Introduction to the

Fascial Distortion Model

Hawaii Association of Osteopathic Physicians and Surgeons

2019 Primary Care Update
Ken Nakasone, PT, PhD, FDM IC, ATC, CSCS • 03.27.2019
I have no financial interest in any of the products used
or discussed in this course.

I am a certified FDM practitioner and am currently

training to become a certified instructor with the
AFDMA, a non-profit association with the mission to
promote the FDM by:
● informing and educating the medical and public communities,
● establishing certification standards for practitioners and
instructors in the USA with cooperation from the European,
Asian and African FDM associations, and
● funding and performing FDM related research
 Stephen Typaldos, DO
March 25, 1957-March 28, 2006

http://www.typaldos.org/memorial/stephen-marge.jpg

Bachelor’s degree: UC-Riverside

Medical degree: University of Health

Sciences, College of Osteopathic Medicine,
Kansas City, MO
11/2014. Why Does It Hurt?. Amazon digital/hard copy
02/2015. FDM Module 1. Maui, HI
11/2015. FAA International Seminar. Tokyo, Japan
02/2016. FDM Module 2. Maui, HI
05/2016. FDM Module 3. Yakima, WA
03/2017. FDM IC Exam. Colorado Springs, CO
10/2018. FAA International Seminar. Osaka, Japan

Stephen Typaldos, DO
Todd Capistrant, DO, MHA
Gene Lenard, DO
Byron Perkins, DO
Keisuke Tanaka, FDM.O.
Kohei Iwata, FDM.O.
 Overview
Ankle injuries
Introduction to ● Literature update

the FDM Fascial Distortion Model

● Define six distortions
and ●
●
Recognize gestures for each distortion
Assessment: CC-MOI-BLG-OF-MOVT
FDM Workshop: FDM for ankle
Assessment and ●
●
Triggerband
Continuum distortions

Treatment of ● Folding distortions

Ankle Pain
Clinical Diagnostic Assessment
● MOI (Delahunt et al; McGovern and Martin; Vuurberg et al; Lin et al; Dublin et al)

● Hx of LAS (Delahunt et al; McGovern and Martin; Vuurberg et al; Lin et al; Dublin et al)

● WB status (Delahunt et al; McGovern and Martin; Vuurberg et al; Lin et al; Dublin et al)

● Assessment of bones (Delahunt et al; McGovern and Martin; Vuurberg et al; Jonckheer et al; Lin et al;
Dublin et al)

● Assessment of ligaments (Delahunt et al; McGovern and Martin; Vuurberg et al; Lin et al; Dublin et al)
Delahunt et al, 2018. Clinical assessment of acute lateral ankle sprain injuries (ROAST):
2019 consensus statement and recommendations of the International Ankle Consortium

Objective Findings
● Pain: numerical rating, FADI ● Dynamic postural balance: SEBT

● Swelling: Figure 8 ● Gait: load/unload, LE biomechanics

● ROM: DF, anterior reach SEBT, WB lunge test ● Physical activity level: exercise
programming, PLOF
● Arthrokinematics: posterior talar glide (DF)
● Patient response outcomes: FADI
● Muscle strength: hand held dynamometers

● Static posture balance: BESS; foot lift test

 Ottawa Ankle Rules

Ankle x-ray series if pain Foot x-ray series if pain or

or tenderness over the... tenderness over the...
Posterior edge or
Base of the 5th metatarsal
tip of lateral malleolus

Posterior edge or
Navicular
tip of medial malleolus

Unable to take 4 steps immediately Unable to take 4 steps immediately

or in ED or in ED

Jonckheer P, T Willems, RD Ridder, D Paulus, K Holdt Henningsen, L San Miguel, A De Sutter & P Roosen (2015)
“...tensional, continuous fibrillar network within the
body, extending from the surface of the skin to the
nucleus of the cell. This global network is mobile,
adaptable, fractal and irregular; it constitutes the basic
structural architecture of the human body.”
Guimberteau and Armstrong. 173

● Fibroblasts can contract and communicate with

other fibroblasts.
● Transmit tension from muscles
● Source of proprioceptive and nociceptive
information
 FDM is an anatomical perspective in which
the underlying etiology of virtually every
musculoskeletal injury (and many
neurological and medical conditions as well)
is considered to be comprised of one or more
of six specific pathological alterations of the
body’s connecting tissues (fascial bands,
ligaments, tendons, retinacula, etc.).
Fascial Distortion Model
Patient is the expert
Provides the diagnosis AND guides the treatment
Results are objective, obvious, measurable and immediate

