Introducing the Fascial Distortion Model

by Stephen Typaldos, DO Clinical Assistant Professor Department of General and Family Practice University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine

Illustration and Design by Gina Belsito Biomedical Communications University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine

Introduction the muscle. This definition allows us of a whole host of commonly seen The fascial distortion model is a to conceptualize the pathology and to dysfunctions from ankle sprains to new anatomical model in which many speculate on how our treatment whiplash injuries. These distortions musculoskeletal injuries are thought choices might affect the dysfunction. are presented and discussed over the to be the result of specific alterations Another example is tendonitis. The next several pages. Some of the terms of the body's fascia. It was developed traditional definition implies that it is used will be familiar to the reader, but in an attempt to improve current the result of inflammation of an in the fascial distortion model they treatments by basing them on a more involved tendon, but clinically this take on other meanings and have anatomical approach. Many of the rarely occurs. In the fascial distortion implications that the reader may not most commonly seen musculoskeletal model tendonitis is defined as a appreciate at first. This paper defines injuries are vaguely defined and often triggerband or less commonly a terminology so assumptions are not respond poorly to conventional continuum distortion present in an derived from other medical models. treatments. One example of this is a involved tendon. The dysfunction now A glossary of fascial distortion model pulled muscle. It is difficult to becomes tangible, and the treatment terminology is presented at the end of visualize what a pulled muscle is, and modality can be specifically selected this paper. All of the drawings are therefore most treatments are not for that particulardistortion type. This based on as much clinical and specifically designed to correct the change in terminology perspective anatomical information as is currently underlying dysfunction. In the fascial can often lead to significantly more available. In time as more data distortion model a pulled muscle is effective treatment results. accumulates through surgical and defined as a muscle that has a There am four principle distortion clinical investigations, more specific triggerband wedged within its belly types and several subtypes which are representations of fascial distortions at a perpendicular angle to the axis of considered to be the etiological cause can be made.

14/AAO Journal Spring 1994 CLINICAL COMPARISON OF PRINCIPLE TYPES OF FASCIAL DISTORTIONS Table I Principle types Movement during Common Most specific of Fascial Distortions D ISTORTION TYPE Etiology treatment location treatment

7 Specific All fascial distortions currently Distorted pathways Triggerband Fascia! Yes known are of one of four types: throughout the technique Bands body triggerbands, triggerpoints, TRIGGERS ANDS, continuum distortions or folding Herniation distortions. These are reviewed and Abdomen. Jones technique of tissue pelvic area, through No or iriggerpoint compared in Table 1. Note that each supraclavicular .. fascia' therapy principle type is differentiated by the plane fossa TRIGGERPOINT,S etiology of its distortion. / ... Near joints at B\St1C, Alteration of the origin and Triggerbands 4. h insertion of qq transition No tendons or Continuum fi • zone figments and technique Al,:oit:::,.. between tissue types costo-chondro Triggerbands are clinically the CONTINUUM DISTORTIONS junction most commonly encountered fascial . distortion and occur as fascial bands Three dimen- Inside joints, Nlyofascial sional become pathologically altered. An No interosseous release 4 distortion .. b.; membranes technique important difference between - I of fascia' triggerbands and the other principle FOLDING DISTORTIONS planes fascial distortion types is that during treatment triggerbands move and the The triggerband subtypes are others do not. In the fascial distortion compared in Table 2. An important model movement is considered to point to realize is that regardless of occur when the tender area of a fascial the specific subtype all am treated band or its palpable distortion is able essentially the same way, that is by to change its location du ring treatment. using triggerband technique. The Therefore any fascial distortion that palpatory differentiation of the can be induced to move is by definition subtypes is necessary so they are not a triggerband and is best treated with confused with other distortions and modalities that correct distorted fascial treated inappropriately. Their bands. treatment is the subject of the There are six clinically recognized accompanying paper Triggerband subtypes of triggerbands: twists, Technique. crumples, knots, peas, grains of salt Twists (fig. 1) are the most common and waves. Note that these subtypes of the triggerband subtypes and can appear anywhere in the body along were named by my patients based on Knots (fig. 3) are the largest of all specific, well-demarcated pathways. what these distortions felt like to them. the triggerband subtypes and are To the physician they feel like the caused by either a portion of a fascial edge of a twisted ribbon. A crumple band becoming irregularly folded on (fig. 2) is a distorted fascial band that itself or occur when a portion of the is wedged between two muscle layers. band that has been ripped off its During treatment, patients describe attachment becomes knotted on top these as causing a burning type of of itself. Knots tend to be found at pain. Like all of the subtypes, twists crossbands, which are fascial bands and crumples are capable of travelling that intersect the triggerband at an through tissues or joints into other angle. The crossbands seem to stop fascial planes. Once a crumple is the progression of the tearing between pushed through the muscle, it then is palpated as a twist.

