Mobilizing The Myofascial System

Mobilizing
the Myofascial
System
A clinical guide to assessment and
treatment of myofascial dysfunctions
Mobilizing
the Myofascial
System
A clinical guide to assessment and
treatment of myofascial dysfunctions
Doreen Killens BScPT, FCAMPT, CGIMS

Forewords Diane Lee BSR, FCAMT, CGIMS
Thomas W Myers
BetsyAnn Baron BCSI, IASI, FQM
Edinburgh
HANDSPRING PUBLISHING LIMITED
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First published 2018 in the United Kingdom by Handspring Publishing
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Permissions
In addition to the specific permissions given in the captions of figures and tables, the author and publishers
are grateful: for permission granted by photographer Michael Slobodian and model Alison McCreary to
reproduce the photographs illustrating Chapters 5 to 14; to Elsevier for permission to reproduce
Figures 1.2, 1.4, 1.6, 2.9, 6.30, 12.12 and Table 1.1; to Serge Paoletti for Figure 2.15 and for information used
in Chapter 1; to the Education Committee of the Orthopaedic Division of the Canadian Therapy Association for
permission to use the Contraindications to Manual Therapy list reproduced in Chapter 13; to Hay House Inc.,
Carlsbad, CA, for permission to quote from Goddesses Never Age by Christiane Northrup; and to Tom Myers,
specifically for material in Chapter 14 but also in general, for inspiration throughout the book.
The right of Doreen Killens to be identified as the Author of this text has been asserted in accordance with the
Copyright, Designs and Patents Acts 1988.
ISBN 978-1-909141-90-2
ISBN (Kindle eBook) 978-1-909141-91-9
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determine the best treatment and method of application for the patient.
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CONTENTS
Acknowledgements vii
Forewords ix
Preface xiii
List of abbreviations xv
SECTION 1 Understanding fascia
CHAPTER 1 Understanding fascia 3
CHAPTER 2 A brief summary of Tom Myers’s Anatomy Trains fascial lines and clinical implications 19
CHAPTER 3 Assessment of fascial dysfunction 41
CHAPTER 4 Principles of treatment with Mobilization of the Myofascial System 51
SECTION 2 MMS techniques for fascia

CHAPTER 5 The cervical spine 61
CHAPTER 6 The craniofacial region (cranium, temporomandibular joint) 83
CHAPTER 7 Dural mobility 103
CHAPTER 8 The thorax 121
CHAPTER 9 The lumbar/pelvic region 135
CHAPTER 10 The pelvic floor 151
CHAPTER 11 The lower extremity 167
CHAPTER 12 The shoulder girdle 195
CHAPTER 13 The upper extremity 211
SECTION 3 Optimizing treatment

CHAPTER 14 Movement and fascia 231
CHAPTER 15 Optimizing therapeutic outcomes

257
References 269
Index 275
ACKNOWLEDGEMENTS
Gratitude. This is the overall tenet by which I try to live Body, with Mobilization of the Myofascial System (MMS)
my life, and this book, Mobilizing the Myofascial System, and Structural Myofascial Therapy (SMFT®). The course is
provides ample opportunity to express it. An enormous a combination of MMS, which is based on manual therapy
debt of gratitude goes out to a long list of colleagues, friends for the articular, muscular and neural systems, and SMFT,
and family who have, by their support and encouragement, which involves techniques that are based in Structural Inte-
contributed to the book. First and foremost I would like to gration for the muscular system. We have found that these
thank Tom Myers, whose poetic descriptions of fascia in two approaches are mutually complementary. In addition
his book Anatomy Trains inspired me to think beyond the to sharing our passion for fascia, we share a deep friend-
standard tools used by physiotherapists to treat musculo- ship, for which I am very grateful. Along with my other
skeletal conditions. This book struck a creative spark in me soul sisters and brothers, and long-time friends (Margie,
that led to the development of an approach to treatment of Rita, Donna, Gioconda, Sharon, Michèle, Betty, and Ken),
the fascial system from the point of view of a physiothera- I would like to thank you for providing encouragement,
pist, an approach I have called Mobilization of the Myofas- love, laughter, and moral support throughout my life.
cial System (MMS). Tom continues to inspire and evolve
his work and has touched the lives of many professionals Elaine Maheu, my friend since our days at McGill
and movement therapists. niversity and my business partner for over 27 years – you
U
set the bar high and inspire others to follow you and do
I would also like to acknowledge the contribution of the same, whether it be at the clinic, through your teach-
Laurie McLaughlin, a colleague, former examiner for the ing around the world, or simply pushing me to do more
Orthopaedic Division of the Canadian Physiotherapy exercise! My life would not be the same without you in it.
Association, and soul sister friend. Laurie and I began to
discover the world of fascia through the lens of physiother- Diane Lee – my mentor, my friend and my inspiration.
apy at about the same time (over 20 years ago). Although I have taken countless courses with you and I am always
she lived in Toronto and I in Montreal, when we would get amazed at how you are able to integrate the available s cience
together, we would exchange and explore fascial treatment with the art of physiotherapy. You continue to evolve, not
techniques that we had each separately developed. We were only as a professional, sharing your insights with therapists
consistently surprised at how similar our approaches were. across the globe, but also personally, sharing who you are,
Our techniques continue to evolve and we each share our with all of your gifts. Thank you for taking the time to dis-
fascial treatment approaches with other physiotherapists cuss and exchange ideas about fascia and how it fits into
across the globe. the world of physiotherapy and thank you for your valuable
input into this book. I remain forever grateful.
BetsyAnn Baron has enriched my life with her appre-
ciation for dance and music, as well as her enthusiasm for I would also like to acknowledge my Canadian manual
learning, especially her zest for all things “fascia.” A former therapy roots and thank my fellow instructors and examin-
ballerina with Les Grands Ballets Canadiens, a massage ers for sharing their excellent manual therapy and c linical
therapist since 1991 and a structural integrator since 2003, reasoning skills. In addition to the intellectual stimula-
she developed an approach to treatment of the fascial sys- tion, their appreciation for dance and laughter made many
tem called Structural Myofascial Therapy (SMFT®). Since orthopedic symposiums and conferences enjoyable and
2007, BetsyAnn and I have been teaching a series of courses memorable. It was a pleasure to be involved with such an
for physiotherapists called Treatment of the M yofascial inspiring group for over 30 years.
vii
ACKNOWLEDGEMENTS continued
To Eve Sanders, who so generously offered to proofread took up a great deal of time. Thanks for waiting so patiently
the text for this book. Her background as a university for me to come back into the fold and take more time to “play.”
English professor and her experience in having been the
recipient of MMS made her an excellent choice for edit- To my mother, Thérèse, who is now a 91-year-old matri-
ing this manuscript. As much as she appreciated the value arch of an extended family. You have always been ahead
of MMS techniques and the contribution it brought to of your time and through your example, have encouraged
her physical well-being, I came to appreciate her gifts as a each of your children, grandchildren, and now, great-
wordsmith. The reader will no doubt value her input. grandchildren to aspire to be all that we can be. I am glad
that my soul chose you to be my mother – I couldn’t have
To Michael Slobodian, my friend and photographer, asked for a better role model. And finally, to my extend-
who so skillfully produced the photos in this book – I am ed family, including my siblings, in-laws and “out-laws,”
grateful for your eye for detail and your artistic gifts that step-kids and grandkids. Your love defines me.
depict “beautiful lines” and yet still manage to illustrate
the MMS techniques accurately. I couldn’t have asked for a Thank you to my students, who continue to ask probing
better collaborator on this project. questions and push me to clarify in words what my hands
are feeling. To my patients, especially the challenging
To Joanna Abbatt, a Pilates and Gyrotonics certified ones, who push me to think beyond “the usual” and sort
massage therapist, who works with dancers, circus per- out “what else could this be.” Thank you for sharing your
formers, and “regular folk” to empower them to move stories and for allowing me to contribute to your healing
conscientiously. Thank you for your input into the exercise journeys.
chapter. Your keen eyes don’t miss a thing!
And finally, thank you to my spiritual guides (yes,
Thank you to the team at Handspring Publishing, in I dare say such a thing!). I feel your presence in my treat-
particular Mary Law and Andrew Stevenson, who started ment room and appreciate your input. I have learned to get
this project off and guided it through its many phases, as myself “out of the way,” so that I can be open to receiv-
well as Stephanie Pickering (copy-editor), Morven Dean ing your guidance. Thank you to my spiritual guide and
(project manager), and Bruce Hogarth (art design). Your mentor, Doreen Mary Bray, for teaching me how to con-
hard work and patient responses to my endless questions nect with “Essence” and whose input changed the trajecto-
and clarifications were much appreciated. You made my ry of my life, both personally and professionally. Gratitude.
first experience as an author a very enjoyable process. Gratitude.
To my husband George, whose unconditional love Doreen Killens

and support is unparalleled. He, along with my daughter Montréal, Québec, Canada
Kelly and my son Michael, has tolerated my fascination with March 2018
the world of fascia, which often led me far from home and
viii
FOREWORD by Diane Lee
I am delighted, and honored, to be asked to write • lack of visceral mobility that requires a specific vis-
a foreword for Doreen’s new book Mobilization of the ceral release technique, or
Myofascial System – a Clinical Guide to Assessment and
Treatment of Myofascial Dysfunctions. You may be won- • the inability of the fascial system to permit the elon-
dering why Handspring Publishing has agreed to produce gation required for the joint to move?
another book on fascia when their company represents sev- Is the lack of joint control due to:
eral authors on the topic already. This is the first book to
be written on fascia by a physiotherapist with expertise in • loss of passive integrity of the joint (articular instability)
manual and manipulative therapy.
• altered neuromuscular recruitment strategies (motor
I have known Doreen Killens for more than thirty-five control deficits)
years and over this time we have witnessed each other’s
interests and teaching evolve in conjunction with our • reduced neuromuscular capacity (strength, endur-
clinical expertise and the research evidence. We were ance), or
both instructors and chief examiners for the Canadian
•
loss of anatomical integrity of the fascial sling
Academy of Manipulative Physiotherapy (CAMPT), a divi-
required for the transference of load?
sion of the Canadian Physiotherapy Association and an
IFOMPT accredited program. In the 1980s, the curriculum What is the relationship between impaired body regions?
of courses was primarily focused on the articular system, as Is one compensating or causal for the other?
were most manual therapy programs world-wide, and while
the program is still strongly based in the articular system, it Physiotherapists are not specialists in one system, rather
has evolved to include more neuromyofascial concepts for they understand the integration and relationships between
manual therapy. However, what appears to still be missing is and within the body regions and systems and have a
an evidence-informed, clinically reasoned approach for the diverse set of tools (assessment and treatment) to address
assessment and treatment of fascial dysfunction. the specific combination of impairments of the individual
patient. The goal is to restore better strategies for function
Physiotherapists facilitate posture and movement train- and performance. While evidence-informed, most experi-
ing by addressing the underlying system impairments enced clinicians will tell you that their clinical expertise
(articular, myofascial, neural, visceral) that compromise is equally important for well-reasoned treatment decisions.
mobility and/or control of the joints of the skeleton. This The patient’s goals are centermost in treatment planning.
perspective differs from many other disciplines and is
one that requires a diverse tool box for both assessment This landmark new book, Mobilization of the Myofascial
and treatment of the whole person that is inclusive of all System, is the culmination of over twenty years of Doreen’s
body regions and systems. For example, is the lack of joint interest, clinical expertise, and understanding of the evi-
mobility due to: dence as it pertains to fascia for physiotherapists with
manual therapy training. The book is divided into three
• a stiff joint that requires a specific articular mobiliza- sections. The first begins with an introduction to all things
tion technique fascia: what is it (definition), its anatomy (macroscopic and
microscopic), the function and pathophysiology of fascial
• an over-active muscle that requires a technique to
dysfunction. Chapter 2 outlines the theories of Tom Myers
reduce the neural drive to the muscle
and his fascial Anatomy Trains which were a starting point
ix
FOREWORD continued
for Doreen’s approach to the fascial lines from a physio- Doreen closes her book with a very personal story about
therapy perspective for mobilization of the myofascial sys- her journey as a mother, physiotherapist, and embodied spirit
tem (MMS). The physiotherapy assessment that integrates and shares many experiences that have shaped her as a cli-
the fascial system with all others (articular, neural, viscer- nician. This information is rarely shared and reflects what a
al) is presented in Chapter 3 followed by Chapter 4 which therapeutic relationship with Doreen would be like. It is truly
outlines the principles of MMS treatment and describes special, as is she. With heartfelt gratitude, I extend my con-
how, and when, MMS techniques can be integrated with gratulations to her on the completion of this text for physi-
other manual therapies for impairments involving mul- otherapists with special training in manual therapy for ways
tiple, and different, systems. The manual physiotherapist to mobilize the myofascial system, and more.
will find the concepts here align well with the principles of
manual therapy treatment. The second section is descrip- Diane Lee, bsr, fcamt, cgims
tive and illustrative of a wide variety of MMS techniques Adjunct Professor, Physical Therapy
for the various regions of the body and the third section Faculty of Medicine, UBC
completes the text with a discussion on additional topics Clinical Specialist Women’s Health, CPA
to consider in treatment for best outcomes (movement, Surrey, BC, Canada
nutrition, hydration, hormones, etc.). July 2018
x
FOREWORD By Tom Myers
All over the world, manual therapists and movement Doreen Killens is one of those synthetic practitioners
professionals are busy forging a new synthesis of how we able to incorporate various methods into a single, coher-
are held together and how we move. This over-arching ent whole. Of course I am happy to see another application
point of view is arising from new knowledge and research of the Anatomy Trains map, and doubly so to see it done
on the brain’s control of movement combined with new accurately. But I am especially pleased to see manual ther-
knowledge and research on auto-regulation in the fascial apy and movement so confidently combined. Work with
system. the musculoskeletal frame can never return to the linear,
one-to-one correspondences that were the grail of the pre-
The alembic for this new synthesis, without which it vious generation. Fractal mathematics, systems theory, and
cannot happen, is the willingness of disparate professions the dawning recognition that everything is related all lead us
to work with each other and learn from each other. The away from the temptation to isolate particular joints, mus-
insights from movement systems like Pilates and strength cles, or movements. Our bodies just do not work that way.
and conditioning training bring new life to physiotherapy.
The intrinsic physiological movements employed in oste- The approach in this book is sound, enjoyable, and opens
opathy are being incorporated into work with developmen- the door to a lifetime career that is both challenging and
tal delay. Movement instruction, touch cueing, and manual satisfying by turns. Working in a world where everything
therapeutic approaches are all blending and mixing into is connected and interacts can be frustrating to those who
a single theoretical basis for learning, enhancing, and need a guide for every step, a defined answer to every prob-
repairing the human movement function. lem. But for the artist – see the last chapter for a fine sum-
mary of the proper attitude to being a therapist – this book
This is a happy convocation, where new developments offers a way forward that is at once effective and engaging.
are being shared from one profession to another, and old
barriers are breaking down to produce a common lan- Tom Myers
guage in which all the “spatial medicine” practitioners will
eventually converse. Clarks Cove, Maine USA
July 2018
xi
FOREWORD By BetsyAnn Baron
I met Doreen Killens in the early 1980s when she was a In the earlier part of her career, during treatment,
young physiotherapist and I was still a professional ballet Doreen would say to me: “Hey Bets, I learned some really
dancer – and her patient. Indeed, I happened to be first cool stuff! This will be perfect for you!” This has evolved
in her treatment schedule after she had taken one of her into: “Hey Bets, let me show you what I’ve been playing
very early postgraduate courses, Muscle Energy. The tech- with this week,” as she delves into exploring and working
niques she learned just happened to be what my injured with the myofascial system.
body needed. This was the beginning of what is now nearly
a 40-year relationship. In 2007, Doreen and I began teaching a continuing edu-
cation curriculum we designed for physiotherapists titled
After I hung up my pointe shoes, I studied massage ther- “Treating the Myofascial Body.” We created a kind of jig-
apy. I practiced on Doreen to get her professional input. She saw puzzle in which the pieces of her work and mine fit
began referring patients to me that needed more attention into a fascinating myofascial whole that we have been able
to muscular tension than she had time for. Thanks to her to pass on to others.
referrals, my practice blossomed with a clientele searching
for specific therapeutic massage. Now Doreen’s groundbreaking myofascial techniques
are the subject of her first book, Mobilizing the Myofascial
We soon began monthly treatment exchanges, not only System. I have been privileged to witness Doreen’s growth
for our own well-being, but importantly, to share tech- both in the treatment room and in the classroom, and I am
niques and discoveries. We each took a variety of courses thrilled that she is transmitting her knowledge to you. It
and swapped the information we had learned. is truly outstanding hands-on work that will add another
dimension to your understanding of what manual therapy
Entering the 21st century, we both began exploring the can achieve.
fascia and the myofascial system, guided by sources that
were both similar and different. Our exchanges became BetsyAnn Baron
more and more fascially focused, often erupting in gales of Board Certified Structural Integrator, IASI, FQM
laughter as we explored body positioning in order to find Montréal, Québec, Canada
and treat the line of tension we were searching for. March 2018
xii
PREFACE
Why write this book? most physical therapists are unfamiliar with fascia, aside
from the “dead packing material” we had learned to push
In my 40-year career as an orthopedic physiotherapist, I
aside in our dissections in order to visualize the “impor-
have amassed many wonderful tools from multiple post-
tant stuff” like muscles and nerves. Physiotherapists, with
graduate courses that I have taken over the years. I have
their varied skill-set in manual therapy, are poised to take
never believed in only one type of treatment, preferring
on this important tissue.
continually to assess and treat my clients as we explore
their healing journey and use “the right tool at the right In the world of orthopedic physiotherapy, the use of
time” (Diane Lee). Despite this, I too have experienced manual therapy techniques has become increasingly more
my fair share of clinical frustrations and this has led me evidence-based and study after study shows its efficacy
to explore this fascinating world of fascia. This approach along with exercise therapy for the management of the
to treatment has brought a deeper level of understanding to most common orthopedic conditions. However, there has
seemingly complex cases. been very little mention of the role of fascia aside from cur-
sory mention of the stabilization role for the thoracolum-
As physiotherapists we like to classify dysfunction as
bar fascia in low back pain. Diane Lee and L. J. Lee have
much as possible, thinking along the lines of joint dys-
noted the myofascia as one of the impairments in their
function vs muscle imbalance vs recruitment problems,
Integrated Systems Model. Knowledge of fascial connec-
etc. Therapists may also be experiencing situations where
tions helps us understand how to direct our approach at
patients are complaining of multiple areas of pain that
the source of the problem (the criminal) and not merely the
do not correspond or fit into the paradigms that we are
painful tissue (the victim).
familiar with, even as fully trained manual therapists.
Perhaps what is missing is the fascial component, an often In 2001, Tom Myers, a structural integrator, wrote
overlooked tissue category that may contribute to persis- the first edition of his book Anatomy Trains: Myofascial
tent musculoskeletal pain. Fascia is innervated, making it Meridians for Manual and Movement Therapists. This con-
a potential pain generator, and it has strong mechanical cept of myofascial continuities has helped me understand
presence that can restrict mobility if not addressed. the multiple ways muscles link and connect to transfer
forces and support the body. It is a framework for under-
The truth is that continuity between tissues does exist.
standing not only static postural support but dynamic
We must be willing to think outside of the box and open up
and optimal movement. Inspired by this book and using
our approach to thinking more globally if we want to move
forward with some of our more challenging cases. it as a guideline, along with clinical applications to some
of my more challenging cases, I developed an approach to
The concept of fascia as a contributor to musculoskel- treatment called Mobilization of the Myofascial System
etal dysfunction is not a novel one. The osteopathic profes- (MMS). It is an approach that has its origins in manual
sion has been writing about fascia for a number of years physiotherapy for the articular, muscular, and neural sys-
and Structural Integration has taken its rightful place in tems. This sets it apart from other books written on the
the field of rehabilitation. Other professionals are also myofascia, primarily by structural integrators, who use
beginning to explore the world of fascia, as witnessed by these concepts to describe techniques that manipulate the
the explosion of research in this field and the number of fascia around the muscular system with slow and deep
participants from various professions in several Interna- maneuvers. Although Mobilizing the Myofascial System: A
tional Fascia Research Congresses since 2007. However, Clinical Guide to Assessment and Treatment of Myofascial
xiii
PREFACE continued
Dysfunctions is primarily intended for physiotherapists the various fascial approaches to treating this area of the
who have been trained in manual therapy, it is also valu- body. However, it is equally important for the clinician to
able for osteopaths, chiropractors, structural integrators, understand how to recognize and diagnose a fascial dys-
and other body workers who are seeking an alternate way function (Chapter 3) as well as being familiar with the
to work with the fascia. basic principles of treatment (Chapter 4).
What is the subject of the book? Dural mobility techniques are described in Chapter 7.
This may be an area unfamiliar to many physiotherapists
The techniques described here are taken from the body
and will give the therapist other tools besides the use of
of work taught in Mobilization of the Myofascial System
the slump test and single leg raise (SLR) to assess and treat
series of courses taught to physiotherapists across Canada
this area of the body. Finally, Chapter 14 will cover how the
and Europe. The courses present a comprehensive system
patient can actively contribute to fascial health via exer-
for working with the whole body and are divided into
cises and various types of movement approaches, includ-
three courses: Upper Quadrant, Lower Quadrant, and an
ing yoga therapy. Last, but not least, Chapter 15 discusses
advanced course entitled Integration of Quadrants. The
ways to optimize therapeutic outcomes, with “out of scope”
techniques chosen for this book represent effective tools
information that should be considered, such as the effects
for some common recurrent dysfunctions encountered in
of nutrition, hydration, and hormone health on fascial
orthopedic manual therapy. This book is intended to be an
tissues. It also covers ways to create an optimal therapeu-
adjunct to the course notes and it is recommended that this
tic environment, not only for the patient but also for the
approach to treatment be learned through workshops and
therapist.
courses. However, the book may also be used as a stand-
alone text to guide the therapist in the use of fascial tech- I hope that you will be inspired by this book and that
niques in their practice. it will open up a whole new therapeutic world for you to
explore. To quote Robert Schleip, a prominent researcher
How is the material structured?
and author in the field of fascia, “After several decades
My intention was to make the book as user-friendly as of severe neglect, this Cinderella of orthopedic science is
possible. It begins with some theory including a historical developing its own identity within medical research.” Wel-
review of fascial approaches to treatment thus far (Chapter come to the world of fascia!
1), as well as a brief review of Tom Myers’s Anatomy Trains
fascial lines, upon which the concept of this treatment is
developed (Chapter 2). The main emphasis is clinical tech- Doreen Killens, BScPT, FCAMPT, CGIMS
niques for various regions of the body (Chapters 5 through
13). The therapist may consult the chapter associated with Montréal, Québec, Canada
March 2018
the cervical spine as an example (Chapter 5) and discover
xiv
LIST OF ABBREVIATIONS
A/P anteroposterior FFL Front Functional Line
AC acromioclavicular FHL flexor hallucis longus
ALL anterior longitudinal ligament FLT failed load transfer
ASIS anterior superior iliac spine GH glenohumeral
ASLR active straight leg raise IFL Ipsilateral Functional Line
BFL Back Functional Line IFOMPT International Federation of Manipulative Physical

Therapists
C/Thx cervicothoracic
ILA inferior lateral angle
CCFT craniocervical flexion test
IMS intramuscular stimulation
CGRP calcitonin gene-related peptide
IO internal oblique
Cr/V craniovertebral
IPT intrapelvic torsion
CTM connective tissue massage
IR internal rotation
Cx cervical spine
ISGT intra-shoulder girdle torsion
DBAL Deep Back Arm Line
ISM Integrated Systems Model
DF dorsiflexion
ITB iliotibial band
DFAL Deep Front Arm Line
LBP low back pain
DFL Deep Front Line
LHB long head of biceps
DRA diastasis rectus abdominis
LL Lateral Line
ECM extracellular matrix
Lx lumbar spine
EDL extensor digitorum longus
MFB myofibroblasts
EHL extensor hallucis longus
MMS Mobilization of the Myofascial System
EO external oblique
MTP metatarsophalangeal
ER external rotation
mTrP myofascial trigger point
Ev eversion
NOI Neuro Orthopaedic Institute
EZ elastic zone
NZ neutral zone
FABER(E) flexion abduction external rotation (extension)
OE obturator externus
FADDIR flexion adduction internal rotation
OI obturator internus
FDA Food and Drug Administration (US)
OLS one leg stand
xv
ABBREVIATIONS continued
P/A posteroanterior SCM sternocleidomastoid
PF plantarflexion SFAL Superficial Front Arm Line
PIL postero-inferior-lateral SFL Superficial Front Line
PIVM passive intervertebral movement SIJ sacroiliac joint
PNF proprioceptive neuromuscular facilitation SL Spiral Line
PSA postural somatic awareness SLR straight leg raise
PSIS posterior superior iliac spine SMFT Structural Myofascial Therapy
QL quadratus lumborum SNS sympathetic nervous system
® right TFGF transforming growth factor
R1 point in the joint’s range where the first resistance to TFL tensor fasciae latae
movement is felt
Th/L thoracolumbar
R2 endpoint of joint’s range
Thx thoracic spine
RA rectus abdominis
TMJ temporomandibular joint
ROM range of motion
TPR transverse plane rotation
RWA release with awareness
TrA transversus abdominis
SAL sitting arm lift
UFT upper fibers of trapezius
SBAL Superficial Back Arm Line
ULNT upper limb neural tension test
SBL Superficial Back Line
vs versus
SC sternoclavicular
WAD whiplash associated disorder
xvi
Section 1
Understanding fascia
Understanding fascia 3
A brief summary of Tom Myers’s Anatomy Trains

fascial lines and clinical implications 19
Assessment of fascial dysfunction 41
Principles of treatment with Mobilization of the Myofascial System 51

xxxxx
0
Understanding fascia 1
What exactly is fascia? Historically, it has often been ignored subjects by means of imaging technology.” In addition, it
as the body has been compartmentalized by the medical helps facilitate “comparison of the results of anatomical
profession. The commonly known fascial sheets such as the studies performed by different researchers.”
thoracolumbar fascia and plantar fascia represent only a small
portion of a much more extensive system. In fact fasciae are However, for clinicians concerned more with the func-
present throughout the entire body, covering not only muscles tion of the fascial net, as, for example, in movement, a
but also joints, bones, nerves, and organs, all the way down to strictly anatomical definition of “a fascia” is not always
the cellular level (Oschman 2000). helpful. Such an overly narrow definition may lead towards
the exclusion of important tissues, including the intercon-
Fascial continuity can be explained via embryology; nections of fascial tissues with joint capsules, aponeuroses,
connective tissue develops largely from the embryonic tendons, ligaments, and intramuscular connective tissues
mesoderm. Contrary to popular opinion, muscles develop (Schleip et al. 2012b). If the purpose of the investigation
within the fascia as opposed to the other way around. Thus, is to illuminate functional aspects such as force transmis-
fascia directs organogenesis (Van der Wal 2009; Scheunke sion or sensory capacities and wound regulation, then
2015). This generative function implies that fascia is much a wider definition of fascia tends to be more helpful
more than a random three-dimensional packing material (Stecco C. 2015a).
that “connects everything.” Research indicates that fascia
also plays a major role as a body-wide autoregulatory sys- French plastic and hand surgeon Dr Jean-Claude Guim-
tem (Langevin 2006). berteau is known for his work documenting living fascia
using an endoscope (in vivo during surgery). This reveals
How, then, should we define fascia? the surprising complexity of fascial layers that “slide” on
each other in a fractal, chaotic manner, accommodating
Fascia: a definition the need for movement and at the same time, the need for
Defining fascia remains a work in progress. Terms used maintaining connection. Fascia appears, in his images,
to describe the fascial net include “collagenous network,” as hydrated, frothy fibrils engaged in a dance, forming
“connective tissue webbing,” and “extracellular matrix.” In micro-vacuoles that change shape with movement. This
2015, a group of researchers in the field of fascia came to evidence of dynamic movement is in stark contrast to pre-
a consensus about its definition. According to this group, vious descriptions of fascia in cadavers, where the fascia
the term fascia denotes: “a sheath, a sheet or any number looks like dry fuzz. In his definitive book, Architecture of
of other dissectible aggregations of connective tissue that Human Living Fascia: The Extracellular Matrix and Cells
forms beneath the skin to attach, enclose, and separate Revealed Through Endoscopy, Dr Guimberteau offers a def-
muscles and other internal organs” (Stecco C. 2015a). inition more functional in scope: “Fascia is the tensional,
continuous fibrillar network within the body, extending
The value of such a “purely anatomical definition,” from the surface of the skin to the nucleus of the cell. This
as Stecco explains, is that it enables “everybody to know global network is mobile, adaptable, fractal, and irregu-
exactly what we’re talking about, to isolate these layers lar – it constitutes the basic structural architecture of the
in cadavers and perform histological and morphological human body.” For Guimberteau, fascia is far more than
analysis, to sample the fasciae during surgery, to evalu- simple connective tissue. Rather, it is our constitutive tis-
ate pathological alterations and to study them in living sue (Guimberteau 2015).
3
Chapter 1
Fascial anatomy tense associated ligaments; ligaments are activated as well

because they are part of this same series of fascia contract-
Fascia comes in different forms: ed by the muscle, not a separate underlying layer, as we
• irregular connective tissue found in loose have been taught to believe. Consequently, ligaments, far
areolar tissue or adipose connective tissue from being active only at the moment of the greatest elbow
extension in a preacher curl, for example, are dynamically
• regular connective tissue (fibers that orient regularly
active in stabilizing the joint all through the movement,
in response to stresses), commonly found in fascial
during both concentric and eccentric contraction. These
sheets, aponeuroses, ligaments, and tendons.
findings redefine our whole concept of functional units
Note that some structures in the body have a blend of within the body (Myers 2011).
both regular and irregular connective tissue, such as the
Van der Wal was one of the first to use “fascia sparing”
linea alba: the posterior third is regularly oriented and
techniques in the dissection of cadavers and a number of
the anterior two-thirds of fibers are irregular (Axer et al.
other researchers have followed suit: Tom Myers of Anatomy
2001a, 2001b).
Trains, Gil Headly, Robert Schleip, and Carla Stecco, to name
Myofascia may be defined as a combination of muscle a few. Thanks to new research and dissection methods, new
tissue (myo) and its accompanying web of connective tis- information about fascial anatomy is being revealed and is
sue (fascia). Although fascia has its own unique charac- slowly filtering down to practitioners. The impact of fascia on
teristics and properties, it functions synergistically with the motor control system and its neurophysiological implica-
muscle as part of a neuro-musculo-fascial-skeletal system. tions cannot be overlooked as we consider the overall func-
Thus muscle and fascia are integrated synergistic units and tion of the patient. It becomes progressively clear that fascia
cannot be separated functionally (Myers 2014). must be viewed as a whole system, leading to different treat-
ment and training strategies.
Fascial continuity
The concept that muscles have clear origins and inser-
Musculoskeletal fascia
tions has become outdated in the wake of current research In the musculoskeletal system, fascia is formed by three
that has shown that there is continuity of fascia through- fundamental structures: the superficial fascia, the deep
out the human body tissues. Some have suggested that the fascia, and the epimysium (Stecco L. 2004).
separations between muscle/tendon and ligaments were
introduced by dissectors themselves, faced with the diffi- Superficial fascia is composed of subcutaneous loose
cult task of telling where the tissue stops being a tendon connective tissue containing a web of collagen, as well as
and starts being a ligamentous sleeve (Van der Wal 2009). mostly elastic fibers. It blends with the deep fascia at the
Traditionally, ligaments were seen as being arranged paral- retinacula of the wrist and ankle and continues with the
lel to the muscles, and only really coming into play when galea aponeurotica over the scalp. This fascia facilitates
fully stretched at the end of joint range. However, research the gliding of the skin above the deep fascia and contains
by Jaap Van der Wal, done 30 years ago but disregarded fat, cutaneous vessels, and nerves (Stecco L. 2004).
because it did not conform to traditional thought at the Deep fascia is formed by a connective membrane that
time, has put that concept into question. Van der Wal’s sheaths and separates all muscles. It also forms sheaths for
careful observation of fascial continuities has concluded the nerves and vessels, envelops various organs and glands
that the muscles and ligaments are actually arranged and, around the joints, assumes the specialized form of
in series that reinforce each other. He named this com- ligaments (Stecco L. 2004).
mon arrangement a dynament. In other words, muscle
contractions, which tense the muscle and its myofasciae The epimysium comprises the fascia that encloses
(epimysium, perimysium, endomysium, and tendon), also the muscle belly itself and is continuous with the tendons.
4
The tendons then connect with the periosteum, which groups individual muscle fibers into bundles or fascicles.
envelops the bone. In this context, bone itself may be seen Finally, at the cellular level, the endomysium wraps indi-
as very dense connective tissue. As Schultz and Feitis vidual muscle cells and fibrils. This has implications for
explain in their book The Endless Web, “muscle does not one of the main roles of fascia – its mechanotransduction
simply attach to bone. Rather, muscle cells float in a fascial function (see roles of fascia below).
net, their movement pulls on the myofascia, the myofascia
blends into the periosteal fascia, and the periosteum pulls Fascia as a mediator between the
on the bone” (Schultz & Feitis 1996). systems
The concept of fascial continuity also applies on a micro- Fascia is not limited to the musculoskeletal system. It is
scopic level (Figure 1.1). If we look at the muscle itself, also present in the fascial envelope layers of the organs
deep to the epimysium, the perimysium is a fascia that and in the perineural sheets of the nervous system
Single muscle fiber

Figure 1.1
Endomysium
Fascia of skeletal muscle
Perimysium, or fascicle
Perimysium
Fascicle
Endomysium
between fibers
Blood vessels
Bone
Epimysium
Tendon
5
Chapter 1
(Paoletti 2006). Improving mobility in one subsystem the functional demands placed upon that tis-
will affect mobility in other regions. In its role as a body- sue. Where there are strong tensile forces, the
wide communication system, fascia serves as “mediator” collagen portion predominates – there are fewer
between the various systems of the organism (Schwind elastic fibers. Conversely, there are more elastic
2006). This concept of a body-wide communication system fibers where the shape of the segment of body
has interesting implications for the health of the human changes repetitively. Due to this adaptive capaci-
body. The reader is directed to Scheip et al. (2012a) for fur- ty, the fascial system is able to meet the changing
ther information on this topic. functional requirements of the body.
4. Ground substance is a viscous transparent sub-

Composition of fascia
stance made up of hydrated proteins (proteogly-
Fascia is composed of cells and extracellular matrix cans, glycoproteins). It is produced by fibroblasts
made up of ground substance, collagen, water, and elastin and mast cells. It is essentially a watery gel – a part
(Paoletti 2006). of the environment of almost every living cell, the
1. Collagen is the most common protein in body. It continuous but variable “glue” that holds cells to-
predominates in the fascial net and is readily seen in gether while allowing substances to be exchanged.
any dissection, or even any cut of meat (Myers 2014). It allows for easy distribution of metabolites when
There are around 20 types of collagen fibers and type sufficiently hydrated and forms part of the immune
1 is by far the most ubiquitous, forming a variety of system barrier, which increases the resistance to
structures including: spreading of bacteria. In areas that are not moved,
the ground substance increases viscosity (like gel)
−− transparent cornea of the eye and becomes a repository for metabolites and tox-
−− tendons, ligaments ins (Myers 2014).
−− lung tissue
−− membranes surrounding the brain. Ground substance is thixotropic, a property that
enables it to become more liquid and less viscous.
2. Fibroblasts are the most common cell type in con-
Thixotrophy (Juhan 1998) is attained by adding
nective tissue. They produce the ground substance
heat or energy to fascial tissue. One way to under-
and precursors for all connective tissue fibers. They
stand thixotrophy in action is to think of a bottle
secrete enzymes involved in catabolism of macromol-
of ketchup that has been left in the cupboard for a
ecules and play a central role in wound healing and
while. Trying to dispense the ketchup in this case
inflammation. They are highly responsive to physi-
may be arduous, as it has become more viscous and
cal stimuli and are instrumental in constructing and
less fluid-like with time. The common response is
maintaining the collagen matrix. Sustained tension or
to then shake the bottle of ketchup in order to get it
pressure on fascial tissue will induce local prolifera-
to pour more easily. Adding heat or energy makes
tion of fibroblasts and alignment of cells along lines of
the ketchup more liquid-like. Fascia reacts in a
force due to tension or pressure. If stress is sustained
very similar way. Manual therapy that is focused on
for a long period, the fascia will become more dense
the fascia, as well as certain movement therapies,
(Paoletti 2006). Mechanically stressing fibroblasts
can help the fascia attain optimal consistency. Ac-
leads to increased connective tissue synthesis and de-
tivating the thixotropic aspect of fascia facilitates
creased production of inflammatory mediators.
movement and optimizes motor control.
3. Elastin cells are also common in connective
5. Myofibroblasts (MFB) are cells found in fascia.
tissue. The proportion of collagen and elastic
They are intermediaries between smooth mus-
fibers within any area of fascia depends upon
cle cells (found in viscera, autonomic nerves) and
6
t raditional fibroblasts (cells that function primarily echanical properties of the connective tissue. Yet stud-
m
to build and maintain the collagenous matrix). Fas- ies have shown that either much stronger forces or longer
cia is thus able to contract in a smooth muscle-like durations would be required for a permanent viscoelastic
manner and thereby influence musculoskeletal deformation of fascia. A change in attitude in myofascial
mechanics (Schleip et al. 2007). Myofibroblasts in- practitioners from a mechanical perspective toward an
terpret mechanical signals and set up biochemical inclusion of the self-regulatory dynamics of the nervous
responses (concept of mechanotransduction). They system is suggested. (Schleip 2003)
are stimulated by either
Nociceptors
−− mechanical tension going through the tissues, or
−− specific cytokines and other pharmacological Fascia contains many nociceptors, mostly A and C fiber
agents such as nitric oxide (which relaxes MFBs) nociceptors, which may explain descriptions of fascia pain
and histamine (which stimulates contraction of as “throbbing, stinging and hot.” A myriad of tiny unmy-
MFBs). elinated free nerve endings are found almost everywhere in
fascial tissues, but particularly in periosteum, in endomy-
There is a higher density of MFBs in people with sial and perimysial layers, and in visceral connective tis-
Dupuytren’s or with past traumatic contractures. In contrast, sues (Mense 2007; Tesarz et al. 2011). Human data indicate
there is a lower density of MFBs in people with Marfan’s syn- that the fascia is more sensitive to pain than either the skin
drome. Within “normal” there is a range of MFB density – the or the muscles (Gibson 2009; Deising et al. 2012).
more you have, the stiffer you are (Myers 2014).
Proprioceptors
It is tempting to deduce that because fascia contains
myofibroblasts, this proves that fascia, in and of itself, can Deep fascia also seems to have a proprioceptive function
“shorten” or “contract” sufficiently to cause significant and so may affect motor control. It is hypothesized that
postural distortion. However, we must remember that fas- myofascial expansions could guarantee motor coordina-
cia and muscle function synergistically and that the myofi- tion among different segments of the body, giving anatom-
broblasts, containing smooth muscle fibers, do not gener- ical support to myokinetic chains (Stecco C. 2015a).
ate near the pulling power of skeletal muscle fibers.
Sympathetic fibers
Fascia innervation Fascia and the autonomic nervous system appear to be inti-
The fascial network is one of our richest sensory organs. mately connected. Stimulation of mechanoreceptors leads to
Fascia is innervated; therefore, it can also be an important a lowering of sympathetic tonus as well as a change in local
pain generator. As such, the contribution of fascia to pain- tissue viscosity. Studies of the anatomy of the thoracolumbar
ful syndromes cannot be underestimated. fascia reveal a close relationship between the sympathetic
nervous system and the pathophysiology of fascial disorders.
Mechanoreceptors Forty percent of thoracolumbar fascia innervation consists
Fascia is densely innervated by mechanoreceptors of sympathetic fibers, known to have vasoconstrictor effect
(Golgi end organs, Pacini corpuscles, Ruffini endings, free on blood vessels, which may then lead to ischemia in fascia.
nerve endings), which are responsive to manual pressure This may help explain the phenomenon of increased intensi-
(Table 1.1). ty of pain with psychological stress, which increases activa-
tion of the sympathetic nervous system (Willard et al. 2012).
Schleip (2003) states:
In myofascial manipulation an immediate tis-
Summary of innervation
sue release is often felt under the working hand. This Robert Schleip sums up the issue of fascial innervation
amazing feature has traditionally been attributed to nicely: “For the sensorial relationship with our own b ody –
7
Chapter 1
Table 1.1 Mechanoreceptors in fascia.

Reproduced from R. Schleip (2003), Fascial plasticity – a new neurological explanation: Part 1. Journal of Bodywork and Movement Therapies. With kind
permission from Elsevier.
Receptor type Preferred location Responsive to Known results of stimulation
Golgi Myotendinous junctions Golgi tendon organ: Tonus decrease in related

Attachment areas of To muscular contraction striated motor fibers
aponeuroses
Ligaments of peripheral Other Golgi receptors:
joints Probably to strong stretch
Joint capsules only
Type Ib
Pacini and Paciniform Myotendinous junctions Rapid pressure changes Use of proprioceptive
Deep capsular layers and vibrations feedback for movement
Spinalligaments control (Sense of kinesthesia)
Investing muscular tissues
Type II
Ligaments of peripheral joints Like Pacini, yet also to Inhibition of sympathetic

Dura mater sustained pressure activity
Outer capsular layers
Other tissues associated with Specially responsive to
regular stretching tangential forces (lateral
stretch)
Type II
Interstitial Most abundant receptor type. Rapid as well as Changes in vasodilation

Found almost everywhere, sustained pressure plus apparently in plasma
even inside bones. changes extravasion
Highest density in periosteum
50% are high threshold
Type III and IV units, and 50% are low
threshold units
whether it consists of pure proprioception, nociception or • protecting against physical trauma (think how
the more visceral interoception – fascia provides definitely abdominal fascia are protective to the underlying
our most important perceptual organ” (Schleip 2012). organs) (Myers 2014)
Roles of fascia • functioning as shock absorber (Paoletti 2006) and in

the transmission of force which then has effects on
Fascia plays several roles in the body: dynamic stability (Huijing & Baan 2003, 2012)
• maintaining structural integrity (Paoletti 2006) • creating a uniformly smooth/slick surface that essen-
• maintaining static postural support (Paoletti 2006) tially lubricates the various tissues that come in contact
8
with each other during movement. This helps prevent shape of the cells and their physiological properties. This is
friction injuries and subsequent tissue degeneration and the mechanism behind the concept of mechanotransduc-
degradation tion, which is the ability of cells to perceive and biochemi-
cally interpret mechanical forces generated either within
• allowing muscles to change shape as they are both
the cytoskeleton or from external sources. The effect
stretched and shortened
of mechanical forces on cell shape is emerging as a key
• one of the most important roles of fascia is its mech- regulatory mechanism at the cellular, tissue, and organ
anotransduction function. It transforms mechanical levels. In place of the traditional concepts of fascia as a pas-
signals into biochemical responses; in other words, sive tension transmitter, a new picture is emerging: one of
turning movement into repair. fascia as a dynamically adaptable organ, an important tis-
According to traditional concepts, cells float next to sue in cell regulation, and a global body-wide communica-
the extracellular matrix and function autonomously tion system:
(Figure 1.2A). A more current view, proposed by Oschman, • Fascia is the “container” through which metabolic,
instead posits that the nuclear material, nuclear mem- endocrine, and immune exchanges take place in all
brane, and cytoskeleton are mechanically linked via the tissues. It is the conduit through which water, pro-
integrines and laminar proteins to the surrounding extra- teins, and immune cells return to the blood via lym-
cellular matrix (ECM) (Figure 1.2B) (Oschman 2000; phatics. Its role in intercellular communication and
Myers 2014). cellular exchange processes helps explain how fascia
is a major player in the body’s defense and immune
Integrins are mechanoreceptors that communicate ten-
system function (Paoletti 2006).
sion and compression from the cell’s surroundings, spe-
cifically from the fiber matrix into the cell’s interior, even • Its role in the regulation of the inflammatory re-
down to the nucleus. These connections act to alter the sponse also has implications for cardiac pathologies
Connective tissue Membrane matrix

or (integrins)
extracellular matrix Cytoskeleton
Cell
membrane (microtubules, microfilaments,
intermediate filaments)
Nuclear matrix
Nuclear (chromatin, histones,
envelope chromatin-associated proteins)
Nucleus
Extracellular matrix
Organelles (collagens, laminins,
fibronectins,
proteoglycans)
A B
Figure 1.2
Reproduced from Tom Myers (2014), Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, 3rd
edition. With kind permission from Elsevier
9
Chapter 1
and cancer. Mechanical information combines with forces in the vicinity of tumors. Thus, both basic and
chemical signals to tell the cell and cytoskeleton what clinical research is needed to understand the full impact
to do. Very flat cells, with their cytoskeletons over- of integrative oncology on cancer biology as well as whole
stretched, sense that more cells are needed to cover person health. (Langevin et al. 2016)
the surrounding substrate (as in wound repair) and
that cell division is necessary. Alternatively, round- In summary, the various roles that fascia plays in the
ing and pressure indicates that too many cells are human body all point to its importance in maintaining a
competing for space on the matrix and that cells are healthy interstitial fluid environment, metabolic homeo-
proliferating too much; some must die to prevent tu- stasis, and immune surveillance, all the while allowing the
mor formation. Between those two extremes, normal body to move. What a fascinating tissue!
tissue function is established and maintained. Under-
standing how this switching occurs could lead to new Fascial pathology
approaches in cancer therapy (Myers 2014). There are a number of factors that contribute to fascial
pathology. Any number of the following, either singly or in
How genes in our DNA are expressed as traits within a
combination, can influence fascial function:
cell is a complicated mystery with many players, the main
suspects being chemical. Each cell in the body has the same • trauma: past or present (falls, contact sports, blows).
DNA, but tissues behave very differently because genes are Inflammation is critical for normal healing processes.
expressed differently. Cells only have two “senses” with However, too much or prolonged inflammation can
which to interact with their environment. They cannot see lead to binding down of fascia and fibrosis (Gautchi
or hear, but they can “feel” mechanical forces and “taste” 2012)
chemical signals. Many studies have detailed chemical sign- • micro-injuries caused by overloading (over-training,
aling pathways, but understanding how the mechanical heavy or repetitive jobs) (Gautchi 2012)
forces affect the cell is also important. A study by Tajik et al.
in 2016 has demonstrated that external mechanical force can • immobility: long periods of bed rest or immobiliza-
directly regulate gene expression. The study also identified tion in a cast (Van den Berg 2007)
the pathway that conveys the force from the outside of the • surgery (scarring, adhesions): the scars themselves
cell into the nucleus, through the fascia (Tajik et al. 2016). may heal well and have good mobility but their impact
on fascial lines is underestimated
Hélène Langevin and Thomas Findley, in their paper
entitled Connecting Tissues: How Research in Fascia • mechanical stress as a result of poor posture
Biology can Impact Integrative Oncology, state the • long term systemic chronic tissue inflammation sec-
following: ondary to diet (see Chapter 15 for more information)
Recent advances in cancer biology are underscoring • chemical insults: toxins in the environment (for exam-
the importance of connective tissue in the local tumor ple, using oil-based paint in an enclosed room for a pe-
environment. Inflammation and fibrosis are well-rec- riod of time) can affect the fascia as they may trigger the
ognized contributors to cancer, and connective tissue body’s defense and immune system
stiffness is emerging as a driving factor in tumor growth.
In that sense, cancer can be considered a disease of the • endocrine effects: patients with diabetes are known
collagen. Physical-based therapies have been shown to to exhibit slow healing responses to injury. It is
reduce connective tissue inflammation and fibrosis and thought that the changes in the endocrine system
thus may have direct beneficial effects on cancer spread- may impact the fascia in particular
ing and metastasis. Meanwhile, there is currently little • emotional stress: stress, whether mental, physi-
knowledge on potential risks of applying mechanical cal, emotional, or spiritual, creates inflammatory
10
chemicals in the brain and body and leads to cellular effect, binding of fascial elements, both microscopic and
degeneration. This process may occur in the brain macroscopic. Nutrition and blood supply to the region
and manifest as memory deterioration. It may are impaired, which in turn promotes the development of
also occur in the fascia, where we store all of our fibrotic nodules and myofascial trigger points. Ultimately,
traumas, whether physical, mental, or spiritual. joints may become restricted and muscles weak through
These traumas create thickened, dense fascia, which full range of motion. Such changes may produce changes
eventually leads to pain and limited range of motion in self-image/body language and in some cases, bony
(Northrup 2016). structural changes.
Whatever the source, these insults may induce biochemi- In addition, as the Steccos stipulate, a stiffer fascia may
cal changes in the connective tissue which will, in turn, have reduce the contractility of a muscle and cause a chronic
effects on its viscoelastic properties. It is proposed that fascial compartment syndrome (Stecco C. 2015b).
tissue injury causes localized ischemia which leads to local-
ized hypoxia. Cytokines (inflammatory mediators such as Connective tissue responds to demand
bradykinin, substance P, and calcitonin gene-related peptide
(CGRP)) are released as well as growth factors and clotting Both extremes of lifestyle – continuous exertion or “couch
factors. Subsequent oxygen deprivation promotes adhesions potato” – will have an important effect on fascia. Habitual
of connective tissue (Shah et al. 2005, 2008). postures will load lines of fascia so that instead of random
“spaghetti tubes” that are filled with proteoglycans and
Injury may cause bracing or splinting of the area in ques- fluid, they become “committed” and create vectors that
tion, providing mechanical tension. This reaction stimu- may pull and tug at joints, muscles, organs, or nerves – in
lates the transition from fibroblast to myofibroblast and fact, any tissue that is surrounded by fascia.
helps maintain fascial tension around the injured area. Ini-
tially, this process is adaptive but may become maladaptive Extracellular elements are altered to meet the demands
if sustained. within the limits imposed by nutrition, age, and protein
synthesis. While it is true that in old age, the proportion
Ultimately, collagen microfibers form in between adja- of elastic fibers decreases and tough collagen fibers pre-
cent layers of fascia to bind them together. This binding dominate, we must keep in mind that the body continu-
of fascial elements is also called “fibrosis,” “adhesion for- ously renews itself in response to how we feed the tissues
mation,” or “scar tissue.” Chaitow and Delany, in their (hence the importance of good nutrition and hydration)
book Clinical Applications of Neuromuscular Tech- as well as the movement demands we make on the body.
niques, state “This adhesion formation disrupts the My 90-year-old mother, who has always maintained a
normal ‘sliding and gliding’ of the tissues. As the fas- healthy diet and regularly walks and attends aqua-fit-
cia thickens, it can disrupt motor patterns, balance and ness classes, has had minimal health issues, including
proprioception. This can lead to chronic tissue loading, those of the musculoskeletal system. Her fascial tissues
further injury, and global soft tissue holding patterns” feel fluid and adaptable. In contrast, I have had some
(Chaitow & Delany 2000). middle-aged patients who do not eat well, hydrate well,
or move well and, in these patients, the fascial tissues
Effects of fibrosis feel dense and stiff, similar to old dried-up leather. One
Fibrosis does not automatically dissipate after the area might argue that perhaps genetics play a role and that
has healed, and it tends to accumulate over time. Like some people have familial characteristics of denser
the cross-links on a net, the more adhesions there are, fascial tissues. There is some truth to this statement.
the stronger the net will be, but the less elastic as well However, there are factors to consider (see Chapters 14
(Schierling 2017). Restricted movement leads to loss of and 15) that can have positive impacts on the health and
ground substance in connective tissue, loss of lubricating function of fascia.
11
Chapter 1
Fascial hydration As a result, a pull or a push on one corner of the connec-

tive tissue framework exerts a force throughout the entire
Research is pointing to the importance of fascial hydration
structure, affecting muscles, bone, nerve, blood vessels,
(Klinger et al. 2004; Reed et al. 2010). The human body is
glands, and organs (Juhan 1998).
composed of 75 percent water, two-thirds of which is con-
tained in the fascia. It is therefore important to maintain New discoveries highlight how tensional patterns within
adequate hydration of these tissues for optimal function. the fascial matrix communicate instantly and effortlessly
It is equally important to move to ensure that water gets what happens throughout the whole system. In his iconic
into various parts of the fascia. Variability of movement is paper, Ingber sums up the process of cellular mecha-
key here, preferably in patterns differing from usual habits notransduction: “Very simply, transmission of tension
(Myers 2017). Chapter 14 outlines the various movement through a tensegrity array provides a means to distribute
therapies and exercises that can help maintain optimal forces to all interconnected elements, and, at the same time
health of fascial tissues. to couple or ‘tune’ the whole system mechanically as one”
(Ingber 2003).
Factors affecting hydration include not only mechani-
cal influences but also pH values, body temperature, and An injury at any given site can be set in motion by long-
bioactive proteins (notably hormones and growth factors term strains in other parts of the body. Small kinks in myo-
TFGF-β1). In the body, pH levels are regulated by the renal fascial force transmission such as those provided by scars
and respiratory systems. An acidic pH in the matrix tends or adhesions have surprising functional consequences,
to increase contractility of myofibroblasts, so lends itself often at some distance from the site.
to tighter fascia. Activities that produce pH changes such
as breathing pattern disorders, emotional distress, or acid- Chain reactions in the body
producing foods could induce a general stiffening in the All injuries do not necessarily induce a change in the
fascial body (Pipelzadeh & Naylor 1998). This impact of pH tensegrity system that may produce a chain reaction.
levels on fascia may explain the recent recommendations Sometimes a reaction will appear soon after the origi-
(not, as yet, backed by evidence) regarding the effect of an nal trauma; other times, it can take weeks or months.
anti-inflammatory alkaline diet for optimal function of This variation in outcome depends on multiple factors,
the connective tissue matrix. including:
Fascia as a tensegrity system • the seriousness of the original injury
Another major concept in fascial anatomy is that of the • the age of the patient
body as a tensegrity system. This is a system in which com- • the capacity of the patient to adapt and compensate.
pression and tension are dynamically balanced. Looking
A lesional chain can start in any part of the body and,
at Figure 1.3, we may consider the solid elements of the
from there, spread either up or down (Paoletti 2006). Pao-
tensegrity array (double lines) represented by the bony
letti cites varied examples of possible chain reactions:
architecture of the body, with the elastic element between
(single lines) representing the fascia. Descending chain reactions
When tension or compression is applied to an area in the • Epicranial fascia → superficial cervical fascia → scapu-
tensegrity system, there is reaction in the rest of the system. lar girdle → upper thorax→ upper limb.
The strain is distributed over the whole structure and not • Psoas → perineum → short muscles of hip → knee or
localized in the area being deformed. Therefore, an increase ankle.
in tension of a tensegrity structure resonates throughout
the whole structure, even affecting the opposite side (see the In the first example, the patient may complain of pain
second drawing in Figure 1.3) (Ingber 2003). in an upper limb, but may get only partial relief with only
12
A B
Figure 1.3
Fascia as a tensegrity system
localized treatment to the upper extremity if the fascial of a salami.” On the other hand, palpation of a tight fascial
chain to the epicranium is not addressed. line often feels like a “guitar string” that has too much ten-
sion (Diane Lee, personal communication).
Ascending chain reactions
Symptoms of trigger points may include pain (both
• Ankle sprain → head of fibula → lateral knee → hip/
local and referred), reflex muscle weakness (caused by
piriformis → sacroiliac joint (SIJ) → thoracolumbar
pain without atrophy), autonomic and trophic disorders,
fascia → latissimus dorsi → shoulder → cervical verte-
restricted movement and perfusion disorders (formation
brae → cranium.
of edema). This process may lead to neuromuscular
• Fall on coccyx → dura mater → intracranial membranes. entrapment and/or changes in proprioception; therefore
• Bladder → round ligament → diaphragm → pericardium → affecting motor output (Gautchi 2012).
throat symptoms.
Muscle release techniques that work exclusively on the
reflexes (e.g., dry needling, Gunn intramuscular stimulation
In the second example of an ascending reaction, a fall
(IMS), positional counterstrain, shockwave therapy) are very
on the coccyx may incur head pain that could persist until
effective for treating trigger points. If, however, these trigger
mobility of the dura is restored (Paoletti 2006).
points tend to recur despite attempts to normalize muscle
balance, control, and strategy, then we must consider anoth-
Trigger points as a fascia-related
er influencing factor – fascia. Gautchi states that muscular
disorder pathology in the form of myofascial trigger points (mTrPs)
How can we differentiate symptoms arising from increased always has a fascial component and can be the cause of fascia
neural drive vs fascial tension? Are they related to one dysfunction. Conversely, dysfunctional fascia can provoke or
another and if so, how? maintain dysfunctions of the muscles (mTrPs) (Figure 1.4).
One way to differentiate between these two disorders is Because of this interaction, an optimal treatment approach
via palpation. Palpation of a hypertonic muscle or trigger must include consideration of both trigger points and fascia.
point frequently feels like “pepperoni stick in the middle Muscle release techniques that work exclusively on the reflexes
13
Chapter 1
1 Fascia
Fascia 2
dysfunction
4
Myofascial Intact
3 trigger points muscle fibers
Figure 1.4
Interrelation between fascia dysfunction and myofascial trigger points. 1. Factors which lead to fascia dysfunction.
2. Fascia dysfunction as possible cause of the origin/maintenance of mTrPs. 3. mTrPs as possible cause of the origin/
maintenance of fascia dysfunction. 4. Factors which lead to the origin of mTrPs. Reproduced from R. U. Gautchi, in
R. Schleip et al. (eds) (2012), Fascia: The Tensional Network of the Human Body (Chapter 5.7). With kind permission from Elsevier
may indirectly decrease fascial pull. However, these tech- type of massage treatment for the connective tissue that
niques insufficiently affect the fascial aspect. Targeting the aimed to de-facilitate the autonomic system. Within four
connective tissues using manual techniques is necessary in months of beginning treatment by a colleague who applied
order to address the changed fascial structures (Gautchi 2012). Dicke’s own techniques, Dicke was out of hospital and she
returned to work within a year. She had normal circula-
tion in her leg and her back pain, angina, kidney and liver
A historical review of fascial approaches problems had all resolved. Dicke and her colleagues then
to treatment spent the next 10 years investigating this new technique,
The concept of fascia as a contributor to musculoskeletal with the aim of understanding its underlying mecha-
dysfunction is not a novel idea, nor confined to one country. nisms and identifying conditions for which it was effec-
Several approaches to treatment of the fascial system have tive. They set up a teaching protocol for all physiotherapy
emerged over the last century. students in Germany and incorporated into it the work of
J. MacKenzie, who researched changes in muscle tone in
Connective tissue massage relationship to organs. In 1942, Dicke, Kohlrausch, Leube,
(Elizabeth Dicke – Germany) and MacKenzie published Massage of Reflex Zones in the
Connective Tissue in the Presence of Rheumatic and Inter-
One of the first professionals to consider fascia was a Ger- nal Diseases. Many general hospitals and orthopedic hos-
man physiotherapist, Elizabeth Dicke, who in the 1930s pitals, physical therapists and health spas in Switzerland,
developed a technique called connective tissue massage Italy, and Germany continue to research and practice CTM
(CTM). This approach to treatment was developed in (Utting 2013).
response to her own frustrations with the system at the
time, as she struggled to manage symptoms from a wide- My first exposure to this treatment approach was in rela-
spread infection of her blood vessels that affected circulation to a case of an elderly lady in a rehabilitation center
tion to her right leg and contributed to the development of who, for two years, had not responded to a variety of treat-
gangrene. She had also developed angina and gastric, kid- ments to deal with an ulcer in her foot. After a 10-session
ney, and liver problems. Too ill for surgery, she was effec- approach with CTM, the wound finally closed. The result
tively left in a side ward to die. She spent months in bed, propelled me to take a course in CTM (my first postgradu-
studying the anatomy of the autonomic nervous system. ate course). I found this approach to be occasionally useful
Based on her experience and analysis, Dicke developed a for my orthopedic clientele at the time.
14
Rolfing/Structural Integration link between fascia and the nourishment of all cells of
(Ida Rolf – USA) the body, including those of disease and cancer (Findley
& Shalwala 2013). Present-day osteopaths use a number
Rolfing/Structural Integration was developed by Ida P. of approaches to address imbalances in the body from
Rolf in the 1940s and 1950s. A biochemist and atomic a whole body perspective, including cranial techniques,
physicist, Rolf sought to experiment with treatments as a visceral manipulation, osteopathic articular techniques,
result of her own frustrations with the various approaches and finally, soft tissue manipulation, which includes
available at that time to treat her pain (osteopathy, yoga, fascial techniques to balance the length and tension of
Alexander technique, Feldenkrais technique). Initially the fascia.
coined Postural Release, her 10-sessions program of myo-
fascial manipulation was developed to help restructure
Myofascial Release (John Barnes – USA)
the body. The aim was to improve the body’s relationship
to gravity, postural integration, and re-educating move- Myofascial Release (MFR) is a form of manual therapy that
ment. Her techniques for manipulating the fascia were was developed by John F. Barnes, PT. It involves the appli-
slow and deep and followed a certain structure or recipe. cation of a low load, long duration stretch to the myofas-
Initially, this approach was known as Rolfing. Other cial complex, intended to restore optimal length, decrease
bodyworkers trained by Ida Rolf soon developed their pain, and improve function. There is anecdotal evidence
own interpretation of her approach. For example, Joseph that MFR has positive effects as a treatment for various
Heller developed Hellerwork, Tom Myers developed Anat- conditions. The approach tends to be localized to a par-
omy Trains Structural Integration (ATSI), and George ticular area of the body (for example, the diaphragm),
Kousaleos developed CORE. Ida Rolf was never comfort- but it also encompasses techniques that have some simi-
able with the term Rolfing and in 1990 the approach was larities with Structural Integration. What differentiates
renamed Structural Integration. Although it is a type of this approach from MMS (Mobilization of the Myofas-
massage technique, its origins are not in massage therapy. cial System) is that MFR does not follow the principles of
assessment and treatment of the fascial lines as described
In 2006, another branch of Structural Integration was by Tom Myers in his book Anatomy Trains.
developed by BetsyAnn Baron, a massage therapist and
structural integrator, with whom I teach Mobilization of Fasciathérapie (Danis Bois – France)
the Myofascial System to physiotherapists. Called Struc-
tural Myofascial Therapy (SMFT), Baron’s technique is less Fasciathérapie is a somatic approach that evolved from
“recipe” than structural integration sessions work (Baron Dr Danis Bois’s osteopathy and physiotherapy practic-
Bodyworks.ca). es in France. With osteopathy, Bois felt he was looking
after an organism but that his practice did not address
SMFT has two key elements: the whole somato-psychic person. He therefore devel-
oped another approach, which he called Fasciathéra-
• postural somatic awareness (PSA), a method of sub-
pie. This is a gentle, non-manipulative manual therapy
jective evaluation
that aims to heighten awareness of the client’s relation-
• deep, hands-on techniques in the myofascial system. ship to pain, tension, stress, and habitual thought pat-
terns. By using this somatosensory approach, the thera-
Osteopathy (USA) pist “dialogues with the body” in order to promote
its self-regulating force. In addition to Fasciathérapie,
More than 100 years ago, Andrew Taylor Still, MD, found- he incorporates a somatic movement practice, called
ed osteopathic medicine. He was one of the first to describe Sensorial Re‐education, a meditation practice, called
fascia and he recognized its role in assisting gliding Sensorial Introspection, and a verbal or expressive com-
of tissues and fluid flow. Even at that time he realized the ponent that accompanies all of the above (Bois 2013).
15
Chapter 1
This approach is primarily used in western Europe. ceptive pain on my hands. However, no matter what I
“Fasciathérapeutes” distinguish themselves from physi- tried from my toolkit, it did not bring about the posi-
otherapists, osteopaths, and “kinésithérapeutes.” tive effect I was seeking. I also experienced situations
in which clients were complaining of multiple areas of
Fascial Manipulation pain that did not correspond or fit into the paradigms
(Stecco family – Italy) that physiotherapists had learned, even as fully trained
The founders of this technique are the Stecco family based manual therapists. These clinical frustrations led Laurie
in Italy, comprising Luigi Stecco, a physiotherapist, and and myself to explore the role of fascia across multiple
his children, Carla Stecco, an orthopedic surgeon, and musculoskeletal conditions.
Antonio Stecco, a physiatrist. They are well known for
Laurie teaches her approach to treatment, which is called
their fascial dissections and their research in this field.
Manual Therapy for the Fascia (ProActive Education,
The Fascial Manipulation method is based on the con-
Laurie McLaughlin.ca).
cept of myofascial units united in myofascial sequences
and involves deep manual friction over specific points The technique that I have developed, called Mobilization
(called centers of coordination and centers of fusion) that of the Myofascial System (MMS), is the one I teach to phys-
are located on the deep muscular fascia and retinacula. iotherapists in Canada and Europe. It is an approach that
Although this approach focuses primarily on the fascia has its origins in manual therapy for the articular, mus-
around the muscular system, more recently, visceral fascia cular, and neural systems. This focus on fascia in relation
has been included. to multiple systems of the body sets it apart from other
Mobilization of the Myofascial System books written on the myofascia, primarily by structural
integrators, who describe techniques for manipulating
(Doreen Killens – Canada)
the fascia around the muscular system. The techniques
This concept was initially developed by the author and employed in MMS are the techniques that will be described
another Canadian physiotherapist, Laurie McLaugh- in this book.
lin, both former instructors and chief examiners for the
orthopedic division of the Canadian Physiotherapy This approach to treatment has brought a deeper level
Association. of understanding to seemingly complex cases. Now when
I see a chronic injury I ask not only what happened to cre-
Manual therapy in Canada is based on a wide vari- ate the injury but more importantly, why is it not clearing
ety of joint mobilization and manipulation approaches up? When local treatment to the area is insufficient, I ques-
taught in the UK (James Cyriax), Norway (Kaltenborn), tion two things:
and Australia (Maitland). As per IFOMPT (International
1. Am I treating a secondary problem and I have not
Federation of Manipulative Physical Therapists) stand-
found the driver in the Integrated Systems Model
ards, the system has evolved to include motor control
(developed by Diane Lee and Linda-Joy Lee) (www.
and muscle imbalance as well as the pain sciences. In
learnwithdianelee.ca,www.ljlee.ca)?
addition to this manual therapy background, I have had
the opportunity to amass many tools from postgradu- 2. Is this recurrent dysfunction (whether it is articular,
ate courses taken over the years, such as the Sahrmann muscular, neural, or visceral) connected to some-
approach, Kinetic Control, NOI (Neuro Orthopae- thing else within fascial system that is maintaining
dic Institute) courses, craniosacral techniques, Barral the dysfunction?
Visceral Manipulation, etc. Despite all the tools at my
disposal, I too have experienced times of clinical frus- The concept of myofascial continuities has become a
tration. These moments arose particularly in situations framework for understanding not only static postural
when I was fairly sure that I had a case of primary noci- support but dynamic and optimal movement. Knowledge
16
of fascial connections helps us understand how to direct physiotherapists consider the contribution of joint dysfunc-
our approach to the source of the problem (the criminal) tion as well as motor control and stability issues when assessing
and not merely to the painful tissue (the victim). I wish their clients. Education is also very important, so that the
to clarify, however, that I am not a “fascia-therapist.” I am client has tools to self-manage his/her condition and not
a physiotherapist with several tools in my toolbox, one of repeat poor patterns when doing functional activities, such
which is the Mobilization of the Myofascial System (MMS). as sitting or bending forward to brush their teeth. However,
The MMS approach is fully described in Chapters 3 and 4. the missing link in this puzzle is frequently the role of fas-
cia, especially in those with chronic, recurring conditions.
Movement re-education approaches
The Integrated Systems Model (Lee & Lee 2011),
There are a number of movement re-education approaches developed by Diane Lee and Linda-Joy Lee, considers the
that encompass the concepts of neuromodulation with func- role that underlying system impairments in the articular,
tional pattern re-education while at the same time providing neural, visceral, and myofascial systems play in a patient’s
valuable input into the fascial system. These include proprio- clinical presentation. The clinical puzzle shown is a reflec-
ceptive neuromuscular facilitation (PNF) (Knott and Voss), tion tool for charting findings (Figure 1.6). It represents
Alexander technique, Feldenkrais and yoga therapy. Chapter the various vectors that may impact a functional task and
15 will summarize these approaches to treatment as well as directs the therapist to treat those vectors (be it articular,
exercises to help maintain optimal fascial health. neural, visceral or myofascial).
Where does Mobilization of the Their category of myofascial impairment pertains to fas-
Myofascial System (MMS) fit into our cial structures that are overstretched, such as in diastasis
rectus abdominis (DRA) or fascia that has become dense,
paradigms as manual physiotherapists?
tethered, and resistant to elongation during movement.
As musculoskeletal manual therapists, we are trained
to put the patient’s subjective complaints in the center
of our puzzle, so to speak (Figure 1.5). This approach
includes consideration of not only subjective complaints Articular
of pain, paresthesia, weakness and so on but also the
patient’s beliefs about and attitudes toward their expe-
rience. Specific functional difficulties are also noted. A
good comprehensive subjective exam allows us to choose Dysfunction
Stability
assessment techniques that guide us to an analysis – that
Education
is, a hypothesis as to which factors may be contributing to
our client’s signs and symptoms.
If our analysis points to a problem that is primarily

pain of central origin, then this must be addressed with
Fascia
appropriate education and brain remapping along the
lines of Explain Pain concepts (Butler & Mosely 2013).
If the analysis of the patient points to a problem with
heightened sympathetic nervous system (SNS) response,
then this must be addressed with techniques to dampen
down the SNS, such as breathing techniques and medi- Figure 1.5
tation. When dealing with primary nociceptive pain, The clinical puzzle
it is appropriate to consider mechanical pain. Most
17
Chapter 1
Figure 1.6
Clinical puzzle for the
Integrated Systems Model.
Reproduced from Lee & Lee
(2011), The Pelvic Girdle: An
Integration of
Clinical Expertise and
Research, 4th edition. With
kind permission from
Elsevier
Lee & L ee ‘07
Skilled manual therapists will have multiple tools/ the therapist should try another approach (another plausi-
techniques to treat all systems; one is not more important ble hypothesis, based on clinical findings).
than another. MMS is a wonderful tool but it should not be
the only one in a manual therapist’s toolbox. Even with the Summary
same client, what may be appropriate to use at the begin- This chapter is meant to introduce the reader to fascia –
ning of treatment may not be so appropriate in later stages. its definition, anatomy, composition, and innervation.
It is important, therefore, to alternate between assessment The various roles that fascia plays in the body have been
and treatment and to re-assess the “comparable signs” to outlined, as well as the pathophysiology of fascial dysfunc-
determine which tool is best for that client at that particu- tions. Finally, the chapter includes a historical view of the
lar time. The optimal therapeutic approach is first to test, various approaches to treatment that have been developed
then to use clinical reasoning to decide which treatment to throughout the world thus far. The next chapter reviews
use (based on the therapist’s assessment findings), and re- the fascial lines as described by Tom Myers, author of
test to see if there has been a change in the objective signs, Anatomy Trains. Many of the techniques in MMS are
including movement patterns. If there is no change, then developed from these concepts.
18
2
A brief summary of Tom Myers’s
Anatomy Trains fascial lines and
clinical implications
Tom Myers, a structural integrator and self-styled Below is a summary of the twelve fascial lines or
“cartographer” of the body, wrote the first edition of his “Anatomy Trains” described by Myers:
book Anatomy Trains in 2001. There have since been two
• one back line called the Superficial Back Line (SBL)
further editions, in which Myers has refined his work as
he continues to explore fascial dissections and clinical • two front lines called the Superficial Front Line (SFL)
applications. Drawing on Myers’s studies with Ida Rolf and and the Deep Front Line (DFL)
on his published dissections of cadavers, the book maps • two Lateral Lines (LL), one on each side of the body
twelve myofascial meridians that wind through the body,
connecting head to toe and core to periphery. Although • two Spiral Lines (SL), one beginning on the right side,
Myers is not the only person to conceive the idea of myo- the other on the left
fascial continuities, his writing style and clear descriptions • three functional lines, termed the Front Functional
of the functionally integrated fascial webbing makes the Line (FFL), the Back Functional Line (BFL), and the
concept easy to apply in the clinical situation, no matter Ipsilateral Functional Line (IFL)
what the background of the practitioner is. The beauty
of the concept of Anatomy Trains is that it can be easily • two anterior arm lines, called the Superficial Front
integrated into the practice of any professional engaged in Arm Line (SFAL) and the Deep Front Arm Line
human structure and movement, be they physiotherapist, (DFAL)
chiropractor, osteopath, structural integrator, massage • two posterior arm lines, called the Superficial Back
therapist, or yoga or Pilates teacher. Arm Line (SBAL) and the Deep Back Arm Line
(DBAL).
Anatomy Trains was a game changer for me. Despite
being a fully trained manual physiotherapist I had had little Superficial Back Line
exposure to the concept of myofascial continuities prior to
reading this book in 2001. Anatomy Trains has since helped The Superficial Back Line (Figure 2.1) involves the fol-
me to understand the multiple ways that muscles link and lowing structures:
connect to transfer forces and support the body. Inspired • scalp fascia, occipital ridge
by Anatomy Trains and using it as a guide, along with my
own clinical experience of particularly challenging cases, I • erector spinae, lumbosacral fascia
developed an approach to treatment called Mobilization of • sacrum, sacrotuberous ligament, hamstrings
the Myofascial System (MMS). It is an approach that has its
origins in manual physiotherapy for the articular, muscu- • gastrocnemius/Achilles, plantar fascia and short toe
lar, and neural systems. Because the concepts in Anatomy flexors.
Trains form the framework for much of my approach to
treatment of the myofascial body, I have devoted the whole
Clinical implications
of this chapter to a summary and review of Tom Myers’s • Patients complaining of chronic low back pain fre-
twelve fascial lines, in addition to describing the clinical quently also complain of cervical pain and/or headache.
implications for each of them. The link between these may very well be the SBL.
19
Chapter 2
A B C
Figure 2.1
A Superficial Back Line upper quadrant; B right and left Superficial Back Line – posterior aspect; C Superficial Back Line
into the foot
• Persistent tension of the plantar fascia may be due not Superficial Front Line
only to tightness of the local plantar fascia itself but
also tension along the SBL. The Superficial Front Line (Figure 2.2) involves the
following structures:
• Tension headaches felt in the epicranial frontal
region may have a fascial component that links to • scalp fascia, sternocleidomastoid muscle, sternochon-
the SBL. dral fascia
• Persistent occipital pain may also be due to SBL • rectus abdominis, rectus femoris, quadriceps, patellar
issues. tendon
• Persistent thoracic or low back pain may also be • short and long toe extensors, tibialis anterior, anterior
due to SBL issues. crural compartment.
20
fascial lines and clinical implications
Pectoralis major Pectoralis minor
Clavipectoral
fascia
Figure 2.3
Superficial Front Line connections between the rectus
abdominis and the pectoral muscles
Figure 2.2 peroneus longus). Consequently, the toe extensors be-