Fascial Types in the FDM

Banded fascia (TB, CD) weightlifters, football players
Coiled fascia (CyD) jumpers, basketball players
Folding fascia (FD) ballet dancers
Smooth fascia (HTP, TF) spectators
FDM DIFFERENTIAL DIAGNOSIS

GESTURES

CC
 FDM FASCIAL DISTORTIONS

Triggerband (TB): contorted banded fascia

Herniated Triggerpoint (HTP):tissue protrusion through fascial layer
Continuum Distortion (CD): transition zone alteration b/w tissue types
Folding Distortion (FD): 3-D alteration of fascial plane at the joint
Cylinder Distortion (CyD): entangled or collapsed coiled fascia
Tectonic Fixation (TF): fascia loses ability to glide
 FDM Body Language or Gestures “Pearls” M.Kasten p.40

Distortion TB HTP CD FD CyD TF

Pushes with
Points to one hand cups Has trouble
Body Sweeping fingers or fist Squeezes or
or more spots joint or finger moving joint,
language motion with into rubs hand
of pain on drawn across feels and
Gestures fingers non-jointed over area
bone joint looks stiff
area

Wakes up at
Burning,
Aching, night, comes
pulling, Aches deep Feels like it is
Verbal pinching or Hurts in one and goes,
tethering, in the joint, stuck, needs
descriptions tightness in spot N/T,
restricted feels unstable to pop
soft tissues paresthesias
motion

Spaghetti
Feels tight, Unstable,
Pulls or heard Just that one legs, Stiff, tight in
Key words stiff or changes
it snap spot weakness, joints
pinches w/weather
numb
 Triggerband (TB): twist, crumple, knot, pea, wave, grain of salt

● Sx: burning, pulling pain along a linear pathway/line

● BLG: sweeping motion with fingers along painful line
● Problem: twisted or wrinkled banded fascia
● Feels like: ribbon or violin string
● Treatment: use your thumb to untwist/iron wrinkled tissue
● Warning: no heat, e-stim and avoid rest
Triggerband (TB): twist, crumple, knot, pea, wave, grain of salt
Triggerband (TB): BLG: sweeping motion with fingers along painful line
Triggerband (TB): BLG: sweeping motion with fingers along painful line
Triggerband (TB): BLG: sweeping motion with fingers along painful line
 Herniated Triggerpoint (HTP): banded, non-banded

● Smooth fascia
● Tissue protrusion and stuck
● Trade-off of motion for strength
 Herniated Triggerpoint (HTP): Non-traumatic muscle hernia

● 26yo; sx x 10d; MOI: weight training

● Nagging pain (exercise) with use; denies sensorimotor deficit
● Palpation, US (0.72cm)
● Fasciotomy then fasciorrhaphy; clear after 6 month F/U
 Herniated Triggerpoint (HTP): Non-traumatic muscle hernia

● 26yo; sx x 10d; MOI: weight training

● Nagging pain (exercise) with use; denies sensorimotor deficit
● Palpation, US (0.72cm)
● Fasciotomy then fasciorrhaphy; clear after 6 month F/U
 Herniated Triggerpoint (HTP): banded, non-banded

● Sx: ache, pinching or catching

● BLG: pushes the thumb/fingers into a specific spot; punches
● Problem: tissue is protruding through a rupture in smooth
fascia Non-banded: protrusion through non-banded tissue
Banded: protrusion through tissue due to a TB
● Feels like: knot or grape
● Treatment: push the knot back through the fascial layer
● Warning: HTP are permanent unless treated
 Herniated Triggerpoint (HTP): banded, non-banded

● Palpate HTP to find appropriate direction (most painful)

● Appropriate force held till distortion releases and protrusion
returns below the tissue layer
● Stubborn cases = milking/rocking thumb back and forth
(thumb only)
● Tissue stretch or slack via
patient positioning or movement
 Continuum Distortion (CD): inverted, everted

● Everted CONTINUUM DISTORTION: unidirectional force (Tx

or compression) shifting osseous component into TZ and
remain stuck

● Inverted CONTINUUM DISTORTION: multi-directional

forces shift into the osseous component and remain stuck and
destroy the TZ functionality (i.e. bone contusions)
 Continuum Distortion (CD): inverted, everted