Spring 1994 AAO Jouma1/15 CLINICAL COMPARISON OF TRIGGERBAND SUBTYPES fascial fibers and thus stop the knot from becoming larger. Table 2

Patient's Associated descnption with other Palpatory during Palpatory tnggerband Common Subtype descnption treatment dimension types? locations

Well-defined. demarcated point of Suture to Anywhere Ribbon edge No including — tenderness that pencil width through joints moves with the Twist treatment

Yes, biome % .,:- Eleethcal Burning I/4" to I/2" twtst dunng Between sensation wide treatment muscle layers Crumple

Nickel to Yes. becomes Knot Tender knot half-dollar pea, grain of Thoracic and diameter salt or twist lumbar areas Knot

Soft smooth Yes. becomes Neck, thighs, Tender lump pea-sized grain of salt or and round. twist dunn and upper / pea-like eng amis PC treatment Peas (fig. 4) and grains of salt (fig. \il. 5) are seemingly just smaller versions Small with Scraping Face. scalp. hard irregular sensation Salt gram-sized No hands. and of knots. Peas are smooth, and are borders feet Grai.?fdat obviously pea-sized, while grains of ,---"1„17C salt are much smaller with irregular Tenderness or Yes. a Any., here, dt: Wrtnkle tightness at Barely palpable distorted band but borders. As a general rule, knots are --,_7C: utaunent sue can have a particularly wave n Car .1011115 found the most centrally, peas are WLI% C found in the neck, upper arms and thighs and grains of salt are found in injured band (fig. 6). The triggerband, the face, scalp, hands and feet. because of its distorted or twisted The wave that is seen when a fibers, becomes shortened. This shortening causes the adjoining fascial bands (usually crossbands) to be pulled toward the distortion at thei r point of attachmentto the injured band. This results in the formation of the wave that is present with most triggerbands. The wave is therefore a distortion in its own right and it can take on a life of its own. It can be pulled or pushed by forces that may act upon it (including triggerband technique, stretching and high velocity low amplitude osteopathic manipulation). When waves occur in ligaments that are close to joints, they tend to become pulled by everyday normal motion in toward the joint. As they become closer physically to the wave is now interacting on the triggerband occurs is found on the joint, the patient experiences a sense structures on and near the joint causing fascia! bands that connect to the of tightness of the joint because the a restriction of joint function. This is

16/AAO Journal Spring 1994 objectively seen as a loss of motion of the involved joint. In acute conditions (i.e., distortions in which no fascial adhesions have formed) the wave is able to travel freely to and from the joint as the forces act upon it (fig. 7), but in general without intervention it is pulled in a direction toward the joint. In chronic pain (i.e., fascial distortions in which adhesions are present) the wave is held firmly in place by adhesions and is immobile (fig. 8). The degree of immobility of chronic pain is determined in part by how far the locked wave is from the joint. The closer the wave is to the joint the less motion the joint will have. High velocity low amplitude often expresses discomfort with the The acute wave can be corrected or osteopathic manipulation (HVLA) is treatment itself. This is in contrast to moved by certain soft tissue a technique that uses the vertebrae or acute pain in which the patient other bony structures as a fulcrum to normally experiences a dramatic slingshot the acute wave away from subjective improvement at the instant the joint at a very high speed. If the of the manipulation. As is expected direction and speed of the wave reach from this model, once the adhesions a certain threshold the joint will are broken with triggerband manipulate and a popping sound can technique, then even the most difficult be heard. If the thrust does not generate to manipulate patients become easy enough speed, the wave will not be to manipulate, and the manipulation moved successfully and the joint will is then a positive subjective not be manipulated. experience. HVLA's role in the fascial In the fascial distortion model the distortion model is primarily in acute two clinical concerns with HVLA are pain and in chronic pain after it has 1) the wave has been forced away, but been made acute by destruction of the techniques, such as triggerband may in time be pulled back into its adhesions. technique, myofascial release, rolling, previous location and 2) adhesions traction or stretching. I prefer would be expected to thwart the speed Triggerpoints of the wave propagation, thus making triggerband technique because it is The term triggerpoint has been used HVLA an impractical treatment to the most specific; it follows the in the past for a variety of fascial distortion until it is far from the injury use in chronic pain. The problem with site and corrects it at the conclusion of the wave eventually returning is the same one that several othe r m odali ties chronic wave held by its pathway (fig. 9). Myofascial adhesions release, rolfing, stretching and traction have. This is seen most commonly in merely pull it away from the joint to a those patients that feel they need to be distant area, but since the distortion is popped frequently. For other patients not actually corrected, it may manipulation appears to be curative. eventually be pulled back into its prior This may be because the wave was location. In chronic pain, normally pushed away into another location only triggerband technique will be where the forces acting upon it were effective because it is specifically able to straighten it out. In chronic designed not only to correct the wave pain, a successful manipulative thrust but also to break the fascial adhesions. is difficult to achieve, and the patient

