The Fasciae: Anatomy, Dysfunction and Treatment

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The Fasciae Anatomy, Dysfunction & Treatment Serge Paoletti ILLUSTRATIONS BY PETER SOMMERFELD T he fasciae

c om prise a wide variety

of body tissues including the mem­ branes, ligaments tendons, and ,

mesenteries. These tissues are all deri ved from the mesoderm, which undergoes coiling or rolling move­ ments during embryonic development. This is the origin of the inherent micro-movements, or motili ty that are ,

so important in many osteopathic approaches to diagnosis and treatment The fasciae are found at eve r y level of the body and constitute

a

bas i c

element of human p hysio logy. They serve as the body's first line of defense, acting independently of the central nervous system, which is why they are referred to as a "peripheral brain." From a mec hani c al point of view, the fasciae are organize d in chains to defend the body again st restrictions.

When a res tr i c ti on goes beyond a specific threshold, the fasciae respond by modifying their viscoe lasticity, changing the co ll ageni c fibers , and transforming healthy fascial chains into lesional chains.

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The fasciae keep a record of every trauma that causes a change in motility. Through the sensitivity of trained hands, we are able to perceive movements on a micro-level and can thus detect motility disturbances, whic h reveal the medical history of a patient. Remedial techniques,

adapted

to each patient, can restore normal motility. In this way, fascial di s t u r

­

bances can be overcome, allowing the body to recover its normal physiological functions. For this reason, we can say that the health of every person is reflected in large part in the fasciae.

The Fasciae: Ana tom y Dysfunction & ,

Treatment is the first book to organize

the wealth of available information concerning fascial tissues from the fields of embryology, anatomy, his­ tology, and pathology. It describes the role and mechanism of the fasciae

,

as well as appropriate testing and tr e a tm en t

methods.

ABOUT THE AUTHOR

Serge Paoletti, no. (U.K.)

is a

graduate of the European School of Osteopathy (E SO) in Maidstone, England. He has taught at that school as well as at the College Internationale d'Osteopathy (CIDO) in St. Etienne

,

France, the Viennese School of Osteopathy (WSO) , the French Osteopathic College (COF) in Paris, and the German Osteopathic School (OSD) in Hamburg.

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The Fasciae

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Table of Contents

Preface, Chapter 1

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XUl

Embryology

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Formation of the Two-layered E m b r yo nic Disk

.

.

.

.

.

.

.

..

.

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.

.

.

.

.

..... 1

1

Formation of the T hree layered Embryonic Disk ...... 4 -

Sheet Differentiation and Em b ryonic Development ...... 6 THE

DERIVATIVES OF

MESODERM..

.6

Paraxial m eso d e rm 7 .

Intermediate m esod erm , 7 Lateral plate,

7

DERIVATIVES OF THE ECTODERM....... 9 DERIVATIVES OF THE ENDODERM..

..10

Summary of Embryonic Development, 12 DERIVATIVES OF THE

Mesoderm,

VARIOUS LAYERS..

.13

13

Endoderm, 1 3 Ectoderm,

13

The Mechanisms U n derly in g EmbryoniC Development HISTOLOGICAL AND BIOCHEMICAL PHENOMENA.. BIOKINETTC

AND

BIODYNAMIC PHENOMENA..

Corrosion fields,

.

. ....

15

15

17

1 7

Densation fields, 17 Contusion fields.

18 v

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Distusion fields, 19 19

Retention fields,

Dilatation fields, 19 Parathelial loosening

fields, 20

Detraction fields, 21

Chapter 2

-

.... 23

Anatomy of the Fasciae

Su perficial Fascia

External Fasciae

.

.

.

.

.

.. . . .

.

.

23

.

24

EPICRANIAL APONEUROSIS....... 24 Temporal fascia, 24 Masseteric fascia, 25 Fasciae of the face, 25

SUPERFICIAL CERVICAL FASCIA....... 26 FASCIAE OF THE TR UNK

...... 2

.

8

Posterior Fasciae. 28 Anteri o r Fascia, 29 Iliac Fascia, 3 I Summary

of the

Fasciae of the Trunk, 33

UPPER LIMB

FASCIAE...

Shoulder

Fasciae, 35

.

.

34

Brachial Fascia, 3 7

Antebrachial Fascia, 38 Fasciae of the Hand, 40 Summary

of Upper Limb Fasciae, 43

LOWER LIMB FASCI AE .......43 Veins, 45 Cutaneous Nerves, 45 Gluteal Aponeurosis, 46 Fasciae of the Thigh, 4 7 Fascia o f the Lowe r Leg, 49 Fascial Elements of the Foot, 50

Summary

of Lower Urn b Fasciae, 53

Internal Fasciae. .

53

MIDDLE CERV ICA L FASCIA .......53 PREVERTEBRAL FASCIA....... 54

ENDOTHORACIC

FASCIA . .

.

... 55

Summary of the Fascia of the Neck, 56

Summary of the TRANSVERSALIS

Endothoracic and Transversalis Fasciae, 60

F ASCIA ... ...60

FASCIAE OF THE PERINEUM AND PELVIS.. Superficial Perineal Fascia, 61

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Middle Perineal Fascia, 62

Deep Fascia of the Perineum, 65 Related Perineal Fascial Structures, 67

Summar)' of the Fasciae of the Perineum and Pelvis, 7 j

Fasciae of the Central Axis ..... 7 4 .

INTERPTER YGOID FASCIA... .... 7 4 PTER YGOTEMPOROMAXILLARY FASCIA..

.

.... 7 4

PALATINE APONEUROSIS ..... 7 4 .

PHAR YNGOBASILAR AND BUCCOPHARYNGEAL F ASC I AE .......

PERICARDIUM

..

.

.

.

.

76

79

Fibrous Pericardium, 79 Serous Pericardium, 8 I

Summary of the Cen t ral Fascial Axis, 82

Diaphragm. ... 83 Internal Thoracoabdominal Fasciae . ...... 83

.83

PLEURA.

Visceral Pleu ra, 84 Parietal Pleura, 85

Summary of the Pleurae, 87 PERITONEUM AND PERITONEAL C AV IT Y. .

Parietal Pe r i to n e u m

,

.88

89

Visceral PeritonelU11, 91 Peritonea] Folds, 9 j

Summary of the Peritoneum, 99

Meninges

.

.

.

. . 100

DURA MATER.... .

.

. 100

Cranial Dura Mater, 100

Spinal Dura Mater, 105 PIA

M ATER. .... 107 Cerbral Pia Mater,

107

Spi nal Pia Mater, 107 ARACHNOID MEMBRANE...

. 1 08 .

Cerebral Arachnoid Mem b r an e,

Spinal Arachnoid Me mb ran e

Chapter 3

-

,

108

I 10

Connective Tissue Anatomy at the Microscopic Level

Connective Tissues.. CONNECTIVE

.

.. 115

TISSUE CELLS ...... 1 1 5

Bound cells, 1 15 Unbound cells, 1 15 Interstitial matrix,

1 IS

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113

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I 16

Ground substance,

I 16

Various types of connective tissue, CARTILAGINOUS TiSSUE .......

Elastic cartilage,

1 17

I 17

Hyaline cartilage,

117

J 17

Fibrocartilage,

..1 1 8

BONY TISSUE..

J 18

DifTerent types oJ bony tissue,

I 19

Various types o f ossification, Periosteum,

120

I 21

Organization of bony tissue,

Related Tissues

.. . 1 22

MUSCLE..

..122

NERVES.

.124

Central nervous system,

J 24

Peripheral nervous system,

125

..126

EPITHELIAL LINING.

System of intercellular Junctions,

126

Relationships between epithelial and connective tissue, Cell differentiation and functional specialization, SKIN .......

126

127

128

Various layers of the skin, Skin functions,

12 8

130

Histological Features of Connective Tissue CONSTITUENTS OF CONNECTIVE

Elastin,

..

131

13 I

Ground substance, Collagens,

TISSUE..

. 131

I

13

133

Connective t i ss ue fibers, Proteoglycans,

J 33

136

Structural glycoproteins,

136

CONNECTIVE TISSUE CELlS....... 1

37

Mesenchymal cells, 137 Fibroblasts,

137

Reticular cells,

13 8

Mast cells, J 38 Macrophages, 13 8 Plasma cells,

13 8

leukocytes,

13 8

Adipocytes,

139

Pigment cells,

139

VARIOUS TYPES OF CONNECTIVE TISSUE .......

Mesenchyma,

J 39

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Wharton's jelly,

139

Reticular tissue,

139

Areolar connective tissue, Adipose tissue,

Dense connective tissue,

Chaper 4

-

140

140 l40

Fascial Pathology,

143

Collagen Diseases, ..... 144 ,

DIS E A SES.......

FOUR MAJOR COLLAGEN

144

OTHER MAJOR COLLAGEN D I S E AS E S .......

Wegener's granulomatosis,

Mixed connective tissue disease,

Marfan's syndrome,

145

Other Diseases of the Fasciae ,

144

145

Rheumatoid arthritis,

SCARS.

1 44

144

.. .. ,

145

.

146

ADHESIONS.. ...

146

' DUPUYTREN S CONT RACT UR E.......

147

CONNECTIVE TISSUE, THE PO IN T OF DEPARTURE FOR MANY DISEASE PROCESSES ...... ,

Chapter 5

-

147

The Roles of the Fasciae,

151

Role in maintaining structural integrity, Role in support,

152

152

Role in protecrion,

153

Role of shock absorber,

154

Role in hemodynamiC processes, Role in defense,

156

156

Role in communication and exchange processes, Role in biochemical processes,

Chapter 6

-

158

160

Fascial Mechanics,

163

Local Mechanics"", .. 1 63 SU S PE N S ION AND Suspension, Protection,

PROTECTION "

166

RETENTION AND SEPARATION .. Retenrion, Separation,

163

163

168

I 68 169

ABSOR PTION OF SHOCKS..

170

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206 20R )

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Listening tests for the th o rax

213

,

Listening tests for the scapular g i r dle , 215 Lis tening tests for the pelvis, 216 Li stening tests for the thoracic fa s ci ae, 218 Listeni n g tests for the cranium, 218 Anteroposterior listening te sts

221

,

Effects of stress on listening, 222 Special areas, 222

225

Palpation and Mobility Tests

225

PALPATION.

Structural changes, 225 Pain, 227

227

MOBILITY TESTS.

Purpose of mobility tes ts Long lever tes ts

,

,

227

228

Local tests, 228

241

SPECIAL CASES..

Iliolumbar li gaments, 242 Sacrotuberous and sacrospinous ligaments, 242 Ante rior longitudinal li gam e n t

,

242

Cervicopleuralligaments, 243

TIMING OF TESTS..

Chapter 8

-

244

Treating the Fasciae

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.

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.

.

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.

247

Objectives of Treatment

249

Modalities and Principles Accu ra cy, 249

Selecti ng the most appropriate technique, 250

.250

INDUCTION.

Principles, 250 General technical aspects, 250 DIRECT TREATMENT.

251

Pr i n ci pl e, 25 I Techniques, 252

Specific Techniques. LOWER LIMB.

.

259

.. 260

Plantar aponeurosis, 260 Tibial fascia, 260

Thigh, 262 Sciatic nerve fascia, 263 PELVIS..

265

Fasciae of the gluteus mus cl es

,

265

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TabJe of Contents

Iliolumbar ligament. 266 Lumbosacral ligament. 267 THORACIC REGION.... .

.

26 8

.

Thoracolumbar fascia. 268 Posterior fasciae. 27 0

.27 2

VENTRAL REGION ..

Anterior longitudinal ligament. 272 Viscera. 272 Diaphragm. 27 3

Sternum. 275 UPPER LIMB.

27 7

Forearm. 277 Elbow. 278 Arm. 279

Shoulder. 280 NECK..

.

.

.

28 1

Shoulder girdle. 28 J Cartilages. 283 Cervicopleural ligaments. 284 CRANIUM

.

.

.... 2 8 6

Scalp. 286 Occipitocervical junction. 286 General treatment of the superior fasciae. 288 VERTEBRAL DURA MATER

.

.

. . 28 9 .

.

GENERALIZED MANIPULATION OF

THE FASCIAE

ANTEROPOSTERIOR RE-EQUILIBRATION .

.. 291

291

STRESS. SCARS

.

AND ADHESIONS...... 293 .

Treatment Sequence . .

.

.

.

.

293

Indications and Contraindications ....... 29 4 Conclusion ...... 29 4

Bibliography . 297 Index. 3 03

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.. 290 .

Preface H

T

E A PON EU ROS ES,

Ll GAM

ENTS, R ETI N A C U LA, and the elastic laminae of arteries,

among many, many other structures, are all part of the fascial system and, by

extension, part of the connective tissues. If one goes back still further to embryology, these all relate to the mesenchyma. All soft tissues, and in particular the fasciae, derive originally from the same embryonic layer, the mesoderm , which is actually at the origin of all bodily tissues apart from the skin and the mucosae. The mesoderm gives rise not only to those elements conventionally defined as fasciae, but also to cartilage and bone, which in reality are no more than particularly dense forms of fascial tissue. The fasciae constitute an uninterrupted sheet of tissue that extends from the head to the feet and from the exterior to the interior. This is a perfectly continuous system that is suspended from bony structures to form a fully integrated supporting framework. The ubiquitous fasciae not only invest the external surface of all the body's diverse structures­ muscles, organs, nerves, vessels-but also form the internal matrices which support these structures and maintain their integrity. For this reason we can say that the fasciae constitute an envelope responsible for maintaining structure and anatomical form throughout the body, right down to the level of the individual cells, which are bathed in the ground substance of the fascial system. This superficial envelope over the entire body is repeatedly divided to create an ever-more complex network of compartments and connections. For enhanced efficacy, the fasciae are anchored to the skeleton, not by simple contiguity, but rather by insinuation into the osseous trabeculae via Sharpey's fibers. In all the diverse anatomical sites of the body, the fasciae show remarkable adaptability in

terms of their shape, structure and composition. The fascial elements in muscular tissues, conventionally described as tendons and ligaments, are the densest and therefore the strongest tissues, making them suitable for the job that they are required to perform - anchoring muscle and bone to bone. Conversely, the areolar tissue, which makes up the fasciae that invest the glands, is relatively loosely structured. xiii

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xiv

Preface

Distributed throughout the body, the fasciae play a fundamental role in human physiology. This role takes many forms: maintaining posture; maintaining the structure of the organs; guaranteeing the anatomic integrity of diverse internal structures; and investing the muscles to support them and allow them to generate force. One important role of the fascial system is to provide "transmission belts" for the endogenous and exogenous forces which the body generates itself and to which it is subjected from the outside. This function allows the body to move in an efficient , coordinated manner and respond to external phenomena. However, these same networks of fascial elements can also participate in the propagation of pathological forces, thereby mediating a chain reaction of damaging consequences. One of their key functions is the absorption of shocks. Finally, these tissues play a primary role in many phYSiological transport processes and defense mechanisms. The ground substance of the fasciae is in direct contact with the cells of the body and provides a medium of exchange that ensures efficient communication between the extracellular and intracellular environments. The fasciae constitute the first defensive barrier against external insults and come into play prior to any kind of mobilization of the immune system. The fasciae are thus capable of autonomous deciSion-making. One could even speak of this system as a "peripheral brain." The fasciae are endowed with "cellular memory" derived from embryonic growth, which is manifested in the form of a regular, rhythmic motility. This "cellular memory " enables the fasciae to register any deformation which they lmdergo and , up to a certain point, to correct it. However, if the deformation is too extreme , it is beyond correction by the fasciae acting alone and progressive pathology can result. Our hands can sense that motility as well as the evidence of damage to the tissues. With certain specific techniques and manipulations, we can help the fasciae to resolve nonphysiological stress patterns and thereby regain their normal functionality.

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Embryology ANY UN DE R S TAN DIN G 0 F functional anatomy must start at the source. For this

reason we begin with a brief review of human embryology starting at the begin­ ning of the second week, when the different layers first appear in the zygote, and continuing through the end of the eighth week, when embryogenesis is com­ plete. The subsequent stages of the process correspond to fetal development.

Formation of the Two.. layered Embryonic Disk During the second week, the blastocyst which was formed during the first week becomes solidly embedded in the mucosal lining of the uterus via the tropho­ blast. The embryoblast and trophoblast subsequently develop to form different

kinds of tissue. The trophoblast differentiates to form: •

the syncytiotrophoblast

•

the cytotrophoblas t

The embryoblast gives rise to the two layers of the embryonic disk: •

the epiblast (ectoderm)

•

the hypoblas t (endoderm)

Initially, the epiblastic cells are connected to the cytotrophoblast, but later, small fissures appear between the two layers of cells. These fissures soon become con­ fluent and give rise to the amniotic cavity. A junction-the amnioembryonic junction-iS established between the amnioblast and the epiblastic layer.

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2

Chapter 1 / Embryology

The trophoblast then develops rapidly, particularly at the embryonic pole where intracytoplasmic vacuoles appear. These later become the lacunar spaces. During this time, away from the embryonic pole, flattened cells peel off the internal surface of the cytotrophoblast to form the exocoelomic (Heuser's) mem­ brane, vv h i ch is continuous with the edge of the hypoblast; together, they form the exocoelomic cavity, which s oon becomes the primary or primitive yolk sac

(Fig. I-I).

Fig. 1-1

Twelve-day Blastocyst

Maternal Sinusoidal Vessels Amniotic cavity

�h\-�

Trophoblastic lacunae

Cytotrophoblast

Extraembryonic splanchnic mesoderm

Extraembryonic somatic mesoderm

Primitive yolk sac

Heuser's membrane

After eleven to twelve days of development, the blastocyst represents a small bump on the lining of the uter us. At the same time, s y ncyti al cells penetrate more deeply into the stroma, secreting a substance that dilates the maternal capillaries so that they turn in to larger-caliber sinusoidal vess el s

.

The lacunary syncytium is now continuous with the endothelial cells of the vessels and maternal blood passes into the lacunary system. Fin a lly arterial and ,

venous capillaries in the lacunary spaces become patent. Maternal blood circulates through the trophoblastic lacunary system as

a

result of the difference in pres­

sure between the arterial and venous capillaries. This constitutes the beg inning of uteroplacental circulation.

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3

Formation of the Two-layered Embryonic Disk Cells continue to peel off at the i n tern al surface of the cytotrophoblast to

form the extraembryonic mesoderm. Soon, large cavities appear in these tiss u e s giving rise to a ne w cav ity, t h e e x traembr yonic coelom, that is going to s urround

the primitive yolk sac and th e amniotic cavity (except where it joins the tropho­

bla st ) .

The extraembryonic mesoderm lining the cytotrophoblast and the am n ion is

called the extra emb r yo nic somatopleure. The layer lining the yolk sac is called the ex tr ae m b r yon ic splanchnopleure.

Around day thineen, the layer of embryonic ec toder m that started to develop

into epithelial cells at the internal surface of the exocoelomic membrane contin­ ues

to proliferate and forms a new cavity, the secondary yolk sac, which is also

known simply as the yolk sac (Fig. 1-2). This is much smaller than the exocoelomic cavity; Significant fragments of the latter are e liminate d , although o cca S ionally exocoelomic cysts persist in the external coelom. Fig. 1-2

Thirteen-day Blastocyst Ma[ernal sinusoidal vessels

Prochordal pla[e

Ih----,

Trophoblas[ic lacunae

Primitive trophoblas[ic villi

Exocoelomic cyst Ex[raem bryon ic somatic mesoderm

Toward the end of the second week, the emb r yo n ic disk consists of two superim­ posed laye rs of tissue: • •

the epibla s t ic layer, forming the floor of the amniotic cavity, and

the hypoblas tic layer, forming the roof of the secondary yolk sac

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4

Chapter I / Embryology

Formation of the Three#layered Embryonic Disk The third week of development is characterized by the appearance of the primi­ tive streak on the ec toderm a l surface opposite the amniotic cavity (Fig. 1-3). It is at this point that the embryo can be said to have a craniocaudal axis as well as dorsal and ventral surfaces and left and right sides. The slightly raised mass of cells at the cranial end of the primitive streak is called the primitive

de the primitive knot,

no

,

or Hensen's knot. Fig. 1-3

Embryonic Disk at the End of Week 2

Cross-sectioned edge of the amnion Primitive streak

Prochordal plate

To mark the effect of the primitive streak, the epiblastic laye r will hereafter be referred to as ectoderm and the hypoblastic layer as endoderm. Some cells from the deep ectodermal layer migrate ou t over the surface of the disk in the direction

of the primitive streak, and then turn downwards into the furrow to create an invagination. The then continue their migration in

a

lateral direction between tbe

ectodermal and endodermal layers to give rise to the intraembryonic mesoderm. This process is called gastrulation.

The cells vvhich form the invagination in the region of the primitive n ode migrate further in

a

cranial direction as far as the prochordan plate where they

form another invagination, which has the same shape as the fi nger of

a

glove.

This invagination which originates at the primitive node is call e d the notochordal (archenteric) canal (Fig.

1-4). Advance

of the notochordal canal is blocked in the

prochordan region by the close association between the ectoderm and the endo­ derm. Around day seventeen, the c hordom esoder m separates the ectoderm and en­ doderm completely, except around the cloacal membrane and the prochordan plate; the notochordal canal closes, giving rise to a dense chord, the defini tive notochord. The primitive streak regresses around week four (Fig.

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1-5).

5

Formation of the Three-layered Embryonic Disk

On about day twenty, the embryo is attached to the trophoblast by only the

allantoic stalk, vvhich will later give rise to the umbilical chord. Fig.1-4

Dorsal View of Cell Migration over Embryonic Disk

Prochordal plare

Cross-secrion of amnion

Norochordal canal

Primirive knor

�:HII'--1f--- Primirive srreak Primirive groove

Fig.1-5

A.

Cephalocaudal Cross-section through a Seventeen-day Embryo

B.

Section through the Embryonic Cranium

C.

Section in the Area of the Primitive Streak

Prochordal plare

Amnion

Cloacal membrane

A

Neurenreric

Allanrois

canal

B Endoderm

Primirive srreak

c Inrraembryonic mesoderm

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Endoderm

6

Chapter 1 / Embryology

Sheet Differentiation and Embryonic Development Between weeks four and eight, the three different sheets each give rise to

a

variety

of specific tissues and organs (Fig. 1-6). During this period, the appearance of the embryo completely changes and, by the end of month two, t he major external features of the body are easily recognizable. Fig. 1-6

Em bryan ic Cross-sections of Liver, Spleen, & Stomach Treitz's fascia Pancreas Kidney

Splenorena l lig.

Omental bursa

Spleen

Gastrosplenic lig. Falciform lig.

Lesser omenrum

DERIVATIVES OF THE MESODERM To ward s day seventeen, mesodermal cells on either side of the mid-line pro­ liferate and form the paraxial mesoderm. The lateral mesoderm

re m ain s

thin

and is referred to as the lateral plate; it later splits to form two distinct lay ers

(Fig. 1-7):

Fig. 1-7

Cross-sections Showing Mesodermal Development

Ectoderm

Mesoderm

A. DAY

C.

17

DAY

Amnion

Neural groove

I

I

20

Somato­

��;111�- pleure

Splanchno­ pleure Endoderm

Neural tube

Endoderm

Intermediate mesoderm

Ectoderm

B. DAY

D.

19

Endoderm

Paraxial mesoderm

Inrernal coelom

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Endoderm

Sheet Differcnl

and Embl)onic Development

• one will form the amnion, the intraembryonic somatopleure, also

knmvn as the somatic or parietal mesoderm layer; • the other will form the yol k sac, the intraembryonic splanchnopleure,

or visceral rr,�oderm layer

as the splanc

also Toge t her

twO layers

,

lhe edges of

coelom. The

between

paraxial mesoderm and the lateral plate is called the intermediate mesoderm.

Paraxial mesoderm Towar ds

, r be paraxi,::l mesoderm cond

of week

to form

somites, \V111Ch develop as fony t vvo to fony four pairs arranged d.ong the crd­ -

niocaudal axis. At the beginning of week f our, the somites begin migra ting towards the no­

tochord ro form the sclemtomes. These consist of immamTe connective tissue cells with:l

for differeIli

enormous cap,\(

; they can

tiate to fonTI

cells as di ver·,c • fibroblasts, which form various types of fibers: reticular fibers, collagen

fihers, elastic fibers; which

• • oste<

:!It:sjze cartilage;

'which syn:

bone

After migld.tioll of the sclerotome, the somile w d.l l becomes Lhe oermomyotorne. From the inner side of this derives tbe myotome, which will give rise to muscles in th e corresponding segment. After detachment of the myotome, the remaining

cells spread Oll[ under the ectodermal layer, vvllicll will later lmd form t

o ut over thern

cie rmis and subcutAneous tissue,

Intermediate mesoderm These cells gi ve rise to both the urinary and genital systems and are sometimes known as gives rise to

cervical

ephrotome they do Set up

soon

this tissue

kidney s

primitive

"ystem of

that run ca

and open 1111.0

the cloaca, w hich are used by later iterations of the kidneys. In the caudal region, these cells give rise to the neph rogenic cord, which will form the kidney when that organ's secretory system has developed (Fin. J

-R).

Lateral As described above, the lateral mesoderm differentiates to form the somatopleure and splanchnopleure, which line the intraem bryon ic coelom.

Whel • the

e rllb ryo folds

fornl';,

on itself the ectO(1(rnl c{)vering it

and ventral walls of the: embryo;

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lateral

8

Fig.1-8

Chapter 1 / Embryology Cross-section through the Intermediate Mesoderm: Day 21

,--- Ectoderm --_
Nephrogenic cord

Splanchnopleure

Somatopleure

Somatopleure

Intraembryonic

Endoderm

Fig. 1-9

coelom

Peritoneum

Cross-sections at Days 24, 26, & 28 Showing Embryonic Involution

Amn i o tic ca v i t y

EctOderm

Neural tube

N o to cho rd

P=--::r---'rl,-+I-

Splanchnopleure

•

Communication between midgut and yolk sac

Dorsa I

mesentery

Somatopleure Midgut

the splanclmopleure will coil around the endoderm to form the wall of the digestive tube

Around the middle of week three, mesodermal cells on each side of the median line and opposite the prochordan plate will begin to form the primordium of the future heart and blood vessels. The extraembryonic vessels form projections which fuse with the walls of the intra embryonic vessels to establish communica­

tion between the embryonic and placental circulatory systems. The mesoderm then gives rise to different derivatives: •

connective tissues, cartilage, bone, and both striated and smooth muscle

•

the pericardium, the pleura, and the peritoneum

•

blood and lymphOid cells

•

the walls of the heart, the blood vessels, and the lymphatics

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Sheet Differentiation and Embryonic Development

•

the kidneys, the gonad s, and their respective excretory and secretory s y s te m s

•

the cortex and medulla of the s upraren al glands

•

the spleen

Therefore, the connecti v e tissues-the p r i n c ipal subject of this te x t-belong to the mesoderm and, more specifically, to the mesenchyma.

Mesenchymal cells p roliferate and migrate to all regions of the embryo, fill-

. ing in otherwise unoccu pi e d spaces and intercalating between the cells which make up the organs All the con stit u ents of connective tissue derive directly or i n di rectly from this primitive system. Mesenchymal cells are the precur sors for most cell types found in adult connective tissue. Certain cells do not further dif­ ferentiate

a nd

multiply in an immature form. These undifferentiated cells play a

central role in the processes of growth and repair as well as in certain defense

mechanisms. Such immature or stem cells retain their embryonic potent ial for proliferation an d can later differentiate to generate new lineages of more sp ecial

­

ized cell types. The mesoderm,

as

explain ed above, is covered by two layers of tissue: an

ex tern al layer the ectoderm, one part of which will cover the mesoderm during ,

embryonic development; and an internal layer, the endoderm, that will be sup­

ported by the mesoderm.

DERIVATIVES OF THE ECTODERM At the beginning of week three at the same time that the notochord is being ,

formed, the nascent central nervous system begins to develop in the form of a thickened plate of ectoderm-the neural plate-which e xpands toward the primitive streak. The lateral edges of this plate subse quently rise to form the neural crests, and a median depression becomes the neural groove. The neural crests later gradually app roa ch one another, even tually forming the neural tube (Fig. 1-10).

Therefore, the early nervous system consists of a stra i g ht cylindrical por­

tion, the m edullary chord, and a l a rger cephalic part, the primary bra i n vesicles, which, towards the end of week four, give r i se to the auditory and optic vesicles.

When the embryo folds back on itself, the ectod er m splits into two different parts. One part will be enveloped by the mesoderm and vvill form the nervous

system, sen d i ng out multiple processes during development into the mesoderm

and then into the endoderm. The other part will go on to cover the mesoderm and form the epidermis. The ectoderm therefore gives rise to the following systems and structures: •

the central and peripheral ner vou s syste m s

•

the sensory epithelia and sense organs

•

the epider m is and its ap pendages (hair, nails, and cutaneous glands)

•

the pitui tar y gland

•

the enamel of the teeth

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10

Fig.1-10

Chapter 1 / Embryology

Development of Neural Crest, Neural Groove and Neural Tube

Neural crest

Intermediate zone of neural crest

Neural groove

Notochord Dorsal root ganglion

Neural tube

Ectoderm

DERIVATIVES OF THE ENDODERM Due to the growth of (he central nervous system and of the somites, the embryo undergoes folding in the longitudinal and transverse planes. This results in the

enclosure of part of the yolk sac in the resultant cavity. This internalization of part

of the yolk sac paves the way for the eventual formation of (he digestive tube (Fig.

1-11 )

.

The endoderm will give rise to the anterior, middle, and inferior segments of the intestine (Fig. 1-12): •

the anterior intestine will be provisionally closed by the closing (pharyngeal) membrane

Fig. 1-11

Cross-section through the Duodenum

Fascia of Treitz

Head of pancreas

ii '" � ii iiii i ��iiiiiiiiiiiiiii

Pancreas and duodenum (in a retroperitoneal position)

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Sheet Differenti(ltion ond Embryonic Development

11

Fig. 1-12

Sagittal section of Endoderm development

Pharyngeal gut

Branchial pouches

5romach

>="\ ""_ -----,f-- Pancreas Vitelline duct Gallbladder

A l la n tois Primitive inte stinal loop

H i nd g u t

Cloacal membrane

•

the posterior i n te s ti n e will be closed by the cloacal membrane that subse quently splits to form the genitourinary and anal

1-13 )

m embr anes

(Fig.

At this point, due to folding in the lateral plane, compartmentalization of the em­ bryo begins with the formation of the

a b do m in a l

wall definin g a tubular cavity,

whi ch \Nill eventually become the intestine. Due to the formation of the caudal fold at the end of week four, the umbilical vesicle and the allantoic stalk fuse to give rise to the

Fig. 1-13

Different Developmental Stages of the Cloacal Membrane

Cloacal membrane

Cloaca

Allantois

Hindgut

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u m bil i c a

l cord.

12

Chapter 1 / Embryology

The endoderm therefore gives rise to the follmving structures: •

the epithelial li n i n gs of the digestive tube, the bla d der and the ,

urethra •

the epithel ial lining of the airways

•

the epi thelial linings of the tympanic c av i t y and the a u ditor y tubes

•

the parenchyma of the tonsils, the thy roid , parathy roid, and thymus

•

the esophagus, stomach, liver, gallbladder, pancreas, and i n te s ti ne

•

the broncotracheal system

•

the closing membrane, the cloaca, and the allantois

•

the branchial clefts

Between weeks five and eight, all these systems will continue develop i n g and various embryonic structures will begin to become ap parent, including the pri mordia of the limbs, the organs (in their correct location), and the head

­

.

This is a period of organization during which the fetus is formed. The next stage focuses on the gr ow th of al read y established structures .

,

• ••••••••••••• • •••••••••••••••••••••••••••••••• • ••• • •• • ••••• • • • • • • • • • • • • • • • • • • •• • • •• • •

•

Summary of Embryonic Development First week: Segmentation of the egg, formation of the blastocy st Second week: Transformation of the blastocyst into the two-layered

embryonic disk comprised of the epiblast and hypoblast

Third week: Transformation into a three-layered disk comp r ised of the ectoderm, mesoderm, and endoderm Fourth week: •

compartmentalization of the e m br yo begi n s

•

l im b buds appear

•

primor d ia of many of the future organs appear

•

fetoplacental circulation begins

Second month: •

numerous organs begin to appear

•

modeling of the external body progresses

•

the volume of the head increases and the eyes, ears and nose ap pear in ,

posi t ion •

the limbs begin to develop

Between the third and sixth months: All the organs-the pr i m o r di a

of which can be seen in the correct place-grow, differentiate, and mat

.

u re

.

By the end of the sixth month:

The fetus is viable

..

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.

. I

13

Sheet Differentiation and Embryonic Development

DERIVATI VES OF THE VARIOUS LAYERS

Mesoderm •

connective tissue, cartilage, bone, and both striated and smooth muscle

•

pericardium, pleura and peritoneum

•

blood and lyrnphoid cells

•

walls of the heart, blood vessels, and lymphatics

•

kidneys, gonads, and their respective excretory and secretory systems

•

cortex and medulla of the suprarena l glands

•

spleen

•

muscular linings and the connective tissues of the digestive s ystem

•

epithelial linings of the diges t ive tube, bladder, and urethra

Endoderm •

epithelial lining of the airways

•

epithelial linings of the tympanic cavity and auditory tubes

•

parenchyma of the tonsils, thyroid and parathyroid ,

•

thymus

•

esophagus, stomach, liver, gallbladder, and bile ducts

•

pancreas and intestine

•

tracheobronchial system

•

allantois and the inner layer of the cloacal and closing membranes

Ectoderm •

central and peripheral nervous systems

•

sensory epithelium and sense organs

•

epidermis and appendages (hair, nails, cutaneous glands)

•

mammary glands

•

pituitary gland

•

tooth enamel

Built of three superimposed layers, the embryo grows and develops in a continu­ ous sequence. Growth is

a ccomp a n ied

by compartmentalization of the embryo:

vertical compartmentalization with the appearance of the cephalocaudal curva­ ture, and lateral compartmentalization with the development of the walls and cavities. During this process the various organs of the body are positioned (Fig. 1-14 &

1-15). As

part of the same process the buds of the upper and lower limbs

appear. As of the moment when the ovum first encounters the spermatozoon, the fertilized egg is in continual, lively movement, movement which terminates in the formation of an organism of extraordinary complexity. Each of the layers is continually combining, associating, and i n teract i n g with its neighbors to grow and develop into the different parts of the human body, all

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14

Chapter 1 / Embryology

this with an amazing degree of consistency and organization. C ell s from a single primordial tissue can differentiate to form bones, muscles, fasciae, nerves, skin, the liver, or the spleen-and all this in

a

near-perfect process, si.nce errors are

relatively rare. Fig.1-14

Section through

an

Embryo at the Beginning of Week 4

�$·lf.:>IIIl---\T-----i.g---H.---!\-- Neph rotome

':;:"-'431ii�Q.I:-r---�f..,i.;---+--;I--

Coelom

�:Al!tIH-'-----+--I-- So m atopl e u re

This growth all occurs according to a pulse-the natural rhythm of the develop­ ing organism. By the end of the second month, as we have seen, the fetus is in place. The subsequent stages are concerned primarily with growth and maturation. Howev­ er, the rhy thm of life which was triggered at fertilization will not now cease until death. It is this rhythm that paces the growth, movement, and performance of all

the functions of the human body The same rhythm derived from embryological memory can be found in the cranium, the fasciae, the organs, everywhere: the

rhythm with which the body adapts to the potentially deva stating perturbations of the external world, maintaining a stable, constant internal milieu, and thereby maintaining its eqUilibrium and health. With our hands, we can sense this rhythm and determine whether the body or any part of it is in harmony or is dysfunctional.

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15

Fig. 1-15

The Mechanisms Underlying Embryonic Development Section through an Embryo at the End of Week 4

Verrebral Mesoderm

primordium

�"'�';';:;'��J

No[Ochord

,'8_-II-----'lr- Myo[Ome

/""7-B--!t'-ll----''--+--\- Coe 10m

Imesrine --+��

Somawpleure

Umbilical cord

The Mechanisms Underlying Embryonic Development How does an egg give rise to a human being) How is such a degree of complexity generated during development) Embryonic development involves cytochemical. biochemical. biokinetic, and biodynamic phenomena, all of which playa pan in directing and organizing the growing cells and tissues.

HISTOLOGICAL AND BIOCHEMICAL PHENOMENA "Cells know where they are in the embryo on the basis of the

local concentrations of specific morphogens."

VolbQrd

-c.

Nusslein­

Studies performed with Drosophila have led to the identification of these morpho gens.

Some thiny genes in Drosophjja define the 'manager' of the embryo. Only three of them encode molecular Signals that determine structure along the anteroposterior

axis. Each of these three Signaling proteins appears in only one specific site and

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16

Chapter I / Embryology triggers the creation of a gradient based on one specific morphogen. One signal is active in the anterior part that will give rise to the head and

thorax. A second signal is active in the abdomen, and a third determines the struc­ tures situated at the two ends of the larva. A concentration gradient of the Bicoid protein is established in the

v ery ear­

liest stages with the highest concentration found at the anterior end. A certain critical threshold concentration is required for this signaling molecule to exert any effect. Once this threshold is reached, a speci fi c gene is transcribed into mes­

senger RNA, which is subsequently translated to form a pr o t e i n. A concentration

gradient of the protein acts on two or three genes determining only two or three regions of activation.

The Bicoid messenger RNA contains all the information necessary for a cell to recognize, transport, and bind it. F ur ther more, it always m ove s in the same direction along structural elements called microtubules.

The Nanos protein is active in the posterior part. Gradients of both the Bicoid and Nanos proteins can only become established if there are no cellular mem­ branes to block their diffusion. However, in most animals, cellular membranes separate the different regions of the egg from the very earliest stages of develop­

ment. The dorsoventral axis of the Drosophila embryo is determined by a gradient that is established across cellular membranes. Similar types of gradient are prob­

ably important in other organisms. The Dorsal protein determines the first embryonic structures along the dor­ sal-vertebral axis. This protein acts as both an activator and an inhibitor of tran­

scription in the nucleus of the cell: when its concentration exceeds a given thresh­ old, it activates a pair of genes, whereas when its concentration is below that threshold, it acts as an inhibitor of another pair of genes. Therefore, when different concentrations of the Dorsal protein in different

nuclei define a gradient, each of the pairs of genes is expressed differently on either one side or the other of the embryo. The concentration of the Dorsal protein is uniform in the embryo; it is its

intracellular distribution that varies along the dorsoventral axis. A protein called Cactus binds to the Dorsal protein to block its entry into the nucleus. However, at the ventral surface of the embryo,

more

than ten other proteins interact to release

the Dorsal protein from the Cactus protein. The proteins are activated by a signal. Molecular relay systems based on sev­ eral different proteins transmit information about the gradients be(\"leen the dif­ ferent compartments. Finally, even if a pro tein is uniformly distributed at the

beginning, its transport into the nucleus can cause activation by generating a concentration gradient. All the activation pathways studied to date lead to the formation of a mor­ phogen gradient that ultimately controls the rate of transcription; depending on its concentration, the gra d ient activates or inhibits the transcription of one or

more target genes. Synergistic interactions between different factors, or bet\"leen several copies of the same factor, can regulate the rate of transcription of specific genes. Certain morphogen gradients exert only one effect and only when the mor-

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17

The Mechanisms Underlying Embryonic Development

phogen concentration is above a critical threshold; if the threshold is not reached, the target gene is not activated. In other cases, the response depends on the abso­

lute concentration of the morphogen; this type of gradient is key vvhen it comes to generating complexity. Interactions between different factors which influence transcription can

hugely modify the responses to gradien ts This helps explain how combinations .

of basically simple systems can give rise to highly complex structures. The superimposition of several different gradients in a given region of the

embryo incr e ases the resolution of such systems and therefore provides another mechanism for generating complexity. Combinatorial regulation and the exploitation of concentration gradients mean that a limited number of genes can give rise to a vast repertory of differ­ ent developmental mechanisms. In the case of Drosophila, the gradients trigger the

expression of genes in transverse bands. These bands correspond to regi o n s of the egg that will eventually become the different segments of the larva. Within tl1e areas corresponding to these macroscopic bands, other systems generate yet finer bands that directly determine the characteristics of each segment of the embr yo. When the egg divides and forms individual celis, the transcription factors can no longer diffuse. At later stages, when the 'manager' of the embryo is established, signals transmitted between nei g h bor ing cells play the predominant role. Embryologists have found that these results not only apply to Drosophila, but to the animal kingdom as a whole, leading to the hope that one day we will better understand the development of the human embryo.

BIOKINETIC AND BIODYNAMIC PHENOMENA The kinetic development of the embryo has been s[Udied by Blechschmidt, who defined the importallt role played by metabolic fields, of which there are eight:

Corrosion fields A corrosion field is established when two layers of epithelial cells associate to

form a thin, two-layered

m

em brane The cells in contact undergo necrosis and .

disappear, permitting communication between the fluids or with overlying tis­ sues. This type of field is established from the second week on and is found be­ tween the mesonephriC tubules and the nephrotiC canal, and in developing blood

vessels. The two dorsal aortas enter into contact and their median membrane de­ generates to form a single vessel. There are many other examples of corrosion fields, for example, the bucconasal, buccopharyngeal, cloacal, and seminiferous membranes.

Densation fields Densation fields are imponant in skeletal development. This type of field is com­ posed of packed spherical cells which are associated with very limited amounts of interstitial substance. The exact amount of interstitial substance distinguishes

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18

Chapter 1 / Em b ryology dense fields from sparse ones. Primoridal cellular masses , from which an org a n is formed , are called bla s ­ tema s . For example, cartilaginous tissue derives from blas tema , b u t only a part

of the blas tema itself b e comes ca r tilag e This is also the origin of l iga m en t s and .

c apsule s .

Normal org anic develo p m e n t i s initiated n o t fro m inside t h e cell , b u t fro m outsi d e . D en s a tion fields are c haracterized n o t only by the gen era l p o s i t ion o f the

file d , bu t by s p ecifi c posi tions of cells and their nuclei. Following Bl e chshmi dt and Gasser ( 1 9 7 8 ) , let u s use the development o f the trachea a s a n e x ampl e .

Example: tracheal development. T h e dorsal epithelium is thicker than the

ven tra l . The cells adj a c e n t to the epitheli um are elonga ted and aligned tangen­

tially ; they will give rise to the tracheal m u s c les and the fi brous membrane . On

the ven tral side, the s troma corresponds to a den s a tion field vvith a n aggregate o f

many spherical cell s in

a

limited amount of interstitial subs ta nce .

The dorsal epithelium grows m ore rapidly than the ventral , which brin gs

about leng thening o f the cells and induces their tan g ential alignmen t . Compres ­ sion at the ventral l evel causes t h e cells to become spherical . These cel l s proli fer­ ate, con d ense , and become cartilaginous tissue (Fig. 1 - 1 6) .

Fig. 1 - 1 6

Den sation F i eld s

The biokinetic principl e of den sa ti on fields also applies to the devel opment of other structura l formations such as the ribs , which are subj ect to high pressure as a result of the increasing mass o f the he ar t and liver Densation fields also infl u ­

e n c e the development o f the n a s a l s e ptum a n d m a n y o ther s tr u c tur es

.

Differen tiation in a densa tion field arises from a biomechanical phenom­

enon resulting from a biodynamic proce s s . The cells in the fields h ave no specific ori ent a tion , that is , they are submitted to the same tension in all directions and conseq uen tly become spherical .

Con tusion fields In

a

densation field spherical cells flatten out and are tran s formed into car tilage

cells. When this process occurs on a circu l ar pla n e along the l ongitu di n a l axis o f

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19

The Mechanisms Underlying E m b ryon i c Develo p ment

dens a tion and proce eds from the center towa rd the periphery, the result is calle d a contu sion field. Con tusion fields are always surroun ded by p eric h ondriu m that fuses with l o o s e p eriph e ral mesenchyma .

A densation field is a zon e of cond e n s a tion of round cell s , while a con tusion

field is a zone of com p ression where cells Batten out .

Contusion fields a r e esp ecially relevant in skeletal d evelopm ent . The limb a m embrane at the interior o f which c ells pro l i fera te in all directions , creating equivalen t forces at all points and pu s hin g the in tercellular fluid toward the periphery. This crea t e s the conditions necessary for a contusion

buds are surrounded by

fiel d .

Con tusion fields thus develop within d ensation fields vvhen there is resis tance

along the longitudinal axis due to the grow th of s p herical cell s . R esis ta nc e to grow th brin g s about compression tha t , in turn , tends to Batten out the cells and transform them into car tilag e - forming cells .

D i s t usi on fields The term d i s t usion is used to refer to a process where there i s sure

an

ou t ward pres

­

alo ng lon g i tudinal axes against a spring - like resi s tance . Th ese fields are also

relevan t to the development of the skele t a l sys tem . In the limbs of a two - m o n th em b ryo , the old car tilag e is localized in the proximal p or ti on and the more recent

car t i lage in the distal por tion . Furthermore, t h e cartilage-forming c ells appe a r first i n t h e cen tral p o r tion , tha t i s , far from the vascular p eriph eral mesenchyma .

If we take the example of a phalang e u n d er comp ression , the c ells los e their B u i d

and a r e not near any bloo d s u p p l y. T h e shape of t h e cell s chang e s and they be com e

sph erical . They grow pri marily al on g a single ax i s . This type o f g rowth is due to the occurrence of a tumefaction that is referred to as a dis t usion field.

The p a t tern of grow th a n d tumefaction p arallels the long i tudi n al axis of the

pre-exi s t ing cart i lag e . Such car tilage grows as if i t were b ein g acted upon by a

pis ton . T he compression is so great tha t Buid is squeezed o u t ,

a

capsule forms

arou nd the cells , and the process of calcification be gins .

Reten tion fields Reten tion fields repres en t an ag grega tion of in tern a l tissue cells tha t began b y b e ­ i n g u ndifferen tiated a n d which g row slowly in a direction dicta ted by a s tre tchin g motion that originates with neig hboring tissues. The s tre tchin g forces to which

these g r ow in g c ells are subj e ct gra dually transform them i n to fibrous connective tiss u e that g ives rise to tendons , ligaments , and aponeuros e s . The forces crea ted by

a

r e tention field ca use peri p heral parts to grow more

rapi dly, a key fac tor in the de ter m ina tion o f h uman m orpho lo g y.

Dilata tion fields Dilata tion fiel ds occur when t i s s u e s a r e s tre tched longitudinally wi thou t transverse com p r ession ; this leads to a thinning of the tis sue s . These fields are relevant to the

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20

Ch(]pter 1 / Embryol ogy

d evelopment o f the muscul a r sys te m The d evelop m en t of this system differs fr om .

site to site, but the fundamental principles are the s a m e for all muscles. Th e pr i m ordi u m of cardiac muscle is lill der less press ure from the coelomic fluid ou ts i de than from the blood inside , with the result that it tends to di l a te . Th is

dila tation \Ni ll g r a du a lly br ing about a reaction in the form of contrac tion . The resu l t of this process o f dilatation and contraction is tha t cardiac cells are able to m o ve about relatively fre e l y wi th respect to one another. The h e a r t s teadi ly dila tes and this increases the resistance of the c irc ul a r muscl e fibers. The volume then increases , but, since i t is fi xed a t either end, the org a n as a whole develops in an

oval shap e . Dilata tion fields are also i m p o rt a n t i n t h e development o f t h e sk el e t al cular system . The r a pidly expan d i n g somites

on

mu s ­

t h e periphery o f t h e derma tom e

grow out i n t h e cranial a n d caudal directio n s , follOWing t h e g en e ral direction o f g rowth i n the em bryo . As

a

r e sult , the cells under the dermatome a l i g n themselves on a cranioca udal

axis paraUel to the axis o f the neural tube. The muscle cells become thinner in the dila ta tion field a n d , a t the same time, intracellular

m yo

fi br i l s begin to form . The

tr a ns ve rs e s triations are p oorly defined a t firs t . After the first mon th, a l ine o f nuclei becomes dis tinct a s a result o f the g r owth of the muscle cells . Once the cells of the derma tome have al i gn ed along t h e ec todermal membrane, the

m yo to me

cells or i e n t a t r i g h t angles to the sep­

tum .

Dilatation fields are u s ually involved in the devel o pmen t of the c urvature of stre tched muscle cells as well as i n the development of tendons. Dila tation fields are thus cha ra c ter i s ti c not only o f longitudinal g r ow t h bu t also of t ran s verse ex­ p a n s i on . The mus c u l a r p r i m or di u m in densely pa c k ed areas cann o t dilate in the t r a ns

­

verse direc tion. Therefore , in such areas , it underg oes compression which leads to the formation of ten din ou s tissu e . In these regions , the fluid content of th e inters titial s ubstance is very low, making i t ex t re m ely viscou s .

Tendons , like a ll h i g hl y compressed tissu e s , have a restrictive func tion . O ther types o f tissu e with only m i n i m al elastic i t y, and which s erve to con tain or restrict o ther s t ru c tu r es , are the fa sciae and the intermuscular septa . Dilatation fields in embryoniC cartilaginous tissue are essential for the grow th

o f muscles and tendon s . T h e g r owt h of car tilag e parallels muscular growth. All muscles have passive functions b e fore becoming capable of active contrac tion . The

m or e

rap i dl y muscle cells grow, the

m ore

r i c hly they become inn erva ted and

the sooner they can c on tra c t . Dilatation fields a l s o a r e i m por t ant i n t h e d e ve lopme n t of t h e in testinal tract.

Parathelial loosening fields Loos e ni n g fields are crea ted by congestion o f the in ters ti tial substance in the in ­ ternal tissues where cellular catabolites exert a m a j o r effect. When the quan t i t y of ca tabolites increases , the volume of the interstitial su b st a n c e increas e s in parallel and vesicles tend to fus e to g e t her.

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21

The Mechan isms Underlying E m b ryonic Develo p m en t A t the beg inning o f developmen t , loose fields wi thin the mesoderm are pre­

c ursors for the formation o f the blood vessels and ly m pha tics . One p a r t icular group , the para thelia I loose fields , i s imp o r tant in the development o f glandular

s trunures .

D e tra c tion fields D e traction fields are involved in the development of bone s . From the topological poin t o f vie·w, there are three types o f bone tissue : •

membranal bones tha t develop from stretched connective tissue

•

cartalaginous bones tha t develop from cartilage

•

bones tha t develop from already exis tin g bone tissue

The kinetics of develop men t of all three types show tha t their d eve lopment is characterized by th e fac t that it is always accompanied by expansion o f the in ter­

ceLl u lar substance in res p onse to some kind o f force .

Fx tracellular processes are primordial for the trig g e r i n g of the ossification p roce s s . Mesenchyma cells slidin g along a rigid support become compressed . T h e flu­ id is squeezed o u t o f the interstitial sub s tanc e , which hardens

as

a consequence.

These regions in which cellular aggre g a te s slide and become compre s s e d agai n s t some hard, suppor ting s tructure are c a l l e d detraction fields

By way o f example , take the development of a frontal bone. The primordium

of the dura mater is a layer of connective tissue which is under tensio n . S trong pu lling by the orbital septum in the direction of the l ower fa ce causes the mem­ brane to s e parate into two lamina e , and a center of ossi.fication beco m e s e s t a b ­ l i s h e d on the external l ayer. I t is t h e pri mordium of t h e ex ternal l a y e r vvhich i s responsible for t h e tension . T h e internal layer accommodates the expansion of t h e growing ara chnoidea mater. Its inrercellular fl u i d is sq u e e z e d om a n d , as a resul t , the in ters titial subs tance hardens a n d a poin t of condensation for the develop­

ment of bone tissue is created. Once hardene d , the internal part o f the tiss u e in t h e area of condensation loses its po tential for growth The tissue forms a coating around the center of condensation and then s p reads b y cellular pro liferation . Over time , the centers of ossifica tion advance a s dive rgent lines , radiating from the p oints o f condensa tion ( d e traction fields) .

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Anatomy of the Fasciae TO 0 U R KNOWl E DG E, there is no text of anatomy tha t deals specifically with the

fasciae. This is why we have decided to present an ou tline of this subject here. This

chap ter repres ents the re sult of a review of many different treatises and articles.

We do not pretend to have succeeded in concentrating all the many an d various aspects of the anatomy of the fasciae into a few page s-inde ed, we have tried to avoid presentin g too much detail. However, it ap peared to us essential to present in one chap ter an overvievv of how the se tissues are organized at the ma croscopic level. as well as s ome id e a of their ana tomy and h i s t o log y at the microscopic level. This ba ckground information is impor tant when it comes to unders tanding their various roles and mechanisms of action. Nonetheless, for readers who may be less than enthralled by a long rehash of anatomical details, or who are interes ted in only a simple survey of fas cial anatomy, succinc t summaries are pr es ent ed at the end of each section t o gether with tables wthich recap how each fascial el ement relates to its corres ponding structures.

Superficial Fascia The sup erficial fascia lies between the adipose layer of the dermis and subcutane­ ous cellular tissue. Th e true superficial fascia s tarts at the zygomatic arch, ins erts into the maxilla, and termina tes at the ankles and wrists. It is •

absent:

on the face

•

over the upper part of the s ternocleidomas toid muscle

•

a t the nape of the neck

•

over the sternum

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24

Chapter 2 / Anatomy of the Fasciae • at the bu t t o cks

for lym p h a ti c vessels, and also plays nutrition and respir a t i on Th e d egre e of severity of b ur n s is

This tis sue l aye r serves as the p oint of o r igin

a key role in cel lu l a r

.

e v a luat ed on th e basis of the d a m a ge suffered by the superficial fascia.

External Fasciae E P I C R A N I A L APONEU R OS I S The e p icra n i a l aponeurosis (also

known a s the ga le a aponeurotica)

is an extensive,

fibrous l a m in a that covers the entire convex surface of the sku ll like

J

sk u llc a p It .

is separated from the periosteum by loose cellula r tissue which allows the lay e rs

to slide over on e an o ther to some ex tent. Conversely, i t is tightly attached to the

skin so these l aye r s are obli g ed to move together.

In t he anteropos terior directi on, t he epi cr a ni a l aponeurosis joins the OCCipital

and frontal muscles. It is ins e r t e d posteriorly, on the

ex t e

rn a l

OCCipital p r o t u b e r

­

ance as well as on the supe r i or nuchal line. I t s l a ter a l e x t en sion co rre s ponds to

th e t e m p or a l and m a sseteric apo n e u r o se s and it ter m i n ates on the supramastoid ,

ridge, t h e external a uditory tube, and the subcutaneous tissue of th e masseteric

regi on

.

Temporal fascia Thick and ver y strong, the t em p or al fascia extends from the superior

temporal

curved line a nd the space includ e d b e t ween the t wo c ur ve d lines to the zygomatic bone as two laminae that a t tach to the l ips of the a r ch ; from th ere i t

masseteric fascia (Fig. 2-1 ;Table 2-]). Ta ble 2-1

C o n n ecti ons of t h e epicra n i a l a p o n euro s i s

ATTACHMENT T O

SKI N A TT ACHMENT TO DU RA MATER

Epic ranial aponeurosis

1 TEMPORAL

MASSETERIC

SUPERFICIAL CERVICAL

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ex t en ds as the

25

Fig. 2-1

External Fasciae

Lateral Fasciae of the Face Temporal fasc i a

Su perncial l am i na

Deep lami n a

Late ral pte rygo id m . Temporalis m . Fora m en ova l e

[9���

N o n-conti nuous zone

I n terpterygoid aponeu rosis

Pariotid duct

Masseter m.

Med i a l pterygoid m. Masseteric fascia

1Vfasseteric fascia It is inserted: • •

behind, on the pos t er ior rim of the as cendin g ramus of the mandible

in front, skirting the

masseter muscle and then passing over its poster ior surface befo r e inserting on the an terior edge of the ascending ramus

•

above, attaching to the zygomatic arch

•

below, at tac h in g to the lower edge of the maxillary where it is

continuous with the superficial cervical fasci a

•

in the b ack along the posterior edge w h ere it joins the parotid fascia ,

and splits to invest the parotid duct

Fasciae of the face The fasciae of the face (Fig. 2-2) consist of:

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Chapter 2 / Anatomy of the Fasciae

•

A superficial fascial sheet, itself composed of tvvo different layers,

namely a thin super ficial layer and a stronger deep layer. These two

layers invest the muscles which control facial mobility and link them to the deep fascia.

•

A deep fascial sheet which is thicker and

in el a s tic.

This is separated from

the superficial fascia by loose areolar connective tissue. The deep fascia invests the bones, the car tilage, the jaw muscles, and various visceral

structures. Like the superficial fascia, it constitutes

a

continuous sheath

that resembles and is derived from the temporal and parotid-masseteric

fasciae. The deep fascia supports the deep vessels and the nerves innervating the jaw.

Fig . 2-2

Fasciae of t h e Face

------------------

-- -------- --------- -- --

-----Dermis

;:=:jr---::w::cJ;:j:��?tV't�tE;J\.l<����ieft�=4___+--

�.��.j��;.i.ii;�!;��iiil��;;.�;.;;.;.�;.��-

Su perflcia I ad i pose t i ssue Superficia l fascia

° 0 0 0 00 0 0° 00 0 °0 ° 0° 0 00 0 < °0 (J0(° 0 o 0 00 00 0 0 ° °0 0 00000 ;-'°'-.:0'-- M u scle 0 °000 °0 ° 00 0 °0 0 °00 0000000 0 0 ° 00000'6000 000 0'0000000000

Fibrou s layer of superflc i a l fascia

-;':'--- Areolar tissue Deep fascia . � .., . .... . I· I'.... . . . .··..•..�. .�. . . '\." �.. , . • . ..� .., .•.... �. . ..I. � .... .... , . .. I' ....- , ....'\. ... , •• ., ..... ..,- .. I\.� .. ' .' ...I\.� . �. .�.. , ...•. . �... /.,,.... .� - .' /.,, ....• .�. . . /.,, . ... . . /.,, ...� .. .. •. . .., /., . • . . . . . ... . .�. -- .... . - -- _ . ..... � . . ... . -- . ..... . . . .

Bone or ca rti l age

S U P E RFI C I AL C E R V I C AL FASC I A This fascia • • • •

(Flg. 2-3)

forms a sealed sheath in the neck. It is attached, at the top:

to the superior nuchal line to the mastoid process to the cartilage of the external auditory tube to the masseteric aponeurosis and the lower edge of the jaw

It is thus an extension of the epicranial aponeurosis. At the bottom:

•

on the anterior edge of the jugular notch of the sternum

•

on the anterior face of the manubrium of the ster num

•

on the upper face of the clavicle

•

on the posterior edge of the spine of the scapula

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External Fasciae A fibrous extension emanates from its deep surfa c e along the anter ior edg e of the trapezius muscle. This deep extensIOn is joined inside to the aponeuroses of the scalene mus cl e s Its anterior part, where it is covered by the muscles of the skin, is thin relative .

to the rest of it.

The superficial c ervical fascia splits to provide a sheath for the sternocleido­ mastoid and trapezius muscl es. It runs in front of the hyoid bone onto which it inserts. Laterally it expands, forming a sheath within which the dig as tric muscle slides and folds back upon itself. Fig. 2-3

S uperficial and Middl e Cerv i cal Fasciae

S u p erficial fascia

Cervical p l exus �=H�

\\--*+--1-- S u perficial ansa cerv i ca l i s

Sternocl e i d o m a stoid m . M i d d l e (Pret racheal) fas c i a

Deep Fascia Omohyoid m .

It joins with the middle cervica l fascia in the anterior, superior, and median sub ­ hyoid regions. In t h e i r

lower regions, the two fa sci a l she ets separate to in s er t on the sternal notch, one in the anterior edge, the other in the posterior edge. The sternal space thus defined is s ealed on the outside by a dhesion of the middle fascia to the anterior edge of the sheath of the s ternocleidomas toid muscle in front , and t h e aponeurosis of the trapezius muscle behind. Below the hyoid bone, this fa scia

splits to form the apon eurosis of the sub­

maxillary glands . Behind, it invests the parotid gland and, together with the mas­ seteric a pon e u rosis constitutes its shea th. ,

Lateral to the anterior edge of the s ternocleidomas toid muscle, a small b and

de tac h e s and inser t s a t the an gle of th e mandible. This small maxillary lig a m e n t suppor ts and stre t ch e s the s te rnocleidom as toid aponeurosis so tha t the muscle

remains flat and protects the und e rly i n g

bundle of vessels

and nerves (including

the carotid vessels, the internal j u g ul ar vein , and the vagus nerve).

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Chapter 2 / Anatomy of the Fasciae

Behind. on th e median line. t h e sup e rfic i a l cervi cal fascia presents a fibrous fold extending from the external occip ita l p ro tube ran c e to the si x t h cervical ver­ teb r a and. o cc a sion al ly. as far as the fi rs t thoracic v e r te bra This is the po s teri or ce r vica l liga m e n t the median p art of which is at ta ch e d to the spinous pro cesses of the vertebrae. The p o s t er i o r cervical ligam en t is a very strong sheet of t i s s u e which is at­ ta c he d to aponeurotic extens ions of the trapezius. sp len iu s and r ho mboi d mus­ cle s . and the serra tus p o s te r i or superior. In some pe o ple this structure is in the form of a cord the size of a pe ncil which juts out when the head is inclined. The supe r fi ci al cervical fascia splits s e v er a l times to invest all the muscles of the nape of the neck. The anterior jugular veins initially c ross the sur fa c e of this fascia in s h e a t hs derived from the basal sheet. Subsequently. t he y pass t hrough the fascia. On the surface of the s uper fi c ia l cervical fascia lie the s up er fici al branches of the cervical plexus: C2. C3. C4. It sho ul d be noted tha t all these. as well as the e xt e rna l jugula r vein. p a s s th roug h the f a s ci a at the p o ste r i or edge of the sterno­ cle i do m as t o i d muscle. The s upe r ficia l cervical fascia is cont inuous with the fa s ci a e of the trunk and th e lower limbs as well as those of the upper limbs. .

.

.

.

FASC I A E OF T H E T R UNK The fas ciae of the trunk are continuous with the s upe rfi ci a l cervical fascia . At the

top . th ey • • •

are inserted into :

the s t e rnu m

the clavi cle the sc apula r spine

From there. the fascial system extends out in two directions to form the fasciae of the trunk on the one hand. and those of the upper limbs on the other hand. Th ere a re numerous divisio n s all al o ng the way fo r min g intermus cular septa and s h e a th s for the numer o u s muscles in th e s e parts of the body. The fasciae of the trunk invest the s a crolumbar mass of the s acro s pin al mus­ cle and the p e c to ra l . trapezius. and latissimus do r s i muscles. Emanations from this c o m p le x form the aponeuroses of the deep muscl es. including the quadratus lumborum. the external i n te r c o s t a l muscles. and the muscles associated with the v e r t ebr a l col u m n . Ap o n e u r o s es o rigina tin g in t he abdomen are those of t h e internal and ex­ t e r n a l o bli qu e muscles. the t r ans v e r s us abdominis. and the rectus abdominis (Fig. 2-4).

Posterior Fasciae

Two different fascial elements will be distinguis h ed : a th o r a co lumb a r system with a median p o rti on which is e s p e Ciall y well defined where it inserts into the spi­ no us processes of the vertebrae; and a lower part which c o n s t i tut es the Copyrighted Material

29

Fig. 2-4

External Fasciae

Cross-section through the Abdomen Sheath of rectus a bd o m i ni s m .

Lin e a a l ba

Transversalis fa s c i a

Superfi c i al fascia

Ex(erna l oblique m .

Per i tone u m

T ra nsversus

.

abdo m i n i s m.

\-----+---H-...

I--

A poneurosis of psoas m.

Thora co lum bar fasc i a

S u perfi c i a l fa s c i a

Intr i n s i c back

mm.

lumbar fascia, a ver y strong sheet which is inserted into the spinous processes of the v e r tebra e, the s acrum , and the iliac crest. The latter extends down into the

gluteal aponeurosis a nd then into the lower limbs; it e xt ends on the s i d e s to form the fa s cia e of the ex ternal and int e r nal o b lique mu scle s o f th e a bd o m en

.

The posterolateral part of the fascia is reinforced by the aponeurosis of th e

la tissimus d o rs i, which links the pelvis and the upper limb since it terminates at the intertubercular sulcus. A long the way, it sends o u t an extension that attaches to the lovver angle of the scapula.

The superior part of the iliocostal fa s ci a is rei nforc ed by the apone ur o si s of the trapezius muscle to w h i ch it is attached. The lumbar fa s cia is att a c h e d along the m e di an line to the spinous proce s s es

of the v er t ebr a e p ar ticul arly those of L2 to S2. Thi s very strong structure is made ,

of in terwo ven oblique, transverse, a n d vertical [lbers, indicating t h a t this r e gi o n

is subject to extreme for ce s The lumbar fascia b ec o m e s progressively thicker and .

gives off numerous strong ligaments, inclu d i n g tho se of the sacrum and the sa­ crospinal and sacrotuberous li g am e nts

.

Anterior Fascia The upper part of the ante ri o r fascia is derived fr o m the aponeuroses of the sub­ clavius muscle and the pec t o r ali s major and m in o r. In the median pa r t of the fascia, where there are no mus cle s it is attached to the s ternum ,

.

This complex is continuous on its sides with the a p o n euros e s of the deltoids

and th e axillary fascia It is indirectly .

c ont inu o u s

with th e aponeurosis of the la­

t is si m us dorsi muscle and joins with the posterior fasciae and th o s e of the u pper

limbs (Fig 2-5).

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Fig.2-5

Chapter 2 / Anatomy of the Fasciae

Th o raco-abdominal Fasciae

Cervic a l branches

Su perfic i al t h o r a c i c branches

-."..,,...'�n.lfYt-- Thoracoepigastric v.

1-7"'-1��� - Epi gastric v.

Continuity in the lower medial and lateral regions is formed by the aponeuroses of the o blique and transverse muscles of the abdomen, and the sheath investing the rectus muscle. All these aponeuroses meet on the median line, creating the linea alba, where the differently ali gned fibers of the two meet. The actual con tact is relatively loose. The fascial tissu e above the urn bilicus is always looser than that below it; this explains why most linea alba hernias are supra-umbilical. However, the loose­ ness is functional during pregnancy: when the swollen uterus migrates upward through the abdomin a l cavity, the linea alba moves our of the way a nd thus per­ mits dilatation of the abdomen without any concomitant g eneration of excess pressure which could lead to the compression of the underlying organs. The same phenomenon occurs in p eopl e who put on weight: a ccumulation of fat around the omentum leads to displacement of the fibers of the linea alba. The linea alba inserts superiorly into the xiphOid process and inferiorly into the pubic symphysis where it continues into the suspensor ligament of either the penis or the clitoris. It should be noted that the anterolateral part of the abdomen is the only place in the body where there is no rigid structure. This is [he reason why the a bdominal fasciae di vide and dive deep into the body. With the aponeurosis of the

transverse muscle, they eventually pene trate down as far as the internal abdominal surface where they come into direct contact with the fascia transversalis and the peritoneum.

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External Fasciae

Also to be noted in s peakin g of the abdomen is the presence of the intern al and external inguinal rings, which represent weak points where intestinal loops can become externalized. causing hernia. The inguinal ca nal contains the round ligament in the female and the spermatic cor d in the male. When the testis de­

scends into the scrotum during adolescence. it tr avels the canal and creates. in the wake of its passage. an inv agination : • • •

in the p eritoneum constit uting the tunica vaginalis

in the fascia transversal is con stitut ing the fibrous tunica in the bundles of the small oblique and transverse muscles tha t will

const itute the tunica muscularis or the cremaster muscle The latissimus dorsi and trapezius muscles stretch the posterior aponeurosis. and the pectoralis major acts on the anterior aponeurosis

.

The posterior part of the sheath of the rectus abdominis is in t errupted about

three centimeters below the umbilicus to form a strong semi-circular line called .

the arcuate line of the sheath of t he rectus abdominis muscle. This is easy to pal­

pate in many subj ects and should not be confused "vith the roO( of the mesentery.

which is much deeper down.

The aponeu roses of the abdominal mu scles join with the lower part of the a bdomen in a line that extends from one anterior super ior ili ac spine to the other.

a cross the entire width of the pu bic symphysis.

Several groups of fibers come together to form the i n g u i nal liga ment. includ­ ing one set of fibers derived from the fascia lata. Thus the canal acts as a relay .

center and represents a point of continuity between the fascial systems of the

abdomen and the lower ex tremities Other fibers origina te in the iliac fascia and .

the transversalis faSCia. so the ingUinal lig a ment also represents a point at which the abdomin al wall meets the internal surface of the abdomen

Reinforcements of the supra-pubic abdominal fasciae

.

(Fig. 2-6) correspond

to

the reflex inguinal lig amen t (Colle's ligament ) the lacunar liga men t (Gimbernat's .

ligament). and the interfoveolar ligament (Hesselbach s ligament) '

.

Iliac Fascia The iliac fascia. an offshoot of the superfiCial

a bdomin al

fascia. warrants special

attention for two reasons: First. by virtue of its situation. it invests the psoas

muscle which.

a p ar t

from the longus colli muscle of the neck. is the only muscle

which is inserted in the anterior vertebrae and which therefore passes inside a body cavity. Second. by virtue of its numerous rel a tionships with other structures like the kidneys. the ureter. and the descending and ascending colon.

Moreover. it is the iliac fascia which splits to invest the lumbar ple xus It al s o .

spans the entire width of the internal iliac fossa. re aching from the superior in­

sertion point of the psoas muscle as far as its insertion into the troch anter. from where it continues as the fascia lata femoralis.

The upper part of the iliac fascia is thin but gra d u a lly thickens as it descends

down into the pelviS. It cont a ins the tendon of the psoas minor muscle extant).

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( when

32

F i g.2-6

Chapter 2 / Anatomy o f the Fasciae

Vert i cal a n d a n teroposterior sectio n s of t h e i n gui n o-abdo m i n a l a n d i n g u i nocru r a l regions

Tra nsversus abd om i n is m .

---t-'�I-l.�

I n t e rn a l

Transversa l i s fascia

o b l ique m .

Apon euros is o f external oblique m.

Aponeurosis of external o bli q u e m .

Superficial

I nter n a l obl i q u e m.

fasc i a

Transverse m. Femoral a rch

Perito n e u m

Iliopsoas m.

Spe rma ti c cord -�P-'r',,*"�I4'-/

Supe rficial fascia

R e troin g uina l space

Tra nsverse m . In te rna l o b l iq u e m .

Vasc u lar sheath

Peritone u m

WC':-- Burns' lig.

Apone urosis of the external o b l i que m.

Great sa p h enous v.

Conjoined ten don

I n g u i n a l l ig .

Spermatic cord

,_..--F,I""I..,-==----- Femora l a r c h S u p e r fici al fascia

C r i b riform fasc i a

-----\,--- Pect i n e us m.

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External Fasciae

The iliac fascia inserts: On the inside

into the lumbar vertebrae where it forms pa s sages for the lumbar

•

arteries and veins •

at the base of the sacrum

•

at the superior opening of the pelvis where it invests the ex ternal iliac artery and vein, keeping these vessels in place on the medial edge of the psoas muscle

On

the outside

•

in to the aponeurosis of the quadratus lu mborum muscle and alon g the external edge of the psoas

•

i nto the iliolumbar ligament

•

into the i n ter n al lip of the iliac crest

At the top It thickens to create the arcuate l i g ame nts at the top of the psoas, into which the

corresponding part of the diaphragm inserts ( anoth er example of fascial continu­ ity) .

At the bottom The iliac fascia is strongly attached to the external half of the inguinal ligament (again, a relay center and point of contin uit y with the abdomina l fascia). Its inter­ nal surface forms the iliope ctine al arch and then continues as far as its insertion into the trochanter, where it is continuous with the fascia lata. This description shows that the iliac fascia joins the lu mbar column and the internal ilia c fossa to form an osteofibrous co mp artment , the abdominal part of which is completely closed . This compartment is open on the side of the thigh above the lateral part of the ingUinal ligament. The iliac fJscia is basically co m posed of bundles of fascial tissue, running in a transverse direction, to which are jOined a few vertically or i ent ed bundles. A sheet of cells separates the iliac fascia from the peritoneum. The iliac fascia invests the psoas muscle without being a ttac he d to it-the two are s eparated by

a

cellular

serous membrane. The nerves of the lumbar plexus are intim ately bound to th is fasci a . . ......... . ........... ...... .. . .... . . ... . ............................... . .... ......... . . .

:

Summary

of

the Fasciae

of the Trunk

This fascial system is continuous with the superficial cervical fascia at the scap­

ular girdle. It terminates below at the upper periphery of the pelvis, where it is continued by the fasciae of the lowe r limb.

The an ter i or and posterior median i nsertion poin ts for this fascial system are:

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.

34 Chapter 2 / Anatomy of the Fasciae

•

the sternum

•

the s pinou s processes of the vertebrae

The fasc i ae are divided to invest the various muscles present in the ab domen

and the thorax. S u p e r iorly the fascial sheet is continuous with the aXillary aponeuroses and the

fas c ial elements of the upper limb. In the lower trunk, where there are very few muscles, the fasciae become ver}'

strong. They give ri s e to many laminae emanating in different directions to support the structures in the thorax and abdomen. In the abdomen, the fascia splits repeatedly and penetrates deeply, even t ually joining with the transversalis fa scia.

The d eep est posterior split constitutes the iliac fascia. At the lev e l of the pelv is the fasciae of the trunk are continuous with the peri­ ,

neal fasciae, particularly the superficial and middle perineal fasciae. Finally, at the anterior level, via the umbilical ligament, the fasciae of tbe

trj..kl'lk

are connected to the deep perineal fascia and tbe fasciae associated with the organs of the lesser pel vi S

.

........... . ....... . ............. . ........... . . . . . . .

. .............. . ....... . . . . . . . . . .

.

. .

U P P E R L I M B FAS C I A E This fascial system joins the superficial cervical fascia at the clavicle, the acromion, and the p rocess of the scapula. It is also continuous with the fasciae of the greater pectoral and latissimus dorsi muscles, and the axillary fascia. Although it is only of medium thickness throughout, it is nevertheless s tr o n­

ger on the side of the extensor muscles than on tha t of the flexors. A complex

network of nerves a nd lymphatics runs through the tissue. In the bottom third of the forearm, the fascia is pierced by the cutaneous branch of the radial nerve

(Fig. 2-7) . It is pierced at the level of the fold of the elbow by the lateral an tebrachial cutaneous nerve. In the lower third of the arm, there is the opening for the basilic vein (to wh i ch it is attached) and from

whic

h emerge the anterior and ulnar

branches of the medial antebrachial cutaneous nerve . Its superior lateral part con­ tains the accessory of the medial antebrachial cutaneous nerve into which there is an anastomosis of the intercostal ar teries. The cephalic vein runs along the external edge of the upper limb. At the level o f the fold of the elbow, it is regularly linked to t he basilic vein via the median c u b i t al vein, and travels part of the way in association with the lateral c u taneou s

antebrachial nerve. It a s ce n ds in the deltopectoral sulcus where it passes th ro u gh the deltoid and clavipectoral aponeuroses before e m p t yi ng into the ax illary vein.

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Fig. 2-7

External Fasciae

Upper Limb Fasciae

Medial brachial cutaneous n.

Cutaneous branch of circumAex a.

Cephalic v.

Internal superficial brachial a.

Basilic v.

Lateral antebrachial cutuaneous n.

Cutaneous branch of the median n.

/ Numerous intermuscular septa derive fro m the inner s u r fa ce of the fascia of the upper l imb ; repeated splitting of these she ets re s ul t s in the creation of sheaths for

all the different muscles o f the limb.

There are points of attachment at the elbow and at the wrist where it is con­ tinuous vvith the palmar aponeurosis. Each successive portion of the upper limb w il l be considered s e p a r at e ly in the folloWing order: the shoulder. the arm, the forearm. and the hand.

Shoulder Fasciae The fa s c i a of the shoulder is cont inu ou s with the s u perfi cial cervical fascia. Its l a t e r a l anterior and posterior portions co rr e s pond to the aponeurosis of

the pec­ toralis major muscle. In froIlt. i t is com pos e d of the aponeurosis of the deltoi d muscle. and behind those of the infraspinous and supra spino u s muscles (Fig. .

2-8).

The fascia is split behind the pectoralis m aj or by t h e axillary clavipectoral

fascia and the subclavian aponeurosis. which is reinforced by the medial corico­

cl av i c ul a r (conoid) liga m ent From the lower edge of the subclavian aponeurosis. a membrane detaches. which is attached to the pectoralis minor muscl e . This structure s pli ts into two separate sheets: Copyrighted Material

36

Chapter 2 / Anatomy of the Fasciae

•

Fig. 2-8

\

an anterior sheet, which joins with the aponeurosis of the pectoralis

major underneath, and is a ttac hed to the skin at the base of th e axilla

Axi l l a : Vert ica l, A ntero posterior Cross-sectio n

Clavi cle

Supe rncial fas c i a

Subcl a vius m.

1&t�-+--tlI--- Axi llary

c lavi pectoral fascia

Fascia-invested ...,.-I----\---tlI- b u n dle of vesse l s and nerves

D e l toid m . I nfraspi n ous

m.

Subscapu lar

-->'--\-1f---

Apo neurosis of pecto ralis m i n or m. (su p ernc ial a n d d e e p lam i nae)

m.

Teres major m. -+--

Apo n eurosis o f latissi m u s dorsi

S u spensory l i gament of axillary fossa

m.

Deep fascia o f axillary fossa

•

Supe rncia l fascia o f axillary fossa

a poste r ior sheet, which continues into the deep axillary aponeurosis and also a t taches to the skin of the armpit via the clavipectoral fascia

The inferior

m edi

al part of the fascia of the shoulder consti tu te s the aponeuro­

sis of the base of the aXillary cavity and is composed of two fascial membranes, namely, the superficial and the deep fasciae: S u perfic i a l fascia

The superficial l a m i n a extends from the inferior edge of the pector ali s the inferior edges of th e latissimus dorsi and the teres

maj or m

Deep fascia

The deep fascia is a fou r sided sheet which is j oined in the front to

the deep layer back to at­

of the su sp ens ory ligament. From t h at point of a ttachme n t it passes -

,

major to

uscles .

tach itself to the entire len g t h of the axillary edge of the scapula. O u tside

,

the deep

fascia adheres to the a n terio r face of the tendon of the lo n g biceps muscle. Its pos­

terior part c om es into contact with the latissimus dorsi and teres major muscles.

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37

External Fasciae Its inferior

m edi al

edge joins the aponeurosis of the serratus sup er ior muscle.

Outside, it is j Oined to the coracobraclYial aponeuroses of the coracobrachialis

and the bi cep s . Behind, it constitutes the axillary arch,

w

h ich invests a bun dle of

vessels and nerves.

Brachial Fascia

The br achi al fascia is continuous with the fasciae of the shoulder. It terminates

at tbe elbow where it inserts into the oleocranon and the medial

and lateral epi­

con dyles of the humerus. An extension of the tendon of the biceps-a genu ine aponeurotic tensor-is attached to its anterior part (Fig. 2-9), Fig.2-9

Upper Arm: Horizo n ta l Cross-sect i o n at t h e Two-t hirds Dista l Poi n t

Musculocuta n eous n .

