Fascia provides structural and functional continuity between the body’s hard and soft tissues. It is a ubiquitous, elastic-plastic, sensory component that invests, supports, separates, connects, divides, wraps, and gives both shape and functionality to the rest of the body, while allowing gliding and sliding motions, as well as playing an important role in transmitting mechanical forces between structures. At least, that is how fascia behaves when it is healthy and fully functional. In reality, due to age, trauma, or inflammation, for example, fascia may shorten, becoming painful and restricted and fail to painlessly allow coherent transmission of forces, or smooth sliding interactions, between different layers of body tissues.1

Adaptation
One way of viewing fascia-related dysfunction that occurs gradually over time, happens suddenly following trauma or inflammation, or which may be part of inevitable age-related changes, is as physiological or biomechanical adaptation or as compensation. Neuromyofascial tissue contraction may result in varying degrees of pain-inducing binding, or “adhesions,” between layers that should be able to stretch and glide on each other, potentially impairing motor function.2
A process evolves that can be neatly summarized as “densification” of previously more pliable tissues, including fascia. This involves interference with complex myofascial relationships, altering muscle balance, motor control, and proprioception.3 These slowly evolving adaptive processes may become both habitual and built-in. For example, in an individual with a chronically altered postural pattern involving a forward-head position, protracted shoulders, a degree of dorsal kyphosis, and lumbar lordosis, there will be both a range of soft-tissue changes, fibrosis, etc., as well as the evolution of ingrained, habitual, postural patterns that are usually difficult to modify unless the chronic tissue features are altered via exercise and/or therapeutic interventions. Thomas Myers has expressed this progressive adaptive phenomenon as involving a process in which chronic tissue loading leads to “global soft-tissue holding patterns,” where clear postural and functional imbalance and distress are both visible, as well as being palpable.4
A shorthand summary of such processes may describe them as being the result of:
• Overuse—e.g., repetitive actions.
• Misuse—e.g., postural or ergonomic insults.
• Disuse—e.g., lack of exercise.
• Abuse—e.g., trauma.
• Any combination of these.
Whatever the single or multiple contributing features may be, the end result is of structural and functional modifications that prevent normal activity, result in discomfort or pain, and which, themselves, make further adaptive demands as the individual attempts to compensate for restrictions and altered use patterns.

Assessment objectives
When evaluating possible interventions, whether therapeutic or exercise related, it is important to ascertain which tissues, structures, patterns, and mechanisms may be involved. For example, is there any evidence of soft-tissue change involving hypertonicity or fibrosis? Is there joint or neurological involvement? Are the tissues inflamed? In other words: why is this happening? What causative or maintaining features are identifiable? What actions might usefully be taken to modify, improve, and correct the situation?
As a starting point, in order to encourage rehabilitation, areas of restriction need to be identified and assessed so that they can be encouraged toward normality. The question of how best to identify such pathophysiological changes is, therefore, one of the key challenges that face practitioners, before manual and/or movement therapies or modalities can be safely applied. Fortunately, a range of palpation and assessment tools is available to help achieve the identification and localization of dysfunction, as will be described later in this article.

Gathering evidence
Clinical decision-making needs to be based on a combination of the unique history and characteristics of the individual, combined with objective and subjective information gathered from assessment, observation, palpation, and examination. The findings of such information-gathering endeavors need to be correlated with whatever evidence exists, research studies, experience, etc., that offer guidance regarding different therapeutic choices. The objectives of palpation and assessment are, therefore, the gathering of evidence regarding function and dysfunction so that informed clinical decisions can be made, rather than being based on guesswork. What’s too tight? What’s too loose? What functions are impaired? Which kinetic and structural chains are involved? What are the causes? What can be done to remedy or improve the situation?
There are many functional assessment methods and protocols, as well as a variety of palpation methods that can assist in this search for information and answers. Some of these have been tested for reliability; others are used extensively without any clear evidence that they are reliable.
This leads to a key recommendation: no single piece of “evidence” gained from observation, or from the results of functional tests and assessment, or from palpation, should be used alone as evidence to guide clinical choices. It is far safer to rely on combinations of evidence that support each other and that point toward rehabilitation and/or treatment options.

