Journal of Bodywork and Movement Therapies (2009) 13, 128–135

Bodywork and

Journal of

Movement Therapies

PILOT STUDY

Application of Fascial Manipulation& technique in

chronic shoulder pain—Anatomical basis and

clinical implications

Julie Ann Day, PTa,�, Carla Stecco, M.D.b, Antonio Stecco, M.D.c

aCentro Socio Sanitario dei Colli, Physiotherapy, Azienda Ulss 16, Via dei Colli 4, Padova, ItalybSection of Anatomy, Department of Human Anatomy and Physiology, University of Padova, ItalycPhysical Medicine and Rehabilitation Clinic, University of Padova, Italy

Received 28 March 2008; received in revised form 10 April 2008; accepted 21 April 2008

KEYWORDSFascia;Musculoskeletaldysfunction;Manual technique;Chronic shoulder pain;Fascial Manipulation

Summary Classical anatomy still relegates muscular fascia to a role of contention.Nonetheless, different hypotheses concerning the function of this resilient tissuehave led to the formulation of numerous soft tissue techniques for the treatment ofmusculoskeletal pain. This paper presents a pilot study concerning the application ofone such manual technique, Fascial Manipulation&, in 28 subjects suffering fromchronic posterior brachial pain. This method involves a deep kneading of muscularfascia at specific points, termed centres of coordination (cc) and centres of fusion(cf), along myofascial sequences, diagonals, and spirals. Visual Analogue Scale (VAS)measurement of pain administered prior to the first session, and after the thirdsession was compared with a follow-up evaluation at 3 months. Results suggest thatthe application of Fascial Manipulation& technique may be effective in reducingpain in chronic shoulder dysfunctions. The anatomical substratum of the myofascialcontinuity has been documented by dissections and the biomechanical modelis discussed.& 2008 Elsevier Ltd. All rights reserved.

Introduction

Shoulder pain is a common affliction that deter-mines symptoms of pain, limited range of move-

ment and varying degrees of functional impair-ment. It is the third most common musculoskeletalcomplaint after back and neck pain. In fact, in arandomised study conducted in Holland (Picavetand Schouten, 2003), it is reported that, in 1998, anestimated 21% of the population had shouldercomplaints, of which 41% had consulted theirprimary care physician in the previous 12 months

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E-mail address: lavitava@gmail.com (J.A. Day).

for this problem. About 50% of patients hadconsulted their physician 6 months after pain onsetand more than 40% had on-going pain after another12 months. Patients with a new pain episode oftenreported (46%) having had previous episodes ofshoulder pain.

Despite the prevalence of this complaint, there islittle overall evidence to guide physiotherapytreatments, whereas there is evidence to supportthe use of some interventions (i.e. supervisedexercises and mobilisation) only in specific andcircumscribed cases (e.g. rotator cuff disorders,mixed shoulder disorders and adhesive capsulitis)(Green et al., 2003).

There is wide agreement that alterations of thedeep muscle fascia could be a source of muscu-loskeletal dysfunctions. Despite a relative lack ofwell-documented information, the necessity toprovide scientific explanations for numerous, highlyeffective manual techniques has produced a num-ber of clinical hypotheses, some working modelsand a series of on-going research (Rolf, 1997;Myers, 2001; Stecco, 2004; Langevin, 2006).

Nonetheless, attempts to study the functionalanatomy of deep muscular fascia can be frustratingand confusing. Long overlooked by classical anat-omy, and relegated to a role of mere contentionand packing, in recent years this highly innervatedand intricately structured tissue is gaining increas-ing attention. However, only a few regions havebeen studied in detail, namely the thoracolumbarfascia (Gracovetsky et al., 1985; Vleeming et al.,1995; Yahia et al., 1992; Loukas et al., 2007), theiliotibial tract (Birnbaum et al., 2004; Faircloughet al., 2006) and the plantar aponeurosis (Kitaokaet al., 1997; Yu, 2000).

When dealing with musculoskeletal disorderstherapists are continuously faced with the dilemmaof focus. What to focus on or, in other words, wherebest to apply massage, pressure, or friction becomesthe key question when, undeniably, the shoulder, asany other joint, is part of an interrelated system andits relationship with the rest of the body is anessential part of its functionality.

One manual technique that provides a rationalefor treatment of specific areas of muscular fascia,together with detailed indications for the localisa-tion of these points, is Fascial Manipulation&. Thispaper presents a pilot study of the application ofthis myofascial technique in chronic shoulder pain.Our attention focused on providing plausibleanatomical explanations for the results obtained.The posterior myofascial sequence of the upperlimb, termed the retromotion sequence (Figure 1)is examined in detail, and its anatomical substra-tum is illustrated. Some of the concepts of the

Fascial Manipulation& model are discussed andpossible clinical implications are considered.