Superficial Front Line come overused in the body’s attempt to stabilize the
foot and the toe extensors are commonly tight. The toe
Clinical implications extensors have a fascial connection to the SFL, which
may also contribute to the problem of hammer toes.
• Postural flexion of the trunk, forward head posture,
or locked knees are all signs of excessive tension in • Abdominal scars may have healed relatively well local-
the SFL (Myers 2014). ly but, if the scar is assessed in relation to the SFL or
DFL of fascia, there is commonly tension that may con-
• Tightness of the pectoralis muscles that contributes to
tribute to dysfunction in another part of the body. For
a forward head posture may have fascial connections
example, a tight fascial line between a caesarean section
to the symphysis pubis area or even the quadriceps
scar and the anterior glenohumeral (GH)/scapular area
fascia (Figure 2.3).
creates a “holding” that can maintain a forward tilt of
• Patients with hammer toes tend to have weakness issues the scapula and/or the GH joint, and become a contrib-
in the foot stabilizers (tibialis posterior, foot intrinsics, uting factor to shoulder dysfunction.
21
Chapter 2
• The sternocleidomastoid muscles are frequently short- Imbalance of the Superficial Back and
ened with a forward head posture. The fascial sling Superficial Front Lines
connecting both SCM muscles at the occipital region
may be a source of occipital pain. The SCMs are part According to Tom Myers, myofascial units are often
of several fascial lines, so tension in this area may arranged in antagonistic pairs on either side of the skeletal
have to be “chased down” to the foot (SFL) or the lat- armature. When one side is held chronically short, either
eral ribcage (Lateral Line). Tension in this line can muscularly or fascially (“locked short”), the other side is
also compress the occipitomastoid suture and be a stretched tight (“locked long”).
contributing factor to cranial dysfunction. The SCM The patient may complain of pain either in the myofas-
exerts a strong pull on the temporal bone, which may cial chain that is locked short (e.g., low back pain) or in the
posteriorly rotate it. This tendency has clinical im- myofascial chain that is under continual strain because it
plications not only for the temporomandibular joint is locked long (e.g., abdominal or sternal pain) (Figure 2.5).
(TMJ) but also for the position of the neck, thorax,
and shoulder girdle (Figure 2.4). Lateral Line
The Lateral Line (Figure 2.6) involves the following
structures:
• splenius capitis, SCM
• external and internal intercostals, ribs, lateral abdom-
inal obliques, iliac crest, anterior and posterior supe-
rior iliac spines (ASIS and PSIS)
SBL SFL SBL SFL
A B
Figure 2.5
Figure 2.4 A Balanced myofascial tension between the Super-
Fascial sling between both sternocleidomastoid muscles– ficial Front and Back Lines; B Superficial Back Line
connecting the occiput to the Superficial Front Line “locked short”, Superficial Front Line “locked long”
22
Scalenes
Diaphragm
Quadratus lumborum
Figure 2.6
Lateral Line Figure 2.7
The scalenes and quadratus lumborum, the deeper
• gluteus maximus, tensor fasciae latae (TFL), iliotibi- components of the Lateral Line
al band (ITB), fibular head, peroneal muscles, lateral
crural compartment.
• Tightness of the Lateral Line may translate into
Clinical implications pain in the area of the iliac crest, a frequent site of
According to Tom Myers, the Lateral Line operates accord- connective tissue accumulation (see Chapter 9 for
ing to the following characteristics: MMS technique).
• It functions posturally to balance front and back, and • The scalenes and quadratus lumborum (QL), techni-
bilaterally to balance left and right. cally part of the Deep Front Line, are deeper parts of
the Lateral Line (Figure 2.7).
• It also mediates forces along other superficial lines
– Superficial Front Line, Superficial Back Line, Arm
Lines, and Spiral Line.
23
Chapter 2
My own clinical experience in relation to the Lateral • splenius capitis, splenius cervicis
Line of fascia has revealed the following:
• spinous processes of C6 to T5, rhomboids major
• Recurrent tension in the scalene muscles may be due and minor, infraspinatus, serratus anterior, external
to compensation for weakness of the deep neck stabi- oblique, internal oblique, ASIS
lizers or a faulty breathing pattern. It may also be due
• tensor fasciae latae, ITB, tibialis anterior, peroneus
to tension in the Lateral Line or in the Deep Front Line
longus
(DFL) (see Chapter 5 for MMS technique).
• biceps femoris, sacrotuberous ligament, sacral fascia,
• Recurrent tension in the QL may be due to compen-
erector spinae.
sation for weak or inhibited lateral hip muscles. QL
is often frequently tight in relation to the Lateral Line Clinical implications
or the Deep Front Line (DFL) of fascia (see Chapter 9
for MMS technique to release QL in relation to these According to Tom Myers, the Spiral Line performs a num-
fascial lines). ber of important functions:
• The iliotibial band (ITB) syndrome may be frustrat- • It helps maintain balance posturally across all planes.
ing to treat if the therapeutic intervention addresses • It connects foot arches with the pelvic angle.
only the ITB. Clinically, it often presents as “tight”,
in combination with muscle imbalance issues of the • It helps determine knee tracking in walking.
hip, which must also be addressed. From the point • In imbalance, it creates, compensates, and maintains
of view of the Integrated Systems Model (ISM) twists, rotations, and lateral shifts in the body.
(Lee & Lee 2011), the ITB and hip issues may also
be the victim of dysfunctions elsewhere in the body, My own clinical experience in relation to the Spiral Line
frequently in the thorax, pelvis, or foot. If we have of fascia has revealed the following:
addressed these factors and still feel that the ITB • Recurrent tension in the area of the external oblique
is tight and warrants manual treatment, then we region may be due to tension of the spiral line con-
must take into consideration that the ITB is connecting it to the opposite iliacus area (or vice versa)
nected to the Lateral Line of fascia. Therefore, treat- (see Chapter 8 for MMS technique). Such tension
ment should encompass not only the ITB but also may contribute to the maintenance of a thoracic shift.
the peronei, the intercostal muscles, and the SCM It may also present as pain in the thorax, the lumbar
(see Chapter 11, Lower extremity, and Chapter 5, spine, or even the cervical spine (Integrated Systems
Cervical spine, for MMS techniques). Model) (Lee & Lee 2011).
• The TMJ muscles (temporalis and superficial • In the right spiral line there is a fascial connection
masseter), although technically not part of the between the right splenius capitis to the spinous
lateral line, are frequently tight in relation to this processes of the C/Thx area, continuing into the
Lateral Line (see Chapter 6 for MMS technique). left rhomboid and serratus anterior muscles (rhom-
Release of these fascial lines frequently diminishes bo-serratus complex) (Figure 2.9). Recurrent ten-
the recurrence of myofascial trigger points in these sion of the right craniovertebral area may be due to
muscles. tension within this part of the right spiral line.
Recurrent tension in the area of C2 on the right may
Spiral Line
also be due to tension this line, especially from the
The Spiral Line (Figure 2.8) involves the following right lamina of C2 (Maitland’s unilateral P/A pres-
structures: sures) to the left scapula/thoracic cage (see Chapter 5
for MMS techniques).
24
Figure 2.8
A Anterior view of the Spiral Line (right
and left); [LD 11:] B posterior view of the
Spiral Line (right and left)
A B
Deep Front Line • psoas, iliacus, quadratus lumborum
The DFL (Figure 2.10) encompasses the fascia that is • anterior longitudinal ligament, pelvic floor fascia,
behind the sternum as opposed to the SFL, which lies levator ani, obturator internus fascia, anterior sacral
anterior to the sternum and is continuous with the rectus fascia
abdominis muscle. The DFL connects the entire body at its • pectineus, adductor longus and brevis, adductor
core. It involves the following structures: magnus and minimus, popliteus, tibialis posterior,
• infrahyoid muscles, suprahyoid muscles, jaw mus- long toe flexors.
cles, cranium, and facial bones
The anterior sacral fascia unites with the muscles of the
• longus colli and capitis, pharyngeal raphe, scalene pelvic floor to the pubic bone via the pubococcygeus mus-
muscles, parietal pleura, pericardium, posterior dia- cle. At the deepest level, this connection wraps around the
phragm, central tendon, anterior diaphragm entire abdomen via the transversus abdominis muscle. The
25
Chapter 2
is part of the DFL (Figure 2.12). Although the tibialis

posterior is posterior to the tibia, it is considered as part of
the DFL of fascia.
Note that the following muscles take part in the follow-

ing section of the DFL (Figure 2.13):
• diaphragm
• quadratus lumborum
Rhomboid muscles Splenii muscles
• iliacus
• psoas
• pectineus.
Functional implications are vast, as the DFL starts (or ends,
depending on your viewpoint!) at the top of the head or
the bottom of the foot. The involvement of the respiratory
diaphragm is an integral part of our core stabilization, and
therefore our breath. This also alludes to the core stabiliz-
Serratus anterior ing function of the hyoid muscles, the core implications of
our pharyngeal raphe (throat) and scalene muscles, and
Figure 2.9 lastly the importance of the activation of the longus colli
Upper section right Spiral Line. Reproduced from Tom and longus capitis in anterior neck stabilization (Uridel
Myers (2014), Anatomy Trains: Myofascial Meridians for 2015). The DFL is thus a key component to all things core.
Manual and Movement Therapists, 3rd edition. With It is also frequently tight in patients with sedentary jobs
kind permission from Elsevier that require long periods of time in the sitting position.
Unless, of course, they endeavor to offset this excessive
time in flexion by doing activities or sports that encourage
anterior sacral fascia also connects to the anterior longitu- movement that “opens up” the front lines of the body (see
dinal ligament in front of the lumbar vertebral bodies and Chapter 14 for more information on movement and fascia).
then travels cephalically (Figure 2.11). The DFL splits into
three portions, anterior to posterior. The anterior portion My own clinical experience in relation to the DFL of fas-
follows the respiratory diaphragm anteriorly and attaches cia has revealed the following:
to the posterior aspect of the sternum and upward to the
• The tibialis posterior and long toe flexors are at the
hyoid muscles. The middle portion follows the crura of the
tail end of this line, so adding a combined movement
respiratory diaphragm to the pericardium, to the pharyn-
of ankle dorsiflexion and eversion (dorsiflexion/
geal raphe and upward to the scalene muscles. The third
eversion) to any structure in the DFL will add ten-
and deepest component of the DFL follows the anterior
sion to this line. For example, recurrent tension in the
longitudinal ligament all the way to the longus colli and
area of the hip flexors may be due to tension of the
longus capitis muscles (Uridel 2015).
DFL connecting iliacus to the central tendon of the
Note that the gastrocnemius muscle is part of the SBL, diaphragm. This part of the DFL may be worked on
tibialis anterior is part of the SFL and tibialis posterior using the MMS techniques described in Chapter 8.
26
A B C
Figure 2.10
A Side view of the Deep Front Line; B anterior view of the Deep Front Line (DFL); C posterior view of the Deep Front Line
27
Chapter 2
Figure 2.11
The Deep Front Line-pelvic floor
fascia connects to the anterior
Diaphragm
longitudinal ligament, the anterior
sacral fascia and the posterior
abdominal wall fascia, encompass-
ing both the visceral fascia and the
diaphragm
Anterior
longitudinal
ligament (ALL)
Posterior abdominal
aponeurosis
Pelvic floor
As a progression, the same technique may be repeat- will assess the Lateral Line of the lower quadrant (see
ed, but this time with the feet positioned in com- Chapter 8 for MMS technique). Connecting the QL
bined foot dorsiflexion/eversion, thereby pre-tensing to the foot by adding active or passive dorsiflexion/
the DFL. eversion will assess the DFL (see Chapter 9 for MMS
technique).
• Recurrent tension in the quadratus lumborum may
be due to tension of either the lateral line (previously • Pelvic floor pain is normally the domain of pelvic floor
described) or the DFL. Connecting the QL to the ITB therapists, who specialize in this area of the body.
28
Quadratus
lumborum
SFL SBL
Iliacus
Psoas major
DFL
Pectineus
Figure 2.12 Figure 2.13

Relationship between the Superficial Front Line, Deep Continuity between the diaphragm, quadratus
Front Line, and Superficial Back Line in the lower leg lumborum, psoas, iliacus and pectineus within the
Deep Front Line
However, if treatment effects plateau, it would be wise be a good place to start for physiotherapists who are
to consider other parts of the body that have a direct not trained in internal pelvic floor techniques (see
or indirect effect on the function of the pelvic floor Chapter 10 for MMS technique).
(such as the thorax in the Integrated Systems Model).
Another consideration is that the pelvic floor muscles With respect to the upper quadrant, the DFL includes
are part of this DFL of fascia and tension in this area several key structures:
can be traced up to the TMJ muscles and/or down to • the anterior cervical spine, including scalenes
the toe flexors. Working on releasing the tension of
the DFL with clients experiencing pelvic floor pain • the muscles of the TMJ, implicated in TMJ and head-
can be very rewarding. Certain pelvic floor muscles ache disorders
are accessible via external palpation (such as obtu- • the muscles around the hyoid bone (infrahyoid and
rator internus and obturator externus), so this may suprahyoid muscles) (Figure 2.14)
29
Chapter 2
Mandible
Mylohyoid
Hyoid bone Temporal

bone
Omohyoid
Mandible
Sternohyoid Digastric
Hyoid bone Mylohyoid
A B
Figure 2.14
A Infrahyoid muscles and fascia within the Deep Front Line; B Suprahyoid muscles and fascia within the Deep Front Line
• the pericardial fascia (deep to the sternum) joints, and the muscles. Tension in the anterior cer-
vical spine may be maintained by excessive tension
• the diaphragm, which is an important fascial element
in the DFL (see Chapter 5 for MMS techniques
separating and connecting the thoracic and abdomi-
mid-cervical region in relation to the DFL).
nal fascial systems (Figure 2.15).
• Patients with complaints of tightness in the throat
Clinical implications often have issues with the fascial line involving the
• Tension in the SFL and/or the SBL can contribute muscles around the hyoid bone. It is not uncommon
to excessive extension in the craniovertebral area, to see a history of abdominal or anterior thorax sur-
thus maintaining a forward head posture. The gery that pre-dates the complaints of tension in the
DFL must then provide a counterbalancing flex- throat. These problems can successfully be treated
ion to the upper cervical region (Figure 2.16). Pa- with attention to the DFL (see Chapter 6 for MMS
tients with chronic neck pain or a history of WAD technique).
(whiplash associated disorder) frequently exhibit • Recurrent tension in the TMJ muscles may be due
weakness of the neck stabilizer muscles. This im- to tension in the DFL, which needs to be addressed
balance between the fascial lines exacerbates their in order to achieve optimal results. The temporalis
condition. and superficial masseter muscles form a sling on
• With a forward head posture, the mid-cervical spine the outside of the head, with the medial pterygoid
is frequently positioned anteriorly in relation to the on the inside (Figure 2.17). Releasing excessive
upper and lower cervical regions (increased lordosis tension between the TMJ muscles and the pericar-
and/or an exaggerated anterior shear). This anterior dium, the diaphragm and even down to the tibialis
pull impacts all of the structures of the mid-cervical posterior can help alleviate recurrent tension in the
region, including the facet joints, the uncovertebral TMJ muscles (see Chapter 6 for MMS technique).
30
Vertebropericardial ligaments Figure 2.15

This diagram illustrates
the intimate relationship
Aortic arch and interconnection be-
tween the pericardium,
Superior sternopericardial ligaments the lung, the diaphragm
and the anterior vertebral
Superior vena cava
column. Adapted from
The Fasciae: Anatomy, Dys-
Pericardium function and Treatment.
With kind permission
from Serge Paoletti
Root of lung Inferior

sternopericardial
ligaments
Diaphragm
Phrenopericardial ligament
Deep and Superficial Front Arm Lines to the pectoralis major. Its connection to the medial
intermuscular septum along the humerus also con-
There are two front arm lines for the upper extremity – a nects it to the SFAL. It is therefore an important area
Superficial Front Arm Line (SFAL) and a Deep Front Arm to consider with patients who have range of motion
Line (DFAL) (Figure 2.18). issues with the shoulder. Decreased flexibility of the
latissimus dorsi muscle also affects the lower lumbar
The Superficial Front Arm Line (SFAL) involves the
spine and sacral area via the thoracolumbar fascia
following structures:
and can be the source of recurring “sacroiliac” pain
• pectoralis major, latissimus dorsi, medial intermus- (see Chapter 9 for MMS technique).
cular septum, flexor group of muscles, carpal tunnel. • The SFAL extends above and beyond the territory of
the median nerve distribution. In treating problems
Clinical implications of mobility for the median nerve, we may consider
• Although the latissimus dorsi muscle originates from interfaces that include the pectoral muscles in
the back of the body, it is part of the SFL of the trunk addition to the flexor retinaculum and the anterior
owing to its anatomical and functional relationship cervical spine.
31
Chapter 2
Temporalis
SBL DFL
Masseter
SFL
Medial pterygoid
Attachment to sphenoid bone

Relationship between the Superficial and Deep Front Temporomandibular joint (TMJ) muscles in relation
Lines and Superficial Back Line in the cervical spine to the upper part of the Deep Front Line – forming a
fascial sling between the medial pterygoid, superficial
masseter and temporalis
A B
Figure 2.18
A Deep Front Arm Line; B Superficial Front Arm Line
32
• Tension in both the SFAL and the DFAL (below) can • Releasing fascia around the clavicle can have a posi-
maintain a forward head posture, via its action on tive effect on improving shoulder mobility and pro-
the position of the shoulder girdle. moting an axially extended posture (see Chapter 12
for MMS technique).
• Dupuytren’s contracture does not simply involve the
finger flexor tendons in the hand. There are also • If periosteum is to be considered “dense fascia,” then
strong fascial connections to the SFAL that may con- (after the appropriate healing time has occurred), the
tribute to this dysfunction (see Chapter 13 for MMS site of a clavicular fracture may benefit from fascial re-
technique). lease of the clavipectoral fascia in order to minimize
the effects of shortening of the clavicle on the upper
The Deep Front Arm Line (DFAL) involves the follow- quadrant (see Chapter 12 for MMS technique).
ing structures:
• Treatment of De Quervain’s tenosynovitis may extend
• pectoralis minor beyond transverse frictions of the retinaculum with
• clavipectoral fascia the thumb in Finkelstein position (thumb adduc-
tion with wrist ulnar deviation) if we consider this
• biceps
fascial line to include the biceps, clavipectoral fas-
• radial periosteum cia and pectoralis minor (see Chapter 13 for MMS
technique).
• thenar muscles.
Deep and Superficial Back Arm Lines
There are two back arm lines for the upper extremity – a
• Adding wrist extension and ulnar deviation can help Superficial Back Arm Line (SBAL) and a Deep Back Arm
release the fascial line associated with tightness of Line (DBAL).
pectoralis minor, a common dysfunction in those
with a forward head posture (see Chapter 13 for The Superficial Back Arm Line (SBAL) (Figure 2.19)
MMS technique). involves the following structures:
Figure 2.19
Superficial Back Arm Line
33
Chapter 2
• trapezius muscles (upper, middle, and lower), del- relation to this line of fascia. Releasing this fascia is
toid, brachialis, lateral intermuscular septum, exten- frequently helpful with recalcitrant problems of
sor muscles of wrist and fingers. lateral epicondylosis (see Chapter 13 for MMS
technique).
Clinical implications • Treatment of a Colles’ fracture post-immobiliza-
• This line extends above and beyond the territory tion can encompass not only the mobility of the
of the radial nerve distribution. In treating prob- wrist joints but also the mobility of the fascia of the
lems of mobility for the radial nerve, we may con- distal radius along this Superficial Back Arm Line
sider looking at interfaces that include the trapezii, (see Chapter 13 for MMS technique).
the deltoid, and the cervicothoracic region in addi-
tion to the area of the radial head and the anterior The Deep Back Arm Line (DBAL) (Figure 2.21)
cervical spine. involves the following structures:
• Recurrent tension in the upper fibers of trapezius • rectus capitis lateralis, rhomboids, levator scapula,
(UFT) may be due to tension of the SBAL, which rotator cuff muscles, triceps, ulnar periosteum, hy-
needs to be addressed in order to get optimal results. pothenar muscles.
Adding wrist flexion to a recurrent trigger point in
this muscle can help release this line of tension (see Clinical implications
Chapter 5 for MMS technique). • This line extends above and beyond the territory
• The deltoid, brachialis, and wrist extensor mus- of the ulnar nerve distribution. In treating prob-
cle group all have a fascial connection through lems of mobility for the ulnar nerve, we may con-
the SBAL (Figure 2.20). Persistent pain and tension sider looking at interfaces that include the rotator
in the lateral elbow area may be due to tension in cuff and the levator scapula in addition to the area
Deltoid
Biceps brachii
Brachialis
Figure 2.20
Brachialis deltoid fascia – connecting the Superficial Figure 2.21
Back Arm Line and the Deep Front Arm Line Deep Back Arm Line
34
of the tunnel of Guyon at the wrist and the anterior Functional Lines
cervical spine.
• The rhomboid muscles are often “locked long”
Back Functional Line
and are therefore an area where recurring trig- • This includes latissimus dorsi, thoracolumbar
ger points are common. Releasing the Front Arm fascia, fascia of the sacrum, gluteus maximus, the
Lines helps to achieve balance. These muscles most posterior margin of the ITB and the patellar tendon
often need re-education to “shorten” rather than (Figure 2.22).
lengthen. However, if the rhomboids are dominant
over the trapezii muscles, this may also contrib- Front Functional Line
ute to a downward rotation position of the scap- • This includes the inferior margin of pectoralis major,
ula, undesirable for optimal function in shoulder the lateral envelope of rectus abdominis, the pubis
elevation. and the opposite adductor longus (Figure 2.23).

Back Functional Line (right and left) Front Functional Line (right and left)
35
Chapter 2
Clinical implications Clinical implications

These lines enable us to give extra power and precision This line is used to stabilize the torso during the pull down
to movement of the limbs by lengthening their lever arm of the crawl stroke in swimming (Myers 2014).
through linking them across the body to the opposite limb
in the other girdle. They could be considered as trunk Fascial lines and their connection to
extensions of the Arm Lines (Myers 2014). acupuncture
Fascia is the defining aspect of our body. It sculpts muscles
Ipsilateral Functional Line in the arms, the organs in the body, even the walnut tex-
• This includes the lateral portion of the latissimus dor- tured surface of our brains. Chinese medicine devotes two
si, the lower outer ribs, the external oblique over the organs to fascia, the pericardium and the triple burner. The
ASIS and onto the sartorius to the tibial condyle of triple burner in particular is the organ with a name, but
the knee (Figure 2.24). no form. It is the channel of fascia, the channel of the Tao.
Fascia is truly an organ with no form of its own, yet it is
everywhere (Keown 2014).
Dr Hélène Langevin, a licensed acupuncturist, is also a
renowned researcher in the field of fascia. In 2002 she sug-
gested that meridians follow fascial planes. It is clear if we
look at certain meridian lines that there are similarities with
Tom Myers’s Anatomy Trains fascial lines (see below and
Figures 2.25–2.27). In her studies, Langevin found an 80
percent correspondence between sites of acupuncture points
and meridians and the location of intermuscular connective
tissue planes. One hypothesis is that the needle grasp in acu-
puncture is due to mechanical coupling between the needle
and the connective tissue. Needle manipulation transmits
a mechanical signal to connective tissue cells via mecha-
notransduction. This observation may explain the therapeu-
tic effects of acupuncture (Langevin & Yandow 2002).
Research evidence
What evidence is there for myofascial chains? In 2016,
Wilke and colleagues conducted a systematic literature
review to evaluate proof for the existence of six myofas-
cial meridians based on anatomic dissection studies. A
search for peer-reviewed anatomic dissection studies pub-
lished between 1900 and 2014, yielded 6584 publications.
Next, duplicate articles and articles not pertaining to the
research question were removed and exclusion criteria
Figure 2.24
were applied (Wilke et al. 2016). The final review yielded
Ipsilateral Functional Line (right and left)
36
Figure 2.25
Similarities between the bladder
meridian (Tai Yang) and the
Superficial Back Line
Superficial Back Line Bladder meridian
62 studies. Of these studies, evidence of each meridian and Functional Line. In the Superficial Back Line, three myo-
its transitions were classified as strong, moderate, limited, fascial transitions (plantar fascia–gastrocnemius; gastroc-
conflicting, or not existent (Wilke et al. 2016). A transition nemius–hamstrings; hamstrings–lumbar fascia/erector
was considered a myofascial link between two muscles. For spinae) were verified in 15 studies. In the Back Functional
example, the gastrocnemius and hamstring are considered Line, three myofascial transitions (latissimus–lumbar fas-
to be a transition of the Superficial Back Line. cia; lumbar fascia–gluteus maximus; gluteus maximus–
vastus lateralis) were verified in eight studies. Finally, the
The results yielded strong evidence for myofascial tran-
Front Functional Line verified strong evidence for two
sitions in three of the six examined myofascial meridians:
myofascial transitions (pectoralis major–rectus abdominis;
the Superficial Back Line, Back Functional Line, and Front
37
Chapter 2
Figure 2.26
Similarities between the stomach meridian
(Tai Yin) and the Superficial Front Line
Superficial Front Line Stomach meridian
rectus abdominis–adductor longus) in six studies. There The researchers suggest that further studies be con-
was moderate evidence for the meridians and transitions ducted on the Spiral, Lateral, and Superficial Front Lines
of the Spiral Line (five of nine verified transitions, based on to determine if there is stronger evidence to support their
21 studies) and the Lateral Line (two of five verified transi- existence and begin to explore evidence for the Deep Front
tions, based on 10 studies). There was no evidence for the Line and Arm Lines. It will be exciting to see the outcomes
meridians and transitions of the Superficial Front Line, of future research regarding the Anatomy Train myofascial
based on seven studies (Wilke et al. 2016). meridians.
38
Lateral Line Gall bladder meridian
Figure 2.27
Similarities between the gall bladder meridian (Jue Yin) and the Lateral Line
Summary and their clinical implications will help illuminate the

basis for many of the MMS techniques. The next chapter
This chapter reviewed the fascial lines as described by Tom describes the assessment of the fascial system and its rela-
Myers in Anatomy Trains. Awareness of these fascial lines tion to the overall physiotherapeutic assessment.
39
Assessment of fascial dysfunction 3
How does a patient with fascial dysfunction present? • “I know that other therapists and doctors have told
me that my right leg and arm symptoms are separate
The subjective exam problems, but that’s not how it feels to me.”
Geoffrey Maitland, one of the grandfathers of manual
Other characteristics of myofascial pain include the
physiotherapy, had a significant global impact on the
following symptoms:
profession. One of the most important messages he con-
veyed to physiotherapists was the importance of a thor- • Pain is dull, aching, and often deep.
ough subjective evaluation. “Not only will a thorough
• Pain may be low-grade to severe in intensity.
subjective exam tell you what the problem(s) are,” he would
say, “but also how to treat them.” This is true for all cases of • There are frequently many areas of local tenderness.
musculoskeletal pain: it is particularly important for cases • There are disturbed sleeping patterns with morning
of fascial dysfunction. stiffness.
The typical questions asked in a good subjective evalua- • Pain does not follow dermatomal, myotomal, or
tion include the following topics: sclerotomal patterns.
• areas of pain and their relationship to each other Does this last category of symptoms not sound suspi-
• complaints of paresthesia, numbness, or other neuro- ciously like fibromyalgia?
logical symptoms
Clinically, I have found that clients with this condition
• previous history of the complaint tend to manage their symptoms well with a combination
• previous medical history, including medications of active exercise, dry needling, craniosacral techniques,
taken and fascial techniques as well as appropriate medication
such as Lyrica (pregabalin) to tone down the nervous
• medical tests performed and their results system.
• previous treatments tried and their effects
Patients with fascial dysfunction are rarely able to iden-
• behavior of pain throughout the day/night tify specific provocative movements that consistently
reproduce their symptoms, unless the activity adds ten-
• factors that provoke and ease symptoms
sion to a tight fascial line (e.g., low back pain brought on
• functional difficulties by walking or standing for a period of time if the Deep
• patient’s goals for treatment. Front Line of fascia is restricted). We must, however, rule
out other dysfunctions that can reproduce these symptoms
A patient with fascial dysfunction may present with the such as hypo- or hypermobility of the zygapophysial joints,
following additional subjective complaints: poor mobility and/or dynamic control of the foot, knee,
hip, lumbar spine, pelvis, or thorax that may contribute to
• “My skin is too small for my muscles.”
the low back pain. Given the connectivity and relationship
• “I feel tension in my leg overall, as if I were wearing a between body regions, every region of the body can con-
twisted pair of pantyhose.” tribute to low back pain.
41
Chapter 3
Other clues that we may be dealing with dysfunction of • Active ROM may or may not produce pain,
the fascial system: but the patient frequently reports a sense of “stiffness”
or “pulling.”
• The patient has difficulty maintaining effects of treat-
ment despite good results obtained during treatment. • Testing of individual joint mobility or muscle length
is within normal limits (or, at times, hypermobile)
• The patient has difficulty maintaining effects of treat-
but restriction is noted with combined, functional
ment despite being diligent in doing recommended
movements.
flexibility, postural, or stabilization exercises.
• There has been a recent growth spurt in adolescence. Muscle length tests
• The patient has difficulty maintaining an optimal These are often within normal limits. If a muscle is restrict-
posture. ed and treatment is targeted to the local muscle, both the
patient and the therapist may feel that results from treat-
The objective exam ment are short-lived and the muscle soon tends to stiffen
up again.
Objectively, the following may be found:
Joint mobility (includes both passive
Observation physiological movements and passive
• Positional faults are noted in observing the patient’s accessory movements)
posture but testing the accessory movements of the
Passive physiological movements are movements in which
joints only gives a partial explanation for this posi-
the practitioner produces the motion while supporting the
tional fault. For example, ideally, when assessing the
limb or spine. The technique is chosen in order to assess
position of the femoral head relative to the pelvis, the
the joint with the muscle in a relaxed position. Accessory
therapist is hoping to find a centered femoral head,
or joint play movements are joint movements that cannot be
a key requirement for optimal biomechanics of the
performed by the individual. These accessory movements,
hip. An example of a positional fault is one in which
including roll, spin, and slide, accompany physiological
the femoral head is positioned anteriorly in relation
movements of a joint. Manual therapists have been taught
to the ilium. If the therapist thinks only of articular
that when assessing passive physiological or passive accesso-
factors, they will presume that the capsule of the hip
ry movements of a joint, attention must be paid to the sen-
joint is the cause of this positional fault. However, op-
sation throughout the whole movement and not simply the
timal biomechanics require not only normal capsular
end feel of the movement.
mobility around the hip joint but also balanced acti-
vation of all muscle and fascial vectors. All joints have range of motion divided into two zones:
Active range of motion (ROM) 1. A neutral zone (NZ) in which no resistance is felt.
The NZ ends once the beginning of the first resistance
• The area in question may demonstrate normal, or to movement is perceived (R1).
near normal range of motion (ROM), but the range
may be decreased if the body is positioned differently. 2. An elastic zone (EZ) in which the first resistance to
For example, if the SBL of fascia is tight, testing active movement (R1) gradually increases until firm resistance
cervical flexion in sitting may be more restricted than is felt (R2) at the end of range. In a normal joint, it is
if it is tested in standing. considered that R2 is due to tension in the ligaments
42
Assessment of fascial dysfunction
and capsule of the joint (see Chapter 4 for more infor- system impairment that is creating suboptimal alignment,
mation on movement diagrams and grades of passive biomechanics, and/or control of a body region.
movement). • In a healthy hip, when the therapist glides the femoral
A normal accessory movement for a joint, although head posteriorly, it floats back up to the surface, much
small in amplitude (usually a few mm of glide or roll), will like the type of “Soap on a Rope” that pops back up to
have a small NZ, where no resistance is felt at the start of the surface of the water after it has been pushed down
the movement, and a gradually increasing EZ until R2 is (Diane Lee, personal communication).
felt. Training is required in order to determine a normal or • If the load and listen test points to an articular
abnormal feel for an accessory movement of a joint. restriction, the therapist will feel that the accessory glide
• When there is a myofascial restriction, accessory move- may be stiff with a relatively harder, capsular end feel.
ments of the joints have a “bouncy” or “rubber-like” end Upon the release of the accessory glide, a small ampli-
feel as opposed to the end feel of a fibrotic or stiff joint, tude movement occurs to allow the joint to re-establish
which is crisper and harder. a more neutral position.
• If the load and listen test points to a myofascial restric-
• A number of levels in the lumbar spine may exhibit
tion, the therapist feels the resistance to the accessory
stiffness with PIVM (passive intervertebral move-
movement but the end feel will not be as hard. More
ment) testing for flexion, for example. If a fascial line
importantly, upon release of the glide, there will be
is restricted, mobilizing these joints often results in
a vector of pull towards the area that is “tugging” on
only partial release.
the joint. This myofascial restriction may be a combi-
• The patient’s joints may have a tendency to be hyper- nation of neuromuscular vectors (increased tone in
mobile, but they still present with decreased range of muscles due to increased neural drive), visceral vec-
motion when active ROM is tested. tors, muscular, and fascial vectors. (Keep in mind that
fascia surrounds all of these systems.)
Vector analysis: load and listen test
This test may be used as a “before” and “after” test, when
This test derives from listening courses developed by Gail using any type of release technique. It is particularly use-
Wexler for the Barral Institute. These listening techniques ful to use before and after a MMS technique. It guides the
differentiate active and passive listening. “Load and listen” therapist as to which myofascial vector(s) have the most
encompasses both aspects of listening. I find it invaluable impact on a particular joint and encourages exploration
in helping to detect the primary myofascial vectors that of that myofascial vector. Release can be done both locally
may be impacting a joint. to the involved muscle and also along its myofascial line
When an accessory movement for a joint is assessed, not (based on Anatomy Trains myofascial meridians).
only is the resistance of this accessory movement noted, (Chapter 11 outlines the load and listen test for the
but, in this test, particular attention is paid to the release hip joint.)
component of the accessory glide. In other words, when you
let go of a correction, where does it pull you? This is what The same concepts for the load and listen test apply to
is termed vector analysis. Vector analysis in the Integrated other joints. For example, if the glenohumeral (GH) joint
Systems Model (ISM) approach has taken the “load and lis- is positioned anteriorly in relation to the acromion, on
ten” concept of the Barral visceral approach and applied it to the load and listen test we may find some limitation in
the musculoskeletal system, to help identify the underlying the posterior glide of the GH joint (the loading aspect of
43
Chapter 3
the test): but upon the release of the anteroposterior (A/P) Assessment of the fascial system
glide (the listening aspect of the test), we may feel a vector
that pulls the humeral head caudally toward the biceps if the Testing for fascial restriction with
Superficial Front Arm Line is shortened. It is then appropri- recurring joint dysfunction
ate to check the myofascial tissues of the Superficial Front
If a joint restriction is recurrent despite good effects with
Line. (Chapter 13 outlines the load and listen test for the
previous treatment, good compliance with mobility and
GH joint.)
stability exercises, and awareness of posture, it may be
Dynamic stability tests that the fascial component to the restriction needs to be
addressed. For example, if anteroposterior (A/P) mobiliza-
Dynamic instability may be defined as a patient exhibit- tions of the C4 and C5 levels are chronically stiff despite
ing a failed load transfer when performing functional tasks good release with treatment, we may consider whether this
such as the half squat or OLS (one leg stand) test. The failed dysfunction is perhaps connected elsewhere along a fascial
load transfer (FLT) in these functional tests may present in line, and whether this may possibly be a contributing factor
one or several areas (Lee & Lee 2011): toward its recurrence. If the therapist suspects that fascia
• The pelvis: “unlocking” of the pelvis may occur. In may be a factor in movement restriction, he/she can then
this situation, the sacroiliac (SI) joint fails to maintain explore which line of tension is most problematic.
a position of sacral nutation in relation to the ilium
The MMS techniques described in this text have two
(the position of optimal stability for the SI joint). The
components:
therapist may perceive this as the ilium moving into
anterior rotation (relative counternutation of the sa- 1. The therapist stabilizes an area of recurrent dysfunc-
crum) when doing a half squat or OLS test. tion with one hand – stabilizing either an accessory
movement of a joint or a recurring myofascial trigger
• The hip: ideally the femoral head should stay centered
point.
in relation to the pelvis throughout a OLS or a squat
maneuver. A common clinical pattern of dysfunction 2. The therapist’s other hand becomes the hand that ex-
is a femoral head that glides anteriorly and/or inter- plores and mobilizes lines of fascia, always using the
nally rotates instead of staying centralized. “star concept” (described below).
• The foot: the foot should be able to maintain its neu- Continuing with the same example of the restricted A/P
tral position, with the talus directly under the tibia, mobilization at C4, the C4 level can be stabilized with an
the forefoot in neutral position in relation to the A/P mobilization angled cranially and then the following
hindfoot. considered:
• The thorax: no lateral shift of the thoracic rings • To explore the SFL the therapist may add:
should occur with functional tests of OLS and squat −− an A/P mobilization to the ipsilateral or contralat-
(Lee & Lee 2011). eral scapula
−− an A/P pressure directed caudally to the tissue an-
Patients with fascial dysfunction frequently exhibit
terior to the sternum
signs of dynamic instability, especially in the area of fas-
−− the rest of this line may then be explored with an
cial tightness. Recruiting muscles that help in motor con-
A/P pressure directed caudally to the rectus ab-
trol is often a frustrating experience for both the therapist
dominis area and/or the symphysis pubis (see
and the client, as fascial tension is frequently a factor that
Chapter 5 for details).
inhibits these stabilizer muscles from “kicking in.”
44
• To explore the DFL the therapist may add: aim is to discover where there is most tension between
−− an A/P mobilization directed caudally to the tissue the stabilizing hand and the fascial tissues anterior to the
posterior to the sternum (pericardium) sternum (for this example of a problem with the Super-
−− an A/P mobilization directed caudally to the right ficial Front Line). The therapist “corrals” the myofas-
and/or left diaphragm cial tissue, “sniffing out” the vector where most tension
−− active dorsiflexion/eversion of the ankles to pre- between the two hands is felt. In the example above, the
tense the DFL by putting a stretch on the tibialis caudal pressure on the tissues anterior to the sternum
posterior, which is at the tail end of this line (see may be done in a straight caudal direction, caudal to
Chapter 5 for details). the right of the patient, caudal to the left of the patient,
or perhaps in a medial/ lateral direction or even in a
• To explore the Lateral Line the therapist may posi-
clockwise/counterclockwise direction. Restriction may
tion the client in side-lying, stabilize the mid-cervical
be felt in several directions. Treatment begins by using
spine with an A/P mobilization and explore the inter-
the most restricted direction and, once released, explor-
costal fascia on the side of the trunk (see Chapter 5
ing and releasing the other restricted directions in that
for details).
fascial line.
How does the therapist know when a particular The same “star concept” applies to any MMS technique,
line of fascia is restricted? for any line of fascia.
The therapist will feel an almost immediate increase
Exploring lines of fascia
in tension of the stabilizing hand (in this case, the A/P
mobilization of the C4) as he/she applies a gentle pressure • Tom Myers’s Anatomy Trains lines, although very
on the anterior aspect of the sternum with the exploratory pertinent to MMS, are not the only way a therapist
hand (for a SFL restriction). It is normal to feel a certain can explore the fascia. The Anatomy Trains is simply a
resistance between the two areas at the end of a caudal map of the “grain” in the myofascial fabric, and so, like
pressure on the sternum, but it is not normal to feel this most maps, only an indication of a good place to look
resistance at the very start of the maneuver being per- (Myers 2014).
formed by the exploratory hand. There should be (in
• The nervous system may also be used as a guideline
Geoff Maitland’s terms) a “toe region” where there is little
(see the femoral nerve fascial technique in Chapter 9
resistance at the beginning of movement. (Please refer to
as an example).
the section on Maitland’s grades of movement in Chap-
ter 4.) When the fascial line is restricted, this toe region is • The patient’s functional problems may also
absent or quite limited and early resistance between the give us a clue as to what to explore. Refer to Chapter 5
two hands of the therapist will be felt. The patient may (Anterior cervical in relation to glenohumeral move-
perceive this as the therapist pushing harder on the level ments) for an example where the patient complains of
being stabilized (in this case, C4) when in reality the thera- arm pain with reaching forward as opposed to reach-
pist is simply preventing the fascial tissues at C4 from ing sideways with abduction.
gliding caudally. • “It hurts right here.” The location of the patient’s main
complaint of pain may also be a good place to start,
Using the star concept stabilizing that area and exploring fascial lines that
The star concept implies that the therapist must not think may be “tethered” to that painful area. The area of
along the lines of an articular glide but rather explore pain is frequently a “victim” of another dysfunction
multiple directions, somewhat like the shape of a star. The nearby (e.g., the lower lumbar area may become
45
Chapter 3
symptomatic during standing or walking if it is com- • using dry needling or IMS techniques to de-facilitate
pensating for an extension dysfunction in the upper muscles that are hypertonic secondary to increased
lumbar area, and/or poor hip extension). Howev- neural drive
er, the symptomatic area may also be tethered by a
• considering other areas of the body that may be
tight fascial line, and this may also play a role in its
impacting the symptomatic area (ISM concept of
recurrence.
drivers)
Reposition and test • last, but not least, considering that there may be a my-
ofascial component to the restriction that needs to be
Another way to help differentiate an accessory joint addressed.
movement restricted by the joint capsule from one restrict-
ed by myofascial vectors, is to repeat an accessory move- An example of this last concept using MMS is as follows:
ment with other regions of the body under tension. For
example, an A/P mobilization of the C4 level in the mid- Recurrent tension in the upper fibers of trapezius (UFT)
cervical region may be compared to the same mobiliza- may be due to tension of the Superficial Back Arm Line
tion (same grade of movement) with the ipsilateral arm in (SBAL), which needs to be addressed in order to get optimal
70 degrees of abduction. If the A/P at C4 is stiffer (which results. In this example, the therapist “stabilizes” the recur-
may or may not reproduce pain), then it implies that fascia rent myofascial trigger point in the UFT by pinching it in an
may be a factor in this recurrent restriction. The fascia A/P direction. If there is tension in the SBAL, the therapist
may be related to the muscular system (e.g., scalenes), the will feel an immediate increase in tension of the “stabilizing”
clavicle, the neural system (e.g., median nerve), the visceral hand on the UFT as soon as he/she adds a component of pas-
system (e.g., pericardium) or perhaps a combination of all sive wrist and finger flexion. Keep in mind that the wrist and
four areas. finger extensors are at the tail end of the SBAL (see Chapter 2).
Using oscillatory movements of wrist flexion while maintain-
Another example is to explore the DFL of fascia in rela- ing the pinch on the trigger point will help to release this line
tion to the recurrent C4 dysfunction. This is done by sta- of tension (see Chapter 5 for MMS technique).
bilizing C4 as above and simply adding active (or passive)
combined dorsiflexion/eversion of the ankles to see if this Testing for fascial restriction with a
affects C4. (Keep in mind that tibialis posterior is at the neural mobility test
tail end of Tom Myers’s Deep Front Line, so adding dor- In order to address problems of decreased mobility of a
siflexion/eversion puts it under tension). If there is abnor- particular nerve, the usual approach in manual therapy is
mal tension in the DFL of fascia, then adding dorsiflexion/ to mobilize the interfaces of the nerve in question. The
eversion will cause an immediate increase in tension in the median nerve, for example, may involve positioning the
hand that is stabilizing C4 in an A/P glide (see Chapter 5 arm in some degree of shoulder abduction, external rota-
for MMS technique). tion, elbow extension, and wrist and finger extension
(depending on irritability of the tissues and where first
Testing for fascial restriction with a resistance is felt when doing the median nerve mobility
recurring muscle trigger point test) and then adding A/P mobilizations or lateral shear
Myofascial tension may have a tendency to recur if the fol- movements at C5, C6, and C7. As well, the nerve mobil-
lowing factors are not addressed: ity test itself may be used as a treatment technique, either
as a sliding technique or a tensioning technique. If, how-
• optimizing balance between muscle groups in the ever, tension of the nervous system persists despite this
area (i.e., stretching tight muscles, strengthening approach to treatment, it is suggested that the therapist
weak ones) explore a little more broadly than the usual interfaces of
46
the nerves. For example, the therapist may use a mobiliz- Neurological contraindications:
ing technique in the anterior cervical spine with the arm in
abduction, external rotation, wrist and finger extension to CNS disease or injury
pre-tense the median nerve and then explore the SFL of the • extrasegmental pain increased by passive
trunk. Or the therapist may also explore other regions of flexion of the neck
the cervical spine, frequently as high as C1 or C2, that may
have an impact on the mobility of the median nerve (see • bilateral or quadrilateral multisegmental par-
Chapter 5 for MMS techniques). esthesia, augmented by passive flexion of
the neck
Indications/contraindications to • paresis or multisegmental paralysis
MMS treatment
• hyperreflexia
The contraindications to treatment with MMS are simi-
lar to the contraindications for manual therapy in general • presence of Babinski/Oppenheim/Hoffmann/
(Box 3.1). CNS, spinal cord or cauda equina disease and clonus
injury are an obvious contraindication to any manual ther- • ataxia
apy but there are also other conditions to consider such as
vascular issues and metabolic and systemic contraindica- • neurological spasticity
tions (Canadian Physiotherapy Association). • bladder or bowel dysfunction
• dysphagia/dysphasia
BOX 3.1 Contraindications to manual therapy
• Wallenberg syndrome (inferoposterior cer-
Contraindications specific to the patient: ebellar artery)
• lack of consent • other signs/symptoms of cranial nerves
• disturbed psychological or emotional state • nystagmus (if associated with dizziness/ver-
• inability to communicate/unreliable historian tigo, requires more diagnostic differentiation)
• inability to relax Spinal cord injury or disease
• constant or continuous undiagnosed pain • extrasegmental pain below the level of the
lesion, which can increase with passive flex-
• intoxication/highly medicated ion of the neck
Bone contraindications: • bilateral or quadrilateral multisegmental par-
• relevant recent trauma (fractures, dislocations) esthesia below the level of the lesion, which
can increase with passive flexion of the neck
• past or present cancer that produces bone
• bilateral or quadrilateral multisegmental
metastases (breast, bronchus, prostate, thy-
weakness or spastic weakness below the level
roid, kidney, intestine, lymphoma)
of the lesion
• active infection (osteomyelitis, tuberculosis,
• hyperreflexia below the level of the lesion
previous bone infection)
• possible presence of hyporeflexia at the level
• significant foraminal or spinal canal reduction
of the lesion
on radiography or other imaging examina-
tions ( for techniques done in extension) • presence of Babinski or Oppenheim sign
47
Chapter 3
• presence of Hoffmann’s sign if the lesion is Age-related contraindications:

above C5–6
• children (skeletal immaturity, consent issues)
• clonus below the lesion level
• elderly (increased risk of osteoporosis, vascu-
• ataxia lar disease, spinal stenosis)
• neurological spasticity below the level of the Metabolic contraindications:
lesion
• bone disease (e.g., osteoporosis, Paget’s disease)
• reflex bladder (the bladder empties when it
is distended) Systemic contraindications:
Cauda equina compression • diabetes (precaution)
• hyporeflexia or areflexia (bilateral or • asthma (pay attention to the side effects of
multisegmental) corticosteroids)
• paresthesia/bilateral or multisegmental pain • endocrine disorders (precaution) – hypothy-
roidism, hyperthyroidism, hyperparathyroidism
• initially overactive bladder (urgency and
increased frequency) then paralysis of the • endocrine disorders (contraindication if treat-
bladder (overflow urination) ed with drugs that affect collagen)
• fecal retention with overload and overflow • pregnancy, contraindicated in the presence of:
of feces
−− any history of miscarriage
• loss of genital sensation
−− hypermobility/instability – recent postpar-
• loss of erection reflex or ejaculation tum (joint instability, risk of postpartum
• signs and symptoms of bilateral or multiseg- hemorrhage)
mental nerve root lesions Medication:
Vascular contraindications: • active inflammatory disease (e.g., rheumatoid
• vertebral artery insufficiency arthritis, psoriatic arthritis, ankylosing spondy-
litis, Reiter’s syndrome)
• vascular disease (aneurysm)
• inactive inflammatory disease (precaution)
• bleeding problems (e.g., hemophilia)
• anticoagulants (Coumadin (warfarin), heparin)
Contraindications related to collagen disease: – pay attention to ASA (acetylsalicylic acid,
• Ehlers–Danlos syndrome aspirin)
• Marfan syndrome • any medication that affects collagen – corti-
costeroids, tamoxifen
• osteogenesis imperfecta
• any medication related to osteoporosis (see
• benign hypermobility syndrome (precaution)
list below)
– laxity of the connective tissue
• antidepressants (precaution)
• acute post-traumatic phase (precautionary
for 6–8 weeks) • harmful medications for bones
48
−− glucocorticoids MMS is particularly indicated for subacute or chronic

conditions.
diseases treated with glucocorticoids
If the condition is acute, the therapist may work either
rheumatoid arthritis, osteoarthritis, bursitis proximally or distally (craniocaudally) to the symptomatic
asthma, COPD, allergic rhinitis region, following Myers’s fascial lines of tension. When
first working with tissues that are in the subacute phase
liver disease of healing, it is wise to use “listening techniques” rather
lupus, psoriasis, severe dermatitis than be too directive until such time that the body gives
you a green light to go ahead (see Chapter 4 for principles
cancers: leukemia, lymphoma of treatment with MMS).
ulcerative colitis, Crohn’s disease
Recent fractures must be given time to heal before using
multiple sclerosis fascial techniques directly on the fracture site, but areas
above and below the fracture may be explored and treated.
post organ transplant
inflammation and eye diseases (glaucoma) Summary
−− methotrexate This chapter described the assessment of the fascial sys-
tem and its relation to the overall physiotherapeutic assess-
diseases treated with methotrexate ment. Chapter 4 will focus on the principles of treatment
cancers with Mobilization of the Myofascial System (MMS).
immune disorders
resistant arthritic conditions
−− cyclosporin A
diseases treated with immunosuppressive drugs
post transplantation
immune diseases
−− other medicines
heparin
cholestyramine (control of blood cholesterol
levels)
thyroid hormones
anticonvulsants
antacids containing aluminum
49
Principles of treatment with
Mobilization of the Myofascial System
4
The aim of this chapter is to introduce the reader to the between the two hands of the therapist. Treatment begins
concepts of using Mobilization of the Myofascial System by using the most restricted direction and, once released,
(MMS) as a treatment for musculoskeletal problems. exploring and releasing the other restricted directions in
that fascial line. Once all directions have been released
MMS guidelines for treatment between the anchoring hand at C4 and the tissues anterior
to the sternum, the therapist may then explore and treat
Treat joints first
the rest of the SFL, including the rectus abdominis in its
Generally speaking, if there is a true joint dysfunction, entirety, all the way down to the symphysis pubis.
especially with a fibrotic or articular feel, it is best to treat
these first, with graded mobilizations and/or manipu- Depth of technique: understanding
lation. However, if several segments in the spine (as an accessory movements and grades of
example) are limited in flexion, there is commonly a myo- movement
fascial component to this restriction on PIVM (passive
A review of Maitland’s grades of passive movement is
intervertebral movement) testing. In this case, myofascial
required here in order to explain the depth of technique
techniques should be used as a first approach to treatment,
needed for the MMS approach.
as it is then easier to focus on one or two levels that are
truly restricted by the joint capsule. Manual physiotherapists have been taught that when
assessing passive physiological or passive accessory move-
Star concept ments of a joint, attention must be paid to the sensation
Treatment is directed by the fascial assessment (see throughout the whole movement and not simply the end
Chapter 3 for assessment). One hand stabilizes the recur- feel of the movement.
rent joint dysfunction or muscle trigger point. The thera-
pist’s other (exploratory) hand seeks the direction of most Grades of passive movement
restriction between it and the anchoring hand, in relation Grades of passive movement, as well as movement dia-
to a particular fascial line, always using a “star” concept. grams, were created as a means of communication between
For example, if the SFL of fascia has been found to be prob- physiotherapists. They are not a science and should not be
lematic in relation to recurrent A/P dysfunction of the C4 used in any scientific or rigid context. Movement diagrams
joint, the therapist will find early tension between the hand are simply a means of allowing one person to express in
that is gently anchoring C4 with a cranial A/P glide and the pictorial form what they are feeling through their hands
exploratory hand that is performing a gentle A/P pressure when they examine a passive movement (Maitland 2005).
on the tissues anterior to the sternum. This exploratory Grades of movement are used as an indication of where
hand uses the star concept to determine the direction(s) of in the available range a treatment technique is being
most tension between the therapist’s two hands. The direc- performed.
tion of the exploratory hand may be in a straight caudal
direction, caudal to the right of the patient, caudal to the Historically, there have been two systems of grading
left of the patient, or perhaps in a medial/lateral direction passive movement. The system developed by Kaltenborn
or even in a clockwise/counterclockwise direction. Note describes three stages of motion related to accessory glides
that there may be several directions where restriction is felt (stages 1, 2, and 3).
51
Chapter 4
R1 is defined as the start of the first resistance felt by the

I
therapist when performing an accessory or passive physi- II
IV
ological movement. R2 is defined as the second barrier or A B
end range of the resistance to the movement performed.
Stage 1, called the “toe region,” is entirely before the start of R1 III R2 = L
resistance (R1). Stage 2, called “taking up the slack,” stops
between R1 and R2 so is well into the resistance. Stage 3, Figure 4.1
called “stretch,” reaches R2 and attempts to move R2 fur- Maitland’s grades of movement: R1 = first barrier of re-
sistance; R2 = second barrier of resistance; L = limita-
ther into range (Kaltenborn 2014).
tion of range. The line A to B represents normal ROM.
In the system devised by Maitland, all joints have range In this example, R2 is about 85 percent of full ROM
of motion divided into two zones:
• A neutral zone (NZ) in which no resistance is felt.
The NZ ends once the beginning of the first resistance Table 4.2 The grades of movement into resistance
to movement is perceived (R1). can be defined as shown
• An elastic zone (EZ) in which the first resistance Grade IV– or Movement into the first third of
to movement (R1) gradually increases until firm grade III– resistance (often described as
resistance is felt (R2) at the end of range, the restric- 25 percent of the distance
tion due to tension in the ligaments and capsule of between R1 and R2)
the joint. Grade IV or Movement in the middle of the resistance
grade III from a third to two-thirds of resistance
Maitland’s grades of mobilization are described as grade (often described as 50 percent of the
I through grade IV (Table 4.1). There are always four grades distance between R1 and R2)
of mobilization, whether the range of motion is normal or Grade IV+ or Movement into the last third of
limited. A Grade V is a grade that defines a manipulation grade III+ resistance (often described as
technique, which is a high velocity short amplitude thrust greater than 75 percent of R and
at the end of the available range, at R2. pushing into R2)
In this system, the grades I through IV are defined

according to where they are in the range in relationship end range resistance) (Figure 4.1). Grades I and II are
to R1 (first barrier of resistance) and R2 (second barrier or found before R1 and are therefore found in the resist-
ance-free range. Grades III and IV are grades that
penetrate the resistance and can be found between
Table 4.1 Definition of Maitland’s grades of mobilization R1 and R2.
Grade I Small amplitude movement near the Grades, therefore, are defined according to resistance
beginning of the range and not to symptoms, although these will be taken into
Grade II Large amplitude movement within the consideration for the appropriate choice of the grade in
resistance-free range; further than a treatment.
grade I but before R1
To make the grades clinically more useful and a more
Grade III Large amplitude movement into accurate reflection of how we progress our treatment
resistance
techniques, Maitland further defined the grades as plus
Grade IV Small amplitude movement into (+) or minus (−) to indicate the amount of resistance into
resistance which the movement is performed (Table 4.2; Figure 4.2).
52
Principles of treatment with Mobilization of the Myofascial System
IV+
resistance between the two hands of the therapist at the
I
II IV V
beginning of movement. The therapist should be able to
A B perform a full (but gentle) A/P pressure on the sternal tis-
sues without feeling a corresponding increase in tension in
IV– III+
the anchoring hand until the very end of range.
R1 R2
III The grades of movement most commonly used with MMS
III–
techniques are the large amplitude movements into the
Figure 4.2 resistance of the tissues; that is, grades III–, III, and III+. The
Maitland’s grades of movement further broken down anchoring hand stabilizes the joint or muscle and the explora-
into plus (+) or minus (−) in relation to resistance. The tory hand mobilizes the fascia, starting with a grade III– tech-
line A to B represents normal ROM. In this example, nique and then progressing to a grade III and finally a grade
R2 is about 80 percent of full ROM
III+. The aim of the technique is to increase the NZ (neutral
zone) between the two hands, working at the point where
R1 is first perceived and gradually “pushing” R2 toward its
For example, a grade IV− moves into less resistance than
normal limit (i.e., B on the movement diagram), where the
a grade IV, and a grade IV+ is into more resistance than a
therapist no longer feels an increase in tension at the anchor at
grade IV. Similarly, a grade III− moves into less resistance
C4. The release between the therapist’s two hands is generally
than a grade III, and a grade III+ is into more resistance
felt within 20–30 seconds (most probably a neurophysiologi-
than a grade III. Both grades IV+ and III+ push into R2. As
cal and/or hydration effect). Because of the quick response of
grades III and IV reach the same point in range, the only
the technique, during a single treatment session the therapist
difference between the two is their amplitude. A grade IV
can easily assess and treat several directions of restriction in
is therefore, not necessarily a progression of a grade III in
relation to one area of the body as well as several areas in a
treatment, in terms of where it is in the range. However, a
particular fascial line.
grade III is a progression from a grade III− and a grade III+
is a progression from a grade III. Similarly, there is a pro-
gression from a grade IV− to a grade IV to a grade IV+. MMS treatment concepts
The definitions given are subjective and can definitely There are four treatment concepts to consider when using
vary from one therapist to the next. It has been difficult MMS techniques:
to use grades in research situations because our ability 1. Choose a recurrent articular dysfunction or muscle
to determine the difference between 75 percent and trigger point and explore a fascial line in relation to it.
80 percent of the resistance is very poor to non-existent.
2. Convert a joint mobilization into a fascial technique.
We have to recognize that these definitions are more
guidelines but may be of use during clinical reasoning as 3. Convert a nerve mobilization technique into a fascial
to the choice of treatment techniques (Maheu 2007). technique.
When using MMS techniques, if we take the example 4. Use the concept of “release with awareness.”
above of a recurrent C4 restriction in relation to the SFL,
it is normal to feel a certain resistance between C4 and the Choose a recurrent articular dysfunction
sternal tissues at the end of a caudal A/P pressure on the
or muscle trigger point and explore a
sternum. However, it is not normal to feel this at the very
start of the maneuver being performed by the exploratory
fascial line in relation to it
hand. Normally, if there is good mobility of a fascial line, This is the most common technique used with the
there should be a “toe region” where there is little to no MMS approach. The idea is for the therapist to anchor
53
Chapter 4
him/herself to a recurrent articular dysfunction (or muscle range and does not come back to the point where R1 is felt.
trigger point) and explore fascial lines of tension in rela- In other words, the therapist works progressively into R2,
tion to the anchor, looking for early tension between the and ends up performing a “grade 10” maneuver. It is dif-
therapist’s two hands. ficult to feel the sense of release if this point is not taken
into consideration; that is, the therapist must come out of
There are a few ways to release this fascial tissue. The the range where R1 is felt before repeating the oscillatory
patient’s response will always dictate the best approach to movement they have chosen (grade III–, III, or III+).
use with that particular patient.
• Work with sustained pressure – some bodies prefer
• The therapist may work with oscillations (start with a “listening” approach to treatment and do not nec-
grade III−, progressing to grade III and then grade essarily respond well to oscillatory treatments. This
III+). The oscillations are continued until there is a is particularly true with patients whose tissues are
sense of softening felt in the hands of the therapist. in the subacute stage of healing or those with a sen-
The patient often perceives this softening as “the ther- sitized nervous system. The concept behind using
apist is not pushing so hard with the stabilizing hand” a listening approach is to load the fascial tissues be-
when, in reality, it is the neurophysiological and/or tween the anchoring hand and the exploratory hand
hydration reaction in the tissues that gives the thera- (establish the first resistance in the line of tension),
pist and the patient a sense of “release.” The therapist and then wait to see what the body wants to do with
will also feel an increase in the “toe region” between this tension. The therapist may feel the tension in-
their two hands; that is, much less resistance. crease between the hands, with the body adding small
When the therapist is able to perform a grade III+ mobi- micro-adjustments in multiple directions. The sen-
lization with the exploratory hand and no longer feels an sation is similar to that of twisted elastic that is at-
increase in tension in the stabilizing hand, then the rest tempting to unwind itself. The therapist follows this
of the fascial line may be assessed and treated in a simi- unwinding, preventing the tissues from going back to
lar way. For example, once the A/P mobilization at C4 has the direction from which they came. The tension tends
been released in relation to the sternal tissues of the SFL, to build up gradually and then suddenly release, with
the therapist may then explore and release the fascia over a fluid-like feel, often accompanied by a therapeutic
the rectus abdominis area and then the fascia over the pulse. Working in this way, it is rare for the patient to
symphysis pubis area. In this way the upper quadrant por- experience much treatment soreness as the therapist is
tion of the SFL may be explored and treated. not being directive and is following what the body will
allow at that present time.
When working with oscillations, it is important to
• Work with “harmonics.” Dr Laurie Hartman, an
remember to come out of the range where initial resistance
osteopath from the UK, has demonstrated the har-
is felt (R1) as the oscillations are repeated.
monic technique in his courses on joint manipula-
From a teaching perspective there are two common tion and describes it in his Handbook of Osteopathic
errors that are noted when using this oscillatory technique. Techniques (Hartman 1997). Harmonic technique is
The first is that throughout this technique the stabilizing a technique where a passive oscillatory movement is
hand that is anchoring a joint or trigger point should not performed to a joint or tissue. In this technique, the
move. The oscillations are performed by the mobilizing recoil of the tissues does the major part of the work
hand that is exploring a fascial line in relation to the stable and the therapist is only a catalyst to the maneuver.
anchor. For example, the therapist may induce internal rota-
tion of the thigh and allow external rotation to take
The second common error that may occur is that the place. The technique is done at a frequency of about
therapist continues the oscillations progressively into the one cycle per second, a frequency that facilitates
54
the neurophysiological effects of treatment and Use the concept of “release with
promotes release. Certain fascial techniques lend awareness”
themselves well to this approach (see Chapter 9, tho-
racolumbar fascia, for an example using harmonic Release with awareness (RWA) is a biofeedback technique
technique). developed by Diane Lee and L. J. Lee in which the patient
is an active participant (Lee & Lee 2011). This technique is
Convert a joint mobilization into a fascial used to dampen down tone in the neural system and may
also be progressed into full stretch, thereby affecting any
technique
adhesions in the fascial system. The patient is asked to bring
Any joint mobilization technique that the therapist uses their awareness to the muscle being palpated and to respond
may be converted into a fascial technique simply by to various imagery cues to facilitate relaxation of the muscle.
repeating the mobilization with a change in position This involvement of the patient takes place as the therapist
of the body, so to increase tension in a particular fascial guides the release with feedback from their hands.
line. For example, an A/P mobilization of the talocrural
joint, which is commonly performed to improve ankle For an example of how this process of biofeedback
dorsiflexion, may be converted into a fascial technique by works, we will consider the case where ankle dorsiflex-
repeating the same mobilization with the patient in a long ion is decreased and there is a neuromuscular vector in
sitting position, which will increase tension to the SBL of the medial gastrocnemius muscle that is preventing the
fascia (see Chapter 11). This approach is particularly useful talus from rocking posteriorly to allow full dorsiflexion to
if a plateau is reached with common physiotherapy joint occur (see Chapter 11). The therapist performs an acces-
mobilizations. sory movement of an A/P rock to the talus with one hand,
and maintains it at the point where initial resistance to the
movement is felt. At the same time, the therapist palpates
Convert a nerve mobilization technique
and monitors the area of the gastrocnemius muscle that has
into a fascial technique most connection with the restricted A/P rock of the talus;
The concept of neurodynamics and its importance as that is, an area where a gentle pressure and stretch of the
a contributor to pain mechanisms has been researched medial gastrocnemius has an almost immediate impact on
extensively (Butler 1991; Shacklock 2005). A positive neu- the accessory movement at the talus, giving the therapist
rodynamic test may result from a decrease in mobility of the sensation that the talus is being pushed anteriorly. As
the actual nerve itself and/or may be due to problems with the therapist provides manual input to the gastrocnemius,
mobility of the myofascial tissues that interface with the the patient is instructed to “soften the muscle, let it go, see
nerve. Any nerve mobilization technique that the thera- if you can find a way to allow my fingers to sink into the
pist uses may be converted into a fascial technique simply muscle.” At the same time, the therapist moves the joint or
by adding a stabilizing maneuver in the area of the nerve muscle to shorten origin and insertion, diminishing ten-
mobilization and repeating the nerve mobilization tech- sion on the muscle spindle. The therapist then waits, allow-
nique (see Femoral nerve fascial technique in Chapter 9). ing the patient and his/her system to cue into the release
The therapist may also like to explore a little more broadly as the therapist gives manual and verbal cues to let go.
than the usual interfaces of the nerves. For example, the Once maximum release is obtained, usually within 10–15
therapist may use a mobilizing technique in the anterior seconds, the muscle is gently taken through a full stretch,
cervical spine with the arm in abduction, external rotation, with the therapist listening to its response and avoiding
wrist and finger extension to pre-tense the median nerve recurrence of overactivity. A full A/P rocking movement
and then explore the SFL of the trunk (see Chapter 5 for is encouraged, using a sustained movement at the ankle.
MMS technique). At the same time, the therapist may encourage a release of
55
Chapter 4
the muscle fascicle in a cranial direction, helping to release In most systems of myofascial manipulation, the dura-
the “fuzz” of connective tissue that has lost its ability to tion of an individual “stroke” or technique on a particular
elongate. Once released, the therapist may seek and explore spot of tissue is between a few seconds and 1.5 minutes.
other areas of the calf that may be limiting this accessory Rarely is a practitioner seen – or is it taught – to apply
movement. I have found this technique to be very useful uninterrupted manual pressure for more than 2 minutes.
clinically. Involving the patient in the release seems to cre- Studies on the subject of time and force dependency of
ate a more long-lasting effect, and carry-over from one connective tissue plasticity (in terms of creep and stress
treatment to the next is excellent (Lee & Lee 2011). relaxation) have shown that either much longer amounts
of time or significantly more force are required for per-
Effects of manual therapy for the fascia manent deformation of dense connective tissues (Currier
(MMS) & Nelson 1992). Additional models are needed to explain
What can we learn from research evidence pertaining to short-term plasticity. (Schleip 2003)
release techniques for the fascia? There are a number of
hypotheses and theories as to why therapists feel a sense of The thixotrophic model suggests that connective tissue
“release” when using any type of fascial technique. Poten- can change from gel to fluid with heat or mechanical input.
tial explanations include: This model suggests that these changes take place primar-
ily in the ground substance of the fascia (Myers 2014).
• freeing the fascial envelope which then helps to de-
crease muscle tension The piezoelectric model suggests that fascia is organized
• lengthening collagen fibers, breaking adhesions be- like a cross-hatched electrical grid that conducts pulses all
tween the collagen fibers, elastin fibers and between the over the body. Collagen in fascia is a semi-crystalline struc-
different layers of the fasciae, thereby changing fibrosis ture, which gives it electrical properties (crystals are piezoe-
lectric, able to generate tiny electrical currents when an object
• draining necrotic cell debris and toxins accumulated is deformed by therapy and/or movement) (Keown 2014).
as a result of tissue degradation This model suggests that manual therapies directed towards
• releasing trigger points the fascia have a direct effect on function of cells by issuing
electrical impulses. Manual pressure generates electrical cur-
• causing a change in sol/gel chemistry of the ground rent that stimulates fibroblasts and fibroclasts. This hypoth-
substance esis may explain effects on the collagen in fascia (Myers 2014).
• improving hydration
Hydration model: Jean-Claude’s Guimberteau’s seminal
• affecting neuromodulation via integrins/mechano- work on living fascia points to its chaotic fibrillar arrange-
transduction ment, with its varying polygonal shapes of a microvacuolar
sliding system, filled with fluid and proteoglycans. His videos
• affecting a shift in energy between the patient and the
depicting living fascia in vitro clearly show how hydrated this
therapist.
tissue truly is and how it constantly changes shape as fibrils
The mechanical model suggests that the practitioner is slide over one another with movement. This may also explain
altering the density, viscosity or arrangement of the col- the fluid release felt in the hands of the therapist when using
lagen in the fascia through the application of manual pres- techniques that work the fascial system. We may be essen-
sure (Paoletti 2006). tially opening up the microtubules and allowing the tissues to
become more hydrated (Guimberteau 2015).
Robert Schleip is a leader of the Fascia Research Group
at the University of Ulm, Germany. In relation to the pos- Neuromodulation model: slow adapting plasticity makes
sibility of fascial techniques affecting the collagen in the sense in order to adjust to patterns of long-term use, but
fascia, he states: we need another explanation for the rapid change we see in
56
treatment. Perhaps the main effect of our treatments to the to the tissues tend to rebound back a little from one treat-
fascial system occurs via neuromodulation. We may effec- ment to the next, but much less than with traditional man-
tively be changing sensory input into the nervous system to ual therapy. Techniques may need to be repeated for a few
change motor output, bringing awareness to the patient about sessions in order to get optimal release, especially if the
his/her tissues. Schleip’s article on fascial plasticity describes problem is long-standing and there are a few “layers of the
the nervous system as a “wet tropical jungle” – much more onion” to work through. However, follow-up with exercises
than the traditional “switchboard system.” He views the nerv- to maintain fascial mobility (see Chapter 14) and to re-edu-
ous system as primarily a liquid system in which fluid dynam- cate motor control help to maintain effects of treatment.
ics play a major role (Schleip 2003). This model suggests that
only the patient can make a difference in their brain map, and Re-assessing functional tests for mobility
the therapist is there to simply act as a coach. and dynamic stability
Some might argue that, instead of identifying and treating Once a fascial line has been released, the therapist should
biomechanical abnormalities with the intent of modulating re-evaluate the effect of this treatment on mobility tests
pain, manual therapy should be used as a vehicle to engage the and dynamic stability tests. This re-assessment of mobility
nervous system in order to modulate pain-related movement. tests could involve the following:
Manual therapies such as mobilization, manipulation, mas-
sage, trigger point release, etc. could be conceived as a physical • active range of motion (e.g., re-assessing side-flexion
modality, similar to thermal and electrical modalities. Their of the lumbar spine following a release of the lateral
role then is not to “fix” the underlying tissue dysfunction, but line of fascia)
rather modulate pain to enable more successful participation • joint mobility (using an accessory movement or a
in exercise and activities (Orthopaedic Division Review). passive physiological movement (e.g., re-assessing pas-
sive wrist extension once the SFAL has been released)
Because the fascia is highly innervated (see Chapter 1), it
may be one of the most potent ways in which therapists can • muscle flexibility (e.g., re-assessing flexibility of hip
modulate the nervous system. flexors once the DFL of fascia has been released).
In the field of fascia research, there is one consensus Dynamic stability tests, such as a OLS (one leg stand)
emerging from several studies, namely the concept that the test or a half squat are also re-assessed. The test used should
collagen in the fascia is actually NOT stretching. Robert relate to a functional problem that the client is complain-
Schleip sums it up nicely: “After years of research into the ing of. For example, a half squat test can be used for those
effects of manual therapies for the fascia,we must let go of who complain of difficulty with sitting. A OLS test can be
concept that we are stretching collagen. What we experi- used for a problem with standing or walking. A common
ence as ‘fascial plasticity’ during our Rolfing strokes is in clinical finding is to find areas of fascial tightness in the
fact due to the plasticity of the neuromuscular system.” region of the “instability,” in particular dynamic instabil-
ity, where non-optimal patterns of movement tend to occur.
MMS in relation to the overall treatment Dynamic stability is usually achieved with optimal motor
approach control, but recruiting muscles that help motor control is
often a frustrating experience for both the therapist and
Patient responses to treatment
the client if there is some fascial tightness in the area. Fascial
Generally speaking, when the MMS approach is used to tension is a factor that inhibits stabilizer muscles from kicking
release fascia, there is very little treatment soreness. This in. When tight fascia is released, there is often improvement
benefit contrasts with some mobilization or manipulation in dynamic stability tests – sometimes partially improved,
techniques, where treatment soreness occurs more fre- sometimes completely. If the dynamic stability tests are com-
quently. Like any other soft tissue technique, the changes pletely improved (i.e., negative), it is not necessary to assess the
57
Chapter 4
stabilizer system. The patient can move directly towards func- • M: move. Use the principles of neuroplasticity to re-
tional and sport-specific training. If dynamic stability tests wire (re-set) brain maps and create more efficient
are still positive, then further tests are needed to see which strategies for function and performance in ways that
strategies for motor control are best for the specific mean- have meaning to goals (Lee & Lee 2011).
ingful task required. This process may also include finding
the drivers that are maintaining the non-optimal strategy for The MMS approach to treatment is one of many tech-
movement (Lee & Lee 2011). niques that may be used to remove barriers to achieving
optimal alignment and movement strategies. (Other tech-
Using IMS or dry needling to release any hypertonic niques may include joint mobilizations and/or manipu-
muscles that may remain (see Chapter 1, section on trig- lation, muscle energy, proprioceptive neuromuscular
ger points as a fascia-related disorder, for the explanation facilitation (PNF), etc.). Because fascia innervation is so
about how these two approaches interact). Clinical experi- widespread, the MMS approach has a powerful neurophys-
ence has shown that myofascial trigger points and fascial iological effect that allows the therapist an open window to
dysfunction frequently coexist. Using MMS techniques re-pattern the brain map. Once the fascial tension related
first in order to release the fascia enables the therapist to to the suboptimal strategy for movement has been released,
treat fewer trigger points with IMS or dry needling. it is much easier to align, connect, and move.
Follow up with an active approach It is strongly recommended to follow up MMS approach

