Does Fascia Matter?

A detailed critical analysis of the clinical relevance of fascia science and fascia properties
8,500 words, updated Aug 30th, 2012 Whats new?
by Paul Ingraham, Vancouver, Canada
SHOW SUMMARY Fascia therapy and science are considered an exciting frontier in massage
and manual therapy, with well-attended fascia conferences featuring rock star gurus in the
massage world. The main idea is that fascia tough connective tissue wrapping around all
muscles and organs can get tight and restrictive, and needs to be released by pulling on
it artfully. Unfortunately, although fascia science may be inherently interesting as biology, no
property of fascia has yet been shown to be clinically relevant. No fascial pathology seems
to be a factor in any common painful problem, and no method of fascial manipulation is
known to fix fascia or even change it.

I have challenged readers to cite clinically relevant fascia science. This article reviews three
good examples: studies about fascias toughness, its contractility, and its fibroblasts. None
confirm any clinical relevance of fascia, and one actually undermines it, showing that fascia
is too tough to release. I also discuss the irrelevance of piezoelectricity, and contradict Gil
Hedleys popular fascial fuzz theory of stiffness. The article criticizes fascia excitement
from a scientific perspective.
Introduction
ZOOM

Sheets of fascia can contract a bit like muscle but how

strongly? Enough to make a difference?
Does fascia sheets and webs of connective tissue have any properties that are relevant
to healing and therapy? Are there good reasons to do manual therapy (massage particularly)
that is aimed at fascia? Fascia gets talked about in therapy offices a lot these days. It is
supposedly the key to many a therapeutic puzzle, and is now routinely targeted by
therapists of all kinds. But is fascia actually important?
This article questions fascia excitement from a scientific perspective.1 Fascia enthusiasts are
rarely specific about why fascia matters, or how exactly fascial work can help people with
common pain problems. They speak with general enthusiasm about the complexity and
ubiquity of fascia as if that alone is reason enough to target it. When trying to get more
specific, there is a strong pattern of poor clinical reasoning about fascia.
This problem was captured perfectly for me by something a massage therapist said to me on
my 40th birthday in 2011. I was getting a massage (because I really do love massage). The
therapist was doing fascial work, of course you cant get a massage in Vancouver these
days without getting some. She was using some mildly uncomfortable pulling and twisting,
trying to manipulate fascia, instead of using the more satisfying Swedish styles I was
craving. She launched into an awkward explanation of her technique, but words failed her:
Well, your problem2 is fascia. The fascia is the thing you have to do something with. If you
fix the fascia, everything gets more well, the fascia will make everything better.
Somehow.

Deja vu? Feel like youve seen this here before? You probably have. This is a like new
compilation of most of the fascia writing Ive done over the last year about four old
articles merged into one, with some re-writing and new information. You can now buy a $5
lecture version from Movement Lectures.

TABLE OF CONTENTS
1.

Introduction

4.

2. 1.1 Barely known to science!

3. 1.2 En garde! The fascia science challenge
Sloppy fascia reasoning

9.

5. 2.1 Electrified by piezoelectricity

6. 2.2 Fuzzy logic: Gil Hedleys fuzz speech
7. NEW Jul 31 '12
New section (Jul 31 '12) No notes. Just a new section.
2.3 The acupuncture connection: is fascia actually magic?
8. 2.4 Not so exotic after all
Real fascia science that supposedly matters

10. 3.1 Fascia is too tough to release

11. 3.2 Does stimulating fascia reduce post-exercise muscle soreness?
12. Minor update Aug 30 '12
Minor update (Aug 30 '12) Added a very useful link to
FasciaResearch.de.
3.3 Does it matter that fascia contains muscle cells?
13. Minor update Aug 30 '12
Minor update (Aug 30 '12) Added some acknowledgement that
fascia contractility may still have some slow-motion power even
if it is quite weak. Ill probably expand on this soon.
3.4 Fascia strong like bull! Or mouse?
14. 3.5 Do weak fascial contractions matter?
15. 3.6 No clinical relevance at all? Not even a teensy bit?
16. 3.7 Is fascial contraction even interesting?
17. 3.8 What does Dr. Schleip think?
18. Conclusions
Results of the Fascia Science Challenge so far
19. 4.1 To be continued
20. Appendices
21. 5.1 Further Reading
22. 5.2 Whats new in this article?
23. 5.3 Notes

Barely known to science!

There is a lot of real fascia research going on these days. However, because none of that
research is clearly clinically relevant some of it might be, but its quite debatable
theres also a lot of speculating about why fascia is important, with leads to some claims
that it has clinically relevant properties and functions that are still barely known to science.
In the history of science and medicine, guesses and fun speculation tend to fill knowledge
gaps but unfortunatey, exotic and new biology is also not very useful biology. No one can
get safe, effective, reliable treatment protocols out of poorly understood biology. If you
could, the biology wouldnt be poorly understood anymore, and youd probably be famous
for pushing back the frontiers of human knowledge.Exotic and new biology is not also not
very useful biology.
Some fascia research is truly interesting, and what many researchers are saying about fascia
is reasonable and does not reach beyond where the data can take us. Unfortunately, far too
many therapists fascinated by fascia are reaching well beyond what the science can actually
support and who knows if it ever will.
Please beware the implication of therapeutic significance from scraps of basic biology. It is
easy to sound cool talking about new biology because biology is cool. It is quite hard to
make biology useful. Certainly a lot of fascia science is right, but I question whether or not
it matters that it is right.
In fact, on one occasion, a rather pedantic experimental psychologist was telling him about a
long, complicated experiment he had done, incorporating all the proper controls and using
considerable technical virtuosity. When he saw Cricks exasperated expression he said, but
Dr. Crick, we have got it right we know its right, Cricks response was, The point is
not whether its right. The point is: does it even matter whether its right or
wrong?
V.S.
Ramachandran,
telling a story
about Francis
Crick

En garde! The fascia science challenge

Fascia is biologically interesting! All biology is. But clinical relevance is the central question
of this article: if fascia science cannot actually inform treatment in some practical ways, then
it makes no sense to be fascinated by it in a therapeutic context. You might as well get
excited about the biology of the immune system, or olfaction, or epigenetics, for all they
have to do with hands-on healing.
Reader suggestions and feedback are welcome, both critical and supportive. However, hate
mail will be ignored. I receive a quite a bit of hate mail on this topic. Please think twice
before you hit send.

