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of related interest
Myofascial Induction™
An anatomical approach to the treatment of fascial dysfunction
Volume 1: The Upper Body
Andrzej Pilat
Forewords by Jan Dommerholt, Robert
Schleip and Andry Vleeming
ISBN 978 1 91342 633 0
eISBN 978 1 91342 634 7

The Myofascial System in Form and Movement

Lauri Nemetz
Foreword by David Lesondak
ISBN 978 1 91208 579 8
eISBN 978 1 91208 580 4

Mobilizing the Myofascial System

A clinical guide to assessment and treatment of myofascial
dysfunctions
Doreen Killens
Forewords by Diane Lee, Thomas W. Myers and BetsyAnn
Baron
ISBN 978 1 90914 190 2
eISBN 978 1 90914 191 9
Myofascial
Induction ™
An anatomical approach
to the
treatment of fascial
dysfunction
Volume 2 The Lower
Body
Andrzej Pilat

Forewords
Jan Dommerholt
Robert Schleip
Andry Vleeming
First published in Great Britain in 2023 by Handspring Publishing, an imprint of
Jessica Kingsley Publishers
An imprint of Hodder & Stoughton Ltd
An Hachette UK Company

Copyright © Andrzej Pilat 2023

Foreword copyright © Jan Dommerholt 2023

Foreword copyright © Robert Schleip 2023
Foreword copyright © Andry Vleeming 2023

Please see the Permissions and Sources list at the end of the book for copyright
acknowledgements.

All rights reserved. No part of this publication may be reproduced, stored in a

retrieval system, or transmitted, in any form or by any means without the prior
written permission of the publisher, nor be otherwise circulated in any form of
binding or cover other than that in which it is published and without a similar
condition being imposed on the subsequent purchaser.

Disclaimer: Neither the Publisher nor the Author assumes any responsibility for any
loss or injury and/or damage to persons or property arising out of or relating to
any use of the material contained in this book. It is the responsibility of the
treating practitioner, relying on independent expertise and knowledge of the
patient, to determine the best treatment and method of application for the patient.

A CIP catalogue record for this title is available from the British Library and the
Library of Congress

ISBN 978 1 91342 635 4

eISBN 978 1 91342 636 1

Jessica Kingsley Publishers’ policy is to use papers that are natural, renewable and
recyclable products and made from wood grown in sustainable forests. The
logging and manufacturing processes are expected to conform to the
environmental regulations of the country of origin.

Handspring Publishing
Carmelite House
50 Victoria Embankment
London EC4Y 0DZ
www.handspringpublishing.com
 CONTENTS

Dedication
About the author
Foreword by Jan Dommerholt
Foreword by Robert Schleip
Foreword by Andry Vleeming
Preface
Online videos
Acknowledgments

CHAPTER 1 Connecting and moving forward: Fascia as a

multifunctional system
Introduction
The fascial system and communication between
body systems
References

CHAPTER 2 Thoracolumbar fascia: The heart of the matter

General considerations related to the fascial system
of the lower quadrant
How load is transferred between the spine, pelvis,
arms, and legs
Thoracolumbar fascia: The heart of the matter
 Conclusion
References

CHAPTER 3 Lower quadrant assessment

Introduction
The characteristics of the lower quadrant
The assessment process
Conclusion
References

CHAPTER 4 Pelvic girdle dysfunctions: Lower back and

sacroiliac structures; Abdominal area
Lower back and sacroiliac structures
Introduction: The lower back
Anatomical considerations related to the lower back
Neurological considerations related to the lower
back
The pelvic girdle and low back pain
The cell–ECM–brain model
Introduction: Sacroiliac structures
Structure and function of the sacroiliac joint
Conclusion
Abdominal area
Introduction
Anatomical considerations related to the abdominal
fascial system
Biomechanical considerations related to the
abdominal fascial system
Blood supply to the abdominal fascial system
Innervation of the abdominal fascial system
Conclusion
References
 MIT procedures for common pelvic girdle
dysfunctions: Lower back and sacroiliac
structures; Abdominal area

CHAPTER 5 Pelvic girdle dysfunctions: Gluteal structures;

Inguinal and pubic structures; Pelvic floor
(external)
Gluteal structures
Introduction
Anatomical considerations related to the gluteal
structures
Biomechanics and the gluteal area
Deep gluteal syndrome
Conclusion
Inguinal and pubic structures
Introduction
Anatomical considerations related to the inguinal
and pubic structures
Symphysis pubis dysfunction and groin pain
Conclusion
Pelvic floor (external)
Introduction
The pelvic floor, posture, and gravity
The pelvic floor system and its supporting
structures
Endopelvic fascia as a part of the dynamics of the
pelvic floor system
Pelvic floor dysfunction
Conclusion
References
MIT procedures for common pelvic girdle
dysfunctions: Gluteal structures; Inguinal
and pubic structures; Pelvic floor (external)
CHAPTER 6 Lower extremity dysfunctions related to the
fascial system
Introduction
Anatomical considerations related to the fascia of
the lower limb
Thigh structures: Fascia lata
Knee structures
Lower leg structures: Crural fascia
Foot structures
Conclusion
References
MIT procedures for common lower extremity
dysfunctions

CHAPTER 7 Fascia and therapeutic movement in

translational practice: From the laboratory to
the clinic
Introduction
Human existence as a biological behavior
The therapeutic process
Conclusion
References

Permissions and sources

Subject index
Author index
 DEDICATION

In May 2016 I had the opportunity to show a sample chapter of this

book to Dr. Leon Chaitow. On reviewing it carefully, he exclaimed: “I
want this book!” He also generously agreed to my request to write
the book’s foreword. I promised he would be the first to read the
book. Sadly, his sudden passing did not allow me to fulfill my
promise.