Bice p s m. Superfic i a l fa scia

Axi l lary n,

Bra n ch of m e d i al cutaneous b rach i a l n ,

Fascia invest ing the rad i a l a n d dee p brachia l aa. .. IiIo.......III0j---

Cutaneous bra nch of rad i al n,

;-P.lM�-�"""-�"'::::::":::

Latera l mu scular septum

Med i a l c u ta n e o u s brachia l n.

Fasc ia invest i n g the median a n d bra ch i a l a r teries

Med i a l m uscular septum U l n ar n,

Triceps m .

It forms two sep ta , which are oriented in the •

the lateral intermuscular

•

the

In the

medial intermuscular septum

s a gitt a l

the various

\

as their

sepewn

sagittal plane :

plane, these septa

secure the aponeurosis to the bone and permit

groups of muscles to op era t e with maximum efficiency, w i th the septa

s tron

g point.

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Chapter 2 / Ana tamy of the Fasciae

Latera l i n term u s c u l a r septum The lateral in termu scular septum of the arm o r i g in a tes in the inter tubercu lar sulcus and unites w i th the pos terior edge of the tendon of the deltoid mus cle. It in serts along the whole length of the external edge of the humerus as far as the epic ondyle. It separates and prov i de s insertion points for both the a n ter ior and pos te r ior muscles . It i s crossed at an oblique angle by the radial nerve and the deep brachial ar tery

.

Med i a l i n te r m u sc u l a r s e p t u m The medial intermuscular s e p tum is w ider a n d thicker than its lateral homologue , origina ting at the poster ior edge of the i n te r tubercu la r sulcus . It continues i nto the ten don of the coracobrachia l muscle 'vv ith which it unites an d , to a certain extent, ins inuates itself. I t is inserted alon g the entire leng th of the humerus as far as the medi al epicondyle of the humerus. It sends out a thin , fibrous ex tension , the medial brachial lig amen t , which extends from the s u p er i or end of the medial intermuscular septum to the lesser tubercle o f the humerus , passing behind the coracobrachial mu scle. Thi s lig a m e n t separates the triceps muscle from the anterior brachial muscle an d provides b o th of them with inser tion poin t s . The anterior ulnar nerve cros s e s the septum i n i t s middle and remains associ ­ ated w i th its po s te r ior p art. Sheaths for various muscles emanate from the deep surface of this fascia , namely, the biceps , coraco brachial, anterior brachial , and triceps muscle s . An apo­ neurotic sheet at its s u perior par t separates the long portion of the triceps from the rest of the muscle. The inferior p art of this sheet is con tinuou s with the sulcus of the ra dia l nerve and houses both the n erve and t he deep brac hial artery in its own apon eurosis. Be tween the biceps an d the an terior brachial muscles li es a thin fa scial layer, which separates them and con tribu tes to their mobili t y. Thi s sheet is cont i nuous

with the a n tebrachial fascia . I n the in terior part , in contact w ith the interior intermuscular septu m , runs the brachial canal , which con tains the brachial ar tery and vein , and branches from the brachi al plexus . This b un dl e of vessels an d nerves has its own fascial sheath , which houses and protects i t . The brach i a l and the antebr achial fasciae send o u t e x ten s i on s to inves t t h e

various nerves an d arteries as well a s the deep a n d s uperficial veins in this r e ­ g i on

.

iin tebrachial Fascia The a n t ebrachial fa scia is con tinuous with the brachial fascia and termin a tes a t the wrist where i t is reinforced by the flexor an d ex tensor retinacu lae. To its s uperior

par t i s attached an extens ion of the te n do n of the biceps muscle . The an terior brachial and triceps muscles also send extensions from behind, which rein force this tissue. The fas c ia is thicker pos teriorly than anter iorly. There are in fe r i or insertion

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39

Ex terna l Fasciae points a t t h e l e v e l of t h e wrist ( throu g h t h e associa tion o f t h e re t i na c ul a e ) a n d i t s poster ior p art is in t i m a t ely associa ted with the p o s terior e d g e of the u ln a . In a ddition , it sends o u t

a s e con d ex tension to the pos te r ior e d g e of the r a diu s

which , to g e t h e r with elements of the skel e ton , denote the an terior and posterior an tebrachial r e gion s .

From i t s deep face issue variou s muscu l a r sheaths which inve s t the different

muscles and provide a lubricating surfa c e so they can easily slide over o n e

(Fig. 2 - ( 0) .

another

In t h e anterior reg ion , t h e fa s cia di vides to sep ar a te the superfiCial from

the d eep l ayer . The same a rra n g emen t is also observed in the p o s t er i or p ar t . The muscles invested by the

antebra chial fa scia can be divided in to a s er ies of

different g ro u p s . The lateral group includes the long supinator muscle and b o th

radial extensor muscles of the wris t ; these three m u scles all seem to b e inve s t e d by the same fa scial elem ent , a fac t of some si g ni fi c a n c e , as becomes clear in clinical p r a cti c e . The s a m e arrangement applies to the medial part with the ulnar flexor an d ex tensor muscles o f the wris t , a l thou g h in this c a s e , the o r g a niza tion is less

cl e a r- cut .

Fig. 2 - 1 0

Fo rea r m : H o r i z o n t a l Cross-sect i o n a t t h e O n e - t h i rd D i s t a l P o i n t

P a l m a ri s l o n g u s m . E x t e n s o r c a r p i rad i a l i s l o n g u s m .

F l exor d ig i t o r u m s u p e r fi c i a l i s m .

F l exo r c a r p i u l n aris m. F l exo r c a r p i rad i a l i s m .

Flexor digitorum p r o fu n d u s

P r o n a t o r teres m .

m.

F l exor po l l i c i s longus m . Extensor c a r p i rad i a l i s b r e v i s m . Exter n a l i n term u sc u l a r

Medial

se p t u m

m u s cu l a r se p t u m

Extensor d i g i t o r u m m . A b d uc to r p o l l i c i s l o n gus m .

I n te rosse o u s fa s c i a I n te r m usc u l a r fas c i a

1. Extenso r p o l l i c i s b rev i s m .

2. Extensor poll icis longus m .

3. Extensor digiti m i n i m i m.

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Extensor carpi u l naris m.

40

Chap ter 2 / Ana tom y of the Fasciae

Fasciae of the Hand The fasciae of the hand c o n tinu e the a nteb rac hi a l fas c i a d i st all y from the reti­ na c u l a e (Fig. 2 - 1 1 ) . Dis tinction is m a d e be tween two different fa scial elemen ts : the

do r sal fascia of the hand and the p al m a r ap o n e u r o sis . Fig. 2- 1 1

H a n d : C ross-sec t i o n

Pa l m a r a p o n e u r o s i s

H y p o t h e n a r a p o n e u r o si s

-+_�_ H y po t h e n a r

Thenar

comparcm e n t

a p o n e u ro s i s

Thenar c o m p a rc m e n t Middle palmar c o m p a rt m e n t

S u p e r fi c i a l d o rs a l a p o n e u ro s i s D e e p d o rs a l a p o n e u r os i s

D o rsal fascia of t h e h a n d Two different layers a r e u s u al ly considered: a s up e rfiCial l ayer a n d a d e e p l a y e r. � SU PERFICIAL LAY E R

The superficial lay e r is thin and covered by t h e e xtensor tendo n s . It i s c o n­ tinuous with the extensor re tinaculum a nd , at the bo ttom , w i t h the ex tensor ten­

d o n s . I t is ins er t e d a t the p hala n ges . On the sid e s , i t is in s e r te d into the external e d ges of t h e first and fifth metacar p al bo n es . � D E E P LA Y E R T h e d e e p l ay e r

i s very thin and covers the do r s al surface of the palmar interos­

s eo u s m us c l e s . Pa l m a r a p o n eu ro s i s A g ain , there are co n s i d e r e d t o be s up er fi c i a l a n d d e ep l ayer s . � SUPERFICIAL PALMAR A P O N E U ROSIS

The su p erficial p a l m a r a p oneurosis c o n s i sts of three s ection s : a middle part,

or the true p a lmar aponeurosis , and two l a t e r al el ements which cover the t h en a r and hyp o thenar eminenc e s .

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41

External Fasci ae

� M I D DLE PALMAR A PO N E U ROS IS

This is triangular in sha p e with the base c orr e s p o n d i ng to the roots of the last four fingers. At the to p , it is continuo us with the antebrachial fas ci a and the flexor retin aculum and ex tends out as the tendon of the p a l m a r i s longus , which is the tensor of the aponeurosis . This is a st ro n g fibrous band located j ust below the skin to which it is c l o s e l y attached via sho r t fibrous e x tension s . Dupuytren described the p r e sence of lo n ger extensions , the c uta n eous papillae, which start at the inferior third of the aponeurosis and ex ten d as far as the interdigital fold . These pap i llae are m aximally stretched d u r i n g ex tension movements and it is the same structures which are resp onsibl e for the retraction of the p a lma r aponeuro­ sis s e en in Dupu y ten 's con tracture . The aponeurosis c ov e r s the flexor tendon s , vessel s , and nerves of the palm of the h a nd and is continuous on both sides with the aponeuroses of the thenar and hyp oth e n ar eminences (Fig. 2- J 2) . It extends into the fingers to form sheaths for the flexor tendons , which are inserted into the phalanges. The middle palmar aponeu r osis contains bo th lon gitudinal a n d transverse fibers. ,

,

Fig. 2 - 1 2

M iddl e a n d Deep P a l m a r A p o n euroses Mid d l e pa l m a r a p oneu rosis L u m brical m.

D ig i t a l vessel s and nerves

F l exor s h e a t h F l exo r tendons -----i'II-'Ik----¥.�1+l<.'

D e e p pal m a r a p oneurosis

Metaca rpo_-----.\I-fj p h a l a ngeal j o i m

Perfora t i n g � be rs

-�U\J[j;����.--\11-1 Super� c i al d orsal a p o n e u ro s i s

Ex t e n sor t e n d o n

P a l mar i n terosseous m.

Dorsal i n terosseous m.

Longitudinal fibers. These continue out of the re ti n a c Ll l a e and the ten don

of the palmariS longus muscle. They descen d , ra d iat i ng out towa rd s the four last fin gers a t the metacarpophalangeal articulations. They form eight slip s , two for each of the four l ast fingers. These slips are a ttached to the lateral surfaces of the first phalanx of each finger and r ep res e n t the most distal component of the super­ ficial fascia of t he upper limb. Before the tendons , fibers com e tog e the r to form pre tendinou s bands Copyrighted Material

42

Chap ter 2 / Ana tomy of the Fasciae

whi ch j oin up wi th pretendinous bands • •

•

the thinner intra tendinous membranes, The fibers .in the terminate in three different ways :

some are a ttached to the d e e p layer of the skin others continue on to reach the deep a poneurosis , They form sagittally d i s p os e d se p ta which, together w i th the superfiCial a n d deep fa sciae, define fascial tunnel s , These tunnels variously inve s t the flexor tendon s , the lumbrical mu s cle s , and the vessels and nerves of t h e fingers . the y send out penetrating fibers to the metacarpophalangeal ar ticulation across the flexor retinaculum and a r o und the j oint to the extensor tendon behind which they j oin up with the similar fibers derived from the dorsum

Transverse fibers. The fasciae are covered by longitu d inally o ri e n t e d fibers at the inferior p a r t of the aponeurosis wh ic h cons ti tute the superfiCial transverse and interdigital l i g aments. � LATERAL PALMAR A PONEU ROSES

The l ateral palmar aponeuroses a r e much thinner t ha n the middle layer and they inve s t the muscles of the t h e n ar and hypo thenar eminen ces. Laterally, the external layer is inserted into the s ca p h O i d and trapezium bones , and a lo n g the outer edge of the first me t a c ar p al bone . M e d i a ll y, i t descends between the thenar muscles before atta c h ing to the anterior edge of the t hi r d met a ca r p a l . The medial l ayer is inserted into the piSiform bone and the medial edge o f the fi ft h metacar­ pa l . Laterally, it is inser ted along the anterior edge of the fifth meta car pa1 Thu s i t forms a comp artment for t h e hy p o th e n ar muscle s . ,

� DEEP PALMAR APO N E U ROSIS A t the top , i t is continuous with the fibrous elemen ts of the wri s t and te r mina tes at the metacarp ophalangeal articula tions. In front of t he heads of the second, third, fou r th , a n d fifth metaca rpals , the ap oneurosis thickens to form the flexor re tina culum. ­

Ta b l e 2 - 2

Con n ec t i o n s o f t h e Uppe r L i m b Fasc i a e

SU PERFICIAL CERVICAL FASCIA

' /

SKIN

APO N E U ROSIS OF THE LATISSIMUS DORSI M.

f-- U p pe r , .1 m b fas c ·l ae �

C L A V I COP ECTO ROAXILLARY FASCIAE

/

1

TERMINATION A T T H E F I N G E RS

MIDDLE CERVICAL FA S C I A

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INTERMUSCULAR S E PTA / P E R I OSTE U M

43

External Fasciae

.. ..

.. . . .. . . . .. . .. . .. . .. .. . .. .. .. .. .. .. . .. . . .. . . .. .. ..

.. .. . .. .. .. .. .

.. .. . .. .. . .. . . . . . . .. .. . . . .. .. .. . . .. . . . .. .. .. .. .. .. .. . . . .. .. . .. .. . . . .. ..

.

Summary

of

Upper Limb Fasciae

The fas c i a e of the upper limb are con t i nu o u s with the s u pe r fici al cervical fa scia and a r t i c ul a t e with the anterior and pos terior thor acic fa s ci a e .

They terminate

in the fing ers after havin g e s tablished s trong connection a t

the elbow a n d the wris t . Numerous vein s , lympha tics , a n d nerves r u n over a n d p a s s t h r o u g h them . These fasciae a r e composed o f v er ti c a lly and obliquely disposed fibers

w hich

interlace with one ano ther and are woven to g e th e r to create a par ticularly stron g tissue.

A series of different membranes emanate from the d e e p surface of the fas ­ cia e : •

i n a perp e nd i cul a r direction : t h e intermuscular s ep t a , which anchor i t t o the perios teum a n d then connect t hr o u gh t o t h e osseous t r abec ul a e ;

•

l on g i tud i n al membranes , whi ch go on to invest the

va

r i o us muscles or

form deep aponeuro tic structures

Finally, t h e fa scia of the upper limb s p l i t s repeatedly to inve s t and protect v e s ­ sels an d n e r v es , b o t h s u perfi c i a l ly a nd deeply. . .

.. .. . .

.

..

.. . .. .

.. .

.

. . .

..

.

.

..

..

..

.. .

.

.. . ..

. . .

.. .

.

..

. ..

. .. ..

..

..

.

.. ..

.

.

.

.

.

.

.. .. ..

.

. .. .. ..

.. .

.. .

. .

.. .

.

.. .. .. . .

.

. .

.

. . .. .

..

.. ..

.

.

L O W E R L I M B FA S C I A E The fascia of the l ower limb is co n t i nuo us with the lumbar an d a b dominal fa sciae . The pos terolateral part of this tissue o r i g i na t es i n the iliac cres t a n d a t the s a crum where it ex tends the lumbosa cral fascia and the s a crotuberous ligamen t . I ts a n t e ­ rior por tion originates from the pubis , the i n feri o r pubic r a m u s , and the ing u i n a l li gamen t . It terminates a t the fee t , h av i n g e s t a blished relay points in the knee and

the ankle . I t i s composed of in t er l a C i n g vertical , horizon tal, and oblique fibers . The fa scia wraps around the thig h and the leg fr o m the top towards the bottom and from the ou tside towards the inside . The w ra p p i n g is more marked around the thig h . Whereas the fascia of the l ower limb is thin p o s teromedially, i t is thi c k an terola terally a n d o n the ou tside where it is referred t o as the fascia l a ta . The fascia lata is the thickest and s trong e s t fascia in the wh ole body. From its deep surface emanate many septa which will be dealt with in the order of the differen t s e g ments of the l ower limb. Over its

su

p erfi cial surface (which is separated from the plane of the skin

by the su p erficial fa SCia) run lymphatics , two m a j o r veins , and vario u s sensory nerves (Fig. 2 - 1 3 ) .

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44

Fig. 2 - 1 3

Chapter 2 / Anatomy of the Fasciae

Lower Limb Fasciae

F e m o r a l n . """"""o:cf';'-5--¥--�

O b t u rat o r n . Lateral fe m o r a l Ra m i o f t h e fe m o r a l n.

c u ta n eo u s n .

M ed i a l sa p h e n o u s v.

Saphenous n . Accessory b r a n c h of s a p h e n o u s n.

G re at s a p h e n o u s v.

S u pe r fi c i a l fi b u l a r ( pe ro n ea l ) n .

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External Fasciae

Veins The two l a rge s t veins are : S m a l l s a p h e n o u s vei n

The small saphenous vein origina tes a t the ex ternal edge of th e foo t and then fol­ lows a course which is situated more or less towards the medial . pos terior part of the leg. In most cases , it passes through the tibial fasci a at the popliteal fossa to

empty into the p opliteal vein . It should be noted tha t this configuration can vary and this perforation of the tibial fascia can sometimes be found in the upper third of the cal f, sometimes in the lower third , and sometimes even at the level of the Achilles tendon. G reat sap h e no u s ve i n The great saphenous vein origin a te s a t the medial edge o f t h e foot, passes i n fron t

o f the medial malleolu s , and follO\vs th e medial side of the leg and thigh before

passing th rough the cribriform fa scia to emp t y into the femoral vein in the in­ gUinal region . The cribriform fascia is a t ta c h ed to and sends an extension out over the tunica ex terna of the vein .

Cu taneous Nerves From the top to bottom and from medial to lateral : Anterior aspects •

the ilioin g u inal nerve (in the inguinal region)

•

the sa p henous n er ve , descending all the way dovvn to the great toe , with an accessory branch i n the m o s t medial p a r t which terminates a t th e

medial aspect of the knee •

the internal obturator nerve on the medial surface as far as the knee

•

the p erforating cutaneous nerve in the medial part as far as the knee

•

the crural branch of the genitofemoral nerve in the media l , su p erior part

• •

the lateral femoral cmaneous nerve in the lateral part the lateral sural cutaneous nerve of the c a l f and the su p e r fi ci al fibular nerve on the lateral p art below the knee

•

the su p e r fi c ial fibular nerve on the lateral leg and the superior, l ateral foot

Poste r i o r aspect � AT T H E B U T T O C K S •

the sacrococcygeal plexus medially

•

the p osterior cutaneous femoral nerve

•

the first and second lumbar roots in the superior p ar t

•

a branch of t h e i li O ing u i n a l n erve i n t h e su p erior, medial p a r t

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46

Chap ter 2 / Ana tomy of the Fasciae The pos terior and medial sides of the thigh are inner vated by the pos terior cu ta ­ neous femoral nerve as far a s the •

p o p l i t e a l fossa :

the medial . pos terior side is innervated by the saphenous and anterior cu taneous nerves

•

the l a teral.

pos terior side is innervated by the la teral cutaneous nerve

� I N TH E CALF • •

the sural n erve innervates the medial part

t he la teral cuta neous nerve of the calf (an accessory of the sural nerve) for the lateral , p o s t erior p a r t

Nex t , the various segments of the fa scial system of the lower limb, its de e p

fa ce , and its numerous extensions vvill b e discussed.

sur­

Glu teal Aponeurosis The gluteal aponeuro s i s originates a t the iliac crest, the sacrum , the cocc y x , and

from vvhich i t extends inferiorly and anteriorly with the fascia l a t a . The a n terior part of this fascia inve s ts the glu teus medius m us cle . When it reaches the anterior edge of the glu teus maximus m u scl e it divides to for m superfiCia l , middle , and deep layers. the sacrotuberous li g ament

,

The superficial and middle l ayers inve s t the super ficial a nd deep surfaces of

the gluteus maximus mu scle . The d ee p layer is h i ghly cellular. It invests succes­ S ive ly • •

It

( superior to i n feri or) :

the p o sterior part o f the gluteus medius muscle the piriformis muscle

•

the g emell u s muscles

•

the quadratus femoris

muscle o f the thi g h

is i n terr u p t e d : •

above the

piriformis muscle ill o r de r to a llow the passage of vessels and superior glu tei muscles

nerves supplying the •

below the piriformis muscle in order to allow the p a s sage of the sciatic

vessels and the sciatic n e r v e

Finally, two cellular membranes inves t the deep surface of the gluteus medius muscl e and the external branes

surface o f the gluteus minim us muscle. These two mem­

are continuous with the deep layer o f the gluteal aponeurosis acro ss the from the

entire leng th of the fa s ci al plane which separates the gluteus medius

piriformis muscle

(Fig 2 - 1 4) .

For this reason , the gl u t e a l aponeurosis divides to form several different

membranes to cover all o f the various muscl e s . These membranes allow t h e differ­

ent muscles to slide over one another. They also define cleavage planes,

wh

i c h we

can u tilize for deep p alp a tio n . No ta bly, we can access the p ir i fo r m i s and g e me l ­

lus muscles via the plane be twe en the gluteus mediu s and the glu teus maxim us

m u s c le s . These will b e d i s cu s s e d in Chap ters 7 and 8 below.

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Fig. 2 - 1 4

External Fasciae

H o r i z o n t a l Cross - sec t i o n t h ro u g h t h e A d d u c t o r C a n a l i n t h e T h i g h

Supe r fi c i a l fas c i a

Rec t u s fe moris m.

V a s t u s med i a l i s m.

Vastus i n te r m e d i u s m .

Med i a l i n t e r m u sc u l a r septum

Vastus l a tera l i s m .

S a r t o r ius m. G re a r sa p h e n o u s v. Ten s o r fas c i a l a t a

Tendon of the adductor magn u s m .

Latera l i n t er m u scul a r se p t u m

Fas c i a i nvesti n g vesse l s a n d n e rves G r ac i l i s m .

B i c e p s fe m o r i s m . ( s h ort h ead) S e m i m e m b r a n o u s m,

B i ce p s femoris (long h e a d )

m.

S c i a tic n .

S e m i te n d i n osus m .

Fasciae of the Thigh

Superiorly, the fascia lata is a ttached to the p u b is a t the inguinal ligament and to the ischiopubic ramus, Pos terolateral ly, i t is continuous with the gluteal ap o ­

neurosi s , T h i s fa scia extends down into t h e tibial aponeurosis w i th several points o f a t tachment to the p a tella , the intercondyla r eminenc e , and the head of the

fibula,

The organization of the medial , superior p a r t of t h e fascia of t h e thigh around the femoral triangle is somewha t speCialized and this fascial element is

u s u ally

d i s tinguished as the cribriform fa scia . Here , the tissu e is thin, l o o s e , and pierced

to a llow for the passage of the great number o f lymphatic vessels makin g their

way fro m the superficial to deeper layers, The m o s t remarkable of all these op e n ­ i n g s i s that which e x i s t s for the grea t saphenous vein : a round t h e periphery o f

this opening t h e fascia thickens to form a ring , called t h e saphenous opening (fossa ovahs ) , to which the sheath of the vein i s attached.

This cribriform fascia is itself a aponeurotic fold which allows a dduction

and in ternal rotation of the thigh withou t exerting excessive tension on the fa s ­

cia , which might result in damage to t h e vessels an d nerves. I t s s u p erficial sur­ face splits to invest the sartorius mus cle, Extensions proj ect from its deep surfa c e

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Chapter 2 / Anatomy of the Fasciae

whi c h inves t each of the var i ous muscles o f the thigh. The fascia lata is linked to the femur throug h two s ep ta , the medial and lateral intermusc ular s epta

1 4) .

(Fig.

2-

M e d i a l i n te r m u s c u l a r s e p t u m

This sep tum extends down from an obli qu e line drawn from t h e grea ter and the lesser trochanter to the m edial condyl e of the knee. It i s a t tached to the medial e d g e o f the linea asp era and its lower part con tributes to the adductor hia tus of the adductor magnus muscle , throu g h which passes the femoral artery. Its thic k , prom i nen t m e d i a l edge is e a s y to pal p ate (it feels like a cord) . D i s t a ll y, i t seems to be c ont i nuous with the media l collateral lig a men t o f the kne e . Its anterior

s urface is i nserted into the vas tus m e di alis muscle and its pos terior surface is in

cont a c t with the adduc tor muscles . It is s tron g ly a t tached to the aponeuroses of the s e mus c les .

On the inside of the an ter i or thigh this fascia divides to form t wo compar t ­ ments : •

a latera l , anterior compar tment which contains th e quadriceps muscles

•

a medi al , pos terior compartment which contains the a d d u cto r muscles , the gracil i s muscle and the femoral vessels

A t h in sep tum separates the m edial , pos terior compartment from the pos te rior

one. Lateral i n te r m u s c u l a r s e p t u m

This sep tum extends down fro m t h e greater trochan ter t o t h e l a teral condyle o f t h e femur. A b ove the l a teral condyle , and after i nser tion i n t o the l a t e r a l l i p of the

linea aspera femo ris , it takes the form of a prominent c o r d . An teriorly it serves

a s a n insertion point fo r t he vas tus lateralis m u s cle and posteriorly for the short

portion o f the biceps femoris muscle . It separa t es the a nter i or and posterior com­ partment s . S h ea t h of t h e fe m o ra l vess e l s

The fascia lata splits to form a s he a th which i nves t s a n d protects t h e femoral v e s ­ s e l s . This sheath extends from t h e ingu inal l i g a m e n t to t h e a dductor fo ramen ; the s uperior part of this canal i s called the femoral canal , and the inferior part is c al le d the a dductor

( or

H unter ' s) canal . This canal is in the s h ape of a triangula r pr i sm

which has been twisted alo n g its axis so that the s urfa c e which is ini tially a nterior b e comes the medial surface at the bottom. Here again , this twisted configura tion of the fascia p ro tects the vessels and nerves o f the femoral canal (including the femoral a r tery and v ein , and the saphe­

n ous nerve and its ac c es s o ry ) from compression and s tre tching when the thi gh i s move d , es p e C ially during ex tern a l rotation and abduction . An ex tra element contributes to the protection of th i s canal by inve s tin g its in ferior p a r t , namely,

the sar torius muscle , w h ich has a similar obliqu e ly s p iral traj ectory as it passes

inferomedially.

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External Fasciae

Fasc i a of the Lower Leg The fascia of the lower leg is directly continuous with the pos terior part of the fa scia lata femoris after insertion in to the p a tella , the tibial condyles , and the a n ­ terior part o f the h e a d of the fibula . Here i t is also a ttached t o the tendons of th e biceps femoris on the outside and the sar torius and the s emitendinosus muscle on the inside. A series of differen t membranes issue from its deep side and then proceed to inve s t muscles and form the medial and lateral intermuscular septa (Fig. 2 - 1 5) .

Fig. 2 - 1 5

Cross-sec t i o n t h ro ugh t h e M i dd l e T h i rd of t h e Leg

Fascia o f the a n t e r i o r t i b i a l a . & co m m on fi b u l a r n . T i b i a l i s a n te r i o r m.

A n terior

S u p e r fi c i a l fa scia

i n te r m u s c u l a r s e p t u m

S u p e r fi c i a l pe ron ea l n .

I n t e ros seo u s m e m bra n e

Peroneus brevis m .

T i b i a l i s posterior m.

G rea t sa p h e n o u s v.

P e r o n e u s l o n g u s m . --+-__-La t e r a l i n termuscular se p t u m

F l ex o r d i g i t o r u m

l o ngu s Flexor h a l l u c i s l o n g u s m . Sol e u s m .

F a s c i a of t h e pos t e r i o r t i b i a l a. & t i b i a l n .

G a st roc n e m i u s m .

D e e p fasc i a of the s o l e u s m.

Pero n e a l a. F a s c i a o f the s m a l l

G a s t rocn e m i u s m .

saphenous v.

Poste r i o r i n ter m u scu l a r septu m

The pos terior intermu scular sep tum extends from the internal surface of the apo ­ neurosis a t t h e lateral e d g e of t h e fibula . This septu m separates t h e lateral , anterior region from the pos terior region . Anterior i n te r m uscu l a r s e p t u m

The anterior i n termuscular sep tum exte n d s from t h e deep surface of the apon eu­ rosis a t the anterior edge of the fibula and divides the lateral , anterior leg into

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Chapter 2 / Anatom y o f the Fasciae

an anterior cornpa r rment a n d

a

lateral compartment that contains the peroneal

muscl e s .

T h e an terior compartment contains t h e ex tensor hallucis l o n g u s and t h e t i b i ­

a lis an terior muscles , both of which a r e inser ted in t h e tibi a l aponeurosis. This compartm e n t also c o nta in s the c omm o n extensor muscles of the toes.

At the head of the tibia there i s an osteofibromuscular s tr uc tur e , formed by

t h e tendinous a r c h of t h e s o l e u s mu scle w i t h the pos terior tibia , wh i ch i nves ts

the sciatic nerve and has the abili ty to compress i t . On the la teral , anterior side of the l e g , the ti b i a l a p oneurosis directly inve s ts the tibia and is s t r o ngly a ttached to

its perios teum .

At the level of the popliteal fossa , the p o s terior part of the tibial aponeurosis

s p l i ts to inve s t the deep

muscles a n d the various vessels and nerves , se p a r a t i n g

them from the soleus and g a s trocnemius muscles , known collect i vely as the tri­

ceps s ur a e . Thi s a llows them to slide easily over the d e e p e r structure s .

Fascial Elemen ts of the Foo t

On the dorsum , the fascial sys tem of the foo t is con tinuous with the tibial apo ­

neurosis via the retinaculum , and on the plantar surface , it t e rm i n a t e s at the toes

(Fig. 2 - 1 6) .

D isti n ct i o n is usually m a de b e tween the dorsal and the plantar apo­

n e uroses .

F i g. 2 - 1 6

V e r t i c a l C ross-sec t i o n t h ro u gh t h e Foot

S u p e r fi c i a l d o rsa l a p o n e u rosis

��������D

Ext e n s o r d i g i to r u m l ongus m m .

o rsalis pedis

a.

Exten sor h a l l u c i s b r ev i s m .

Lumbrica l m m .

E x t e n s o r digi to r u m brevi s m m .

O p p on e n s d i g i t i m i n i m i m.

T i b i a l i s a n terior m.

Flexor d i g i t i m i n i m i m . ,--'I�-��

Peroneous l ongus m . Peroneus brevis m.

Lateral a p o n euro s i s

A b d u c tor h all u c i s m.

Deep p l antar a p o n e uros i s Q u a d r a t u s p l a n ta e

I n tern a l a p o n e u ro s i s

m.

Flexor d i g i torum b r e v i s

a.

Flexor h a l l u c i s brevi s m .

Su perfi c i a l p l a n t a r a p o n e urosis

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Ex ternal Fasciae

Dorsal a p o n e u roses

These are three in numb e r : � SU PERFICIAL APONEUROSIS

This aponeuros i s i nvests the ex tensor tendon s . On the sides i t i s at tach ed to the medial and lateral edges of the foot wh e r e it is con tinuous wi t h the plan tar a p o n e uro sis . � APON E U ROSIS O F T H E S H O RT EXT E N SO R M U SC L ES O F T H E TOES

This c orr e s p o n d s to

a

d i v isi o n o f the superficial aponeurosis. I t i nve s ts the

short e x t e n s o r muscles o f the toes , the vessels of the fo o t , a nd the a nterior tibial n erve. L at e r al l y i t is i n se r t e d into t h e l a teral edge o f the fo o t , and media l l y it is continu o u s with th e su p e r fi c i a l a p o n e ur o s i s . � D E E P APO N E U ROS I S

This emanates from the extensor retinaculum a n d inve s ts t h e dorsal surface of the metatarsals a n d t he i n t e r o s s e ous m u s c le s . P l a n t a r a p o n e u roses

There are two pl a n t a r aponeuroses , one superficial and the o ther dee p . � SUPERFICIAL PLANTAR A PO N E U ROSIS

This aponeurosis is separated fro m the skin by a t h i ck laye r of a d ipose tissue an d , like the s u p e rfi C ial palmar aponeurosis , can b e divided into t h r e e different compa r tm e n ts : •

a central cOmparlTI1ent

•

a medi al compartment

•

a lateral compartm en t Centra l compartment. This i s an extremely strong membrane which is

thick all over, bu t espeCially in i t s posterior aspect. I t h e l ps maintain the lon­ gi t u dina l arches of the foo t . This apone urosis corre sponds to a triangle which r a d i a te s out a n te riorly fro m its points of a t t a ch m e n t at the m e t a tarsal p halangeal

a r t i c ula t i ons to the calcaneal tub e ro S ity po s t e r i or ly. I t c o n tai n s ver y s tr on g , longi­ tu d i n a l l y disp o s e d fibers which form p r e t e n di no u s bands anteriorly. These are su­

pe r im p o se d wi th t r an sv er s e l y orien ted fi b ers , espeCially in th e an terior par t ; at the metacarpophalangeal a r t i c u la t i o n s , these l a tter fibers form s up e r fi Ci a l transverse ligaments which su p port the a n ter ior pl an t a r arch. On the sides it is c o n t inu o u s with the lateral a n d medial aponeuroses. Medial comp artment. T h is tissue is

much thinner than the central plantar

aponeurosis and ex tends from the medial tubercle of the calcaneum to the roo t o f t h e g re a t t o e . O n t h e o u tside i t i s continuous with the middle a p o n e uro s is , and

on t h e in s i d e with the superfiCial pla ntar a p oneurosis .

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Chapter 2 / Anatom y of the Fasciae

Lateral compartment. Posteriorly this aponeurosis is a t t a ch e d to the la teral tubercle o f the calcaneus ; a n teriorly it attaches to the fifth metacarp a l . On the inside i t is continu o u s with the middle aponeurosis , an d on the o u tsi de with the su perfic i al aponeurosis. A t the point wh ere the middle a p oneurosis con tinu es throu gh into the l a teral a n d medial aponeuroses , it sends ou t s agittal extensions which at ta c h : •

media l ly t o t h e navicular bone, firs t cuneiform bone, a n d the inferior surface o f the firs t m e tacarpal

•

l a te r ally to the sheath o f the l on g peroneal muscle a n d

the fifth

met a c a r p a l These septa form three separate compartments on the plan tar side of the fo o t : a m e di al ,

a

middle, a n d

a

la tera l compartme n t . None o f these compartments i s

sealed a n d they are crossed b y nu m ero us ves sels a n d nerve s . � DEEP APONEU ROSIS

The deep ap o n e ur o s i s inves t s the interosseous muscles. Posteriorly, i t termi­ nates in the form o f fibrous componen ts of the ta r s us, a n d an teriorly, i t is con­

t inuou s with the deep tra n s verse

li g a m e n t . lower limb a s

m e ta t arsal

I t should b e remembered tha t , i n the

i n the upper l imb ,

t he

t i b i a l fa scia r ep ea tedly divides to i nv est the various s u p e r fi ci al and deep comp o ­ nents of t h e vascular a n d nervous system s . M o s t no t ably, this includes the sciatic nerve which , t o g ether with its many bra n ches , is invested with a fa s cial sheath throughou t its en tire l e n g th down t h ro u g h the common, superfic ial , and deep fibular nerves . As will b e seen later, thi s sheath is often involved i n pa tholog y a f­

fecti n g this n erve .

Table 2- 3

Co n n ect i o n s o f t h e Lower L i m b Fasciae

DORSAL FASCIA

r

A B DO M I N AL FASCIA

G L U T EA

l

FASCIA

r

SKIN

I L I AC F A SC I A TRANSVERSALIS

/ � �

(- lower l i m b fasciae ---7

FASCIA

I NTERMUSCULAR SEPTA

1

PERINEAL FASCIAE TERM I NATION AT T H E TO ES

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PERIOSTEUM

53

Internal Fasciae

.

.

.

. .

.

. . . . . . . . . . .

. ... .. . .

.

.

. .

.

. . .

. .. ... . .

.

.

. .

..

. . . . . . . .

. . .

. .

. . .

. .

. . .. .

.

. . . . . . . . . .

.

. . .

.

.

.

Summary of Lower Limb Fasciae This system is c o n tinu o us with the fascia of the trunk t hro ugh the gluteal aponeuro s i s . I t is a t t a c hed a t the kne e and the

ankles , a n d t er m i n a t e s in t h e foo t .

I t s u ppo r t s a complex ne twork of vein s , lymphatics , a n d nerves which regu­

larly p e r fo rate its surface.

I t is composed of ver tica l , o blique, a n d horizontal fibers which are woven to­ g e ther and interlace to genera te an ex trem e ly s t r o n g t i s s u e . A series of different membran e s emanate from its deep surface : •

in a perpendicu lar direction ,

the intermuscu l a r septa , which anchor the

fascia to the perio s t eum and from there continu e through the osseous trabeculae •

l o n g i tu d i n a l membranes , which go on to invest

the various muscles or

form d ee p aponeuro tic structures

Fin a l ly, the fa scia o f the upper limb spl its repea te d l y to inve s t and pr o t ec t ves­ sels and nerves , b o th s u per fi cia l l y and deeply It also a r ticulates with : •

the thoracic fascia

•

the s uperficial and deep p eri n ea l fasciae via the aponeuroses of the pir i formis and internal obturator muscles

• •

the iliac fascia via th e aponeurosis of the pso a s muscle and fina l l y, the deep abdominal fascia and the transversalis fascia at the inguinal ligament

.

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

.

I n te r n a l Fasciae The in ternal fasciae will be deal t with in the followi n g order : •

t h e fascia e of the neck ( [he cervical and prevertebral fasciae)

•

th e fasciae of the thorax

•

the fa s ci a e of the abdomen

•

t h e fasciae of the pelvis

M I D D L E C E R V I C A L FA S C I A The middle cervical fas cia extends fr o m the hyoid b o n e to the p o s terior face o f

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Chapter 2 / Ana tomy of the Fasciae

the clavicle and the s ternum . Its sides inve st the omohyoid muscles and it i s con­ tinu ous with the superficial and deep fasciae at the an terior edge of the trapezius muscle (Fig. 2 - 1 7) . Fig. 2 - 1 7

Cross-sec t i o n th r o u g h t h e N e c k a t C6

Mee t i ng poi n t of s u p er fi c i a l a n d d e e p fa s c i a e M ee t i n g of v i s c e r a l a n d m i dd l e cervical fa sciae

A n te r i o r j u g u l a r v .

Thyroid fa s c i a

S t e r n o c l e i d o m a sto i d m . Stern o t h yroid m .

M ee t i n g poi n t of visceral a n d vasc u l a r fas c i a e

External jugular v.

P h a ryngo ­

Vasc u l a r s h e a t h

b a s i l a r fasc i a

S u p e r fi c i a l cerv i c a l

Preve r t e b r a l fa s c i a

fasc i a M i d d l e cerv i c a l fas c i a D e e p cerv i c a l fa s c i a Sympathetic cervical n.

M i d d l e sc a l e n e m .

Vertebral vessels

Brach ial plexus

far as the lower end of the larynx . Lower down , the two fasciae separate to defme the subs ternal spa ce through which passes the a n t erior j u g u lar vein .

In the fro n t , the mi ddle cervical fascia i s j oined to the superfi Cial fascia

as

At the lev el of the anterior n e ck musc l e s , the middle cervical fa s cia splits into a s up e rfiCial sheet for the s ternocleidomas toid and o m o hyoi d muscles , and a deep sheet for the thyrohYOid and s terno thyrOid muscle s . Exp ansions proj ect fro m its deep fac e which c o nn e c t with t h e periphary n g e a l membrane and t h e vascular bundle of t h e n e c k which s u r rounds the common ca­ rotid artery, the internal j u g u l a r vein , and the vagus nerve , ea c h component bei n g inve s ted w ith its own sheath . It a l s o sends ou t an ex tension [0 the th y r o id gland and contribu tes to the fa scia of tha t org a n .

In t h e inferior, lateral p a r t , a fter attachment t o the c l avicl e , are extremely strong extensions to the brachiocephalic venous trunk and the s ubclavian vein

which keep these veins open and

in place . They also contribute to

,

th e subclavian

fas ci a . The middle cervical fascia extends down in[O the anterior thorax i n the form

of the endothoracic fasci a . P R E V E R T E B R A l FA S C I A The fro n t o f this fa scia inve sts the prever tebral muscles o f the neck, hence i ts al-

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In ternal Fasci ae

tenlate n a m e , nuchal fa scia . It is a t tache d : •

superiorly t o the basilar apophysis o f the o ccipital bone

•

laterally to the transverse processes of the cervical vertebrae where it is continuous with the apneurosis of the scalenes . Through this i t j oins

with both the deep fa ce of the superficial fas cia in front of the anterior edge of the trapezius muscle , and the middle cervical fa sci a . In this way, it separates the visceral sheath in front from the muscular sheath of the neck behind. An teriorly on the m e dian line , it is connected to the pharynx and the esophagus via

a

very loose sheet of cellular tissue . Laterally i t extends to the c arotid arteries ,

the in ternal j ugular vein , and the vagus nerve , a s well a s t o the an terior branches o f the spinal n e rves which are invested by the prevertebral fa scia e . Pos teriorly, extension s of this fascia inves t the prevertebral muscle s : t h e lon ­ gus colli muscle of the neck and the rectus capitis anterior muscles ( b o th mi­ nor and maj or) . I t should b e noted that these muscles are the only suboccipit a l muscles to be located in front of t h e ver tebral c o l u m n and are therefore within the cavit y. It a lso supports the sympa thetic nerves a n d communicating branches which are held in a continu a tion of the prever tebral fascia or in a special sheath. A fter insertion in the first thoracic ver tebra , i t con tinue s down in the form of t h e pos terior endo thoracic fa scia (Fig. 2 - 1 8 ) .

E N D O T H O R A C I C FA S C I A The endothoracic fa scia lines the inner surface of the tho racic cag e , lying in terior to the ribs and the i n ternal in tercos tal m u scles to which i t i s a ttached via fibrous connec tions (Fig. 2 - 1 9 ) . Behind , a s Rouviere h a s shown , opposite the l a teral fa ce o f the vertebral col u m n , the endothoracic fascia is denser and is a ttached t o the ver tebrae via fine li g a m en t s . Higher u p , t h e endothoracic fascia covers t h e pleural dome a n d is a t tached to the periosteum of the fi r s t rib, especially s trongly to i ts pos terior por tion . In addi tion , in front , it is also a t tached to the sheath of the subclavia n artery ( e s ­ tablishing a link w i t h t h e cervical fascia) . H e r e i t thickens Significan tly t o form

a fibrous transverse s e p tum within which s eparate ligaments which suspend the p l e u r a are distinguished : •

the costopleural ligament

•

the trans verse cupular ligament

•

the pleurover tebral ligament

Its l ower part covers the diaphragm to which i t is very tightly a t tached and by means of which it extends down into the abdominal wall through the fascia transversa l i s . I ts inner face i s strongly a ttached to the parietal pleura , which i s thereb y a ttached to the thoracic wall . I t is thick and rela tively soft around the mediastinu m , a l though i t changes into a fibrous layer where i t is j oined to the pericardium immediately underneath the pleur a . The pleura a t taches t o t h e thoracic wall by means o f t h e endothoracic fascia :

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Chapter 2 / Ana tomy of the Fasciae

56

anter iorly i t does so a t the s ternu m , and pos teriorly between the posterior angle of the ribs and the vertebral column , and also to the vertebral column i tself. .

. . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . .

Summary of the Fascia of the Neck 1. A

superficial fa scia which extends d ownward from the cra nial fa sciae and thoracic outlet , continuous with the fasciae of the : - t h o ra x

termin a t es around the - upper limbs.

• It

inve st s

the s up er fi c ial muscles , nerves , and veins o f the anterior

and pos terior n e c k .

•

co n tinu o u s with t h e middle cervical a n d prevertebral fasciae at the la teral e d ge of the trapezius muscle in the anterior neck .

It is

2 . A middle fascia present in the an terola teral p a r t of th e neck which origi­

h y o i d bone , passes down through the sternum , a n d continues endothora cic fascia .

nates a t the into t he •

It

invesrs the d eep a n t erior, l a t e ral muscles.

•

It

invests the neurovascular bundle (the caroti d ves sels , the the vagus n e r ve) which pass through the neck .

j u gular vein , and •

It g o e s

on to b e part of the th y ro l aryn g ea l fascia .

•

[t connects wi th the superfiCia l and de e p fasciae, and with the pharyngobasilar fa sci a .

3 . A d e e p fascia .

•

Th i s

o ri g in a t es

in t h e basilar apophysis

of the occiput.

• It extends downward via the endothoracic fascia after i n se r t i o n in to T I . • Pos teriorly, it is a ttached to the vert e b r a e . •

It

tr a n sv

e rs e processes of the c e r v i c a l

forms the scalene fascia and thr ou g h this j oins the middle and the pre v e r t e br a l muscles.

s u p e r fiC ia l fa sciae, and invests

• It supports the cervical plexus and, in the form of an extension , the

cervical ganglia . • Finally, i t is connected to the pharyn gobasilar fascia by an teroposterior me mbran es. '. "

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" ." ." "" " ".

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57

Fig. 2 - 1 8

InternoJ Fasc i a e

Sag i tta l Sect i o n S h o w i n g t h e F a s c i a e o f t h e N e c k

Hyo i d b o n e Thyrohyoid m e m brane

-, T h y r o i d c a r t i lage --1------__

Trachea --+--f-.t-f1 M i d d l e cervi c a l fas c i a S u perfi c i a l cerv i c a l fa s c i a

T h y r o i d fas c i a

P h a r y n g o b a s i l a r fas c i a

-/--J----1�'!I-___1

T h y r o p e r i c a rd i a l l a m i n a Deep b u n d l e o f _I-"��r-' m i d d l e fas c i a Thymic compartment

Esophagus

Fasc i a i n ve s t i n g ( h e brach i o c e p h a l i c t ru n k

Deep ce rvi c a l fas c i a

T h y r o p e r i c a rd i a l lamina E n d o t h o ra c i c fas c i a S u pe r i o r s t e r n o ­ p e r i c a rd i a l l i g.

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58

2- 1 9

Chap ter 2 / Ana tomy of t h e Fasciae

V e r t i c a l Sec t i o n t h ro u g h t h e T h o r a c i c Wa l l R i b a t ta c h m e n t

V i sceral p l e u ra

S u b p l e u ra l con n e c t i v e l a yer

F i broe l a s t i c l a ye r

I n t e r n a l i n tercos t a l m .

E x te r n a l i n t ercosta l m .

S u b mesothel i a l layer

Endothoracic fa s c i a Mesoth e l i u m

S u p e r fi c i a l fa sc i a Space e n a b l i n g p l e u ra l g l i d i n g

Tab l e 2 - 4

Con n ec t i o n s of t h e Su perfi c i a l Cerv i c a l Fac i a

EPICRANIAL APONEUROSIS

t T E M P O R A L A P O N E U RO S I S

t

MASSETERIC FASCIA

T

SKIN

/

MI DDLE CERVICAL FASCIA

S u p e rficial cervical fas c i a TRANSVERSALIS

D E E P C E RV I C A L

FA S C I A,

FASCIA

I LIAC FASCIA THORACOA B DOM I N A L FA S C I A E

� FASC IAE OF THE UPPER AND LOWER LIM BS

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59

Ta b l e 2 - 5

In terna l Fascia e

C o n nect i o n s o f t h e M i d d l e Cerv i c a l F a s c i a

SUPERFICIAL FASCIA

T /

FA S C I A O F T H E U PPER LIMB

M i d d l e cervi c a l fascia PREVERTEBRAL FASCIA, PHARYNGOBASILAR FASCIA

RENAL FASCIA FASC IAE OF TH E

/ 1

PERICARDIUM

EN DOTHORACIC FASC I A

>

1

TRANSVERSA L I S FA S C I A

1

LOWER LIMB

D I A P H RA G M PLEURA

<

P E R I TO N E U M FASCIA PROPRIA, ABDOMI N A L APON E U ROSES

P E R I N EA L FASC IAE

Ta ble 2-6

Con nect i o n s o f the Deep C e rvi c a l F a s c i a

EPICRANIAL A PO N E U ROSIS

MI DDLE A N D SUPERFICIAL CERVICAL FASCIA E

Deep cervical fasci a

PHARYNGOBASILAR

/

FASC I A

1

E N D OT H O R A C I C FASC I A

RENAL FASCIA

1 I L l A C FASC I A

�

1

TRANSVERSALIS FA S C I A

1

�

PERICARDIUM D I A P H RAGM P L E U RA

P E R I TO N E U M

�

PERI NEAL FASCIAE

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RENAL FASCIA I LIAC FASCIA

Chapter 2 / Ana tomy of the Fasciae

60

T R A N S V E R S A L I S FA S C I A

The transversalis

fascia lines the inner surface of t h e abdomen . I t ad h e re s tightly

to the pari etal peri toneum via the fa scia propria and it

the

two. Its lower p a r t spli t s to form a s a c

formed from a t h e maj or

re t

vessels

is d i ffi cu lt to di s t i ng u i s h s u rr o u n di n g t h e k i d n e y. This sac i s

r o ren a l fa scia , th e middle part of which is attached behind t o

a n d t h e vertebrae, and from a p r er e n a l fascia . T h e s e two fasciae

j oin on the sides in fr o n t to form the sac which contains the kidney s . The top of this fascia

is

attached to the

I t s lower part

is

diaphragm ,

and

the

bottom to the ilia c fa sci a .

in contact with the organs o f the lesser pelvis and

tinuous with the p a r i e t a l peritoneum. It extends

a

is

con ­

diverticulum into the in g ui na l

canal , vvhich fo r m s the fi br o u s sheath of the cord . The transversalis fa scia is also continuous wi th the shea t h of the extern a l iliac arterie s . In i t s a n t er i or and middl e

p a r t s , it is str en g th e n ed by the in gu i n a l falx (Henle 's lig a m en t ) and the interfo­ veolar (Hesselbach 's) l igamen t . P o s te r i o rl y i t originates a t t h e l a te r a l e d g e of t h e lumbar r eg i o n where i t i s connected t o the iliac fas cia : i t s ventral portion is in timately a s s o ci a t e d wi th the

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' .

.

.

o

0

o

Summary of the Endo thoracic and Transversalis Fasciae th e neck. The cervical and prevertebral fasciae continue to form the en d o thoracic fa sci a , which itself continues to form th e transversalis fascia a ft er a d etour to create the

These c o r r esp o n d to con tinua tions o f the fasciae of

diaphrag m . T h e endothora cic fascia connects : •

on the outside , with the inner surfa ce of the t ho rac i c cavi t y

•

on

•

inferiorly, wi th the diaphragm and then the transversalis fa scia

the in si de ,

with the pleura and the pericardium

The transversalis fascia j o in s : wi th the diaphragm and the e n d o t ho r a c i c fa s ci a

•

s u p e r io rly,

•

o n the outside, with the deep abdominal fasciae and the renal fa s ci a

•

i n te r io r l y, with the pe r i t o n e u m

•

inferiorly,

with the

fasciae of the l e ss er pelvi s of, on the o n e hand , the

lower limb and , on

the o th e r hand , its extensions toward the inguinal l i g am en t (forming a c ha nn e l o f c o m m u n i c a tion to the outSide )

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61

Interna l Fasciae l inea a l b a I t is for m e d o f transverse fi b e r s p lus esp e ci ally in its anterior p o r ti o n .

,

,

ver t ic al and o b l iquely inclined fibers . It varie s in thickness , b eing thickest in the subumbilical part

The an terolater a l part of the fa s c i a transversalis i s in contact with t h e a b d om i ­ p osterior p a rt is separated by the renal fascia . This , as d iscussed in the previous sect i on , rests on the iliac fascia , which itsel f results from the s pl i t t in g of the pos terio r a b d o min a l fas ci a e The ili a c fa scia i s attached medially to the vertebral b o d ie s , a n d to the inser­ tion of the psoas muscle on the inominate bone La teral ly it is a t tached to the

nal fa sciae fr om \vhich its

.

.

qua d r a t u s lumborum .

Higher up, the il iac fascia is thickened at vvh a t is kn own as the media l a rcu a t e li g a m en t a te nd i no u s arch in the fascia that covers the superior part of the psoas ,

muscl e . On t he inside, this is attached to the body of the s e cond lu mbar vertebra and then passes around the p s o a s in fro n t to t e r mi nate at the base o f the tra n s ve r s e

process of the first l u m b ar v e r te b r a . The iliac fas c ia is

a t ta

c he d to the inguinal lig a ment in fro n t , while its me di a l p a r t i s thickened to form a s trong , fibrous lamella , t h e ileopectineal li g ament which defin es the ou ter edg e of the femoral ring. B e l ow the arch , the iliac fascia ex tends to the tro c h a n t eri c inser tion of the iliopsoas and c ont rib u tes to the fa scia ,

lata .

FASC I A E O F T H E P E R I N E U M A N D P E LV I S The p er i neal fasciae serve to close t h e lower part of the a bdo m ina l cavity. These very strong fa scia e are i n ser t e d around the p erimeter of the p elV i S and c onta i n openings in the antero p o s t e rior direction . In the an terior p a r t , there are necessar­

ily differences b e tween males and female s . They suppor t a n d re i nforce t h e three muscular p l a n e s of t h e lesser p elvis and are therefore three i n number : •

the superfiCial fascia of the p e rin e u m

•

the middle fascia of the perineum

•

the deep fa scia of the perineu m , or urogenital d ia p hr a g m

Superficial Perineal Fascia

This subcutaneous fascia ex t ends onl y as far a s t h e a n terior perineum . Its attach­ ments are : • •

on the sides , to t h e anterior lip of the isch i o p ub i c rami sup er i or ly as it extends a n t e riorly, i t i s continuous with the s u perfiCi al ,

fascia of th e p enis in m en In women , it disappears on the inside in th e .

conn ective tis s u e of the lab ia minora anteri o rly and is continuous with ,

the fascia of

•

the clitoris Its base extends fr o m one ischium to the other and defines the border between the a n t er i or and posterior perineum . Here, it curves p osterio r ly u p war d s and, haVing skirted the posterior edge of the superfiCial Copyrighted Material

62

Chopter 2 / Ana tomy of the Fasciae

transvers e muscle, i t j oins with t h e lower sheet of t h e middle fa scia . It s en d s ex tensions out to t h e central tendon of the perineum

2 -2 1 ) . •

(Figs. 2 - 2 0

&

Extensions emana ting from its deep surface line the deep p e rin e al fascia

as well a s the ischiocave rnosus and bulbospongiosus muscles. These extensions are fused with the deep sheet o f the

Fig. 2 -20

Fasciae

of

m id

d le fa scia .

the Pelvis ( Female)

S u p e r i o r re([al a .

\

T r a n svers a l i s fa s c i a

Presacral fas c i a

S u perfi c i a l fa s c i a of t h e a b d o m e n

R e c to u teri ne pouch

Med i a n u m b i l i c a l l i g.

-+-�r\ iI

-

Dee p p e r i n e a l fa s c i a A n ococcygea l body

Vesica-vag i n a l s e p t u m

Su p e r fi c i a l p e r i n e a l fa scia

C e n t ra l t e n d o n o f the peri n e u m

Rectova g i n a l fas c i a

A

//

Dee p p e r i n e a l M i d d l e p e r i n e a l fas c i a ( s u p e r fi c i a l a n d deep b u n d les)

fas c i a

.--/ I

�

Middle Perineal Fascia This structure is a l s o known as t h e u r og e ni t a l d i aph r ag m or C r uveilhier 's fa s­

ci a Trian g u l ar in s ha p e i t only occupies the anterior, or u ro g e n i t a l tr i a ngle , of .

,

the perineum . Many differen t , s o m e ti m e s contradictory de s c r i p t i o n s have been published by, among o t he r s Gregoi re and Rouvi. ere. This is evidence o f the com­ ,

plexity of th i s fascial eleme n t . In our opinion , the clearest and

m os

t useful under­

s t a n di n g of the ana tomy h ere is tha t described by Tes tut a nd R o u v i e r e

.

This fa s ci a consists of tvvo layers , o n e b elow the muscles of the middle p l a ne and the other above ; the deep transverse fascia , and the urethra is in fro n t .

Copyrighted Material

p e r in e al

muscles a re situated behind t h e

63

Fig. 2-21

Interna] Fasciae

F r o n t a l V i e w of t h e M a l e P e l v i s S e c t i o n e d th r o u g h t h e I s c h i o p u b i c R a m i

O b t u r a t o r vess e l s a n d

Asce n d i n g s h e e t of the pe l v i c fas c i a

n.

O b t u r a t o r i n tern u s m . ...-.�.rn O b t u ra t o r extern us

r;.)6�IiI-- U reth r a

m. --1",",'''''''''''''

Levator a n i m .

!!I4��'r- I s c h i o re c t a l fo ssa

A p o n e u ro s i s of t h e o b t u ra t o r i n te r n u s m .

Ischiopubic rami I s c h i ocavernosus

Dee p p e r i n e a l fasc i a

m.

Deep t r a n sverse p e r i n ea l m .

M i d d l e peri n e a l fascia ( s u p e r i o r and d e e p s h eets)

B u l bospongi osus

S u p e r fi c i a l per i n ea l fas c i a m.

I n fe r i o r l ayer

T h i s thick . s trong fa scial l ayer. also known

as

the puboprostatiC. perinea l . or Car­

cassonn e 's ligamen t . inserts la terally in to the medial surface of the ischium and into the internal lip of the lower edge of the ischiopubic ramus immediately be­ low the a t tachments of the corpus cavernosum a n d the ischiocavernosus muscle s . I t s a n terior ( bu t not i ts pos terior) part is a ttached to t h e ischiocavernous muscles. It extends transversa lly and . along the median lin e . is tightly a s s o ciated with the dense fi b rous tissue around the corpus spongiosum and the urethra . Its pos terior e d g e j oins the superfiCial fa scia of the p erineum inferiorly. and the deep layer of the middle fascia superiorly. Po s teri orly. it sends out ex ten sions to the cen tral tendon of the perineum . Anteriorly. it is con tinu ous with the supe ­ rior layer. The lower layer of t h e middl e p erineal fa scia creates a secure a ttaclU11 ent between the bulb and the corpus spongiosum of the peni s . which i t securely anchors to the ischiopubic r a m i . I ts natur e is not the same throughou t . Po steriorly. where i t invests the deep transverse p erinea l muscle. i t is thin . whi l e i t is thicker a n d stronger close to the membranous ureth r a . A t this point the fascia resembles

a

lig ament. Further an­

terior. it is thicker a n d continues to for m the inferior pubic ( arcuate) ligamen t . which closes the superior. an terior p a r t of t h e perineum .

Copyrighted Material

64

Chapter 2 / Anato m y of the Fasciae

S u p e r i o r laye r

This l ay e r covers the s u peri o r surface of the deep t r a n sv er s e perinea! mu scle

and is also known as the deep lay e r. Pos t er i orly, i t j o in s the superficial layer of the fascia and sends e x te n s ion s out towards the central tendon o f the pe r i ne u m (Fig. 2 - 2 2 ) . I t s extreme anterior part unites with the in ferior l ay er t o form the ing uinal aponeuro tic fold , also known a s the conj oined te n d o n , finally terminating at the arcuate li g ament of p u bi s . On the s ides , the superior layer of the middle p e r i n e a l fa scia is a ttached to the i s c h i o p u bi c ramus above th e in s e r ti on p o i n t of the deep t r a n sv e r s e muscle. It sends ou t an extension to the aponeurosis of the i n te r n a l ob tura tor. This ex t e ns i on splits to form a fib r ou s conduit , known as the p u den d a l canal or Alcock's canal, thr o u gh which pass th e pudendal vesse ls and nerves. of the s triated s p h i n c t er of the urethra . For this

Fig. 2-22

re a s

on

it

S u p e rfi c i a l a n d M i d d l e P e r i n e a l F a s c i a

.�---,;o=--

Sacros p i n o u s l i g.

M i d d l e p e r i n e a l fa scia ( s u p e r i o r s h eet) Deep t r a n sverse peroneal m. Presacra l fas c i a E x t e r n a l sp h i n c t e r of t h e u re t h r a M i d d l e peri n e a l fas c i a ( i n fe r i o r s h e e t ) S u pe r fi c i a l tra n sverse

m. of peri n e u m

S u pe r fi c i a l p e r i n e a l fas c i a

The pos terior p a r t of the middle fas c ia of the perineum has a l a m e lla w h i c h as­

c e n d s b e t\veen t h e p r o st a te and the membranous ure thra in front and the rectum

behind. A t t h e top , i t han g s fr o m the rectouterine (fem ales) o r t h e rectovesical (males) p ou ch , which is also

known as Dou g l as ' pouch. It for m s the r e c tov e s i c a l

se p tum, also known as Denonvilliers a p o neur o s i s .

This fas cia s p li t s into two membranes :

• •

a posterior membrane which fo r m s the rectovesical s eptum an an t e r i o r membrane which inv e s t s the semina! vesicles , the vas d efer e n s ! , and the posterior portion of t h e prostate Therefore, i t forms Copyrighted Material

65

Internal Fasci a e the prostatic cavity with the anterior part derived from the mi ddle fascia of the perineum In females , the rectovesical septum is replaced by a thin membranous lamella

whi ch for m s the r ecto vag i n a l sep tum . In males , the two layers of the middle fascia

of the perineum enc l ose the b ulbourethral ( Cowp er s ) glands . This contains two '

openings : •

the opening of the dorsal vein of the p enis , betvveen the a rcuate ligament of pubis and the transverse ingUinal falx

•

fur t her pos terior is the opening of the membranous portion of the urethra , w i th its external sphincter situated even furrher posterior

Deep Fascia of the Perineum This is

a

far more ex tensi ve fascia than the two tha t

we r e

previously discussed .

It ex ten ds into b o th th e anterior and pos terior perineum , and even b eyond the confines of the perineal region , to climb back up the lateral walls of the p elviS and reach pa rts of the su perior ap erture o f the minor p el v i s

Fig. 2-23

(Fig. 2 - 2 3 )

F r o n t a l V i e w of t h e M a l e P e l v i s S e c t i o n e d t h ro u g h t h e A n u s

I n te r n a l o pe n i n g i n to t h e o b t u rator c a n a l

Arcus te n d i n e u s

Extension of the deep fasc i a to t h e rec t u m

Obtu rator i n te r n u s m .

Levator a n i m . -�-----\

F a s c i a o f the o b t u ra to r m.

Deep fa s c i a i n vesti n g t h e levator a n i m.

Pudendal vesse l s and n. (pudendal can a l ) Perineal mm. a n d m i d d l e pe r i n e a l fa s c i a

Anus

E x te r n a l s p h i n c t e r

The sup erior part of the pelvic cavity con tains eigh t muscl e s : • •

the levator ani

mu sc

l es in th e cen tral part

the ischiococcygeal mus cles behind

•

the obturator

•

the piri formis m uscles in the posterolateral par t

muscles

on the side

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66

Chapter 2 / Anato m y of the Fasciae The s e eight muscles are e a ch invested by a sp e cific fa scia . All these fa s cia e c o m e

tog e th e r to form th e d e e p p e rin e al fa s cia whic h , t og e th e r with the action of the

above- m en tioned mu s cl e s , clo s e all the perinea l o p eni n g s apart from those in the

median plane. Thu s , the extensive p e r i n e a l fascial system has (he overall shap e of a

funnel . In order to facilita te de s c r ip ti on , i t can b e d i vid e d into two symmetrical

halves , both o f which can be considered i nd e p e n d en tly in terms o f: • •

a lateral edge

a m e dial e d g e

s u p e rio r surface

•

a

•

an inferior s ur fa ce

Late ral edge

The la teral e d g e inserts :

an teriorl y, on the pos terior s urface of the body of the pubis and the

•

horizontal ramu s

•

on

•

(conn ec ting

wi th the an terior abdominal faSCia)

the fi b rous arch which defines the bo ttom of the medial o p e nin g o f

the obturator canal a n d t o which i t contributes

behind thi s same can a l , i t cl im b s back u p a s far as the p elv i c intet and i n s e r ts a t the arcuate line where it fu s e s with the i l i a c fascia ( connectin g

with the la teral a b d o min al and the p elviC fascial systems) •

i t t h e n descends [Ow a r d the grea ter scia tic n o t c h along t h e superior edge o f the piriformis m u s cle

•

finally, it arrives in contact w i th t h e p r e s a cr al aponeruosis and a ttaches

inside the an terior aspects o f the sacral fo r a m i n a ( c onn e c ti n g with the abdominal faSCia) M e d i a l edge

The two h a l v es of the p elV i C fascia o n ly contact one another at two points on the

m e dian line : •

perineal raphe

•

anococc y g e a l raphe

An t e r i o r [0 the p er ine al raphe , they are s e p ara t e d by a trian gular space

formed

by the m i d d l e fa scia o f the p e r in e um . Be twe e n the two raph e s , t\NO ha l ves of the p e l v i c fascia are se p a ra te d by the r ec t a l o p e n i n g and j oi n up again a t the fibrous s h e a th o f the pelvic rectu m . A t the l ev el o f the pro s t a t e , i t unites with the l a teral aponeurosis of the pros tate, and thro ugh this link, 'Nith the middle fascia . I n fe r i o r s u rface

The inferior su r fa c e rests d i re c tly on the u n d e r ly i n g muscl e s and is j O i ne d [0 the m by a thi n layer of cellular tis su e . S u p e r i o r s u r face

The superior surfa c e is s e p a r a t e d from the peri toneum by a space which co n tai n s

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67

In ternal Fasciae

the urethra , the vas d e fe r e ns , and the vessels and n erves which supply the pelvic vi s cera . The deep perineal fascia is not o f uniform thickness b u t co n ta i ns t hree t h ic k e n e d liga m ento u s areas which radia t e o u t fro m t h e i sc h ial r idg e to form a three po i n ted star : -

•

the tendin ous arch of the levator ani, which extends to t he i schi u m

•

a band of reinforcement which r uns along the anterior edge of the

•

a band of reinforcement which descends down along the j u ncti o n o f

greater sciatic notch of ischi um the coccygeal muscle on o n e side, a n d th e p i r i for m is along wi th the sacral plexus on the o ther It s hould b e noted that the aponeurosis of t h e ob turator internus m uscle- t he

s u perior part of w hi ch is assoc i a t e d with the middle and s uperior fa sciae of the perineum-continues dmvn thro ugh the sacrot u b e r o u s li g a m e n t and extends onto the a n t e rio r surface of the glute u s maximus muscl e , which extends b elow this l i g amen t ( j oi n i n g with the s u p e rfi cia l fa sc i a ) . The deep pe r i nea l fa scia sends ou t ex tensions to t h e central tendinous point of the perineu m . In (he anteropos terior directio n , i t i s (s ur ro u n d e d by its sphincter) , the ure thra

(at

p e r for a t e d

by the rectum

its exit point from the p ros tate)

,

and in women , the va g ina . The deep p e r ine a l fascia is i n s er t ed all around the p e ­

r iphery of t h e vagina and is o n e o f the m ain s tructures s u p po r t i n g i t .

T h e d e e p perineal fascia is attac h e d to the colon v i a extensions (cont i n u o u s

with the vi s c er a l fas c i a) , and i ts p o s terola tera l part ( the fa scia inves ting the piri­ for m is m u s cle s ) supports the l u m bosacral ple x u s

.

Other fasc i al elements are present in the p e l vi s and compartmentalize it by

dividing the front from the back . The following will be considered in detail : •

the p r esacr a l apon e u ros i s

•

the rectovesical or rec tovaginal septa ( preViou s ly m en t i o n ed)

•

the ves i covaginal sep tum and the parametrium in females

•

the u mb il ica l li g am en t s

•

the s acrog e n ital folds a l o n g with th e membranes covering the internal iliac ar tery and hypog a s t r ic

pl e x u s

The first four struc tures are v ascu l a r membranes o r i e n t ed in the frontal

p la n e

.

The

last sep tum has a sagittal or ien tation.

Rela ted Perineal Fascial S tructures P resacral a p o n e u rosis

This aponeurosis descends from the abdomen with the middle r ecta l a r tery (it is co n t i n u o u s \'-ri th the ab domina l fa sc i a e ) , l i n i n g the in terior surface of the s a cr u m . It j oins the pos terior surface of t h e rectum v i a i t s fibrous sheath , which is call e d

the retrorectal fascia . T h e re trorec tal fascia ex tends from the ter mi n a t i o n of the

sigmOid m eso c olo n down as far as the floor of t h e p elVi S . T h e pos terior p a r t of t h e d e e p p e r i n e a l fa scia terminates at t hi s s truc ture ,

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Chapter 2 / Anatomy of the Fasciae

which s upports the lamella of the s acr o g e ni t a l folds. I t also supports the s ac ral pl ex us and the co c cy g eal body. Rectove sical a n d rectovagi n a l septa See previous discussi on . Ves i covag i n a l a p o n e u ro s i s T h e bla dder is sepa ra t e d from the vagina by

a

cel l u la r s e p t u m , the vesicovaginal

fascia . The j ux tavesi c al terminal segment of the ureter trans versely c ro s s e s the t h ickness of this fas c ia . The rectovaginal and vesicov a g in a l septa ex tend to the

broad ligamen t of the uterus , which is ing t h e

a

thi c k e n ed part of t h e pe rit o n e um inve s t ­

uterus , the fallopian t ubes , t h e ovaries , a n d th e r o u nd l i g a m e n t s of the

uterus (Fig. 2 - 2 4) .

This ligament has a very com p licated shape and only a br ief

de scr i p tion will be g iv e n . Fig. 2 - 2 4

A r ra n g e m e n t o f t h e Pelvic Fasciae

U m b i l i c a l fasc i a I n te r n a l i l i a c a . Sac roge n i ta l fo l d

Rectovesical s e p t u m Sac r u m

P u boves i c a l l ig. --r--ti���;�" M e d i a l u m b i l ical l i g.

Levator a n i m . Deep peri n e a l fas c i a

The bro a d li g am e n t of the uterus is form e d by two p e ritoneal sheets which line, respectivel y, the anterior and pos t e rior surfaces of the org an . S tar ti n g from the lat­ eral edge of the u terus , these two j uxtaposed sheets (which are con tinuous wi th one ano ther) pass ou twards to r each the lateral wall of the p elvis , where they fold

back to form the pelvic pa r i e t a l pe rit o n e u m . In a simila r fashio n , at t h e bo ttom .

the two sheets be gi n t o s p read away from one another as th ey move back a cross the Boor of the p elvis. Where they fold back , one turns forwa rd and the o ther

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In ternal F([5c i a e

turns b a c k t o form t h e pel v i c peritoneum of the b a s e o f t h e pelvis

Fig. 2 - 2 5

(Fig. 2 -2 5 ) .

S u pe r i o r V i ew o f F e m a l e P e l v i s

Bladder

Ro u n d l i g

.

An terior sheet Fa l l o p i a n t u b e Ova r i a n l i g.

�""""",-r.=0tti:'>--- Mesosa l p i n x

Poste r i o r s h e e t o f broad l i g. Recto u t e r i n e p o u c h S u s pe n sory l i g. o f o v a r y

Ex t e r n a l i l i a c a.

U terosacra l l i g.

The broa d l igament has thus formed the shape of a transverse quadrilateral s ep tum

which i s acutely inclined in a forward and downward d irectio n with a m arke d ly ,

concave con figura tion oriented p o s teriorly (Fig. 2 - 2 6) .

Distinction i s usually •

m

a d e be tween two different parts :

the inferior part, which is thic k , immobile, and tightly associated with both the wall of the p elviS and [he ce r vi co i s thrni c region of the uterus ,

as wen as the vagina . It corres p onds [0 the p arametrium suppor ting the uterus and to the paravagina , the superior vaginal support •

the superior part or mesometr ium , which includes three differeD [ p a r t s : - the mesosalpinx

- a funicular part called the round ligament

- the mesovariu m , which is

s u p p o r t e d by the ovarian l i g a m e n t and

the

supensory li gament of the ovary U m b i l i c a l fas c i a

This a t t a c h e s to the vascular tentoria of t h e u mbilical a n d vesical a r t eri.es , which i t supports l a t e r ally from t h e median line. It is a l s o a t tached to t h e median umbilical ligamen t

(Fig. 2-2 7) .

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Fi g. 2-26

Chap ter 2 / Anatom y of the Fasciae

B ro a d L i ga m e n t

-�iI--- Mesosa l p i n x

Pe r i to n e u m a t base o f u t e r u s

S u pe r i o r e d g e

La teral edge

An terior sheet E x te n s i o n of u terosa c r a l l i g.

I n fe r i o r e d g e

Fig. 2 - 27

U m b i l i c a l Fascia

Med i a n u m b i l i c a l l i g.

Me d i a l u m b i l i c a l fa s c i a Rectus a b do m i n i s m . U m b i l ical a. P reves i c a l space

B l adder

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Fasciae o f the Cen trol Axis

I t is tri.angular in shape and markedly concave towa rds the back . It is arrached to the umbilicus a t its top and travels a short way posteriorly and inferiorly to

reach the top of the bladder. On its arriva l at the bladder, it suddenly broadens and folds back on itself to form a sulcu s , which is concave pos terio rly. This touches

the anterior a n d lateral surfaces of the bladder and then descends along its sur­ faces u nt i l it reaches the floor of the pelvis where i t terminates i n the following m anner : • •

on the median line , it fuses with the pubovesical ligaments

laterally, it j oins vvith the pelvic aponeurosis of the pubovesical lig a ments as far as the anterior edge of the two sciatic notches

The l a teral edges of the umbilical li gament e x tend obli q u ely from the greater sciatic no tches to the um bilicus . They are a t tached to the abdomino pelvic wall at s everal poi n t s : • •

a t the borrom , to the aponeurosis of the internal obturator at the top, to the sheath o f the transversalis fascia up to three or four centimeters below the arcuate line of the sheath of the rectus abdominis mu scle

The inferior part of the umbilical ligament crea tes a retropubic space (also known as the Re tzillS space) be tween the bladder and the abdomin a l wall. Sacrogen i t a l fo l d s

These s tructure s , a l s o known as the sacrorec togeni topubic membranes of Delbe t , correspond t o t h e ten toria o f the in ternal iliac ar teries. The membranes ex tend in a sagittal direction from b ehind and inside the s a cral foramina a s far as the pos­ terior surface of the pubic bone an teriorly. They travel a long the l a teral b orders of the pelvic viscera , towards which they extend fibers . On their medial surfa c e s , they a r e doubled u p and reinforced b y a nervous lamella corre sponding to the hypog a s tric pl exus (Fig. 2 - 2 8 ) . .. . " " " " " " " " " " " " " " " " "

" " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " . ..

Summary of the Fasciae of the Perineum and Pelvis There are three fasciae in the perineum which close the inferior part o f the abdomen . Thes e three fasciae are reinforced by the muscle systems that they inves t . T h e anterior peritoneum contains : •

the superficial fa scia of the perineum , which j oins the following fa scial elements : - the superficial abdominal fasciae - the fasciae of the lower limbs

- the aponeuroses of the gluteal muscles

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Chapter 2 / Anatomy o f t h e Fasciae

•

iddl e

whi c h is c o mp o s e d of two separate la ye r s and which j o i ns the following fascial e l e m e n t s the

m

fascia of the perine u m ,

- the superficial fa s ci a of the perineum

- the

deep p e r i nea l fascia

- the deep abdominal fa sc ia e •

deep pe r i n e al

the

fa scia , an ex tremely st r on g tissue which i nv e sts the

en t i re peri toneum and j oins the fol l owi ng fascial elemen ts : - the bottom of t h e m i ddle fa sci ae of th e perineum

- t h e de e p abdominal fasciae and the umbilical fa scia - l ate r a l ly, the aponeurosis of the in te rn a l obturator, which links i t to the o u t si d e

- the a p o ne u r o s i s of the coccygeal muscle and, at a p o s t e r ol a t e r a l poin t ,

; these two ap o n e ur o s e s make up part of the dee p pe r in e a l fa scial system . T hro u g h its c onn e c t io n with the p i r i fo rm i s , this fascia es tablishes ano ther link w i th the o u t s i d e . the aponeurosis o f the piriformis

mu s cle

- the pr e s a cr a l septum p o s te r i o r l y - t h e e n ti re p er i p h e r y of the t r ans ve rs alis fa sci a

Above these fascial element s , and often derived fr o m the m , are : • two central anteroposterior structures : the s a c ro g e n i ta l folds . These fo r m compar tmen ts in a s a g i t t al or i e n ta ti on w i t h s e ve r a l s e p ta w hi c h run from front t o back : •

the umbilical ligament

•

th e

•

ve s i c ov a g in a l sep tum (in fem ales)

th e r e c t ov agi n a l septum (in

females) a n d

the rec toveslCal sep tum (in

mal es ) •

the presacral septum

The top of this region i s fo r m e d by the peritoneum in males , a n d by a com­ bi n a t i o n of the periton eum and the p a r a m e tri u m in females.

A p a r t ic u la r s tr u c ture in this r e g i o n

wa r r a n ts s pe Cial atten tion : the ce n t r a l

tendon of the perineum . This fi b r o u s structure is lo c a t ed be tween the anus

a nd the root of the scrotum i n m a l e s , and be tween the rectum and the inferior root of the labia maj ora in females. I t r ep re sen ts the lowermost point o f the perineum an d , by extension , of the en tire thoracoabdominal cavity. It is fo r m ed by extensions o f all three of

the

faSCial elements of t h e

t o g e the r "vi th all the p erineal muscle s , a p a r t from the ischio­ cavernosus and coccygeal muscle s . T h er e for e , it represents th e ' thre a d ' which is u s e d t o close t h e bo ttom of the thoracoabdominal cavity.

peri.neum

.

..

..

.. . . .. .. II II II • • II II • II II II II II . .. II • • • II . . .. .. .. .. .. .. .. .. .. .. .. . .. .. .. .. . .. .. .. .. .. .. .. .. . . . .. .. . .. .. . .. .. . .. .. .. .. . .. .. .. .. . .. .. .. . .. .. . . ..

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..

.

73

F i g. 2 - 2 8

Fasci a e of the Centra l Axis

Sacrogen i t a l fo l d s

P reves i c a l fascia

Sacroge n i ta l fol d s

Ves ical compartm ent

Genital com p a r t m e n t

U teroves i c a l fasc i a I n te r n a l i l i a c a . U tero recta l

fa scia Latero-vi sceral com p a r t m e n t

Recta l compartment

Retrorectal fas c i a

Tab l e 2 - 7

C a n n e c t i o n s o f t h e Peri n e a l F a s c i a e

T R A N S V E R SAL I S FAS C I A

PE R I T O N E U M

I

r �

( U RA C H U S )

M E DIA N U M B IL I C A L L I G A M E N T

V E S I C O VAG I N A L S E PTU M, R ECTOVAG I N A L S E P T U M

S A C RO G E N I TA L fOL D S

1/

Peri neal fascia �

� P R E SACRAL f AS C I A

O BT U RATO R F A S C I A

PIR i f O R M I S f A S CIA

fASCIAE O F T H E LOW E R LIMB

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Chap ter 2 / Ana tom y of the Fasci ae

Fasciae of the Ce ntral Axis I N T E R P T E R Y G O I D FA S C I A

This q u adrilateral fas cia is a t t a che d : •

on t o p , g oin g fro m t h e b a c k t o th e front - to the two l i p s o f the p e tro tympanic fissure ( a l s o known a s the glasserian fissure) - to the process o f the pe trous part of the tem por al bone lying

b e tvve en the pe t r o ty m pa ni c and ty mp a nom a s toid fissures - to the process of the sph en o i d bone - t o the medial edge of the fora men ovale •

on the b o t tom - to the maxilla immed i a tely above the in ser t i o n o f th e med ial p teryg oi d and also on the lingula o f the mandible

•

Its p o s te r i or edge i s free.