Fascia enthusiasts routinely denounce this article, accusing me of ignorance of the current
Science of Fascia. Thats understandable. However, I am pretty up on massage-related
research its my full-time job so I feel confident challenging critics to cite even one
example of fascia research with clear, direct relevance to what happens in treatment. If such
a thing exists, I will be happy to publicly discuss it, and acknowledge my oversight. I could
be wrong about fascia. I even hope that I am. Maybe it is important to manipulate fascia
specifically.
This article covers three main examples of allegedly clinically relevant fascia research below.
(That may not sound like much, but the article is already several thousand words long, so be
careful what you wish for.) I will add more in time. All three are actually good examples of
fascia science with poor clinical relevance. We do not have a winner yet.
Before we get to that, though, Id like to start with a couple stranger examples of sloppy
fascia science piezoelectricity and fuzz and some of the general issues with fascial
therapy.
There is a crack in everything
Thats how the light gets in.
Leonard Cohen,
Anthem
PART 2
SLOPPY FASCIA REASONING

Electrified by piezoelectricity
A popular notion is that piezoelectric effect charge generated by flexing crystals is at
work in fascia. It is hardly clear that this is actually the case. However, even if we took it as a
fact, in what way is it at work? Do we know the physiological intricacies of that
phenomenon? Do we know why it evolved? What it does, how it does it? Can we affect it?
And, if we dont know these things, how can we possibly use it to devise a reliable therapy?
Obviously we cannot.
Is this a straw man? Nope. A straw man would be an idea that no one actually believes or
takes seriously and therefore meaningless to criticize. Certainly not everyone interested in
fascia thinks that fascial piezeoelectricity is real or important. However, enough do that its
no straw man! It may not represent the best thinking in the field, but it is certainly out there.
Piezoelectricity is barely mentioned in connection with fascia in the scientific literature.
Fascia is not discussed at all not even as a controversial concept in the Wikipedia page
on piezoelectricity, while other biological exploitations of the effect are mentioned.3 This
doesnt mean that there is no piezoelectric effect in fascia. But if there is, its a poorly
understood and exotic phenomenon, at best.

For contrast, consider the known example of piezoelectricity in bone: its well-documented
that piezoelectric effect is used as a way of guiding bone remodelling in response to
stresses,4 which is super cool. Its a terribly clever system!
Its also a terribly good example of a clinically irrelevant biological property. It has nothing to
do with anything a manual therapist could ever do to a bone. It is beautifully evolved to
change bone extremely slowly in response to extremely specific stimuli which, presumably,
cannot remotely be simulated by manual therapy. Trying to affect that system with your
hands would be quite futile, I think. And that is going to be the case for the great majority of
physiological systems, known and unknown even if you understand them, it doesnt mean
you can use them, or affect them with your hands.

Fuzzy logic: Gil Hedleys fuzz speech

Another fine example of imprecise scientific enthusiasm is Gil Hedleys extremely popular
fuzz speech. In this video with a bazillon views, Hedley plays fast and loose with a
dissection observation: there are cobwebby layers of fine, loose connective tissue between
thicker sheets of fascia. The anatomy is interesting anatomy is always interesting but
Gil Hedleys interpretations are dubious. His leaps of logic are charismatic, but also large and
precarious.
That stiff feeling you have is the solidifying of the fuzz, Hedley confidently explains. He
thoroughly makes the case that fuzz explains the sensation of stiffness.
At best, that is an unsafe assumption, and one that ignores many other highly relevant
factors like neurology, say, or the fact that hes looking at a dead person. He does not
know what happens to that tissue in a living body. In fact, that fuzzy texture only manifests
post mortem according to biotensegrity expert, Dr. Steven Levin.5 This is a very
interesting passage, worth reading carefully, but note the emphasized phrase particularly:
In Guimberteaus video, Strolling Under The Skin, what you see there is that the fuzzy
stuff is really dynamic tissue that is under constant change. Tissues dont slide, there is no

shear, they reconfigure with each movement. The dynamics of a cell ceases with death.
Ca++ [calcium ions] flood into the cell and it stiffens thats rigor mortis. It starts within
minutes of death, as soon as the circulating ATP [energy molecule] runs out. The fuzz is
connective tissue that is stiffened during rigor mortis, and it doesnt happen unless you
die. It occurs within minutes of death, and you can almost watch it happen. It is like snot
hardening. The mucus booger that comes out of your nose quickly hardens and becomes
quite stiff; at death, the mucus that connects all our tissues, does the same.
All that melting the fuzz is conjecture based on misinterpreted observations on dead tissue.
Even so called fresh cadavers are but poor players in the game of life.
Almost any amount of normal movement is sufficient to sustain a normal range of motion.
Fuzz solidification either isnt happening or doesnt matter, because its effortless to move
through. Also, there are other explanations for the sensation of stiffness: better, evidencebased, and un-fuzzy explanations. I discuss them in some detail in Quite a Stretch.

The acupuncture connection: is fascia actually magic?