I am honored to dedicate the book to this great person, clinician,

researcher, writer, lecturer, educator, editor, and visionary.

Andrzej Pilat
 ABOUT THE AUTHOR

Andrzej Pilat

Andrzej Pilat is a physical therapist. Born in Poland, throughout his

professional life he has practiced across continents. This has given
him the opportunity to be involved in a variety of aspects of physical
therapy: health care (a bustling hospital environment; the mystery of
an operating room; the adrenaline of intensive care units; and the
intimacy of a private practice); teaching (in a university setting,
tutoring graduate and undergraduate students); research (decoding
the human body’s enigma by dissecting unembalmed cadavers);
management (he has been chair of domestic professional
associations and international organizations); publishing (he was an
editor for the Venezuelan Manual Therapy journal); and information
dissemination (he is the author of several papers and books). These
experiences have led him to a better understanding of people’s
culture, customs, and attitudes towards diseases, thus awakening
his interest in therapeutic approaches and treatments that will adapt
as effectively as possible to the individual, as opposed to the
disease. In his quest, Andrzej has experienced a fruitful array of
different approaches to physical therapy, with a wide range of
exercises, modalities, applications (devices), manual applications,
and concepts – learned from well-known masters, such as Maitland,
Mulligan, McKenzie, Upledger, Barnes, Greenman, and others. The
study of different concepts of manual therapy has occupied the last
35 years of his career and he has become intensely interested in
fascia in the search for answers to the (always) global response of
the body to disease and healing.
Andrzej’s experience as a photographer has allowed him to
immerse himself in the intimacies of the unembalmed cadaver,
capturing in pictures the beauty of the inner body architecture. The
pages of this book reflect these experiences by taking the reader on
a fascinating journey through the puzzle of the fascia, from a
microbiological, anatomical, biomechanical, neuroscientific, and even
psychological and philosophical approach.
Today Andrzej leads the Myofascial Therapy School, Tupimek, in
El Escorial (Madrid), Spain, where he gives instruction in Myofascial
Induction Therapy (MIT)™, in collaboration with certified teachers
both in Spain and worldwide. Andrzej lectures in specialized
workshops and teaches for different master’s programs in local
universities and abroad. He has participated in numerous
international congresses about fascia, manual therapy, and physical
therapy in general. In recent years, his participation in webinars has
resulted in a growing international following. Myofascial Induction™:
An anatomical approach to the treatment of fascial dysfunction is the
result of five years of intense research through a vast amount of
scientific evidence about the fascia’s increasing importance to
people’s health and illnesses.
 FOREWORD by JAN
DOMMERHOLT

I do not recall when and where I first met Andrzej Pilat, but I
suspect it was at either a myofascial pain congress, a fascia
congress, or a physiotherapy course or conference somewhere in the
world. Often Andrzej’s travels coincided with mine, and every time I
attended his lectures several thoughts and associations came to
mind. It was clear to me that this man is an innovator in the field of
physiotherapy and beyond – someone who follows in the footsteps
of other innovators from many different fields, dispelling the many
erroneous belief systems so common in our discipline. I have a
feeling that already, during his time as a physiotherapy student,
young Andrzej would have been questioning his tutors and
challenged their teachings and convictions about physiotherapy
treatment methods. In a time when the terms evidence-based and
evidence-informed physiotherapy had not been invented, Andrzej
was probably way ahead of many of his professors in his critical
thinking skills and vision for the profession.
During our lifetime, physiotherapy has evolved from a tradition-
based therapy to an evidence-informed approach. Charles Kettering
is quoted as saying: “If you have always done it that way, it is
probably wrong” – words that could easily have been uttered by
Andrzej Pilat. During a myofascial pain conference in Bangalore,
India several years ago, Andrzej and I had numerous opportunities
to reflect, share ideas, admire each other’s creative presentation
styles, share a beer or two, and ponder about the future of
physiotherapy. His attention to detail, his phenomenal dissection
videos, animations, and photographs were most impressive, not to
mention his good nature and willingness to share his perspective
with anyone willing to listen. Attendees of the congress recognized
his brilliant mind, creativity, and tenacity, and our chats were
frequently interrupted by requests to take selfies with Andrzej! In a
time where many physiotherapists have adopted a mindset that
because “pain is in the brain” and “the issues are not in the tissues,”
so “hands-on therapies are a thing of the past,” Andrzej continued to
defy such developments and instead explored new developments
beyond what most of us could ever have imagined. Albert Einstein
reportedly stated that: “You can’t solve a problem on the same level
that it was created. You have to rise above it to the next level.” That
observation is applicable to Pilat at many levels. Myofascial
Induction™: An anatomical approach to the treatment of fascial
dysfunction is the ultimate proof of the innovative pathway which
Andrzej has carved out, often against the contemporary viewpoints
of other scientists, social media influencers, and established
traditions.
At the time I was preparing this foreword, Colleen Kigin, PT, PhD,
FAPTA was presenting the 52nd Mary McMillan Lecture as part of the
centennial celebration of the American Physical Therapy Association.
By pure coincidence the title of her lecture was “Innovation: It’s in
our DNA.” Although I am personally not convinced that “the [physical
therapy] profession is rich with innovators,” Dr Kigin hit the nail on
the head when she summarized, that physical therapy innovators
have the ability to connect the dots, accompanied by intense
questioning, observing, networking, and experimenting. I have read
several older chapters about myofascial induction written by Pilat in
other textbooks, but this book goes far beyond anything I have read
before or seen during Pilat’s lectures. It was such a pleasure and
enrichment to learn about tensegrity, the embryological development
of the extracellular matrix, fascial anatomy, pain sciences, allostasis,
interoception, and additionally, myofascial induction – all in one
book! The many outstanding illustrations, including line drawings,
exquisite anatomy photographs, and diagrams complement the text
together with links to supporting videos online showing Andrzej at
work. While at times, Pilat becomes rather philosophical, he never
loses track of educating clinicians and scientists across a wide
spectrum in the current knowledge of fascia. I admire and
congratulate Andrzej Pilat for this phenomenal book. It is such an
honor to introduce you, the reader, to this outstanding publication.

