The Thinking Practitioner Podcast:
Episode 53: Fascia: A Deep Dive (with Dr. Antonio Stecco) 

©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe

Whitney Lowe:

Welcome to the Thinking Practitioner podcast.

Til Luchau:

A podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.

Whitney Lowe:

I'm Whitney Lowe.

Til Luchau:

And I'm Til Luchau.

Til and Whitney:

Welcome to The Thinking Practitioner.

Til Luchau:

Hi, I'm Til Luchau. ABMP is proud to sponsor The Thinking Practitioner Podcast. ABMP membership gives massage therapists and bodyworkers exceptional liability insurance, numerous discounts, and great resources to help you thrive like their ABMP podcast available at abmp.com/podcasts or wherever you listen.

Whitney Lowe:

I'm Whitney Lowe. Even if you're not a member, you can get free access to Massage and Bodywork Magazine where Til and I are frequent contributors and special offers for Thinking Practitioner listeners at abmp.com/thinking. So Til, how are you today?

Til Luchau:

I am doing very well. I got to teach one of my first in-person classes over the weekend and it was just delightful.

Whitney Lowe:

I saw it. You were up in my neck of the woods up here in Oregon.

Til Luchau:

That's right. It is right there in Portland and we actually live streamed it as we taught it, which was a new experiment. But besides having to juggle three things at once, it went really great.

Whitney Lowe:

Cool. All right. Very good.

Til Luchau:

How about you, how are you doing?

Whitney Lowe:

I'm doing well. I'm out of the woods, I've been ill for a little while and back into the land of the healthy once again. So I'm feeling good today and looking forward to our conversation. We have a wonderful guest with us today. Who is joining us today?

Til Luchau:

I'm excited about our guest. Dr. Antonio Stecco is our guest. Let me introduce you, Dr. Stecco, before I check in with you, you are assistant professor at Rusk Rehabilitation, New York University. You're a physiatrist, the President of the Fascial Manipulation Association since 2010. Assistant to the President of the International Society of Physical Medicine and Rehabilitation, the ISPRM, from 2012 to 2014. President of the International Myopain Society since 2020. Your scientific activity is devoted to studying the human fascia or fascia, multiple, from macroscopic, histological and pathophysiological points of view. You have performed over 100 cadaver resections for research purposes. Since 2007, you've taught theoretical and practical courses about the fascial manipulation method on five continents. You're the author of more than 40 papers about the fasciae, a co-author of five books and a co-author for multiple chapters of international text published by the respected publisher, Elsevier, whom are one of our sponsors today's show, Handspring, which consists of people that formerly worked with Elsevier and are now running Handspring Publishing. So welcome, Dr. Stecco.

Antonio Stecco:

Well, thanks for the invitation, really a pleasure to be here and great to have the possibility to talk about fascia.

Til Luchau:

Exactly. Yeah. You are someone that I've been wanting to talk to for years. So I'm really glad that you made the time to join us from Italy, where you are now. I first got exposed to your work when I was reading a newsletter from Budiman Manasny from Australia, the Terra Rosa Newsletter, where he interviewed you, and put, I think, a diagram or two. But you were very precisely describing the layers in fascia in the body and the superficial fascia, the gliding layers that exist between the different layers of fascia. It was an insight to me because having worked with fascia and the body for many years, to hear it described in that way and hear it described so precisely. I actually took a hold of my own arm while I'm reading your interview and going, "Oh my God. He's right. Feel that, that's awesome." So it was an exciting moment for me to get that precision and clarity.

Til Luchau:

Since then, I've learned that you've done quite a bit of research, like your bio says on the actual anatomy and structure and location of the different fascial structures in the body, as well as some really interesting research on some of the mechanisms behind the properties of fascia itself. So I'm very pleased to have you.

Antonio Stecco:

Yeah, I mean, I was always, I mean, waiting to introduce a little bit more of this material and it is my pleasure to have the possibility to give my contribution to whoever wants to know a little bit more about this tissue.

Til Luchau:

Well, I'm in that group in spite of having worked with it for many years. I'm in that group of people that want to know more, and I have learned a bunch from your search, and your writings, and your presentations at some of the conferences I've been to. But could you give us a little more background if you're willing? Just what else would be interesting for our listeners to know about you? How did you get interested in this line of work, that kind of thing?

Antonio Stecco:

Well, honestly, I'm the third one of the family, because my father was the first physiotherapist in Italy, long time ago. So he was able to make research, like hands-on research, how apply force and tissue can change. Then he started to do a dissection in animal first, then in human, and how to understand what is the role of fascia in the body. On top of that, I have my sister that is an astute professor in the department of anatomy. She's an orthopedic surgeon and she's dedicated to research the biomechanical role of fascia in our body. So I'm the third one, that is why they say like the Stecco family they want is bring over the research in fascia because we are, but there's a big group on the side of us that are helping us to do research. I'm talking about NYU, I'm talking about other groups worldwide that are helping us.

Til Luchau:

What timeline more or less was your father doing his initial research? You mentioned animal and different kinds of research into fascia, when was that going on?

Antonio Stecco:

I mean, it was more than 40 years ago. Let's say that the first book that my father published was in 1987. That is the first book. Since then, he had published more than 15 books about it in different language. I mean, it's like eight book that were translated then in different other language with a new edition. But there's a long way from there to now, even about knowledge about fascia, even about the innovation of this tissue. Because everything changed when we come out with the first article about the innovation of fascia. So as soon as we prove it, fascia is a very well innervated tissue, I mean, of course the value of fascia changed completely because it became a tissue that have a key role in perception in proprioception. In fact, we said, "Fascia is the order for proprioception. If something go wrong, fascia can become a pain generator."

Whitney Lowe:

I'm curious, would you say that there's been a, this has been my perception, there's been a bit of a shift in emphasis over the last several years of looking at that role of neurological innovation of fascia, as opposed to some of our former models that we were mechanically pulling, stretching, or manipulating? Would you say that there's been a shift of attention looking a lot more at some of these neurological components here as well?

