Fascial Dysfunction and the Fascial Manipulation® Approach

(This article provides a concise anatomical and physiological framework for understanding how targeted fascial interventions can influence pain, movement, and injury risk.)

The human body functions as a complex, integrated biological entity, and scientific consensus increasingly recognizes the fascial system as its primary connective architecture. A recent proposition defines the fascial system as a “layered body-wide multiscale network of connective tissue that allows tensional loading and shearing mobility along its interfaces,” forming a foundational anatomical system that integrates all structures of the body (Stecco et al., 2025).

This three-dimensional architecture has two principal components: a fibrous component composed of collagen-rich layers responsible for force transmission, and a loose connective tissue component characterized by a hyaluronic acid (HA)-rich interstitium that permits gliding and shear mobility between layers (Stecco et al., 2025; Fede et al., 2021). Disruption of this balance can lead to fascial dysfunction, commonly in the form of fibrosis or densification.

Fibrosis represents a largely irreversible alteration of the fibrous component, marked by excessive and disorganized collagen deposition. Densification, in contrast, is a potentially reversible dysfunction of the loose connective tissue. Both conditions can be associated with trauma, surgery, and systemic factors. In densification, HA molecules aggregate, increasing extracellular matrix viscosity and reducing tissue gliding without altering the fibrous architecture (Pavan et al., 2014; Stecco et al., 2022), but persistent densification may eventually contribute to fibrotic changes (Stecco et al., 2022).

Advances in imaging have improved visualization of these alterations. Dynamic ultrasonography (Pirri et al., 2021a), elastosonography, elasto MRI, and T1ρ MRI enable early detection of changes in tissue stiffness and HA content, assisting differentiation of reversible densification from established fibrosis (Stecco et al., 2022).

Distinguishing densification from fibrosis is clinically important, as treatment should target the appropriate fascial component. Densification may respond to manual therapies, movement-based interventions, and thermal applications, with temperatures >40°C shown to reduce HA viscosity (Pavan et al., 2014). Enzymatic approaches, such as recombinant hyaluronidase injections, also improve tissue mobility (Raghavan et al., 2016). Fibrotic changes, however, are less responsive to conservative treatment (Pavan et al., 2014).

Beyond its mechanical role, the fascial system is richly innervated (Suarez-Rodriguez et al., 2022). Fascia closely interacts with peripheral nerves: the superficial fascia envelops cutaneous nerves, while the deep fascia is associated with deep peripheral nerves carrying sensory and motor fibers (Pirri et al., 2021b). Impaired gliding or thickening may restrict nerve mobility, contributing to entrapment neuropathies with pain and functional impairment (Stecco et al., 2019).

Movement itself can be better understood through a fascial perspective as well. Stecco’s myofascial unit (MFU) concept proposes that muscles, their associated fascial tissues, nerves, and vasculature function as an integrated entity. Dysfunction in any component, such as fascial densification, can disrupt force transmission, proprioception, and motor coordination, causing pain and inefficient movement patterns (Stecco et al., 2023).

The Fascial Manipulation® (FM) method is a therapeutic approach grounded in this integrative model. It adopts an individualized yet global perspective, assessing dysfunction along multisegmental myofascial sequences, diagonals, or spirals rather than isolated muscles. Practitioners identify altered Centers of Coordination and Centers of Fusion, applying targeted friction to restore the gliding capacity of the loose connective tissue.

FM aims to reverse densification, normalize tension, and restore physiological gliding between fascial layers, leading to clinical improvements; a randomized controlled trial demonstrated that FM prevented the recurrence of ankle injuries in athletes with chronic ankle instability, with results maintained at one year follow up (Brandolini et al., 2019).

In conclusion, viewing the body through the lens of the integrated fascial system and targeting dysfunctional components with precise, individualized, globally oriented methods like Fascial Manipulation® offers a robust paradigm for treating chronic pain, movement dysfunction, and injury prevention.

References

1. Brandolini, S., Lugaresi, G., Santagata, A., Ermolao, A., Zaccaria, M., Marchand, A. M., & Stecco, A. (2019). Sport injury prevention in individuals with chronic ankle instability: Fascial Manipulation® versus control group: A randomized controlled trial. Journal of bodywork and movement therapies, 23(2), 316-323.

• Fede, C., Pirri, C., Fan, C., Petrelli, L., Guidolin, D., De Caro, R., & Stecco, C. (2021). A closer look at the cellular and molecular components of the deep/muscular fasciae. International journal of molecular sciences, 22(3), 1411.

• Pavan, P. G., Stecco, A., Stern, R., & Stecco, C. (2014). Painful connections: densification versus fibrosis of fascia. Current pain and headache reports, 18(8), 441.

• Pirri, C., Stecco, C., Fede, C., De Caro, R., & Özçakar, L. (2021a). Dynamic ultrasonography for assessing the nerve-fasciae relationship in entrapment syndromes. Medical Ultrasonography, 23(1), 118-119.

• Pirri, C., Stecco, C., Petrelli, L., Macchi, V., & Ozcakar, L. (2021b). Ultrasound imaging, anatomy and histology of nerves and fasciae: They never walk alone. International Journal of Clinical Practice, 75(4), e13956.

• Raghavan, P., Lu, Y., Mirchandani, M., & Stecco, A. (2016). Human recombinant hyaluronidase injections for upper limb muscle stiffness in individuals with cerebral injury: a case series. EBioMedicine, 9, 306-313.

• Stecco, A., Giordani, F., Fede, C., Pirri, C., De Caro, R., & Stecco, C. (2023). From muscle to the myofascial unit: current evidence and future perspectives. International journal of molecular sciences, 24(5), 4527.

• Stecco, A., Cowman, M., Pirri, N., Raghavan, P., & Pirri, C. (2022). Densification: Hyaluronan aggregation in different human organs. Bioengineering, 9(4), 159.

• Stecco, A., Pirri, C., & Stecco, C. (2019). Fascial entrapment neuropathy. Clinical Anatomy, 32(7), 883-890.

1. Stecco, C., Pratt, R., Nemetz, L.D., Schleip, R., Stecco, A. & Theise, N.D. (2025) Towards a

      comprehensive definition of the human fascial system. Journal of Anatomy, 00, 1–15.

1. Suarez-Rodriguez, V., Fede, C., Pirri, C., Petrelli, L., Loro-Ferrer, J. F., Rodriguez-Ruiz, D., … & Stecco, C. (2022). Fascial innervation: a systematic review of the literature. International Journal of Molecular Sciences, 23(10), 5674.