AAO Journal/17 Spring 1994 waves being moved along connecting bands combined wave being moved along fascial to form one large wave band to the conclusion of its pathway

fig.9 r/ distortions that have different etiologies and treatments. I prefer fascial distortion as a general term, and then I use terms such as triggerband, continuum distortion, triggerpoint and folding distortion as more specific descriptions. I believe that there is only one type of true non-banded triggerpoint. This is the one I refer to hemiated as a herniated triggerpoint. triggerpoint However, there are two subtypes of these. One involves a fascial band distortion (i.e., triggerband) that results in a herniated triggerpoint and is therefore a combination of a triggerpoint and a triggerband, and the other involves herniation without a fascial band distortion. The treatment of a non-banded herniated triggerpoint (fig. 10) is to force the protruding tissue below the fascial plane. This is accomplished by holding firm pressure onto the affected area with the physician's thumb until a release is felt. Correction of the banded herniated trigger- points (fig. 11) is initially the same. Following the release the triggerband is then corrected using triggerband technique. The two triggerpoint subtypes are compared in Table 3. Triggerpoint distortions are clinically the cause of many types of abdominal and pelvic pain, particularly those that do not respond to surgical intervention. In addition, principle distortion types is critical in triggerbands becoming intertangled. they are important factors in fascially obtaining successful treatment results. It is not a triggerpoint at all, although frozen shoulders (see Triggerband Another type of fascial distortion upon palpation it may seem similar. Technique) and in bursitis-like injuries is a banded pseudo-triggerpoint It is treated by correcting one trigger- of the upper thighs and gluteal areas. (fig. 12) . It is a raised and tender area band at a time until all the distortions Differentiating them from other of fascia that is caused by two or more are resolved. continued on page 30

18/AA0 Journal Spring 1994 CLINICAL COMPARISON OF TRIGGERPOINT SUBTYPES

Table 3 Subtype Etiology Palpatory Differentation Treatment

, Herniation of Correction is completed . ggerpTnoint therapy tissue through at the end of non- banded triggerpoint therapy or Jones technique NON-BANDED HERNIATED fascial plane TRIGGERPOINTS

Triggerpoint Herniation of At completion of therapy or Jones tissue through a triggerpoint therapy a technique followed -cc banded fascial is palpable ---4•--,... -r-°,1.4., plane distorted by U by triggerband BANDED HERNIATED':"'; a triggerband technique TRIGGERPOINTS iP.'!