Jan Dommerholt PT, DPT

Bethesda Physiocare, Inc.
Myopain Seminars
Lecturer, Department of Physical Therapy and
Rehabilitation Science, University of Maryland
Bethesda, MD, USA, September 2021
 FOREWORD by ROBERT
SCHLEIP

Fascia is a connecting (t)issue. While Western conventional medicine

underestimated it for centuries as a mere packaging organ, recent
advances in assessment methods – such as shear wave ultrasound
elastography or harmonic generation microscopy – have triggered an
avalanche of new discoveries and insights into the collagenous tissue
network that keeps many researchers and clinicians around the
world on their toes. Although many aspects remain to be explored,
recent publications have shown that this network not only influences
muscular force transmission in a significant manner but also
constitutes our richest sensory organ.
One of the fascinating aspects of the fascial network is its
connective nature, which makes it difficult for precision-minded
thinkers to describe its clear boundaries and distinctions in a
satisfactory manner. While this fact is frustrating to some, it has also
piqued the interest of esoteric healing practitioners who wish to
project far-reaching hypothetical abilities, such as telepathic intuition
or cosmic resonance transmission, into this elusive tissue network.
Indeed, among the many different scientific and therapeutic
congresses I have attended, I have never seen such a diverse and
interdisciplinary audience as at fascia-oriented congresses, ranging
from biomechanical engineers, plastic surgeons, meat scientists,
matrix biologists, and orthopaedic researchers to osteopaths, yoga
teachers, meditation instructors, martial arts gurus, and Reiki
practitioners.
 What does this aspect have to do with the excellent book you are
holding in your hands right now? Let me explain after completing the
next two paragraphs.
Having been a holistic therapy practitioner and missionary myself
for several decades, my personal path has led me more and more to
the humble, questioning approach of those scientists who are
interested in unraveling the mysteries of the human body in many
small and careful steps. When it comes to drawing conclusions about
cause-and-effect relationships in the fascia-oriented field I personally
tend to side with those researchers who work with a curious “we
don’t know” attitude. This approach can be frustrating as it is often
less exciting and less charismatic than allowing our wishful thinking
to generate broad assumptions and easy explanations about the
implications of a perceived fascial phenomenon.
On the other hand, I must confess that for therapeutic treatment
of myself or my family members, I continue to appreciate the
healing attention of therapists who work with a more holistic and
intuitive approach. In my experience, their quality of touch, loving
presence, and wonderful enthusiasm are priceless components of a
healing relationship. These qualities are less often found – at least
not with the same depth – among my respected scientific
colleagues. Or to put this observation the other way around: When
listening to the personal explanations of the best therapists in our
field about the healing mechanisms involved in their work, one must
often be prepared to hear interpretations that any of my
undergraduate Life Science students would easily recognize as
premature logical conclusions.
If you have already guessed how this situation relates to the
author of this book and the brilliant book he has written, you have
my collegial applause. Yes, the author, Andrzej Pilat, is indeed a very
rare exception to the common disparity described here. I consider
him one of the best manual therapists I know, and I do not say that
lightly. When I see Andrzej at work, I feel as if I am watching a
master artist, like Michelangelo as a painter or like a Butoh dancer in
slow motion. But the most impressive aspect for me is his
connection with the client: Both seem to be united in a joyful and
almost hypnotic process of discovery.
Nevertheless, when Andrzej describes his work in terms of
suggested fascia changes, I feel like asking all my students to join
me in listening to him with eager attention. The way he weaves
together various findings and issues of the latest international
research is truly outstanding. The author of this brilliant book has
not only been a passionate manual therapist for many decades but
has also been actively involved in academic fascia research, including
the first Fascia Research Congress (Harvard Medical School
Conference Center, Boston, 2007), all subsequent such events, and
in several similar congresses which he hosted himself and used to
interact personally with the leading scientists in our field.
Those of you who have had the pleasure of attending one of the
international Fascia Research Congresses know that Andrzej Pilat’s
presentations tend to be absolute highlights. After his presentation,
he is usually surrounded by a crowd of enthusiastic attendees who
want to collaborate with him in one way or another, or to find out
how they can get their hands on the fantastic photos and videos of
fascia anatomy that he has shown. For many years, his constant
response to the latter request has been: “Give me a little more time
to finish my book, which will contain all of this and much more.”
Here it is, dear friends and companions in the field of fascia
research: the long-awaited – and I think truly historic – contribution
of Andrzej Pilat to our common field of fascination. Many of the
fascial images, based on fresh tissue dissections, are the best
presented outside of professional conferences. One cannot help but
admire the beauty of the complex architecture of the wonderful
connecting tissue called fascia. The book also provides an up-to-date
overview of what is currently known about the many functions of
this tissue. Finally, this masterpiece in print introduces you to a
fascia-oriented manual treatment method that you will surely want
to experience yourself after reading the first few chapters. I
congratulate the author for this fantastic achievement. Myofascial
Induction™: An anatomical approach to the treatment of fascial
dysfunction is a milestone contribution to the literature on fascia.

Robert Schleip Dr biol.hum., Dipl.Psych.