•

I ts a nter i or edg e : - is a t t a c h ed t o the po s t er i or edge of the lateral wing of the p t e ryg oid

fa s ci a - lower down , it extends towards the l ater a l side of the base of the tongue where i t j oins t h e an terior extension of the b uc c in a t or fa scia The i nterpt e ry g oid fascia is no t uniform all over : •

its p os te r ior portion is thick and s tron g and is a l so know11 as the

•

i t s anterior por tion is i tse l f divided i n tvvo by the p terygomandibular

sphenomandibular ligam en t

raphe P T E R YG O T E M P O R O M A X I L L A R Y FA S C I A Located ou tside the i nterp teryg o i d fascia , i t is in s er t e d •

(Fig. 2 - 2 9 ) :

a t the top in to the greater wing of the sphenoid bone

•

at the fron t to the supe r i o r part o f the medial p teryg oid w i n g

•

its s up erio r edge becomes free and thickens below and outside the foramen ovale to form the recessus epi tympanicus

•

at the bo ttom its insert i on i s con ti nuous vvith the in te r p t e ryg oi d fascia

PA L AT I N E A P O N E U R O S I S The p a l a tin e aponeurosis is an extremely s trong fibrous membrane which inve s ts

the two veli p a l a t ini muscles and help s shape the soft palate. It is con tinuo us with the p a l a tine arch and occupies (he

an terior

half of the soft p a l a te for which it

provide s the skel e t a l framework . It i s attache d :

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Fi g. 2-29

Fasci a e o f t h e Cen tra l Axis

Parasa g i t t a l Sect i o n t h ro u g h t h e P h a r y n x, E u stach i a n T u be and [ h e Pte rygo i d M u scle

O t i c ga n g l i o n Eusta c h i a n t u b e

---

Massete r i c n .

L a t e r a l pte rygo i d m .

P terygote m p o r o m a x i l l a ry fas c i a ( e x t e r n a l b ra n c h ) P h a ryngeal fas c i a

Max i l lary a.

T e n s o r ve l i p a l a t i n i m . Pterygo t e m p o r o m a x i I l a ry fa sc i a ( i n te r n a l b r a n c h )

I n fe r i o r a l veo l a r n .

P a l a to p h a rynge u s m .

P a l a t i n e ton s i l

I n t e r p h a ryngeal fa s c i a

P h a ry n g e a l c o n s t r i c t o r m m .

P h a r y n g o b as i l a r fa s c i a

1'-,,"��-iO?v'--- S u b m a n d i b u l a r gland

D i g as t r i c t e n d o n

•

a t t h e front t o t h e posterior e d g e of the palatine arch

•

on the sides to the l ower edge and to the hook of the medial wing of the pterygoid process

•

at the back, i t disappears into the thickness of the s o ft palate

It mainly

consists of the tendinous fibers o f the veli palatini mu scl e s with which ,

it is continuous at th e bac k .

The veli pala tini muscles are continuous wi t h the fas ciae of th e pharynx ,

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Chapter 2 / Ana tomy of the Fasciae

which send out extensions to inves t the descending por tions of the tensor and levator veli pala tini muscles . P H A R Y I'J G O B A S l l A R A N D B U C C O P H A R Y N G E A L FA S C I A E The pharyn gobasilar fascia i s a s tron g , fibrous membrane whi.ch covers the esoph­ agus and the trachea . I t continues up i n t o the maxillopharyngeal space, investing the walls of the pharyn x and extending down in to the medias tinum . Above the superior constrictor of pharynx mu scle , i t j oins the buccina tor fascia and both are attached to the base of the cranium : • •

on the basilar side of the occipital bone at the pharyngeal process on the inner side of the petrous part of the temporal bone anterior to and within the carotid foramen

•

on the fibrous plate which covers the anterior lacerate foramen

•

on the pos terior, la teral part o f the base of the pterygoid process

•

on the lower, fibrous wall of th e a u ditory tube

•

on the p terygom axillary ligament

Anteriorly, a n outgrowth extends out folloWing the course of the palatoglossus muscle up to the tongu e . From the pharyngobasilar and buccinopharyngeal fas ­ c i a e proj e c t extensions which cover t h e descending parts of t h e tensor and levator veli pala tini muscles of the soft palate. Below the tensor veli palatini , the pharyn­ g oba silar fascia is reinforced by the p terygoman dibular raphe. When i t reaches the pos terior edge of the thyroid , the pharyngobasilar fascia folds back on itself to form two sheets •

(Fig. 2 -3 0 ) :

the deeper o r in ternal shee t is continuous with the visceral portion and covers the trachea and the larynx as well as forming the thyrolaryngeal fascia

•

the external sheet extends-from inside to outside-over the pos terior side o f the la teral lobe of the thyroid gland and , at the external limit o n this side, j oins with the deep sheet of the mi ddle fa scia , which completes the inves tment o f the thyroid gland in front

From the an terior part o f the visceral portion , along the inferior edge of the thyroid gland , a deta chment extends outs which follows the course of the maj or thyro id veins , encloses the left brachiocephalic venous trunk , and continues as far as the pericard i u m . Thi s extension is called the thyropericardial or cervicoperi­ cardial lamina (Rouviere) . To g e ther, the cervic opericardial lamina , the adj acent part of the pericardium , the deep sheet of the middle fa SCi a , and the superior s ternopericardial ligament define a compartment whic h is occupied by the thymus

(Fig. 2 - 3 1 ) .

In the neck , there are sagittal extensions of the fa scia or septa which a ttach it to the deep cervical fascia and thereby to the an terior processes o f transversal fasciae. I t is j Oined via a pos terior extension to the s tylOid fascia to form the s t y ­ lopharyngeal fa sci a . I t is a l s o attached to the greater and l e s s e r horns of the hyoid

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Fig. 2-3 0

Fasci ae o f the Cen tral Axis

Fasc i a e o f t h e N eck: Sa g i t t a l Sect i o n

H yo i d b o n e T h yrohyoid m e m b ra n e T h yr o i d cart i l age

Trachea -+---.--.i--+M i d d l e cerv i c a l fa s c i a -+-+-11 S u p e r fi c i a l c e r v i c a l fa s c i a

T h yro i d fas c i a

P h a ryngoba s i l a r fas c i a

T h y r o p e r i c a rd i a l l a m i n a Deep b u n d l e o f -1--"'Y-1I�,1 m i d d l e fa scia T h y m i c co m pa r t m e n t Fascia i n ves t i n g t h e b rach ioce p h a l i c t r u n k

Eso p h ag u s

f-....

-

-

Deep c e rv i c a l fas c i a

T h yro p e r i c a rd i a l lamina E n d o t h oracic fas c i a S u pe r i o r sterno­ pericard i a l l i g.

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Chapter 2 / Ana tom y of t h e Fasciae

bone. A t the level of the superior cons trictor of pharynx muscle , i t extends into the p harynx to form an intrapharyngeal fa scia . I t s form is that of an incompl e t e cylinder because i t only inves t s th e p o s terior and lateral w a l ls of th e pharynx. Fibrous and s trong a t the t o p , it is thinner and more cellu lar lower down . I t is continuous with the cellular lining o f the esophagus a t the back and w i th the pericardium in fro n t .

Fig. 2 - 3 1

T h y m i c Com p a r t m e n t

D e e p s h e e t of m i d d l e cervical fas c i a S u p e r fi c i a l s h e e t o f m i d d l e c e r v i c a l fa scia

.w--- C e r v i c o p e r i c a rd i a l l ig. B ra c h i o cep h a l i c venous t r u n k

Th y m i c c o m p a r t m e n t V e r t e b roperi card i a l l i ga m e n t s S u p e r i o r ste r n o p e r i c ard i a l l i g.

E n d o t h o r a c i c fa scia

I n fe r i o r ste r n o p e r i c a rd i a l l i g.

Ta b l e 2-8

Con nect i o n s of t h e P h a ryngobasi l a r Fascia

D U R A M A T E R, B A S E

OF

THE SKULL

t

I N T E R PT E R Y G O I D F A S C I A

t

PTERYGOTEM POROMAXILLARY FASCIA

t

/

PALATI N E FASCIA

l'

Phary ngobasilar fasci a DEEP

C E R V I CAL

FAS C I A PERICARDIUM

�

DIAPHRAGM

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MI DDLE

CERVICAL

FASCIA

79

Fasci a e of the Cen tra l Axis

P E R I CA R 0 I U M T h e p e ric ar di u m is the fib r o s e r ou s sac tha t surrounds the h e a r t It co n s i s ts of tw o .

different l ay ers (Fig. 2 - 3 2 ) : •

a n interna l . serous l ay e r c ompri s e d o f tw o s e p ar a t e s h ee t s : .

-a -

•

v is c e r a l sheet m olded a round

the h eart and the v a r io u s vess e l s

a n o th e r p a r i e t al sheet which covers th e fo rm e r

an external . fibrous l a ye r which hermetically se a l s the parietal s he e t

inside a n d serves both to protect and i m m obi l i z e the heart We will foc n s main ly on the fi b r o us pericardiu m . dealing brie fl y afterwards with

t he serous pe r i ca r diu m . Fig. 2 - 3 2

P e r i c a rd i u m Aorta

P u l m o n a ry a.

Layers o f s ero u s

pericardium

L i g . between serous a n d fi b rous p e r i c a rd i u m

Leh arr i u m

F i b ro u s p e r i c a rd i u m Left ven t r i c l e

Fibrous Peri cardi um As previously n o t e d . t h e fibro u s pe ricardium is c o n tinu o u s with the buccopha ­

ryngeal fascia . The fi brous pericardium is a thick . s tro n g membrane which c o v e r s the p a ­

rie tal l a y e r of the serous p ericard i u m fo rmin g a fi b r o u s sac which is c r o ssed b y .

th e m a j or ves s e l s of t h e hear t . S tr on g li g a m e n t s a t t a c h it t o t h e d i ap hragm . t h e a n terior a n d p o s te r i o r walls of t h e thorax . a s well a s to s tructures of the ne c k

.

F i b ro u s sac The fibrou s sac has a p ea rl y white appearance and is com p o s e d of interlacin g .

c ur v e d fibers tha t are o r i e n t ed i n a l l d i r e c t i o n s These .

c o n de n s

e i n t o bands which

form fibrous r i n g s around the variou s vessels . Its shape is like tha t of a cone w hi c h

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Chapter 2 / Anatomy of the Fasciae

h a s been trunca ted a t the base, and i t invests the hear t . I t s base lies on the dia­ phrag m , more specifically on b o th the a n t erior leafiet of the central tendon and the an terior part of the l e ft lea fi e t . However, i t i s separated from the diaphragm by a thin she e t of cellular adipose ti s s u e which i s continuous with the endothoracic fascia . This is called the phrenopericardial ligamen t . I t s a n terior surface is adj acent t o the anterior edg e of the l u n g s , the an terior recess o f the pleura , and the s ternocos tal cartilage s . Its pos terior s urface i s adj a ­ c e n t to the orga n s o f th e pos terior m edias tinum , especially the thoracic esopha ­ g u s . The trunca ted tip tapers off into the vessels at the base of the heart above the serous p ericardium and is, a s has already been mentione d , con tinuous with the buccophar yngeal fa scia . The per icardium sends o u t a large number o f extensions which form the

l i g a ments for i ts a ttachment (Fig. 2 -3 3 ) .

P h re n o p e r i c a rd i a l l i gam e n t s

T h e s e three ligaments a r e t h e s tron g e s t o f a l l and a r e continuous wi th the endo­ thoracic fascia : •

the anter ior ligament is attached to the anterior leafiet

•

the right l i g ament i s a t tached to the inferior vena cava

•

the left is locate d to the left of the inferior vena cava

The la tter two fit tightly around the in ferior vena cava .

Ste r n o p e r i c a rd i a l l i gam e n ts

The superior s ternopericardial ligament j oins the manubriu m of the s ternum to the pericardi u m . This is a n ex tension of the deep layer of the middle cervical fascia and is also con tinuous with the an terior wall o f the visceral s he a th of the n e c k . The inferior s ternopericardial ligament j oins the lower base of the xiphOid process to the p ericardium .

Ve rtebro pericard i a l l i gam e nts

These are fibrous bands developed in the thickness o f the s ag i t tal s ep t a . Their ins e r t i ons are con tinuous with those of the sagittal septa o f the buccinator fascia on the prever tebral fa scia a s o f the sixth cervical ver tebra . Up t o the third thoracic vertebra , they terminate a t the b o ttom a t the upper part of the pericardium.

Cerv i c o p e r i c a rd i a l l iga m e n t s

T h e cervicopericardial lig aments form wha t i s known as t h e thyropericardial lamina o f Ri che t , an extension o f the visceral sheath o f the neck. This detaches a t the sheath o f the thyroid glan d , forms a fron tal lamina which defines the thy m i C

compartmen t , and termina tes a t t h e anterior surface o f t h e pericardium .

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Fasciae o f the Central Axis

V i s ceropericard i a l l i ga m e n t s

These are s i mple auxiliary fibrous tracts which j oin the pericardium : •

posteriorly to the thoracic esophagus : these are kn own as the

•

superiorly to the tracheal bifurca tion : these are known as

esophagopericardial ligaments tra cheopericardial and bronchopericardial ligamen ts •

Fig. 2-33

latera lly to the pulmonary veins to fo rm the alae of the pericardium

P e r i ca r d i a l L i ga m e n ts

Vertebro p e r i c a rd i a l l i ga m e n ts

Aortic arch

S u p e r i o r s t e r n o p e ricard i a l l i ga m e n ts

S u pe r i o r vena cava --------f.

P e r i c a rd i u m

I n fe r i o r s t e r n o p e r i c a rd i a l l ig,

Root of l u n g

D i a p h ragm

Serous Peri card i um The serous p e r ic ar dium co nsists of two different l ayers : • •

the visceral layer, which is molded around the heart the parietal sheet, whi ch invests the visceral sheet and is intimately associated with the fibrous pericardium Copyrighted Material

Chap ter 2 / Ana tomy of the Fasciae

82

These two layers fold back on them selves to demarcate a sealed space around the maj or vessels . The fibrous peri cardium is inelastic and is innervated by the phrenic nerve. The serous pericardium receives vasomotor and sensory nerve fibers c o m in g from the coronary plexus. Stimul ation of these ner ves does not induce any kind of pain . Con n e c t i o n s o f t h e P e r i c a rd i u m

Ta b l e 2-9

D U RA MATER - C RA N I A L BASE

l'

I NTERPTERYGOID FASCIA

l'

I NT E R PTERYGO M A N D I B U LA R FASC I A

l'

PA LAT I N E FASC I A

l'

PHARYNGO BAS I L A R FASCIA

T PLEURA

?

MI DDLE CERVICAL FASCIA

(-- Pericard i u m

1

E N D O T H O RA C I C

FASCI A

D I A P H RAGM

TRAN SVERSALIS FASCIA

�

P E R I TO N E U M

:

.

.

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Summary of the Central Fascial Axis The central fa scial axis is composed of: •

in terptery g oid and pterygo temporomaxillary fa sciae, and the palatine aponeu rosis , which anchor it a t the base of the skull. I e continues into

the : •

pharyn gobasilar and buccop haryngeal fasciae, which is i ts e l f con ti nuous with the pericardium

This axis is con ti nuous : •

superiorly with the meninges via the cranial ner ves

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D i a p hrag m , In terna l Thoracoabdominal Fasciae

83

•

aro u nd its edges and going i n fe r i o rly from the top : -

p o st e r i o rly with the deep cervical fascia via the sagittal membranes and with the endo thoracic fascia anteriorly and the perica rdi al ligaments posteriorly

- an teriorly

with the middle cervical fascia , together with which i t o f the thyroid gland an d the t hy miC c av i t y

constitutes the sh e a t h

- laterally with the pleura a t the level of the thorax • .

.

inferiorly

with the diaphragm

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .

.

.

Diap h ragm The di a p hr ag m

is the main muscle involved in breathing , ye t aside from this role, it can also b e considered as an im p o rt ant fascial element . The central tendon is fibro u s . I t descends fr o m the transverse septum that originates in the cervical area of the embryo and therefore brings with i t the entire fascial column which we have been d i s c ussin g . The d iap h r ag m forms a connection between the thoracic and abdominal fas ­ cial s y s t e m s a t the same t i m e a s i t separates these two maj or body cavities (Fig. 2 - 3 4) . Its upper part is covered by the endo thoracic fascia doubled u p w i th the pleura . T h i s fascia ex tends down into the abdomen in the form of the transversalis fascia . Its inferior surface is lined by the peritoneum , and the renal fasciae project from this area . I t is also a tta c hed to the fasciae associ a ted with th e psoas muscle. The peri ton e u m also serves to a t tach the liver and the stomach to the dia ­ phragm . At i ts superi or s urfa c e , it is i tself suspended by a fascial shea th formed by the pericardium, the buccopharyngeal fascia , and then the interpterygoid fas c i a a n d t h e palatine aponeurosis. This fixes everything to the base o f the skull . In the an teroposterior direction , this s h e a t h is stabilized by the vertebro p eri­ c a rd ial and s ternopericardial ligaments. The diaphragm represen ts a con tinua tion between the fa sciae of the base of the skull , the neck , and the thorax , and those of the abdomen . It is a r el ay poin t and an important shock absorber, as 'Nill b e discussed in detail in Chapter 6 b e ­ low.

I nternal Th o racoabd o m i nal Fasci ae PLEU RA

There are two pleurae, one r ig h t and one left , entirely distinct from one ano ther. Copyrighted Material

84

Fig. 2-34

Chap ter 2 / Ana tomy of the Fasc iae

Li n ks betwee n T h o rax, A b d o m e n and K i d n eys

Right l u n g P l e u ra

D i a p h ragm

C o s w d i a p h ragma t i c recess Liver S u prare n a l g l a n d R e n a l - S u p r a r e n a l fa s c i a P r e r e n a l fa s c i a Retro r e n a l fas c i a Right k i d n ey Fa s c i a o f T re i t z Peri w n e u m S u b- r e n a l fa s c i a T o l d t ' s fa s c i a Asce n d i ng c o l o n

They are s e r o u s membranes composed of two layers : •

a visceral l ay er, which i nve s t s the lung

•

a p arietal l ay e r which lines the walls of t he th o r a c i c c av i ty ,

The parietal and visceral lay e r s are continuous vvi th one the lung , w h e r e t h e p l e u r a fo ld back on them selves.

a no t

h er

at the hilum o f

B etween the two l ayers there is a virtua l . fl u id-filled cavity, the pleural cavity

Visceral Pleura The visceral pl eu ra covers the who le surface o f the l un g except for an area on its m e dias tinal side a t the hilum , where it folds back to fo rm the p a r i. e t a l pleura . The

fold line con tinu es on below the hilum in o r de r to form the pulmonary liga men t .

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Interna l Thoracoa bdom i n a l Fasci (Je

T h e vis cera l pl e ura pene trates wi thin the lung to lin e t h e p ul m o nar y fissure s , a fter which i t splits to cover the various lobes of the lung (Fi g . 2 - 3 5 ) . The visceral pleura is j oined t o the pul m o n a ry p a re n c hy m a via a thin la y e r

of subpleural cellular tissue wh ich c on t i n u es i n t o the p a renc h y m a to form the framework o f t h e lun g , or p u lm o n a r y intersti tium . Fig. 2-3 5

A n te r i o r Borders of t h e P l e u ra a n d L u n gs

O b l i q u e fi s s u re

H o r i zo n t a l fi s s u r e

P a r i et a l p l eu ra

O b l i q ue fi s s u r e

Costod i a p h ra g m a t i c recess

Pari etal Pleura The parietal p l e ur a lines alm o s t all o f the deep surface o f the thoracic c avi t y. It is

i nn e rv a t e d by t he intercos tal , thoracoabdominal , and phren i c nerve s . I t j oi ns the

wall via the endo thoracic fa s ci a which it then divides on the inside . Dis tinc tion ,

is usually made be tween differen t se g men t s of the pleura : •

a co s tal s e g me n t or the c o s tal p l e ura

•

a m e dias tinal segmen t , or the medias tinal pleura

•

a diaphragmatic s eg men t or the diap hrag m a ti c p l e ur a

,

,

These thr ee elements continue independently to form the p l e u r a l pouche s . Costa l p l e u ra This segment lines the d ee p surface o f the ribs and the intercostal spaces from

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Chapter 2 / Ana tomy of the Fasciae

which it is separated b y the endo thoracic fa scia . •

Anteriorly, it extends as fa r as the edges of the sternum and then folds back pos teriorly to form the medias tinal pleura .

•

Inferi orly, it fo lds back to form the diap hragm atic pleura

D i a p h ragmatic p l e u ra

Thinner than the costal pleura , this segment is a t tached to the endo thoracic fa scia

and thus to the superior surface of the cupulae o f the diaphrag m , s trongly but

incompletely. On the left , i t leaves a portion of the d iaphragm free for insertion of the pericardium . On the right, it covers the entire part of the cup ula ou tside an anteropos terior line which passes along the lateral edge of the opening for the i n ferior vena cav a . M e d i ast i n a l p l e u ra

The medias tinal pleura covers a ll the medi a s tinal struct ures in an an teropos terior

directi on , from the s ternum a t the front as far a s the cos tover tebral sulcus a t the b a c k . These structures are : •

i n the anterior medias tinum : the p ericardiu m , the phrenic nerve and accompanying vessel s , the thymus , the right brachiocephalic trunk , and the superior and inferior vena cava

•

in the posterior medias tinum : the trach e a , the esophag u s , the azygos

vein , the right vagus nerve on the right, the descending thoracic aorta , the hemiazygos vein , and , at the top, the thoracic duct on the left

A t the ro o t of the lung , the mediastinal pleura forms a quaSi-circular sl eeve around

the componen ts o f the roo t , lining its an terior, pos terior, and superior surfaces.

On the ou tside , around the hilu m , i t folds back to form the visceral pleura The folding of the pleura near the hilum continues into the diaphragm via the trian­ gularly -shaped pulmonary lig amen t .

T h e l i g ament of t h e left l u n g is more or l e s s vertical , whereas tha t of t h e right lung forms an oblique angle a t the bottom and behind, where i t is distorted by the inferior vena cava.

On the inside, each of the pulmonary ligaments meets the lateral edge of the esophag us via the esophageal fa sci a , to which they are s trongly a t tached . P l e u ra l d o m e

A pleural d o m e t o p s e a ch l u n g . It is strongly at tached t o the end o thoracic fas cia , which thickens significan tly in order to consti tme the cervico thoracic diaphragm .

Within this diaphragm , the fol l OWing l i g a m ents which s us p e n d the p l e u r a can be dis tingUished (Fig. •

2 - 3 6) :

the cos topleural ligam en t

•

the transverse cupu lar ligamen t

•

the pleurovertebral ligamen t

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In ternal Thorocoa bdom i nal FasciCle

Pleural Dome

Fig. 2- 36

T r a n sverse c u p u l a r l i g.

Costo p l e u ra l l i g. Root C8 P l e u roverte b ra l l i g.

Root T 1 I n fe r i o r t r u n k o f brac h i a l p l e x u s

P l e u ra l d o m e A n te r i o r sca l e n e m .

•

•

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . • . e. o

Summary of the Pleurae The pleura consists of two l ayers separated by a vi rtual space whi ch is lubri­ ca ted to allow the l aye r s to slide agains t one ano ther. •

The inner l aye r or visceral pleura , invests the lung and splits deep down ,

t o form the fissures of the l u n g and invest the various lobes and lobul e s . •

T h e ou ter layer, or p a rietal pleura , anchors t h e l u n g t o extern a l structures and allows it to function a s a pump

It

j oins : •

on the inside, the pericardium

•

a r o u n d its edge, the endo thoracic fascia , and th ereby the i n n e r thoracic wa ll

•

at the b o t tom , the diaphragm

•

a t th e top , t h e endo thoracic fascia , and thereby the cervical fas c i a e via the s usp e n s o r y ligaments of the p le u r a

.

.

: .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Chapter 2 / Anatomy of the Fasciae

Table 2 - 1 0 C o n n ec t i o n s o f t h e P l e u ra

CERVICAL FAS C I A E

PERICARDIUM

�

Pleura �

E N DOTHORA C I C FASC IA

1 DIA PH RAGM

T R A N S V E RSA L I S F A S C I A

�

P E R I TO N E U M

P E R I TO N E U M A N D P E R I TO N E A L C AV I T Y The pe r itone um i s a serou s membrane which li n e s th e de ep s urface o f t h e ab­

dominal cavity, the p elvic c avi t y and all the org a n s therein . The p eritoneum un­ ,

dergo e s multiple changes a t vario u s stages o f e m b r y o n i c and fe t a l d eve l o pm e n t

u n til , in the adult, it is extensively folded b a ck o n itself, c r e a t in g

a

highly co mp l e x

surface which is e x p l a i n e d b y embryology (Fig. 2 - 3 7) .

As is the c a s e with all s erous membranes , it c o ns i s ts of two

•

a

layers :

parie tal l aye r l in in g the deep s urface of the abdominal cavit

a visceral lay e r c ov e r in g the superficial surface of the abdom i n al vi s c e r a

•

These two l ayers define a v ir t u a l c av it y na m el y the p er iton e a l c avi t y with the ,

lowest p o i n t b e i n g D o ug l a s p o u ch '

and t he

-

,

t h i s is the rectouterin e po u ch in fe m a l e s

rectovesical pouch in males . The p e r i t o n e a l cavi ty can be r ep re s e n te d

as

b a s i c a lly a closed sac which contains all the abdominal organs and other viscera .

It s h oul d be noted , however, tha t the p e r i ton e um i s n o t h e rm e tica ll y sealed

in the

female because t h e r e is an o p en ing a t the l evel o f th e ovary called the Fane line. This

discon tinuity allows the p e rito n e a l flu i d to flow across the fa l l o p i a n t u bes

a n d als o a c co u n ts for w hy as c e n d in g p er i ton eal i n fections of gynecological o r i g in ar e p os s i bl e

in wom e n

.

In m a le s , wh e n the testes de s c e n d the peri toneum forms an invagination like ,

th e fin g e r of

a

g l ove

at the l evel of the teste s ( the tunica vag inalis t es ti s) which ,

takes wi th it th e transversalis fas c ia ( a tunica fibrosa ) and fi bers of the tr a ns v ersalis and crem a s ter mu scle s

.

The p a rie ta l peritoneum is often se p a r a t e d from th e abdominal wall by sub­

pe r itonea l tissue . While abundant and l o o s e a t t h e lower part of t h e w a ll where the peritoneum i s e a S i ly de tached , everywhe re else i t is rela tively sp ar se tight,

and solidly a tt a c he s the peri toneum to the wall o f the cav i t y.

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89

Fig. 2- 3 7

In ternal Thoracoa bdominal Fasciae

The Male Peritoneum

Diaph ragm

��::;� ;; �"

C o ro n a ry l i ga m e n t of l i v e r

Liver

Lesser o m e n t u m --H���

S t o m a c h -H------,fhJ

T r a n sverse m esoco l o n

T r a n sverse colon S u b - m esoco l i c s pace Greater o m e n t u m

Pari etal Peri toneum The p a rie t al peri toneum lines the deep surface of the abdominal cavity. Distinction is made among : •

the diaphragmatic p a r ie tal peritoneum

•

the po st e r io r parietal p eritoneum

•

the anterior pa r i e tal peritonewn

•

the inferior or p elv i c parietal peritoneum

D i a p h ragma t i c parietal p e r i to n e u m

This is s tro n gl y atta ched t o the in ferior surface of t h e diaphragm , except a t the level of the corona ry ligament of the liver anteriorly, as will be explained later.

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Chap ter 2 / Ana tomy of the Fasciae

Poste rior parietal p e r i to n e u m This lines t h e transversalis fa scia and thereby t h e pos terior w a l l of t h e abdomin al cavity. However. i t is separated from the abd o m i n a l wa ll by the retrope r i toneal

s p a ce which contains : •

in the cen ter. the large prevertebral v es sel s ( the aorta and the vena cava )

•

la terally. the kidneys . the suprarenal g lan ds . and t he ureters

The ureter is a t tached

to the pe r itoneum a n t e riorl y via j.ts connective tissue s he a t h

formed by the subperitoneal fas c i a . The u reter moves with the peri toneum unless it becomes d e ta ched . Anterior pari etal p e r i to n e u m This lines the d e ep su rfa c e of the anterol a teral wall of the abdominal cavity from

which i t is separated by a subperitoneal ce llular space. This space gradually na r­ rows as it co n ti n ue s forwa rds towards the median line. In its subumbilical part. i t s tea dily recedes from the wall . inhibited from be­ hind by the um bilicoprevesical apon eurosis. Here. the p erineum is li fted by the

m edia n umbilical li gament and the medial umbilical ligaments . which go on to

form thre e fo ssae : •

the internal ing u inal fossa

•

t h e medial ingu i nal fossa

•

the l ateral inguin al fossa

The

l ateral fo s s a cons titu tes the medial opening of the in guinal

c a na l

thr ough

which the s p ermatic cord p a s s e s . These fossae correspond to weak points abdominal wall thro ugh which

a

in

the

loop of intestine can be forced . crea t in g an in ­

g uinal hernia . Just above the inguinal l i g a m ent the a n terior parietal p eriton eum .

is s e p arate d from the parietal plane by a cellular space called the retroing uinal spa c e . or Bog ros space. Pelvic p a r i e t a l p e r i to n e u m T h e pelvic pa r i etal peritoneum lines the walls of t h e pelvic cavity a n d . o n the sides and the median line . covers the subperitoneal space and all the viscera i t con ta in s (nam ely. from back t o front . the rectum . the internal g e n i tal org an s . and the bladder) . It covers the lateral and s uperior surfaces of the b l add e r to which it is s t r o n g .

ly a ttached . Behind the bla d de r : •

in males . i t covers the base of t h e seminal vesicle s . forms t h e rectovesical pouch. and goes on to cove r t he rectum. behind

w

h i c h it for m s the

pa rarectal fossa on each sid e ; •

i n females . it is strongly a t ta ched to t h e parametrium . which covers the uterus and its accessorie s . and forms two s tructures : - the an terior. rela tively shallow vesicou terine pouch - the posterior. rectouterine pouch

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In ternal Tho racoa bdominal Fasciae

It s h o u ld be remembered tha t these s t r u ctures can b e a foc u s for both collec tion of fluids (espeCially the lower rec touterine pouch) as well as trapping of intestinal loo p s .

Visceral Peri toneum This lines the deep s urface of the parietal peritoneum and the superficial surface of the abdominal viscera . It is strongly a t tached . The peritoneal layer s d e fin e th e

peritoneal cavi t y, which is occupie d by the viscera of the dig e s t ive tra c t . This cavity is divided by a number of different folds which create septa , fos s a e , and

reces s e s , The la r g e s t o f t h e s e recesses is t he pos terior cav i ty o f the omenta , w h i c h divides the per i to n eal cavity into two part s : •

the greater p e ritone al sac

•

the l e s s er peri toneal sac , known a s the omen tal bu r sa

Ano ther impor tan t fo l d o f the per i tone u m links the transverse colon to the pos­

terior wall and forms an o blique septum a t the bottom and a t the fron t , which

d iv i d e s the greater peritoneal cavity into two different com p a r tments. These are known as the supra colic and infracolic compartments , o r the s u p e r ior and infe­ rior compartmen ts of the abdomen,

Next we will concentrate on the peri toneal fold s , Their o r ga n i z a tion is highly

co mplex and , in orde r to gain a b etter unders tandin g , i t is wo r th re turning to their embryolo g y

Peri toneal Folds The peritoneal serous membrane is h i g hl y com p l ex because of a large number of

different types of folds which are referred to as : •

mesen tery

•

ligam e n ts

•

omenta

Mese n tery The mes entery a t ta c h the abdominal viscera to the p e r ito n e a l wall an d p r ov i de

them with their b lood supply and innerva tion . A m es e n t e r y i s formed when ever the p a r i e t a l peri toneum covering an organ folds back upo n itself to inves t the

org an and the nerves and vessels supplying it. The pa r ie tal area circumscribed by t h e s e t w o l ayer s

represent the insertion roo t of the mesen tery The l e n g t h of the me s en t ery affords e a c h organ a certain d e g r e e of mobility w ithin the peritoneal cavity

In the primary e mbryological a r r a n gem e n t the foll OW ing can be dis tin­ ,

gui s h ed :

at the level of the stomach

•

a mesog a s tri u m

•

a m esen t

•

a mesocolon at the level of the large intestine

e r y a t the level of the small i mestine

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Chapter 2 / Anatomy of the Fasciae

By vir tue of the le n g th e n i n g of the p ri mi t i ve in t e s tine and g a s tric and intes tinal rotation, c e r t a i n organs are p r ess e d up a g a in s t the p o s terior abdominal wall . The

p o s terior l a y er of the meso thelium fu ses with the po s te ri o r p a r i e ta l peritoneum The fasciae essentially become avascular cl e av age planes which are a s sociated

more or le s s s trongly w i t h the walls of the organs tha t they inve s t . After birth , t h e terminal p a r t of t h e e s op ha g u s the entire initial p a r t of the s tomach, and the left end o f the p a n c re a s , are c ou p l ed th ro ugh the posterior me­ ,

s o g as tr i um wi th: •

the duodenopancreas , which is i tse l f linked through Tr e i tz s fa scia

•

the a s c e ndin g and de s ce nd in g colon a re linked th r ou g h To ldt's fa scia

'

The s tomach , the fi r s t part of the d u ode num , the s m all intestine, the transverse colon , and the sigmo i d c o l o n r e m a in m ob i l e a n d ar e j o i n ed to the wall by mes­ e n t er i e s

.

Mese nteries The connectin g fa sciae tha t make up t he mesenteries are d e r i ve d from the m e s o ­ thelia

(Fig. 2 -3 8) .

.. M E S E N T E R I E S O F T H E S T O M A C H

These two m e s e nt e r ies a re cons tituted b y the falx-like folds of peritoneum that e n c l o s e va s cular bundles . The first i s the g a s tropancreatic fo l d , which ex­ tends Fig. 2-38

O m e n ta and M e s e n t e ry of S t o m a c h

G a s t ro p h re n i c l i g.

Lesser o m e n t u m

G a s t ro s p l e n i c l i g.

Left p h re n i c oc o l i c l i g.

Right p h re n i coco l i c l ig.

G a srrococo l i c l i g.

Tra n sverse m es o c o l o n

G reater o m e n t u m

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In terna l Thorocoabdom inal Fasciae

from the celiac t r u n k at t h e u p p er third of the lesser curva ture . Its lower e d g e , concave a t the bo ttom and orien ted to the front and righ t , delineates the omental foramen at the top , giving access a t the back to the cavity of the omenta . It e n ca s e s th e hepa tic and left gastric a r t e r ie s . The h e p a t i c fold is also known as the duoden opancreatic ligamen t. It is or­ rien ted in the op p o si te direction with its superior edge free and concave a t the top, defining the lower p a r t of the fo ra m e n . .. M E S E N T E R Y O F T H E S M A L L I N T E S T I N E

The mesentery of the j e j u n o i leu m , usua lly s i m p l y referred to a s the m e s ­ entery, i s a t t ac he d to the pos terior vvall of the abdomen and p r o vid e s the blood

su pply and innerva tion to the bulk of the small in testine. I t is in the shape o f a s e gm e n t of a circle. It co n s i s t s of two parts : the roO ( , which is immobile and v e r y s t ro n g ly attached to the p o s t er i o r abdominal wall , es p ecially a t its middle seg­ men t ; and the intes tinal border, which i s highly m ob i le a s it connects to the edge of the intestines which are five to six meters i n l eng th . About fifteen centime ters in leng th and eighteen m i l l i m et e r s in diameter, the roo t of the mesentery draws an oblique broken line that goes i n fe rio rly and to the r ig h t from the duodenojej unal j unction. Distinction is u s u a l l y made between three different segments : •

•

•

The superior segmen t travels obliquely inferiorly and to the r igh t It ex tends from the duodenoj ejunal junction , w here it is s t r ongly attached to the left transverse process of th e second lumbar ver tebra b y the muscle ofTrei t z , and to the lower e d ge of the third part of the duodenum , anterior to the body of L3 . The shorter middle vertical segment represents the most solidly fixed element and it is here that the superior mesenteric ves sels penetrate the mesentery. It proj ects onto L 3 and L4. The inferior segment becomes oblique again . traveling in fer i or l y and to .

th e ri g h t . It extends from the L4 / L 5 d i s k to the ileocecal junction above the r i gh t common iliac a r t e ry, crossing the ureter and the sperma tic (or ovarian) vessels . .. T R A N S V E R S E M E S O C O L O N

This forms a transverse lamina s tre t c h i ng from the right abdominal wa l l to

the left wa l l .

Obliquely running inferiorly and an t e r io r ly it divides the peritoneal cavity into the superior (supracolic) and inferior (infracolic) compar tments . It a ttaches the tran sverse colon to the posterior wall . Its anterior edge is very loose. espeCially on th e left , and the posterior edge is attached to the posterior wall. It crosses the head of the pancreas , to which it attaches. Then it passes from the duodenoj ej unal junction along the lower edge of the body of t h e pancre a s . I t s left part goes on to form t h e lower wall of the pos terior cavity of the omenta (Fig. 2 - 3 9 ) . ,

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Fig. 2 - 3 9

Chapter 2 / Ana tomy of the Fasciae

Fasc i a e of t h e P a n creas and D u o d e n u m

Lesser o m e n t u m

F i rsr p a r t o f r h e d u o den u m

Fascia o f Tre i tz S u b m e soc o l i c p a n c rea t i c fa s c i a

R i g h r exten s i o n o f t h e o m e n r a l b u rs a

P a n creas S u b m e s oc o l i c p a n c re a r i c fa s c i a Tra n sversa l i s fas c i a

Tran sverse m e socol o n

P e r i ro n e u m

� SIGMO I D MESOCOLON

The sigm o i d colon is a t t a c h e d to the pos terior wall by a t wo-rooted meso­ c ol o n : m ed i a

l direction . g oing

•

The primary ro ot descends ve r ti c ally and in the

•

The secondar y roo t runs o blique ly infer iorly and to the left . going

from the inferior mesocolon to the an terior face of S 3 . from the inferior mesocolon to the medial edge of the left psoas along the l a teral edge of the common iliac and ex ternal ili ac a r t e r i e s finally ,

crossing the spermatic (or ovarian) vessels and t h e meter.

The me socolon o fte n sends out e x te n s i o n s which anchor the ,

si

g m o i d colon to

the wall and to the neighboring o r g a n s These include small lig a m e n t s which j oin .

the colon to the wall of the

com m

o n iliac

art

e r y thereby e xt e n din g the secondary ,

roo t tmvards the left, j o in the s i g m o id mes ocolon to the left fall opian tube. and s tr et ch from the sigmoid mesocolon to the right layer of the mesen tery. Fasc i a e

As p rev i o u s l y men ti oned. t he s e r ep r ese nt a j o i n i n g of di ffe r e n t mesenteries.

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In ternal Thoracoa bdom inal Fasciae

'

� T R E I TZ S FASC I A

The fascia linking the du odenum and the head of the p an c re a s , i t p r ov i des a solid anchor for these organs. It inserts at t h e j u n c tion be tween the second and third p a r t s of t h e duodenum and extends to the transverse process of L 2 . The

muscle ofTreitz itself sends ou t an extension to the left pi l l ar of the d i a p h r a g m a t the right edge o f the esophagus , whic h con tinue s a round th e aortic o p ening. '

� T O L DT S FASC I A

Toldt 's fascia is the fa scia connecting th e posterior wall of the a scending and

d e s ce n di n g c o l o n . For the a s ce n ding colon, it extends from the cecum to the right colic flexure. I t a t taches the colon to the p o s terior

p arie t al peritoneum . However, in a few cas e s ,

there i s no co n ne c tio n a n d therefore t h e c o l o n i s comp l e tely fre e in t he abdomi­

nal cavi ty. I t continues downwards to merge in t o th e l i g am e n t s which j oin the l a teral edge of the cecum to the lumboiliac wall . The internal e d g e of the cecum is also

j oined to the iliac wall via the r e t r o c o l ic ligament, which i s n o more than an extension o f the lower i n s e rt i o n o f the r o o t o f the mesen tery. Th e root of the m esentery provides a p o i nt of a t tachmen t for the ap p e n di x , tha t is , the m esoap ­ p endix , which i ts elf s e n ds ou t an ex tension downwards in the form of the ap­ pen dico-ovarian l iga m e n t .

The upper part o f To l d t 's fascia extends as far as the r i g h t colic flexure and forms its deep atta chment p lane. Here , the follo w i n g can be dis t i n g uished : a

reno c o li c lig amen t that a t t ac h e s it to the k idneys , a n d

a

phrenicocolic l i g a m en t

that a t taches to the dia p hragm . It should also be remembered that o ther ligaments are associated with the right colic flexure : •

the middle plane wi th the cystoduodenocolic and h epatoc o l i c ligam ents

•

the s u pe r fi C i a l plane \"lith the omen tocoloparietal ligament

For the descending colon , Tol d t 's fascia extends from the l e ft colic flexure to th e

s ig m o i d colon . It a ttaches the colon to the pos terior p e ri to n e u m and c ont i nu es a t the b o t tom into the sigmoid m esocolon . Its u p per p a r t forms th e deep a t tach­

ment p l a n e for the left colic flexure . It should also be remembered t h a t o ther

li ga men t s are associated with the

left colic flexure : •

the middle plane wi th the splenocolic l i g amen t , which extends down i nto the gastrosplenic a n d spl e nop a n c reat i c ligaments

•

the superficial plane ( the larger) 'with the left phrenicocolic ligamen t , c r ea t i n g t h e

b e d for the spleen , whose b a s e lies on i ts superior surface

It should be noted that the various segments of the colon detach e a s i ly from the posterior wall and t h a t their p eritoneal a ttachments tend to ex tend towards the

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Chap ter 2 / Anatom y of the Fasci a e

center of the abdomen. This explains w h y it is much easier t o brin g them back towards the median line o f the abdomen than it is to stretch them l a terally. l i ga m e nts The designation peri toneal l igamen t is g i ven to peritoneal lamina having two lay

­

ers which j oin visceral elements to one another or to th e ab d o m i n a l wall , and which do no t contain any significant vascular plexu s . Certain ones a re derived by folding of the peri toneum and others are extensions of the mesenteries or the

omen t a . There are

a

great number o f such li g a m e n t s Some provide very strong .

a t tachmen t ; o thers are inconstant and variabl e , and their role in s tabil iza tion is rela tively minor. � ROU N D LIGAMENT OF THE LIVER

This is a remnant of the umbilical vein which runs within the free edge of a vas t sagittal fold called the falciform or suspensory liga m e n t It crea tes .

a

vertica l ,

anteropos terior septum whic h goes from t h e umbilicus t o the posterosu p erior surface o f the liver and j oins the convex side o f the liver to the diaphragm and the an terior wall of the abdominal cavit y. I t is comp osed of t wo layers j oined at the anterior portion a s far as the umbilicu s , where i t con tinues in to the medial umbilical ligament ( a remnant of the urachus) . Superiorly, at the level of the p o s terosuperior e d g e of the liver, the two layers separate : one carries on to the right over the right lobe of the l Iver while the o ther carries on to the left over the en tire breadth o f the left l o b e , where it con tinues as the superior layer of the coronary lig a m e n t . � CORONARY LIGAMENT

Th e coronary l i g ament j oins the p o s terior side of the liver to the diaphragm. I t consists of two layers : •

an an terosuperior layer, which fol d s back from the diaphragm to the liver along its pos teros uperior edge. On the median line, it continues as the falciform ligamen t , as previously explained.

•

an inferior layer, which folds back onto the vertical portion of the d i aphra g m carries along its inferior edge and over the vena cava , and ,

finally the transverse part of the l i ga m e n t u m venosum ( the rem nants of the fe tal ductus venosus) where i t rej oins the posterior layer o f the lesser omentum . The coronary ligament sends out three extensi ons around the inferior vena cava : •

the inconstant mesohepa tocaval extension ,

whi ch extends around the

inferior vena cava •

the right and l e ft tria ngu lar ligamen ts , formed when the superior layer j oins up with the inferior layer of the coronary liga m en t

These two li g amen t s terminate in a free edge which ex tends vertically from the diaphragm to the upper surface of the liver.

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Inte rnal Thoracoa bdom i nal Fasciae

I t s h o u l d b e remembered that , from an embry o l o g ical p o i n t o f view, the li v e r deve l o p s in t h e transverse s e p tum

( which

cons titutes the central tendon of the

d i ap h r ag m ) , which is itself derived from the bra ch i a l a r c h .

Because of its in cr ea s e in v o l um e , it descends d own in to the abdominal cavity, s t re t c hin g out i ts atta chments t o for m the fal c i form , coronary ligament , a n d the l esser omen tum At t h e same tim e , it becomes sur ro unded b y the fibrous ca p sul e o f t h e liv e r which comes from t h e central tendo n . Subse q uently, it i s completely

c overed by the peritoneu m , excep t for in the plane in which the coronary liga ­ ment i s gi ven o ff. where i t i s i n direct c o n t a c t with the diaphra g m . � GASTROPHRENIC LIGAMENT

This is found where t h e t wo layers o f the g a s tr i c p e r i toneum fold back over

the diaphragmatic peri wneum . I t extends from the posterior side o f the great

tubero si ty to the left leaflet of the d ia ph r ag m . I t co n t inu es to the rig h t as the hi gh

part of the lesser omen tum , a n d to the left with the g as tr o spleni c l ig a m e n t . � GASTROCOLIC LIGAM ENT

Derived from the g r e a te r omentum , t h is ligament extends from the grea ter c u r va t u re o f t he s tomach down to t h e transverse colon . � BROAD LIGAM ENT

The broad lig a m e n t can be considered a s a t tac h in g the peritoneum to the

u terus and i ts accessorie s , as pre vi o u s ly discussed. � S U S P E N SO RY L I G A M E N TS O F T H E C O L I C F L EX U R E S

These are t h e ri g h t and left p arie t oco lic ligamen ts , la teral e x ten s i o ns o f the

greater omentum , which represent the most important a ttachments o f the flex ­

u r es of the colon . O m e n ta

The se a re lamina of the periwneum , some of which contain one or more vascular plexuses a n d connect to one o r ano ther o f the organs located in the p e r it o n e a l cav i ty. T h er e are four different omenta , three of which are a ttached to t h e s tom­ ach . Note t ha t the l a s t two described here are more co m m on ly referred t o as

ligaments. � LESSER OMENTUM

This quadrilateral lamina i s also known a s the g as t ro he p a tic omentum . It is

lo c a t e d in th e fron t a l p lane and ex tends from the lesser g astr ic curva ture over the r igh t edge of th e esophag u s and the fir s t part of the duodenum to the interior surface of the liver c l o s e to the hilum . It then makes a right angle turn b a ckwards

t o follow the fissure of the ligam e n tum ven osum and the left vertical sulcus as far as the p os terior surface of the liver before inserting into the diaphragm .

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Chapter 2 / Ana tom y of the Fasci a e

I t s ho u l d be rememb ered tha t t h e lesser omen tum receives extensions of

t h e c oronary and the g a strophrenic l ig a m e nt s . On the ri g ht,

it l eaves a free e d g e ,

which w i l l constitute t h e epiploic foramen , to give a c c e s s to t h e pos terior omen­ tal fo ssa . In its mass are found the bile ducts and the va scular p l e xu s of the liver.

� G R EATER O M E N T U M

This quadrilateral l a m ina i s also kn own a s the g a s trocolic omentu m . I t invests

the intestine a t the front like a more or less exten sive apron Superiorly, i t i s at­

t ache d to t h e s t o m a c h 's greater curva ture , forms the g a s t ro col i c ligamen t , and then p a s s e s a t the front from tbe transverse colon (to which it is attached) a s i t descends i n t o t h e abdominal cavity. I t term inates w i t h a free edg e

.

Laterally, it sends o u t e x te n s i o n s to the abdom inal wall which go

on

to form

the suspensory li g a m e n t s o f the colic flexure s . The left edge o f the gas trocolic li g am en t con tinu es s u per i o rly in t h e leftward direction wi th the g a s trosplenic

omentum . This is a broad p eritoneal lamina which consists of four s u peri m po se d layers

.

� GASTROSPLEN IC OMENTUM

This is more commonly kn ovvn a s the g a s tros pl e n i c ligam en t. It is a superior­ ly direc ted c on t inu a t io n of the greater omentum . This t wo l ay e r e d lamina e x tends -

from the greater cur vature of the s tomach as far a s the an terior side o f the hilum of the spleen . Here , the two lay e rs sepa ra t e : •

the anterior l ay er goes on to l i n e the ant erior side of the medial surface of the s pl een

•

the p o s ter i o r layer folds back on itself at the hilum to form the ri g h t an terior l ay e r of the s plenop an creatic omentum

� SPLENOPANCREATIC OMENTUM

Composed of two l a y er s the splenopancreatic omentum o r li g a m en t is in­ ,

serted in front and behind a t the level o f the tail of the pancreas and in the pos­ terior parie tal plane . I t extends a s far a s t h e hilum of the spleen . Its r i g h t anterior

l ayer is continuous with t h e posterior layer of the s p l eno g a s t r i c omentum . Its short pos terior l ay e r tur n s back to become the pos terior parietal peri toneum .

� P O S T E R I O R O M E N TA L F O S S A

The four omenta define a n area to the rear o f the s tomach which i s flattened in the anteroposterior direction-the posterior cavi t y of the omen ta-whic h is demarcated : •

pos teriorly by th e pos terior parietal peritoneum

•

an teriorly by th e lesser omentu m , the pos terior surface o f the stomach,

and the transverse colon

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Internal Tho racoa bdomi nal Fasciae

•

inferiorly by the transverse mesocolon

•

on the left , by the g a s trosplenic and splenopancreatic omenta

This cavi ty communicates on the right with the grea ter peritoneal cavity via the epiploic foramen . The pos terior c avi ty of the omenta provides a lubricated surfa ce across whic h the stomach can slide and affords the s tomach mobility within the abdom inal cavity The main nerves supplying the peritoneum are the phreni c nerve , the tho­ raco a b dominal n erves , and the sensory and vasomotor nerves coming from the lumbar plexus . The root of the mesentery contain s pain nerves which are par ticu­ larly sensi tive to stretching distortions .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

.

Summary of the Peri toneum The peritoneum consis ts of two layers separated by

a

virtual s p a ce which a l ­

l o w s t h e m to slide with r e s p e c t to one ano ther. Parieta l peri toneUIll . Lines the deep surface of the abdominal cavity and con ­

nects : •

superiorly "vi th the diaphragm

•

la terally with the transversalis fascia

•

in feriorly with the orga n s of the true pelViS a n d the perine u m via the following sep t a : - the vesicorectal sep tum - the vesicovaginal sep tum - the rectuvaginal sep tum - the pros tatic septum

Viscera l peritoneum. Does not make dire c t contact with the parietal perito­

neum but i s a t t a c lled to it m a ny times over via : •

ligaments

•

mesen teries

•

fa sciae

•

Olnen ta ,

which provide suppor t for elements of the vascular and nervous s y s tems and also inves t all the abdominal org ans. •

In males , the peritoneum ex tends into an invagination passing throu g h t h e ingUinal canal as far as t h e scro tum .

•

In females , the peritoneum is n o t herme tically sealed and is in

communica tion w i th the fallopian tubes via Farres lines. ,"

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Tab l e 2� 1 1

Chap ter 2 / Anatomy of the Fasciae

C o n n ec t i o n s o f t h e Peri t o n e u m

E N DO T H O RA C I C PLEURA

FASCI A

PE RICARDIUM

� T / DIAPH RAGM

R E N A L FA S C I A, I L I A C F AS C I A

(-- Peritone u m �

l �

T R A N S V E R SA L I S FASCIA MEDIAN UMBI LICAL LIGAMENT

PARAMETRIUM,

ORGANS OF THE TRUE PELVIS

/ 1 � P R ESACRAL FASCIA

V E S I C O R E C TA L SEPTUM

� l /

VESICOVAG I NA L SEPTUM

PERINEAL FASC I A E

Men i nges The brain a n d the s p inal cord are en tirely envelo p ed b y three concentric mem­ bran e s , the menin g e s , whi ch consist of ( from t h e •

the dura mater

•

the ara chnoid mem brane

•

the pia mater

outside inwards) :

We will first deal w i th tho se in the craniu m , and then in the spinal cord (Fig. 2 -

4 0)

D U R A M AT E R

Cranial Dura Mater The cranial dura ma ter is a thick ( b e tween 0 . 3 and 1 0 millimeters in thick­

nes s - thick est around the foramen magnum ) , fibro u s mem brane which is ex ­

tremely s trong. It is composed of bu ndles of connective tissue mixed with elas tic fibers wh ich line the internal surface of the cranial c avi t y and are so intimately associa ted with the perios teum tha t they are difficult to separa te. The distinction be tween the periosteum and the dura ma ter is only very apparen t at the foramen

magnum, where they s epara te, and the d u r a ma ter c o n tinues downward to i nve s t the spinal cord . According to recent research in do g s , the th ickness of the dura ma ter va r i e s a ccording to the intracranial pressure : the higher the pressure , the

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Meni nges

thicker the m embrane (Ku chi waki

1 9 9 5 ) . The outer and inner surfaces of the

,

dura mater are distinc t . Fig. 2-40

Me n i n ges and Cere b r o s p i n a l F l u i d

S u p e r i o r sagi t ta l s i n us Corpus callosum

P i a mater

M e n i ngea l gran u l a t i o n s A ra c h n o i d

C i s tern o f great cerebra l

Th i rd y e n tricle -+----'\Cr.",,-""'=--

;; i ih� ��!Siiii::;

v.

D u r a m a ter Straight s i n u s C o n A uence o f s i n u ses

CSF I n fe r i o r s a g i t t a l s i n u s D i a p h ragm o f s e l l a [ U rca

Ce n t ral canal of the s p i n a l cord

-----\-+- \ \ \ \ \\ P i a mater D u ra m a t e r (SF F i l u m Ter m i n a l e

O uter s u rface

The outer s u rface of the dura m a ter o f the brain lines the entir e surface of the cranial cavi ty, attaching to the wall via fi b rous vascular and

n e rv o u s

extensions.

The mode of a t tac hm e n t differs i n the vault and t h e base o f the cranium . •

VA U LT

.

A t t a chmen t is relatively weak , apart fr o m a t the su ture s , where i t is s t r o n g I t is relatively e a s y t o d e tach , a s reflected by

lowi ng area the " de tachable r egio n •

"

t h e fact t h a t Marchant n a m e d t h e fol ­

:

an tero p os teriorly, from the p oste r ior edges of the lesser wi n g s of the

s p hen o i d bone u p to within two or three centime ters fr o m the i nternal OCCipita l pro trub erance

•

superoinferiorly, from a few cen timeters lateral to the falx cerebr i to a horizon tal line drawn between the p osteri o r e d g e of the lesser wing s

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Chapter 2 / Ana tomy of the Fasciae

which touches the u p per edge of the p etro u s portion of the t em poral bone, and then passes above the horizontal po r ti on of t h e la teral sinus � BASE

Here the d u ra mater i s very strongly a ttached to t h e periosteum , espec i all y at t h e following points : •

the cris t a ga l l i

•

the pos terior edges of the lesser wings of the sphen o id

•

the p o s terior and a n t e r i o r clinoid processes

•

the upper edge of the petro us part of the temporal bone

•

t h e rim of the foramen mag num

The s tr en g th of a t tachment of the dura ma ter varies w i th a g e , tending to be s tron­ ger in adults than in ch il d ren and s t e ad i l y increa sing with a d vancing age, even in the normal as opp osed to the disease s ta te .

It i n vest s all th e vessels and nerves crossing the cranium w i th ex tens ions that follow with them th r o u g h the ir respective openin g s . Beyond the openings , they separate to continue into the extracranial periosteum . These e x t ensions inve s t : • •

t h e hy p oglo s s al nerve a s fa r a s the an terior condylar fossa the vagus , glossopharyngeal , and spinal

n erve s

,

and the internal j u g u la r

vein as far as below the jug ular foramen •

the fa cial and auditory nerve in th e internal a u di t ory tu b e , where it fuses with the periosteum

•

the mandibular nerve i n the foram.en ovale m a x i ll ar y

nerve in the foramen ro tundum

•

the

•

the olfa c t o r y fibers as far as the nasal fo ssae

In the optic canal and the superior orbi tal fis sure , the dura mater co n tin u es into the orbit where it j oins wi t h the perios teum of this cavity. It also proVides she a th which g o e s a s far as the eyeball where it is

c o n t i nu

The dura m a ter forms a fa lciform fold above the optic n erve of the optic

ne

a

fibrous

o u s with the sclera .

( th e

tentorium

r ve ) which goes from the sphe n oid lim bus to the a n te r i or clinoid

process . In the optic canal , the nerve is attached to the walls through this shea th , which explains why it can be da m age d when fractures spread to the canal

or

when the sinus is in fected . All these e x t ensio n s fur ther s t r eng the n the a t tachment of the dura mater at the base of the skul l . In t h e cranial suture regions , fi n e bundles o f va scular and nervous ele m e nts in areolar connec tive

tissue emanate from the dura mater and pass via sinuses

across the cranium to supply the scalp.

I n n e r s u rface

The inner surfa c e of the dura m a ter sends out ex tensions which separate the vari­ ous parts of the enceph a lo n and keep them all in the correct position inside the head.

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Men i nges

Th ere are fi ve of these compartmen ts : •

the tenrorium cerebelli

•

the falx cerebri

•

the fa lx cerebelli

•

th e diaphragm of sella turcica

•

the tentorium of the olfac tory bulb � TENTO R I U M CEREB E LLI

The ten torium cerebelli i s a horizontal septum betwe en the superior side of the cerebell u m , which i t invests , and the lower side o f the occipital l o b e s , which lie over i t . It h a s two surfaces a n d two edges. T h e upp er surface is higher in the middle

than a t the sides du e to its inser ti o n a t the median line of the falx cerebr i . On ei­ ther side lie the occipi tal l o b e s . The lower surface is in the shape of a vaul t ; i t lies on the cerebellum and the falx ce rebelli is inserted into i ts median p a r t . T h e an terior edge or lesser circumference is markedly concave a t t h e fro n t ; i t fonns t h e tentorial n o tch (which i s traversed by t h e brain s t e m ) together with the anterior edge of the basila r pontine s u l c u s . The an terior edge of each end of the tentorium cereb elli p a s s e s over the p e trous part of the temporal bon e , where it crosses the greater circumference outside the pos terior clinoid process and goes on to a t tac h a t the top of the la teral edge of the anterior clinoid proces s . T h e ends of t h e two e d g e s of th e tentorium cerebelli form a trian g l e , t h e third side o f which is represented by a a nteropos terior line j oining the two clinoid pro cesses. This triangle is filled by a l a m i n a of dura m a ter in which are buried the oculo mo tor and trochlear nerves . Ex tension s emanate from each of the three sides and descend towards the b a s e of the skull where they are soli dly a ttached . They ex tend from the a n terior surface of the p e trou s p a r t of the temporal bone as far as the super ior orbi tal fissure and the base of the sella turcica . Thes e extensions cons titute the m edial , latera l , and p o s terior wal l s of the cavernous sinus . The pos terior edge (or greater Circumference) is concave pos teriorly a n d i n ­ s e r t s i n t o the internal OCCipital protruberance , in to t h e two lips of the sulcus of the la teral sinu s , into the upper e d g e o f the p e trous part o f the temp oral bone, and

final ly into the pos terior clinoid process. All along this e d g e a re the lateral sinuses behind and the superior p e trosal sinu ses on the sides. Near the top of the p e trous p a r t of the temporal bone there is an opening in the pos terior edge of the tentorium cerebelli through which passes the trig emi­ nal nerve. This openin g gives access to the trig e m inal cave, which contains the trigeminal g a n glion . � FALX CEREBRI

The falx cerebri is a vertical septum located in the longitudin al cerebral fis­ sure which separa tes the two hemispheres of the brain . We will consider its two s u rfaces , its two edges , its base, and its top. The s u r­ fa ces cover the internal surfaces of the cerebral h emisph eres. The p o s terior aspect of the base is inclined infe ropo s t eriorly, continuous on the median line with the

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Chap ter 2 / Ana tom y of the Fasciae

tentorium cerebelli , w h i ch it keeps s t r etched . The s traight sinus runs all the way along the line of in ters ection b etween the falx and the tentorium . The anterior aspect o f the falx i n se r ts into the crista galli o f the e thmoid bone. It se n ds out

an

e x tension into the foramen caecum of the frontal bone. The upper edge is markedly convex ; it oc cupies the

m ed i an

line from the in ­

ternal occipi tal protru berance to t he fo ramen caecum. The superior sagittal sinus is found along this e d g e . The l ower edge is convex and t hi n . I t is apposed to the upper surface of the corpus ca ll o s u m , but only i ts pos terior part is in d i r e ct con ­ tact with i t . The inferior s agi t t a l sinus is found i n s i d e thi.s lower edge. � FALX CEREBELLI

The fal x cereb elli is a m edian , v er t ica lly disposed la mina which separa tes the two hemispheres of the brai n : •

I t s lateral surfaces are apposed t o th e cerebellar hemispheres .

•

The base, oriented towards the top , j oins the median part of the

•

The top , oriented towards the bottom and th e front , branches at the

tentorium cerebelli. level of the foramen magnum wit h both b r anches traveling aro u n d this opening and co n t i n u i ng on to the j u g ular for a m e n . Each contains the lower p a r t of the corresponding posterio r occipital sinus . •

The convex posterior edges are inserted i n t o the i n ter n a l occipital crest and contain the posterior occipital sinuses.

•

The fre e , concave edge of the an terior edge is con n ected to the vermis cerebelli . � O I A P H RAGMA SELLA

T he diaphragm a sella is a tens i le horizontal s e p tum which is inserted : •

at the upper edge of the po s ter i or aspect of the body of the sphenOid

•

to the posterio r lip of the prechiasmatic sulcus , and to the fo u r clinoid processes at the front

I t j o ins the wall o f the cavernous sinus all along the line a t which the superior and

medial walls of the sinus mee t . I t i s composed o f two layers : •

a superficial layer, which is the actual diaphragm of sella turcica

•

a deep layer, wh i ch lines the sella t u rcica and is con tinuolls with the diaphrag m at the prechiasmatic sulcus

The diaphragma sella inve s t s the pituitary gland and is pierced in order to a llow passage o f the infundibulum hy p othalami I t c o nta i ns the caverno us sinuses. .

� TENTORI U M O F T H E O LFACTO RY B U L B

This is the name given to a s m a l l , crescent-shaped fold o f the dura mater which is s tretched out on either side of the

m edian

line over the anterior end

of the olfactory bulb be tween the c r i sta g a lli and the a n terior edge of the orbital tuberosities o f the fron tal bone. This structure i s often abs e n t

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.

10 5

Menin g es

I n n ervat i o n T h e dura ma ter of t h e brain and t h e

scalp a r e i n n e r va ted by the trigeminal n erve ,

the cavern ous nervo u s plexus , and a u tonomic nerves. Differen t meningeal rami

can be dis tin g u ished : •

rami by e thmoidal fi b ers fro m the n a s a l branch of the oph thal m ic . One of thes e m e n in g eal rami , the a ur i c ul a r branch of the vagu s nerve , b r a n c h es off from the ophth a lmic nerve and d i s tr i bure s in the te n tor i um cerebelli . The m eningeal ramus of the mandibular ne r ve passes through the foramen rotundum , and that of the maxillary nerve all lerior

throu gh the foramen oval e .

•

pos terior r a m i v i a branches of t h e va g u s a n d t h e grea ter hypoglossal

the dura m ater of the posterior fossa , as well as meningeal branches of ( 1 to (3, which pass through the foramen

n erves , distributing in magnum

Spinal D u ra Mater

The spinal dura m a ter is

a fi brous sheath which con tains the spin a l cord and the s p in a l roots (Fig. 2 -4 1 ) . I t extends from the foramen magnum down to the

second sacral vertebr a . I t fits inside of the vertebral canal . Superiorly i t is solidly

a t ta ched a t the third c er vi ca l ver tebra and around the foramen magnu m , where it is con t i nu o u s with the dura ma ter o f the brain . The vertebral arteries cross it a t the a tlantO-OCCipital j unction . Hg. 2-4 1

Spi n a l M e n i nges

�\,

/ /

� -�

y

P i , m , '" �

A '''h o o ; d

"'--

D u ra macer

� � �

'\

""""0;::--

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Chap ter 2 / Ana tomy of the Fasciae

Inferiorly i t continu es b eyond the lower end of the cord to inves t all the elements of the cauda e q uina and the filum termina l e . I t termina tes as a pouch a t the sec­ ond sacral vertebra bu t continues w i th the dural part of the filum termi nale as far as the coccy x , which i s a lso known a s the coccygeal lig ament. This ligament

is a t tached to th e posterior ve r t ebral liga ment by a clo sed or fenestra ted median s e p tum. The external surfa c e is separated from the walls by the epidur a l space, which contains veins and semi-fluid lipi d material tha t is especially abundan t at the back. The r a te of en try and exit of this lipid m a terial depends on the intrathoracic and mtra-ab dominal pressure . Pos teriorly i t is completely free. Anteriorly the epidural space is very n a rrow and the dura mater is j oined to the pos terior ver tebral ligament by fibrous exten­ sion s , which are par ticularly dense in the cervical and lumbar regi ons . Recent dissec tions h ave demons trated the existence of

a

fibrous , anteropo s ­

t e r i o r b r i d g e which a t taches the d u r a m a ter to t h e a t l a n ta - o ccipital membrane a t the OCCipital level (Hack , et. a l , J 9 9 5 ) . Thu s , it is continuous w i th the rectus capitis p o s terior muscle. Spinal nerves and roots cros s the dura ma ter, bringing wi th them extensions of the fascia a s far a s the intervertebral foramen where , a fter t h ey have sent out some tracts to the perios teum of the interver tebral foramen , they gra dually be­ come continuous with the membrane investing the nerve Fig. 2-42

(Fig. 2 - 42 ) .

E x te n s i o n s of s p i n a l m e n i nges

A rac h n o i d A tt ac h m e n t s of a ra c h n o i d

P i a m a ter D u ra m a t e r

Neurilemma

Research h a s shown t h a t lumbar dural ligaments exi s t which extend from the dural tube to the common pos terior ver tebral lig ament and from the sulcus of the nerve root to the internal part of the s talk inside the neural canal (Yaszemki a nd \iVhit e , 1 9 9 4) . There are also o th er connec tions b e tween the dura ma ter and

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1 07

Men inges

the nerve roots , a b ove and beyond those listed h ere. In ad d i t i o n dur a l veins are ,

found in these tissues .

The connection betvveen nerve and vertebral li g a m e n t arises in the dural sheath of the root at the level of the d is k and terminates in the la teral e x t e ns i on of the vertebral ligament. The t h i c kn e s s of this li g a m e n t varies at different levels and also between d i ffere n t indi vidu a l s .

The inner surface covers t h e p a r i e t a l layer of the arac h n o i d membrane . I t is j o i ne d to the pia mater via a connecti ve tissue tra c t : •

in t h e anteroposterior direction , where it is co mp ose d o f simple filaments

•

transversely, where it corresponds to a tru e membrane which occupies the entire d e p t h of the spinal co rd

-

th e dent i cu l a t e li g a m en t

The purpose of all these extensions is to immobilize and loca te the spinal cord a t the cen ter of the tube cre a ted by t he fibro us dura ma ter, and to enhance its

protection. The dura mater o f the sp i n a l cord is i nner v a te d by the m e nin g ea l branch of

spin a l nerves. P I A M AT E R The p i a m a ter is the innermo s t of the three m e n in g e al membrane s . It is a cellu­ lovascular stru cture. The p i a mater forms a sp e c ia l sheath ca l l e d the neurilemma , which invests all the n er v es e m a n a ting from the cr a niu m and the spinal c o r d and fo ll ows them u n ti l their termination .

Cerbral Pia Ma ter The pia m a t er of the brain is th in n e r, more amply suppli e d with blo o d , and less s tron g ly a tta ched to other s truc tures than its spinal cord portion . The p ia mater covers the external surfa c e of the e n ce pha l o n and insinuates

i tself into all its depths and sulci. It is more s tro n g l y at tached at the pr o tru b er an ce and p e d un c l es than a t the cereb ellum o r cerebr u m . At the same ti m e , it is less

vascular and s t ronger. The i n n er surface is in d i re ct con tact with th e nervous ti ssue and is loosely

attached to it v i a connecting filaments and , m or e importantly, by the myriad tiny vessels which cross in both di r ecti ons b e tween the two t i ssu e s . The exte rnal surface is connected to the s u b - a r achnoid space through which

circulates the cerebrospinal fluid. A t the level of the great transverse cerebral fis­ sure ( Bich a t 's fissure) , the pia mater of the brain insinuates i tself into the interior br a in to form the telae choroideae ve n t r i c u li and the choroid plexi.

Spinal Pia Ma ter This is con tinuous with the pia mater of the brain and extends at the b ot to m around the filum terminale as the coccygeal li g am e n t , which inserts a t the b a s e o f

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C h apter 2 / Ana tom y of the Fasci a e

t h e coccy x . This l i ga m e n t i s small b u t v er y strong a n d i s important in imm o b i l i z ­ ing the lower m o s t end of the s p in al cord .

The inn er surface is att a che d to all parts of the underlying ne r v o us tissue by means of numerous c O ill1e c t ive tissue s e p t a which penetrate into t h e white mat­

ter. It also s en d s out extensions into the pos t e ri o r and anterior median s u l ci . Th e ex ternal surface is ba t h e d in c e r e br o spi n al fluid . I t is connected to the dura mater via b o t h an teropos terior and l a teral extensions.

There are are tiny emanations of connec tive tissue , p ar ti c u l arl y small a t the front but denser and s tr o n g er at the back , known as an teropos terior extensions.

Th ey form

a

septum on the median line whi c h is par ticularly co m p le t e in the

thoracolumbar r e g i on . The d e t i cu l a t e l i g am e n t s of the s p i n a l cord are lateral extensions that ex tend

t r an s ve r s e ly from the pia mater to the dura mater, sta r ti ng a t the l a teral masses

o f the atlas b o n e and a s fa r a s th e first lumbar ver tebra . They a re located b e t ween th e anterior and posterior roots of the s p ina l nerves. The l a ter al e dg e is s cal l o p e d or dentel l a t e , wi th the proj ections atta ching to the dura m ater b etween the open­ in g s for the two n e i g h b o r i n g s p ina l nerves . Between each p air of proj ection s , the l a teral e d g e of the lig am e n t is fre e and all o w·s the passage of the roots of the same

sp i na l nerve. The most c e p ha l i c of the dentate l i g a m e n t s is a t tac hed to the ver te­ bral a rter y and the h y po gl o s sa l nerve near the for am e n magnum .

A RACH N O I D M E M B RAN E The a rachn oid membrane is a thin con n e c t ive tissue mem brane fo und be tween t h e pia ma ter and t he dura ma ter. It is ti gh tl y associated w i th the latter at all

p o in t s . It de fi n e s two s p a c es , n am e ly, the subdural a n d th e s u b a r ach n o i d s pa c e s . The more or less v i r tual subdural spa c e is crossed by numerous a rte r i e s , veins , a n d n erve fi b ers which are en tering or l eaV in g the central nervous sys tem . In its spinal p orti o n , i t is a l s o c r o s s e d by various trabeculae of connec tive ti ssue and the

denticulate l iga m e n t s which j oin the pia m a t e r to the d ur a ma te r.

The ar a c h n o id membrane first ap p e ar s in the e m b r yo b e t we e n d ay s twelve and thir teen. At thirty weeks , it i s still thin a n d often incomplete , bu t it is stron­ ger by week thirty - eigh t . I t c o n t inue s to thicken and e l ab o r ate m o re c o n n ec t ion s

t hr o u g h out fe tal d eve lo p m e n t and for three y e ar s a ft er bi r th . Th e d e n t a t e lig ament of the s p i n a l c or d fi r s t a p p e a r s a r ou nd d a y for ty-one.

Cerebral Arachnoid Membrane The visceral l ay e r of the a r a c hn o id membrane i s apposed to the dura mater and

d o e s not follow the p i a m a ter i n i t s invaginat ions i n to the sul c i and fi s s u r e s of the brain , bu t rather passes flat over the m . Here , the sub- arachnoid spaces are

enlarg e d , forming cavities where v a r yi n g volumes of cerebrospinal fluid can ac­

c u m ula t e

(Fig. 2 -43 ) .

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1 09

Men i nges

These cavities are called cistern s . Among the most importa n t are the : •

chiasmatic cistern (also known as the cistern of the lamina terminalis) ,

in front of the optic chiasm

•

pontine cis tern , which is l ower down on the ventral surface of the pons

•

supracallosal cis tern , 'which is superior

•

cerebellomedull ary cis tern (also known as the cis terna magna) , between

(0

the corpus callosum

the med ulla oblongata and the cerebellum •

interpenducular cistern , b e tween the two cerbral peduncles

•

cistern o f the great cerebral vein (also known a s the superior cistern) , in the middl e portion of the transverse cerebral fissure

Fig. 2-43

C e r b ra l c i s t e r n s

S u praca l l osal c i stern

Cistern o f great cerebra l v .

C h i a s m a t i c c i s terrn

Ara c h n o i d

I n t e r pe n d u c u l a r cistern Pon r i n e c i s t e r n Cere b e l l o m e d u l l a ry c i s te r n

The arachnoid m embrane of the brain contains arachnoid granulations (also known as pacchionian bodies) , which are small elevations concentrated around the sinuses and representing the s truc tures through which the cerebrospinal fluid i s reabsorbed . These granulations grow from the inside towards the outs i d e , obey­ ing a force which pushes them out to come in to cont act with the inner wall o f t h e cranium . There they c a n crea te depressions on t h e inner surfa c e of the skull called granular foveolae . These can be deep, especially in the elderly, and can eve n , i n a very small num ber of extrem e cases , pierce the t o p of the skull a n d proj ect out j us t below the integument.

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Chapter 2 / Ana tomy of the Fasc iae

Spinal Arachnoid Mem b rane This is continuous with the ara chnoid membrane of the brain a t the fo ramen m agnum and extends t o the cauda equina , tigh tly associated with the dura ma­ ter a t all points. I t l i n es a ll the vessels , nerve s , an d dentate ligaments , and travels with the nerve roots as far as the intervertebral foramen , where it folds back on i tself. Parts of the inner surface of the arachnoid m e m b ra n e are doubl ed up by a

supplemen tary so

m

e mb r a n e the lep to m eni nx (Nicholas a n d Weller, ,

.1 9 8 8 ;

Parkin­

n 1 99 1 ) . ,

The l epto m e n in x is fo u n d a t the level of the spinal co r d b u t not in the ce­ rebrum (Fig. 2 - 44) . I t is most obvious in the thoracic region The s u b - arachnoid

space i s s eparated from th e perivascular spaces (Virc how- Robin spaces) by a l ayer of pia mater in the spinal col u m n , but not in the brain . Fig. 2 -44

C ross-sec t i o n t h r o u g h t h e S p i n a l C o r d a n d i ts M e n i nges

L e p to m e n i n x

Dorsa l s e p t u m

D e n t i c u l a t e l i g.

N e rve roots

D u ra m a ter P i a m a te r

B l ood vessel

The lep tomeninx lines the inner m o s t s urfa c e of t h e m e d i a n

a r ach n o id

membran e

a n d folds back on i tself at the m edian line to for m posterior s ep ta , which loosely

link the arachnoid mem brane and the pia

m a t er.

It should b e no ted tha t a la teral

septum i s fou n d at the thoracic level . This lep tom eninx also lines the pia mater and the dentate ligamen ts. The col ­ lage n fi b ers in the den tate ligaments are thic ker on the dura m a ter side than they are on the pia m a ter side. The le p tomeninx is a fen estrated s t r u c t u r e and contains

trabecu l a e , which are attached to t h e nerves and vessel s of the pia mater as well

as to the p i a m a ter itself. The pia mater is j oined to the spinal cord by groups o f

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111

Men i nges

c ollagen fibers which are denser at the thoracic level , but the s e attachments are not fen estrated.

A fenes tra t ed bu t l ess obvi ous lep tomeninx s tru c tur e is also found a t the ven­ tral level , sur ro un din g the an terior spinal artery. No s e p t a have ever bee n obs erved in this region .

The lep tomeninx and the lig aments are more pr o n o un c ed in hu m ans , pr o b

­

ably because of our ability to take an erect position . The rea son for the fen e s trated con figuration around vessel s is alm os t c e rt a in ly rela ted to the d a mp ing of pres ­ sure wav e s g enera t ed when c h an g i n g pos ture. The fen e s tra t i o n would also be useful in maintaining the s tabilit y of the nerves , ves sels , and spin a l c o rd in the

su b-arachnoid spa ce . The lep tomeninx defines a space be tween it s el f and the pia ma t e r in which cerebrospinal fluid circulates. A t the spinal c or d level , the flu i d is reabsorbed via the perivenous sheaths and the paraver tebral lymph nod e s .

The a ra c hnoid membrane and the pia ma t e r of the brain are innerva te d by the ner vo u s p lexuses which are associated with the vessels . Ta ble 2 - 1 2 C o n n e c t i o n s of t h e Me n i n ges

P E RIOSTEU M AND SCALP

l'

EMISSARY VEINS

l'

ENDOCRAN IAL VAULT

1

POST E R I O R LO N G I T U D I N A L L I G A M E NT, L A T E R A L S I D E O F V E R T E B R A E,

( D E N T I CU LA TE

LIGA M E N T

)

� M

. enmges ------;,

P E R I P H E R A L FASCI A E TH ROUGH N ERVE EXTENSIONS SAC RUM

F I L U M TERM I N A L E

COCCYX

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PERIOSTEUM OF I NTERVE RTEBRAL FORAMEN

112

F i g. 2-4 5

Chap ter 2 / Ana tomy of the Fasciae

Overa l l A r r a n g e m e n t of t h e F a s c i a e w i t h Po i n ts of Con t i n u i ty

E p i c r a n i a l a p o n e u rosis

Men i nges

Deep cervical fas c i a

P h a ryngobasi l a r fa s c i a

S u p e r fi c i a l cerv i c a l fascia

M i d d l e c e rv i c a l fas c i a

E n d o r h o r a c i c fas c i a

E n d o t h o r a c i c fa s c i a

P l e u ra

f---tft---ll---l----c ----ft--; Perica rd i u m

D i a p h ragm

Tran sversa l i s fa s c i a

Periton eum

FASC I A L A R T I C U LAT I O N S

P e r i n e a l fas c i a e

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Connective Tissue Anatomy at the Microscopic Level "A tissue can be defined as the first level of multicellular

organization: it corresponds to a group of differentiated c el ls

which together form a unit th at is a ter rit orial functional and ,

physi ol ogic al entity."