Continued from page 18 opposite force to the continuum distortion. When the direction and Continuum Distortions force are adequate, the injury suddenly Continuum distortions are reverses and clinically the injured area clinically the primary cause of ankle then resembles it pre-injury condition. sprains, pulled ribs, contusions and Continuity and continuum are two many other acute injuries seen daily terms used frequently in the fascial in the emergency room setting. In distortion model. Although they may addition, along with triggerbands, they seem redundant, they are not, and the are associated with chronic problems implications of each are important in such as frozen shoulders, costo- understanding fascial distortions. chondritis and low back pain. Continuum is an anatomical model in Continuum distortions are thought to which tissues are viewed as being in occur when the forces of injury cause a constant state of physiological flux an alteration of the transition zone in which one tissue type can be between two tissue types (fig. 13). transformed into another tissue type transitional zones between musculo- Continuum technique is designed to through its transition zone depending skeletal tissues are discussed, but the reverse this shifting of tissue upon the external forces applied to it. continuum model applies to all tissue components by applying equal and In Continuum Technique only transition zones and therefore

fcb 4:A ig; Tcl ligament ligament W

unmineralized4,; unmineralized fibrocartilage r fibrocartilage mineralized (1; mineralized fibrocartilage ,:7t1 et; : fibrocartilage 1,3

lamellar 00 c -t * -■„:„.,;• Hrt..r.. lamellar bone • cl, A4-.L•7 --- •LI . ' bone . ," i• „ .,._"Z.,. ,",- .iS•, ' -..`:k: ' fig. 13 normal continuum artist's rendition of shifted continuum

30/AAO Journal Spring 1994 Table 4 TRIGGERPOINT AND CONTINUUM DISTORTIONS distortions are found in or near a joint, or at the origin or insertion of tendon COMPARATIVE CONTINUUM CATACORY TRIGGERPOINTS DISTORTIONS or ligament with bone. True triggerpoints are most common in the Etiology Herniation of tissue through Alteration of transition zone fascia' plane between tissues abdomen. Palpatory-wise they are quite different to the experienced Near joints at the origin and Abdomen, supraclavicular physician. Continuum distortions are Common location insertion of tendons, ligaments, fossa and costo-chondro junction smaller, firrner and have little give. Triggerpoints are larger, have less- Size Dime to nickel Pea-sized or smaller defined borders and are much softer.

Palpatory sensation to \ itamin A or E soft-gel The release that occurs during Boggy marble physician capsuP le correction is also different. The continuum distortion is like a button Moderately tender to Palpatory sensation to patient Moderate tenderness excruciatingly painful slipping into a button hole, while the triggerpoint is a melting sensation. Time of treatment until release Variable-- seconds to minutes begins Variable-- less than a minute The differences are clinically important because how they are Duration of time once release 15 seconds to 3 minutes 1-5 seconds beginuntil completios n envisioned will direct what force and finesse is actually used. In treating Sensation experienced by "Button slipp i ng into a button either of these, it is the skill of the physician and patient during "Melting" release hole" treating physician that will ultimately determine the success of the treatment. potentially effects all types of tissues. The term continuity refers to the interconnections of all the bodily tissues. In the context of fascial distortions it refers specifically to the fact that individual fascial fibers pass through various tissues and that an alternation of any given portion of that fiber will result in pathological changes elsewhere along that same fiber. Triggerband technique is based on the model of continuity, whereas continuum technique is based on the continuum model. Although I have already spent some time talking about both continuum distortions and triggerpoints, I think that it is still worthwhile to compare them face to face (Table 4). Despite the fact that they are etiologically different, some physicians may have difficulty discerning the two. Continuum distortions are the result of shifting in the tissues transition zones, and triggerpoints are the protrusion of tissue above its fascial plane. As a general rule, continuum