to treatment with movement therapies that can optimally
The clinical reasoning framework for treatment prescrip-
integrate the changes in the patient’s body:
tion according to the Integrated Systems Model (Diane Lee
and L. J. Lee) contains the acronym RACM (release, align, • exercise to maintain flexibility of fascial line
connect/control, move). Every treatment session has com- • ball release
ponents of the following:
• stretch with awareness
• R: release. This applies to cognitive, emotional, so-
cial, and physical barriers. A variety of techniques • yoga therapy
may be used to release overactive muscles and ad- • using tools to enhance fascial mobility.
hesions (myofascial, articular, neural and visceral
impairments). The technique chosen depends on Chapter 14 has more information on this topic.
vector analysis. Release can be a joint mobilization or
manipulation, a visceral technique or an MMS tech- Summary
nique, depending on the findings of the vector analy-
This chapter has described the guidelines and concepts
sis. It may also simply be a verbal cue (“let go of your
used for treatment using MMS techniques. It has also
hyoid,” “lift your sternum,” “create some space”).
defined how this approach may be used in the context of
• A: align: cues/corrections to align the body both within the overall treatment strategy that many physiotherapists
and between regions. Teaching the patient to find their use to manage musculoskeletal conditions. Finally, a brief
neutral spine is also included in this section. summary, based on current research in the field of fascia,
• C: connect/control: cues for activation and co- offers explanation of the possible ways in which fascial
ordination of the deep and superficial muscle sys- techniques may affect the body. The following Chapters, 5
tems. This phase involves extensive use of imagery to through 13, are descriptions of MMS techniques that may
rewire brain pathways and maps. be used in the various regions of the body.
58
Section 2
MMS techniques for fascia
The cervical spine 61
The craniofacial region (cranium, temporomandibular joint) 83
Dural mobility 103
The thorax 121
The lumbar/pelvic region 135
The pelvic floor 151
The lower extremity 167
The shoulder girdle 195
The upper extremity 211

The cervical spine
5
When treating patients with problems in the cervical −− mobilization/manipulation of the cervical spine
spine, manual therapists are trained to assess and treat and thorax
joints that are prone to limitations with a forward head −− stabilization exercises for the cervical spine
posture. In particular, common findings in cases of joint −− release of trigger points to the cervical muscles with
restriction include a lack of flexion between the occiput manual or dry needling techniques.
and C1, a lack of extension in the C/Thx region and the
mid-cervical area exhibiting limitations in both flexion 2. Tension in the anterior cervical spine/throat area.
and extension of the zygapophysial joints. Anterior pal- Postural analysis
pation of the cervical spine (Maitland’s A/P mobiliza-
tions) are also commonly used to mobilize periarticular Ideally, in the sagittal plane, a vertical line should pass
tissue in the anterior aspect of the neck, which has been through the external auditory meatus and the bodies of
found to be useful in improving mobility of the cervi- the cervical vertebrae. If a plumb line were to be dropped
cal spine as well as treating interfaces for problems with from the chin, it should contact the sternum. Postural
decreased mobility of the nervous system. analysis may be used as a guideline to explore particular
fascial lines. For example, restriction of the Superficial
In addition, the muscles of the upper quadrant are (SFL) or Deep Front Line (DFL) of fascia may maintain a
assessed and treated for imbalance between hypertonic, forward head posture. This tension can develop as a result
tight muscles and weak muscles. However, mobilizing of trauma, including surgical scars to the abdominal area.
joints and stretching and strengthening individual muscles As well, certain activities of daily living, such as excessive
can achieve only partial benefits if the fascial system is not time spent in a sitting position for work or leisure activi-
taken into consideration. ties, can be a factor in creating these fascial lines of tension.
This chapter will describe techniques to release the fol- If there is restriction in the Lateral Line of fascia, this
lowing fascial dysfunctions: may create a lateral tilt or side shift of the thorax, the cervi-
cal spine, the lumbar spine or the pelvis, and contribute to
1. Craniovertebral area (occiput, C1, C2) in relation to
recurring issues with these areas.
the SBL and SFL.
If there is restriction of the Spiral Line of fascia, it may
2. Mid-cervical spine (C2–6) in relation to the SFL, the
also contribute to a lateral tilt or side shift of the thorax
DFL, the glenohumeral (GH) joint, the scapula, the
or the cervical spine, as well as unilateral tension in the
Lateral Line, the Spiral Line and the neural tissues of
abdominal oblique muscles. It may also impact the posi-
the upper extremity.
tion of the scapula and therefore, the function of the shoul-
3. Cervicothoracic area (C7–T2) in relation to the der complex. Postural analysis should be re-assessed after
Lateral Line and the DFL. using MMS techniques in order to evaluate their impact on
global posture.
4. The upper fibers of trapezius (UFT) in relation to the
SBAL and the SFL. Positional tests
Indications for MMS for this chapter The therapist takes note of the position of the cervical
spine in relation to the patient’s meaningful task (sitting
1. Recurring neck pain despite the following treatment or standing). The occiput should sit squarely on top of C1,
approaches: with no side-flexion or rotation – the position of the ears
61
Chapter 5
may be used to determine the relative alignment. There assess the strategy to stabilize the thoracic spine and the
should be no global deviation in relation to the thorax or scapula (Lee 2003). This test should be assessed before
shoulder girdle. Intersegmental palpation of the cervical and after using MMS techniques, as fascial restrictions
spine should not reveal any lateral shifts (usually associated may inhibit the dynamic neck stabilizers from working
with contralateral rotation in the mid-cervical spine). Any optimally. If the test is still positive after releasing tight
shifts and deviations may be due to restriction of a particu- fascia in relation to the cervical spine, then the therapist
lar segment (either articular or myofascial) or due to a lack should assess and treat the stabilizer function of the cervi-
of dynamic control of that region. Positional tests should cal muscles.
be assessed before and after using MMS techniques.
Concepts of treatment using MMS
Active range of motion tests For this chapter, we will be using primarily the first concept
Cervical movement testing should be performed before of treatment when using MMS techniques; that is, choose a
and after MMS techniques, in order to evaluate the impact recurrent articular dysfunction or myofascial trigger point
of the techniques on ROM. These movements include cer- and explore a fascial line in relation to it. The therapist
vical flexion, extension, rotation and side-bending as well anchors him/herself to a recurrent articular dysfunction
as craniovertebral flexion, extension and cervicothoracic or myofascial trigger point and assesses the fascial lines of
flexion and extension. The therapist evaluates the quality tension in relation to the anchor, looking for early tension
and quantity of movement as well as reproduction of any between their two hands.
symptoms. The emphasis should be on movements that
most correspond to the patient’s functional problem(s). The following approaches may be used, depending on
how the tissues respond:
Functional tests • work with oscillations (grades III−, III, III+)
Sitting arm lift (SAL). This test is a variation of the prone
• work with sustained pressure
arm lift test, developed by Linda-Joy Lee as a test for eval-
uating dynamic stability of the thorax and cervical spine • work with “harmonics” (Laurie Hartman).
(Lee 2003). It evolved from the active straight leg raise Please refer to Chapter 4 for further detail on concepts of
test (ASLR) (Mens et al. 1999, 2001). The sitting patient is treatment using MMS.
asked to flex their arm from a neutral position to approxi-
mately 90 degrees of flexion and to note any difference in The following techniques are suggested for addressing
effort required to lift the right or left arm. (Does one arm fascial restrictions in the cervical spine.
seem heavier or harder to lift?) The strategy used to sta-
bilize the cervical spine during this task is observed. The MMS techniques: craniovertebral region in
cervical spine should not laterally shift or rotate during relation to the Superficial Back Line of
this task. It is important to observe what happens to the fascia (SBL)
cervical spine during the moment that the arm begins to Tom Myers’s description of the Superficial Back Line of
lift and not simply at the end of the required shoulder flex- fascia involves the scalp fascia, the occipital ridge, the erec-
ion. If there is movement in the cervical spine during this tor spinae muscles, the lumbosacral fascia, the posterior
task, the therapist corrects the cervical segment passively aspect of the sacrum, the sacrotuberous ligament, ham-
towards the midline (e.g., if a segment laterally shifts to the string muscles, gastrocnemius/Achilles tendon, plantar
right, the therapist corrects the segment by gently shifting fascia and short toe flexors. (Refer to Chapter 2 for a full
it towards the midline (left) and de-rotates the segment description and illustration of this line of fascia.) These
towards neutral). The SAL is repeated and any change in fascial connections become very apparent when working
effort and/or pain is noted. This test may also be used to with the MMS techniques described in this chapter.
62
The cervical spine
Techniques for the SBL are described below: cesses or facet joint area). If no tension is perceived, then
the SBL of fascia in relation to this region is not tight. If
MMS central occiput with the cervicothoracic this fascial line is tight, the therapist will feel an increase
region (SBL) (Figure 5.1) in tension in the anchoring hand, as if the suboccipital tis-
sues were being pulled caudally. The patient perceives this
as the therapist increasing his/her pressure on the occipi-
tal region. If tension is perceived (quick resistance is felt
between the two hands of the therapist), then it can be
mobilized as per the approaches outlined in Chapter 4.
MMS right occiput with the cervicothoracic region

(SBL) (Figure 5.2)
Figure 5.1
MMS central occipitalis with the C/Thx region
Stabilizing hand The patient is in a prone position. The

therapist anchors onto the central suboccipital region with
the one hand (third finger of the hand at the most central
point) and pulls it gently in a cranial direction, maintain- Figure 5.2
ing the tension on this region. MMS right occipitalis with the C/Thx region
Mobilizing hand The therapist then explores the area of

the C/Thx spinous processes or facet joints, first by slowly Stabilizing hand The therapist anchors onto the right
sinking into the tissues of the C/Thx region in a postero- suboccipital region with the one hand and pulls it gently in
anterior direction and then gently pushing in a caudal a cranial direction.
direction, all the while maintaining the depth of the fas- Mobilizing hand As per the technique above. Both the
cial line. The therapist looks for the angle where he/she left and the right occipital region may be explored in a
perceives immediate tension in the hand palpating the similar fashion.
occiput. The tension between the two hands of the thera-
pist may be felt most with the mobilizing hand performing Note that the craniovertebral region can also be explored
A/P pressures in a simple caudal direction, or caudal to the down the spine and into the sacrum. This area is also part of
right of the patient or caudal to the left. This technique can the SBL and, depending on the depth of the technique, may
be explored anywhere from C7 to the T4 level (spinous pro- also be a way to mobilize the posterior dura (see Chapter 7).
63
Chapter 5
MMS techniques: craniovertebral region in Stabilizing hand The patient lies in a supine position. The
relation to the Superficial Front Line (SFL) therapist anchors onto the right suboccipital region and/or
of fascia the occipitalis muscle (an area about 3 cm square) with the
right hand and pulls it gently in a cranial direction, main-
The occipital region is frequently tight in relation to the SFL taining the tension on this region.
as well. This line involves the scalp fascia, sternocleidomas-
toid (SCM), sternochondral fascia, rectus abdominis to the Mobilizing hand The therapist uses their left hand to
symphysis pubis. It then begins again at the origin of the rec- explore the tissues of the contralateral mid-cervical spine,
tus femoris and includes the quadriceps muscles, the patellar using A/P pressures (Maitland technique) from C1 to C6
tendon, the short and long toe extensors, tibialis anterior, and on the left side. The therapist looks for the angle where he/
the anterior crural compartment. Although we may think she perceives immediate tension in the hand that is stabi-
of the occipital region as a posterior structure and part of lizing the occiput. The tension between the two hands of
the SBL of fascia, Tom Myers describes a fascial connection the therapist may be felt most with the mobilizing hand
between both SCM muscles that extends towards the back of performing A/P pressures in a simple caudal direction,
the occiput like a sling (refer to Chapter 2 for illustrations and or caudal to the right of the client or caudal to the left. If
a full description of this line of fascia). This sling of fascia is this fascial line is tight, the therapist will feel an increase
what connects the occipital region to the SFL of fascia. in tension in the anchoring hand, as if the tissues of the
right occipitalis were being pulled caudally. The patient
The techniques for this line are described below. perceives this as the therapist increasing his/her pressure
Although the techniques described here are for the right on the occipitalis. If tension is perceived (quick resistance
side of the craniovertebral region, they may also be per- is felt between the two hands of the therapist) then it can
formed on the left side. be mobilized as per the approaches outlined in Chapter 4.
MMS right occipitalis with A/P pressures of the MMS right occipitalis with A/P pressures of the
contralateral Cx (Figure 5.3) ipsilateral cervical spine (Figure 5.4)
Stabilizing hand As per the technique above except

that the therapist uses their left hand to anchor the right
occipitalis.
Mobilizing hand As per the technique above except that
the therapist uses their right hand to explore the tissues of
the ipsilateral mid-Cx spine with A/P pressures.
The SFL also includes the pectoral region, which contrib-
utes to the “turtle” position in forward head posture, where
the shoulder girdle area is held anteriorly. Mobilizing the
fascia of the occipital region in relation to the shoulder gir-
dle is often helpful to re-establishing a more optimal pos-
ture. It can be mobilized as follows:
Figure 5.3
MMS right occipitalis with A/P pressures of the
contralateral Cx
64
The cervical spine
Figure 5.6
MMS occipitalis with anteroposterior-caudal “glides” of
the shoulder region – contralateral
Figure 5.4 Stabilizing hand For this technique, the therapist’s right
MMS right occipitalis with A/P pressures of the hand uses the same anchor on the right occipitalis region,
ipsilateral Cx as described above.
Mobilizing hand The therapist’s left hand explores the
shoulder and shoulder girdle area with an “anteroposterior
MMS right occipitalis with anteroposterior caudal caudal glide” of the tissues in the area of the lateral clavicle
glides of the shoulder region – ipsilateral or and/or the GH joint, using the “star concept” to find the
contralateral (SFL) (Figures 5.5, 5.6) direction of most tension between their two hands. Some-
times tension is felt most with a posterior tilt or lateral
“glide” of the scapula. Both the ipsilateral and contralateral
shoulder girdle may be explored in this fashion. If this fas-
cial line is tight, the therapist will feel an increase in ten-
sion in the anchoring hand, as if the occipitalis moves cau-
dally. The patient perceives this as the therapist increasing
his/her pressure on the occiput. If no tension is perceived,
then the SFL of fascia in relation to this region is not tight.
If tension is perceived (quick resistance is felt between the
two hands of the therapist) then it can be mobilized as per
the approaches outlined in Chapter 4. The therapist main-
tains the anchor on the occiput to prevent it from moving
as he / she performs repeated A/P mobilizations of the ipsi-
lateral or the contralateral shoulder area.)
NB This technique may be progressed by exploring the
Figure 5.5 occipitalis in relation to the rest of the SFL of fascia; that is,
MMS occipitalis with anteroposterior-caudal “glides” of the sternal region, the rectus abdominis and the symphysis
the shoulder region – ipsilateral
pubis (described below in relation to the mid-cervical spine).
65
Chapter 5
MMS techniques: mid-cervical region in the tissue. If this fascial line is tight, the therapist will
relation to the Superficial Front Line (SFL) feel an immediate increase in tension in the anchor-
ing hand, as if the mid-Cx region translates anteriorly
Techniques for this line are described below. Although and caudally. The patient perceives this as the therapist
described for the right side of the mid-cervical spine, they increasing his/her pressure on the anterior Cx spine. If
may also be performed on the left side: no tension is perceived, then the SBL of fascia in relation
to this region is not tight. If tension is perceived (quick
MMS A/P pressures of the right mid-Cx in relation to resistance is felt between the two hands of the therapist)
the sternum (SFL) (Figure 5.7) then it can be mobilized as per the approaches outlined
in Chapter 4. (The therapist maintains the A/P pressure
to prevent the segment from moving as he/she performs
repeated A/P mobilizations of the manubrial/sternal
area in the direction(s) of most restriction.)
MMS A/P pressures of the right mid-Cx in relation to

the rectus abdominis (SFL) (Figure 5.8)
Figure 5.7
MMS A/P pressures of the mid-Cx with the sternum (SFL)
Stabilizing hand The patient is in a supine position. The

therapist’s right hand anchors to an area of the anterior
mid-cervical spine that is chronically stiff (often C4), using
an A/P mobilization in a cranial direction (grade IV−).
Figure 5.8
Mobilizing hand The therapist’s left hand explores MMS A/P pressures of the mid-Cx with the rectus
the manubrial and sternal area with an anteroposterior abdominis (SFL)
caudal glide of the tissues, making sure that the touch
is light and stays in the plane of the SFL. The therapist
looks for the angle where he/she perceives immedi-
Stabilizing hand As per the technique above.
ate tension in the hand anchoring the anterior cervical
spine. That tension may be felt most when the mobiliz- Mobilizing hand As per the technique above except that
ing hand moves the fascia in a simple caudal direction, the therapist explores the rectus abdominis (ipsilateral
or caudal to the right of the client, or caudal to the left. and contralateral) caudally towards its insertion at the
Sometimes the tension is most felt when moving the symphysis pubis. If tension is perceived (quick resistance
sternal tissues mediolaterally or in a clockwise/counter- is felt between the two hands of the therapist) then it can
clockwise direction, always maintaining the depth of be mobilized as per the approaches outlined in Chapter 4.
66
The cervical spine

the symphysis pubis (SFL) (Figure 5.9)
Figure 5.10
MMS A/P pressures of the mid-Cx with anteropos‑
Figure 5.9 terior-caudal “glides” of the shoulder region –
MMS A/P pressures of the mid-Cx with the symphysis ipsilateral (SFL)
pubis (SFL)

the therapist explores the area of the symphysis pubis
(right, left, and center).
MMS A/P pressures of the right mid-Cx with

anteroposterior caudal glides of the shoulder
region – ipsilateral or contralateral (SFL) (Figures
5.10, 5.11)
This is a similar technique to that described in relation to Figure 5.11

the occipital region except that the anchor is at the mid- MMS A/P pressures of the mid-Cx with anteropos‑
cervical spine. terior-caudal “glides” of the shoulder region –
contralateral (SFL)
Mobilizing hand The therapist’s left hand explores the region translates anteriorly and caudally. The patient per-
shoulder and shoulder girdle area with an anteroposterior ceives this as the therapist increasing his/her pressure on
caudal glide of the tissues in the area of the lateral clavi- the anterior cervical spine. Similar concepts for mobilizing
cle and/or the GH joint, always looking for the immediate this line of fascia apply as per previous techniques.
line of tension between the therapist’s two hands as a gen-
tle pressure of the caudal hand is performed. Sometimes
MMS techniques: Cx in relation to the
tension is felt most with a posterior tilt of the scapula. If
Deep Front Line of fascia (DFL)
this fascial line is tight, the therapist will feel an immediate Tom Myers’s description of the Deep Front Line of fascia
increase in tension in the anchoring hand, as if the mid-Cx involves the temporomandibular joint (TMJ) muscles,
67
Chapter 5
the longus colli and capitis, infrahyoid and suprahyoid Stabilizing hand As per the techniques for the Cx in rela-
muscles, the cranium and facial bones, as well as the tion to the SFL, using a grade IV− A/P mobilization in a
pericardium, anterior diaphragm, posterior diaphragm, cranial direction.
central tendon of the diaphragm, psoas, iliacus, pelvic
Mobilizing hand Using the left hand, the therapist explores
floor fascia, anterior sacral fascia, adductor magnus,
the area of the pericardium, first by slowly sinking into the
adductor brevis, adductor longus, popliteus, and finally
tissues posterior to the sternum and then, gently moving in
the tibialis posterior and the long toe flexors. A number
a caudal direction, all the while maintaining the depth of the
of the fascial techniques to evaluate and treat tension of
fascial line posterior to the sternum. The therapist looks for
the DFL make particular use of combined dorsiflexion/
the angle where he/she perceives immediate tension in the
eversion of the ankle, thereby increasing tension of the
hand anchoring the mid-cervical spine with an A/P pres-
distal aspect of the DFL. Deep inspiration may also be
sure. That tension may be felt most in the pericardial area in
used, which involves the diaphragm. These fascial con-
a simple caudal direction, or caudal to the right of the client
nections become very apparent when working with the
or caudal to the left. Sometimes the tension is most felt when
MMS techniques described below. (Refer to Chapter
moving the pericardial tissues mediolaterally or in a clock-
2 for illustrations and a full description of this line of
wise/counterclockwise direction, always maintaining the
fascia.)
depth of the tissue. If no tension is perceived, then the DFL
Techniques for this line are described below. Although of fascia in relation to the anterior cervical spine is not tight.
the techniques described here are for the right mid-cervical If this fascial line is tight, the therapist will feel an increase in
spine, they may also be performed on the left side. tension in the anchoring hand, as if the mid-Cx region trans-
lates anteriorly and caudally. The patient perceives this as the
therapist increasing his/her pressure on the anterior cervical
spine. Similar concepts for mobilizing this line of fascia apply
the pericardium (DFL) (Figure 5.12)
as per previous techniques.
MMS A/P pressures of the right mid-Cx in relation

to the diaphragm (ipsilateral/contralateral) (DFL)
(Figures 5.13, 5.14)
Figure 5.12
MMS A/P pressures of the mid-Cx with the pericar-
dium (DFL)
Figure 5.13
MMS A/P pressures of the mid-Cx with the ipsilateral
diaphragm (DFL)
68
The cervical spine
Figure 5.15
MMS A/P pressures of the mid-Cx with knee flexion
Figure 5.14 (both SFL and DFL)
MMS A/P pressures of the mid-Cx with the contralat-
eral diaphragm (DFL)
MMS A/P pressures of the right mid-Cx with knee
flexion + shoulder flexion (both SFL and DFL)
(Figure 5.16)
anterior diaphragm area with a caudal/lateral glide of the
tissues, always looking for the immediate line of tension
between the two hands. Appropriate depth of tissues is
required. The fascia around the rectus abdominis and
oblique abdominal muscles may be accessed with this
technique if the technique is done superficially (this would
be a technique for the SFL). However, in order to access
the diaphragm which is part of the DFL, the therapist must
first slowly sink into the tissues posterior to the lower ribs
and then gently move in a caudal/lateral direction. This
technique may be done with either the ipsilateral or the Figure 5.16
contralateral diaphragm. MMS A/P pressures of the right mid-Cx with knee flex-
ion + shoulder flexion (both SFL and DFL)
MMS A/P pressures of the right mid-Cx with hips
extended, knees flexed (both SFL and DFL)
(Figure 5.15) The techniques above may be further progressed by adding
bilateral shoulder flexion.
All techniques in the section above may be further pro-
gressed by positioning the patient in supine, with the hips
extended and knees flexed, and the table adjusted in height
to ensure a comfortable position for the client’s low back.
This position puts additional tension on both the SFL and
the DFL of fascia.
69
Chapter 5
Another way to progress the techniques is to add a com-

MMS A/P pressures of the right mid-Cx with ankle bined movement of ankle dorsiflexion/eversion, thereby
dorsiflexion/eversion (DFL) (Figure 5.17) stretching the tibialis posterior muscle, the tail end of the
DFL of fascia. The patient is asked to actively dorsiflex and
evert both ankles, which increases the tension of the DFL
from below. If the line is very tight, simply adding active
dorsiflexion/eversion will immediately increase the ten-
sion in the mid-cervical area where the therapist is anchor-
ing with an A/P pressure, directed cranially. If this fascial
line is tight, the therapist will feel an increase in tension
in his/her hands, as if the tissues of the anterior cervical
spine were being dragged in an anterior and caudal direc-
tion. The therapist maintains the anchor of the mid Cx in
a postero/cranial direction and waits until a softening of
the system is perceived. The patient then releases the feet;
the therapist may feel that the A/P pressure “gives” a lit-
tle more in a postero/cranial direction. The slack of the
tissues is taken up by the therapist as the patient contin-
ues to actively dorsiflex/evert the ankles. This continues
until there is no further change perceived in the thera-
pist’s hands, and generally requires approximately five or
six cycles. This technique can be progressed further by
including the diaphragm, and asking the patient to take
deep breaths in and out. Finally, the techniques may be
progressed by asking the patient to maintain dorsiflexion/
eversion as the therapist explores the pericardium, dia-
phragm, etc. This approach applies to all the techniques
outlined in the above section.
Case report 5.1 Caroline’s story*
This 52-year-old patient consulted for complaints of

chronic, persistent right cervical pain, felt both anteriorly
and posteriorly. There was history of mild whiplash two
years prior to treatment, as well as a history of adhesive
capsulitis in her right shoulder four years ago, which was
treated with distension arthrography and physiotherapy
with 85 percent return of ROM. She wore orthotics in
her shoes and had previously been treated by a manual
therapist for the articular dysfunctions in both her feet.
She presently had no complaints of foot pain. X-rays
Figure 5.17 and magnetic resonance imaging (MRI) showed some
MMS A/P pressures of the mid-Cx with ankle DF/ mild degenerative changes in the mid-cervical spine.
eversion (DFL)
70
The cervical spine
Her neck was sensitive to her husband’s “abrupt driving * Please note that the patient’s name has been changed
habits” and this made the patient very nervous about to protect her privacy
her neck if she was a passenger in her husband’s car.
She had had previous treatment for her neck by another
physiotherapist, who had used cervical mobilizations, MMS techniques: mid-cervical region in
ROM exercises, and dry needling techniques, with only relation to the glenohumeral joint
partial relief of symptoms. On examination, it was noted Fascial restrictions between the mid-Cx spine and the GH
that there were some pain-sensitizing issues and yellow joint is a factor that must be considered in cases of persistent
flags, as she discussed her husband’s contribution to her “shoulder” restriction, cervical tension, and a loss of mobil-
symptoms. Keeping this in mind, we proceeded with ity of the neural system. Described below are a few common
the assessment of her condition and found slight articu- patterns of fascial restriction. Any movement of the GH
lar restrictions, with a lack of flexion at C4–5 and C5–6 joint may be used with these techniques. Shoulder abduc-
as well as stiffness reproducing local pain with A/P pres- tion, external rotation and flexion are demonstrated below.
sures at C4, C5, and C6 on the right side. The craniocervi-
cal flexion test (CCFT) was done to assess the action and
MMS A/P pressures of the right mid-Cx with passive
endurance of her deep neck stabilizers. Her score was
GH abduction (Figure 5.18)
low, being able to maintain only 22 mgHg pressure for
5 seconds. In addition there was a deficit in the cervical
proprioceptive function. Evaluation of the fascial system
revealed tension in the Superficial and Deep Front Lines
of fascia, with restrictions noted particularly between
the A/P pressures of C4–6 on the right with the sternum,
symphysis pubis and right anteroposterior caudal glides
of the shoulder region (SFL techniques) as well as the
pericardium and right anterior diaphragm (DFL tech-
niques). All of these issues were treated with the appro-
priate techniques and her pain decreased by 60 percent
from the initial treatment. After eight treatments she had
hit a plateau. By then, her CCFT testing was normal and
the deep extensors of the cervical spine also tested as
within normal limits. Cervical proprioception tests had
much improved and there was no longer any tension
with the fascial techniques above. Taking into consid-
eration her previous history of foot problems, I then
explored and treated the anterior cervical spine fascial
techniques with movement of her feet (dorsiflexion/
eversion), which pre-tenses the DFL. It was only after we
released this fascial line all the way down to her feet that
her chronic cervical symptoms resolved. We could then
surmise that her previous foot dysfunctions may have
contributed to tension in the DFL of fascia, affecting the
cervical spine. Perhaps her “back-seat driver” habits of
Figure 5.18
putting pressure on imaginary brakes increased tension
MMS A/P pressures of the mid-Cx with GH passive
in the cervical spine via the DFL! abduction
71
Chapter 5
Stabilizing hand The patient is in left side-lying position.

The therapist’s left hand anchors to an area of the anterior
mid-Cx spine that is chronically stiff (often C4) using an
A/P mobilization.
Mobilizing hand The therapist’s right hand supports
the uppermost upper extremity and performs a passive
physiological movement of the GH joint into abduction,
stopping as soon as an increase in tension is perceived
in the hand palpating the mid-cervical spine in an A/P
direction (to the first resistance or R1 of Maitland’s
movement diagram). If there is tension in this line of
fascia, it will seem like the mid-Cx region translates
anteriorly before full GH abduction can be achieved
(usually around 90–100 degrees of abduction). The ther-
apist maintains the A/P pressure and simply prevents
the segment from moving anteriorly. The patient per-
ceives this as the therapist increasing his/her pressure
on the cervical spine. The therapist performs repeated
passive physiological abduction of the shoulder while
maintaining a steady pressure on the cervical spine,
always to when R1 is perceived (a grade III− passive physio-
logical movement in Maitland terms). This movement is
Figure 5.19
repeated until a release is felt between the therapist’s two
MMS A/P pressures of the mid-Cx with GH passive ER
hands, progressing from a grade III− to a grade III and
finally a grade III+. It generally requires approximately
five to eight cycles.
glenohumeral flexion (Figure 5.20)
glenohumeral external rotation (Figure 5.19) Stabilizing hand As per the technique above except that
the therapist uses their right hand to stabilize the mid-Cx.
Mobilizing hand As per the technique above except that the therapist uses their left hand to perform a passive phys-
the therapist performs a passive physiological GH external iological GH flexion movement.
rotation movement.
72
The cervical spine
usual levels of C5 to C7.) As well, the nerve mobility test

itself was used as a treatment technique, both as a sliding
technique and a tensioning technique. A similar approach
was used for the radial nerve, the only difference being
that the arm was positioned in internal rotation and the
wrist and fingers were flexed. Three treatments later, she
reported that abduction movements were no longer
problematic but that when she reached forward into
flexion to get something from a cupboard, she could
still feel her arm symptoms. Previously positive tests and
techniques were negative, so I then proceeded to test the
mobility of the anterior cervical fascia in left side-lying
with passive physiological shoulder flexion (technique
above). Although she had very little tension in the mid-
Cx with passive shoulder abduction and external rotation,
45 degrees of shoulder flexion increased tension in the
anterior mid-Cx, as if the myofascial tissues in this direc-
tion were tethering the cervical spine anteriorly. We used
this MMS technique until she was able to obtain full shoul-
Figure 5.20 der flexion without subsequent pull on the mid-Cx and
MMS A/P pressures of the mid-Cx with GH passive successfully treated her remaining symptoms. Prior to this
flexion case, I had not explored the anterior cervical fascia with
shoulder flexion. This was a perfect case of “listen to the
patient. He/she will tell you what the problem is and how
Case report 5.2 Beverly’s story to treat it” (Maitland 1992; Vail IFOMPT Conference, Vail,
Colorado, 1992).
This 45-year-old patient had initially come for treatment

with complaints of tension in her right arm whenever MMS techniques: mid-cervical region in
she performed reaching movements requiring abduc- relation to the scapula
tion. Evaluation revealed positive neurodynamic tension Fascial restrictions are also common between the mid-
tests for the median and radial nerve on the right, with cervical spine and the scapula. A similar approach is
mobility issues at the interfaces of the mid-cervical spine, used but this time, the mid-Cx is assessed in relation
especially with lateral shears to the left and A/P mobiliza- to the scapular movements rather than shoulder move-
tions from C2 to C7. Treatment was directed to improving ments. Ideally, the therapist should not feel the mid-
the mobility of the median nerve (positioning the arm in Cx translate anteriorly before the scapula attains full
abduction, external rotation, elbow extension and wrist movement in any direction (particularly scapular eleva-
and finger extension) and then adding A/P mobilization, depression, retraction, and upward rotation). This
tions and lateral shear movements from C2 to C7. (Keep technique can be useful for cases of persistent scapular
in mind that fascia around the nerve extends beyond the dysfunctions despite exercise programs or in cases of
chronic cervical tension.
73
Chapter 5

scapular depression (Figure 5.21)
Figure 5.22
MMS A/P pressures of the mid-Cx with scapular elevation

Figure 5.21 scapular retraction (Figure 5.23)
MMS A/P pressures of the mid-Cx with scapular
depression
Stabilizing hand As per the technique above, in left

side-lying.
the therapist performs a passive physiological depression
of the scapula.

scapular elevation (Figure 5.22)

Mobilizing hand As per technique above except that the
therapist performs a passive physiological elevation of the
scapula.
Figure 5.23
MMS A/P pressures of the mid-Cx with scapular retraction
74
The cervical spine

the therapist performs a passive physiological retraction of
the scapula.
MMS techniques: mid-cervical region in

relation to the Lateral Line
Tom Myers’s description of the Lateral Line of fascia involves
the splenius capitis, the SCM, external and internal intercos-
tals, ribs, lateral abdominal obliques, iliac crest, anterior and
posterior superior iliac spines (ASIS and PSIS), gluteus maxi-
mus, tensor fasciae latae, iliotibial band (ITB), fibular head,
peroneal muscles, and the lateral crural compartment. (Refer
to Chapter 2 for illustrations and a full description of this line
of fascia.) The technique below may be considered in cases of
persistent tension/pain in the cervical or thoracic area.
MMS right lateral mid-Cx with lateral ribcage

(Figure 5.24)
Stabilizing hand The patient is in a left side-lying posi-

tion. Using the left hand, the therapist stabilizes the lateral
Figure 5.24
aspect of the cervical spine with a lateral to medial pres-
MMS: lateral mid-cervical spine with lateral ribcage
sure of the tissues (i.e., toward the plinth). This hand-hold
involves both the articular components as well as the lat-
Note that the directions of the mobilizing forearm follow the
eral cervical musculature, including the scalene muscles
diamond shape of the intercostal muscles. The ribcage may
and levator scapulae. In addition, the patient’s shoulder
be explored in this manner both in the lower thoracic region
may be flexed to increase tension on the latissimus dorsi
and in the middle thoracic region. This is a general technique
and its fasciae.
and not specific to a thoracic ring, although correcting a spe-
Mobilizing hand The therapist’s right forearm explores cific thoracic ring may also be done with this technique. The
the lateral ribcage/intercostal area, using the star concept. therapist looks for the angle and the area(s) on the ribcage
The therapist may explore moving the lateral ribcage in a where he/she perceives immediate tension in the hand pal-
number of possible directions: pating the mid-cervical spine (to the first resistance or R1 of
• in a caudal direction (toward the patient’s feet) Maitland’s movement diagram). If there is tension in this line
of fascia, it will seem like the mid-cervical region translates
• in a caudal-anterior direction (the therapist must laterally before full caudal glide of the thoracic ribcage can be
adjust their forearm to begin the maneuver slightly achieved. The therapist maintains the medial pressure of the
posterior to the lateral ribcage), and/or cervical spine and simply prevents the segment from moving
• in a caudal-posterior direction (the therapist must laterally. The patient perceives this as the therapist increasing
adjust their forearm to begin the maneuver slightly his/her pressure on the cervical spine. Similar concepts for
anterior to the lateral ribcage). mobilizing this line of fascia apply as per previous techniques.
75
Chapter 5
MMS techniques: mid-cervical region in Mobilizing hand The therapist’s left hand explores the
relation to the Spiral Line thoracic ribcage on the left side with a caudal/lateral glide
of the tissues, always looking for the immediate line of ten-
Besides restrictions in the SBL of fascia, persistent tension sion between the two hands. Appropriate depth of tissues is
or pain in the craniovertebral (Cr/V) area (occiput and C2) required: sometimes tension is found with a more superficial
may also be due to restrictions with the Spiral Line of fas- glide of the ribcage; sometimes with a deeper/more anterior
cia. Exploring these two areas in relation to the opposite component to the caudal/lateral glide. If no tension is perceived,
thorax is frequently beneficial if the spiral line is a prob- then the spiral of fascia in relation to C2 is not tight. If this fas-
lem. (Refer to Chapter 2 for a full description and illustra- cial line is tight, the therapist will feel an immediate increase in
tion of this line of fascia.) tension in the anchoring hand, as if C2 pulls into right rotation,
relative to C3. The patient perceives this as the therapist increas-
MMS unilateral P/A of C2 on the right in relation to ing his/her pressure on C2. If tension is perceived (quick resist-
the right Spiral Line (Figure 5.25) ance is felt between the two hands of the therapist), the therapist
performs repeated caudal/lateral movement of the ribcage on
the left while maintaining a steady pressure on C2 on the right,
always to when R1 is perceived. This is repeated until a release
is felt between the therapist’s two hands; this generally requires
approximately five to eight cycles.
MMS right occiput in relation to the right Spiral Line

(Figure 5.26)

MMS unilateral P/A of C2 in relation to the right Spiral MMS right occiput in relation to the right Spiral Line
Line
Stabilizing hand The patient is in a prone position. The Stabilizing hand The patient is in a right side-lying posi-
therapist uses his/her right thumb to perform a unilat- tion. The therapist uses his/her right thumb to perform a
eral P/A pressure on the lamina of C2 on the right side flexion (cranial glide) of the occiput on the right side. The
(grade IV−). arms of the patient may be offset (uppermost arm more
76
The cervical spine
anterior) in order to further protract the scapula and add MMS C/Thx spine with right anterior
more tension to this line. cervical area
Mobilizing hand As per the technique above. This particular technique does not address either Tom
Myers’s SFL or his SBL. It addresses the fascial tension that
MMS techniques for the cervicothoracic can occur between the anterior and posterior structures of
region the cervical region (DFL?) and thus contribute towards a
The fascia of the cervicothoracic (C/Thx) region may be forward head posture.
explored in relation to the lateral line as well as the deeper
fascia of the DFL. The following techniques are suggested: MMS C/Thx spine with right anterior cervical region
(ipsilateral) (Figure 5.28)
Figure 5.28
MMS C/Thx spine with right anterior cervical region
(ipsilateral)
Figure 5.27
MMS C/Thx spine with lateral ribcage Stabilizing hand The patient is in a prone position. The
therapist stabilizes the anterior cervical spine on the right
side with an anteroposterior pressure directed cranially –
MMS right C/Thx spine with lateral ribcage
this technique can be performed at several levels of the
(Figure 5.27)
mid-cervical spine, notably C4, C5, and C6 levels.
Mobilizing hand The therapist then uses their left hand
Stabilizing hand The patient is in a left side-lying posi-
to explore the area of the right C/Thx spinous processes or
tion. The therapist stabilizes the lateral aspect of the
facet joints, first by slowly sinking into the tissues of the
spinous processes of the C/Thx spine (C7–T2) with a lateral
C/Thx region and then gently pushing in a caudal direction,
to medial pressure of the tissues (i.e., towards the plinth).
while maintaining the depth of the fascial line. The thera-
Mobilizing hand As per the technique for MMS right lat- pist looks for the angle where he/she perceives immediate
eral mid-Cx with lateral ribcage. tension in the hand palpating the anterior cervical region.
77
Chapter 5
Tension may be felt most when the C/Thx spine is mobilized MMS upper fibers of trapezius
in a simple caudal direction, or caudal to the right of the
client or caudal to the left. This technique can be explored The upper fibers of trapezius (UFT) are frequently hyper-
anywhere from C7 to around T4 (spinous processes or facet tonic and facilitated. Dry needling may help restore a more
joint area). The therapist may also explore the upper ribs, normal tone to this muscle; however, tight fascia around
especially ribs 1 and 2, using a caudal glide of the costo- the muscle may contribute to its tendency to be recalci-
transverse joint of the rib as a handle to explore this fascia. trant. The UFT are part of Tom Myers’s Superficial Back
If no tension is perceived, then the fascia in between the Arm Line, and as such, may be put under tension with the
anterior cervical spine and the C/Thx region is not tight. addition of wrist and finger flexion. (Refer to Chapter 2
If this fascia is tight, the therapist will feel an immediate for a full description and illustration of this line of fascia.)
increase in tension in the anchoring hand, as if the mid-Cx
region translates anteriorly and caudally. The patient per- MMS UFT with wrist and finger flexion (SBAL)
ceives this as the therapist increasing his/her pressure on (Figure 5.30)
the anterior Cx spine. Similar concepts for mobilizing this
line of fascia apply as per previous techniques.

(contralateral) (Figure 5.29)
Figure 5.30
MMS UFT with wrist and finger flexion
Figure 5.29
(contralateral)
Stabilizing hand The therapist “pinches” the UFT
between the thumb and fingers and may explore the
Stabilizing hand As per previous technique. muscle along its length for tension.
Mobilizing hand The therapist explores the tissues of the Mobilizing hand The therapist flexes the patient’s wrist
left C/Thx region, including the upper ribs. The technique and fingers, stopping as soon as an increase in tension is
is similar to the previous one. perceived in the hand palpating the UFT. If there is tension
78
The cervical spine
in this line of fascia, it will seem like the tension in the UFT niques; that is, convert a nerve mobilization technique into
increases before full wrist and finger flexion can be achieved. a fascial technique. (Refer to Chapter 4 for further detail on
The therapist maintains the pinch of the UFT and simply concepts of treatment using MMS.)
prevents the tissues from gliding caudally. The patient per-
ceives this as the therapist increasing his/her pressure on the MMS techniques: mid-cervical region in
muscle. The therapist performs repeated caudal movement relation to neural tissues of the upper
of the wrist while maintaining a steady pressure on the UFT, extremity
always to when R1 is perceived. This action is repeated until
a release is felt between the therapist’s two hands; this gener- Indications
ally requires approximately five to eight cycles. • Persistent tension/pain in the cervical spine and/or
Although not technically part of Tom Myers’s SFL, the upper extremity.
UFT muscle is often fascially tight in relation to this line. It • To mobilize the neural interfaces in relation to the
may be mobilized as follows: upper extremity.
MMS UFT with the SFL MMS A/P pressures of the right mid-Cx with
scapular retraction, arm in upper ULNT2a position
Stabilizing hand As per the previous technique. for the median nerve (Figure 5.31)
Mobilizing hand The caudal hand explores the manu-
brial and sternal area with an anteroposterior caudal glide
of the tissues, making sure that the touch is light and stays
in the plane of the SFL similar to the technique for the
anterior cervical spine in relation to the SFL. The thera-
pist looks for the angle where he/she perceives immediate
tension in the hand anchoring the UFT. That tension may
be felt most when the moving hand mobilizes the fascia
client or caudal to the left. Sometimes the tension is most
felt when moving the sternal tissues mediolaterally or in a
clockwise/counterclockwise direction, always maintaining
the depth of the tissue. If no tension is perceived, then the
SFL of fascia in relation to this region is not tight. If ten-
sion is perceived (quick resistance is felt between the two
hands of the therapist) then it can be mobilized as per the Figure 5.31
approaches outlined in Chapter 4. MMS A/P pressures of the mid-Cx with scapular retrac-
tion, arm in ULNT2a position for median nerve
This technique can also be used to explore the SFL all the
way down to the rectus abdominis and symphysis pubis, as
well as the shoulder/lateral clavicle area as per the MMS
Stabilizing hand The patient’s arm is placed in about 30
technique mid-Cx with anteroposterior caudal glides of
degrees of abduction, with the wrist and fingers extended
the shoulder region – ipsilateral or contralateral. (Tech-
to pre-tense the median nerve; the therapist’s right hand
nique not pictured.)
anchors to an area of the anterior mid-cervical spine that
For the following techniques, we will be using primar- is chronically stiff (often C4) using an A/P mobilization in
ily the third concept of treatment when using MMS tech- a cranial direction.
79
Chapter 5

ipsilateral shoulder and shoulder girdle area with an MMS A/P pressures of the right mid-Cx with
anteroposterior caudal glide of the tissues in the area of the scapular retraction, arm in ULNT3 position for the
lateral clavicle and/or the GH joint, always looking for the ulnar nerve (Figure 5.33)
immediate line of tension with gentle pressure of the caudal
hand. Sometimes tension is felt most with a posterior tilt or
a lateral glide of the scapula. This technique can be explored
anywhere from C1 to C7. Similar concepts for mobilizing
this line of fascia apply as per previous techniques.

scapular retraction, arm in ULNT2b position for the
radial nerve (Figure 5.32)
Figure 5.33
MMS A/P pressures of the mid-Cx with scapular retrac-
tion, arm in ULNT3 position for ulnar nerve
Stabilizing hand As per the technique above, with the

patient’s arm placed in about 80 degrees of abduction,
with the elbow flexed, forearm pronated, wrist and fingers
extended, to pre-tense the ulnar nerve.
Mobilizing hand As per the technique above.
Figure 5.32 MMS: Mid-Cx in relation to the shoulder

MMS A/P pressures of the Cx with scapular retraction, girdle/clavicle
arm in ULNT2b position for radial nerve
The mid-Cx may also be explored in relation to the shoul-
der girdle and clavicle (see Chapter 12).
Stabilizing hand As per the technique above, with the
patient’s arm placed in about 30 degrees of abduction, the MMS: C/Thx, mid-Cx and Cr/V area in rela-
wrist and fingers and thumb flexed to pre-tense the radial tion to mobility of the dura
nerve.
The mid-Cx may also be explored in relation to the dura
Mobilizing hand As per the technique above. (see Chapter 7).
80
The cervical spine
Summary niques for the cervical spine have also been described in
relation to the glenohumeral joint and the scapula, along
This chapter has described MMS techniques that may be with an MMS technique for trigger points in relation to
used for each region of the cervical spine: the cranioverte- the upper fibers of trapezius. This concept may apply to
bral area, the mid-cervical region and the cervicothoracic any recurrent trigger point associated with dysfunction
area. These techniques have been described in relation of the cervical spine. The next chapter will focus on tech-
to Tom Myers’s fascial lines, in particular the Superfi- niques for the craniofacial region and the temporoman-
cial Back Line, the Superficial Front Line, the Deep Front dibular joint (TMJ).
Line, the Lateral Line, and the Spiral Line. MMS tech-
81
The craniofacial region
(cranium, temporomandibular joint) 6
When treating headaches, manual therapists are trained to that is so common. This tension can develop as a result of
assess and treat the joints of the cervical spine (especially trauma, including surgical scars to the abdominal area.
the upper cervical spine), the temporomandibular joints (One may think of the impact of caesarean section scars,
(TMJ), and the muscles of the upper quadrant (looking old appendectomy scars, hernia repairs, etc.) As per the
for imbalance between hypertonic, tight muscles and weak cervical spine, excessive time spent in the sitting position
muscles of the cervical spine and scapula). However, mobi- can also be a factor in creating these fascial lines of tension.
lizing joints and stretching individual muscles can achieve
only partial benefits if the fascial system is not addressed. If there is restriction in the Lateral Line of fascia, this
may create a lateral tilt or side shift of the thorax, the cer-
This chapter will describe the clinical findings of restric- vical spine, the lumbar spine, or the pelvis. It may also
tion in the fascial lines in relation to the following areas: become a contributing factor for dysfunctions of the Later-
al Line, more notably recurring issues with TMJ dysfunc-
• the muscles of the temporomandibular joint (TMJ) in
tions and headaches.
relation to the SFL and the DFL
• the fascia of the scalp (epicranial fascia) in relation to Concepts of treatment using MMS
the SFL and the Spiral Line For this chapter, we will be using primarily the first concept
• the tongue in relation to the SFL and the DFL. of treatment when using MMS techniques; that is, choose a
recurrent articular dysfunction or myofascial trigger point
Although the techniques for the dura and fascia within and explore a fascial line in relation to it. The therapist
the cranium are relevant to this chapter (because these tis- anchors him/herself to a recurrent articular dysfunction
sues are frequently problematic in clients with head and or myofascial trigger point and assesses the fascial lines of
facial pain), they are described separately in Chapter 7. tension in relation to the anchor, looking for early tension
between their two hands.
Indications for MMS for this chapter
1. Recurring craniofacial pain despite the following The following approaches may be used, depending on
treatment approaches: how the tissues respond:
−− mobilization/manipulation of the cervical spine • work with oscillations (grades III−, III, III+)
and thorax
−− stabilization exercises for the cervical spine and • work with sustained pressure
thorax • work with “harmonics” (Dr Laurie Hartman).
−− mobilization of the TMJ
−− release of trigger points to the cervical, thoracic Please refer to Chapter 4 for further detail on concepts of
and/or TMJ muscles with manual or dry needling treatment using MMS.
techniques
−− treatment of cranial dysfunctions.
TMJ muscles: anatomical overview and
palpation
2. Tension in the anterior cervical spine/throat area.
The muscles around the TMJ are common sites of recur-
rent tension and frequently involved in dysfunction of the
Postural analysis fascial lines (Figures 6.1, 6.2). They include temporalis,
If there is restriction of the DFL of fascia, this may have an superficial masseter, medial pterygoid, mylohyoid, bucci-
impact on posture, in particular the forward head posture nator, and the supra- and infrahyoid muscles.
83
Chapter 6
Anchoring onto the TMJ muscles

Anchoring onto the temporalis muscle
(Figure 6.3)
The temporalis muscle may be palpated along its entire
Temporalis
breadth, including the anterior, middle, and posterior por-
tions of the muscle belly itself as well as the tenoperiosteal
junction of the muscle in the area of the greater wing of
the sphenoid bone. The therapist looks for recurrent ten-
sion in the various parts of the muscle, which is frequently
accompanied by pain on palpation. The therapist “hooks
Superficial onto” the area of the muscle where there is most tension
masseter and pulls with both hands in a cranial direction.
Figure 6.1
Temporalis and superficial masseter muscles
Figure 6.3
Anchoring onto temporalis
Mylohyoid
Anchoring onto the superficial masseter

(Figure 6.4)
The superficial masseter muscle may be palpated along its
Figure 6.2 entire breadth, including the zygomatic attachment, the
Mylohyoid muscle mandibular attachment and the mid-portion of the muscle.
The muscle may also be explored from its anterior portion,
posteriorly towards the ear. The therapist looks for recur-
rent tension in the various parts of the muscle, which is
84
The craniofacial region (cranium, temporomandibular joint)

Anchoring onto superficial masseter Anchoring onto medial pterygoid
frequently accompanied by pain on palpation. The thera-

pist gently hooks onto the area of the muscle where there is
most tension (often the anterior aspect of the mid-portion
of the muscle) and pulls with both hands in a combined
lateral/cranial direction.
Anchoring onto the medial pterygoid

(Figure 6.5)
The medial pterygoid muscle is best palpated along its attach-
ment under the mandible of the jaw. The muscle may also be
explored from its anterior portion, posteriorly towards the
ear. The therapist looks for recurrent tension in the vari-
ous parts of the muscle, which is frequently accompanied
by pain on palpation. The therapist gently hooks onto the
area of the muscle where there is most tension and pulls with
both hands in a combined lateral/cranial direction.
Figure 6.6
Anchoring onto the mylohyoid (Figure 6.6) Anchoring onto mylohyoid
The mylohyoid muscle is best palpated along its attachment
under the mandible, close to the center. The muscle may which is frequently accompanied by pain on palpation. The
also be explored from its anterior portion and posteriorly therapist gently hooks onto the area of the muscle where
towards the ear, about 2 cm on either side. The therapist there is most tension and pulls with both hands in a com-
looks for recurrent tension in the various parts of the muscle, bined lateral/cranial direction.
85
Chapter 6
MMS techniques: temporomandibular joint

muscles in relation to the SFL of fascia
Tom Myers’s description of the SFL of fascia involves the
scalp fascia, SCM, sternochondral fascia, pectoral muscles,
rectus abdominis to the symphysis pubis. It then begins again
at the origin of the rectus femoris and includes the quadri-
ceps muscles, the patellar tendon, short and long toe exten-
sors, tibialis anterior, and the anterior crural compartment.
(Refer to Chapter 2 for a full description and illustration of
this line of fascia.) These fascial connections become very
apparent when working with the MMS techniques described
in this chapter. The following techniques are demonstrated
in relation to the superficial masseter muscle; however, any
of the TMJ muscles may be explored in a similar fashion.
MMS right superficial masseter with antero-

posterior caudal glides of the shoulder region (SFL)
(Figures 6.7, 6.8)
Stabilizing hand For this technique the therapist’s right

hand uses the anchor onto the right superficial masseter
Figure 6.7
muscle (described above).
MMS right superficial masseter with anteroposterior-
Mobilizing hand The therapist’s left hand explores the caudal “glides” of the shoulder region (SFL) – ipsilateral
shoulder and shoulder girdle area with an antero-pos- shoulder
terior caudal glide of the tissues in the area of the lat-
eral clavicle and/or the glenohumeral (GH) joint, using NB This technique may be progressed by exploring the
the “star concept” to find the direction of most tension superficial masseter in relation to the rectus abdominis and
between their two hands. Sometimes tension is felt most the symphysis pubis, thereby exploring the upper quadrant
with a posterior tilt or lateral glide of the scapula. If this aspect of the SFL. (See Chapter 5 for similar techniques in
fascial line is tight, the therapist will feel an increase in relation to the anterior mid-cervical area.)
tension in the anchoring hand, as if the superficial mas-
seter muscle moves medially and caudally. The patient Although demonstrated on the superficial masseter, this
perceives this as the therapist increasing his/her pres- technique may be used with any of the TMJ muscles.
sure on the superficial masseter. If no tension is per-
ceived, then the SFL of fascia in relation to this region is
MMS techniques: TMJ muscles in relation
not tight. If tension is perceived (quick resistance is felt
between the two hands of the therapist) then it can be
to the DFL of fascia
mobilized as per the approaches outlined in Chapter 4. Tom Myers’s description of the Deep Front Line (DFL) of
(The therapist maintains the anchor on the superficial fascia involves the TMJ muscles, the longus colli and capitis,
masseter to prevent it from moving as he/she performs infrahyoid and suprahyoid muscles, the cranium and facial
repeated A/P mobilizations of the ipsilateral or the con- bones as well as the pericardium, anterior diaphragm, pos-
tralateral shoulder area.) terior diaphragm, central tendon of the diaphragm, psoas,
86
MMS right superficial masseter in relation to the

pericardium (DFL) (Figure 6.9)
Figure 6.8
MMS right superficial masseter with anteroposterior-
caudal “glides” of the shoulder region (SFL) – contralat-
eral shoulder
Figure 6.9
iliacus, pelvic floor fascia, anterior sacral fascia, adduc- MMS right superficial masseter in relation to the
pericardium (DFL)
tor magnus, adductor brevis, adductor longus, popliteus,
and finally the tibialis posterior and the long toe flexors.
A number of the fascial techniques to evaluate and treat Stabilizing hand Using the right hand, the therapist
tension of the DFL makes particular use combined dorsi- anchors onto the superficial masseter and pulls it gently
flexion/eversion of the ankle, thereby increasing tension of in a craniolateral direction, maintaining the tension on
the distal aspect of the DFL. Deep inspiration may also be this muscle.
used, which involves the diaphragm. These fascial connec-
tions become very apparent when working with the MMS Mobilizing hand The therapist then uses the left hand to
techniques described below. (Refer to Chapter 2 for illus- explore the area of the pericardium, first by slowly sinking
trations and a full description of this line of fascia.) into the tissues posterior to the sternum and then gently
pushing them in a caudal direction, all the while maintain-
Note that the photos for the techniques below are demon- ing the depth of the fascial line posterior to the sternum.
strated using the superficial masseter; however, all the TMJ The therapist looks for the angle where he/she perceives
muscles noted above may be used with these techniques. immediate tension in the hand palpating the superficial
87
Chapter 6
masseter. Using the star concept to find the direction of

most tension is useful here. That tension may be felt most
client or caudal to the left. Sometimes the tension is most
felt when moving the pericardial tissues mediolaterally or
in a clockwise/counterclockwise direction, always main-
taining the depth of the tissue. If no tension is perceived,
then the DFL of fascia in relation to this muscle is not tight.
If this fascial line is tight, the therapist will feel an increase
in tension in the anchoring hand, as if the superficial mas-
seter muscle pulls medially and caudally. The patient per-
ceives this as the therapist increasing his/her pressure on
the superficial masseter. Similar concepts for mobilizing
this line of fascia apply as per previous techniques.
MMS right superficial masseter in relation to the

diaphragm (DFL) (Figures 6.10, 6.11)
Stabilizing hand As per technique above.