- J. Racadot, Precis

D 'Histologie Humaine

will briefly go over the microscopic anatomy of the con­ tiss ue This b ackgro und will help in understanding some of the subtleties of fascial techniques and place them in a global p e rs p ec tive As noted in C oujard et. aI, Bernandin and Kaiyos prop os ed a biochemical definition of connective tissue based on the presence of four specific types of macromolecules: col l agen, elastin, proteoglycans, and structural glycoproteins. In connective ti ss u e, interac­

IN THIS CHAPTER we

nective

.

.

tions among stationary cels, motile cells, and a matrix create a relatively loosely structured

network. The bound cells are named according to the type of tis su e

in

which they are found, that is, connective cells, cartilage cells, bone ce lls etc. (Fig. ,

3-1). The matrix or interstitial substance is made

up of a ground substance and

various types of fibers. Distinction is made among the follow in g types •

Connective tissues - mesenc hym e

•

of tissues:

Cartilaginous tissu es

- hyaline cartilage

- reticular tissue

- elastic cartilage

- interstitial tissue

- fibrocartilag e

- fibrous tissue

- bone

- adipose tissue

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114

Fig. 3-1

Chapter 3 / Connective Tissue Anatomy at the Microscopic Level

Origin s of Connective Tissues

A

Ectoderm

B C

M esoderm

D

M es enchymal cell

Endoderm

1 2 3 4 S 6 7 8 9

Hematopoietic st em cells

Smooth m. cells Fibroblasts

F i b rocy t es Osteoblasts Os teocytes Odontoblasts Hyaline chondrocyte Elastic chondrocyte

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10 11 12 13 14 1S 16 17

Fibrous chondrocyte Chondroclasts M a s t cells Lipoblasts Adipocytes Reticular cells M acrophages Endothelial cells

11 5

Connective Tissues

Connective Tissues As stated above , conventionally there are distinctions mad e amon g the different types of connective tissue . In reali ty there is no clear demarcation line between one type and another and they can all b e considered different d ensities of the ,

same t is s ue The key physical and mechani cal properties of connective tissue are: .

• elasticity •

viscosity

•

plas ticity

•

s tre n g th

Connective tissue is made up of various types of cells supported in an in t e rs t i t ial matrix.

CONNECTIVE TISSUE CELLS

Bound cells •

fibrocytes (a mature form of fibroblast)

•

mesenchymal cells

• reticular cells • pigment cells •

adipocytes

Unbound cells •

macrophages

•

m a st cells (the most abundant)

•

lymphocytes

•

plasma cells

• granulocytes

Inters ti tial ma trix This matrix m a inly consists

of a netwo rk of di fferent fi b ers

.

Ret i c u lar fibers Similar in s tru c tur e to collagen fibers, reticular fibers form a ne twork around the

blood capillaries and are found in the basal substance in the llIinary d ucts

.

Col lage n fibers

Made up of groups of fibrils held to g e ther by an amorphous cement. They are relatively inextensible and are always found in the tissues in the form of bundles of fibers. T h e y are espeCially abundant in the tendons , the tympanic membrane , and certain fasciae.

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Chapter 3 / Connective Tissue Anatomy at the Microscopic Level

Elastic fibers

Found in many connective tissues, for example, in the coronary arteries and cer­ tain l igam ents , like the ligam enta flava.

Ground substance This is l ar g ely secreted in situ by connecti v e tissue cells and plays an important role in homeostasi s, n o tably in the metabolic exc han g e processes which occur between cells and the blood.

Various types of connective tissue Mesenchyma

This is th e em br yonic c onn ecti ve ti ssu e . Reticular tissue Distinction is made between: •

lymphoid ti ssu e (lymph n odes)

•

myeloid tissu e ( b on e marrow)

Interstitial tissue Interstitial tissu e , or stro m a , is rather loosely structured. Its function is to pack the spaces and provide a lubricating layer between other structu res ( e . g. ,

muscles and

internal o rgan s) . The stroma plays an important role in many metabolic processes, notably in

tiss ue regeneration. It contains: •

collagen fibers

•

elasti c fibers

•

reticular fibers

•

grou nd subst a n ce

•

ce ll s

Fibrous tissue Fibrous or dense connective tissue con tain s a pa rtic u l arl y high p r opo rtion of col­ lagen fibers, with a lower density of cells and less groun d substance than in stro­ ma. This is the form of connec t ive tissue fOlUld in tendons as well as the plantar and volar fasciae. Adipose tissue

Distinction is u su a ll y made between two different types: •

white adipose tissue,

•

brown ad ipose ti ssu e

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117

Connective Tissues

The l atter type is high ly represented in new-borns. In a dul t humans, it is only found in cert a in specific parts of the body (e.g., the adipose capsule of the kid­ ney). Adipose tissue is composed of adipo cy tes suspended in an interstitial matrix. Distinction is usually made between: •

fat stor age tissue, the quantity of which depends on nutritional

status, mostly found in subcutaneous cushions "vhere it is ready for consumption when energy is needed •

structural adipose tissue, the quantity of which is independent of nutritional status which is found in such pla ces as the: ,

- j oints - bone marrow - adipose tissue of the cheek

CARTILAGINOU S TIS S U E Cartilaginous tissue i s made u p o f cel l s i n a highly hydra ted (70% water) inter­ stitial substance which cont ain s hardly any vessels or nerves. It is the n ature of

the interstitial substance which defines the different types of cartilaginous tissue,

with distinction usu a l ly made among: •

hyaline c a rtil age

• elastic cartil ag e • fibroc ar tilag e

Hyaline cartilage This form consists of an in terst iti a l su bstance cont a inin g small coll agen fibrils and

isolated networks of elastic fibers. Most of the body's ca r tilaginous tissues are in­ vested by a con t inuous extension called the perichondrium. This type of cartilage is found in the joints, the cos tal articulations, the airways, connecting cartilage, and the skeletal frame.

Elastic cartilage The interstitial substance of elastic cart il age contains a higher proportion of elas­ tic fibers and fewer collagen fibrils than h yaline cartil a ge. This is found in such tissues as the pinna of the ear and the e piglot tis.

Fib rocartilage Fibrocartilage contains few cells but is r ic h in collagen fibers. It is notably found in the intervertebral disks and (he ligaments associated with the pubic symphysis. The intervertebral disks are kept in place by hyaline ca rtilage which is strong­ ly attached to the bodies of the vertebrae. The disk extends from the inner face

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Chapter 3 / Connective Tissue Anatomy at the Microscopic Level

of the vertebral body and adheres to thin layers of hyaline cartilage. When

a

disk

ruptures through the vertebral end plate, it forms structures known as Schmorl's nodes. The posterior longitudinal ligament is strongly attached to the disk. At this point, we find a fascial continuity between cartilaginous, fibrous, and bony tis­ sue.

BOI\lY TIS SU E Bony tissue is composed of: • bone cells or osteocytes •

ground substance

•

collagen fibrils

• a cement substance •

various salts

All bony tissue is based on just two fundamental components, namely, ground substance and collagen fibrils. Therefore, bony tissue can be thought of as a fas­

cia which has undergone thorough consolidation. The fibrils represent one of the organic constituents of bone (as opposed to the salts, which are the mineral constituents) . The strength of bone partially depends

011

its organic components, and when

these are deficient, it loses elasticity and tends to break easily. Therefore, bone, like all the other types of fascia, is characterized by three key properties-elasticity, plastiCity, and strength.

Different types of bony tissue Distinction is made between two different types of bony tissue on the basis of how the fibrils are organized: •

reticular bony tissue

•

lamellar or haversian bony tissue

Reticular bony tissue Reticular bony tissue is formed when connective tissue is converted into bone. It is most abundant during development, but persists into adulthood around the cranial sutures.

Lamellar bony tissue Lamellar bony tissue accounts for all the other bones in the body. It is clearly stratified with lamellae of ground substance alternating with layers of osteocytes. These layers are organized concentrically around a haversian canal to form the ba­ sic unit of compact bone, the osteon (Fig. 3-2). Neighboring osteons are separated by interstitial lamellae. The longitudinal haversian canals are interconnected by the more or less obliquely inclined Volkmann's canals.

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119

Conneclive Tissues

The way in which the osteons are construc t ed and organi z ed d ep en ds on the load borne by the specific bone. In this manner the tissue is characterized by the sa m e kind of v ariability and adapta tion as the fasciae .

The fo r mation of bone is mediated by osteoblasts, specialized mesenchymal cell s (the cells from which all tissues are derived ) . The osteoblasts secrete osteoid,

a spec i a l kind of interstitial substance compos ed of a soft ground s ubst ance an d collagen fibers. Fig.3-2

Two Osteocytes and Part of an Osteon

Lamellae Haversian canal

Lacuna Cement

.. '

.

.

Dendrites

/l

.� �Tr .

···

. . .

..

/

"

.

. .... .. .

.�

:

..

OSTEOCYTES

..'

Various types of ossification Distinction is usually made between two differ en t modes of ossification:

,.

• endoconnective ossification; also known as direct or fibrous ossification

:

• cartilaginous ossification; also knO\'V11 as in di rect ossification, as i t

involves the r eplace m en t of pre-existing car til age

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Chapter 3 / Connective Tiss ue Anatomy at the Microscopic Level

Endoconnective ossification

This refers to the formation of bone from connective tissue. The nature of the bone, initially fibrous, gradually changes to a lamellar structure. This type of os­ sification is found in: •

the bones of the calvaria

•

the facial bones

•

the clavicle

Cartilaginous ossification

Cartilaginous

o ss i

fi cation describes the process in which pre-existing cartilagi­

nOLlS structures are replaced with bony tissue. This process involves cells called chondroclasts,

w hich

absorb the cartilage and thus allow its replacement with

bony tissue produced by osteoblasts. Distinction is usually made between two different forms of car tilaginous os­ sifica tion: •

endochondral ossification, which occurs within the cartilage aro u n d the epiphyses

•

perichondral ossification, which progresses from the perichondrium and only occurs in the diaphyses

Periosteum The periosteum is a fibrous, elastic membrane which covers the entire bone apart from its cartilaginous portions. It is continuous with both the fascial sheets and the tendons which attach the muscles to the bones (further evidence of the unin­ terrupted continuity of the fascial system). The strength of attachment of the periosteum to the bone varies enormously: •

It is very tightly attached to short bones.

•

It is less strongly attached to long bones, although in these bones the association tends to be tighter at the epiphysis than along the diaphysis.

These characteristics of the periosteum are due to the presence of: •

tendons and fasciae, which have th e effect of fixing the periosteum to the bone mass

•

nerves and vessels extending from

the periosteum

into the bone, which

similarly hold the two tissues together •

Sharpey's fibers, which are connecting fibers that emanate from the periosteum and are e m bedded in t he bone (another example of fascial continuity: from the periosteum to the bone where all fasciae terminate)

Inner periosteal surface

Vessels and nerves project f rom the inner surface of the periosteum into the bone.

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Connective Tissues

Also on this surface is a lay er of en do steum , which is involved in the radial growth of bones.

Outer peri osteal surface It is the outer surface of the per i osteum which is in contact with the muscles, tendons, a nd fasciae. In certain p l aces, this tissue is very close to the skin with just

a simple fa s cia or thin, sp arse cellular layer separating the two (e.g., a t the ti bia and the zygomatic bone). Structure Distinction is usually made between two different la yers in this fibrous tissue: •

an external layer of connec tiv e tissue, which is rich in elastic fi bers

•

a deep layer based on simila r but finer comp on en ts

The deep la yer is the thin n er of the two and its network of elastic fibers is woven more tightly. Connective a nd ela sti c fi bers (s ometi mes known as a r c hifo r m Ran­ vier fibers) project from this inner su r face and are embedded in the b one . One of the functions located in the deep layer is the gener ation of osteoblasts.

These generally dis app ear once growth is fi n ishe d but the y can re tur n at any time to regenerate bony tissue following damage.

The pe r iost eu m is highly vascul ar a nd provid es all th e nutritional ele m en ts

which are n eed ed by b on e. If the peri osteu m is destroyed, the bone becomes necrotic. The periosteum is innervated by a very dense network of n er ve fibers,

which accou n t s for its exquisite sensitivity. Some of these fibers pass over into the bony tissue in associat i on with blood vess els. The periosteum also con t a in s a dense network of ly mphati cs .

Org anization of bony tissue Bony t issu e consists of cells (osteobla s ts, osteocytes, and osteocl a sts) in a matrix. Matrix

The matrix consists of an organic ground substance containing mineralized col­ lagen fibers and a v ari et y of mineral salts. � ORGANI C MATRIX

This consists o f : •

a

ver y dense network of collagen fibers. Tubular fibrils which are present

withi n bony tissue have been sh own to be extensions of fibrils in the tendons and fasciae which ar e inserted into the b on e-thes e are called S harp ey 's fi bers . • a ground sub stan ce, which is rel a t i vely sparse and contains a variety of

different mucopolysaccharides, g lycoproteins , and structural pr otein s as

well as wat er and electroly tes

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Chapter 3 / COIU1cctive Tissue Ana tomy at the Microscopic Level

� MINERAL SALTS

It is its mineral content which makes bony tissue hard, especially cry s ta lline hydroxyapatite, a salt containing calcium and phosphate. Deposition and reabsorption of bony tissue

T hrou g hout life, bony tissue is subject to

c onti nuous

turnover, a p roc ess which

involves both catabol ism and anabolism. � DEPOSITION

A bon y tissue precursor substance, a m ix tu re of glycoproteins, mucopolysac­

charides, and tropocollagen, is synthesized and secreted by osteoblasts This pre­ cursor substance then becomes mineralized by the deposition of calcium phos phate, which subsequently crystallizes in the form of hy droxyapatite

­

.

� REABSORPTION

Two processes are involved in the reabsorption of bon y tissue: osteoclast-mediated reabsorption, which is stim u l ated by [h e local

•

presence of parathyroid hormone. Osteoclasts secrete

a

va r iety of

effector molecules: H + ions which attack the mineral material; acid hydrolase enzymes which break down glycoproteins and mucopolysaccharides, and collagenase enzymes which break down collagen . periosteocytic re a bsorp t ion : certain osteoclasts are particularly Iytically

•

active and induce demineralization and l ysis of s u rrounding bony tiss u e

Related Tissues To conclude this section, we will br iefly review cer t ain features of other tissues that are very closely associated with the connective tissues. The connective tissues proVide these other tissues with both ph ysica l and material support

MUSCLE Muscle tissue ca nnot be considered independently of the fa scial system which completely invests all the muscles of the body and provides both reinforcment and in se r tion points. Moreover, like all fasciae, t h o s e which invest muscles act as a conduit for the nerves an d vessels without which the muscles could not func­ tion. A muscle is constr ucted of a series of different levels of fibers (Fig. 3-3). Each

level is invested by a speCific t yp e of connective tissue. The muscle as a whole is surrounded with an element of the fascial system called the epimysium. The epimysium divides to form the septa of the perimysial network which invest rhe primary fascicles. The perimysium further divides to form the connective tissue

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Related Tissues

covering which defines each separ a te muscle fiber, the endomysium. Finally, each muscle fiber is co mp osed of a group of myofibrils. The myofibril corresponds to the m os t basic unit of mus cl e tissue and is covered by a delicate membrane called

the sarcolemma.

Fig. 3-3

Skeletal Muscle Structure

Myofibrils Sarcolemma

Myocyte Nucleus

Motor

n.

Fascial envelope

Bundle of m. fibers

V e sse l s Perimysium Endomysium

Extensions continuous with the muscle tissue project from the ends of muscles to form the tendons where fasciae or membranes converge to form a thick cord which is both ex treme ly strong and elastic.

Tendons are formed of two different t ypes of connecti ve tissue: •

fi brous tissue

•

loose cellular tissue

The basic unit of the tendon is a primary bundle of fibers g rouped to g e th er inside

a

sheath. These primary bundles group with one another to form second­

ary bundles, which de fine another level of fiber. The secondary blwdles, in turn, group to g ether to form a ter ti a r y structure, the tendon itself, which is invested with a third level of membrane.

In certain tendinous bodies, some of the softer connective tissue has been replaced by true bony tissue-these are the so c a lled sesamoid bones, the most -

remarkable of which is the patella.

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Chapter 3 / Connective Tissue Anatomy at the Microscopic Level

Two different types of muscle tissue are recognized: • smooth muscle • stri ated muscle

Smooth muscle tissue These have: • a cen tral nucleus • myofilament-containing cytoplasm • a plasma membrane covered in a basement membrane into which are

inserted bundles of collagen fibers

Striated muscle tissue Each of these cells contains several hundred nuclei located against the plasma membrane, with the whole syncytium covered in

a

base m ent membrane.

Muscle fibers are assembled in bun dles together with interstitial, highly vas­ cular connective tissue. Muscles are attached to skeletal elements via aponeuroses and tendons based on collagen fibers emanating from the end of each myocyte

.

NERV ES Nerves are composed of conducting nerve cells together with

a

mesenchymal

system for t he i r support and protection.

Central nervous system The tissue which invests and p r OV i des support for the central nervous system is caned the neuroglia. This tissue is made up of modified ectodermal elements and

it fulfills the conventional functions of conne ctive tissue, that is, it provi des p hys i­ cal support, a medium for the exchange of materials, and, when pathological processes are active, mediate s reabsorp tion and repair. Three different types of cells are involved in this system:

Astrocytes Protoplasmic astrocytes are more abundant in the gray matter while fibrillary astrocytes predominate in the white matter and have lon g thin cytoplasmic pro­ ,

cesses. After the destruction of central nervous tissue, they form glial scar tissue. The

as

troc y tes fulfill a supporting role and are fo un d around the periphery of

the brain where th ey form the glial membrane. They send processes out to nearby blood vessels. The walls of the se vessels, together with the basement membrane, separate the ectodermal cerebral tissue from the mesodermal capillary tissue, that is, these structures constitute the blood-brain barrier which blocks the passage from the blood of mate ri als which are not wanted in th e brain. Ast r oc y t es are relat ively immobile.

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Related Tissues

Oligodendroglia Oligodendrocytes ass oci a te

with

nerve cells in the g ray matter; in white matter

they are found in row s between the nerve fibers and are believed to be involved

in myelin production. Their cell bodies are consta ntly pulsating-alternatelycon ­

tracting

and dilating-with a regular rhythm.

Microglia When nervous tissue is damaged. these cells phagocytose a n y debris. c h a n gi n g s h ape when they do so . Th ey are highly motile and rapidly move around between

the c ytoplasmic p r oces ses of the as trocytes, constantly changi n g sh ape .

The neuroglia invests a nd protects the neurons w hich correspo n d to the basic unit of the central nervous system. A typical neuron co n sists of a cell body cell's ac tive

metabolic center),

( the

a number of rel atively short, radiating processes

(t h e dendrites). and one pr i n cipal process (the axon) which conducts

the ner­

vous Signal and which mayor may not be s u rrounde d by a mye linated Schwann cell sheath. The central part of a nerve cell contains the semi-fluid cytoplasm, which is continuou sly flOWing away from the cell bo d y.

Peri phewl nervous system The basic unit of the p er iph e r a l nervous system is the nerve fiber . At the center of a nerve fiber is

the

axon of a n er ve cell, the body of which is im planted in eithe r

the spi nal cord or one of the craniospinal ganglia. This axon is su rrounded by a cellular sheath from

which

This, in turn, is enclosed

it may or may no t be separated by

m

a

layer of myelin .

a connective tissue sheath (the endoneurium) tha t

is made up of lo n gi tu din ally dis pose d collagen fibrils which, t oge ther with the basement membrane, form the endoneural me m bra ne or neurilemma. Individual nerve cells are bundled togethe r to form fascicles or funiculi. which repres ent the functional anatomical unit of th e nerve. Within the fascicle, the cells are s u pp or ted in a special areolar connective tissue structure c al led the endoneurium. The fascicles are invested b y the perineurium. w hich is mainly composed of lo n git udi n ally dispose d fibers, al t hough the pres ence of s ome cir­ c u la r elas tic fibers i.n this layer helps make peripheral n erve s resistan t to physical

stress. In the limbs. the perineurium is rein fo rced around the joint s . The entire nerve (consisting of one o r more fascicles) i s inves ted by the

epi­

neurium, a special areolar connective ti.ssue structure w hi ch also contains fatty

tissue, blood ves s els, and ly mp h atiC S

(Fig.

3-4). Each nerve makes its way to i ts

ultimate d estin a ti on in a ssociat i on with a fascial support structure which protects it and keeps it supplied with blood over its ent i re length. Therefore. each nerve consists of a c on nect iv e tissue sheath

(the epineurium)

e nclos in g bundles (faSCicles) of nerve fibers, each bundle in turn surrounded by its own connective tissue sheath called the perineurium. Each i ndiv idu al fiber in a bundle has its o wn distinct type of connective tis sue sheath called the endoneu­ rium. The perineurium acts as

a

b a r r ier to d iffusio n and separates the epineur i um

(which has a prot ective role) from the endoneurium.

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Chapter 3 / Connective Tissue Anatomy at the Microscopic Level

Fig.3-4

Cross-section through a Nerve and Associated Fascial E le men ts

Epineurium Neurilemma

Perineurium Endoneurium

Arrerial capilla ry Lymphatic vessel

EPITH ELIAL LI N I NG The tissues of the epi thelial lining are composed of tightly-packe d cells which

form sheets covering the entire ou ter surface of the body and lining all the inter­ n a l cavities of the body.

System of intercellular junctions Neighboring cells are joined to one another by in terdigitations of their plasma membranes but, m ore importantly, via special cell-cell junction structures which hold the epithelial sheets together with remarkable efficiency. There are three dif­ ferent types of epithelial junction: Tight or occluding junctions The two adjacent plasma membra nes are very tightly joined via linear arrays of transmembrane proteins on each cell which lock in to one another, analogous to how a zipper works. Adherent junctions Adherent junctions are based on the presence of adhesive-like material be tween adjacent cells. Gap junctions Adjacen t cells are jOined through pores which are created by transmembrane pro­ teins which come together to form a channel; these pores allow the direct transfer of material be tween the cells.

Relationships between epithelial and connective tissue The apical surface of any internal epithelium is in direct contact with the lumen

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127

Related Tissues

of the cavity it is lining, where a s its basal s ur fa ce rests on some form of connec­ tive tissue vvith a sheet of amorphous e x tracellu lar material in between, called the basement membrane (Fig. 3-5). It functions as a supporting structure wi th vaxia­ ti ons in te nsi on, a nd as

a

barrier. In this way it can influence fi l tra tio n, diffusion,

and exchange processes. Basement

m e m brane

s are comprised of two dis tinc t l aye rs:

r layer, the basal lamina, whic h is composed of glycoproteins

•

an u pp e

•

a deeper layer, the reticular lamina, which is co mposed of reticular

and t y pe IV c ollagen

fibers Fig.3-5

Links Between Fasciae and C a p i l l aries

Fascia

Connective filaments

Lym phatic vessel

Intercellular connections

Cell differentiation and functional specialization Different epithelia have different functions and c orresp ondi n gly consist of dif­ ferent cell types to mediate these diverse fu nct i ons Epithelial cells have a short .

lifetime and epithelia are regenerated from undifferentiated cells which form the layer in contact with the basement membrane. The different cell types include: •

the keratinized cells of the ep ider mis which play an i m p ort a n t ,

pro tective role •

the pigment cells of the retina, which produce melanin to protect aga ins t UV radiation

•

s ens ory cells and primary sensor y neurons, like those found in the inner ear and in the systems involved in the senses of taste and smell

•

epithelial cells, which are involved in exchange processes, such as those making up the mesothelial surfa ces of the serous mem branes and the epit h e lia of the a lve ol i of the lungs

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Chapter 3 / Connective Tissue Anatomy at the Microscopic Level

•

ciliated cells, in the airways and the ducts of the gen ita l system, such

as

the uterine tu bes •

gland cells

•

cells which are specialized in ab sorption processes, such as those in

striated membranes which make

up

the lin i ng of the renal tubules

SKIN The skin covers the entir e external surface of the body and has a total

area

of about

J .6 square meters. Around the body open i ngs the skin is continuous 'Nith the ,

mucous membranes.

Various layers of the skin Distinction is usually made

b e tween

three different

layers (Fig. 3-6).

Going from

the most superficial inwards, these are: •

Fig. 3-6

the ep i der mis

•

the dermis

•

the

subcutaneous fascia

The Skin Hair Epidermis Dermal papillae

Meiss ner's c orpus c le Scratum corneum

Stratum lucidum Stratum spinosum

Dermis

Stratum basale Free n. ending Arrector m.

Subcu­ taneous

Ruffini corpuscle

tis sue

Sweat gland Pacinian corpuscles

Vessel

Sebaceous gland

Adipose tissue

Epidermis

The epidermiS is

a

stratified, keratinized epithelium comp o s e d

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of a variable num-

1 29

Rela ted Tissues

ber of l ayers . The cells of the epi de r mi s accomplish their migration from the layer a dj acent to the b a s emen t membrane o u t to the surface within a period of abo u t thin y day s . Going from the d e epest layer ou twards , the layers of this tis s u e include : •

the s t r a t um basale : This layer of cells rests on a basement membra n e which s e p a r a t e s the epidermis from the dermis . Numerous proj ections extend into the dermis , an c horing the basal layer cells and providing a s urface for exchan g e (especially of nutrien ts)

.

• the stra tum spinosum : In this layer, the spaces betwee n cells are grea te r

and the cells are full of tonofibrils , which con fer stability. • the stratum lucidum, w h ere eleidin and kera tin first appear • the s tratum corneum , where ke r a tinizat i on and desquamation take place

Derm i s D u e to its abundance of collagen fibers , the dermis is t h e p an which is respon ­ sible for m o s t of t h e skin s physical s tr eng th . Lea ther is de r ive d from the derm i s . '

T h e ela s tiCity o f t h e skin is mainly due to the chan g e s in angle be tween t h e dif­ feren t planes in the dermi s . N e two r ks of elas tic fibers insure re i n tegration of the fi brous layers a fter t hey have been deformed. It is the transverse l i n k s which allm"l th e return to normal after the skin has been folded over on i tself or deform e d . As the fibers age, t h e links weaken a nd t h i s results in the fla ccidity a n d vlIinkling s e en in adulthood and old a g e . T h e dermis contains the h a i r follicle s , va riou s types of glands , bloo d ve ssels , connective tissue cells , migrating immune system cells , and a variety of nervous s y s t e m structures. I t consi s ts o f t wo l aye r s : •

the stratum papillare

•

the s tra tum re ticulare � S T R A T U M P A PI L L A R E

The p apilla r y dermis lies immedia tely below the epidermal basement m em­ bran e and is l i nked to the epidermis throu gh reticula r fi b ers em a na t i ng from the bot tommo s t layer of epidermal cell s . � S T R A T U M R E T I C U L A RE

The reticular dermis cont a in s a dense net work of cross -linked co l lag en fibers a n d i. e is this layer which makes skin tissue resistan t to tearin g and breakag e . The fi bers of the derm i s tend to be oriented in a specific d i rect i on so tha t i f the s k i n is p erfora t ed t h e resultan t wound tends to b e in the form of an elongated ,

window rather than a s y mmetrical hole . Surgeons are familia r with and explO i t this ' g rain ' , preferring t o m a k e their incisions parallel to the fibers rather than a cross them , because wounds m ad e in this way tend to h e al m o re qui ckly.

Extreme s tr e ss will tear fibers and lead to the appearance of permane n t s tretch marks . S u bcutaneous tissue

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Chap ter 3 / Connec ti ve Tissue Anatomy at the M i c rosco p i c Level

The subcu taneous tissue, or subcutis , is a loosely structured fa scia which is con ­ tinuous \"li th the dermis and provides l ubrication b e tween the d i fferen t layer s . I t a c t s a s a fat storage tis s u e in which t h e s tored fa t also proVides thermal ins u l a ­ tion . T h e sta tus of t h e subcutaneous adip o s e tissue reserves is u n d e r hormona l con tro l . T h e subcutaneous tissue overlies t h e superficial fascia excep t where t h e l a t­ ter is n o t presen t , notably on the fa ce where the s ubcu taneous tissue is in direct con t a c t with the muscles (which makes grimacing and o ther fa cial expression all the e a sier) .

Skin functions Protective fu n c t i o n T h e skin pro tects t h e b o dy from c hemical , physical, a n d thermal insults , a s wel l a s a g a in st a t tack from a wide range of p a thogenic agents . I m m u n e fu n c t i o n T h e skin is rich i n immunocompetent cells and is an important i m m u n e organ . Th e r m a l regu l a t i o n The skin h e l p s re gul a t e in ternal body temperature by m o dulating blood flow through surface vessels and through the p erspiration respons e . Regu l a t i o n of t h e b o d y 's fl u i d ba l a n ce The skin b o th protects again s t water loss and also mediates the elimination of small amounts of excess wa ter and electroly tes in perspira tion. S e n sory fu n c t i o n B y virtue of i ts m a ny nervous s tructure s , t h e s k i n is sensitive t o pressure , tempera ­ ture , and pain . It is also important in communica tion through its capacity to turn r e d or white , and its horripilation response . The electrical resis tance of the skin changes under the influence of emotional stre s s . Finally, the skin reflects an d acts a s a n indicator of wha t is happening in the deeper tissu e s , especially in terms o f the composition of t h e g round subs tance. Hartmut Heine, who participated in the work on the importance of the ground substance vvith Alfred Pischinger, showed tha t the ground subs tance sends out e xtensions towards the surface in the form of cylinders surr01.ll1 d ing nerves and blood ves s el s . These ' H eine cylinders ' modify the s t r ucture o f the skin and m ay represent a sensory organ for magnetic and electromagnetic forces . S u c h a phenomenon may explain how s timulation of the skin could induce long term modification o f intern a l regulatory processes. This cylinder sys tem represelHs

a

fascial component which puts the deep fasciae in communica tion with the sur­ face " in a visible fashion ."

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Histolog ica l Fea t u res o f Connec tive Tissue

H istol ogica l Featu res of Connective Tissue Connective t i s s u e is a heterogenous mix of various cells a n d fi bers a s well as back­ ground materials

(Fig. 3 - 7) .

CONST I TUENTS O F CONNECT I VE T I SSUE

Ground subs t ance Gro und substance is a ho m o geno u s m edium which can vary in consistency from fluid to semi - fl u id ( i . e . , a gel) . I t i s a colloidal solution o f various mucopolysa c ­

charides-including b o th sulfa ted species (e . g . , chondroi tin sulfa te a n d heparin

sulfate) and no n - su l fa ted species ( e . g. , hyalu r on ic a cid) , and is rich in proteogly­

c a n s and s tructural glycopro tein s . T h e b i n d in g of va r i able quanti ties of w a te r in t h e tissue sp a ce i nduces c h an g ­ es in the viscosity of g round subs tance. A viscous g ro u nd s u bst a nce helps prevent the spread of pa t h o g en i c agents , a n d the degree o f viscosity also i n B u e n ce s the m etabolic activity of cells in the v i c i ni t y. A t body temperature, h a l f o f the bound

water is i n the form of liq u id crystals. The g ro u n d s u b s ta n c e p r ovides a highly hydra ted environment for the fibrous pro teins thereby h e lp i n g them fulfill their various roles in lubrica tion , shock ab­ sorption , a n d resis tance to co m p r ess i v e forces . By virtue o f t h eir electrical charge, the components of the ground subs tance also affect a variety of o ther fa ctors , both within the c o nn e c t ive tissue and ou tside of it . Ground substance is key in cellular nutrition because it provides the e x cha nge medium for subs tances diffu sing out of the dens e cap i llary ne twork into the sur­ rounding ti ssue. The proteoglycans and s truct ural proteins for m a m olecu l a r sieve th r ou g h which must pass any thing that is exchanged in ei ther di r ectio n b e tween the cell and the circulator y system . Species vvhich are either too larg e or which carry an i nco m pa t i bl e ele c trical charge are filtered ou t , tha t is . either ex cluded or retaine d . The pore size o f this molecular filter depends on the concentration of proteoglycans in tha t s p e C ifi c connective tiss u e comp a r tmen t . The overall n e g ative ch a rg e of the proteoglyc a n s insures tha t the g round substance i s b o th isosmo tic and iso tonic a t a ll tim e s . The ground substance of connective tissue c a n be considered a s t h e labora­ t o r y in w h i c h a l l the diverse j obs o f the t i ss u e are taken care of.

Coll agens Collagen is the m o s t abu n d a n t o f all t h e pro teins found in the human b o dy a n d a ccounts for 6 0 to 7 0 % of t h e overall mass o f connective ti s s u e . Trop ocolla g en is the basic sub-unit from which all forms of collagen are buil t. Tro pocol lage n

Trop o c oll agen is ex tre m e ly r i c h in g lyc i n e , which distin guishes it Copyrighted Material

( alon g

with

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Cha p ter 3 / Connec tive Tissue AnG tomy a t the Microsco p i c Level

elas tin) from other pro teins found in the bo dy. One q u a r ter of all the amino acids in tropocollagen are derived from prolin e . C o l l agen sy n t h e s i s

M o s t of t h e body 's collagen is syn thesized by fi brobla sts , although i t c a n a l s o b e produced by smooth muscle cell s , and endothelial a n d epi thelial cell s . Pro tocol­ lagen is first synthesized on endoplasmic re ticulum-bo und ribosomes , and then its proline and lysine residu e s are hydroxylated by the action of two enzymes , tropocollagen -proli n e-hy droxylase and tropocollagen - lysine-hydroxyla s e . Next, its hydrox y groups and some of its hydroxylysine groups are glycosylated by conj u ga tion with sugar residues ( galactose or glucosylgalactose) . Once they have been released from the ribosome , three a-chains of protocollagen are align ed in parallel and then helically coiled t o g e ther to form the pro tocollagen sub - u nit . Pro tocollagen s e ems to be transported o u t of the cell via Golgi vesicles and / or vesicles which bud off from the endoplasmic reticulum . The extracellular process o f fi brillo g en esis invol ves cleavage and results in the release of func tional tropocollagen This cleavage reac tion can be incomplete, as is

known to be the case in the type of collagen found i n basement m embra n e s . Tropocollagen t h e n undergoes polymerization to form fibrils . This process seems to depend on the amount of carbohydra te a s s o ciated with the tropocol­ lagen molecule , w i th the rate o f fibril formation being inversely proportional to the quantity o f sugar ( the type of collagen found i n basement membranes is par ticularly rich in carbohydrate and does not form fibril s ) . Extrac ellular maturation to form fibrils and collagen fibers is mainly depen­ den t on the amount of proteoglycan and glycosaminoglycan in the environ­ ment. Collagen is h i ghly resis tant to the action of all pro teolytic enzymes and is only broken by certain specific collag enase activi tie s . T h e r a t e o f collagen turnover varies enormously b e tween d i fferen t tissues . I t is very low in s table tissu e s , b u t i t can b e very high in cer tain situa tions ( e g. , dur­ ing wound healing and in the u terus during g e s tation) . Ty pes of co l l agen

Four different types of collag en are known : •

Typ e I, the most common (found in the dermis , bone, and tendons) makes extremely s trong fibrils which are highly resistant to stress .

•

Type II , rich i n proteoglycans , does n o t readily form fibrils and i s mostly found in c artilaginous tissu e .

•

Type III, extremely r i c h in hydroxyproline and cysteine, this i s an important type of collagen in fe tal skin and , in adults , is found in association with Type I collagen in the papillary dermis , the vessel s , the intestine, the u terus , and the lun g s .

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Histolo g ical Features of Connec tive Tissue

•

Type IV is s p ec ifi c to the b a se m en t

membrane

and contains a high

p e r c ent a g e of car boh ydrates and h ydroxy l y sine . Each of t h es e four types of col l ag e n may be s y n thesized by differen t cells or the

same cell may syn theSize s e ver a l different types (e. g. , fibroblasts s y n thesize Types , I , II , and

III) .

Elastin Elastin is a fibr o u s protein which is the am o r p h o u s component of e l a s t i c fibers . Its precursor is tropoelastin, which is syn theSized in the endo pl as mic reticulum

of mesenchymal cells ( fib r o bl a s ts and s m o o th muscle cells) . Mature el a s t in is fo rmed when cross -links are created b e tween different m o l e cul e s of tropoelastin.

Elastin turnover is ver y slow and its breakdown require s specific el as ta s e activity. Fig. 3-7

Fasc i a l C o m p o nen t s

E lastic fi ber

M ast cell

Pla s m a cell

L y mp h at i c v essel M acrop h a ge

F i b roblast

Connective tissue fibers Three different types of fiber are found in the grou nd substance : •

collagen fibers

•

clas tic fibers

•

reticular fibers

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Chapter 3 / C01ll1ec t i ve Tissue Ana tomy at the M i c roscop ic Level

The quantity and propor tions of each vary from fascia to fas ci a . Co l l agen fi bers Collag en fibers are the most abundant in connective tissue, accounting for 60 to 7 0 % of its overall m a s s . Collagen fibers are white in color, long , and completely inela s tic. They are made up of bundles o f parallel , unbranched fibrils , although the bundles themselves may b e covalen tly cro s s - linked to one ano ther (Fig. 3 - 8 ) . The fibrils are held tog e ther b y a cement subs tance which also c o a ts e a c h fiber.

In chemical term s , collagen fibers are composed of collag en , the compound which yields gelatin on bOiling. I t m a inly consi s t s of the amino acids glYCine, praline , and hydroxyproline. Because i t is comple tely inelas tic , it confers on any tissue in which i t is present both fleXibil i t y and s tren g t h .

In the e arly 1 9 5 0 's Wyckoff a n d Kennedy showed tha t collag en fibrils form a tubular s tructure . In 1 9 5 9 Erlingheuser, theorized tha t the se s tr uctu r e s may circu ­ l a te cerebrospinal fluid throughout the body.

Fig. 3-8

A C o l lagen F i be r Fibril

Sheath

Co l l agen fi be r

E l a s t i c fi bers Ela s tic fibers are lon g , thin , and extensively cross-linked one to ano ther. They can b e s t r e t ched to one - a n d - o n e - half ti m es their

r es

ti n g leng th . In chemical terms ,

elas tin fi bers are composed of elas tin , an albuminoid compound which is highly

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Hisrological Fea tu res of Connec ti ve Tissue

resis tant to heat as well a s to acids a n d b a s e s . Ela s tin fi b e r s a r e yell owi s h in color. The fibers are made u p of an amorphous component and a microfibrillar

c o mp o n e n t With a d v anci n g age, the propor tion of the a m orphou s component .

increases and the microfibrils tend to become pushed out towards the edge. • the amorphous component is based on ela st i n itself •

the microfibrillar componen t c o r r e s pon ds to a structural glycoprotein

The tro p oelas tin fro m which these fibers a re g ener a t ed i s pro du ce d by the fi bro­ blasts of the skin and tendon s , and by s m o o th muscle c ells in t h e walls of maj or bloo d vessel s . As i s the ca se for collag e n the op t im a l tempera ture for the func­ ,

t ionality of e l a s t i n i s 3 7 ° C. Reti c u l a r fi be rs

Reticular fibers are small

c ol

l agen fi b ers which are fo u n d in small numbers in

a micro filament-rich groun d substan c e . They are h e avi ly branched and a re also

cross- linked to one a no ther to form a fine, extensive ne twork . Commonly, ins t e a d of being coval ently cros s - linke d , they sim p ly c ro s s over one ano t h e r

Fig. 3 -9

Reti c u l a r fi bers

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(Fig. 3 - 9) .

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Chap ter 3 / Connec tive Tissue Anatom y a t the Mic rosco p i c LeveJ

Re ticular fibers are often fou nd in b as e m e n t membranes and, in co n t i nui t y with

col lag en fibers , in lymphoid and h e m a t o p o i e t i c tissue s . They d o n o t i n chl d e gr o u n d substance. The y are also found in areolar conn e ctive ti s s ue and in adipose tissue. Fibrillar eleme n t s ( coll a g en fibrils and fibers) may a l s o b e p r e s e n t

.

Reticular fi bers are d i s t i nct from normal collagen fi be r s in th a t they contain

h i g her proportions of aspartic acid and hy droxy am i n o a cids , and less pr o l i n e In add i ti o n t h e y are ass ociated wi th a gre a te r amount of car b o h y dra t e ,

.

Pro teo g l y ca.n.s Pr o te o gl y can s are very high molecular we i g h t species co mp o sed of p ol y pe pt i d e

chains to which are c o n j ug a t ed long polysaccharide chains called g l y co s a m i n o

­

glycan s or mucopolysaccharides . Pro teoglycans bind l a r g e quantities of both vva � te r a n d ca t i o n s , which m a k e s them ideal for t h e bu l k � fo rm i n g function that th e y

fulfill in the extracellular medium or ground s u b s t a n c e of connec tive tissu e . Thei r p hys i co c h e mi c al p r o pe r ti e s are an ess ential fac t or in the viscoela s ti c properties of

j oin ts and other s t r u c tures which are r e g ul a rly s u b j e c t to m echanical deforma­ tion .

Pr o te o g lycans can a c t as a storage reservoir for fo ur nutri tional elements : • ca r b o hy dr a t e in the form of gluc os e a nd gala c to s e • a l b umin in t h e form of NH groups •

lipid in hy d ro c a rb o n c hai n s

• wa t er, the essential componen t ; any reduc tion in wa t e r content will

c a u se retraction of the pr o te o g l y ca n mass Pro teoglycans , s tructural gl y co p r o t ein s and the g l y co c alyx ( a m em b r a ne which ,

covers the external fa ce of the c e l l and which m edia tes d i a lo g with the ground '

'

s u bs t a n c e) are mediators and informa tion-ca rrying c h ann e l s The first step in pro­ .

te o gl y c a n s y nt h e S i S occurs inside the gr anul ar endopla smiC r et i c u lum and is fol

�

l owed by m a t ur a t i o n in the Gol g i appara tu s , and then t r a nspor t o u t of the cell . Different types of pr o te o gly ca n are found in different tissues : • d er ma ta n s u lfa t e is m o s tl y fo u nd in the skin , the tendon s , and the walls

of the arteries •

kera t an sulfate o ccu rs in the cornea , the ca r t ila g e and the pu lp y nuclei ,

of the in terver tebral disks • hyaluroniC acid is found in the mo re vi s c o us b o d y fluids ( e . g. , the

vi t r e o us h umo r a n d s y n ovi al fl uid)

Structural glycop ro teins S tr u c tu r a l g l y co p r o t ei n s p l ay an imp or ta n t role in the formation o f intermolecu �

lar cross-links and in o ri e n t i n g fibrous pro teins. There see m s to be a r ela t io ns h ip

betwe en the regularity of c ollagen fibers and th e ir association w ith glycoprotei ns .

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Hi stolog i c a l Fea t u res of Connecti ve Tissue

In e l a s tic lamella e , thes e components a llow the assembly o f molecules of tropo­

elas tin .

CON N ECT I VE T I SS U E C E L LS

Mesench y mal cells The cy toplasm sends ou t processes which often give the cell a s tellate morphol­ og y. These processes are often in in timate contact with neighbor ing cells although such adhesion points are always temporary and each cell remains independent and a ut onomously m o til e . In adul t tissue, they exist a s a common precursor cell which is ready to differen tiate to form fi broblas t s , macrophages , or the parenchy ­ mal cells of the suprarenal glands.

F i b ro blas ts The fibrobl a s t is the m o s t common cell type in connec tive tissue and is present throughou t life . I r is these cells which produce both the ground substance and the precursors for all connec tive tissue fibers. They also secrete a range o f enzymes involved i n the catabolism of certain macromolecules and the turnover of essen­ tial s truct ures like the basement m embran e . Finally, they play a central role in the occasional processes of wound heali n g and infla mmatio n . I n these cells , proto collagen is produced i n the endopla smic re ticulum , m a ­

tures in the Golgi app a r a tu s , a n d is t h e n transported o u t o f t h e c e l l i n t o the m a ­ trix . Fibroblasts a l s o syn theSize t h e glycosaminoglycan s . Fibroblast b ehavior i s highly responsive t o physical s ti muli, so any kind o f sustained tension o r pressure on a fa scial tissue ,;vill induce : • •

local prolifera tion of fibroblasts aligmnent o f the cells along the lines of force due to the tension o r pressure

•

increased secretion o f macromolecules to consolidate the local fascial sys tem in response to the stress

If stress is sustained for

a

lon g period, the fascia will become more dense and ,

when dissected . the tissue will be seen to be more tigh tly s tructured and its sur­ face will present a m ore pearly sheen. A t the same tim e , the way the network is organized changes acco rding to the direc tion of the lines of force. The fibrobl a s t i s the main protagonist in ground substance organiza tion and i t i s the only type of cell which can coordinate the information coming from

o ther cells and diverse nervous inputs to produce a ground substance with a c o m ­ position m a tched to t h e particularities of t h e curren t situation .

The fibrobla s t is incapable of distinguishing b e tween " good and b a d , " and , if its function is impaire d . it secretes a ground substance whi ch has s tructure b u t which i s n o t physiologi cally normal. In s u c h an abnormal environment , other cells can give rise to chronic disease processes or tumors.

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Cha p ter 3 / Connec tive Tissue An a tomy at the Microsco p i c Level

Reti cular cells Reticular cells are larg e . s tar-shaped cell s . Most are mesenchymal in origin , al­ thou g h the maj ority of those found in the thymu s and the tonsils are p robably derived from the endoderm.

Mas t cells Mast cells are i m m unocom p e tent cells whi ch are released in to connective tissue to mediate defense mechanism s . Areolar tissues are par ticularly rich in mast cells , p articularly those in org ans which contain a high concentration of heparin . They s y n t hesize histami n e , heparin , dopamine, s ero tonin , and hyal uronic acid, and secrete them all into the matrix .

Macrop ha g es Macrophages are phagocy t es . While som e are relatively stationa r y, o thers are hi g h ­ ly mobil e , m oving be tween cells a n d fi b e r s and i n g e s t i n g a n y bacter ia , cellular debris , or foreign m a t ter that they encounter. They are derived from monocytes , circula ting blood cells which differen tiate into macrophag es once they have m i ­

grated o u t of a vessel and ar rived "i n the tissue. The maj or role of these mo bile cells is in defense mechanisms in which they participate by phagocy tosing unwanted ma teri a l , and s ecre ting toxic enzymes a n d o ther biolog ically a ctive specie s . This is the predominant cell type i n b o th loose a n d dense connective tis s u e . Their numbers are elevated and their activi ty is p o ten tia ted in pa tholo gical s t a te s . Mul tinucl e a te foreign body g i a n t c e l l s (which re s u l t from t h e fu sion of m a c ­ rophag e s and / or epi theliOid c e l l s ) are found in inflammatory fo ci where t h e d e ­ b r i s is too l a r g e to be phagocytosed by n o r m a l macrophag es.

Plasma cells Plasma cells are rela tively rare in norma l connective tissue , apart from in the la mina propria of the s tomach wall and in the hema to p o ie tic org ans. However, they are present in great numbers in chronically inflamed conn ective tissue (e . g. , in th e gastroin tes tinal tra c t , the lymph nodes . or the spleen ) . These are the cells

which are responsible for prodUCing antibodies.

Leukocytes Leukocy tes-lymphocytes , monocy tes , and polymorphonuclear cells-migrate out of the circula tion in to the tissue s . They are mobili zed to mediate inflamm a­ tory response s and defend against a t tacking p a thogens .

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H i s tolog ical Fea tures of Connec r i ve Tissue

Ad ipocytes Adipocytes a re found in the c ollage n fiber n etwork in all kinds of tissue, either on

their own or in cl u ste r s . In cer ta in area s , like aro u n d the kid n ey or the suprarenal glan d , they are constantly in a c y cle of g rowth and turnover. In a dults , most a d i ­ pocytes a r e found in white adipose tissu e , althou g h ano ther form , brown adip o s e tissue, is predom i n a n t i n n ew- borns .

The

m a in

fun c tion o f these cells is fat s torage . This c a n serve a variety o f

purposes : • the first and m o s t i m por ta n t reason for s toring fats is to h ave a reserve

of n eu tral lipi d (created by the pr o ce s s of lipogeneSiS) which can be released i n t o the circulation (lipoly sis) when extra e n e rg y is re q uired • a layer of lipid also a c ts a s an effi cient thermal insulator • fa t t y tissue is also important in terms of m echanical pro tection in that i t

a t tenuates pressure a n d a c ts as a shock absorber

Pigmen t cells Various cells syn theSize a n d s tore different t y p e s o f p i gment w i th specific chem­ ical n a t ures and pa rticular colors . The most Wi dely known is melani n , a dark

brown or black pigment whi c h is foun d in melanocytes.

VA R I O U S T Y PES O F CONNEC T I VE T I SSUE

Mesenchym a Mesenchymal tissue is found in the e m b r yo and is characterized by a g r o u n d subst a nce w i t h a high water conten t and which con tains no fi b ers .

Wh arton 's j ell y Wharton's j elly is the

u m b ili cal

a

soft , homogenous intercellular su b st a nce which is fou n d i n

cord. I t contains fewer c e l l s t h a n mesenchyma bu t i t s g round sub­

stance is more viscous and it con tains a few fibers . I t is n ever found in a dults apar t from certain p a tholo g ical conditions ( e . g. , in p a ti e n ts with papilloma or myxoma) .

Reti c u l ar tissue Re ticu l a r tiss u e is the most primitive form of connective tissue fou n d in adult s . It is m a de up of re ticul ar cells and very fine , silver- s taining fibers. Some of the cells are bound to the fibers , o thers a r e unbound. This type of tissue is found i n : • lymph nodes • spleen and liver • bone marrow

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Chap ter 3 / Conne c t i ve Tissue Ana tomy at the M i c rosco p ic Level

Areolar connec tive tissue This is base d on a l o o s e network of co l lagen elas tic , a n d reticular fibers in a rich, ,

s oft g r o u n d substance. All th e cells which are found in o ther types of a du lt con­ nective t issue are also present in areolar connective tissue , cell s

a part

from re ticular

.

A ny exchang e process be tween the blood vessels and the parenchyma of or­ g ans n ece s s arily involves p a ssage through this me dium , which makes i t impor­ ta nt in cellula r nutrition . This type of connec tive tiss u e in the submucosa is

a

key

factor in the mo tili ty of the g a s troin testinal trac t . The m echanical properties o f areolar connec tive tissue are plas t icit y a n d elas­ ticity, both o f which are l a rgely due to the cons i s t e nc y of th e grou n d substance.

Within this tissue are found immunocomp etent cells , blood vessel s , and nerve s . I t forms t h e s t r o m a of mos t of t h e s o l i d organs where i t func tions a s a k i n d of packing ma terial in the : • g as trointes tinal submucosa • mucosa of t h e airways an d g e nitourinary tr a c t • cutaneous der m is

submesothelial layer o f serous membranes

•

I t is part o f the make-up of periphe ral nerves and muscles , and is

a lso

found in

both s uperficial and deep fascia e .

Adip ose tissue Adipose tissue is a speCial t y p e of connective tissue which i s hi ghl y vascular a n d rich in adipocytes. I t is par ticularly abunda n t i n certa i n a r e a s like t h e ki dneys , the ischioana l fossa , the ome n tu m , the subcu taneous tissue, and the mesentery. In e m b r yo gene s is , spherica l capillary plexi dev elop in these areas even before

a ny fa t has b e en dep os i te d A lob ule of adipose tissue grows in the terri tory of .

such

a

plexu s until neighboring lobules com e in to contact wi th one ano ther, al ­

thou g h they remain s eparated by fibrous s ep t a . In s u bcu tane ous tissue , such septa are called c u taneous l ig aments. Thes e lobules of a dipos e tissue act a s cus h io n s to absorb excess pressure as well a s serving as fa t storage d epo t s . Two different typ e s of adipo s e tissue exi s t , white fa t and brown fa t . In human a dults , almost all of the a dipo s e tissue is w h i t e . Brown a dipose tissue p r ed o m i

­

nates in new - borns.

Dense connec tive t issue Dense conne c tive tissue i s full of fib e r s a n d , bein g exceptio n a lly stro n g , plays a key mechanical role. It con tains few blood vessels but dense n etvvorks of collagen and elas tic fibers. Distinc tion is usually made be tween two different types of dense connect ive tissue :

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Histolo g ical Fea t u res of Connec tive Tissue

•

irreg ular

•

regular

I rregu l a r d ense connec tive tissue I rr e g u lar dense connective tissue resembles areolar connective tissue, but contain s a

de ns er network of thicker collagen fibers w hic h makes it fi r m e r and s t ron g er

(Fig. 3 - j 0 ) . It is fou nd in the dermis , the capsules of certain organs , the dura mater, th e deep fa scia e , the periosteum , the perichondrium , carti lage , and bon e . Fig. 3- 1 0

Den se, I r regu l a r C o n n ec t i v e Tissue

F i b rocyte

C o l l agen fi bers

Elastic fi bers

Reg u l a r dense connective tiss u e This type of dense connective tissue is fou n d in t h e tendons , the apone uroses , the

li ga m en t s , and

th e s troma of the cornea . Tendons are made up of thick collagen

fibers which are tightly bund l e d to g e ther in a parallel arran g e m e n t . These bundles are separated from one another by sheets of areolar connective

tissu e , a nd the en tire s t ru c tur e is invested by a fibrous sheath composed of more dense con nective

tissue (Fig. 3 - J J ) .

Aponeuroses are composed of sheets of fibers arranged i n parallel , with al­ ternating sheets disposed a t

right

an gl es to one another. Fasciae ( which c an be

co nsidered as re sulting from the coming t o g e ther of aponeuroses) have the same basic s tructure . From a histological point of view, li g aments re s e m bl e tendon s . Ela s tic liga­ ments (liga m e n ta Elava ) contain , in a dd i tio n , bundles of thick e l a s t i c fibers ar­ rang ed in p ar al l e l and separated

by

small

amounts of areo la r

Fi broblasts tend to be more sparse in t h is type of fiber.

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connective tissue.

142

Fig. 3 - 1 1

Cha p ter 3 / Connec tive Tissue Ana tomy at the Microsco p ic LeveJ

A r te ria l C o n nective Tissue

Endothel i u m

Basal mem brane B a s a l mem b ra n e

I n te r n a l elastic layer

I n tern a l e l a s t i c membrane

I n te r n a l l a y e r of m. tissue

Layer o f m . t i s s u e

External elastic

m e m b r a n e --R�::"-';',I<'l�--...;�.,..... .. � ..,.,.. :-< "!:�iJ--- T u n ica ex te r n a

A RT E R y

·· · ····· ·········

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ARTER I O L E

............ ....

CA IJ I L LA R Y

Fascial Pathology CONNECTIVE TISSUE, AS discussed above, is found in all compartments of

the body. As all the various tissues are in intimate contact with one another, it seems obvious that whichever particular part of the body has some dysfunction or disease, to some extent connective tissue will necessarily and automatically be involved. Regardless of whether a given health problem is neurological, rheuma­ tologic, cardiovascular or gastrointestinal, it is clear that any abnormality with all its particularities will be reflected in the status of the connective tissue. It is gen­ erally believed that problems in connective tissue diffuse distally via the nervous system. Connective tissue and collagen diseases ar e classified as specific diseases in textbooks of pathology, but all such conditions share a common characteristic, namely, degeneration of the ground substance of the connective tissue. The

sur­

prising phenomenon is the far-ranging nature of these diseases, which usually involve multiple systems. However, is this really so surpr ising in view of the ubiq­

uity of connective tissue? These two types of disease also share certain other features: •

the clinical symptoms of inflammatory diseases

•

poor prognosis for total recovery

•

non-specific symptoms and frequently atypical clinical pictures which render diagnosis difficult

Damaged connective tissue takes time to recover, a process that cannot be rushed. The return to a normal state within the actual connective tissue itself may take two to three years. There is no possibility for regulation if the connective tissue is mechanically paralyzed, as is seen i.n progressive, chronic, degenerative pro­ cesses.

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Chapter 4- / Fascial Pathology

Collagen Diseases FOUR MAJOR COLLAGEN DISEASES There are four •

m a jo r

col lage n diseases that are relatively prevalent at present:

systemic lupus erythematosus

•

scleroderma

•

polyarteri tis nodosa

•

ermatomyositis

We will not analyze or e ve n describe these diseases in any detail, but rather merely

note that there is a great degree of over lap among their many and diverse symp­ toms. These diseases can involve jus t about any part of the body but p r i marily ,

affec t the: •

skin

•

mu sc

les

•

joints

•

chest

•

nervous sy stem

•

i n te rnal organs

The more or less inte nse involvement of multiple systems in collagen disease un­ derlines the importance of the connective tissue, which is distributed throughout all parts of the body. As an example, consider the cutaneous

m an i

fe s t atio n s of just

one of these diseases, schleroderma.This provides a good illustration of how con­ nective tissue problems can cause pathology. Scleroderma is characterized by ex­ cessive accumulation of collagen. In p a tien ts wi th this condition, atrophied, thin

epidermis ends up covering a compact mass of collagen fibers tha t run parallel to the epidermis. Fingerlike projections o f collag en extend down from the dermis into the subcutaneous tissue and bind the skin to the de epe r lay ers of tissue.

OTHER MAJOR COLLAGEN DISEASES There are other Significant d isease s that affect the connective tissues. Some of the

major ones include:

' Wegener s granulomatosis An autoimmune vasculitis which is charac terized by severe involvemen t of the

upper respiratory tract, the lungs and kidneys.

Mixed connective tissue disease The most common overlap being rheuma tic disease syndrome, which is charac-

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terized by a combination of clinical features relating to systemic lupus erythema­ tosus, scleroderma, and other collagen diseases.

Marfan's syndrome A disorder in which certain parts of the connective tissue are weakened. It is char­

acterized by excessive height, abnormally long limbs, especially at the extremi­ ties, reduced vision due to dislocation of the lenses, arachnodactyly, overly lax joints , and some visceral abnormalities such as aortic aneurysms.

Rheumatoid arthri tis Now classified as a collagen disease. It is characterized at the tissue level by syno­ vitis, vasculitis, and rheumatoid nodules. Rheumatoid nodules are usually sub­ cutaneous and are most common around pressure points, such as the elbows. Similar nodules may occur in the pleura, the lungs, and the heart, and, rarely, in the capsule of the liver or the vocal cords. The nodule consists of an inner zone of fibrinoid necrosis surrounded by a cuff of macrophages that is, in turn, sur­ rounded by a layer of fibrous connective tissue containing large numbers oflym­ phocytes and plasma cells.

Other Diseases of the Fasciae In addition to the specific collagen diseases mentioned above, there are other

abnormalities that involve connective tissue which do not usually present as dra­ matic a clinical picture, but are certainly more common. First, we shall discuss scars and adhesions. These abnormalities and non -func­ tionalities are of special interest to osteopaths because they are so frequently en­ countered in their daily practice. Furthermore, in the long term, scars and adhe­ sions can act as foci of irritation that can, in turn, interfere with the functioning of the joints and viscera. This initially leads to the type of symptom which is re­ ferred to as functional, since such manifestations are often subclinical and do not correspond to any abnormality that can be detected in conventional radiological or biochemical tests. Scars and adhesions are genuine primary lesions that must be examined with the greatest care. Later we shall discuss different studies of the connective tissues, in particular those fOCUSing on its ground substance, that tend to show that the disease process often arises in the matrix, especially when it has become overwhelmed by exog­ enous factors. We will make reference to the work of Snyder, who in 1956 proposed that [he ground substance is both the laboratory of the connective tissue and a propitious terrain for the development of pathological processes.

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Chapter 4 / Fascial Pathology

SCARS Vv'ound healing involves tissue remodeling with granulation and the proli feration

of elastic and connective fibers. The ultimate aim of this process is to regenerate as ne arly as possible the tissue's original structure. Notwithstanding the sophis­ tication of th e repair mechanisms, they cannot always be perfect; the traces left by any scar which impinges on the deep fasciae serve as an example While in most cases the repair is made without any consequences, in a significant propor­ tion of cases the resultant scar can disrupt the fun ct i oning of the surrounding tissues. This can manifest as irritation which may, in tu rn, lead to restrictions or even frank adhesions which interfere with both mechanical and physiological function. Excluding retractile scars and keloids, both of which are relati veil' rare, even an ordinary scar may end up causing pathology This can have very serious consequences for the pati en t as in cases of cau s algi a In particular, a pruritic scar ,

.

may perturb connective tissue and lead to changes in its structure, plasticity, and elasticity secondary to the concomitan t tension and stress at the focus of i rr i ta­ tion. Sooner or later, this will lead to mechanical dis t urb a n c e of the fasciae over a more or less extensive area

.

When the scar is in the abdominal region-the most common site due to the large number of appendectomies that are performed-it will interfere with the mechanics of the neig hbor ing organs, subjecting them to tens 1011 and con­ stant irritation. The organ will tend to lose its mobility and become fixed. We have a lready seen that normal physiological function depends on fasc ial mobility; therefore. such immobilization of an organ will lead to dysfunction and, in the long term, disease. Scar tissue can also become pathological as a result of foreign bodies which became trapped at the time of the

injury.

Fo reign bodies are only reabsorbed

slowly, if at all, and when they persist, they can induce acidosis in surrounding tissues which compromises the composition and function of the local ground substance. Electrical measurements made in 'disturbed' scar tissue show that its resis­ tance is of the order of 1,400 k ilo oh ms higher than that of surrounding normal -

skin. For all of these reasons a scar mus t be

c ons idered

as a potential source of

problems.

ADHESION S Adhesions are a common problem and may result from scarring, inflammation and infection, irritation, or any kind of increase in stress anywhere in the body.

They are particularly common in the thorax and abdomen. Simple incision into the periton eu m is quite likely to trigger some kind of adhesion. The tendency to form adhesions increases with age and a surprisingly high n um ber of adhesions are routinely observed in the pleura, the lungs, and the peritoneum at autopsy The sequelae of adhesions are similar to those of scars in that they often lead to the formation of solid, inelastic, fibrous connections to an organ. We shall re-

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. .. ,

turn la ter to the

vi

cio us circle of hypomobility, dysf u n u ion , and disease.

' DUPUYTREN S CONTRACTURE In the context of connective tissue disease, mention should also be made of Du­

puytren's contracture. This is a condition characterized by thickening and retrac­ tion of the middle palmar aponeurosis. The e tio logy of this hi g hl y specific and localized fascial probl em is unknown.

CONNECTIVE TISSUE, THE P OINT OF DEPARTURE FOR MANY DISEASE PROCESSES Studies of th e histology and the role of connective tissue have shuwn that any kind of injury, shock, or stress automatically has an effect on the local connective tissue. We may conclude that there is no pathology that does not have any impact on the fasciae. In fa ct , no disease process can spread un ti l it has overcome the defensive capacities of connective tissue. Eppinger (noted in Pischinger) has pos tulated that disease starts in the gr ou n d substance and spreads from there to parenchymatous cells. Specific symptoms and the typical characteristics of the disease take form only later, after cellular le­ sions have developed-distinctly l ater than the prodromal symptoms of the vari­ ous infectious entities. Connective tissue can be irritated by many different factors, in fact, by any situation that involves stress being put on the fasciae , for example, physical injury, mechanical stress, c hem ical insults, and endocrine effects. Postoperative shock is a prime exam.ple: the body takes apprOXimately 21 days to recover from the shock of surgery The ground substance is not only the starting point for messages destined for the cell and the endocrine and nervous systems, but is also itself modified when

tissue function is impaired. Even very mild stimulation of short duration induces partial depolarization of proteoglycan molecules. In a normally fu nctio n i n g sys­ tem, this depolarization is compensated for by a charge of opposing polarity. However, if such stimulation and depolarization is sustained , structural changes can occur in the ground substance which result in a marked increase in its viscos­ ity

such

that it becomes more gel-like in consistency Such changes remain local­

ized at first, si nce the spread of in forma ti on is l i m i ted by the i n s u lati n g properties of the serou s membranes, the septa, and the fasciae. At first it is diffi cul t to detect disturbances in the connective tissues, all the more so since such disturbances do not usually give rise to symptoms which are typical of i rri ta tion . As a result, the tissues can often con ti nue transmitting an abnormal Signal for

a

relatively long time, thereby mislea d i ng t h e reg u l a t or y

cellular, tissue, endocrine, and nervous systems for a prolonged period. Changes i n regulatory processes spread out gradually, and the symptoms can spread to the

opposite side of the body with the indirect participation of the vertebral axis. Any additi o n a l stimulation of this pr i m ed system will freq u e n tly lead to an inappro­ priate and ex aggera ted response.

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Chapter 4 / Fascial Pathology

Remot e pr obl ems ( e .g. , in an org a n ) may occ ur, increasing even further the

irritation at the o rigina l focus and leading eventually, in the absence of interven­ tion, to exhaustion and to a reactional block which can resul t in s erio us disease.

Perger

( noted

in Pischinger ) points out that 25% of patient s presenting with

a

" block of basic regulation" developed a tu mor in t he years that fol lowed. The ro le o f regu l atory probl ems in the etiology of tumor development cannot be neglecte d . Furthermore, both an active potential and increased conductivit y have been

observed on the same side of the body as the pa thol ogy in c hro nically sick indi­ viduals.

The damage is localized at first in the dermatome and the myotome, but through the action of the auton omic nervous system, the injury modi fi es local vasomotor functions as well as other autonomous functions in the entire cor­ responding qua d rant. Any increase in the intensity of stimulation , or any kind of activat ion of central regulatory mechanisms, will lead to the development of sy mp t o ms in the whole area surrounding the focus of primary damage. Fo llowing on from the local probl ems , systemic disease can develop if sec­

ondary and tertiary factors corne into play. The connecti ve tissue then reac t s as

a

unit, though not necessarily in the same way in all places. Differences are all the more prono unced if the rate of progress of the c hro nic problem has accelerated. The timing and duration of the ori ginal insult have a major impact in terms of how the disturbance spreads around the body as a vvhole. Ce rtain mesen c hymal cells in adult co n ne cti ve tissue remain at an immature

sta ge of develo pmen t and these embryonic-type s te m cells can, in case of need, differentiate into other lineages of more specialized cells. As a rule, these cells are in a dormant state but, in case of injury or disease, they can undergo m it o tic proliferation to help manage the effects of the insult .

It appears that the activation of defense mechanisms in connec tive tissue oc­ curs independently in the per i p h ery, with the cen tral system only intervening at a later stage. This is born out by the observations that both the highest b asel ine measurements and the most severe damage are always found on the side of the body that is most severely pe rt urbe d . Damaged tissue (from inflammation, scar­ ring, adhesions, etc.) that cannot be reabso rbed is responsibl e for 'such differences

between the two sides of the body. Two other researchers discussed in Pischinger's excellent book add to this concept. Kellner has demonstrated that the b ody 's acid-base balance is deter­ mined by a fundamental homeostatic mechanism: when the milieu is aci d i c , neutral pH i s re -es tablished by the lysis of fi broblasts , but when the milieu is alkaline, the same cells proliferate. Mc laugh lin found that embr y onic epithelial

cells cultured in vitro tended to grow in an undifferentiated and disorganized way

Th e addition of mesenc hy mal cells induced differentiation of the epithelial cells. Moreover, in the presence of these other cells, a baseme n t melD brane was formed and the cells formed

a

s trati fied pattern. These two experiments tend to show that

connective tissue co mp rises

a

sel f- organizi n g system which does not depend to

central c ontrol mechanisms. In response to persistent stress, funct ional difficulties arise and the activity

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149

of the ground substance in terms of its role as

a

molecular filter is compromised.

This can lead to changes in ground substance composition and, therefore, to en­ hanced susceptibility to chronic disease. Heine (discussed in Pischinger) has shown that 30 minutes suffice to stimu­ late a significant increase in collagen content in the alveolar septa of badly injured traffic accident victims. Speransky (noted in Korr) performed experiments in ani­ mals which demonstrated that profound modifications of lung tissue (similar to those seen in pneumonia) could be brought about by various modes of nervous stimulation, including intense stimulation of cutaneous and muscular receptors in the area innervated from the medulla oblongata or the upper part of the spinal

cord. Mechanical or direct chemical stimulation of the nerve center was observed to have similar effects. Thus, it appears that connective tissue has some degree of autonomy and that it may have its own, independent defense systems. It also represents the point of

departure of many pathological processes, a point of departure which is itself independent. This mechanism does not exclude the possibility that peripheral or central stimulation of the afferent nerves may also lead to perturbation of con­ nective tissue. This point has to be kept in mind when diagnOSing any kind of disruption or disease in any part of the body.

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The Roles of the Fasciae

AS WE HAVE seen, the fasciae fulfill many different roles in the body, and the

unique adaptability of their basic structure equips them for these different func­ tions. The fasciae, and by extension connective tissues in general, are found through­ out the body. The results of anatomical and phy siological studies lead to the con­ elusion that connective tissue plays a major role in the maintenance of all body functions. Different studies dealing with the subject show that the connective tissue provides the ultimate guarantee for the proper functioning of the body, and thus for its health. As George Snyder stated back in 1956, "the connective tissues not only bind the various parts of the body, but, in a broader sense, connect the numerous branches of medicine." The different roles of the fasciae will be studied in the following order: •

in maintaining structural integrity

•

in support

•

in protection

•

as shock absorbers

•

in hemodynamic processes

•

in defense

•

in commlUlication and exchange processes

•

in biochemical processes

A continuous network of connective tissue links all the different organs and parts of the body. Anatomical studies have shown that there is no discontinuity between the different tissues, but that they are linked together to function in perfect har­ mony (Fig.5-1).

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Fig. 5-1

Chapter 5 / The Roles of the Fasciae

Fascial Support

Role in maintaining structural integrity The fasciae maintain the anatomical integ rity of the indi vidu a l A person would .

retain a perfectly human appear ance even if one removed all the body systems but the fasciae. The same would be true if one attempted to retain only the vascular

or

nervous system, as the fasciae provide the supporting and gUiding s tructures for both of these systems. This confi rms once again the interdependence of the differ­ ent structures of the body

a nd

the impOSSibility of diss ociatin g them.

The muscular system only functions by virtue of the fasciae, as we shall see when we consider the mechanics of this sy stem of tissues. Moreover, it is beca use

of the fasciae that the joints can maintain their stability and function. The muscu­ lar sy stem constitutes the motor of the j oints but the coordination of that system ,

is completely depen de n t on the mechanical properties of the fasciae. Different organs maintain their shape and are attached to the bones by virtue of the fasciae. The fasciae thus maintain the anatomical integrity of the organs and thereby make it possible for them to function correctly.

Role in support The fasciae support the nervous, ar terial, venous, and lymphatiC systems. Anatom­ ical studies show that these different s y stems are intimately linked to the fasciae. Indeed, these systems are themselves constitu ted of fasciae, which maintain their shape and form. Furthermore, they are surrounded by a fascial envelope that, in turn, is linked to and shaped by denser, stronger fascial elements. The nervous and vascular systems interact with the fascial system. During embryoniC development, the vascular and nervous systems grow and migrate together with the fasciae in a parallel, coordinated series of steps.

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The Roles of the Fasciae

The supporting role becomes particularly evident at the level of the deep cer­

vical fascia: th e se cannot be separ a t e d from the cervical plex us or the sympathetic cervical ganglions. A similar picture is seen in the mesenteries , which support an abundance of different vessels and nerves.

Role in protection The fasciae play a fundamental role in maintaining the physical and physiological integrity of the human body. Present throughout the body, they protect the dif­ ferent anatomical structures against the varied and pote ntially dangerous forces of tension and stress to which the body is constantly exposed. In fulfilling this role, the fasciae of the different body compartments show an impressive degree of adaptability and variation. In th e periphery, where potentially damaging forces are greatest, the fasciae

tend to be thicker and denser. In and around the joints, the fasciae which form the synovial membranes an d , to an even greater e x t ent , those which constitute

the ligaments, are extremely strong and stable. Although these fasciae are strong, they are never ri gi d ; complete rig idity is only found in pathological situations, and f u nctional fasciae always retain some degree of elasticity, enough to fulfill their role in the specific tissue in which they are found. When the work load is heavy, thickened fasciae can completely replace mus­ cle bundles. The most typical examples of this phenomenon are the powerful iliotibial tract and the highly resistant lumbosacral aponeurosis. Another protective role, as we shall see in more detail later, consists of the abil i t y of the fasciae to act as shock absorbers. In response to over-exertion or to forces

whi

ch are too violent, the fasciae absorb some of the energy of the exces­

sive shock so as to protect muscles, organs , and other structures from damage. Such intervention is triggered by stimulation of the nerve endings in fascial tissue. It has been demonstrated that while the anterior longitudinalligamenr has a pas­ sive fun c tion it is richly innervated. It shows strong neurological activity when ,

stimulated (Bednar,

1995).

Throughout the entire length of the cerebrospinal axis, the fasciae protect the brain and spina l cord against excessive variations in pressure as well as poten­ tially damaging shocks. The fasciae in these tissues are remarkably adaptable and in g e n iou s. A single connective tissue envelope would be insufficient to protect such delicate st r u ctures ; thus, a tr iple envelope of fascial s h eets has evolved, and

,

in order to further enhance the efficacy of the system, two hydraulic buffering systems have been ad ded in the form of the cerebrospinal fluid and a dense net­ work of veins. The protective role of the fasciae is also key in the vascular and nervous sys­ tems that the fasciae not only support, but also protect from compression, stretch­ ing, and other insults. It may be recalled that the major arteriovenous and ner ve trunks are found in

the deep fasciae and that the latter are either sheathed in fascial envelopes (e.g., the adductor canal) or are located in the most stable par ts of the fasciae (e.g , the .

root of the mesenrery).

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Chapter 5 / The Roles of the Fasciae

Finally, to protect vital and fr agil e organs, the fasciae not only invest them with a resistant sheath, but also cushion them with an additional layer of tissue. This cu shi oni ng layer can b e based on either a very fluid and plas ti c form of tis ­ sue, such as adipose tissue ( e . g., th e adipose cushion around the ki dn ey ) , or

a

ver y

loos el y woven tissue, such as areolar tissue.

The organs themselves have a fascial envelope that maintains their structure. Extensions from the envelope penetrat e into the inter i or of the organ where they split frequently to d i vi d e the organ into a seri es of different compartments, with the contents of each isolated to a greater or lesser extent from those of its n eigh ­ bors. One consequence is that it limits the rate of spread of infection from one

part of an organ to a not her . The clearest examples of this kind of com par tm en tal­ ization are to be found in the liver and the lun gs .

Role of shock absorber The elastic fascia e often act to da mp en th e for ces to whi ch th e body is subject. The lattice-like macromolecular structure of the proteoglycans parti ci pa tes actively

111

th e mechanical cohesiveness of c onn ec tive tissue.

The proteoglycans are shock absorbers that act like lubri ca nts which, under intense, r epeated stress, change texture to become more viscoelastic. The proteo­ gly cans a nd hy al uroni c acid impose a cross-linked molecular superstructure upon the gr ound substance and invest and fill the spaces b etween collagen and elastic fibers; this vis coela s t ic bufferin g material is indispensable for the normal func­ tioning of cells and tissues. The work ofYahia, et aI. (1993) confirms this; they inv es ti gat ed the vis coela sti c behavior of the lumbodorsal fasciae and found that it

steadily changed over time in response to rep eated ch allenges with a heavy load.

Furthermore, the fasciae attenuate the effects of hi gh pressure by channel­ ing th e energy in different directions to prevent damage to the organs. Fascial shock absorber function is potentiated by t he ad ip ose tissue, which is particularly abundant in certain vulnerable regions, for example, around the kidney, over the

abdomen, and over the greater omentum. Similar accumulations of adipose tissue a re found in region s which are s ubj ec t to pa rticularly high levels of pressure, such as around the ischiorectal fossa. An aside is ap pr op ria te here on the shock absorber function of the meninges. We have seen that these str u ctur es line the skull as well as the spinal column and

protect the cerebrospinal axis. However, the meninges also contain the cerebro­

spinal fluid, and thereby act as a fluid envelope that ser ves as shock ab sorb er for the brain, protectin g it against any variation in pressure to w hi ch it is ex pos ed . The fluid also has a nutritional and defensive role. Most of the fluid is secreted by the choroid plexus with approximately 20% coming directly from the venous paren chyma in the Virchow-Robin p er i vascu la r spaces. The fluid is reabsor bed both by t h e veins via the villi and Pacc hion i 's ara chn oid granul at i ons , and b y the

l ymphatics in the neural sheath. Then it is transferred into the thor acic can al . In the adult, the volume of cerebrospinal fluid is 140ml ± 30ml, of w hic h 3 Sml a re in the ventricles, 2Sml in the cer eb r al subarachnoid spaces and cisterns, and 7 Sml in the s pinal subarachnoids. Its qu a lit at ive composition res embles that

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The Roles of the Fasciae

of plasma and lymph, but the various components are in different proportions. It also contains a number of hormones and other substances whose role is not yet clear. New cerebral substances are being discovered constantly and this research is furthering our understanding of the role of the cerebrospinal fluid. The most recent instance is a substance with strong soporific activity discovered by Richard Lerner (Huidobro-Toro and Harris, 1996). Cerebrospinal fluid is produced at the rate of 0. 5-1.0 I per 24 hours. Fluctua­ tions in the volume of the cerebrospinal fluid due to expansion and retraction of the system constitute one of the driving forces of the cranial mechanism which has a frequency of 8-12 cycles per second. In fact, it appears that this rhythm of 8-12 cycles per second is probably more characteristic of a 'pathological' state

due to a kind of sympathicotonia, which is related to the stress of modern life. The cranial rhythm in primitive societies is approximately 2. 5 periods per min­ ute, which leads us to believe that this frequency more closely corresponds to the natural, equilibrium state.

Observation of these rhythmiC movements of the brain and fluctuations in the volume of the cerebrospinal fluid have given rise to a hypotheSiS according to which it is the circulation of the cerebrospinal fluid through the fasciae which is causing these rhythmiC movements. It appears, however, that there is no continu­ ity between the cerebrospinal fluid and the peripheral tissues, particularly at the level of the ner ve roots. Rydevick et a1. injected [3H]methylglucose, either intravenously or directly into the cerebrospinal fluid and found the follOWing distributions of isotopes: •

after injection into a nerve root, 58% in the cerebrospinal fluid versus

•

after injection into a peripheral nerve, 95% in the intramural vessels and

35% in the intramural vessels none

in cerebrospinal fluid

Most of the nutritional requirements of the nerve roots are supplied by the cere­ brospinal fluid whereas those of the peripheral nerves come almost exclusively from the blood. There is no evidence that any cerebrospinal fluid ever reaches the peripheral nerves. The cranial and spinal ne rves beyond the osseous openings are invested by connective tissue through which lymph circulates. The meninges thus have a close relationship with the lymph spaces; there is no direct continuity, but these two contiguous systems partiCipate in multiple exchange processes. This is altogether logical since, if there were continuity be­ tween the cerebrospinal flui.d and the periphery, there would be a major risk of the spread of infection to the brain (since there are so many ports of entry for foreign microorganisms in the periphery). The fact that exchanges occur exclu­ sively by diffusion constitutes a safety buffer comparable to those found in many

other regions of the body. Therefore , the cerebrospi.nal fluid communicates with the extracellular fluid in the same way as the latter communicates with the intra­ cellular fluid. Throughout the system, communication is by diffusion or active transport, but never direct. The different fluids differ in chemical composition but are in

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Chapter 5 / The Roles of the Fasciae

permanent contact, assuring continuity and communication through the ent ir e the body.