Postural assessment
A general evaluation of posture and movement patterns offers initial clues as to areas that are either underactive or overactive in their ranges of motion or functionality.

Crossed syndromes
Patterns of imbalance, such as upper- and lower-crossed syndrome patterns, have classically been interpreted as demonstrating hypertonic extensor muscles overwhelming inhibited abdominal flexors.5
P. E. Greenman explained this perspective as follows: “Muscle imbalance consists of shortening and tightening of muscle groups (usually the tonic ‘postural’ muscles), and weakness of other muscle groups (usually the phasic muscles), and consequent loss of control on integrated muscle function. The lower-crossed syndrome involves hypertonic, and therefore shortened, iliopsoas, rectus femoris, tensor fasciae latae, the short adductors of the thigh, and the erector spinae group with inhibited abdominal and gluteal muscles. This tilts the pelvis forward on the frontal plane, while flexing the hip joints and exaggerating lumbar lordosis.”6 In addition, it is not uncommon for the quadratus lumborum to shorten and tighten, while the gluteus maximus and medius weaken. The upper-crossed syndrome involves, among other muscles, hypertonic cervical extensors, upper trapezius, pectorals, and thoracic erector spinae, with inhibited deep-neck flexors and lower fixators of the shoulders.
J. Key’s research team noted that this pattern may involve “a posterior (pelvic) shift with increased anterior sagittal rotation or tilt,” together with an anterior shunt/translation of the thorax and the head.7 In such instances, diaphragmatic control and altered pelvic floor function might result.

The soft-tissue palpation puzzle: Problems are not necessarily where they appear to be!
In the descriptions of crossed syndromes, individual muscles are named. However, it has become obvious in recent years that the concept of individual muscles is flawed. The multiple fascial connections between “named” muscles and other muscles means that their action is not independent. Force is transmitted in many directions, offering muscles additional leverage and functionality, as well as adding load to sometimes-distant muscles. Individually named muscles can no longer be considered to be discrete and separate, operating individually. P. Huijing has pointed out that agonists and antagonists are coupled structurally and mechanically via the fascia that connects them, so that when force is generated by a prime mover it can be measured in the tendons of antagonist muscles.8
A. Franklyn-Miller and colleagues have shown that, for example, a hamstring stretch produces 240 percent of the resulting strain in the iliotibial tract and 145 percent in the ipsilateral lumbar fascia compared with the hamstrings.9 Strain (load) transmission, during contraction or stretching, therefore affects many other tissues beyond the muscle being targeted, largely due to fascial connections. Importantly, this suggests that apparent muscular restrictions, such as “tight hamstrings,” might not originate in the affected muscle but elsewhere. In the case of hamstring restriction, there may be fascial dysfunction in the tensor fascia lata, or the ipsilateral thoracolumbar, creating, encouraging, or maintaining hamstring symptoms. This sort of fascial interconnectedness exists throughout the body, so as knowledge accumulates as to what structures are linked to others via fascia and at which orientation, understanding sources of dysfunction should become more predictable.

Palpation and assessment and load-transfer: The thoracolumbar fascia
Palpation and assessment strategies need to take account of this load-sharing phenomenon. The scale of the palpation puzzle can be seen in the illustration of the huge number of potential links available from just one massive fascial structure, the thoracolumbar fascia. This ties together the erector spinae, latissimus dorsi, quadratus lumborum, psoas, transversus abdominis, and diaphragm muscles, as well as countless other minor muscle structures.