Visiting Professor, IUCS Barcelona, Spain
Director, Fascia Research Group,
Ulm University, Germany
Research Director, European Rolfing Association
Munich, Germany, September 2021
 FOREWORD by ANDRY
VLEEMING

The complexity of fascia and its functions has been well

documented, and it is evident that some of its secrets are yet to be
unfolded. As this information expands, it is convenient to have a go-
to source to help us bring this knowledge together and explore tools
useful in applying this information in the clinical setting.
Developed over years of dedication and enthusiasm this book
delivers exactly that. It is systematically organized to take the reader
through the relevant clinical research and literature. It does so in a
way that enables us to gain a greater understanding of this three-
dimensional sensory organ. Let me explain why…
Because it is a continuous matrix fascia is not easy to map. It
reaches out to all corners of the body and to every cell. It provides
the framework that helps support and envelop muscles, organs,
blood vessels and neurons, enabling the body to function as a
whole. Its various mechanical properties are intriguing and complex.
Addressing this complexity, this book does a wonderful job of
bringing us up close and personal to the topographical anatomy. It
also helps us explore, through illustration, the anatomical continuity
of the fascia and how it relates to other body systems. This is
achieved through the use of wonderful photographs and diagrams
that help the reader visualize what lies beneath the skin.
To start you off in this exploration, the opening chapters provide
the reader with an overview of what is currently known in the field.
This includes an in-depth description of fascial topographical
anatomy, its layers and architecture. The book then explores
embryological development, histological characteristics,
neurodynamics, and the role of force transmission relating to the
fascia.
The later part of the book invites the reader to explore the
clinical applications of Myofascial Induction Therapy. This section is
neatly categorized into treatment regions – craniofacial,
craniocervical, the thorax, upper and lower extremities – with each
region providing detailed information regarding clinical assessment
and dysfunction. The relevant manual techniques are clearly
described in a format that is easy to follow. Evidently much thought
has been given to the layout of this book, employing wonderful
photography and well-designed diagrams, enabling us to get a
deeper understanding of the fascial system. If you wish to expand
your knowledge of the anatomical approach to the treatment of
fascial dysfunction Myofascial Induction™: An anatomical approach
to the treatment of fascial dysfunction will be a very welcome
addition to your collection.
My warmest congratulations to you, Andrzej Pilat.

Professor Andry Vleeming PhD

Chairman, Interdisciplinary World Congress
on Low Back and Pelvic Girdle Pain
Antwerp, Belgium, September 2021
 PREFACE

The truth of science is always provisional, but still scientific research

is the best method to obtain reliable information.

In 2003 I published my first book on fascia and Myofascial Induction

Therapy: Terapias miofasciales: Inducción miofascial. This was based
on the limited scientific information then available and at that time
images of fascial anatomy were very scarce. I had to undertake a
detailed search for evidence to corroborate the criteria presented in
that book. Today, 18 years later, the picture is very different. The
problem now is how to make the best selection from the mass of
high-quality scientific information on fascia that is available today.
This detailed and richly illustrated book distils that information, and
puts it into the context of my own extensive study of human tissue,
creating a unique textbook and manual on the fascia and on how to
manage its dysfunctions.
Over the past 15 years I have undertaken many dissections of
unembalmed cadavers and this work has allowed me to open up
new perspectives in the field of fascia research. Through these
anatomical explorations I discovered the harmony, omnipresence,
architectural complexity, diversity, and continuity of this amazing
fascial system. No less fascinating (although complicated and
laborious) was the photographic effort necessary to capture this
infinite, diversified, and colorful network. Through
macrophotography I discovered the hidden beauty that is the
continuum of the endless fascial web. As a result of this detailed
research, the extensive approach to fascial anatomy presented in the
book (with the support of numerous full-color photographs and
videos) encompasses not only the topography of the fascial tissue
but also shows its elegance, structural continuity, and coherence
within the chaos. It invites the reader to explore its microstructure
and to recognize its essential role and active participation in body
movement.
Within the contemporary conceptual framework new terminology
differentiates between anatomical structure (fascia) and function
(fascial system) – a complex biological system responsible for
communication (transmission of information) between body
components and with the environment.
The movement of each human (for example, walking) is personal
and almost impossible to duplicate. The uniqueness in the
configuration of each individual’s fascial system is part of this
process. In order to achieve the desired movement our brain
manages its complex neural network, selecting for activation those
motor units that enable optimal performance for the task in hand. It
is obvious that in this process, the muscles (muscle tissue) are the
main engines of movement. However, it should be remembered that
none of the muscle fibers acts in isolation. They are fascial
structures that transmit dynamic adjustments according to demands.
Following this reasoning, the question is: What is the significance
of fascia for body movement and what is its relevance in the
therapeutic processes?
In this context, the book deals with fascia and kinesis, the latter
defined in the Merriam-Webster dictionary as “a movement that
lacks directional orientation and depends upon the intensity of
stimulation.” A human being can choose his movement at will. This
attribute is guided by the brain. The brain uses past experiences to
anticipate movements. The brain does not see the future, but makes
intelligent predictions about what will happen in the immediate
future. It is a learning process that involves the senses
(exteroception). In this way we perceive the world. In parallel, the
same senses are influenced by body condition (interoceptive
messages) based on experience, which is personal. The plasticity of
the nervous system allows body movement to accommodate to
diverse circumstances (for example, facing dangerous situations)
based on experience and current information. The nervous system
and the fascial system share the principles of plasticity, and adjust
movement in an anticipatory and individual way for each person.
This process facilitates the ability to easily recover or adapt to
misfortunes or changes (resilience).
Myofascial Induction™: An anatomical approach to the treatment
of fascial dysfunction describes the properties of the endless and
omnipresent fascial network and provides therapeutic solutions for
different types of fascial dysfunction. The material is presented in
two volumes:
Volume 1 analyzes in depth the theoretical aspects related to
fascia and focuses on the therapeutic procedures of Myofascial
Induction Therapy (MIT™) for the upper body; Volume 2
summarizes and expands on the theoretical aspects and explains the
therapeutic procedures of MIT™ for the lower body, where the lower
extremities have the function of supporting the weight of the body in
the bipedal position and making movement possible through the
coordination of their powerful muscles.
The chapters of Volume 2 cover the theoretical aspects of fascial
system behavior in the lower body segment. The later sections of
Chapters 4, 5, and 6 detail the practical applications of Myofascial
Induction for the lower body.
In the theoretical sections, after defining the fascia as a complex
multifunctional biological system, its role of communicator between
body systems is discussed in relation to the following issues:

human existence as a biological behavior

the role of fascia in exteroception, interoception, proprioception,
and nociception
the influence of fascia on homeostasis
 the response of fascia in relation to General Adaptation Syndrome
the important role of fascia in allostasis and development of
allostatic load
thoracolumbar fascia as the heart of the matter
the role of fascia in pelvic girdle behavior
fascial dynamics related to pelvic floor dysfunction
fascia and nerve entrapment syndromes of the lower extremity
the complexity of the fascial compartment system.

In the practical sections of Chapters 4, 5, and 6, the reader will find

a wide range of manual therapeutic procedures which can be
selected and used in combination to build up the MIT treatments.
These processes are explained in detail and are richly illustrated with
diagrams and photographs of their practical application on the body
and of hand contacts on samples of dissected tissues.
The final chapter summarizes practical aspects of clinical
applications, discussing subjects such as:

the basic goals of the therapeutic process

touch as a therapeutic modality
the hand as a therapeutic tool
practitioner skills
patient’s skills.

The introduction to each chapter offers the reader some

philosophical background as a reminder that philosophy allows us to
relate the strictly scientific with the empirical. Praxis and empiricism
are the basis of science.
I invite you to join the scientific fascial adventure that allows us
to uncover areas of knowledge which may have been forgotten or
which are not yet recognized as being related and which might still
reveal relevant information. Once discovered, these facts can help us
to better understand the kinesis of our body and so help the
individual to change their body image and to improve their quality of
life.

Andrzej Pilat
Madrid, December 2022
 ONLINE VIDEOS

Chapter 4
Video 4.1
Dynamics of the abdominal fascia

Video 4.2
Transverse stroke applied to the psoas

Chapter 5
Video 5.1
Continuity of the gluteal fascia with the thoracolumbar fascia and
fascia of the thigh

Video 5.2
Relationship of the sciatic nerve and the piriformis muscle in the
subgluteal fold
 Chapter 6
Video 6.1
Anatomical continuity of the skin, superficial fascia, and deep fascia
in the knee area

Video 6.2
Anatomical structures of the deep fascia of the thigh

Video 6.3
Cross-section of the metatarsal zones

Video 6.4
Longitudinal induction applied to the plantar fascia

Video 6.5
Longitudinal stroke applied to the anterior and lateral compartments
of the lower leg

Video 6.6
Deformation of the deep fascia related to movements of the patellofemoral joint
 Video 6.7
Anatomical relations of the deep fascia of the thigh and
the epimysium of the quadriceps

Video 6.8
Longitudinal stroke applied to the posterior border of the iliotibial
band (demonstrated with knee extended)
 ACKNOWLEDGMENTS

The discovery of the double helix of DNA, whose structural

coherence hides in code the morphogenetic and informational
potential of life, opened the way to modern biology. It also marked
the beginning of the close collaboration between biology, physics,
and progressively other disciplines such as computing. The relatively
simple interactions between different pairs of nucleotides reveal the
almost infinite capacity to store information in the DNA
heteropolymer. It is the intimate connection between interaction and
information that constitutes the fabric of living matter. Biological
complexity is based on specific interactions between molecules.
These interactions create complex networks that are balanced by
their interconnection. These networks control and regulate the
exchange of signals that govern intracellular functions and
multicellular behavior throughout the development and functioning
of the organism.
This fascinating advance of science forced the change of
paradigms and integration of scientific streams. The analysis of the
behavior of the fascia, as the integrating structure of the body, did
not escape these requirements.
Thus, the act of writing this book on fascia turned into a long and
fascinating scientific adventure. Although not an expert in the
aforementioned disciplines, I was fortunate to have the advice and
help of friends who made this trip possible and enabled me to finally
dock at the destination harbor. My sincere thanks to all listed below
for having accompanied me on this long and winding journey.
First of all, I would like to thank the editorial team at Handspring
Publishing (Mary Law, Andrew Stevenson, Sally Davies, Bruce
Hogarth, Morven Dean, and Hilary Brown) for their dedication,
patience, professionalism, and attention to detail in search of
editorial perfection.
I would like to thank my family for allowing me the long months
(years) dedicated to writing the book, especially my wife Yulita,
for her unconditional support and her contribution to so many
tasks, and also my children Eva, Mártin, and Kamil.
Thank you to my friend, architect Michele Testa, for teaching me
to select and synthesize the avalanche of scientific information to
solve seemingly insoluble problems.
I would like to thank the ETM Tupimek team, particularly my son
Mártin Pilat, Germán Digerolamo, and Eduardo Castro-Martín for
their extensive help, reviews, and critical reading of the
manuscript as well as their contributions on issues that I was
unaware of. Also, I am grateful to Javier Rodríguez and Jorge
Sánchez for their help in preparing the illustrative material and to
Rafael García for his help in the search for scientific information.
Thank you to the PROMPT team, especially Francesco Testa, Iván
Arellano, and Andrea Fiorucci for developing the illustrative
material for the book and reflecting my thoughts in the drawings.
I am extremely grateful to the late Professor Dr. Horacio Conesa
for allowing me to live the adventure of discovering the enigmas
of the fascia in anatomical dissections.
I would like to thank Dr. Nicolás Barbosa for his art of dissecting
fascia during the long hours of anatomical work that we shared.
I would also like to thank Professor Dr. Maribel Miguel-Pérez and
Dr. Albert Perez-Bellmunt for their critical review of my anatomical
interpretations.
Thank you to Dr. Ramón Gassó for his analysis and helpful
opinions on fascial physiology.
I thank the photographer Óscar Ruiz for his art of capturing
therapeutic applications in photographic subtlety.
Thank you to Ailén Botta Mazzone for her patience and grace in
modeling the applications of therapeutic procedures.
I would like to thank Javier Álvarez for introducing me to the
world of the analysis of fascia through images and for obtaining
the samples for the book.
Finally, my special thanks to all who have been part of this
adventure.
1
Connecting and moving forward:
Fascia as a multifunctional system