Antonio Stecco:

Yes, of course. I mean, fascia is there since ever. I mean, in part, we have atlas of anatomy that explain the role of fascia. We're talking about 17th century. Okay. I mean, we know that, quite well, the biomechanical role of fascia. So we know there's a more than 30% of muscle fiber merge into the fascia. So we know that the gluteus maximus merge with 80% of muscle fiber in the fascia lata. The same the deltoid for instance. So we know that without have a clear understanding of the human fascia system, you are losing at the least one third of your biomechanics. So without no fascia system, you cannot know more than 60% of your biomechanics. So this is not tolerable for anybody that was working with the human body. But that was the first step. The second step is really the innovation. So fascia is way more innervated than tendon and ligaments. So we know, even from our perspective that now everybody say like, "Watch out before to talk about tendinitis."

Antonio Stecco:

Because a lot of time there is no inflammation over there, minus the paratenon, so the sheath of the tendon that is alterated. That is what inside the fascia system, because the tendon sheath is a bilamination of the deep fascia. So it's from there that the pain is coming. So you can have tendinosis, degeneration of the tendon. Or they say, you can have tendinopathy that nobody know what is, but normally it's a paratendinopathy, so alteration of the paratenon. So this big shift is moving the attention from the tendon to the paratenon, okay, from the ligament to the surrounding structure. Honestly, when you do a dissection, other than few particular ligament, like the cruciate ligament and so on, I will bet that not so many people will be able to recognize that clear ligament. Because a lot of time is just a fascia enforcement that, over time, the anatomists have isolated, clean up to represent in the atlas.

Antonio Stecco:

But if you do a dissection, don't believe that you will see a beautiful muscle along without anything around. You will not see a ligament without anything around. I mean, when you do a real dissection, you will see that the anatomy is no more complicated, it's more sophisticated what it look like. But this sophistication allowed us to do amazing motion that the robots are far away from what we are doing. So we are not able to build up the robots that are able to do the motion that we are doing, because we are far away to understand our biomechanics. Related to all this system that I'm talking about, muscle spindle, Golgi tendong organ, corpuscles, fascia. Okay. So there is all neurological control we call like a peripheral coordination of the motion related to the fascia, muscle spindle, Golgi organ corpuscle, that allowed you make a amazing coordination of the motion with all the model units that we have in different muscle.

Til Luchau:

You've made some interesting points about if fascia is the organ of perception, and you've been saying that, and you mentioned your early paper that showed innovation. Then other people have been saying that, Robert Schleip for years, for example. You've made some interesting points that the superficial fascia's location of being far from the bones gives it a special advantage in being a preceptor in a location for the mechanoreceptors. Did I get that right?

Antonio Stecco:

All right. Good question. So we normally said we have superficial fascia, deep fascia, visceral fascia. Okay. Superficial fascia is within the hypoderma, okay, the subcutis. So in the middle of the fat, basically. Superficial fascia is way more innervated than a deep fascia. Why's that? Because the superficial fascia have Pucinni, Ruffini, Meisner, they have everything that is needed for exteroception. So perception, what coming from outside.

Til Luchau:

Exteroception, yeah.

Antonio Stecco:

Pressure, pulling, humidity, and so on. So the superficial fascia is very rich in autonomic afferent nerves and some mechanical afferent nerves. So superficial fascia will be very important when you talk about allodynia, hyperalgesia, when you talk about lymphedema, when you're talking about painful cellulitis, when you talk about eczema, like activation of even hyperhidrosis or dry skin. So that is like the role of skin with superficial fascia. Right below the superficial fascia, you have a very important sliding layer. So if you try to glide your skin, that glide is mostly permitted because there is an layer of gliding between superficial fascia. So deep fascia, when you do pinch a roll, when you glide the skin, you don't affect the fascia at all. When you move the finger, the skin doesn't move, but deep fascia move. So the really border is between superficial fascia.

Antonio Stecco:

So deep fascia is related to mechanics to muscle traction to tendon traction. So that gives you information about how you move in the space. Superficial fascia perceive information from outside. So exteroception, so pressure, pulling, compression, temperature, humidity, everything come from outside. So, I mean, they have the same name, but they have completely different function. So you have to understand what is the disfunction of the patient? Because the way that you're going to approach with manual therapy will be completely different. So we [inaudible 00:14:24] about this because I mean, everybody's doing amazing. Everybody believe it to do amazing stuff with their hand, but before you have to understand what is the problem? Which level I have to go? What is the target of my treatment? From where is coming from the problem? Sometimes there is a combination too, superficial and deep fascia as well.

Antonio Stecco:

On top of that visceral fascia as well, that we don't have to forget. So this is where we are making research most of our research and where we are giving our contribution for clinician. Because again, you can do amazing with your hand, but you have to know where to put your hands properly.

Til Luchau:

That's great. That's specificity is what really caught my eye in the first of part of your work that I was exposed to. You're making an important distinction between what the superficial fascia perceives and then the layer just underneath it, the deep fascia around the muscles, and you're saying that is more related to proprioceptive function with the super fascia being more exteroceptive. I got to say, it's really stimulating and reassuring to hear that distinction in this field, which is all about connection and fascia itself, which is so sometimes undifferentiated or so continuous, to have you make these clear distinctions is really mentally stimulating for me. So thank you for that. What about the mechanical properties of fascia and pain? This is something that I've wanted to hear more about your views on this. You've spoken about densification and the way that fascia's mechanical properties can be part of the pain generation process. Can you give us some of background on that?

Antonio Stecco:

Right. I mean, that is the core of our research and where we started. So we know pretty well that the fascia is like a, you can say like a flat tendon, but it's not just the flat tendon. It's a multiple layer structure. So imagine to have like a three socks along all your leg, three, three long gloves along your upper limb, because I have to open up parenthesis, like in the limbs, we call like aponeurotic deep fascia. In the trunk, we call epimysium deep fascia. Why is that? Because in the limbs, you have long gloves and long socks. In reality is three, one over the other like three socks and three long gloves. In the trunk, you have like a sandwich. Each muscle is surrounding and completely attached with two layer of fascia, again in three different depth, upper, middle, deep. So going in the periphery, I mean, the fascia is a highway that allows you to transmit the force from the core to the periphery and vice versa to bypass the joint.