Mobilizing hand The therapist’s left hand explores the ante-
rior diaphragm area with a caudal/lateral glide of the tissues,
always looking for the immediate line of tension between
the two hands. Appropriate depth of tissues is required. The
fascia around the rectus abdominis and oblique abdominal
muscles may be accessed with this technique if the tech-
Figure 6.10
nique is done superficially. (This would be a technique for
MMS right superficial masseter in relation to the ipsi-
the SFL.) However, in order to access the diaphragm which lateral diaphragm (DFL)
is part of the DFL, the therapist must first slowly sink into
the tissues posterior to the lower ribs and then gently push in
a caudal/lateral direction. This technique can be done with at the same time and the therapist pulls both hands gently
either the ipsilateral or the contralateral diaphragm. in a cranial-lateral direction.
Movement The patient is asked to actively dorsiflex and

MMS superficial masseter with dorsiflexion/
evert both ankles and take a deep breath in, thereby increas-
eversion of the ankle (pre-tensing the DFL via the
ing the tension of the DFL from below. If this fascial line is
tibialis posterior) (Figure 6.12)
tight, the therapist will feel an increase in tension in their
hands, as if the tissues were being pulled in a caudal-medial
Stabilizing hands For this technique the therapist’s hands direction. The therapist maintains the hold towards a cra-
use the same anchor on both superficial masseter muscles nial-medial direction with both hands until a softening of
88
Figure 6.11
MMS right superficial masseter in relation to the con-
tralateral diaphragm (DFL)
the s ystem is perceived. The client then releases the feet and
breathes normally: the therapist may feel that both hands can
glide a little more cranially. The slack of the tissues is taken up
Figure 6.12
by the therapist as the patient continues to actively dorsiflex/
MMS superficial masseter with ankle DF/eversion
evert the ankles and take deep breaths. This sequence contin- (DFL)
ues until there is no further change perceived in the therapist’s
hands and generally requires approximately five or six cycles.
This applies to all the techniques outlined in the above
Finally, the techniques may be progressed by asking
section.
the patient to maintain dorsiflexion/eversion as the
therapist explores the pericardium, diaphragm, etc. NB This technique may be used with any of the TMJ muscles.
89
Chapter 6
Figure 6.13
MMS temporalis with anterior
pelvic tilt
intercostals, ribs, lateral abdominal obliques, iliac crest,

MMS temporalis with anterior pelvic tilt (Figure 6.13) anterior and posterior superior iliac spines (ASIS and
PSIS), gluteus maximus, tensor fasciae latae, iliotibial band
Stabilizing hands As per technique above except that (ITB), fibular head, peroneal muscles, and lateral crural
the therapist anchors onto both temporalis muscles (see compartment. Although technically not part of the Lateral
anchoring technique at the start of the chapter). Line, the TMJ muscles have clinical connections with this
line. (Refer to Chapter 2 for illustrations and a full descrip-
Movement The patient is asked to perform an anterior
tion of this line of fascia.)
pelvic tilt, thereby increasing the tension of the DFL from
below. If this fascial line is tight, the therapist will feel an
increase in tension in their hands as if the tissues were MMS right superficial masseter with the lateral
being pulled in a caudal direction. The therapist main- ribcage (Figures 6.14–6.16)
tains the hold with both hands towards a cranial direction
until a softening of the system is perceived. The patient Stabilizing hand The patient is in a left side-lying posi-
then releases the pelvis back to a more neutral position tion. The therapist’s left hand anchors onto the superficial
– the t herapist may feel that both hands can glide a little masseter, using a craniolateral “hook.”
more cranially. The slack of the tissues is taken up by the
therapist as the patient continues to actively do an anterior Mobilizing hand The therapist’s right forearm explores
pelvic tilt. This continues until there is no further change the lateral ribcage/intercostal area, using the star concept.
perceived in the therapist’s hands and generally requires The therapist may explore moving the lateral ribcage in a
approximately five or six cycles. number of possible directions:
NB This technique may be used with any of the TMJ muscles. • in a caudal direction (toward the patient’s feet)
• in a caudal-anterior direction (the therapist must
MMS techniques: temporomandibular adjust their forearm to begin the maneuver slightly
joint muscles in relation to the Lateral posterior to the lateral ribcage), and/or
Line of fascia
• in a caudal-posterior direction (the therapist must
Tom Myers’s description of the Lateral Line of fascia adjust their forearm to begin the maneuver slightly
involves the splenius capitis, SCM, external and internal anterior to the lateral ribcage).
90

MMS right superficial masseter with the lateral ribcage MMS right superficial masseter with the lateral ribcage
(caudal direction) (caudal-posterior direction)
Note that the directions of the mobilizing forearm

follow the diamond shape of the intercostal muscles.
The ribcage may be explored in this manner both in the
lower thoracic region and the middle thoracic region.
This is a general technique, but it may also be used in
relation to a specific thoracic ring. The therapist looks
for the angle and the area(s) on the ribcage where he/
she perceives immediate tension in the hand anchoring
the right superficial masseter. If this fascial line is tight,
the therapist will feel an increase in tension in their
anchoring hand, as if the tissues were being pulled in
a caudal direction. If tension is perceived (quick resist-
ance is felt between the two hands of the therapist), then
it can be mobilized as per the approaches outlined in
Chapter 4.
MMS temporalis with lateral ribcage (Figure 6.17)
This technique is performed as above except that the

Figure 6.15 therapist anchors onto the temporalis muscle (anterior,
MMS right superficial masseter with the lateral ribcage middle and/or posterior aspect) and also explores the mus-
(caudal-anterior direction)
cle in its entirety.
91
Chapter 6
MMS techniques: TMJ muscles in relation

to the Spiral Line
As with the Lateral Line, the TMJ muscles have clinical
anecdotal evidence of their involvement with the Spiral
Line. (Refer to Chapter 2 for illustrations and a full descrip-
tion of this line of fascia.)
MMS temporalis with lumbar rotation (Figure 6.18)
Stabilizing hands For this technique the therapist’s

hands use the same anchor on both superficial mas-
seter muscles or both temporalis muscles at the same
time. The therapist pulls both hands gently in a cranial
direction.
Movement The patient is in a crook-lying position. He/
she is asked to let their knees slowly drop to the right, there-
Figure 6.17 by inducing lumbar rotation to the left. If the Spiral Line is
MMS right temporalis with lateral ribcage tight, the therapist will feel an increase in tension in their
hands as if the tissues were being pulled in a caudal direc-
tion. The patient perceives this as the therapist increasing
Figure 6.18
MMS temporalis with lumbar rota-
tion
92
his/her pressure on the superficial masseter muscles or the

temporalis muscles. The therapist maintains the hold with temporary relief of her head pain. Chronic pain is usually
both hands in a cranial direction until a softening of the multifactorial and this case was no exception. The initial
system is perceived. The patient then brings the knees back physiotherapy evaluation revealed problems with artic-
to a more neutral position – the therapist may feel that both ular mobility in the cervical and craniovertebral joints,
hands can glide a little more cranially. The slack of the tis- muscle imbalance issues in the upper quadrant, includ-
sues is taken up by the therapist as the patient continues ing weakness of the cervical and scapular stabilizers,
to actively rotate to the right or the left. This continues decreased dural mobility, and hypertonic TMJ muscles.
until there is no further change perceived in the thera- All of these issues were addressed with the appropriate
pist’s hands and generally requires approximately five or techniques. However, it was not until the fascial tech-
six cycles. niques in relation to the TMJ were introduced that the
patient began to show subjective improvement in her
NB This technique may be used with any of the TMJ muscles. head pain symptoms. As well, her dentist testified that
her bite had returned to a fully normal position. Treat-
Case report 6.1 Lois’s story* ment of the fascia of the TMJ muscles (temporalis, deep
masseter, medial and lateral pterygoid muscles, buc-
Lois was a 40-year-old university English professor with cinator complex) in relation to the DFL, Spiral Line and
complaints of chronic pain in the area of the temporal Lateral Line techniques were used as well as MMS tech-
and occipital regions bilaterally, as well as tooth pain in niques to the occipitalis (see Chapter 5) and the anterior
the left lower mandibular area (tooth 37). She also had a sacral fascia (see Chapter 10). In addition, the fascia of
history of cervical and scapular pain that had resolved the problematic tooth was found to be tight and was
a couple of months earlier. This head and tooth pain released, both in relation to its mandibular attachment
interfered with her sleep and was particularly bad in the and also in relation to the DFL of fascia. This approach to
morning. At its worst, she was unable to concentrate, treatment solved her tooth pain and decreased her head
experienced nausea, and was unable to tolerate the pain to the point where she was able to concentrate,
upright position. The pain began after a neck injury in a sleep better, and resume her writing. A combination of
car accident two years prior, followed shortly thereafter MMS along with movement therapies (Qi gong, Pilates,
by a dental laser procedure that exacerbated her cer- aerobic exercise) is the program that allows this patient
vical, scapular, head, and tooth pain. The dental injury to now be more functional.
affected her bite so that her upper and lower teeth no * Please note that the patient’s name has been changed
longer touched on the right side. A dental specialist to protect her privacy.
had recommended shaving down the teeth in order to
normalize the patient’s bite, but the patient did not go
through this procedure. She had had a number of treat-
ments to address her issues: Botox, acupuncture, dry Buccinator/pharyngeal constrictor
needling, dental appliances, cranial and general oste- complex and its fascia (Figure 6.19)
opathy, lidocaine injections (administered by doctors in
a pain clinic). These approaches helped her cervical and
scapular pain but not her tooth pain and provided only This muscle complex comprises the buccinator muscle, which
runs from the orbicularis oris muscle surrounding the mouth,
93
Chapter 6
Pharyngeal constrictor Buccinator Orbicularis oris
Raphe
Figure 6.19
Buccinator/pharyngeal constrictor complex
Figure 6.20
MMS right buccinator with raphe
and then connects to a fascial raphe that is easily palpable just
anterior to the superficial masseter muscle. It then continues
posteriorly to connect with the pharyngeal constrictor mus-
cle, which attaches to the occiput and to the anterior aspect thumb inside the mouth and the index on the outside of
of the body of C2. The pterygoid plates of the sphenoid bone the cheek. Using the left hand, the therapist pulls gently
also have a fascial connection to this complex. It is frequently towards the patient’s mouth, using the star concept to seek a
problematic with cases of recurrent TMJ d ysfunction, as ten- direction where there is the most tension between the thera-
sion here may retract the mandible, leading to TMJ disc dys- pist’s two hands (there may be a cranial or caudal compo-
function and myofascial TMJ pain. Releasing this complex nent to the medial pull). The therapist maintains the hold
often helps to release other frequently tight TMJ muscles, with both hands until a softening of the system is perceived.
such as the masseter and pterygoid muscles. The patient’s respiration may be used to facilitate release.
MMS right buccinator with raphe (Figure 6.20) MMS right buccinator with sphenoid (Figure 6.21)
Stabilizing hand To release the right buccinator/ Stabilizing hand The therapist’s left hand maintains the
pharyngeal constrictor complex and its fascia, the therapist same position in the mouth but now becomes the stabilizer,
uses the thumb of the right hand to palpate the raphe on as the therapist pulls the tissues gently in a caudal direction.
the outside of the patient’s right cheek and anchor it with
Mobilizing hand The therapist changes the position of
a gentle pull towards the occiput – the rest of his/her hand
their right hand to encompass the greater wings of the
encompasses the head and occiput.
patient’s sphenoid bone, just lateral to the eyes (anchoring
Mobilizing hand The therapist’s left hand “pinches” the both the left and right side of the sphenoid). The thera-
right cheek, as close to the raphe as possible, with the left pist gently pulls the sphenoid bone in a cranial direction,
94
Figure 6.21
MMS right buccinator with sphenoid Figure 6.22
MMS right buccinator with occiput
looking for early tension between the two hands. If there is

tension in this fascial line, the therapist will feel an increase gentle active chin-nod movement to the fascial technique.
in tension of their anchoring hand. The patient perceives It may also be assessed and treated in relation to the DFL
this as the therapist increasing his/her pressure on the by simply adding bilateral ankle dorsiflexion/eversion or
raphe of the buccinator. The therapist maintains the hold anterior pelvic tilt and repeating the process.
with both hands until a softening of the system is perceived.
The patient’s respiration may be used to facilitate release. Anterior cervical fascia: supra- and
infrahyoid region
MMS right buccinator with occiput (Figure 6.22) This area is important to explore, especially with those
patients complaining of tension in the throat, or those with
Stabilizing hand As per the previous technique. persistent cervical or TMJ pain.
Mobilizing hand The therapist changes the position of
his/her right hand to encompass the occiput, with the index MMS right suprahyoid fascia (Figure 6.23)
and middle fingers focused on the right occipital condyle,
and pulls this occipital area in a medial direction, looking Stabilizing hand The therapist’s left hand hooks onto the
for early tension between the two hands. The patient’s res- right side of the hyoid bone, pulling it gently towards the
piration may be used to facilitate release. left and slightly caudally.
Mobilizing hand The therapist’s right hand explores the
Adding the fascial component muscles and fascia of the caudal edge of the mandible on
These three techniques to release the buccinator/pharyngeal the right side, pulling them gently in a cranial and later-
constrictor muscle complex can be progressed by adding a al direction. If this fascial line is tight, the therapist will
95
Chapter 6

MMS right suprahyoid fascia MMS right suprahyoid fascia with clavicle – ipsilateral
feel an immediate increase in tension in their stabilizing

hand. The therapist maintains the hold with both hands
until a softening of the system is perceived. The patient’s
respiration may be used to facilitate release. The fascia can
also be assessed and worked in relation to the DFL by sim-
ply adding bilateral ankle dorsiflexion/eversion or ante-
rior pelvic tilt. The slack of the tissues is taken up by the
therapist, as the patient continues to actively do an anterior
pelvic tilt and/or dorsiflex/evert the feet. This continues
until there is no further change perceived in the thera-
pist’s hands; this generally requires approximately five or
six cycles.
MMS right suprahyoid fascia with clavicle (SFL)

(Figures 6.24, 6.25)
Stabilizing hand The therapist’s right hand explores the

muscles and fascia of the caudal edge of the mandible on the
right side, pulling it gently in a cranial and lateral direction.
Mobilizing hand The therapist’s left hand explores
Figure 6.25
the shoulder and shoulder girdle area with an ante-
MMS right suprahyoid fascia with clavicle –
ro-posterior caudal glide of the tissues in the area of contralateral
the whole clavicle and/or the GH joint, using the star
96
concept to seek the direction where an immediate line

of tension is felt between the therapist’s hands as gen-
tle pressure is applied with the caudal hand. This can
be done using either the ipsilateral or the contralateral
clavicular/shoulder area, as the therapist explores the
SFL of fascia. If this fascial line is tight, the therapist
will feel an immediate increase in tension in the hand
anchoring the suprahyoid region. The therapist main-
tains the hold with both hands until a softening of the
system is perceived. The patient perceives this as the
therapist increasing his/her pressure on the mandible. If
no tension is perceived, then the SFL of fascia in relation
to this region is not tight. If tension is perceived (quick
resistance is felt between the two hands of the therapist)
then it can be mobilized as per the approaches outlined
in Chapter 4. (The therapist maintains the anchor on the
suprahyoid region to prevent it from moving as he/she
performs repeated A/P mobilizations of the ipsilateral
or the contralateral shoulder area.)
MMS right suprahyoid fascia with pericardium (DFL) Figure 6.26

MMS right infrahyoid fascia with pericardium
The area of the manubrium, sternum, and pericardium
may also be explored in this fashion (for the DFL of fas-
cia). The fascia can also be assessed and worked in relation
to the DFL by simply adding bilateral ankle dorsiflexion/ MMS techniques: scalp fascia
eversion or anterior pelvic tilt. The slack of the tissues is
Tension in the fascia of the epicranium is a common prob-
taken up by the therapist as the patient continues to active-
lem with those patients who suffer from tension headaches.
ly do an anterior pelvic tilt and/or dorsiflex/evert the feet.
The epicranium is also connected to the intracranial fascia
This continues until there is no further change perceived
and, if tight, can maintain cranial dysfunction (Paoletti
in the therapist’s hands; this generally requires approxi-
2006). Patients with this problem report decreased head
mately five or six cycles. (Technique not shown.)
pain if they or someone else pulls on their hair (large sec-
tions of hair, not individual hairs!). The hair (if present)
MMS right infrahyoid fascia with pericardium can be a useful lever to move and tension the epicranial
(Figure 6.26) fascia below it.
Stabilizing hand To release the right infrahyoid fascia in MMS scalp fascia (epicranium): “hair-pull technique”
relation to the SFL or DFL, the therapist’s left hand hooks (Figure 6.27)
onto the right side of the hyoid bone, pulling it gently
toward the left and slightly cranially. For this technique, the therapist grasps the patient’s
Mobilizing hand As per the above two techniques for the hair (global hold) and pulls gently in a cranial direc-
suprahyoid fascia. Figure 6.26 depicts the technique per- tion. Various parts of the scalp and epicranial fascia can
formed in relation to the pericardial fascia (for the DFL of be accessed this way. If the client has little to no hair, the
fascia). scalp fascia can be accessed by using a lumbrical grip of
97
Chapter 6
Figure 6.27
MMS scalp fascia (epicranium) – “hair-
pull technique”
Figure 6.28
Adding anterior pelvic tilt to “hair-
pull”
the therapist’s fingertips to gently pull the scalp tissue in a the tension of the SFL or DFL from below. If these fascial
cranial direction. lines are tight, the therapist will feel an increase in tension
in their hands. The patient perceives this as the therapist
A number of movements from below may be added to
pulling harder on the hair or scalp. The therapist main-
this hair-pull technique to explore the SFL and/or the DFL
tains the hold with both hands toward a cranial direction
of fascia. For example:
until a softening of the system is perceived (usually within
a few seconds). The patient then releases the pelvis back to
Add anterior pelvic tilt to “hair-pull” (Figure 6.28) a more neutral position; the therapist may feel that both
hands can glide a little more cranially. The slack of the
While the therapist maintains the “hair-pull” the patient is tissues is taken up by the therapist as the patient contin-
asked to perform an anterior pelvic tilt, thereby increasing ues to actively perform an anterior pelvic tilt. This action
98
Figure 6.29
MMS scalp fascia in relation to the
Spiral Line – shown using frontalis
continues until there is no further change perceived in the Tongue

therapist’s hands and generally requires approximately five
or six cycles. Lung
Mediastinum
Diaphragm
MMS scalp fascia in relation to the Spiral Line
(Figure 6.29) Quadratus lumborum
Psoas major
Location of Iliacus
(shown using frontalis muscle) pubic symphysis
The therapist maintains the “hair-pull” or tension on the

Adductor group
frontalis, as shown. The patient is asked to let flexed knees
slowly move to the right, thereby inducing lumbar rotation
to the left. If the spiral line is tight, the therapist will feel Knee capsule
an increase in tension in one or both hands. The thera- Popliteus
pist maintains the hold with both hands towards a cra-
nial direction until a softening of the system is perceived,
Deep posterior
usually within a few seconds. The patient then brings the compartment
knees back to a more neutral position; the therapist may
Flexor digitorum longus
feel that one or both hands can glide a little more cranially.
The slack of the tissues is taken up by the therapist as the Tibialis posterior
patient continues to actively rotate to the right or the left.
Flexor hallucis longus
This sequence continues until there is no further change
perceived in the therapist’s hands; this generally requires
approximately five or six cycles.
Figure 6.30
Dissection of DFL including tongue. Reproduced from
MMS techniques: the tongue and its fascia Anatomy Trains: Myofascial Meridians for Manual and
(DFL) Movement Therapists, 3rd edition. With kind permission
from Elsevier
Tom Myers’s dissections of the Deep Front Line have
shown that the tongue is one of the most prominent cra-
nial components of this line (Figure 6.30). Working with with those clients complaining of tension in the area of the
the patient’s tongue has been found to be clinically useful throat and mandibular area.
99
Chapter 6
MMS tongue with pericardium (DFL) (Figure 6.31) MMS tongue with shoulder: ipsilateral or
contralateral (SFL) (Figure 6.32)
Figure 6.31
MMS tongue with pericardium (DFL)
Figure 6.32
MMS tongue with shoulder – ipsilateral or contralat-
eral (SFL)
Stabilizing hand The therapist holds onto the patient’s
tongue (using a paper towel) and gently pulls it anteri-
orly and in a cranial direction. Other directions may be Stabilizing hand As per the technique above.
explored as a progression, such as (gently) pulling the Mobilizing hand Using the caudal hand, the therapist
tongue in a cranial direction to the right or in a cranial explores the shoulder and shoulder girdle area with an antero-
direction to the left. posterior caudal glide of the tissues in the area of the lateral
Mobilizing hand The therapist then explores the area of clavicle and/or the GH joint, always looking for the immedi-
the pericardium in a posterior and caudal direction, look- ate line of tension with gentle pressure of the caudal hand.
ing for the angle where the therapist perceives immediate This technique can be performed using either the ipsilateral
tension in the hand holding the tongue. If no tension is or the contralateral shoulder area. If the ipsilateral shoulder is
perceived, then the DFL of fascia in relation to the tongue explored, the tension of the tongue fascia may be felt more eas-
is not tight. If there is tension in this line it will feel to the ily by adding contralateral movement of the tongue in addi-
therapist as though the tongue wants to pull back posteri- tion to an anterior and cranial pull (i.e., pulling the tongue to
orly toward the throat area. The patient perceives this as the right if using the left shoulder area and vice versa).
the therapist pulling harder on the tongue when in reality
This technique may be used to explore the Superficial
the therapist is simply stopping the tongue from moving.
Front Line of fascia all the way down to the symphysis
If tension is perceived (quick resistance is felt between the
pubis, as well as the fascia of the DFL. The following case
two hands of the therapist), then it can be mobilized as per
report illustrates this point.
the approaches outlined in Chapter 4.
100
Case report 6.2 Rita’s Popsicle pericardium, followed by the tongue and abdominal
story area. These techniques reproduced her craniofacial pain.
One treatment to release this DFL solved her Popsicle
problem. We may hypothesize from this case report that
This 47-year-old patient had come for therapy with
the patient’s many bouts of inflammation secondary to
complaints of pain in the area of the right TMJ, noting
her IBS created some fascial tension in the abdominal
difficulty chewing French bread. There was no history
area, thus increasing tension into the tongue via the DFL
of trauma to the TMJ and her medical history noted a
of fascia.
long-standing problem with irritable bowel syndrome,
presently controlled with medication. Initial assessment
and treatment of her condition involved the cervi- Summary
cal spine and the TMJ, noting articular and myofascial
The techniques in this chapter have focused on the myo-
restrictions in both areas. She responded well to manual
fascial connections in relation to the TMJ muscles, the
therapy and exercises to address muscle imbalances in
epicranium, and the tongue. These tissues are frequently
both areas. After three treatments, her initial problem
problematic in cases of persistent head, face, and TMJ pain
was no longer a factor, but she noted that licking a Pop-
and should be explored using MMS techniques. The next
sicle reproduced pain in her TMJ. The previously noted
chapter will focus on MMS techniques for the dura and
problems were re-assessed but the biomechanical exam
fascia within the cranium.
was negative. Considering that the tongue was involved
in this latest subjective complaint, it too was evaluated
for mobility and strength. That test too, revealed no
problems. However, using the techniques above, it was
noted that there was considerable tension in the DFL
of fascia, with tension noted between the tongue and
101
Dural mobility 7
When treating headaches or spinal pain, manual thera-
pists are trained to assess and treat the mobility of the dura Falx cerebri
via techniques such as the straight leg raise (SLR) and/or
slump technique. However, using this single approach to
treatment may be insufficient, as the interfaces for neu-
ral structures must also be taken into account. We must
consider that the dura does not end at the craniovertebral
region, but extends to the cranium.
The cranium has a number of connections to the pelvic

floor:
• articular connections: coccyx, sacrum, pelvis, lumbar
spine, thorax, cervical spine, cranium
• myofascial connections: Deep Front Line of fascia
(including the diaphragm), dura, falx cerebri, tento-
rium cerebellum Tentorium cerebelli
• neural connections: phrenic nerve, vagus nerve, dura,

falx cerebri, tentorium cerebellum.
Figure 7.1
This chapter will focus on the myofascial connections Falx cerebri (a vertical structure that runs from front to
between the cranium and the pelvic floor, as these tissues back and separates the brain into right and left halves)
are frequently problematic in cases of persistent head pain, and tentorium cerebelli (a horizontal fascia that con-
nects to the falx cerebri and to both temporal bones)
spinal pain, coccyx pain, and pelvic floor pain.
Of note is that the dura, falx cerebri, and tentorium The falx cerebri and the tentorium cerebellum are con-
cerebellum are all considered to be myofascial tissues tinuous with the dura that surrounds the brain. The dura
as well as neural tissues (Diane Lee, personal communi- then extends caudally to surround the spinal cord and
cation). Within the cranium, the falx cerebri of the dura ultimately ends at its attachment to the coccyx. The dura
attaches to the crista galli of the ethmoid bone, which can must have some inherent flexibility in order to accommo-
be palpated indirectly via the glabella of the frontal bone date movement of the spine. The spinal canal elongates
(this feels like a small indentation on the forehead). This as much as 9 cm during flexion of the whole spine (Louis
area will be used as a hook to anchor the falx cerebri. 1981), but the sliding of the neural structures in the spine
The tentorium cerebelli is a horizontal fascia on either is complex and not fully understood. Neck flexion pro-
side of the falx cerebri that envelops the cerebellum and duces cephalad sliding of neural contents in the lumbar
attaches to the falx cerebri within the cranium, at a junc- region (Breig & Troup 1979). However, the SLR produces
tion called Sutherland’s fulcrum (Figure 7.1). Pulling on caudal sliding of nerve roots in the lumbosacral interver-
the ears in a posterolateral inferior direction provides for tebral foramina (Goddard & Reid 1965; Breig & Troup
the practitioner a lovely lever by which the tentorium cer- 1979). Movement of the spine around neural structures
ebellum can be tensioned. is a complex series of lending and borrowing of neural
103
Chapter 7
tissue, producing convergence toward C5–6 and L4–5,

the most mobile of spinal segments (Shacklock 2005; Base of skull
C1
Louis 1981; Adams & Logue 1971). C1
C2
C2
C3
The dura has a number of areas where mobility is C3
C4
naturally more tethered. These are at the junction of C4
C5
occiput/C1, C2/3, the cervicothoracic junction, the mid- Posterior dura C5
C6
thorax (T4–6), the thoracolumbar junction, the lum- C6
C7
bosacral junction, S2/3 and the coccyx. Recurrent pain Anterior dura C7
C8
in these areas is not uncommon. It is also interesting T1
to note that a number of horizontal fascial structures T2
T1
attach to the dura at many of these levels (the diaphragm T2

T3
at the Th/L levels, the thoracic inlet at the C/Thx levels, T3
T4
and the pelvic diaphragm). T4
T5
T5
The posterior dura is closer to the spinous processes than T6
T6
the anterior dura and is generally stretched in slump posi- T7
T7
tion (Figure 7.2). The anterior dura is closer to the anterior T8
T8
longitudinal ligament and is tensioned along with the DFL T9
T9
of fascia. As such, lumbar extension, knee and hip exten-
T10 T10
sion are maneuvers that will tension the anterior dura.
T11
T11
Signs and symptoms of dural mobility dysfunction T12
include the following: T12
L1
• headache and retro-orbital pain via the nerve sup- L1
ply of the dural membranes (trigeminal and vagus L2
nerves, 1st, 2nd, and 3rd cervical nerves) L2
• face pain and abnormal tone of the temporomandib- L3

L3
ular joint (TMJ) muscles via the trigeminal nerve and
the trigeminal ganglion, which is covered with dura L4
and vulnerable to dural stress (Liem 2005) L4
• limitation in mobility of the cranial bones, the sa- L5

crum, and the coccygeal bone (Liem 2005) L5
• neurodynamic mobility issues, such as a positive

slump test or upper limb neural techniques (ULNTs) S1
S2
• in the ISM approach, if no corrections make the pa- S3
tient feel significantly better, the problem is frequently S4
not in the skeleton but in the dura/nervous system. S5
The dura may also be impacted by dysfunctions in the

craniosacral system, as these dysfunctions affect tension in
Figure 7.2
the cerebral falx and/or tentorium cerebellum. In addition,
Posterior and anterior dura
the dura may be impacted by dysfunctions in the neck,
104
Dural mobility
clavicle, thorax, and/or sacrum, so the whole body should • work with oscillations (grades III– , III, III+)
be considered (ISM model).
• work with sustained pressure.
This chapter will describe the MMS techniques that are
Please refer to Chapter 4 for further detail on concepts of
used to restore mobility of the following:
treatment using MMS.
• the posterior dura
MMS techniques: posterior dura
• the anterior dura
The following techniques may be used to assess and treat
• the coccyx
the mobility of the posterior dura. The astute reader may
• the anterior sacral fascia. remark that these techniques may also be considered a way
to release tension in the Superficial Back Line of fascia
As well, the following MMS balancing techniques will (SBL) that encompasses the erector spinae muscles. The
be described: difference is in the depth of the technique and the inten-
• balancing the falx cerebri and the tentorium cerebellum tion of the therapist – the posterior dura is deeper than that
of the fascia of the SBL of the back.
• balancing the occiput with the sacrum.
Indications for these techniques include the following: MMS posterior dura: thoracolumbar junction in
relation to S2/3 (Figures 7.3, 7.4)
• trauma to the head (post concussion)
• trauma or surgical techniques involving the dura (for
example, post epidural)
• fall on the buttocks or the coccyx
• recurrent tension in the slump and/or ULNT position
despite using slider or tensioner techniques.
Please note that treatment of the craniosacral system, an
osteopathic approach, may also be necessary for full resolu-
tion of the patient’s head pain. Despite my initial skepticism,
I have found this approach invaluable for treatment of head
pain. The scope of this book does not cover this method,
although the balancing techniques described below are
based on some of the craniosacral techniques.

For this chapter, we will be using primarily the first con-
cept of treatment for using MMS techniques. However,
instead of choosing a recurrent articular dysfunction or
myofascial trigger point, the therapist will anchor onto the
areas of the dura that have a tendency to bind down when
its mobility is impaired. If early tension is found between
Figure 7.3
the hands of the therapist, the following approaches may be
Posterior dura – hand position P/A S2/3 ®
used, depending on how the tissues respond:
105
Chapter 7
Figure 7.4
Posterior dura – P/A S2/3 ® + Th/L
Stabilizing hand The patient is in prone position. The

therapist anchors onto the Th/L junction (T11–L1) via MMS posterior dura: mid-thoracic spine in relation
a cranially directed P/A on the right side of the spinous to S2/3 (Figure 7.5)
process. The inferior aspect of the spinous process pro-
vides a perfect “hook” that the therapist can use to stabi- Stabilizing hand The therapist anchors onto the mid-Thx
lize this level. region (T4–6) via a cranially directed P/A on the right side
Mobilizing hand The therapist then applies a P/A pres- of the spinous process. The inferior aspect of the spinous
sure to the right S2/3 region of the sacrum. process provides a “hook” that the therapist can use to sta-
bilize this level.
If the posterior dura is tethered at this level, the thera-
Mobilizing hand The therapist then applies a P/A pres-
pist will perceive an immediate increase in pressure on
sure to the right S2/3 region of the sacrum, as per the previ-
the thumb that is stabilizing the right side of the spinous
ous technique. If the posterior dura is tethered at this level,
process of T11 (and/or T12, L1), at the same time that a
the therapist will perceive this as an immediate increase
gentle P/A pressure of S2/3 is performed (Figure 7.4). The
in pressure on the thumb stabilizing the right side of the
patient perceives this as the therapist pushing harder on
spinous process of T4 (and /or T5, T6), at the same time
T11, when, in reality, the therapist is simply preventing
that a gentle P/A pressure of S2/3 is performed. Similar
T11 from moving caudally. The therapist may use oscil-
concepts for mobilizing this line of fascia apply as per the
lations at S2/3 (grade IV− to grade IV to grade IV+) until
previous technique.
no further increase in tension is perceived at T11. This
may be repeated for levels T12 and L1 if tension is found This technique may be repeated for levels T5 and T6 if
at these levels. tension is found at these levels.
106
Dural mobility
Figure 7.5
Posterior dura – P/A S2/3 ® +
mid-Thx
above. If the posterior dura is tethered at this level, the thera-

MMS posterior dura: C2 in relation to S2/3 (Figure 7.6) pist will perceive an immediate pressure on the thumb stabi-
lizing the right lamina of C2, at the same time that a gentle
P/A pressure of S2/3 is performed. The patient perceives this
Stabilizing hand The therapist anchors onto C2 via a uni-
as the therapist pushing harder on C2, when, in reality, the
lateral P/A pressure on the right side of the lamina of C2.
therapist is simply preventing C2 from moving into right
Mobilizing hand The therapist then applies a P/A pressure rotation relative to C3. Similar concepts for mobilizing this
to the right S2/3 region of the sacrum, as per the technique line of fascia apply as per the previous technique.
Figure 7.6
Posterior dura – P/A S2/3 ® + C2
107
Chapter 7
MMS posterior dura: occipital flexion in relation to MMS posterior dura: thoracolumbar junction in
S2/3 (Figure 7.7) relation to L5/S1 (Figure 7.8)
Figure 7.7
Posterior dura – P/A S2/3 ® + Occ flex
Stabilizing hand The therapist anchors onto the ipsilat-

Stabilizing hand The therapist anchors onto the Th/L
eral occiput via a cranially directed P/A pressure on the
junction (T11–L1) as per the technique for the posterior
right side of the occiput. An area about 2 cm square may be
dura in relation to S2/3.
explored at the occiput using this technique.
Mobilizing hand The therapist then applies a caudally
directed P/A pressure to the center of the sacrum using
sure to the right S2/3 region of the sacrum, as per the
their forearm, looking for the immediate line of tension
previous technique. If the posterior dura is tethered at
between their two hands. If the posterior dura is tethered
this level, the therapist will perceive this as an immediate
at this level, the therapist will perceive an increase in pres-
increase in pressure on the thumb stabilizing the occiput,
sure on the thumb that is stabilizing the right side of the
at same time that a gentle P/A pressure of S2/3 is per-
spinous process of T11 (and /or T12, L1), at the same time
formed. The patient perceives this as the therapist “push-
that a gentle caudal P/A pressure of L5/S1 is performed. The
ing harder” on the occiput, when, in reality, the therapist
is simply preventing the occiput from moving caudally.
T11, when, in reality, the therapist is simply preventing T11
Similar concepts for mobilizing this line of fascia apply as
from moving caudally. The therapist may use oscillations at
per the previous technique.
L5/S1 (grade IV− to grade IV to grade IV+) until no further
The above techniques may also be explored in relation increase in tension is perceived at T11. This may be repeat-
to the lumbosacral junction, an area that is frequently ed for levels T12 and L1 if tension is found at these levels.
involved in tethering of the posterior dura. The example
MMS techniques: anterior dura
below shows how the above technique may be altered to
work this particular interface. It can be used for the mid- The following techniques may be used to assess and treat
thoracic region, as well as for C2 and the occiput. the mobility of the anterior dura. The anterior dura is
108
Dural mobility
Figure 7.8
Posterior dura – P/A caud sacrum +
Th/L
considered part of the Deep Front Line of fascia (DFL),

which may be tensioned via knee flexion in prone, as well
as by adding dorsiflexion/eversion of the ankle (which ten-
sions the tibialis posterior muscle, the tail end of the DFL).
MMS anterior dura: thoracolumbar junction in

relation to ipsilateral knee flexion +/– dorsiflexion/
eversion ankle (Figure 7.9)
Stabilizing hand The therapist anchors onto the Th/L

junction (T11–L1) via a cranially directed P/A on the right
side of the spinous process. The inferior aspect of the
spinous process provides a “hook” that the therapist can
use to stabilize this level.
Mobilizing hand The therapist then performs a pas-
sive physiological movement of right (ipsilateral) knee
flexion, looking for the immediate increase in tension
of the stabilizing hand. If the anterior dura is tethered Figure 7.9
Anterior dura – DF/EV + knee flex + Th/L
at this level, the therapist will perceive this as an imme-
diate increase in pressure on the thumb stabilizing the
right side of the spinous process of T11 (and /or T12, L1),
until no further increase in tension is perceived at T11.
before 90 degrees of knee flexion has been achieved. The
This may be repeated for levels T12 and L1 if tension is
found at these levels.
T11, when, in reality, the therapist is simply preventing
T11 from moving caudally. The therapist may use repeat- Progression Once 90 degrees of knee flexion has been
ed passive physiological movements of knee flexion in an attained without a corresponding increase in tension at the
oscillatory manner (grade IV− to grade IV to grade IV+) Th/L levels, the therapist may then progress the technique
109
Chapter 7
by adding passive physiological dorsiflexion/eversion of

the ipsilateral ankle at 90 degrees of knee flexion. As per MMS anterior dura: C2 in relation to ipsilateral knee
the above technique, the similar concept of perceiving an flexion +/– dorsiflexion/eversion ankle (Figure 7.11)
increase in tension at the stabilizing hand exists, and is
treated in a similar manner.
MMS anterior dura: mid-thoracic spine region in

relation to ipsilateral knee flexion +/– dorsiflexion/
eversion ankle (Figure 7.10)
Figure 7.11
Anterior dura – DF/EV + knee flex + C2
Stabilizing hand The therapist anchors onto C2 via a uni-

lateral P/A pressure on the right side of the lamina of C2, as
per the technique for the posterior dura in relation to S2/3.
Figure 7.10
Mobilizing hand The therapist then performs a passive
Anterior dura – DF/EV + knee flex + mid Thx physiological movement of right (ipsilateral) knee flexion,
looking for the immediate increase in tension of the stabi-
lizing hand. If the anterior dura is tethered at this level, the
Stabilizing hand The therapist anchors onto the mid- therapist will perceive an immediate increase in pressure
thoracic spine region (T4–6) via a cranially directed P/A on on the thumb stabilizing the right side of the lamina of C2
the right side of the spinous process, as per the technique before 90 degrees of knee flexion has been achieved. The
for the posterior dura in relation to S2/3. patient perceives this as the therapist pushing harder on C2,
Mobilizing hand The therapist then performs a passive when, instead, the therapist is simply preventing C2 from
physiological movement of right (ipsilateral) knee flexion, moving into right rotation relative to C3. The therapist may
as per the technique above. Similar concepts for mobilizing use repeated passive physiological movements of knee flex-
this line of fascia apply. This may be repeated for levels T5 ion in an oscillatory manner (grade IV– to grade IV to grade
and T6 if tension is found at these levels. IV+) until no further increase in tension is perceived at C2.
Progression As per the above technique, the thera- Progression As per the above technique, the thera-
pist may then progress the technique by adding passive pist may then progress the technique by adding passive
physiological dorsiflexion/eversion of the ipsilateral physiological dorsiflexion/eversion of the ipsilateral
ankle at 90 degrees of knee flexion. It is treated in a ankle at 90 degrees of knee flexion. It is treated in a
similar manner. similar manner.
110
Dural mobility
MMS techniques: coccyx

MMS anterior dura: occiput in relation to ipsilateral
knee flexion +/– dorsiflexion/eversion ankle The following techniques may be helpful in cases of coc-
(Figure 7.12) cydynia as well as in problems with dural mobility.
MMS A/P coccyx on the right + P/A base of sacrum

on the right (Figures 7.13, 7.14)
Figure 7.12
Anterior dura – DF/EV + knee flex + Occ
Stabilizing hand The therapist anchors onto the ipsilat-

eral occiput via a cranially directed P/A pressure on the
right side of the occiput. An area about 2 cm square may be
explored at the occiput using this technique.
Mobilizing hand The therapist then performs a passive Figure 7.13
physiological movement of right (ipsilateral) knee flexion, MMS A/P coccyx on the right + P/A base of sacrum on
looking for the immediate increase in tension of the stabiliz- the right – skeleton
ing hand. If the anterior dura is tethered at this level, the ther-
apist will perceive an immediate increase in pressure on the Stabilizing hand The patient is in a left side-lying
thumb stabilizing the right occiput before 90 degrees of knee position. The therapist gently anchors onto the anterior
flexion has been achieved. The patient perceives this as the aspect of the right side of the coccyx using their third
therapist pushing harder on the occiput, when, in reality, the digit and performs a unilateral A/P pressure on the right
therapist is simply preventing the occiput from moving cau- side of the coccyx.
dally. Similar concepts for mobilizing this line of fascia apply.
Progression As per the above technique, the thera- sure to nutate the right side of the sacrum (right S1 seg-
pist may then progress the technique by adding passive ment) using the pisiform area of the cranial hand, and
physiological dorsiflexion/eversion of the ipsilateral ankle at looks for the immediate line of tension between the two
90 degrees of knee flexion. It is treated in a similar manner. hands. If the dura is tethered at this level the therapist will
111
Chapter 7
Figure 7.15
MMS A/P coccyx + P/A Th/L – skeleton
Figure 7.14
MMS A/P coccyx on the right + P/A base of sacrum on
the right
perceive this as immediate pressure on their third digit

performing the A/P on the coccyx, at the same time that
a gentle P/A pressure of the right S1 is performed. The
patient perceives this as the therapist pulling harder on
coccyx, when, in reality, the therapist is simply prevent-
ing the coccyx from moving anteriorly. The therapist may
use oscillations at the right sacral base (grade IV– to grade
IV to grade IV+) until no further increase in tension is
perceived at the coccyx. For sensitive patients, a non-oscil- Figure 7.16
MMS A/P coccyx + P/A Th/L junction
latory or “listening” technique may be more appropriate
for this region.
Progression The stabilizing hand remains the lying position. In addition, the coccyx A/P maneuver
same. The mobilizing hand may explore other areas may be performed centrally, with the patient lying on
where the dura may bind down, such as the Th/L area either side.
(Figures 7.15, 7.16), the mid-Thx area, C2 and the occiput Balancing the falx cerebri and the tentorium
(not shown). cerebellum
The technique above may also be performed on the The following techniques are useful to help balance the
left side of the coccyx with the patient in a right side- dura within the cranium. They are a way to integrate the
112
Dural mobility
entire dura, from the cranium to the feet. These tech- • Hold 2: occiput/frontal-nasal (alternate hold)
niques are also very useful at the end of an MMS treat- (Figure 7.18)
ment for any part of the body, and, in particular, for those
The therapist’s second and third digits are on either side of
patients who are prone to headaches and/or have highly
the frontal bone next to the nasium (fronto-nasal sutures).
reactive nervous systems.
The therapist’s caudal hand cups the occiput. Both hands
pull gently in a cranial direction.
Balancing the falx cerebri
As the therapist maintains their position on the patient’s
cranium, movement from below is added:
There are two basic positions of the therapist’s hands that
may be used to connect to the dura and falx cerebri within
the cranium. The hand-holds are the stabilizing aspect of
these techniques. Either or both may be used.
• Hold 1: occiput/ethmoid (Figure 7.17)
The middle finger of the therapist’s cranial hand is on
the glabella, an indentation felt on the frontal bone, the
index and ring ringers on either side of the frontal bone
in line with the glabella. The therapist’s caudal hand cups
the occiput. Both hands pull gently in a cranial direction.
Figure 7.18
Balancing the falx cerebri – hold 2: occiput/frontal-nasal
A. Add ankle dorsiflexion and plantarflexion

(Figures 7.19, 7.20)
The therapist maintains a cranial glide of both hands as the

patient performs active ankle dorsiflexion (DF) and plan-
tarflexion (PF). If the falx cerebri is tight, the therapist will
feel that the tissues under their hands will want to move
in a caudal direction with ankle PF. The therapist main-
tains the hold with both hands towards a cranial direction
Figure 7.17 until a softening of the system is perceived. The client then
Balancing the falx cerebri – hold 1: returns to DF, and the therapist may feel that both hands
occiput/ethmoid can glide a little more cranially. The slack of the tissues in a
cranial direction is taken up by the therapist as the patient
113
Chapter 7
Figure 7.19
Falx cerebri + ankle DF
Figure 7.20
Falx cerebri + ankle PF
continues to actively DF and PF the ankles; this is repeat- The same hold on the head is maintained as per tech-
ed until no further change is perceived in the therapist’s nique A; however, the patient is asked to actively move his/
hands. It generally requires approximately five or six cycles her eyes in a variety of directions. For the falx cerebri the
of ankle DF/PF. most common restriction is noted with movement of the
eyes in a cranial or caudal direction.
B. Add eye movement
Falx cerebri with eye movement up (Figure 7.21)
The muscles of the eyes have strong fascial connections
to both the falx cerebri and the tentorium cerebellum. As While the therapist maintains the cranial hold above, the
such this can be used to mobilize these fasciae inside the patient moves his/her eyes up towards the top of the head.
cranium, in particular when the patient complains of pain Usually this movement increases the slack on the falx,
related to movement of the eyes and with reading. allowing the therapist to further glide these tissues in a
cranial direction.
114
Dural mobility
While the therapist maintains the cranial hold above, the

patient moves his/her eyes down toward their feet. This
movement usually increases the tension on the falx. The
therapist perceives this tension as a tendency for both of
their hands on the cranium wanting to move in a caudal
direction. The patient perceives this tension as the therapist
pulling harder in a cranial direction. The therapist simply
maintains the original tension of the falx in a cranial direc-
tion until a softening of the system is perceived. Movement
of the eyes up and down is repeated until the therapist per-
ceives no further increase in tension with eye movement.
Falx cerebri with both ankle and eye movement

together (feet and eyes up/feet and eyes down)
This technique is a progression of the technique described

Figure 7.21
above. If both ankle dorsiflexion and plantarflexion and
Falx cerebri with eye movement up eye movement up and down no longer increase the tension
on the cranium, the therapist may proceed with the com-
bined technique below.
Falx cerebri with eye movement down (Figure 7.22) While the therapist maintains the cranial hold above,
the patient moves his/her eyes up toward the top of the
head at the same time as active dorsiflexion of the ankles
is performed. Usually this movement increases the slack
on the falx, allowing the therapist to further glide these
tissues in a cranial direction. The patient is then asked to
move the eyes down toward their feet at the same time as
active plantarflexion of the ankles is performed. Usually
this movement increases the tension on the falx. The thera-
pist perceives this tension as a tendency for both of their
hands on the cranium wanting to move in a caudal direc-
tion. At the same time, the patient perceives this tension
as the therapist pulling harder in a cranial direction. The
therapist simply maintains the original tension in a cranial
direction until a softening of the system is felt. Movement
of the eyes up with ankle dorsiflexion and eyes down with
ankle plantarflexion is repeated until the therapist senses
no further increase in tension with this combination of
movement. (This technique is not pictured.)
Figure 7.22 The falx cerebri can also be mobilized in relation to the
Falx cerebri with eye movement down DFL of fascia by adding dorsiflexion/eversion of the ankle
and inspiration to move the diaphragm.
115
Chapter 7
fascia. If the DFL is tight, this movement will increase the

Falx cerebri with tension of the DFL: DF/eversion + tension on the falx. The therapist perceives this tension as
deep inspiration (Figure 7.23) a tendency for both of their hands on the cranium wanting
to move in a caudal direction. The patient perceives this
tension as the therapist pulling harder in a cranial direc-
tion. The therapist simply maintains the original tension
in a cranial direction until a softening of the system is per-
ceived. Movement of both ankles in and out of combined
dorsiflexion/eversion is repeated until the therapist per-
ceives no further increase in tension with eye movement.
Progression This technique may be progressed by asking
the patient to take a deep breath in at the same time as he/
she performs active dorsiflexion/eversion of the ankles.
The deep breath activates the diaphragm, which is also an
important part of the DFL.
Balancing the tentorium cerebellum within

the cranium
“Ear-pull” technique for the tentorium cerebellum

(Figure 7.24)
Figure 7.23
Falx cerebri with tension of the DFL – DF/eversion +
deep inspiration
Figure 7.24
“Ear-pull” technique for the tentorium cerebellum
While the therapist maintains the cranial hold, the patient
moves both ankles into a combined movement of dorsi- The ear-pull technique is commonly taught in the crani-
flexion/eversion, which increases tension on the DFL of osacral approach to treatment. It is a way to improve
116
Dural mobility
mobility of the temporal bones as well as the tentorium

cerebellum, a horizontal fascia on either side of the falx
cerebri that encompasses the cerebellum and attaches to the
falx cerebri within the cranium (Magoun 1976). The falx
cerebri is continuous with the dura and may be affected by
tension in the tentorium cerebellum.
The technique is performed as follows: the patient

is lying in a supine position. The therapist’s thumbs are
inside the ear canal, and care is taken not to block the
canal. The therapist’s fingers gently grasp the posterior
aspect of the ears, as close to the cranium as possible. The
therapist then gently pulls simultaneously in three direc-
tions (posterior, inferior, lateral) at a 45 degree angle until
the slack of the tissues between the two hands is taken up.
If there are no articular restrictions of the sutures around
Figure 7.25
the temporal bone, the therapist should have a membra- Eyes to the right while maintaining “ear-pull”
nous end-feel between their two hands. This membranous
feel is considered optimal.
Fascia around the eye muscles and the optic nerve is inti-
mately related to the intracranial fascia; therefore, restric-
tions in mobility of the fasciae in this area may contribute
to dysfunctions of eye movement. This may translate clini-
cally as difficulty with reading and headache. Adding eye
movement to the ear-pull technique is a way to mobilize
this intracranial interface.
Add eye movement (Figure 7.25–7.27)

The therapist maintains the pull on the ears as the
patient actively moves the eyes to the right. Ideally, the
therapist should feel no increase in tension of the tento-
rium cerebellum with eye movement. If there is tension
in the tentorium, it will be perceived by the therapist
Figure 7.26
as an increase in tension of the hand holding the left
Eyes to the left while maintaining “ear-pull”
ear – as if the tissues on the left ear will want to “pull
in” to the cranium at the same time as the patient moves
the eyes to the right. The therapist simply maintains the no further change is felt between the therapist’s hands as
ear-pull, but the patient perceives it as the therapist pull- the patient moves the eyes to the right.
ing harder on the left ear. The position is maintained
until a softening in the system is perceived. The patient Other directions may also be added, such as moving the
then brings the eyes back to the center. This action gen- eyes to the left. If the right tentorium cerebellum is tight,
erally needs to be repeated only two to three times, until the therapist will feel an increase in tension of the right
117
Chapter 7
Figure 7.27
Eyes to the right and up in a diagonal while maintain-
ing “ear-pull”
ear. Generally speaking, moving the eyes up or down has

little effect on the tentorium cerebellum. However, mov-
ing the eyes in a diagonal direction often increases the pull
and is worked in a similar way to that described above. The
diagonal directions to be explored are as follows:
• up to the right corner
• down to the right corner
• up to the left corner
• down to the left corner.
Ear-pull with tension of the DFL: dorsiflexion/

eversion + deep inspiration (Figure 7.28)
Figure 7.28
The tentorium cerebellum may also be affected by move- With tension of the DFL – DF/eversion + deep inspira-
ments of the DFL of fascia (dorsiflexion/eversion + deep tion while maintaining “ear-pull”
inspiration). While the therapist maintains the ear-pull,
the patient moves both ankles into a combined movement
of dorsiflexion/eversion, which tensions the DFL of fascia. tension as the therapist pulling harder on the ears. The
If the DFL within the cranium is tight, this movement will therapist simply maintains the original tension in a poste-
increase the tension on the tentorium cerebellum. The ro-inferior-lateral (PIL) direction until a softening of the
therapist perceives this tension as a tendency for one or system is perceived. Movement of both ankles in and out
both of the hands on the temporal bones wanting to move of combined dorsiflexion/eversion is repeated until the
towards the center of the head. The patient perceives this therapist perceives no further increase in tension.
118
Dural mobility
Balancing the occiput with the sacrum which the occiput is felt to move into physiological cra-
nial flexion and extension but the sacrum is stagnant;
The craniosacral mechanism is hypothesized to work based
that is, it does not exhibit the gentle physiological rocking
on a reciprocal tension membrane system. During the phase
motion of nutation and counternutation that occurs with
of physiological cranial flexion, the sacrum should move
cranial flexion and extension. This stagnation may occur
into counternutation; that is, the base of the sacrum should
after a fall on the buttocks or a blow on the head. Another
tilt posteriorly as the apex of the sacrum moves anteriorly.
dysfunction is one in which the occiput and the sacrum
The opposite occurs during the cranial extension phase – the
do not move synchronously; that is, as the occiput moves
sacrum moves into nutation (Figure 7.29).
into cranial flexion, the sacrum nutates and vice versa.
This rhythmical movement occurs at a frequency of The following technique can resolve both of these issues.
between 8 and 14 cycles per minute, according to the
craniosacral approach, and can be readily palpated by Occiput-sacral balancing (Figure 7.30)
trained therapists. A common dysfunction is one in
Figure 7.29
Axis of Craniosacral mechanism: during
rotation the flexion phase of the craniosacral
Flexion Dural membrane Axis of movement, the sacrum should move
rotation into counternutation as the occiput
moves into cranial flexion (similar to
the biomechanics of craniovertebral
Sacrum Flexion Occiput
extension movement but with a dif-
ferent axis of motion)
Figure 7.30
Occiput-sacral balancing
119
Chapter 7
The therapist faces the back of the patient, who is in a side- at the sacrum and/or the occiput from going back into
lying position. This is a central technique so either side- the direction from which they came. The tension tends
lying position may be used. to build up gradually and then suddenly releases, often
within a minute. This release is accompanied by a fluid-
One hand cups the occiput, with the palm of the like feel and often, a therapeutic pulse.
hand or the therapist’s fingers as close as possible to the
base of the occiput. The therapist’s other hand cups the MMS anterior sacral fascia
sacrum, with the palm of the hand as close as possible
to the sacral base (S1). The therapist sinks into the tis- This technique is demonstrated in Chapter 10 on MMS
sues, feeling the myofascial tissue release as they do so. techniques for the pelvic floor.
The therapist then applies a gentle but firm distraction
between their two hands until they feel the connection
Summary
between their two hands. This technique is best done The techniques in this chapter have focused on the myofas-
using sustained pressure. The idea behind a listening cial connections between the cranium and the pelvic floor,
approach is to load the fascial tissues; that is, estab- primarily the posterior and anterior dura and the tentori-
lish the first resistance in the line of tension, and then um cerebellum. These tissues are frequently problematic in
wait to see what the body wants to do with this tension. cases of persistent head pain, spinal pain, and pelvic floor
The therapist may feel the tension increase between the pain. These techniques are also valuable as a way to “calm
hands, with the body adding small micro-adjustments down” the nervous system post treatment. They are par-
in multiple directions. The sensation is similar to that of ticularly beneficial for those patients who tend to experi-
twisted elastic that is attempting to unwind itself. The ence treatment soreness or post-treatment headaches. The
therapist follows this unwinding, preventing the tissues next chapter will focus on techniques for the thorax.
120
The thorax 8
When treating the thorax, manual physiotherapists are The diaphragm
trained to assess and treat the thoracic zygapophysial
joints, the costotransverse and costovertebral joints, as The diaphragm, apart from its primary role in respiration,
well as the anterior sternochondral and costochondral has many other functions that affect the health of the body.
joints. The scapular and trunk muscles are assessed for It is important for spinal stability and plays a role in the
muscle imbalance issues, and a variety of techniques optimal functioning of the pelvic floor and the floor of the
may be used to decrease tone in hypertonic muscles, as mouth. It is also essential for proper organ function and
well as train/strengthen weak muscles. However, there for the function of the vascular and lymphatic systems, as
has been less emphasis on myofascial tissues that have the aorta, the inferior vena cava, and the esophagus all pass
a strong impact on the biomechanics of the thoracic through the diaphragm (Clifton-Smith & Rowley 2011).
rings, and therefore play a role in the optimal function- When the diaphragm functions properly, and allows even
ing of the thorax. These myofascial tissues include the distribution of breath into the lungs, it creates a balance
following: between the front and back body (Holly Herman, personal
communication).
• the diaphragm
An issue that has become common in modern times is
• the intercostal muscles
lack of tone in the diaphragm, and as a result, poor func-
• the muscles that connect the thorax to the scapula tion. As children we are constantly running, jumping,
(serratus anterior, serratus posterior) yelling, and singing: activities that keep the diaphragm fit
and functioning at top form. As we age and move toward
• the muscles that connect the thorax to the pelvis
a more sedentary lifestyle, the diaphragm experiences less
(quadratus lumborum, abdominal muscles, erector
demand and loses its tone. Following this pattern, a dia-
spinae muscles).
phragm that ought to comfortably move 5–6 inches verti-
These muscles form part of every line described in Tom cally might only move 1–3 inches.
Myers’s book, Anatomy Trains. If tension persists in these
Improper breathing patterns can create a variety of physio-
muscles despite using techniques to decrease tone and pro-
logical problems (reduced availability to oxygen, respiratory
mote muscle balance, then we must consider the myofas-
alkalosis, “anxiety breathing,” headaches, general fatigue,
cial lines related to the affected muscle.
etc.). These poor respiratory patterns can also have biome-
Indications for MMS for this chapter chanical implications as well, including restricted thoracic
spine movement, increased forward head posture, altered
1. Recurring thoracic pain despite the following treat- shoulder function and scapular mechanics, increased tone of
ment approaches: the erector spinae muscles and accessory breathing muscles
−− mobilization/manipulation of the thoracic spine (sternocleidomastoid (SCM), scalenes, upper trapezius) and
−− stabilization exercises for the thorax decreased pelvic floor strength, leading to potential instability
−− release of trigger points to the thoracic muscles of the lumbar spine (Clifton-Smith & Rowley 2011).
with manual or dry needling techniques.
2. Tension in the anterior thorax area (sternum, dia- Despite its complexities, at the end of the day, the
phragm, abdominals). diaphragm is simply a muscle. Like any other muscle in the
121
Chapter 8
body, it needs to be maintained in order to function at its • Those that are in relation to the mobility of the dura
best. The importance of breath in yoga practice encourages are described in Chapter 7.
proper tone in the diaphragm, which can increase lung • Those techniques that are in relation to the mobility
capacity, and, in turn, longevity. of the lumbar spine are found in Chapter 9 and those
Lack of mobility of the diaphragm may impact not in relation to the pelvic floor are found in Chapter 10.
only the vascular and digestive systems, but also the • The techniques that explore the thorax in relation
thoracic spine joints. Persistent thoracic pain may be to the shoulder girdle and upper extremity are de-
due to adhesions in the DFL of fascia, where there is scribed in Chapters 12 and 13.
insufficient play in the tissues between the thorax pos- These divisions are, of course, artificial, as the thoracic
teriorly and the diaphragm anteriorly. Similar issues myofascia, like all myofascial tissue, is a continuum, all
can occur with the thorax in relation to the pericardial the way from the top of the head down to the toes. The
tissues, as the pericardium attaches to anterior aspect of techniques introduced in this book have been sorted into
T4, T2, C6, and the thoracic rings. Any type of cardiac various regions simply to facilitate learning.
or abdominal surgery tends to exacerbate the tension in
these tissues. Postural analysis
A forward head posture is a frequent finding in the gen-
This chapter will focus on the myofascial connections
eral population and in particular with those suffering from
between the thorax and the pelvis and explore fascial lines
chronic spinal pain. As manual therapists, we are trained
that may be affected. These include the following:
to mobilize joints of the thoracic spine that are prone to
• antero-posterior fascia of the thorax in relation to the limitations with a forward head posture. The common
pericardium and the diaphragm (DFL) findings in the thorax are an increase in kyphosis, often
accompanied by articular restriction of the zygapophysial
• antero-posterior fascia of the cervicothoracic region in and costotransverse joints of the thorax. However, the mid-
relation to the pericardium and the diaphragm (DFL) thoracic region may also exhibit flatness, demonstrated by
a lack of flexion in this part of the thorax. In both cases,
• antero-posterior fascia of the thoracolumbar region in
the restriction may be articular (decreased antero-superior
relation to the pericardium and the diaphragm (DFL)
glide of the facet joints and/or decreased antero-superior
• iliacus fascia in relation to both the SFL and the DFL glide at the costotransverse joints for a flexion dysfunc-
tion; decreased postero-inferior glide of the facet joints
• quadratus lumborum fascia in relation to the Lateral
and/or decreased postero-inferior glide at the costotrans-
Line
verse joints for a extension dysfunction). Restrictions of the
• serratus anterior fascia thorax may also be due to non-optimal mechanics of the
thoracic rings. The ISM approach looks for areas of lateral
• serratus posterior inferior fascia. “ring shifts” in the thorax, indicating a ring that is rotated
Additional techniques that explore the thorax in relation in relation to the one above and/or below it.
to other areas of the body are discussed in other chapters: Regardless of the approach used (traditional manual
physiotherapy or the ISM approach), the therapist must
• The techniques that explore the thorax in relation to
also consider that restrictions in the thorax may also be
the cervical spine are described in Chapter 5.
myofascial in origin. Joint or muscle dysfunction can-
• Those that explore the thorax in relation to the cra- not fully explain all sources of restriction for the thorax.
nium and temporomandibular joint (TMJ) are de- For example, restriction of the SFL or DFL of fascia may
scribed in Chapter 6. maintain a forward head posture. This tension can develop
122
The thorax
as a result of trauma, including surgical scars to the The following approaches may be used, depending on
abdominal area. In addition, certain activities of daily liv- how the tissues respond:
ing such as excessive time spent in the sitting position for
• work with oscillations (grades III−, III, III+)
work or leisure activities, can be a factor in creating these
fascial lines of tension. • work with sustained pressure
If there is restriction in the Lateral Line of fascia, this • work with “harmonics” (Dr Laurie Hartman).
may create a lateral tilt or side shift of the thorax. If there Techniques applied in relation to serratus anterior respond
is restriction of the Spiral Line of fascia, it may also con- particularly well to the release with awareness (RWA)
tribute to a lateral tilt or side shift of the thorax, as well approach. This is the fourth treatment concept for MMS
as unilateral tension in the abdominal oblique muscles. It that is outlined in Chapter 4. Please refer to this chapter for
may also impact the position of the scapula and therefore further detail on concepts of treatment using MMS.
function of the shoulder complex. Both of these lines may
Figure 8.1 depicts several layers of fascia found between
also contribute to scoliosis.
the sternum and the cervicothoracic and mid-thoracic spine:
Concepts of treatment using MMS • the superficial (investing) cervical fascia (which con-
For this chapter, we will be using primarily the first concept nects the hyoid bone to the sternum)
of treatment when using MMS techniques; that is, choose a • the deep cervical fascia, including:
recurrent articular dysfunction or myofascial trigger point −− the pre-trachial fascia (which surrounds the tra-
and explore a fascial line in relation to it. The therapist chea, esophagus, and thyroid and is continuous to
anchors him/herself to a recurrent articular dysfunction the mediastinum and pericardial fascia)
or myofascial trigger point and assesses the fascial lines of −− the pre-vertebral fascia (which surrounds the
tension in relation to the anchor, looking for early tension vertebral column and muscles in the posterior
between their two hands. cervical spine).
Pharynx
Buccopharyngeal fascia
Prevertebral fascia
Superficial (investing layer)

Esophagus
Fascia of infrahyoid muscles
Trachea Pretracheal fascia
Manubrium
Aorta
Pericardium
Figure 8.1
Fascial layers of the cervical spine
123
Chapter 8
Figure 8.1 helps the therapist understand the following

techniques that were developed to help restore the mobil-
ity of the fascia “in between” the anterior and the poste-
rior aspects of the body. Restoring mobility of these tissues
helps to decrease symptoms in the posterior thorax as well
as the front of the chest and abdomen. It may also facilitate
the correction of an excessive thoracic kyphosis.
MMS techniques: anterior/posterior thorax
A/P thorax on the right in relation to the

pericardium (DFL) (Figures 8.2–8.4)
Figure 8.3
MMS techniques ant/post thorax – stabilizing hold on
the thorax
Stabilizing hand The patient is in the left side-lying posi-

tion with the thorax and lumbar spine in a neutral posi-
tion, hips and knees bent.

MMS A/P thorax with lumbar spine neutral MMS A/P thorax in relation to the pericardium
124
The thorax
The therapist anchors onto the mid-thoracic region

(T3–10) via a caudally directed P/A on the right side of the A/P thorax in relation to the diaphragm (DFL)
spinous process. Note that this example is for the right side (Figure 8.5)
of the thorax – the left side of the thorax is treated similar-
ly, but with the patient in right side-lying position and the
therapist stabilizing the left side of the spinous processes of
the mid-thorax region.
Mobilizing hand The therapist explores the area of the
pericardium, first by slowly sinking into the tissues pos-
terior to the sternum and then gently pushing in a caudal
direction, all the while maintaining the depth of the fas-
cial line posterior to the sternum. The therapist looks for
the angle where he/she perceives immediate tension in
the hand anchoring the mid-thoracic spine with a caudal
P/A pressure. The star concept is a useful approach to
determine which vectors pull the most on the stabilizing
hand. The tension may be felt most when the pericardial
tissues are pushed in a simple caudal direction, or caudal
Figure 8.5
to the right of the client or caudal to the left. Sometimes
MMS A/P Thx in relation to the diaphragm
the tension is most apparent when moving the pericar-
dial tissues mediolaterally or in a clockwise/counter-
clockwise direction, always maintaining the depth of the The three previous techniques can be explored equally in
tissue. The patient perceives this tension as the therapist relation to the diaphragm.
pushing harder on the thoracic vertebra when, in reality,
the therapist is simply preventing the thoracic spinous Stabilizing hand As per the technique above.
process from moving. If no tension is perceived, then Mobilizing hand The caudal hand explores the anterior
this part of the DFL of fascia in relation to the thorax diaphragm area with a caudal/lateral glide of the tissues,
is not tight. If tension is perceived (quick resistance is always looking for the immediate line of tension between
felt between the two hands of the therapist), then it can the two hands of the therapist. Appropriate depth of tissues
be mobilized as per the approaches outlined in Chapter is required. The fascia around the rectus abdominis and
4. (The therapist maintains the pressure on the spinous oblique abdominal muscles may be accessed with this tech-
process of the thorax to prevent it from moving as he/she nique if the technique is done superficially. (This would be
performs repeated A/P mobilizations of the pericardial a technique for the SFL.) However, in order to access the
fascia in the direction(s) of most restriction.) This may diaphragm, which is part of the DFL, the therapist must
be repeated for all thoracic levels if tension is found at first slowly sink into the tissues posterior to the lower ribs
these levels. and then gently push in a caudal/lateral direction. This
125
Chapter 8
technique can be done with either the ipsilateral or the

contralateral diaphragm.
Progression The above techniques may be repeated in the
same side-lying position but the DFL of fascia is pre-tensed
by placing the hips at 0 degrees of extension, the knees
flexed at 90 degrees of flexion (Figure 8.6).
Figure 8.7
MMS A/P C/Thx region
develop trigger points, which may result in referred symp-

toms similar to the thoracic outlet syndrome and/or the
carpal tunnel syndrome. Hypertonic scalene muscles may
also maintain pain and dysfunction in the C/Thx region.
For this technique, the therapist anchors onto the C/Thx
region (C7–T2) via a caudally directed P/A on the right
side of the spinous process. The therapist may also explore
anchors on the upper ribs, usually at the level of the costo-
transverse joint. (The technique may also be performed on
the left side.) The mobilizing hand explores the pericardial
fascia as per the previous technique.
MMS techniques A/P thoracolumbar region

(DFL) (Figure 8.8)
Figure 8.6 The technique above may also be adapted to use with persis-
MMS A/P Thx with tension on the DFL (hips extended/
tent Th/L dysfunction. In an upper chest breathing pattern,
knees flexed)
the diaphragm does not move downward (shorten). This pat-
tern may result in overactivity of the erector spinae muscles,
which may lead to hyperlordosis, with increased tone at the
MMS techniques A/P cervicothoracic region Th/L junction. The lower ribs tend to point upwards rather
(DFL) (Figure 8.7) than remaining in a more caudad position. For this technique,
The technique above may also be adapted to use with per- the therapist anchors onto the Th/L region (T11 and T12) via
sistent C/Thx dysfunction. When the diaphragm does a caudally directed P/A on the right side of the spinous pro-
not function optimally, the patient tends to develop an cess. (The technique may also be performed on the left side.)
upper chest breathing pattern. The scalene muscles, in The mobilizing hand explores the pericardial fascia as per the
their attempt to compensate, can become overactive and previous technique or the anterior diaphragm.
126
The thorax
the muscles maintaining this ring shift as well as muscle

reeducation patterns to re-train thoracic rotation. Again
he noted improvement in his symptoms but he still had
a low-grade ache especially with sleeping supine and
at the end of his working day. He was then referred to
me for an assessment of the fascial system and the fol-
lowing was noted:
• a pes cavus deformity anteriorly (from birth)
• A/P MMS techniques for the mid-thorax were very
tight bilaterally and reproduced his thoracic pain
(even with his hips and knees flexed 45 degrees)
Figure 8.8 • A/P mid-Cx MMS techniques in relation to the

MMS A/P Th/Lx region DFL (pericardium and diaphragms) also very tight,
reproducing cervical pain, an occasional com-
plaint of his (see Chapter 5 for technique)
• A/P C/Thx and Th/L MMS techniques also prob-
lematic, although less than the mid-thoracic
Case report 8.1 Mac’s story*
techniques.
This 54-year-old musician complained of chronic deep These dysfunctions were treated with MMS techniques
ache in the mid-thoracic region, exacerbated by work- in the side-lying position, and later, progressed by plac-
ing at his computer, playing his guitar, and sleeping ing the hips in 0 degrees of extension, with knees at
supine with legs straight. There was no history of trau- 90 degrees flexion to increase tension on the DFL.
ma and his symptoms had occurred gradually over the Ultimately, we used suction cups to the area of his pes
past five years. His radiology reports were unremark- cavus with movement in a cranio-caudal direction,
able, with mild spondylosis reported. He had previ- and combined this with the MMS techniques for A/P
ously consulted a chiropractor and an osteopath, with mid-thorax in side-lying. This approach solved his long-
no results. He had also seen a manual physiotherapist standing chronic mid-thoracic ache and he could finally
who had mobilized the C/Thx and the mid-thoracic sleep supine with his legs straight without bringing on
regions to improve extension and rotations and had his symptoms. We could then surmise that his work
used dry needling to ease tension in the hypertonic (guitar playing and computer) as well as the pes cavus
extensors of his thoracic spine. This approach improved that he had from childhood, contributed to a tight DFL
his symptoms by about 50 percent but then his condi- of fascia. Perhaps the fascial tension between the peri-
tion plateaued. He was then seen by a therapist who cardium and diaphragm areas in relation to the cervical
had received training in the ISM approach. This thera- and mid-thoracic spine was a factor that maintained his
pist had noted a ring shift to the right (an intrathoracic chronic thoracic ache.
torsion left) at ring 4 with thoracic right rotation. This * Please note that the patient’s name has been changed
was treated with techniques to release the tension of to protect his privacy.
127
Chapter 8
MMS techniques iliacus there may be so much tension in this area that the t herapist
feels as though they are on a trampoline. Because the ili-
The diaphragm, psoas, iliacus, and quadratus lumborum acus is a wide muscle that lines the medial aspect of the
(QL) share a fascial connection at the lumbar vertebrae. ilium, several areas may be used as the anchor from which
When proper diaphragmatic breathing is not observed, the following techniques are explored and treated.
these muscles are prone to disuse, weakness, and trigger
point development – all of which can play a role in back Mobilizing hand The therapist’s left hand explores the
and hip pain (Clifton-Smith & Rowley 2011). These mus- opposite ilium, gently moving it toward “outflare” (an
cles also form a part of the DFL of fascia, but the iliacus osteopathic term that describes a movement of the ilium
also seems to have clinical correlations to the SFL and the in a latero-posterior direction), but with the star concept
Lateral Lines of fascia. in mind. The therapist looks for the angle where he/she
perceives immediate tension in the hand anchoring the
Indications for this technique are the following:
right iliacus. If this fascial line is tight, the therapist will
• pain in the area of the abdominal area feel an increase in tension in the anchoring hand, as if the
• restriction in hip extension – plateau with mobiliza- right iliacus muscle pulls in toward midline. The patient
tions of the hip capsule to increase extension; plateau perceives this change as the therapist increasing his/her
with techniques to stretch the psoas muscle pressure on the right iliacus. If tension is perceived (quick
resistance is felt between the two hands of the therapist),
• restriction in lumbar extension – plateau with mobili-
then it can be mobilized as per the approaches outlined in
zations to increase extension of the lumbar facet joints
Chapter 4. (The therapist maintains the pressure on the
• restriction in hip abduction (due to a tight DFL). right iliacus to prevent it from moving as he/she performs
repeated mobilizations to the left ilium in the direction(s)
MMS right iliacus with opposite ASIS (SFL) of most restriction.)
(Figure 8.9)
MMS right iliacus with opposite external oblique
(SFL)/anterior diaphragm (DFL) (Figure 8.10)
Figure 8.9
MMS right iliacus with opposite ASIS
Stabilizing hand The therapist gently places their right

Figure 8.10
thumb on the right iliacus muscle, exploring tension from MMS right iliacus with opposite EO (SFL)/anterior
the ASIS toward the symphysis pubis. The pressure is light diaphragm (DFL)
and is performed in a mediolateral direction. At times,
128
The thorax
Stabilizing hand As per the technique above. be mobilized as per the approaches outlined in Chapter 4.
This technique is also helpful for dysfunctions of the Lat-
eral Line of fascia.
area of the left external oblique (for the SFL) and/or the
left anterior diaphragm, which has a deeper palpation (for
the DFL), gently moving it in a cranio-lateral direction, MMS right iliacus with pericardium (DFL)
always with the star concept in mind. The therapist looks (Figure 8.12)
for the angle where he/she perceives immediate tension
in the hand anchoring the right iliacus. If tension is per-
ceived (quick resistance is felt between the two hands of the
therapist), then it can be mobilized as per the approaches
outlined in Chapter 4. This technique is also helpful for
dysfunctions of the Spiral Line of fascia.
MMS right iliacus with ipsilateral external oblique

(SFL)/anterior diaphragm (DFL) (Figure 8.11)
Figure 8.12
MMS right iliacus with pericardium (DFL)

area of the pericardium, first by slowly sinking into the tis-
sues posterior to the sternum and then gently pushing them
in a cranial direction, all the while maintaining the depth
of the fascial line (posterior to the sternum). Using the star
Figure 8.11 concept, the therapist looks for the angle where he/she per-
MMS right iliacus with ipsilateral EO (SFL)/anterior ceives immediate tension in the hand palpating the right
diaphragm (DFL) iliacus. That tension may be felt most in a simple cranial
direction, or cranial to the right of the client or cranial to
the left. Sometimes the tension is most felt when moving
the pericardial tissues medio-laterally or in a clockwise/
Mobilizing hand The therapist’s left hand explores the counter-clockwise direction, always maintaining the depth
area of the right external oblique (for the SFL) and/or the of the tissue. If no tension is perceived, then the DFL of
right anterior diaphragm (for the DFL), gently moving fascia in relation to this muscle is not tight. If this fascial
it in a cranio-lateral direction, always with the star con- line is tight, the therapist will feel an increase in tension in
cept in mind. The therapist looks for the angle where he/ the anchoring hand, as if the right iliacus muscle pulls in
she perceives immediate tension in the hand anchoring towards the midline and cranially. The patient perceives
the right iliacus. If tension is perceived (quick resistance this as the therapist increasing his/her pressure on the ilia-
is felt between the two hands of the therapist), then it can cus. Similar concepts for mobilizing this line of fascia apply.
129
Chapter 8
MMS right iliacus with ipsilateral symphysis pubis

(SFL) (Figure 8.13)
Figure 8.14
MMS right iliacus with lateral leg/ITB
immediate tension in the hand anchoring the right iliacus.