Role in hemodynamic processes The vascular and lymphatic systems cannot be dissociated from the fascial system. The return circulation in the form of the venous and lymphatic systems does not

include any active pump as powerful as that which sends the blood to all parts of the body via the arteries. Furthermore, the latter have a rigid structure, unlike t he ly mph atiC S and the veins, which are rela ti vely flaccid and collapse rea di ly. For this reason, these vessels are e q u ipped with valves to facilitate the return of blood and ly mph, although they cannot perform this function without help. It is actu al ly the fasciae that provide the pumping force for the return circula­ tion of blood and ly m ph. As we shall see, the fasciae are con tin u a ll y pulSing with a frequency of about 8 to 1 2 cycles per minute. These contractions act as a pump which drives the fluids through the vessels. It should be noted that the transport of lymph through the lymp hatiC S de­

pends on sequential contractions of the valvular segments. The lymph is trans­ ported by waves of contraction with a frequency of 10 to 1 2 cycles per minute.

This is equivalent to the period of the fasciae-but of course the lymphatiC sy s ­ tem is primarily composed of fascial elements. This subtle mechanism is reinforced by muscular contractions vvhich are also

channeled by the fasciae. Anatomy shows us that the fasciae are not continuous parallel bands, but rather are constituted of different layers arranged in oblique, transverse, and circular orientations. The different orientations of the fascial fibers mean that the overall configuration of the fasciae corresponds to a spiral arrange­ ment. Hence, when they contract, th ey have a tendency to compress the structures that they are investing, thereby pushing the fluids back towards the heart, just like a dishcloth that is being

w r ung

out .

However, if the fasciae are the motor of the return circulation, the y can also be a disrupting element: if a fascia is in a state of abnormal tension, it is easy to

understand that the associated vascular system

w il

l be subject to sustained pres­

sure, which will induce stasis. The lymphatiC S and veins perforate the fasciae through more or less rigid ring structures that let the tubes traverse the fasciae without encumbrance. Hovvever, if any of these annular openings is ever put under great t ension it can be converted ,

into a t ourniq ue t .

Role in defense The ultimate function of the connective tissue is to re-establish norm al defense functions. Their defensive role is cer t ain ly a major aspect of the phy siology of the fasciae. The fight against pathogeniC agents and infections starts in the gr oun d substance in which there is an intrinsic local mechanism which is active prior to any kind of in tervention on the part of the sp eC i al i ze d immune system. Whether or not the pathogeniC agent has time to spread-and hence the health of the sub­ ject-depends on this local mechanism.

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The Roles of the Fasciae

The process of defense is

c har acteri z ed

by fou r cell ul ar p hases :

•

at the b e giill1ing , the site of invasion is walled off by m a crophages

•

this is followed immediately by attack by smaller p hagocy tic cells­ microphages (a local reaction, but with the passive participation of the w hole body)

•

subsequently, there is a m acrophage phase with the active par ticipation

of the whole body . •

the final stage involves speciali zed lymp hocytes (leading to sterilization of the in fec ti on and establishment of a chronic sta te)

The m a crophage p hase is triggered by a monocy t e factor, and in the absence of this facto r, there is no such pha s e . The first local defense reactions are triggered "v hen a series of sig n aling mol­ ecules is rel e ased into the tissue (prostaglandins, leukotrienes, i nterferon , etc . ) The triggering of the m a cr o p h age and mic roph a ge phases does not o n ly dep end on b ioc he m ic a l factors, but also on bio p h ysical ones like the abrupt drop in pH at the site of i n j ur y. This acidosis can damage cell membranes. Conversel y, m aj or bio p hy s ical chan ge s at the s ite of injury can set in m otion an imm e d iate emer­ gency rea ctio n that triggers a primary defense response to limit the extent of the damage. This occurs in two phases : •

D isr u p tio n of the bonds which are keep in g the large reticular cells

confined in the basal system. Their release as macrop hag es results in the i solation of the site of invasion. •

Modi fica t ion of the permeability of the capillary walls, which results in

the onset of the m ic rophage phase. T h ese pheno mena are accom panied by the extravasation of serum into the tis­ s ues, which leads to edem a . This edema is not detrimental to the efficacy of the

defense system, as was believed at one time; on the contrar y, it may even dilute the noxious agent. The extravasation of serum al s o means t hat , if the specific mi­ croo r gan is m has been encountered before, any anamnestic serum globulins are recruited to act at the s ite of attack.

This defense mechanism, as po inted out earlier, sta rts at the l evel of the groun d substance. The ground s ub s tance is lin k e d to the endocrine glands by c a pillaries, and to the central nervous system by the free termi nal ends of autonomic and other nerves. Both of t hese organizing systems are located in the cerebral trunk. The ground s u bst ance can thus exert a direct influence on the higher regulatory centers when certain species (interleukins, p rosta gl a n dins , i nter fe ro n, protease s , etc . ) are released into it. There is exchange of infor m ation between the capil­ laries, the a u tonomic nerve fibers, and the motile cells of the g round s u bstance (m ac rophag es , leuko c y te s , and monocytes). The result is an endocrine netwo rk o f

e x traordinary comp lexi ty and sophistication. The advantage of network-based systems is enhanced adaptability and effi­ ciency. The aim of the body is to mai n tain a con stan t internal milieu by mean s o f homeostatic regula t io n .

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Chapter 5 / The Roles of the Fasciae

In phylogenetic terms, the ground substance is more ancient than either the nervous or the endocrine system. As a result, the generation and turnover of ground substance is governed by a primitive compensatory cellular organiza­ tional system based on the synergistic action of fibroblasts and macrophages. Fi­ broblasts can react within seconds by synthesizing the appropriate proteoglycans and structural glycoproteins in the quantities required. These are destined to be phagocytosed by the macrophages. As the quality of the ground substance be­ comes progressively more compromised, the fibroblast b egins to secrete a kind of ground substance

w

h ich has structure, but which is not fully functional. When

exposed to this defective ground substance for extended periods of time, any cell can, according to Heine, become pathological or malignant (Pischinger, 1991). Other substances are also important in terms of the defensive function of the

grou nd substance. The proteoglycans and glycosaminoglycans constitute the first system of defense; being highly viscoelastic, they absorb shocks, resulting in the disSipation of energy. Selye (as noted in P i s chinger) considered connective tissue to be the regu­ lator of the stress syndrome. The stress syndrome leads to premature aging as a result of a lack of adaptability, largely due to the loss of the energy reqUired for adaptation. This defensive role of connective tissue is illustrated by the functions

of the peritoneum and of the greater omentum. The major functions of the peri­ toneum are to reduce friction, to store fat (in the greater omentum), and to resist infection. The greater omentum tends to orient itself towards the site of infection (by mechanisms which are as yet poorly understood), and to move closer to the site, thereby increasing the local blood supply. In this manner, it helps prevent the spread of infection. It appears, on the

basis of our current knowledge, that only at relatively late

stages do the speCialized cells of the immune system play an active role in fighting infections. The ground substance appears to represent the first defensive barrier.

Role in communication and exchange processes The connective tissue, and espeCially the ground substance, are in contact with the cells of the body. The vascular, lymphatic , and nervous systems terminate in th e ground substance and do not extend beyond the level of the cell. All of these different systems provide nutrients to the ground substance and carry informa­ tion from the periphery. Similarly, they remove the waste products of metabolism and take back information from the cells. The cells are bathed in extracellular fluid, an d a dialog occurs with the ground substance via that fluid. The function of the ground substance is, as we have seen, to prOVide

a

defensive barrier to protect the cells from damage.

Once the ground substance has been overwhelmed by a pathogeniC agent,

the cell itself may be affected and degeneration and morbidity may ensue. In ad­ dition to its defensive role, the grow1d substance is in permanent contact with the cell, furnishing it with the products that it needs for its functioning as well as transporting in the opposite direction the products of cellular metabolism and messages.

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The Roles of the Fasciae

The connective tissue is considered to be a unitary complex that invests spe­ cialized parenchymatous cells and helps them to survive, as well as regulating some of their key functions. As noted in Pischinger, as early as 1767, Bordeu understood that connective tissue was there not only for padding and support , but also for the regulation and nutrition of the organs. He also recognized its importance in vascular and nervous function. Connective tissue is an element which links the parenchyma with the vascu­ lar and nervous systems. Exchanges with cells occur by diffusion, osmosis , and active processes across the serous membranes Fig. 5 -2

(Fig. 5-2)

Exchange Processes Between Cells and Fasciae

Lymphatic vessel

Nerve

\

Capillary .

Collagen fibers

Elastic fibers Glycocalyx

Cell

-

-Ground substance

Proteoglycans

The ca rbohydrate rich surface film of the cell. the glycocalyx, is the functional -

intermediary between the intracellular environment and the extracellular space. It communicates with the receptive cell envelope via glycosaminoglycans and proteoglycans. and establishes contact between the intracellular milieu and the ground substance. Perturbations of the latter may alter the carbohydrate composi­ tion of the glycocalyx and thereby modi fy the bebavior of the cell. There are also binding proteins such as fibronectin, laminin, and chondro­ nectin which act as intermediaries between the cell su r face and the ground sub­ stance. Fibronectin is important in growth. mobility. and cell differentiation. and participates in the binding of the cells to the ground substance, and therefore in the superimposition of different layers of cells. Tenascin, a recently discovered

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Chapter 5 / The Roles of the Fasciae

g ly copro tein , is believed to be im por t ant in interactions betw een different cells . Heparin, found in the vesicles of m ast cells and b aso phi ls , is released when it

is needed. It

ip at es in al l aspects of the regu la t i on of the ground su bs t ance :

p a r t ic

•

it re gulat es lipoly s is and

•

it stimulates the aggregation of lym pho id cells

• •

the levels of lipoproteins in the blood

it ac tiva tes the protein kinases of mu scle cells it stimulates sy n thesi s of the grou nd substance, and participates in the s ynthesis of c oll ag e n and its p olym er i z at ion to for m fi br ils

Basement membranes are made of

a

speCial form o f grou n d substance. They are

in d i spens able for the normal epithelial grow t h and also invest Schwann cells, ter­

minal axons, striated and smooth

muscl e

cells, and the cells of the myoc ardium .

C han ges in b a sem ent membrane structure can have serious consequences for the

integrity and function of org ans. Basement membranes block the sprea d of inflammatory

p rocesses

from the

connective tissue to the ep ith eliu m . This activity seems to be due to the high con­ centration of vi tam in C in th es e structures which traps, detoxifies, and therefore blocks the passage of the free radicals generated in infla mmat or y reac tio n s . The parenchy m a is

i h ed via a secr etory current which flows across the

n o ur s

cap illary membranes towards the plasma membrane where the metabolite-rich fluid is available for th e par en chymat ou s cells. At that po i n t, this fluid com es into contact with the e x treme l y dense network of lymphatiCS that

runs

through con ­

nective tissue.

Role in biochemical processes F ollowin g the research work of P hil ippe Bour d inaud (i nspi red by the work of

Dan Urry, a chemical eng i n eer at t h e University of Minn eso ta ) on the bioc hemi ­ cal action of the ost eo path 's hand on

hum an connective tissue, we now know

that the elastin, reticular, and collagen fibers (all bioplymers) found in the fascial matrix are able to retrac t under the influence of pressure hi gh e r than the physi ­ o log ic al pressure for which their biochemical compos ition fits them. When the

pressure of the i nt e r s t i t ia l milieu returns to normal, they in turn return to th e ir no rmal l en gth . The ph e n om e non of r et ract io n occurs becau s e , under the influence of high

pressure, water

l

l es in the fascial matrix reorganize to form cage-like struc­

m o e cu

tures around the hyd rophobic ends of the fibers. The reverse transition is also possible, that is, t hey can return to their or i gi nal l en g th if the pressure in the

fascial matrix is released or returns to a normal phYSiological level. This occurs through the for m a ti on of hy d ro gen bonds between the water molecules and the

fascial matrix and the hy drophi lic ends of the fibers. This response is elicited at ver y small energy levels, of

the order of a few micro me ters , nanometers, or even

an gs t roms . It is re produ cible every time energy is introduced into the system. It is important to speCify here that all forms of energy have the capacity to bring

about this ph enome n on of reverse transition of bi opo ly m ers , in clu d i ng pho ton ic , thermal, chemical, electrical, and e le ctromagnetic energy. However, it sh ou ld be

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The Roles of the Fasciae

note d that me chanical e ne rgy is five times more effective in this respect tha n any oth er form . Proteins are therefore capable of pe rformin g work if stimulated with ener­ gy, i ncl u d in g me chanical e ne rgy. This is the most effective univ e rsal mechanism,

which involves the folding or el ongation of the se biopolymers. This u ni ve r sa l

me chanism unde rlie s most bioenergetic conversion p r oces se s. This means that anatomical structure s like reCiprocally stretched cranial

m e m b r anes , the spin a l cord dura mater, ligaments, articular caps ul es , te ndons,

apone urose s, and cartil age s-in short, all fascial elements found in the human body-are ca pabl e at the in fi nitely minute level

( of

the or der of mi c rome ter s,

nanome te rs, or e ve n angstroms) of be ing induce d to re tract unde r the influence of e l evate d pressure, and subse quently to return to th ei r initial di me nsi on s if the physiological pr e ssur e of the surr ounding medium is re s tore d . These sci entific discove rie s le nd concre te support to the oste opa t hi C th e ory

handed d ow n by the maste rs \",ho have always cla imed that oste opathi.c me thods can have profound effects on cellular m eta b olic proc e s se s.

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Fascial Mechanics

THE M EC HAN I CA l BE H AV lOR of the fasciae plays an essential role in all bodily

functions and in the maintenance of the anatomical integrity of its various parts. III the final analysis. the fascial system functions as a unit. but for a better under­ standing of the underlying mechanisms. we shall first study them at the local level before analyzing the mechanics of the system as a whole (Fig. 6-1).

Local Mechanics The local mechanics of the fasciae have many and varied consequences. and these tissues perform vital roles in areas as diverse as suspension and protection. reten­ tion. separation. shock absorption. and pressure attenuation.

SUSPENSION AND PROTECTION

Suspension The fascial elements

w

h ic h play a role

in suspending the various structures of

the

body are the internal ones. for example. the mesentery. the ligaments. and the true fasciae. They guarantee internal cohesion by providing points of attachment which keep each organ in its proper place. The resultant support is firm but. in most cases. not rigid . so that each organ retains some degree of mobility. that is, there is some play in the attachment system. Mobility is not only essential for

the ability to respond to the diverse forces to

w

hic h the human body is regularly

subject. but also enters into the general context of the mobility of t he body itself - mobility which is essential for the full expression of the body's many different functions and physiological processes.

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Fi g . 6-1

Chapter 6 / Fascial Mechanics

Fascial Mechanics

Epicranial aponeurosis

Dura mater

Pharyngobasilar fascia

Superficial cervical fascia Middle cervical fascia Deep cervical fascia

Endothoracic fascia

Pleura

Pericardium

Diaphragm

1------flLf-tt-- Dura ma ter Peritoneum Transversalis fascia

FASCIAL ARTICULATIONS

.....

The fascia play an i m por ta n t role in the suspensi o n of o ther structures, n o t only in t he body cav i ti es but also in the periphery (Fig. 6-2). Fascial elements such as the ,

a pone urose s and ligaments cons ti tute the support system for all the muscles and joints, whereas the tr u e fasciae support all the vessels and nerves. This all enco m -

­

passing peripheral system invests and proVides poinrs of attachment for all the vessels, nerves,

mus c

l es and joints, and is itself anchored at fixed points on the ,

bones. Thus, the fascial system plays a central ro l e in maintaining th e anatomical

integrity of the bo d y as a whole and its co m p o n e n t structures.

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Fi g. 6-2

Fascial Suspensio n

The integrity o f the structure o f bone tissue depends o n the functional state of the tissue itself and, by extension, on the physiological condition of the body as a whole. By itself, a bone is useless-its functionality and its interactions with other skeletal elements depend exclusively on the means of attachment that unite it to neighboring bones. It appears then that, although the skeleton provides the framework and the anchor points, it is nevertheless completely dependent on soft tissues for main­ tenance of its cohesion and function. Therefore, there is an inevitable, reciprocal interdependence between the skeleton and the soft tissues-and thereby between structure and function and function and structure. The role of the fasciae in suspending other structures varies according to the region of the body under consideration. The fasciae have different capacities for stretching in different locations, for example, the skin can stretch ten times more than can a tendon-this reflects the fact that the tendon is composed of type I fibers arranged in parallel, whereas a variety of different types of fiber are present in the skin and the bundles run in all directions. The thickness of collagen fibers is organ-specific, but also changes with age. The elastiCity of the fasciae tends to

decrease with age. There is thickening, shortening, and calcification of the fibers as a result of all the forces resisted, and the damage inflicted, in earlier years. The function of suspension shows remarkable adaptability to different situa­ tions. Thus, during pregnancy the uterus becomes enormously distended, which necessitates lengthening of all the associated ligaments-without any kind of pain. Not only is the uterus distended, but it pushes into the abdominal cavity, distending the fasciae of the abdominal wall, again without causing any pain. In other, nonphysiological situations in which the uterine ligaments are subjected to stress and tension, they respond by becoming thicker and undergOing calcifica­ tion; nothing like this happens during pregnancy.

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Chapter 6 / Fascial Mechanics

After parturition, the uterus reverts gradually to its normal state, that is, it retracts to recover its original tonus and elasticity. This phenomenon is pre-pro­ grammed and may lead one to think that the fasciae have some kind of mechani­ cal 'memory'. Let us look at the case of obesity,

a

condition that may be considered p a tho­

logical. Some people put on an enormous amount of weight,resulting in an accu­ mulation of adipose tissue at all levels. The considerable increase in volume neces­ sitates distension of the fasciae to contain the surplus

tissue.

However, when the

,,,,eight is lost again, especially if the process is gradual, the fasciae nearly always regain all their original tonus and elasticity. Is this not an altogether remarkable example of adaptation) There are other examples. The kidney is contained in a fascial sac which is suspended by various ligaments and the renal artery. If the system of suspension

becomes loosened, the organ experiences prolapse and the renal artery becomes stretched. Hovvever, the kidney can be successfully restored to its normal position by

osteopathic manipulation

and, provided that this is done in time, the kidney

is soon re-established in its correct position and its supporting structures regain their tonus. The fasciae demonstrate a remarkable degree of malleability that permits them to adapt constantly to the forces to w hich they are subject. However, they are also capable of reverting to their original configuration because they are pr e ­ '

programmed' to recognize the body's normal physiological state, as long as they are given some outside assistance within a reasonable time frame.

Protection In addition to their role in maintenance, the fasciae also underlie a protective

mechanism which guarantees the physical and phYSiological integrity of the body. The mechanism of protection depends on

a

number of d if feren t

factors and

is based not only on the solidity, but also on the contractility and elasticity of the fasciae. Maintaining anatomical integrity. The fasciae, by virtue of their strength, protect the anatomical integrity of the dif­ ferent parts of the body and help the organs preserve their shape. This does not depend on complete rigidity but, on the contrary, is the result of fleXibility and adaptability. The exact degree of suppleness varies between different parts of the body.

Thus, the fasciae that invest the kidneys and the liver, or those that maintain the structure of the arteries, although endowed with a measure of elastic poten­

tial, have much stronger tonus than the fasciae of the intestines, stomach, veins, and urethra. These are all organs that are subject to variations of shape and pres­ sure, depending on their state of fullness. Fasciae which must constantly adjust their dimensions to accommodate vari­ ations in tension tend to have a particular type of composition, with relatively

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high densities of reticular and elastic fibers, and a less dense ground substance. Maintenance of the shape of the muscles is also depen de nt on the fasciae but, in th i s case, the fascia e tend to be much denser and stronge r. This makes them less

pron e to deformation so th ey are more s ui t abl e for p rov iding su ppor t

the kind of sol i d

that muscles ne ed to generate force.

Protecting against changes in tension

The fascia e constitute the fi r s t line of defense against s ign i fi c a nt variations in ten­ sion and ab sor b shocks so as to pro t ec t the integr it y of the structures that they

invest and support. The y a ct just like real shock absorbers which, by virtue of the ir properties of con tra ct i l ity and elasticity, attenu a t e the forces to which the body is subj ec t , absorbing and dissip atin g the energy of severe shocks to preclude dam­ age to the organ with which they are asso ci a t e d .

This pro tec ti ve and buffering a cti vity is most evident in th e case of the me­ ninges, the m e m b r ano us sheets which are desi gned to pres e r v e the cerebrospinal a x is from shocks and su dd en variations in pressure that mi ght da mag e delicate

nervous tissue. An ad di tion al element is invol ve d in this region to reinforce the shock absorbin g activity of the meninges, namely, the c erebrosp ina l fluid. In the pe riphery, at particularly sensitive sites such as the kidneys and the ischiorectal

fossa, a similar function is provid e d by ad ipose tissue which is, in effect, just an­ other, more fluid variety of conn e ctiv e tissue. It should be recalled th a t contracti lit y an d elasticity are two imp orta n t factors in the mechanica l functioning of the fasciae and tha t the el ast iCity of these tissues

ten ds to decrease with age-this phenom e non is, in fa c t, an important fac to r in the aging p roc ess as a whole. A good e xamp le of this is the gra d ua l c h an g es that

occur in the skin with aging. When part of the skin is pinche d, a fol d is formed; this fold will disap p e ar, but it does so more and more slowly with a dvancing age . The rate of d is app ea r a nc e of the fold provides a measurement of the strength of the co va l en t cross-links between the fibers , and hence of the overall elastiCity of the conn ective t iss u e . T h e dyn a mi C S and the me chanics of a given connective tissue dep e n d on

the loca l concentration of proteoglycans and hy a lu roni c acid. The rate of pro­ teoglycan synthesi s and m e tabol ism can be

a

(he redi t y, i nfec t ions ,

ffect ed by both int r i ns ic

spontaneous m uta t ions) and e xtrin si c (malnutrition, stress, microbial

p hysi c al injury) factors. In response to su s t a in ed, abnormal forces, the ground substance can become denser and the collagen fibers may become consolidated to in du ce

a

com p l e te

change in th e structure of the connective t i ss ue , particula rly at the p oints of inser­ tion . If s uch abnormal forces are sustained over the long term, calcification may ensue. Thus , certain a ttachments to ligaments and fasciae become p rogr essive ly

more calcified when exposed to severe and persistent tension. This phe n o m e n on

occurs esp ecia l ly frequently in a nd around the calcaneus, the elbow, the sho u lde r, and the vertebral column, to just mention a few cases which are often encoun­

tered in clinical pr a ctic e.

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To counter the effects of constant irritation, inflammation, and other serious, repeated types of insult, the connective tissue has developed a defensive mecha­ nism based on its transformation into bone tissue. This represents an extraordi­ nary system of adaptation and compensation, all the more remarkable in that the effects are completely reversible. This topic will be discussed in more detail later.

R ET E N T I O N A N D S E PA R A T I O N "T he fasciae unite and separate everything, separate and unite everything" -L. Issartel

Retention There is not a single part of the body that is not invested by some kind of fascial

element. The study of anatomy demonstrates that the human body is constituted of large envelopes that enclose more or less extensive regions. Within these major compartments, there are additional fasciae to enclose ever finer sub-structures without, however, creating any kind of discontinuity. For example, in the th1gb, a single, large cylindrical sheath invests all the muscles of that region as a unit. However, this large cylinder is sub-divided into multiple compartments by inter­ muscular septa, which separate different groups of muscles with different func­ tions. Inside each of these sub-compartments, groups of muscles are invested by another kind of sheath of fascial tissue which demarcates individual

m u s cles .

Inside each muscle, yet another fascial sheet surrounds each bundle of muscle fibers which, in turn, are compartmentalized by yet another level of membrane enclosing the individual myofibrils. The abdominal caVity is lined by a large membranous sac that contains all the viscera, isolating them from neighboring structures and thus maintaining a certain cohesion as well as insuring constant pressure. This structure, the perito­ neum, is, however, also subdivided into mesenteriesa and ligaments that consti­ tute the structural envelopes of the various organs. The function of the fasciae is thus to maintain the anatomical structure of the soft tissues. The fasciae are at one and the same time a structural component, sup­ port unit, and framework. Any weakness of the fasciae may lead to herniation of the internal organs and other structures. Such herniation may lead to rupture and impairment of physiological function. The organs could not fulfill their functions in the absence of the fasciae. Hol­ low organs would be massively distended, and their function would be compro­ mised beyond recovery, given the fact that the epithelia of all organs are anchored in basement membranes and this configuration is essential for normal tissue turnover. An artery devoid of fasciae would be flaccid and easily occluded by the slightest compression-the Circulatory system would be completely nonfunc­ tional. Any of the fluid-filled organs, deprived of its fascial framework, would be unable to maintain its shape and would Similarly be completely nonfunctional.

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Without fascial support, muscles would be u nable to generate any force from contraction. As has been poi nted out, the fasc iae have a more or less inelastic, r i gi d structure. A m uscl e, when contracting, requires points of support to have

any effect. These points of support are created by bridges which anchor them to (he bon es, but these alone would be insufficient (especi all y when contraction includes rhe d isplac em en t of one segment with respect to another) if t he muscles

were not also supported by fasciae. The fasciae not only provide point s of attach­ ment for the muscles, but also points of support, which permit the muscles to

r ealize their full power. The retent i on function of the fasciae also s er ves (0 protect organs and muscles against shocks and sudden variations in pressure by absorbing some of the energy. Without this capacity for retention, these str u ctur es would soon suffer from tears

and other in ju r ies. The fascial retention function is also im p ortan t in the ch anne l in g of physi010gical forces: without the fasciae, movement would be imp ossi b le to produce,

control, or coordinate.

Separation All anatomic s tru ctures are linked by fasciae, but these same elements are also a means for separ atin g structures without any loss of cohesion.

Separation is broug ht about by compartmentalization and the creation of planes of cleavage. Cleavage

Planes of cl eavage serve to avoid rigidity and to retain the mobility that is a fun­ damental re quirem ent for even the tiniest structures of the body. Th ey also help endow any given organ or structure with some degree of indep endence from its nei ghbors. Every par t of the body, while rem a i n i n g in in tima t e contact with its n ei ghbors , is also separated from them by pl an es of cleavage. These consist of areas of areol ar connective tissue that fill the spaces between organs and also, as previously n oted, link structures together.

There are two main points of interest regarding planes of cleavage : •

T hey help organs, enti re muscl es , and individual bundles of muscle fibers slide over one other. This allows for changes in shape and tension ,

and makes coordinated movement possible . •

They represent crossing-over points where deep palpation is possible.

When, in the cou rse of tests and treatments, we want to examine dee p-seated zones, we have to trav erse the barrier rep resented by the m u scl es . When we at­ tempt to penetrate such a layer of muscle tissue, we are frustrated by resistance due to the tension of the muscle, that is, its reflex contraction. In other words, there is a thick, dense structure between our hand and the area of interest-this

makes pal p ati on difficult or com plete ly impossi bl e .

Planes of cleavage make it possible to by p ass this barrier. Thus, if one wants to p alpate the pi r ifor mis muscle or the sacrospinal ligament, one must make use of

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the cleavage plane between the gluteus maximus and the glu teus medius muscles. If one wants to palpa te the sciatic nerve a t the p o s terior face of the thigh. the only possible approach is the cleavage plane between the adductor and hams tring m uscles. Likewise , in order to palpate a kidney, the only effective approach is via the m eeting poin t be tween the external edge of the rec tus muscle and the oblique muscle of the abdomen. If one wants to p alpate a common anterior vertebral ligament, the only pos­ sible approach is via the linea alba . However, it should be remembered that this p oin t of cleavage is subject to variation; for exa mple , durin g pre gnancy, displace­ ment of the linea alba is an important factor in the ability of the abdomen to undergo the massive dis tension which is necessary . But unfortunately. sometimes , imperfect postpartum re-joining re sults in separation of the differen t constituent layers of the linea alba so that the intestinal loops can easily be felt through it. Fina lly, being familiar with the pattern of cleavage planes in the ab dominal c av i t y makes it possible for the surgeon to m ake smaller incisions and still be able to clearly sepa r a te the various org a ns from one other. Compartmentalizati o n Repeated split ting and division o f the fascial sheets generates a complex network

of more or less isolated compartments . This makes it possible to maintain differ­ ent pressures in differen t places , and also helps block the spread of infections or inflammatory mediators from one part of an organ to another. This compartmentalization protects organs from the spread of abscesses in surrounding tissu e . However, as we have seen , there is also segment a tion within

the organs: the most typical example is the separate lobes comprising the liver and lung. The aim of this a dd i tional compartmentaliza tion is to pro tect the vital organs and to ensure that their functions con tinue to be performed even when p art of the organ has been damage d . Thus, for example , a liver can still perform its phYSiological role as long as at least 30% of the original functional tissue is operational .

A B S O RPTI O N O F SHO C K S W h e n the body i s subject to any kind o f violent trauma a t the surface, a shock wave is generated which propagates towards the in terior. Such shock w aves can con duc t and del i ver huge a moun ts of energ y to the deep tissues , thereby causing serious damage to many different internal structures and organs if the in tensity o f the ori ginal shock is strong enough. The role of connective tissue is to absorb that shock wave and to dissipate it in different directions so as to a ttenu a te it and protect the physical int egrit y of the body. If the intensity of th e shock exceeds a certain thresh old, the connective tissue can no longer absorb en ough of the energy and injury will result, possibly fatal; the most common fatal injuries are rupture of the spleen or the liver, and fracture of the kidney. By virtue of the orientation of the fascial fibers. connective tissue a cts as

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buffer and disperses the energy in different directions so a s to attenuate the i nten­ s i ty of the shock wave and absorb its energy In cer tain situ a tions, however, the energy cannot be fully absorbed and dis ­

Sipated . Either the shock was too violen t o r it s truck a n area which was already subject to abnormal tension. What can occur in this case is the formation of "vh a t Elmer Green h a s calJed an "energ y cyst ," t h a t is, the concentration o f a s i g n ifi­ cant amount of energy within the connec tive tissue, energy tha t sooner or later will have deleterious effects. Such a cys t of energy manifests by ob structing the

normal conduction of electricity through the tissues of the body It acts like an ir­ ritant, which can contribu te to the development of an area which is a propitious focus for the kind of phenomena conventionally associated with irritation. This leads to a n increase in entropy an d loss of function in the surrounding tissues. A c y s t of energy can result from trauma, inva sion by

a

pathogen, phYSiological

dysfunction, or even emotional stress . I t seems s trange that s oft tissue can, b y itself, accumulate a n amount o f energy that rem ains imprisoned within i t . We have seen that the role of the ground sub­ stance is par tly that of a shock absorber, and that, in order to accomplish this task, it explOits a number of different mechanisms to res tore its normal phYSiological status after a compromising event. In cer tain situations these mechanisms are in­ sufficient and the ground substance can no longer fully resolve the s tress . It then retains the memor y of the s tress in an a u t onomous m a nner, independent of any hi gher con trol mechani sm. To be sure , the hi gher control sys tem may intervene in order to enhance the p ossibility of disc harging the energy, and thereby avoid sequelae, but i t cannot obliterate the stress This is demonstrated by Frankstein's experimen t , as noted in Korr. A cat , w hen injected in the paw with oil of turpentine, will immedia tely place its paw

in the position of triple wi thdrawal. With time, the cat recovers normal use of its paw. When, severa l m onths la ter, the cat is decerebr a ted , the injured paw imme­ diately resumes the triple withdravval posi tion . Interruption of the higher regu­ latory processes has brou ght the original trauma back out ag ain in the presen t . One speaks here of cellular o r per ipheral memory, m ore specifically of "ground su bs tance memory." When the buffering capacity of connective tissue is overwhelmed, tha t is, when a traumatic insult or any other kind of injury has surpassed a certain in­

tensity, local stres s sets i n . Usually it develops, sometimes over a period of years , without any symp toms; but ultimately , in mos t ca ses , s ome kind of disease s t a te will result. This occurs by mea ns of an autonomous l ocal mechanism but, through the intermediary of the nervous system, such a phenomenon can quickly spread to a much broa der area. This involves the mechanism of spinal seg ment facilita ­ tion. In a facilitated s pinal segmen t , resis tance to the conduction of electrical impulses is reduced . The segmen t is highly irri table, and any additional s timu­ lus-even a very weak one-will bring about a strong response, the magnitude

of which is ou t of all proportion to the intensity of the addinonal s timulus. The segmen t where facili ta tion has occurred will induce modifications in

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Chapter 6 / Fascial Mechanics

the tonus of

the

muscle associated with it, whic h will be associated with

a

con­

comitant reduction in the mobility of the segmen t as well as a palpable change in

t iss u e structure. It may be recalled that this change can be induced directly-by­ passing the reflex a rc-t h rough modification of the composition of the ground subst ance. Such im paired ground substance function will have repercussions at the surface of the skin through

the

intermediary of the "Heine cy lin ders

"

(see

chapter 3, page 130). Sy mpathetic stimulation, in tur n, leads to

a

chang e in the texture of the skin

sweat

as well as to c ha nges in the ac tivit y of the

glands. E ventuall y the problem ,

will sprea d distally to organ s th at depe n d on the metameric territory, which will also become dy sf unctional in th e absence of outside intervention. A facilitated segment, unfortunately, has a tendency to self-perpetuate and spread

ABSORPTION OF PRESSURE The body is

subject

at all times to tensions pulli ng forces, shocks, and stresses of ,

many different kinds. It is unlikely that the human being would be viable-in any case, its functions wou ld be greatly impaired

-

if there were no defensive barrier

c ap a ble of absorbi n g potentially damaging forces. The shock absorb ing role is in g re at part m ediat e d by the fasciae and is de­ penden t on the biochemical compo s ition of this special kind of tissue, esp ecially on i ts elastic components, on its special anatomical s truc ture, and on the presence of the adipose tissu e cushions which are part of it.

Biochemical composi tion We have seen in the prec e d in g chapters how the buffering capacity of connec­ tive tissue derives from the composition of the ground substance, esp eC i a lly its p roteogly can content. It shoul d be recalled that the proteogly cans modify the viscoelastic properties of tissues, the properties which are most imp o r tant in de­ termining how they respond to changes in pressure. The ratio of ground substance to fibers d ep e nd s on the forces to which a

t issue is subject. Thus, in a ligament which is subj ect to strong forces but always in the same direction, the ground substance will be relatively sparse, while the fibers will be very abundant and ali gned in parallel bundles along the axis of the predominant forc e . The result o f the bufferi n g activity o f the fasciae i s t o att enuate the intensity of any po ten tially damaging force and to absorb some of the energy, whatever the nature of the original ins u lt. If stress persi sts, t h e fa sciae

w ill

modify their struc­

ture in response to it. Thu s, wherever any ten sio n is appl ied in a sustained manner, the collagen fibers increase in number and align th e m s e lves in the direction of the force. This can even tuall y give rise to fi brosis

.

Hurschler et aI., in studies of p a thological fasciae, pa r ticular l y in patients wi th anter ior tibia l co m p a r t m en t syndrome, did not find any difference s in the absolute amount of collagen presen t ; they did, h owever, observe an increase in the thickness of the fibers as well as incre a sed rigidity.

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There is, in the case of pa thological fasciae, a decrease in the extent to which the fi bers are cross -linked. In some patients, the fibers appear to be thicken e d ; in others, they appear both thickened and adhesions to muscles were de tected; and in a third group the fibers appeared histologically normal. This makes us think ,

that each su bject respon ds in a different manner to the same kind of pathology, probably according to their overall " s t a t e of health." When dealing with an indi­ vidual, one must therefore integrate the disease in a holistic conte x t. This is what Korr is referr ing to when he says "there are no illnesses, but only ill people." Page notes that connecti.ve tissue forms the membranes across wh'ich the

osmotic processes of nutrition and elimination occur. Abnormal pressures and tensions will therefore also have an impact on the osmotic exchanges between different fluid compar tments The eqUilibrium between the circulating blood and the tissue fluids mus t be maintained so that the physiological balance of the bod y can find i t s full ex­ pression. Any membrane tension can distur b the hemodynamic processes of the body with the result that the effiCiency of tissue drain age will be reduced and ,

metabolites will begin to accumulate. This will ineVitably lead to progressive lo­ cal dy sfu n ction. Yahia et al. prepared specimens from pathological lumbar fasciae and observed marked t h ic k enin g with re-orientation of all the fibers in the same direction.

Elastic components A fascia is not a totally rigid structure. Wherever it is observed, it alw ays has some degree of elastiCity which allows it to attenuate pressure and increases its breaking point. In the course of violent exertion, the muscles ar e suppor ted and reinforced by elastic connective tissue Without some elastiCity in the system, the muscles .

would soon reach their breaking point and irreparable damage wo uld result . In practice, rupture is rare, evidence of the powerful viscoelastic and contractile po­ tential of the fascial sy s tem. Yahia et al. studied the e ffect of s tretching forces on specimens of fascial tissue. They found that the more the fasciae were stretched, the more rigid they became; thus, in order to obtain t he same gi ven deformation in a shorter period of time, a greater load had to be used. Furthermore if the fasciae were submitted ,

to a constant load, the extent of deformation steadily decreased over time.

Adipose tissue In additi on to its roles in fat storage and thermal insulation, adip o se tissue also acts as a shock absorber. The importance of this ki nd of t is sue in tha t function varies among differen t parts of the body. In the sk in adip ose tissue acts as a cushion which attenuates the intensity of ,

shocks, although its efficac y in this respect depends on its thickness, which varies from region to regi on Thus, a blow on the arm, where there is a relatively thick .

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Chapter 6 / Fascial Mechan i cs

layer of a dipo s e tissue , is much less p a in ful than a blow on the tibial fa ce of the calf, w h e r e there is practically none. In the ab dom e n , in addit i on to filli n g the space s between the various organs ,

i nte rnal cushions of adipose tissue s i gnifi cantly attenuate the pressures that are n orm a lly g e n era t e d inside the abdominal cavi t y. Th:ls protects all th e organs

so tha t

th ey can conti nu e functionin g normally. Around the ki.dney, th e r e is a p a rticul arl y thick l ay e r of ad i p os e tissue. In ad­ dition to keepin g th e kidn e y in place (prolapse of the kidney is common during rapid we i g h t loss when fat around the kidney

is

e lim i nat e d too quickly) , this

adipose pad protects the organ from physical trauma which , if violen t

e nou g h

,

could cause i.ts rupture.

There are considerable amounts of adipose

tissue a ss oci a t ed

with the p erine ­

u m , which , in view of it s l o c a t i o n , r o l e , and anatomical s t ru c tur e , w a r ra n t s s p ecia l

fa sciae. As a brief reminder, the p erineum is composed of three superimposed l ayers o f fa s ci a e : t h e s u p e r fi c i a l p e r i ne a l fa s c i a , t h e m idd l e fascia o f t h e an t e r i or perineum , and the d ee p p e r in e a l fascia t h a t c orr e s p o n d s to the sheet of t i s su e th a t s ea l s the abdominal cavity. The se fascial envelopes i nv e s t a variety of d iffe r e n t mu scles that rein fo r ce and u n d e rli e the m . This constr uction would b e p erfe c t i f i t did n o t include g a p s i n th e antero­ posterior direction w h e r e the sp e cia l str uctures of the tr u e pelvis are l oca t ed , that i s , the rectum, the bladder, and, in fem al e s , the vagina . The vagina i s a m a j or introversion in which both the cervix of th e uterus and the neck of the bladder are s ituat ed. The central p a r t of the p eri n e u m is filled , in the an teroposte rior direction , by a t t e n tion. It pe r fectly illustra tes a number of different key p roper ties of t h e

the s tr u c tu r e s of the t ru e p elv i s, all of which are more or l e s s con cave m shape

The p e rin e um is attached to these stru ctures and is suppor te d by them. Lat e rall y, there is a pai r of l on gitud in a l s tr u ctures , the ischioanal fo ssae, which are also filled with adip os e tissue.

The perineum re pre s e n ts the most s t eeply i nclined part of the thoracoab ­ domi n a l ca vit y and it

s up por ts

an entire ' fl ui d ' colul1"m which cont ain s n ot only

the organs of the actual p er i n e um , b u t also those of the abdomen and thor a x . This represents a cons i d e r ab l e weight wh ich , since the perineum i s n ot hermeti­ cally sealed, would p r edi s pos e the perineal org ans to p rolap s e if it al l had to be borne in the ver tical plane. In fact, such prol a pse i s ac t ually (and fo r tu n a t e ly )

a

rare eve n t. To avo i d prol a p s e and to support t h e ov e rl y in g visceral column , as well as to

make efficient sphincter function pos s i bl e and absorb the pressures g e n e rated lo­ cally, the perineu m is endowe d wi th

s eve r a l

t o protect it : •

e l a s ti City and solidi ty

•

a sp e cial anatomical archi tecture

•

an a di pos e cu shion

•

addi tional shock absor b e rs

•

coord in a t e d

m ovement

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properties and fea t u re s whi ch serve

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E l asti c i ty a n d s o l i d i ty In order to support the organs . t he peri ne al fasciae mus t comb ine two essential .

but apparen tly mutually exclu sive properties. namely. elas ticity and solidity : •

solidity to support the enormous pressures that can arise. especially

•

elas ticity in order to absorb the high pressures which are c o n s tantly

when coughing or in the course of violen t exertion

bei ng genera te d . and also to permit free movemen t of the sphincters If ei ther of t hes e qualities is comprom ised , the function of the perineal organs will be affected . There is a danger of dysfuncti on of the bladder and the u teru s , a n d , sooner or later, these same organ s may experience prolap se. Spe c i al a natomi c al arc h i tecture It wa s p o inted ou r that the p erineal organ s have a roughly concave form in the anteropos terior and sagit tal directions . This perm i t s distribu tion of the pressures from the overlying region in all directions . rather than exclusively ve r t i c a lly. Kam ­ ina notes that the "internal static pressures are all the better insofar as the physi­ ological ori.entation of the genitalia is con served or accentuated and the su pp or t­

ing element s are solid . " O n exertion . because o f t h e overall con figuration of ehe pelvis . intra - abdomi­ nal pressure is mainly directed toward s the back . that is . towards the ver y s trong anococcygeal region . There is a pos teri or transfer of pressure from the viscera a n d . in par ticular. the u terus . the cervix of which is supporte d by the posterior perineum. Fur thermore. the leva tor ani muscles con tract t o oppose the force generated a s a result of the press ure. They h ft the tendinous center of the perineum that pushes the pos terior v agina l wall in an anterior direction. thus incl in ing the va ­ gina a t a n angle t o the posterior cul-de - s a c . the so-called ' vaginal angle.' EVidently. when it comes t o an atomical architecture. one has to keep in mind the i nclina tion of the pel vi s . and the exis tence of lumbar lordosis and abdominal tonu s. Any increase in lumbar lordosis or loss o f abdominal tonus \Nill tend to in ­ duce an teversion of the pelvi s . If this occurs . the res ultan t forces on the perineum

will [end [0 be focused at the v ulval cleft and excessive pressure will be exer ted on the bladder and u ter u s . Weakening of the perine u m will very soon lead to prolapse of the neck of the bladder or of the u t erine cervix. Ad ipose cush i o n The adipose tissue i n t h e ischioanal fossae exis ts n o t only t o fi l l a n emp ty space and pro tect the local vessels and ner ves . b u t also to absorb pressure. It acts as an elas tic bu ffer that b o t h attenua tes a n d a bs o r b s pressure. Ad d i ti o n al s h o c k a bsorbers The perineal cavi t y is cl osed posterolaterally by the piriformis muscle that is in­ ves ted by fasciae derived from the deep perineal fa scia. The piriformis muscle. as

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Chap ter 6 / Fasci a ] Mechan i cs

well as herme tically s e a li n g th e p e l vi c girdl e in t he back , cons titutes an additional s h o c k a b so r b in g element in the true p e lvi s . The pelvis has two l ateral op en i n g s , the o btu r a t or foramin a . What purpose

do the s e serve ? Apa r t from p ro v i d i n g an insertion point for t he two o bturator

muscles , t h ey are filled with the o b t ur a tor membrane, an elastic sheet that vibra t es in respons e to pressure on the true pelvis, rather li k e the gills of a fish. These s tr u c tu r e s therefore con s titute an additional for c e mo d u l a ting s y s t em -

.

Coordinated movem ent I t should n o t be forgo t te n tha t the true pelvis lies b el ow

a

si gn ifi c a n t vi sceral

mass in t he abdomen , and tha t this abdo min a l mass is confined a t the top by the p i s ton - a c tion diaphragm , whi c h is c on s t a n t l y mo v i n g up and down . Part o f the resul t a n t pressure on the v i s c e ra l co lumn is transmitted dow n towards the or g ans o f t he pelvis. The soft tis s u e s of the p er i n e um , by vir tue of their elas ti C it y abso r b ,

and

c o m p e n sa te

for this constant m ovement an d the r eb y preclude d a m ag e to

i n t e rnal s tructures . There is th e n som e d e g r ee of coordination with the d i. a p h r a g m in the for m o f a sl i ght dovvnward movement during inha l a tion. This m a y be demon s trated

b y br e a t hing a t the same time a s the perineum is b e in g contra c ted : you will see tha t breathing i m m e d i a t el y becomes more difficult and you will be able to feel t h e increase in p r e ssure Overal l , thanks to the solidi ty, pl as t i City and vi s co el a s­ .

,

tic pr op ert i e s of th e fasciae, the p r e s su re transmi tted by the thoracoa bdominal column i s not all exer ted v er t i. c a lly bu t i s d i s t r i b u t e d to and s u p port e d b y all the ,

v a r iou s compon ents of the p e lvi c girdle •

B elow and behind , a t the l eve l of th e central fibrous ring of the

perineum , is the most a cu t e ly inclined c avit y, where all o f the fa s c i a e and most of the perineal muscles c o nve rge . It s e rve s as the thread vvhich

closes th e b ag and may b e considered the most solid point . •

Laterally there is a primary shock a b s o r ber in the form of a p a d of ad ip o se tissue. S till more l a ter a ll y there a re the obturator membranes in ,

fron t and the p i riform is muscles fllIther b a c k . •

F in al l y, in front , s o m e of the force i s absorbed b y the anterior

peritoneum and the s ym phy s i s .

Ana tomi cal design The fa sciae, anchored to the skeleto n , are n o t a simp l e t ube c o m po se d of p er fec t l y p a r all e l ver tical bands. The architecture of the fascia e consis ts of several s uper im

p o s e d , i n te r d e p end e nt layers , a r r a n g e d in vertical , horizon tal , and o bl ique c o n

­

­

fi g ur atio ns to enhance t h e tissue's s o l idi ty and po te nt i a te i ts c apa c i t y to resist any

for ce to which it is expos e d

.

Debnar et a l . a nalyz e d s p e cimens of thoracolumbar fascial ti s su e and dem­ onstrated that they a r e composed of num er o us laminae of c oll a g en fibers , each a rr a n ge d a t a different a n g l e with respect to the ot h e rs Gerlach a n d Lierse s tudi e d .

t h e fas cia e o f the lower limbs a n d found t he following (Fig

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6-3):

177

Fig. 6-3

Fasciae o f the Lower L i m b ( a fter

Gerlac h )

� A N T E RI O R F A SC I A E H A V E :

•

horizon tally oriented fibers , some of which are a t t a c h ed to the ilio tibial

•

ver tically disposed fibers in the upper part of the t h i g h ; thes e fibers are

tra c t , with o thers disappearing posteriorly

interwoven with the horizon t al fibers •

o b l i q u ely disposed fibers , lower down and on the insid e , with their l ower ends continuing into the interior of the tibia . Thes e fibers are thinner than the vertical ones, excep t at the level of the hip , where they are s trong er

� P O S T E R I OR F A S C I A E H A V E :

• •

s tron g , ver tic a lly disposed fibers

h o r i zo n t a lly disposed fibers , es p eci a lly dense b el ow the gluteus maximus muscle and in the lower par t of the thi g h where they ,

t e rmina te in the popliteal fossa The lowe s t fibers are archiform , at first obliquely disposed below and inside , and then vertica l ; they continue via the aponeurosis o f the p o s terior tibial muscle.

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Chap ter 6 / Fascial Mechanics

� I N T ER N A L FASC I A E H A V E: •

both vertically and obliquely disposed fibers , the latter originating from

•

an ant erior group of obliq u ely disposed fibers below and in fro n t , and

the fascia lata a pos terior group of similarly disposed fi b ers below and behind . The anterior fibers merge with the patellar retinaculu m , and the lateral fi bers with the medial collateral ligamen t . The internal lateral part consists of very dense, ex tremely s trong fibers which are easy to palpate. � EX T E R N A L F A S C I A E H A V E :

•

very povverfu l , verticall y disposed fibers which form the iliotibial tra c t . This tract is linked t o t h e femur by t h e external intero sseous membrane.

The inferior fasciae form p a r t o f the pa tellar re tinaculum and of the ex ternal l a teral ligamen t . Th e fibers of the thigh continue into the leg and the foo t where they show the same basic s tructural p a t tern . The fa sci a e of the lower limbs a n d , in fac t , the fasciae in g eneral , have an overall spiral configura tion wh i c h permits them to a c t like a ' floor clo th ' which ' s oaks up flui d , a s wa s previously discu s s e d . Further m o r e , this design increases '

t h e ir abil it y to resist force a n d maintain the body ' s normal anatomical s tr u c t u re .

G e n era l Mecha n i cs N ERVO U S CON D U C TION O F PAI N Pai n impulses from the p eripher y are conducted t o the dorsal horn o f the spinal cord . From ther e , the signal is rou ted via tracts inside the spinal cord to speci fi c higher central nervous sys tem cen ters which process the informa tion and then send b a ck an appropria te response. This ou tline is h i g hl y simpl i fi e d , and the real si tuation i s far more comple x : there is a c tu all y a whole ne twork of peripheral recep tors which send signals along ana tomically c h aracterized pa thway s , but it seems that conduction chan n els are not a s simple a s one mig ht think , and that there are importan t circuits which we do not

un

d er s t a n d at all .

Not all the info r m a tion arriving at the dorsal horn of the spinal cord induces a response b e c a u s e we are in a state o f cons tant nervous s timula tion . For a reac­ tio n , it is n e c essary that there be a series of differen t , corroborative signal s ; on the basis o f this observati o n , Melzach and Wa l l developed the gate theory. In the dorsal horn of the spinal cord there is a regula tory mechanism to in­

crease or decrea s e the rate a t which n ervous impulses are t r ans m i t ted . This mech­ anism depends on the a c tivity o f A-beta and A-delta nerve fibers , as well a s signals coming down from the brain . When the quantity o f information passing throu g h t h e g a te exceeds a c e r t a i n thresho l d , the regions of t h e brain r e s pon S i ble for pain sensa tion become activated. A flow of impulses arrive a t the tract c ells of the dorsal horn and, up to

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certain threshold of tolerance, these c e l ls exert an i n hi bi tory activity and t h e g a te r emai ns closed . When the a ccumula tion of s i g n a ls exceeds the threshold , the in­

hibi tion is lift e d , th e gate open s , and pain is fel t . H owever, the idea o f a p urely sp ina] mechanism poses certain problems . The gate t heory is b a sed on presy n ap tic control bu t it is known that there are also posts ynaptic i n hi b i tor y mec h an i s m s Th i s i s evi den ce o f .

a

back-up mechanism ,

but also indica tes t hat les i ona l trig g eri n g o c cu r s a n d c erta in ly in the p er iphery ,

before in tervention of the reflex ar c Therefore , it would appear t ha t no t al l the .

i n formation passes throu g h the higher cente r s , but that some i s treated by the '

pe r i p her al brain.' Experiments have shown that rats are still able to learn to .find

their way throu g h a m aze in s earch of foo d even a fter decerebration . The spinal cord has its own memory, a nd can both take decisions a n d s olve pro blems. I t i s importan t to n o te that this peripheral brain function is also found in the fa sciae . The fa sci a e are channels for the conduction of s up er fici al sensory stimuli whi c h follows a p a th o ther than tha t invol vi n g the spin a l cord . As far b a c k a s the e a rly nineteenth c en t u ry Bichat c al l e d this phenom enon ' in termembrane symp a ­ ,

thy. F o r exam p le, i f the thi gh i s scratched, irrita tion can b e felt at some r emote '

p O i n t , like on the b a c k . T h is p er i p h e ral conduction of sensitivi ty i s perfectly illu s trated b y t h e phe­ nomenon of causal gi a . This c ondi t ion can induce pain so a c u t e tha t some vic tims are driven to commit suicide. Moreover, in some of the m os t r efr a c tory cases , while radicotomy, sympathec tomy, cordo tomy, or sect i onin g of the spin al cord

may g i ve temporary remi s s ion , the pain can return to the same degree. Where does i t come from and where doe s it pass t h rou g h ) D efin i tely not the nervous system of the spi n a l cord , because that has been eliminated . It seems tha t there exists an au tonomous sensory n e twork which cons titutes the primary peripheral or g an i za tion and which fun c t i ons in an en t i rely inde p en

­

dent manner. L i g h t ly to u ching a sensit i ve area can trig g er a c ute p a in , a n d some­

times the p a i n will ma n i fes t wi th o u t any o bvious s timulus a t all . Pain can s p read in an unpredi c ta bl e way to dis tant par ts of t h e body which have no re l a tionship w i th the initial fo c u s o f pain . Often , pain p ersis ts lon g a fter the tri g g e ring s timulus has d isappe are d This phenomenon escapes any kind of logi c a l e x p lanat i on if only a sp e C i fi c rigid , and ,

direct sensory sys tem i s c onsid e r ed Thus , normally, a half-full bladder is no t fel t .

a n d does not induce the desire t o urin a t e . Fullness induces t h e urin a tion response by st i mula ting mechan ore c epto rs However, p a tients with cystitis feel the need to .

u r ina t e even when the bladder is far from ful l . T h e u t e r u s is doubly innerva ted . Its b o d y is inn erva te d b y a group o f fibers

from the thora columbar region and i s only p a i nfu l i n t h e event o f mas sive dila­ ta tion , serious infection , during de l ive ry an d , in c ert a i n women , a t the time of ,

m en s t r u a t i on . Cer tainly, i n the last case, the fasciae are in a state o f maximum summa tion a nd the si m p l e fa c t of mens t r ual conges tion suffices to t r i g g e r the pain . The cervix is innervated by the hyp og a str i c p l exus and is a focus of intense

pain i f i t i s d ila te d by even a few centi m e ters. Not only do differen t t i ssues rea c t

differen tly t o stimuli but, within even the same organ , the reactions t o the same kind o f s timulus can be comple tely differen t .

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Chapter 6 / Fasci a l Mechanics

It seems ever more evi dent tha t the fasciae are n o t only the focus of sensi tiv ­ i t y, b u t tha t they are also capable of indep enden tly processing in formati on . Pis­ ching er attributes this capacity to a fundamen tal sys tem . It i s gu a ra n teed by the home osta tic mechanisms of the sy s tem th a t is , correction \"'1 th a minimum loss ,

of en erg y, mistakes resulting from the in tr usion of per t urbing factors. The s e perturbing factors u sually a c t in a u n ilateral fashion, only compromis­ i n g mobili ty and func tion in the a ffected segment . Even before the appearance o f fran k , clinical symptoms , t h e dis turbance is alre ady well - es t ablished and already e n tails the expenditure of more energ y to main tain normal functionali ty. Then , by

a

s e gm en t al reflex channel , the involvem ent spreads more deeply, perh aps even

to the vis cera . Finally, a c h ronic condition is es tablished and the en tire side o f the body m ay become involved and dysfu n cti onal

.

Yahia et at , s t udyi n g the thoracolumbar fascia , discov e red the presenc e of corpuscle s of Ruffini and Paccini. Ruffini 's corpuscl e s are charac terized by a sim ­ ple axon with very dense d e ndritic n e t work containing collagen fibers . Mechano ­ receptors are m ai n ly concen trated around blood vessels and in areolar connective tissue with bundles o f dense collag en fibers. Nervous conduc tion i n the fa sciae seems to be p a r t of the symp a thetic sys­ tem , which is important not only in the mechanics bu t also in the bi o chemis try of the tis sues. To a les ser exten t , the parasympa thetic system is also involved. The s ymp a th e ti c system controls the circulation a n d metabolic activity and has an enormous in fl u ence on p H and on the elimina tion of waste produ c t s . I f the fa scia e have their own i nnervation , i t m ean s th a t they a r e no t r i gid but capable o f some level of m o tion . This has been i nves ti ga te d by Yahia et a! . , who s tudied explan ted specimens of fa scial tissue . They showed tha t s tretchin g induced sponta neous contrac tion , tha t is , an in cr e a se in the viscoela s ticity of the tissu e in response to the ins u l t . Boabighi e t al . s h owed t h a t c o ll ag en fibers con t ain regula r undula t ions the ,

shape of which is comparable to the waves formed at the surface of moving fluids . The mea n ampli tude of these un d ula tions was 6 microme ters , and their mean wave leng th was 60 microme t ers

(Table 6- 1 ) .

Therefore, the fasciae should b e considered as s tructures which are capab l e of some de g ree of a u tonomous mo tion . The source of this mo tion should b e so u g ht

i n the embryo. Embryolo gical developmen t is n othing more th an a state of per­ p e tual m o t i on which , in th e end , results in the cons truction of a hu man bein g. Rememb er, as discussed a t length in C hap t er j , tha t at the very be g innin g of life there are thre e different but intima tely a ss oci a te d l a yers of tissue , n a mely the ,

,

ectoderm , the mesoderm , and the endoderm . These thr e e layers migrate to form

the skeleton, the cavi t ies and the organs These migrations occur Simultaneously ,

Each laye r migrates in a coordina ted way and in t erac ts and i n terpene trates i ts

n ei g h b o r s . A ' memory ' of this per pe t u al mo tion will persis t , and this m emory can b e de tecte d in the cranium , the vis cera , and the fasciae. Its amplitude i s some­ where be tween eight and fou rteen periods per m i nute , with a cer tain degree o f

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variation be tween differen r parts o f the body. This perpetu al m otion fa cilitates cellular exchan g e processes and a cts a s a pump to drive fluids around the body. It woul d seem tha t this moti on is maintained by the sympathetic nervous

s y s tem , and th a t any change in its rhy thm-an incre a s e , decrease, or its disap ­ pearance-re p resen ts an importan r diagnostiC aid , as vvill be discu ssed in detail la ter on .

Ta b l e 6- 1

H i s c o l o g i c a l P r o p e r t i es of t h e Fasciae

STRUCT U R E Bra c h i a l a po n e u ro s i s

F i ber D i a meter ( m i c rometers)

A m p l i tude ( m icrometers)

Wave l e ngth ( m i c rometers)

1 30

8.5

30 .

Antebrach i a l a p o n e u ro s i s

1 55

E x t e n sor re t i n a c u l u m

200

.

.

.

200

1 .5

U p per a p o n e u rosis of t h e exte r n a l o b l i q u e m .

1 55

8.5 .

m.

1 70

.

.

70 .

.

.

.

.

. . . • .

70 30

. - .

.

.

.

. .

. . .

. .

.

. - .

.

. . . .

5.7

A m e r i o r fasc i a l ata

1 50

8.5

I l i o t i b i a l t ra c t

1 55

4.5

.

85 .

1 .5

. . .

30

.

285

. . . - . . . .

30

- .

A n k l e extensor reti n a c u l u m

.

1 .5

F l e x o r re t i n ac u l u m

extern a l o b l i q u e

.

85

.

Lower a p o n e u ro s i s of t h e

.

.

.

. . . . .

.

75 .

.

80

MOR P HOLOG I CA L C H ARACTER I STICS Connective tissue is rich in collagen fi bers assembled into dense, almost paral­ lel bundles, the orienta tion of which follows the direction in which mechanical forces tend to be imposed. The difference in intensity be tween mechanical forces leads •

us

to observe, in a general way :

In the upper limb, the an terolateral fasciae tend to be thicker and

s tron ger than the posteromedial ones . •

The same kind of tendency is observed in the lower limb, a p a r t from within the leg , where the a nreromedial fascia covering the tibia is the thickest of all.

•

In the palms of the hands and soles of the fee t , the fasciae are extrem ely

thick and strong •

In the neck and trunk , as a rule the posterior fasciae are stronger than the an terior fasciae.

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Chap ter 6 / Fascial Mechanics

This differenc e in various parts of the body can be expla ined by th e i r bio me­ chan i cal characteri s tics. The thicke s t , s tron g e s t fasciae e i ther hav e to work harder or have a tough re tention fun c t i o n to per form . They a re the most important in m ain ta in in g posture and for m . As preViously n o te d it i s the in tensity o f the force ,

to which they are subj ect which determines the characteristics of d ifferent fas ­

ciae, s o the differences observed a p p e a r to b e entirely l o g ica l . B o a b i g h i e t a l . have

s tu died the biomechanical properties o f va riou s fa sciae (Ta bJ e 6 - 2 ) . Tab l e 6-2

B i om ec h a n i ca l P ro p e r t i e s of C e r ta i n F a s c i a l E l e m e n ts

Lengt h e n i n g

S T R U CTU R E

Brac h i a l a po n e urosis B i c i p i ta l a pon e u r o s i s .

.

.

.

.

.

.

.

.

.

.

.

.

.

A n t e b r ac h i a l a p o n e u r o s i s . . . . . . . . .

.

.

.

.

.

.

.

.

.

.

Defo r m a t i o n

Strain

(%)

(N/mm2)

( Y o u ng's m o d u l e ]

88

1 .7

2

42

2.9

12

43

1 .2

3

5S

1 .0

(N/mm2)

. .

Extensor reti nacu l u m

3 .

F l ex o r re t i n ac u l u m

76

1 .3 . .

Pa l m a r a p o n e u ro s i s

47

2.4

D i g i t a l fas c i a

S3

2.6

.

.

.

.

.

.

. . . .

.

.

. .

.

.

the extern a l

obl i q ue m.

.

1 00

.

.

.

.

.

.

.

.

.

..

.

.

.

.

2 .

.

.

.

.

.

.

.

.

7 13 .

A po n e u ro s i s o f

.

.

. .

.

.

.

. .

1 .2

3

2.5

18

.

.

. . . .

.

. . . . . . . . . . .

Lower a p o n e u ro s i s o f t h e

62

i n t e r n a l o b l i q ue m .

. .

Fascia lata I l ioti b i a l t r a c t . ... .. .

. .

. .

. . .

.

.

.

.

.

.

.

. . .

.

.

.

.

. . . . . .

48

0.6

2

35

3.8

19

6S

1.1

3

.

A n k l e extensor r et i n a c u l u m

Analy s is of these results shows tha t the bre akin g s treng th of one group of fa sciae

is as high as Yo u n g s module . This group inclu des the b icipital aponeurosi s , the '

palmar and digita l fascia e , the iliotibial tract, and the in ferior aponeuro sis o f the external oblique muscle. Moreover, this same group h a s mean va lues which are l o wer for stretchin g a nd corresponds to those fascial elements vvhich were cla s s i ­ fied above a s among the thickest and s tronge s t . Morphological analysis rev e a l s

:

•

tha t the lower limbs have a natural tendency towards external ro ta tion

•

that the upper limbs have a natural ten dency towa r ds in te r n al r ot a ti o n

In Chap ter

7

on fascial tests , i t will be seen that this gene r a l tendency c a n some ­

ti m e s be dis to rte d

.

Ano ther rem a rkable p a r ti cula r ity concerns the alignment of the extremities

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with respect to the tr u n k . Wh i le the lower limbs are in series with the trun k a n d t h e p e lv i s , t h e u p pe r l i m b s seem

b e co n ne c te d in p aral l el to th e

to

thorax, like

grafts t h a t have been s tuck on to the body The p ra c t i cal relevance of this observa ­ t i o n w i l l b e dea l t w i th la ter.

M A I N TA I N I N G P O S T U R E Although

the

m u s cul a r s y s t e m is cen tr a l in the main tenance and co r re c ti o n of

p o s ture , the muscles canno t a chieve this task wi thou t t h e in timate p a r t i ci p a tion

o f the fa s c ia e . A s previou sly n o te d , no mus c l e can be fu n c t i o n a l without the fas ­

cial sys tem . Moreover, in some ins t a n ce s , the fas c i a e c o mp l e t e l y take over from muscles in the main tenance o f p os t u re . Wi th respecc to th i s rol e , certain fa s c i ae are m o r e active than

o the

rs .

C a thie

( 1 9 7 4) menti ons the followi n g fascia e : the glu t e a l . cervical , and lumbosacr a l fas ­ cia e , a n d t h e ilioti bial trac t . He o b ser ve d c l e a rly melts , which confirms tha t t h e harder

a

visible bands

on th e se fa scial e l e ­

fa scial elemen t h a s to work , t h e m o r e i t

wil l co n so l id a t e i t s col l a g e n n e twork . This i s why the fas c i a e a re the first s tructures to react t o inj ury Recen t

r es u l t s

his tological

supp o r t the hyp ot hes i s

fa scia may p l ay a sensory role in t h e

vertebral column

tha t

the thoracolum bar

m ec h a ni s m . On an t erior

flexion of the trunk , n o additional electrical ac tivity is obse r ve d in the pos terior muscl e s . Their action is su p pl a n ted by the vertebral l i g aments .

If the muscles are the m o tors of p o s ture , it would seem that they intervene i n a more obvious way

in

the dynamic situati o n . Insofar as t he

concern e d , the fa sciae seem to be more i m p or t a n t

static situation is fo r maintaining position-the

virtue of which is tha t i t s ave s A s a g e n e r al rule , it i s

energy t h e external

fa sciae that are i nv o l v e d in m a in taini n g

posture, while th e internal fa sciae tend to be more im po r ta n t in s u pp or t func­ tio n s . In a dd i ti on , their a n a to my a n d

a rchitecture show

that t h ey are ideally suited

for maintaining p o s tu r e.

FA S C I A L C H A I N S

General remarks Anatomical analysis of the fa sciae cl e a rl y sh ow s us t ha t the system is c o nti nu ou s from the cranium to t h e fee t . As previously n o ted , t h ere are both internal and ex­ ternal fa scial chain s , e a c h commu nica ting vvith the other. T here i s n ever any kind o f in terruption in

the

fascial system ; each gives into the nex t in a comple tely har­

monious sequenc e . They

s i mp

l y form a

s erie s

of transfer points on the bones to

enhance their cohesion and improve their effica cy. De p ending on the o r ien ta t i on of the fa s c i a l fibers , these c ha i ns may

be vertical or oblique (Fig. 6-4) . al. . i n work on the thoracolumbar fa s ci a , showed that its s uper­ fici a l l a m in a was c on t i nu ous with the apo n e u rosis o f the gluteus m a x im u s . A t the level of the sacrum , some of the fibers con tinue di r e c t l y on the same side, while o the rs cross over t o form a transfer poin t ( some tim es called a relay p o i n t ) on the Vleemin g e t

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Chap ter 6 / Fascial Mechani cs

pos terior superior iliac p roc e s s and the i l ia c cres t , wh ere t he y meet with fibers

from the aponeurosis of the l atissimus dorsi muscle. The su pe r fi ci al l ay e r j oins with t h e deep l ay e r at the level of the s a c r um a n d con ti n ues i n t o the s a c ro t u b e ro u s lig a m e n t . F i g. 6-4

Fasc i a l C h a i n s

Traction a t a given p oi n t o n the s u p e r fi ci al thoracolumbar fascia i nd u c e s displace­ ment o f the fascia to a greater or le ss e r exten t i n t he direc tion of th e force ; this di s p la ce ment can be con tralateral (due to the ob liqu e ly di. s p o s ed fi b er s ) . Traction

on the b i cep s femoris and its fa sci a i n d uces di sp l a c e m e n t of the deep layer by the sacrotuberous lig a m e nt as far as the lower l umbar vertebrae ; again , con trala teral di s pl a ce m ent c a n oc c u r. The lumbar fa s c i a can be m oved by v a r io u s m u s cl e s , in clud i n g the latissimus

dorsi, h am s t ri n g s , abdominal ob li qu e , and the g l ut e u s maximu s . The con tralateral

glu te u s maximus and la t issi m u s dorsi muscles create a p e r p en dic u l a r force at the sacroiliac j oint . The thoracolumbar fa s cia transmits forces be tween the vertebral column , the pelvi s , an d the lower limb. This fa scial con ti nu it y is confirmed by the work of Gerlach and L ie r s e , who

studied the fasciae of the t hi g h . This b e gin s a t the top a t the in g u i nal l i g am e n t , iliac cre s t , s a crum , and coccyx . Its l ower part contributes to the ligaments of the kn ee and c on tinu es down i n to the fasciae of the l e g. M oreover, it is con n ec ted to the perineum via the intermu scular s e p t a . A lamina of co nn e c ti v e tissue emanat ­ i n g from t h e fa s c i a lata forms t h e in ternal a n d external interm uscular septa . This fixes the fascia lata and the iliotibial tract to the femur, thereby crea ting a solid unit consis ting of bon e , fasc i a , an d ten d on .

Role o f the chains The role of the chains can be

an aly ze d

•

tr an s m i s s i on

•

co o r di n ation and harmonization

in t e r m s of t hree m ain fun c tions :

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•

damping

Transm ission For the purpose o f simplifica tion , the fasciae can be consid ered a s ropes which transmit forces thro ugh the body Of cour s e , the m o tor drivin g this sys tem is

muscular contractio n , but this only fun ctions when a s s o ciated with the fas ci a e . In order to transmit their energy in an e fficient a n d coordina ted fashion ,

these ropes mus t be anchored a t certain points . T h e s e anchor points a r e usually provided a t j oints , which a c t as pulleys for the ropes Fig. 6-5

(Fig. 6 - 5 ) .

Fasc i a l P u l ley a n d C h a i n syste m s

Coord i nation and har m onizat i o n For any movement t o be effective, t h e energy which produces i t m u s t be appro ­ priately channeled . In the case of the bo dy, the muscles also need to be effectively coordinated so tha t the motor forces can b e made to act in concer t . Harmonization and coordination take place a t the level of the fasciae. Thus , when executing a complex s e t of movements like tho s e invo lved in walki n g ,

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Chapter 6 / Fascial Mechanics

a whole series of mechanisms whic h involve the entire bo dy a r e bro u g h t into play. Th e fi rs t r e qu ir em e n t is that th e erect posi t io n be mai n ta in e d This e n tails .

per man ent , ongoing

r ea dj u s t me n t of the vertical pos i t i on w i th respect to a base,

that i s , the fee t , w hich represen t a re l a ti vel y limited area of s up p o r t The e re c t po­ .

sitio n must be m a int a in e d with m i ni m u m expendi ture of e ner g y, which is l a rgely achieved b y exploitation of the fas c i a l rope and pulley sy ste m . When it comes to actually walkin g , a whole set of complex movements m u s t be coord in at ed in o rd er th a t progress is m a d e in the de si r e d direction. In other wo rd s

,

one or more fa scial c h ain s must be brou g ht into play in o rde r to ac­

co m p l is h

an

accurate, effective movemen t . The simple act of wa lki n g necessarily

entails a who l e series of com p ensa tory m o v e m e n t s , for example , balancing with the upper lim b s , inclin ation of the trunk , and so on. I t is ob v io u s that i f there were n o harmoniza tion a m o n g all these different movement s , even a function as routine a s wal k in g would become ove r l y compli­ ca te d if not impossible. Of c ours e , a wh o l e array of s y s te ms i s involved in this ,

harm onization , in clu di ng the muscles , nerves , and centers of balance. However, it would be imp o ssi b l e without the fasciae. Eve r y movemen t that we execute is ac tually th e sum of m a ny d ifferen t com ­ p o n en t m oveme nt s , i n clu din g flexi.ons , e xt ens i o n s , and ro ta t i o n s In everyd a y life , .

every movem ent is usually a co m bina tio n o f a n u m be r of parame ters : the archi­ tec ture o f the fascial fibers wi t h their different arran g ements (vertical , o bli q u e , or transverse) seems to be id eally suited to harmonize t he se com b ina ti o n s of fa ctor s so as to re n de r the over al l m ov eme n t funct i o n a l

.

Da m pen i n g The fa scial chains transmit t h e movemen ts o f ev er y d ay life b u t are

a lso

invo lved

in cop ing w i th v iol en t exer tion and traum a . In the case of violen t exer tion , the bo dy as a whole p ar t icipa tes to dis tribute the effects ove r as ex te nsive an area as poss ible so that the breakin g point of no one p a r t is e xc ee d e d The m u s c l e s are .

th ere to provide the e nerg y necessary for th e exer tion , but the fa sciae ar e there to coordin a t e and diSSipa t e the energy. In ad di ti on , they p rovi de a s tro n g point for the muscles and , by vi r t u e of their special viscoelastic proper ties , absorb a n d d ampe n o u t part of the e n er g y. Tr auma u s ua l ly occurs in an unexpected way, and the muscular s ys t e m is

thus

u nprep are d to d e fe nd against it by ab s o r b i n g any of the g rL'a t q ua n ti t y of en er g y that i s sud d e nly unleashed o n the body. Therefo re it is up t o the fa sciae t o absorb, ,

d a mp en , and try to channel th i s energ y in di ffe r en t

directions in o rde r to a t tenu­

ate i ts da m a g in g effects an d avoid inj ury to the o rg a n s . When the energ y is too g re a t or conce n tra t e d on a ver y lim ited area , s t r uc tu r es m a y tear and organs may ,

be d ama g e d

.

Studies conducted into the chan g es in fasciae followi n g injury have shown that their viscoelastic properties c a n be profoundl y c h a n g e d Such modifica tions .

occu r imm ediately a fter the critical even t , show in g that the fa scia e have ab sorbed a Significan t p art o f the e nerg y of the acciden t .

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Ma i n Fas c i a l Cha i n s Given the ubiquity o f the fasciae, it could be s aid tha t fa s cia l c ha i n s are p resen t every where in the bod y. Certainly, if one conce n t r a t e s on a par ticular a re a , it is always possible to i denti fy

a

fascial chain because i t is this u nit which acts a s the

transmission belt for the propa g a tion of force. However, as we have seen , the ma j or body functions always involve the body a c t i n g as a whole. This means that the i m porta n t chains are far more extensive,

link i n g the entire body from one end to the other. Even at thi s level , we cou ld describe a large n u mber of d i fferent chain s . However, a n a tomical a nalY S is of the

fa sciae, i n c l ud i n g the direction and thickness of their fibers , and their collagen con ten t , as well as the more specific function of certain parts of the body com­ pared with others , leads us to believe tha t c ertain fascial c ha i n s are preferen tially b rou gh t i n to pl ay in human m ec h a n i cs

.

We w i l l focus on a few of the most im por ta n t fascial chain s . The transmission of force towards the in ter i or of a fa s c i al chain occurs not only upwards or down­ wards , but also from the ins ide towards the outside and vice versa. At cr o s s over poin t s , these chains can even pass from one side of the body to the other Some of .

the chains in the trunk m ainly function in an obliqu e direction and therefore also link Olle side of the b ody to the other. Obviously, any fasci al chain will behav e in

the same way, whether the energ y is a scending or desc end i n g .

We will look at a few in t ernal e x te r na l , a n d m enin g eal chains , althou g h it ,

should always be borne in mind that all such cha in s a re permanen tly interrelated w i th one an other

.

E X TE R N AL C H AIN S

Starting i n the lower limb Three different fascial chai n s whic h s t a r t here will be de s cribed : •

one la teral

•

one

an t erio r

•

one

pos ter ior

Lateral chain Starting in the foot, it rises throug h the foll owi n g

elements (Fig. 6 - 6) :

•

the la teral fa scia of the le g

•

tra n sfer points at the knee and the head of the fibula

•

follows the anterolateral surface of the thig h via the iliotibial trac t and

•

transfer points at the hip and pelvis

the fascia lata

Here it meets w ith a hor izontal chain linked to the perineum via the p i r i fo rmi s a n d in ter n al o btur a tor m u s c le s

.

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Fig. 6-6

Chapter 6 / Fascial Mechanics

Lateral C h a i n

From the pelvi s i t ascends : •

ei ther

along an anterior pa thway following t he rectus ab do m in i s mus cle

and then the thoracic fa sciae •

transfer points a t the clavicle

•

finally a rriving a t the latera l cranium via the superfi cial fascia ;

•

or

•

arrives at the pos terior part o f the scapular girdle, where i t forms a

•

where i t meets wi th the obl i q u e chain of the scapular girdle through

•

finally arriving at the pos terior part of the base of the skull via the

a l ong a pos terior pa thway following the thoracolum bar fascia

transfer poin t at the s c apu l a the fa sciae o f the external rotator muscles o f the shoul d er fasci a e of the trapezius , spleniu s . and l on g i s simus capi tis muscles Anterior c h a i n Starti n g in the foo t . it rises thro u g h the following elem e n ts •

(Fig. 6 - 7) :

the anteromedial fascia o f the leg

•

forms a transfer point a t the medial s urface of the knee

•

where part o f any force can be transmitted to the anterolateral part of the thigh by the oblique fascial fibers

•

then follows the fasci a e of the adductor muscles

•

forms a transfer poin t a t the pubis and the inguinal ligament before rising . like the p revious chain , through the rectus abdominis m uscle

and then possibly passing over to the o ther side via the fasciae of the oblique muscles

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•

At the p e l vi s it meets with two internal chains : ,

one represented by the fascia ilia c a another perineal chain via the superficial perineal fascia

Fig, 6-7

A n terior C h a i n

Fig. 6 - 8

Posteri or C h a i n

Posterior chain S tarting at the foo t •

(Fig. 6-8 ) :

follows the posterior fascia o f the calf

•

form s a transfer p oint a t the kn ee

•

prefe rentially follows the fa s c ia of the bicep s femoris

•

forms a transfer po i n t a t the bu t tocks w i t h the isc hi u m sacrum , coccyx , ,

the sacrotu berous ligament, and then finally a t the iliac cre s t . From there i t rises be hin d in the sa me way as the external chain , and can also cross over to the o t h e r side via t he obliqu e fibers of the thoracolumbar fascia . •

At the bu ttoc ks it m ee t s up with two ot h e r chain s : ,

one horizontal chain : the perineal c h a i n through the coccyx and the sacrospinous and s a crotu b erous ligaments the o th er a v e rti c a l chain : the dura ma ter chain thr o u g h the coccyx ,

and the fi ber s which are continuous be tween the dura mater and the sacrotuberous ligament via the sacrum and the coccyx

S tarting in the upper lim b We will cover one medial a n d one la teral ch ai n

.