Antonio Stecco:

So in this way, you can get much more power in the extremity, decreasing the stress in the intermediate joints. So for instance, in the knee, you have a huge load that will come from the glutes, the fascia lata, okay. The gluteus medium. So a lot of tension from this big muscle will be transmitted like a tube down to the knee. It will bypass, it will continue from fascia lata to crural fascia, because there is no border. Okay. So please keep in mind that what you see in the atlas is a simplification. When you do a real dissection, you will not see the IT band at all. IT band is an artifact. IT band is a long, longitudinal [inaudible 00:18:15] of the fascia lata in the thicker area on the lateral side. You will never ever see IT band in a real dissection until you don't cut. Okay? So you will transmit the force, but what is the problem? Each single layer, we consider like a three layer, they transmit the force in a different direction. Okay.

Antonio Stecco:

That is quite related to the three play of motion, more saggital, more frontal, more horizontal motion. So the three layer has to be independent. It has to be independent to glide in relation to underlying muscle. So what you have between a three layer, what we call loose connected tissue? So we have adipose cell, and hyaluronon. So you basically, you have that lubricant that you really need to create an independency. So if you have this independency, each layer can pull in a different direction. It can connect synergic muscle in different body segment to allow you to make a motion very harmonic, because you bypass the joint and you have to cordon it through the muscle spindle, different motor unit that work in synergy in different body parts. But if this lubricant become viscous like a glue, of course, there will be more stiffness. It is a double problem.

Antonio Stecco:

You have a lack of low transmission, but you can get an exceed tension. So all the mechanical receptor in that line of tension will be irritated. So you will have like a peripheral sensitization. That is what we know clearly is the typical spreading pain that you have, that, why not, majority of the time, the patient perceive like a sciatic type pain, but that sciatic type pain have nothing to do with the sciatic nerve. Sciatic nerve just carry on, not carry up. The hyperalgesia, like the irritation of the afferent nerves inside the fascia, that is stiff, and so is over compressing the receptor right there. It's for this reason, you have a sciatic pain more lateral, more posterior, more anterior, because in relation where you have a lack of gliding, you have, in case of the stiffness, decrease in range of motion, pain, and also decrease of proprioception and lack of force, because you are not able to recruit the muscle down there.

Antonio Stecco:

So this is where we have introduced the concept of densification. So it's more dense. It's now the lubricant become more dense, and so if you put like between like a three piece of paper, instead of put like a nice oil, you put honey, the three piece of paper, this seems very rigid, but the three piece of paper are the same. It's the interface that change. So for this reason, when a manual therapist put a hand over a body say, "Oh my gosh, you feel like stiff for like a piece of wood," but then the MRI doesn't show up anything. So worldwide, there is this conflict, because you say, "Look, there is like a fibrosis," sometime you say, and then no one is able to prove, because again, the densification can be so sever that it seems to be a fibrosis, but watch out. I really recommend to everybody, you have to do a clear distinction between fibrosis and densification.

Antonio Stecco:

They feel the same, but fibrosis is an exceed amount of a connected tissue cause type one type three that you clearly see with the MRI, with ultrasound is at a dramatic event. You need a trauma, surgery, infection, burning lesion, long immobilization, like in spasticity.

Til Luchau:

And I imagine it's more chronicity, the more time involved in the-

Antonio Stecco:

Right, right. Like a long, long term mobility. Densification can occur overnight, can occur right after a small trauma, but lucky for us, it can be resolve very fast as well. So that will make the big change when the people will be able to make a distinction, because otherwise there will be a lot of conflict with the radiologist and clinician because everybody feel and perceives different stuff.

Til Luchau:

So the way we can tell the difference is how quickly it responds? Is that the main indicator of the difference between densification and fibrosity?

Antonio Stecco:

At the end of the day, yes. That you can have like a past treatment diagnosis because you cannot change a fibrosis in a cycle or in a session.

Til Luchau:

And you said they feel the same from a clinical point of view.

Antonio Stecco:

I mean, fibrosis is more severe, but if you have a really chronic patient, densification can be so bad that to really taut in the gliding. I mean, it would be not possible to distinguish one from the other. So I want to say that if it's a severe densification, I will bet that the people from outside's not able to distinguish, other than treatment after the treatment.

Til Luchau:

Okay. So how does manual therapy affect that lubrication quality? Nevermind the fibrosity for a second, but that sliding and gliding, what's going on with the mechanism there in your opinion?

Antonio Stecco:

Okay. So that is a good question. That is where we are doing research. I will be happy to share, I mean, eventually some data about that. So we call densification because basically the hyaluronan or hyaluronic acid, whatever you want to call, it can aggregate, if aggregate doesn't bound any more water. So you start to have like a sponge, imagine a sponge with large hole and with a thick septa versus a sponge with a very small hole and very tiny septa. So which sponge do you prefer to use? The one with small hole. So the normal exeteromatics is a sponge with a small hole. It can carry on. It can hold a lot of water. The sponge with a big hole, a big septa, it seems, I mean, is the weight is the same, but this one will not able to carry the water, does that make sense, because the hole. So this point will become more rough, more rigid. So imagine to have that sponge like a lubricant between interface.

Antonio Stecco:

So what you can do? We are lucky because we have a different option. So heat modality, and friction can separate, can break this septa, can separate the exchange of hyaluronan, and so you can decrease like disaggregation and restore the quality of the lubrification. But I want to underline that this can be done even with heat modality, because we know worldwide people say, "Look, the doctor told me that I'm inflamed, but instead to put ice, I have like a hot shower, I feel better. I put a hot package. I feel better." So of course it's not an inflammation because if you are inflamed, heat will not get better, will make worse. So whenever the patient say, "Look, the weather change, my knee hurts," that is myofascia pain because the hyaluronan is temperature sensitive. So if you have a drop of the temperature, it become more stiff. It irritate more receptors, so you have allodynia from there.