Unraveling the puzzle
As we focus attention on the assessment of relative shortness in named muscles, we need to maintain awareness that multiple fascial connections exist that bind together muscles with different names into a virtual interconnecting tensegrity structure. An important distinction needs to be made in our search for culprit areas of restriction. There is a need to identify both the location of restriction (for example, shortened hamstrings), as well as the source of the restriction that could be in the hamstrings, but also possibly in the thoracolumbar fascia or elsewhere.
Testing particular key muscles for relative restriction/loss of full range of motion, as well as for functional efficiency, allows a more focused evaluation as to where restrictions exist. There are strategies that can help to identify areas that may be responsible for dysfunction:
1. General observation: e.g., of normal posture and movement, such as standing and walking as described above.
2. Observation of functional movements or postures: e.g., walking, long-sitting, and bending, as well as V. Janda’s hip abduction and hip extension tests.10
3. Specific tests for muscle shortness: (see Table 1, Postural Muscle Assessment Sequence, available online at www.massageandbodywork.com).
4. Direct manual palpation: see palpation exercises described later.

Functional assessment: Hip abduction test, hip extension test
There are hundreds of functional assessment methods that offer evidence of overuse, inhibition, restriction, and other aspects of dysfunction, as well as, potentially, discomfort or pain, when being demonstrated. Due to space constraints, just two examples are described below.

Hip abduction test
This assessment can be performed by including palpation; however, it is possible that adding digital touch to the muscles being evaluated would add sensory motor stimulation that might reduce the reliability of any findings. Observation alone is encouraged initially, with direct palpation being added subsequently.
The aim of this test is to screen for stability of the lumbopelvic region. The client should be side lying with the superior leg resting on the lower leg, which is flexed at the hip and knee (Image 3A). The uppermost leg should be in line with the torso. The client is requested to slowly lift the leg toward the ceiling. If normal, the leg should abduct to 20 degrees with no internal or external rotation, or hip flexion, and without any ipsilateral “hip-hike” (pelvic cephalad elevation). There should be an initial moderate contraction of the lumbar erector spinae and/or quadratus lumborum, in order to stabilize the pelvis. However, this should not involve any obvious contraction, merely an indication of toning.
The test is regarded as positive if any of the following are observed:
1. Ipsilateral external hip/leg rotation which suggests overactivity and probable shortening of the piriformis.
2. Ipsilateral external pelvic rotation, which suggests piriformis and other external hip rotator overactivity and probable shortness.
3. Ipsilateral hip flexion, which suggests overactivity and probable shortening of the hip flexors, including the psoas and/or tensor fascia latae.
4. Cephalad elevation of the ipsilateral pelvis before 20 degrees of hip abduction, which suggests overactivity and shortening of the quadratus lumborum.
5. An obvious hinging should be noted at the hip, rather than in the waist area, if the gluteus medius and tensor fascia lata are working optimally, and the quadratus lumborum is not overactive.
6. Any pain reported in performance of the abduction movement. For example, discomfort noted on the inner thigh may represent adductor shortness.
7.     Any combination of the above.

Hip extension test
The aim of this test is to evaluate coordination of a number of muscles during prone hip extension (Image 3B). The client should lie prone with the arms at the side and feet extending beyond the table end. The client is then requested to lift a specific leg toward the ceiling. An initial toning contraction of the thoracolumbar erector spinae, to stabilize the torso before the limb extends, is considered normal if the action is achieved by coordinated activity of the ipsilateral hamstrings and gluteus maximus.
The test is considered positive if any of the following are observed:
1. Knee flexion of the extended leg suggests overactivity and probable hamstring shortness.
2. Delayed or absent ipsilateral gluteus maximus firing. Absence of a meaningful contraction of the gluteus maximus at the outset of the extension movement is considered significant, as this should be a prime mover. Inhibition may indicate overactivity of the erector spinae group and/or of the ipsilateral hamstrings.
3. False hip extension: the hinging/pivot point of the leg, during the first 10-degree extension, occurs in the low back rather than at the hip itself, suggesting overactivity of the erector spinae and inhibition of the gluteus maximus.
4. Early contraction of the contralateral periscapular musculature suggests a functional low-back instability, involving recruitment of the upper torso as compensation for inhibition of the intended prime movers.
Observed posture, together with observation of movement patterns, as well as in long-sitting, hip abduction, and hip extension tests, offers clues as to which muscles/groups of muscles may be overactive and potentially shortened, and which may be inhibited. This information can be refined by testing specific muscles for shortness, as indicated in Table 1 (available online at www.massageandbodywork.com).
Having identified muscles with reduced range of motion, local areas, or areas distant from them, may be sought that could be affecting them. These may then be usefully assessed (see discussion of thoracolumbar fascia, page 67).