● Sx: specific spot on pain on a bone

● BLG: single finger points to a specific spot
● Problem: sudden movement disrupts the banded fascia fluid
connection to the bone
● Feels like: small grain of rice, but difficult to palpate
● Treatment: push on the CD until it shifts, pops or melts, thus
shifting it back to neutral state
Continuum Distortion (CD): inverted, everted
Continuum Distortion (CD): BLG: points to one spot of pain on bone
 Folding Distortion (FD): unfolding, refolding

● Folding fascia (joint capsules, intermuscular septa,

interosseous membranes, spinal paraventricular fascia)
● External forces distort the tissues and deprive them of their
original ability to subsequently expand or contract
○ Unfolding: Tx MOI
○ Refolding: Compression MOI
● Pain deep in the joint, decrease with Tx or compression
● Place palm of hand over joint or draws a line across the joint
 Folding Distortion (FD): unfolding, refolding

● Sx: deep ache in the joint that feels like it restricts movement
but when tested, the ROM is normal
● BLG: cups hand/draws a line over the joint
● Problem: folding fascia gets stuck after opening or closing due
to the imparted forces
● Treatment: “repeat the injury” unfolding = Tx; refolding =
compression. Treatments should not be painful
● Warning: Permanent unless treated
Folding Distortion (FD): unfolding, refolding
Folding Distortion (FD): unfolding, refolding
Folding Distortion (FD): unfolding, refolding
 Cylinder Distortion (CyD): partial collapse, widespread, entangled

● Coiled fascia
● Most difficult to eliminate
● Very strange and mysterious sx
● Patients may have difficulty describing sx at times and show
no abnormalities on objective findings
 Cylinder Distortion (CyD): partial collapse, widespread, entangled

● Sx: bizarre pain that fluctuates or jumps from one area to

another, N/T, tremor, impression of swelling
● BLG: hand appears to squeeze or sweep the pain away
● Problem: coiled fascia collapses or tangled
● Feels like: difficult to feel, may have to use a pet comb to feel
the tangle
● Treatment: untangle fascial coils with hands, cups, pet comb
● Warning: referral to psychiatrist is common
Cylinder Distortion (CyD): partial collapse, widespread, entangled
 Tectonic Fixation (TF)

● Smooth fascia
● Chronic injury, injuries not properly treated
● “Desire to crack neck or back” or “needs to pop feeling”
● Not associated with pain, may be other distortions
● Restore lubrication within the smooth fascia
Tectonic Fixation (TF)
 Tectonic Fixation (TF)

● Sx: joints that won’t move

● BLG: grabs joint and tries to jiggle it; tries to move joint with
force
● Problem: fascial layers are stuck to each other instead of
gliding
● Treatment: slow pumping of fluid between the fascial layers,
followed by joint mobs; heat may increase lubrication of joint
Fascial Distortion Model Workshop:
Assessment and Treatment of Ankle Pain

Ken Nakasone, PT, PhD, FDM IC, ATC, CSCS

 Case descriptions
● Burning or pulling pain at the back of the foot, lateral ankle or along the
Achilles tendon

● Painful spot (s) at the ankle

● Pain deep in the joint and a feeling of instability

● Diffuse pain at the back of the ankle/foot

 Gestures
● Sweeping motion with the hand around the ankle and up the lower leg

● Indicates one (or several) painful spots on the bone

● Cups the ankle with one or both hands

● Clasps the ankle with one hand and rubs finger over it
 CD, TB, FD
CD
Anterior ankle, common. Treat old AACD if present in Hx.
Reason for restricted DF

TB
8 common pathways

FD
Medial or lateral; unfolding or refolding

Priority order for LAS

AACD > TB/FD > CD > CyD. If thrust, may develop AACD
 Continuum Distortion (CD): inverted, everted

● ECD: thumb technique

● ICD: thumb technique followed by a thrust manipulation
(thumb levels off inverted part with unaffected part)
● Very painful. Excessive force is not the goal
● Tissue specificity is key. Know anatomy and get to the tissue
by moving superficial tissue out of the way
 AACD
Tibial/Fibular/Deep ankle
(medial/lateral/middle)
● Treat old AACD if present in Hx
○ Medial tibialis anterior tendon
○ b/w TA tendon and EHL tendon
○ b/w EDL and EHL tendon
○ Clear EDL tendons
○ Lateral EDL tendons
● Direction of force is parallel to AITFL
● Dorsiflex ankle with pressure
● Watch patient/athlete’s reactions
 Triggerband (TB): twist, crumple, knot, pea, wave, grain of salt

● Technique
○ Subjective complaints/body language: starting point
○ Start beyond edge of TB @ right angle into tissue
○ Shovel twist out
○ Push twist along pathway
○ Appropriate force needed to restore
twisted banded fascia to original.
 Ankle Triggerbands

