Connective tissue, Fascia and its relevance
Fascia can be found throughout the human body and does not look too dissimilar to cotton wool or a spiders silk under magnification. It is a densely woven collagen fibre matrix that is thought to penetrate every tissue within the body and cover muscles and organs. Fascia is a form of connective tissue and as per the name connects structures throughout the body. There are also specific deep and superficial layers of fascia, which aid with functional movement, support structures within the body and provide stability. Without fascia ones, muscles would lack their distinctive shape. It is relatively easy to see fascia within a piece of raw chicken breast or other meat. A chicken breast typically has a thin translucent portion of fascia between the breast meat and the tenderloin.
In normal, circumstances fascia is a well hydrated, smooth, translucent, slippery and a durable material. However, the properties of fascia can change as a result of other factors including injury, dehydration, specific medical conditions, changes to other tissues/structures and possibly other factors such as diet (nutrients). The anatomist Tom Myers has been conducting work relating to fascia and the fascial network for well over 20 years. During, his research Myers has identified multiple specific facial lines which are thought to support functional movement namely; the superficial front and back lines, lateral line, spiral line, arm lines, functional lines and deep front line. At least, four distinctive types of fascia have been identified and with each providing a different function. The four types of fascia identified to date include inter-structural, spinal, structural and visceral.
As with various tissues and structures within the body, things can go wrong or become dysfunctional. The fascial network supports facilitates and even makes functional movement more efficient. The human body consists of many tissues, structures, and layers, with fascia separating and holding everything together. Primary human movement requires multiple muscles and layers to either contract, relax or stabilise for any given action. Also, muscles have different origins, insertions, or attachment points, e.g. from "a to b" in the simplest muscles. The section about Soft Tissue Release (STR) explains more about muscle origins and insertions. For muscles to be able to move and not interfere with the function of other muscles or structures, they need to glide over each other. Fascia conveniently separates the muscles into separate bags or compartments, allowing each muscle to slide over the next unhindered. However, fascia can become dysfunctional, which impacts how muscles then slide over each other. In essence, parts of the fascia can become sticky. This stickiness then affects other tissues, mobility and often leads to myofascial pain, including Chronic Pain (see the related article about Chronic Pain and treatment). Myofascial trigger points are, in essence, sections of stickiness within muscles (see later). Releasing the fascia and other connective tissues is the aim of myofascial release therapy to increase mobility to relieve pain. There are various ideas as to why fascia can become dysfunctional, including posture (muscular fatigue), lack of hydration, specific medical conditions, trauma, diet, activity levels and age. Tom Myers (the anatomist) has noted that the fascial lines he has identified perform different supportive functions and that dysfunction in one area can impact other areas. Kinetic Chain theory also takes a holistic view of the body, with one section affecting another.
The Kinetic Chain and Fascia
Kinetic Chain theory is a concept from engineering and is sometimes called the kinematic chain. The theory looks at human movement and how rigid lever structures (bones) work with joints to create an overall movement chain. Hence, mobility in one area of the chain can impact the rest of the chain. These segments or sections form a "kinetic chain" when one moves. If all parts of the chain are operating correctly or normally, one tends not to experience pain, discomfort or restricted mobility. If tissues, joints or other structures are not functioning correctly, this can affect how a specific segment moves and general mobility. Logically, if one section is not working correctly (as in a spinal fusion), it would soon lead to other areas in the kinetic chain also encountering problems. However, sometimes such surgeries are the only option to stabilise structures after trauma. The image shows the basic idea of the kinetic chain sections or joint structures, though human movement is far more complicated:-
- Cervical Spine (Neck)
- Thoracic Spine (Upper Back)
- Lumbar Spine (Lower Back)
The body is extremely good at adapting to avoid pain, so it may take a while to notice changes to the kinetic chain. The supportive fascial lines identified by Tom Myers (the anatomist) have a major impact on the “kinetic chain”. Mechanically, the “kinetic chain” concept makes a great deal of sense and dysfunction in one area of the “kinetic chain” can affect both sides of the body and not just (higher) or (lower) than the affected segment or side. Equally, myofascial trigger points within tissues can impact multiple body areas due to the resulting changes in the fascial network. Often a symptom of an injury or problem is not the cause, as might be the case with Achilles tendon pain. Hence, treating the wrong thing in a self-treatment context is easily done, leading to related or seemingly unrelated injuries later. The article on Biotensegrity takes a much more detailed look at how changes in one body area affect another. The changes during pregnancy are a great example of Biotensegrity and tissue adaption in action (see Biotensegrity in Pregnancy diagram). Sections of the “kinetic chain” above and below the pelvis adapt to changes in weight distribution.