ARTT palpation features of local dysfunction
Fascial, or general musculoskeletal dysfunction, involving pain and/or restriction, for example, is commonly associated with a number of predictable features that can be summarized using the acronym ARTT:
A stands for asymmetry, since one-sided fascial dysfunction is more usual than bilateral.
R stands for range of motion restriction. In almost all cases of fascial or general musculoskeletal dysfunction, there will be a reduction in the range of movement available to the tissues involved.
T stands for tenderness or sensitivity/pain, which is common but not universal. A research team led by G. Fryer confirmed that sites in the thoracic paravertebral muscles, identified by deep palpation as displaying “abnormal tissue texture,” also showed greater tenderness than adjacent tissues characteristic of dysfunction.11 Fascial dysfunction frequently involves a particular quality of a sharp, cutting, or burning sensation when moved, compressed, or stretched.
T stands for textural or tissue changes. Dysfunctional tissues are commonly associated with hypertonicity, fibrosis, induration/hardening, edema, or other palpable modifications from the norm. Fryer’s team also examined the possibility that tissue texture irregularity of paravertebral sites might be due to greater cross-sectional thickness of the paraspinal muscle bulk.12 Diagnostic ultrasounds showed that this was not the case. Changes in the “feel” of fascia, when dysfunctional, have been described as “densification”: a word that neatly summarizes what is commonly palpated. Another Fryer team research project examined the EMG activity of deep paraspinal muscles, lying below paravertebral thoracic muscles with “altered texture,” that were also more tender than surrounding ones. This demonstrated increased EMG activity in these dysfunctional muscles (i.e., they were hypertonic).13
All four elements of ARTT are not always apparent when dysfunctional tissues are assessed/palpated. However, it would be unusual for there to not be at least two, and ideally three, of these characteristics in evidence when fascia is functioning other than optimally.

ARTT exercise
Have the client stand flexing from the waist, as you stand in front, viewing the paraspinal musculature from the head. One side of the paraspinals will commonly be more “mounded” than the other. Note the level at which this occurs, and have the individual lie prone.
In this example, let’s assume it is the lower thoracic/upper lumbar area on the left. At this stage, you will have established that the “A” (asymmetry) in ARTT is identifiable. Now palpate both left and right sides of this area of the back in order to evaluate the relative tone on each side. The more mounded side, left in this example, will inevitably be felt to be “tighter,” more hypertonic.
Testing for the “R” element of ARTT is easily achieved by gently attempting to lengthen the paraspinal tissues, either via simply pressing into them, or by trying to flex the tissues laterally with your thumb, finger, or hand. There will be reduced range of motion on the hypertonic shortened side.
Once you have sensed the difference in tone, one side to the other, palpate a little deeper into the musculature, possibly from a slightly lateral angle rather than vertically, and sense any differences you can identify in the texture of the tissues. It should usually be possible to sense greater rigidity and possibly, depending on chronicity, some fibrotic elements on the hypertonic side. If so, you will have established one of the “T” (texture or tissue) elements of ARTT.
Pressure applied into the tissues on each side should establish that, in most instances, the hypertonic side will be tender (producing the second “T”) in ARTT.
Translating ARTT into fascial assessment is less obvious than when applying it to muscles or joints, since many fascial restrictions may be deep and not directly palpable. However, superficial fascia and loose areolar tissues are easily evaluated.

