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Why fascia matters medically (get ready to cringe)

Paul Ingraham ARCHIVEDMicroblog posts are archived and rarely updated. In contrast, most long-form articles on PainScience.com are updated regularly over the years.

A few years ago I published an article about the over-hyped importance of fascia, the sheets of connective tissue that bind us together. It covers several popular, dubious theories about why massage therapists and other manual therapists should try to manipulate fascia specifically. I’ve updated the article several times, but recently it struck me that I had strangely neglected something basic:

What is the actual clinical significance of fascia in medicine? Why would it come up for a family doctor? Why would a surgeon think about fascia?

The answer is boring but critical: fascia functions as an important infection barrier. Much like skin prevents pathogens from getting into the bottom in the first place, layers of fascia limit their spread. For example, from Gray’s Anatomy for Students:

A typical example of a fascial layer would be that overlying the psoas muscle. Infection within an intervertebral body secondary to tuberculosis can pass laterally into the psoas muscle. Pus fills the psoas muscle but is limited from further spread by the psoas fascia, which surrounds the muscle and extends inferiorly into the groin pointing below the inguinal ligament.

But there’s a dark side to this vital function — one of the most unpleasant malfunctions in medicine. If fascia stops the spread of disease, what happens behind the barrier? Well, it can get grim: a blocked infection is also a trapped infection, and if it burns out of control it can destroy the contents of the compartment. Journalist Miles O’Brien lost a forearm to compartment syndrome — see “Just a Flesh Wound” — a raging infection that came out of nowhere and inflated his forearm like a high-pressure sausage. Since fascia is so tough and will not yield, circulation gets cut off and all the flesh in the compartment begins to die. The compartment must be sliced wide open to bleed off the pressure — a huge, grisly wound and a slow, difficult recovery even if all goes well. And it didn’t all go well for O’Brien:

Things tanked even further once I was on the table. And when I lost blood pressure during the surgery due to the complications of compartment syndrome, the doctor made a real-time call and amputated my arm just above the elbow. He later told me it all boiled down to a choice… between a life and a limb.

~ “Just a Flesh Wound”, O'Brien (Milesobrien.com)

Now that is clinical relevance. That’s how the properties of fascia medically matter — its toughness as a wrapping, primarily.

A gory example of a forearm fasciotomy.

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