The biomechanical model of the FascialManipulation& technique

The manual therapy technique known as FascialManipulation&, presents a biomechanical model todecipher the role of fascia in musculoskeletaldisorders considering that the myofascial systemis a three-dimensional continuum. Other authorspresent different models that all part from thisbasic concept of continuity (Busquet, 1995; God-elieve, 1996; Myers, 2001). In Fascial Manipula-tion&, the body is divided into 14 segments: head,neck, thorax, lumbar, pelvis, scapula, humerus,elbow, carpus, digits, hip, knee, ankle, and foot.Each body segment is served by six myofascial units(mf units) consisting of monoarticular and biarti-cular unidirectional muscle fibres, their deep fascia(including epimysium) and the articulation thatthey move in one direction on one plane. A new

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Figure 1 Retromotion myofascial sequence of upperlimb.

Application of Fascial Manipulation& technique in chronic shoulder pain 129

functional classification is applied to body move-ments to facilitate analysis of motor variations. Allmovements are considered in terms of directions onspatial planes and are defined as follows: antemo-tion (AN), retromotion (RE), lateromotion (LA),mediomotion (ME), intrarotation (IR) and extra-rotation (ER). Within each mf unit, in a preciselocation of the deep muscular fascia a specificpoint, termed centre of coordination (cc) isidentified. Each cc is located in the point ofconvergence of the vectorial, muscular forces thatact on a body segment during a precise movement.Biarticular muscles link unidirectional mf units toform mf sequences. One sequence is considered tomonitor movement of several segments in onedirection on the three planes. Sequences on thesame spatial plane (sagittal, frontal, or horizontal)are reciprocal antagonists (i.e. AN is the antagonistof RE and vice versa) and are considered to beinvolved in the alignment of the trunk or limbs.Other points, termed centres of fusion (cf), locatedon the intermuscular septa, retinacula, and liga-ments, monitor movements in intermediate direc-tions between two planes and three-dimensionalmovements. The cf can interact either along mfdiagonals or in mf spirals, according to theexecuted movement. Musculoskeletal dysfunctionis considered to occur when muscular fascia nolonger slides, stretches, and adapts correctlyand fibrosis localises in these intersecting pointsof tension, known as cc and cf. Subsequentadaptive fibroses can develop as a consequence ofunremitting non-physiological tension in a fascialsegment.

Based on this functional classification, a systema-tic objective examination together with an analysisof three-dimensional movements of the implicatedsegments can pinpoint dysfunctional cc or cf.Comparative palpation then determines the selec-tion of points requiring treatment in each indivi-dual case.

The manual technique itself consists in creatinglocalised heat by friction by using the elbow,knuckle, or fingertips on the abovementionedpoints. The mechanical and chemical stress effectson connective tissue are well known and a localrise in temperature could affect the groundsubstance of the deep fascia in these specificpoints. Tensional adaptation can then propagatealong an entire mf sequence, diagonal, or spiral,re-establishing a physiological balance. A funda-mental element of this method lies in the fact thatthe myofascial sequence is not only a functionalconcept but has an anatomical substratum offascial continuity and muscular expansions ontothe fascia itself.

Methods and materials

Clinical study

Twenty-eight subjects with chronic posterior bra-chial pain (13 males and 15 females, mean age 62.7,Table 1) were treated by the same practitioner in anoutpatient physiotherapy department, according tothe methodology of Fascial Manipulation&.

Informed consent for participation was obtainedprior to treatments. Subjects who showed evidenceof clinical neurological deficit, rotator cuff rupture,systemic inflammatory disease such as rheumatoidarthritis or had suffered direct trauma to theshoulder were excluded from the study. All subjectshad had symptoms for more than 3 months. Prior tocommencing treatment subjects were asked toevaluate the severity of their pain on a VAS scalefrom 1 to 10 [10 ¼ worst possible pain, 0 ¼ no pain].This subjective evaluation was repeated after threetreatment sessions and the sessions were thensuspended. At a follow-up, 3 months after the endof treatments, a third measurement was recorded.The first two treatment sessions (Figure 2) wereeffectuated 1 week apart from each other and athird treatment 2 weeks later. The mean value ofthese measurements was then calculated and theanalysis of the differences in pain was accomplishedby comparing the results obtained with appropriatestatistical tests (Kurskal–Wallis test and Dunn’smultiple comparison test as a control).