Antonio Stecco:

So you can make diagnosis since the beginning patient say, "Do you feel better with the heat or with the cold?" "With heat." All right, this is myofascia pain. What about the weather? "If the weather change, how you feel?" "I'm so bad. My neck hurts. It's terrible." That is myofascia pain. Has nothing to do with arthritis or arthrosis. Okay. So that is the way to go, but unfortunately heat modality doesn't last. So if you heat, you decrease the viscosity, but this excess of incorrect quality of hyaluronan can re-aggregate. In few hour, few days you are like before. So for this reason you need a friction manipulation that is able not just to separate the change of hyaluronan, but is able to cut the fragment can be wash out because hyaluronan is very long protein. So if you cut in fragment, it can be wash out and then specific cell that we have discovered in Padua, the fasciacytes, they can produce new hyaluronan, the correct one, and so you really fix the problem because you restore the normal physiology in this area.

Antonio Stecco:

`Last year we have published an article and we have proved for the first time ever that with manual therapy, we can do this because in NYU we have find out a new MRI, the T1 Rowe, that is able to qualify and quantify the type of hyaluronan between the fascia. It was amazing because we got the cover of the journal because it was the first time ever that the manual therapy was proved manual therapy changed the biology of the tissue. That was, in my opinion, it was, I mean, a big step for us.

Whitney Lowe:

Yeah. I've got a question too. If we can go back for a moment to your discussion of the discrepancy between the superficial and deep fascia and what you're talking about here in terms of the manual therapy effects, would you suggest or say that there's really different manual therapy strategies that would use like technique wise, if you were aiming to have more of an impact on superficial fascia versus deep?

Antonio Stecco:

It has to be. It has to be because the quality of the tissue is different. The depth is different and the pathology's is different. So I mean the more important message is this. You have to adapt the treatment to the targets that you are addressing. So if you have a clear diagnosis, you have a clear treatment, a clear result. If you have a clear diagnosis, your treatment will be random or not specific and you're not hope to have a specific result. So this is a very important message. I want to explain it. I have to say that it is not as difficult. I mean, we are published article to explain what does superficial fascia? What does deep fascia? So they have a very different role in our body, and even embryologically the evolution of one fascia, the deep from the superficial is different. So they're really different tissue. They have the same name, but they're really different tissue with different role in our body. So adjusting manuality is the way to go to get better and faster results.

Til Luchau:

And so how would you characterize, just to follow through on Whitney's question, how would you characterize the different approach for the different layering, if you wanted to affect the superficial fascia, for example, compared to affecting a deeper fascia?

Antonio Stecco:

I mean, deep fascia, you have to go through all the adipose tissue. So the aim is to have like a rather small surface and you have to get to this surface of the muscle. So when you feel the surface of the muscle, it means that you're already manipulate the deep fascia. Okay. Mind you, you cannot have a large surface because if you have a large surface, you will not be able to go through the adipose tissue. Doesn't make sense. So that is already step one. Okay. Step two is that the deep fascia is really made by collagen fiber. So you will feel like a rough surface. When the layer doesn't glide, you feel like a rough surface, like a crunching surface because the layer doesn't move. So you really feel, you can perceive the collagen fiber. If someone can start to palpate the effects of the wrist, it will feel like a crack, crack sensation that is really the collagen fiber. So, I mean, a t-shirt you identify, you feel, you understand when it get better, because at the beginning it would be rough, rigid, grooved.

Antonio Stecco:

Then over time become soft, nice with a nice move gliding. So you know when it's pathological, you know when it get better and we have proven with student, we did like a interability test. If you explain once what is a densification, the student are able to repeat properly with a currency of 0.7, no, 0.84 as a mean value. That is really high in manual therapy. We know manual therapy the interability is very low and that is like the major problem of manual therapy.

Til Luchau:

I don't always feel the same thing. The next time I go back and feel something or if somebody else feels what I just felt, they may not always feel the same thing. That's what you're talking about.

Antonio Stecco:

Exactly, exactly, exactly. So, I mean, that is the limitation sometime of manual therapy. But if you explain where to go, because we normally teach a map where there is the more critical area that has to be assessed because in our body not all the area's seen. There are area where the glide has to be preserved to our key area for biomechanics. Areas are less important. So for this reason, if you have surgery, a scar in specific area, you know for sure that will joint problem, biomechanical problem. Scar in another area will not. On the same, if you have a scar that doesn't reach deep fascia, you really don't care. If you do a quadrantectomy in the breast and you don't get to the deep fascia, you will never have any muscle problem. If you have a biopsy of a lymph node, that can [inaudible 00:33:37] the biomechanical problem because you reach deep fascia, can have adhesion between layers, so that is another point to understand the depth. The depth make the difference. You're talking about superficial fascia.

Antonio Stecco:

Superficial fascia you will see the rigidity of the honeycomb of the skin sector in the superficial fascia that become rigid. So you need a wider surface to try to make it more homogenous, more adaptable, all these honeycomb of connective tissue that gel the level of fat. So, I mean, the manuality's completely different. Superficial fascia can have a large surface. Sometime you work like one hand against the other, like a knuckle against knuckle to try to manipulate the tissue. So, I mean, it is really a different way to go. I mean, it's a different tissue, the manuality, one and the other, they will nothing to do one to the other. I mean, we normally explain how to do one or how to do the other. Of course, that is related to the diagnosis as well that you do.

Whitney Lowe:

I was just going to say, I'm curious about one of the arguments that is frequently brought up about what we're actually doing with our hands to these tissues. I'm curious to hear your thoughts on this. If the superficial fascia glides so easily over the top of the deep fascia, how do we impact or affect that deeper fascia with what we're doing with manual therapy if that tissue is just gliding over the deeper tissues so easily?

Til Luchau:

You're talking about the frictionless interface argument.

Whitney Lowe:

Yeah. Often described as the frictionless interface.

Til Luchau:

If there's no friction there, how do we get a hold of deeper structures of affect them at all?

Whitney Lowe:

Yeah.