Another popular notion about why fascia matters is that the meridians of Chinese medicine
correspond directly to fascial anatomy and function. If you polled therapists doing fascial
manipulation, I think you would find that a great many believe that they are doing the same
thing that an acupuncturist is doing just in a different way. They believe that fascial
therapy works for the same reasons acupuncture works.
Indeed, most fascial therapists probably believe that acupuncture works. And therein lies the
problem. Unfortunately for fascial release therapy, acupuncture is not a good ally: it has
been failing many fair, good quality scientific tests for years now, and is simply not what it
seems to be.
Acupuncture as we know it today is not so ancient after all: its current form is a modern
invention of the pediatrician Cheng Danan (, 1899-1957) in the early 1930s67 For
most of history, acupuncture existed primarily as a method of bloodletting exactly like the
prescientific medieval European practice.Before that, for most of history, it existed primarily
as a method of bloodletting exactly like the prescientific medieval European practice. And
then theres the myth of acupunctures popularity.8 Even its alleged popularity and
widespread use in China is quite trumped up it is, for instance, not actually used for
anaesthesia.9 These are rather embarrassing facts for acupuncture.
Acupuncture is obsolete Eastern folk medicine propped up by Western hype and wishful
thinking. The proposed association between fascial meridians and the chi meridians of
traditional Chinese medicine is meaningless. Even if meridians and all the other rubric of
acupuncture were real, though, acupuncturists are unable to demonstrate their power
clearly: their needles are consistently no more helpful than placebos. Even pro-acupuncture
researchers have repeatedly admitted that the effect of the needles is small at best. And if
the acupuncturists cant manipulate these meridians effectively enough to achieve clearly
measurable effects, why would pulling on fascia be able to do it?
Acupuncture lore has no business in a serious discussion about fascia and its possible
importance in therapy.

SY Does Acupuncture Work for Pain? A review of modern acupuncture evidence and
myths, particularly with regards to treating low back pain and other common pain problems

Not so exotic after all

Piezoelectricity, fuzz, and fascial meridians are three good examples of popular but poor
reasons why fascia supposedly matters. There are other reasons, both better and worse, and
discussion of genuine fascia science is still coming. But first I want to make it clear that
common fascia talk often fails to even reach the level of being science-y. Despite all the
talk of exotic properties of fascia, fascias clinical importance is usually expressed only in
terms of a couple extremely simplistic rationales, which dont seem exotic at all:
1. its everywhere and connects everything (well, yeah),
2. and it gets tight (not clear, see below).
A strong theme in fascial therapy is the emphasis on the interconnectedness of anatomy via
fascia, always making the point that pulling on any one part of fascia affects the whole body,
like pulling on the corner of a sweater affects all the threads. (That sweater analogy appears
virtually everywhere online that fascia is mentioned. It gets really tiresome, actually. Didnt
think it mattered much ten years ago. Still dont.)
The main idea of fascial therapy is that the stuff can get tight and restrictive, like clothing a
size too small, and needs to be released, and that therapists can achieve this by various
methods of yanking on it. The yanking may be extremely intense, too some flavours of
fascial therapy are among the most painful of all hands-on techniques.10
And thats what fascial therapy boils down to most of the time, in the wild. I have personally
encountered lots of talking about fascia that is exactly this rudimentary and even worse,
like the example I quoted in the introduction The fascia will make everything better!
Many therapists are perfectly capable of discussing the topic more intelligently, of course,
but low quality reasoning and communication about fascia is distressingly common (and my
exposure is quite extensive, due to the large volume of email I receive).
Consider this gem of simplistic rationalization, reported by Barrett Dorko, PT:
Restricted fascia is full of pockets. When the tissue starts to release, these pockets are
opened up. When these pockets open, the sensations that were trapped in them are
released.
Such overconfident, poor quality clinical reasoning isnt universal just excessively
common within the culture of fascia enthusiasts.
Now, lets get to some real fascia science.
The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge.
Stephen Hawking

PART 3
REAL FASCIA SCIENCE THAT SUPPOSEDLY
MATTERS

Fascia is too tough to release

My original challenge to readers (in the fall of 2011) to suggest fascia science that supports
fascial therapy was kicked off with a fine example: one that is just about the exact opposite
of what I asked for, underminding the clinical relevance of fascia rather than supporting it.
Despite the extraordinary number of comments I received on early versions of this article,
few readers answered my challenge directly. Of the handful of scientific papers that were
suggested to me, this was the most interesting:
Three-dimensional mathematical model for deformation of human fasciae in manual
therapy
Chaudhry et al. Journal of the American Osteopathic Association. Volume 108, Number 8,
p379-90. Aug 2008.
Chaudhry et al is indeed clinically relevant to fascial therapy but not in a supportive
way. This fascia science actually contradicts the big idea of fascial therapy.
The main point of manipulating fascia11 is to physically change it in some way to achieve
what is usually described as a release. Although the concept of release may correspond to
some other physiological phenomenon another discussion it certainly cannot be
explained in general by physically changing the fascia.
What Chaudhry and colleagues showed is that fascia is much too tough to release" by
mechanical deformation. Although they oddly imply in their summary that it might be
possible to do so with the superficial nasal fascia, the main text of the paper makes it clear
that even that thin tissue is extremely tough, and would only mechanically deform if
subjected to surprisingly intense forces. This is consistent with well-established properties of
fascia, namely that its extremely tough stuff. Collagen is like that.
If I could write my own conclusion to this paper, it would go more like this:
CONCLUSION: You cannot change the structure of fascia, because it is tougher than Kevlar.
If the stuff were much thicker than it is, people would be bulletproof.12
CLINICAL IMPLICATIONS: If you want to physically change someone's fascia by force,
you're going to have to get medieval. This directly contradicts a major popular rationale for
fascial manipulation.
This paper is only clinically relevant to fascial therapy insofar as it presents evidence that
discourages and undermines existing common practices and beliefs. Therefore, perhaps it
was a poor choice to cite it in this context.

Funny. Not actually possible. But funny! (Drawing by

Claude Serre.)