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C hapter 6 / Fascial Mechan i cs

Med i al chain Starting a t the h and •

(Fig. 6 -9 ) :

follows the anterom edial edge o f the muscles t o the medial epichodyle of the humerus

•

forms a transfer point a t the el bovv ;

•

here, some o f the energy can be transmi tted into the l atera l chain by the

•

fol lows the medial intermuscular sep tum

oblique fibers of the aponeurosis of the biceps •

then extends via the coracobrachial fascia

•

forms

•

terminating at the a nterola teral cranium via the superficial cervical fascia

a

transfer p o i nt at the a cromion and the clavicle

and the aponeuroses of the s calene muscles Lateral chain The l a teral chain works most heavily in the u p p e r limb and, a s will be d i scussed l a ter on , i t i s in this chain that o s teopa thic h e lp will most often be needed . S t a r ting at the wrist (Fig.

6-9),

the chain follows :

•

either the an terola teral edge of the fascia along the radius

•

or the pos terolateral edge of the s am e fascia

•

forms

•

follows the lateral intermuscular septum ;

•

at th e deltoid " V, " i t can continue in two d i fferen t d i r ect i o n s :

a

transfer point a t the la teral surface of the elb ow

an anteromedial p a th via the medial part of the del toid fa scia . Here I t transverses along a c h a i n composed o f t h e pectoral fasciae and then follows the same p a th

as

the internal chain .

or along a posterolateral pathway via the lateral

ed g

e of the deltoid

fa scia , forming a transfer point a t the spine of the scapula Here, i t meets up wi th the pos terior oblique chain represen ted by the fa sciae of the latissimus dorsi and the la teral ro tator muscles , and finally arrives at the base of the skull by follOWing the same path as the pos terior c h a i n

.

In ternal chains We will fo cus on three internal chains : •

one p eripheral

•

one cen tral

•

one mixed

Peri p h eral chain We will s tart with this c hain at the perineum , but it should be remembered that it is linked to the external chains throu g h the perineal fas c i a and those of the pirifo rmis and ob turator muscles . S t a r ting at the perineum

(Fig. 6 - 1 0) :

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Fi g . 6-9

Med i a l a n d L a t e r a l C h a i n s

•

Fi g. 6- 1 0

Peri p h e r a l C h a i n

it continues up through ei ther the transversalis fascia or t h e peri toneum

•

for m s a transfer poinr at the diaphragm

•

follows the endothoracic fascia

•

a r r i ve s at the s capular girdl e , where it forms a transfer point

•

then follows approXimately the same path a s the external chains to

finish a t the base of the skull It should b e n o ted tha t the peripheral chains can also pass by the pleurae to ar­ rive a t the shoulder a t some fas c i a e a b ove the pl e u r a ( s o m e times k n ow n as the diaphragm of Bourgerey) and from there passes up to the b a s e of the skull like all

the o ther chain s . Central chain We will start with this chain at the di aph r agm , bu t it should b e remembered tha t below this lies a vvhole s y s te m of supporting fa sci a e , and tha t the abdominal fas­ ciae are conrinuous with the pelviC fas ciae. From the d iaphragm , this chain follows : •

the pericardium

•

the pharyn g obasilar fascia

•

a t the thoracic outle t , i t makes connection with the deep and middle cervical fa sci a e , and therefore some energy could be redirec ted towards the supporting bones ;

•

subsequently, it forms a transfer point at the hyoid bon e ; here also, the superficial cervical fascia could absorb some energ y ;

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Chap ter 6 / Fascial Mechanics

•

it then arrives at the base of the skull via the p terygotemporomaxillar y and interp terygoid fa sciae

•

from where i t can continue into the dura m a ter of the brain via nervo u s extensions which bring i t to meet u p ,'lith the above-men tioned fas ciae

M ixed c h a i n From the perineum , i t fol lows : •

t he umbilico-prevesical fascia

•

forms

a

tr a n sfe r point at the umbilicus

•

where i t meets the fa scia transversalis

•

or follows the round ligament of the liver and the falciform ligament

•

forms a transfer point a t the diaphragm

•

from

w

h i ch it follows the same p a th a s either the peripheral or the

central chain described above

Menin g eal chain Its lmver point of depar ture is t h e coccyx , bur, a s p reviously noted , it may be i n ­ fluenced b y t h e internal chains , the p e r i n e a l fasciae , or t h e external c h a i n s which form transfer points a t the cocc y x , the sacr u m , and the pubis Fig. 6- 1 1

(Fig. 6 - ] j ) .

M e n i nge a l C h a i n

I t then rises i n the vertebral column where i t m akes contact w i t h m any transfe r points with the ver tebrae (which serves a s a s a feguard a n d back-up s y s tem) : •

anterior : wi th the com mon posterior ver tebral lig ament over the entire leng th of the colmnn , two transfer points of which are particularly strong :

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th e lower pan of the coccyg eal ligament

its upper a ttachmen t poin ts a t C 2 and C 3 ; •

lateral : the d u ra ma ter sends out two lateral menin g e a l extensions which travel with the nerve a s fa r as the intervenebral foramen . Here, i t is s tro n g ly attached around the edge of the b on e , thereby forming bila teral s trong p o ints as well as s p i n a l roots . This prevents over­

stretching of the roo t s and the spinal cord . •

Then it e n t e r s the cranial cavity via the foramen magnum , around which i t is s t r o n g ly attache d . Inside the cranium , t h i s chain spre ads out spherically to a t ta c h all over the cranial cavity. The a r t i c u la t i o ns a re most

pronounced a t the base of the skull . In order to guarantee i m p r oved mobility and t o enhance i ts pro tective function , it forms two large septa :

the tentorium cerebelli , which p r ov i de s enhanced hori zontal anchoring the falx cereb elli and falx cerebri, which are a t ta ched to the c r i s t a galli and which provide enhanced sagittal anchoring

It is continuous with the exte rior s u rfa ce o f the crani u m : •

a t i t s base, throu gh its extensions a round the cranial nerves

•

over the vaul t , with the epicranial fa sciae via the dural venous sinuses

MAJ O R P O I NTS O F DAM P E N I N G Fascial chains transmit m ob i l i t y t hr o u g h o u t the body bu t are also a foc u s for

forces which m i g ht dis turb their fun c ti o n . So tha t these forces are n o t automati­

cally transmitted all aIon g the chain , there are s pec i a l d am p e nin g points dis­

tribu ted throughout e a ch chain . Some of these , locate d at c o nve r g e n c e points , are p a r ti c u I a rly important

(Fig. 6- 1 2) . We

will speci fi cally mention , moving from

belmv upwa r d , the : •

pelvic g irdl e

•

d i a p hr a g m

•

s c ap u l a r g i r d l e

•

h y o i d bone

•

occipi tocervica l junc tion

Pelvic g i rdle Transfer point between the lower limbs and : •

the trunk

•

the perineum

This represents a poin t of c onve r g e n c e for forces , in response t o which i t is per­ m a n en t ly adaptin g , con t r o llin g , and redire cting by virtue of its m o b i l i t y and ar­

chitecture. Here , descending , ascending , and transverse (via the internal c h ai n )

forces are dampened and diSSipa ted as soon as th e y reach a c r i t i c a l l evel .

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Fig. 6- 1 2

Chap ter 6 / Fascia] Mec h an i cs

P o i n ts W h e re S h o c k s C a n Be A bsorbed

Diaphragm Apa r t fro m its role a s the main muscle of respira t ion , the diaphragm also fulfills o ther vital fu nctions, mechanical a s well as phYSiol o g ical : •

It hermetically se p ara tes the thoracic and abdominal cavities , tha t i s , separates a r e gio n o f nega tive pressure from o n e where the pressure steadily rises

•

as

one moves in a caudal directio n .

It is subj ect to pulling forces a c ting i n two different directions : cephal a d , because of the thoracic , peripheral , and central fasciae cauda l , because of the abdominal fasciae and the weight of the

or g an s it supports . Despite these opposing forces , to be able to con tinu e to a dequ a tely fulfill its func­ ti o n s , it must a t all times remain flexible and functiona l , in which it is aided by the pressure difference. These functions are in :

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•

respiration

•

hemodynamic mobilization

•

suspendi ng the abdominal mass

•

as a visceral motor which , by vir tue of i ts cons ta n t pis ton mo tion , ke ep s the organs moving incessan tly, thereby enhancin g their capac i ty to function efficiently

I t s anatomical desi gn points to i ts mechan ical function. It is composed of a pe ­ ripheral muscular portion , which is appl ied to the internal edge of the thoracic cavity, and which constitutes the diaphragmatic dr ivi n g force . However, th is costal part cannot be attached if the diaphrag m is to b e per fectly functional in this re­ spect Therefore, it must be attached elsewhere. It is th is fun c tion vvhich is looked a fter by the pu rely fascia l par t of the organ , namel y, the central ten don .

The central tendon is suspended by a strong fascial s heet, the pericardium , which provides a strong poin t around which the diaphragm can pre s s in order [0 open up du ring inha lation. I ts pressure on the abdominal mass is rel atively

mild in the nor m al situation , given tha t the latter is no t a s tron g point and is predisposed to bei n g pushed down and forwards. This is why, as was previously explained , the per ineum and the diaphragm work together s y nergistically and in h a rmony with one another. Duri n g st renuous exer tion, the diaphragm exerts more pressure on the ab­ dominal mass , which is bein g made rigid by contrac tion of the abdominal mus ­ cle s , or contraction of the muscles of b o th the abdomen and the pelvis at the same time. Many s t udies h ave been conducted to elucidate the mechanics of the dia­ phrag m . Paiva e t aI . , studying s upine patients , showed that the contact between dia­ phragm and lung is uniform and corresponds to an area which is more or less equal in a ll subj ects , whatever their weight . There is a uniform pressure grad ien t ac ting o n the di aphragm, a nd t h i s remains the same whe ther t h e subj ect is at res t or exer ting her self, and despi te the differen t organs found on either side . The press ures measured at the diaphragm were 9 . 7 centimeters o f wa ter on the righ t . and 9 . 2 on the left The radius of cur va ture of th e diap h ragm is n o t even , but ins tead decreases as the heig ht decre ases . When the diaphragm contracts an d the volume o f the lung i ncreases , the radius decreases wi th heigh t and it becomes more spherical . It can improve the convers ion of tension in to pressure when the volume of the lung increases .

Verschakelen et a l . me a s ured the displacem en t of the di ap hragm durin g ex­ hal at i o n and found that the re adin gs increased from fro n t to back with 1 0 0 % beh ind . 9 0 % i n the middle . a n d 6 0 % in fron t . Movemen t of the diaphragm is coupled with that o f the ribs and the abdomi ­ nal mu scu l a ture. The correlation i s closer with i ts median a n d p osteri or parts. The pos terior pa rt is espeCially c l osely coupled with displacemen t of the abdominals .

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Chap ter 6 / Fascial Mechanics

During normal inha la tion , the di aph r a g m shor ten s , with the shortening of th e p o s t e r i o r part u su ally bei n g more marked than that of the a n terior part. After

ph re nic o to my, Decramer et a1 . showed that the pos terior part elong ates during inhalation, while th e anterior part e l o n g a tes i n s ome animals and shor tens in o thers . On the subject of the diaphrag m , let u s p ause one moment to consider its

innervation because this can c e r t a i nly explain cer tai.n lesional p a tt e r ns seen in the

cervicosca p ular re g ion Fig. 6- 1 3

(FiBS. 6- 1 3

&

6 - 1 4) .

E m bryo n i c D i a p h ragm ( a fter Langm a n / S a d l e r )

Aor r a

M u s c u l a r i n grow r h fro m b o d y wa l l

Esophagus

I n fe r i o r vena cava

P leuroperitoneal mem b r a n e Seprum r r a n sversum

Initially located in the cervical my otome, the transverse septum which vvi.ll de­ velop into the diaphragm s teadily migrates dow n ward during embr y o g enesis to ev ent u ally assume its defini tive positio n . Supplied from the b e g inning by the ph r e n i C nerve, it travels down ward t o g e ther with it. During i t s

m i g rati on the phrenic nerve does n o t s i m p ly follow the diaphrag m , but also sends out numer­ ,

ous collateral fib ers all the way. These colla teral nerves will go on to innervate o ther s tructure s , including the : •

thymus

•

pericardium

•

p a r i e tal p l e ur a

•

sup erior and inferior vena cava

•

p erivascular fibrous c aps ul e s (Glisson's cap sules)

•

tri g eminal g an g li a

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Fig. 6- 1 4

Deve l o p m e n t o f t h e E m bryo n i c D i a p h ragm a t Week 5 (after La n g m a n / S a d l e r )

F o r eg u t

P e r i c a rd i a - p e r i t o n e a l ca n a l s

S e p t u m u a n svers u m --+�:-T--

Body w a l l

L i v e r cords

It also a n a s tomoses with c r a ni a l

nerves

X and XII , the subclavian n erve , and the

easy to un d er s t a nd its impor tance a n d why th e scapular girdle is o ften the fo cus for i ncompreh ensible p rob lem s . The n e uro­ nal channel co ns ti t ut e d b y the p hr e ni c nerve often explains such problem s .

cervical s y mpa the tic s . Therefore, i t is

To fin ish , it s h oul d b e noted tha t the d ia p hr a g m re p r e s e n t s a n i m p o r t a n t point insid e t h e thorax for t h e d a mp e n ing of m e chanica l forces transmicted by the fa sci a e , and also for a t t e nua tin g pressure varia tion s .

Scapular girdle Al l the fasciae-both inter n a l and ex tern al-conver g e a nd form a tran s fe r point

at t h e s c apu l a r girdle. This is a v e r y hard-working area a n d i s very likely t o suffer in t h e even t of an y kind of fas c i a l dy sfunc tion . This region must be c on s t a nt ly c o n tr ol l ing and adjusting to c o mp e n s at e for work bei n g done lower down in reg ions ­

which are rela tively ri g id , and hi g h e r up in r e g i o n s which are hypermobil e . T h e s c a p ul a r g irdle mu s t p e rm a n e n tl y perform a ba l an c in g a c t t o harmonize

all the forces which converge there , and th e reby pro tect the vital areas which are lo cate d b o th a bove and below it. Moreover, a t t ached to it i s ano ther h y p er m o bile s e g m en t , na m e l y

,

of the b o dy,

the upper limb, which r epr es e n ts the most hard-working a r e a

in m e c h a ni c a l terms. It is also a fo cus fo r ver tic a l , obliqu e , and trans­

verse forces . For all o f these reason s , the architec ture of this region is very s p e c ia l i z e d , oriented towards h y p e rm o b i lit y. It i s the only region , apart from the s ternocla­

vi cul a r j unction , where t h e anchor points are exclUSively c r e a ted by soft t i s sue s .

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Chapter 6 / Fascial Mechanics

The convergence of in t ernal , ex ternal , ascending , and des cending forces provides an explanation for why the cervicos capular j u nction is so o ften the site of res tric­ tions.

Hyoid bone The central peri cardium -pharyngobasilar fascial chain has points of peripheral tran sfer, the pericardial ligam e n ts , and connections w i th the middle a n d deep cervical faSCiae , bu t they are not as impor tan t as those o f the scap u l a r gird l e . Still, serious tension due to maj or forces could b e transmitted sud den ly into the base o f the skull , with poten tial danger to intracranial s truc tures . To avo id this si tuation , a special struc ture is interposed at the top of this fas ­ cial chain, namely, t h e hyoid bon e . Comple tely suspended b y bands of mus cular, fascial tissue , the hyoid bone floats in all spatial planes , held in place by its at­ tachments to the mandible , mastoid bon e , s t ylOid process , scapula , and thyroid cartilage . The central fascial chain forms a transfer point at the end of t h e pharyngo ­ basilar fascia at the hyoid bone, after which it con tinues up via the i n terp tyeryoid e t p t e r ygotemporomaxillary fas ciae. The hyoid bone , apar t from its role in fixing the thyroid cartilag e for vo cal ­ ization , is also present in order to dampen and distribute force traveling in the central chain , either in an an terolateral direction via the superficial cervical fascia, or in a pos terior direction towards the temporal bone via the digas tric mu scle and Riolan 's bo uque t .

Occipi tocervical j unc tion The cranial ' sphere ' posed on i ts OCCipi tal support constitutes a point of conver­ gence be tween all the descending cervicocranial chains ;md the underlying chains. This point of convergence is also relevant to forces trave ling in the in tracranial chains and the vertebral dura mater chain, which form a trans fer poin t here. Therefore , i t represents a particu larly hard- working region, which explains the num erous muscles which con trol it , long or shor t , in order to adapt i t con ­ s tan tly to all the possible var i a tions in ten sion , w i th the aim of pro tecting , as effe ctively as possibl e , the cen tral ' computer ' and its information-conduc ting ex­ tension s . All t h e fasciae a r e inserted around i ts e d g e . It repre sents the fi r s t descending and the las t ascending shock abs orber. Thus , the tran smission of forces i nto the cranial cavi ty is inhibi t e d . In addition , inside the cranial cav i t y, there is a "vhole system of buffering membranes to mitigate any excess energy which passes this barr ier. It should be rem embered tha t , in the craniu m and in the spinal cord ,

a

hy draulic sys tem is in place there as a back -up for the m embrane protection . The frequent demands made of the occipitocervical j u nction explain why this region is so often

a

site of restricted mobility.

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lES I O N A l C H A I N S These represent the p at h which m e mbranous tensions can follow to propagate

over a long dis tance. There is, i n p ra c tice ,

an

infinite num ber of different potential

p at hw ays al o n g w hich d amaging chain react i o ns could propagat e , bu t e x p e r ien ce

has taugh t u s t hat such sequences t en d to fol l ow certain p a t terns which , in gen ­ eral , correspond to th e fa scial chains discussed in t he previous section . These l e ­ sional chains a r e therefore distor tions - fascial chains which have b e e n p e r tu r b e d

so t h at tbe y have become dysfunctional. Instead of harmoniously dis tribu tin g m ove m en t s and excess energ y, these chains have been converted into areas o f restriction that

are a

source of irri tation a n d in hib it e d mo b ili t y.

Many diffe ren t fa c tors can tri g g er a da m ag i n g chain reactio n , including tra u ­

ma

( e . g. ,

a

sprain ,

a

f a l l dir e c t ly o n t o t h e coccyx , or a dire c t bl ow on a n a r e a o f

soft tissue) , s cars , infe c tion , inflamma tion , and emotional stres s . Such factors can induce a po i n t of fa scia l d ysf unction which , if uncorrected , can compromi se the qual i ty of th e tissue and may, with tim e , propagate all alon g the fa s ci al chain to give rise to dysfunction in the fu ture. The s e con dar y pr o ble m may actually m a n i ­

fest far from t h e site of the pri mary point of dy s fun c tio n . A lesional chain can s tart anywhere and can travel e i ther a ver y shor t distance or very far, for exampl e , a primary prob le m in the foo t can eventual ly manifes t at the occipi tocervical j un c ­ tion or e v e n i n the craniu m .

All inj uries d o n o t n e cess aril y induce a damaging chain rea cti on . Some time s a reaction will appear soon a fter t h e o r i g i n al t r a u m a , w he r ea s o ther times , i t can take weeks or even m o n ths to manife s t . This w i l l depend on a number of factors : •

the seriousness of the o r i gi na l inj u r y the age of the p a tient

•

the capacity of the pa t i e n t to ad a pt and compensate

•

ObViously, th e younger the patient , the b e tter the body will be able to d efe n d itself A healthy, ph Y S i o l o gi cally functional b od y will do all in i ts p ower to a tt e nu at e

the effects of a lesion or localized restriction, and wil l attemp t to dissipa te any excess energy by dis tribu ting it a cros s as wide an area as possi b l e .

With ad vancing a g e

( and the

necessary conc o mita n t accu mulation of a his­

t o ry of insult s ) , the body will become less and less comp eten t at d efe n d in g i ts e l f ag ain s t the effects of such lesions , its capa ci ti e s for compensation and a da p t ation will dim i ni s h , and , if t he force is too gre a t , the sys tem will be ov er wh e lm e d and a da m agi n g chain reaction may bec ome established. This may have ex tremely seri­ o u s cons e quence s .

I t sh o u l d be rem embered that the t iss u e s re tain a record of all the in j u ri e s t he y have suffered and tha t , wha tever their nature , these accumulate an d , at some

t ime , will ine V itably be recalled by the b o d y. Temporal trau matic summa tion is far fr o m b ein g an absolute r u l e . Cert ai n

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Chap ter 6 / Fasci a l Mec h a n i cs

p eop l e d evelop dys fu n ctio n rapidly. w hi l e o thers continue for years-even fo rev­ er in some case s

-

wi t h no p r o b l e m s whatsoever. This depends on the individual's

inherent v i ta l i ty ' and capacity to deal with the c o n s t r a i n t s of life . '

An important fa ctor w h e n it comes to l imi t i n g the sprea d of a lesion is the da m p e n i ng a reas . which are many in nu m b e r and dis tribu ted t hr o u g h o u t the b o d y Dampening s t r u c t u r e s i n cl ude a di p o s e tissu e . h y dr a u li c s y s t ems ( e . g. . the

ce r e b rospi na l fluid) . speCial a r ch i t e ctur a l configura tion s . a nd j o in t s

.

Gra d ua l l y over tim e . as one d a mp e nin g s y s tem is worn out . the force is trans­ fe r r e d onto the next one. I t will b e inhibited at the maj or points o f da m pe n i n g ,

identified i n a p r e v iou s sec tion . but. once t h e s e i n turn have b een o v erw h e lm e d

.

i t will fi n a l l y reach i ts t a r g e t and there m e d i a t e i ts dele terious e ffects. It is obvious tha t . when a propag ating c ha i n reaction enco unters a n e x is tin g weak poin t (an a r tic u la r. ti ss ular. or visceral weak poin t ) . i t w i l l accelerate the rate of degenera­ tion there. A lesion a l chain can s t ar t in an y part o f the b o d y an d . fr om there , spre a d e i ­ ther u pw a r d s o r downwards. T h e direction d e p en d s

on

ex a c t ly where i t sta r ted ,

fac tors related to the forces involve d . and the p e r son s capaci t y to compensate and '

a d ap t . Therefore . we m u s t consider a s cen di n g and d es ce ndin g chain reactions.

Descendin g chain reactions Most of these occur. in order of importa n c e . in the craniu m . the cervical verte­ brae . the s c a p u la r gi r dl e . t he pel V i S the lower limb s . t h e thora x . the di aphragm . ,

and the abdomen . We will des cr i b e some of the more fr e que n tl y encolln tered e x a m p l es b e a r in g in m ind that their p a t h w a y s are usuall), d ete r m i n e d b y t h e p a t ­ .

t e r n o f the relevant fa s c i a l ch a i n . •

S tarting from a r e s tr i c t i on in the e p i crani a l fasci a . a d esce n d in g chain rea c t io n can become established through the su p e r fi Ci al cervical fascia

down to the scapular g ir dle o r b e y o n d that . down thro u g h the u p p e r ,

thorax or the upper limb. •

If the point of depar ture is at the base of the skull

(in

the broad sense)

or intracranial , it could b e condu cted by th e deep cervical fascia and the aponeuroses of the scalene muscles to rejoin the p a th of the previously men tioned reaction . •

If the restric tion is locate d in the mediastinum or the thor ax . the p e r t u rb a t i o n m a y e ventu a ll y reach the abdominal fasciae o r as far a s the

true p e lvis •

.

Fina lly. if the per tu rb a ti on is at the level of the psoas muscle, the

perineum . or the short muscles of the hip, the chain r e a ct i o n may propagate downwards . eventually causing a p r o bl e m in the kne e or even the ankl e . I t w i l l be n o ticed t h a t d e s cen d in g chain re a c t i o n s travel less fa r th an the fa sci a l chains described a bov e -i t is rare to encoun ter a p r im ary problem in the head giv i n g rise to a s eco n da r y problem in the foo t . alt ho u gh this ca n occ ur.

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Ascendin g chain reac tions Ascending chain rea ctions are m ore common than descending on es , no doubt due to the fa c t tha t the cons tan t pressure on the ground which is necessary for our stabil i t y, together wi th our constant b a t tle against gravity and the fac t that o u r o r g a n s are in a state of suspension , a l l mean that mos t o f t h e mechanical work we are obliged to do involves traction in a downward direction , In contrast to descending chain reactions , ascending ones o ften prop a g a t e over l o n g distances, We will cover a few common examples here , The most common chain reaction which s tarts at the foo t transmits along the la teral chain , Following a sprained ankle , traction on the external fascia can have effects at the head of the fibula o r a t the external part of the knee and genera te functional pain a t those fo ci,

If the lesional chain con tinues to a s cend , it can cause disturbance in the hip (an d then in the true pelVis via the fasciae o f the piriformis and interna l obtur a tor m uscles) and then in the sacroiliac j oi n t . From there , it can spread via the thora­ columbar fa scia o r the la tissimus dorsi m u s cle to the should er. Finally, if its sprea d is n o t cur tailed , i t m a y finish i n t h e cervical vertebrae or the craniu m , O f cours e ,

a s noted , its point o f dep a r ture c a n b e loca ted anywhere from t h e knee upward s , A direct fall onto the coccyx can tri g g er a damaging chail1 reaction i n the

dura m a ter which can spread , from el emen t to elemen t , as far a s the intracranial membranes, A problem i n t h e p erineum can be tra n s m i t ted by either t h e abdominal vis­ cera or by the tra n s versalis fasci a , Transferring a t the d i aphr a g m , i t can continue on up via the pleural sys tem o r the endothoracic fa scia to reach the scapular girdle a n d , ultima tely, the cervical vertebrae or th e cranium , Next we will consider the example of a dam aging c h a in reaction tha t we have encountered several times and which , a t first impression , would seem to be more theoretical than rea l It can s ta r t i n either the bladder or the umbilico- prevesical .

fascia and continue succeSSively via the round ligamen t , the fa lciform l i g a m e n t , t h e diaphra g m , and the pericardium to r e a c h t h e pharyngobasilar fa scia , where i t manifests as a thro a t probl em , A pa tient consul ted recen tly for a sore throa t and painfu l swallowing, This woman had recen tly undergone an endoscopic procedure and had a scar near her median umbilical ligamen t , Pressure on this scar was found to exacerba t e h e r throa t sym p toms, T h e scar was the point of departure for an ascending chain reaction which resulted in pain in the thro a t . The p a tient's throa t problem was resolved by correcting a restriction tha t vva s located affecti n g the median um bili­ cal l i g a m en t . This i s far from an isolated e x a m p l e , a n d i t und erlines t h e reali ty o f fascial chains and the fa c t tha t they can prop a g a te lesion s , It i s o ften vital to extend the field of inve s t i g a tion to remote p a r ts of the body in order to gain a full under­ s tanding of a p a r ti cu l a r problem ,

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Fascial Tests The Purpose of the Tests The fasciae repre sent a sen sitive receptor s y s t e m which is pr one to different forms

of perturba tion in everyday l ife Such dis turbances can be du e to: .

•

tramna

•

obstetrical problems

•

poor posture

•

s

•

inflammation

•

accidents

•

tension , bad postural habits (usually occu pation-related)

•

fa l se movements

•

s tress

ur g er y ( s c arr ing adh es i ons) ,

These insults will i n du c e biochemical changes in the connective tis s u e which

will,

p ro p e r ti es and thereby its very struc­ fibers will te nd to align a lo n g the axis

in t u r n have effects on i ts viscoelastic ,

ture . Its denSity will increase , the collag e n

of the lines of for ce , and the tissue will lose elasticity. All such c han g es in the fas­ ciae can be detected and assessed by palpation, and can some times even be seen directly with the eye. The purpose of

a

fascial test is to use the exquisite sensitivity of our ha n ds to

detect a variety of problems which might be a ffe ctin g the underlying ti s s u e s in ,

order t o obtain information to orient and g ui de the choice of therapeutic modali­

ties.

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Chapter 7 / Fascial Tests

Test Methods Fascial restrictions are detected usin g the hands. It could be said that testing is based on applyi ng one fascial system to another: one with problems being lis­ tened to by another in order to sense and understand those problems. We have already discussed the idea of' fascial memory: which represents the

recording of an impression of the various traumas (in the broadest sense) expe­ rienced by an individual. Our purpose is to detect these impressions and, if pos­ sible, to resolve or at least attenuate them. As we have seen, the fasciae are endowed with a contractile mechanism by virtue of their innervation, which is derived durin g development. This mecha­ nism induces minute but constant movement with a periodicity of between eight and fourteen cycles per minute. In addition, the fasciae act as ropes and pulleys in the transmission of forces. These observations have led

us

to develop two distinct

types of tests: •

listening tests

• m obil i ty tests These two types of tests are not mutually exclusive. In fact a listening test is j u s t a ,

special type of mob il ity test in which the actual movement is simply an extremely small one-not induced or even visible, but rather sensed. Those tests referred

to as mob i l i t y tests involve, as the name indicates, a much larger movement, one which is visible and which generates ten sion at some point.

listening Tests A listenin g test involves p l aC i n g a hand on some part of the body in order to de­

tect any underlying chan ges The hand must be kept perfectly passive in a recep­ .

tive mode so that it can detect extrem ely small movements. Investigations in to the sensitivity of the hand have shown that it can detect movements as small as

ten microns in am p li tude. A difference of only five per cent was found bet'vveen measurements made by the hands and those recorded using a sophisticated ap­ paratus.

TEST PROTOCOL A listening test requires certain elementary precautions, without which its re­ sults are worthless. ObViously, a listening test cannot be undertaken by anyone at any time-efficacy requires an enormous amount of practice as well as the confidence on the part of the practitioner that a hand can indeed detect such tiny movements. The validity of the results of the test depend on: •

the manual contact

•

the practitioner being in harmony with the patient

•

the neutrality of the practitioner

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Test Methods, Listening Tests

Manual contact Given that the amplitude of t he movements to be detected is o f the order of a few microns, it is obvious that even the tiniest grain of sand could invalidate the results of the test. The first p reca ution is to ensure that your hands are not too cold, for this would provoke a guarding reaction. The hand should be placed flat on the area to be investigated, with as great an area of contact with the patient's tissues as pos­

sible. This is done for two reasons: • The greater the area of contact, the greater the number of receptors

stimulated, and therefore the greater the amount of information collected. •

The flatter the h and, the easier it will be to obtain accurate information about the underlying fasciae.

Above all, contact with the finger tips is to be avoided. The tissues are exquisitely sensitive and if palp at i on is too aggressive, nothing will be heard, just silence. This is because it often does not take much to induce a reflex spasm.

The pressure applied should be very moderate. If the pressure is too great, the level of li s tening that is des ired will be exceeded and you will no longer be able to perceive movement. Remember that the most important receptors in this context are the pressure receptors in your hand. The hand must rest gently on the surface of the skin, exerting on ly its natural weight. At the same time, the two skin surfaces should be in firm contact, as if you were trying to create

a

sucker effect. The hand is 'stuck' to the tissues to make

it easier to feel their m otility.

Harmony with the patient A listening test represents the most fine type of palpation. The tissues have a mem­ ory of what happened to them in the past, and the purpose of the listening test is to access this information and understand the patient s history. The d ialog is a '

passive one: the patient is unaware of the infor mati on being t ransmitted to the osteopath from their fasciae; it is at the same level as their unconscious. If the practitioner fails to establish a good 'rapport' with the patien t there will be no ,

exchange of information in the other direction. The patient and their tissues must be treated with respect, and we should act as if we were asking per mi ssion to establish a dialog with the ti s sues

.

Neutrality of the practitioner All tests should be conducted in a spirit of complete neu trality in order to guar­ antee efficacy.The practitioner should not have any preconceived ideas and should remain perfectly passive just tuned in and l istening ,

.

It is the p a ti en t s rhythm wh i ch is important. If the practitioner's rhythm is '

imposed on the patient in any way, there will be no response, or the response detected will be m isleading This aspect is not so easy for those untrained in this .

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Chapter 7 / Fascial Tests

type of p alpation. If t he motili ty takes some time to

m an i fest,

an inexperienced

p ractitioner will tend to p roject their own rhy thm i n to the pati ent's tissues, wi th the result that the practi tioner is simply d e t ec t i n g their own motion. All of the prac titi oner's atten tion should be focu sed exclusively on the contact

zone a nd he or she s hould b e guided only by the underlying tissues. This wm require complete awareness and full c oncentrat ion because the resp onse , when it comes, will be rapid. Ie is only when al l the se requirements have b e e n met that the t e st p rope r can

beg in . Only in this way will the tissues be in a posi tion to communicate with the p rac t i tioner and reveal their pe rturbations , problems, and histo ry. Once y o u h av e l e arn e d how to p roperly listen to the patien t , it is sur pris­

ing ho w qUickly t he tissue s b eg in to ' t a lk.' The sooner that mut ual confidence is es tablished, the sooner there will be a re sponse. At this point, you will have th e impression o f movements with a much g reater amp litude, as if the fact of being in harmony

with the p atient am pl ifies the tiny movements being assessed .

However, a s hor t lapse of conce ntration or some sudden moveme nt by the practitioner can b ri n g the dialog to an abrupt e n d . It does not take ver y long to test the motility of a ti ssue , alt h ou g h if the basic rules are not adhered to, i t is quite possible to spend hours in con tac t wi th a tissue without deriving any i n for­ mation whatsoe ve r.

LISTENING TESTS The pur p ose of a listenin g test is to d e tect abnormali ties in soft tissues. Since ab­ normality can only be defined in terms o f no rma lity, we will now try to de fine what constitu tes the normal, i nsofar as there is suc h a thing.

Norm The norm encompasse s a numbe r of diffe re n t fac tors which can be i mm e di ate ly assessed wi th the hand: •

The temperature o f the tissue. Althou g h different par t s of the skin can have a different temperat ure , onl y a certain range is normal. In assessing te mperamre, the practitioner must some times compare the te mperature of the p atient's skin ,"lith their o wn, o r with some other part of the p atient's body.

It is common to detect

a

higher te mperature than t he normal thre shold as a re­

s ult of a re a c tion in the underlying tiss ue . S ometimes, especially in the feet and

hands temperatures whi c h are b e low th e lower thresh old o f n o rmalcy are also ,

encountered . •

The texture of the tissue . The tissue should be yielding-neither too t ight nor too loose-and s h oul d be ple asant to the tou ch . It should give eaSily and be elas tic, that is, r e g ai n its original shape after it is depressed . The tissu e 's n ormal e lasticity will d epend on the specific fascia under

consideration .

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Listening Tests

•

The mobility of the tissue. Although certain tissues tend to have a preferred direction of movement (dis cussed more later), in g eneral, the

m obili ty

of a tissue may be considered normal when it is mobile

in all spa tial planes. When t h e hand is placed on the tissue, you should get an impression of fioating in all the spatial planes, as if your hand were res ting on a soft surfa ce which is floating on a ba sin fill ed with water. No one direction should be preferred to a nother, and, if the

surface is act i vely displaced , the underlying tissue should follow without resistance. •

The rhythm of the tissues. It has already been pointed out that (he tis sues pu lse rhythmically, with a frequency of between eight and fourteen cycles per m i nu te In the va s t majority of cases , a rhythm that is fa s ter .

or sl ower than this can be considered abnormal. However, it should be borne in mind tha t some people vvithont there b eing

an

m ight

have a fa ster or slower rhythm

abnormality

It is also important to know that this rhy thm can change depending on the pa­

tient's condition at a certain time. Rhythm is especially easy to detect in certain parts of the body, notably, the anterior part of the lower limbs, the thorax, and the skull. On the other hand, there are parts of the body where it is very difficul t or even impossible to dete ct, i nclu di n g the posterior side of the thigh, the buttocks, on the back, and over the abdomen .

(A

small digression about the abdomen:

Altho u gh i t is difficult to feel the rhy thm o f the superficial fascia, it is relatively easy to bypa s s this l a ye r an d assess the rhythm of the

v a r ious

underlying fa scial

elements deeper down.) The human body so m e ti me s presents us wi th contradictions which are real, even if th e y are completely incomprehensible.

Standing listening tests Initially, it is common to perform a test with: •

the pa tient in a n erect, standing position, with their legs slightly apart, head pointed forwards, and eyes closed

•

th e practitioner b ehind the patient with their hand gently on the p atient's head, but e x ert i ng no pressure

In this position, a particular type of movement of the body is oft en detected in the

form of forward bendin g , sidebending, or backward bending. The fact of h aV i n g established a stationary p oi n t on the skull creates

a

connection between the floor

and the head, and all the fasciae between these two points are going to be able to move as long a s t hey have such a fixed point. For this reason, the body may i.ncline

in

an

entirely involuntary fa shion , with the fixed point a cting as a focal point for

the tensions which induce flexion of the body towards i t . This c a n reveal both that there i s an underlyi.ng p roblem, as well a s something about the context of the problem, although no formal diag n osis can be made on the ba sis of this test alone, as it is a screen.

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Chapter 7 / Fascial Tests

This is a perfect example of how fascial dynamics affect the overall mechanics of the body. When per forming this type of test in patients who are depressed (in whom the fasciae are usually affected), one must be especially attentive because these patients have a tendency to fall backwards-be ready to support them.

Listening tests for the lower limbs The general method for all listening tests involves placing the hand on a certain region of the body with a view to detecting underlying abnormality. It is also pos­ sible to place the two hands at some distance apart and feel if the motility which establishes itself between the two points is normal or not.

After years of experience, and with particularly exquisite sensitivity, the ul­ timate goal is to be able to place one or both hands on any part of the body and detect a center o f tension anyvvhere el s e in the body. This is not a minor ambi­ tion-some achieve it, but it must be admitted that they are rare. To come back to the lower limbs, we are now going to cover the protocol for the various tests with its variations: the patient , of course, is supine and com­ pletely relaxed. Place the hands flat on the dorsal side of the feet: feel whether movement is harmonious or whether there seems to be any tendency to pull in a specific direc­ tion. Such pulling would indicate a pathological axis: a change in organization in connective tissue due to some trauma (of any kind) has created

a

preferred vector

of nonphysiological movem ent. Subsequently, the tension should be followed b a ck step by step, until the precise starting point is identified. ,

In order to confirm what you feel passively, shift the hand ever so slight­

ly-more as if you were about to shift it, or thinking of shifting it, rather than actually shif ting it. If the shift is in the direction of the center of tension, no resistance will be offered. On the other hand, if the movement is in the wrong direction, straight away you will feel tension opposing the movement. The modalities and principles underlying

mo ti l ity

tests are the same f or all

parts of the body and therefore do not require further description. All listening tests are performed with the patient in a supine position. We prefer to start at the foot and move upward towards the pelvis in a step-by-step manner. Listen ing to the ankle

Place one hand on the dorsal side of the foot, and the other on the lower edge of the tibia. In a normal situation, you should feel movement betvveen the two hands w hic

h harmonizes in all spatial planes, as if you were manipulating a sphere.

Listening to the knee

Place one hand over the tibial condyles, and the other on the lower part of the

femur, excluding the patella. In a normal situation, lateral, superior, and inferior translation should be free, as should rotations, with the latter often dominant 7 -1).

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(Fig.

209

Fig. 7-1

Listening Tests

Listening to the Knee

Listening to the thigh and lower leg

Place one hand flat in the middle of the thigh. and the other on the anterior. lat­ eral side of the tibia. The cephalad han d should feel internal and external rotation. with th e fonner being dominant. External rotation should dominate in the caudal hand

Fig. 7-2

(Fig. 7-2).

Listening to the Thigh and Leg

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Chapter 7 / Fascial Tests

We have seen that the fasciae of the lower limb are composed of fibers running in different directionsin the linked thigh-leg mechanism, it is the medially oblique fibers which predominate in the thigh, and laterally oblique fibers in the lower leg.

Listening to the entire lower limb The practitioner takes up a position to the side of the pa tient, facing cephalad. Place one hand flat on the anterolateral side of the lower part of the thigh Feel movement of the whole lower limb, with external rotation predominant, In fact, the anterior external parts of all the fasciae are thicker and stronger. This listening test can be performed on both sides (Fig. 7-3). Fig. 7-3

Listening to the Entire Lower Limb

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Listening Tests

Listening tests for the upper limbs As previously mentioned, listening tests for the

up

p er limbs are more tr ick y than

those for the lower limbs. In some cases, a listening test ca n no t even be success­ fu l l y p er for m ed in this region. The difficulty is due to the special features of the upper l i mbs which would s ee m to be connected in parallel, r ather than in series, ,

to the rest of the body. If your hand is placed on t he dorsal surface of the patient's

hand in the no rma l manner, the sensation of m oti li t y is significantly less than in the lovver limb-and the situation is the same with local listening tests. Listening to the arm a n d forearm

Place one hand on the ex ternal anterior surface of the arm below the deltoid 'Y,' and the other below the elbow fold over the epicondyle muscles. Use the cepha

­

lad hand to feel a movement with external rotation predominant; the caudal hand will feel a

Fig.7-4

m ovem en t

with internal rotation predominant (Fig. 7 -4).

Listening to the Arm and Forearm

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Chapter 7 / Fascial Tests

Listening to the entire upper limb

The practitioner takes up a position at the side of the patient, faci ng cephalad One hand is placed over the elbow jOint at the inferior part of the humerus, w here the predo m i nan t movement will be internal rotation. This listening test can be performed on both sides simultaneously (Fig. 7-5). .

Fig.7-5

Listening to the Entire Upper Limb Bilaterally

Is this due to the powerful chest muscles and their associated fasciae pulling the upper limb into internal rotation? We have already mentioned the natural ten­ dency of the u pper part of the body towards internal rotation. Therefore, it would appear that, in terms of the direction of i ts motility. the behavior of the upper limb is exactly opposite that of the lower limb. Could this be to establish a general eqUilibrium and thereby to create functional balance?

Listening tests for the abdomen Here. we are not g oin g to consider in detail all the possible listening tests for the abdomen-this has been cov ered already in many oth er texts. including Viscera!

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Listening Tests

Manipulation JI by Jean-Pierre Barral. Rather, we will simply point out the difficul

­

ties e ncountered in this region.

The main difficulty is re l ated to the l arge number of structures which are

e ncountered und e r th e han d , in c lu di ng the pe r i toneum , the fa sciae, th e li ga

­

ments, the mesenteries, and the organs themselves. Another difficulty is the depth of pa lp a tion - how many layers there are between the superficial fascia and t h e

renal fascia I The gen e ral principl e with res p e ct to the abdomen is to p lace the han d flat arollnd the umbilicus and feel for any te n sion . In ord e r to narrow down the di­

agnos is , it may be necessary to move the hand in the dir ec t i on of any p erceiv e d tension to pin down i ts orig in a s closely as pOSSible. In the norm a l situation, the motili t y of the abdomen is similar to tha t of a ll the other tissues, that is, th e hand should float over the abdominal cavity with freedom in all spa tial planes .

Listening tests for the thorax The thor a x is

a

region in which the tissue is parti cula rly motile. The di fficulty is

in distin guis h in g between the superfiCial and the deeper ti ssu e s , where there are

two m a jor fascial sy s te ms . n a mely. the pericardium and the pl e ura e . In a ddi tion ,

in the lower thorax, there is t h e diaphragm.

The patient should be in a supine position, w ith the prac t ition e r pos iti oned

at the hea d . Lower part of the thorax Spread the hands wide open on the sides of the thorax , w ith the finge rs follOWing

the ribs post e ri orly. and the thumbs pointed medi ally. Test the thorax as a whole.

and then make a side-to-side comparison. In

a

nor m a l p er so n , thi s elast ic c y li nd er

should seem to be able to move around in all planes without any blockage.

An alt e r nati v e method has th e practitioner by the s ide of th e pati e nt a nd fac ing c eph ala d

(Fig.

7 6) -

­

.

Upper part of the thorax This region is esp eCi a ll y difficult because of the presence, in addition to the su­ perfiCial fa s ci a e . of the p er i cardium , the dome of the pleura, and the fasciae \vhich

are contin uous with the scapul a r girdle. � TWO-HAND TEST

(FIG. 7-7)

With both hands wide open on the sides of th e thorax, and

the base

of the hands pla ced j ust below the clavicle, spread the fingers to cover the p e ctoral muscles and point the thumbs in a medial direction. In t he normal situation, the movement felt tmder the hand s should be harmonious. If th er e are tensions present, these may be: •

in the medial direction, if the problem is in the sup erfiCial fascia directl y

over th e ster num

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Chapter 7 / Fascial Tests

• in the medial direction, but with the hand feeling as if it is sinking, if

the problem is in or around the pericardium •

in the vertical direction, if the problem is located in the pleural dome

• in the superolateral direction, if the problem involves the periscapular

region Fig.7-6

Listening to the Lower Thorax

� STERNAL TEST

Experience has shown that problems of the upper thorax tend to be focused in the sternum or nearby. This test is done by plaCing one hand covering the entire

sternum, with the base of the hand at the sternal notch. If the hand is in close enough contact with the skin (as if it were a sucker), the motility of the sternal fasciae and those below can be sensed. The sternum can be conceived as an inverted sacrum being held in the hand. Tiny displacements of the hand can be made to induce the sternum to 'tLwe]' through all the spatial planes, helping us to identify any point of resistance.

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Fig. 7-7

Listening Tests

Listening to the Upper Thorax

,/

Listening tests for the scapular girdle For these tests the patient is always supine. The practitioner should be seated be­ hind

the patient's head, with the thumbs on the amerior edge of the trapezius

muscles near the transverse process of C7. This allows the open hands to rest on the pleural dome, the clavicles, and the root of the shoulder

(Fig. 7 -8). The

thumbs

will register any resistance around the first rib, while the hands will register re­ sistance affecting the fascial insertions around the clavicle or tension around the joims.

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Chapter 7 / Fascial Tests

Some l eft r i ght -

imbalance is common. In ri gh t ha nded people, the right clav­ -

icle shoulder complex can have a slight tendency to point forwards and inside. of course a similar phenomenon is seen on the left-hand side of those who are left­ ,

ha n ded If this tendency is too pr onou n ce d impairment of function can result. .

Fi g. 7-8

,

Liste n i ng to t h e Ent i re Sho u lder Girdle

/ '\

Listening tests for the pelvis This region contains the articulation point between the powerful lumbosacral fasciae and those of the lower limb, including various strong ligamen ts notably the s a c rotub er ous Moreover, it contains all the structures in the various cavities ,

.

of the true pelvis. Finally, there is the terminal insertion of the dura mater into the sacrum. This gives an idea of the diversity of information available in this region-although its s heer volume can someti mes make the results of

a

list enin g test difficult to

interpret.

For these tests the patient should be prone. The practitioner should take up a p osition by the side of the patient, facing cephalad. One

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hand covers the sacrum

217

Listening Tests like a s u cker: with its base covering the inferior lateral an gle s of the bone (Fig. '

7 -8). Fig. 7-8

Li stening ro the Pelv i s

I f all i s well, the sacrum should be floating

harmoniously between the hips.

There

are a number of common positive findings: •

If the fingers are pulled cephalad, the problem probably resides in the

lumbosacral junction or •

I the base

the lumbar fasciae

.

of the hand is pulled towards the feet, the problem may be

affecting the coccyx or the sacrotuberous liga ment •

.

If the hand tends to sink dovvn between the hip bones, the possibility of

restrictions in the true pelvis should be considered. •

If the hand

is pulled to one side,

the problem could be located at the

sacroiliac joint, the sacrospinous ligament, or even the ligaments of the

hip, pelvis, or trochanter. •

Finally, if the base of the hand is pulled towards the table and cephalad, the possibility of abnormal tension in the dura mater should be considered.

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Chapter 7 / Fascial Tests

Listening tests for the thoracic fasciae With the patient prone and the practitioner at their side facing cephalad. either place both hands on either side of the vertebral axis, or just one hand covering the spine and the su r ro u n di ng area (Fig. 7 -9). Motility is difficult to sense in the lower thoracic region-positive responses are usually indicative of distortion. It is much easier to sense higher up on the back. To feel here, place both hands on the scapulas. Very soon, their movement becomes eviden t as if they were Boating over the thoracic cavity. The position .

of the scapulas with respect to the thorax seems to result in amplification of the movement. In the event of distortion. the scapula will tend to be p u ll ed towards the location of the problem. Fig.7-9

Listening to the Thoracic Fasciae

Listening tests for the cranium In this region. there are several different parameters that can be tested. This com­

plicates the diagn o s ti c process. The following must all be taken into account: •

the intracranial membranes

•

the exocranial membranes and the cervical fasciae which are continuous 'vvith them

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Listening Tests

•

the spinal meninges

•

elements of the cenrral fascial
The patient should be supine, regardless of which fascia is being ev aluated . Intracranial membranes

We do not intend to go inro detail concerning cranial techniques. We find the standard five-finger hold perfe ctly suited for a genera l cranial li stening test. If

dis tort ion is detected, this can be a followed up with a falx cerebelli technique. Support the posterior part of the head with the palm of the left hand,

•

and with the thumb and ring finger pointing out to cover the tenrorium c e rebe lli

.

Place the other hand over the vault, with the middle finger pointing in a

•

sagittal direction alon g the falx cerebelli.

One of the probl ems associated 'with accessing the i n t ra cr a nial membranes is the pr e se n ce of the exocranial fasci ae and the b on y structures between them and the hand. As previously discussed, the interior and exterior of the cranium are in co mmun icati on and therefore can influence one a n o t he r. For effective intracranial listening, one must 'project' oneself inside the skull. Exocranial membranes and their extensions The p osit i on is the same as above. Obviously, as the external fasciae of the skull are subject to problems, they should not be ig n ored. If any super fic ial tension is

detected, the point of resistance shoul d be identified because such a point is ex­ tremely di srup tive vvith respect to cranial and cervicoscapular mechanics, as will

be discussed la ter

.

We have al ready menrioned how fascial tension can begin at the base of the

skull, especially i nvol vin g the cervical fasciae. If the lesion is ascending, it will cause

a

restriction in cranial motility. This is particularly tr u e for the aponeuroses

of the sternocleidomastoid muscles and, to an even greater extent, for those of the posterior superficial cervical fascia, which tend to involve the temporal bone in the pathological process.

When the skull is taken into the hand, the hand wi ll be p ull ed in a caudal direction along the axis of the problematic fibers. Spinal meninges Place your hands over the p oster i or base of the skull, with the fi ng er s crossed over one ano t her in the form of a very shall ow 'V' Then induce a very mild traction follOWing the longitu di nal axis of the spine. One you have engaged the tissues, slig htl y increase the degree of traction to steadily descend as far as the sacrum

(Figs.

7-10 &

7-11).

The dura mat er is fi rm l y attached at (2 an d (3 and also, via radicular exten­ sions, ar oun d both sides of the intervertebral foramina. These attachmenrs are not purely theoretical-the dura mater is solidly anchored to the vertebral perios­ teum to enhance protection of the sp i nal cord and the nerve roots. We did ana-

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Chapter 7 / Fascial Tests

tomical investigations into these anchors using pigs and found that tremendous

force was necessary to pull them out. In the normal s i t u a tion light traction on the dura mater e l ici ts ,

no

response.

Since the dura mater is not extensible, any focu s of restriction will be easy to feel

because it will no longer float free in its bony c ha nn e l. With

a

li ttl e practice, it is

easy to diagnose re si s t ance in any direction along the dura ma ter

.

Fig.7-1 0

Position of Hands for Testing the Meninges

Fig.7-11

Spinal Meninges Test

Central fascial axis The central fascial axis begins around th e edges of the foramen magnum. When there is a restricti on along the length of the axis, any problem anywhere which involves it will transmit an effect to the base of the cranium.

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L i s teni ng Tes ts

The hand position for li stening to this axis is the same as that for the spinal meninges , described above. The th umbs are directed towards the angle of the mandible (Fig. 7 - 1 2 ) . In the nor mal situation, this axis i s completely free. I f there i s a problem, two

phenomena will be obser ved : •

Palpatory : The hands will be pulled in a caudal direction , with the skull moving according to the rhythm of the patient's breathing .

•

Visual : Looking along the central axis , you should see a rhythmic movement that goes up and down the longitudinal axis of the body. If there is severe res triction tha t involves the pericardium and diaphragm , the visceral part of the nec k , made up of the various cartilages , will sink down into the thorax by a m a t ter of centimeters.

Fig. 7- 1 2

Cen tra l Fasc i a l A x i s Test

An terop os teri or listening tests The patient should be supine . The practitioner is positioned at the patient's hea d , cradling the base o f t h e skull with one hand, a n d eliCiting light traction . The other hand is placed fiat over the sternum (F ig. 7- 1 3 ) .

This techniq ue tes ts the general sy nchronization of the fasciae, especially the thoracic and cer vicocran ial fasciae. Mild suboccipital traction affects all the pos­ terior fasciae. In the normal s ituation , the hands should sense

a

full , free, and rhythmic

movemen t . If problem s are present , the movemen t will be asynchronous and will ten d to prefer certain direc tions over others.

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Chapter 7 / Fascial Tes ts

7- 1 3

A n teroposte r i o r L i ste n i n g Test

Effects of stress on listening In certain highly stressed individuals,

t is s u e

m o t i l i t y will be p e r t u r b ed

,

with

movemen t slowed down and reduced in amplitude. What is fe l t will be a lack of

fre e d o m in the floating of th e tissu e s , as if th e y were un certain in which d i rec rion they should be moving. In a dd i t i o n there will be a fe eling of retraction and the ,

hand will fe el like it wants to clench. This can be felt anywhere , bu t is most evi­ dent around the cranium and in the thora x , m o s t common ly o ve r t b e s ternum .

Sp ecial areas Certain parts o f the b o dy are more vulnerable and re t a i n particularly long -lasting i m p r e s si o n s when subj ecr to any kind of injury. The fasciae in t h e s e areas c o u ld be said to have a particularly l o n g - term me mory. PlaCing the hands over these ar­

e a s is often suffi cie nt to d e t e ct fascial tensions that are s ec o n d a ry to v e r y a ncient insults.

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Lis tening Tes ts

These areas are concentrated over the craniu m, the cervical ver tebra e , the up­ per thoracic vertebrae, the sternum, the coccyx , and the epigastrium , as well as in scar tissue and at original points of impact. Craniu m and cervical vertebrae The region of the crani u m and cervical spine represents an impor tan t crossroads for n e r ves and blood vessels . It is also highly mobile, which serves

a

fu nctional

role, bu t is also importan t in adapta tion and compensation mechanisms . The re­ gion of the upper cervical ver tebrae and the base o f the

sk

ul l i s a focus for a

m u l titud e of con strain ts, and is in a constant sta te of readj ustment in order to i nsure optimal functioning at the higher information processing and command cen ters . In the event of severe trauma, it is the cervical ver tebrae and the occipitocer­ vical j unction which represent the ul timate point at which damage can be attenu­ ated. Therefore , it is not surprising that fa scial tension and restricted mobility is not uncommon in this region-i t is no t going too far to say that it is rare n o t to find some kind of problem here. The mos t common kinds of tension to leave their mark here are those rela ted to childbirth . A fairly common phenomenon i s lateral translation o f the cervical vertebrae with compensation between the atlas and the occiput . This is usually the resul t of a traffic accident or some o ther kind of shock from the side . More o ften than no t , the patient has comple tely forgo t t en the original event, but the tissues have not . U p per thoracic ver tebrae The upper thoracic vertebrae support the cervica l ver tebrae a n d are often distort­ ed as a resu l t of overlying distortion . For example, after a rabbit punch , it is o ften this re gion which is obliged to absorb much of the excess energy and which , as a resul t ,

be co m es

pathological. One of the most dangerous types of shock is that

associated v'lith a fall flat on the back , espeCially when the person is still a child . Such a shock sets up a serious chain of even ts, including respiratory spasm, which can lead to anxiety and even panic attacks . Such an inj ury, together with its associa ted s tress , will leave i ts mark on the tissues . When we put our hand on th is are a , we ""rill feel marked rigidity and ten­ sion i n the tissues, as if the skin were too tightly stretched. It usually suffices to simply ask the patient if anything happened to learn about the i n j ury, because it will have left an u n forgettable impression . Moreover, as preViously discussed , the upper thoracic regio n is a very i m ­ portant fascial mee ting point which i s constantly working. As a result o f shocks , stress , and tension , this region is subj ect to an ever-increasing number of restric­ tions of steadily mounting severity, ultimately resulting in changes in local s tatic properties. The back begins to arch and the shoulders slide forward-leading to the rather telling expression , " I ' m carr ying the whole world on my shoulder s ' " Ster n u m

This i s a common s i te for tension secondary t o repeated , uncompensated stres s .

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Chapter 7 / Fascial Tests

A listen i n g test here may show the tissues to be tense and fixed, with a tendency t o retract towards the cen ter. This can leave the impression that the hand is grow­ ing hollow while the sternum is retracting in a pos terior direction . In victims of motor vehicle acciden t s , the seat belt can o ften leave a restriction , which is easy to d e tect in a lis tening test in the form o f an obl i q u e pulling of the han d , crossing the u p p e r t h o r a x . Coccyx

In the same way as a fall fla t on the b a ck leaves a la s ti n g impression, anyone who h as ever fallen on their coccyx i.s unl ikely to forget i t . If there is a n i n s tance where

the expression " seeing s tars " is applicable, i t is wh en this r e g i o n i s hu r t . Apart fr om any local damag e , a fall o n the coccyx is often associated with shocks i n the abdomen and thorax , which can t ra v el a ll t he way up to the cranium . A fter such an in j ur y, i t is not uncommon to develop p a i n fu l tension in one o f the organs , and even a prolap se can re sul t .

As a re s u l t o f this s h o c k , the co c cy x is us u a l l y in j u r ed i n flexion a n d side­ bending. Loc a l palpation can detect the e ffects of such

a

shock many years later,

even if it h a s become silen t . We can say th a t the i mp ressio n is there for life. Epigastri um

Many people somatize stress to the e p i g a s trium-an idea em bodied in the

ex­

pression about having " b u t te r fli es in one 's s toma ch . " Such stress will s timu l a te the solar p lexus , which will in turn have repercussions thr ou g hou t the abdominal

r e g io n . Lis tening in such a region will g ive the impression of a h a rd , overly tense area , depression o f which is resisted and cau s e s pain . Palpation gives a n lmpres ­ sion of a hard ba l l being

u n d er

the hand. The organs a r e immobile a n d dis ten ded.

Just the fac t of pla c in g the hand induces very pronounced aortic pulsa tion , which can be par ticula rly

wo r

r y ing for th e p a tient.

S cars

N o t all scars lead to loss o f fu nction , bu t , as we have seen , it is n o t uncommon .

They therefore must be tes ted s y s tema tically becau s e , when they become disrup­ tive , t h ey constitute th e primary cause of m echan ical or phYSiological imp air­ men t . A listening test c an easily reveal the d irec tion of any tension being ind uc e d by a restric tive scar. Impact p o i nts

When the body experiences a shock , it m u s t be absorbed in some way in or d er to avoid damage to fra g ile i n t er n al s tr u c t u re s . The energy of a dire c t impact like a punch is first a

at

tenu a te d by the skin , the fas ci a e , and the a dipose c u s hi on . When

blow s trikes a relatively p oor ly protected region where the shock absorbing

capac i t y of the ti s s u es is limited, such as the tibia or s k u ll , the e ffect on the un­ d erl ying fasciae is all the more pronounce d . T h is can create res tric tions which

correspond to the points of departure o f a pathological lesi on or restri ction . Such ' traces ' of shock impa c t po in ts mus t be sou ght a ssid u ou s ly beca u s e they are often key to the success of our treatm ent strategy.

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Pa lpation and Mobil i ty Tes ts

Shocks to the cranium , especially tho se to the p o s terolateral p a r t , can cause changes in the connective tissue 'which lead to a descendin g chain reaction of damage, transmi t ted thro ugh succes sive structures from the area of occipitocervi­ cal j unction throu g h the cervical vertebrae, the cervicothoracic j unction , and the shou lder. In a lis tening te s t , the most common observa tion is pOi n t -like restriction.

Serious shock s , s uch as those incurred in tra ffi c accidents or throu gh a faJ ! onto the wris t , can overwhelm the shock-absorbing capacity of the soft tissues and

must therefore b e dealt wi th by s trong er s tructures , namely, the bone-periosteum complex . Bone has a cer tain degree o f plas tiCity and is constructed in such a way as to absorb shock s . However, s trong shocks will never theless leave an impression on bone tissue and can tr igger a p a thological proc ess. Relevant here is a recen t case his tory of a p a tient who had been involved in

a head-on collision in his car. The patient had been g r ippi n g the s teering wheel and most of the energ y was transmitted to his left radiu s . A listening test indica ted that the bone was compressed to a certain exten t , and tha t the fi be r s o f the tissue in tercala ted with one a n o ther. In fa c t , the bone had almost broken .

Pa l pati on a n d Mo b i l ity Tests PA L PAT I O N Listen ing tests a re purely passive and a re p erformed using the entire surface of the hand. By contra s t , palpation is performed with the digital pad a t the tips of the fin g ers and involves the exertion of varying degrees of press ure , depending on the area to b e reached . Before continuin g , here we will make a short digres sion . Before touching the p a t ient , it is vital to make a visual asse ssment of the a rea to be tested; the in­

for m a tion so ob tained can b e extrem ely useful. Things to l ook for are the color and condition of the skin , including whether i t is thick or thin , and whether any spo t s , b l emishes , or lumps are presen t . For exampl e ,

a

sl ight curving of the linea

alba off to the side indica tes some kind of problem in the area corresp ondin g to the direction o f the curve. Remember tha t the skin , through the in termediary of the Heine cylinders discussed in Chapter 3 , can reveal what is happening in the deeper tissues . The p urpose of palpation is to detect a n y change which m i g h t have occurred in a tissue. Such chan g es may be s tructural or the foci of pain.

Struc tural changes Structural changes vvill be observed first in the skin and then in the underlyin g fa sciae, a ccording to a progression from the outer m o s t layer to the interior.

I n the skin Normal skin is flexibl e , regular, and elas t i c . Abnormal skin may b e : •

indura ted

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Chapter 7 / Fasci al Tes ts

• i n filt r a t e d •

edematous

Moreover, abnormal skin may have lost some or al l of i t s natural elas ticit y. Some­ t i m es , i t will b e impossible to create a s kin fold a nd , in other cases , the fo ld will persi s t for a relatively long time , ind i ca ting modification of the cross-linking bonds.

In t h e u nderl y i n g fasciae Th e fa sciae immediate ly below t h e skin should be thou ght of as flexible s he ets

whi ch have , n eve r theless , a cer tain d eg ree o f firmness. D i fferen t fa sciae have dif­ ferent deg r ees of firmn e s s , from the most e a sily depressible regions , like th e a n ­

terior neck, to areas where t h e fa sciae must b e par ticu larly s trong , like in sertion points , l i ga me n ts , and some of the m esen teri e s . As a g enera l rule , a h eal t h y fa scia may o r m a y n o t have r i dges a n d i s com ­ ,

posed of parallel bands a l l a l i g n e d in the s ame direction . Distortion of its structure will modify i ts viscoel a s tic properties and change the way it feels on p al p a tion A .

loss of el as tiCity will trans l a t e as increased resistance to palpation- the fa scia will feel abnormally tig ht and more force will be required to penetrate it. ,

Ch a n g es to collagen fibers in the fa scia will m ani fes t in a vari e t y of ways : • Some bands of fas cia will be not i ce abl y tighter than n eighboring

s tr u c tures. Sometime s , these will have a sharply -define d edge, oriented o bliquely or a t a right angle to the genera l direc tion of the fibers . These bands are indicative of abnormal influences and they are directed towards the focus of the problem . They are easy to p a l p a te and , on dissection , are seen to be due to rela tively dense bundles of fibers which have a particularly pearly sheen . • There w ill be abnormally tense bands of fa scia tvvisting around a

longitudinal axis parallel to the g en eral direction of the fibers -us u ally longer than the oblique of perpendicular bands. • Certain fascia e , like the fasc i a lata , are natural ly r i dg e d : under the

influence of excessive tension , the r idg es have a tendency to become

more p ronounced analogous to wha t happen s when a curtain is drawn. ,

• In o ther circumstances , within a fascial band or a normal fascia , small

nodules can b e felt. Most of these are oval in sha p e and can va ry in size from tha t of a grain of rice to that of an olive s tone ; o ther, rounder nodules ca n vary i n size from that of a grain of sand to one of sea s a l t . The oval- shaped nodul es are usually found i n the membranes which separate muscles ; the rounder ones can occur any w her e . All the s e nodules a r e hard, approaching the h ardn ess of bo n e t i ss u e . • Finally, p al p a ti on may reveal areas that a r e extremely indurated o r even

calci fied . These can extend for a ma t ter of a few millimeters to as far

as two centimeters. Such indurated areas are most commonly found around the sho ulder, the elbow, the deep ve r t e bral ligamen ts , and the plantar aponeurosis.

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Pa lpa t i on and Mobili ty Tes ts

These areas have such a hard texture because what is happeni n g is tha t s o ft tis sue is in t h e process of being converted into bone. In response to s tress which is too grea t , the fa scia , ligamen t , or muscle is s t a r ting to calci fy. This phenomenon

'vvh ich leads to the ossification of soft tissue has been extensively s tudied by Ste ­ vens on e t aI . ,

who concluded that i t i s the bone-producing protein o s teogenin

that makes i t poss ible to convert m u scl e tissue into bone.

As will b e discussed la ter, this process is n o t a lways-happily for us -irre­ versible .

Pain I t i s said tha t pain i s often misl e a ding , a n d that i t should be treated with c a u tion

in l i g h t of both the amount of variabi lity among p a tien ts , and the fac t that it can m a sk un derlying problems. Neverthel ess , when taken into a ccount with the ap­ propriate precau tions , i t can be a very usefu l indica tor. Mild pressure exerted on a fascia should not cause p a in . However, if it i.s dam­ aged , i ts sensitivi t y can be markedly enhanced and it can become frankly painful . espeCially in the vicinity of the above -men tioned band s and nodules. This can mean that the patient can barely stand even ver y lig h t palpa tion in calcified fa sciae or around certain compromised ligaments . Extrem ely a cu t e p ain-such a s that follOWing a burn-can b e triggered by even

a

very light touch .

Pain is associated with the release of certain pros tag landins . Aspirin and o ther pain killers block pros taglandin synthesis and thereby prevent the effects o f this critical gro up of substances , the func tion of which is to sound the ala rm tha t tis­ sue damage has occur red or i s occurrin g. Effective treatmen t always results in a maj or reduc tion in the number of pain ­ ful foci, and sometimes in their complete disappear ance. Apart from the immedi­ a t e benefit in terms of the actual p a in itself, this has anoth er, perhap s less obviou s advant a g e , i n that i t helps to convince the p a tien t of t h e va l id i t y of t h e appro a c h .

After all , he or she only came to see y o u b e c a u s e o f " a pain there " S o , a l though pain may repre s e n t n o more than the tip o f the iceberg , it is nevertheless o n e o f t h e fac tors that c o m e tog e ther to constitute t h e os teopa thic lesion .

M O B I L I TY T ESTS Mobility tests follow o n n a t u rall y from palpation- they are closely a ssocia t e d .

Purpose of mobili ty tests The purpose of this type of t e s t is to d e t e c t any impairment of mobility, be i t in the skin , a l i g ament, a n intern al s t r ucture, or a j o in t . It i s a follow - up modality to confirm the findings of a listening tes t . Since mobility tes tin g i s relevant to a l l parts o f the bo dy, i t re q ui r es a very profound u n derstanding of ana tomy The more advanced our understanding of the anatomical s tructures b eing p alpated the higher will be the resolution o f our ,

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Chapter 7 / Fascial Tests

mob i li t y testin g , and , as a res u l t , the more effe ctive the trea tme n t s tra t e g y. There a re two differe n t types of mobility tests : •

lon g lever tes ts

•

l o ca l tests

Long lever tes ts Lon g l ev e r tests , sometim es r e fe r r e d to as s e c t io n a l tes t s , are p e r fo r m ed on seg­ ments or more extensive are a s . Restric tion in a pa r t icula r j oint or area may be due to

purely local cause, but i t may also be derived from fascial tension elsewhere

a

which is cre a ti n g a l o n g l es i o n a l ch a in

.

These are the classic tes t s that i n vol v e the movemen t a n d quality of a g ene r al area : pla n t a r flexion. dorsal flexion , a n t erior flexion o f the head or

the trunk, etc.

Th e y are easy to p e r fo rm , although it is not s o easy for beginners to pin down

a t th e outse t whether the res triction is p ur e l y local or p a r t of

a

long fa sc ia l lever.

With some p ractic e , however, it is e a s y to t e l l the difference. It is importam to make this distinction because th e r e qU ir ed corrective a c t io n depends not only on th e character of the restriction , but a ls o on the area under co ns i d er a t ion

.

U n for tun a t el y, these l on g lever tests are often ig nore d or p e r form ed im­

pr op e r l y Never theles s , it is this kind of test wh"ich g i ve s the p a ti ent an o b j ect ive demonstration of the improvemen t me d i a t ed by t h e treatment in the form of e nha n ce d mobility, an enh a n ce m en t which is often acc o mp a ni e d by a reduc tion in the level of pain .

Local tests A lo c a l test is a spe c i fi c tes t d e S ig n ed to e sta b l is h an accurate diagnosis of the pathological fo cu s . It defines the na ture of th e restriction, its l o cati o n and its ,

d e pth It n a t ur a lly fo l low s o n fro m lis teni n g tests and palpation, and is used to .

confirm or exclude the p o ssibil i t ies already r a ise d . In the en d , i t leads di re ctly to the treatmen t . so the more e ffective t h e execution of the tes t , t h e more suitable and effe c tive the s tr a te g y eve n tually a d o p t e d is likely to b e . O f cours e , a l l this as­ sumes th at the pr a c titi on er has ex tensive exper ience in p a lpa t ion and an in tima te a n d a c cur a te kn o wl e d g e o f

an ato m i cal

topo g r a p hy

We wi l l discuss local tests fro m the ou ts i d e i n , s tarting a t the s u r fa c e and g o in g

down from there through the deeper tissues , from the skin t hr o u g h the

sup erfiCial and de ep fasci a e to th e internal organs

.

Skin The b o tt ommos t layer of the skin i s a tt a ch e d t o the s u pe r fi C i a l fascia . As preViously d i s cu s s e d , a pr o b l e m in the deep tissues c a n have e ffe c ts at the skin , w h eth e r i t b e ch a ng e s i n skin s tructure or an actual lesional chain involvin g b o th superficial

and deeper eleme nts. De p e ndi n g on the size of th e area , the m e t ho d involves us­ ing either the p a d a t the tips o f "vo or three fi ng e rs or the entire hand to g ently manipulate the skin in all d ir e c ti o ns In s i mple terms, aB one is doing is slidi n g .

o n e plane o f tissues o ver another.

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In the normal situa tion , the mobility of the skin should be similar in a l l di­ re c tions , while if there is any restri c tion prese n t , the m obil i ty o f t he skin in t h a t direction vvil l be reduced or mi ss in g altogeth er, thus giving an immedi a t e indica ­ tion of the location of the res triction and its direction . By incr e a s ing the pressure, one can reach deeper t i ssues and test different p l a nes

.

Peripheral fasciae

We are n o t going to try to descri be all the various tests for all the fa scia e-mo­ dali ties are m ore or l e s s the same for a l l s e g m ents. However, we will g o over some o f the most common tests and some of those which can be key for our tre a tmen t

s trategies. � LOW E R L I M B

Plantar a p oneurosis. Wit h the p a tient lying p r o n e flex the knee s o that ,

pl an t ar aspect of the foo t is facing u p wards and exert p r ess u r e on the p l a n ta r apo n e ur osi s Soon , you will feel a cord u n d er your fingers. As you increase the .

pres s u re, the p a in l evel will rise until it can no l o n ge r b e tolerated. N ex t , hook the p a d of your last three or four fin ge r s around the inte r n a l edge

of the li g a m e n t and pull it t o w a r ds the outside. If t h e r e is a r e s t ri c t i o n present, the movement will soon b e rest ri c ted and the p a tient will exp erience p a in

(Fig.

7 - 1 4)

Fig. 7 - 1 4

P l a n ta r A p o n e u r o s i s Test

Anteromedial fascia of the le g This fas cia lies d ire c tly over the tibia . With .

t he p a tien t supine, slide the tips of two or three fingers alon g the fascia fro m the ankle to the knee

(Fig.

7 - 1 5) . If there are any restrictions , you will encounter

an edematous patch of skin which \Nill block the pa ss a g e of y o u r fin g er Focus ­ .

ing here, try t o m ove the skin a n d th e u nderlyin g fa scia . Thi s movement will b e res i s ted and m a y cause pain-the fascia s e ems to be s t u c k to the periosteu m .

S ometimes , you will obs e r ve a small fascial band which will block t h e a dvance o f your fing e r ; i n the ch a p t e r on treatmen t , we will discuss why i t i s important t o i nv e s ti g a t e this kind of res triction .

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Fig. 7- 1 S

Chapter 7 / Fascia1 Tests

Tes t i n g t h e A n teromed i a l Fascia of the Leg

Anterolateral and posterolateral compartments of the leg. This test in­

volves the planes o f j ux taposition of the muscular fasci a e and th e tib ia . 'vVi th the p a tient supine, the kn e e i s bent and the fo o t placed flat on the table. With the tips o f b o th thum b s , moving from the ankle towards t he knee , feel the a n t erolatera l compartmen t ; the pos terior muscular compartment is evaluated with the fin g er

tips (Figs 7 - 1 6

&

7 - 1 7) . If there

are any restriction s , it will be difficult to reach the

deeper tissues with the fing ers and the patient will feel p a in if you try This tes t ca n be very usefu l for the sequelae of scia tica , a fracture, sprained ankle , or refractory pain in the calf

Fig. 7 - 1 6

Te s t i ng t h e Posteromed i a l C o m p a r t m e n t of the Leg

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F ig, 7 - 1 7

Palpa tion and Mo b i l i ty Tes ts

Testing t h e Ante r o l a t e r a l Co m p a r t m ent o f t h e Leg

Sciatic

n erve

fascia. Th roug h o u t its length, the sciatic nerve is

i nve s t ed

by

a

kind of fa scial pro tecti on , In the normal situatio n , the sci a ti c nerve cannot be fel t in p a l p a t i o n b u t this c a n chan ge in t h e event o f pa tholo g y. Wi th the p a t ien t prone , t h e practi tioner takes up a p o s i ti on to the side of the pa tien t . Begin pa lp a t io n a t the g l u t ea l fold. Remember that t h e sciatic nerve

runs

down the length of the t hi g h along the cleavage p l an e between the biceps fem o ­ ,

r i s on o n e side and the semimembranosus and semi tendinos u s muscles on t h e o th e r Find this c leavag e plane a n d s t e a d i ly penetrate d e ep er a n d deeper with the .

finger ti p s , and try to manipulate the deep p l a n es in the longi tudinal and trans­ verse directions

(Fig. 7 - 1 8) ,

Continue on down through the popliteal fo ssa t o the Achilles tendon, passin g b e tween t h e two g emellus muscl e s , A t this leve l , it is some times useful t o p la c e

the lmee in mild flexion (Fig. 7- 1 9) , In p a tien ts

wi th sciatic pa thol o g y,

i t w i l l b e difficult to m ove the deep planes

and any a t t empt to do so will induce pain . As to o ccur in the

up

a

g eneral rule , restrictions tend

p e r part of the thigh and i n the middle part of the calf. M o s t

commonly, the focus of t h e restriction consists of an a rea extending over s everal centi m e ters. However, sometimes the focus o f the r e s t ric ti on will be relatively

short and l o cated at the j u nction between the top one- third and the b o t tom two ­

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F i g. 7- 1 8

Chapter 7 / Fascial Tests

S c i a t i c N e rve Fasc i a Test ( Proxi m a l )

J ---� ---

F i g. 7- 1 9

S c i a t i c N erve Fasc i a Test ( D i s t a l )

� BACK

Gluteal and vertebral muscles. Wit h the p a t i en t prone , the pra ctitioner stands to one side. The fing ertips are used to feel the upper insertion planes of the gluteal muscles under the iliac cre s t (Fig. 7 - 2 0 ) . In this region , i t is common

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Palpation and Mobili ty Tests

to find extremely tense , painful fascial bands which are seriously disturbing the m echanics of th e p elvis. Con tinu e to use the finger tips to feel back

a

l ong the vertebral muscles as far

up as the cervicoth oracic region , possibly carrying on u p to the occipitocervi­

cal j un c tion (Fig. 7 -2 1 ) . If one goes deep enoug h , you will fairly often encounter bundles of fibers which roll b el ow the fingers. These bundles can be as thick as a fi n g er .

A tense area may be found s tar tin g a t the inferior lumbar level and extending upwards withou t in terruption to fairly hi g h in the thoracics. I t is wor th follow­ ing such a tense area up wa rd s because often its termination point corresponds to some kind of thoracic restri c tion which is causally related to th a t of the lumbar

region . At the superior thoracic level , you may encoun ter obliquely aligned bands of fascia which are associated with the m e dial muscular attachment points of the scapula and the pos terior a n d superior serratus m uscles. A t this p O in t , the re i s a belt wh i c h corresponds to where fibers r u n nin g in different direc tions cross over one a n oth e r.

Fig. 7-20

Test i ng [he G l u t e a l Fasciae

Fig. 7 - 2 1

Tes [ i n g [ h e F a s c i a e of [ h e Pa raverte b r a l M us c l e s

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Chap ter 7 / Fascial Tests

Scapula. With the patient prone, the practi tioner stands to the side and plac­ e s their hands flat over the two scapula s . Move them in all directions to test how easily the underlying planes of tissu e slide over one ano ther

(Fig. 7-2 2 ) .

N ex t , specifically test the areas above and below the spine o f the scapula with the finger tip s . Above the spine, you will fi n d areas of painful tension located be­ tween the muscle fibers and oriented horizontally. Below the spine , the areas of tension will b e obliquely aligned in the direction o f the shoulder, with the most revealing points concentra ted around the latera l , superior edge of the scapula . These are the areas where the problems lie in the m a j or i t y of patients with shoul­ der problems . Fig. 7-22

Scap u l ar Test

� ANTERIOR TRU NK

We will focus on two particularly active areas , the s ternum and r ile clavicl e. Sternum. With the patient supine the practitioner stands to the side and places one hand comple tely flat on the sternum as for a listening tes t . When well ­ positioned over the s ternum , move it in all directions. Over the sternu m , the fas­ cia is in direct contact with the bone, a s is the case over the tib i a . To make things easier, you can use b o th hands by crossing them , with the base of one on the s ternal notch , and that of the o ther over the XiphOid process

(Fig. 7 - 2 3 ) .

Slide your finger tips along the s ternum . I f there i s a restriction presen t , your passage will b e blocked by a horizontally oriented fibrous barrier. Foci of restric­ tions-often hyper- acme -will b e encoun tered around the median line and in the cartilaginous parts of the s ternum .

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The s ternu m is a ver y hard-working are a , and is ac tive in all movements af­

fecting the thorax. Fascial p r o b le m s here are common . Moreover, as previously noted , this r e g ion is particul a r l y susceptible to all types of s tress-related prob­ lems .

Clavicle. The c l avi cl e is a m e e ting poi n t for differen t fa sci a l elements as well as b e ing a c onsis t e n tl y h a r d wo rk in g r e g ion . I t can cause p roble m s -

in t h e

over­

lyin g s tr u c tu res and also, because o f its un derly i ng a t tachments , i n the brachial plexus and the subclavian ar tery. The tes t is mainly relevant to s u bcl av i a n struc­ ture s , that is , t he clavipectoral fascia and the conoid , trapezoid and a cromiocla ­ ,

vicular liga m ents Fig. 7 - 2 3

.