Antonio Stecco:

Well, I mean, it is not difficult because again, the deep fascia doesn't move because the deep fascia have a, we call myofascial expansion. The deep fascia have multiple connection with the muscle. The muscle have a basal tone, so the fascia have a basal tone. So when you do surgery, you cut the deep fascia, deep fascia go away. Then when time to do a suture, you have to pick up the fascia, pull together and make the suture. So for this reason, when you go deep with your knuckle or with your elbow, you go there, the fascia stay there, doesn't move. You are able to make friction over there. On the opposite, the superficial fascia move. If for this reason you have to use maybe knuckle against knuckle to treat or squeeze with two finger as pincher roll, because otherwise the more weight.

Til Luchau:

You need to trap the superficial fascia between two things while you can work directly on the surface of the deep fascia, you're saying.

Antonio Stecco:

Right.

Til Luchau:

You've done some really interesting studies around imaging these processes as well, both through ultrasound and then you mentioned your recent research on getting imagery of the actual lubricity of the tissues.

Antonio Stecco:

Right. At this time we use like a dynamic ultrasound to see the gliding before and after. We use something that it's called elastostenography that evaluate the stiffness of the tissue with the ultrasound. But now in NYU, we use an MRI. The name is TRO that is able to understand the quality of the loose tissue. So if it is, we call bound or unbound. So if it's self-aggregated or bound to water, that is really explain the physiology of the tissue, the physiology of the lubricant, the interface. So that is a really two steps forward than what we were used to do.

Til Luchau:

The other thought that's tossed around a lot is the idea of separating a pain phenomena from the physical qualities of the tissue, and probably, I know in my own thinking, that relationship has loosened where I don't always assume something painful has a physical manifestation, let's say.

Antonio Stecco:

You are right. This is like the key element because nowadays everybody believe that where is the pain is the problem. But unfortunately it is not because where is the pain is where there is a high concentration of receptor, an incorrect stimulation receptor. So, first of all, I mean, if you cut the nails, doesn't hurt. If you cut the fingertips, hurts a lot, because this is not innervated, this is innervative. Okay, this is already a step. But the second step is that over the joint, you have hundreds of vector discharged there. If any of this vector are pull incorrect, you will stretch the capsule or the third cap, whatever you will feel the pain in the shoulder. Okay? So when you have a tear of the supraspinatus, a tear of the third cap, it just a sign that there is a poor biomechanics, but doesn't tell you what is wrong because you have to take consideration all the single vector to go there.

Antonio Stecco:

If one of this vector doesn't pull properly, there is an incorrect mechanics in the shoulder. Of course, the first supraspinatus that is the most in a ugly position will be irritated, will be compressed. It will tear. So the same, you can explain to the knee. We know that we taught the knee replacement. They take off cartilage, bone, meniscus, capsule, ligament, 20% of the people that are still in pain worldwide, because the pull on the fascia right there is still there. Okay. So you know for sure this patient, they need a treatment. Again, there is all the fascial acid discharge there. The fascia cap is a tissue you are not able to break. Trust me when I do the dissection course, I give as sample fascia cap between two coker to the participant. We ask them to pull longitudinal and transversal.

Til Luchau:

This is a piece of cadaver fascia that you ask people to try to pull apart.

Antonio Stecco:

Right. A piece of cadaver. Longitudinal, nobody worldwide were never able to break, never. Transversal, it give you a hard time, but then you can break. Just to let you know how strong is this tissue. We're talking about some data in our laboratory of biomechanics, the machine is not able to break the sample fascia. At this time there was no, with classical machine, you are not able to break the sample fascia. It's so resistant, it's not able to break. Because I have to carry, I mean, some that is more than 30, 40 kilogram because they, our machine work for until that level, because the study's small sample. So just to let you know how much load the fascia is able to carry. Think about it as a tube that go all around the leg, okay. The [inaudible 00:41:04] is remove. So a lot of picture of anatomy that don't represent, but when you do a dissection, you will clearly see, you can feel what exactly is the tissue or what is the role of that tissue?

Til Luchau:

So your work has inspired in my thinking a model that goes from let's focus less on trying to change the fascial length, which was my original training as a Rolfer to let's think more about the glide and lubricity and the relationship between different fascial layers. As I understand it, your thinking is that pain is a result of that mechanical stimulation on the nerve endings, maybe from a denser or more crowded situation locally, histologically, maybe from forces being transmitted to that area. Is that more or less correct?

Antonio Stecco:

It's correct. And this can explain also the referring pain, because nowadays referring pain, like spreading pain, is really hard to explain because every patient have a different referring pain. A lot of time they're referring pain bypassed the border of the muscle. It doesn't match the dermatomes. So how you can explain that? How you can explain it even over time, the same patient have a different radiation? Because this stiffness can modify during the time. So you can have a spreading pain more posteriorly and then spreading pain more anteriorly because you have work posteriorly. Think about a tissue like your t-shirt. If you put together your t-shirt and your shirt and you walk, you will join the line of force. Along all this line of force, you will irritate the mechanical receptor so you have a painful perception, not where it's stuck, because where it's stuck, you don't even stimulate the receptor.

Antonio Stecco:

You overstimulate where there is line of force. And if you make another addition far away, you have such a huge line of force that would feel like a sharping pain, like you always see in, maybe, sciatic. A lot of time, you have a densification in the calf, densification in the glutes, on the pelvic region, and so you have a really tight line of force that will mimic, I mean, the nerve. My reality is that the free-ending nerves that are irritated, that are carried on by the nerves, but the nerve had nothing to do until you don't have a lack of force. Okay. Anesthesia is another story. Okay. But if the velocity of transmission of the nerves is preserved, pain, severity with the pain, it doesn't mean severity of the pathology because myofascial pain can terrify like a very acute, very debilitating pain, but the MRI will be negative. So, I mean, I'm not scary about pain because you can manage, you can deal.

Antonio Stecco:

Patient, they are really in agony, you cannot make a miracle because myofascial pain can be really severe and lucky for us, with our hand, we can make diagnosis and treatment at the same time. That is amazing.