Funny. Not actually possible. But funny! (Drawing by

Claude Serre.)

Does stimulating fascia reduce post-exercise muscle soreness?

Perhaps but the clinical relevance of this data is tenuous at best so low that I would
never normally be interested in this paper. In fact, I would never have chosen to read it
myself, because I dont think its good enough science. I spent some time on it only as an
gesture of good faith to a critic, who supplied the paper as an example of basic fascia
science that matters. It was probably not a good choice for that purpose.
In vitro modeling of repetitive motion injury and myofascial release
Meltzer et al. Journal of Bodywork & Movement Therapies. Volume 14, Number 2, p162-71.
Apr 2010.

This is a test tube study showing that naked cells handled stress better (fewer signs of harm)
if they were treated with simulated myofascial release (MFR). A meaningful, accurate
simulation of manual therapy on naked cells is an amusing notion, and its clear that what
happened to those cells differs dramatically from what would happen in a real living body.
Even if true and reproducible, this data would mainly support the rationale for MFR
specifically for post-exercise soreness something of a dead end for clinical relevance,
because exercise-induced soreness has little to do with the main claims of fascial release
therapy, which primarily concerns correcting postural asymmetries, eliminating alleged
restrictions, and treating chronic pain.
Post-exercise soreness is comparatively trivial, and patients usually dont seek therapy for
it.13 Theres a lot of research showing that exercise-induced soreness is basically invincible
anyway.14 A meaningful, accurate simulation of manual therapy on naked cells is an
amusing notion.For this property of fascia to be clinically relevant, it would have to imply
that MFR might be able to treat chronic pain from other causes not the transient
annoyance of soreness after a game of soccer.
This isnt a rejection of all possible clinical relevance of the data. My point is that there are
so many problems that its relevance is watered down to quite a thin sauce way too thin.
I do concede that the paper shows some evidence that fibroblasts have interesting and
perhaps positive responses to mechanical forces. That is inherently interesting biology, and
perhaps well worth investigating further but its a long reach to postulate any clinical
relevance to what most therapists do, most of the time, with patients fascia.
Reach is what the authors do, however. I suspect they are deeply interested in validating
the notion that fascia is important, because they seem to be seeking evidence to support
their pre-conceptions typical of The National Center for Complementary and Alternative
Medicine-funded research, and a hallmark of low quality science. Its quite likely that if
neutral researchers with no interest in fascial therapy did this experiment they would
not get or report the same results.

Does it matter that fascia contains muscle cells?

The next example of fascia science was suggested to me by Gil Hedley. Since he clearly
believed me to be ignorant of fascia science and in dire need of educating, I asked him to
recommend some reading to me a favourite paper showing something interesting and
clinically relevant about fascia. As expected, he recommended a paper I was already familiar
with, because it is something of a classic of fascia science: Robert Schleips 2006
dissertation on the contractile properties of fascia. Much more interesting stuff than the
previous two examples. I will get into much more detail about this paper than the first two.
Fascia is able to contract in a smooth muscle-like manner and thereby influence
musculoskeletal mechanics
Schleip et al. Proceedings of the 5th World Congress of Biomechanics, Munich. Volume ,
Number , p51-54. 2006.

Schleip and colleagues convincingly showed that fascia contains muscle cells and that they
can contract slowly and weakly. That is undeniably interesting biology! But the point of
this analysis is to ask: Does it even matter whether its right or wrong? Is it clinically
relevant? Does it improve how we do therapy? Can we use the knowledge to affect the body
with hands? That is the question.
It is also a question that Dr. Schleip and his colleagues have addressed themelves on their
website, FasciaResearch.de. What follows is my own analysis, which is generally consistent
with theirs. However, interested readers should definitely have a look at their article: it is
readable and chock full of useful perspective, answering questions like Does fascia contract
in response to emotional stress? and Can fascia contract on its own?
Fascia Contractility FAQ, a webpage on www.fasciaresearch.de.
Important update: Dr. Schleip has read this article and corresponded with me about it
amiably, and expressed clear agreement with my main point. Although he also had some
thoughtful criticisms, we agree on what matters, and he shares my frustration with clinical
overconfidence in fascia. I invited him to make a statement for my readers about this: look
for it at the end of this part of the discussion.

Fascia strong like bull! Or mouse?

Before we get to clinical relevance, Ill quickly explain what Schleip et al. found: a kind of
muscle cell in rat fascia, which they described as rather unexpected.15 They also tried out
various methods of stimulating them in vitro (test tube) and found that, by golly, those
muscle cells did what muscle cells do: they contracted! Slow, weak contractions. But they
contracted.

Perspective
By any measure, fascial contractions are dramatically less
powerful than muscular contractions. If anything, this
diagram gives far too much credit to the power of fascia,
which would barely register at all if depicted
more accurately.
Its certainly not difficult research to understand.
Some important context that fascia fans will appreciate: for a long time, fascia was and often
still is incorrectly thought of as a fairly lifeless, inert substance, the Saran Wrap of biology. I
still hear various educated people referring to it in this way. However, massage therapists
and chiropractors (in particular) are prone to swinging to the opposite extreme and talking
about fascia as though it is more interesting than a lifetime subscription to National
Geographic. The truth is somewhere in the middle.16 Dr. Schleips research demonstrates
this. Fascia is not inert.
But neither is it all that lively at least not in terms of contractility. We are not talking about
a lot of muscle cells here. If you had blueberries with your cereal in the same proportion,
youd be disappointed not enough blueberries! Its just a few muscle cells scattered
throughout the fascia. Theres so few that they are visible only when you look very closely
and in just the right way.
Nor are we talking about particularly strong contractions. Fascia isnt going to be ripping
apart any chains with its bare hands. The maximum force generated by a small bundle of
contractile rat fascia was around 35mN.17 In plain English thats not very dang much or
the somewhat more precise about what it takes to set an AA battery rolling on a nice
smooth surface. (It took me a long time to work that out. I have a weird job.) Thats not bad

for a bundle of rat fascia, perhaps, but it doesnt really hold a candle to middle-of-the-night
charlie horses either.
Compared to the power of muscle contraction, fascia power barely even registers.
The bull versus mouse comparison is a little unfair though, because its not just a matter
of strong versus weak. Although fascial contractions may be weak compared to muscles,
they could nevertheless be powerful in another way their effects might, for instance,
accumulate over time to produce contractures (permanent seizing up of tissues). So its
still worth considering how these contractions might be clinically relevant.