Spring 1994 AAO Jouma1/31 Folding Distortions The term fascial plane has been Schematic of Dislocated used primarily by physical therapists Shoulder Causing a and proponents of m yofascial release. Folding Distortion They tend to view the fascia as being present in a planar presentation which pathologically develops restrictions. Shoulder before injury M yofasci al release technique is often normal a very effective approach to fascial anatomy distortions, but I believe not necessarily for the same reasons that have been commonly expressed. Fascia unfolding Although fascial planes do exist, they as shoulder do not exist in the same sense that this dislocates piece of paper has a planar presentation. Within the fascial planes are fascial bands (fig. 14), which means that an alternation of the plane Fascia is in effect altering the fascial bands. torquing as In addition, most fascial planes are the patient Refolding Orthopedic not static entities that rest in the body responds to occurs with the pain by manipulative like this paper can rest on the table. correction of residual twisting the folding The planar presentation is dynamic shoulder dislocation with and moving. As an arm is raised the incomplete distortion untorquing present interosseous fascial plane shifts and fig. 15 partially unfolds. If the forces are increased on the arm such as occurs with lifting, the fascia unfolds more. It is this unfolding of the fascial planes that is an important, and until Shoulder with Schematic of now, unknown fascial phenomenon. folding Correcting a So, as forces are applied to the fascial distortion Shoulder Folding plane it is able to unfold to be able to Distortion accommodate the stress. This spreads the forces more evenly throughout the fascia and other musculoskeletal structures that are interconnected. But since the fascia unfolds under stress, Traction is it must be able to refold once the firmly applied Once traction is stopped the fascia refolds into a configura- forces are removed. It is this ability as the that often is lost with injury and that distortion is tion more similar to its pre- untorqued injury state myofascial techniques are the most effective in treating. 4°.' To visualize this better, think of the fascial plane as a piece of paper se that is folded in fours. As forces are AP applied to the edges of the paper, it fig. 16 pulls apart. First it becomes a half, then three-quarters and then a full page. But if the paper is twisted during unfolding it will be contorted. For

32JAA0 Journal Spring 1994 proper refolding, the forces must be Fracture of Forearm Resulting in Folding Distortion directed so that the contortion is Fascia reversed. If this does not occur then Normal Radius distorts as bones the refolding cannot be done in a way forearm fracturing separate that restores the fascia to its pre- injured arrangement. I believe this is what myofascial release does; it restores fascial folds to their pre- injured states by simultaneously interosseous unfolding and untorquing the fascial membrane distortion. It must be remembered that there may be fascial band distortions as well, and for optimal results these need to be corrected. At times the fascial planar distortion cannot be corrected until the fascial band distortion has been resolved. In any case, the understanding of fascial folding distortions, fascial planes and myofascial release are all important principles in the fascial distortion model. Fig. 15 demonstrates what may happen as a shoulder dislocates and is Schematic of Correcting a Fracture Folding Distortion corrected by orthopedic manipulation. Bone After the fracture has healed the folding Although many times the result is reset with distortion can be treated.Traction is adequate, some of these patients folding applied in several directions a once to distortion unfold the fascia continue to have residual pain and Fracture present decreased range of motion. This is thought to occur because the fascial plane remains torqued and distorted. In fig. 16, myofascial release is used to gently unfold the distortion and then untwist it before refolding occurs. The shoulder itself does not need to 111 be dislocated to accomplish this, although firm traction is often necessary. A total correction of the Once traction is stopped folding distortion does not occur with the fascia refolds into a this treatment alone. Stretching and configuration more similar to its pre-injury strengthening, triggerband technique state and normal everyday use of the t fig. 18 shoulder may also be necessary for a complete resolution of the distortion. Figs. 17 and 18 show what may healed is to correct the distortion with hands are necessary to accomplish happen to the fascial planes as a myofascial release. To be successful, this. Again, physical therapy, fracture occurs. The fascia is unfolded, forces must be applied in several stretching, strengthening and torqued and then refolded with directions at once to first unfold the triggerband technique may be helpful distorted fascial planes resulting. The fascia and then untorque it before it once the folding distortion has been best treatment after the fracture has refolds. Often two or more sets of successfully treated.

