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Advanced Anatomy: Myofascial Meridians  (3 Continuing Education Hours)

This course is approved for 3 hours of Continuing Education for Massage Therapists by the Texas Department of State Health Services: Approved Provider: MARK SCOTT URIDEL CE0009  and for Registered Yoga Teachers by the Yoga Alliance. Mark S. Uridel is approved by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) as an approved continuing education provider.

This course provides foundational information about the myofascial system in the human body and indentifies the major myofascial meridians.  Pictures are provided to point out major anatomical structures and guidelines are given for the practical application of massage and yoga when working with the myofascial meridian system. The massage techniques are not demonstrated via video because on-line courses are not allowed to contain technique content.

Learning Objectives:  After reading this course, you will…

  • be able to describe the anatomy of fascia.
  • be able to explain the anatomy of the myofascial net.
  • be able to describe the anatomy of the myofascial meridians throughout the body.
  • be able to identify access points along the myofascial meridians for bodywork applications.

Introduction

In most anatomy courses, the emphasis is placed on the bones and muscles while the fascia, the connective tissue web that surrounds the muscle, is neglected.  This fascia not only surrounds the muscle, but invaginates the muscle tissue to the cellular level and morphs into the tendon that attaches the muscle to the bone. 

The fascia affects the structure and function of muscles and therefore it affects the posture and movement of our body. To disregard the fascia is to disregard a major component of our body structure that affects us down to the cellular level. As you see below, the epimysium surrounds the whole muscle, the perimysium surrounds bundles of muscle fibers and the endomysium surrounds individual muscle fibers. These all join at the end of the muscle forming the tendon.

Anatomy of Fascia

From basic anatomy we know that there are 4 tissue types: epithelial tissue, nerve tissue, muscle tissue and connective tissue.  Although we make distinctions between these tissue types, remember these tissues interact with one another in complex ways.  Epithelial tissue forms boundaries as in between our inner world and the outside world (eg. the skin) and between cavities inside our body (eg. membranes).  Epithelial tissue is also involved in secretion (eg. glands) and absorption (eg. intestinal wall).  Nerve tissue functions in communication and control.  It sends electrochemical signals from the brain to all parts of the body and back.  Muscle tissue has the primarily function of contraction, whether it is the cardiac muscle that contracts the heart, the smooth muscle that contracts around the blood vessels and our digestive tract, or the skeletal muscle that contracts to move us and hold our posture.  Connective tissue is the unique tissue that holds everything together.  On one end of the spectrum is loose areolar connective tissue like the visceral and parietal fascia that gently suspends the internal organs within their cavities and wraps them in layers of connective tissue membranes.  Cartilage is a type of connective tissue that gives cushion and support to our joints.  Ligaments connect from bone to bone providing passive support to our skeletal structure.  Bone is also considered a type of connective tissue and the outer coating on bone (the periosteum) is a type of fascia that provides a strong connection for ligaments and tendons.  Dense Connective Tissue (DCT) forms strong yet flexible connections between muscles and bone (eg. tendons) and also forms the deep fascial connections we will be looking at in this course.  The deep fasciae envelop all or our bones (periosteum and endosteum); cartilage (perichondrium), and blood vessels (tunica externa) and become specialized in muscles (epimysium, perimysium, and endomysium) and nerves (epineurium, perineurium, and endoneurium).

Fascia is composed of reticular fibers (collagen) and elastic fibers (elastin) in an extracellular matrix (ECM) aka ground substance.  The high density of collagen fibers is what gives the deep fascia its strength and integrity.  The amount of elastin fibers determines how much extensibility and resilience it will have.  These collagen and elastin fibers are suspended in a gelatinous extracellular matrix made of proteoglycans, fibrillin, fibronectins, laminin and polysaccharides like hyaluronic acid.
Proteoglygans (glycosaminoglycans) are carbohydrate polymers and are usually attached to extracellular matrix proteins.  Proteoglycans have a net negative charge that attracts water molecules, keeping the ECM and resident cells hydrated.  Fibrillin is a glycoprotein, which is essential for the formation of elastic fibers found in connective tissue. Fibrillin is secreted into the extracellular matrix by fibroblasts and becomes incorporated into the insoluble microfibrils, which appear to provide a scaffold for deposition of elastin.  Fibronectins are proteins that connect cells with collagen fibers in the ECM, allowing cells to move through the ECM. Fibronectins bind collagen and cell surface integrins, causing a reorganization of the cell's cytoskeleton and facilitating cell movement.  Fibronectins are secreted by cells in an unfolded, inactive form.  Binding to integrins unfolds fibronectin molecules, allowing them to form dimers so that they can function properly.  Fibronectins also help at the site of tissue injury by binding to platelets during blood clotting and facilitating cell movement to the affected area during wound healing.  Laminins are proteins found in the basal laminae of virtually all animals. Rather than forming collagen-like fibers, laminins form networks of web-like structures that resist tensile forces in the basal lamina. They also assist in cell adhesion. Laminins bind other ECM components such as collagen.  Hyaluronic acid in the extracellular space confers upon tissues the ability to resist compression by providing a counteracting turgor (swelling) force by absorbing significant amounts of water.  It is a chief component of the ECM gel. 