Subjects were requested to abstain from anychanges in usual medication.

Treatment procedure

A standardised procedure of anamnesis recordedage, occupation, sport activities, health history,symptoms, pain behaviour, and location. Any knownpainful movements, concomitant and previouspain, previous fractures, and surgical operationswere also recorded. After the formulation of aninitial hypothesis, specific movement tests aimedat testing the function of the mf units in selectedbody segments identified altered movements on all

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Table 1 General characteristic of subjects.

Gender Mean age Number

Male 67 13Female 58.8 15

Total 62.7 28

J.A. Day et al.130

three spatial planes (sagittal, frontal and horizon-tal). Movement tests were evaluated according toFascial Manipulation& protocol, on a scale from 1 to3 asterisks: pain ¼ *, weakness ¼ * and limitedmovement ¼ * (Table 2). The cc and/or cf of themost dysfunctional mf units (those with two orthree asterisks) were then subjected to a compara-tive palpation assessment prior to selection of thepoints for treatment in each session. Followingresolution of each cc or cf, the associated move-ment test was re-evaluated. A maximum of fourfascial points were treated in each session. The ccand/or cf treated in each subject during each

treatment session had an individual combinationthat was chosen according to the results of themovement and palpation tests, together with otherFascial Manipulation& criteria for selecting pointsfor treatment.

Anatomical study

In accordance with the choice to examine subjectswith posterior upper limb pain, analysis of theposterior region of the arm was also performed viadissection of 15 cadavers (11 men, 4 women, meanage 84.4 years, Table 2), neither embalmed norfrozen previously. With the cadaver in the proneposition, dissections consisted of an analysis of theposterior region of the shoulder and upper limb.Direct visual observations and photographs (CanonEOS 350 digital camera) were taken withoutmagnification. After removing the skin and sub-cutaneous fat, the muscular fasciae and theirstructure were examined. Particular attention waspaid to the direction of the collagen fibre bundles,the relationship of every muscle with its fascia, andthe presence of any muscle fibres inserted directlyinto the overlying fascia. Similarly, the presence ofany myofascial expansions (considered as fibrousextensions originating from the muscle and con-tinuing beyond the muscle itself) into the brachialand antebrachial fascia were also noted, withparticular attention to their spatial relationships.

All these expansions were photographed andsubsequently catalogued.

Results

Clinical study

Pain distribution involved the scapular region andthe triceps region in all subjects of the study group.Nine subjects also reported referred pain to theposterior region of the forearm. In seven subjects,distal paraesthesia, mostly to the fifth finger, wasalso reported. In all cases, a functional deficit inthe range of shoulder movements was noted duringmovement tests. At the initial assessment, amajority of subjects (53%) presented a deficit inmovement on the sagittal plane (Table 3). In one-third of cases, movement in the cervical region wasalso altered. No significant limitation in movementwas noted in the elbow, even though in 30% ofcases, pain extended to and below the elbow. Ingeneral, a dominance of sagittal plane limitationsemerged from our analysis, and cc and/or cf alongthe anterior and/or posterior myofascial sequences(AN, RE) were treated in 15 subjects out of 28.

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Table 2 Subjects examined.

Subject Age Gender

1 87 F2 84 M3 80 M4 86 M5 92 M6 75 M7 93 M8 84 F9 62 M

10 90 M11 89 F12 86 M13 85 M14 79 F15 94 M

Mean age 84.4 11 Male4 Female

Figure 2 Photograph of treatment of a centre ofcoordination.

Application of Fascial Manipulation& technique in chronic shoulder pain 131

After the three treatments a mean pain reductionof 57% was recorded (mean value of VAS prior totreatment: 77mm; mean value after three treat-ments: 32.8mm) (po0.0001) together with a goodrecovery of movement. The initial benefit wasgenerally maintained (mean value of VAS: 38.2mm,p40.05) at a short-term follow-up. In eight cases,there was a partial increase in reported pain afterthe suspension of treatment, and in three cases,pain had returned to its initial level (Table 4).

Anatomical study

From our anatomical dissections, we have seen thatthe posterior region of the upper limb, in corre-spondence to the retromotion sequence from

Fascial Manipulation&, has the following structure.Beginning at the hand, we have seen that the fasciaof extensor digiti minimi and abductor digiti minimiis continuous with the deep muscular fascia of theposterior region of the forearm. Some of the fibresof abductor digiti minimi originate directly fromthe fascia, therefore, when these muscles contractthey can transmit tension directly to the posteriorantebrachial fascia. This fascia is tensioned distallyalso due to its insertions onto the flexor retinacu-lum, pisiform and pisohamate ligaments. Theextensor carpi ulnaris extends a tendinous expan-sion onto the deep fascia of extensor digiti minimiand abductor digiti minimi (Figure 3). Moreproximally, some fibres of the proximal part ofextensor carpi ulnaris and extensor digiti minimioriginate from the antebrachial fascia. Fibrous

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Table 3 Results of +ve movement tests on three planes in segments examined at the first visit in 28 subjects.

