.

Fig. 4.25. Treatment.

The therapist places their elbow in the

sulcus between the fifth lumbar verte¬
bra and the PSIS. waiting for the pa¬
tient to relax, then slowly begins to ma¬
nipulate the underlying collagen struc¬
tures in a transverse direction.

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76 FASCIAL MANIPULATION

CC of retromotion of the lower limb

Collagen fibres oj
the popliteal
retinaculum

re-ex
descending
muscular fibres
of gluteus
maximus

re-la
myotendinous
junction of triceps
surae

Fascia lata

re-ge
in the fascia over
biceps femoris and
semitendinosus.

Fig. 4.26. Deep fascia of the posterior region of the

re-pe -
thigh and knee (fascia lata).

Fig. 4.27. Deep fascia of the posterior re¬

gion of the leg.

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 MYOFASCIAL SEQUENCE OF RETROMOTION 77

CP and sites of pain of retromotlon sequence of the lower limb

Fig. 4.28. Distribution of referred pain of retromotion ccfs).

The red stars are situated over the joints. As movement occurs here, then this is where incoordination also
manifests. The cc of retro-genu and retro-talus are located halfway on the thigh and lower leg, whereas the
cc and the cp of retro-coxa and retro-pes almost overlap.

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80 FASCIAL MANIPULATION

Mf unit of retro-talus re-ta

Fig. 4.35. Site ol pain and its origin.

Site of pain or CP:

Achilles tendinitis, heel pain, plantar
fascitis... these are some of the diag¬
noses typical of disturbances in this mf
unit.

Origin of dysfunction or CC:

the Achilles tendon sheath becomes in¬
flamed if it is misaligned and this oc¬
curs if the muscle fibres contract asyn¬
chronously.

Fig. 4.36. Movement verification.

Ask the patient to walk on tiptoes (spe¬

cific for tendinitis) or on their heels
(more specific for heel spurs or pe¬
riosteal pain).

Fig. 4.37. Treatment.

Patient prone, therapist manipulates

with elbow over myotendinous pas¬
sage of the triceps surae at the centre of
the two gastrocnemii heads, insisting
more towards the lateral head.

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 MYOFASCIAL SEQUENCE OF RETROMOTION 81

Mf unit of retro-pes re-pe

Fig. 4.38. Site of pain and its origin.

Site of pain or CP:

pain in external border of foot does not
allow weight-bearing, patient is forced
to walk on their heel. Callus formation
on V° toe is common in chronic cases.

Origin of dysfunction or CC:

fibrosis of the lateral compartment of
the foot can determine abductor digiti
minimi spasms, with deviation of the
lateral phalanges.

Fig. 4.39. Movement verification.

The patient’s gait is indicative but not

selective: ask patient to weightbear, in
succession, on the heel, forefoot, inter¬
nal and external border of the foot to
determine the most painful part as this
is useful for the post-treatment verifi¬
cation of pain reduction.

Fig. 4.40. Treatment.

Patient side lying, lateral border of foot

uppermost; therapist uses knuckle to
palpate the base of the fifth metatarsal
head for any fascial alteration.

Copyrighted material
 ...The authors present a novel model concerning the contribution of fascia to
neuromuscular coordination through a specific topography of centers within the fascial
network (centers of coordination, centers of perception, and centers of fusion). While this
is a completely new model, it is presented in a very convincing manner. The evidence
given in this book in support for this intriguing model, covers not only corroborating
phylogenetic and neurophysiological details, but includes thousands of hours of
anatomical cadaver research, performed by the original founder of this approach, Luigi
Stecco, as well as his daughter Carla Stecco MD and son Antonio Stecco MD. Their
diligent cadaver studies have resulted in several new anatomical discoveries and
descriptions, published in peer-reviewed scientific anatomical journals. Anybody who
has followed the emerging new publications on fascia in the scientific literature in the
last few years will have noticed these important contributions. This family team has
studied fascial morphology and topography in detail, which is not only impressive but
also resulted in the novel descriptions and findings that support the new model for
neurofascial coordination presented in this book....

PICCIN

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