Fascia - the tissue we probably underestimated

For most of my career as an orthopaedic surgeon, fascia was not something I thought about very much.

I knew certain parts of it well. There was the tensor fasciae latae, a muscle on the outer side of the hip that soon merges into the iliotibial band, or IT band. This thick band of connective tissue runs down the outside of the thigh and attaches just below the knee. Tension and irritation in this region can contribute to pain or stiffness around the outer hip and knee.

Then there was the plantar fascia beneath the foot. Problems in that structure are a common source of heel pain, although what is often called inflammation is not always a simple inflammatory condition.

Apart from these familiar examples, I mainly regarded fascia as packaging.

It was the material we passed through on our way to the apparently more interesting structures underneath: bones, joints, muscles, tendons, nerves and blood vessels.

Those were the parts we could see on imaging, examine directly or repair during surgery. Fascia was simply there, wrapping everything up and preventing the contents from falling out.

That view was convenient.

It was also incomplete.

The Younger Man Who Pointed Me Towards Fascia

A few years ago, I became acquainted with a considerably younger man who runs a training centre. Much of his work is based on bodyweight exercise, mobility and flexibility.

He introduced me to Thomas Myers and his book Anatomy Trains.

Myers proposed that muscles should not always be viewed as isolated units acting independently. He described lines or chains of myofascial tissue extending through different parts of the body and suggested that movement and tension could be understood partly through these longer connections.

The model grew mainly from clinical observation, anatomical dissection and many years of practical experience.

Some aspects of these myofascial connections have received support from anatomical research. Other aspects remain models that may be useful for thinking and treatment without yet being proven explanations for everything that happens in the living body.

A map can be useful without every line on it being a motorway.

Robert Schleip has played a different but equally important role. He and other fascia researchers helped move the subject from the treatment room into the laboratory.

Research has shown that fascia is not merely inert wrapping. It is living connective tissue containing collagen, elastic fibres, blood vessels, nerves and different types of cells. Some of those cells, including myofibroblasts, can generate tension and may contribute to changes in tissue stiffness.

Fascia is also richly supplied with sensory nerve endings. It participates in proprioception—the body’s awareness of its position and movement—and may contribute to pain.

This does not mean that every unexplained pain originates in fascia. Pain is rarely that polite or that simple. Muscles, joints, tendons, nerves, connective tissues, previous injuries, sleep, stress and the nervous system can all take part in the same story.

Fascia may be an important character without being the entire cast.

What Is Fascia?

Fascia is not one single sheet wrapped around the body like a plastic bag.

The word describes a family of connective tissues that surround, connect, separate and support muscles, muscle groups, bones, nerves, blood vessels and organs.

An orange provides a rough visual comparison.

When we peel an orange, we see the white tissue beneath the skin, between the segments and around each individual segment. It separates the parts while also holding the fruit together.

The human body is, fortunately, considerably more complicated than an orange. But the comparison illustrates how connective tissue can both divide and connect.

Fascia helps tissues maintain their position while allowing different layers to glide against one another. It also participates in transmitting force.

When we move an arm or a leg, the movement is not produced by one muscle working in splendid isolation. Muscles, tendons, joints, nerves and connective tissues negotiate every movement together.

Like most negotiations, the process works best when everybody is willing to move.

A Living and Responsive Tissue

Fascia changes in response to load, movement, injury, illness and age.

Long periods of inactivity may affect how freely tissue layers move. Injury and surgery can lead to scar formation. Repeated loading can produce adaptation, while appropriate movement and progressive loading can improve the capacity of the entire musculoskeletal system.

There is also increasing interest in the relationship between fascia, the autonomic nervous system and our internal sense of the body.

It is tempting to take the next step and say that emotional trauma is physically stored in fascia or that all chronic tension can be released by treating it. Those are much larger claims than current evidence allows.

The nervous system, emotions and bodily tension clearly influence one another. Anyone who has raised his shoulders during a stressful meeting already knows that the mind and body are not separate organisations.