Do weak fascial contractions matter?

Schleip et al.s basic finding seems sound enough, and I see no reason at this time to
dispute the observation that fascia can contract. If theres anything wrong with their
research methods, I dont know what it is. But for the property they described to matter to
therapists who are choosing to focus their therapeutic attention on fascia for any
biological property to be clinically relevant it must be significant enough to have an effect
on health. (It then must also be something that we can do something about, but lets start
with it mattering in the first place.)
Schleip et al. characterized the raw power of fascial contraction quite differently than I just
did. I deliberately made it sound trivial, within the bounds of their numbers.18 In their words,
however, in the large sheets of fascia in the low back, the contraction could be strong
enough to influence low back stability and other aspects of human biomechanics.
Stability? Even if you exaggerate their numbers, they would still only account for a small
fraction of the postural muscle power involved in dynamic spinal stabilization, never mind
the generally mind-blowing structural toughness and resilience of the human spine. The idea
that low back stability could be affected in any way by such a small, slow-motion force is a
bit much for me to swallow.1920
And thats based on an estimate of the theoretical maximum force generated by the biggest,
thickest blankets of fascia in human anatomy. In most places in the body, fascia is much less
substantial tough for its weight, but mostly quite thin and wispy, and a lot of it even
microscopic.21 The forces generated must be dwarfed by that of muscle itself in rough
proportion to the number and size of contractile cells involved.
That fascial contractions might influence other aspects of human biomechanics is a bit
vague. A general example of such aspects might be that contracting fascia could be
involved in biomechanical asymmetries tighter on one side than the other. The validity of
such a concern depends on just how sensitive you think human biomechanics are to forces
so subtle that no one really had any idea that fascia contraction was even happening before
this study. As regular readers here will know, I think biomechanics are over-rated as a factor
in all kinds of pain problems, and theres extensive evidence that human beings are
wonderfully adaptable and cope surprisingly well even with gross deformities, never mind
subtle assymetries and imbalances. I make that case in great detail in another article.22

The wording of the conclusions of Schleip et al.s paper is synonymous with saying that
fascial contraction is relevant only if structuralism is a useful mode for doing and thinking
about therapy. Also, their phrasing shows a strong bias in favour of the importance of
fascia. And the study was funded by the International Society of Biomechanics, the Rolf
Institute of Structural Integration, and the European Rolfing Association.23
Weak, slow fascial contractions strike me as being scientifically valid and interesting, but
clinically minor. Once again, far from making me interested in fascia as a target for therapy,
fascia science is convincing me of just the opposite.

No clinical relevance at all? Not even a teensy bit?

If it makes anyone feel better about all this, Im happy to concede that fascial contractility
might be a little bit clinically relevant. Other evidence might even reveal something
important although that would surprise me. It doesnt hurt my main point to make these
concessions. To make my point, all I have to establish is that the clinical relevance is
debatable and probably minor at best, rather than the slam dunk it would have to be to
support even half of the excitement about fascia you see in the therapy industry today.24
What about fascia and trigger points? Schleip et al. dont bring trigger points (muscle knots) into
this discussion, but a lot of other people certainly have. The notion is that a trigger point is
being squeezed and sustained by clenching fascia, but this clinical concept suffers even
more than other examples from the relative weakness of fascial contractions. I explore this
specific claim of clinical relevance in detail in my trigger points tutorial.
In his original dissertation, Schleip limited his speculation about clinical implications to the
broad generalization that it can influence musculoskeletal mechanics, such as spinal
stability. In a follow-up paper for Medical Hypotheses,25 he and several colleagues generally
suggest that fascial contractility is a factor in muscle stiffness. The high water mark for
potential clinical relevance is spelled out in this passage:
This offers the possibility of a new understanding for many pathologies that involve a
chronically increased myofascial tonus. Examples include conditions such as torticollis, low
back pain associated with paraspinal compartment syndrome, tension headaches, and
others. Similarly a decreased fascial tone could be a contributing factor in conditions that
are often associated with decreased myofascial tension, such as in back pain due to
segmental spinal instability, peripartum pelvic pain, or fibromyalgia. While usually other
factors play a major role as well in these pathologies, it is possible that their progress
could be influenced additionally by the regulation of fascial tissue tone
The emphasized phrase is key its an understatement. For instance, other factors dont
usually play a major role in those conditions, they always do. And the role of those factors
isnt just major, but probably nearly total relative to the presumably minor (and still
unconfirmed) contribution of a little fascial tension. Some of the items listed are particularly
implausible to me. Ive already mentioned how hyperbolic it is to suggest that fascia could
have any serious impact on spinal stability.
Another peculiar item here is fibromyalgia, a fascinating condition that might conceivably be
affected in some small way by fascial contraction, but which is overwhelmingly a nasty