Figure 8.13
Similar concepts for mobilizing this line of fascia apply.
MMS right iliacus with ipsilateral symphysis pubis (SFL)
MMS right iliacus with medial leg/adductors (DFL)

Stabilizing hand As per the technique above. (Figure 8.15)
Mobilizing hand The therapist’s left forearm (or heel
of the hand) explores the area of the right symphy-
sis pubis, gently moving it in a caudo-medial direction,
always with the star concept in mind. The therapist
looks for the angle where he/she perceives immediate
tension in the hand anchoring the right iliacus. If ten-
hands of the therapist), then it can be mobilized as per
the approaches outlined in Chapter 4. This technique is
also helpful for mobilizing the fascia in the area of the
inguinal ligament.
MMS right iliacus with lateral leg/iliotibial band

(Lateral Line) (Figure 8.14)
Figure 8.15
MMS right iliacus with medial leg/adductors (DFL)
Mobilizing hand The therapist’s left hand explores the right
lateral thigh/iliotibial band (ITB), gently moving the tissues Stabilizing hand As per technique above.
in a caudal direction with an internal rotation component, Mobilizing hand The therapist’s left hand explores the right
always with the star concept in mind. The therapist looks for medial thigh/adductors, gently moving the tissues in a cau-
the angle and the area(s) on the thigh where he/she perceives dal direction, often with an external rotation component,
130
The thorax
always with the star concept in mind. The therapist looks for The therapist must ensure that the patient is comfortable,
the angle and the area(s) on the thigh where he/she perceives especially in relation to the lumbar lordosis. A footstool is
immediate tension in the hand anchoring the right iliacus. generally placed to support the patient’s legs, and the table
Similar concepts for mobilizing this line of fascia apply. must be lowered to the point where the patient is able to
comfortably tolerate the lordotic position of the spine.
Note that the iliacus fascia may also be explored in
relation to any abdominal scars from previous surgeries, The quadratus lumborum (QL) muscle is a frequent
including caesarean section scars. The scar itself may be source of recurrent tension in the area of the lower thoracic
relatively mobile but the scar in relation to the SFL or DFL and lumbar spine. This muscle may be overactivated if the
of fascia is frequently problematic. The anchor is then on lateral hip stabilizers are inadequate (primarily gluteus
the scar rather than the iliacus. Similar techniques may be medius). However, tension in the area of the QL may also
applied here. be maintained if the fascial lines related to this muscle are
Progressions There are two ways in which these iliacus tight. The QL may be explored in relation to the Lateral
techniques may be progressed. One is to pre-tense the DFL Line (upper quadrant technique is described below) and in
by asking the patient to actively dorsiflex/evert his ankles relation to the DFL (described in Chapter 9).
as the techniques are repeated. The other is by repeating
the techniques with the hips extended/knees flexed, as MMS techniques: right quadratus lumborum in
described below. relation to the lateral thorax (Lateral Line – upper
quadrant) (Figures 8.17, 8.18)
MMS right iliacus pre-tensed with hips extended/
knees flexed (Figure 8.16) Stabilizing hand The patient is in left side-lying posi-
tion with the hips and knees in neutral, the right shoulder
flexed. Using the right thumb, the therapist anchors onto
the right QL in three areas: the center of the belly of the
muscle, its origin at the 12th rib, and its insertion onto the
iliac crest. The anchor for the belly of the muscle is in a
lateromedial direction (toward the plinth). For the origin
of the muscle at the 12th rib, the anchor is also in a latero-
medial direction but also angled cranially. For the inser-
tion of the muscle at the iliac crest, the anchor is also in a
latero-medial direction but also angled caudally.
Mobilizing hand The therapist’s left forearm explores the
right lateral ribcage, always with the star concept in mind.
The therapist may explore moving the lateral ribcage in a
number of possible directions:
Figure 8.16 • in a cranial direction (toward the patient’s head)
MMS right iliacus pre-tensed with hips extended/
knees flexed • in a cranio-anterior direction (the therapist must
adjust their forearm to begin the maneuver slightly
posterior to the lateral ribcage), and/or
All of the techniques above for the iliacus may be repeated
with the patient’s body placed on the edge of the plinth, hips • in a cranio-posterior direction (the therapist must
at 0 degrees of extension and knees at 90 degrees of flexion adjust their forearm to begin the maneuver slightly
in order to pre-tense both the SFL and the DFL of fascia. anterior to the lateral ribcage).
131
Chapter 8
Figure 8.18
MMS right QL with lateral thorax (cranio-posterior
direction)
Figure 8.17
MMS right QL with lateral thorax (cranial direction) ing the right QL. If tension is perceived (quick resist-
ance is felt between the two hands of the therapist), then
Chapter 4.
Note that the directions of the mobilizing forearm
follow the diamond shape of the intercostal muscles. Note that the MMS techniques for the right QL in rela-
The ribcage may be explored in this manner, both in the tion to the Lateral Line for the lower quadrant are described
lower thoracic region and the middle thoracic region. in Chapter 9.
This is a general technique although it may also be used MMS techniques serratus anterior
in relation to a specific thoracic ring. The therapist
looks for the angle and the area(s) on the ribcage where The serratus anterior muscle is commonly implicated in dys-
he/she perceives immediate tension in the hand anchor- function of the scapula and shoulder complex, with weakness
132
The thorax
a common feature in scapular dyskinesia, particularly with

shoulder flexion. It is also frequently implicated in thoracic
ring dysfunction as a hypertonic fascicle of serratus anterior
may create a vector that pulls on the thoracic ring and makes
it difficult to perform isolated scapular movement independ-
ent of the thorax. It therefore impacts the mechanics of the
thoracic spine and shoulder girdle function.
If the serratus anterior is found to be problematic, a release

with awareness (RWA) approach works well. This is the
fourth treatment concept for MMS outlined in Chapter 4.
Release with awareness right serratus anterior

(Figure 8.19)
Release with awareness (RWA) is a biofeedback technique

developed by Diane Lee and L. J. Lee in which the patient
is an active participant. The patient is asked to bring their
awareness to the muscle being palpated and various imagery
cues are used to facilitate relaxation of the muscle. This
engagement of the patient occurs as the therapist is guid-
ing the release with feedback from their hands (Lee & Lee
2011). Please refer to Chapter 4 for a full description of this
technique. Figure 8.19
MMS right serratus anterior with thorax
Stabilizing hand The patient is in left side-lying posi-
tion with the hips and knees in neutral, the right arm by “see if you can find a way to allow my fingers to sink into
the side of the trunk or in a combined shoulder quad- the muscle.” At the same time, the therapist moves the
rant position, with the patient’s hand resting on his/ scapula to shorten origin and insertion (protraction),
her forehead. (This technique may also be performed diminishing tension on the muscle spindle. The thera-
in sitting.) Using the fingers of their right hand, the pist then waits, allowing the patient and his/her system
therapist gently palpates the fascicle of serratus anterior to cue into the release at the same time as the therapist
that is hypertonic. (Note: there may be more than one gives manual and verbal cues to let go. The verbal cue
fascicle in a given area of the lateral thorax and each “Let your scapula float back towards your spine” usually
fascicle should be explored from its anterior attachment works well here. Once maximum release is obtained,
on the rib as far back posteriorly towards the scapula as usually within 10–15 seconds, the muscle is gently taken
possible.) through a full stretch with scapular retraction, with the
Mobilizing hand The therapist’s left hand encom- therapist listening to its response and avoiding recur-
passes the patient’s right scapula, guiding it initially rence of overactivity. The therapist may then encourage
toward protraction, followed by retraction. As the thera- a release of the muscle fascicle in the direction of scapu-
pist provides manual input to the serratus anterior, the lar retraction, helping to release the “fuzz” of connective
patient is instructed to “soften the muscle,” “let it go,” tissue that has lost its ability to elongate.
133
Chapter 8
Stabilizing hand The patient is in left side-lying position

MMS right serratus posterior inferior (Figure 8.20) with the hips and knees in neutral. The therapist’s right
hand stabilizes the spinous processes of T11 to L3 with
a caudally directed P/A on the right side of the spinous
processes.
Mobilizing hand The therapist’s other hand explores the

lower thoracic rings, which may extend beyond ribs 9–12 if
we consider fascial connections. A release with awareness
technique may be performed here, as per the above example.
Another way to release this area is to use the first con-

cept of the MMS approach. In this case, the therapist’s right
hand explores the area of the lower thoracic ribs, gliding
them in a cranio-lateral direction, always with the star
concept in mind. The individual ribs may be explored indi-
vidually but a more global exploration of the lower ribs may
also be done. The therapist looks for the angle where he/
she perceives immediate tension in the hand anchoring the
Figure 8.20
MMS right serratus posterior inferior spinous process. If tension is perceived (quick resistance is
felt between the two hands of the therapist), then it can be
The serratus posterior inferior muscle is not typically
sought out by therapists who look for myofascial restric- Summary
tion that may impact the thorax and/or lumbar spine. The The techniques in this chapter have focused on the myofas-
serratus posterior inferior originates on the supraspinal cial connections in relation to the thoracic region, in par-
ligament, and the spinous processes of the upper two to ticular the pericardium, the diaphragm, iliacus, quadratus
three lumbar vertebrae (L1–3) and the lower two thoracic lumborum, serratus anterior and serratus posterior inferior
vertebrae (T11–12). It inserts on the lower borders of ribs 9 muscles. These tissues are frequently problematic in cases of
to 12 (latissimus dorsi lies above this muscle). Functionally, persistent thoracic, C/Thx, Th/L, anterior chest and abdom-
it is an accessory muscle of expiration that helps depress inal pain and should be explored using MMS techniques.
the ribs during exhalation. It may be a factor that limits
optimal lateral costal breathing and maintains tension The next chapter will focus on techniques for the lum-
throughout the Th/L area. bopelvic area.
134
The lumbar/pelvic region
9
When treating patients with problems in the lumbopel- should be no kinks, shifts, hinges, or transverse plane rota-
vic area, manual therapists are trained to assess and tions throughout the entire spinal curve (Lee & Lee 2011).
treat the joints of the lumbar spine, the sacroiliac joint,
and the symphysis pubis. In addition, the muscles of Restrictions in the various fascial lines may contribute to
the abdominal region, the posterior thoracolumbar and postural dysfunction. If there is restriction of the DFL of fas-
pelvic/hip muscles are assessed and treated for imbalance cia, this may help to maintain a forward head posture. This
between hypertonic, tight muscles and weak muscles of tension can develop as a result of trauma, including surgical
the lumbopelvic-hip area. However, mobilizing joints scars to the abdominal area. (One may think, for example,
and stretching and strengthening individual muscles can of the impact of caesarean section scars, old appendectomy
achieve only partial benefits if the fascial system is not tak- scars, hernia repairs, etc.). In addition, certain activities of
en into consideration. daily living, such as excessive time spent in the sitting posi-
tion for work or leisure activities, can be a factor in creating
This chapter will describe the clinical findings of restric- these fascial lines of tension. Because the pelvic floor mus-
tion in the following areas of fascial dysfunction: cles form part of the DFL this may also impact the mobility
and function of the hip joint. Restriction in the Lateral Line
• the thoracolumbar fascia
of fascia may create a lateral tilt of the lumbar spine or the
• the quadratus lumborum (QL) in relation to the pelvis. It may also become a contributing factor for recur-
Lateral Line and the DFL ring issues with the iliotibial band (ITB).
• the lateral sacral fascia in relation to the hip
Position of the pelvic girdle
• the sacrotuberous ligament in relation to the hip, the
SBL, and the DFL The pelvic girdle is assessed in the standing position, with
the therapist positioned directly behind the patient. Please
• the femoral nerve fascia. refer to Diane Lee’s and L. J. Lee’s book The Pelvic Girdle
for details on the postural assessment of the pelvic girdle
Indications for MMS for this chapter
(Lee & Lee 2011). The therapist’s hands palpate the anterior
1. Recurring lumbopelvic-hip pain despite the follow- aspect of the pelvis bilaterally and the therapist notes the
ing treatment approaches: resting position in three body planes (anteroposterior tilt,
−− mobilization/manipulation of the lumbar spine, lateral tilt, transverse plane rotation). The pelvic girdle as a
thorax, and sacroiliac joints unit should be neutral in all three planes: coronal, sagittal,
−− mobilization of the hip joint capsules and transverse. The innominates should not be rotated rel-
−− stabilization exercises for the thoracolumbar- ative to one another (no intrapelvic torsion (IPT)) and the
pelvic-hip area sacrum should not be rotated.
−− release of trigger points to the thoracolumbar-
pelvic-hip muscles with manual or dry needling Active range of motion tests
techniques. Lumbar movement testing should be performed before and
after MMS techniques, in order to evaluate the impact of
Postural analysis the techniques on ROM. These movements include lum-
In an optimal postural alignment, the primary spinal curves bar flexion, extension, rotation and side bending as well as
should be maintained (i.e., gentle lumbar lordosis, gentle, even combined movements. The therapist evaluates the quality
thoracic kyphosis and gentle, even cervical lordosis). There and quantity of movement as well as reproduction of any
135
Chapter 9
symptoms. The emphasis should be on movements that the two bones should move as a unit and there should be
most correspond to the patient’s functional problem(s). no anterior rotation of the ilium relative to the sacrum
(Lee & Lee 2011). Failed load transfer (FLT) may once
Functional tests again be due to poor dynamic stability of the lumbopel-
vic hip complex, as well as dysfunction above and below
Squat test
this region (ISM model). If the driver is indeed the pel-
Assessment of the pelvis with half squat vis, then it has to be evaluated more thoroughly.
If the subjective exam points to difficulty with squatting or These positional and functional tests may be used
sitting, then this functional test is required. The squat task before and after treatment with the MMS approach. Keep
may be used to assess control of the foot, knee, hip, lumbar in mind that fascial restrictions may inhibit the dynamic
spine, pelvis, or thorax. In this example, it is used to assess stabilizers of the lumbopelvic-hip complex from working
intrapelvic control. The therapist palpates the ilium with one optimally. If the OLS or squat test still shows FLT after
hand and the ipsilateral inferior lateral angle (ILA) with the releasing tight fascia in this area, then the therapist should
other hand. Note that the therapist’s entire hand is palpating assess and treat the muscles that help stabilize this region.
as much of the ilium as possible – the therapist avoids using
only the thumb at the posterior superior iliac spine (PSIS), Concepts of treatment using MMS
as this reduces the reliability of this palpatory test. The ILA
For this chapter, we will be using primarily the first concept
is used for palpation of the sacrum as it is more precise than
of treatment when using MMS techniques: that is, choose a
using the depth of the sacral sulcus (which is frequently
influenced by atrophy of the sacral multifidus muscle). If
and explore a fascial line in relation to it. The therapist
there is good strategy with a squat, the two bones should
anchors him/herself to a recurrent articular dysfunction
move as a unit and there should be no anterior rotation of
or myofascial trigger point and assesses the fascial lines of
the ilium relative to the sacrum. If anterior rotation of the
tension in relation to the anchor, looking for early tension
ilium does occur (a relative counternutation of the sacrum),
between their two hands.
it is termed failed load transfer (FLT) (Lee & Lee 2011).
The source of this FLT may be due poor dynamic stability The following approaches may be used, depending on
of the lumbopelvic hip complex, but it may also be due to how the tissues respond:
dysfunction above and below this region (ISM model). If the
driver is indeed the pelvis, then the pelvis has to be evaluated
more thoroughly. (Refer to Diane Lee’s and L. J. Lee’s book • work with sustained pressure
The Pelvic Girdle for details on the assessment of the pelvic
• work with “harmonics” (Dr Laurie Hartman).
girdle (Lee & Lee 2011).)
Refer to Chapter 4 for further detail on concepts of treat-
One leg stand test (OLS) ment using MMS.
If the subjective exam indicates difficulty with stand-
ing, walking, or running, then the functional test of a
MMS techniques for the thoracolumbar fascia
one leg stand (OLS) is required. The pelvic girdle may The thoracolumbar area is often an area with a tendency
be assessed in a similar way as for the squat test, but towards tightness, perhaps because it is the hub for a number
the functional movement assessed is one in which the of myofascial tissues, including the diaphragm. Tension in
patient shifts his/her weight onto one leg and lifts the this area can limit thoracic rotation and lumbar side-flexion,
other off the floor. The weight-bearing side is assessed especially if a plateau has been reached with mobilizations of
for FLT. Once again, if there is good strategy with a OLS, the appropriate facet joints and costotransverse joints.
136
of the Th/L fascia is not tight. If tension is perceived (quick

MMS for the right thoracolumbar fascia in relation resistance is felt between the two hands of the therapist),
to the opposite ilium (Functional Line) (Figure 9.1) then it can be mobilized as per the approaches outlined
in Chapter 4. (The therapist maintains the anchor on the
left ilium to prevent it from moving as he/she performs
repeated P/A mobilizations of the thoracolumbar area.)
MMS for the right thoracolumbar fascia in relation

to the ipsilateral ilium (Lateral Line) (Figure 9.2)
Figure 9.1
MMS for the right Th/L fascia I (Functional Line)
Stabilizing hand The patient is in prone position with the

lumbar spine in left side-flexion, the right shoulder in flex-
ion. The therapist stands on the left side of the patient. The
therapist anchors onto the area of the patient’s left ilium in
a caudal/lateral direction, using the star concept to anchor Figure 9.2
MMS for the Th/L fascia II (Lateral Line)
into the area of most tension.
Mobilizing hand Using the right hand, the therapist

Stabilizing hand The patient is in prone position as per
explores the area of the right lower thorax, gently gliding
the technique above. The therapist stands on the left side
the Th/L fascia in a craniolateral direction. The tension
of the patient. The therapist gently anchors onto the area of
may be felt most when pushing in the area of the facet joints
the patient’s right ilium in a caudal/medial direction, as if
or the ribs but we must keep in mind that we are not mobi-
pulling the ilium into posterior rotation.
lizing joints, but rather the fascia around these structures.
Once again, the star concept is a useful approach to deter- Mobilizing hand The therapist explores the area of the
mine which vectors pull the most on the stabilizing hand. right lower thorax with the right hand, gently gliding
The tension may be felt most when the Th/L tissues are the Th/L fascia as per the technique above. If this fas-
pushed in a simple cranial direction, or cranial to the right cial line is tight, the patient perceives this tension as the
of the client, or cranial to the left. The patient perceives this therapist pulling harder on the right ilium, especially on
tension as the therapist pushing harder on the left ilium the anterior portion of the ilium. This technique also
when, in reality, the therapist is simply preventing the ili- commonly reproduces the patient’s “sacroiliac” pain.
um from moving. If no tension is perceived, then this part In reality, the therapist is simply preventing the ilium
137
Chapter 9
from moving. Similar concepts for mobilizing this line Mobilizing hand Using the inferior aspect of the spinous
of fascia apply. processes as a lever, the therapist explores the central lower
thorax and upper lumbar spine with the other hand, gently
Sometimes the patient has tension and restriction in the
gliding the tissues in a cranial direction. The therapist may
central lumbar spine. If a plateau is reached using central
explore the area between L3 and T10 in this manner. (L4 and
P/A pressures on the spinous processes, then the follow-
L5 may be a little more difficult to do in this position because
ing fascial techniques may be explored. The first technique
of the lumbar lordosis.) Once again, the star concept is a use-
relates to the SBL of fascia. The second technique is a mod-
ful approach to determine which vectors pull the most on
ification of the first, in which the therapist uses various hip
the stabilizing hand. The tension may be felt most when the
movements to pre-tense the fascia.
Th/L tissues are pushed in a simple cranial direction, or cra-
nial to the right of the client or cranial to the left. The patient
MMS central sacral/thoracolumbar fascia (SBL) perceives this tension as the therapist pulling harder on the
(Figure 9.3) sacrum when, in reality, the therapist is simply preventing
the base of the sacrum from moving cranially. If no tension
is perceived, then this part of the Th/L fascia is not tight. If
tension is perceived (quick resistance is felt between the two
hands of the therapist), then it can be mobilized as per the
approaches outlined in Chapter 4.
MMS central sacral/thoracolumbar fascia + bilateral

hip abduction (Figure 9.4)
Figure 9.3
MMS central sacral/Th/L fascia (SBL)

lumbar spine in a neutral position. The therapist stands on
the either side of the patient. Using the palm of their hand, Figure 9.4
the therapist anchors onto the area of the patient’s sacral MMS central sacral/Th/L fascia + bilateral hip abduction
base with a P/A pressure in a caudal direction.
138
This is a variation of the technique above, as the therapist

explores the placement of the legs in a variety of positions,
depending on the patient’s functional complaints. In this
example, if the patient complains of low back pain with
horseback riding, it may be appropriate to add bilateral hip
abduction and examine its effect on the central Th/L fas-
cia. It is assessed and treated as per the previous technique.
MMS quadratus lumborum in relation to the Lateral

Line
The techniques below are used to release persistent tension

in the area of the right quadratus lumborum muscle (QL).
They may also be used to release tension in the ITB and/or
the lateral lower leg.
MMS right quadratus lumborum + Lateral Line

(lower quadrant) 1 (Figure 9.5)
Stabilizing hand The patient is in left side-lying posi-

tion with the hips and knees in neutral, the right shoul-
der flexed. Using the left thumb, the therapist anchors
onto the right QL in three areas: the center of the belly
of the muscle, its origin at the 12th rib, and its inser-
tion onto the iliac crest. The anchor for the belly of the
muscle is in a lateromedial direction (toward the plinth), Figure 9.5
using the star concept to anchor into the area of most MMS right QL + Lateral Line (lower quadrant) I
tension. For the origin of the muscle at the 12th rib, the
anchor is also in a lateromedial direction but it is also
angled cranially. For the insertion of the muscle at the hand anchoring the right QL. If there is tension in this
iliac crest, the anchor is in a lateromedial direction but line of fascia, it will seem like the QL translates laterally
it is also angled caudally. before full caudal glide of the thigh fascia can be achieved.
The therapist maintains the medial pressure on the QL
Mobilizing hand The therapist’s right hand explores the and simply prevents it from moving laterally. The patient
right lateral thigh/ITB proximally to distally, and always perceives this as the therapist increasing pressure on QL.
with the star concept in mind. The therapist may explore If tension is perceived (quick resistance is felt between the
the lateral thigh in a number of possible directions: two hands of the therapist), then it can be mobilized as
per the approaches outlined in Chapter 4. (The therapist
• in a caudal direction (toward the patient’s feet) performs repeated movement of the lateral thigh fascia
• in a caudal-anterior direction in the direction(s) of most restriction while maintaining
a steady pressure on QL, always to when R1 is perceived.
• in a caudal-posterior direction. This is repeated until a release is felt between the ther-
The therapist looks for the angle and the area(s) on the apist’s two hands and generally requires approximately
thigh where he/she perceives immediate tension in the five to eight cycles.)
139
Chapter 9
despite treatment directed towards mobilization of the

MMS right quadratus lumborum + Lateral Line lumbar or hip joints and/or techniques to lengthen the
(lower quadrant) 2 (Figure 9.6) appropriate muscles (e.g., psoas).
MMS right quadratus lumborum + ipsilateral

posterior diaphragm in lumbar spine extension
(DFL) (Figure 9.7, 9.8)
Figure 9.7
MMS right QL in relation to the DFL – hand position
Figure 9.6
MMS right QL + Lateral Line (lower quadrant) II

the therapist explores the right lateral lower leg in relation
to the right QL.
MMS quadratus lumborum in relation to

the Deep Front Line (DFL)
The QL muscle also forms part of the DFL and, as such,
Figure 9.8
may also be explored in relation to this fascial line. This MMS right QL + ipsilateral posterior diaphragm in
approach is particularly beneficial in situations where Lx extension (DFL)
lumbar extension and/or hip extension remains limited
140
Stabilizing hand The patient is in a prone position with

the lumbar spine in extension. The patient supports him/
herself on the elbows, with the hands cupped under the
chin. This position minimizes overactivity of the lumbar
extensors. (If there is too much tension in this position,
these techniques may initially be performed in the neutral
lumbar position, without extension.) The therapist stands
on the right side of the patient. Using their right thumb, the
therapist anchors onto the right QL, as per the techniques
above (Figure 9.7). Each of the techniques below may be
repeated with a different anchor on the QL (origin, inser-
tion, and belly of muscle), but the most commonly used
anchor is that of the insertion of the QL at the ilium. In
that case, the anchor is directed caudally.
Mobilizing hand The therapist explores the area of the Figure 9.9
right lower thorax with the left hand, gently gliding the MMS right QL + contralateral posterior diaphragm
area of the posterior diaphragm in a craniolateral direction in Lx extension (DFL)
(Figure 9.8). Once again, the star concept is a useful
approach to determine which vectors pull the most on the
MMS right quadratus lumborum + central tendon
stabilizing hand. The tension may be felt most when the
of diaphragm in lumbar spine extension (DFL)
posterior diaphragm is pushed in a simple cranial direc-
(Figure 9.10)
tion, or cranial to the right of the client, or cranial to the
left. If no tension is perceived, then this part of the DFL is
not tight. If there is tension in this line of fascia and the
anchor is at the belly of the muscle, it will seem like the
QL translates laterally before full craniolateral glide of
the posterior diaphragm area can be achieved. The ther-
apist maintains the medial pressure on the QL and simply
prevents it from moving laterally. If the anchor of the QL
is at the ilium then the therapist will perceive that this area
wants to pull up in a cranial direction. In either case, the
the right QL when, in reality, the therapist is simply pre-
venting the anchor from moving. Similar concepts for
mobilizing this line of fascia apply.
MMS right quadratus lumborum + contralateral

posterior diaphragm in lumbar spine extension Figure 9.10
MMS right QL + central tendon of diaphragm in Lx
(DFL) (Figure 9.9)
extension (DFL)
The technique is similar to the one above except that The technique is similar to the one above except that the
the therapist explores the contralateral posterior dia- therapist explores the area of the central tendon attach-
phragm area. (Figure 9.9) ments of the diaphragm in the central Th/L region (using
141
Chapter 9
central, cranially directed P/A pressures on the spinous or R1 of Maitland’s movement diagram). If there is ten-
processes of T10 to L2) (Figure 9.10). sion in this line of fascia, it will seem like the QL translates
laterally before full knee flexion can be achieved (usually
For the DFL of fascia the therapist may also explore the QL around 120 degrees of flexion). The therapist maintains
in relation to structures more caudal to it. Adding knee flex- the medial pressure on the QL and simply prevents it from
ion or hip IR are some ways to increase tension on the DFL: moving laterally. The patient perceives this as the therapist
pushing harder on the right QL when, in reality, the thera-
MMS right quadratus lumborum + ipsilateral knee pist is simply preventing the anchor from moving. Similar
flex in lumbar spine extension (DFL) (Figure 9.11) concepts for mobilizing this line of fascia apply.
Alternatively, passive physiological hip internal rotation
(IR) may be explored with this technique, as the hip external
rotators form part of the pelvic floor and hence, the DFL of
fascia.
MMS right quadratus lumborum + ipsilateral hip

internal rotation in lumbar spine extension
(Figure 9.12)
Figure 9.11
MMS right QL + ipsil knee flex in Lx extension (DFL)
The technique is similar to the one above except that the

therapist uses passive physiological knee flexion to add
tension and explore this part of the DFL. The therapist
stops as soon as an increase in tension is perceived in the Figure 9.12
MMS right QL + ipsil hip IR in Lx extension (DFL)
hand that is anchoring the right QL (to the first resistance
142
The technique is similar to the one above except that the Stabilizing hand The patient is in left side-lying, with
therapist explores IR of the ipsilateral hip. the hips extended at 0 degrees and the knees flexed at 90
degrees. The therapist’s left hand anchors onto the right QL.
The DFL fascia in relation to QL may also be explored in
relation to the anterior diaphragm, if the technique is done Mobilizing hand Using the right hand, the therapist
in side-lying with the hips extended. explores the area of the right anterior diaphragm, gently
gliding it in a cranial direction, using the star concept.
The treatment approach is similar to that of the tech-
MMS right quadratus lumborum + anterior niques above.
diaphragm in side-lying (DFL) (Figure 9.13)
MMS right quadratus lumborum + dorsiflexion/
eversion in side-lying (DFL) (Figure 9.14)
Figure 9.13
MMS right QL + anterior diaphragm in side-lying Figure 9.14
(DFL) MMS Right QL + DF/Ev in side-lying (DFL)
143
Chapter 9
With the patient in the same position as for the technique

above, the QL fascia may be further explored by using half squat positions revealed negative findings. Her right
passive physiological combined ankle dorsiflexion/ever- foot mechanics were good and the flexibility of the
sion with the knee flexed, as this maneuver adds tension muscles around the foot and ankle was also within nor-
to the tibialis posterior muscle, the tail end of the DFL. mal limits and pain-free. The next area to explore in the
The therapist stops as soon as an increase in tension is per- assessment of this lady’s condition was the mobility of
ceived in the hand that is anchoring the right QL (to the the fascial lines. Using the techniques above, it was not-
first resistance or R1 of Maitland’s movement diagram). If ed that there was no tension of QL in relation to the Lat-
there is tension in this line of fascia, it will seem as though eral Line. However, there was considerable tension of QL
the QL translates laterally before full combined dorsiflex- in relation to the DFL (here was the “Aha!” moment I was
ion/eversion can be achieved. The therapist maintains the looking for). Adding dorsiflexion/eversion to stretch the
medial pressure on the QL and simply prevents it from tibialis posterior in side-lying (technique above), I could
moving laterally. The patient perceives this as the therapist feel a definite connection of a shortened fascial line
pushing harder on the right QL when, in reality, the ther- with her right QL. Two treatments later, she was pain-
apist is simply preventing the anchor from moving. If ten- free and once again enjoying her sporting activities.
hands of the therapist), then it can be mobilized as per the * Please note that the patient’s name has been changed
approaches outlined in Chapter 4. (The therapist performs to protect her privacy.
repeated passive physiological dorsiflexion/eversion while
maintaining a steady pressure on QL, always to when R1
is perceived (a grade III− passive physiological movement MMS lateral sacral fascia in relation to the hip
in Maitland terms). This is repeated until a release is felt
between the therapist’s two hands and it generally requires A number of muscles (and their corresponding fascia)
approximately five to eight cycles. connect to and/or cross over the posterior aspect of the
sacrum. Many patients incorrectly refer to pain in this area
as “sacroiliac pain”. While the sacroiliac joint (SIJ) could
Case report 9.1 Elena’s story* be a factor in their pelvic pain, myofascial tissues are more
commonly the source of their complaints. The lateral bor-
This 42-year-old patient had come for therapy with com- der of the sacrum is an area where a number of muscles
plaints of right low back pain (LBP), especially in standing attach, in particular the hip external rotators and the glutei
and sitting positions, and with gym exercises requiring muscles, as well as the longissimus muscles. Overactivity
a squat maneuver. She had a history of LBP in the past, of iliocostalis may also tug on the long dorsal ligament
successfully treated by another therapist, who used (LDL), causing pain over the SIJ. The techniques below are
a combination of mobilizations, dry needling, and sta- designed to release the fascia of the lateral border of the
bilization exercises. When this latest incident occurred sacrum in relation to the hip.
she went back to see her original therapist, who used
a similar approach to the one that had been success- MMS right lateral sacral fascia + hip external
ful in the past, but this time it was not. Elena had also rotation (Figure 9.15)
had a right fibular fracture six months prior, from which
she recovered well. Her right quadratus lumborum was
particularly painful – what she described as “her pain.” Stabilizing hand The patient is in prone position with the
Dry needling this muscle at this point did not change lumbar spine in a neutral position. The therapist stands on
her pain. Dynamic stability testing of the thoracolum- the right side of the patient. Using a P/A pressure on the
bar-pelvis-hip complex with one leg stand (OLS) and right lateral sacral tissues, the therapist explores areas of
tension from S1 toward S5.
144
Figure 9.15
MMS lateral sacral fascia + hip ER
Mobilizing hand The therapist’s caudal hand supports the

right lower extremity at the ankle and performs a passive
physiological movement of hip external rotation, stopping as Figure 9.16
soon as an increase in tension is perceived in the hand pal- MMS lateral sacral fascia + hip IR
pating the right sacral border (to the first resistance or R1
of Maitland’s movement diagram). If there is tension in this
line of fascia, it will seem as though the sacrum moves lat-
MMS lateral sacral fascia + hip extension
erally and caudally before full hip external rotation can be (Figure 9.17)
achieved (usually around 45–50 degrees of rotation). The
patient perceives this as the therapist increasing pressure on
the sacrum. The therapist performs repeated passive phys- The technique is similar to the one above except that the
iological ER of the hip while maintaining a steady pressure therapist explores passive physiological hip extension.
on the sacrum, always to when R1 is perceived (a grade
III− passive physiological movement in Maitland terms). MMS lateral sacral fascia + hip adduction
This sequence is repeated until a release is felt between the
therapist’s two hands and generally requires approximately
five to eight cycles. Some patients, when lying in a prone position, seem to favor
placing their legs in an abducted position. These patients
also tend to stand with their legs apart and, when asked to
MMS lateral sacral fascia + hip internal rotation place their legs “underneath their hips” find that this posi-
(Figure 9.16)
tion is uncomfortable. Clinically, I have found that in these
cases there is tension between the lateral sacral fascia and
The technique is similar to the one above except that the the ITB area. In this case, the therapist feels an immediate
therapist explores passive physiological hip internal rotation. increase in tension in the hand that is anchoring the lateral
145
Chapter 9
fibers are joined by the tendon of biceps femoris (Vleeming

et al. 1989). It also forms part of the SBL of fascia and so
must be considered when exploring techniques to improve
lumbar flexion or slump. Because of its intimate relation-
ship with the pelvic floor area, it may also be explored in
relation to the DFL of fascia. Finally, it must also be con-
sidered as a factor in myofascial restrictions in relation to
the hip joint and in cases of recurrent hamstring tension.
Sacrotuberous ligament fascia in relation

to the SBL
MMS sacrotuberous ligament in relation to the SBL

(erector spinae) (Figures 9.18–9.20)
Figure 9.17
MMS lateral sacral fascia + hip extension
sacral region as he/she performs passive hip adduction,

starting from an abducted position and moving the thigh
towards neutral. The treatment approach is similar to the
one above except that the therapist uses passive physiological
hip adduction. Ideally, the therapist should be able to attain
20 degrees of hip adduction past neutral before tension is felt
in the lateral sacral fascia (technique not pictured).
Sacrotuberous ligament fascia Figure 9.18

MMS sacrotuberous ligament – reference points
The sacrotuberous ligament is one of the stabilizers of the
sacroiliac joint; sacral nutation increases tension on this
ligament (Vleeming et al. 1989). It originates from the
medial ischial tuberosity of the ilium and inserts into Stabilizing hand The patient is in prone position with the
the posterior superior iliac spine (PSIS), the posterior lumbar spine in a neutral position. The therapist stands on
sacroiliac ligaments (with which it is partly blended), to the left side of the patient. The therapist locates the mid-
the lower transverse sacral tubercles and to the lateral mar- point of the right sacrotuberous ligament. (The reference
gins of the lower sacrum and upper coccyx. Myofascially, points are the ischial tuberosity and the tip of the coccyx.)
it spreads toward a merging with the fascial sheath of the Using the right thumb, the therapist applies a gentle but
internal pudendal nerves and vessels. The superficial lower firm pressure on the ligament in craniolateral direction
146
gliding the fasciae in a cranial direction (Figure 9.20).

Once again, the star concept is a useful approach to
determine which vectors pull the most on the stabiliz-
ing hand. The tension may be felt most when the erector
spinae fascia is mobilized in a simple cranial direction,
or cranial to the right of the client, or cranial to the left.
The patient perceives this tension as the therapist push-
ing harder on the right sacrotuberous ligament when,
in reality, the therapist is simply preventing the anchor
from moving. If no tension is perceived, then this part of
the SBL is not tight. If tension is perceived (quick resis-
tance is felt between the two hands of the therapist), then
Chapter 4.
MMS sacrotuberous ligament in relation to the SBL

Figure 9.19
MMS sacrotuberous ligament – thumb placement (biceps femoris) (Figure 9.21)

MMS sacrotuberous ligament in relation to the SBL MMS sacrotuberous ligament in relation to the SBL
(erector spinae) (biceps femoris)
(that is, at a 45 degree angle perpendicular to the fibers of

the ligament).
therapist explores the tissues of the SBL below the sacrotu-
Mobilizing hand The therapist’s left hand explores the berous ligament, in particular the biceps femoris, usually
tissues of the SBL above (the fascia of the erector spinae), with a caudally directed motion.
147
Chapter 9
MMS sacrotuberous ligament fascia in repeated passive physiological IR of the hip while main-
relation to the hip taining a steady pressure on the ligament, always to when
R1 is perceived (a grade III− passive physiological move-
MMS: right sacrotuberous ligament + hip internal ment in Maitland terms). This is repeated until a release
rotation (Figure 9.22) is felt between the therapist’s two hands and generally
requires approximately five to eight cycles.
MMS sacrotuberous ligament + hip external

rotation (Figure 9.23)
Figure 9.22
MMS sacrotuberous ligament + hip IR
Stabilizing hand As per the technique above except that

Figure 9.23
the therapist uses their left hand to anchor the right sacro- MMS sacrotuberous ligament + hip ER
tuberous ligament.
Mobilizing hand The therapist’s right hand supports the
right lower extremity at the ankle and performs a passive The technique is similar to the one above except that
physiological movement of hip internal rotation, stopping the therapist explores passive physiological hip external
as soon as an increase in tension is perceived in the hand rotation.
palpating the sacrotuberous ligament (to the first resis-
tance or R1 of Maitland’s movement diagram). If there MMS sacrotuberous ligament + hip extension
is tension in this line of fascia, it will seem as though the (Figure 9.24)
tension at the sacrotuberous ligament has increased before
full hip internal rotation can be achieved (usually around
45 degrees). The patient perceives the therapist increasing The technique is similar to the one above except that the
his/her pressure on the ligament. The therapist performs therapist explores passive physiological hip extension.
148
Figure 9.25
MMS sacrotuberous ligament in relation to the DFL
(contralateral posterior diaphragm)
dorsiflexion/eversion, all in relation to the sacrotuberous

ligament. The example below depicts the technique in rela-
tion to the contralateral posterior diaphragm.
Figure 9.24
MMS sacrotuberous ligament + hip extension MMS modified Butler technique for femoral nerve
(Figure 9.26)
Sacrotuberous ligament fascia in relation to the DFL For the following techniques, we will be using primarily
(Figure 9.25)
the third concept of treatment when using MMS tech-
niques; that is, convert a nerve mobilization technique into
Stabilizing hand As per the technique above, except that a fascial technique. (Refer to Chapter 4 for further detail on
the lumbar spine is in extension, therefore adding tension concepts of treatment using MMS.)
to the DFL.
The technique for mobilizing the lumbar interfaces for
Mobilizing hand The therapist’s left hand explores the the femoral nerve is well known (Butler 1991). It generally
tissues of the DFL, similar to MMS techniques for the qua- involves mobilizing the ipsilateral L2–4 facet joints with
dratus lumborum (QL) in relation to the DFL. The thera- the lumbar spine in extension, the ipsilateral knee flexed
pist therefore explores the posterior diaphragm (ipsilateral 90 degrees, and the cervical spine flexed. Thinking a lit-
and contralateral), ipsilateral knee flexion and ipsilateral tle more broadly, with the myofascial tissues in mind, a
149
Chapter 9
Figure 9.26
MMS modified Butler technique for
femoral nerve
therapist may modify this technique by adding a stabiliz- Summary

ing hand in the area of the opposite ilium (similar to the
technique for the thoracolumbar fascia I at the beginning The techniques in this chapter have focused on the myo-
of this chapter). The therapist may also explore beyond the fascial connections in relation to the lumbopelvic area.
levels of L2 to L4 to include the levels above and below and These include techniques in relation to the thoracolumbar
to incorporate the thoracolumbar fascia and lower ribs. fascia, the quadratus lumborum fascia, the lateral sacral
The concept for treatment remains the same as for other fascia, the fascia of the sacrotuberous ligament and the fas-
MMS techniques. cia around the femoral nerve. These tissues are frequently
problematic in cases of persistent thoracolumbar, lumbar,
Note that the femoral nerve may also be impacted by and pelvic pain and should be explored using MMS tech-
tension in the area of the inguinal ligament as well. This niques. The following chapter will focus on techniques for
technique is described in Chapter 11. the pelvic floor.
150
The pelvic floor 10
Why the pelvic floor? Is this not a separate domain in the for the abdominal wall that may be helpful for pelvic floor
world of physiotherapy? problems because of their connections via this double bag
encasing.
The pelvic floor is the home of urologic, obstetric,
gynecologic, reproductive, colorectal, and gastrointesti- This chapter will describe MMS techniques developed to
nal systems. It is integral to posture, respiration, spinal assess and treat myofascial connections between the pelvic
stability, continence, upper extremity movement, and floor muscles (extravaginally) and the DFL. Although not
lymph fluid balance (Hodges et al. 2007; Clifton Smith shown, pelvic floor therapists may use intravaginal tech-
& Rowley 2011). niques to achieve similar objectives.
Pelvic floor physiotherapists have a wealth of knowledge The following techniques will be described:
in this area; however, they too, may become frustrated with
• the obturator internus (OI) muscle in relation to
the effects of their treatments if they do not consider the
the DFL
body as a whole. The ISM approach (Lee & Lee 2011a) is
one way to determine whether the pelvic floor is a “driv- • the ischiococcygeus muscle in relation to the DFL
er” and the source of the patient’s meaningful functional • the obturator externus (OE) muscle in relation to
problem, or whether, instead, it is the reactor to some other the DFL
“driver” in the body. This area may be the thorax, the cra-
nium, or the foot. • the anterior sacral fascia.
Another possibility for recurring problems in the area of Indications for these techniques include the following:
the pelvic floor/pelvis/hip region is that the muscles of the • pelvic floor pain that has not optimally responded to
pelvic floor (accessible either externally or intravaginally) therapy by trained pelvic floor therapists
must also be viewed as a part of a fascial line, in particu-
lar the DFL. Much can be gained by assessing and treating • trauma to the pelvic floor (via sport, postpartum)
a tight DFL as it relates to recurrent tension in the pelvic • a history of abdominal and/or pelvic surgery (caesarean
floor muscles. sections, inguinal hernia repairs, etc.)
An additional factor to keep in mind is that the abdominal • persistent hip/groin pain and limitation
wall exhibits fascial continuity through to the pelvic floor • persistent buttock and sacral pain
and the lumbar spine (Stecco C. et al. 2005) (Figure 10.1).
• when the load and listen test for the hip demonstrates
The “double bag” structure that encases the deep vectors in the area of the pelvic floor (refer to Chapter 11
abdomen and surrounding structures demonstrates just for a description of this test as it relates to the hip).
how each layer is interconnected. This is one reason why
women have a tendency to low back pain after pregnan-
cy, especially in caesarean birthing. This has to do with For this chapter, we will be using primarily the first concept
fascial restrictions that alter function, movement, and sta- of treatment when using MMS techniques; that is, choose a
bility in the pelvic floor. Chapter 8 describes techniques recurrent articular dysfunction or myofascial trigger point
151
Chapter 10
Figure 10.1
The Deep Front Line-
pelvic floor fascia connects to
Diaphragm the anterior longitudinal liga-
ment, the anterior sacral fascia
and the posterior abdominal
wall fascia, encompassing
both the visceral fascia and the
diaphragm
Anterior
longitudinal
ligament (ALL)
Posterior abdominal
aponeurosis
Pelvic floor
and explore a fascial line in relation to it. The therapist • work with oscillations (grades III−, III, III+)
anchors him/herself to a recurrent articular dysfunction
or myofascial trigger point and assesses the fascial lines of
tension in relation to the anchor, looking for early tension • work with “harmonics” (Dr Laurie Hartman).
between the two hands.
Because it is a sensitive area, it would be advisable to use
The following approaches may be used, depending on the listening approach to treatment with sustained pres-
how the tissues respond: sure rather than the oscillatory approach, certainly for the
152
The pelvic floor
first treatment. Please refer to Chapter 4 for detail on con-

cepts of treatment using MMS.
MMS for the pelvic floor and external

rotators of the hip: the DFL
The small hip external rotators (piriformis, obturator inter-
nus, obturator externus, gemelli muscles, quadratus femoris)
have important implications for optimal functioning of the
sacroiliac joint (SIJ), the hip, and the pelvic floor (Figure 10.2).
Piriformis Obturator internus

Gemelli Obturator externus
Superior
Inferior
Figure 10.3
Obturator internus (OI) muscles: the left OI muscle
Quadratus Obturator
femoris internus is connected to the right OI muscle via a fascial
sling through the pelvic floor. This connection also
affects the position and function of the hip joints
Figure 10.2
Hip external rotators – connecting the pelvic floor
and hip
to the other. So from a fascia perspective, in order to ful-
ly explore the right OI fascia, it should be evaluated in
The obturator internus (OI) is a fan-shaped mus- relation to both the right and left hip movement, as well
cle that originates partly from the inner surface of the as up the chain of the DFL to the diaphragm and beyond
obturator membrane that covers most of the obturator (Myers 2014) (Figure 10.3).
foramen. Its tendon inserts on the greater trochanter of
the proximal femur.
MMS right obturator internus fascia: in
relation to the pelvis (DFL)
What is less known, however, is the fascial continuity
between the OI muscle on the right and the OI on the left,
MMS right obturator internus fascia: in relation to
with the pelvic floor connecting the two. This functional
ipsilateral sacral base (Figures 10.4–10.7)
sling via the pelvic floor connects one greater trochanter
153
Chapter 10
Figure 10.4
MMS anchoring onto right obturator internus (OI)
Figure 10.7
fascia – hand placement on skeleton
MMS right OI fascia in relation to ipsilateral sacral
base – body

the lumbar spine in neutral. The therapist stands on the
right side of the patient for the right OI technique. Using
the fingers of the left hand, the therapist slowly and gen-
tly palpates the muscle at the medial aspect of the ischial
tuberosity, gliding in a cranial and lateral direction.
right sacral base (S1) with the right hand, using a unilateral
Figure 10.5 P/A pressure. If this fascial line is tight, the therapist will
MMS anchoring onto right OI fascia – hand feel an increase in tension in the anchoring hand, as if the
placement on body OI muscle pushes out medially. The patient will perceive
this tension as the therapist pushing harder on the right
OI when, in reality, the therapist is simply preventing the
anchor from moving. If no tension is perceived, then this
part of the DFL is not tight (with the lumbar spine in neu-
tral position). If tension is perceived (quick resistance is
felt between the two hands of the therapist), then it can
be mobilized as per the approaches outlined in Chapter 4.
Progression Note that all of the techniques of the pelvic
floor may be progressed by repeating them with the lumbar
spine in extension. In this case, the patient supports him/her-
self on the elbows, with hands cupped under the chin. This
position minimizes overactivity of the lumbar extensors.
Figure 10.6
MMS right OI fascia in relation to ipsilateral sacral
base – skeleton
154
The pelvic floor
MMS right obturator internus fascia: in relation to MMS right obturator internus fascia: in relation to
ipsilateral ilium (DFL) (Figures 10.8, 10.9) contralateral ilium (DFL) (Figure 10.10)
The technique is similar to the one above except that the ther-
apist explores the ipsilateral (right) ilium with a P/A pressure
along the iliac crest. The star concept is a useful approach
to determine which vectors pull the most on the stabilizing
hand. The tension may be felt most when the ilium is pushed
in a simple anterior direction, as if to produce an anterior
rotation of the ilium, or in an anterolateral direction.
Figure 10.10
MMS right OI fascia – in relation to contralateral ilium

therapist explores the contralateral (left) ilium with a P/A
pressure along the iliac crest. The star concept is a useful
approach to determine which vectors pull the most on the
stabilizing hand. The tension may be felt most when the ilium
Figure 10.8 is pushed in a simple anterior direction, as if to produce an
MMS right OI fascia in relation to ipsilateral ilium – anterior rotation of the ilium, or in an anterolateral direction.
skeleton

ipsilateral posterior diaphragm (DFL) (Figure 10.11)

therapist explores the area of the ipsilateral (right) lower
thorax with the right hand, gently gliding the area of the
posterior diaphragm in a craniolateral direction. The star
concept is a useful approach to determine which vectors
pull the most on the stabilizing hand. The tension may
be felt most when the posterior diaphragm area is pushed
in a simple cranial direction, or cranial to the right of the
client, or cranial to the left. The patient perceives this ten-
sion as the therapist pushing harder on the right OI when,
Figure 10.9 in reality, the therapist is simply preventing the anchor
MMS right OI fascia in relation to ipsilateral from moving. If no tension is perceived, then this part
ilium – body
of the DFL is not tight with the lumbar spine in neutral
155
Chapter 10

therapist explores the area of the contralateral (left) lower
thorax with the right hand.

central tendon diaphragm (DFL) (Figure 10.13)
Figure 10.11
MMS right OI fascia – in relation to ipsilateral
posterior diaphragm (DFL)
position. It may, however, be explored as a progression,

with the lumbar spine in extension (as described above). If
tension is perceived (quick resistance is felt between the two
hands of the therapist), then it can be mobilized as per the
approaches outlined in Chapter 4. (The therapist maintains
the pressure on the OI to prevent it from moving as he/she Figure 10.13
MMS right OI fascia – in relation to central tendon
performs repeated P/A mobilizations of the posterior dia-
diaphragm (DFL)
phragm in the direction(s) of most restriction.)
MMS right obturator internus fascia: in relation to The technique is similar to the one above except that the
contralateral posterior diaphragm (DFL) (Figure 10.12) therapist explores the area of the central thoracolumbar
(Th/L) area. The central tendon of the diaphragm attaches
into the lumbar vertebrae L1–3 but the esophageal opening
is at T10 and the aortic opening at T12, so it is worthwhile
exploring T10–L3 with this technique. The therapist gen-
tly glides the area of the Th/L fascia in a cranial direction,
using the inferior aspect of the spinous processes as a lever.
Once again, the star concept is a useful approach to deter-
mine which vectors pull the most on the stabilizing hand.
The tension may be felt most when the Th/L tissues are
pushed in a simple cranial direction, or cranial to the right
of the client, or cranial to the left. The patient perceives
this tension as the therapist pushing harder on the OI mus-
cle when, in reality, the therapist is simply preventing it
from moving.
Figure 10.12
MMS right OI fascia – in relation to contralateral
posterior diaphragm (DFL)
156
The pelvic floor

MMS right obturator internus fascia: in relation to therapist explores the area of the ipsilateral (right) greater tro-
ipsilateral greater trochanter (Figures 10.14, 10.15) chanter with the right hand, using a P/A pressure. If this part
of the DFL is tight, the patient will perceive this tension as
the therapist pushing harder on the right OI when, in reality,
the therapist is simply preventing the anchor from moving. If
no tension is perceived, then this part of the DFL is not tight
with the lumbar spine in neutral position. It may, however, be
explored as a progression, with the lumbar spine in extension
(described above). If tension is perceived (quick resistance is
felt between the two hands of the therapist), then it can be

contralateral greater trochanter (Figure 10.16, 10.17)
Because of the sling of fascia between both greater trochan-

ters, it is possible that the right OI fascia may be affected
Figure 10.14 by tension in the left hip. The technique is similar to the
MMS right OI fascia in relation to ipsilateral greater one above except that the therapist explores the area of the
trochanter – skeleton contralateral greater trochanter.

MMS right OI fascia in relation to ipsilateral greater MMS right OI fascia in relation to contralateral
trochanter – body greater trochanter – skeleton
157
Chapter 10
Figure 10.17
MMS right OI fascia in relation to contralateral greater
trochanter – body
MMS right obturator internus fascia: in

relation to the hip
MMS right obturator internus fascia: in relation to Figure 10.18

MMS right OI fascia – in relation to passive
passive physiological hip movement (ipsilateral or
physiological hip IR (ipsilateral)
contralateral) (Figures 10.18, 10.19)

therapist uses passive physiological hip movements to add
tension and explore this part of the DFL. This may be done
with the ipsilateral hip or the contralateral hip. The exam-
ples below describe a MMS technique for the right OI in
relation to ipsilateral and contralateral hip internal rotation.
However, passive physiological hip extension and abduction
are also useful to explore the DFL of fascia. In the case of
right hip IR, the therapist uses the right hand to support the
lower extremity at the ankle and performs a passive physio-
logical movement of hip internal rotation, stopping as soon
as an increase in tension is perceived in the hand palpating
the OI (to the first resistance or R1 of Maitland’s movement
diagram). If there is tension in this line of fascia, it will seem
like the right OI will push into the therapist’s hand before
full hip internal rotation can be achieved (usually around 45
degrees of rotation). The patient perceives this as the ther-
apist increasing his/her pressure on the OI. The therapist Figure 10.19
MMS right OI fascia – in relation to passive
performs repeated passive physiological IR of the hip while
physiological hip IR (DFL) (contralateral)
maintaining a steady pressure on the OI, always to when R1
158
The pelvic floor
is perceived (a grade III– passive physiological movement

in Maitland terms). This is repeated until a release is felt MMS right ischiococcygeus fascia: in relation to the
between the therapist’s two hands and generally requires hip and DFL (Figure 10.21, 10.22)
approximately five to eight cycles.
MMS right ischiococcygeus fascia
The ischiococcygeus is a muscle of the pelvic floor located

posterior to levator ani and anterior to the sacrospinous
ligament. It is a triangular plane of muscular and tendi-
nous fibers, arising from the spine of the ischium and sac-
rospinous ligament, and inserting into the margin of the
coccyx and lower sacrum.
In combination with the levator ani, it forms the pelvic

diaphragm (Figure 10.20).
It assists the levator ani and piriformis muscles in closing

in the back part of the outlet of the pelvis. In “butt grippers”
(those patients who use their hip external rotators excessively
in an attempt to stabilize the pelvis/hip region), this muscle Figure 10.21
is frequently hypertonic (Lee & Lee 2011b). If local treatment MMS right ischiococcygeus fascia – in relation to
to the muscle is insufficient, then the therapist should con- contralateral greater trochanter
sider mobilizing this muscle in relation to the DFL of fascia.
Piriformis
Ischiococcygeus
Pubic bone Coccyx

Iliococcygeus
Pubococcygeus
Urethra Vagina Rectum
Figure 10.22
Figure 10.20 MMS right ischiococcygeus fascia – in relation to
Lateral view of the pelvic floor muscles including ipsilateral hip extension
ischiococcygeus
159
Chapter 10

the lumbar spine in neutral. The therapist stands on the
right side of the patient for the right ischiococcygeus tech-
nique. Using the fingers or thumb of the left hand, the
therapist anchors onto the origin of the muscle at the lower
sacral border/coccyx area, using a P/A pressure.
Mobilizing hand The therapist explores similar areas of
the DFL as described in techniques related to the obturator
internus fascia. The examples below depict a MMS tech- Inguinal ligament
nique in relation to the contralateral greater trochanter

and in relation to ipsilateral hip extension. However, keep Obturator
externus
in mind that any passive physiological hip movement may Adductor Pectineus
magnus
be explored. As well, these techniques may be progressed
by repeating them with the lumbar spine in extension. Adductor
brevis
MMS right obturator externus fascia Adductor

longus
(Figures 10.23, 10.24)
Adductor
magnus
Gracilis
Figure 10.24
Obturator externus in relation to pectineus and the
adductor group of muscles
The obturator externus muscle (OE) is a flat, triangular

muscle that covers the outer surface of the anterior wall of
the pelvis. It originates from the external obturator mem-
Obturator externus
brane and the rim of the pubis and ischium and inserts
onto the trochanteric fossa on the medial surface of the
Figure 10.23 greater trochanter. It may be palpated in the space between
Obturator externus muscle – covers the front of the
short adductors and the pectineus muscle. It is particular-
wall of the pelvis and inserts into the back of the
hip bone
ly important to proceed slowly and gently when palpating
this muscle, as this is generally a sensitive area.
160
The pelvic floor
Stabilizing hand The patient is in a supine position, with

MMS right obturator externus fascia: thumb the ipsilateral hip in approximately 45 degrees of flexion,
placement (Figure 10.25) supported by the therapist’s thigh. The therapist stands
on the right side of the patient for the right OE technique.
Using the thumb of their right hand, the therapist anchors
onto the OE muscle, gently sliding in the space between
short adductors and the pectineus muscle.
Mobilizing hand The therapist explores the right hip
adductors with the right hand, generally in a caudad direc-
tion, using the star concept. The adductor fascia may be
explored from the hip to the medial knee. If this part of
the DFL is tight, the patient will perceive this tension as the
therapist pushing harder on the right OE when, in reality,
the therapist is simply preventing the anchor from mov-
ing. If no tension is perceived, then this part of the DFL
is not tight. If tension is perceived (quick resistance is felt
between the two hands of the therapist), then it can be
Figure 10.25 mobilized as per the approaches outlined in Chapter 4. A
MMS right obturator externus (OE) fascia – thumb listening approach is suggested.
placement
MMS right obturator externus fascia: in relation to

dorsiflexion/eversion (DFL) (Figure 10.27)
hip adductors (DFL) (Figure 10.26) The technique is similar to the one above except that the
therapist uses passive physiological ankle dorsiflexion/
eversion to add tension to the DFL of fascia.
Figure 10.26
MMS right obturator externus (OE) fascia – in relation Figure 10.27
to hip adductors (DFL) MMS right OE fascia – in relation to DF/eversion (DFL)
161
Chapter 10

MMS right obturator externus fascia: in relation to therapist explores the contralateral anterior diaphragm
ipsilateral anterior diaphragm (DFL) (Figure 10.28) area (using a star concept). Appropriate depth of tissues is
important in order to access the DFL of fascia.

pericardial fascia (DFL) (Figure 10.30)
Figure 10.28
MMS right OE fascia – in relation to ipsilateral anterior
diaphragm (DFL)
The technique is similar to the one above except that the Figure 10.30
therapist explores the ipsilateral anterior diaphragm area MMS right OE fascia – in relation to pericardial fascia
(using a star concept). Appropriate depth of tissues is (DFL)
important in order to access the DFL of fascia.
The technique is similar to the one above except that
MMS right obturator externus fascia – in relation to the therapist explores the pericardial fascia (using a star
contralateral anterior diaphragm (DFL) (Figure 10.29) concept). Appropriate depth of tissues is important in
order to access the DFL of fascia.
MMS anterior sacral fascia

The anterior sacral fascia is innervated and may be the
source of pain in the area of the sacrum. One indication
that the anterior sacral fascia may be an issue is if the
patient complains of pain localized to the sacral area, yet
the therapist’s palpatory findings in the posterior aspect of
the sacrum are negative.
The technique to mobilize the anterior sacral fascia is a

modification of the technique in Chapter 7 that is used to
balance the occiput with the sacrum. The anterior sacral
fascia is accessed indirectly by placing the patient in a
Figure 10.29
side-lying position, with the hips at 0 degrees of extension
MMS right OE fascia – in relation to contralateral
anterior diaphragm (DFL)
and the knees flexed 90 degrees. Because extension of the
hips and knee flexion add tension to the DFL of fascia, this
162
The pelvic floor
technique is believed to mobilize the anterior sacral fascia, feel the tension increase between their hands, with the
which is also part of the DFL. body adding small micro-adjustments in multiple direc-
tions. The sensation is similar to that of twisted elastic
The therapist faces the back of the patient. One hand attempting to unwind itself. The therapist follows this
cups the occiput, with the palm of the hand as close as unwinding, preventing the tissues either at the sacrum
possible to the base of the occiput. The therapist’s oth- and/or the occiput from going into the direction from
er hand cups the sacrum, with the palm of the hand as which they came. The tension tends to build up gradu-
close as possible to the sacral base (S1) (Figure 10.31). ally and then suddenly releases, often within one min-
The therapist sinks into the tissues, feeling the myo- ute. This release is accompanied by a fluid-like feel and,
fascial tissue release in the process. The therapist then often, a therapeutic pulse. The therapist may also modi-
applies a gentle but firm distraction between their two fy this technique by anchoring onto the area of S2, S3 or
hands until they feel the connection between the two S4 instead of simply using the sacral base (S1).
hands. This technique is best done using sustained pres-
sure. The idea behind a listening approach to treatment
is to load the fascial tissues (establish the first resistance
in the line of tension), and then wait to see what the
Case report 10.1 Katherine’s
body wants to do with this tension. The therapist may
story*
Internal pelvic floor muscles and the DFL
Katherine was a 22-year-old student teacher with com-

plaints of left lateral sacral pain, as well as vaginal and
coccygeal pain of three years’ duration. There was no his-
tory of trauma except for a mild cervical strain due to a
boating accident that occurred one year prior to the start
of her lower quadrant symptoms. She had had a histo-
ry of headache as a result of grinding her teeth but that
was controlled with frictions to the temporomandibular
joint (TMJ) muscles and a night splint. Her lower quad-
rant symptoms began after climbing a large snow bank.
She had been diagnosed with piriformis syndrome and
had seen other physiotherapists, who had used manual
therapy to the sacroiliac (SI) joint and lumbar spine, dry
needling for the lumbar and piriformis muscles as well as
stabilization exercises, with little change to her symptoms.
An MRI of the lumbar pelvis was negative. She had con-
sulted with a number of gynecologists, who could offer
no explanations for her pain. She had also seen a physio-
therapist who specialized in pelvic floor dysfunctions, and
this approach to treatment helped to decrease her symp-
toms by about 30 percent. Once the pelvic floor therapist
reached a plateau with treatment, she referred Katharine
to me, asking for a fascial assessment. Katharine’s symp-
toms were increased by walking more than a half hour,
using stairs, and doing lunges and squats. This stopped
Figure 10.31 MMS anterior sacral fascia
163
Chapter 10
her from playing sports (she was a former track and field • Left hip ROM test:
athlete), and she was concerned about climbing stairs in
• Flex/add 1/3 with anterior groin pain
the school where she would be starting her new job. In
−− IR in 90 degrees of flexion = 25 degrees, reproduc-
addition, sexual intercourse was painful.
ing sacral pain at the end of range
Initial evaluation revealed the following: −− ER in 90 degrees of flexion = 45 degrees
−− FABER’s test = ½, reproducing sacral, vaginal and
• Positional tests of the pelvis demonstrated a coccygeal pain
transverse plane rotation (TPR) to the right, with an −− extension = 10 degrees.
intrapelvic torsion (IPT) to the right. • Load and listen test for A/P loading of the hip joint re-
• Positional tests for the femoral head showed the left vealed myofascial vectors from the pelvic floor area to
femoral head to be anterior in relation to the ilium. begin with, followed by vectors in the iliacus and abdomi-
nal area on the left (see Chapter 11).
• Positional tests for the thorax demonstrated ring 9 to
be laterally shifted to the left (therefore an intrathoracic • Fascia evaluation: DFL restriction especially in relation
rotation to the right). to the following:
−− left obturator internus in relation to the left and
• Normal lumbar active ROM, with pain only at the end of right sacral base, the left and right ilium, both pos-
range of extension. terior diaphragms, left tibialis posterior (dorsiflexion/
• Passive intervertebral movements (PIVMs)and accessory eversion); initially with the lumbar spine (Lx) neutral
movement tests (PAVMs) for the lumbar spine were and later, with the Lx in extension
within normal limits. −− left A/P coccyx with the left sacral base, and with
dorsiflexion/eversion (refer to Chapter 7)
• Sacroiliac mobility tests were also within normal limits, −− left lateral sacrum with left hip IR, hip extension and
but the accessory movements in A/P glide had a hip adduction.
“gummy” end feel.
My initial hypothesis was that her left hip was driving the
• Lumbar instability tests (A/P shears, rotation stability)
sacral and coccygeal pain, with myofascial vectors in rela-
were negative.
tion to the DFL of fascia mostly responsible for decentral-
• Positive dynamic instability test with the quarter izing the femoral head during a squat maneuver.
squat test:
−− the left SIJ demonstrated an “unlocking” (left sacral • Further fascial evaluation revealed other areas of
base counternutated relative to the ilium) the DFL that were affected (and subsequently
−− the left hip increased its anterior glide treated):
−− the left knee and foot were unremarkable −− left sacrotuberous ligament with right hip IR (Lx in
−− activation of the transversus abdominis muscle did neutral, then later in extension)
not improve the quarter squat task −− left iliacus with the DFL (refer to Chapter 8)
−− correction of the thorax ring shift did not correct the −− left quadratus lumborum (QL) in side-lying with the
SIJ unlocking DFL (refer to Chapter 9)
−− correction of the hip position improved but did −− left QL in Lx extension with hip extension and hip
not completely correct the SIJ unlocking (difficulty adduction (refer to Chapter 9)
was noted in achieving full correction of the hip −− left obturator externus in relation to the adductors,
position). the psoas, pericardium and the tibialis posterior
164
The pelvic floor
(dorsiflexion/eversion). In subsequent treatments, we some time to “peel away” these layers. However, one
also used hip FABER as a passive physiological move- year later, she was working, climbing stairs without prob-
ment in relation to the OE lems, coaching volleyball, playing basketball, and had
−− anterior sacral fascia resumed a pain-free sex life. She thanked me for “giving
−− temporalis (R > L) in relation to the DFL (pericardi- her life back to her.” It is stories like this that keep us going
um, diaphragm, tibialis posterior with dorsiflexion/ as therapists when we occasionally have a bad day!
eversion) (refer to Chapter 6)
−− internal pelvic floor (left pubococcygeus) in rela- * Please note that the patient’s name has been changed
tion to the bladder, the anterior diaphragm, the to protect her privacy.
pericardium, the adductors, with tibialis posterior
(dorsiflexion/eversion). In subsequent treatments,
we also used hip FABER as a passive physiological
Summary
movement in relation to the left pubococcygeus The techniques in this chapter have focused on myofascial
muscles. connections in relation to the lumbopelvic area, specifically
in relation to the obturator internus in relation to the DFL
As the fascial restrictions began to release, we then fol- and the hip, the ischiococcygeus, the obturator externus in
lowed up with a stabilization program to improve lum- relation to the DFL and the anterior sacral fascia. These tis-
bopelvic-hip control in a variety of positions. (Note that sues are frequently problematic in cases of persistent Th/L,
in her previous treatments with other practitioners, she lumbar, pelvic floor, and hip pain and should be explored
had tried stabilization exercise programs but had found using MMS techniques. Pelvic floor therapists may also use
them challenging to do and they had had no positive intravaginal techniques to achieve similar benefits.
results.) Note that this was not a “quick fix” case as there
were many layers to her fascial dysfunction and it took The following chapter will focus on techniques for the
lower extremity.
165
The lower extremity 11
When treating patients with problems of the lower Indications for MMS for this chapter
extremity, manual therapists are trained to assess and
treat the joints (the hip, tibiofemoral, patellofemoral, • Recurring lower extremity pain despite the following
superior and inferior tibiofibular joints, and the ankle treatment approaches:
and foot joints). In addition, the muscles of the lower −− mobilization/manipulation of the joints of the hip,
quadrant are assessed and treated for imbalance between knee, patella, tib/fib joints, ankle and foot
hypertonic and/or tight and weak muscles. The mobil- −− release of trigger points to the lower extremity
ity of the nerves of the lower quadrant is also assessed muscles with manual or dry needling techniques
and treated. However, mobilizing joints and nerves and −− stabilization and strengthening exercises for the
stretching and strengthening individual muscles can lower quadrant.
achieve only partial benefits if the fascial system is not
taken into consideration. • Quadriceps fascia should be considered when look-
ing for non-articular restrictions of knee flexion.
• Similarly, tight fascia of the lower leg is a common
between the hip, thigh, knee, lower leg and ankle/foot.
factor that may impact the range of the ankle, espe-
They include the:
cially with dorsiflexion.
• quadriceps fascia in relation to the SFL and DFL
• Complete assessment of hammer toes should involve
• iliotibial band (ITB) in relation to the Lateral Line not only an assessment of the foot and toe joints but
(covered in Chapter 9) also an assessment of the fascia of the anterior lower
• fascia of the biceps femoris and its role in external leg and metatarsal fascia.
tibial torsion
Postural analysis
• fascia around the inguinal ligament and its role in the
pelvic outlet syndrome Position of the femoral head in relation to
• fascia of the adductors in relation to the DFL the ilium (Figure 11.1)
• fascia around the knee and superior tib/fib joints (in (photo shows the right side)
relation to the SFL and DFL)
A centered femoral head in relation to the acetabulum
• fascia of the lower leg (medial and lateral) in relation is a key requirement for a healthy hip. It requires balanced
to the foot activation of all muscle vectors. The therapist assesses
• plantar fascia and flexor hallucis longus (FHL) the position of the femoral head of the hip by using the
fingers of their right hand to palpate the femoral head
• anterior lower leg fascia in relation to hammer toes midway between the anterior superior iliac spine (ASIS)
(SFL) and the symphysis pubis, just below the inguinal ligament.
• concept of converting joint mobilizations in the lower The therapist’s right thumb palpates the posterior edge of
extremity into fascial techniques the greater trochanter. The therapist then compares the
position of the hand that is palpating the femur to the posi-
• Release With Awareness techniques for the foot and
tion of their left hand, which encompasses the anterior and
ankle.
167
Chapter 11
Position of the foot (Figure 11.2)
DFL LL
A B
Figure 11.2
Effects of the Deep Front Line and Lateral Line on
the foot
In neutral standing posture, the head of the talus should be

