Jane was a 58-year-old woman who came to see me for severe low back pain. It had started about four years ago, without any obvious cause. She found that bending over was very painful and she couldn’t sit comfortably or walk for more than a few blocks without her back aching. She felt some pain in her buttocks but had no leg pain, weakness or numbness. She had attended several physical therapists and tried fascial stretching, dry needling and exercise. Sometimes her pain improved for a few days, but it always came back. She had been assessed by other physicians and eventually had an MRI. The MRI demonstrated many findings of an aging spine including narrowed discs and arthritis in the lower spine joints (the L5-S1 facet joints). Injecting freezing around those joints did not reduce her pain.

She had been diagnosed with “chronic pain syndrome” but was wondering if prolotherapy or platelet rich plasma (PRP) might help her pain.

When I examined her, she had a lot of difficulty with both bending forward to touch her toes and getting back to standing. She was very tender over the base of her spine and over the tail bone. The skin in that area didn’t move easily over the bone. During the interview I had asked her about previous trauma and she had recalled slipping on ice about 8 years ago and landing on her buttocks. She had been very sore for a couple of weeks, but the pain had eventually stopped.

I wondered if that fall had resulted an injury of the fascia over her low back and tailbone.

Here are a few things worth knowing about fascia.

Over the last 10 years, fascia has been identified as an important cause of pain, weakness and loss of movement.

Fascia can be seen on ultrasound and MRI scans.

Fascia envelopes every individual muscle but also runs in specific patterns across muscles. You can tension this line of fascia like an elastic band. For instance, during the wind-up, baseball pitchers tension a line of fascia that runs from the hand holding the ball, down the front of the arm across the chest to the top of their opposite leg just before they release the ball. The release of this tension increases the force of their throw by 30%.

Fascia makes a slippery substance called hyaluron that helps one muscle to slide over another and keeps the lines of blood vessels and nerves sliding happily between and through muscles.

When fascia is damaged, the hyaluron becomes dried and sticky, and the fascia becomes tacked down and can’t slide normally. Surgical scars can also stop fascia sliding normally.  Injuries that happened years ago can cause pain at the site of initial fascial injury or somewhere else along the line of fascia. For instance, if the baseball pitcher injures the fascia on the top of the thigh opposite his throwing arm, and it becomes tacked down there, he might complain of pain and tightness in the front of shoulder of his throwing arm. Although the problem lies in his thigh it may not be painful there at all.

The Stecco family in Italy have pioneered a treatment strategy for this condition called Fascial Manipulation. The evaluation prior to fascial manipulation requires knowing the anatomy and physiology of fascia, your personal history of pain and trauma, and a detailed examination to analyze your pain, movement and strength to find and treat areas where the fascia is no longer sliding. The Stecco’s work is gradually making its way into mainstream medical practice. The Steccos release the adhesions with a kind of manual therapy. Japanese physicians inject saline or 5% dextrose, sometimes with some freezing between the layers that are stuck. I have found both therapies helpful.

For Jane, I used the ultrasound machine to inject 5% dextrose to release the areas that were no longer sliding normally. Within three visits she reported a 70% reduction in pain and was able to bend and sit comfortably. In her case, prolotherapy and PRP would not have been helpful and may have made her pain worse by causing additional inflammation.

Fascia is often overlooked as an important cause of chronic pain, but there are effective tools to treat pain, weakness and loss of movement due to fascial injuries.

And when it comes to the management of chronic pain, the more tools you have in your toolbox, the less everything looks like a nail.


Fascial Disorders: Implications for Treatment.

Stecco A, Stern R, Fantoni I, De Caro R, Stecco C.PM R. 2016 Feb;8(2):161-8. doi: 10.1016

j.pmrj.2015.06.006. Epub 2015 Jun 14.