KEY POINTS
● The physiological properties of fascial micro- and
macrostructures in relation to body movement
● The characteristics of movement
● Definition of the internal environment
● The participation of fascia in homeostasis and allostasis
behavioral responses
● Correlation of movement with the processes of exteroception,
proprioception, and interoception
● Analysis of the nociceptive role of fascia

Introduction
The discovery of the double helix of DNA, whose structural
coherence conceals the morphogenetic and informational potential
of life in code, opened the doors to modern biology. It also marked
the beginning of close collaboration between biology, physics, and
progressively other disciplines such as computing. The relatively
simple interactions between different pairs of nucleotides reveal the
almost infinite capacity to store information in the DNA
heteropolymer. It is the intimate connection between interaction and
information that constitutes the fabric of living matter. Biological
complexity is based on specific interactions between molecules.
These interactions create complex networks that are balanced by
their interconnection. These networks control and regulate the
exchange of signals that govern intracellular functions and
multicellular behavior throughout the development and functioning
of a living organism such as the human body.
Each person is characterized by the individuality of their
movements that adapt according to the demands of their body and
the environment and to the resources available at a given time.
Movement patterns vary from person to person. Equally, the same
individual modifies their movement pattern when performing the
same task multiple times. These differences in movement patterns
are more apparent amongst people suffering from the same
dysfunction or disease (e.g., mechanical low back pain).
In traditional anatomical and biomechanical research performed
on embalmed cadavers, muscles are presented as independent
units. This suggests a series of unrelated elements instead of a
unique and continuous configuration linking the structures of the
body (Pilat et al. 2016). Such an approach makes the analysis of the
dissected elements difficult when integrated into a higher level of
organization (Huijing 2009). This leads to an understanding of
human body movement based on segmental anatomical and
biomechanical knowledge. However, a body is more than the sum of
its parts and it is so by virtue of the new properties that arise from
the relations between parts. The specificity of body behavior comes
from the complex integrated functioning of its entirety, and not just
from the structural and functional nature of the separate
components.
In parallel, in the traditional model the concept of “fascia” is
related to some anatomical structures such as the tensor fasciae
latae, the palmar fascia, the thoracolumbar fascia, and muscle
sheaths:
In this perspective, muscle forces are transmitted serially, and the
torque developed around a joint depends only on the muscle’s
torque arm geometrical configuration. Movement patterns are
therefore, analyzed through a linear framework of isolated muscle
groups, based on singular muscle attachments and isolated joint
actions. (Garofolini & Svanera 2019)

Anatomical studies of unembalmed cadavers have provided a new

perspective on fascia, which differs from the traditional “fibrous
sheet” that “hides” the muscle (Pilat et al. 2016).
Without minimizing the importance of treatment protocols, it is
worth highlighting the need to customize applications according to
the individual patient’s requirements. These processes accentuate
the need to understand body movement as a set of synergies that
facilitate the exchange of information, communication, and
interaction between each other (see Volume 1, Chapter 17). “Motor
synergies represent the coordination of neural and physical elements
embedded in our bodies in order to optimize the solutions to motor
problems” (Garofolini & Svanera 2019).

At the base of movement organization there is a (somatic)

equilibrium point that exists on the fascia where the neurologically-
and mechanically-generated tensions dynamically balance out. This
somatic equilibrium point is at the base of postural control, afferent
flow of information to the nervous system about the state of the
muscles, and of the coordinative pre-activation of muscular
contraction sequences specific for a synergy. (Garofolini & Svanera
2019)

The physiological basis of movement is summarized below, justifying

the need to focus on systemic reasoning in relation to body
movement (see Volume 1, Chapter 2). The objective of this chapter
is to argue for the personalization of therapeutic procedures and to
justify the inclusion of fascia in this process.
The fascial system and communication
between body systems
In Volume 1, Chapters 1, 2, and 3, fascia is defined as an
omnipresent, highly hydrated, richly innervated, vascularized
network with a contractile capacity – a prodigious complex biological
system, which provides mechanoreceptive information to the body,
facilitating communication, interaction, adaptation, and protection
(Fig. 1.1). From an anatomical and functional perspective fascia is
characterized by the continuity of its path, although its morphology
changes along its course, adjusting to mechanochemical
requirements and the different conditions and situations of each
region of the body (see Volume 1, Chapters 2, 3, 6, 7, and 8). Thus,
fascia acts as a single functional continuum, a nonfragmentable,
complex biological system (Chen et al. 2021).

Figure 1.1
Systemic interrelationships of the fascia as part of connective tissue

Intersystem links
The evidence for the anatomical continuity of fascia is discussed in
detail in Volume 1, Chapter 3. However, in recent years, research has
also provided new and extensive information on the intrinsic
continuity and intersystem dynamics of the fascial system.