Stern u m Test

The test is done with s i de

,

with their

the p a ti ent

supine and the practitioner s t a n d i n g to the

thumb and index finger on either side of the clavi c l e . Gradu ­

a lly feel around t h e clavicle in order to reach the underlying so ft tissues

(Fig.

7 - 2 4) . If t he tissues in this a re a com p letely relax , the two fi n gers will be able

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Chapter 7 / Fascial Tests

to m e e t on the inferior side of the bone . If some kind of tension is presen t , penetration is inhibited a n d t he p a tient s o o n feels pain. To make things easier, you can have the pa tient r a i se the con tralateral arm ; better still , posi ti o n the p a tient on their s i d e , which will relax them most effec­ tively. If the tension i s acute , this last position is more sui table for palpation . Fig. 7-24

Clavi c u l a r Fasciae Test

� NECK

Here , we will j u s t cover a test for the carti l agino u s tissue and for the ph a ryn ­ g o b a silar fascia . This is a very im p ortant regio n in the regulation of the pharynx , the la r ynx ,

and the thyroid gland. As was desc r ibed in the ana tomy chapter , this z one articu ­

late s with the cervical vertebrae. The hyoi d bone is an importan t shock abso rbe r and dissipator of tensions which are transmitted via the central axis and from o ther sources. The hyoid bon e a nd thy r oi d ca r tilag e are m ech a nically linked in the process o f voice production , with the car t i l age attached to the hyoid bone to p rovide play in the a r ytenoid cartilage and th e reby make the vocal cords vibra te . Remember that the vocal cords vibrate a t about 2 0 , 0 0 0 Hertz

(r ising

to 3 6 , 0 0 0 in the case

of the h i g h e s t soprano VOices) . Obviously, even the mildest disrup tion in this region can have serious consequences for the voice, among o ther phY S iological functions.

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Palpa tion and Mobili ty Tests

General test for the neck. With the patient supine , the practitioner s tand s to t h e side and places their cephalad h a n d o n t h e p a tien t 's forehe a d . Three fingers o f the other hand are placed alon g the contral a teral side of the visceral axis o f the neck , while the thumb is placed on the ip silateral s i de . Firs t , turn th e head towards the left and , at the same tim e , exert some traction towards the right using the fing er tips

(Fig.

7

-

2 5)

.

Then turn the head towards the

righ t while pu shin g gently with the thumb towards the left . For grea ter specific­ ity, one can take the axis of the neck between thumb and index fing e r a n d test segment by segmen t . If there a r e any res triction s , t h e m obili ty of t h e neck will b e reduced a n d the manipula tions ma y i n du c e acu te pai n . When p erforming this tes t , a reflex coug h is a very common response , especially when t h e fixed s i d e is mobilized a t the thyroid -cricoid level . Fig. 7-25

G e n e ra l Neck Test

I t is not unusual to observe the following phenomena when performing this general tes t :

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Chapter 7 / Fascial Tests

•

A rubbing noise can b e heard, which can be very loud in certain case s . Sometimes this noise is perfe c tly normal ; w h a t is not normal i s i f i t i s associated with pain , usually retropharyngeal . a n d proj e cted o n t o the cervical vertebrae.

•

Acute pain can be fel t , induced by s tre tching at the l evel of one of the cervical vertebrae. This is often associated with symptoms a t the same spot reported by the pa tient.

I t is imp ortant not to forg e t tha t the visceral axis of the neck is linked to the anterior processes of the transverse fas ciae by the fibrous tra ct that has an a n tero ­ p o s terior orientatio n . Hyoid b o n e . Palp a ting t h e hyoid b o n e can provide information about a num­ ber of different s tr u c tures , inclu ding the superficial and middle cervical fasciae, and the pharyngobasilar fasci a . Palpa ting i t will also l e t u s better appreciate its relationship with the s tyloid process o f the temporal bone via the Riolan bouqu e t and i ts relationship with t h e scapula via t h e omohyoid muscle. The hyoid bone i s a U-shaped fibrocar tilaginous structure and it is this shape which m akes human speech possibl e ; the equivalent in anim als is differen t , hav­ ing a far more open s tructure . H owever, there is Significant normal anatomical varia tion in the shape of this structure. In many individuals , usually women , the hyoid bone is relatively closed , like a tuning fork , whereas i n many others, more commonly m en , i t is often open , like

a

pair of antlers.

The tes t is done w i th the p a tient supine and the practitioner on the side, with the sides of the hyoid bone placed b e tween the thumb and inde x finger of their caudal hand. The bone is displaced to the rig h t and the left, and then anteriorly and posteriorly

(Fig.

7 - 2 6) . It is then til ted to the side by one fing e r on i ts lower

part and the opposite finger on its upper p ar t . One side will often be found to be highe r than the o ther (usually the left-hand Side) , bu t , as long as the tension remains moderate , this can be considered a s a normal variation. The next step is to palpate the entire anterior aspect of the throat. This is done by taking the thyrOid car tilage between thumb and index finger of one hand and the hyoid bone in th e oth er. T hen move the hyoid bone back and forth with re­ spect to the thyroid c artilage

(Fig. 7 - 2 7) .

Hyoid-cricoid test. This i s ano ther important subhyoid cartilage that should be tested. The patient remains supine and the h yoid cricoid cartilage is taken be­ -

tween the thumb and i nde x finger. Each s t r uc ture is moved w i th respect to the o ther to test its flexibility and the presence of any restrictions . � C RA N I U M

Mobility testing around the skull involves manipulating the scalp with respect to the underlying bone tissue . In the normal situa tion , the skin slides over the bone without either tension or pain . Obviously, the skin over the forehead and the base of the skull i s more mobile than elsewhere . If there are any foci of restriction (secondary to the kind of shock we have already discu s sed) , a var i e ty of phe n o m ena can be observed :

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Fig. 7-26

H y o i d Test

Fig. 7 - 2 7

/"-.

.

-

/'

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! est

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Chapter 7 / Fasci a l Tes ts

•

A very tense, easily isolated band of fascial tissue may be fel t , sometimes feeling like a small thread, a few centimeters in length. This type of tension i s most common in the parietotemporal region .

•

An edematous , infiltrated area with a diameter of the order of two centimeters may be felt. The middle of this area is often depressed , corresponding to the focus of the restriction affecting the perioste u m . S u c h zon es a r e very difficult t o move a n d a r e often associa ted with pain like tha t due to a s ting by an insect (which can be acute) .

•

A hollow patch over the bone may be found. This is encoun tered at the suture sites and over the sutural bones. The finger will feel a depressed area , as if the fascia is being sucked down towards the interior. In these areas too, a ttempts to displace the tissue will induce pain.

A b d omen We do not intend to exhaustively cover all t h e t e s t s for t h e viscera , bu t w e would emphasize the importance of palpation and mobili ty testing in the abdomen . If there is one region of the body in which osteopathy is purely applied anatomy, it is this one. For correct diagnosis and e ffec tive treatment s trategie s , when i t comes t o p appa tion , it i s essential t o be completely familiar with the topographic anatomy of the region and with all its characteristics . Lis tening tests can be of enormous u tility in the diagnostic proces s , bu t they can never be enough on their own . Both palpa tion and mobil i t y testing must b e performed as well. Apart from the fact that palpation reveals areas which are sensitive or whic h contain points of restriction , the technique is also essential for unders tanding the exa c t status of an area which has been detected as abnormal in a lis tening test. I t is obvious that if a practi tioner detects irregular bump s , areas of indura­ tion , or deformations under their fing er s , caution should be the watchword and the p a tient should be referred to the appropriate speCialis t . Such morphological changes can only be detected throu g h careful palpa tion by an experienced prac­ titioner. The problems which arise with the abdomen are related to the dep th of the tissues to b e palpated , and the fact that many o ther s tructures may lie between the surface and the element of intere s t . This complicates the process of differen tial diagnosis . Never theless , with a combina tion of practice and intimate knowledge of the local ana tomy, such diagnosis is often possible . Palpa tion, as has already been emphasize d , mus t be as accurate as possibl e . Therefore , depending on t h e s tructure of interes t , it mus t some times be deep , and also, despite in tervening s tructures , it must concern the relevant area i tself, rather than some proj ection of it . If we are p a tient and look carefully for the most ap­ propria t e route of access , the fasciae almost always let us through ; thus , without too much difficulty, we can manage to palpate even

a

mesenteric artery, the sus ­

pensory muscle of the duodenum , or a kidney via the anterior approach. Abdominal palpa tion should be immedia tely followed by a mobility test on the org an , mesentery, or ligament in question . Mobility varies enormously be­ tween different segments : for exampl e , while the i n tes tines are extremely mobil e ,

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the liver and the ligamen ts a re much less so, and it is practically impossible to significantly displace the suspensory muscle of the duodenum or a m esenteric ar tery. However, i t should never be forgotten that all tissues have some degree of elasticity-it is th is tha t one is testing when one is focused on a region or s truc­ ture with very limited mobility. Abdominal palpation and m obili ty testing can be unpleasant for the p a tient , even painful . Bu t acute pain should p u t the practitioner o n guard . Unlike the case of the peripheral fasciae , where almost intolerable pain can occur in the absence of any major health problem, acute p ain in the abdomen m ay well indicate seri­ o u s pathology and should be treated a ccordingly.

Scars and ad h e sio n s � SCARS

A s previously discussed , foreign m aterial can b e trapped in scar tissue and this can dis turb a variety of physiological and biological p rocesse s . In addi tion , scars can trig ger adhesions which will inevitably change the viscoelastic properties of the local tissues and thereby lead to loss of function . Therefore , all scars must be s y s tematically investi g a ted. Apar t from palpating the superficial tissue and the surface of the scar, it is also impor tant to test the mobility of the underlying scar tissu e . Using the tips of one or two fingers, manipulate the entire area of scar tissue in all direc tions , making sure to penetrate deep enou g h ; the exact depth will depend on the location of the scar. If there are any adhesion s , there will be a clear blo ckage offering more or less resistance to the displacement of the tissue. In most cases , the adhesion follows one speCific axis. � ADHESIONS

Adhesions secondary to infection or inflamma tion ( a s opposed to scarring) tend to be less ' visible ' and can only be detected by palpation and mobility test­ ing. A s a general rule , such a dhesions are located in the viscera , the true pelVis , the abdomen. and the thorax. Post mor tem dissection often reveals the presence of fibrous bridges between the pleura and the lun g s ; the problem here is tha t this tissue is impossible to reach dire c tly.

S PEC I AL CA SES We will consider the tests for cer tain ligaments separately because they corre­ spond to very common problems which represent a Significant p ropor tion of osteopathiC practice . and respond well to os teopathiC tre a tmen t . These lig aments a r e the :

• iliolumbar • sacrotuberous and sacrospinous • anterior longitudinal • cervicopleural

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Iliol umbar ligaments We will d e s c ri be the t e s t for the right iliolumbar lig a m en t . The p a tient should be s t a n d in g , w i th their l eg s s l i gh t l y apa r t . T h e practiti oner stands behind the patient and is i n conta c t with them . Your left arm is u n der the p a t i e n t 's l e ft a r m , encircl­

i n g the lower part o f the p a ti e nt 's che s t . Slide your r i g h t thumb along the d e ­ s c en d ing part of the iliac c res t , moving dovvnwards and fo r w a r d s to arrive at the s p ac e be tween L4 and L 5 , where you will encoun ter the iliolumbar l ig a m e n t .

In some patients , the lig a ment will be c om pl e t ely relaxed and difficult to feel.

In m o s t however, i t will b e ten s e , easil y isol a t e d , and sli ght l y sensitive . Its diam­ eter i s s i m il a r to tha t o f a p e n c i l . In a third gro u p of p a tients , i t is so t ense that it feels c a lci fied , and it is difficult to displace and ex tremely sensitive . In order to make p a l p a tion easier, y ou

can

p erform a leftward translation o f

the pelvis a t th e same time a s i nc l in in g the trunk to th e r ig ht , and , i f necessar y, ro t a ting the p a ti e nt to the r i g ht as well (Fig. 7 - 2 8) . Support the patient on your l e ft a r m so that he or she re m a ins c om pl e t e l y relax e d .

T h i s t e s t for t h i s l i g a men t is only e ffe c t i v e and meanin g ful if the p a tien t i s s tanding u pright . W i t h t h e p a tie n t supin e , t h e result is o f little relevance because

the sta tic properties of thi s l i g a m ent mean tha t , unless it is supporting some w e igh t , it is not working and is therefore d i ffi c u lt to t e s t . Dissection reve a ls that the iliolumb a r li g a m ent is a c tu al ly a c ir c u l ar s tr u cture , simil a r in size to a penci l . It has a particularly pearly sheen , be aring witness to the

c h a n g e s in connective t i ssue s tructure indu c ed by ex trem e ly he av y work .

Sacrotu berous and sacrospinous ligaments Here, we will j us t m e n tion some im p or tan t relevant points. F ir s t , the p a tien t should b e p ro ne when p a lp a ti n g for th e s e l i g am e n ts , which are su b j e ct to huge tension s , s o tha t sometimes t hey feel pOSi tively indurate d . The s a c r osp i n o u s l i g a ­ m e n t is mor e di fficu lt to d e t e c t bec a u se it l i e s b elow a major m a s s of muscle tissue. When p al p a ting t h e se , alway s bear in m i nd their rel a tio n shi p w i t h th e

p iri form is muscl e and the sciatic nerve . Finall y, do not fo r g e t that the sc i a ti c l ig a

­

m en ts ar e re l a ted t o th e p e l ViC re g ion

Anterior long i tudinal ligament It is sometimes wo r th t est in g t his l ig a men t i n p a ti e n ts w i t h lum b o s a cr a l pro b ­ lem s . To do s o , h ave the p a tient lie supine , w i th their knees b en t , and stand t o t h e side. Place the finger ti p s o f both h a nds on t h e l ower p a r t of the l i n e a alb a . Gradu­ ally and g e ntly, descend u ntil you come into c ont a ct with t h e bon e . This may take

some time and it does require fi n e s s e . Perform a longitu dinal s tre tchin g m a nip u ­ lation while spreadin g the fing ers of each hand in opposite directions. Then , very g en t ly, p e r fo r m a t ra n s ver s e s t retch i n g m a ni p ul a tio n

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(Fig. 7 - 2 9) .

243

F i g. 7-28

Pal p a t i on nnd Mob i l i t y Tes ts

I l i ol u m ba r Liga m en t Test

! { { �\ Pal p a ti on of t h i s ligament can sometimes i n d u ce a c u t e pain , which spre ads to

the lumbosacral re g i o n or even as far as one of the

ne

r v e roo t s . It is evident tha t

this test is only p ossible w i th thinner p a ti e n ts whose abd o m e n can be depressed wi t hou t too much difficu l ty. It is not wor th att e mp t i n g to p erfo r m in a plethoric patient. I t is generally easier in women . It is almost not wor th sp ecify i ng tha t this pa lpa t i on must termin ate a t the

aor t i c bifurcation.

Cervi cop leural ligamen ts Three in num ber, these ligaments attach th e cer vicothoracic diaphragm to the firs t rib and the cervical ver tebrae. They are , going anter iorly fro m the back , the :

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244

Fig. 7 -29

Chap ter 7 / Fascial Tes ts

A n te r i o r L o n gi t u d i n a l L i ga m e n t Test

•

costopleural lig ament

•

transverse cupular ligamen t

•

pleurovertebral lig ament

In the normal s i t u a tion , these ligaments are very difficult to isolate,

but, if there

is significan t tension , they can be e a sHy fel t . This is done wi th the p a tient supine and the practitioner behind their hea d . We will describe the test done on the r ig h t side. In order to make palp a tion easier, slightly raise the p a ti en t s head and side­ '

b e n d i t (0 t h e r i g h t , w i th your right thumb i n front of the trapezius muscle u p to the level ofT !

,

that is , of the cos topleura l ligamen t . A fter this has been clearly fel t ,

move your thumb anteriorly by draWing an a r c o f a circle i n a forward direction to try and i s o l a t e firs t the transverse c u p u lare l i g amen t , and then the pleurover te­ bral l igament

(Fig. 7 - 3 0 ) .

This palpa tion can b e performed with the p a tient sittin g , b u t this will make i t more difficult because o f o ther fascial tensions which wil l b e superi mposed . Remember that the cervicothoracic ganglion is located close to the costo­ pleural ligamen t , and that the liga m en t itself splits into t wo branches before it termina t e s . The Tl roo t p a s s es thro u gh these two branches .

TIM ING O F T ESTS Once an area has been tested-wherever i t is in the body - a cer tain schedule s hould be followed in order to m a ximize the amoun t of information g a ther e d :

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245

Fig. 7-30

Palpation and Mobi l i ty Tests

Cerv i co- P l e u ra l L i ga m e n t Test

•

Fir s t of all , learn how to inspect the area visually. As previously

•

Next, perform a m o tility test, which achieves two ends , in that it both

mentioned, this can be highly instructive. reassures the patien t and permits you to initiate the contact with their tissues . •

Then perform palpati on and mobility tes t s .

We reitera te that i t i s d a n g erous to depend on any Single param e ter. In o s teopathy, the diagnostic proce dure is one o f convergence based on a ccumulating as much information as pos sible-including c linical findin g s , radiological image s , and the resu l ts o f medica l , listening , and mobility tests-in order t o iden tify the etiol o g y of t h e patien t 's problem w i t h as s m a l l a margin of error a s possibl e .

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Treating the Fasciae Objectives of Treatment Any insult, whatever its nature, will have some kind of effect on tissue structure. The injured tissue will change texture to become more granular, edematous, or indurated with a concomitant increase in the sensitivity of the local muscles and

fascial elements. These changes, through biochemical and phy sical phenomena, will cause loss of fascial function which will, in turn, induce changes in the

physiological behavior of parts of the body or organs Bednar et al. have documented degenerative changes in fasciae due to the separation of bundles of collagen fibers with the concomitant formation of myx­ oid tissue, which is heavily infiltrated by lymphocytes and pla s m a cells. Vascular proliferation is associated in certain patients with abnormal capillaries without any external basement membrane, and in others with the presence o f

tiny foci of

calcification. As previously discussed, if the insult is extreme or

s us

tained for too long a

time, exchange processes between the ground substance and cells will be affected. This can cause intracellular regulatory problems which can become chronic and cause morbid i ty.

One of the major etiologies of the loss of fascial function is trauma. Follow­ ing any serious accident, one must consider the effects on the fasciae of all p ar ts of the body. Changes in the tissues may be immediate or may only appear in the hours or days follOwing the traumatic event. Treatment of such injuries should

begin as soon as possible, preferably with fascial techniques. Changes V\rithin connective tissue will have effects on both the sensory and sympathetic nervous systems. This will lead to perturbation of afferent impulses

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Chapter 8 / Treating the Fascia

which "vill, in turn, cause spinal facilitation, th e reby cr ea ting a

v i ciou s cy cle . sym pa t he ti c transmission will disrupt a vari e t y of proce s ses , in­ c l u ding gl andu lar function , secretory p roc e sses , vasomo tor activi ty, and organ function . Facilitation of

Increased sympathetic tonus can , frankly, be dang erous. I n the normal situa­ nervous system plays a very i mpor ta nt role in the pro te cti v e and a dapti v e a d j us tments made to the internal milieu in response to changes in the outside e nviron men t, muscular e f fort , emotional stress, and so forth. Notably, it inhibits th e activity of internal organs, which are not di re c t l y involved in the response to such si tuations , and reduces the amount of blood flowi ng to these org ans and to the skin, r e direc ting it to s tria te d muscle tissue. These periods are u sua l ly relat iv el y brief and are followed by a period of re spi te and r es c. Persistent sympathicotonia, however, will lead to reduced blood flow and secretory activity, as well as s phin cter al spasm, vvh i c h will eventually result in tissue dam age and loss of fun ction in the part of the organs con ce rn e d. tion, the s y m p a th e ti c

It should be noted that clinical s ymptoms may evolve over time . Hyperhy dro ­ sis can tu r n in to h y p o hy d ro s is , and an gio sp a sm can give way to vasomotor atony with stasis, i nflammat ion, and edema. In other wo r d s , a chronic state b egins to p rod u ce d egenera tive changes. S ym p a thi coton ia which may be o bv ious at the beginning canno t remain so a nd tends to become m a s k e d in some way. the endocr in e system, prolonged s y mp at hi co tonia will affect the responses c ir cula ting hormones. Similarly, it can lead to local relative ischemia in the endocrine glands themselves that is likely to have far-reaching effects. These can occur in tissues distant from the actual gl a n d that is compromi se d or the area which is facilitated. In

of tissues to

The processes which are t r igge r e d in t h e facilitated segment mean that, once established, fa cil i tation can p ers i s t l ong after the disappe aran ce of the stimulus which or ig in ally induced the response. This is the meaning of facilitation . Taking these various pieces of in forma tion together, it becomes evident tha t damage to c on n ective

tissue can

in d u c e- i n

the shorter or longer term-a le­ becomes self-perpetuating through the action of the nervous system. The role of the nervous system in this process is to create a state of fa cilita tion, th e r eb y generating a vicious cycle w hic h , if it is not broken, will resu lt in degener a tive pr oc e sse s a nd p hysi ologi cal di s turba nc e at some point in the more or less distan t future.

sional process which su bs e qu e n t l y

The goal of the osteop athic ap proac h is therefore to break this cycl e by cor­ ten s ion , and tissular irritation , as well as revers in g t h e sympathiCO ­ tonia, so that the fun ction ality of the fasciae can be restor e d in full. recting spasm,

Releasing tissu es and correc ting posture are of primordial importance in the maintenance of blood flow. As long as the h em odyn amic picture is not dist urbed, tissue ex change processes will occur completely nor mally. The tissues will all be ad e qu a t e ly s uppl i ed with all the substances that they need for norma l function­ ing (h or m on es , nutrients, e t c . ) , and the wa ste p rod ucts of metabolic processes will be ef fiCi ently re m ov e d , th e r e by avoi ding local stasis, which can cause serious Copyrighted Material

249

Modalities and Principles

problems. When the nervous system is free of problems. it can express itself fully to help ex c hange processes and circulate the information necessary for maintain­ ing homeostasis. Therefore. we must be on constant alert to ensure that the tis­ sues are free of all constraints because these can cause loss of function which. in time. can lead to degenerative phenom ena . Thus. by way of ex ample. if the fa sc ial system around a spe cific joint is exerting sustained pressure over a relatively long time frame. the state oflubrication of the j oin t will be disturbed. This disturb a nce will lead to degeneration and. u ltim ately. to premature wear on the joi n t

.

As de sc ribed in the previ o us c h a pter. the type of fascial testin g we advocate

involves decoding messages whi ch are sent from the tissues. Once a m essa ge has been received and understood. a treatment strategy is chosen based on the most appropriate modality in the li ght of the information that has been colle cted.

Modalities and Principles Here we will define a general prin c ipl e for the correction of tissue p robl ems. This prin c iple is applicable to all fasciae. with certain provisos for differences among different parts of the body and different pathologies. As we have said. the general pn nc ipl e involves restoring tissue function. that is. fir st restoring its motility and mobility. which will lead to restoration of normal hemodynamic function and muscle t one. In Chapter 7 it was expl aine d how contact is first established through our hands. and how this is foll owed by d ia l o gu e This dialogue makes it possi bl e to .

decode the me ss ages sent by th e fasciae. Tre a tment is. in effect. an extension of the testin g proc edure As we shall see when we turn to specific techniques. most fas­ cial correction is directly induced by the test Once abnormality has been detected in a tissue. the modus operandi consists of continuing and extending the dialogue with the tissue to proVide it with the help it n ee d s to eliminate the restriction, The practitioner who has hit herto remained in receptive mode-a purely passive role-now svvitches over to a more active one. .

.

For real efficacy. there are two main considerations: •

accuracy

•

selecting the most appropriate teclillique

Accuracy Accuracy is the key to succ ess in all osteopathic modalities. The more accurate the osteopathic approach. the more effective will be the resolution of tension and the more qUickly will the normal physiologica l functionality of the tissue be

restored. In th e vast majority of cases. when a tissue has been damaged. it is inc a pable

of resolVing the damage on its own But. as previously emphasized fasciae have a .

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Chapter 8 / Treating the FCiscia

capacity for memory and some level of intelligence, and t her efore they recognize the problem-it seems as if they are waiting for help from without to give the m

the means to restore t hei r own natu r al f u nctionality. The more accurate and suit­ able the help, the easier it will be for the fascia to 'converse' with the practition e r, and the m o re likel y that the problem will be corrected.

Selecting the most appropriate technique Determining the most appropriate t echniq u e d epe nds on the area to be treated, the t ype of tissue involved , and the sp ecific pathology or distortion. E fficac y de­

pends on both a cc u racy and s election of the most appropriate technique. Fasci a l treatment involves two •

ma

in

corrective modalities:

induction

• di rec t tr e a t men t

I N D UCTIO N Principles Induction follows d irectly from listening. A positive li s te n i ng test reveals that a tis ­ sue is preferentially attracted towards a particular res t r icti on. All the surrounding forces are focused on this point, which exacerbates the tensions there. Therefore, the technique consists of foll OW ing the direction of the tensions in all para meters ,

Sometimes

there may be just a single axis of tension, but there may also be others.

Tissue re-equilibration must be achieved on the basis of all the various axes, and, if we ignore just one of the several lines of tension present, the

therapy will be

ineffective becaus e a d i sru p t i n g factor will persist.

General technical aspects The general approach to induction is [0 let the hand find its vvay to the restriction by li stenin g . S im ply finding it in this way eliminates some of the axes of restric ­

tion

a nd will therefore also have reduced the forces which apply a t that point. even up to a couple

Then exert mild pressure over the spot for s everal seconds, or

of minutes, until the re l a x a t ion of the tissues is sensed via the hand. Release the pressure and listen again. C y c l e s of induction and listening are continued until the tissue is free in all of its parameters. In this technique, when we contact the restriction the second time, we must

change the parameters of the axes. This is because, while one axis of tension

may

have been resolved, another may appear. If we do not con t i n u ally modify our ma­ neuvers in accordance with the tension vectors that are present, we will end up blocking the mot il ity of the tissues. This will get in the

way of the treatment, and

correction will then be impossible.

In some patients, y ou may encounter very extensive adherent restrictions, or very old ones, which are d ifficul t to resolve with simple

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quili bra t ion. In these

251

Modalities and Principles

ca ses, correction wi ll require a more active kin d of help to the tissues. The pres­ sure at the focus of the res triction must be slightly grea ter in order to induce mild stretchin g. Onc e the focal point is en g a g e d , g ra dua ll y release the pressure slightly,

and then stre tch ag ain to in cr ea s e the amplitude of the movement. Repeat thes e steps five or six times in a row.

The hand can also be us e d to s tre tc h away from the focal poin t of a restriction in order to oppose the surr ou n din g tension forces. Then come back to above the focal point to cre at e pres sure there, and repeat the same series of steps in o ther

directions a matter of five or six times each way As a general rule, when we are p u r s u i n g this kind of trea tment, the tim e it

will take for the ti ssu e s to become free is of the or d er of three to five minute s. After five minutes, i t i s usually tim e to s t o p, as too muc h stimulation may indu ce a response which is co unter to that being sought, that is, rein fo r c eme n t of the

pre-existing tensions. When one returns to an area that was rece n t ly treated, the amount of improvement is often surprising. What happ e n s in th e s e cases is tha t

the lag time for the response to treatment is increas ed. Sometimes this lag time can be as long as twenty-four hours, or even a ma tter of days, depe n din g on the h i sto ry of the l esion and the capa city of the patient to adapt. It goes without s ayin g that in the process of induc tion, as much as in lis ten­ ing' jt i s vital to respect the rhy thm of the pa tient's tissues. The minme move­ ments tha t we make should be in harmo n y with those of the tissues ; jf they are

not, the capa city of the fa sciae to re sp o n d will be overwhelmed, and only reflex s pa s m s will be induced, to the exclu sion of all o ther re sponses. Induction is more suitable for large , true fascial sheets or for generalized

eqUilibrium, while it tends to be less effective for ligaments, the mesenteries, and fa scial bands and indurations. When th e area to be tre ated is very extensive, the tec hni q ue i nvol v e s p l a Cin g the hands far ap art, thus cre ati n g two fixed points around which a whole s ection of fa scia can be manipulated and harmonized. In practice, when a fa scia is inhibited, it re quir e s an external s tabilization point

around which to reinitiate its motili t y

DIRECT TREATMENT

Principle Direct fa scial treatmen t is based on u sin g the tips o f one or more fin g e r s to en­ ter into direct co nta c t with the

inj ure d

area in order to manipul ate, stretch, and

inhibit it with a view to relea sing the restriction. This is mainly applicable t o certain speCific anatomical fea tures, i n c l u d ing the l iga m en t s mesenteries. modi­ .

fied fascial insertion points, a n d s ections of fascia e in which bands. restrictions. or areas of induration have been detected. Therefore, it is most commonly used for long-standing res trictions and well-established modifications deep in tis su e s

,

both of which are situations in which induction is no t powerful enough to re­ e s tablish normalcy

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Chapter 8 / Treating the Fascia

Here , as previously discussed, one encounters modifications to viscoelas­ tic properties and changes in fascial structure associated with the appearance of bands (usually with a pearly she en, and sometimes t wisted) or areas of induration (varying from the size of a grain of sand to that of an ol iv e pit) . Exchange pro­ cesses in such tissues are profoundly disturbed , and serious tensions are perma­ n entl y present , which leads to a vicious cycle of degenerative phenomena . In these areas , the fascia is overwhelmed and no longer capable of defending itself-it is e xha usted It is no t itself capable of overcoming this exhaustion on its ovvn and therefore needs help from vvithout in order to resume the nor m a l physi­ ological functions which were undermined by the original insult. .

Therefore, one mus t use a n appropriate technique (e.g., massage or stretch­ ing) to 'wake up' the damaged fascial tissue so that it can regain its normal func­ tionality If lef t untreated, such 'le thargy' on the par t of the tissues can last for y ears, and, unfor tunately, can act as a trigger and focal point for chronic degen­ erative processes. In our experience it is always wor thwhile to intervene in these situations even if they have been present for a long tim e, as some function can always be re­ gai n e d although perhaps on l y a very small fraction . For the patients a very small incremental recovery of fun c tio n can lead to a major improvement in quality of life and sense of well-being. ,

,

It is always somewhat surprising to people to realize that sometimes, for unknown reasons, the tissues are able to recover their proper functions and activi­ ties even aft er a long period of dormancy Everyone has heard of cases of people recovering functions or getting rid of chronic pain after small falls or other m i n or traumas. We regard these as minor "shocks" to the nervous system that can lead to the reorgan iz a ti o n of physiological circuits and pathways They remind us that on e should never give up and that , a s long as the patients are willing and inter­ ested in getting treatment, we should never regard any case as bemg hopeless. .

Techniques Direct tec h n iques involve establishing direct contact with the structure to be treated and then exerting pressure or str etc hin g force, the degree of which will vary according to the specific structure or area, the condition of the patient, and the cause of the damage. Gentle contact and very moderate force is required to restore freedom of movement in cer tain tissues , while o thers will require firmer contact and relatively strong manipulation in order to 'wake them up: as will be discussed more later. In c er ta in areas , the pressure exer ted can be near the limit of the patient's tolerance-in these cas e s, it would seem that th e p re s sure r e q u ired for elimination of the restriction corresponds to the Lewit needle effect. Levvit proposed that the efficacy of an injected d ru g depends less on the actual agent bein g administered than on the intensity of pai n induced a t the injection site, and the accuracy with which the needle (in our case, the finger) is placed at the point of maximum sensitivi ty

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Modalities and Principles

With r e s pe c t to pa i n , it was pr ev i ously mentioned that it can be a useful in­ associated with pain, whic h is , in som e cases , h ighly acute. It is p a rticularly common in association with fascial bands, isolated sp ots of induration, and fa scial insertion points. Whe n it comes to fascial p ath o l o g y, pain can be said to be an important diagnostic clue, and tha t i ts attenuati on or elimina tion is one of the markers of s uc c e s s fu l treatment. It should be taken into account, but its i n ten s ity should be g aug e d in light of the nature of the patient, where the da m ag e is l o c at e d , and the type of injury It is a fact that some patients tolerate pain relat i ve l y well, while the thre sh ol d for others is much lower. Pressure tha t induces S ign ificant levels of pain is j usti fi ed in certain areas (e.g., the pla n t ar aponeurosis), while in others, it should be avoided ( e . g. , the intertubercular sulcus). dicator, but is often mi s l e a din g. Damage to the fascia is almost always

In all cases , if we have settled up on a treatment app ro a c h which involves painful pres su re , it is unwise to prolong it beyond a certain tim e or lev e l because

to in du ce a response c o un t e r to that desired. If the tr e at ­ and p er fo rmed cor r e ctly, all pain from the t e c hnique should dis a ppe a r within a very shon per io d of time . If the tre a tment i s inappropriate or p o o rl y executed, and the fa s c ia reacts violently, residual pain ca n p ersis t for several days , even if the tre at ed area was or ig ina l l y p er fe c tly silent. excessive pain is lik ely

ment is ac cur a te

The techniques of d ir e ct fascial treatment ca n

be broken down on th e basis

of five g e ne r a l princ iple s : • massage pr e ssu r e • stretching • slidin g

pressure

• the sp e C ial

case of li g a me n ts

• st ru ct ur al t e c hniqu e s

Massage pressure This is relev ant when the zone to be treated consis ts of a single p oint or is

very

small in area, for exampl e , a fascial insertion point or a nodular are a . After t h e area

has been scrupulou sl y examined, ap p ly a g reate r or lesser degr e e usually with the thumb. At the same time, p erform a stretching mo­ tion and ro t a te the thumb as if you w e r e giving a massage (Fig. 8-1). Rather than i m m ed iat ely exertin g full pressure, s t a r t g en tly and step it up gradually-wait for the fasciae to open to let you th ro u gh . For maximum e ffi cacy, d e sp i t e the pain which you might in d u c e and the pre s su re you will have to u s e , it is important to follow th e response of the fasciae, which will s t e adily bring you to maximum pr e s sure . of p r e ss ure ,

Maintain the pressure for a few seconds , and th en recommence the manipu­ lation, s till being g ui d ed b y the fascia itself. Four or five cycles ar e often sufficient to indu ce S i g nifi ca nt improvement. S im i l a rl y, four or five r ep eti tio n s of a move­ ment are often i dea l for the other techniques ( a part from structural techniques). Do not repeat m o re than five times; inste ad, resume the treatment at a la ter date if necessary.

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Chapter 8 / Treating the Fascia

The purpose of this form of t reatment is to eliminate as much of the indu­ ration as pos sible , A good tip is to imagine that you hav e

b etween y ou r fi n ger s

a friable body which you are steadily reducing to dust. The fascia is exhausted, and th e pressure of

ssage is gradually lifting th is exhaustion, The motility and

ma

mobility of the fascia are restored, and within a very short time the

( w hich appeared to be

Fig. 8-1

induration

calcified) disappears,

D i rect Technique: Massage Pressure

Stretching These techniques a re relevant to fascial bands or areas of fascia of a few centime­ ters in size, As discussed above, the fascial bands a re often extremely tense, with

very shar p ly defined edges,

First, establish the location of both ends of the band and then pl ace the tip

of a finger at at each of these two points, Perform traction alon g the longitudinal axis of the band, tak ing into account any

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m ovem e nt

of the

ng fascia

u n derlyi

(Flg,

255

Modcllities and

8-2).

Principles fi ng ers around the

sh ar p edge

of the band. Steadily increase pe r p e n d i c ul a r tranion, still taking fascial movement into account with lo n g itu din a l traction. This second maneuver will be more painful tha n the first, so it is impor tant to perform the tec hni q u e with sensitivity so th a t the pain does not lead to guarding. Fig.8-2

Next, hook one or t wo

Stretching Technique

comes to working with fasciae (whi c h will us ua l ly be in deep r e gions, or in a cleavage plane be tween t w o fasciae). s tead i ly d escend into the deeper tis­ su e s , either with the fi ng ers of both hands, or with just the thumbs ( depen di ng on the size of the area to be treated) until co ntact . At his point, perform l o n g itu ­ dinal tranion via opposite movements of the fi n g ers of each hand. M a i n tai n i n g the longitudinal trac tion fo r c e , n ext p e rfo r m traction at right angles to the fascial When it

plane (Fig. 8-3). Take fascial movements into

ac

co u n t Juring aJI manipulations. This a pp lie s to

techniques, and won ' t be mentioned ag ain. If the tensio n is superficial and threadlike, s i m pl e trac ti o n per p e ndicular to the fibers will usually su ffi c e. In all cases, t he g oal is to stop th e fascial spasm, relieve cong estion, and thereby el iminat e tension and irritation. Here, a good tip for successful treatment is to imagine that you have a thick past e which you want to reduce to a th in film so that it can be easi ly manipulated be twe en the fi n g e r s.

all

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Fig.8-3

Chapter 8 / Treating the Fascia

Deep Stretching Technique

\

Sliding pressure

These techniques apply to l a rge circular areas whi ch are adhe ren t to the deep periosteum, either over a long length (e.g., th e tibial fascia) or following a cleav­ age fa s ci a .

� COVERING AN EXTENSIVE AREA

Slide your fi nger

along the fascia, e xer t ing moderate pressure (Fig. 8-4).

number of different situations are possible:

the fascia is abn orm al l y ridged, exert brief pulses of pres su re with flatten out the ridges and allow p assage to the next. Tbis is akin to smoothing out a cr u m pled piece of paper. If you encounter a ten se, twis ted fascial band, you should still exert brief pulses of pressure, but a dd a rotational movement in order to restore the fascia to the correct position. Thi s will resolve the tension so that you can p r o c eed with the sliding m oveme n t. A final possibility is t h a t your thumb may be blocked by a tense, edematous area. In this case, exert slightly more pressure and, if necessary, some rotation until the fascia relaxes to a llow continuation of the sliding displac e m e n t .

• If

the thumb to

•

•

� ALONG A CLEAVAGE FASCIA

As

in the preceding

case,

the tec hniq u e consis ts of sliding the thumb al o ng

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Fig.8-4

Modalities and Principles

Treating an Extensive Fascial Restriction

the cle av age plane be tween two different fascia e . You will meet cert a in p la ces which are more tense and painf ul Stop there and exert greater pr e ssur e c o u p led .

,

with rotation or p e rp e n di cu la r tracti o n . � OVER A CIRCULAR AREA

Circular restrictions are often encountered where the fascia is in direct con­ tact with the periosteum. The area is ede ma tous and raised, with its center over

the connection of the r es t r icti on to the periosteum. Apply sliding pressur e all ar o u nd the e dg e of the area, and then gradu all y progress towards the c ent er

(Fig. 8-5a).

Next, make contact at the restriction a nd ,

while ex e r tin g fa irl y strong pressure, make s tre t ch in g displacements in all direc­ ti o n s Finally, wi t h the feeling of being adhered to the t i ssues , you will indu c e .

a rotation an d th en str e tch p ri m ari ly in the direction of the main restrictions,

which is usually lat e r al ly

(Fig. 8-Sb).

The goal of all these tec hniques is the same as in the oth er cases. A u s efu l tip here is to im ag in e that you are ho l din g between your fingers an ice cube 'which is gr a d ual ly melting-always seek fluidity.

Ligaments By vir t u e of their sp e Cia l functions, ligaments are a cl a s s apart and require speCific treatment modalities. As a g ene ra l rule, make contact with the thumb and then exert pressure at right ang le s to the direction of the fibers of the ligam e n t . If pos­

sible, try to m ake an additional contact using the palm of the other hand in th e mos t suitable location to enable the two hands to work together. One ha nd will exert a stretching p r essur e and the o ther will exert a similar stretching pressure,

but will ch a n g e p ositi o n sli ghtl y in o r der to work in all the necessary pl an e s .

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Fig. 8-Sb

Chapter 8 / Treating the Fascia

Treati ng a Circular Restrict i o n

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Specific Techniques

If possible, after e stablishin g conta ct with the li g amen t it is a good idea to try to move the body around the ligament in order to allow it to relax. For example, vvh.en treating the sacrotuberous l iga m ent you should contact the middle of the lig ament with one thumb, and then s tretch the lig ament perpendicular to its axis. At the same time , the other hand is placed on the sacrum near the insertion, and increases the traction by following the direction of the fibers of the fascia. When damaged, certain liga ments become very tense and feel heaVily indu­ rated on palpation. It is necessary to restor e the el astiCity of such lig aments. This kind of strategy is reRected in the ilio lu mbar liga m e nt technique below. ,

,

Structural techniques

I use the term 'structural techniques ' to refer to those that are more forceful and have a greater amplitude of motion tha n techniques based on listening and in­ d u c t i on Str u c t ur al t echniques remain the ideal modality for tr ea ting fascial prob­ lems, especiall y th o s e of the short, deep fascial elements which are difficult to access by palpation. In most cases, structural lesions are first and foremost fascial lesions. In a large proportion, somatic dysfunction can only be sustained by the surrounding soft tissues, which gradually change, become fibro tic, and adhere to an ever greater e x te n t to the area of dysfu nctio n This is ineVitably accompanied by ongOing degenerative processes. O bViou s ly if the lesion involves the vertebral fasciae, it will be very difficult to gain access to the deep fascia e and their extensions, such as the many joint ligaments. Moreover, if the lesion is long standing, it will be under such high ten­ sion that calcification may ensue. Structural techniques are the most suitable, and definitely the most effective, in these situations. These techn iq u e s involve induc­ ing rapid stretching of the tissues to prevent their spasm. This induces relaxation, which will in turn restore fre e movement to the join t. Not all structural lesions are exclUSively m aintained by a fascial process. The ti biotarsal, metacarpopha langeal. and interphalangeal articula tions in particular seem to be sub ject to some other kind of process. Of course, the lesion is associ­ ated with a tissular component, but resolution of the tis sue problem does not necessarily correct the lesion as a whole. In practice, in these pa r ticu lar joints there is s u p e r i mposed a phenomenon of artic ul a r 'va cuum' which sticks the vari­ ous elements of the joint together, rather like a suction cup. As long as we have not succeeded in freeing up the join t and regenerating some pressure within it, it can never be fully fu nctio n al. .

.

,

Specific Techniques We are not going to systematically cover all the techniques applicable to the vari­ ous fasciae. Rather, we will focus on the general principles of treating fasciae, as introduced in the preceding section, by looking a t certain particularly pertinent examples dravvn from different parts of the body. Copyrighted Material

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Chapter 8 / Treating the Fascia

LOW E R

LIMB

Plan tar aponeurosis A s a result of the many dis tortions to which the foot is subj ect , seriously abnor­ mal tension is common in the plantar aponeurosis . Such tension will inhibit foot function, can prevent successful therapy based on structural techniques , and is sometimes the cause of a pathological h ee l sp ur. With the patient prone and their leg bent, penetrate deeply to feel the cord­ like s tructure which supports the plantar arch. First, apply s lidin g pressure, con­ centrating on the area which is most sensitive. Then hook the ligament ,-,v ith the tips of the fingers and stretch it in a transverse direction (Fig. 8 - 6). This technique is extremely painful, so one mus t first warn the patient and obtain their permission. Never exceed the limit of tolerable pain. Given these basic precautions , the manipulation should be firm but brief. Results are often very fa st-in the vast maj ority of cases, one or two sessions will suffice , alth ou g h more may be necessary if the lesion is of long s tanding and the original inj u ry wa s ver y serious. Fig. 8-6

Treat m e n t of t h e Pla n t a r A p o n euros i s

If there is a pathological heel spur originatin g from the calcaneal tuberosity, treat the plantar aponeurosis firs t , and then concen trate your efforts on the tuberos­ i t )' itself, applying pressure ,-,vith rotation. Then treat the fascia around the heel , and ascend back upward along the achilles tendon as far as th e calf, where ten­ sion most commonly resides in the cleavage plane between the two bellies of the g a s trocnemi u s muscles. Again, the pain from treatment should not la st too long. Often the process becomes reduced and sometimes disappear s a l to g ether .

Ti bial fascia The fascia which directly inves ts the t i b i a is often involved i n lower limb lesions and is often key to successful treatmen t of knee and ankle problems.

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Spec i fi c Techn i q ues

This is treated wi th the p a tient supine and their kn ee ei ther ex tended or ben t , with the fo o t resting o n the table . Apply sliding pressure along the fascia with str e tching massagin g , and rota tion a t any poin ts of restriction . Ascend back up to ,

the medial tibial plateau

(Fi8.

8 - 7) . Once all res trictions have been relaxed, it will

be possible to slide the finger all the way along the fascia withou t encoun tering any impediments to progress or inducing any pain . Tre ating the tibial fascia is often key to a problem of a sore ankl e associated \"'i th difficulty with respect to plan tar flexion. FolloWing dis tortion , the su d d e n s tre tching entailed by an in appropriate movement is e n ti rely absorbed by the tibial fasci a . Although this preserves the lig aments of the ankle, i t can create ten ­ sion and induce res trictions of the tibial fascia itself. Fig. 8-7

Trea t m e n r of the T i b i a l Fascia

It should also b e pointed out that the tibial fascia is a common area to which

gyn ecological problems are proj e c t ed . This causes changes in fascial reflexe s , usu-

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Chapter 8 / Treating the Fascia

ally a ro u n d the m i d dl e o f the lateral aspect of the tibia , and a r o un d the medial

condyle, in the form of edema , i n fil t r a t i o n , and p a i n . Tre a t in g such areas o ft e n has

an impact on the un d er ly i n g g y necological p rob l em . Sometimes the function of the entire ti bial fa s c i a is impaired without the re bein g any s p e c ifi c focal points of r e s tr ic t i o n . The tre a tme n t will co n s i s t of l is te n ­ i n g a n d i n du c ti o n : either in a g e n er al (also known as global) mode , b y placing

one hand o ve r the lower part of the tibia and the o t h e r over the upper par t ; or by a d o p ti n g a m o r e l o c a l iz e d a p p r o a c h , g r ad u a l l y moving closer and cl o s er to the l oca lized structure s . On c e this has re l e a s e d , you should finish b y using a g eneral technique that a ffects the entire fa s cia .

Thigh In the vast m aj o r i t y of cases , p r o bl e m s here involve just the lateral or j u s t the m ed i al t h i gh .

Lateral th igh Thes e

a

r e distorti o n s i nvo l V i n g the fas cia lata . Wi th t h e p a t ient supine and their

l e g s s tretched o u r , use the ti ps of two or t h r ee fing ers to apply s l i d in g press ure

along the ilio tibial tract (Fig. 8 - 8 ) . Yo u will often encounter a ripp l i n g in t h e tis­ sue s , s o rt o f like a corru g a te d roof. You must s teadily work to reduce th e i n tensity

of the r i pp l i n g , one r i d g e a t

Fig. 8·8

a

time.

Trea t m e n t o f the L a t e ra l Fascia o f t h e T h i g h

--

=-----� \_--� Painful p o in ts will be encoun tered all along t h e fascia in the form of nod­ ules-these can be redu ced by m a ss a g e and r o t a t i o n a l movement s . H e r e , a s i n all

c a s e s of fa scial trea tmen t , effective the r a p y will resul t in r e du ced tension , major

r e d u c t i o n in the a s s o c i ate d p a i n , and of course improved functionali t y.

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Specific Techni q ues

Medial th igh W i t h the p a t i en t supine , kn e e and hi p slig h t ly ben t , t h e practitioner ta kes u p a p o ­ sition to the side of the patien t , with their kn ee on the table.

R e s t the l a teral a s p e c t

o f the p a tient 's thigh against your own thi g h . Place the fing er t ip s o f b o th hands alon g the cleavage p l a ne between t h e adductor muscles , and then a p p l y a s tretch­ ing pressure (Fig. 8 - 9) . I f t h e r e is a m ore seri ous restricti o n , place b o th thum bs on the upp er edge o f the a dductor muscles a n d p e rfo r m a transverse s t re tching movemen t , pushing towards the table.

Fig. 8-9

Trea t m e n t of the M e d i a l Fasci a of the T h igh

Sciotic

nerve

foscio

We will finish w i t h t h e l ower l i m b by talking about trea tm ent of t h e sciatic nerve fascia . In the previous chap ter, it was men tioned tha t this can b e the site of chron­ ic irritation , a.n d the reason for the persistence of scia.tica . Sometimes problems

wi th this fa s ci a can even be the cause of scia tica . Per tinen t to this is an anecd o t e which is Significan t in our approach to fasciae.

J u s t about all o s te op a th s i n Euro p e have had p a ti e n t s who have re p o r t ed visiting some kind of b on e - s etter who " p u t their nerves back where they b e l on g " and, in

the case of scia tica especially, sometimes with spectacular resu lts. The technique actually consists of using the thum b-with the p a tient e i t he r prone or stand­ i n g - t o trace the p a th of the sciatic n erve all the way back to the butt ocks , or even t o trace the t e n s i o n up thr ough the lumb odorsal fascia a s far a s the cervi cal ver t ebrae. of cours e , in nearly all cases , the patient retains an indelible m emory

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Chapter 8 / Trea ting the Fascia

o f th e thu m b ligh tly caressing the area to be tre ated and l e aving a se n sa tion which took a long t i m e to disappear. Is the patient 's scia tica i mprove d ever y tim e )

This has always s u r p rised us a nd vve sought an e xp l ana t i on for man y years. In the end , the explanation is a simp l e one, y e t it is a p rofoun d understanding o f

anatomy which provi d e s i t . The scia tic nerve i s inves ted b y a fa scia , and tension in the ner ve inevi tably causes irrita tion of the fa sci a . The bone-setter is not working the ner ve, but ra ther t h e fascia . This i s an example o f how t radi tional remedies n early always have some kind of foun d a tion in truth. The ' s tre s s ' in d u c ed by t h e technique s eems to ' wa k e ' the amnesic fa s c ia up,

which sud denly realizes tha t its function i s impaired. Th e s tron g s t i mulus ban ­ ished the exhaus tion and res tored the mem or y of t h e normal physiological s i t u a ­ tion . We have adapted this principle and have often u s e d i t w i t h success. The pa tient i s prone . After y ou have iden t i fied the restricted area (which i s

usually around the middle of the thigh , a s described earl ier) , in troduce the finger tips of both hands deeply and then perform transverse, lon g it u dina l stretching

(Fig. 8 - J 0) .

Move down the leng th of the fa s c ia

as

fa r a s the calf, a t which poin t i t

will be more comfortable for you if you pla ce one thig h on the t able a n d apply pressure ab ove the pa tien t 's bent leg. Regardless of your p o sition , you then pro ­

ceed to s tretch or use pres sure to inhi bit the s p e c i fi c po i n t

(Fig. 8- 1

1).

I t i s not necessary, in the vast m a j o ri ty o f cases , to use such s t rong pressure that the p atient fee l s pain . Nor, of cour s e , is it ne c essary to work the entire lower

limb with the thumb, because the same res u l t can be ob tained by the much gen­ tler procedure.

Fig. 8- 1 0

T rea t m e n t o f t h e Sc i a t i c N e rve Fasc i a

)

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Fig. 8 - 1 1

Specific Tech n i q ues

Trea t m ent of the S cia t i c Nerve Fascia

After such an approach , we o ften observe improved fun ction , no tably a t tenua ­ t i o n or disappearance of Laseg u e 's sign . O f cours e t h i s te chnique is n o t t h e only ,

tre a tm e n t

m od a

l i t y for scia tica, and is always c o upled with a scrupulous exam i ­

na t i on for pos sible causes. Moreover, i t o fte n needs t o be combined with oth er t e chni q ues.

P E LV I S We will n o t go into how to release the sacrotuberous and sacrospinous lig aments or th e pirifor m i s muscle in any detail because these techniqu es are familiar to all. However, we would em p ha size that the s a cro sp in o u s lig a men t is o ften a key fac­ tor in pro b le ms o f the pelvis a n d the lower limb. I t should therefore b e inspec t e d as

a

rou tine procedure . We \;vill concentrate ins tead on two spec i fic techniques

for : •

the fa scia e o f th e gluteus muscles

• the il iolumbar and lumbosacral li g aments

Fasciae of the glu teus muscles These fa sciae cover an extensive area and are quite active, especially in the s tand

­

in g pOSition . With the p a tient prone use the thumb to a s tre tchin g or inhibition technique

can

ap

p l y sliding pressure. Alternatively,

be u s e d . Tre a tment s h o u l d be applied to

th e followin g area s :

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Chap ter 8 / Treating the Fasci a

•

the line of insertion along the iliac crest where fascial bands and

nodular areas are often encountered •

(Fig. 8 - 1 2)

the fasciae inves ting the various muscles whic h t rave rse o bli quely and inferola terally ; to b e effec tive, you must penetrate deeply between the various bundles o f fibers

•

the insertion line of the fascia all the way along the l a teral edge of the sacrum as far a s the contact with the bone . Fascial bands and nodular areas are often encowl t ered here as well

Fig. 8 - 1 2

Trea t m e n t o f t h e G l u te a l F a s c i a e

Better results are often o b ta ined if the techniqu e is performed wi th the p a t i ent standing. For example, to trea t the fascia on the righ t , s tand behind and support the p a tient. Pass your left arm below tha t o f the p a tien t , and encircle the m . Then , while supporting the p a tient on your l eft arm , translate the pelvis towards the left as you incline the chest towards the right. This will relieve the tension at the level of the fas cia and help your work with your r i g h t hand.

Ili olum bar l igamen t This tigh t , rop e - like s t r u c ture is found between the transverse muscles of L4 and

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Specific Techniq u es

L5 and t he iliac cres t . It is e s s en t i a l t h at this be treated if y o u want to norm alize

the lumbosacral j u n c t ion.

A s p r eviously discussed, this t echnique de p en ds on the pa tient s t anding erect ; i t is not effective with the patient prone because th is l i g a m en t m u s t su p po r t

we i g h t in o r d e r to be r e a dy for treatme n t . Tak in g , by vvay of exampl e , trea tmen t o f t h e ligament on the r i gh t -h an d s ide : The pa tient s t an ds with their legs sligh tly apar t . The practitioner should take

up

p o sit ion behind the patient and in c o n t a c t with their b a ck . Pa ss your l e ft arm

a

under tha t o f the pa tient to encircle and s tabilize them . Position your r i g ht thumb over the

middle of the li g a m en t and exer t pressure a t r i g ht a n g l e s .

Ve ry o ften , even mild pressure proves excessively pa infu l a n d i t i s v i r t u a lly

i m po s s ible to depress th e l i g a m en t , which fe els as if it is calcified. Therefore, for this lig a me n t , it is o ften necessary to m o bilize the whole body to reinte grate the l ig a m en t i n t o th e g e n e r al layout . To do t h i s , flex the p atient (to a gre a te r or lesse r extent) by simply p ul l i n g back a small distance on the ir p elvi s . The pa tient 's fee t should not move a t a ny ti m e d u r in g thi s m an i p ula ti on . Then b r i n g the p a ­ t ien t i n to r i g h t s i d eb e n d i n g a n d then left rotation (Fig. 8 - 1 3 ) . Throughout a l l o f these m an ipula tion s , maintain pressure on the li g a m en t "vi th t h e right thumb, the

amount o f p r e ssu re d ep en d i n g on the de g ree of ass o ci a t e d pain . You m u s t r e p e a tedly re a d j u st the p o sition of the body a round the l i ga m e n t as th e technique progresses. Come back to the o r i g in a l position before re int r odu c in g

t h e va r iou s p a ram e ters . The difficul ty with this t ec hni q ue is r e la te d to the fa c t tha t t h e pa tien t is a fraid of fa lli n g and tends to tense up , w h i c h makes the p ro c e d u re im p o ssi ble .

Therefore, it is i m p o r t a n t to c a refu lly explain wha t is g oin g to hap pen a nd w h a t i s ex pe c ted of t h e p a tient. Then proceed o n l y a s l o n g as h e or sh e is t o t all y relaxed.

In o r d e r to reassure the pa tien t , make sure th ey a re bein g firmly su pp o r t e d , and

fo r extra reassurance, y o u c a n b r i n g your left leg round in contact with the side of the p a tient ' s , whic h p ro v id e s a second s u pp o r t p l a ne . This can be used as a first l i ne tre a t m en t , but for maximum e f fi ca c y, it sh ou l d be undertaken a fter other

t e ch n i q u es , for e x a m ple , a fter a r ticular techniques on the soft tissues of th e p e l ­ vis , or a fter s tructural correction . When executed correctly, this technique resul t s i n

a ma j or

i m p rovem e nt in

th e c a p a C i t y for an terior flexion , which will fa c ilitat e the process of normaliza­ tion .

Lumbosacral ligamen t This t ec hniq u e i s more o r less the same a s t h e one described above for the ilio­ lumbar li g a m e n t . Place one thumb ov e r the upper par t o f t he sulcus and pu t the

pa tien t into

a

p o s i ti o n of extension , r i g ht s ideben din g , and left ro t a tio n . It should

be mentioned tha t this ligamen t is not involved nearly as often as the iliolumbar li ga m en t .

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Fig. 8-1 3

Chapter 8 / Trea ting the Fascia

Trea t m e n t o f t h e I l i o l u m ba r L i ga m e n t

! f { �\ T H O R AC I C R EG I O N

Thoracolumbar fascia O n e of t he quintessential fascial reg io ns , thi s one i s pron e to many fa scial prob­

lems . I t is t r e at e d with the p a t i en t prone. S t a r ting a t the sacru m , apply a sliding

pressure , m oving up a s far a s the cervical vertebrae

(Fig. 8 - 1 4) . You will encounter

fascial b ands , nodules , and circular b u ndl e s of fibers which are both extremely tense and very extensive.

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F i g. 8 - 1 4

Specific Techn i q u es

Trea t m e n t of t h e T h o rac o l u m ba r Fasc i a

you h ave r e a ched the in terscapular region , y o u will

often encounter ten­ sions running in an ob l i q u e direction towards the scapula s . The posterior fa c e of the scapula is often a fo cus for fascial tension , b o th above and b el ow the process.

Once

To trea t these, appl y a sliding pressure in an oblique di r e ctio n towards the shoulder (Fig. 8 - 1 5 ) . Isolate the tensions be tween t h e m uscular bundles a n d isolate the n o dular zones , some of which will b e like very tense, h y per s e n s i t ive balls of t is s u e Tre a t the s e with s tre tchin g , p r e s s u r e, ro tation , and inhibition . Do n o t for g e t to a p p l y s lidin g pressure all a l o n g the lateral edg e of the s c ap u l a where dis tortion .

,

is common (Fig. 8 - 1 6) .

Treatment o f t he

thoracic region i s sometimes more effective with the

seated. In t hi s position the

force of gr avi ty

p at i e n t who

c a n be of h elp. I n elderly pa t i e n ts

difficult to move and for whom p r ud e n c e is the wa tchword , nique with the p a t i e n t s eated is usually s u fficient for l umbosacral be employed b y itself with immediate, lon g -las ting resul t s . are

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270

Fig. 8- 1 5

Cha p ter 8 / Trea ting the Fascia

Trea t m e n t o f t h e S c a p u l a r Fasciae

Fig. 8- 1 6

Trea t m e n t o f t h e L a t e r a l Sca p u l a r F a s c i a e

Pos terior fasciae Cer tain individu als suffer fr o m gen e r al i ze d tension o f the pos terior fasciae , w i th

di ffi cul t y be n d i ng forward s . If th ey a r e l y in g dovm and one of their lower limbs is r a ise d the fl exion a n gl e will be very res tricted and pain will soon be induced. A general fascial t e chnique ca n qUi ck ly improve the p a t i e n t s condition- this te c h niq ue is equivalent to a lum bar r o l l b u t \"'i th no local speCifiCity ,

'

,

With the p a t i e n t lying on their side, the p ra cti t i o n e r stands facing the pa­ tient. Bring the upp e r part into mild posterior ro t a t i o n by a n t e r i or and cephalad

traction on the extremity that is

in

m a i n t ai n e d in a straight position ,

the t a ble

c on t

a c t with the table. The l eg on th e t abl e is

while the o th e r one is flexed a nd da ngl e d o ff

.

Contac t is m ad e with o n e elbow on the upper p a r t of the thora x

and

the o t he r

on the pelvi s . Introduce some t ensi on

by increasing the ro tati o n and adding lon ­ same time, usin g your foo t , hook the leg off the table so as to bring it into flexion and a d du c t i o n , there by in c re a si n g the ten­ sion. Make su r e tha t it remains as st rai gh t as p o ssi ble thr o u g hou t this pro ce dure (Fig. 8 - 1 8) . A varian t i nvol v e s the practitioner p O S i ti o ning him or herself behind t h e p a t i e n t s l e g from the o u ts e t . gi t u di n a l

traction (Fig. 8 - 1 7). At

the

'

The fin a l p a r t of the t echnique i nv o lve s p e rfo rming a

rapid stretch by

m e ans

of a non -specific thrust. B o th ar m s execute a l o n g i tu di n a l s tretch , while the left leg is used to a cc e ntu a te the flexion adduction of the p a ti e n t s lower limb. This techniq u e should b e p e r fo r m e d on both sides and the resulting im p rov e m e n t in mobility should be significant , imme d i a t e , and l o n g - l a s ti n g '

.

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Specific Techni q ues

Fig. 8- 1 7

G e n e r a l T rea t m e n t o f Poste r i o r Fasciae: Move m e n t o f T r u n k

Fig. 8-1 8

G e n e r a l Trea t m e n t of Poste r i o r Fasc i ae: Move m e n t of Leg

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V E N T R A L R EG I O N The ventral region is divided into tvvo different p arts , nam el y the t horax and the ,

abdomen , which are separ a ted by the diaphragm . The trea tmen t of abdom i nal fas­ ciae involves the anterior ver t ebral li g ament and the viscera-classic fas ci al a rea s . T h e s up erfici al abdomin a l fasciae a r e rarely i nvo l v ed i n p a tholo g y We will follow this with d e s cr i ptions o f tre a tments for the d i aph ragm and thor a x For the latter .

,

m o s t treatmen ts are directed at the s t ernum .

An terior longi tudinal ligamen t The pa tient is supin e , l e g s ben t , and fee t resting on the tabl e . The practitioner takes up a po s it ion to the side of the pati en t a n d , using the fi ng ers of both hands,

gradually depre sses t h e linea alba to make contact with the li g ament. A fter e xe r t

­

in g m ild press u r e , execu t e a l on g itu di n al s t r e tc h i n g movem ent by movin g the hands away from one another (Fig. 8 - 1 9) . Follow this w ith

a

tr a nsverse s tretc h .

T h i s techni q ue must b e performed g en t ly a n d should b e avoi d ed if i ts execu­

tion pre s e n t s any p r ob l em . It is often useful and e ffective i n pati e n t s with cb rollic low back pain or sciatica. Remember not to go above the aortic bifu rcation . Fig. 8- 1 9

Trea t m e n t o f t h e A n t e r i o r L o n g i t u d i n a l L i ga m e n t

Viscera I t i s n o t at all our intention to review all the visceral techniqu e s , as this h a s been

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Spec i fi c Techni q ues

done comprehe nsively in many other texts , primarily those of Jean -Pierre B a r­ ral . We vvould only point out that fa scial techniqu es are j u s t as applicable to the viscera . In fac t , visceral treatment is no thing more or less than a kind of fascial treatmen t .

I n this regi o n , listening a n d induction is sys tema tically combined with di rec t trea tmen t . As a g eneral rul e , i t is b e s t t o b e g in with lis tening a n d induc tion and proceed to direct treatment if necessary This can then b e followed by a n o ther ro u n d of lis tening and induc tion a s a way of finish i n g. If there is any part of the body in which p a s s a g e through the varions levels of fa scia mus t be done with caution and g e n tlenes s , it is the abdomen. Always wait until the fa sci a e let you through and never, under any circ u m s tances , try to break through a resistant barrier. As a general rule , the listenin g and induc tion phase will involve sliding the hand towards the restric tion , maintaining some d e g ree of pressure there , and then , if necessary, slightl y increasing the level of pressure to induce s o m e stre tching. Then re t urn to the s ta r ti n g p osition and rep e a t the operation . Al though you will o ften find an axis of tension or a preferred direc tion of movement, always bear in mind that re -equilibration mus t includ e all three s p a ­ tial planes , and that if one plane is favored, it mus t b e cons tantly readj u s te d with respect to the o thers if the technique is to be successful . Pro gress can only be made by moving with the fascia e . I t should be enough to follow them and then make them work with a very sli ght chan g e .

If t h e techniques of listening a n d induction prove i n s u ffici e n t , y o u mus t pro­ ceed to direct treatm ent. The principle is the same as for a ny o ther fascia , b u t m o r e caution s h o u l d be exerci s e d . I t w i l l be n e c e s s a r y to p e n e t r a t e d e e p i n t o t h e abdom en , a n d this c a n only be d o n e with the con sent o f the fa sci a e . Yo u mus t wait a s long

as

necessary for the chance to pass , a n d i t is vital to follow the move ­

men t of the fa sciae a t all time s . All this means that you m u s t overcome a ny desire to g e t ahead of wha t the fasciae will allow. The a c t u al techn i ques are b a s e d on s t retchin g , pressure , rotation , and inhibi­ tion . The fa scial bands mainly correspond to the mesen tery, the fascias o f Toldt and Treitz , and even the vessels i n the case o f real adh esions . N o dules are p a r ticu­ larly common around the sphincters ( the pyloriC sphincter, sphincter of Oddi, and the iliocecal valve) .

Diaphragm Bo th fascial continu ation and fascia itself, the importance of the diaphragm in hu­ man p hysiology has already been discus s e d . Therefore , it should be understood how importan t i t is th a t its movement should be free and unencu mbere d . G e n eral tec h n i q u e

The patient is s upine w i t h their l e g s b e n t and fee t resting on the tabl e . T h e prac­ titioner takes up a posi tion to the side of the p a ti en t , faCing cephala d . With hands

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Cha p ter 8 / Trea ting the Fascia

s prea d open w i d e make as much contact as possible w i th th e lower rib s , with the ,

thumbs poin t in g towards the x ip h o id process (Fig. 8 - 2 0) .

Focusing o n b o th m o b il i ty and m o til i ty first equilibrate one hemi thorax a t a ,

t im e , and th en reharmonize them with respect to each o ther. By the t i m e th is is

done, the d i a phr ag m and its related

s t ru ctures

should be able to move feely

in all

spatial planes . Fig. 8·20

Treatm e n t of the D i a p h ra g m: G l o ba l Tec h n iq ue

Muscular techniq ue Wi th the p a ti e nt and the practitioner in t h e same p o s i t i on s as above, place both

hands on one si d e of th e thorax with t h e thumbs penetrating bet ween the ribs to

co nta c t the muscle insertions. Gradually a dva n c e the thumbs as cephalad as pos­ s i b l e Correct any r es t ri c t i on encountered w i t h s tretchin g a n d i nhi bi ti o n pressure .

by m o vin g the thumbs in opposite di r ect i o n s

other side of the th o r a x.

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(Fig. 8 - 2 1 ) . Then p ro c e ed to trea t the

275

Fig. 8·2 1

Speci fic Techniques

T rea t m e n r of t h e D i a p h ragm: M uscu l a r Tec h n i q u e

This t ec hn i q u e should b e followed up b y a g ener al i z e d reharmonization pro­ cedure. Since the pillars of the diaphr ag m are not directly accessible, they are more amen able to the struc tural t e ch n iq u e that mobilizes the lumbar vertebrae to which they a t ta c h . N ever elicit pain when ap pl yi ng this second techniqu e , be­ cause it will im m e d i a t e l y tri g ger a reflex spasm which will push the fingers ou t .

Sternum Ag ain , in this reg ion , the fascia is in direct contact with the bone. Moreover, in the

deeper area is the pericardium . As previously men tioned , this is particularly s ens i ­ tive to stress and so is commonly subj e c t to fascial di s tor tio n . Fascial bands and

nodular areas are very common i n t hi s region , p a rticularly in the central portion, and secondarily on the sides and a t the apex of the s ternum . Work on the sternum can S i g n i fic a n tly improve palpitation s , ta chycardia , s tres s , and anxi ety.

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Chapter 8 / Treating the Fascia

Ind uction With the p a tient supine the practitioner t ake s

up a po s i t i on to the side or at the head of the patien t . Place one h a n d over the sternum , making as much contact as p oss ible and exerting a sucker effect. Here , the co m m o n problems are twis ting , pos terior attraction, axial tightening of the sternum , o r s o m e combina tion of these. The g en e r al th e r ap e u tic princi p l e is t h e same as anywhere else : s t a r ting a t a favored axis , re-harmonize the s ternum in a ll its parameters so tha t it once again ' floats ' c o m p le tel y freely (Fig 8 - 2 2 ) . ,

Fig. 8-22

I n d uc t i o n o f t h e S te r n u m

D i rect techni q ue Wi th the p a tie n t s till in

the same position , apply

along the lateral e d g e s i n the man­ is particularly useful to follow up this techslidi.ng pres s u re all

l eng t h of the s t ernum , both its m e dian segment and its ner

of all d i r ec t

techniqu e s . Here it

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,

277

Speci fic Techn i q u es

nique with listening an d i nduc t i on.

Often, acute pain will result and i t is importan t to correctly modulate the pressure. If inappropriate pressure is applied, the patient may continue to feel pain (usually a b u rn i ng or insect bite type of pain) for several days . If the pres­ sure llsed was really excessive, the pain may persist for a matter of weeks , which risks becom ing a genuine inconvenience for the patient and a pos s i b le source of anxiet y. U PPER LIMB The upper limb is working almost a l l the time and we consider i t as some thing

of a special case. This is based on its morpholo g y, how i ts fa sciae function , and its responses . Des p i te its non-s top activi ty, i t presents fewer problems than other parts of the b ody, apart fro m i ts root, which, by contrast, seems to accumula te pro blems, the rea sons for which we have already discussed. It responds poorly to techn iques based on lis tening and induction , but is relatively a menable to direct techniques. We w i ll deal separately with techniques for : • • • •

t h e forearm the elbow the arm the shoulder

Forearm Fascial bands are less common here. More common are tensions in t he cleavage planes i n the shape of s t ra i g h t or twisted ropes . Nodules are also common and a r e often very painful . With t h e patient supine, apply sliding pressure to the anterior or posterior face o f the forearm , moving up a s far as the elbow. As a rule, this sliding will b r i n g you towards the medial or la teral epicondyle along two favored axes which are the most common sites for restrictions , especially on the la teral (radial) side. In g enera l . the hardes t working region is along the edges of the brachioradialis muscle, especially its anteromedial edge. When manipulating the medial (ulnar) par t , the pressure should b e s trong er. If the tension there is strong , it will be terminated in the lower part by the prona­ tor quadratus and in the upper part by t h e o b li qu el y oriented muscles. This will sometimes feel like a hypertrophic ball and w il l be very pain fu l As you advance, feel the tense fibers running longi tudinally and try to stretch them in a perpendicular direction (Fig. 8 -2 3 ) . Similarly, feel the circular areas deeper down and correct them using massage, rotation , and inhibi tion. Working on the forearm often elicits pain . Sometime s , pain-inducing degrees of force must be used in order to guarantee efficacy, therefore always forewarn the patient and obtain their consen t . Given this , the results can b e truly impressive . .

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F i g. 8-23

Chapter 8 / Trea ting the Fascia

Trea t m e n t of t h e Fasc i a e of t h e Forearm

These techniques for the forearm are par ticularly e ffe ctive for cramps in the hands , morning stiffness of the fingers , p a i n when using the fingers , and ra­ dicular arthrit i s . When they are combined with work on the thu mb, they can be

effective in patients w i th carpal canal problems a n d , of cou r s e , with any kind of tendin i tic irritation in the forearm o r the elbo·w. Shoulder problems s o m e ti m e respond to fascial treatment of the fo r e a r m This j us t re quires that one follow the .

chain of fascial elements.

Elbow The elbow represents a relay point between the an t e ro l ate r a l and p os te ro l a t e r a l fa scial chains of the forearm , a n d t h e l a teral c h a i n of the upper arm . In this re­ gion , the fasciae are p articularly hard-working and the most common problem

is ten d i n i t i s on the l ateral side. Tendinitis of the medial epichondyle i s much less common . Osteopaths are o ften consulted for epicondyli tis , which responds ,,veil to fascial treatmen t . T h e treatment is d o n e w i t h t h e p a t i e n t s u p i n e . Before you arrive at t h e actual elbow, you must tre a t t he fa scial chain of the forearm . In the vast ma j ority of

cases , this chain is con tinuous with the medial anterior edge of the brachioradia ­ lis mus cle

.

Next comes the epicondyle, where fascial bands of n odular insertion areas a re common . Thes e can a c t as foci of calcifica tion . Exert firm i n h i b i t i o n pressure on

the pr o ble m point a n d , if necessary, stretch the fibers ( 8 - 2 4) . The success of the t e c hniq u e seems to be propor tional to the amount of pressure used . As a result ,

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Spec i fi c Techni q ues

the technique is often a ssociated with particularly acute p a in and should therefore be accomplished quickly. For best results , you mus t extend work on the elbow with trea tment of the lateral chain of the a r m .

Fi g. 8-24

Trea t m e n t o f the Fasc i a e of t h e El bow

In general . fun ctional improvement is immediate. A s in every cas e , the difficult

issue is how to gauge the degree o f needed pressure. Above a n d b eyond a cer tain level , more pressure is useless and can even exacerbate the symptoms. In practice, the amo u n t of pressure n e eded depends on the etiology of the tendon itis , and pain-inducing pressure is quite inappropriate in some forms . Your j udgment

must

depend on careful ques tioning of t h e patient a n d your own experien c e .

Arm In the arm , most problems involve the la teral chain , as this is where most of the

tensions focu s .

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Chapter 8 / Treating the Fascia

Wi th the patient supine , exert a sliding pressure from the elbow up to the deltoid ' V ' (Fig. 8 - 2 5 ) . H ere , there

will

cas e s , a circul a r area of in fi lt ra t ion

longitu dinal fa scial bands with , in some which can be t re a ted by m a s s age a n d ro ta­ be

tion .

d e l to i d V is o ften a focus of hyper trophy, which sho uld be t re a ted with inhibi tion pressure and t rans v er s e s tre tching. Then continue e i ther forwards or backwards , or even via the middle of the deltoid, depending on the direction of the tension . The

Fig. 8 - 2 5

Trea t m e n t o f t h e F a s c i a e o f t h e A r m

)

V\ ; :----

Shoulder

.

The s houl d er is the ultimate fascial j u n c ti o n vvhere a lar g e number of diffe r en t aponeuroses and o ther fascial elements mee t The fa sciae aroun d the scapula have to work very hard , and the treatment o f this reg i on is ex tremely critical, requiring

.

e x t ensive explor a tion In additio n , in s trictly local term s , fascial treatment can be of enormous benefit.

,

T h e pa t ien t should be sary for a

s e a ted ,

as

the e ffect

of the wei g ht of t h e arm i s n e ces

good re sul t becau se it prOVides some traction . The the p a ti en t , supporting their back . Apply

up a po s i t io n behind

p r a c t i tioner takes

a sl iding pressur e

along th e cl e avage plan es of t h e del toid muscl e , m oving towards the

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­

d el toid

'V'

281

Speci fic Tech n i q ues

(Fig. 8 - 2 6 ) . Yo u "vill o ft e n encounter deep fa scial bands , which should be treated by inhibition pre ssure a n d transverse s tre tchin g . Fig. 8-26

Trea t m e n t of the Fasciae of the S h o u l de r

Next , treat t h e a r e a around t he scapula using t h e s a m e techniques a s above. Some­ times i t i s wor th checking the upper end - p oint of the medial brachial chain by introdu cing the thumb into the a x il l ary fo ssa . Do not i g nore the fa scial chain of the upper l im b bu t for this , a s previously discussed, the p a tient should be s u ­ ,

pin e . As w i t h everywhere els e , trea tment of the fasciae of the shoulder elicits p ai n ,

bu t , i n this region , i t i s especia l ly impor tant t o know how t o control the amount of p ai n you are causing. Too much pressure will induce too s trong a reaction ,

which will end up by exacerbating the symptom s . The intertubercular sulcus , often a focus for ex tremely painful irri t a tion , warrants special caution and mu s t

n eve r be su b j e ct to exaggerated pressure . N ECK

Shoulder g i rdle Wi th t h e p a t i e n t supine t h e pra c ti tio n e r ta k e s up a p o s i t i on behind the p a ti en t 's he a d . Place your thumbs in front of the anterior e d g e of the trapezius muscle ,

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Chapter 8 / Trea ting the Fasci a

pointing towards t h e fi r s t rib, a n d close to t h e vertebral a x i s . R e s t your index fing ers on, and parallel to, the subclavicular fa scia e . Press with the palms o f the hands on the lateral clavicl es and the apexes of the shoulders. The middle fin gers rests on the p e c toral muscle while the ring and li ttle fingers are on the shoulders and deltoid muscles (Fig. 8 -2 7) . Exert mild p ressure with the t h um b s . Often , one side will b e more resis tant than the o ther and may feel like a round ball which is difficu l t to depress Per­ form lis tening and induc tion , with the thumbs following the m ovemen t of the tissu e s . Fig. 8-27

T re a t m e n t of the Fasciae of the S h o u l d e r G i r d l e

/ \

Nex t , you can increase the pressure and combine it with lig h t rotation and s tretch­ ing in the app ro p riate direc tions . The ' b all' will gradua lly resolve under the action of the thumb, and the p a tien t 's p a i n in response to the press ure will disappear. At the same time, the fing ers should be con trolling the tensions at the level of the shoulder s . If this tension is too grea t , perform listening and induc tion in order to bring i t back to normal . This technique s h o u l d not involve any heavy pressure and should b e comple tely p ainless. Relaxa tion should occur w i thin no more than three minutes , a t m o s t .

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Spec i fi c Techn i q ues

You will oft en find major tension around the shoulder which a c tually pre­ ven ts this techniqu e . Should this be the case , perform a d i rect

long

lever tec hn i q ue. This

is done by supporting the p a tient 's head very sec urely with one hand under the base o f the skull , and additional support from your abdomen . Your o ther hand is p l a ced on the apex of the shoul der. Exert pressure using the hand at the shoulder whi l e simultaneously sidebending and rotating the cervical vertebrae toward the opposite side. The Sllccess of this techn ique depends on side bendin g along with the correct level of flexion or extension and the r i g h t degree of rotation in order to ob tain the maximum abou t of tensio n . This technique a l s o represents a g eneralized treatment for the lateral fasciae o f the neck. When this is finished , perform the preceding technique.

Carti lages The cartilages of the neck have signi fi cant fa scial connections and often require trea tmen t . Wi th the patient supine the practitioner i s posi tioned o n either side o f the pa tient's hea d . We will u s e the right side in the examples below. This technique req uires sequential opera tions , starting wi th the general and proceeding to the more specific. Firs t , place your left hand on the patient 's forehead , with the fingers o f your right hand placed alon g the left e d g e o f the thro a t . Rotate the head to the left while translating the throa t s traight to the right

(Fig. 8 - 2 8 ) .