Til Luchau:

Well, I mean, a lot of us have experienced that with our manual therapy. I know in your method as well, you've studied that carefully. Here's the question that I wanted to ask you when I was in Berlin, I think it was 2018, and you kindly sent me of some references. The question I'm wanting to ask you have, have you, or do you know of other research that correlates that local density of the tissue with pain phenomenon itself? You done some really careful work on being able to change the density and the way manual therapy does that. Do we know that pain is the result of density or the result of mechanical pressure? Has that been tested?

Antonio Stecco:

I would like to introduce Helene Langevin, that is the director of the complementary medicine in NIH.

Til Luchau:

Yeah.

Antonio Stecco:

So Langevin have published an article that they explained that where in peak, it was in human, human with lumbar pain. The fascia is 25% thicker and 59% with less shearing, less [inaudible 00:45:32].

Til Luchau:

Yeah.

Antonio Stecco:

If you take a look at our study about neck pain.

Til Luchau:

Yeah.

Antonio Stecco:

The fascia in people with chronic pain, the fascia's thicker and there is more space between layer. If you take a look at the Siddhartha study about trigger point, but all the study about trigger point. Trigger point is a stiff area, more hypoechogenic. What do you mean hypoechogenic? With more fluid? More black.

Til Luchau:

Yeah.

Antonio Stecco:

So what is this fluid in the trigger point? What is the fluid that generate the trigger point?

Til Luchau:

Let me see. Let me catch up. I'm sorry, Dr. Stecco. Let me just catch up. So Langevin's study showed the denser and less gliding fascia in the thoracolumbar fascia of subjects with back pain. Your study of neck fascia showed thicker fascia of the cervical fascia, I believe it was, or SCM fascia in people with pain. And then you're also saying there's more fluid in the trigger point zones. Okay. So is that correlation or cause?

Antonio Stecco:

All right. This is a correlation because the trigger point at the end of the day, that black, it can be aggregate hyaluronan. That is a fluid way more viscous than surrounding area.

Til Luchau:

Yeah.

Antonio Stecco:

So everybody's looking from different perspective, the same manifestation, because to thoracolumbar more stiff, trigger pointing more stiff. Cervical fascia is more thicker. The cervical fascia, more thicker. The cervical fascia have more black in the middle. The trigger point is a black hole. Okay. So you see, everybody's finding the same result from different perspective. What I can say that I never checked the muscle in the cervical area, but it could be, I think, the middle was more black. The guys from [Siddhartha 00:47:34], from the trigger point group, they didn't check the fascia, but from my eyes that fascia was not normal. So the possibilities that the beginning start with a small densification inside the muscle, the perimysium. When you get to the deep fascia, the deep fascia start to just spreading pain. It start to affect the distal and the proximal part. So you start to generate the compensation.

Antonio Stecco:

So you start to have like a low back and you start to have a glutus pain, upper back. Because when, if deep fascia become rigid, you have like a stiff highway that start to generate compensation, different body segment. So time after time, so to have other problem, and as we know our patient get chronic. Patient chronics have more symptom on and off in different part of the body because fascia can do that.

Til Luchau:

Well. Okay. So how you doing, Whitney? Anything you want to work into our conversation here? I got more questions, but I don't.

Whitney Lowe:

Yeah. Go ahead with what you're going to ask. I've got several questions I imagine that are probably similar to what you were going to say. So go ahead with what you were going to ask.

Til Luchau:

All right. So again, Dr. Stecco, your model is elegant in its understanding of the local effects, and then how larger effects within the structure could biomechanically predispose us to pain as well. Some of your work has shown changes that you see three to or six months after the manipulation that you've seen on your imagery, or I believe it was if I understood it, if I read it right, that some of your changes lasted. What's the mechanism of that lasting? Why does it persist, do you think?

Antonio Stecco:

Okay, there's two major reason. First reason you do not have to just resolve the pain. It's not enough. You have to restore biomechanics. So the patient come with knee pain. If you don't take care of the pelvic region, if you don't take care of the other side, because I've walked incorrectly for months, you will not get this guy back to the track as it was. So you have to take care also the opposite side, even if the patient doesn't have symptom, but maybe just a decrease of range of motion. So again, it is not enough to treat the pain. Treat the pain is easy. Restore the biomechanics to full biomechanics, another story. You need a more, I say, holistic, a more wide vision of the patient. It is the first major reason why we can get the long-lasting result. The second is that is not enough to warm up the area. You have to manipulate the point to catalyze a specific inflammatory process that will last 48 hour that will help, will keep our manipulation, will restore the normal physiology.

Til Luchau:

So in your method, you're doing that intentionally as I understand. You're inducing an inflammatory reaction.

Antonio Stecco:

Right, like shock wave can do the same. So you need, I mean, if you warm up, you just decrease the viscosity. In that area, it will stay the same quantity and quality of a loose [inaudible 00:51:05] tissue. It can quick re-aggregate. So you do like laser, infrared, whatever you want, then the patient, after a few day, come back, say, "Look, it was better, but now I'm like before." If you stimulate this inflammatory process, it's a very particular inflammatory process that it doesn't have to occur where the patient feels the pain, but in the critical area that we have mapped where the biomechanical is important. Because again, the area of the symptom is not the root of the problem. The area of the symptoms where there is the discharging of incorrect factor. So if you restore the normal physiology in this center of coordination, this area where the motion, the final vector generated, then you are able to give a long-lasting result, but to restore the physiology, you have to wash out the incorrect quality quantity of hyaluronan, so you have to cut down and fragment.

Antonio Stecco:

Otherwise this long change doesn't wash out. So the inflammatory process is able to call it what we call it, hyaluronic daze, the enzyme cut down and fragment, and then it can wash out. So this factor process, you can do work with the aggressively needling. If your needling's quite aggressive, you will do it. Shock wave radial, focal shock wave you can do okay. Deep friction manipulation, you can do, but you cannot do with a light laser. Okay. A light infrared because it is a heat modality that is not able really to give, if it's a major densification. If it's a minor, it can. Otherwise it's not. So that is the two major principles why we are able to give longer as the result.