Exercises: Skin and fascia palpation
Ideally, the exercises here should be practiced on “normal” tissue as well as on areas where dysfunction is apparent or suspected. In addition, practice on tissues that are overlying large muscle masses and also where there is minimal muscle between the palpating contact and underlying bone. The more variety of tissues, and individuals of different ages and physical condition, that are involved in palpation exercises, the more rapidly palpatory literacy will be achieved.14

Exercise 1
Skin drag
• Remove any watches or jewelry before starting the exercise.
• With no pressure at all, only the very lightest of touch of one or two finger pads, stroke the skin of the area where the watch had been, so that you move from skin that was not covered by the strap, to cross over that area and back again several times.
• Do you notice an obvious difference as you cross this more “moist” area, compared with the dryer areas?
• Increased skin hydrosis (sweat) changes should be palpable. What you are feeling is known as “drag,” and you are using drag palpation to identify increased hydrosis, which is often associated with hypertonicity, tissue dysfunction, and fascial resistance to sliding.
• When you are comfortable that you can recognize the feeling of drag and using no pressure at all, only the very lightest of touch of one or two finger pads, stroke the skin of your anterior thigh (for the purpose of this exercise), in various directions.
• Then do the same on the lateral thigh, overlying the densest aspects of the iliotibial band.
• Try to sense and identify areas of drag. These will be far less obvious than the area under a watch strap, but should make themselves known when smooth finger movement over the skin becomes slightly “rough.”

Exercise 2
Sliding and rolling superficial fascia
• Place two or three finger pads on the skin of the anterior thigh with minimal compressive force (ounces only) and slide it (the skin together with superficial fascia, to which it is bound) toward the knee, until you feel resistance. Then return to where you started and slide the skin toward the hip.
• Compare the ease of movement in one direction with the other.
• Was there greater resistance in one direction or the other?
• Perform the action over areas that displayed drag sensations, as well as those that did not.
• Now perform the same actions on the lateral surface of that leg, overlying the iliotibial band. Compare ease of movement with the anterior surface, or areas free of drag, as well as those displaying drag.
• After exploring one leg, perform the same evaluations on the other leg, as well as in other easily accessible areas of the body, such as the anterior and lateral calf areas, comparing and remembering the different feel of these tissues as you lift, slide, and roll them.
• Compare your findings. Was there greater resistance to sliding skin/superficial fascia in some locations compared to others, and did this correlate with drag?
• Was there greater resistance on one surface of the leg, or one aspect of the leg, compared with the other?
• What differences did you notice when trying to perform the same exercises on areas with little muscle cover, or where there were dense fascial layers (iliotibial band)?

Exercise 3
Testing skin elasticity
• Now gently hold a pinch of skin between your index and middle finger pads, and your thumb in an area already tested for skin “slideability,” as in Exercise 2.
• Lift this to sense its degree of elasticity, which will differ greatly in different areas of the body.
• What you are holding is skin and superficial fascia, together with some of the adipose/areolar/loose connective tissue that lie between those layers and the underlying dense connective tissue. This “loose” material includes a variety of cells and substances, such as proteoaminoglycans, which facilitate the slideability of the various layers of tissue on each other.
• When this facility is reduced or lost, dysfunction, restriction, and pain are almost inevitable consequences.
Repeat this light pinch-and-lift in various parts of the thigh, both where there is a thick layer of muscle and also where there is minimal muscle and more fascial tissue.
• Now see if you can “roll” the skin and superficial fascia between fingers and thumbs, in the different areas you are testing, in various directions.
• Did you notice that where reduced sliding (Exercise 2) was observed, skin is less easy to lift/stretch and roll?
• In general, the greater the degree of underlying hypertonicity and shortening, the greater will be the resistance to free sliding on underlying structures of the skin/superficial fascia.
• In many instances, there will be a correlation between drag, and lack of easy sliding capacity, and loss of elastic quality.
Note that several elements of ARTT are being demonstrated via this exercise. A degree of increased tenderness is also likely in areas where drag is noted, where there is reduced ability to slide and to roll. Sometimes rolling the tissue will be more uncomfortable, adding the final element of ARTT (tenderness).