As the technique pro­

ceeds , slig htly increa s e the pressure from the right hand , especially at the point of maximum tension . Then rotate the head to the r i g h t and , using the thumb, push the cartilages out towards the left . Nex t , tre a t the hyoid bone following the general princi p l e of inducing mild s tretching away from the fo cus of resistance, gradually increa sing tl1e force as you continue

(Fig. 8 - 2 9) .

Stage three involves taking the hyoid bone between the thumb and index finger o f your left hand and the thyroid car tilag e between the thumb and index

fing er of your right hand . Perfo r m coun ter- transla tion of the two c a r tilages in order to put the point of resistance under tension

(Fig. 8 - 3 0) .

Proceed in the same

way to s tage four and treat the thyroid and cricoid cartilages in a similar m anner. Thi s technique can soon become ex tremely painful and is frankly distressing for certain patien ts . Therefore, it i s important to increase the pres sure very gradu ­ alIy. When performed correctly, i t can be of gre a t ben e fi t to p a tients with a sore thro a t , hoarseness , or irritation , or whose voice has chan g e d in some way. We once treated a patient who, following an inappropriat e movemen t , sud­ denly fo und that they could no longer sing in tun e . Cartilage treatment to the neck immediately restored the patient's voice to normal . We have also treated an opera singer who, whenever she had a stiff neck , could no longer reach the high notes. Again , a simple cartilage trea tment resolved the problem. We have seen many, many cases like thi s .

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Chap ter 8 / Trea ting the Fasc ia

Cervi copleural ligamen ts The p a tient is su p i n e with the practitioner s ta t io n e d behind their h e a d . Take the ,

base o f th e skull in your hand and su pp o r t the p a tient 's head on your abdom en . With the thumb of t h e o ther h a n d , make contact with the ligament to be treated. Sidebend the head ipsila terally while m o n i t o ring the relaxation of the l i g am e n t

'vvith t h e thumb and exerting mild pressure there to take up any sla ck . R e a d j u s t the position in all planes with the thumb mainta in i n g the tension of the ligament . U s ua lly you will need to slightly flex , extend , r o t a t e and sidebend ,

t o get t h e maximum effect. Wai. t until relaxation is com p lete , with constant read­

j u s tment o f p o si tio n .

The final phase i.nvolves m a in tainin g c o n t a c t with the li g ament a n d b r i n g i n g the cervical c o l u mn into sideb ending towards the oppOSite side

(Fi8. 8 - 3 j ) . This

t ec h niqu e warrants a high d e gr e e of caution b e c a us e of the s t r uctures associa ted with the pleural dome . If the manipulation is p o orly e x ec u t e d i t is not uncom­ ,

mon to i n d uce redness o f the fa ce, dizziness , and even mild malaise. Fig. 8 - 2 8

G e n e r a l T r e a t m e n t o f t h e A x i s of t h e N eck

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285

F i g.

Spec ific Techn i q u es

8- 2 9 " "H"y o" i d" Trea,,trne n t "

. . . . . . . . . . . . .

(

F ig .

em 8 � 30. ,Treatm . . .

,. . . ,

of t h e H y o i d a ,n d T h Y r o i d � a r t i lag� , , ' , , .... .

/"-

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.

-

./

286

Fig. 8- 3 1

Cha p ter 8 / Treating the Fascia

Trea t m e n t o f t h e Cervico- P l e u r a l L i g a m e n t s

(

\

\

() ,

CRAN I UM

Scalp The p a tient is s u p in e , with the practitioner s t a tio n e d behind their h e a d . You will find circular areas o f sli g h t swellings along w i th d e p r ess ed areas arou n d the s u ­ tures . U s in g your fi n g e r tip , apply s l id i n g pressure convergin g towards the center of the restric tion ( F ig. 8 - 3 2 ) . For circular area s , con tinue into the center and the r e exert mild pressure, displacin g the fascia in all directions with respect to the p eri-

0s teum (Fig. 8 - 3 3 ) . A s previ ously men tioned , the circular raised areas are often s equel a e o f shocks

and can give rise to lesional chains

whi

ch propagate downward s . De p res si on s a r e

u s u a lly a s socia ted with tiredness , overworking , headaches , and s tre s s .

Occipi tocervical j unction The o ccipitocervical j u nction is t h e ultimate area of adaptation a n d compens a ­

tion . I t is a focus for unremitting t e n s i o n a n d i t is r a r e tha t its movements are compl e t ely fre e.

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287

Fig. 8-32

Spec i fi c Techn i q u es

Trea t m e n t of t h e Exocra n i a l Fasciae: C o n verge n t P ressu re

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fig. 8-33

. . . . . - . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . .

Trea t m e n t of t h e Exocra n i a l Fasciae: C i rc u l a r R u b b i n g

. . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

. . . . . . . . . . . , . . . . . .

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Chapter 8 / Trea ting the Fascia

The patien t is su p in e , with the practitioner stationed behind their head. Position the fing ers of b o th hands in the area of so ft tissue j u s t below the b a s e o f the skull (Fig. 8 -3 4) . Exerting mild press ure with the fingers , and monitor the relaxation of th e tissue s . You can move your hands apar t to generate lateral stretching. Finally, a t the same time, maintaining the pressure, flex your fingers to g enerate local stretching in a longitudinal direction . After this, place the finger tips on the cu rved line of the OCCi p i t al ridge. Here, the auricul a r branch o f the va gu s nerve p a s s e s thro u g h an area o f o s t e ofib r ous tissue and it is not uncommon to find that i t is compressed. This i s a good op­ p o rtu n i ty to palpa te and then t r e a t a cranial nerve . W ith j u st the pressure from the weight of the head , wait for the tissues to rela x . If the fing ers detect a fascial band or nodular area , treat i t a ccordingly. Fig. 8-34

Treat m e n t of t h e O cc i p i tocerv i c a l J u n c t i o n

General treatmen t of the superior fasciae The p a tient is supine, w i th the practitioner sta tioned behind their hea d , support­ ing the base of the skull with both hands in an open V-shape. The thumbs should

be placed along the mastoid process and m a n d ib le . Generate very mild traction a t the same time a s r ea d ju s t i ng the flexion of the occiput on the a tl a s to make the traction a s speCific as possible (Fig. 8 - 3 5 ) . I n this p o si t i o n , i t i s possible to exa mine all the posterior a nd l a teral fas ciae . Depending o n the k in d s of tension detecte d , readj ust the entire s uperior segmen t by s m a l l m oveme n t s of flexion and extension , sidebending , and r o tatio n , and

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Specific Techni q ues

then wai t for the tissues to rela x , Obvio usly if there is a profound dis turbance a t ,

some r e m o t e poin t , you should specifically tre a t t h e problem a t its sour c e The .

more accurate and spe cifi c the trea tmen t , the more likely i t is to be e ffective . This te c h n ique is suitable when the t wis ting is g en eralized or as a follow-up proced u re LO s o m e kind of speci fic treatment m o dali ty. With prac ti c e , you will be abl e to go down quite l ow in order to c omple te the technique, bu t it would be an illusion to think th a t every thing can be trea ted with this technique . Fig. 8-35

G l o b a l T re a t m e n r o f the S u pe r i o r F a s c i a e

V E R T E B R A L D U R A M AT E R The di ffer e nce be tween this techn ique and the preceding one i s very subtle, The p a tient is supine , with the prac ti tioner s tationed behind their hea d , Bo th of the prac ti ti oner s hands are more or less aligned , one next to th e o ther, alo ng the '

curve d line of the occipi tal bone. The first s tep is to readj u s t the a tla s / occipu t flexi on / ex tension to align the force s along the axis of the dura m ater, Genera te very m il d traction , more a s if you were about to induce such trac t i on ra ther than ac tually induCing i t . Gra du ally increase the trac tion as its e ffec ts move down the colu m n

(Fig. 8 - 3 6) ,

When you detect

a

res tr icti on s top there a n d , if necessary, adj u s t sidebending ,

and rota tion to focus the forces and wait fo r the rel a xa t ion of the tissues whil e slightly i n cre a sin g the tens ion Then release the tension and resume it until you ,

fee l freedom o f m ovemen t . O bviou sly, if a serious res t riction i s detec t e d , y o u m u s t perform a prelim i ­ n a r y structural tec hniqu e ra ther t h a n hopin g for relaxation, which m a y t a k e an inord i nate amount of tim e . However, fo r minor tension or a s a complemen t to a ,

s tructural t e c hnique this m e thod can be very effective and p erfe c tly suit a b le ,

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.

290

Fig. 8-36

Chap ter 8 / Treating the Fascia

Trea t m e n t o f t h e Verte b r a l D u ra M a t e r A x i s

G E N E R A L I Z E D M A N I P U L AT I O N O F T H E FA S C I A E On th e whole , we have b e en describing local tech niques, b u t rel a tively g e neral­

ized o r global manipulations of the fa sica are also possible, either pr o c e ed i n g region by succ e ssiv e region or addressing an extensive area from the outset. Let us take the lower limb as an example With t h e patient supine place one hand on t h e dorsal s u r fa c e o f the foo t and

the o ther in the middle of the tibia . An indu c t i o n movement will o c c u r between the hand s . Harmonize t h i s movement in a ll spatial planes. Proceed region by suc­ c e s si ve region up to the h i p . Then , with one hand on the foo t and the other at the hi p , re-harmonize the entire limb

(Fig. 8 - 3 7) .

It i s also p o ssible to s ta r t

from the

outset at this stage. Starting from the hip , you can move up thr o u g h the successive

r eg ion s as far as the cranium . With a great deal of p ra c t i c e , it is p o s s i b l e to monitor fascial problems fro m

their point of depar ture , na m e ly, the cranium . A g ain , this i s releva nt to genera l ­ ized tension rather than s p e c i fic focal points of restric tion . I t shou l d be recog-

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29 1

Spec i fi c Techn i q u es

n ized that wan tin g to monitor eve r y thin g from

a

single point is e x tremely ambi­

tious and i t m ay well b e wiser to s tar t at the po in t o f the actual restriction , or at l e a s t in proximi ty to i t .

Fig. 8 - 3 7

G l o b a l Trea r m e n t of r h e F a s c i a e : Lower L i m b

A N T E R O P O S T E R I O R R E � E Q U I LI B R AT I O N This process involves res toring the coordination b e tween the movements o f the pos terior and anterior fa scial elements of the body. Th e p a tie n t is supin e , with the practitioner s t a tioned behind their he a d , cra ­ dling the base of their skull in the left hand . Placing the right h a n d on the s t er­ num , u se the l e ft hand to g e n erate a ver y mild tra ction in order to monitor the po s t e r i or

fasciae (Fig. 8 - 3 8 ) .

Monitor the a n terior fa sci a e with the righ t hand ,

movin g along the central axis from the thorax t o t h e epi g a s trium . B y means of lis t ening and induction , harmonize the movements sensed under the hands until co m

pl e te freedo m is ob tained and both hands are p erfec tl y synchronized .

ST R E S S Many people are permanently i n a state o f s tres s , which leaves its mark on the fasciae , dis t urbing their mo tilit y and creating tension , which can fur ther affect their mood. The effect i s rather like wear ing clothes that are too t i g h t . There is no panacea for this situ a ti on and the most suitable treatment stra t e g y will b e di ffer for each p erson . Nevertheless , o s teopathic techniques can help many peop l e , es­ pecially i f t h e treatment is undertaken a t an early stage.

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292

Fig. 8 - 3 8

Chap ter 8 / Trea ting the Fascia

A n teroposterior B a l a n c i n g

With t h e p a tient supine t h e practition e r takes u p a p osition on either side. place one hand as flat as possible over the epig a s trium . Often you will feel a tense, hard are a ,

as

if ever y thing is forming a block , accompanied b y abnormally s trong aor­

tic pulsations . The tissues will gradually be gi n to move and rela x . It i s impor tant for the pra ctitioner to remain perfec tly passive and not t o try to force the resistant barrier. Ideally, the hand should be able to sink freely into a comple tely ft.exible abdomen . Do not forget tha t the solar plexus lies just below your hand , and tha t its dysfunction can upset the p hysiology of the en tire area , especially below the transverse m esocolon . Once this area has relaxed , treat the diaphragm and then continue on to the s t ernum . Rem ember tha t the cardiopulmonary pl ex u s proj ects to this a re a with ,

a l l the consequences of i ts dysfunction, which is o ften related to s tress . Finally, t urn to the patien t 's cranium . In each area simply place your hand on the area in ques tion and leave it t h ere un til the tissues relax . When you are a ll done, perform an anteroposterior equilibra tion and finish with generalized manipula tion of the fa sciae. Usually th i s entire process ta ke s 2 0 - 3 0 minutes .

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293

Treatment Seq uence

This trea tm ent is not the only possibility- depending on the particular pa­ ti en t , many different variations are p ossible. However, i t has the advantage of conferring a certain degree of well -being which can be long -lasting , particularly if the trea tmen t is undertaken at an early stage in the buildup of s tress.

S CARS A N D A D H E SIO N S It is becoming increaSingly rare to encounter a patient with no kind of scar. When a scar b ecomes a problem , it should be tre a ted wi thou t fail because it can repre ­ sent a primary restriction. Tre a t the superfiCial scar at the l eve l of the scar tissue by longitudinal and transverse stre tching. Then continue down to the deeper tis s u e , because the source of the d isturbance is often a t this level . Treatment is performed b y iden tifying t h e favored axis of motion and then gradually stretch i n g away from the restriction . Come back to the point of dep ar­ ture and stretch agai n , taking note of the possibilities in the tissu e s , a n d gradua lly including o ther axes. If necessary, immobilize the fascia on the opposite side of the scar with your other hand. Finish up with listenin g and indu ction, which should reveal improved mo tility of the underlyin g tissues. We reiterate tha t the goal is not to eliminate the adhesion s , as this is n o t re­ ally possibl e . However, irritated adh esions tend to lose elasticity and end up by inhibiting and eventu ally immobilizing local tissues and org ans. For this reason , the goal is to regenerate some degree of elastiCity, as this is the potentia l of all tis­ sues. As a result, the a dverse effect of the scar on the organ will be eli mina ted or significantly attenu a ted , which will help to preserve its functio n . Two common examples are : •

Constipation that comm only follows appendectomy. In some cases , s impl e mani pula tion around the postopera tive scar can re -e stablish norma l intestinal passage.

•

Dyspareunia following an epiSiotomy, which prevents sexual relations. A single se ssion of treatment of the scar tissu e can be sufficient to restore the patient's normal condition . We could men tion many more examples. N o t all scars respond well to os­

teopathic trea tment b u t we believe tha t i t would be wrong to d e ny patients our potenti ally beneficial alternative solution.

Treatm e n t Seq uence First of all, it should be empha sized that tre atment ought first and foremost to be focused on local problems . I t is more ele gant, more logical , and more effective to g o to the root of the problem in order to correct i t. Only la ter should a g eneral­ ized correction be considered , such as correction of remote problems transmi t ted from the primary restricti on via a lesional chain . We can then re-equilibrate the

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294

Chapter 8 / Trea ting the Fascia

en t i re

bo dy around a fo cal point of restriction which

in d u c e d the

entire , more or

les s ex tensive chain reaction .

Re-equilibration of c e rtain fasciae does not necessarily require direct treat­ ment. Li s t enin g should be im m ed i a t e l y fo llowed by induction , and then re­ checked with another lis tening t e s t .

I f dir e c t treatment must be undertaken, b e g in with l i s tenin g and i n du c t i o n wh en e ver p o ss ibl e . This will p u t you in c o n t a c t with the pa tien t 's t issu es

e s tablish communication with them . It may also h e lp rita tion

as a

fi r s t s te p

.

After this , proceed to d ir e c t

and lower the threshold of ir­

treatment and then con tinue by

list e nin g and indu c tion , and finally, a l is t e nin g t e s t

.

At the end of the treatment s e s s i o n it is i m p o r t a nt to re -test all parame ters , ,

in c lu d i n g pain d e mon s t r a t e

a nd

fu nctional mobility. It is importa nt to remember that this will

to the pa tient th e

e ffe c tiveness of the o s teopathiC appro a c h

.

Indications and Contraindications Fascial t e chni q u e s are non -ag gres sive and can induce profound c h a n g e s in th e

tissues as we l l as in immune m e c hanisms and metabolic processes. Given all these benefi t s , the r e l e va nc e of these tech n iqu e s is p r a c t i c a l l y unlimited. I t wo u l d ap ­ pear l o g i c a l t ha t li s t e ning and induc tion can be applied

to a l m o s t any c a s e . Contraindications tend to b e rel a tive rather th a n formal . We would advise ex­ treme caut io n when dealing with infections , and it i s not recommended t o apply direct te chn iq u e s on hypers ensi tive or a cut e l y infl a m e d ti ss ues . Di rect techniq ues must n ev e r be used on any tensi on or mass which has not been formally identified a s a fo c us of tissular t e n s io n As a g e n er a l r u l e , one of the over-riding c o n tr a in d ica ti on s is n e ve r to care for a pa t i e n t unless you have u n der s t oo d their his tory and p r ob l e m s . Knowing when to send a p a tie n t to someone better eqUipped to deal with them corresponds to e l e m en ta ry cau tion and c o mm on sense. Even thou g h fa s c i a l treatment is r el ev an t t o a l m os t all p a t i en t s i t is not a panacea . It occupi es an important p o si t i o n in th e r ap y bu t should not be a cc or d e d more im p o r t anc e than it merits. .

,

Conclusion When A T S till first defined the p r i n ci p l e s of

os t e op ath y well over a cen tu r y ago,

he em p haSized the imp o rtance o f the fa sciae. This is what he s a i d in his P h i l osophy

of Osteo p ath y : "I

know of no part of the body tha t e q u a l s fa scia as a hunting ground. I b elieve th a t m o r e r i c h g o l de n th o u g h t will appear to the m i n d s eye a s the s tudy of the fa scia is p u r s u e d than any division o f t h e body. S til l , one part is just a s gr e a t and useful as any o t h e r in its p l a c e No part can be d i sp e n se d '

.

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295

Conclusion

with . But the fa scia is the ground in which all causes of dea th do the destruction of life . Every view we take , a won d er appears. Chapter 1 -

" The fas ci a gives one of, if not the greates t , problem s to solve as to the part it takes in life and d ea t h It belts each muscl e , vein , nerve , a n d all organs of the body. It i s almost a network of nerves , cells and tubes , running to and from i t ; it is crossed and filled \vlth , no dou b t , millions of nerve centers and fi bers to carry on the work of secreting and excre ting fluid vital and destructive. By its action we live , and by its fa ilure we shrink , C hapter 1 0 or swell , and di e . .

-

E ve r y d ay new advances in histology and bioc h e m i s t r y confirm S till 's intuition. Recent studies have shown that the fasciae play a cen tral role in human physiol­ ogy. All the various connective tissues in the body can actually be viewed as a sing le, complex unit which invests speCific parenchymatous ce ll s , allowing them to s u r v i v e and regulating their metabolism . Tissue movements resulr from con­ s tant dynamic i n t er acti on s among mechanical influences , phYSiological factors , and their biological consequences. Advances in research are leading to an ever more profound un ders t anding of the role of tissu e s , a n d new results are constantly reinforcing the importance of these roles. New discoveries expand our knowledg e and enable us to under­ stand the subtle mechanisms of tlut marvelous machine , the human body. This improved understanding allows us to develop more effective approaches to cor­ rect d y sfu n c tion and , a s a resul t , to restore normalcy. This further confirms Still 's intuition . The u biq u i t y of tissues an d th e mul t ipl i Ci t y of their roles that we have tried to describe leads us to consider restrictions o f the fasciae as an i n t e gral part of the osteopathiC lesion (also known as somatic dysfunction) , eve n as its principal cause. S tructure and function are two aspects of a Single, indivisible enti ty. Let us leave the last word to S till : ,

" There is t hey are n o rhin g we have

no real difference between s tructure and function ; j u s t differen t sides of the same coin . If we learn about function from the s tructure, all it means is tha t not been looking at it in the right way"

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Dis: 7 (3)

0-

Index Bold page

-

nuolbers indicate that lI,e item appears

in

an illustration.

lower limb origins, 1 8 8 -1 8 9

A

meningeal. 1 92-1 9 3 Anterior

Abdomen listening tests, 212-213

29 links, 84 Accuracy in treatment, 24 9-2 5 0 Adductor canal, 48

Anterior pa rie ta l peritoneum, 9 0

fascial

Anterior peritoneum. 7 Anterior trunk

treatment techniques, 2 9 3 Adipocyres, 13 9 Adipose cushion. 175,224

I 16-11 7 . 140

i n kidneys, 1 7 4

spinal. 110-111 Archiform Ranvier fibers, 1 2 1 Areolar connective tissue. 140

decrease in elastidty. 165. 1 6 7

Arm

I

fascial treatment. 280

cavi ty, I

listening test. 2 I I

Anatomical design. 176

listeni ng to,

anterior fasciae. 1 7 7

fasciae, 1 7 8

Anatomical integrity,

I 7 7 1 78 role o f fa s ci a i n

Arterial connective tissue.

listening test. 208

.

maintaining.

vasculitis, 144

Autonomic nervous system. 14 8

Anococcygeal raphe. 66

Autonomous motion. 1 8 0 AxLLla cross-section.

189

l

Astrocytes, 124

Antebrachial fascia, 3 8-39 Anterior chains.

142

Ascending chain re a c t io ns 20

Autoimmune

166-16 7

Ankle

211

treatment technique, 2 7 9

i n t er n al fasciae. 178 fasciae,

test, 229,

cerebral. l 0 8- 1 09

of, I S4

shock absorption function of. 1 S4

posterior

fascia

Arachnoid membrane. 1 0 8

and pressure a bsorp t i o n. 1 7 3-1 7 4

external

leg

19

elasticity and solidity of. 1 7 5

Amniotic

I 72

tests. 2 3 4- 2 36

231 230 Antrroposterior balancing technique. 292 Anteroposterior listening test, 22 I, 222 Anteroposterior re-equilibration. 29 J Aponeuroses, role of retention fi eld s in development of. An teromed.ia]

local tests. 241

and

10cOlI

Anterolateral leg compartment test,

Adhesions,14S. 146-14 7

Aging,

I

Anterior tibial compartment syndrome,

Adherent junctions, 1 2 6

Amnio e mbryonic junction.

272

244

Anterior longitudinal ligament test. 242.

Abdominal cross-section,

protl'cti v e role

I 77

Anterior longitudinal ligament. treatment technique,

loc a l tests, 240-241

Adipose tissuc,

fasciae.

Anterior intermuscular septum, lower leg. 49-50

36

Axons, 125

303 Copyrighted Material

3C

Index

''')neurosis, 7 +

II'

pericardium, 79-83 Back

pharyngobasilar and bllccopharYllgeal

local tests, 232-233

idSLlJC,

7 6-78

Barral, Jean-Pierre, 213

pterygotemporornaxillary fascia,

74

8 2 -83

'nternal,191

rroteins, 159

Centr]1

phenom'''ll

Central nervous

role of fascia ill, 160-161 Biodynamic rhellomena, in embryonlc development.

17-21

Cerebral arachnoid mpmbrllllc, 108-109 "'Jrer, 107

Cereht,Ii

Cerehe }Spill,,1 lluid,

182

l:Lomccilanical proPErLc;" Blastocyst

ISS

Cervical fasciae. supcrfiClai and middle.

27

Cervical vertebrae

d,lYS, 3

lateral translatloll of, 223 listening tests

Bloor! hrlill barrier, 114

of of,ni,'

",O\sels, role

21

loosening 'mo,22 7

CerVi

Bony tissuc, I I 8

CervIlCp ,.,

ligaments lechniques,

Cervicoplellral ligamellts test.

Chernic,i ;nsuh, 147 ChilcJblflit

18

223

Chronil

of. 118-1! of ossihcatFA,

I I

Sl"cepribilnv

',8

Ciliat';

J 20

Circular restriction lrealment technique,

Bound cells, I IS

Clavicular fasciae

Brachial [1scia, 3/ J 8

[.lsclal mechanics o f, 169-170

medial imermusclLiJr seplum, 38

hurr ",'!'",lryngeal fascid,

I) /

Plc;;sure along,

70, 9 I

158

test, 136

Cleavage

lateral intermuscular septum, 38

:,
286 243-244

Cervix. innervatLon of, 179

C",)steum, 120 _1" i

ligament,

223

Crrvicothoraclc Junction. 225

19

organizatLon of, 121-122

re ti cular, I

for,

ligament'.

!,'ositionireal",uplul' 122 Bones, role of detraction helds in development oC 2 I lamellar, I 18-1

101

"hock absoprtion

at twelve (bys, 1

"'Ilversion

109

Cerehr.li

unL eyonic develcpllllill.,

Illolumhar ligament

at thirteen

111 SystCllt, 124 astrocytes in, I 24

(('nrr,1i taslui axis IPst,

in embryonic dcvelopmem, 15-17

phenomcll:t,

I

ill1enr, superh, III 1',I,IIHar aponellro"r'" S I

CloaL']'

140

11i'll']ne, developl11t"

.' 'Hles,

11

COlC) t:

7,·,

;;'st for, 224

Bu[[ocks. cutaneom nerves. 4�-16

testing considnatiolls, 2 I 7 ColiC flexures,

9S

suspensatory ligaments of.

97

Collai!pn disea'ts, 14'+

Jinks to \",�arc>'1 ,<�()nne's ligament.

144-145

Wegener's granulorLlatoslS, 144

Cartilage role of contuslon fields in dcvclopmcnc of.

19

iI,':<,1L10US tissue. I I cartilage.

I

I

17

134

Collagen synthes", 132 Comnll,IIlll,llWlIl. role of [asci']

·160

Com ',,, lnIUl),tiization

n hrocartilage, I I

""·"lectioLl. I 54

ind,

:'",l'ine carrilage, Cell migration, over embryonic disk,S

I 3 1-133,

types, 132-133

upper limb treatment teclU11ques, 283 Cartilaginous ossification, I 19. 120

I I 5,

ColI�gen fibers.

169

Connective tissues, I I 5 arterial.

Cellular memory, 1 7 1,204, 20S. 223

141

and injury 199

biochemical definition. I 13

injllr)' and, 222

h(mv

:I,is fasciae, 74

l,SSlIf, I 18-122

in, I

IS

',IS tissue,

rpterygoid lisreiling tests, 2)

Copyrighted Material

I I

I 1�

305

Index

Deep cervical fascia, 5 6

cell types, 137-139 cellular constituent;, 131-137

connections, 59

fiber types, 13 3 -136

supportive role of, 153

ground substance in, I 1 6

Deep perineal fascia, 65-67

hisrological features, 131-142

Deep stretching technique, 256

inrerstitialmatrix in, I 15-11 6

Defense, role of fascia in, 156-158

microscopic anatomy, I 13-1 14

Dendrites, 12 5

origin in mesoderm, 8, 9,

114

Denonvilliers aponeurosis, 6+

as poilu of departure for disease processes, 147-149

of stress sYlldrome, 158

as regularor

with epithelial tissues, tissue types, 116-117, 139-142 unbound cells in, I 15

Depressed patients, tcsting, 126-127

Derrnomyotome, 7 Descending chain reactions, 200, 2 2 5 Detraoion fields,

Contraindicalions, 2 9 4

Diaphragm

fi,'lds, 1 8- 19

2J

general tr eatment teclwique, 273-27+

Coronary ligament, 96-97 Corrosion

208

Dermis, 1 2 9 -130

Contractility, 167 Contusion

18

Dense connective tissue, 140-1 + I

related lissues, 122-130 relationships

Densation fields, 17,

global treatment technique,

fields 17

274

muscular technique, 274-275,275

,

Coml pleura, 8 5 -86

points of dampening, 194-197

Cosropleural ltgamel)[, 55, 86

Diaphragma seila, 10+

Cranial dura mater, 100-105

Diapluagmatic parietal peritoneum, 8 9

Cranial rhythm, 1 55

Diaphragmatic pleura,

Cranium

Dilatation fields, 19-20

central fascial axis tcst, 220- 2 2 I

Direct Ireatment, 251

exocranialmembranes test, 219

ligaments, 2 5 7 - 2 5 9

intracranial membranes lest, 219

principles, 2 5 1-25 2

listening tests for, 2 1 8 -219, 22 3 local tests,

sliding pressure, 256- 257

238-240

stretching, 254-255

occipirocervical junction treatment, 28 6-2 8 8

structural techniques, 2 5 9

sc alp treatmenr, 2 8 6

techniques, 2 5 2-259

shocks to, 2 25 spinall11eninges test,

Distusion

219-220

Doug�s' pouch, 64, 8 8

Cross-linking

in parhological fasciae,

Duodenulll, embryonic cross-seoiona] view, 10

173

Dupuyten's contracture, +

modification through injury, 226 Cross-seer ions, embryonic liver,

spleen, stomach,

Cruveilhier's fascia, 6 2

6

I,

147

J 00

Dura mater,

cranial dura mater, 100-105 illllcr surface, 102-104

Cutaneous nerves

innervation, 105

+5

outer surface,

+6 lower limb, + 5

calf area,

10 I-I 0 2

spinal dura lllater, 105-107

posterior aspect, 45-+6 Cytotrophoblast,

I

Dorsal protein, 1 6

Cribriform fascia, + 5 , +7

al1lerior aspects,

fields, 1 9

Dorsal aponeuroses, foOl, 5

superior fasciae treatment, 2 88

decrease

86

testing, 220

I

E D

Ectoderm connecLive tissue originating in, derivatives of.

Dampening, 200 in diaphragm, 194-197

in hyoid bone, 198

formation

9,

in tw o-layered embryonic disk, I 17

Elastic carLilage,

major points of. 193

Elastic fibers, I 16, 134- 1 3 5

in occipitocervical junction, 19 8

Elasticit y,

role o f fascial chains

in scapular girdle, foot fasciae, 5

15,

I I 8, 167

in, 186

197-198

decrease with age, 165 of fascia, 153 testing, 206

Deep aponeuroses palmar,S I

I

of adipose tissue, 174

in pelvic girdle, 1 9 3

I

Elastin, 133 Elbow, treatment technique, 27 8, 279

Copyrighted Material

I J+

13

306

Index

144 parasagittal section, 75

Ermatomyositis,

Embryo arachnoid membrane development, 108

Eustachian tube,

at seventeen days, 5

Exchange processes, 159

Embryoblast differentiation, Embryology,

1

Exocoelomic membrane, 2

I

Exocranial fasciae

mechanisms underlying embryonic development,

circuJar rubbing technique,

15-21

287 287

convergent pressure technique,

three-layered embryonic

disk formation, 4-5 1-3

two-layered embryonic disk formation, Embryonic development

Exocranial membranes test, 2 I 9

Extensor hallucis longus, 5 0 External chains

autonomous motion in, 180

internal, 1 9 0- 1 9 2

bioki netic and biodynamic phenomena underlying, 1 7 -2 J cross-seer ion week 4, 14

lower limb origins, 1 8 7- 1 8 9

at day 2 I, 8

at days

meningeal, 1 9 2- 1 93 upper limb origins, 1 8 9- 1 9 0 External fasciae, 24, 1 7 8

24, 2 6 , 28, 8

end of week 4,

epicranial aponeurosis, 24-26

15

lower limb fasciae,

histological and biochemical phenomena underlying, 15-17

truncal fasciae, 28-34

mechanisms lUlderlying, 1 5

upper limb fasciae, 34-43

sheet differentiation and , 6- 1 4

External rotation, in lower limbs, 182

summary, 1 2

Extraembryonic mesoderm,

196

Embryonic diaphragm,

43-53

superficial cervical fascia, 2 6-28

3

Extraembryonic somatopleure,

EmbryoniC disk

3

Extraembryonic splandlnopleure, 3

cell migration over, 5 end of week 2,4 formation of tllree-Iayered, 4-5 formation of two-layered, Embryonic involurion,

F

1-3

8 Face

Endochondral ossification, 120

Endoconnective ossification, 1 19, 1 2 0

fasciae of. 25-26

Endocrine effeers, 14 7

lateral fasciae,

Endocrine glands, capillar y links to ground substance, 15 7

Endoderm connective tissue originating in, derivJtives of. 1 0- 1 2 ,

I

FaLx cerebri, 1 Farre l i n e , 8 8

03-1 0 4

Fascia

14

anatomical design, 1 7 6-1 7 8

13

formation in two-layered embryonic disk, saginal section development,

25

Falx cerebelli, 1 04

biochemical processes

and,

160-161

communication and exchange processes of,

11

158- 1 6 0

Endomysium, 123

components,

Endotboracic fascia, 55-56

continuity

summary, 60

133

of,

1 83

Energy cystS, 1 7 1

defense roles, 1 5 6-158

Epiblast, I

elastic components of, 1 7 3 generalized manipulation techniques, 2 9 0-2 91

Bpiblastic layer, 3 Epicranial aponeurosis,

24

hemodynamic processes and, 1 56

fascial' of face, 25,2 6

links to capiUaries,

masseteric fascia, 25

lower limb,

127

177

superfiCial cervical fascia as extension of. 2 6

protective role, 153- 1 54

temporal faSCia, 24

pulsation frequency, 1 5 6

Epidermis, 1 2 7 , 1 2 8-129

roles of, 1 51

Epigastrium, listening test for, 224

shock absorber role, 1 54- 1 5 6

Epimysium, 1 2 2

structural i n te g ri t y role, 1 52

Epineurium, 1 25

support roles of, 1 5 2 - 1 53 Fascial anatomy

Epithelial lining, 1 2 6 cell differentiation and functional specialization,

arrangement with points of conti nuity,

112

central axis, 7 4-83

1 2 7 - 1 28

epithelial-connective tissue relationships, 1 2 6- 1 2 7

diaphragm,

gap junctions,

external fasciae, 24-53

1 26

83

S 3- 7 3

intercellular junctions, 1 2 6

internal fasciae,

tight/occluding junctions, 1 26

internal thoracoabdominal fasciae, 83- 1 0 0

Copyrighted Material

307

Index

meninges, 100-112

su p e r fici a l fascia, 2 3 Fasci al c h ai n s , l83-184,

-

24

coordination and harmonization by, 185-186 dampening by, 186

Grip juncti on s, 126 Gastro col ic ligaments, 97

Gastrocoli c omemum,

external chains, 187-193

Gastrulation,

I

major dampening points, 193-198 me ningeal chains, 192-193

,

Gemellus mu sc l es, 46 General fascial mechanics, 178

role of, 184-185

fascial chains, 183-186 nervous

ge ner a i mechanics, 178-186

posture maintenance, 183

.

local mechanics, 163-178

General neck test,

suspension, 163-166

Gluteal aponeurosis, 46

204. See also C ell ular Fascial pathology, 143 a d hesi o n s, 146 147 collagen di se ases, 144-145 Dupuytren's contracture, 147 ,

memory

-

miscellaneous diseases, 145 scars, 146

chai n

systems, 185

Fascial restriction trea tment technique, 257 Fascial supp or t , 152

Glut e al fasciae test, 233 Glu te a l fasciae treatment, 266

Gluteal mu s cles Glut e us

Gly c oc alyx,

Greater omenmm, defensive role of COI1J1cctive tissue in 158 ,

Greater peritoneal sac, 92

cellular me mory of,

m o b ili t y t('sts, 227-241

degeneration a n d fascial pathology,

purpose of, 203

J 43

o r ig in of i n fect i ons in, 156

special cases, 241-245

ratio lO fibers, 172

te st methods, 204

role in pathological processes, 1 45

Female pel v i s fascia, 62

H

superior view, 69 Fem o ral canal, 48

Hand fasciae, 40

Femoral vessels, sheath of, 48

cross-section, 40

Fibroblasts, 137

deep palmar aponeurosis, 41, 42

I 17-118

dorsal,40

Fibronectin, 159-160

lateral palmar aponeuroses, 42

79-81

longitudinal fi b ers, 41-42 middle palmar aponeurosis, 41

Fingertips, aVOi d i ng contact with, 205

skin in, 130

Foot fascial eiemems, 50

Hand sensi t ivity

,

Heine

I

plantar aponeuroses,S

204

J

I

,

225

Henle's ligament, 60

vert ical cross-section, 50

horizontal cross-section,

cy l i n ders J 30,

Hemodynamic proce s ses, role of [ascta Hensen's knot, 4

Forearm

39

Heparin, 160 Hesselbach's ligament, 60 Heuser's memb r ane , 2

li sten i n g lO, 211

HislOlogical phenomena, 181

treatment, 277,278

Functional symptoms,

palmar aponeurosis, 40-42 transverse fibers, 42 Haversian canal, 118,119

deep ap oneu rosis, S 2 d orsal aponeuroses,S

listening test, 21

171

comparative evolutionary age of, 158

palpation tests, 225-227

Fluid ba.iance, role of

J 59

Great saphenous vein, 47

capillary links to end ocrin e glands, 157

listenin g tests, 204-225

Fibrous pericardium, Fibrous sac, 79-80 Fibrous tissue, J 16

,

Gluteus muscles, treatment techniques, 265-266

biochemical compOSition, 172-173

tests, 203

Fibrocartilage,

rest, 232-233 medius mu scle 46

G roun d s u bstanc e, I 16, 13 l

Fascial s uspe ns i on , 165

Fascial

237

Gla n d cells, 12 8

187-20 I

Fascial me mor y

Fascial pulley and

I-I 83 conduction of pain, 178-18 I

morphological characteristics, 18

Fascial mechanics, 163,164

chains,

4

Gat e the o ry 178-18 J

transmission via, 185

main fascial

98

Gastrophrenic lig a m e n ts , 97

internal chains, 190-l92 lesional chains, 199 - 2 0

G

-

184, 187

145

connective tissue, 131-142

in embryoniC development, l5-17

Copyrighted Material

in,

156

Index

i 1 S-I 16

1"':L!nter's car:

llil
Hyaline carlliage, i 17

illlersririal tissue, i 16

Hyaluronic acid, 154, 167

Intesti nal traer mobility of, 240

Hydroxyapatite, 122 :Ivoid and

cartilage

Hvoid and

r1nTiJId test, 239

285

mle of di),,' '.Iion fields in r.kvrlnpment of,

In L'ccranial

Hyoid hone

f11fmli[2fH::S

test, 2 j

intracranial pressurc, 100

local test for, 238

Inrraembryonic somat"I,ieure, 7

points of dampening, 198

Irregular dense connenlve tissue,

shock Il\oid test,

K

L lyoid tteatlllt:m, 285 Hypcrmobility, in scapular girdle, 197-198 Hypoblast,

141

ion by, 236

Kidneys

I

adipose tissue in, 174

FiPoblastic disease

bsciallink

146-14-'

listening tcst, 208

209

listening to,

Huc fascia,

:I I

3,

l

61

ili',costal fa'" Iliolumbar ligaments

I 18-1 19 91 bter:d chams, 1 gg, 191 Lamellar bony tissue,

test, 242

Large intestin e, mesocolon,

treatment rpchmque, 266-267,268

II. ,tibial t r a c . , I d,nd disease II) Hnobiliza.

187-1

146

·neningea L

Immune function, skin role in, 130

I

upper limb origins, 190

Impa ct points, listening tests for, 224--225

Lateral comranment, superficial plantar aponeurosis,S 2

Indications for rrf.1tmcnt, 29+

I.atf'r"I inguin;'] f"'<;l 90 I interml.h'lnLu ,eptuJ11, Ihl:c:1i I-.[sciae, 48

Induction, ,

?

I

"'"(1uration, )

pahnar 2p()lleUrOses, 4�:'

in testing, 226

Lateral plate, 7-9

Infection, prevention by fascial compartmentalization, 170

Lateral scapular fasciae. treatment,

ics;uinal falx.

iJstening

JII,:uinallig')fIH"liI., 31,61

I nguin al

270

Leg

r ings , 3 I

Leptomeninx,

Inguino-abdominal regl On , 32 InguinocruraJ region,

omentu' Leukocytes, 138

7

Ligaments

l�rmembrJnc i)'mpathy, 1 upper

hroad lig2f.1!Cl'1, 97

hilrl:> 1 [fciae, 43

coronary,

internal challi", 190

gastrocoiJc, 91

cenrral chain, 191-192

gastrophrenic, 97

chain, 192

peripheral i"lernal fast

98

Lesser perironeal sac, 9 I

adJ1erenr JunctIOns, 126

mixed

reactions, ) DO

descendiny;

Interfoveolar ligament, 60

ll.lermusculclr

I

11

ascendrng chain reacrions, 201

I 2(1- I

h,,;:rceliulaI Illl ctlons, 126

Intermediate mesoderm,

I 10,

Lesional chains, 199-] 00

32

l,lt'.er perio'.I' ..li ."1) face,

210

lstening 10,

histological resemblance to tendon" 141

1l.1l.ns, 190-

I

Leek of lTIni.ii!f.'), HI r!Jle of densoul,n fields in, I

l, 178

endothoraClc fascia, 55-56

role of relt.llllon llelds in development 01'.

middle cervical faSCia, 53-54

SthpenSlon role oC 163

neck fascia summary, 56

perinelln,

pelvis,

Linea alba, 30, 61, 170

6

curving of /:> Lis" ling rests. )

prevertei-r.iI Cr[scia , 54-,))

)06

,1bdomen, 212-2 J 3

t.ransversallS fascia, 60-61 Internal inguinal fossa, 90

anteroposterior, 221

Internal rotation, upper torso tendency toward, 212

coccyx. 224

lilierpterygr,icl �lrcia, 74, 81.

craniU111, 21

Copyrighted Material

2

�I

'

309

Ind ex

c r a n i u m and ce r v i c a l ve r t e b r a e , 2 2 3

lowe r l e g fascia e , 49, 5 0

e ffeu

p l a n ta r a p o n e u ro s i s tes t , 2 2 9

o f stress

on,

222

e p i ga s t r i u m , 2 2 4

poste r i o r i nt e r m u s c u l a r se p t u m , 49

i m pa d p o i n t s , 2 2 +-2 2 5

s u m m a r y, 5 3

for

t h i g h fas c i a e , 4 7 -48

lower l i m bs , 2 0 8-2 1 0

ve i n s ,

n o r m s , 2 0 6-2 0 7

+5

Lower l i m bs

p e l v i s , 2 1 6- 2 1 7 sc a p u l a r g i rd l e , 2 1 5 - 2 1 6

a n kle list e n i n g test, 2 0 8

sca r s , 2 2 4

knee l i s t e n in g t e s t , 2 0 8

s p e c i a l a re a s ,

l a t e r a l th i g h trea t m e n t , 2 6 2

2 2 2-2 2 5

l i steni n g tests fo r, 2 0 8

standi ng t e s t s , 2 0 7-2 0 8

ste r n u m ,

l i s ten i n g t o , 2 1 0

2 2 3-2 2 4

medial thigh trea t m e n t ,

test p rotow l , 2 0 4- 2 0 6 tho racic fa s c i a e ,

2 I 3-2 1 5 l i m bs , 2 1 1 -2

s c ia t i c n e r v e fas c i a t r e a t m e n t , 2 6 3 - 2 6 5

t h o ra x , uppe r

speci fic trea t m e n t te c h n iques , 2 6 0 -2 6 5

I 2

t h i g h a n d lower leg l i steni n g tests , 2 0 9- 2 1 0

LI pper t h o r a c i c verte b r a e , 2 2 3

th igh t re a t m ents , 2 6 2 - 2 6 3

L i ve r

ti b i al fas c i a techn iq u e , 2 6 0 -2 6 2

com p a r t m e n t a l i za t i o n i n , 1 7 0 e rn b r y o n ic c ro ss -sect i o n ,

lowe r thorax

6

l i sten i n g t e s t , 2 I 3

l a c k of m o b i l i t y, 2 4 1 p rotec t i ve role of fa s c i a l c o m p a r t m e n ta l i z a t i o n i n , 1 54

li s te n i n g to , 2 1 4 L u m b a r fa s c i a , 2 9 L u m ba r p lexu s ,

96

roLl n d l i g a m e n t of,

263

p l a n ta r a p o neurosis techniq u e , 2 6 0

2I8

3I

l u m b o s a c r a l a po n e u rO S i S , 1 5

loca l fa s c i a l rn e c h a.n ics

3

l u m bosacral l i g a m e n t t r e a t ment, 2 6 7

press u re absor p t io n , 1 7 2- 1 7 8

lungs

reteIJ t i on a n d s e p a ra t i o n i n , 1 6 8- 1 7 0

ante r i o r bord e r s , 8 5

s h o c k abso r p l i o n , 1 7 0- 1 7 2

c o m partmen taliza t i o n o r, 1 7 0

s u s pe n s i o n a n d p ro t e c t i o n i n , 1 6 3 - 1 6 8

protective role of fa s c i a l com part m e n ta l i z a t i o n

local tests , 2 2 8

in,

1 54

abdomen, 240-24 I

t ru n k , 2 3 4-2 3 6 bac k , 2 3 2-2 3 3 c l a v i c l e , 2 3 5 -2 3 6 a nterior

-

c ra n i u m , 2 3 8 - 2 4 0

M a c ro p h a g e s , 1 3 8 , 1 5 7

h y o i d bone , 2 3 8

M a l e p e l v i s , fro n t a l

h)'o i d - c r icoid tes t , 2 3 8

fa sciae, 234

sca p u l a ,

M a r fa n 's s y n dro m e , M a s s e te r i c fascia , 2 5 M a s t cells ,

sk i n , 2 2 8 - 2 2 9

leg

tests, 2 2 8

u p p e r l i m b fa s c i a e , 1 9 0

posterolateral c o m p a r t m e n t s test,

230

conneCll o n s , 5 2

a lso [nrerst i t i a l matrix

Med ial c h ai n s , 1 9 1

a n t e r i o r i n te r m u s c u l a r s e pt u m , + 9 - 5 0

a n Lero mcd i a l fascia tes t s , 2 2 9

See

Mec hanica l stres s , 1 4 7

Lower l i m b fa s c i a e , 4 3 , 44, 1 7 7

and

38

in bony t i s s u e , 1 2 I - I 2 2

fasc i a e , + 9

a n tero l a teral

I

Matr i x , 1 1 3 ,

loose n i n g field s , 2 0-2 1 Lower

1 +5

Massage p ressure, 2 5 3 - 2 5 4 , 2 5 4

sc i a t i c n e r ve fa sc i a , 2 3 I

lever

65

Manual conract, in test protoco l , 2 0 5

2 2 9- 2 + I

sca rs a n d a d he s i o n s , 2 + 1

Lo n g

view, 63,

Ma l e p e r i tone u m , 89

nec k , 2 3 6-2 3 8

peri pheral

M

Media l compartm e n t , s u perfiCi a l p l a.ntar aponeuro s i s , 5 M e d i a l i n g u i n al fo ssa , 9 0 Med i a l i n t e r m u s c u l a r sep t u m th i g h fasciae, 4 8 u pper l i m b s , 3 8

cutan e o u s nerves, 4 5 -46

Mediast i n al p l e u r a , 8 6

e x t e rn a l c h a i n s , 1 8 7 - J 9 3

M e n i n g eal c h a i n s , 1 9 2 , 1 92, 1 9 3

e x ternal rota t i o n by, 1 8 2

M e n i n ges , 1 0 0

foo t fascia l e l e m e n t s , 5 0- 5 2 glo b a l t reatm e n t

techn ique, 2 9 1

ara chnoid m e m b r a n e , 1 0 8- 1 1 2 and cerebro s p i n al A u i d , 1 0 1

g l u t e a l apon euros i s , + 6

connectio n s , 1 1 1

l e g cross-sect io n , 4 9

cross - s e c t i o n , 1 1 0

l o c a l t e s t s fo r, 2 2 9 - 2 3 2

d u ra m a t e r, 1 0 0- 1 0 7

Copyrighted Material

I

310

Index

hand positions fo r test i n g , 220

N

pia m a ter, 1 0 7- 1 0 8 protect i ve role of, 1 6 7

Nanos protein, 1 6

relationship w i th l ym ph spaces, 1 5 5

N e c k fa s c i a

shock a b s o r p t i o n fu nction of, 1 5 4

axis treatme n t , 2 8 4

sp i n a l , 1 0 5

cartilage t r e a t m e n t , 2 8 3

Mesen c h ym a l c e l l s , 9 , 1 1 6 , 1 3 7 , 1 3 9

cervico p leu ra l l i g a m e n t s treatm e n t , 2 8 4-2 8 5

con nective tissue o r i g i n a t i ng i n , I 1 4

cross-sect i o n , 54

role i n i n j u r y and d i sease, 1 4 8

genera l test fo r, 2 3 7 -2 3 8

Mesentery, 9 1 -9 2

local lests for, 2 3 6-2 3 8

s i g m o i d mesocol o n , 9 4

sag i t tal sect ion , 57, 7 7

o f small i n tes t i n e , 9 3

shoulder g i r d l e trea t m e n t , 2 8 1 - 2 8 3

o f stomac h , 92, 9 3

s u m m a ry, 5 6

s u s p e n sion role o f, 1 6 3

treatmen t te c h n i q u e s , 2 8 1 -2 8 5

transverse mesocol o n , 9 3

Neph rogen i c cord, 7

Mesoc o l o n , 9 1

N e p h ro t o m e , 7

Mesoderm

Nerve t i s s u e , 1 2 4

conn e c t i ve ti ssue o r i g i n a t i n g i n , I 1 4

a stro c y t e s , 1 2 4

cross-sectional developm e n t , 6

centra l nervous s y s te m , 1 2 4- 1 2 5

deri vati \'es of, 6-9 , I 3 M e s o g a s t r i urn , 9 I

cross sect i o n , 1 2 6

Mesova r i u m , 6 9

m i crog l i a , 1 2 5

Metabolic fields , I 7

o l i godendrog l i a , 1 2 5 peripheral n e r v o u s syste m , 1 2 .1

comus ion fi e l d s , 1 8- 1 9

N e r v o u s s y s te m , d i ffu s i on of con nect ive t is s u e problems

corro s i o n fields , 1 7

via , 1 + 3

den s a r i o n field s , 1 7 - 1 8

Neu ral cres t s , 9

detraction fields, 2 I d il a t a t i o n fi e l d s , 1 9 - 2 0

Neural p l a t e , 9

d i stusion fiel d s , 1 9

Neural t u b e , 9

parathel i a l looseni n g fi e l d s , 2 0 - 2 I

Neuroglia, 1 24

re tention fi e l d s , 1 9

N e u rons, 1 2 5

Micro g li a , 1 2 5

N e u t r a l i ty, pract i t i o n e r, 2 0 5-2 0 6

M i cropha g e s , 1 5 7

N o r m s , i n l i s t e n i n g t e s t s , 2 0 6- 2 0 7

M i croscopic a n a tomy, conn ective tissue, I 1 3 - 1 1 4

Notochord , 4

M i d d l e cer v i c a l fa sc i a , 5 3 - 5 4 , 5 6

Notoc h o rd a l c a na l , 4

con n e c t i ons , 5 9

N uc h a l fascia , 5 5

M i d dl e p a l m a r a p o n e u ros i s , 4 1 M i ddle p e r i neal fa sci a , 6 2 , 64

infer ior layer, 63

-

s u p e r ior layer, 64-6 5

0

Obesi ty, e l a s t i c i t y or fa scia i n , 1 6 6

Mineral salts, in bony t i s s u e , 1 2 2

O b t u rator fora m i n a , 1 7 6

M i x e d chai n s , i n ternal, 1 9 2

O c c i p i t o c e r v icaJ j u n c t i o n , 2 2 3

M i xed connective t i sslle d isease, 1 4 4- 1 4 5

dampeni n g by, 1 9 8

M o b i li t y

tTealment tec h n i q u e , 288

of intes t i n a l lract, 2 4 0 restr i ction at occipitocer v i cal j u nction , 1 9 8 s u spension and , 1 6 3

O l facto r y bulb, t e n tot i cl m o f, 1 0 4- 1 0 5 Oligodendro g l i a , 1 2 5 O m en ta , 9 7

testing , 2 0 7

lesser omentu m , 9 7 -9 8

M o b i l i t y te s t s , 2 2 7

of stom a c h , 92

craniu m , 2 3 8

O m e n ta l b ur s a , 9 1

loca l tests , 2 2 8 - 2 4 1 lon g lever lests , 2 2 8

Org a n i c m a tr i x , i n bony t i s s u e , 1 2 1 - 1 2 2

p u r pose of, 2 2 7 - 2 2 8

O s s i fi cation , types o f, 1 1 9- 1 2 0

M o r p h o l o g i c a l fa s c i a l c h a rac t e r i s t i c s , 1 8 1 - 1 8 3

Osteoc y t e s , 1 1 9

Moti lity testin g , 2 4 5

Osteo n s , I 1 8 , 1 1 9

Muscle tissue, 1 2 2 - 1 2 4

Osteopathy e ffeers o n ce l l u lar meta b o l i c p rocess e s , 1 6 1

ro l e of fascia in fu n c t i o n i n g of, 1 5 2

scars a n d a dhesions i n , 1 4 5

structure , 1 2 3 M u sc u l ar s y s t e m , role o f d i l a t a t i o n fi e l d s i n d evelo p m e n t o f, 2 0 M y oto m e , 7

O u te r periosteal surface, 1 2 1 Ovarian l i g a m e n t , 6 9 Ovary, s u s pensory l i g a m e n t , 6 9

Copyrighted Material

31 1

Index

presacr a l aponeu ros i s , 6 7 - 6 8

p

rectovesical a n d reCl ovaginal sep a , 6 8 sacrogen i ta l fol d s , 7

1 09

Pa cci1 i o n i a n bod i e s .

n e r vo u s co n d u ct i o n

o f. 1 7 8- [ 8 1

i n p a l p a tion t e s t s . 2 2 7

sticking o f fa s c i a to, 2 2 9

Pa l ma r apone uros i s , 40--4 2

Per i p h er a l c h a i n s ,

Pa l p a t i o n tes t s . 2 2 5 s t r uct ura l c h a n ges a n d , 2 2 5 - 2 2 7 Pa ra t h e l i al loose n i ng fi e l d s , 2 0-2 [ Pa ravertebral m u s c l e s fascia test ,

233

Parax I a l mesoder m , 6

[ , 99

Pa r i e t a l p l ell l'a , 8 5 . 8 7 d i a p h rag matic p l e u r a . 8 6 m e d i a s t i n a l pleura, 8 6 p le u ra l dom e . 8 6- 8 7

Pe riton eal cavi t y, 8 8 Per i l o n e a l folds, 9 1 Per i t o n e a l l i g a m e n t s , 9 6-9 7 Periton eum , 8 8 a n t e r i or p a r i et a l peritone u m , 9 0

d i a p h r ag m a t i c parietal p e r i toneum , 8 9

fe m a l e , 62 l u m bosa c r a l l i g a m e n t t rea t m e n t , 2 6 7

63

fas c i a e , 9 4-9 7 l igaments , 9 6-9 7 m al e . 89 o m e n t a , 9 7 -9 8

ro u n d l i g a m e n t , 69

parietal p e r i t o ne u m , 8 9-9 1

s u m m a r y. 7 [ - 7 2 t rea t m e n t t E c h n i q u e s , 2 6 5 - 2 6 8 Pe lvic g i rd l e . p o i n ts o f d a m p e n i ng . [ 9 3

muscl es. 6 5

Pe l v i c p a r i e t a l pe r i ton e u m . 9 0-9 1 Pe l v i c res t r i c t io n s , 2 [ 7

pelvic p a r i e t a l perito n e u m . 9 0-9 [ p e r i t o n e a l fo l d s , 9 [ -9 9 posterior p a r i e t a l per i to n eum . 9 0

s lU11 mar y, 9 9 To l d t 's fa s c i a , 9 5 -9 6 Tre i t z 's fas c i a , 9 5

Pe l v i s l t s t e n i n g t e s t s , 2 [ 6-2 [ 7 l i s t e n i n g to. 2 1 7

v i sceral peritone um . 9 1 Perpe rual m o t i o n , [ 8 0 p H . d ro p at s i t e of i n j u r y. l 5 7

Pe r i c a r d i a l l i g a m e n ts . 8 1

[ 57

PhagocytiC cel l s ,

Peri caJ"di u m . 7 9 c e r v icope r i c a r d i a l l i g a m e nts , 8 0 co n n ec t io n s . 82

Pha r yn g o ba s i l a r fa sci a , 7 6- 7 8 , 8 2 , 2 3 8 con nections, 78 t es t i n g , 2 3 6

d a m p e n i n g by. [ 9 5

7 9-8 [

phreno p e r i ca rd i a l l ig a m e n t s , 8 0

8 [ -8 2

srern o p e r icard ial l i ga m e n t s , 8 0 vertebroper ica rdial l i g a m e n t s , 8 0 vi scero per i cardial l ig a m e n ts , 8 [ Pe r i c h o n d r a l OSS i fi ca t i o n . [ 2 0 Pe richondriu m ,

I 17

Pe ri nea I fa sciae connections, 73 e l a stic i t y a n d so l i d i ty o f. 1 7 5 Pe r i n e a l l i ga m e o r . 6 3

Pha r y n x . pa rasag g i ta l section , 7 5 Phreno perica r d i a l l i g am e n t s , 8 0 Physical inj ury,

[ 47

d ro p in pH at s i t e of. [ 5 7 a n d fascia l c h a i n reactions, 1 9 9 Pia m a t e r. [ 0 7 cerebral pia m a te r. 1 0 7 spinal p i a mater, [ 0 7 - 1 0 8 Pigment cells. 1 3 9 Pi r i formis m u s cle, 4 6 s h o c k a bs o r p t i o n by. [ 7 5 Pla n t a r apone u roses .

5[

Pe r i n e a I raphe. 6 6

local tests for, 2 2 9

Pe r i n e u m

test fo r,

adipose t i s s u e roles i n , [ 7 5 deep fa sci a , 6 5 - 6 7 fa scia o f,

[

d e fe n s i ve r o l e of con n ective tis s u e i n , 1 5 8

i l i ol u m ba r l i g ;\ ln e 1 1 l treatm e n t . 2 6 6-2 6 7

serous p e r i card i u m ,

Pe r i p h e r a l m e m o r y, 1 7

coronary lig a m e n t o f. 9 6-9 7

6[

a r r a n g e m e n t o f. 68

fi b rous p e r i card iu m .

l ocal t e s t s fo r, 2 2 9 lower l i m b tests, 2 2 9-2 3 2

mesentery, 9 [ -9 2

costal p l e u r a . 8 5 - 8 6

Pel v i c

Periphera l fas c i a e

Pe r i p h e ral n e rvous system , 1 2 5

7

Parietal p e r i to n e u m . 8 9 -9

male,

1 91

internal , [ 9 0- [ 9 [

pain and , 2 2 7

Pe l v i c i a s c i a e .

u m b i l ical fas c i a , 6 9- 7 1 vesi covag i n al aponeu rosi s , 6 8- 6 9 Pe r i o s teum , 1 2 0 - 1 2 1

Pa l at i n e apone u ro s i s . 7 4- 7 6

P a r i e t a l mesoder m .

I

s u perfi c i al peri n e a l fa scia , 6 1 -6 2

Pa i n

61

fa s c i a l s u m ma ry. 7 [ - 7 2 m i d d l e p e r i n e a l fa scia . 6 2 - 6 5

229

treatm e n t techn i q u e , 2 6 0 , 260 P l a s m a ceJ l s . [ 3 8 Plastici ty, [ 1 5 .

[ 18

P l eura , 8 3 - 8 4 anterior b o r d e r s , 84

Copyrighted Material

312

Index

a t tadunents . 5 6

R e c tollte r i ne p o u c h , 8 8

connect i o n s . 88

Rec{Ovag i n a l sep t u m ,

par ietal rl e u r a .

8 5 -8 7

Rectove s i c a l se p t u m ,

67. 68. 72 64. 67, 68.

72, 88

s u m m a ry. 8 7

R e c t u s a b d o m i n i s m u s c l e . a r c u a t e l in e ,

visceral p l e ura , 8 4- 8 5

Re fle x coug h . 2 3 7

P l e u ra l cav i t y,

84

Re g u l a r d e n s e c o n n e c t i ve t i s s u e ,

Pleur a l d o m e , 8 6 , 8 7

R e g u l a t o r y proble m s , in e t i o l o g y

Pleu rover rebral l i g a m e n t .

55,

86

3I

I+I of t u m o r

d evel o p m e n t ,

1 48

Po l y a r t e r ius n o d o s a , 1 44

Re lay p o i n t s , 1 8 3

Pos ter ior c e r vi.ca l l ig a m e n r , 2 8

R e ten t i o n , fa scia l m e c h a n i cs of, 1 6 8- 1 6 9

Po s t e r i o r cha i n s , 1 89

fields,

Retention

l ower l i m b o r i g in s . 1 8 9

19

R e l i c u J a r bony tiss ue, I 1 8

Posterior fa sciae, 1 7 7- 1 7 8

1 38

R e t i c u l a r ce l l s .

l e g move m e n t t e c h n i q u e , 2 7 1

Ret i c lI la r fi b e r s . 1 1 5 , 1 1 6 , 1 3 5, 1 3 5 - 1 3 6

t r u n k movem e n t tec h n i q u e . 2 7 1

I

Reticular lami n a ,

Posre r i o r i n te r m u s c u l a r s e p t u m , l owe r l e g , 4 9

27

Ret i c u l a r t i ss u e , 1 3 9

Poster i o r pa rie t a l p e r i to n e u m , 9 0

Reverse t r a n s i t l o n of b i o p o l y m e r"

Po sterior thora c i c fas c i a e tre a t m e n t , 2 7 0

Rh e u m a t i c d i se a s e s y n d ro me, 1 4 4- 1 4 5

Post e r o l a tera l l e g compa n m e n t tes t .

230

Rheu m a to i d a r t h r i t i s .

Posteromed i a l l e g com p a r t m e n t t e s t , 2 3 0

R h y th m , te s t i n g ,

1 60

1 45

207

Pos toperative shoc k . 1 4 7

Round l i g a m e n t , fem a l e p e l v i S .

Postu re, r o l e of fas c i a i n mai n t a i ni n g , 1 8 3

Ru ffi n i 's c o r p u sc l e s , 1 8 0

69

Prescacra l apo n e u ros i s , 6 7 - 6 8 P r e s s u r e abso r p ti o n a d i po s e t i ss u e a n d . 1 7 3 - 1 7 6 . 1 7 5

-

and a n atom i c a l arch i t e c t u r e , 1 7 5

5 67. 7 1 .

a n d a n atomica l d e s i g n , 1 7 6- 1 7 8

Sac rogen i t a l fo l d s .

b i o c h e m ical co m po s i t ion of g r o u n d s u b s ta n ce a n d .

Sacro rectog e n i to p u b i c m e m bra n es of

1 7 2- 1 7 3

73

a n d c o o rd i n a ted movem e n t ,

J

7 1

Sacro t u be ro u s l i ga m e n t s t c s t . 2 1 7 , 2 4 2

76

Sca l p treatm e n t tec h n i q u e , 2 8 6

e l a s t i c c o m p o n e n t s o f fascia . 1 7 3 fa s c i a l m e c h a nics of. 1 7 2

Sca p u l a test, 2 3 4

shock a b so r p t i on a n d . 1 7 5 - 1 7 6

Sca p u l a r fa s c i a e tre a t m e n t . 2 7 0 Scapul ar g i r d l e

P revene b r a l fas c i a , 5 4-5 5

) I 5-2 I 6

P r im i r i ve y o l k s a c k , 2

l i s t e n i n g tem fo r.

Pr i n c iples of trea t m e n t , 2 4 9

p o i n ts of d a m p e n i n g , 1 9 7- 1 9 8

accuracy, 2 4 9-2 5 0

Scap u la r tes t . 2 3 4

direct trea t m e n r , 2 5 1 -2 5 2

Sca rs , 1 4 5 , 1 4 6 l i stening tests for. 2 2 4

te c h n i q u e s e l e c ti o n , 2 5 0 Pro n e p h ro i ,

Del he I ,

S a c ros p i n o u s l i g a m ents t e s t , 2 I 7 , 2 4 2

7

l o c a l t e s ts . 2 4 1

Prostagl and i n r e l e a s e , pain a n d , 2 2 7

test i n g m o b i l i t y, 2 4 1

Pro s t a t i c cav i t y. 6 5

t r e a t m e n t tech n i q ues , 2 9 3

P r o t e c ti o n

Schmor l 's node s . I 1 8

fa s c i a l m e c hanics o f.

J 6 6- 1 6 8

S c i a t i c nerve fa scia t es t . 2 3 1

role of fa scia i n , 1 5 3- 1 5 4 Pro t e o g lycan s ,

131,

d i s tal , 2 3 2 prox i m a l , 2 32

1 3 6, 1 54, 1 6 7

Psoas mu s c l e , i.uac fa scia a n d ,

3I

S c i a t i c n e r ve fa scia trea t m e n t t e c h n i q u e ,

Pter y g O i d m u s c l e , parasag i t ta l sec t i o n , 7 5 Prer ygo remporomax i l l a r y fa scia , 7 4 , 8 2 Pu bopro s t a t i c l i g a m e n t , Pu l m ona r y U g a m en r ,

63

J

S c l e rod e r m a ,

44

See 1 58

Seg m e l1ta t i o n .

84

Selye, Hans ,

S e n s o r y fu nct i o n ,

role

of

,kin

in, 1 30

S e r o u s pe r i ca r d iu m , 8 1 -8 2 Sha r p e y 's fi b e r s , 1 2 0 , 1 2 1

46

Sheet d i ffe re n t i a r i o n ecto d e r m der i v a t i ves .

R Rap p o r t , i m porlance i n test pro{Oco l , Re a c t i o na l bloc k s , 1 48

Corn p a r r ll 1 e m a l i za t i o l ]

S e p a ra t i o n , fa s c i a l mechan ics oC 1 6 9- 1 7 0

- Q Q u a dr a t u s fe moTis m u s c l e ,

2 6 3 -2 64, 264,

264-265

9

a n d e m b r y o n i c dev e l o p m e nt , endo d e r m d e r i v a t ive s , 1 0- 1 2

205

l a y e r d e r i vat i ves ,

1 3- 1 4 6-9

mesoderm d e r i va t i ve s .

Copyrighted Material

6

313

Index

Str u c t u ra l g l y coprotei n s , 1 3 6- 1 3 7

S h o c k a bsorp t i o n , 2 2 +

by ad ipme t i s s ue

fas c i a l m e c h a n ics

S t r u ct u r a l in t e g r ity, role of fa scia i n ,

1 73

,

of. 1 7 0 - 1 7 2

S u p e r fic i a l c e r v i c a l fa sci a , 2 6-2 8 , 5 6

by h yo i d b o n e , 2 3 6

p o i n t s o f fa scia l , 1 9 4

S u p e rficia l pa lmar a po n eur os i s

Shou l d e r fas c i a e , 3 5 -3 7 t rea t m e n t , 2 8 0 , 2 8 1

40 1 6 2 64 a p o n ellfos i s , 5 I

S up e r fi c i a l p e r i n eal

S h o u l d e r g i rd l e

Supe r fi cial p l a n t ar

216

fascia ,

6

,

-

,

S u p e r i o r fa s c i ae

trea t m e n l t e c h n i q u e s , 2 8 1 , 282, 2 8 3

g lobal

S i g m o i d mesoco l o n , 9 4

S i g n a l i n g prole i m , i n Drosop h i la

e mbryos, 1 5 - 1 6

o f d e n s a t i o n fi e l d s i n ,

treatmem tecim i q u e , 289

t r e a t me n t te c hn i q u e , 2 8 8 S u p p o r t, role o f fas c i a i n , 1 5 2- 1 5 3

S u s p e n s a torl' lig a m e n ts , colic A e x u re s , 9 7

Ske l e t a l deve l o p m e n t

ro l e

58

connections ,

S u p e r fici a l fa sc i a , 2 3 - 2 4

role of fa s c i a i n , 1 5 4- 1 5 6

Usten i n g to,

1 52

S u b c u t a n e o u s t i s s u e . 1 2 9- 1 3 0

1 7- 1 8

S u s p en s i on , fa s c i a l m e c h a n i cs o f. 1 6 3- 1 6 6

role o f" d i s t u s i o ll fi e l d s i n , 1 9

I

S y n c r i o t ropho blast ,

S k e l e t a l muscle s t r u c t u re , 1 2 3

S ystemic

l u p u s e r y t h e m a rosus , 1 44

Skin, 1 2 8. 1 28 de r m i s , 1 2 9 e p i d e r m i s , 1 2 8- 1 2 9

-

iu n c r i o n s , I 3 0 l a y e r s , 1 2 8- 1 3 0 local tem for, 2 2 8-2 2 9

Tec h n i q u e s , 2 5 9 a n t e ro p o s t e r i o r re-eq u i l i b ra t i o n , 2 9 1

cran i u m

an d s e n s o r y fu n c t i o n , 1 3 0

g e n e r a l fa s c i a l

s u bcu t a ne o u s t i s s u e , 1 2 9- 1 3 0

Sma l l i n testine, m e s e n t e r )' of. 9 1 , Smoo tl1 m uscle t is s u e . 1 2 4 S o ft t i s s u e , convers ion i n to b o n e ,

i n d i c a t i o n s a n d con t ra i n d ica t i o n s , 2 9 4

227

lower U m bs , 2 6 0-2 6 5

for l i gamen ts , 2 5 7-2 5 9 massage p re s s u r e , 2 5 3 -2 5 4

pelvis, 2 6 5 - 2 6 8

Soma t i c meso d e r m , 7

1 1 0- 1

arac h n o i d m e m b r a n e ,

sca r s a n d adhesions U"e alln en t , 2 9 3

1 I

S r i n a l cord , c ross - s e c t i o n w i t h m e n i n g e s ,

s l i d i ng press u re , 2 5 6-2 5 7

110

S l re s s , 2 9 1 -2 9 3

S p i n a l d u ra m a l er, 1 0 5- 1 0 7

stre t c h i n g , 2 5 4- 2 5 5

m e n i nges 1 05 ,

s t r u c t u ra l , 2 5 9

e x t e n s i o n s , 1 06

th ig h , 2 6 2-2 6 3

220 S p i n a l men i n ges te s t . 2 1 9- 2 2 0 S p i n a l s e g m e n t fac i l i ta t i o n , 1 7 I - I 7 2 S p l e e n , emb r y o n i c c ross-sect io n , 6 tesl fo r,

thora c i c r e g ion , 2 6 8 -2 7 I

trea t m e n t sequence, 2 9 3 - 2 9 4 u p p er l i m b s , 2 7 7 -2 8 1 ven t r a l regi o n , 2 7 2- 2 7 7

S t a n d i n g l i s t e n i n g teslS, 2 0 7- 2 0 8

m a t e r, 2 8 9 -2 9 0 e p ic r a n i a l apone urosi s , 2 4

ve r tebral d ura

S t e rn a l l i sre n i n g tes l , 2 1 4

Te m p o ra l fa sc i a ,

S t e r n o p e r i ca r d i a l l i g a m e n t s , 8 0

Te n a s c i n , 1 5 9- 1 6 0

Sle[ll u m d i r-ecr

manipulation, 2 9 0-2 9 1

93

Solar p l e x u s Slress, 2 2 4

Spinal

treatments, 2 8 6- 2 8 9

d i recr t reann e m , 2 5 2 -2 5 9

s t r u c t u ral c h a n g e s In , 2 2 5 -2 2 6

Spi nal

T

tec h n ique,

Ten d o n s , 1 2 3

2 7 6-2 7 7

i n d u cr icm , 2 7 6 , 2 7 6

h i s tO l o gi cal resemblance to l i g a m e n t s , 1 4 1

Ireat m e n t tech n i q u e s , 2 7 5

role o f dilatati o n fields

Stern u m tes t , 2 3 4 , 2 3 5 St oma c h e l11 hr y onic cross-sec t i o n ,

in

role o f rete n t ion fields i n

developme n t o f, 2 0

dev e l o p ment o f.

in , 1 6 7 - 1 6 8 Ten t o r w11 cereb e l l i , 1 0 3 Te s t m e t h o d s , 2 0 4

Ten s i o n , c h a nges 6

o m e n t a and m e s e n l e r y of. 9 2

S trat u m p a p i U a re , 1 2 9 Stra tll !l1 re t i c u la re, 1 2 9 St re n g t h , I 1 6 , I 1 8

t i m i n g considerat io n s , 2 4 4- 2 4 5 Te s t p r o t O c o l , 2 0 4 ma n u a l cont a c t , 2 0 5 p a t i e n t rappo n , 2 0 5

Stress, e ffe cts on l i s t e n i n g te s t s , 2 3 2 S t ress s y n d ro m e , ro le o f c o n ne c t i ve t i s s u e Stress t re a l m e n t tec h n i q u e s .

2 9 1 -2 9 3

in,

1 58

pract i t i o n e r n e u t r a l i ty, 2 0 5 -2 0 6 Te x t ure, i n l isten i ng test s , 2 0 6

Strelc h i n g t e c h n i q u e , 2 5 5

Ther m a l re g u l a t i o n , s k i n fun cr i o n i n , 1 3 0

S t r iated m u sc l e t i ss u e , 1 2 4

Th i g h

S t ruct u r a l

changes

p a l p a t i o n tests a n d ,

lateral fascia treatmen t , 2 6 3

2 2 5-2 2 7

i n u n d e r l y i n g fasc i a e , 2 2 6-2 2 7

l i s t e n Lng tes t , 2 J 0 l i stening to,

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209

19

314

Index

U p p e r limb fas c i a e . 3 4 . 3 5

T h i g h fas c i a e , 4 7 -48 horizon t a l cross - s e c t i o n , adductor c a na l , 4 7

a n tebra c h i a l fasc i a , 3 8 -3 9

lateral intermuscular sep t u m . 4 8

brachial fa sc ia , 3 7 -3 8

med i aJ in t e r m u s c ular sept u m , 4 8

connec t i o n s , 42

shea t h o f fe m o r a l vessel s , 4 8

e x ternal c ha i n s , 1 8 9- 1 9 0

Thoracic fa s c i a e

h a n d fa scia e , 4 0-43

l istening tests , 2 1 8

i n ternal rotation b y, J 82

l i stening to, 2 1 8

medial c h a i n . 1 9 0

poste rior fasci ae treaonent , 2 7 0- 2 7 1

s h o u lder fa sciae, 3 5 -3 7

rhoracolu m b a r fa scia trea tm e n t , 2 6 8

su m m a ry. 4 3

Thoracic wali , ve r t ical sectio n , S8

Upper limbs

Thor a c o - a b d o m i n a l faSCiae, 30

a r m a n d forea r m l i s ten i n g tes t , 2 1 1

Thoracolu m b a r fa scia treatmen t , 269

a r m t re a t m e n t . 2 7 9

Thora x , l inks to, 8 4

cartilage t rea.tment tec h n iq u e s , 2 8 3

Thorax l i s t e n i n g tests , 2 I 3

cerv icop leuf
lowe r thora x . 2 I 3

e lb ow trea t m e n t tec h n i q u e , 2 7 8

s t e r n a l tes t , 2 1 4

fo rearm lTeat ment , 2 7 7 -2 7 8

upp e r thorax, 2 1 3 -2 1 4

l i s t e n i n g t es t , 2 I 2

Three- layered e m b r y o n i c disk forma tion , 4-- 5

neck t re a t m e n t t e c h n i q u es, 2 8 1 -2 8 5

Thym i c c o m p a r t men t , 78

s h ou l d er g i rd l e trea t m e n t , 2 8 1 , 2 8 3

T i b i a l fa sci a , tre a t m e n t , 2 6 0 . 2 6 1 , 2 6 2

s h o u l der tre a t m e n t , 2 8 0

Ti b i a l i s a n t e r i o r m u s c l e s , 5 0

t r e a t ment tech niq ues . 2 7 7

T i g h t j u nct i o n s , 1 2 6

Upper thora cic ver tebra e . l i s te n i n g tests for, 2 2 3

Ti m in g . of fa scial tests, 2 44-- 2 4 5

Upper thora x

Tis s u e temperature, 2 0 6

l i s t e n i n g t es t . 2 1 3 -2 1 4

Toe s , apone uroses o f s h o r t e x tensor m u scles , 5 J To l d t 's fa scia , 9 5 - 9 6 Trachea l developm e n t , as e x a m p l e o f d e n s a t i o n fi e l d s , 1 8 Tra n s fer p o i n t s , 1 8 3

l is t e n i n g t o . 2 1 5 U rog e n i tal diaphrag m . 6 2 Uterus

Transvers a l i s fascia , 6 0-6 1

d o u ble i n n e r v ; n i o n of. J 7 9

Tr a nsverse c u p u.l ar l ig a m ent, 5 5 , 8 6

ela s t i c i t y d u r i n g p re g n a n c y, 1 6 5

Trans v e rse mesoco l o n , 9 3 Tre a t m e n t sequence, 2 9 3 -2 9 4 Trea t m e n t s accura c y of. 2 4 9 -2 5 0

-

d i rect . 2 5 1 - 2 5 9

v

Vag i nal a n g l e , 1 7 5

ind u c t i o n , 2 5 0 -2 5 J

Va srus l a teralis m u sc l e , 4 8

moda l i ties and pri n c i p l e s , 2 4 9-2 5 9

Ve i n s , lower l i m b , 4 S

obj ectives , 2 4 7 - 2 4 9

Ve n tra l r e g i o n

techn i q u e select i o n , 2 5 0

ant e r i o r lon g i t u d i n a l l ig a m e n t treatm e n t , 272

Tre i tz's fa sci a , 9 5

d i a p l1Iagm t rea t m e n t tec h n i q u e s , 2 7 3 -2 7 5

Tro p h o b l a s t d i fferentiat i o n ,

s t e r n u m treatm e n t , 2 7 5 - 2 7 6

Tro pocollagen, 1 3 1 - 1 3 2

treatm e n t t e c lln i qu e s , 2 7 2

Tru n cal fa sciae, 2 8

vi scera l trea t m e n t tec h n i q u e s , 2 7 2 - 2 7 3

a n terior fascia , 2 9 -3 1

Verte bral d u ra m a ter treat m e n t , 2 8 9 , 290

i l i a c fa scia , 3 1 - 3 3

Ve rtebral muscles te s t , 2 3 2 -2 3 3

poste r i o r fas c i a e , 2 8- 2 9

Ve rtebro p e r i card ial l i g ame n t s , 8 0

s u m m ary, 3 3 -3 4 Tu mor deve lopmen t , regulato r y p ro b l e m s in ori gin o f. 1 48

Ves i covagi n a l aponeurosis. 6 7 . 6 8 -69 , 7 2 Viscera l Man i pula t i on [ I , 2 1 2 -2 1 3

Two - h an d tes t , u pper thorax, 2 I 3 - 2 1 4

V i s ceral p e r i t o n e um , 9 9

Two - l ayered embryoniC d i sk for mation , 1 -3

Viscer a l p l e u r a , 84-- 8 5 , 8 7 V i sceral t r e a t m e n t tec h n i q u e s . 2 7 2 -2 7 3

u

Vi scosi ty, I I S

U m b il ica l fa scia , 69-7 1 , 70 U m b i hcal liga m e n t s . 6 7

-

Unbound ceUs, I 1 5 U pper arm

w

We gener's granu l o m a to s i s , 1 44

hor i z o n t a l cross -sect i o n , 3 7

W h a r t o n 's j e l l y, 1 3 9

l i sten i n g test, 2 1 2

W h i te a d ipose t is s u e , 1 1 6 , 1 3 9 . 1 40

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