Spring 1994 AAO Joumal/33 Glossary Chronic Injuries: Musculoskeletal Contusion: A continuum distortion dysfunctions in which adhesions have of the periosteum. Acupressure Points: Specific formed. Costochondritis: Chest wall pain anatomical sites along acupuncture Combination Distortion: A distortion resulting from a combination of meridians that are treated by holding that is made up of two or more continuum distortions and pressure on them in the belief that this principle fascial distortions, such as a will correct dysfunctions elsewhere triggerbands. continuum distortion and a in the body. Triggerband pathways triggerband present together. Cranial Technique: Treatment offer a possible anatomical modality in which the rhythm of mechanism for this to occur. Continuity Model of Anatomy: An fascial fluid is palpated in the cranial anatomical model in which individual area and gentle alterations of the Acupuncture Points: Specific fascia] fibers pass through various rhythm are made to influence fascial anatomical sites in which acupuncture structures and tissues and that an distortions at a distant site. needles are placed. These commonly alteration of any given portion of that match crossbands of triggerbands and fiber will result in pathological Crossbands: Fascial bands that are the meridians often match triggerband changes elsewhere along that fiber. It found in the same plane and at a pathways. also includes the concept that fascial different angle to a triggerband. They fibers are continuous with and become are often the anatomical starting place Acute Injuries: Musculoskeletal the fibers that make up bone, dysfunctions in which no adhesions in triggerband technique. ligaments, tendons and other have formed. adjoining tissues. Cross-link: A single fascial fiber that is present at a 90 degree angle to a Adhesions: Fascial fibers that are Continuum Distortion: A principle aberrantly attached to other fascial band which it is restraining. fascia] distortion type that occurs anatomical structures and result in When injuries to cross-links occur, when there is an alteration of the dysfunction and restriction of those this may cause the band to twist or transition zone between two tissue allow its fibers to tear and separate. structures. types. This most commonly occurs at the origin or insertion of ligaments or Crumple: Arthritis-like Pain: Pain that is A distorted fascial band tendons with bone. interpreted by the patient as arthritis wedged between muscle layers-- but is instead of a fascial origin. triggerband subtype. Continuum Model of Anatomy: An anatomical model in which tissues BandedHerniatedTriggerpoirus: One Double Twist: A triggerband are viewed as being in a constant state of two subtypes of triggerpoints that distortion in which the fascial band is of physiological flux in which one are characterized by herniation of twisted twice. These are thought to be tissue type can be transformed into tissue through a banded fascial plane the cause of the "Headlight Effect". another tissue type through its that is distorted by a triggerband. transition zone depending on the Failed Back Surgery Syndrome: An Banded Pseudo-Triggerpoint: A forces applied to it. ongoing pain the lumbar spine that fascia] distortion that occurs when has a fascia] etiology that was not Continuum Technique: A manual two or more triggerbands overlap. correctable by surgical intervention. modality that is used to correct continuum distortions. The thumb of Bursitis: A painful area under a muscle Fascia: The primary connective tissue the physician is used to first locate that is tender to touch. Most of these of the body that makes up tendons, are triggerbands, although some are and then treat the area of shifted ligaments, fascial bands, myofascia, continuum. Force is applied in equal either triggerpoints or continuum adhesions and other tissues that amount and opposite direction to distortions. surround and engulf muscles, bones, which the injury occurred and is held nerves and organs. CarpalTunnelSyndrome: Acondition until there is resolution of the in which median nerve conduction is distortion. Fascial Band: A collection of parallel impeded by a triggerband distortion. fascial fibers.

34/AAO Journal Spring 1994 Fascia! Distortion: A pathological triggerband pathway some distance used to correct folding distortions if alteration of fascia that results in ahead of the actual point of the the forces are directed so that the dysfunction of the affected fascia and treatment. This is likely the effect fascia is first unfolded and then its associated structures. The four from a double twist in which the untorqued before refolding occurs. principle types are triggerbands, second twist is pushed ahead by the triggerpoints, continuum distortions pressure being applied to the first Non-bandedHerniatedTriggetpoint: and folding distortions. twist. One of the two subtypes of triggerpoints that is characterized by Fascial Distortion Model: A medical High Velocity Low Amplitude herniation of tissue through a non- model in which most non-orthopedic, Osteopathic Manipulation: A banded fascial plane. non-neurological and non-organic thrusting technique in which joint musculoskeletal dysfunctions are restrictions are alleviated by sling- Osteoarthritis: A condition in which considered to be the result of injured shotting the triggerband wave the fascia in or near a joint has taken or altered fascia. distortions away from the affected on characteristics of the adjoining joint at a very high speed. bone. Fascial Fiber: A collection ofparallel collagen fibers. Jones Points: Anatomical locations Pea: A triggerband subtype that has a of commonly palpated triggerbands, similar etiology to that of a knot, but Fascia! Plane: Fascial tissue that is triggerpoints and continuum clinically has a much smoother and present in an orientation such that it is distortions. rounder palpatory presentation. broad and wide but has little thickness. Knot: A triggerband subtype that Plantar Fascitis: A triggerpoint Fascitis: An infection that involves occurs when either a portion of a involving the plantar fascia. If a heel the fascia. fascial band has become folded on spur has formed this is evidence that top of itself or when a portion of a over time the continuum between Fibromyalgia: Multiple fascial band has been ripped from its fascia and bone has shifted distortions that involve large areas of attachment and has become knotted dramatically. the body and have an excessive on top of itself. amount of fascial adhesion formation. Pressure Points: Small, well- Massage: A treatment of myofascia demarcated areas of the body that Folding Distortion: A principle fascial that moves triggerbands away from elicit tenderness with palpation. To distortion type that is the result of a the involved muscle. be adequately treated they must be three dimensional alteration of its differentiated into their anatomical fascial plane: These commonly occur Movement: The motion of a etiologies of fascia] distortion types. as the result of a fracture ordislocation. triggerband distortion along its Many are either triggerpoints or pathway. This occurs in acute pain continuum distortions, but Frozen Shoulder: Any fascially and during certain treatments such as triggerbands and banded pseudo- injured shoulder that has reduced triggerband technique, rolfing or triggerpoints also are described by motion to the extent that daily traction. patients as being pressure points. activities are impaired. Muscle Energy Technique: A Principle Types of Fascial Grain of Salt: A triggerband subtype treatment modality in which muscle Distortions: Pathological alterations that is a much smaller and firmer contractions are used to force the of fascia that have distinct etiologies. version of a knot. triggerband away from a crossband There are four currently known: that is in or near a muscle. triggerbands, triggerpoints, contin- Groin Pull: A triggerband present in uum distortions and folding distor- the groin area. Myofascial Energy Technique: A tions. For a new principle type to be treatment modality in which sustained recognized it must have a completely Headlight Effect-. During triggerband manual traction is applied until a different etiology than any other type technique this occurs when the patient triggerband distortion is moved out of fascial distortion previously has an awareness of the course of the of an affected muscle. It also can be described.