The internal environment

Effectiveness means achieving goals with an appropriate (optimal)
choice and performance of resources in any circumstances, mainly in
unexpected, emergent situations (Fig. 1.2). In order to function
optimally (be effective) each cell of a multicellular structure (such as
the human organism) needs:
● an integumentary tissue (border tissue) that delimits its contents
in relation to the external medium through which it exchanges
matter and energy
● an internal liquid medium, characterized by optimal physical-
chemical parameters that constitute its immediate environment
● an effective communication system that allows it to act in
coordination with other cells, so that the organism functions as an
integrated whole.

At the end of the 19th century, Claude Bernard called this liquid
internal medium, which is in continuous dynamic equilibrium with
the external medium, the internal environment (in contrast to the
external environment with which the organism must maintain a
constant exchange of matter and energy). Bernard stated that
stability of the internal environment is the essential condition of “free
life” (Haldane 1929, Gross 1998). Figure 1.3 shows the relationship
of the body’s systems with the internal environment (Batuecas 2018,
Vaticón 2018).
The main component of the internal environment is the
interstitium which is composed of extracellular matrix (ECM) (the
substance of the interstitium), ground substance, and cells with
specialized functions. The interstitium is a network of fluid-filled
cavities that lies under the skin, covers all organs and cells, and acts
as a shock absorber to prevent tissues from being torn by the
movement of muscles, viscera, and vessels. These cavities are
formed from an external structure of collagen and elastin (proteins
that give the structure its resistance and elasticity).
Benias et al. (2018) found that freezing biopsy tissue before
fixation preserved the anatomy of the structure and thus
demonstrated that the interstitium is supported by a complex
network of thick collagen bundles. The authors state that: “These
anatomic structures may be important in… mechanical functioning of
many or all tissues and organs,” including the fascia. Recent research
by Cenaj et al. (2020) affirms the continuity of interstitial spaces of
the colon and mesenteric fascia within and across organ boundaries,
including within perineurium and vascular adventitia traversing
organs and the spaces between them “with significant implications
for molecular signaling, cell trafficking, and the spread of malignant
and infectious disease.” Interstitial fibrosis (a progressive condition
that is characterized by fibrous connective tissue replacing normal
tissue) is produced by injury, infection, and infiltration of
inflammatory cells into the small spaces between tissues. It can
create alterations in the ability of tissues to glide over one another
and compensatory processes leading to subsequent dysfunction,
which can ultimately lead to various pathologies.

Figure 1.2
 Systemic properties: the effectiveness of the system

Figure 1.3
Relationship of body systems with the internal environment (Batuecas 2018,
Vaticón 2018)

An essential component of the internal environment is the

extracellular matrix (ECM) (see Volume 1, Chapter 4) which “is a
non-cellular three-dimensional macromolecular network composed of
collagens, proteoglycans/glycosaminoglycans, elastin, fibronectin,
laminins, and several other glycoproteins. Matrix components bind
each other as well as cell adhesion receptors, forming a complex
network into which cells reside in all tissues and organs” (Theocharis
et al. 2016).

Mechanotransduction
Cells perceive (sense) their physical environment (the ECM) through
the mechanotransduction process, converting mechanical impulses
(forces and deformations) into biochemical signals, thus activating
various signaling pathways. Mechanotransduction has crucial roles in
physiology. “In mammals, embryonic development, touch, pain,
proprioception, hearing, adjustment of vascular tone and blood flow,
flow sensing in kidney, lung growth and injury, bone and muscle
homeostasis as well as metastasis are all regulated by
mechanotransduction” (Coste et al. 2010).
Adhesion complexes at the cell surface physically (mechanically)
link the ECM to the cytoskeleton (which extends from the cell
nucleus to the cell membrane) through focal adhesions, comprised
of integrins, talin, and vinculin, and connect the ECM to actin
filaments. Intracellular forces are then transmitted through the
cytoskeletal network (i.e., actin filaments, microtubules, and
intermediate filaments). The cytoskeleton is coupled to the nucleus
through nesprins (proteins located mainly in the outer membrane of
the cell nucleus). Finally, lamins (nuclear proteins which have a
structural function and line the inside of the nuclear membrane) bind
DNA, thus completing force transmission between the ECM and the
interior of the nucleus and reaching the cromatin structure (the
complex of genomic DNA and associated proteins in the nucleus of
the cell) (Fig. 1.4) (Jaalouk & Lammerding 2009).
Recent research on the ECM points to the importance of its
interaction with the contractile structures. “Emerging evidence shows
that cells are able to sense and store a memory of their past
mechanical environment” (Mathur et al. 2020, Chalfie 2009). As
already described in Volume 1, Chapter 5, fibroblasts are essential
cells in the dynamics of the ECM and are constantly adapting. Their
behavior is related to the process of biological memory. Kirk et al.
(2021) define biological memory as “the process of a sustained
altered cellular state and functions in response to a transient or
persistent environmental stimulus.” This process is related to the
fibroblasts’ positional, mechanical, inflammatory, and metabolic
memory and has implications in body homeostasis and disease (Kirk
et al. 2021).
In response, these mechanical signals can adjust cellular and
extracellular structure and functions, such as migration, proliferation,
adhesion, invasion, differentiation, apoptosis, and gene expression,
that are vital for maintaining homeostasis (Jaalouk & Lammerding
2009). Changes in cellular structure and organization, or changes in
the cellular environment, can disturb the mechanotransduction
process and result in altered cellular function.