Exercise 4
Apply tests 1, 2, and 3 to somebody else’s sacrum and/or lower back and, as you do so, try to evaluate directions of relative restriction in the ability of superficial tissues to slide. You are now on your way toward palpatory literacy.

Clinical summary
• Global evaluation via observation— static and during movement— offers indications of areas that are restricted or dysfunctional.
• Functional assessments allow you to identify specific structures that deserve further investigation.
• Direct palpation isolates local areas of tissue change.
Your only remaining concern is what to do about what you have identified. Fascia in Sport and Movement (Handspring Publishing, 2015), from which this article was adapted, offers solutions to those concerns.

Notes
1. Helene Langevin et al., “Ultrasound Evidence of Altered Lumbar Connective Tissue Structure in Human Subjects with Chronic Low-Back Pain,” presentation at 2nd Fascia Research Congress, 2009.
2. F. Grinnel, “Fibroblast Mechanics in Three-Dimensional Collagen Matrices,” Fascia Research II: Basic Science Implications for Conventional and Complementary Health Care (Munich: Elsevier GmbH, 2009); W. Fourie and K. Robb, “Physiotherapy Management of Axillary Web Syndrome Following Breast Cancer Treatment: Discussing the Use of Soft-Tissue Techniques,” Physiotherapy 95 (2009): 314–20.
3. L. Stecco and C. Stecco, Fascial Manipulation: Practical Part (Italy: Piccini, 2009).
4. Thomas Myers, Anatomy Trains, 2nd ed. (Edinburgh: Churchill Livingstone, 2009).
5. V. Janda, “Evaluation of Muscular Balance,” in Craig Liebenson, ed: Rehabilitation of the Spine (Baltimore: Williams & Wilkins, 1996).
6. P. E. Greenman, Principles of Manual Medicine, 2nd ed. (Baltimore: Williams & Wilkins, 1996).
7. J. Key, Back Pain—A Movement Problem: A Clinical Approach Incorporating Relevant Research and Practice (Edinburgh: Churchill Livingstone, 2010).
8. P. Huijing, “Muscular Force Transmission: a Unified, Dual, or Multiple System,” Archives of Physiology and Biochemistry 107 (1999): 292–311.
9. A. Franklyn-Miller et al., in Fascial Research II: Basic Science and Implications for Conventional and Complementary Health Care (Munich: Elsevier GmbH, 2009).
10. V. Janda, 1996.
11. G. Fryer, T. Morris, and P. Gibbons, “The Relationship Between Palpation of Thoracic Paraspinal Tissues and Pressure Sensitivity Measured by a Digital Algometer,” Journal of Osteopathic Medicine 7 (2004): 64–9.
12. G. Fryer, T. Morris, and P. Gibbons, “The Relationship Between Palpation of Thoracic Tissues and Deep Paraspinal Muscle Thickness,” International Journal of Osteopathic Medicine 8 (2005): 22–8.
13. G. Fryer, T. Morris, and P. Gibbons, et al., “The Activity of Thoracic Paraspinal Muscles Identified as Abnormal with Palpation,” Journal of Manipulative and Physiological Therapeutics 29, no. 6 (2007): 437–47.
14. Leon Chaitow, Palpation and Assessment Skills (Edinburgh: Churchill Livingstone, 2010).

Leon Chaitow, ND, DO, is a director of the Ida P. Rolf Research Foundation and Honorary Fellow of the University of Westminster in London. For more information, visit www.leonchaitow.com.