What are Myofascial Trigger Points (MTrPs or TrPs)?
A Trigger Point is a taut band of hyperirritable muscle tissue, which is not the same as a spasm. Muscle spasms involve all the fibres within a muscle contracting simultaneously, which is often extremely painful. Spasms result in a strong and uncontrollable muscle contraction pulling the origin and insertion points of a muscle closer together. There are many causes for muscle spasms, though Trigger Points can certainly play a part. Unlike spasms, Trigger Points are small sections of taut fibres within the muscle and fascial network. These taut bands have effectively become stuck in a contracted state, which affects the overall muscle function. Fascia will play a part in forming such MTrPs, as it is present throughout the body.
The following diagram represents a typical skeletal muscle and a magnified section of muscles fibres. Trigger points are not visible to the human eye, and the shaded area of the muscle is purely to illustrate the concept. However, one might be able to feel a knotted sensation, with or without pain. The thin and thick muscle fibres are visible in the diagram. One can also see evenly spaced sections (sarcomeres) in the unaffected fibres. Affected fibres have small blob-like or bulging areas and uneven sarcomere spacing. In many respects, it is as if the sections in the affected fibres have become glued together. These bulges will change tensional forces within the affected muscle fibres and alter the pressure on surrounding structures. These microscopic changes result in a larger affected area or a trigger point (TrP). The tiny changes within the muscle fibres and the trigger points impact overall biotensegrity (see related articles later).
Illustration of Myofascial Trigger Point and taut bands of muscle fibres
There are also different types of Trigger Points, latent and active. People tend to be aware of active trigger points, as one can feel muscular pain in an area, which may refer elsewhere in the body when pressed. One can also often feel the taut bands of tissue or what some might call "knots". Latent trigger points are also taut bands, though they tend not to cause pain or symptoms when pressed. Hence one may be oblivious to their presence. However, taut bands within tissue structures will subtly affect mobility in some way, shape or form. Trigger Points can occur for many reasons, including trauma, habits and more. The articles on Tissue Healing, Adaption, and Biotensegrity are hugely relevant (see related articles section).
Controversial history of Myofascial Trigger Points
The concept or existence of trigger points has a somewhat controversial history. Part of the issue is that TrP's are not visible to the human eye and historically could not be seen on imaging (x-rays, CT, MRI and Ultrasound). Hence, General Medicine held the view that TrP's do not exist. However, it is possible to feel the telltale signs of TrP's within soft tissues. Soft tissue therapists and bodyworkers have always known about TrP's, though under different names throughout the history of manual therapy. Many soft tissue structures and related issues do not show up on imaging. The presence or absence of pathology on an image may or may not indicate the root cause of a problem. A high proportion of people seeking routine imaging for unrelated conditions have disc or back-related pathologies and yet no symptoms. Equally, imaging for somebody with back pain may prove inconclusive as to the cause (see article on Lower Back Pain). In other, cases imaging can highlight an obvious root cause. Diagnostic ultrasound and MRI imaging have improved dramatically over the years and can now show more soft tissue structures. Research now exists showing the presence of trigger points in the upper trapezius muscle of migraine sufferers, using T2-weighted MRI.
Massage and Myotherapy Registrations
Terry brings over 15 years of experience working in the MSK field back to Australia from the UK. His training covers a wide variety of treatment methods and soft tissue therapy (STT) skills. Terry's main area of interest lies in trauma and myofascial pain relief. He also taught as a senior course coach on one of the first myotherapy courses in Brisbane and is highly qualified. His skills are now available at the Morningside clinic, where he works as a Myotherapist.