Til Luchau:

And a certain amount of pressure is needed, you're thinking.

Antonio Stecco:

The pressure you need to get to the surface of the muscle. So, I mean, in the face, you don't get so much pressure. I mean, if you have 10 centimeters of adipose tissue, you will need more. But when you get to the [inaudible 00:53:15], you already make friction in the deep fascia. Deep fascia is above the muscle. So you know where you have to go.

Whitney Lowe:

Back to what you were saying too, a moment ago, about the restoration of biomechanics, what does that look like in terms of the therapeutic interventions? Is this trying to get people to do particular movement patterns after we've done our physical tissue manipulation, or what does that look like?

Antonio Stecco:

I mean it's easy [inaudible 00:53:42] what look like? I mean, you know that if there is stiffness in one side over time, that will just overuse, and so the opposite side will become stiff to compensate. So you have to work both the side of the arm. If you have a lot of pain and you are limping, the other leg will over work to carry on. So if it's couple weeks, it's not a big problem, but if it's a couple month, couple year, you will have a lot of stiffness for overuse collateral. So you just try to evaluate and we have a build up what we call the human fascia system, the biomechanics of human fascia system. We have subdivided the body in three plane of motion, frontal, [sizdal 00:54:33], horizontal. We have identified which area are more related for motor unit, the workforce specific direction. So you basically, through this map, that is a public available, they can download the app for free if they want it.

Antonio Stecco:

I mean, they can find out in Apple store, in Google Plus. It's for free. You can see which point, which area work together. So if you find out there's a dysfunction in the frontal plane, you will want to take care of other point in the plane that work in the opposite side, and you check. If you feel they are stiff, you treat, if they are smooth, nicely, you just let the patient go. The final sensation has to be a sensation of lightness. So the patient has to feel at the end of the treatment, maybe sore because I have treated them for range of motion. But the sensation of lightness, the head has to be light. The leg has to be light. Okay. Because when there is a tightness, you have a bombardment from the periphery, you feel like someone is pulling you down. If you release a tension, you have a sensation like a global lightness. So that is another sensation will give you like the green light to let the patient go, and I mean, know that what you have done have restored biomechanics properly.

Til Luchau:

Yeah. What do you think about the role of sensation? Robert Schleip tells the story of his informal studies of people being anesthetized with hypothesis that our work would be less effective with them. So your explanations are physiological. What do you think about the role of sensation in the work? Would it work on somebody who's anesthetized?

Antonio Stecco:

I mean, there is a couple article that I think are important. So in the ankle where we have a little bit information, because we say that the retinacula, for instance, on top of the ankle, are the key element of the fascia system for proprioception. So we focus there because it's really the king of the proprioception. So there is two study that were done not from our group, from other groups. So they tried to anesthetize with lidocaine the ligament if the patient didn't lost the proprioception. Then they anesthetize the full foot. Then at that time, the patient lost the proprioception. So is not the ligament. It is something else. Okay. That study cannot prove that it is the retinacula, but we publish other four article in athletes, soccer player where we specifically treated the retinacula. Subject apps were suffering of functional and constability, and we prove we're able to improve the stability in a performance, just working the retinacula.

Antonio Stecco:

So retinacula are very easy to recognize because it's a thick area of the deep fascia. So with the ultrasound, with MRI, you can really see these retinacula. You can see the damage, because they are so rigid that sometime really you can tear the retinacula. It's the only element you can really tear after ankle sprain because lot of people, they call ligament. Some atlas they make a misunderstanding between ligament and retinacula, but the retinacula are extremely full of receptor, full of receptor. Ligament almost zero. Okay. So they looks the same at your eyes, but innervation will be different. So again, innervation make the difference. Poor innervative, you don't really care much. Huge innervation, You care a lot. So if you understand these eyes, I mean, this is like, some information can be helpful to understand in the same location, like a ankle, what is doing what. Ligament is a passive element, just a mechanical stability.

Antonio Stecco:

The retinacula give you the active stability. For instance, in the hip, majority of stability is passive. You cannot subluxate the hip. It's impossible. The ankle, if you want, with your hand, you can almost subluxate the foot because the stability of the ankle is active. So who is making the stability? The muscle. Who is telling the muscle what to do? The brain. Who is telling to the brain what's going on there? The retinacula. That is the best element. It's like a wristband with some periosteum insertion, some muscle insertion like extensor brevis, adductor pollicis and some tendon insertion because all the tendon, they go through a bilamination of the retinacula. So retinacula fields bone, muscle, and tendon. It's a tight wristband. It's completely full or receptor. So there is nothing better than retinacula to feel the movement in joint, nothing better.

Til Luchau:

Interesting.

Antonio Stecco:

We have retinacula over the patella as well. We have retinacula in the wrist. We have retinacula in the elbow. So in the most critical joint, we need retinacula. So for this reason, we say that the retinacula are there because nature want to give us three degree of freedom in the wrist in a small space. So here you have eight bone plus radia, ulna plus carpa. So this is a crazy joint. Crazy. So, I mean, this is not the best that you can have. This is like a compromise to give you like a three degree of freedom. It is a narrow surface. You don't want to make any supersession. So you need a retinacula that is really tell you what's going on. It try to adjust the tension of the muscle. In the ankle. You have three retinacula because you have a huge amount of load over there that has to be managed. So you can restore functional instability. So worldwide functional instability is still untreatable.

Antonio Stecco:

We say, "Look, we have proof that we have treated with nine month follow up this patient. You can fix functional instability." You just have to know where is the problem. Retinacula is the answer.

Til Luchau:

Yeah. We'll put some links to your work. You did some interesting work around imaging. I'm looking at the imaging of crural fascia and epimysial fascia thickness in basketball players with previous ankle sprains. We'll make sure we get some good links into some of your thinking about reticnacula as well. So we're back to the idea of fascia as a sensory organ, of the fasciae talking to the brain, and we began the conversation with you talking about your family legacy and how that really propelled you into this work. You've been at this for quite a while. You've been doing a substantial body of research. I'm just curious, what has changed in your own thinking? What has surprised you in your research? How do you think about things differently now than maybe when you did your research career?