Triggerband Pathways
1/Lateral ankle triggerband: lateral calf (sock
line), posterior to lateral malleolus, distal 4th
or 5th metatarsal, toe

2/Anterior ankle triggerband: anterior calf

(sock line), anterior to lateral malleolus, distal
4th or 5th metatarsal, dorsal surface
 Ankle Triggerbands

Triggerband Pathways
3/Fibula posterior triggerband: difficult to
verbalize and locate pain; deep pressure next
to Achilles tendon (not on it)

4/Inner ankle triggerband: medial calf (sock

line), posterior to medial malleolus, medial 1st
metatarsal
 Ankle Triggerbands

Triggerband Pathways
5/Endocervical (external condyle) underside:
short index finger sweeps under medial
malleolus

6/Inner ankle to sole triggerband: medial calf

(sock line), posterior to medial malleolus, sole
towards 5th metatarsal, plantar surface, firm
pressure
 Ankle Triggerbands

Triggerband Pathways
7/Tibia posterior triggerband: patient
determined pathway between posterior tibia
and achilles tendon

8/Achilles tendon triggerband: calcaneus along

either side of the Achilles tendon to ¾ of the
lower leg.
 Unfolding Distortions Treatments

1. Vertical traction
2. Traction thrust
3. Vertical traction and traction thrust in seated position
4. Whip technique (Typaldos)
5. Whip technique (Harrer)
6. Unfolding thrust in seated position
 Unfolding
Distortions
Treatments

● Vertical traction
● Traction thrust
● Vertical traction and
traction thrust in seated
position
 Unfolding
Distortions
Treatments

● Whip technique
(Typaldos)
● Whip technique
(Harrer)
 Unfolding
Distortions
Treatments

● Unfolding
manipulation in
sitting position
 Refolding Distortions Treatments

● Refolding
manipulation
in sitting
 Refolding Distortions Treatments

● Refolding
manipulation
in supine
 Refolding Distortions Treatments

● Refolding
manipulation
in prone
References
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Hiller, TW Kaminski, PO McKeon, KM Refshauge, A Remus, E Verhagen, BT Vicenzino, EA Wikstrom and PA
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recommendations of the International Ankle Consortium. Br J Sports Med 2018; 52: 1304-1310.

Dubin JC, D Comeau, RI McClelland, RA Dubin, and E Ferrel. Lateral and syndesmotic ankle sprain injuries: a
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Guimberteau, JC and Armstrong, C. Architecture of Human Living Fascia: The extracellular matrix and cells
revealed through endoscopy. 2015. Handspring Publishing Limited
References
Jonckheer P, T Willems, RD Ridder, D Paulus, K Holdt Henningsen, L San Miguel, A De Sutter & P Roosen
(2015): Evaluating fracture risk in acute ankle sprains: Any news since the Ottawa Ankle Rules? A systematic
review, European Journal of General Practice, DOI: 10.3109/13814788.2015.1102881

Kasten, Marjorie. FDM An Introduction to the Fascial Distortion Model. Repairing the Fascia, Eliminating Pain,
Restoring Function. AFDMA. 2010.

Lim, MS, McInnerney, NM, and EJ Kelly. Symptomatic non-traumatic muscle hernia in the dorsal forearm.
JPRAS Open 3 (2015). 26-28.

Lin, CF, MT Gross, and P Weinhold. Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury,
and clinical guidelines for diagnosis and intervention. J Orthop Sports Phys Ther 2006, 36(6): 372-384.
doi:10.2519/jospt.2006.2195.
References
McGovern, RP, and RL Martin. Managing ankle ligament sprains and tears: current opinion. Open Access J
Sports Med 2016.

Typaldos, Stephen. FDM Clinical and Theoretical Application of the Fascial Distortion Model-Within the
Practice of Medicine and Surgery (4th Edition). 2004.

Tanaka, Keisuke. Stay in the Model: The Fundamentals of Fascial Distortion Model. (Volume One). 2018.

Vuurberg G, Hoorntje A, Wink LM, van der Doelen BFW, van den Bekerom MP, Dekker R, van Dijk CN, Krips R,
Loogman MCM, Ridderikhof ML, Smithuis FF, Stufkens SAS, Verhagen EALM, de Bie RA, Kerkhoffs GMMJ.
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Med 2018;52:956.
Ken Nakasone, PT, PhD, FDM IC, ATC, CSCS
(808) 375-0968
808ken@gmail.com