Body segments examined Frontal plane Sagittal plane Horizontal plane

LA ME RE AN ER IR

* ** *** * ** *** * ** *** * ** *** * ** *** * ** ***

Scapula 3 3 1 2 1 2 1 2 1 1Humerus 3 6 5 1 1 5 1 4 3 7 2 3 1 1 2 2Elbow 1 1 1Wrist 1 2Digits 2 1Neck 1 2 1 4 1 1 1 2 2 1 1Thorax 3 1 2Lumbar 1 2 1 1 1Pelvis 1 2Hip 1 1Knee 1

Total ¼ 112 8 12 6 2 1 4 27 4 7 8 9 5 8 2 1 3 4

Table 4 Graph of subjective pain evaluation.

0

2

4

6

8

10

12

SUBJECTS

VA

S

Before Treatment After 3° Treatment Follow Up at 3m

J.A. Day et al.132

septa originating from the internal surface of theposterior antebrachial fascia were also seen. Thesesepta extend between extensor carpi ulnarisand anconeus on one side and extensor digitiminimi on the other side, giving origin to numerousfibres of the same muscles except anconeus, whichdoes not appear to have insertions into its overlyingfascia.

In all dissections, we found that this same fasciaalso provides insertion for an important tendinousexpansion of the triceps brachialis muscle, some-times called the tricipital fascia. The triceps fibresthat insert into the antebrachial fascia are allaligned in a longitudinal direction. They completelycover the anconeus muscle as well as the proximalinsertion of the muscles that originate from theepicondyle. Hence, the posterior antebrachialfascia is subject to and can transmit tension bothproximally and distally. Once the subcutaneousloose connective tissue was removed, the deepfascia of the forearm and elbow regions appearedas a sheer sheath covering the underlying muscles.Collagen fibres with different orientations wereclearly visible (Figure 4). The antebrachial fascia iscontinuous with the brachial fascia.

In all dissections, the latissimus dorsi fasciaproved to be continuous with the brachial fascia.Furthermore, latissimus dorsi sends a fibrous laminato the triceps brachii fascia, creating a type ofthickening in the posterior portion of the axillaryfascia and, subsequently, in the brachial fascia(Figure 5). A fibrous arch extending from thetriceps fascia to the tendon of latissimus dorsifurther reinforces the connection between the twofasciae. The latissimus dorsi also inserts into theoverlying fascia by means of numerous muscularfibres. Proximally, the posterior part of deltoidalso tenses the brachial fascia over the tricepsmuscle. The deltoid muscle not only tenses thefascia, via the numerous septa that intersect it,but it also sends some muscular fibres to theaponeurosis that covers the muscles below thescapular spine. Medially, the deep fascia of poster-ior deltoid continues with that of trapezius andrhomboids.

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Figure 4 Posterior elbow and forearm region. EUC:extensor carpi ulnaris, ECD: extensor digitorum, A:anconeus, FUC: flexor carpi ulnaris, O: olecranon, andT: triceps.

Figure 5 Posterior region of the upper arm. LD:latissimus dorsi muscle, BR: brachial fascia, and E:expansion.

Figure 3 Hypothenar region: Continuity of extensor carpiulnaris tendon with the deep fascia of extensor digitiminimi and abductor digiti minimi AM: abductor digitiminimi muscle, EUC: extensor carpi ulnaris, E: expansion.

Application of Fascial Manipulation& technique in chronic shoulder pain 133

Discussion

This study suggests that fascial anatomy canprovide a biomechanical explanation for the effec-tiveness of myofascial treatments in musculoskele-tal dysfunctions. It can serve as a guide forinterpreting pain distribution but also as a topo-graphical map for choosing specific, key areasfor effective treatment. In particular, this pilotstudy has explored the possible effectiveness ofapplications of Fascial Manipulation& in an extre-mely common dysfunction such as chronic shoulderpain. A characteristic of this method is that itevaluates and treats points at a distance from theregion where subjects experience their pain. Theassociated anatomical study has provided a clearerunderstanding of the validity of some of theanatomical bases of this method.