But that does not prove that a particular memory is hiding in a strip of connective tissue, waiting for somebody with a massage ball to find it.

Curiosity is justified. Certainty is not.

Myers, Schleip and Rolfing

Both Thomas Myers and Robert Schleip have backgrounds connected with Rolfing and Structural Integration, methods influenced by the work of the American biochemist Ida P. Rolf.

Rolf proposed that posture and movement should be understood in relation to gravity. If the body was poorly organised, she believed that muscles and joints would have to work unnecessarily hard, contributing to fatigue, stiffness and pain.

Historically, Rolfing developed a reputation for being extremely painful.

There was almost an unspoken belief that if the client could still hold an intelligent conversation, the treatment had probably not reached the correct depth.

Modern Structural Integration is often gentler. Many practitioners now place greater emphasis on sensory input, movement and the nervous system rather than trying to force tissues into submission.

The client may also be taught new ways of moving instead of merely lying on a table while somebody attempts to rearrange him.

That development makes sense. A treatment may create an opportunity for change, but daily movement determines what happens afterwards.

When Fascia Became Responsible for Everything

For a long time, most ordinary people had never heard the word fascia.

Then fascia became fashionable.

Suddenly it appeared everywhere: in books, courses, social media, massage balls, foam rollers, cups, metal tools, tapes and increasingly sophisticated devices.

This attention has been valuable. A tissue that was often overlooked is finally being studied seriously.

The problem begins when a useful idea becomes a universal explanation.

Fascia has been blamed for almost every pain, restriction, postural problem and unexplained sensation in the body. Words such as adhesion, restriction, release, detoxification and resetting are sometimes used with far more confidence than the evidence supports.

It is convenient when one tissue explains everything.

Unfortunately, the human body has not read the marketing plan.

No special fascia religion is required.

Fascia deserves attention, research and sensible treatment. It does not need to become the alpha and omega of the human body.

Can Fascia Cause Pain?

Fascia contains nerve endings and can contribute to pain. Changes in connective tissue may also be associated with injury, inflammation, scarring, altered loading and reduced movement.

But saying that fascia can be involved is different from saying that fascia is the cause.

Chronic pain is particularly complicated. The location where pain is felt does not always reveal precisely where it began. Sensitivity can change, the nervous system can become more protective and several tissues may contribute at the same time.

It is therefore possible that some pains traditionally attributed only to muscles, tendons or joints also involve fascial tissue.

That is an interesting possibility and a reason for further research.

It is not permission to diagnose every difficult shoulder, painful back or stiff hip as a fascial disorder.

The scientifically honest answer is sometimes:

“We do not yet know exactly.”

That answer is not evidence of weakness. It is where good research usually begins.

Foam Rollers, Balls, Cups and Other Tools

People can work with these tissues in several ways.

Massage, manual treatment, movement, stretching, foam rollers, massage balls, cups and instrument-assisted soft-tissue techniques may all provide useful sensory and mechanical stimulation.

Research suggests that foam rolling can temporarily improve range of motion and may reduce muscle soreness after exercise, although the effects are generally modest.

That is useful.

Its exact mechanism is less certain. The effects may involve changes in sensory input, pain perception, local circulation, muscle tone, tolerance of movement and interaction with the nervous system.

Terms such as release and loosening often describe what people genuinely feel after treatment. But they should not always be interpreted literally as proof that dense scar tissue has been mechanically broken apart or that an anatomical knot has been permanently flattened.

A person can feel freer and move better even when the explanation is more complicated than the advertisement on the box.

Manual treatment and tools can therefore be worthwhile. Their value depends on the person, the problem, the method and what the treatment enables him to do afterwards.

If a foam roller helps you move more comfortably, use it.

If a ball beneath the foot makes the morning walk easier, that is a meaningful result.

If cups, massage or a well-designed instrument-assisted treatment reduce discomfort and help you return to movement, there is no scientific prize for refusing them.

A foam roller is a training aid, not a medieval interrogation device.

More pain does not automatically mean more benefit. The aim is to provide useful stimulation, not to defeat the tissue in single combat.