Figure 11.1 centered in to the distal tibia/fibula. The position of the talus
Position of hip in relation to the ilium is assessed by palpating both the medial and the lateral aspects
of the dome of the talus. The forefoot should be neither exces-
sively supinated nor pronated, and the lower leg should not be
posterior aspects of the ilium. A patient who stands using rotated internally or externally (Lee & Lee 2011).
a “butt gripping” strategy frequently exhibits overactiva-
tion of the deep hip external rotators (including piriformis, • If there is restriction of the Deep Front Line of fascia,
obturators, gemelli muscles and quadratus femoris). This this may have an impact on the foot, in that it may
strategy tends to pull the greater trochanter posteriorly and pull the calcaneus into inversion and the forefoot into
“forces” the femoral head anteriorly (Lee & Lee 2011). These supination.
muscles may be treated locally by using muscle release • On the other hand, a restriction of the Lateral Line
techniques (manually or via dry needling) but if tension may maintain the calcaneus in eversion, with the
recurs it would be wise to consider the fascial lines asso- talus plantarflexed and adducted, and promote
ciated with these muscles, in particular the DFL of fascia. over-pronation of the mid-foot (Figure 11.2).
168
The lower extremity
Either extreme will affect the weight-bearing areas of the If the subjective exam points to difficulty with squatting or
foot and it may become a “driver” (primary or secondary) sitting, then this functional test is required. The therapist pal-
for dysfunctions in the rest of the body (ISM approach). pates the ilium with one hand and the femoral head with the
other hand (as per the positional test). The patient performs a
• Imbalance in fascial lines may also have an impact
half squat as the therapist assesses if it there is failed load trans-
on the knee, maintaining either a valgus or varus
fer (FLT). If there is a good strategy, the hip starts in a centered
position.
position and remains so throughout the squat test. A common
• Excessive tension of the biceps femoris and its fascia pattern with a FLT is that the hip may start in an anterior posi-
is frequently a factor that causes excessive external tion and either translate anteriorly more so and/or internally
tibial torsion (“duck feet”). rotate (Lee & Lee 2011). This may be due to weak posterior
fibers of gluteus medius, which controls excessive hip internal
Functional tests rotation (IR), but this “weakness” may simply be an inhibit-
ed muscle secondary to the myofascial dysfunction present.
Squat test Repeating the functional test, as well as the manual muscle
test, after using the appropriate MMS technique, will let the
Assessment of hip with half squat (Figure 11.3) therapist know if there is true weakness of the gluteus medius.
Assessment of knee with half squat (Figure 11.4)

Assessment of hip with half squat Assessment of knee with half squat
169
Chapter 11
The therapist may also assess the knee joint using this test. The foot may also be assessed for FLT with the squat test.
One hand palpates the distal femur and the other palpates the Normal biomechanics for dorsiflexion at the talocrural
proximal tibia. Normally, in full extension, the tibia is posi- joint requires an A/P glide of the talus in relation to the
tioned in slight external rotation relative to the femur. If the inferior tib/fib joint as well as an accessory rocking motion
strategy for movement is good, with knee flexion we expect to (Maitland A/P tilt). However, dorsiflexion may also be lim-
see some internal rotation of the tibia at the start of the squat ited by excessive tension in the SBL of the myofascial tis-
as the knee de-rotates its “screw home mechanism” of tibial sues. If dorsiflexion is limited at the talocrural joint (either
external rotation. The tibia should remain centered relative to because of articular restrictions or fascial restrictions), the
the femur throughout the rest of the squat test. If there is FLT, common compensatory pattern in the half squat position is
the distal hand will exhibit a torque or twist relative to the for the talus to plantarflex and adduct rather than staying
femur, usually into external tibial torsion. The therapist must centered under the inferior tib/fib. To do this test the thera-
keep in mind that the source of this twist may not be in the pist palpates both sides of the dome of the talus in standing
knee itself. There may be a driver elsewhere in the foot, hip, and assesses its motion as the patient performs a half squat.
pelvis, or thorax, for example (Lee & Lee 2011). The half squat Ideally, the talus should remain centered throughout the
is, however, a good functional test to use for re-assessment. motion. The therapist may also assess the ability of the first
ray of the mid-foot to pronate (navicular, first cuneiform,
first metatarsal base). Pronation of the first ray is required
Assessment of foot with half squat (talus and first for normal biomechanics in weight-bearing dorsiflexion. A
ray) (Figures 11.5, 11.6) common sign of FLT is that the mid-foot stays in a supinated
position and fails to pronate during a squat. One of the

Assessment of foot with half squat (talus) Assessment of foot with half squat (navicular)
170
The lower extremity
sources of this dysfunction may, of course, be joint stiff- For higher load tasks, the therapist may combine func-
ness, but myofascial tension of the anterior lower leg (espe- tional tests to include a combined OLS with a half squat on
cially tibialis anterior) and the fascia of the SFL may pull at the weight-bearing leg (not pictured).
the joints of the first ray and prevent them from pronating
in relation to the hindfoot. Clinical reasoning using functional dynamic
stabilization tests
One leg stand test
These positional and functional tests may be used before
If the subjective exam indicates difficulty with standing, and after treatment with the MMS approach. For example,
walking or running, then the functional test of a one leg if the subjective exam points to a problem with sitting and
stand (OLS) is required. The hip, the knee and the foot may the patient complains of pain in the sacroiliac (SI) area, it
be assessed in a similar way as for the squat test but the func- is recommended that the half squat test be used to assess
tional movement assessed is one in which the patient shifts dynamic stability at the SI joint, as well as the thorax, hip,
his weight onto one leg and lifts the other off the floor. The knee and foot and ankle (and sometimes the cervical region
weight-bearing side is assessed for FLT (Lee & Lee 2011). or the cranium!) (ISM model). If there is FLT at the SI joint,
The example below shows the test performed for the hip. correction of the non-optimal strategies for the whole body
(usually the thorax and the whole lower quadrant) should
Assessment of hip with one leg stand (Figure 11.7) be performed to see which of these factors has the most
positive impact on the dynamic stabilization of the pelvis.
If correction of the hip improves the SI joint stabilization
strategy (partially or completely), then that points to the
hip as a driver or co-driver that is contributing to the SI
dysfunction. If the foot correction has the most impact on
the SI joint stabilization strategy then the foot may be driv-
ing the SI dysfunction. The treatment strategy in this case
would be to treat the driver and/or co-drivers and re-assess
the impact of this treatment on the dynamic stability of
the pelvis. In this way, the therapist can have a test – retest
strategy in order to immediately evaluate their hypothesis
and effects of their treatment.
“Load and listen” test for the hip

(Figures 11.8, 11.9)
If there is failed load transfer (FLT) at the hip during
functional tests (and particularly if it is found to be
the “driver” in the Integrated System Model) then the
next appropriate test to perform would be a load and
listen test. This test derives from listening courses
developed by Gail Wexler for the Barral Institute. These
listening techniques differentiate active and passive
listening. Load and listen encompasses both aspects of
listening. I find it invaluable in helping to detect the
primary myofascial vectors that may be impacting a
Figure 11.7 joint.
Assessment of hip with OLS
171
Chapter 11
Figure 11.9
Load and listen right hip (body)
Figure 11.8
Load and listen right hip (skeleton)
for an articular restriction. More importantly, upon
release of the glide (the listening aspect of the test),
the therapist will feel a vector that “tugs” on the joint,
The test that is described here is an example in which the
pulling the femoral head beyond center. This myofas-
hip is held anteriorly, a common finding. The patient is in a
cial restriction may be a combination of neuromus-
supine position, with the leg supported by the therapist’s thigh
cular vectors (increased tone in muscles due to in-
in the position where FLT occurs (often at about 30 degrees
creased neural drive), visceral vectors, muscular and
of hip flexion). A gentle distraction and posterior glide of the
fascial vectors. A myofascial vector is usually a larger
hip joint should be performed. When an accessory move-
amplitude movement than an articular vector.
ment for a joint is assessed, not only is the resistance of this
accessory movement noted, but in this test, particular atten- This test may be used as a “before and after” test, when
tion is paid to the release component of the accessory glide. using any type of release technique. It is particularly use-
• In a healthy hip, when the therapist glides the femoral ful to use before and after a MMS technique. It guides the
head posteriorly, it floats back up to the surface, much therapist as to which myofascial vector(s) have the most
like the type of “soap on a rope” that pops back up to impact on a particular joint and encourages exploration
the surface of the water after it has been pushed down of that myofascial vector. Release can be done both locally
(Diane Lee, personal communication). to the involved muscle and also along its myofascial line
(based on Anatomy Trains myofascial meridians).
• If the load and listen test points to an articular restric-
tion, the therapist will feel that the accessory glide The following possibilities are some examples that may
may be stiff with a relatively harder, capsular end-feel. guide the therapist into determining which neuromuscu-
Upon the release of the accessory glide, a small ampli- lar vectors may be impacting the hip joint (D. Lee, Course
tude movement occurs to allow the joint to re-estab- notes from ISM Lumbar/pelvis/hip course):
lish its more neutral position.
• A pull of the femoral head into external rotation and
• If the load and listen test points to a myofascial in a posterior direction implicates the involvement of
restriction, the therapist may find some limitation in the hip external rotators, namely piriformis, quadra-
the posterior glide of the hip joint (the loading as- tus femoris, and the gemelli muscles (see Chapter 10
pect of the test) but the end feel will not be as hard as for MMS sacrum techniques).
172
The lower extremity
• A pull of the femoral head medially toward the cen- • the sigmoid colon or descending colon on the left
ter of the body and into ER implicates the obturator
• the bladder or uterus, centrally.
muscles (obturator externus and obturator internus)
which form part the pelvic floor (see Chapter 10 for Visceral manipulation techniques would then be appropri-
MMS techniques). ate here. Jean-Pierre Barral, a French physiotherapist and
osteopath, has developed a comprehensive curriculum for
• A pull of the femoral head in the superomedial di-
the assessment and treatment of visceral impairments. The
rection, without spin, that stops at the pubic ramus,
reader is referred to the Barral Institute for further infor-
implies the involvement of the adductor muscles
mation (www.barralinstitute.com). Visceral techniques
(brevis, longus, pectineus) (see MMS technique de-
may be progressed by mobilizing these tissues in relation
scribed in this chapter).
to the DFL of fascia, using the same concepts as for MMS.
• A pull of the femoral head in the superomedial di-
rection, without spin, that feels like it is beyond the Concepts of treatment using MMS
inguinal ligament, implies the involvement of iliacus
and psoas muscles (see Chapter 8 for MMS tech- For this chapter, we will be using primarily the first concept
nique). of treatment when using MMS techniques; that is, choose a
• A pull of the femoral head into an anterior tilt implies and explore a fascial line in relation to it. The therapist
the involvement of rectus femoris muscle (see MMS anchors him/herself to a recurrent a rticular dysfunction
technique described in this chapter). or myofascial trigger point and assesses the fascial lines of
All of these neuromuscular vectors may be treated with a tension in relation to the anchor, looking for early tension
number of techniques designed to release muscle hyperto- between their two hands.
nicity, such as contract-relax, strain/counterstrain, release
with awareness, dry needling, etc. However, if results of The following approaches may be used, depending on
these approaches are difficult to maintain, the therapist how the tissues respond:
should then explore the fascial line(s) related to the mus- • work with oscillations (grades III−, III, III+)
cles involved.
Many of the muscles around the hip are involved with
• work with “harmonics” (Dr Laurie Hartman).
the Deep Front Line (DFL) of fascia. If the DFL is shortened
it may maintain dysfunction in and around the pelvis/ Please refer to Chapter 4 for detail on concepts of treat-
hip area. Chapter 10 outlines MMS techniques to release ment using MMS.
the DFL in relation to the pelvic floor. Chapter 8 outlines
MMS techniques to release the DFL in relation to the ili- The fascia around the inguinal ligament
acus muscle. After treatment, re-assessment of positional and its role in the femoral pelvic outlet
tests, functional tests and the load and listen test for the hip syndrome
joint are appropriate. The inguinal ligament, a band of dense regular fibrous
connective tissue in the anterior pelvic region, is rarely
Visceral vectors A pull of the femoral head in the supero-
addressed by physiotherapists. It should be considered,
medial direction, without spin that feels like it is beyond
especially with patients complaining of chronic groin and/
the inguinal ligament may also imply mobility issues with
or thigh pain. The inguinal ligament may be chronically
the fascia of the visceral system. Some examples include:
irritated secondary to an anteriorly positioned femoral
• the ascending colon, caecum or appendix on the head. In this case, a thorough assessment of the hip, includ-
right side ing its possible myofascial vectors, is required. If there is
173
Chapter 11
fascial thickening of this ligament, it may be a source of area(s) on the RA where he/she perceives immediate ten-
impingement for the femoral nerve, artery and vein as they sion in the hand anchoring the right inguinal ligament. If
pass through the groin (femoral pelvic outlet syndrome). there is tension in this line of fascia, it will seem as though
the inguinal ligament pulls cranially with minimal cranial
MMS right inguinal ligament fascia in relation to glide of the mobilizing hand. The therapist maintains the
the rectus abdominis (SFL) (Figure 11.10) caudal pressure on the inguinal ligament and simply pre-
vents it from moving. The patient perceives this as the ther-
apist increasing his/her pressure on the ligament. If ten-
Stabilizing hand The patient is in supine position, with
the leg supported in slight flexion via the therapist’s thigh.
hands of the therapist) then it can be mobilized as per the
Using an A/P pressure, the therapist uses their left hand to
approaches outlined in Chapter 4. (The therapist performs
explore the whole inguinal ligament area from its origin at
repeated cranial glides of the RA fascia in the direction(s)
the symphysis pubis to the ASIS. Both the superior and the
of most restriction, while maintaining a steady pressure
inferior aspects of this ligament should be explored. In the
on the inguinal ligament, always to when R1 is perceived.
following case, the therapist anchors onto the tissues just
This is repeated until a release is felt between the thera-
superior to the ligament.
pist’s two hands and generally requires approximately five
Mobilizing hand With their right hand, the therapist to eight cycles.) The therapist may then explore the SFL a
explores the SFL of fascia, especially the rectus abdominis little higher up, toward the fascia on the anterior aspect of
(RA) (ipsilateral and contralateral) toward its insertion the sternum.
at the 5th to 7th costal cartilages and the xiphoid process
of the sternum. The therapist looks for the angle and the
MMS right inguinal ligament fascia in relation to
the quadriceps (SFL) (Figure 11.11)
Stabilizing hand As per the technique above, except that

the therapist anchors the tissues just inferior to the liga-
ment, using a cranial glide if they are exploring the SFL
below the ligament.
the therapist explores the ipsilateral quadriceps fascia all
the way to the knee.
MMS right inguinal ligament fascia in relation to

the adductors (DFL) (Figure 11.12)

Figure 11.10
MMS right inguinal ligament fascia in relation to the
rectus abdominus (SFL) the therapist explores the ipsilateral adductor fascia all the
way to the knee.
174
The lower extremity
The area of the inguinal ligament is one interface of the

MMS right inguinal ligament fascia in relation to femoral nerve that is not commonly explored with manual
the femoral nerve (Figure 11.13) therapy techniques. It may be used if the therapist is con-
sidering the possibility the patient may be showing signs of
pelvic outlet syndrome.
the therapist explores the fascia of the femoral nerve as it
Figure 11.11
quadriceps (SFL)
Figure 11.13
femoral nerve
emerges from under the inguinal ligament to supply the

anterior aspect of the thigh and medial leg.
Note that the inguinal ligament may also be explored

in relation to the hip movements (hip flexion/extension,
abduction/adduction, rotations and combined movement of
FABER). If there is fascial tension between the inguinal liga-
ment and the hip, the therapist will feel an increase in tension
of the hand that is anchoring the inguinal ligament before
full range of motion of the hip is attained. This restriction
is usually noted at the beginning of range. For example, the
therapist supports the patient’s leg at 90 degrees of hip flex-
Figure 11.12 ion and feels an increase in tension at the inguinal ligament
MMS right inguinal ligament fascia in relation to the as he/she begins to slowly extend the hip toward the table.
adductors (DFL)
The case report illustrates this example.
175
Chapter 11
Case report 11.1 Noémie’s story* diaphragm, right thoracic ring 8 and in relation to
passive physiological movements of the hip into
extension, abduction, and adduction, and later
Noémie was a 45-year-old circus performer with com- with FABER (see MMS technique above).
plaints of right anterior abdominal pain and right sacroil-
iac pain, especially with maneuvers involving standing on Treatment consisted of MMS techniques for both the ili-
the right leg. Symptoms were brought on gradually, with acus and inguinal ligament. After treatment, positional
no history of trauma. She had previously been treated by tests for the pelvis and hip were negative. There was no
an osteopath, who worked on improving the mobility of FLT at the pelvis or the hip with the OLS test, even with-
the pelvis, the sacrum, and the visceral system, with slight out active recruitment of the thoracolumbar multifidus
improvement in her condition. She was presently being muscles. Over the next few weeks she reported ease
treated by another physiotherapist, who used mobiliza- with any circus maneuvers requiring right OLS and her
tions of the lumbar spine, dry needling for hypertonic lum- SI pain was considerably decreased.
bosacral muscles, and stabilization exercises to improve
right one leg stand (OLS). The therapist had noted that * Please note that the name of the patient has been
training the lower thoracic deep multifidus muscles had changed to protect her privacy.
a good impact on the right OLS and half squat strategies.
She referred the patient to me to see if there were myofas-
cial vectors that might be impacting the ability of the SI to The quadriceps fascia in relation to the
stabilize. My assessment revealed the following: SFL and DFL
• The pelvis was positioned in a left TPR (transverse The quads fascia may be a factor that limits knee flexion, espe-
plane rotation) and a left IPT (intrapelvic torsion). cially if there has been a history of trauma, including surgery.
• The right hip was positioned anteriorly in relation

to the ilium. MMS right quadriceps – “wiggle/waggle” –
medial/lateral (Figure 11.14)
• The right OLS test revealed FLT of the right SI joint
as well as the right hip. The SI stabilization was
This technique is aptly named (despite it sounding rath-
partially improved with activation of the thora-
er unprofessional!) as the therapist literally wiggles the
columbar stabilizers, but did not affect the dynam-
quads fascia in relation to the femur. This technique may
ic stability of the hip.
be done in a mediolateral direction, or with a clockwise–
• The load and listen test for the right hip revealed a counterclockwise maneuver.
myofascial vector in the area of the right iliacus. Once
Stabilizing hand The patient is in supine position with
this vector was released (using the technique in
the leg straight. (However, if knee flexion is limited, the
Chapter 8), the second load and listen test revealed
quads fascia may be also explored with the knee in various
a vector in the area of the right inguinal ligament.
degrees of knee flexion.) The therapist uses both hands to
• The right iliacus fascia was tight in relation to the right grasp the tissues of the quadriceps muscles and pull them
symphysis pubis, the right anterior diaphragm and the gently in an anterior direction. The quadriceps fascia may
right quadriceps, with and without dorsiflexion/ever- be explored centrally, medially, or laterally, both proximal-
sion of the ankle (see Chapter 8 for MMS technique). ly and distally on the thigh.
• The right inguinal ligament fascia was tight in rela- Mobilizing hand Using a lumbrical grip to maintain the
tion to the right rectus abdominis, right anterior quadriceps fascia away from the femur, the therapist mobi-
lizes the tissue in a mediolateral direction, creating a shearing
176
The lower extremity
Figure 11.14
MMS right quadriceps “wiggle/waggle” – medial/ Figure 11.15
lateral MMS right quadriceps “wiggle/waggle” – clockwise/
counterclockwise
moment between their two hands. The therapist looks for

tension between the two hands, usually accompanied by
some pain. If no tension is perceived, then this part of the MMS right quads + SFL (plantarflexion)
quads fascia is not tight. If tension is perceived (quick resis- (Figure 11.16)
tance is felt between the two hands of the therapist), then it
can be mobilized as per the approaches outlined in Chapter 4. Stabilizing hand The therapist uses the left hand to
anchor onto the quadriceps muscles of the thigh (medial,
MMS right quadriceps – “wiggle/waggle” – lateral, or central), using a lumbrical grip to pull the quad-
clockwise/counterclockwise (Figure 11.15) riceps fascia away from the femur. The group of muscles
may be explored both proximally and distally.
Stabilizing hand As per the technique above. Mobilizing hand The therapist uses their right hand to
Mobilizing hand As per the technique above except that perform a passive physiological movement of the ankle and
the therapist explores the quadriceps fascia with both toes into plantarflexion. The therapist stops as soon as an
hands moving in a clockwise/counterclockwise maneuver. increase in tension is perceived in the hand that is anchor-
ing the quads (to the first resistance or R1 of Maitland’s
The quads fascia may also be explored in relation to the movement diagram). If no tension is perceived, then the
front lines of fascia, namely the SFL and /or the DFL. quads fascia in relation to the SFL is not tight.
177
Chapter 11
Figure 11.16
MMS right quads + SFL (PF)
If there is tension in this line of fascia, it will seem

as though the quad muscles will pull caudally and MMS right quads + DFL (dorsiflexion/eversion)
posteriorly before full plantarflexion of the ankle and (Figure 11.17)
toes can be achieved. The therapist maintains the crani-
ally directed anterior pull on the quads and simply pre- Stabilizing hand As per the technique above.
vents it from moving. The patient perceives this as the Mobilizing hand The quads fascia may finally be further
therapist “pulling harder” on the quads when, in real- explored by using passive physiological combined ankle dor-
ity, the therapist is simply preventing the anchor from siflexion/eversion, as this maneuver adds tension to the tib-
moving. If tension is perceived (quick resistance is felt ialis posterior muscle, the tail end of the DFL. The approach
between the two hands of the therapist), then it can be to treatment is similar to that of the technique above.
(The therapist performs repeated passive physiological
PF while maintaining a steady pull on quads, always to MMS right adductors in relation to the DFL
when R1 is perceived (a grade III− passive physiologi- (Figure 11.18)
cal movement in Maitland terms). This movement is
repeated until a release is felt between the therapist’s Recurrent tension in the adductors may be due to overuse
two hands and it generally requires approximately five of this muscle if the pelvis does not stabilize well. It may
to eight cycles. also be due to tension of the myofascial line of the adductor
muscle, usually the DFL.
Figure 11.17
MMS right quads + DFL (DF/Ev)
178
The lower extremity
Figure 11.18
MMS right adductors in relation to
the DFL (DF/Ev)
Stabilizing hand The patient is in a supine position. The

therapist anchors onto the adductors of the thigh, explor- MMS right pes anserinus in relation to the DFL
ing the group of muscles proximally and distally. (Figure 11.19)
Mobilizing hand The therapist explores the tissues of the

The pes anserinus area is frequently diagnosed as “bur-
DFL of fascia, looking for quick resistance between the sta-
sitis.” While this may be true in some cases, the area is
bilizing hand and the mobilizing hand. Areas of the DFL
also the site of fascial restrictions, especially in relation
that may be explored in this position include the iliacus,
to the DFL, as the adductors form part of this line of
the ilium itself, the anterior diaphragms, the pericardium
fascia.
(see Chapter 9) and the tibialis posterior (shown in Figure
11.18 – similar to technique above for quads fascia with Stabilizing hand The patient is in a supine position. The
the DFL). therapist anchors onto the area of the pes anserinus distal
to the medial knee, exploring this area in its entirety. The
The fascia around the tibiofemoral, anchor is generally done in a cranial direction if the distal
patellofemoral, and superior tib/fib joints aspect of the DFL is explored.
(in relation to the SFL and DFL) Mobilizing hand The therapist uses their right hand to
Other problematic areas of the DFL may be explored as perform a passive physiological movement of combined
outlined in the next section. DF/eversion. The therapist stops as soon as an increase
Figure 11.19
MMS right pes anserinus in relation
to the DFL
179
Chapter 11
in tension is perceived in the hand that is anchoring the

pes anserinus (to the first resistance or R1 of Maitland’s
movement diagram). If no tension is perceived, then the
pes anserinus fascia in relation to the DFL is not tight.
If there is tension in this line of fascia, it will seem like
the pes anserinus fascia will pull caudally and before
full combined dorsiflexion/eversion of the ankle can be
achieved. The therapist maintains the cranially directed
anterior pull on the pes anserinus and simply prevents it
from moving. The patient perceives this as the therapist
“pushing harder” on the pes anserinus, when, in reality,
the therapist is simply preventing the anchor from mov-
ing. If tension is perceived (quick resistance is felt between
the two hands of the therapist), then it can be mobilized as
per the approaches outlined in Chapter 4. (The therapist
performs repeated passive physiological dorsiflexion/ever-
sion while maintaining a steady pull on the pes anserinus,
always to when R1 is perceived (a grade III− passive phys-
iological movement in Maitland terms). This is repeated
until a release is felt between the therapist’s two hands;
this generally requires approximately five to eight cycles.
MMS right patellofemoral joint in relation to DFL

(Figure 11.20)
With patella-femoral joint dysfunction, the glides of the Figure 11.20

patella in relation to the femur are frequently restricted. MMS right patellofemoral joint in relation to DFL
Once the therapist has plateaued with this treatment, he/
she should explore the fascial lines in relation to this joint.
Stabilizing hand Using their left hand, the therapist oral traction as the anchor, restriction of this line will feel
explores the glides of the patellofemoral joint (distraction, like the patella wants to compress towards the femur as
cranial, medial, lateral glides, rotations clockwise and soon as DF/eversion is added. Similar concepts for mobi-
counterclockwise, medial and lateral tilts), using the stiff- lizing this line of fascia apply as per previous techniques.
est glide(s) for the anchor.
Mobilizing hand The therapist uses their right hand to MMS right tibial tuberosity in relation to DFL
perform a passive physiological movement of combined (Figure 11.21)
dorsiflexion/eversion. The therapist stops as soon as an
increase in tension is perceived in the hand that is anchor-
ing the patella. If there is tension in this fascial line, the As per the technique above except that the therapist
therapist will feel an immediate increase in tension of the anchors the lateral aspect of the tibial tuberosity, gliding it
stabilizing hand as soon as dorsiflexion/eversion is per- medially. This technique is particularly useful in patients
formed. For example, if the therapist is using a patellofem- with chronic Osgood–Schlatter’s.
180
The lower extremity
Vertical
Figure 11.21
Figure 11.22
MMS right tibial tuberosity in relation to DFL
MMS right superior tib/fib joint in relation to DFL
MMS right superior tib/fib joint in relation to DFL MMS right popliteus in relation to the DFL
(Figure 11.22) (Figure 11.23)
As per the technique above except that the therapist As per the technique above except that the therapist
anchors the posterior aspect of the superior tib/fib joint, anchors onto the area of the popliteus muscle on the pos-
gliding it anteriorly and cranially. This technique is partic- terior aspect of the knee, exploring this area in its entire-
ularly useful in patients with recurrent or persistent lateral ty. This technique is particularly useful in patients with
knee pain of myofascial origin. recurrent or persistent posterior knee pain or Baker’s cyst.
181
Chapter 11
Figure 11.24
MMS right lateral lower leg with IR
Mobilizing hand The therapist’s right hand supports the

heel and lateral foot with the hand and forearm, and per-
forms a passive physiological movement of internal rotation
of the lower leg, stopping as soon as an increase in tension
Figure 11.23 is perceived in the stabilizing hand (to the first resistance or
MMS right popliteus in relation to the DFL R1 of Maitland’s movement diagram). If there is tension in
this line of fascia, it will seem as though the lateral leg fascia
The fascia of the lower leg (medial and will want to move anteriorly. The patient perceives this
lateral) in relation to the foot as the therapist increasing his/her pressure on the lateral
leg. The therapist performs repeated passive physiological
Tight fascia of the lower leg may impact the range of motion internal rotation of the lower leg via the heel and forefoot
of the ankle, especially dorsiflexion. The techniques below while maintaining a steady pressure with the stabilizing
may also be useful to explore with patients complaining hand, always to when R1 is perceived (a grade III− passive
of chronic tension in the lower leg and/or difficulty with physiological movement in Maitland terms). This is repeat-
going down stairs. ed until a release is felt between the therapist’s two hands,
which generally requires approximately five to eight cycles.
MMS right lateral lower leg with internal rotation
(Figure 11.24)
MMS right lateral lower leg with dorsiflexion
(Figure 11.25)
knee flexed 90 degrees. The therapist stands on the side of
the patient opposite to the leg being treated. Using an A/P As per the technique above, except that the therapist
pressure, the therapist anchors onto the fascia of the lateral anchors the lateral aspect of the lower leg fascia in a cra-
leg muscles, exploring areas of tension, usually in the distal nial direction, while the mobilizing hand performs passive
half of the leg. physiological ankle DF.
182
The lower extremity
Figure 11.25
Figure 11.26
MMS right lateral lower leg with DF
MMS right medial lower leg with ER
MMS right medial lower leg with external rotation physiological movement in Maitland terms). This movement
(Figure 11.26) is repeated until a release is felt between the therapist’s two
hands a generally requires approximately five to eight cycles.
knee flexed 90 degrees. The therapist stands on the same side MMS medial lower leg with dorsiflexion (Figure 11.27)
of the leg being treated. Using an A/P pressure, the therapist
anchors onto the fascia of the medial leg muscles, exploring As per the technique above except that the therapist
areas of tension, usually in the distal half of the leg. anchors the medial aspect of the lower leg fascia in a cra-
Mobilizing hand The therapist’s left hand supports the heel nial direction as the mobilizing hand performs passive
and medial foot of the patient, using their hand and forearm, physiological ankle dorsiflexion.
and performs a passive physiological external rotation move-
ment of the lower leg, stopping as soon as an increase in ten- The plantar fascia and flexor hallucis longus
sion is perceived in the stabilizing hand (to the first resistance Plantar fascia pain has been the bane of therapists, as it
or R1 of Maitland’s movement diagram). If there is tension in is known to be resistant to treatment. The term fasciitis
this line of fascia, it will seem like the fascia of tibialis posteri- may, in fact, be something of a misnomer, because the
or and the toe flexors will want to move anteriorly. The patient disease is actually a degenerative process that occurs
perceives this as the therapist increasing his/her pressure on with or without inflammatory changes, which may
the medial leg. The therapist performs repeated passive physi- include fibroblastic proliferation (Young 2016). Studies
ological external rotation of the lower leg via the heel and fore- have introduced the etiologic concept of fasciosis as the
foot, while maintaining a steady pressure with the stabilizing inciting pathology. Fasciosis, like tendinosis, is defined
hand, always to when R1 is perceived (a grade III− passive as a chronic degenerative condition that is characterized
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Chapter 11
to work out the proper foot and ankle mechanics, so

appropriate manual therapy directed toward joint
mobility and muscle imbalance issues is essential here.
Rolling gently/slowly on a ball before sleep and on wak-
ing may reduce the pain and stimulate blood circulation.
From a fascia point of view, the therapist must consider
the SBL, especially in chronic cases and/or if working
directly on the plantar fascia has negative effects. Plan-
tar fasciitis is often the result of tension in the Achilles
complex, the hamstrings, or even up at the suboccipi-
tal muscles. The techniques below may also be useful
to explore with patients complaining of chronic plantar
fascia pain (Myers 2015).
MMS right plantar fascia with forefoot adduction

+/− knee flexion (Figure 11.28)
Figure 11.27
MMS right medial lower leg with DF
histologically by fibroblastic hypertrophy, absence of

inflammatory cells, disorganized collagen, and chaotic
vascular hyperplasia with zones of avascularity (Khan et
al. 1999, 2002). These changes suggest a non-inflamma-
tory condition and dysfunctional vasculature, which may
be seen on ultrasound (Chen et al. 2013). With reduced
vascularity and a compromise in nutritional blood flow
through the impaired fascia, it becomes difficult for
cells to synthesize the extracellular matrix necessary
for repairing and remodeling. With regards to function-
al risk factors, reduced dorsiflexion has been shown to
be an important risk factor for this condition. As well,
tightness in the hamstrings, gastrocnemius soleus, and
the Achilles tendon are considered risk factors for plan-
tar fasciitis (Bolivar et al. 2013). It is interesting to note
that all of these structures form part of the SBL of fascia.
In addition, weakness of the gastrocnemius, soleus, and
intrinsic foot muscles is also considered a risk factor for
plantar fasciitis.
Treatment approach varies. Some people will respond
better to heat, though more will respond positively to ice
in terms of pain reduction, especially in the acute phase.
Figure 11.28
A hydrocortisone injection can be helpful if it is done MMS right plantar fascia with forefoot adduction
precisely at the site of inflammation but this approach +/- knee flexion
will be ineffective if there is no “fasciitis.” It is important
184
The lower extremity

knee flexed 90 degrees. The therapist stands on the side of the
patient opposite to the leg being treated. Using a medial to
lateral pressure, the therapist anchors onto the plantar fascia,
exploring areas of tension, from its origin at the t uberosity of
the calcaneus toward the heads of the metatarsal bones. The
lateral band should also be explored in a similar way.
Mobilizing hand The therapist’s right hand performs
a passive physiological movement of forefoot adduction,
stopping as soon as an increase in tension is perceived in the
stabilizing hand (to the first resistance or R1 of Maitland’s
movement diagram). The therapist must keep the ankle in
a neutral position of about 0 degrees of dorsiflexion and
the forefoot in a neutral position between pronation and
supination throughout this technique. If there is tension
in this line of fascia, it will seem like the thumb that is
anchoring the plantar fascia will want to move medially.
The patient perceives this as the therapist increasing his/
her pressure on the plantar fascia. The therapist performs
repeated passive physiological forefoot adduction while
maintaining a steady pressure with the stabilizing hand,
always to when R1 is perceived (a grade III− passive phys-
iological movement in Maitland terms). This is repeated
until a release is felt between the therapist’s two hands and
generally requires approximately five to eight cycles. Figure 11.29
MMS right FHL in the plantar aspect of the foot
Progression Once tension has been released throughout
the whole plantar fascia, the technique may be progressed by around the first toe and performs passive physiological
adding passive knee flexion. While doing so may seem con- dorsiflexion of the first metatarsophalangeal (MTP) joint,
trary to what should be done to release the SBL, clinically it is making sure to maintain dorsiflexion of the ankle with the
very applicable. Perhaps an element of the plantar fascia and forefoot in neutral position for pronation/supination and
the flexor hallucis longus involves the DFL of fascia, which abduction/adduction.
could explain why knee flexion seems to increase tension.
MMS flexor hallucis longus in relation to the

MMS flexor hallucis longus in the plantar aspect of inferior tib/fib joint
the foot (Figure 11.29)
Tension of this muscle and its fascia is also a factor that can
Because the flexor hallucis longus (FHL) muscle is small, “push” the medial tibia anteriorly in relation to the fibula
injuries associated with this muscle and its tendon are at the inferior tibiofibular joint. This is one element that
often overlooked. What is perceived as plantar fascia pain may contribute to external tibial torsion. The therapist can
can frequently be a problem with the mobility of the FHL modify the technique above to perform the same move-
and its fascia. The technique for this muscle is similar ments of the first toe with the foot in the same position, but
to the technique above except that the therapist anchors the patient is in a high sitting position instead of the prone
the FHL tendon at various points on the plantar aspect of position. The therapist uses an A/P pressure on the medial
the foot while the mobilizing hand of the therapist hooks tibia as their anchor (not pictured).
185
Chapter 11
Anterior lower leg fascia in relation to Stabilizing hand The patient is in a supine position. The
hammer toes therapist anchors onto the area of the fascia of the tibia-
lis anterior, the extensor hallucis longus (EHL) and/or the
Complete assessment of hammer toes should involve not
extensor digitorum longus (EDL), anchoring the myofas-
only an assessment of the foot and toe joints, but also an
cial tissues in the A/P, cranial direction.
assessment of the flexibility of the toe extensors and the
fascia of the anterior lower leg and metatarsals. Besides the Mobilizing hand The therapist’s caudal hand performs
problem of finding proper shoes to accommodate the ham- a passive physiological movement of toe flexion, stop-
mer toes, patients with this issue also complain of pain in ping as soon as an increase in tension is perceived in the
the plantar aspect of the base of the metatarsal joints since stabilizing hand (to the first resistance or R1 of Mait-
these joints must “live” in dorsiflexion, secondary to the land’s movement diagram). If there is tension in this line
abnormal tension of the dorsal muscles and fascia. of fascia, it will seem like the thumb that is anchoring
the anterior lower leg fascia will want to move caudal-
MMS anterior lower leg in relation to hammer toes ly. The patient perceives this as the therapist increasing
(Figure 11.30) his/her pressure on the anterior lower leg. The thera-
pist performs repeated passive physiological flexion of
the toes (individually or together as a group), always to
when R1 is perceived (a grade III− passive physiologi-
cal movement in Maitland terms). This technique is
repeated until a release is felt between the therapist’s two
hands and generally requires approximately five to eight
cycles. Note that the second and third toes are frequent-
ly the most problematic.
Progression The technique above may be progressed by
repeating it with the ankle in full plantarflexion.
MMS dorsal metatarsal fascia in relation to

hammer toes (Figure 11.31)
The technique above may be modified to explore and

release the dorsal intermetatarsal fascia. The stabilizing
hand (in this case, the left hand of the therapist) seeks out
the intermetatarsal fascia, anchoring these tissues with an
A/P glide directed cranially and diagonally. The mobiliz-
ing hand repeats the same technique as above. Once again,
the area of the second and third metatarsals is frequently
problematic.
The fascia of the biceps femoris

Recurrent tension in the biceps femoris muscle may be due
Figure 11.30 to overuse of this muscle if the pelvis does not stabilize
MMS right anterior lower leg in relation to hammer
well. It may also be due to tension of the myofascial line of
toes
this hamstring muscle, usually the SBL.
186
The lower extremity

MMS right dorsal metatarsal fascia in relation to MMS right biceps femoris fascia with hip ER
hammer toes
on the lateral thigh. The therapist performs repeated pas-

MMS right biceps femoris fascia with hip external sive physiological external rotation of the hip while main-
rotation (Figure 11.32) taining a steady pressure with the stabilizing hand, always
to when R1 is perceived (a grade III– passive physiological
Stabilizing hand The patient is in prone position with the movement in Maitland terms). This is repeated until a
lumbar spine in a neutral position. The therapist stands release is felt between the therapist’s two hands and gener-
on the left side of the patient. Using a P/A pressure direct- ally requires approximately five to eight cycles.
ed laterally, the therapist anchors onto the biceps femoris
Note that this technique may also be performed in
fascia, exploring areas of tension from its proximal attach-
the same position, but using passive physiological knee
ment just below the greater trochanter to its distal attach-
flexion/extension as the exploratory movement (not
ment toward the lateral knee.
pictured).
Mobilizing hand The therapist’s caudal hand supports
the lower extremity at the ankle and performs a passive
Biceps femoris/vastus lateralis in relation to tibial
physiological movement of hip external rotation, stopping
torsion (duck foot) (Figure 11.33)
as soon as an increase in tension is perceived in the hand
palpating the biceps femoris (to the first resistance or R1 of
Maitland’s movement diagram). If there is tension in this One of the myofascial vectors that may be causing
line of fascia, it will seem like the lateral hamstrings move excessive external tibial torsion is the fascia of the lat-
medially before full hip external rotation can be achieved eral thigh, in particular the biceps femoris, vastus later-
(usually around 45–50 degrees of rotation). The patient alis, and the posterior aspect of the iliotibial band (ITB)
perceives this as the therapist increasing his/her pressure (Aguilar 2015).
187
Chapter 11
physiological extension of the knee while maintaining a

steady pressure with the stabilizing hand, always to when
R1 is perceived (a grade III– passive physiological movement
in Maitland terms). This technique is repeated until a
release is felt between the therapist’s two hands and generally
requires approximately five to eight cycles.
Joint mobilizations converted to MMS

techniques
The second concept of treatment using MMS techniques is
that any joint mobilization may be converted into a fascial
technique. This approach is particularly useful when the
therapist has reached a plateau with treatment using joint
mobilizations and/or manipulations. The following exam-
ples may be used for the lower quadrant.
MMS A/P talus in slump +/− cervical flexion

(Figure 11.34)
Figure 11.33
Right biceps femoris in relation to tibial torsion
(duck foot)
In his video, Aguilar demonstrates a home exercise

program using a ball in the seated position to anchor the
affected fascia. This approach may also be used as a tech-
nique to perform in clinic.
Stabilizing hand The patient is in a seated position, with
their weight shifted toward the affected leg. The therapist
palpates the distal half of the lateral thigh, anchoring the
fascia with a lateral/cranial pull of the tissues. The ther-
apist may explore these tissues caudally toward the knee.
Mobilizing hand The therapist maintains internal rota- Figure 11.34
MMS right A/P talus in slump +/− Cx flexion
tion of the tibia as he/she passively extends the patient’s
knee, stopping as soon as an increase in tension is per-
ceived in the hand palpating the biceps femoris (to the
first resistance, or R1 of Maitland’s movement diagram). If The therapist performs an A/P glide of the talocrural joint
there is tension in this line of fascia, it will seem as though with the patient lying supine and compares this glide to one
the lateral hamstrings move medially and caudally before that is performed with the patient sitting in a slump position
full knee extension can be achieved. The patient perceives (lumbar, thoracic, and cervical spine flexed, legs extended).
this as the therapist increasing his/her pressure on the This slump position adds tension not only to the posteri-
lateral thigh. The therapist performs repeated passive or neural structures but also the fascia of the SBL. The A/P
188
The lower extremity
glide of the talus is repeated until the therapist no longer structures are irritated and when the condition is deemed
perceives a difference with the A/P glide performed in to be irritable.
supine (usually within one minute). Test/re-test maneuvers
may include a SLR test, ankle dorsiflexion, and/or the slump MMS A/P superior tib/fib in slump (Figure 11.36)
test itself. Care must be used when the neural structures are
irritated and when the condition is deemed to be irritable.
MMS P/A superior tib/fib in straight leg raise/

plantarflexion (Figure 11.35)
The superior tib/fib joint is a common interface problem for

mobility of the superficial peroneal nerve. The clinical test
most commonly used to test the mobility of this nerve is
straight leg raise (SLR) combined with plantarflexion and
inversion. Indications for this technique are patients who
complain of tension in the posterolateral knee area that has
not changed with localized treatment and/or patients with
decreased mobility of the superficial peroneal nerve.
The therapist performs a P/A glide of the proximal fib-

ula with the patient in crook lying position. He/she com-
pares this glide to one that is performed with the patient
in side-lying, with the affected leg “up” and positioned
in SLR/plantarflexion. The P/A glide of the superior tib/ Figure 11.36
MMS right A/P superior tib/fib in slump
fib joint is repeated until the therapist no longer perceives
a difference with the P/A glide performed in crook lying
position (usually within one minute). Test/re-test maneu-
vers may include a SLR test with ankle plantarflexion/ This technique is similar to the one above except that an
inversion, and/or the slump test performed with plan- A/P glide is assessed in crook lying and compared to the
tarflexion/inversion. Care must be used when the neural same glide in slump position.
Figure 11.35
MMS right P/A superior tib/fib in
SLR/PF
189
Chapter 11
Release with awareness techniques for the

foot and ankle (RWA) (Figures 11.37–11.39)
Figure 11.39
Patient 2 right foot after RWA
of ankle and foot dysfunction is one in which is depicted in

Figure 11.37) (Patient 1). The patient was instructed to stand
with the feet as parallel as possible. Focus on the left foot:
Figure 11.37
Patient 1 position of feet in standing • the talus is plantarflexed and adducted in relation to
the tibia
• the navicular is externally rotated (more supinated)
in relation to the talus
• the medial cuneiform is externally rotated in relation
to the navicular and
• the base of the first metatarsal is also more externally
rotated in relation to the medial cuneiform.
Note that the right foot is also problematic, but in this case,
the first ray is positioned in such extreme supination that
the forefoot is unable to adduct in relation to the hindfoot
and the patient stands with the leg in external tibial torsion.
A full assessment of the joint mobility of the entire foot

Figure 11.38 and ankle should be carried out and appropriate treatment
Patient 2 right foot before RWA done. However, in many cases a plateau is quickly reached
with treatment using joint mobilizations and/or manip-
ulation. We must consider the fascial element of these
This is the third concept of treatment using MMS tech- restrictions. This situation is one in which the technique of
niques and is described in Chapter 4. A common pattern release with awareness (RWA) is particularly useful.
190
The lower extremity
RWA is a biofeedback technique developed by Diane Lee In order to achieve full ankle dorsiflexion, the talocrural
and L. J. Lee (Lee & Lee 2011) in which the patient is an active joint requires mobility in the posterior glide of the talus
participant. The patient is asked to bring their awareness to and in an A/P rock or tilt. The posterior glide usually
the muscle being palpated and various imagery cues are used responds to mobilizations and/or manipulation but if a
to facilitate relaxation of the muscle. The patient’s participa- plateau is reached with this approach, the following tech-
tion is elicited at the same time that the therapist is guiding nique may be used. From a fascial perspective, there is
the release with feedback from their hands. I have found this commonly a neuromuscular vector in the medial gastroc-
technique to be very useful clinically. Involving the patient nemius that prevents the talus from rocking posteriorly to
in the release seems to create a longer-lasting effect and car- allow full dorsiflexion to occur.
ry-over from one treatment to the next is excellent.
Stabilizing hand The therapist performs an accessory
Figures 11.38 and 11.39 show Patient 2 before and direct- movement of an A/P rock to the talus with one hand and
ly after one treatment to the right foot and ankle, using maintains it at the point where initial resistance to the
RWA. Note that Patient 2’s left foot also requires work! movement is felt.
Exploring hand At the same time, the therapist pal-
It is important to address the whole foot when using this
pates and monitors the area of the gastrocnemius muscle
approach; so all of the following techniques must be used
that has most connection with the restricted A/P rock
within a same treatment in order to achieve optimal outcomes.
of the talus; that is, an area where a gentle pressure and
stretch of the medial gastrocnemius in a cranial direc-
RWA right A/P talus + fascia on medial aspect of tion has an almost immediate impact on the accessory
lower leg (Figure 11.40) movement at the talus, giving the therapist the sensation
that the talus is being pushed anteriorly. As the therapist
provides manual input to the gastrocnemius, the patient
is instructed to “soften the muscle,” “let it go,” “see if
you can find a way to allow my fingers to sink into the
muscle.” At the same time, the therapist moves the joint
or muscle to shorten origin and insertion, diminishing
tension on the muscle spindle. The therapist then waits,
allowing the patient and his/her system to cue into the
release at the same time as the therapist gives manual and
verbal cues to let go. Once maximum release is obtained,
usually within 10–15 seconds, the muscle is gently taken
through a full stretch, with the therapist listening to its
response and avoiding recurrence of overactivity. A full
A/P rocking movement is encouraged, using a sustained
movement at the ankle. At the same time, the therapist
may encourage a release of the muscle fascicle in a cra-
nial direction, helping to release the “fuzz” of connective
tissue that has lost its ability to elongate. Once the tissue
releases, the therapist may seek and explore other areas
Figure 11.40
RWA right A/P talus + fascia on medial aspect of of the calf that may be limiting this accessory movement.
lower leg (There is usually more than one area.)
191
Chapter 11
as the hand on the navicular bone moves into internal

RWA pronation right first ray with tibialis anterior rotation/pronation, using a sustained pressure (as per the
(Figure 11.41) technique above). Once the area is released, the therapist
may seek and explore other areas of the lateral lower leg
that may be limiting this accessory movement.
Progression This technique may be progressed by placing
the ankle in full dorsiflexion and repeating the technique.
This technique is also used to release the rest of the first

ray (medial cuneiform in relation to the talus, and the base
of the first metatarsal in relation to the medial cuneiform),
if they are restricted.
RWA right inter-metatarsal fascia + A/P talus

(Figure 11.42)
Figure 11.41
RWA pronation right first ray with tibialis anterior
Stabilizing hand With this technique, the therapist per-

forms an accessory movement of a P/A glide of the navicu-
lar into pronation in relation to the talus, with the ankle in
neutral position for dorsiflexion/plantarflexion.
Exploring hand At the same time the therapist palpates
and monitors the area of the tibialis anterior muscle that
has most connection with the restricted navicular bone; Figure 11.42
that is, an area where a gentle pressure and stretch of RWA right intermetatarsal fascia + A/P talus
the tibialis anterior cranially and laterally has an almost
immediate impact on the accessory movement at the
talonavicular joint, giving the therapist the sensation that Last, but not least, the plantar aspect of the foot is
the navicular is being pulled dorsally into external rota- explored as the therapist maintains the ankle in full
tion. As the therapist provides manual input to the tibialis dorsiflexion, with the first ray in a more neutral posi-
anterior, the patient is instructed to “soften the muscle.” tion (i.e., not supinated). The therapist explores the
The therapist shortens the origin and insertion, waits a few inter-metatarsal area or the insertion of peroneus longus
seconds to allow the patient and his/her system to cue into on the base of the first metatarsal, using a caudal/distal
the release, and then takes the muscle through a full stretch glide. The hand under the foot is the anchoring hand.
192
The lower extremity
Similar concepts of releasing from within are used, at Summary

the same time as the therapist promotes full ankle dor-
siflexion, using the web of their hand on the dome of The techniques in this chapter have focused on the myofas-
the talus. cial connections in relation to the hip, the thigh, the knee,
the lower leg, and the ankle/foot. The concept of convert-
Release with awareness (RWA) techniques for the foot ing joint mobilizations in the lower extremity into fascial
and ankle (as described above) help restore optimal bio- techniques was also covered. Release with awareness tech-
mechanics in the foot and ankle, and if the foot is a driver niques may be used throughout the body but are partic-
in relation to other parts of the body, this technique may ularly useful to release neuromuscular and fascial vectors
also improve dynamic stability of the knee, hip, sacroiliac that may be impacting the foot and ankle. The next chapter
joint (SIJ), thorax, and neck. will focus on techniques for the shoulder girdle.
193
The shoulder girdle 12
When treating patients with problems in the shoulder gir- • stabilization and strengthening exercises for the up-
dle area, manual therapists are trained to assess and treat per quadrant.
the sternoclavicular (SC), acromioclavicular (AC), and
glenohumeral (GH) joints. In addition, the muscles of the Positional tests for the shoulder girdle
upper quadrant are assessed and treated for imbalance For this section, particular attention is paid to the following:
between hypertonic and/or tight and weak muscles. How-
ever, mobilizing joints and stretching and strengthening Position of glenohumeral joint in relation
individual muscles can achieve only partial benefits if the to the scapula (Figure 12.1)
fascial system is not taken into consideration.
between the clavicle, sternum, manubrium, cervical, scap-
ula and GH joints. These include:
1. The sternoclavicular fascia in relation to the:
−− manubrium
−− anterior cervical spine/scalenes/sternocleidomas-
toid (SCM)
−− occiput and mastoid process of the temporal bone
−− C/Thx (cervicothoracic) and/or mid-Thx (thoracic
spine) region
−− scapula
−− ipsilateral or contralateral thoracic ring.
2. The clavicle fascia in relation to the:
−− GH joint
−− deltoid, pectoralis major muscles
−− ipsilateral sternoclavicular joint Figure 12.1
−− anterior cervical spine Position of GH in relation to the scapula
−− occiput and mastoid process of the temporal bone
−− neural tissues of the upper extremity. From the side, the therapist can assess the humeral head
position relative to the acromion. For the right shoulder,
Indications for MMS for this chapter the therapist palpates the anterior and posterior aspects of
Recurring shoulder girdle or cervical pain and dysfunction the lateral acromion with the left index finger on the ante-
despite the following treatment approaches: rior aspect and the thumb on the posterior aspect of the
acromion. The right hand palpates the anterior humeral
• mobilization/manipulation of the joints of the SC,
head with the right index finger and the thumb is placed
AC, and GH joints
over the posterior humeral head. Traditionally, it is has
• release of trigger points to the muscles of the been taught that one third of the humeral head should be
shoulder girdle area with manual or dry needling anterior to the acromion but the reliability of this suppo-
techniques sition is questionable. The therapist should also assess if
195
Chapter 12
the humeral head is positioned inferiorly in relation to the contribute to cranial, scapular, cervical, and/or thoracic
acromion (Watson 2013; Konieczka et al. 2017). dysfunction (Lee 2018).
Position of the scapulae in relation to the In this discussion of ISGT, a brief review of SC joint
thorax (Figure 12.2) biomechanics provides important context. Because the
SC joint has a fibrocartilaginous disc, the joint has both
a medial joint (between the manubrium and the disc) and
a lateral joint (between the disc and the medial end of the
clavicle).
The biomechanics of the SC joint are as follows:
• With scapular elevation there is normally an inferior

glide at the lateral joint as well as an anterior rotation
at the medial joint.
• With combined elevation and protraction, the clavi-
cle should rotate anteriorly.
• Anterior rotation of both clavicles should occur with
cervical flexion.
• With cervical right rotation the right clavicle poste-
riorly rotates, the left clavicle anteriorly rotates, the
first thoracic ring rotates and sideflexes to the right
Figure 12.2
Position of the scapulae in relation to the thorax
(the manubrium right rotates and sideflexes as part
of this), the right temporal bone posteriorly rotates,
the left temporal bone anteriorly rotates and the cer-
From the back of the patient, the therapist can assess the vical vertebrae right rotate and sideflex. The opposite
resting position of the scapulae for elevation/depression, occurs for cervical left rotation. In either case, there
upward or downward rotation, internal or external rota- should be no excessive medial translation of the clav-
tion. The symmetry of scapulae is noted as well as muscle icle (either right or left), as this suggests there are hor-
bulk/wasting of shoulder external rotators, winging of the izontal compressive factors (Lee 2018).
scapula (implying serratus anterior weakness), prominence
of inferior angle of the scapula (implying pectoralis minor In order to palpate for positional tests related to this tor-
tightness) (Green et al. 2013; Watson 2013). sion, the therapist places him/herself behind the patient
(Figure 12.3). The therapist places their index and middle
Position of the clavicles: palpation for fingers on the superior and inferior aspect of each of the
intra-shoulder girdle torsion patient’s clavicles, in order to determine their relative posi-
tion in space.
The shoulder girdle involves the SC joint, clavicles, manu-
brium, and scapulae. Ideally, with the patient in the sitting The model in Figure 12.3 demonstrates an ISGT to the
or standing position, both clavicles should be in a rela- left. If there is an ISGT to the left, the clavicles “live” in a
tively neutral position with regards to anterior or poste- position where the left clavicle is posteriorly rotated, the
rior rotation, and there should be a sense of space between right clavicle is anteriorly rotated and there is increased
the clavicles and the manubrium. An intra-shoulder girdle medial compression of the right SC joint. If there is an ISGT
torsion (ISGT) is considered undesirable as this twist may to the left and the right SC joint is compressed medially,
196
The shoulder girdle
and the position of the clavicles and SC joints (correction

of an ISGT) (Lee 2003).
If the correction of an ISGT has most positive impact on
the SAL test, then the load and listen test is used in order
to determine the vector(s) that may impact the mobility
of the SC joints. (Note that there is frequently more than
one vector.)
Load and listen test for sternoclavicular

joints
The accessory movements for the SC joint may be per-
formed with the patient in a supine position. If the restric-
tion is articular, the end feel of the accessory movement
will be hard and fibrotic. However, if there is a myofascial
restriction, the therapist feels the resistance to the acces-
Figure 12.3
sory movement but the end feel will be softer and more
Position of the clavicles – palpation for ISGT
“rubbery.” The therapist should then have the patient sit
or stand and try to correct the ISGT. For an ISGT to the
then the inferior glide of the right SC joint becomes quite left, the therapist should decompress the right SC joint
limited. The joint may be compressed medially by articular through the clavicle and then de-rotate the clavicles gen-
dysfunction but more often, there are myofascial vectors tly and gradually, using both hands at the same time. In
that can compress this joint. For example, the upper fib- this example, the therapist would guide the right clavicle
ers of trapezius (UFT), scalenes, or subclavius muscles may into posterior rotation and the left clavicle into anterior
create excessive medial compression of the SC joint. If the rotation, while continuing to create space between the two
shoulder girdle is unable to come out of this position, it clavicles. A certain resistance will be felt with this correc-
may impact not only the cervical range of motion in right tion but much valuable information will be gleaned if the
rotation but also the mobility of the thorax, scapulae, and therapist pays attention to the release component of this
shoulders, especially if the ISGT is deemed to be a primary test, listening (passively) for vectors that are “tugging”
driver of dysfunction. on the clavicles and SC joints. In this example, particular
attention is paid to the vectors that affect the right SC joint.
Functional tests: sitting arm lift test Vectors may be long or short, pull in a cranial or caudal
direction, and may feel either superficial of deep.
The sitting arm lift (SAL) test is similar to the active
straight leg raise test but is used for the upper quadrant. There may be a combination of neuromuscular vectors
The test assesses if there is a difference in effort required (increased tone in muscles due to increased neural drive),
to lift the arm to 90 degrees of shoulder flexion. The arm visceral vectors, muscular, and fascial vectors. The thera-
that the patient perceives as more difficult to lift is then pist pays attention to where the first pull is felt, be it on the
re-tested with other areas of the body corrected. For exam- right or the left clavicle, and then tries to determine the
ple, with a positive SAL test on the right, the therapist cor- direction of pull. Once this is first vector released, then the
rects the positional faults noted in certain areas, in order therapist seeks a second vector on a repeat load and listen
to evaluate its impact on the SAL test. Common areas for test, and so on until no further tension is felt on the release
correction include the cervical spine, the thoracic spine component of the load and listen test. At this point, posi-
(including the thoracic rings), the scapula, the GH joint tional tests for the ISGT should also be negative.
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Chapter 12
The possibilities for vectors are varied but the most fre- lar dysfunction and assesses the fascial lines of tension in
quent are outlined below: relation to the anchor, looking for early tension between
their two hands.
• The right SC joint is pulled medially and caudally to-
ward the manubrium/sternum (this could be joint re- The following approaches may be used, depending on
striction at the sternomanubrial junction or a deeper how the tissues respond:
pericardial fascial pull).
• The right SC joint is pulled toward the right anterior
cervical spine (uncovertebral joints, scalene muscles, • work with sustained pressure
or the SCM). • work with “harmonics” (Dr Laurie Hartman).
• The right SC joint is pulled higher up, toward the Release with awareness (RWA) techniques also work quite
right occiput or the right mastoid process of the tem- well for the techniques in this chapter (concept 3 for treat-
poral bone. ment using MMS).
• The right SC joint is pulled posteriorly toward the Please refer to Chapter 4 for detail on concepts of treat-
C/Thx and /or the mid-Thx regions (this implies ten- ment using MMS.
sion in the fascial planes in between the anterior and
the posterior thorax). Sternoclavicular joint fascia
• The right SC joint may be pulled toward the first rib The following techniques are suggested for exploring and
on the right (subclavius). treating fascial dysfunction in relation to the sternoclav-
icular joints. The technique(s) used will be determined by
• Either SC joint may be pulled toward a particular ring in
the load and listen test when correcting an ISGT (described
the thorax (ipsilaterally or contralaterally).
above).
• The right SC joint may be pulled toward the symphy-
sis pubis (SFL of fascia). MMS right sternoclavicular joint in relation to
All of these neuromuscular vectors may be treated with a ipsilateral scalenes (Figure 12.4)
number of techniques designed to release muscle hyper-
tonicity, such as contract-relax, strain/counterstrain,
Stabilizing hand The patient is in sitting or supine posi-
release with awareness, dry needling, etc. However, if
tion. The therapist uses their left thumb to anchor onto the
results of these approaches are difficult to maintain, the
right SC joint (a laterally and caudally directed decompres-
therapist should then explore the fascial line(s) related to
sion glide).
the muscles involved.
After treatment, re-assessment of positional tests, func-
right scalenes with the fingers of their right hand, gen-
tional tests, and the load and listen test for the clavicles is
tly gliding the anterior cervical spine and scalenes in
recommended.
a craniolateral direction. Several levels of the cervical
spine may be explored with this technique. If this fascial
Concepts of treatment using MMS line is tight, the therapist will feel an immediate increase
For this chapter, we will be using primarily the first con- in tension in the anchoring hand, as if the right SC joint
cept of treatment when using MMS techniques; that is, pulls medially and cranially. The patient perceives this
choose a recurrent articular dysfunction or myofascial as the therapist increasing his/her pressure on the SC
trigger point and explore a fascial line in relation to it. joint. If no tension is perceived, then the SFL of fascia in
The therapist anchors him/herself to a recurrent articu- relation to this region is not tight. If tension is perceived
198
The shoulder girdle

MMS right SC joint in relation to ipsilateral scalenes MMS right SC joint in relation to ipsilateral occiput
(quick resistance is felt between the two hands of the

therapist), then it can be mobilized as per the approaches MMS right sternoclavicular joint in relation to the
outlined in Chapter 4. (The therapist maintains the cau- cervicothoracic region (Figure 12.6)
dal and lateral pressure to the right SC joint as he/she
performs repeated A/P mobilizations of the scalene mus-
cles in the direction(s) of most restriction.) Alternatively,
the therapist may want to use a release with awareness Mobilizing hand The therapist explores the cervico-
(RWA) technique. thoracic (C/Thx) region posteriorly, using the star con-
cept to seek and release tension between their two hands.
MMS right sternoclavicular joint in relation to The tension may be felt most when the C/Thx region is
ipsilateral occiput (Figure 12.5) mobilized in a simple caudal direction, or caudal to the
right or left of the client, or with a clockwise or coun-
terclockwise twist. The patient perceives this tension as
the therapist pushing harder on the right SC joint when,
Mobilizing hand The therapist explores the right occiput, in reality, the therapist is simply preventing the right
using a cranially directed P/A on the right side of the medial clavicle from moving. If no tension is perceived,
occiput. An area about 2 cm square may be explored at the then the fascia between the clavicle and the C/Thx area
occiput using this technique. The concepts for release are is not tight. If tension is perceived (quick resistance is felt
similar to the technique above. Cues for lengthening may be between the two hands of the therapist), then it can be
something along the lines of “allow your neck to grow long.” mobilized as per the approaches outlined in Chapter 4.
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Chapter 12

the therapist explores the mid-thoracic region posteri-
orly. This technique addresses the anteroposterior fascia
between the SC joint and the mid-thoracic region, which
also includes the pericardial fascia.
MMS right sternoclavicular joint in relation to

ipsilateral scapula (Figure 12.8)

the therapist explores the right scapula in all its directions
(elevation, depression, medial and lateral slide, upward and
downward rotation), looking for an immediate increase
Figure 12.6 in tension of the stabilizing hand on the SC joint as the
MMS right SC joint in relation to C/Thx region
scapula is moved. The concepts for release are similar to
the technique above.
MMS right sternoclavicular joint in relation to mid-

thoracic region (Figure 12.7)
Figure 12.8
MMS right SC joint in relation to ipsilateral scapula
Figure 12.7
MMS right SC joint in relation to mid-Thx region
200
The shoulder girdle
Fascial twists and their impact on the vascular

and neural systems (thoracic inlet)
manubrium (Figure 12.9)
In the upper quadrant, the jugular vein drains into the
Stabilizing hand The patient is in supine position. The subclavius vein and the brachiocephalic veins merge to
therapist uses their right thumb to anchor onto the right become the superior vena cava behind the second thoracic
SC joint with a laterally directed decompression glide, as ring. Flow of venous drainage may therefore be disturbed
he/she encourages posterior rotation of the right clavicle. secondary to cranial dysfunction, to tension in the pecto-
ralis minor, the serratus anterior muscles, the clavicles and
Mobilizing hand The therapist explores the area of the the upper rings (ring 1 to ring 4), and in fascial twists in
manubrium with the palm of their left hand, gently gliding relation to these areas.
the manubrium to the left and caudally. As with all MMS
techniques, the star concept is a used to determine which In addition to the vascular system, the neural system
vectors pull the most on the stabilizing hand. The tension may also be impacted by such fascial twists. The nerves
may be felt most when the manubrium is pushed in a sim- that are particularly affected in the region of the thoracic
ple caudal direction, or to the left of the client, or with a inlet are the phrenic nerve, the vagus nerve and the sympa-
clockwise or counterclockwise twist. The patient perceives thetic trunks. Phrenic nerve irritation may lead to overac-
this tension as the therapist pushing harder on the right tivation of the diaphragm and therefore affect its function.
SC joint when, in reality, the therapist is simply prevent- The vagus nerve has many functions, in particular its role
ing the right medial clavicle from moving. If no tension in the parasympathetic control of the heart (improving
is perceived, then this part of the fascia is not tight. If ten- heart rate variability), the bronchi and the gastrointesti-
sion is perceived (quick resistance is felt between the two nal tract. Fascial twists may therefore have wide impact on
hands of the therapist), then it can be mobilized as per the these systems (Lee 2018).
approaches outlined in Chapter 4.
The following techniques can be used if there is a fascial
hold between the sternoclavicular joint and the upper tho-
racic rings.

ipsilateral ring (Figure 12.10)

Mobilizing hand As per the technique above except
that the therapist explores the ipsilateral thoracic ring,
looking for an immediate increase in tension of the
stabilizing hand as the ring is mobilized. For example,
if the second thoracic ring is shifted right and rotated
left, the second ring on the right will seem to be posi-
tioned anteriorly in relation to the ring above and/or
below it. In this case, if fascia between the right SC joint
and the second ring is an issue, the therapist will feel
Figure 12.9 an immediate increase in tension of the hand anchoring
MMS right SC joint in relation to manubrium the right SC joint as the therapist attempts to move the
201
Chapter 12

MMS right SC joint in relation to ipsilateral ring MMS right SC joint in relation to contralateral ring
right second ring posteriorly and to the right around the (Figure 12.12). The clavipectoral fascia is a thick, bilat-
thorax, so as to de-rotate the ring. The concepts for eral connective tissue structure deep to pectoralis major
release are similar to the technique above. muscle. It extends superiorly from the clavicle, medially
from the costochondral joints, and superolaterally from
MMS right sternoclavicular joint in relation to the coracoid process.
contralateral ring (Figure 12.11) It converges in the axilla, where it acts as a protective
structure over the neurovascular structures of the axilla.
A similar approach to the technique used above is used The sheath reunites at the inferior border of subclavius
here except that the therapist explores the contralateral muscle and forms a well-defined thickening called the cos-
ring. In this case, the correction would be to move the ring tocoracoid ligament, spanning the distance between the
posteriorly and to the left around the thorax and evaluate coracoid process and the first costochondral joint. The fas-
the impact of this maneuver on the right SC joint. cia continues loosely downward until it divides again at the
superior border of pectoralis minor and encloses the mus-
MMS clavicular fascia cle. The fascia thickens to become the suspensory ligament
of the axilla. Here, the suspensory ligament of the axilla is
A number of muscles attach to the clavicle. These include attached to the axillary fascia that forms floor of the axilla.
the upper fibers of trapezius (UFT), the sternocleidomastoid There is an opening through which two structures enter
(SCM), deltoid, pectoralis major, subclavius, and sterno- and leave the deep compartment of the pectoral girdle:
hyoid muscles. These muscles can impact the mobility
of the clavicle and therefore affect its biomechanics. The 1. The cephalic vein enters from the arm to join the ax-
clavicle is also the hub for a number of fascial connections illary vein.
202
The shoulder girdle
Subclavius
Clavicle
Subclavius
Clavipectoral fascia
Costocoracoid ligament
Pectoralis minor
Pectoralis minor
Biceps brachii
(short head)
Clavipectoral fascia
Axillary fascia
A B
Figure 12.12
The clavipectoral fascia in relation to the Deep Front Arm Line. Reproduced from Tom Myers, Anatomy Trains:
Myofascial Meridians for Manual and Movement Therapists, 3rd edition. With kind permission from Elsevier
2. The lymphatic vessels from the infraclavicular nodes • post fracture of the clavicle to encourage optimal
pass through the hiatus to join the apical nodes of the alignment.
axilla (KenHub 2017; Volker, 2017).
Fascial twists in the area of the clavipectoral fascia may then MMS right clavicle + glenohumeral traction
impact the function of the vascular and lymphatic systems. (Figures 12.13, 12.14)
The supraclavicular space (superior to the clavicle) con-

tains the supraclavicular nerves and the external jugular Stabilizing hand The patient is in supine position. The
vein. It also has connections to the deep cervical fascia. therapist uses their right hand with a gentle lumbrical grip
to anchor onto the posterior-lateral edge of the clavicle,
A number of MMS techniques related to clavicular guiding and anchoring it into anterior rotation.
fascia have been developed. Indications for these tech-
niques include: Mobilizing hand The therapist uses their left hand to
encompass the anterior and posterior aspects of the right
• persistent pain/tension in the shoulder girdle and GH head, gently adding a traction maneuver to the joint
shoulder in a lateral and inferior direction (through the axis of the
• persistent pain/tension in the cervical spine humeral head). As always, the therapist is looking for the
immediate line of tension between the two hands, which
• persistent pain/tension in the thorax
indicates fascial tension. The patient perceives this tension
203
Chapter 12
MMS clavicle + deltoid (Figure 12.15)
Figure 12.13
MMS position on anterior clavicle
Figure 12.15
MMS clavicle + deltoid

Mobilizing hand As per the technique above, except that
the therapist explores the deltoid muscle, gliding the ante-
rior portion of the deltoid caudally and laterally. The ante-
rior deltoid is explored proximally to distally, toward the
deltoid insertion, an area that is fascially rich.
MMS clavicle + pectoralis major (Figure 12.16)
Figure 12.14 Stabilizing hand As per the technique above. Keep in