disease of the nervous system. Suggesting it as a main example26 of how fascial

contraction might matter makes about as much sense to me as saying that people with
cancer might have some contracted fascia would it matter if they did?
The most interesting item listed is compartment syndrome, which is decidedly not a
common complication or cause of back pain, but certainly is a problem (especially in the
shins).27 Compartment syndrome is excessive pressure in a fascial compartment, like a
sausage swollen in its wrapping. If fascia were to start squeezing a compartment for some
reason, it might be a problem. It is the one item listed where there is a clear, direct and
logical connection between fascia can contract and a way that it could contribute
significantly to a health problem. That is clinical relevance. And yet there is still a clear
problem with the scale of the forces here. Compartment syndrome is by definition only a
problem when the pressure is significant, probably dramatically exceeding the maximum
force with which fascia could squeeze the compartment. Visualize a hot water heater that
isnt venting pressure the valve is busted, and its in danger of blowing. The pressure
inside is immense, and it would make no practical difference if the hot water heater itself
was a little larger or smaller. Again, fascial contraction is probably not nearly strong enough
to matter. Still, at least its easy to see how it could matter in principle, and the numbers
might favour fascial contraction as factor.
So you see how this goes: for one candidate example after another, the clinical relevance of
fascial contraction is dubious or minor.

Is fascial contraction even interesting?

One of the lower moments in biology history was the labelling of non-coding DNA as junk
DNA in 1972. The first time anyone with a scrap of imagination heard that, they thought,
Yeah, right. As biologists slowly figured out what all that junk is for,28 there was a lot of
Well, yeah, okay, thats more like it. Of course. Its interesting science, but in some ways
those discoveries are still overshadowed by the way were all not so very surprised.
Similarly, the presence of muscle cells in fascia is no shocker. I never believed fascia was
entirely inert any more than I believed in the junkiness of any DNA. If you spend much time
studying biology, it quickly becomes apparent that there are no sharp lines or divisions, and
that we consist of an incomprehensibly diverse and interconnected community of cells. That
connective tissue has a small population of muscle cells strikes me as blindingly
unsurprising. Muscle blends exquisitely into tendon, with no clear demarcation at the cellular
level: at the microscopic level, its like walking through the overlapping zone of two heavily
integrated adjacent neighbourhoods, and the further you go away from the muscle, the
fewer muscle cells you see, and the more fibroblasts and their fibres. That connective tissue
has a small population of muscle cells strikes me as blindingly unsurprising. Fascia surrounds
and fractally wraps every muscle inside and out, for crying out loud how could it not have
a few muscle cells and overlapping properties?
I didnt know that before it was confirmed, but I certainly dont find it particularly surprising.
I suspect that the slightly contractile properties of fascia are simply at one end of a
continuum of motor function. Our muscular system is overwhelmingly our primary means of
reacting to stimuli the major output of our nervous systems and in general terms the
slight contractility of fascia is probably just the fringes of that functionality, a little bit more

of the same. There are probably some subtle differences, but they are subtle and arcane and
ultimately just a slight variation on the biological theme of muscularity. Im not saying its
completely uninteresting, but its overshadowed by the much more interesting muscular
system as a whole, about which fascia is simply a mildly intriguing subtopic. And, in terms of
clinical relevance, the muscular system itself is in turn overshadowed by neurology.

What does Dr. Schleip think?

Recently Dr. Schleip read my article and wrote to express his basic agreement with my key
point about his research: Your comments on the small size of fascial contractions are right
on, at least when viewing these within the periods of seconds to minutes, as is usually
applicable for bodywork techniques. He also wanted me to know that he shares my
annoyance with the over-zealous claims and projections of therapists doing fascial work.
He is not thrilled with the way his research is being used to justify premature overconfidence
in fascial therapy.
He also offered some thoughtful criticism on some specific points (and I made some
changes, and will probably make more). Nevertheless, he had no major objections, and was
generally pleased with what he read here: You have my respect for your detailed and
critical analysis of the present work on fascia. Most of the people who criticize you have not
done a portion of your reading work and could certainly learn a lot from the debate you
started.
I invited him to make a statement for my readers about this. Here is it in full, with some
emphasized highlights:
I share your emotional frustration with the current trend among bodyworkers of
attributing anything wonderful or astonishing to the properties of fascia. In fact,
our Fascia Research Group at Ulm University has been receiving an almost exponentially
increasing number of inquiries from enthusiastic healers (and martial art teachers)
worldwide who wish that we would sanctify their claims that fascial contraction provides the
explanation for their observed miracle powers. While I do tend to believe that the fascial net
plays much larger roles in human functioning than previously assumed in orthopedic
medicine, I am afraid that such over-zealous claims and projections are
undermining the seriousness of the investigation and academic rigor that
characterizes the work of the current leaders in fascia research, such as P. Huijing, H.
Langevin, T. Findley, P. Standley and A. Vleeming.
As a bodywork clinician myself, I have learned that there is hardly a more dangerous
attitude among therapists than the hero healer/manipulator who is damn sure
about his diagnosis and supposed treatment effects . This of course applies as much
to fascia-oriented therapists as it does to those who base their work on supposed
neuromuscular or other physiological effects, most of which are still unproven. There is
hardly a more dangerous attitude among therapists than the hero healer who is damn sure
about his diagnosis & supposed treatment effects.While scientists can learn a whole lot
from the intuitive and experiential wisdom of complementary therapists, particularly about
the non-fragmented and connecting properties of the fascial net, we bodyworkers can learn
at least as much from the careful, questioning approach of good scientists, who are willing
to doubt their own assumptions and to refrain from premature confidence and

over interpretation of their findings. It is this mutual learning and interdisciplinary

enrichment which in my opinion characterizes the best qualities of the current fascia
research field, as expressed in the international Fascia Congress series and associated
activities.
Again, Dr. Schleip and I do not agree about everything but that is unimportant compared
to our shared values and commitment to cautiously reserving judgement. We have each
placed our bets on this topic, but not closed our minds. I fully support and endorse his
enthusiasm to explore the biology and he supports and endorses the value of my critical
analysis.
PART 4
CONCLUSIONS
Results of the Fascia Science Challenge so far

Piezeoelectricity may occur in fascia, but its clinical relevance is nil not
enough is known about it to even speculate about how it could be exploited in
manual therapy.