No single tool or treatment session is likely to create permanent change without continued movement and appropriate loading. Fascial treatments should be judged by the same standards as other health interventions: what do they improve, for whom, by how much and for how long?

Stretching the Whole Chain

Because fascial tissues connect and transmit force across regions, it may be useful to include movements that involve more than one joint at a time.

This does not mean that the entire body is one continuous elastic band that can be pulled at the left ankle to repair the right shoulder.

But our habitual movements do not occur in isolated textbook compartments. Reaching, rotating, walking, lifting and throwing all require cooperation between several regions.

Slow, controlled movements through comfortable ranges can be useful, particularly when we have become stiff or inactive.

Some researchers and practitioners also emphasise spring-like or elastic movements. Connective tissues can store and return mechanical energy, as we see in walking, running and jumping.

For older adults, “elastic movement” does not have to mean leaping off a box and hoping the fascia has read the same research paper.

It may simply mean rhythmic, controlled movement appropriate to the person’s strength, balance and experience.

What About Water?

Fascial tissue contains a substantial amount of water, and normal hydration is necessary for all tissues to function properly.

From that sensible fact, an enormous claim sometimes follows: that drinking extra water will unstick fascia, dissolve adhesions or wash toxins out of the connective tissues.

The evidence does not justify such certainty.

A dehydrated person should certainly drink. But an additional litre of water does not travel directly to a tight hip and negotiate the release of an adhesion.

Hydration matters.

But if drinking more water alone were enough to loosen fascia and dissolve adhesions, rehabilitation would consist of little more than a water bottle and a toilet.

Unfortunately, it is not quite that simple.

Hydration is important.

It is simply not liquid surgery.

What Can We Do Ourselves?

The encouraging part is that caring for the fascial system does not require us to abandon familiar principles of movement, loading and recovery.

Most useful measures are reassuringly ordinary:

• Move regularly instead of remaining in one position for hours.

• Move in more than one direction. Walking is excellent, but it does not meet every movement need of the shoulders, spine and hips.

• Strengthen your body with slow controlled movements.  Work through a range of motion you can manage with good form, and gradually increase it as your strength and mobility improve.

• Introduce new loads progressively rather than trying to compensate for ten inactive years in one heroic weekend.

• Use rollers, balls, massage, cups or other tools if they help, but do not allow the tool to replace movement.

• Sleep, recovery and ordinary hydration still matter.

• Seek professional assessment when pain is severe, persistent, unexplained or accompanied by weakness, numbness, fever, injury or other worrying symptoms.

Fascia responds over time.

So does the rest of the body.

The body adapts to what we do regularly, not to what we intended to start doing last Monday.

Why This Interests Me

Fascia has given me, as an orthopaedic surgeon, a broader way of considering how bones, joints, muscles, tendons, nerves and connective tissues work together.

It has also made me think differently about my own training.

As I grow older, preparation, mobility and recovery seem to matter more. On some days, my body needs a staff meeting before it is prepared to begin work.

Fascia may be part of the reason movement becomes easier once the meeting is underway.

For most of my professional life, fascia was a supporting actor. I now believe it deserves at least a proper audition for a more important role.

But an audition is not a coronation.

Thomas Myers has offered a valuable way of visualising continuity through the body. Robert Schleip and other researchers have helped give fascia a stronger scientific foundation. Practitioners and companies are developing tools that may become increasingly useful as research improves.

We should examine those ideas and tools with open minds.

An open mind, however, is not the same as an empty one.

Not every proposed mechanism has been proven. Not every treatment claim will survive careful testing. That is not an attack on the field. It is how a promising field becomes a credible one.

Fascia is not a magical explanation for every illness, pain or limitation.

Nor is it useless packaging.

It is a living, sensory and mechanically important family of connective tissues that we probably underestimated for far too long.

We should neither worship it nor ignore it.

We should study it, move it, load it appropriately and remain curious about what it may still teach us.

Curiosity is not a weakness of science.

It is where science begins.