Antonio Stecco:

I mean, lot of changes after we understood the interface, because we basically, we are quite robust in the, let's say, the anatomy. So the layer of fascia, the collagen fiber type one, type three, the three layer. How is the fascia in the arms? How in the fascia in the trunk? We are quite strong over there, but the big step after innervation was to understand that what's exactly going on. What is the densification? So what is the process? And just recently, I mean, with the article of last year, we understood this like a three dimension, superstructure of hyaluronan. So this aggregation that will generate like this sponge with a big hole instead to have a small hole. So this is brand new information that the MRI, this new MRI have prove it.

Til Luchau:

This is just to make it get clear for myself. You're talking about the actual tissue having a sponge like structure, but also the aggregated molecules having a relationship like that.

Antonio Stecco:

Yeah. Yeah. Sorry. So like the honeycomb is like the subcutis, like from the skin to superficial fascia, we have this septa, the level of fat, like a honeycomb.

Til Luchau:

The tissue honeycomb. Yes.

Antonio Stecco:

Yeah. [crosstalk 01:03:09] superficial fascia between, but in reality, like at molecular level, so you cannot see with your eyes with microscope, at molecular level, the single chain of hyaluronan can attach a jelly like a sort of sponge. Okay. That can have a big hole or small hole. Okay. It is quite brand new because if you have small hole is a soft, smooth sponge. So a very nice lubricant. If you have a big hole, it's a very rigid, rough sponge that will join like glue. So this is something that we have just discovered and We have tried to use that also hyaluronidase in humans, in US, like in Johns Hopkins, in NYU, we are doing, to decrease this viscosity in neurological patient, patient with spasticity. So this extremely severe subject with a really major limitation of quite a life, we inject the hyaluronidase to restore range of motion, not just passive, also active. This is seven years study we have performing NYU, and now we have a move the study in Johns Hopkins.

Antonio Stecco:

We are treating more than 200 patient with spasticity. Again, what has really surprised us that we are able to improve even active movements because before to get to fibrosis, it take decades. So we have patient of 15 years and they are not yet fibrosis in the muscle by just a dramatic, full thickness densification. So we have a therapeutic window that in this patient that can be used to avoid fibrosis and get improved quite a life.

Til Luchau:

Fantastic. Nice. It's fascinating stuff. Anything we want to ask Dr. Stecco while we had his attention?

Whitney Lowe:

Yeah. I just think, it provides such rich questions and things for us to think about. What is the nature of what we're doing under our hands? There's just, I think, a lot of different things that seem that we're now learning maybe happening under there with those sensations that we feel. So it's fascinating to hear some more about what's going on in the laboratory, looking into that.

Til Luchau:

And to give us a more specific understanding about the layering, but then also what's happening perhaps at a molecular level when we touch and when we use pressure and the role of change in that.

Whitney Lowe:

Yeah.

Til Luchau:

Dr. Stecco, how can people learn more about you and your work?

Antonio Stecco:

Well, they can go in www.fascialmanipulation.com, and then they can read a little bit. They can check it out, our article from there. So that is the easy way to get the information. Of course, there's a lot of article that also open source. So, they can take a look. But again, we have a lot of books about theoretical part, about the physiology, the atlas of physiology, the atlas of anatomy, fascia. So, I mean, they can have like a quite robust material from where start to understand anatomy, physiology and biomechanics. It is the ABC to understand the fascia world. This is like at the beginning. Of course, they can move on then in the clinical part. I mean, they are welcome to get more information about how this information can be bring to the clinical part to their office.

Til Luchau:

We'll be sure to put that link in the show notes, as well as a link to your FM App, et cetera, and some of those studies we've mentioned. Thank you for your time. Whitney, who's our closing sponsor for today?

Whitney Lowe:

Yes. So today we're going to be sponsored by Books of Discovery and they have been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, eTextbooks and digital resources. And in these trying times, this beloved publisher is dedicated to helping educators with online friendly, digital resources that make instruction easier and more effective in the classroom or virtually.

Til Luchau:

Books of Discovery likes to say learning adventures start here. They see that same spirit here on the Thinking Practitioner podcast and they're proud to support our work, knowing we share the mission to bring the massage and bodywork community enlivening content that advances our profession. Check out their collection of eTextbooks and digital learning resources for pathology, kinesiology, anatomy, and physiology at booksofdiscovery.com, where Thinking Practitioner listeners save 15% by entering thinking at checkout.

Whitney Lowe:

We would like to say a thank you to all of our sponsors and also to all the listeners, the people who are hanging out with us here. Hope you've gotten some great insights into fascial work with our discussions today. You can stop by our sites for handouts, show notes, transcripts, and any extras. You can find that off of my site at academyofclinicalmassage.com. Til, where can people find that from yours?

Til Luchau:

My site, advanced-training.com. In the show notes, we'll put links to Dr. Stecco's site, et cetera. If there's questions or things you want to hear us talk about email us at info@thethinkingpractitioner.com or look for us on social media. Just my name, Til Luchau. Whitney, yours?

Whitney Lowe:

Yes. Today, my name is Whitney Lowe. You can find me there as well. If you will also get a chance to rate us on Apple podcasts, as it does help other people find the show and you can hear us on Spotify, Stitch, Google Podcast, or wherever else you happen to listen. Please do share the word and tell a friend. Of course, if you're unable to find us in any of those locations, you can hear us on a bonus track on the greatest hits of the humpback whale songs as well. So thank you again, Dr. Stecco, for joining us today in this conversation. It was a wonderful, enlivening, fascinating deep dive into the world of some soft tissue topics that I think will be really fascinating to look into.

Antonio Stecco:

Well, thanks for invitation, and it was great to have spent this time with you also, so thanks a lot.

Til Luchau:

All right. It's an honor. Thanks much. Take care.

Whitney Lowe:

Okay.

Antonio Stecco:

Take care.