Gil Hedleys theory that congealing fascial fuzz causes stiffness is

simplistic and wrong. It is not a plausible explanation for the sensation of
stiffness, or a mechanism of action for fascial therapy or stretching.

Fascial meridians relate fascial therapy to the meridians of acupuncture,

which dont exist or even if they do cant actually be exploited for any
therapeutic effect even by acupuncturists.

Chaudhry et al showed that fascia is too tough to release. Indeed, even

thin fascia is so tough that it is basically inconceivable that it could be physically
changed (stretched, loosened) without vice grips. This directly contradicts a
major popular rationale for fascial manipulation, and is only clinically relevant to
fascial therapy insofar as it presents evidence that discourages and undermines
existing common practices and beliefs.

Meltzer et al concluded that stimulated fibroblasts might be happier

fibroblasts specifically, they might be more resistant to post-exercise
soreness. The results of this test tube study are questionable, but even if you
take the data and interpretation at face value, it is a long reach from a test tube
study to clinical reality. Treating post-exercise muscle soreness is not even a
common goal for manual therapy.

Schleip et al established that fascia is contractile to a trivial degree, but not

that it matters. It is somehat unsurprising biologically, and clinically trivial. It is
not a factor in any of the common problems most manual therapists work with
maybe none at all and even if it was it is somewhat unlikely that hands-on
therapy could relax it.

To be continued
There is more fascia science, and I will extend this article with more analysis in the future. I
honestly hope that there is clinically relevant fascia science that would be terrific. So far,
however, I see no good reason for therapists to be fascinated by fascia and to make it a
target tissue.
Other alleged fascial properties and clinical relevance issues I intend to address eventually
(definitely not a complete list):

The claim that fascia contains memories in some sense. I will likely dispute both
the property and its relevance.

The claim that fascia is structurally important and tensegrity is interesting

(agree), and that this is clinically relevant (disagree). Much of my rebuttal on this
score already exists in my article about structuralism.

PART 5
APPENDICES

Further Reading

SY Your Back Is Not Out and Your Leg Length is Fine The story of the
obsession with crookedness in the physical therapies.

SY Pain is an Opinion What recent pain science can do for your chronic pain
right now. The role of the nervous system in chronic pain is the major alternative
to focussing on fascia. It has much clearer clinical relevance.

SY Does Massage Therapy Work? A review of the science of massage therapy

such as it is.

SY Trigger Points & Myofascial Pain Syndrome A guide to the science of

muscle pain, with reviews of every possible self-treatment and therapy option,
even for the most difficult cases. Includes a section on the relationship between
fascia and trigger points (e-book customers only).

Greg Lehman, a chiropractor and physiotherapist has a thoughtful new fascia

article, Fascia Science: Stretching the power of manual therapy

Todd Hargrove, a Rolfer and writer (BetterMovement.org), has a good post on

fascia and foam rolling and fascia under the microscope

Whats new in this article?

Minor update (Aug 30 '12, section #3.4) Added some acknowledgement that fascia
contractility may still have some slow-motion power even if it is quite weak. Ill probably
expand on this soon. See section #3.4, Fascia strong like bull! Or mouse?
Minor update (Aug 30 '12, section #3.3) Added a very useful link to
FasciaResearch.de. See section #3.3, Does it matter that fascia contains muscle cells?
New section (Jul 31 '12, section #2.3) No notes. Just a new section. See section #2.3,
The acupuncture connection: is fascia actually magic?
Major update (Jul 25 '12) Article launched as a compilation of about four previous
articles on this topic, with revisions and some new information.

Notes
1. It is quite negative. I have fun taking therapy seriously. Criticism and
deconstruction of ideas is normal and healthy and necessary for therapy
professions to grow and change. BACK TO TEXT

2. I didnt actually have any problem. It was supposed to be a relaxation massage,

in a spa. Yes, she was a Registered Massage Therapist a well-trained and fully
certified massage therapist. And thats probably exactly why she felt compelled
to strut her stuff and troubleshoot my case and talk about fascia. BACK TO
TEXT

3. Obviously, Im not citing Wikipedia as a particularly credible authority on this

subject (although I actually think Wikipedia tends to be pretty good far better
than encyclopedias used to be). Im citing it because a Wikipedia article is at
least a good survey of the scope of a topic. Virtually any reasonably important
idea will at least get a mention. If it doesnt get even a mention in fairly

thorough coverage accuracy aside its probably not terribly important.

BACK TO TEXT

4. The full details of how bone responds to stress are spelled out in Dr. Harold
Frosts Mechanostat model. For more information, see Tissue Provocation
Therapies. BACK TO TEXT

5. The quoted passage is from my personal correspondence with Dr. Levin, and is
used with his permission. For information about Dr. Levins work, see
Biotensegrity: A new way of modeling biologic forms. BACK TO TEXT

6. The Acupuncture and Fasciae Fallacy. Kavoussi. www.sciencebasedmedicine.org.

2011. BACK TO TEXT

7. Ramey. Acupuncture and history: The ancient therapy thats been around for
several decades. ScienceBasedMedicine.org. 2010. BACK TO TEXT

8. How popular is acupuncture? McKenzie. www.sciencebasedmedicine.org. 2011.)

BACK TO TEXT

9. Acupuncture Anesthesia: A proclamation from Chairman Mao. Atwood.

ScienceBasedMedicine.org. 2009. BACK TO TEXT

10. Some fascial therapy is gentle, but I have personally encountered intense fascial
therapy in the wild on numerous occasions. I prefer gentler therapy and usually
request it. Despite being a confident and assertive communicator about my
preferences, I have still had many unpleasantly intense fascial therapy
experiences. BACK TO TEXT