MMS right clavicle + G/H traction mind that the anchor may also be explored with a star con-
cept, depending on the direction of the mobilizing hand.
In this case, because the fascial tissues of the pectoralis
as the therapist pulling harder on the right clavicle when, in major will be explored in a medial direction, the stabilizing
reality, the therapist is simply preventing the clavicle from hand should incorporate a lateral glide component.
moving as he/she performs a traction to the GH joint. If no
tension is perceived, then this part of the fascia is not tight. Mobilizing hand As per the technique above, except that
If tension is perceived (quick resistance is felt between the the therapist explores the pectoralis major muscle, glid-
two hands of the therapist), then it can be mobilized as per ing the tissues in a medial/caudal direction, away from the
the approaches outlined in Chapter 4. This technique may clavicle and as always, using the star concept to seek out the
be used with any accessory movement of the GH joint. fascial line with most tension.
204
The shoulder girdle

Mobilizing hand As per the technique above, except
that the therapist explores the ipsilateral SC joint,
gliding it medially, away from the hand that is anchor-
ing the lateral aspect of the clavicle. This particular
technique, in addition to mobilizing the subclavius fas-
cia, is also useful to treat the fascia of the clavicle bone
itself. If we consider bone to be very dense fascia, it too
can be mobilized to stimulate optimal alignment, espe-
cially post fracture, once the bone has healed (see Case
report 12.1, Michael’s story).
MMS clavicle + A/P cervical spine (Figure 12.18)

Figure 12.16
MMS clavicle + pectoralis major
Mobilizing hand As per the technique above, except
that the therapist explores the tissues superior to the
MMS clavicle + ipsilateral sternoclavicular joint clavicle; in this case, the anterior aspect of the cervical
(Figure 12.17) spine, which includes the scalene muscles as well as the
uncovertebral joints. The therapist performs an A/P
glide in a cranial direction and may explore several
levels of the cervical spine in this manner. Clinically, the

MMS clavicle + ipsilateral SC joint MMS clavicle + A/P Cx
205
Chapter 12
mid-cervical spine, especially C4, is often implicated with

this technique. If no tension is perceived, then this part
of the fascia is not tight. If tension is perceived (quick
resistance is felt between the two hands of the therapist),
then it can be mobilized as per the approaches outlined
in Chapter 4.
MMS clavicle + A/P C1 (Figure 12.19)

Mobilizing hand As per the technique above; Figure Figure 12.20
12.19 demonstrates the technique of an A/P at C1. If the MMS clavicle + A/P mastoid process
craniovertebral region is chronically tight despite mobili-
zations and/or manipulation of the upper cervical joints,
it is worth exploring the fascia that attaches to the levels recurring cranial dysfunctions, as tension from the SCM
involved – in this case, the anterior aspect of C1. and its fascia may contribute to posterior rotation and/or
internal rotation of the temporal bone.
MMS clavicle + flexion occiput (Figure 12.21)

the therapist explores the occiput, pulling it into flexion.
Recurring tension in the craniovertebral (Cr/V) region,
especially a tendency toward a limitation in Cr/V flexion,
is an indication for exploring this fascial technique.
Figure 12.19
MMS clavicle + A/P C1
MMS clavicle + A/P mastoid process (Figure 12.20)

the therapist explores the mastoid process of the temporal
bone with an A/P glide. A number of muscles attach to the
mastoid process, such as the sternocleidomastoid (SCM),
Figure 12.21
the posterior belly of the digastric muscle and the splenius
MMS clavicle + flexion occiput
capitis. The SCM and its fascia are of particular interest for
206
The shoulder girdle
on the lateral clavicle as he/she performs repeated passive

MMS right clavicle + glenohumeral abduction physiological abduction of the shoulder, always to when R1
(Figure 12.22) is perceived (a grade III– passive physiological movement
in Maitland terms). This is repeated until a release is felt
Note that in this example GH abduction is demonstrated between the therapist’s two hands and generally requires
but all passive movements of the GH joint may be explored approximately five to eight cycles.
with this technique.
Stabilizing hand As per the technique above. MMS right clavicle + glenohumeral lock (Figure
Mobilizing hand The therapist’s left hand supports the 12.23)
patient’s upper arm and performs a passive physiological
movement of the GH joint into abduction, stopping as soon Stabilizing hand As per the technique above.
as an increase in tension is perceived in the hand palpat-
ing the clavicle (to the first resistance or R1 of Maitland’s Mobilizing hand As per the technique above, except that the
movement diagram). If there is tension in this line of fascia, therapist explores the GH lock position (Maitland technique
it will seem like the tension on the clavicle increases before to mobilize the periarticular tissues in combined abduction,
full GH abduction can be achieved (usually around 90–100 horizontal extension, and slight internal rotation).
degrees of abduction). The therapist maintains the anchor

MMS right clavicle + GH abduction MMS right clavicle + GH lock
207
Chapter 12
MMS right clavicle + glenohumeral quadrant

(Figure 12.24)

the therapist explores the GH quadrant position (Maitland
technique to mobilize the periarticular tissues in combined
flexion, abduction, and internal or external rotation).
Figure 12.25
MMS right clavicle + ULNT1
neural tissues of the upper quadrant (ULNT1). Other

neural mobility tests may also be explored with this tech-
nique. For this technique, the therapist must compare
the ULNT1 test on its own and re-evaluate it with the
anchor at the clavicle. Traditionally, the typical interfaces
for this nerve are in the area of the mid-cervical spine or
the flexor retinaculum at the wrist. Because the clavicle
Figure 12.24 is intimately related to the clavipectoral fascia and the
MMS right clavicle + GH quadrant
supraclavicular fascia, it too must be considered when
exploring interfaces that may impact the mobility of the
neural tissues in the upper quadrant. In this test, the
therapist will use the component of the test that adds
MMS right clavicle + upper limb neural tension an immediate increase in tension at the hand anchor-
test 1 (ULNT1) (Figure 12.25) ing the clavicle. Once that component is released (simi-
lar concepts of using passive physiological movement as
Stabilizing hand As per the technique above. per technique above), then the next component of the
ULNT1 may be explored and treated until the patient has
Mobilizing hand As per the technique above, except equal mobility of the test with or without the anchor at
that the therapist performs the test for mobility of the the clavicle.
208
The shoulder girdle
of directions (see techniques above), particularly in

Case report 12.1 Michael’s story
relation to the SFL (clavicle in relation to the pectoral
muscles and rectus abdominis) and the anterior func-
This case hits close to home as it involves my son tional line of fascia (left clavicle with right ilium). The
Michael, who is presently 25 years old. When he was intraclavicular fascia also was remodeled to encour-
14 years old, he fell skateboarding and sustained a age healing in the most lengthened position possible.
severe fracture of his left clavicle – it had fractured into This work was followed up with a strengthening pro-
three pieces, with the middle portion angled vertically. gram to his scapular upward rotators. Initial treatment
He was initially placed in a sling and told to go home was performed weekly, and then periodically over the
– the assumption was that the bone would heal on its next year, as bone (and fascia) remodeling took place.
own. Lyn Watson, a shoulder specialist in Melbourne, Throughout his growth spurt, Michael could feel the
Australia, whom I consulted, stated that, in Australia, need for more fascial release and periodically through
they would operate on such a case. Needless to say, the years, as his system adjusted to a new gym pro-
I made sure to go with Michael to his follow-up appoint- gram. Today, he is fully functional and grateful that his
ment. I had a number of concerns about the long-term mother is a physiotherapist with skills in MMS!
function of his shoulder girdle, including the possibility
that it would heal in a shortened position and forever
impact his upper quadrant function. Unfortunately, Summary
I could not convince the chief orthopedic doctor to
perform surgery. He assured me that healing was The techniques in this chapter have focused on myofascial
coming along and I should just allow nature to take connections in relation to the shoulder girdle, including
its course. Knowing that bone was essentially dense those in relation to the sternoclavicular joint as well as the
fascia, I proceeded to remodel the clavicular fascia, clavicle itself. These tissues are frequently problematic in
initially with a listening approach and later, as healing cases of persistent shoulder girdle, cervical, thoracic, or
progressed, with a more directive, MMS mobilization head pain, depending on the vectors that may be impacting
approach. The clavicle fascia was tight in a number this area. The following chapter will focus on techniques
for the upper extremity.
209
The upper extremity 13
When treating patients with problems of the upper Superficial Front Arm Line (SFAL)
extremity, manual therapists are trained to assess and
The Superficial Front Arm Line (SFAL) involves the fol-
treat the joints (the glenohumeral, humeroulnar, supe-
lowing structures: pectoralis major, latissimus dorsi, medi-
rior and inferior radioulnar joints, and the wrist, finger,
al intermuscular septum, flexor group of muscles, carpal
and thumb joints). In addition, the muscles of the upper
tunnel. (Please refer to Chapter 2 for a full description and
quadrant are assessed and treated for imbalance between
illustration of this line of fascia.)
hypertonic, tight muscles and weak muscles. The mobil-
ity of the nerves of the upper quadrant is also assessed Clinical implications
and treated. However, mobilizing joints and nerves, and
stretching and strengthening individual muscles can • This line extends above and beyond the territory of
achieve only partial benefits if the fascial system is not the median nerve distribution. In treating problems
taken into consideration. of mobility for the median nerve, we may consider
looking at interfaces that include the pectoral mus-
This chapter will describe the clinical findings of restric- cles and latissimus dorsi in addition to the flexor ret-
tion in the following fascial dysfunctions: inaculum and the anterior cervical spine. (See MMS
flexor retinaculum with shoulder abduction.)
• deltoid fascia
• The rotator cuff muscles are considered part of the
• supraspinatus fascia in relation to the SFL and the
DBAL, but the insertion of supraspinatus anteriorly
DFL
may clinically be considered as part of the SFAL. It
• fascia of the long head of biceps is also often affected by tension in the SFL and the
• brachialis fascia DFL of the trunk. This tension can contribute to an
anterior position of the humeral head in relation to
• forearm fascia the acromion and to forward head posture in gen-
• flexor retinaculum fascia eral. (See Supraspinatus in relation to the contralat-
eral shoulder (SFL) and to the pericardium and dia-
• fascia in relation to Dupuytren’s contracture phragm (DFL).)
• fascia in relation to de Quervain’s tenosynovitis • Dupuytren’s contracture does not simply involve the
• fascia in relation to the distal radius (post-Colles’ finger flexor tendons in the hand. There are also
fracture) strong fascial connections to the SFAL that may con-
tribute to this dysfunction. (See MMS Dupuytren’s in
Indications for MMS for this chapter relation to the long head of biceps (SFAL) and MMS
• Recurring upper extremity pain despite the following Dupuytren’s in relation to the contralateral shoulder
treatment approaches: (SFAL with the trunk SFL.)
−− mobilization/manipulation of the joints of the
shoulder, elbow, forearm, wrist, and hand
Deep Front Arm Line (DFAL)
−− release of trigger points to the upper extremity The Deep Front Arm Line (DFAL) involves the following
muscles with manual or dry needling techniques structures: pectoralis minor, the clavipectoral fascia, biceps,
−− stabilization and strengthening exercises for the radial periosteum and thenar muscles. (Refer to Chapter 2
upper quadrant. for a full description and illustration of this line of fascia.)
211
Chapter 13
Clinical implications lower), deltoid, brachialis, lateral intermuscular septum,

extensor muscles of wrist and fingers. (Refer to Chapter 2
• Adding wrist extension and ulnar deviation can help
for a full description and illustration of this line of fascia.)
release the fascial line associated with tightness of
pectoralis minor, a muscle that commonly contributes Clinical implications
to an anterior tilt of the scapula and therefore may af-
• This line extends above and beyond the territory of
fect shoulder girdle function. Tightness of this fascial
the radial nerve distribution. In treating problems of
line may also maintain a forward head posture. (See
mobility for the radial nerve, we may consider look-
MMS pectoralis minor in relation to the DFAL.)
ing at interfaces that include the trapezii, deltoid, and
• Releasing the fascia around the clavicle can have a the cervicothoracic region in addition to the area of
positive effect on improving shoulder mobility and the radial head and the anterior cervical spine. (See
promoting an axially extended posture. (Refer to MMS P/A radial head with elbow extension/prona-
Chapter 12 for clavicle fascia techniques.) tion/wrist flexion for an example.)
• If periosteum is to be considered “dense fascia,” then • The deltoid, brachialis, and wrist extensor muscle
(after the appropriate healing time has occurred), the group all have a fascial connection through the SBAL.
site of a clavicular fracture may benefit from fascial Deltoid fascia should be considered when looking for
release of the clavipectoral fascia (see Chapter 12 for non-articular restrictions of the shoulder. (See MMS
MMS technique) in order to minimize the effects of anterior deltoid with glenohumeral internal rotation
shortening of the clavicle on the upper quadrant. and MMS posterior deltoid with glenohumeral exter-
nal rotation.)
• The attachment of the long head of biceps is commonly
affected by tension in the SFL and the DFL of the trunk. • Persistent pain and tension in the lateral elbow region
This tension can pull the humeral head anteriorly in may be due to tension in relation to the SBAL of fas-
relation to the acromion and contribute to a forward cia. Releasing this fascia is frequently helpful with re-
head posture. (See MMS long head of biceps with con- calcitrant problems of lateral epicondylosis. (See MMS
tralateral rectus abdominis (SFL).) Tension of the DFAL lateral brachialis with elbow extension/pronation.)
may also contribute to a flexed position of the elbow in
• If periosteum is to be considered “dense fascia,” then
a standing posture, as the body attempts to offload the
(after the appropriate healing time has occurred) the
glenohumeral head. Adding wrist flexion to a stretch of
site of a Colles’ fracture may benefit from fascial re-
the biceps (elbow extension, pronation) also converts
lease of the distal radius in relation to the SBAL in
this into a fascial technique. (See MMS long head of bi-
order to optimize wrist mobility. (See MMS Colles’
ceps with elbow extension/pronation/wrist flexion.)
fracture fascia in relation to the SBAL.)
• Treatment of De Quervain’s tenosynovitis may extend
beyond the use of transverse frictions of the reti- Deep Back Arm Line (DBAL)
naculum with the thumb in the Finkelstein position The Deep Back Arm Line (DBAL) involves the follow-
(thumb adduction, with wrist ulnar deviation) if we ing structures: rectus capitis lateralis, rhomboids, levator
consider this fascial line to include the biceps, clavi- scapula, rotator cuff muscles, triceps, ulnar periosteum,
pectoral fascia and pectoralis minor. (See MMS Fin- hypothenar muscles. (Refer to Chapter 2 for a full descrip-
kelstein’s in relation to the shoulder (DFAL.) tion and illustration of this line of fascia.)
Superficial Back Arm Line (SBAL) Clinical implications

The Superficial Back Arm Line (SBAL) involves the fol- • This line extends above and beyond the territory of
lowing structures: trapezius muscles (upper, middle, and the ulnar nerve distribution. In treating problems of
212
The upper extremity
mobility for the ulnar nerve, we may consider look- component of the load and listen test. At this point,
ing at interfaces that include the rotator cuff and the positional tests for the GH joint should also be negative.
levator scapula in addition to the area of the tunnel The possibilities for vectors are varied but the most fre-
of Guyon at the wrist and the anterior cervical spine. quent are outlined below:
Postural analysis for the upper quadrant • A pull of the humeral head inferiorly and anteriorly im-
plies the involvement of the long head of biceps.
• Position of the humeral head in relation to the
acromion. • A pull of the humeral head in the supero-
antero-medial direction may imply the involvement
• Position of the scapulae in relation to the thorax.
of the coracobrachialis, subclavius, or clavicle.
• Position of the clavicles.
• A pull of the humeral head in the anteromedial direc-
Please refer to Chapter 12 for details of postural analysis as tion may imply the involvement of the pectoralis ma-
it pertains to the upper extremity. jor muscle and/or the fascia of the SFL of the trunk. If
the vector feels deep it may also involve visceral fas-
Load and listen test for the shoulder
cia, such as that of the lungs and pericardium.
The load and listen test is useful for detecting myofascial
vectors that may have an impact on the position and there- All of these neuromuscular vectors may be treat-
fore the function of a joint. The test is described in detail ed with a number of techniques designed to release
for the hip joint in Chapter 11, but a similar approach can muscle hypertonicity, such as contract–relax, strain/
be used in relation to the glenohumeral (GH) joint. counterstrain, release with awareness, dry needling, etc.
However, if results of these approaches are difficult to
If the patient presents with an anteriorly positioned GH maintain, the therapist should then explore the fascial
head in relation to the acromion, the therapist may per- line(s) related to the muscles involved.
form an A/P glide of the GH joint in a supine or seated
position. If the restriction is articular, the end feel of the Concepts of treatment using MMS
posterior glide (for example) will be hard and fibrotic.
However, if there is a myofascial restriction, the therapist For this chapter, we will be using primarily the first concept
will feel the resistance to the accessory movement with an of treatment when using MMS techniques; that is, choose a
end feel that is softer. A certain resistance will be felt with recurrent articular dysfunction or myofascial trigger point
this correction but valuable information will be gleaned and explore a fascial line in relation to it. The therapist
if the therapist pays attention to the release component of anchors him/herself to a recurrent articular dysfunction
the test, listening (passively) for vectors that are “tugging” or myofascial trigger point and assesses the fascial lines of
on the GH joint. Vectors may be long or short, pull in a tension in relation to the anchor, looking for early tension
cranial, caudal, or medial direction, and may feel either between the two hands.
superficial or deep. The following approaches may be used, depending on
There may be a combination of neuromuscular vec- how the tissues respond:
tors (increased tone in muscles due to increased neural • work with oscillations (grades III−, III, III+)
drive), visceral vectors, muscular, and fascial vectors.
The therapist pays attention to where the first pull is felt • work with sustained pressure
and then tries to determine the direction of pull. Once • work with “harmonics” (Dr Laurie Hartman).
this first vector is released, then the therapist seeks
a second vector on a repeat load and listen test, and Please refer to Chapter 4 for detail on concepts of treatment
so on until no further tension is felt on the release using MMS.
213
Chapter 13
MMS pectoralis minor fascia tains the pinch of the pectoralis minor and simply prevents
the tissues from gliding laterally and caudally. The patient
perceives this as the therapist increasing his/her pressure
MMS right pectoralis minor in relation to the DFAL
on the muscle. The therapist performs repeated movement
(Figure 13.1)
of the wrist into flexion and ulnar deviation while main-
taining a steady pressure on the pectoralis minor, always
to the point when R1 is perceived. This action is repeated
until a release is felt between the therapist’s two hands and
generally requires approximately five to eight cycles.
MMS deltoid fascia
MMS right anterior deltoid with glenohumeral

internal rotation (Figure 13.2)
Figure 13.1
MMS pectoralis minor in relation to the DFAL
The pectoralis minor muscle is frequently hypertonic and

facilitated. Dry needling may help restore a more normal tone
to this muscle; however, tight fascia around this muscle may
contribute to its tendency to be recalcitrant. The pectoralis
minor is part of Tom Myers’s Deep Front Arm Line (DFAL),
and as such, may be put under tension with the addition of
wrist ulnar deviation, with wrist and finger flexion.
The patient is in supine position. The therapist uses their

left hand to “pinch” the pectoralis minor between the thumb Figure 13.2
and fingers, especially in the area of recurring trigger points. MMS right anterior deltoid with GH IR
The muscle may be explored along its length for tension.
Mobilizing hand With the patient’s arm in pronation
The fascia of the anterior deltoid may be a limiting factor to
with the elbow extended, the therapist performs ulnar
gaining range of shoulder internal rotation.
deviation of the wrist and flexes the patient’s wrist and
fingers, stopping as soon as an increase in tension is per- Stabilizing hand The patient is in supine position. The
ceived in the hand that is anchoring the pectoralis minor. therapist uses their right hand to anchor the anterior del-
If there is tension in this line of fascia, it will seem like the toid into external rotation. The muscle may be explored
tension in the pectoralis minor increases before full wrist along its length, towards the deltoid insertion (an area
and finger flexion can be achieved. The therapist main- rich in fascia).
214
The upper extremity
Mobilizing hand The therapist’s left hand supports the The fascia of the posterior deltoid may be a limiting factor
patient’s wrist and forearm and performs a passive physi- to gaining range of shoulder external rotation. This tech-
ological movement of the glenohumeral joint into internal nique may be useful to regain this ROM.
rotation (IR), stopping as soon as an increase in tension
Stabilizing hand The patient is in supine position. The
is perceived in the hand palpating the anterior deltoid
therapist uses their left hand to anchor the posterior del-
(to the first resistance, or R1 of Maitland’s movement
toid into internal rotation. The muscle may be explored
diagram). If there is tension in this line of fascia, it will
along its length, toward the deltoid insertion.
seem as though the tissues of the anterior deltoid will
push into the therapist’s thumb before full glenohumer- Mobilizing hand The therapist’s left hand supports
al internal rotation can be achieved (usually around 70 the patient’s wrist and forearm and performs a passive
degrees of IR). The patient perceives this as the therapist physiological movement of the glenohumeral joint into
increasing his/her pressure on the anterior deltoid. The external rotation (ER), stopping as soon as an increase in
therapist performs repeated passive physiological IR of tension is perceived in the hand palpating the posterior
the shoulder while maintaining a steady pressure on the deltoid (to the first resistance, or R1 of Maitland’s move-
anterior deltoid, always to when R1 is perceived (a grade ment diagram). The approach to treatment is the same as
III– passive physiological movement in Maitland terms). for the technique above.
This technique is repeated until a release is felt between
the therapist’s two hands and generally requires approxi-
MMS Supraspinatus fascia in relation to
mately five to eight cycles.
the SFL and the DFL
MMS right supraspinatus in relation to the

MMS right posterior deltoid with glenohumeral
contralateral shoulder (SFL) (Figure 13.4)
external rotation (Figure 13.3)
Figure 13.4
Figure 13.3 MMS right supraspinatus in relation to the
MMS right posterior deltoid with GH ER contralateral shoulder (SFL)
215
Chapter 13
Stabilizing hand The patient is in supine position. Using

a craniolateral hold, the therapist uses their left hand to
anchor the insertion of the supraspinatus at the greater
tubercle of the humerus on the right side.
Mobilizing hand With the star concept in mind, the thera-
pist’s right hand explores the left shoulder and shoulder gir-
dle area with an anteroposterior caudal glide of the tissues in
the area of the lateral clavicle and/or the glenohumeral joint,
always looking for the immediate line of tension in relation
to the hand that is anchoring the supraspinatus. If this fascial
line is tight, the therapist will feel an increase in tension in the
anchoring hand, as if the tissues of the supraspinatus were
being pulled medially towards the center of the body. The
patient perceives this action as the therapist increasing his/her
pressure on supraspinatus. If tension is perceived (quick resist-
ance is felt between the two hands of the therapist), then it can
be mobilized as per the approaches outlined in Chapter 4. Figure 13.5
MMS right supraspinatus in relation to the pericar-
dium (DFL)
pericardium (DFL) (Figure 13.5)
Stabilizing hand As per the technique above. contralateral diaphragm (DFL) (Figure 13.6)
Mobilizing hand The therapist explores the area of

the pericardium, first by slowly sinking into the tissues Stabilizing hand As per the technique above.
posterior to the sternum and then gently pushing in a
caudal direction, all the while maintaining the depth Mobilizing hand The caudal hand explores the ante-
of the fascial line posterior to the sternum. The thera- rior diaphragm on the patient’s left side with a caudal/
pist looks for the angle where he/she perceives imme- lateral glide of the tissues, always looking for the imme-
diate tension in the hand anchoring the supraspinatus. diate line of tension between the two hands. Appropri-
That tension may be felt most in the pericardial area in ate depth of tissues is required. The fascia around the
a simple caudal direction, or caudal to the left of the cli- rectus abdominis and oblique abdominal muscles may
ent. Sometimes the tension is most felt when moving be accessed with this technique if the technique is done
the pericardial tissues mediolaterally or in a clockwise/ superficially (this would be a technique for the SFL).
counterclockwise direction, always maintaining the However, in order to access the diaphragm, which is
depth of the tissue. If no tension is perceived, then the part of the DFL, the therapist must first slowly sink into
DFL of fascia in relation to this muscle is not tight. If the tissues posterior to the lower ribs and then gently
tension is perceived (quick resistance is felt between the push in a caudal/lateral direction. This technique can
two hands of the therapist), then it can be mobilized as be done with either the ipsilateral or the contralateral
per the approaches outlined in Chapter 4. diaphragm.
216
The upper extremity
Figure 13.6
MMS right supraspinatus in rela-
tion to the contralateral diaphragm
(DFL)
MMS right supraspinatus in relation to the MMS right long head of biceps with elbow extension/
contralateral iliacus (DFL) (Figure 13.7) pronation/wrist flexion (DFAL) (Figure 13.8)
Figure 13.7
contralateral iliacus (DFL)
Stabilizing hand As per the technique above. Figure 13.8

MMS right long head of biceps with elbow
Mobilizing hand The caudal hand explores the contralat- extension/pronation/wrist flexion (DFAL)
eral iliacus, either similar to the iIiacus position outlined
in Chapter 8 or using the ilium to explore posterior and
anterior rotations, using a star concept. This technique The long head of biceps (LHB), because of its attachment
may also be performed for the ipsilateral iliacus. to the superior portion of the glenoid labrum and the
217
Chapter 13
anterosuperior capsule of the glenohumeral joint, may

cause the humeral head to displace anteriorly in relation to
the acromion. The fascia of the long head of biceps should
be explored, both in relation to the elbow and in relation to
the SFL of the trunk.
anchor the long head of biceps (LHB) in the bicipetal groove.
An area of approximately 5 cm may be explored in this way.
Mobilizing hand The right hand of the therapist per-
forms passive physiological elbow extension, with the fore-
arm pronated and the wrist flexed, stopping as soon as an
increase in tension is perceived in the hand palpating the
LHB (to the first resistance or R1 of Maitland’s movement
diagram). If there is tension in this line of fascia, it will
seem as though the tissues of the LHB will push into the
therapist’s thumb before full elbow extension in pronation Figure 13.9
can be achieved. The patient perceives this as the thera- MMS right long head of biceps with RA (DFAL with
pist increasing his/her pressure on the LHB. The thera- SFL of trunk)
pist performs repeated passive physiological extension of
the elbow with the forearm pronated and the wrist flexed
pressure on the LHB. If tension is perceived (quick resistance
while maintaining a steady pressure on the LHB, always
is felt between the two hands of the therapist), then it can be
to when R1 is perceived (a grade III– passive physiological
movement in Maitland terms). This action is repeated until
a release is felt between the therapist’s two hands; this gen-
erally requires approximately five to eight cycles. MMS right lateral brachialis with elbow extension/
pronation (SBAL) (Figure 13.10)
MMS right long head of biceps with rectus
abdominis (DFAL with SFL of trunk) (Figure 13.9) Lateral elbow pain may have several sources, but one com-
mon source of tension is commonly found in the lateral
brachialis area.
Mobilizing hand With the star concept in mind, the right
hand of the therapist explores the rectus abdominis area
anchor the lateral brachialis muscle, located posterior to
(contralaterally and ipsilaterally all the way down to the
the biceps. An area of approximately 4 cm may be explored
symphysis pubis) with an anteroposterior caudal glide of the
in this way.
tissues, always looking for the immediate line of tension in
relation to the hand that is anchoring the LHB. If this fascial Mobilizing hand Same as per the MMS for the long head
line is tight, the therapist will feel an increase in tension in of biceps with elbow extension/pronation/wrist flexion.
the anchoring hand, as if the tissues of the LHB were being The technique may be explored by starting with the fore-
pulled caudally and medially towards the center of the body. arm supinated, then progressed to neutral, and then finally
The patient perceives this as the therapist increasing his/her to full pronation.
218
The upper extremity
Figure 13.10
MMS right lateral brachialis with elbow extension/
pronation (SBAL)
MMS P/A right radial head with elbow extension/

pronation/wrist flexion (Figure 13.11)
Figure 13.11
Another source of lateral elbow pain is tension of the fascia MMS P/A right radial head with elbow extension/
around the head of the radius. It is also a common interface pronation/wrist flexion
for problems with mobility of the radial nerve.
Stabilizing hand The patient is in supine position. A P/A followed by MMS techniques in relation to the posterior
pressure of the radial head is performed as the anchoring aspect of the wrist extensors (Figures 13.15 and 13.16).
maneuver.
Mobilizing hand Same as per the MMS for the long head MMS anterior aspect of right wrist extensors with
of biceps with elbow extension/pronation/wrist flexion. elbow extension/pronation/wrist flexion (SBAL)
(Figure 13.12)
The following MMS techniques may be used to explore
tension and decreased range of motion in the forearm
(pronation/supination) and the wrist and fingers (flexion/ Stabilizing hand The patient is in supine position. Using
extension, radial and ulnar deviation), particularly if a their left hand, the anterior portion of the wrist extensor mus-
plateau in treatment has been reached with mobilization of cle group is explored and anchored with a cranial/lateral glide.
the affected joints. The first three techniques will involve
MMS techniques in relation to the anterior aspect of Mobilizing hand Same as per the MMS for the long head
the wrist extensors (Figures 13.12 to 13.14). This will be of biceps with elbow extension/pronation/wrist flexion.
219
Chapter 13
Figure 13.12
MMS anterior aspect of right wrist extensors with
elbow extension/pronation/wrist flexion (SBAL) Figure 13.13
pronation
pronation (Figure 13.13)
wrist extensors (to the first resistance or R1 of Maitland’s
movement diagram). If there is tension in this line of fas-
Stabilizing hand The patient is in supine position with cia, it will seem as though the anterior portion of the wrist
the elbow flexed. The anterior portion of the wrist extensor extensors will push into the therapist’s fingers before full
muscle group is explored and anchored by the therapist’s pronation can be achieved. The patient perceives this as the
left hand, with a “glide” of the tissues into supination. An therapist increasing his/her pressure on the anterior aspect
area of approximately 4 cm may be explored in this way. of the wrist extensors. The therapist performs repeated
Mobilizing hand The therapist’s right hand grips the passive physiological forearm pronation while maintaining
radial aspect of the patient’s wrist and hand, with their a steady pressure on the wrist extensor group, always to the
thumb between the patient’s thumb and index finger. point when R1 is perceived (a grade III– passive physiologi-
The therapist performs passive physiological pronation of cal movement in Maitland terms). This sequence is repeat-
the forearm, stopping as soon as an increase in tension is ed until a release is felt between the therapist’s two hands
perceived in the hand palpating the anterior aspect of the and generally requires approximately five to eight cycles.
220
The upper extremity
Figure 13.15
MMS posterior aspect of right wrist extensors with
supination
Figure 13.14
ulnar deviation MMS posterior aspect of right wrist extensors with
supination (Figure 13.15)

ulnar deviation (Figure 13.14) Stabilizing hand As per the technique above except that
the therapist explores the dorsal aspect of the wrist exten-
sor muscle group with their right hand and anchors it with
Stabilizing hand As per the MMS technique above, a “glide” of the tissues into pronation. An area of approxi-
except that the therapist anchors the anterior aspect of the mately 4 cm may be explored in this way.
wrist extensors with a cranial glide of the tissues.
Mobilizing hand As per the MMS technique above,
the therapist uses their left hand to perform passive physi-
except that the therapist performs passive physiological
ological forearm supination.
wrist ulnar deviation.
221
Chapter 13
MMS posterior aspect of right wrist extensors with

ulnar deviation (Figure 13.16)
Figure 13.17
MMS interosseous membrane with ulnar deviation
Figure 13.16
MMS posterior aspect of right wrist extensors with Mobilizing hand As per the technique above.
ulnar deviation
Flexor retinaculum
Stabilizing hand As per the MMS technique above, The flexor retinaculum is a fascia that forms the roof of
except that the therapist anchors the dorsal aspect of the the carpal tunnel and is considered part of the SFAL of
wrist extensors with a cranial glide of the tissues. fascia. It originates from the distal radius and ulna and
Mobilizing hand As per the technique above, except that the continues distally to attach to the scaphoid tubercle and
therapist performs passive physiological wrist ulnar deviation. trapezium laterally and the pisiform and hook of the
hamate medially. It is a common interface for problems
with mobility of the median and ulnar nerves as the tun-
MMS right interosseous membrane with ulnar
deviation (Figure 13.17) nel tends to become narrow, with the hamate/pisiform
and scaphoid/trapezium approaching each other to
increase the arch of the wrist. It can be mobilized locally
Stabilizing hand The therapist anchors the interosse- and in relation to the median and ulnar nerves by adding
ous membrane between the radius and ulna on the dorsal shoulder abduction, a maneuver that increases tension to
aspect of the forearm, using a cranial anchor. both nerves.
222
The upper extremity
Dupuytren’s contracture
MMS flexor retinaculum (SFAL), with and without
shoulder abduction (Figure 13.18) There are strong fascial connections between the finger
flexors and the SFAL of fascia, as well as the fascia of the
anterior trunk (SFL). Dupuytren’s usually begins as small
hard nodules just under the skin of the palm, most com-
monly affecting the 4th, the 5th and the 3rd digits. Treat-
ment with fascial techniques can minimize signs and
symptoms, especially if treated before contractures start to
interfere with the function of the hand.
MMS anchor for Dupuytren’s (Figure 13.19)
Stabilizing hand The therapist uses their thumb to

anchor the nodular fascial tissue, exploring the tendon
itself, as well as either side of the tendon. The direction
of the anchor depends on where the mobilizing hand will
Figure 13.18
MMS right flexor retinaculum with shoulder abduc-
explore. The anchor is in a distal/ulnar direction if the
tion (SFAL) other hand explores the radial aspect of the hand. The
MMS technique Using both thumbs, the therapist stabi-

lizes the dorsal aspect of the distal radius and ulna. He/
she then uses their third digits to explore the fascia in the
area of the pisiform/hamate and scaphoid/trapezium, gen-
tly pulling the fingers apart. If there is sufficient mobility
in the flexor retinaculum there should be some “give” in
the tissues when trying to pull them gently apart. If there
is tension, it may be felt in a straight medial/lateral direc-
tion or in a diagonal direction (e.g., between the pisiform/
hamate and the radius).
The therapist may use either the mobilization

approach with MMS, or a more sustained pressure until
tension is perceived to lessen between the therapist’s
two hands. This technique may be progressed by adding
passive wrist and finger flexion/extension while main-
taining a stretch on the retinaculum. The flexor retinac-
ulum technique may also be performed in positions that Figure 13.19
increase tension on the median and/or ulnar nerve (e.g., MMS anchor for Dupuytren’s
shoulder abduction).
223
Chapter 13
anchor is in a distal direction (always with the star concept on the affected digit. If tension is perceived (quick resistance
in mind) if the other hand explores more proximal areas in is felt between the two hands of the therapist), then it can be
relation to the hand. mobilized as per the approaches outlined in Chapter 4.
MMS right Dupuytren’s in relation to hand fascia MMS right Dupuytren’s in relation to the long
(SFAL) (Figure 13.20) head of biceps (DFAL) (Figure 13.21)

fascia on the radial aspect of the hand, either distally or
proximally in relation to the nodule. The therapist may
also use passive physiological movement of flexion/exten-
sion of all of the fingers of the hand (not only the finger
most involved). If this fascial line is tight, the therapist
will feel an increase in tension in the anchoring hand, as
if the tissues of the nodule were being pulled proximally
and medially towards the center of the hand. The patient
perceives this as the therapist increasing his/her pressure
Figure 13.21
MMS right Dupuytren’s in relation to the ipsilateral
shoulder/LHB (DFAL)

area of the ipsilateral glenohumeral joint and long head
of biceps with an A/P glide directed cranially, but also
with the star concept in mind. If this fascial line is tight,
the therapist will feel an increase in tension in the anchor-
ing hand, as if the tissues of the nodule were being pulled
Figure 13.20 proximally. The patient perceives this action as the thera-
MMS right Dupuytren’s in relation to hand fascia pist increasing his/her pressure on the affected digit. Simi-
(SFAL) lar concepts for mobilizing this line of fascia apply as per
previous techniques.
224
The upper extremity
Figure 13.22
MMS right Dupuytren’s in relation to the contralat-
eral shoulder (SFAL with SFL of the trunk)
Figure 13.23
MMS right Dupuytren’s in relation to the contralateral
diaphragm (SFAL with DFL of the trunk)
MMS right Dupuytren’s in relation to the
contralateral shoulder (SFAL with SFL of the trunk)
(Figure 13.22) either ipsilaterally or contralaterally, using the same con-
cepts as for the techniques above.
De Quervain’s
Mobilizing hand This technique explores the links between
De Quervain’s tenosynovitis is a condition that may be diffi-
the SFAL and the SFL of the trunk. This time the therapist’s
cult to treat unless the therapist considers factors besides over-
left hand explores the area of the contralateral shoulder and
use that may contribute to this pathology. For example, an
scapula. A more laterally directed glide of the shoulder/
abduction lesion of the elbow (secondary to a fall on the out-
scapula usually creates the most tension with this technique.
stretched hand) can alter the biomechanics of the forearm and
the wrist and therefore increase the load on the thumb mus-
MMS right Dupuytren’s in relation to the contralateral cles. (This condition is generally treated with a manipulation
diaphragm (SFAL with DFL of the trunk) (Figure 13.23) to restore optimal biomechanics.) Once the acute stage starts
to settle, the therapist traditionally performs deep transverse
frictions to the group of thumb tendons. This technique is
usually performed in the Finkelstein position (thumb flexion
Mobilizing hand This technique explores the link and adduction with wrist ulnar deviation), which increases
between the SFAL and the DFL of the trunk, anterior fascia tension on the retinaculum surrounding the tendons. The
that is deeper than the SFL of the trunk. The therapist’s therapist should also explore the fascia in relation to these
left hand explores the area of the diaphragm or the iliacus, tendons, usually in relation to the DFAL (Figure 13.24).
225
Chapter 13
Figure 13.25
MMS Finklestein’s in relation to DFAL
in this line of fascia, it will seem like the hand holding the
wrist will want to go into radial deviation. The patient per-
ceives this action as the therapist increasing his/her pres-
sure on the wrist. The therapist performs repeated passive
Figure 13.24 physiological cranial glides of the affected fascia while
MMS positioning the right wrist in Finklestein’s test maintaining the wrist and thumb in Finkelstein’s position.
This sequence is repeated until a release is felt between the
therapist’s two hands and generally requires approximately
five to eight cycles.
MMS Finklestein’s in relation to the DFAL (Figures MMS techniques post Colles’ fracture
13.25, 13.26) If we consider bone as dense fascia, then we can under-
stand how fascial techniques may be used to regain opti-
mal range of motion and function of the wrist and forearm
Stabilizing hand The therapist holds the thumb and
post-fracture. Of course, the therapist should wait until the
wrist in the Finkelstein position (see above). If there is pain
bone has had sufficient healing time (minimum six weeks)
associated with this test, the therapist should stop just
before beginning these techniques. It is also wise to start
short of the start of painful symptoms.
gently, using listening techniques at first to see what the
Mobilizing hand The therapist’s left hand explores the body can tolerate (see Chapter 4). With time, the approach
fascia of the DFAL (radial periosteum, biceps, clavipecto- can become firmer and more directive, if needed. The fact
ral fascia, pectoralis minor), usually in a cranial direction, that the anchoring hand is stabilizing the site of fracture
but always with the star concept in mind. If there is tension also helps to make these techniques safe.
226
The upper extremity
Figure 13.27
MMS right Colles’ fracture fascia in relation to the
forearm (SBAL)
this technique may become more specific by anchoring

the distal radius with a smaller, firmer hold (e.g., using
the thumb).
Figure 13.26
fascia of the SBAL (extensor muscles of wrist and fingers,
MMS Finklestein’s in relation to the pectoralis minor
(DFAL) brachialis, deltoid, trapezii muscles), usually in a cranial
direction, but always with the star concept in mind. If
there is tension in this line of fascia, it will seem like the
hand holding the distal radius will want to move dorsally
MMS right Colles’ fracture fascia in relation to the and cranially. The patient perceives this as the therapist
SBAL (Figures 13.27, 13.28) increasing his/her pressure on the radius. The therapist
performs repeated passive physiological cranial glides of
the affected fascia while maintaining the anchor on the
Stabilizing hand The therapist uses the thenar eminence radius. This is repeated until a release is felt between the
of their right hand to stabilize the dorsal aspect of the distal therapist’s two hands and generally requires approximately
radius (site of fracture) with a broad anchor. With time, five to eight cycles.
227
Chapter 13
Summary
The techniques in this chapter have focused on the myofas-
cial connections in relation to the upper quadrant, namely
the shoulder, elbow, forearm, wrist and hand. The next
chapter will discuss a more active treatment approach to
help maintain the effects of treatment with MMS.
Figure 13.28
MMS right Colles’ fracture fascia in relation to the
deltoid (SBAL)
228
Section 3
Optimizing treatment
Movement and fascia 231
Optimizing therapeutic outcomes 257

Movement and fascia
14
The overall goal of any physical therapy is to move well. It • New discoveries in fascia research imply that tradi-
is difficult to feel well if one is unable to move well. Some- tional isolated approaches to exercise can be counter-
times the ability to move well is inhibited by restrictions of productive – more holistic movement forms such as
certain tissues in the body, whether it is due to a hypomo- yoga may be far more useful for training the fascia.
bile joint or a tight myofascial line. Appropriate interven-
tion by skilled therapists can facilitate a pathway to enable Stretching
the body to move more freely. However, manual therapy of
If we look to research for evidence of the benefits of stretch-
any kind is a passive treatment. In order to achieve opti-
ing, the results are mixed and not as universally promising
mal therapeutic results, manual therapy must be followed
as some advocates maintain. As Tom Myers observes,
by active movement. Complementary forms of movement
could include a specific stretch exercise to maintain the On the surface, stretching seems like a great warm-up
effects of treatment and/or retraining movement patterns activity, a pre-game or pre-run stretch. It ‘wrings out’
that relate to the patient’s meaningful task. The oft-repeat- the tissue, refreshing the water, breaks up any adhesions,
ed line that “Neurons that fire together wire together” and prepares the body to move quickly without injury.
(Hebb 1949) applies in these situations. Therapists draw Doesn’t it? No, it doesn’t – research has fairly consistently
on the concept of neuroplasticity to help create new neural shown no benefit in terms of muscle soreness, injury pre-
networks for function and performance. For such neuro- vention, and it may reduce strength or sport performance
logical remapping to occur, the patient’s body and brain from 5% to 20% (Herbert et al. 2011). A second argument
needs new and novel experiences, not simple rote exercises against stretching as a form of human maintenance is
done in front of the television. Optimal movement requires that we do not do a lot of movement in our daily life at
focused attention. Adopting new strategies for movement the end range of motion. Stretching, as it is commonly
may be even more challenging for those patients who are practiced in many yoga classes, sports prep, and even
taking neuropathic pain medications, such as gabapentin, rehabilitation involves taking the stretch to the end-range
as these medications have a tendency to desensitize the of motion. It has simply not been shown that exploring
nervous system. Nevertheless, movement needs to be a pri- the end-range of motion with active or passive stretches
mary goal of therapy. improves the quality of movements in daily life. Finally,
all the research points to training being very highly spe-
With regards to maintaining fascial mobility, Tom Myers cific – when you train a motion, you train for that motion
(in his blogs on Anatomy Trains) summarizes current only. It does not bleed over into other motions so easily
thoughts about the critical role of movement in that process: or so generally as we have supposed. If you are training
• New discoveries in fascia research hold tremendous yourself in a twisting stretch, you are ‘training’ for that
implications for changing not just human form but specific stretch, and it may not translate into more or bet-
also behavior and emotional patterns. ter motion in daily life. (Myers 2015)
• The emerging understanding of the central role There are better arguments for stretching at the end of
played by the fascia in bodily health puts new em- activity rather than at the start of activity: The warmed
phasis on the role of movement therapies in heal- muscles and fascia are more amenable to change, so
ing. Myers predicts a medicine of the future in perhaps more increase in ROM can be obtained by
which the emphasis on movement as therapy will stretching after exercise. Even the stretched out yogi
play a central role. who can put their hands on the floor can have areas
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Chapter 14
of the hamstrings that are painful and held very tight. • Fascial fitness (Robert Schleip and Johanna Bayer)
Everything around that tight spot is loose and limber to
• Medical therapeutic yoga (Dr Ginger Garner)
allow the movement in the joint, but the careful ‘comb-
ing through’ the tissue I do as a body-worker reveals Ginger Garner’s book Medical Therapeutic Yoga: Bio-
these islands of supreme tension within the ocean of psychosocial Rehabilitation and Wellness Care (Hand-
availability. (Myers 2015) spring Publishing) is highly recommended reading.
Myers also suggests the following: Dr Garner has developed a biomechanically safe yoga
practice that involves a functional movement assess-
1. Do self myofascial release (SMR) yourself – with a ment algorithm and requires kinesthetic awareness and
ball or a roller. Find the places that you feel are stuck respiration. She states: “Healthy movement is dictated
or dense, and roll over them with your body weight, not by the amount of movement you have, but how well
moving very slowly and with awareness to get into you can control your available movement. Controlled
the worst of it and open it up to hydration. In his flexibility is a tenet of my approach to using yoga ther-
blog on foam rollers and self myofascial release he apeutically in any condition where human movement is
does, however, state a few precautions about their use required” (Garner 2016).
(Myers April 2015).
The focus in this chapter will be on stretches and yoga
2. Find a good body-worker, osteopath, or even experi-
poses for each the fascial lines described by Tom Myers. A
enced yoga teacher who can help you find the stuck
note of caution, however. Yoga is a wonderful tool but it is
places you don’t know about. (This author would
not for everyone and there are injuries that can occur from
add physiotherapist to that list!) You work the stuck
doing “bad yoga.” As therapists, we must be careful not to
places you do know about. Other spots may be just
take the yoga asanas out of context for the sole purpose of
as stuck, but not producing pain or being obviously
fascial lengthening. My suggestion to therapists who are
limiting (Myers 2015).
not familiar with yoga is to find a qualified yoga therapist
Other integrative therapies who understands the proper form and alignment of these
postures and try a number of classes first before you pre-
There are a number of integrative therapies that are com- scribe these asanas for your patients. The body needs some
plementary to the treatment approaches by various profes- preparation in order for the fascial tissue to react more effi-
sionals (physiotherapists, osteopaths, massage therapists, ciently – a body that is not warmed up will not react the
etc.). The following list is not exhaustive but includes some same way as one that is warm. Taking a whole yoga class
complementary treatments that incorporate movement: that is progressively building is not the same as choosing
• Feldenkrais approach (Moishe Feldenkrais) the odd asana.
• Alexander technique (F. M. Alexander) Before launching into a description of these poses, the
• Tai-Chi question that begs to be answered is “What is the optimal
time to hold a yoga pose?” In his blog (September 13, 2016),
• Chi-Gong Tom Myers responds to this question:
• Pilates (Elizabeth Larkam, Fascia in Motion: 1. Suggested times holding a pose vary from for five to
Fascia-focused Movement for Pilates, 2017) 10 minutes, although Iyengar recommended three
• MELT method (Sue Hitzmann) minutes. Individual variation is what is important,
as there isn’t a number that works for everyone. For
• Resistance flexibility (Bob Cooley, Dr Christiane
some, the physiological changes may be done in a
Northrup)
shorter time, for others, it might be rewarding and
• Fascial stretch therapy (Ann and Chris Frederick) delicious to hold the pose for a half hour.
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Movement and fascia
2. Myotatic reflex release: when a muscle is first level of the lumbar or cervical spine. The sacroiliac joint
stretched, the myotatic reflex is released; that is, its (SIJ) should maintain its neutral position in nutation of the
own stretch reflex tries to re-contract the muscle back sacrum unless the pose calls for full flexion of the spine (as
to its original length. If the stretch is maintained, the in the cat part of the cat/cow pose).
reflex gives up after a time and the muscle lengthens.
Again, that time varies with the person, but mostly Across all poses, there are some common concepts for
with the training. After a certain time in the pose, the practitioner of these poses to keep in mind. These
there’s an ‘Ah!’ feeling as the body relaxes into the are common themes taught by most yoga therapists and
pose. That moment will come sooner for the trained articulated beautifully by Melissa Kreiger, yoga therapist
yogi and will take longer for the neophyte. The deep (Kreiger 2018):
fascia within the muscle does not begin to stretch • Breath moves in, breath moves out – keep using
until this relaxation occurs, suggesting that new stu- breath throughout your practice, breathing into the
dents should hold the pose longer – say, three min- area of perceived tightness to create more space.
utes from the ‘Ah’.
• Maintain a sense of softness and space in the body.
3. Move within poses. The ability of the tissue to plas-
• It’s OK if stretches are strong – it’s not OK if stretches
tically/visco-elastically deform will depend on local
hurt; everything should feel safe and comfortable.
hydration of the specific tissue – not how much water
one drinks, but how “wet” is the specific fascia that is • It’s not about getting low – it’s about creating length
being challenged to stretch. By not going into the ulti- and space through the body.
mate stretch position, i.e., by only going to 75 percent
of stretch capacity, you may look like the stiffest per- Superficial Back Line stretches
son in the room in terms of the form of the asana,
but you will be able to move within the pose, rather Supine hamstring stretches (Figure 14.1)
than holding still for the full ten minutes. While there The spine is neutral, the hands are gently clasped togeth-
may be some value in disciplining yourself to stay er behind the knee; active knee extension is performed,
still, your body will thank you for the extra hydration keeping the foot in neutral position. The spine stays long
gained by moving around within the pose. and the knee does not have to straighten completely. This
stretch can be done with or without extension of the
The stretches and yoga poses described below offer ways
opposite leg. The pull is easier if the opposite leg is flexed
to maintain flexibility in each of the fascial lines. The
and is more challenging if the opposite leg is extended on
stretches and poses for each line of fascia are arranged in
order of difficulty. The easier poses are described first, fol- the floor.
lowed by more advances poses that require more flexibility Supine hamstring stretch with active ankle
and motor control. dorsiflexion (Figure 14.2)
Precautions and contraindications This variation adds more tension to the SBL of fascia.
These poses are contraindicated in cases of acute joint pain. Active dorsiflexion of the ankle may be added to the stretch
Precautions to be aware of are excessive hip anteversion above, in an on/off fashion or in a more sustained manner.
(positive Craig’s test) and femoroacetabular impingement
Supine hamstring stretch with active ankle
(FAI), especially where “hip openers” are concerned. The
plantarflexion/inversion (Figure 14.3)
thoracic spine should be monitored and corrected for any
ring shifts, in particular for any poses involving thoracic This variation adds more tension to the Spiral Line of
rotation. Any poses involving extension should be done in fascia because it involves the lateral myofascial struc-
a manner that avoids abnormal shearing at any particular tures. It also mobilizes the superficial peroneal nerve.
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Chapter 14
Figure 14.1
Supine hamstring stretch
Figure 14.2
Supine hamstring stretch with ankle DF
Figure 14.3
Supine hamstring stretch with ankle PF/Inv
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Movement and fascia
Figure 14.4
Supine hamstring stretch with abduction
Figure 14.5
Supine hamstring stretch with adduction
As with the technique above, active plantarflexion/ Superficial Back Line yoga poses
inversion may be added in an on/off fashion (especially
if mobility of the nerve is a problem) or in a sustained Cat part of cat/cow (Figure 14.6)
fashion.Supine hamstring stretches with abduction, This pose is focal to the part of the SBL that involves the
adduction (yoga strap assisted): trunk, head, and neck. It also affects the posterior spiral
and posterior arm lines. The pose begins in a four-point
1. The spine is neutral, ASISs are level, the right leg
kneel position, with the hands spread wide underneath
is guided into abduction (Figure 14.4). This pose
the shoulders, and the knees under the pelvis. The spine
stretches the medial line, Spiral Line and (because of
is flexed, beginning with the coccyx, producing poste-
the adductors), the DFL of fascia.
rior pelvic tilt and moving gradually up the kinetic chain
2. As above, but the right leg is guided into adduction, to include cervical flexion. It is generally done with
which also stretches the Lateral Line and Spiral Line exhalation. This pose may be progressed by adding slight
(Figure 14.5). For a variation, hip external rotation hip flexion, as this maneuver specifically targets the
may also be added. lumbosacral fascia.
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Chapter 14
Figure 14.6
SBL yoga pose – cat part of cat/cow
Child pose (Figure 14.7) This pose also affects the trunk, head and neck portions of
the SBL, as well as the posterior functional line. It requires
optimal mechanics of the hip and knee and should not
reproduce pain in either of these areas. The pose begins
in a four-point kneel position as above, but the pose may
also be done with the knees apart. The movement is one of
leaning back toward full flexion of the hips and knees, as
well as reaching forward with the arms in scaption (mid-
way between shoulder flexion and abduction). The fore-
head may rest on the floor or on a yoga block. The breath
is directed toward the back body and/or the shoulders. If
the pose is done with the heels apart and intentional imag-
ing of creating a sense of space between the ischial tuber-
osities, this pose may also help maintain mobility of the
pelvic floor muscles (including obturator internus), espe-
cially if the lumbar spine is in a lordotic position. This then
becomes a useful pose for maintaining mobility of the pel-
vic floor portion of the DFL of fascia.
Lateral child pose (Figure 14.8)

This is a variation of the child pose, in which the thora-
columbar fascia and latissmus dorsi can be put on stretch
(especially if the arm is in a “thumbs up” position, which
externally rotates the arm). This pose affects the posterior
functional line of fascia, which, if tight, can tug on the sac-
roiliac area as the patient attempts to do activities involv-
Figure 14.7
ing shoulder flexion. This pose is also useful to stretch the
SBL yoga pose – child pose
quadratus lumborum, psoas, and iliacus, which are part of
the DFL of fascia.
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Movement and fascia

Lateral child pose SBL yoga pose – standing forward bend
Standing forward bend (Figure 14.9) Pigeon pose for buttocks (Figure 14.10)
This pose is done in a standing position, with the trunk This pose is useful for stretching the gluteal muscles as well
folded forward at the hips so that the belly rests on the as a number of myofascial lines because of the asymmetrical
thighs. The knees are slightly bent and the elbows are nature of the pose. To stretch the right side, the right leg is
cupped by the hands so that the arms “hang loose” to bent and placed so that the right heel rests near the groin.
produce distraction of the trunk. The buttocks reach long The left leg is positioned in hip extension, behind the trunk.
towards the ceiling. The neck and head also hang loose. The practitioner reaches forward toward the floor with the
Breath is directed toward areas of tension. The pose may trunk. The elbows may be bent or straight. The stretch can
be altered by adding micro-movements into shoulder flex- be modified by adding micro-movements of the pelvis to the
ion/extension, abduction/adduction (“rock the baby”). The right or the left and by varying the degree of right knee flex-
standing forward bend pose is a stretch for the SBL, but it is ion. It can also be done with spinal extension, which empha-
also particularly useful as a way to create length and space sizes a stretch on the DFL of fascia. This pose may also be
between the thoracic rings. repeated for the other side.
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Chapter 14
Figure 14.10
SBL yoga pose – pigeon pose
Seated toe flexor stretch (Figure 14.11)

This is a variation of the thunderbolt pose, in that the toes
are in dorsiflexion instead of plantarflexion. The pose
starts from a four-point kneel position. The toes are in full
dorsiflexion, taking care to keep a neutral position for the
rest of the foot; that is, weight-bearing equally on the first
and fifth metatarsals. The pelvis rocks back towards the
heels until a stretch is felt in the plantar aspect of the feet.
Progressing towards the kneeling position increases the
stretch. This stretch is particularly good for the foot por-
tion of the SBL as well as the DFL of fascia.
Downward-facing dog (Figure 14.12)
This pose is an advanced posture that stretches the whole
SBL. It requires full glenohumeral flexion as well as good hip
flexion. The spinal curves should remain in neutral, especial-
ly the lower lumbar and upper thoracic curves, which tend
toward excessive flexion in this pose. The head should hang
down completely in this pose, with no active contraction of
the cervical extensors. If spinal curves are maintained, the
heels may or may not reach the floor and the knees may or
may not achieve full extension, depending on the extensibil-
ity of this SBL of fascia. This pose should be avoided in those
with acute sciatic nerve irritation.
Walk the dog (Figure 14.13)

This pose is a variation of the downward-facing dog, which Figure 14.11
focuses on the lower part of the SBL. The pose is frequently SBL yoga pose – seated toe flexor stretch
used as a “warm-up” to the full downward-facing dog pose.
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Movement and fascia
Figure 14.12
SBL yoga pose – downward facing dog
Figure 14.13
SBL yoga pose – walk the dog
From the position of downward-facing dog, one knee is flexed DFL. It is simple to do and can be done first thing in the
as the other remains extended. The pose requires slow, alter- morning and/or just before bedtime. The patient is in a
nating movement from one leg to the other, with emphasis on prone position, with the lumbar spine in extension, elbows
the leg that is in dorsiflexion, heel toward the floor. underneath the shoulders, hands supporting the chin.
The patient is asked to breathe deeply, with the emphasis
Downward-facing dog for soleus stretch (Figure 14.14) on expiration (small breath in, long, slow breath out). The
This pose is also a variation of the downward-facing dog. umbilicus is encouraged to sink toward the floor on expi-
The main difference is that the knees are deliberately ration. It is recommended to maintain the position and the
flexed so as to stretch the soleus muscle and its fascia. breathing for approximately two minutes. This exercise
may reproduce low back pain on expiration. This is accept-
Deep Front Line stretches able, as long as the pain resolves within a few minutes after
the exercise. Even in those patients with hypermobile lower
Prone extension breathing (Figure 14.15)
lumbar spines, this exercise is a safe way to regain upper
This exercise is one of my “go to” exercises, frequently pre- lumbar and thoracolumbar extension without irritating
scribed for those patients with decreased mobility of the the lower lumbar spine.
239
Chapter 14
Figure 14.14
SBL yoga pose – downward facing dog for
soleus stretch
Figure 14.15
Prone extension breathing exercise for DFL
Progression of prone extension breathing exercise the hands is applied to stabilize this area. The patient’s
(Figure 14.16) tongue touches the roof of the mouth, as if to say the letter
The exercise above is progressed by adding bilateral knee “N”. The cervical spine slowly extends back, with care, to
flexion and ankle dorsiflexion/eversion, either on the breath perform the movement segmentally and not shear forward
out or sustained throughout the two-minute exercise. at the mid-cervical spine. The patient should feel a stretch
in the front of the cervical/throat area. The stretch is main-
Upper quadrant Deep Front Line stretch tained for 10–20 seconds and normal breathing is encour-
(Figures 14.17, 14.18) aged. A variation of this exercise is to stabilize one side of
This exercise is a very good stretch for the upper quadrant the upper thorax/subclavicular area with both hands and
part of the front lines, whether the SFL or the DFL. The perform cervical extension and side-flexion to the right or
patient’s hands are crossed and placed over the manubrial/ left. (Figure 14.18 shows this exercise for the right side of
sternal area centrally. A posterior and caudal pressure of the DFL of fascia.)
240
Movement and fascia
Figure 14.16
Progression of prone extension breathing
exercise for DFL

Upper quadrant DFL stretch exercise Modification for right side of DFL
241
Chapter 14
Deep Front Line yoga poses Cobra pose (Figure 14.20)

This pose begins in a prone position, with the hands and
Cow part of cat/cow pose (Figure 14.19)
wrists directly beneath the shoulders. Keeping the cervical
This variation produces myofascial tensile force through spine neutral, the arms are used to extend the thoracic and
the SFL, anterior functional, anterior arm and DFL of fas- lumbar spine. The transversus abdominis is contracted to
cia. The pose begins in a four-point kneel position, with dynamically stabilize the trunk during this pose. The pel-
the hands spread wide underneath the shoulders, and the vis should not rise from the floor.
knees positioned under the pelvis. The spine is extended,
beginning with the coccyx, producing an anterior pelvic Sphinx pose (Figure 14.21)
tilt and gradually moving up the kinetic chain to include This pose is considered a variation of the cobra pose and is
cervical extension. It is generally done on the inhale. done in a prone position, with the body propped up on the
Patients with spinal stenosis and spondylolysthesis should forearms. This pose is particularly helpful to stretch the
be careful not to reproduce pain in the trunk or extremities fascia of the mid-thoracic region. The pose is done with
with this pose. isometric shoulder flexion so as to move the body away
Figure 14.19
DFL yoga pose – cow part of cat/cow
Figure 14.20
DFL yoga pose – cobra pose
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Movement and fascia
Figure 14.21
DFL yoga pose – Sphinx pose
from the forearms, and the breath may be used to further on the roof of the mouth will add further stretch to the
extend the mid-thoracic region in this position. DFL of fascia.
Upward-facing dog (Figure 14.22) Lunge (Figure 14.23)

This is an advanced pose that emphasizes spinal exten-
This pose is a pre-requisite for the Sun Salutations in yoga.
sion. It affects both the SFL and DFL of fascia, as well as
It stretches both the SFL and DFL of fascia on the side of
the anterior functional line and the anterior arm lines.
the straight leg and the SBL of the bent leg. It may be done
The beginner may find it easier to initiate the movement
with the hands on the floor or on yoga blocks, or with
through thoracic extension first, followed by lumbar
the arms in shoulder flexion and the chest lifted, as pic-
extension. The beginner may also leave the pelvis and
tured. The knee of the front leg stays over the ankle, the
lower extremities in contact with the floor, as in cobra.
front foot is in neutral position and the patella is aligned
The advanced practitioner may clear the knees off the
over the second metatarsal. If more stretch is required,
floor in this position.
then the practitioner should extend the straight leg farther
The cervical spine may stay in a neutral position, but back. Care is taken to keep the pelvis level in the transverse
adding cervical extension while maintaining the tongue plane (facing forward) and to control the position of the
Figure 14.22
DFL yoga pose – upward facing dog
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Chapter 14
Figure 14.23
DFL yoga pose – lunge
spine and pelvis using the dynamic stabilizers of the trunk

(transversus abdominis, deep multifidus).
Warrior 1 pose (Figures 14.24, 14.25)

Figure 14.24
This pose is similar to the lunge except that it is done
DFL yoga pose – warrior 1 with DF/Ev
standing, which requires more dynamic stabilization and
proprioception. In this position, the foot of the back leg
the left leg is straight and the right hip and knee are
can be placed either in dorsiflexion/eversion (Figure 14.24)
flexed. The left foot is parallel to the short edge of the
or in plantarflexion with the toes extended (Figure 14.25).
mat, and the heel of the right foot is in line with the heel
The arms are in full flexion, with the forearms supinat-
of the left foot. The right foot faces the corner of the mat
ed so that the thumbs face backwards. If more stretch is
and maintains a neutral position (not collapsed into pro-
required, then the practitioner should extend the straight
nation). The arms are extended out into abduction with
leg farther back and/or lower the body towards the floor.
the palms facing down. The head is turned to the right
This pose may also be repeated for the other side.
and the gaze is forward. The right knee is stacked directly
Warrior 2 pose (Figure 14.26) over the right ankle and the shin is perpendicular to the
floor. The patella is aligned over the second metatarsal.
Warrior 2 pose strengthens both the upper and lower If more stretch is required, then the practitioner should
extremities and stretches the adductors of the back leg. extend the straight leg farther back. The pelvis faces the
As with warrior 1 pose, warrior 2 also improves stamina, left side of the mat. This pose may also be repeated for the
endurance, balance and concentration. In this picture, other side.
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Movement and fascia
Figure 14.26
DFL yoga pose – warrior 2
pelvic region. A yoga block is placed under the sacrum,

with the cranial edge of the block placed at the base of the
sacrum (S1). The arms are by the side or may be positioned
at 90 degrees of abduction in order to open up the anterior
arm lines. The cervical spine is in neutral position (avoid
Figure 14.25
chin poking). One or two legs can be extended, depending
DFL yoga pose – warrior 1 with PF
on comfort. Deep breaths are encouraged in this position.
Supported bridge with yoga block at sacrum Supine with yoga block at mid-thorax +/− frog
(Figure 14.27) position (Figure 14.28)
The anterior sacral fascia may be accessed with this pose, The DFL of the mid-thoracic region is accessed with this
so this is particularly useful for DFL restrictions of the pose. A yoga block is placed under the mid-thoracic region,
Figure 14.27
DFL yoga pose – supported bridge with
yoga block at sacrum
245
Chapter 14
Figure 14.28
DFL yoga pose – yoga block at mid-thorax
Figure 14.29
Happy baby pose
with the caudal edge of the block placed at about the T7 level. neutral position. Experimenting with small rocking motions
The arms are at 90 degrees of abduction in order to open up into lumbopelvic flexion/extension or rotations is encouraged.
the anterior arm lines. The cervical spine is in neutral posi-
tion – the head may need support of a second yoga block or a Windshield wiper (Figure 14.30)
folded towel under the occiput in order to maintain a neutral This pose improves mobility in the Spiral Line and arm
cervical spine. The legs can be extended, as above, or placed lines but is particularly good for DFL restrictions, if done
in a “frog” position, with the soles of the feet together and the with certain modifications. The pose begins in a crook-
hips abducted and externally rotated. This position adds ten- lying position, with the arms placed at 90 degrees of abduc-
sion to the adductors of the hip, also part of the DFL. Various tion in order to open up the anterior arm lines. The feet are
angles of hip flexion in this position may be explored to find on the outside edge of the mat or even off the mat, if more
the areas of most restriction. Deep breathing is encouraged. stretch is required. In Figure 14.30, the right knee moves
medially toward the floor within available FADDIR (flex-
Happy baby pose (pelvic floor, adductors) ion/adduction/internal rotation) as the left knee moves
(Figure 14.29) toward FABER (flexion/abduction/external rotation). The
This pose promotes mobility of the hips in FABER (flexion/ neck rotates toward the right side. The opposite windshield
abduction/external rotation) as well as spinal flexion and wiper movement can also be performed, as the practitioner
sacral counternutation. The medial arches of both feet are alternates from one side to the other. If a deeper stretch
grasped by the hands and the hips open so that the knees for the DFL is desired, the knees may be fully flexed, with
are directed toward the floor. The cervical spine maintains a the heels closer to the buttocks. As the right leg moves into
246
Movement and fascia
Figure 14.30
DFL yoga pose – windshield wiper
FADDIR, the right ilium may reach anteriorly and caudal-

ly (“reach long towards the knee”) to deepen the stretch.
Deep breathing in this position is encouraged in order to
activate the diaphragmatic portion of the DFL.
Superficial Front Line stretches

Clavicular opening stretch (Figure 14.31)
This exercise is indicated for patients who show signs of
ISGT (intra-shoulder girdle torsion (see Chapter 12). The
intention of the exercise is to create a sense of space between
the two clavicles and the front body and to minimize the
excessive medial compression at the sternoclavicular joints.
The fingers are loosely placed on both clavicles and the
cervical spine is in a neutral position. The patient feels the
motion of the clavicles coming apart slightly on inspiration
and coming back together on expiration. Once that sensory
experience is understood, the patient is asked to maintain
the sense of space between the two clavicles on expiration as
well as inspiration and to repeat this three to five times. Cre-
ating the sense of space between the clavicles comes “from
within” and not from using the hands to do the motion.
This exercise may be progressed by adding other movements
Figure 14.31
(such as axial extension or thoracic rotation) as the practi-
Clavicular opening stretch exercise
tioner maintains the sense of space between the clavicles.
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Chapter 14
Quads in side-lying with plantarflexion of foot Superficial Front Line yoga poses
and toes (Figure 14.32)
Seated toe extensor stretch (Figure 14.33)
The stretch is a variation of the standard quadriceps
stretch exercise that is performed in a side-lying position. The thunderbolt pose starts from a four-point kneel position.
In Figure 14.32, the right hip is flexed and supported by The toes are in full plantarflexion, taking care to keep a neu-
the arm so as to protect the lumbar spine from excessive tral position for the rest of the foot; that is, avoiding placing the
extension. The top (left) knee is fully flexed and the prac- foot in plantarflexion/inversion. The pelvis rocks back toward
titioner grasps the leg by the toes, to gently pull toward hip heel sitting until a stretch is felt in the dorsal aspect of the feet
extension. The fact that ankle and toe plantarflexion has and/or toes. Care must be taken to avoid knee pain with this
been added makes this more of a SFL stretch than a simple pose. Progressing toward the kneeling position increases the
quadriceps stretch exercise. Care is taken to keep the left stretch. This stretch is particularly good for the toe extensors
knee in line with the hip. This pose may also be repeated that are at the tail end of the SFL of fascia. Tension in this area
for the right side. can contribute to the development of hammer toes.