Figure 1.4
Mechanotransduction process: force transmission from the extracellular
matrix to the cell nucleus structure (see Volume 1, Chapter 8). *Chromatin is
a complex of genomic DNA and associated proteins in the nucleus of the cell.
After Jaalouk DE & Lammerding J (2009) Mechanotransduction gone awry.
Nature Reviews Molecular Cell Biology 10(1):63–73

PIEZOS (and TRPV1)

The 2021 Nobel Prize in Medicine was awarded to David Julius and
Ardem Patapoutian for the discovery of temperature and touch
receptors, which has provided insight into how heat, cold, and
mechanical force can initiate the nerve impulses that allow us to
perceive and adapt to the world. Julius identified the TRPV1 ion
channel as a heat-activated nociceptor in the peripheral nervous
terminus, providing insights into the molecular mechanisms of
thermoreception (Ernfors et al. 2021).
Patapoutian discovered a new class of sensors that react to
mechanical stimuli in the skin and internal organs, revealing “crucial
missing links” in understanding the relationship between the senses
and the environment. He took a giant step in developing the
research of Joseph Erlanger and Herbert Gasser who received the
Nobel Prize in Medicine in 1944 for their “discoveries related to the
differentiated functions of single somatosensory nerve fibers. These
discoveries established important principles for the propagation of
action potentials along skin and muscle sensory nerve fibers”
(Ernfors et al. 2021).
Patapoutian identified the mechanically sensitive piezo ion
channels. These channels contain two structurally and genetically
similar proteins, PIEZO1 and PIEZO2, which are mechanically
activated and mediate touch perception, proprioception, and
vascular development. A mechanosensitive ion channel is an ion
channel that can sense changes in the mechanical force of the cell
membrane and react quickly. It is suggested that piezos consist of
two segments – the extracellular and the intramembranous
components. When a mechanical force acts on the cell membrane,
the extracellular component will drive the intramembranous segment
thus opening the orifice for ion flow. This reaction of the ion channel
can convert the mechanical signal sensed by the membrane into an
electrical signal or a chemical signal (Creative Diagnostics 2021).
Each type of receptor has a slightly different use (Fig. 1.5). PIEZO1
is part of the blood pressure monitoring system as well as other
internal systems that rely on pressure sensing, such as the
respiratory, gastrointestinal, or urinary systems. PIEZO1 receptors
are also found in the inner lining of blood vessels and can detect
increased blood flow during physical exercise. The PIEZO1 channel
also responds to a variety of mechanical force activation and can
induce chronic inflammatory diseases in multiple body systems (Fig.
1.6). PIEZO2 is the main mechanical sensor for touch.
Proprioception, which is also based on PIEZO2, is the recognition of
the body and its segments in three-dimensional space. Piezos are
involved in mechanotransduction in several critical processes,
including tactile sensation, balance, and cardiovascular regulation
(Mahmud et al. 2017). PIEZO1 also plays an important role in
regulating CNS processing (Fig. 1.7) and participates in the
regulation of the baroreceptor reflex (Fig. 1.8). This discovery was
considered a landmark finding in the understanding of the important
life activity of mechanical force in mammals. Changes in mechanical
forces (such as osmotic pressure) that maintain life activities can
influence cellular dynamics as a result of alterations in piezos,
consequently triggering different pathological processes:
● Haliloglu et al. (2016) report that: “Sensory ataxia and
proprioception defect with dorsal column involvement together
with arthrogryposis, myopathy, scoliosis and progressive
respiratory failure may represent a distinct clinical phenotype, and
indicate recessive mutations in PIEZO2.”
● Mahmud et al. (2017) report that the dominant mutations in
PIEZO2 can cause different forms of distal arthrogryposis.
● García-Mesa et al. (2017) demonstrate the “occurrence of Piezo2
in cutaneous sensory nerve formations that functionally work as
slowly adapting (Merkel cells) and rapidly adapting (Meissner’s
corpuscles) low-threshold mechanoreceptors and are related to
fine and discriminative touch but not to vibration or hard touch.”
● Mikhailov et al. (2019) suggest the involvement of
mechanosensitive PIEZO1 in peripheral trigeminal nociception,
which provides a new view on mechanotransduction in migraine
pathology and suggests novel molecular targets for antimigraine
medicine.
● Wang & Hamill (2021) conclude that: “Our proposed, non-
synaptic, intrinsic mechanism, where Piezo2 tracks the highly
predictable and ‘metronome-like’ intracranial pressure pulses…
would have the advantage that a physical force rapidly
transmitted throughout the brain also contributes to this
synchronization.”
● He et al. (2021) investigated the role of the mechanotransduction
of PIEZO1 in hypertrophic scar formation. They observed that
PIEZO1 was overexpressed in myofibroblasts from scar tissue. In
vitro cyclic mechanical stretching revealed increased PIEZO1
expression in human dermal fibroblasts. The authors state that
the involvement of mechanical force is a key regulator in
hypertrophic scar formation.
● Shin et al. (2021) suggest that PIEZO2 is widely expressed by
neuronal and non-neuronal cells of the peripheral nervous system
and by neurons in the spinal cord and brain. They conclude that
PIEZO2 is not only involved in the detection of external
mechanical stimuli in the skin but may also serve to detect
internal mechanical cues in the nervous system or link to other
unexplored intercellular and intracellular signaling pathways in
pain circuits.

As fascial tissue is the safeguard of body homeostasis, an alteration

in mechanotransduction can affect organ development and function
and can trigger pathological processes giving rise to inflammatory,
autoimmune, and degenerative changes and tumor progression
(Jaalouk & Lammerding 2009).

Homeostasis
In 1926 the physiologist Walter Cannon coined the term
homeostasis, defining it as: “The capacity that living organisms have
to maintain constant the characteristics of their internal
environment” (Cooper 2008). Batuecas (2018) points out: “Cannon
uses the word ‘constant,’ which, if interpreted in a strict sense,
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