11. According to a great many therapists. Not all, but probably most. Its spelled out
clearly by a prominent fascial therapy pioneer, Luigi Inventor of Fascial
Manipulation Stecco. This is someone who has the respect of large numbers of
fascial therapists; his thinking about how fascial therapy works can be
considered strongly representative not only of common thinking about fascial

therapy, but the bleeding edge. In a review of ther rationale for a workshop, he
repeats the basic idea of tissue stuckness in need of releasing in an impressive
array of fancier terms. This is just a small sample:

Once a limited or painful movement is identified, then a specific

point on the fascia is implicated and, through the appropriate
manipulation movement can be restored.

restore gliding between the intrafascial fibers

restitution of elasticity to the fascia

If this normally very slippery membrane becomes rigid, stuck or

densified a lack of sliding within the fascia can occur.

the densifications need to be slowly dissolved.

the aim is always to create localised heat to modify the density of

the ground substance of the fascia

BACK TO TEXT
12. People are not bullet proof thanks to their fascia, alas wouldnt that be handy!
And yet the hyperbole is definitely true in a sense. Fascia is mostly much too
thin to actually be bulletproof. If fascia was just as thick as a Kevlar vest, it might
well be just as bulletproof (or a little more, or a little less). This is just like how
spider silk is stronger than steel cable pound for pound, it is. The catch in
the comparison is probably that Fascia probably doesnt have the same
puncture resistance property that Kevlar does. There are many kinds of
toughness (i.e. bones resist compression exceedingly well, but are quite
vulnerable to torsion). The point was simply that the research showed quite
clearly that the forces required for plastic deformation of fascia significantly
exceed what can be applied to it with hands. Whatever therapists are feeling
when they claim to detect a release, its not that. BACK TO TEXT

13. If its bad enough to think that you need help, youre also too sore to want
anyone to touch you (let alone push on you). In any case, post-exercise muscle
sorness is usually all wrapped up before patients can get to an appointment.
BACK TO TEXT

14. SY Ingraham. Delayed Onset Muscle Soreness (DOMS): The mysteries of muscle
fever, natures little tax on exercise. SaveYourself.ca. 5662 words. BACK TO
TEXT

15. Is it really surprising? Ill return to that question below. That phrasing doesnt
actually come from the paper, so you wont find it there, but from a poster they
made to summarize the paper. BACK TO TEXT

16. Or perhaps somewhat to one side of the middle BACK TO TEXT

17. A millinewton is 1000th of Newton, which is a measurement of force. A full

Newton is not a lot: enough to accelerate a mass of one kilogram at a rate of
one meter per second squared, without friction. Imagine what it would take to
get a small weight moving a little bit in space. Now divide by a thousand.
BACK TO TEXT

18. Id like to think I made it sound accurate, and the result just happens to be
trivial. BACK TO TEXT

19. A little personal perspective: my lovely wife has titanium in her back, installed to
stabilize a massive fracture of her T12 vertebra in 2010. Such is the toughness
of spines that the titanium fixations installed to protect her actually broke on
both sides came loose from the brackets screwed into her bones. Similarly,
severe scoliosis can twist titanium fixations like pretzels as it advances. Those
are the kinds of forces involved in the back. Fascial contractions are a miniscule
part of such impressive equations. BACK TO TEXT

20. It is also noteworthy that the contractions they described were slow motion
contractions, taking many seconds to develop at their fastest. BACK TO TEXT

21. Analogy: in the circulatory system, there are only a few gigantic blood vessels,
but countless fine and microscopic ones. The fascial system is similar: a few
large, obvious sheets of fascia, a bunch of more modest and delicate structures,
and then a nearly infinite network of extremely thin and microscopic structures.
This is why I say that we are wrapped in fascia fractally. BACK TO TEXT

22. SY Ingraham. Your Back Is Not Out and Your Leg Length is Fine: The story of
the obsession with crookedness in the physical therapies. SaveYourself.ca.
10040 words. BACK TO TEXT

23. Despite what it seems like, I am not actually accusing Schleip et al. of having
any overt or serious conflicts of interest. In general, COIs are more common and
less of a big deal in science than people think: where there is science there is
funding, such is life, and funding sources affect science in muddy, complicated
degrees ranging from not really at all to truly, madly, deeply. This seems like a
borderline case to me, somewhere on the edge of being a problem. Its safe to
say that these organizations probably would not fund or continue to fund
research that came to the opposite conclusion, i.e. not strong enough to
influence low back stability and other aspects of human biomechanics. BACK
TO TEXT

24. This is another form of what I call failing the impress me test. Usually I bring
that up to make the point that there needs to be strong evidence that
treatments works before they can be considered proven small and
temporary treatment effects should not impress anyone. In this case, though, its
the clinical relevance of fascial contractility that is failing to impress. BACK TO
TEXT

25. Schleip et al. Passive muscle stiffness may be influenced by active contractility
of intramuscular connective tissue. Medical Hypotheses. 2006.
PubMed #16209907. BACK TO TEXT

26. If youre not going to list really good, relevant examples here, where are you
going to do it? BACK TO TEXT

27. I have written quite a lot about compartment syndrome with regards to their role
in shin splints (see Save Yourself from Shin Splints!). The lower leg is by far the
most common place in the body for compartment syndromes, both in the shins
and the calf. They are more or less unheard of elsewhere in the body rare and
generally minor and self-limiting. If fascial compartments were prone to
problematic contraction, wed constantly be getting compartment syndromes
all over the body. BACK TO TEXT

28. Basically, only a fraction of the genome is for coding proteins, but that important
minority is regulated and tweaked by the rest of the non-coding DNA. So a (very
rough) analogy is that the coding DNA is like software that makes you who you
are, but the junk DNA is the operating system that it needs to run on. Not so
junky. BACK TO TEXT