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.