SFL stretch – quadriceps with ankle and toe PF SFL yoga pose – seated toe extensor stretch
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Movement and fascia
Spiral Line yoga poses It is also a good stretch for the buttock muscles, as well
as the posterior and the anterior functional lines. The pose
Pectoralis stretch with lumbar rotation (Figure 14.34) is begun in the crook-lying position. To stretch the right
pectoral muscles, the pelvis is displaced slightly toward the
right. The right arm is placed in a combined position of
flexion/abduction. The knees drop to the left side, which
puts the Spiral Line and anterior functional line under ten-
sion, deepening the stretch of the pectoral muscles. This
position also stretches the right buttock muscles and the
posterior functional line of fascia. If additional stretch of
the lower quadrant is desired, the left hand can rest on
top of the right distal thigh. The patient is encouraged to
breathe into the chest, torso, and hips and allow gravity
to do the work. Experimenting with the angle of flexion/
abduction of the shoulder is suggested in order to find
those “delicious” places where most tension is felt.
Thinking about keeping the clavicles open, turning the
head towards the right side, and thinking of letting the
right pelvis “reach long” toward the knee all help to deepen
the stretch. This pose may also be repeated for the left side.
Lord of the fishes (seated spinal twist) (Figure 14.35)
This pose stretches multiple myofascial lines, especially
the Spiral and Functional lines. In the sitting position, the
right leg rests, foot flat and knee flexed, on the outside of
the left knee. The left leg is straight, but may be placed in
FABER for a more advanced pose. The lumbar spine main-
tains a neutral position and the weight of the practitioner
is equally distributed between the two ischial tuberosities.
The right arm reaches back to provide stability and a lever
Figure 14.34
arm so that the thorax rotates to the right as the right leg
Spiral Line yoga poses – pectoralis stretch with lumbar rotation
is gently pulled into further FADDIR (flexion/adduction/
internal rotation). The thorax “reaches long” toward axial
This position is particularly useful to stretch the pectoralis extension, in order to encourage optimal biomechanics of
major and minor muscles, muscles that are frequently short- the thoracic rings (i.e., the thoracic rings should stack up
ened in those patients whose work or sports require much underneath each other, like a stack of dinner plates). This
pectoral work (such as computer work or manual therapy!). pose may also be repeated for the left side.
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Figure 14.35
Spiral Line yoga pose – lord of the fishes
Threading the needle(Figure 14.36) be taken into consideration in order for this pose to be
done safely. Please refer to Ginger Garner’s book Medical
This position is particularly useful to stretch the scapular
Therapeutic Yoga: Biopsychosocial Rehabilitation and Well-
muscles and the thoracolumbar fascia in relation to a spi-
ness Care (Handspring Publishing), for details on proper
nal twist. In Figure 14.36, the pose begins in a four-point
execution of this pose (Garner 2016).
kneel position. For thoracic right rotation, the practitioner
reaches forward with the left arm “underneath the trunk” Lunge/twist (Figure 14.38)
until the left scapula is anchored to the floor. With the left
scapula anchored, the right hand pushes into the floor to This pose combines a lunge with thoracic rotation and is
create maximum pull in the left thoracic/scapular area. particularly useful to stretch the anterior functional line,
The practitioner is encouraged to breathe into the area of as well as the DFL of fascia. From the standing position,
perceived tightness to create more space. with the right foot parallel to the edge of the mat and the
left foot angled to the corner of the mat, the practitioner
Triangle pose (Figure 14.37) flexes the left hip and knee, making sure that the patella is
This pose is an advanced triplanar pose (frontal, sagittal, aligned with the second metatarsal. The left forearm may
and transverse) that stretches all myofascial lines. Because be used to support the body on the left thigh. In order to
it is an advanced pose, there are many elements that must encourage optimal biomechanics of the thoracic rings, the
Figure 14.36
Spiral Line yoga pose – thread the needle
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Movement and fascia
thorax “reaches long” toward axial extension at the same

time as the thorax rotates to the right. The cervical spine
also rotates right. The right arm may be placed in flexion
so that it is in line with the body or with the hand behind
the back (as pictured). This pose may also be repeated for
the other side.
Lateral Line stretches

“C” exercise supine with breath (Figure 14.39)
This exercise is a relatively easy exercise that helps to
improve the mobility of the Lateral Line of fascia. It is done
in a supine position and requires no props, so it can easily
Figure 14.37 Triangle yoga pose
Figure 14.38 Lunge/rotation yoga pose Figure 14.39 Lateral Line stretch – “C” exercise
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be done in bed. To stretch the left side, the pelvis is shifted Shirley’s exercise (Figure 14.41)
to the left; both legs are extended and shifted to the right. This pose was described to me by a colleague (physiother-
The legs may be crossed at the ankles to further the stretch. apist Shirley Kushner). It is a combined Lateral Line and
The arms are flexed overhead, with the right hand clasping DFL stretch pose that is done in a supine position. The
the left wrist to pull the left arm towards the right side and picture depicts a stretch for the left side. The left leg is
encourage thoracic right-side-flexion. The practitioner is tucked under the right, with the hip in slight adduction
encouraged to breathe into the area of perceived tightness and full available external rotation. The right foot lies on
to create more space. the anterior distal aspect of the left thigh to anchor it. The
Cross leg sitting Lateral Line stretch (Figure 14.40) right hand grasps the left wrist to create side-flexion of the
trunk to the right. As usual, the practitioner is encouraged
This more advanced stretch is done in sitting, with the
to breathe into the area of perceived tightness to create
right leg under the left leg, the left ankle over the right dis-
more space.
tal thigh. Note that the right hip is not in an abducted posi-
tion – it is in slight adduction and full available external
rotation. The practitioner sits upright, careful to maintain
lumbar lordosis. The left hand grasps the right flexed
elbow to encourage side-bending of the trunk to the left.

Cross leg sitting Lateral Line stretch Shirley’s exercise
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Movement and fascia
Lateral Line yoga poses As usual, the practitioner is encouraged to breathe into the
area of perceived tightness to create more space.
Standing side-bend (Figure 14.42)
Later, micro-movements into rotation or flexion/exten-
sion may be added.
Gate pose (Figure 14.43)
Figure 14.42
Lateral Line yoga pose – standing side-bend
Figure 14.43
Lateral Line yoga pose – gate pose
This yoga pose is done in standing. The feet are shoulder-
width apart and the knees slightly flexed. The hands are
clasped together in prayer position, with the index fingers This pose is particularly useful to stretch the Lateral Line
in “steeple” position. Imagining that the body is like a piece of fascia (the right Lateral Line in Figure 14.43) as well as
of bread in a toaster, the practitioner is encouraged to reach the adductors of the other leg. Starting from a kneeling
long toward the tips of the index fingers as the trunk side- position, the practitioner straightens the left leg into avail-
bends to the right or left. The image of a piece of bread in able abduction, with the left foot parallel to the edge of the
a toaster encourages the body to stay in the frontal plane, mat. The practitioner uses the left arm and rests it against
allowing little movement into flexion/extension or rotation. the left lateral leg (avoiding the knee). He/she uses the right
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arm to reach upward to produce left side-bending of the right. The spine stays long in this pose, as the lumbar spine
torso without rotation or flexion, always sending breath maintains a neutral position. The thorax actively rotates
into the side body. This pose may also be repeated for the to the left throughout this pose in order to keep the thorax
other side. facing forward. This pose is more about creating space in
the body rather than getting low. It may also be repeated
Sitting Lateral Line stretch (Figure 14.44) for the other side.
To stretch the left lateral body in the sitting position, the
practitioner sits with the right leg extended out to the side
Variation for thoracolumbar fascia (Figure 14.45)
and the left leg flexed and externally rotated at the hip. The The pose above may be adjusted to produce a stretch for the
right forearm drops down and rests on the right thigh, as thoracolumbar fascia. In the same seated position as above,
the left arm reaches overhead to side-bend the trunk to the the practitioner uses the left arm to reach forward as far
Figure 14.44
Lateral Line yoga pose – sitting
Figure 14.45
Variation – thoracolumbar fascia stretch
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Movement and fascia
down as possible the lateral aspect of the right leg. This will with the hands clasped behind the back or by using a yoga
produce a stretch in the right hamstring area. However, if strap (as pictured). The practitioner grasps the belt with
the practitioner uses their right hand to push against the both arms pronated and the hands placed apart, shoulder-
floor and create a “C” position of the thoracolumbar area width distance. Keeping a neutral spine throughout, the
(side-bending to the right) this provides a nice stretch to arms are gently pulled up to the ceiling to produce bilateral
the left thoracolumbar fascia. As usual, the breath is used shoulder extension. The pose may be progressed by main-
to accentuate the stretch. taining the shoulders in the extended position as the prac-
titioner leans forward over the thighs, with full hip flexion
Front Arm Line yoga poses and the knees slightly flexed.
Shoulder opener with belt (Figure 14.46) Eagle pose (Figure 14.47)
This pose is useful to stretch the anterior lines of the arms This pose stretches the posterior arm lines (including the
as well as to open up the chest area. The pose may be done rotator cuff muscles) and the posterior spiral and functional

Front Arm Line yoga poses – belt shoulder opener Eagle pose
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lines. It is also used to work hip and knee stability and to find a regular activity that challenges the body to
balance. The shoulders and elbows are flexed to 90 degrees, move in “out-of-the-ordinary” ways and that promotes
with the scapulae engaged to prevent excessive protraction. mind–body–spirit health.
The right elbow is placed in the bend of the left elbow and
the arms are intertwined until the palms touch. The right Chelsea Lee, a yoga therapist from Vancouver, British
leg crosses over the left leg and, if possible, hooks around Columbia, sums it up well:
the left calf. If not, the right toes may gently rest on the
While yoga postures can help one to lengthen, strengthen and
floor. The arms are gently lifted towards the ceiling. Bal-
align the body so that it can move more optimally, the internal
ance is maintained in this position.
alchemy that occurs through this process is really what will make
The above list of yoga poses is simply a suggestion and the most meaningful change in the experience off of the mat and
by no means exhaustive. A regular practice of yoga (and in life. It’s more than stretching the hamstrings and improving tho-
there are many kinds), guided by a good teacher, is a way to racic rotation. You will discover a heightened awareness of your
maintain overall flexibility, strength, and balance. Other body, breath and mind while generating healthy stress in a safe
practices (mentioned in the list of other integrative move- and contained space, so that when the pressure is on outside of the
ment therapies) also achieve similar goals. The point is studio, you have tools to help you show up as your best self.
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Optimizing therapeutic outcomes 15
There was a time when I debated whether this chapter • high blood glucose levels (sugar)
should be included in this book. My left brain certainly
• alcohol
could agree with the concept of including discussion of
the effects of nutrition, hydration, and hormone health on • hydrogenated oils
treatment outcomes. However, I would be remiss if I did • aspartame.
not include the more nebulous, right brain approach to
treatment, which includes information not only about cre- High blood glucose levels (sugar)
ating an optimal therapeutic environment for the patient,
but just as importantly, about creating an optimal thera- Dr Christiane Northrup, board certified Ob/Gyn (obstet-
peutic environment for the therapist. Treating from the rics/gynaecology) and author of several books on women’s
“whole” brain, allows for more “holistic” approaches to health, recommends an anti-inflammatory alkaline diet
treatment and more fulfilling outcomes for both therapist for optimal function of the connective tissue matrix. She
and patient. sums up the effect of a high sugar diet as follows:
Sugars affect your body at a cellular level, even
It is important for physiotherapists to be aware of “out
whole grains. The genetically altered grains of today
of scope” information, as nothing is separate in the body.
are very different from those our grandparents enjoyed.
We must consider the whole body/whole person that stands
They have a much higher gluten content. That causes
before us in our treatment room and recognize that there are
cellular inflammation, because the cells don’t know what
other systems, such as the gut, that may influence musculo-
these particles are and they want to neutralize them
skeletal and brain health. Our clients may need a different
by surrounding them with fluid. Your hormonal sys-
health professional to help “clean up their physiology,” pre-
tem responds to all the sugars by having your pancreas
venting them from wasting time and money on some of our
pump out more insulin to get the extra sugar in your
treatments, especially if they are not responding as expected.
blood to go into cells, where it can be used. The inflam-
Effect of nutrition on the body’s tissues mation causes oxidative stress, destabilizing the cells.
This may show up as physical discomfort, aching mus-
Have you ever been in a situation where your patient’s tis- cles, bloating, headache, insomnia and weight gain. Over
sues feel like dried-up leather? Certainly not like the juicy time, chronic degenerative disease such as heart disease,
fascia that Dr Jean-Claude Guimberteau has demonstrated arthritis, high blood pressure, Alzheimer’s, diabetes,
in his in vivo videos. One common reason why certain peo- and cancer are a result. Fortunately, this domino effect
ple tend to develop dense, tight fascia is due to their dietary of sugar / inflammation / disease can be counteracted
habits. According to a study by Pavan and colleagues, diet, and reversed by lowering blood sugar intake and pay-
exercise, and overuse syndromes can modify the viscos- ing attention to the types and forms of sugars you eat.
ity of loose connective tissue within fascia, causing den- (Northrup 2015)
sification (Pavan et al. 2014). It is important to note that
an acidic diet can lead to systemic issues that maintain an Tom Myers also advocates cutting out sugars and other
inflammatory environment and thus lead to the densifica- acid-producing foods: “Sugar is sticky, and that’s what it
tion of fascia. The common culprits in the average North does in the body. It’s hard to force water into sticky areas.
American diet include: Depending on your constitution, cheese or meat or peanuts
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or other allergens could be causing this stickiness. Not my to a great extent dependent on the oils you consume
area of expertise, but a good nutritionist can advise you.” every day.
In his talk about “Food Pain and Dietary Effects of Dr Blatman also mentions the many negative side effects
Inflammation”, Dr Hal Blatman (Blatman 2016) advocates of hydrogenated oil. More notably, hydrogenated oils have
avoiding inflammatory foods, including white sugar, white been associated with rising cholesterol levels (Sartika 2011),
flour, potatoes and fruit juices. He also includes in this list an increase in incidence of diabetes (Chartrand et al. 2003),
bread, pasta, cereal and wheat grain (often used as a thick- and a change in cell membrane composition (Clandinin et
ener in processed soups and sauces). He quotes a study in al. 1991). In addition, saturated fatty acids have been shown
which sugar-sweetened beverage consumption was shown to activate skeletal muscle cells to release inflammatory
to promote inflammation in healthy young men (Aeberli mediators that trigger macrophages (Pillon et al. 2012).
et al. 2011).
Here is an interesting fact that resonated with me from
Alcohol listening to Dr Blatman’s Food and Pain lecture. If one eats
a bag of Cheezies, or some French fries, the trans fats that
Alcohol of any kind is a sugar and so is metabolized simi-
are ingested will be used to form the cell wall of hemo-
larly. Again, moderation is the key.
globin. Trans fats render the red blood cell useless for bind-
Hydrogenated oils/trans fats ing to oxygen, which ultimately affects delivery of oxygen
to our muscles and our brain, contributing to increased
When we think of hydrogenated fat, margarine comes to
pain. The cell life of a red blood cell is four months. This
mind. When margarine was first formulated, hydrogen-
means that there are useless cells remaining in the body
ated gas was put into vegetable oil in an attempt to stop it
for four months resulting from eating one bag of Cheezies!
from growing mold, thereby improving shelf life. Today, all
Imagine the hemoglobin cellular function of the person
partially hydrogenated vegetables oils and most processed
who eats a bag of these daily. It is not “Oh well, its just one
foods contain trans fats. One major reason that trans fats
bag and only today.” No, it lasts four months.
have been allowed to persist is that food additives, in use
before the US FDA enacted the Food Additive Amendment Aside from dietary changes, there are ways that we
in 1958, did not require FDA approval. In other words, can enhance the composition of the cell membrane and
trans fats were grandfathered in as acceptable because they minimize the development of inflammation and pain.
were in use as of 1958 (Kaslow 2018). Dr Blatman advocates the use of fish oil supplements.
This recommendation is backed by a number of studies
Dr Kaslow sums up the effect of trans fats hydrogenated
that show improvement in joint tenderness and swelling
oils on the cell membrane:
in patients with rheumatoid arthritis (Kremer et al. 1990),
Hydrogenated trans fats affect the cell membrane and prevention of atherosclerosis (Shewale et al. 2015), and
so govern their function and communication with oth- cancer (Hardman et al. 1999).
er cells. Trans fats are absorbed into the cell membrane,
where healthy essential fats should be integrated. The Aspartame
human lipase enzyme is ineffective with the trans con- This common sugar substitute is widely used in processed
figuration, so trans fat remains in the blood stream for a foods, including baked goods, soft drinks, canned foods,
much longer period of time and is more prone to arterial dairy products, and scores of other foods and beverages.
deposition and subsequent plaque formation. Trans fats While the sweetener remains popular, it has also trig-
raise LDL cholesterol and lower HDL cholesterol levels gered controversy in recent years. Critics have claimed
in your blood, which is the opposite of the ideal cardio- that aspartame has long-term repercussions on the body.
vascular ratio. Thus the very basic and crucial actions When the body processes aspartame, part of it is broken
of cells and the proper functioning of your body are down into methanol, which can then break down into
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Optimizing therapeutic outcomes
formaldehyde (Hertelendy et al. 1993; Trocho et al. 1998). Hydration

Clearly not a desirable substance to ingest! Another study
noted an increased risk of non-Hodgkin’s lymphoma and The human body is 75 percent water. Two-thirds of the
leukemia with drinking more than one can of diet soda or a body’s water is contained in the fascia. Hence the impor-
high consumption of regular soda per day (Schernhammer tance of drinking water for optimal fascial health and,
et al. 2012). especially, when working with the fascial system. Fascia has
less blood supply than muscles, so structures such as liga-
Balancing the gut microbiome ments, tendons, and cartilage have a more difficult time
healing as a result of injury. Fascia relies on water seep-
The gut microbiome is essential for human health and
ing into the area in order to stimulate the repair process.
physiology. It is defined as the collective genomes of the
Tom Myers notes that it is important to MOVE in order
microbes (composed of bacteria, bacteriophage, fungi,
to get water into fascial tissues, preferably in patterns dif-
protozoa and viruses) that live inside and on the human
fering from our usual habits. “If you do the same exercise
body. We have about ten times as many microbial cells as
or movement routine all the time, the water will be driven
human cells. Microbes can be categorized as symbiotic
down familiar pathways, and will end up in your bladder.
(healthy flora) or dysbiotic (toxic flora). Toxic flora thrive
What movements can you do that are unusual? Take a
on white flour, sugar, and the residue of red meat. Healthy
belly dance class, learn tumbling, try contact improv – do
flora thrive on green leafy vegetables. We all have a mix-
something unusual to push the water into these dry and
ture of both kinds of flora and ideally, our immune system
sticky places.” An appropriate amount of rest time is also
keeps the toxic flora under control. However, triggers such
important, in order to allow fascial tissues to re-hydrate
as viral or bacterial infections, fungal/yeast infections,
(Myers 2017).
NSAIDs, and radiation/chemotherapy can induce what is
called a “leaky gut syndrome,” where intestinal permeabil-
Hormone health
ity is altered. This can lead to hypersensitivity responses
to foods, inflammatory bowel disease (Crohn’s), irritable Menopause in women brings about hormonal changes that
bowel syndrome, chronic inflammatory joint disease, can affect the soft tissues of the body. The perimenopausal
eczema, and chronic fatigue syndrome (Blatman 2016). stage begins around age 45 and can last a decade or more.
Animal studies show that different microbial populations Initially, progesterone levels decline, which may manifest
can dramatically affect susceptibility to chronic inflam- in feelings of sadness, as progesterone acts like a natural
mation (Ferreira et al. 2011; Willing et al. 2011; Wlodarska valium. In the early 50’s, the ovaries shut down, which then
et al. 2011). This dynamic may also have repercussions in affects the level of estrogen in the body. The brain does not
relation to obesity, atherosclerosis, autism, and allergies, as react as quickly (producing “memory burps”) and women
well as asthma and celiac disease. Knowing what we cur- become thicker in the middle of the body. This thickening
rently know about the pathophysiology of fascial dysfunc- is the body’s attempt to compensate for the loss of estrogen,
tion and the effect of chronic inflammation on fascia, we as breast tissue and abdominal fat produce estrogen.
can also add fascial dysfunction to the list of repercussions
Christiane Northrup points out that, in an attempt to
possible when the gut microbiome is not balanced.
deal with menopausal symptoms, medicine turned to syn-
Michael Pollan, author of Food Rules: An Eater’s thetic hormone replacement therapy (HRT). This trend
Manual, distills 64 food rules to guide Americans away abruptly reversed in 2002, when the Women’s Health
from the Western diet of processed “edible food-like sub- Initiative study showed higher rates of breast cancer and
stances” and toward diets that originated in traditional heart disease in thousands of women who were given HRT
food cultures. He sums up his philosophy nicely with in the form of Prempro (a combination of Premarin, which
three short instructions,“ Eat food, not very much, mostly is horse urine, and Provera, which is synthetic progestin).
plants” (Pollan 2009). Thankfully, Dr Northrup states that there are other options
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for relief from menopausal symptoms, with bio-identical stress, hormonal changes and inflammation. Although
hormones, such as bioidentical estrogen gel applied to the inflammation is critical for normal healing processes, too
skin along with oral bioidentical progesterone. much or prolonged inflammation may lead to binding
down of fascia and fibrosis, or, as the Stecco’s call it, densi-
Northrup notes that males also undergo hormonal fication of fascia.
changes with andropause, as their testosterone levels drop.
This shift causes muscle tone to decrease and it makes it In summary, what we put into our bodies, how we move,
more difficult to build healthy muscle. There is also an how we manage hormonal changes and stress – all these
effect on bone health, with an increase in osteopenia /oste- factors play a role and impact the health of the fascial
oporosis. Women too have similar symptoms, as their tes- system. If our patients have difficulty with maintaining
tosterone levels (although lower than males) also decrease. effects of treatment with any kind of manual therapy, or
if they plateau with treatment, it is wise to consider appro-
A functional medicine doctor is best trained to recom- priate professional help to address these additional dimen-
mend what approaches may be best for optimal hormone sions of health.
health.
Creating an optimal therapeutic
Stress hormones environment for the patient
Dr Northrup suggests that in perimenopause or meno- It is important for the patient to receive treatment in an
pause, the number one hormone to be concerned about is environment that optimizes the therapeutic outcome.
cortisol. This stress hormone is designed to be released in The following are a few suggestions to consider:
the body in situations of acute stress, in order to help us
• Treat in private spaces when possible. This privacy not
deal with physical danger quickly. It also temporarily acti-
only helps control the level of noise, but also allows
vates the immune system in the case where a bacteria or
for confidential and safe conversations between ther-
virus has entered the system. An inflammatory response
apist and patient.
then occurs; white blood cells gather around the patho-
gen to isolate it before attacking it. The problem is that if • Use ambient lighting (preferably natural).
the cortisol and its partner, epinephrine (adrenaline) are • Ensure neutral to warm room temperature (it stimulates
not cleared from the system quickly and, instead, linger the parasympathetic nervous system).
for days, weeks, or even months, they have the opposite
effect of lowering your immunity and energy. According to • Consider the whole person – bio-psycho-social
Dr Northrup, model – energetic and spiritual dimensions (more on
this below).
Stress – mental, physical, emotional, or spiritual – cre-
ates inflammatory chemicals in the brain and body and • In addition to treating with manual therapy and
may lead to cellular degeneration. This response may exercise, the therapist may also consider educating
occur in the brain and manifest as memory deterioration. the patient on ways to desensitize the sympathetic
It may also occur in the fascia, where we store all of our nervous system (SNS). These tools can help to tone
traumas, whether physical, mental, or spiritual. These down the vagus nerve, decrease anxiety, and deal
traumas create thickened, dense fascia, which eventually with negative thoughts:
leads to pain and limited range of motion. Chronic fear, −− slow, rhythmic, diaphragmatic breathing. Breath-
anger, sadness and resentment keep stress hormones in ing from the diaphragm and into the pelvic floor
your system, setting the stage for poor health, including and sacrum, rather than shallowly from the top of
depression, cancer and heart disease. (Northrup 2015) the lungs, stimulates and tones the vagus nerve.
−− alternate nostril breathing
The mechanism by which trauma can create densifica- −− humming
tion of fascia is unknown. Perhaps there is a link between −− Mindfulness Meditation
260
−− MUSE – a brain sensing headband that helps one treating mostly chronic conditions, is that the pendulum
to focus during meditation as it gently guides a has swung too far to the side of believing that all pain is of
meditation session through changing sounds of central origin.
weather, based on the real-time state of the brain.
In reality, “The magic happens in the middle” (Peter
Creating an optimal therapeutic O’Sullivan). The optimal therapeutic intervention involves
environment for the therapist accessing both the scientific literature and structured
learning in the classroom in order to create a solid base
Creating an optimal environment also applies to the thera-
from which to begin the clinical reasoning process as well
pist. A number of issues come to mind here, gleaned not
as tapping into the resources of intuition, deep wisdom and
only from my past 40 year experience as a physiotherapist,
creativity. Working with the fascial system is a great way to
but also from the insights of many other therapists, whose
combine both perspectives.
opinions and reflections I value.
Heather Williamson-Vint, a physiotherapist from Brit-
Accessing both sides of the brain
ish Columbia, Canada, sums it up well:
I believe that the best treatment approach is a combined Our ego serves us well in life. It allows us to conquer
approach, one that appreciates the importance of sound fears, attend school and grind out papers and acquire
assessment, based on a left-brain, linear, structured knowledge. Our ego can also get in the way of the “art” of
approach but that also makes room for another element, healing. If we learn to lead with the heart as well as the
the right-brain, creative, intuitive approach. Unfortunate- mind, then intuition can play a role in our treatments,
ly, many physiotherapists are either left-brain thinkers or rather than reason alone. Ego is our link to control. It is
right-brain thinkers. A few state their views passionately cultivated by fear, whereupon many of us diminish this
on social media, dismissing or even vilifying the approach- sense of fear through developing our egos, our inner “con-
es of fellow therapists who think differently than they do. trol freaks” that sadly, when put in the lead, can take us
Therapists who rely solely on the intuitive, creative down paths that aren’t our ultimate best routes. The art
aspects of the brain tend to “go with the flow” often not of letting go, physically and subconsciously, isn’t taught
explaining what they are doing for the patient. This in physiotherapy programs but can be cultivated with
approach unwittingly creates a more passive role for the experience.
patient, and frames treatment as a process in which the The importance of a good subjective exam
therapist alone does the “healing”. Few objective tests are
used to evaluate the effects of their treatments. Diagnosis is “Listen to your patients. Not only will they tell you what
based mainly on palpatory findings and clinical reasoning the problem is but also how to treat it.” This was the
is often lacking. single most important take-home message I received from
Geoffrey Maitland’s presentation on the subjective exam
By contrast, left-brained, analytical minds may be at the IFOMPT Conference in Vail, Colorado, in 1992. In
great at creating structure, using a test/retest approach particular, I remember a slide in which he demonstrated
to see if they are on the right track with their therapies, the use of P/A pressures on the upper lumbar spine with
but they may have difficulty thinking “outside of the box” the patient in a prone position, his lumbar spine extended
when their standard tools are not working for the patient. and the ipsilateral knee flexed. At the time, there was very
Such an approach may lead the therapist to conclude little discussion in the world of manual physiotherapy
that the patient must have a central pain component to about the importance of maintaining mobility of the
their problem. Admittedly, many chronic conditions do nerves, but essentially, Maitland was a depicting a tech-
have a mixture of both primary nociceptive and central nique that later came to be described as a way to improve
pain phenomena, but my personal experience, based on mobility of the femoral nerve. Maitland had offered no
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explanation for why he used this technique, except to say −− the therapist is producing a movement that is too
that it corresponded with the patient’s subjective com- deep or a grade of movement that is too high for
plaints and brought about positive treatment outcomes. the state of the irritability of the tissues
He was certainly ahead of his time! Maitland’s message −− the maneuver is done automatically, the therapist
has served me well throughout my career. Patients live in not “tuning in” to what they are sensing under
their body and have a sense of what is going on, even if their hands.
it is subconscious. They can convey important cues to the • “Seduce the tissues” rather than imposing a certain
therapist if the therapist pays careful attention to what they direction and force into the patient’s tissues. Knock
are saying. on the door and ask to be “let in.” Wait for the body’s
response. When wondering if the patient can tolerate
Manual therapy
a certain maneuver, use the “listening” approach (see
The fact is that any time we skillfully lay our hands on a Chapter 4). In doing so, we can be reassured that the
patient, we are performing manual therapy. The idea that body will not allow any changes that it is not ready
there is a dichotomy between “hands on” or “hands off” to receive.
is essentially saying that we give up what makes us truly • Trust your hands. They never lie. Listen to the body’s
physiotherapists. For too long, certain people have looked response – a system-wide response in the parasym-
at manual therapy as a purely passive treatment; clearly, it pathetic direction, much like a system “sigh,” is a sign
is not. We touch people when they are moving. We touch that you are moving in the right direction. Increased
people to facilitate moving. We touch people to enhance sweating, anxiety, and a shallow, apical breathing
movement. This is manual therapy. (Diane Lee) pattern are all signs of a sympathetic reaction,
Dialoguing with the tissues and signal that we must change something in our
treatment approach.
• When using any manual therapy, it is important to
“dialogue with the tissues”. When we move any tissue
Art and science
of any kind, we must connect to the resistance in the • What we do in healthcare is both an art and a science.
tissues between our hands. Maitland’s movement dia- One cannot exist without the other. Art and science
gram helps put on paper what we are feeling in terms butt heads beginning in elementary school, where
of early or late resistance, and the end-feel. oftentimes physical education and art are abandoned
as unnecessary topics expendable in the face of such
• “Rather than forcing a tissue to do something, pull subjects such as math and reading. However, art
a certain way, trying to mold it physiologically to allows our species to learn. Art makes sense of the
respond, we must listen to the tissue, our own intu- unspeakable, and gives us insight when there are no
ition, as to line of pull, tolerance of tissue to handling, words. (Dr Ginger Garner)
load, stress and stretch. Once the listening element is
put into practice regularly, it becomes instinctual, just • Manual therapy is an art form. We have to work
like noting anteriorly tipped scapula or asymmetric at it in order to improve. The brain map for a new
load bearing.” (Heather Williamson-Vint) manual approach is initially small. Practice and the
neuroplastic changes in the brain will make the brain
• Patients can feel threat in their bodies when your map for this experience larger. Subtle changes then
hands produce a movement that is interpreted as become huge. (Diane Lee)
“unsafe”. This “unsafe” interpretation may be due to
the following: Research
−− the maneuver is being performed too quickly, • Clearly, there is a need for ongoing research in every
without waiting for “permission” from the patient’s field of manual therapy and the MMS approach is
tissues no exception.
262
• However, we cannot expect for there to be evidence Things I wish I knew as a young therapist
for every patient we see. RCT’s are not the best way to
measure optimal treatment options – individual pro- • We do not “fix” or heal patients. In reality we function
grams that follow a clinical reasoning approach are more as a coach – helping to bring awareness to our
the way to go (Gwen Jull, keynote address, IFOMPT, patient’s mind/body. Only they can make a difference
Québec City, 2012). in their brain map. (Diane Lee)
• There are many variables that we must consider in • There is no such thing as a cure in the body. We only
a treatment session and these variables make the help the patient manage it better by helping them under-
clinician’s daily experience with patients difficult to stand their condition and by empowering them to take
research. Your treatment room is your research lab charge of their healing.
(Diane Lee and Gregory Grieves – first edition of • Education is a large part of what we do for a patient,
Modern Manual Therapy). whether that is teaching them how to position their
Psycho-socio-emotional vs physical back to safely brush their teeth or simply de-escalat-
ing their fear. Don’t underestimate education.
• “As physiotherapists, we get to work on the physical
body, which I think of as a membrane between the • Part of the education piece for our patients is
external world all around us, and each individual’s to watch for their “languaging” of their painful expe-
own internal world. Their perceptions of pain, health, rience. For example, “I’m falling apart”, “My body is
stress, life fulfilment, and general day-to-day thoughts killing me” or “I have to expect this at my age”. Our
and emotions, can influence this physical vessel. We reality is shaped by our thoughts. Negative thought
would be remiss as clinicians to not fully embrace the patterns adversely affect the experience of pain as
psycho-social and spiritual elements in the process of they contribute to the DIM’S (Danger in Me) neu-
healing from injury.” (Heather Williamson-Vint). rotags. Instead, we can empower our patients with
messages like “You can be sore but safe. Your hurts
• “As we plod along in our human journeys through life, won’t harm you”. (NOI notes, 2017)
we can’t help but spend a bit of time at “the bottom of
the barrel.” We experience challenges, tragedies, and • Ageism is a negative perception of getting older and
difficult situations aplenty. A lot of how we navigate of older people. It is a really big personal and soci-
this and come out the other side, for worse or for bet- etal DIM (Danger in Me neurotag) and it needs to
ter, comes down to socio-emotional resilience: “An be challenged. Young and old people can be ageist.
ability to recover from or adjust easily to misfortune Older people can be ageist about themselves. Health
or change.” Our own tissues also experience resilience: professionals and sometimes government depart-
“The capability of a strained body to recover its size ments and companies are ageist. Let us challenge
and shape after deformation.” Using this comparison, it, first by obliterating some myths about pain and
our physical body is the barrier between our inter- ageing. (NOI notes, 2018)
nal and our external worlds. Basically, how we cope • Even though X-rays and scans may show things such
with our external environment displays itself in our as narrowing of joint spaces, such alterations have
physical self. We can come out of a difficult experi- NO relation to increased pain. These are age changes
ence jaded, distrustful and at the same time, stooped, and more age does not equal more pain. (NOI notes,
dehydrated and poorly oxidized. Or we emerge more 2018) (APTEI, VOMIT: Victim of Medical Imaging
knowledgeable of our physical, emotional and men- Technology, 2014)
tal limits and can redirect ourselves with our tools,
avoiding some major health challenges.” (Heather • “We are what we focus on. As therapists, we all have
Williamson-Vint) the “pain chasers” that try to relocate the pain as soon
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Chapter 15
as their treatment is finished. That pain pathway is so • Follow your intuition. Don’t suppress it because it
etched into their nociceptive memory banks (espe- isn’t “scientific”. But back it up with critical thinking
cially those with more chronic pain) that it is easy and clinical reasoning.
enough to find. I tell clients to trust in their body’s
• Be willing to shift your beliefs and paradigms as data
potential to heal. Once they “buy in” to this process,
and clinical experience guides us. (Peter O’Sullivan)
the rest follows fairly smoothly. Giving a gentle nudge
of self-responsibility and self-management to people • Stay curious and hungry for knowledge. I frequently
is both worthwhile and empowering. As a clinician, end the fascia courses that I teach with a quote from
I find it most rewarding to see the evolution of body Tom Myers: “The more I learn, the farther the hori-
and thought awareness take place in some patients. zon of my ignorance extends.” I hope I never get to
Once a client becomes aware of the stretches, exer- the point where I feel that I have all of the answers.
cises, breathing patterns, postures, imagery and/ Then there would be no more room to grow.
or mantras that they find useful for self-care, they • Value intellectual humility. (Peter O’Sullivan)
can use these to pre-empt old pain patterns or toxic
thoughts before they take hold of the whole person. • What you have learned at university is just the tip of the
Being able to control our thoughts and re-align our iceberg. You learn from treating your patients, espe-
bodies consciously is a huge part of living a life in bal- cially the more challenging cases. You learn through
ance and wellness”. (Heather Williamson-Vint). taking postgraduate courses. You learn through ask-
ing questions. You learn by teaching. Don’t stop.
• Look out for patients who may feel that they are
victims of their pain. Perhaps they feel that their • Take as many postgrad courses as you possibly can –
workplace or their family dynamic is the perpetrator. they stimulate your brain and keep challenging your
The corollary to this is that we, as physiotherapists paradigms. A word of caution, however; don’t get hung
and body workers, can become the rescuer. “Be careful up on any one approach to treatment and believe that it
of this triangle. We are none of these things. These will solve all your patients’ problems. It is best to have
are simply a perception of our reality that plays out in many tools in your clinician’s toolbox. Pull out what
our physical world. We can change all this with a per- you need for the right patient at the right time. Good
spective shift and the right encouragement. Patients clinical reasoning will help you sort out which tool(s)
with healthier perspectives and the ability to change a you will need for your particular client.
negative internal script to a more positive one have • Find yourself a mentor who can facilitate your
better results, regardless of what tricks are up the learning. I have had many mentors in my career
therapist’s sleeve.” (Heather Williamson-Vint) and I learned a great deal from each of them.
• Nurture compassion, both for your patients and, per- In turn, I hope and believe that I have “given back”
haps more importantly, for yourself. Therapists tend by mentoring another generation of skilled clinicians.
to have perfectionist traits. Developing compassion • Embrace social support. Cultivate friendships that
for yourself and your imperfections is vital to your will feed your mind, body, and soul.
well-being.
• Deepen your spiritual connection.
• Don’t be so hard on yourself. We cannot help every-
one. We can only facilitate the path for the patient but Spirit
it is up to him/her to choose the path.
Connect to your purpose / meaning.
• Don’t compare yourself to any of your colleagues.
Only compete with yourself – are you a better ther- Spirit is not necessarily about religion (although it can be).
apist than you were last year? Some people see it as connecting to purpose, meaning, to
264
true essence of self and the world around. As Shelley Prosko, me, “Mommy, why do you work?” I thought about it for
PT, explains in her WOW chat with Diane Lee, “Every- a moment and replied, “Well, if I didn’t work, then we
thing is impermanent except for Essence.” Lao Tzu, an wouldn’t live in a home with a pool in the backyard”. “I
ancient a Chinese philosopher credited with founding the don’t care”, she replied. “We would have to live in a smaller
philosophical system of Taoism, states, “Care about what house”, I countered. Once again, she replied, “I don’t care.”
other people think and you will always be a prisoner.” What she was really trying to tell me is that my work had
taken up too much time and that she needed more of me.
So what is reality? Reality will often differ, depending on Evidently, although we had quality time, the quantity
how we sense, perceive, and interpret information. Learn was insufficient for her. I went to bed that night, think-
to witness yourself and get to know your own personal ing about our conversation and started to reflect on why I
biases and filters from which we observe the world. really worked. Of course, the money allowed the family to
Learn how to “step away” and witness yourself reacting enjoy a certain quality of life, but then I thought, “What if I
to a certain situation. “Hmmm, I’m doing this again”. Not won the lottery tomorrow? Would I still continue to work?”
in a judgemental away – just an awareness of your tenden- The answer was a resounding “YES”. The next evening, at
cies and patterns playing themselves out. Our biases and Kelly’s bedtime ritual, I brought up the topic once again. “I
personal beliefs contribute to how we react to situations. Be thought about what you asked me last night, Kelly, and I
mindful of the “reactive” state. We are never in our power realized something. Do you see these hands of mine? They
there and cannot be effective healers. are God’s gift to me and I use them to help make people feel
better. Now your job is to find out what your gift or gifts are
Use your gifts – Kelly’s story and use them to make the world a better place. But I hear
you. I have been working too much and need to cut down
Our children are some of our greatest teachers.
some of my teaching so we can have more time together.”
Their demands on our time are a gift, since they force Her response was simply “OK – sounds good”, but the les-
us to develop a better work-life balance. If it wasn’t for my sons we both learned from that conversation stayed with
two children, I would be much more of a workaholic than us. In future conversations, she would often bring up the
I already am! Kelly and Michael are now grown adults and topic of “using our gifts to share with the world”.
they continue to inspire me, using their gifts in their own
My story
special way to make the world a better place.
My story about learning to connect to Spirit is more dif-
This lesson was brought home for me when Kelly was five ficult for me to share than Kelly’s story, as it forces me go
years old. I had opted to stay home for one year when she to that vulnerable place, where I know I will be opening
was born and then went back to work. Technically, it was myself up to criticism. But I choose not to let fear dictate
a part-time job at the clinic, but with administrative tasks my life, so here goes.
of managing a clinic, teaching manual therapy courses for
the Orthopaedic Division of the Canadian Physiotherapy I grew up in a family of five children, where education
Association, and working as an Examiner (and later, Chief was of primary importance. The emphasis in school in
Examiner) for that same Association, it became clear to those days was science, and my left-brain resonated with
my daughter that I had other responsibilities aside from this approach. My parents helped encourage my develop-
being her Mom. She was in a home daycare for a couple ment in the arts through dance and piano lessons, and
of years, and then a more structured educational daycare. gymnastics was my sport of choice throughout high school.
By the time she was five years old, she was in kindergarten We all trotted off to church on Sundays and religion to me
and came to realize that some mothers stayed home with was a bunch of “shoulds” and “should-nots”. There was lit-
their children and did not work. One night, in the process tle talk in those days of developing a personal relationship
of being tucked into bed after reading stories, she asked with God. Going through adolescence and early adulthood
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Chapter 15
brought with it a certain “disillusionment” with the gradually been downloaded “from above” throughout the
Church, although I still believed in God or a higher source past 20 years. My only “job” before I start my workday is
and I still appreciated the traditions associated with Chris- to do a quick meditation to clear my energies, so that I
tian holidays, such as Christmas and Easter. can “get myself out of the way” to be able to hear the mes-
sages from above without having to filter through my own
Moving forward through my middle years, I was busy
issues. When I spend a few minutes in the morning at the
establishing a clinic and raising young children and gave
start of my workday, the day generally runs smoothly and
little thought to all things Spirit. I have always had a sense,
with ease. This personal connection to the Universe has
however, that something very important would happen to
also helped me immensely with personal life challenges. I
me when I was 38 years old.
truly do not know how I would have handled certain situa-
My father’s health crisis precipitated a spiritual crisis tions without the tools I had developed to connect to Spirit.
within me. At the time, I was seeing a patient who insisted
So how does one recognize that our Spirit guides are
that she needed to speak to me about my Dad – that she had
communicating with us? Initially, I would ask a question
information that I needed to know so that I could help him.
in a “yes” or “no” format. I could not “hear” an answer
I had not told her anything about my father’s health issues.
but it would come to me in a guttural, kinesthetic way,
He had been diagnosed with prostate cancer a few months
an almost imperceptible nodding motion of the head for
back and had undergone radiotherapy treatments. Finally,
“yes” and a gentle side-to-side shaking for a “no”. The first
I took some time to hear my patient out. She told me that
time I experienced this, I thought I was making it up, but
she had spirit guides who told her that my father was ill
I have learned to discern true communication from wishful
with prostate cancer and that it had spread to his back (all
thinking on my part. Sometimes, I do not get an answer, as
true). Her spirit guides wanted to let me know that, I too,
if Spirit is trying to tell me “it’s not yet time”. Another way
had spirit guides, and I could learn to use them to help treat
to differentiate wishful thinking from Spirit communica-
my Dad. “But I don’t treat cancer – I treat musculo-skeletal
tion is that the answer comes to you even before you have
conditions!” I exclaimed. You can imagine how my left-
finished formulating the question! It is as if they are a step
brain, logical mind reacted to this information! It was a
ahead of you and know what you will be asking! Certainly,
struggle that took some time to work through.
not left-brain thinking.
In the end, I suspended my beliefs in an attempt to try
Ultimately, I was able to learn to communicate beyond
to help my father. This decision led to the development of
ways that require a yes or no response. In many ways, it
a personal relationship with God / Higher power/ Universe
is like an idea that pops into your brain from nowhere.
– call it what you will. It opened up a whole new world of
This is how many of the MMS techniques came about.
energy, as my hands learned to feel things on a whole other
I stored the information I read about the Anatomy Trains
(energetic) level. I also came to recognize that I too, had
Lines in my “left-brain” all the while, keeping the patient’s
spirit guides, some to help me personally in my life and
subjective and functional complaints in mind, along with
others, specifically to guide me in my treatment sessions
the information gleaned from my assessments and using
with my patients. I had to learn how to communicate with
a clinical reasoning approach. I then learned to combine
them and to invite them when I was unsure how to proceed
it with the creative, intuitive workings of the right brain.
with a particular patient. I have learned to listen to their
Such moments are when work becomes play. “It’s OK to
advice. When my mind decides otherwise, the results are
make things up – as long as it’s helping people feel better
never as good, so I have learned to listen, and to trust. My
and move better. Just play. Just play.” (Diane Lee)
guides never cease to surprise me. I also must give credit
where credit is due. Much of the MMS treatment approach I believe that Spirit guides us and encourages us to use
that I use with my patients, and that I teach throughout all of the resources we have at our disposal as therapists –
Canada and Europe, is actually information that has mind, body and soul.
266
Connecting to Spirit for help with my challenging is “metabolizing life”. It has inert and contractile com-
patients has become a regular habit. I don’t do this for ponents, responds over time to habitual posturing and
every patient, of course, but if I question what my next step chronic stress. Are they adequately oxidized (think rib
should be, or even how much treatment a certain patient expansion, how much lung capacity is used due to posture
can tolerate within one treatment session, I ask. And of the thorax), are their tissues adequately hydrated, or
I always get the appropriate answer. Some answers do not acidic, stiff and painful to touch? All these physical issues
come but if you invite the divine to come and be a part of have other layers to them. Nutrition is very influential, and
your healing space, miracles really can happen. The trick the gut and its relationship to mood is now a topic being
is in the asking – Spirit will never impose itself. It must be increasingly researched. What about the effectiveness
invited in. of gut peristalsis and general well being if its suspension
among the fascia in the peritoneal cavity is compromised?
Fascia in the Fifth Dimension These thoughts convey the far-reaching impacts of fascia
This brings us to muse about fascia in the fifth dimension. and its overall influence on our holistic well-being. I see
Heather Williamson-Vint summarizes her perspective: fascia as a five-dimensional tool to gain access to the indi-
“Bodies are more than cells, and organ systems, obviously. vidual in all their planes of existence.”
They tell a wonderful story of where the client has been in
My hope is that the reader will take on this world of fas-
their lives, not just physically but mentally as well. Their
cia, as they accompany their patients through their healing
beliefs also affect the physical system and its chemical
journeys, using both sides of the brain to access logic and
constituents. Is the world a trustful, safe place? Or is the
science as well as creativity and intuition. There are a num-
world one best trod upon carefully, with held breath, in
ber of fascial approaches to treatment and all have value. I
subconscious fascial tension?
have simply shared my own approach to treatment, based
When someone comes for treatment, we have the privi- on my background as a physiotherapist. My wish is that
lege of working directly with someone’s “life script”. The my contribution to the paradigm shift in rehabilitative care
fascia is a structure that holds this information. It also brings about interdisciplinary education and research, so
serves as a wonderful literal metaphor for how someone that therapists and patients alike can benefit.
267
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273
INDEX
A C tongue and fascia 99–100

Deep Front Line, in relation to 100
with pericardium 100
with shoulder 100
Abdominal scars 21, 131 Carpal tunnel syndrome 126 Craniosacral mechanism 119
Active range of motion (ROM) tests 42, 62 Cervical spine Craniovertebral region 64–65
Active straight leg raise test (ASLR) 62 fascial layers of 123 Superficial Back Line of fascia (SBL), in
Acupuncture 36 MMS techniques for relation to 62–63
Alcohol, effect on body’s tissues 258 active range of motion tests 62 Cranium 103
Alexander technique 17, 232 active straight leg raise test Cytokines 11
Anatomy Trains 19 (ASLR) 62
Anterior dura, MMS technique case studies 70–71, 73
for 108–111
coccyx A/P maneuver 111–112
cervicothoracic (C/Thx)
region 77–78, 631
D
C2 region 110 craniovertebral region 64–65
ipsilateral occiput 111 functional tests 62 Deep Back Arm Line (DBAL) 19, 212–213
mid-thoracic spine region 110 mid-cervical region 66–77, 79–80 clinical implications 34–35
thoracolumbar junction 109–110 positional tests 61–62 structures 34, 34f
Anterior sacral fascia 25–26 postural analysis 61 Deep cervical fascia 123
MMS approach to 162–165 Superficial Back Line of fascia (SBL), in Deep fascia 4
Anteroposterior fascia relation to 62–63 Deep Front Arm Line (DFAL) 19, 211–212
of cervicothoracic region 122 upper fibers of trapezius (UFT) 78–79 clinical implications 33
of thoracolumbar region 122 Cervicothoracic (C/Thx) region 77–78, 123 structures 33
of thorax 122 Chain reactions in body 12–13 Deep Front Line (DFL) 19, 38
Anxiety breathing 121 ascending reaction 13 clinical implications 26–30
Articular restriction 43 Chi-Gong 232 MMS quadratus lumborum in relation
Aspartame, side effects of 258–259 Clavicle fascia 195 to 140–144
Clavicular fracture 33 MMS right adductors in relation
Collagen 6
B microfibers 11
Colles’ fracture fascia 34
to 178–179
MMS techniques iliacus along 128–130
stretches 239–241
MMS approach for 226–228 structures 25–26, 27f
Back Functional Line (BFL) 19, 35–36 Connective tissue anterior portion 26
Barnes, John F. 15 massage (CTM) 14 middle portion 26
Baron, BetsyAnn 15 response to demands 11 muscles involved 26
Barral, Jean-Pierre 173 role in local tumor 10 posterior portion 26
Bayer, Johanna 232 CORE technique 15 tibialis posterior 26–29
Blatman, Hal 258 Craniofacial region, MMS techniques for upper quadrant 29–30
Body-wide communication system 6, 9 buccinator/pharyngeal constrictor yoga poses 242–247
Bois, Danis 15 complex 93–95 Deltoid fascia, MMS approach
Brachialis deltoid fascia 34 case study 101 for 214–215
Buccinator/pharyngeal constrictor postural analysis 83 De Quervain’s tenosynovitis 33, 212
complex 93–95 scalp and epicranial fascia 97–99 MMS approach for 225
MMS technique Spiral Line, in relation to 99 Diaphragm 121–122
Deep Front Line, in relation to 95 supra- and infrahyoid region 95–97 functions 121
with occiput 95 temporomandibular joint (TMJ) improper breathing patterns,
with raphe 94 muscles 83–85 implications of 121
with sphenoid 94–95 Deep Front Line, in relation to 86–90 mobility issues 122
Butler technique 149–150 Lateral Line of fascia, in relation Dicke, Elizabeth 14
“Butt grippers”, 159 to 90–92 Dupuytren’s contracture 33, 211
Spiral Line of fascia, in relation MMS approach for 223–225
to 92–93 Dura 103
275
INDEX continued
anterior 104 with tension of DFL 115–116 Feldenkrais method 17

mobility dysfunction 104 structure of 103 mobilization of myofascial system
posterior 104 Fascia 267 (MMS) 16–18
Dural mobility, MMS technique for anatomical definition 3 movement re-education
anchoring areas 105 composition of 6–7 approaches 17
of anterior dura 108–111 continuity of 3, 5 myofascial release (MFR) 15
coccyx A/P maneuver 111–112 as contributor to musculoskeletal Rolfing/Structural Integration
C2 region 110 dysfunction 14 technique 15
ipsilateral occiput 111 deep 4 structural myofascial therapy
mid-thoracic spine region 110 DFL of 26–29 (SMFT) 15
thoracolumbar junction 109–110 factors influencing functions 10–11 yoga therapy 17
falx cerebri, balancing with impact on motor control system 3 assessment of 44–47
cranium 112–116 innervation 7–8 Fascia-related disorder 13
along ankle dorsiflexion (DF) and irregular connective tissue of 3 Fasciathérapie 15–16
plantarflexion (PF) 113–114 mechanoreceptors in 8 Feldenkrais method 17, 232
with eye movement 114–115 as mediator 5–6 Femoral nerve fascia 135
occiput/ethmoid 113 musculoskeletal 4–5 Femoral pelvic outlet syndrome 173–175
occiput/frontal-nasal 113 regular connective tissue of 3 Femoroacetabular impingement (FAI) 233
with tension of DFL 115–116 roles of 8–10 Fibroblasts 6
occiput-sacral balancing 119–120 body’s defense and immune system Fibrosis 11
of posterior dura 105–108 function 9–10 Findley, Thomas 10
C2 in relation to S2/3 region 107 in cancer biology 10 Flexor retinaculum, MMS approach
mid-thoracic spine in relation to S2/3 gene expression, regulation of 10 for 222–223
region 106 inflammatory response, Frederick, Ann 232
occipital flexion in relation to S2/3 regulation of 9 Frederick, Chris 232
region 107 mechanotransduction function 9 Front Functional Line (FFL) 19, 35–37
thoracolumbar junction in relation to protection against physical trauma 8
L5/S1 region 108 as shock absorber 8
thoracolumbar junction in relation to
S2/3 region 105–106
static postural support 8
structural integrity 8
G
tentorium cerebellum, balancing with transmission of force 8
cranium of skeletal muscle 5 Gall bladder meridian 39
ear-pull technique 116–117 sparing 3 Garner, Ginger 232, 250
with eye movement 117 superficial 4 Glenohumeral (GH) joint 43–44
with tension of DFL 118 as tensegrity system 12–13 Glycoproteins 6
Dynamic stability tests 44, 57–58 Fascial anatomy 4–6 Grades of passive movement 51–53
Fascial continuity 3 Ground substance 6
Fascial fitness 232 Guimberteau, Jean-Claude 56, 257
E Fascial hydration 12
Fascial lines, connection with
Gut microbiome, balancing 259
acupuncture 36
Ear-pull technique 116–118
Elastic zone (EZ) 42–43, 52
Fascial Manipulation method 16
Fascial mobility 231
H
Elastin cells 6 Fascial pathology 10–11
Epimysium 4–5 Fascial restriction, testing for Hair-pull technique 97–98
with neural mobility test 46–47 Hammer toes 21
with recurring joint dysfunction 44–46 Hartman, Laurie 54
F with recurring muscle trigger point 46
Fascial sheets 3
Headly, Gil 4
Heller, Joseph 15
Fascial stretch therapy 232 Hellerwork method 15
Failed load transfer (FLT) 44, 136, 171 Fascial system High blood glucose levels (sugar), effect on
Falx cerebri of dura approaches to treatment of body’s tissues 257–258
balancing with cranium 112–116 Alexander technique 17 High sugar diet, effect of 257–258
along ankle dorsiflexion (DF) and connective tissue massage (CTM) 14 Hitzmann, Sue 232
plantarflexion (PF) 113–114 consideration of muscle or trigger Hormone health 259–260
with eye movement 114–115 points 13–14 Hydration 259
occiput/ethmoid 113 Fascial Manipulation method 16
occiput/frontal-nasal 113 Fasciathérapie 15–16
276
INDEX continued
Hydrogenated oils/trans fats,

side effects of 258
Lateral sacral fascia 135
in relation to hip, MMS approach M
Hypertonic scalene muscles 126 to 144–146
Leaky gut syndrome 259
Lee, Diane 13, 16, 17, 55, 262, 266 Maitland, Geoffrey 41, 45
I Lee, Linda-Joy 16, 17, 55
Left-brain thinkers vs right-brain
grades of mobilization 51–53
Manual therapy 262
thinkers 261 Mechanoreceptors 7
Iliacus fascia 122 Load and listen test 171–173, Medial pterygoid muscle 83
Iliotibial band (ITB) syndrome 24 197–198, 213 anchoring onto 85
Improper breathing patterns, implications Lower extremity, MMS technique for Medical therapeutic yoga 232
of 121 biceps femoris muscle 186–188 MELT method 232
Infrahyoid muscle 83 case study 176 Mid-cervical region 79–80
Integrated Systems Model (ISM) 17, dorsal intermetatarsal fascia 186 Deep Front Line, in relation to 67–70
104–105, 122, 136, 151, 169, 171 indications for 167 glenohumeral joint, in relation to 71–73
Integrins 9 inguinal ligament 173–175 Lateral Line, in relation to 75
Interosseous membrane, MMS approach joint mobilization converted to scapula, in relation to 73–75
for 222 MMS 188–189 Spiral Line, in relation to 76–77
Ipsilateral Functional Line (IFL) 19, 36 lower leg 182–183 Superficial Front Line (SFL), in relation
Ipsilateral inferior lateral angle (ILA) 136 hammer toes, in relation to 186 to 66–67
patella-femoral joints 180 Mobilization of myofascial system
pes anserinus area 179–180 (MMS) 16–18, 43–44
J plantar fascia and flexor hallucis
longus 183–185
effects of 56–57
exploring fascial lines of tension 53–55
popliteus muscle 181 guidelines for treatment 51–53
Joint mobility 42–43 quadriceps fascia 176–179 hydration model 56
Joint mobilization technique 55 release with awareness indications/contraindications to 47–49
converted to MMS 188–189 techniques 190–193 craniofacial pain 83
Jull, Gwen 263 superior tib/fib joint 189 lower extremity pain 167
tibial tuberosity 180–181 lumbopelvic-hip pain 135
Lumbopelvic-hip complex, MMS approach to neck pain 61
K active range of motion tests 135–136
Butler technique 149–150
shoulder girdle or cervical pain 195
thoracic pain 121
case study 144 upper extremity pain 211
Kaltenborn, F. 52–53 functional movement of pelvis, mechanical model 56
Kinesis 15 assessment of neuromodulation model 56–57
Kousaleos, George 15 one leg stand test 136 overall treatment approach 57–58
squat test 136 patient responses to treatment 57
of lateral sacral fascia in relation to piezoelectric model 56
L hip 144–146
pelvic girdle position, assessment
RACM (release, align, connect/control,
move) 58
of 135 re-assessment of mobility tests 57
Langevin, Hélène 10, 36 postural analysis 135 star concept 45, 51
Larkam, Elizabeth 232 of quadratus lumborum in relation to thixotrophic model 56
LaoTzu 264 DFL 140–144 treatment concepts 53–56
Lateral brachialis, MMS approach of sacrotuberous ligament Muscle length tests 42
for 218–219 fascia 146–150 Muscle release techniques 13–14
Lateral Lines (LL) 19, 123 DFL, in relation to 149 Musculoskeletal fascia 4–5
clinical implications 23–24 hip, in relation to 148–149 Myers, Tom 15, 121, 231–232, 257, 259
MMS techniques iliacus along 130 reference points 146 Mylohyoid muscle 83–84
stretches 251–252 SBL, in relation to 147 anchoring onto 85
“C” exercise 251–252 for thoracolumbar area 136–140 Myofascia, definition 3
cross leg sitting Lateral Line Lumbopelvic-hip pain, treatment Myofascial meridians 36–38
stretch 252 approach to 135 Myofascial pain, characteristics of 41
Shirley’s exercise 252 Myofascial release (MFR) technique 15
structures 22–23 Myofascial restriction 43
yoga poses 253–255 Myofibroblasts (MFB) 6–7
Myotatic reflex release 233
277
INDEX continued
N Pelvic floor
domain of 151
Rolf, Ida 15, 19
Rolfing/Structural Integration technique 15
“double bag” structure 151
recurring problems in 151
Neck flexion 103
Nerve mobilization technique 55
Pelvic floor, MMS technique for
of anterior sacral fascia 162–163
S
Neutral zone (NZ) 42–43, 52 articular dysfunction or myofascial trigger
Nociceptors 7 points 151–153 Sacroiliac (SI) joint 44, 233
North American diet, effects of 257–259 case study 163–165 Sacrotuberous ligament fascia 135
Northrup, Christiane 257, 259 hip external rotators, implications MMS technique for
Nutrition, effect on body’s of 153 DFL, in relation to 149
tissues 257–259 indications for 151 hip, in relation to 148–149
alcohol 258 of obturator internus fascia 153–162 reference points 146
aspartame 258–259 Pelvic floor pain 28 SBL, in relation to 147
high blood glucose levels Pilates 232 Scalene muscles 126
(sugar) 257–258 Pollan, Michael 259 Scalp and epicranial fascia 97–99
hydrogenated oils/trans fats 258 Positive neurodynamic test 55 Spiral Line, in relation to 99
Posterior dura, MMS technique Schleip, Robert 56, 232
O for 105–108
C2 in relation to S2/3 region 107
Scoliosis 123
Self myofascial release (SMR) 232
mid-thoracic spine in relation to S2/3 Sensorial Introspection 15
region 106 Sensorial Re-education 15
Objective evaluation 42–44 occipital flexion in relation to S2/3 Serratus anterior fascia 122
Obturator internus (OI) 153 region 107 Serratus posterior inferior fascia 122
Obturator internus fascia, MMS technique thoracolumbar junction Shirley’s exercise 252
for 153–162 L5/S1 region, in relation to 108 Sitting arm lift (SAL) test 197
ankle dorsiflexion/ eversion 161 S2/3 region, in relation to 105–106 Slump technique 103
central tendon diaphram 156 Posterior superior iliac spine (PSIS) 136 Spinal canal 103
contralateral anterior diaphram 162 Pre-trachial fascia 123 Spiral Lines (SL) 19
contralateral greater trochanter 157 Pre-vertebral fascia 123 clinical implications 24
contralateral ilium 155 Prone extension breathing structures 24–25
contralateral posterior diaphram 156 exercise 239–240 yoga poses 249–251
hip adductors 161 Proprioceptive neuromuscular facilitation Spirit 264–267
hip movements and 158–159 (PNF) 17 Squat test 136, 169–171
ipsilateral anterior diaphram 162 Proprioceptors 7 Star concept 45, 51
ipsilateral greater trochanter 157 Prosko, Shelley 264 Stecco, Antonio 16
ipsilateral ilium 155 Proteoglycans 6 Stecco, Carla 16
ipsilateral posterior diaphram 155–156 Stecco, Luigi 16
ipsilateral sacral base 153–154 Sternoclavicular joint fascia 195
ischiococcygeus fascia 159–160
pericardial fascia 162
Q biomechanics of 196
functional tests for 197–198
thumb placement 161 Sternoclavicular joints, MMS technique for
Occiput-sacral balancing 119–120 Quadratus lumborum fascia 122 case study 209
One leg stand (OLS) test 44, 136, 171 MMS technique for 149 cervicothoracic region 199
Optimal therapeutic Quadratus lumborum (QL) clavicular fascia 202–208
environment 260–261 muscle 131, 135 contralateral ring 202
developing 261–267 Quadriceps fascia 167 fascial twists and 201
indications for 195
P R
ipsilateral occiput 199
ipsilateral scalenes 198–199
ipsilateral scapula 200
ipsilateral thoracic ring 201
Paoletti, Serge 12, 31 Release with awareness (RWA) 55–56, manubrium area 200
Passive accessory movements 42–43 133, 167 mid-thoracic region 200
Passive physiological movements 42–43 for foot and ankle 190–193 positional tests for 195–197
Pectoralis minor fascia, MMS approach Resistance flexibility 232 clavicles 196
for 214 Rhomboid muscles 35 glenohumeral joint 195–196
Pectoralis minor tightness 33 scapulae 196
278
INDEX continued
Sternocleidomastoid muscles 22
Straight leg raise (SLR) technique 103 T layers of fascia involved 123
release with awareness (RWA)
Stress hormones 260 approach 123, 133
Stretching 231–232 of right quadratus lumborum 131–132
Deep Front Line (DFL) stretches 239– Tai-Chi 232 of serratus anterior muscle 132–134
241 Temporalis muscle 83–84 of serratus posterior inferior muscle 134
Lateral Lines (LL) stretches 251–252 palpating 83–84 Thorax, restrictions in 122
“C” exercise 251–252 Temporomandibular joint (TMJ) Tongue, anatomy 99
cross leg sitting Lateral Line muscles 32, 83–85, 122 Tongue and fascia, MMS technique
stretch 252 anchoring onto 84 for 99–100
Shirley’s exercise 252 MMS technique for 83–85 DFL of fascia, in relation to 100
Superficial Back Line (SBL) DFL of fascia, in relation to 86–90 with pericardium 100
stretches 233–235 Lateral Line of fascia, in relation with shoulder 100
Superficial Front Line (SFL) to 90–92
stretches 247–248 Spiral Line of fascia, in relation
clavicular opening stretch 247
seated toe extensor stretch 248
to 92–93
Tentorium cerebelli 103
U
standard quadriceps stretch 248 Tentorium cerebellum, balancing with
supine hamstring stretches 233–235 cranium Upper extremity, MMS technique for
Structural Integration technique 15 ear-pull technique 116–117 biceps with elbow 217–218
Structural myofascial therapy (SMFT) 15 with tension of DFL of fascia 118 biceps with rectus abdominis 218
Subjective evaluation 41–42, 261–262 with eye movement 117 Colles’ fracture fascia 226–228
Superficial Back Arm Line (SBAL) 19, 212 Thoracic outlet syndrome 126 deltoid fascia 214–215
clinical implications 34 Thoracic pain 121–122 De Quervain’s tenosynovitis 225
structures 33–34 Thoracolumbar fascia 135 Dupuytren’s contracture 223–225
Superficial Back Line (SBL) 19–20, 37 innervation 7 elbow extension/pronation/wrist
clinical implications 19–20 MMS technique for 136–140 flexion 219–220
imbalance of 22 central sacral area 138–139 Finkelstein position 226
stretches 233–235 ipsilateral ilium 137–138 flexor retinaculum 222–223
yoga poses 235–239 opposite ilium 137 interosseous membrane 222
Superficial back line yoga poses quadratus lumborum lateral brachialis 218–219
cat part of cat/cow 235–236 muscle 139–140 pectoralis minor fascia 214
child pose 236–237 Thorax, MMS technique for postural analysis 213
pigeon pose for buttocks 237–238 anterior/posterior cervicothoracic radial head 219
standing forward bend 237 region 126 supraspinatus fascia 215–217
Superficial (investing) cervical fascia 123 anterior/posterior thoracolumbar wrist extensors 219–222
Superficial fascia 4 region 126
Superficial Front Arm Line (SFAL) 19, 211 anterior/posterior thorax
clinical implications 31–33
structures 31–32
with lumbar spine neutral 124
pericardium, in relation to 124–126
V
Superficial Front Line (SFL) 19, 21, 38 with persistent C/Thx
clinical implications 21–22 dysfunction 126 van der Wal, Jaap 4
imbalance of 22 articular dysfunction or myofascial trigger Vector analysis 43–44
MMS techniques iliacus along 128–132 points 123 Visceral system 173
stretches 247–248 case study 127
clavicular opening stretch 247 iliacus
seated toe extensor stretch 248
standard quadriceps stretch 248
with ipsilateral external oblique/
anterior diaphram 129
W
structures 20 with ipsilateral symphysis pubis 130
yoga poses 248 with lateral leg/iliotibial band 130 Wexler, Gail 43, 171
Superficial masseter 83–84 with medial leg/adductors 130–131 Williamson-Vint, Heather 261, 262, 263,
anchoring onto 84–85 with opposite ASIS 128 264, 267
Supine hamstring stretches 233–235 with opposite external oblique/anterior
Supra- and infrahyoid region 95–97 diaphram 128–129
Supraspinatus fascia, MMS approach with pericardium 129
for 215–217 pre-tensed with hips extended/knees
Sutherland’s fulcrum 103 flexed 131
Sympathetic fibers 7
279
INDEX continued
Y for Lateral Lines (LL) 253–255

gate pose 253–254
child pose 236
downward-facing dog 238
sitting pose 254 downward-facing dog for soleus
standing side-bend pose 253 stretch 239–240
Yoga poses thoracolumbar fascia lateral child pose 236
for Deep Front Line (DFL) 242–247 stretch 254–255 pigeon pose for buttocks 237
cat part of cat/cow pose 242 for Spiral Lines (SL) 249–251 seated toe flexor stretch 238
cobra pose 242 lunge/rotation pose 250–251 standing forward bend 237
happy baby pose 246 pectoralis stretch with lumbar walk the dog pose 238–239
lunge 243–244 rotation 249 for Superficial Front Line (SFL) 248
Sphinx pose 242–243 seated spinal twist 249–250 Yoga therapy 17, 122
upward-facing dog pose 243 threading the needle pose 250 optimal yoga pose 232–233
warrior pose 244–245 triangle pose 250–251 precautions and contraindications 233
windshield wiper pose 246–247 for Superficial Back Line (SBL) 235–239
yoga blocks 245–246 cat part of cat/cow pose 235–236
for Front Arm Line
eagle pose 255–256
shoulder opener with belt 255
280

Mobilizing The Myofascial System

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Mobilizing

Doreen Killens BScPT, FCAMPT, CGIMS

First published 2018 in the United Kingdom by Handspring Publishing

Copyright ©Handspring Publishing Limited 2018

British Library Cataloguing in Publication Data

Library of Congress Cataloguing in Publication Data

Commissioning Editor Mary Law

SECTION 1 Understanding fascia

CHAPTER 1 Understanding fascia 3

CHAPTER 3 Assessment of fascial dysfunction 41

CHAPTER 4 Principles of treatment with Mobilization of the Myofascial System 51

SECTION 2 MMS techniques for fascia

CHAPTER 6 The craniofacial region (cranium, temporomandibular joint) 83

CHAPTER 7 Dural mobility 103

CHAPTER 8 The thorax 121

CHAPTER 9 The lumbar/pelvic region 135

CHAPTER 10 The pelvic floor 151

CHAPTER 11 The lower extremity 167

CHAPTER 12 The shoulder girdle 195

CHAPTER 13 The upper extremity 211

SECTION 3 Optimizing treatment

CHAPTER 15 Optimizing therapeutic outcomes

To my husband George, whose unconditional love Doreen Killens

A/P anteroposterior FFL Front Functional Line

AC acromioclavicular FHL flexor hallucis longus

ALL anterior longitudinal ligament FLT failed load transfer

ASIS anterior superior iliac spine GH glenohumeral

ASLR active straight leg raise IFL Ipsilateral Functional Line

BFL Back Functional Line IFOMPT International Federation of Manipulative Physical

PF plantarflexion SFAL Superficial Front Arm Line

PIL postero-inferior-lateral SFL Superficial Front Line

PIVM passive intervertebral movement SIJ sacroiliac joint

PNF proprioceptive neuromuscular facilitation SL Spiral Line

PSA postural somatic awareness SLR straight leg raise

PSIS posterior superior iliac spine SMFT Structural Myofascial Therapy

QL quadratus lumborum SNS sympathetic nervous system

® right TFGF transforming growth factor

A brief summary of Tom Myers’s Anatomy Trains

Assessment of fascial dysfunction 41

Principles of treatment with Mobilization of the Myofascial System 51

Fascial anatomy tense associated ligaments; ligaments are activated as well

Single muscle fiber

4. Ground substance is a viscous transparent sub-

Table 1.1 Mechanoreceptors in fascia.

Receptor type Preferred location Responsive to Known results of stimulation

Golgi Myotendinous junctions Golgi tendon organ: Tonus decrease in related

Ligaments of peripheral joints Like Pacini, yet also to Inhibition of sympathetic

Interstitial Most abundant receptor type. Rapid as well as Changes in vasodilation

Roles of fascia • functioning as shock absorber (Paoletti 2006) and in

Connective tissue Membrane matrix

Fascial hydration As a result, a pull or a push on one corner of the connec-

If our analysis points to a problem that is primarily

Lee & L ee ‘07

Pectoralis major Pectoralis minor

Figure 2.2 peroneus longus). Consequently, the toe extensors be-

SBL SFL SBL SFL

Deep Front Line • psoas, iliacus, quadratus lumborum

is part of the DFL (Figure 2.12). Although the tibialis

Note that the following muscles take part in the follow-