Our anatomical study demonstrates that myofas-cial continuity, provided by muscular insertions ontofascia, exists along the entire posterior upper limb.This continuity can offer a different prospective tothe explanation of referred pain. In our study group,nine subjects had referral of pain from the posteriorshoulder to the posterior forearm area, withoutclinical signs of neurological deficit. Their distribu-tion of pain did not correspond to a precise nerveroot, but it could be interpreted in terms of fascialconnections along a limb. In particular, the anato-mical study demonstrated that the muscular expan-sions into the fascia are present in all subjects andthat they could stretch precise portions of fascia.We hypothesise that these muscular insertions allowthe fascia to perceive stretch produced by a muscleand that this tension can be transmitted at adistance, both in a distal and a proximal direction.While the three-dimensional dispersion of forceswithin anatomical regions of the human body has yetto be thoroughly explored, studies of myofascialforce transmission confirm that the actual stiffnessof the general fascia and fascial compartmentsappear to be very important for the quantity ofmyofascial force transmission (Huijing and Baan,2003). Both Paoletti (2002) and Stecco (2004)hypothesise that the deep fascia between two jointsis directly involved in safeguarding a perceptive anddirectional continuity along a specific myokineticchain or sequence. It could be that fascia actssomewhat like a sensitive transmission belt betweentwo adjacent joints and synergic muscle groups. Theprecise stretching of selective regions of the fasciaedue to these muscular expansions could activatereceptors embedded in the fasciae (Barker, 1974;Stecco et al., 2006).

Transformation of the extracellular matrix of thedeep fascia from sol to gel, for example, due to

over-use syndromes, strain, and repetitive stressinjuries would modify the capacity of the endofas-cial collagen fibres to slide over one anothercausing a change in stiffness. This could producetwo effects: firstly, a mechanical or tensionalreaction and secondly, a possible alteration inafferent signals. In the first case, in an attempt tocompensate for localised changes in viscosity,tension could extend along a mf sequence, ormyokinetic chain, either in an ascending ordescending manner, or else, between agonist andantagonist myofascial sequences on one spatialplane. This could possibly be the explanation forthe dominance of the sagittal plane involvement(53%) together with the posterior brachial paindistribution found in our study group. In fact,patients with referred myofascial pain that doesnot correspond to a specific nerve root distributionare common in clinical practice (Baldry, 2001).Furthermore, seven subjects of our study reporteddistal paraesthesia mostly involving the fifth finger,which is the distal end of the retromotionsequence, as reported above. According to FascialManipulation& theory (Stecco, 2004), distal para-esthesia may occur when the fascia is not free toglide and subsequent fascial tension along asequence culminates in the terminal part of asequence. Stecco (2004) also suggests that thismechanism implies a basal or resting tension of thefascia. The documented insertions of muscle fibresonto overlying fascia could contribute decisively tothe maintenance of a basal tension (Stecco et al.,2007). Recent studies providing evidence ofmyofibroblasts within the fascia (Schleip et al.,2006) suggest another component that may con-tribute to a basal fascial tension or fascialcontractility.

An understanding of the anatomical continuity ofthe deep fascia supports this paradigm shift as ithelps to explain how alterations in one bodysegment can result in changes in a distant segment.Like trigger points, an alteration of a cc, forexample in the deep fascia of the triceps muscle,can result in referred pain in both a distal and aproximal direction. Considering the above myofas-cial expansions, fascial continuity could be respon-sible for the referral of pain along a sequence, evenin the absence of nerve root disturbance. In thepresence of non-neurological referred pain in somepatients from the study group, manual treatmentof a proximal cc over the deep fascia together witha distal point produced interesting results in termsof pain reduction and restored movement. Clini-cally, this indicates that work along an entiremyofascial chain in order to alleviate extendedmyofascial pain may not be necessary.

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J.A. Day et al.134

Concerning alterations in afferent signals, anyincorrect activation of receptors embedded in theimpeded fascia could result in inaccurate proprio-ceptive afferents. Consequent incoherent musclerecruitment would produce repercussions on jointmovement (e.g. impingement) and poorly coordi-nated joint movement can cause periarticularinflammation, resulting in activation of nociceptorsaround the joint.

The biomechanical model proposed by theFascial Manipulation& technique offers interestingpossibilities for more in-depth studies.

Conclusion

In conclusion, this study suggests that fascialanatomy can provide a biomechanical explanationfor the effectiveness of myofascial treatments inmusculoskeletal dysfunctions. Fascial anatomy canalso serve as a guide to interpreting pain distribu-tion and a topographical map for identifyingspecific, key areas for effective treatment.

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