Spring 1994 AAO Jouma1/35 Pseudo-sciatica: Any one of several Tendonitis: A triggerband, or less Triggerband Technique: A manual triggerband pathways that mimic the commonly a continuum distortion, approach to treating distorted fascial course of the sciatic nerve. present in a tendon. bands in which the distortion is located and corrected along its entire pathway Pulled Muscle: A muscle that has a Tennis Elbow/Little Leaguer's Elbow: by using physical force from the triggerband wedged within its belly A tender area over the lateral or medial physician's thumb. at a perpendicular angle to the axis of epicondyle that is caused from a the muscle. triggerband or less commonly a Triggerpoint: A principle fascial continuum distortion. distortion type that results from a Release: The sensation experienced herniation of tissue through a fascial by both physician and patient at the Traction: A treatment modality in plane also known as a herniated instant of correction of a triggerpoint, which a pulling force is applied in one triggerpoint. continuum distortion or folding direction to an affected area of the distortion. body. Very small triggerbands can at Triggerpoint Therapy: A technique times be corrected with this modality, used in the treatment of triggerpoints Rolfing: A treatment of muscle fascia and if the direction and force are in which the physician's thumb is that may result in breaking of appropriate, some folding distortions used to push protruding tissue down adhesions and forcing of a triggerband may also respond to traction. below the fascial plane. out from an involved muscle. Transition Zone: The intermediate Twist: A triggerband subtype that ShiftingoftheContinuurn:This occurs area between two tissue types that occurs when a portion of a fascial when forces are applied to the contains characteristics of both tissue band becomes rotated on itself. transition zone between two tissues types. and the percentages of their Wave: A triggerband subtype that is components become altered. Triggerband: A principle fascial palpated as a wrinkling in the distortion type characterized as being crossband of the adjoining Sprain: A nonspecific description of a distorted fascial band. triggerband. a fascial distortion. Ankle sprains are most commonly continuum Triggerband Pathway: The Whiplash Injury: A injury that results distortions. Cervical, lumbar and anatomical course that a distorted from a sudden introduction of flexion shoulder sprains are often fascial band is found to have during and extension to the cervical spine. triggerbands. its correction using triggerband Most of these are triggerband technique. Most patients with the same distortions of the cervical fascia, but Strain Counterstrain Technique: A clinical problems tend to have continuum distortions also may occur treatment modality in which a anatomically the same distortion at the origin and insertion of the triggerband is forced away from an pathways. cervical ligaments. involved muscle by alternating the direction of muscle contractions.

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