Reference: Kielty CM, Baldock C, Lee D, Rock MJ, Ashworth JL, Shuttleworth CA. Fibrillin: from microfibril assembly to biomechanical function. Biol. Sci. 2002;357(1418):207–17.

Several types of cells inhabit this matrix of fibers and ECM ground substance.  Fibroblasts are full-time residents of the ECM.  A fibroblast is a type of cell that synthesizes the extracellular matrix and collagen.  If the fascia is injured, fibroblasts are responsible for synthesizing the repair components that create scar tissue.  Adipocytes are fat cells that are sometimes present in fascia, especially in the superficial fascia just below the skin.  A mast cell (or mastocyte) is a resident cell of several types of tissues, including fascia, and contains many granules rich in histamine and heparin. Although best known for their role in allergy and anaphylaxis, mast cells play an important protective role as well, being intimately involved in wound healing and defense against pathogens.  Macrophages, white blood cells, are wandering part-time residents in fascia.  Their role is to phagocytose (engulf and then digest) cellular debris and pathogens either as stationary or as mobile cells, and to stimulate lymphocytes and other immune cells to respond to the pathogen.  Due to its diverse nature and composition, the ECM can serve many functions, such as providing support and anchorage for cells, segregating tissues from one another, and regulating intercellular communication.  The plasticity and pliability of our fascia is related to the quantity and quality of collagen and elastin fibers, the consistency of the ground substance and the hydration of the tissue.  Many factors influence this, like our diet, our posture and movement habits and the level of mechanical stress and mental/emotional stress in our lives.

The Myofascial Net

So you can see that fascia is a complex and important connective tissue in the body.  The fascia not only provides an important structural function, but is involved in communication, wound healing and immune function.  Fascia interpenetrates and surrounds muscles, bones, organs, nerves, blood vessels and other structures.  The Myofascial Net is an uninterrupted, three-dimensional web of connective tissue and muscles that extends from head to toe, from front to back, from interior to exterior.  Now we will explore the way the deep connective tissue fascia and muscles are interconnected throughout our body in continuous lines, or meridians.  This material is presented in a fairly linear fashion where one myofascia connects to another often with a boney attachment in between.  Some of the myofascial meridians are straight forward and some are more complex.  Ultimately, understanding the interplay of these meridians will be important to fully understand the practical application and functional implications of this information.  At the end of each section, I will attempt to provide this applied insight for bodyworkers and movement specialists.

The Superficial Back Line

The Superficial Back Line is a myofascial meridian that connects the entire back side of the body from the plantar surface of the toes to the brow-line of the frontal bone on the forehead. This symmetrical line originates on the plantar surfaces of the toe phalanges of both feet and follows the plantar surface of the foot, including the intrinsic flexors of the toes (quadratus plantae and flexor digitorum brevis) and the plantar fascia. 

Quadratus Plantae & Flexor Digitorum Brevis

Plantar Fascia

At this point the intrinsic flexor muscle tendons and plantar fascia attach into the calcaneus (heel bone) and the connective tissue wraps around the heel and unites with the Achilles tendon.  The Achilles tendon serves as an insertion for the triceps surae muscle group, which is comprised of the gastrocnemius and soleus muscles.

Achilles Tendon and Gostrocnemius Muscle

The gastrocnemius inserts on the left and right femoral condyles and functionally links to the hamstrings.  I say functionally because the gastrocnemius and hamstring tendons do not attach to the same place. The hamstrings are comprised of three muscles.  The semitendinosus and semimembranosus insert on the proximal medial tibia and the biceps femoris inserts on the head of the fibula.  So both the hamstrings and gastrocnemius cross the knee- the hamstrings from the top and the gastrocnemius from the bottom.  As they cross the knee, they come in contact with one another and when the knee is straight, they form a “functional link” in the superficial back line.  So, although there is not a true myofascial continuity here, when the knee is straight, it is "as if" these muscles are connected.  When the knee is bent, this functional link is broken and the superficial back line is divided into the lower leg portion and the upper portion (that we will now see). 

Functional Attachment of Gastrocnemius and Hamstrings

The hamstrings originate on the ischial tuberosity, sitting bone, and it is here that the hamstrings connect with the fibers of the sacrotuberous ligament.  The sacrotuberous ligament is a strong, wide and thick ligament that connects from the sacrum to the ischial tuberosity.  Since we have two sitting bones, there are two sacrotuberous ligaments that attach to the back of the sacrum on each side of the spine of the sacrum.  At this point, the sacrotuberous ligaments become continuous with the sacrolumbar fascia, the connective tissue attachments of the erector spinae muscle group to the lower back (lumbar vertebrae) and sacrum. 

Hamstrings- Ischial Tuberosity- Sacrotuberous Ligament - Lumbosacral Fascia

The erector spinae is a large muscle group made up of the iliocostalis muscles, longissimus muscles and spinalis muscles (lateral to medial)Each of these muscles overlaps its superior counterpart.  Iliocostalis lumborum overlaps iliocostalis thoracis, which overlaps iliocostalis cervicis.  Longissimus thoracis overlaps longissimus cervicis, which overlaps longissimus capitis.  Spinalis thoracis overlaps spinalis cervicis, which overlaps spinalis capitis.  These muscles all have myofascial continuity on their respective side of the spine.  At the top of the spine, these muscles attach to the base of the occipital bone.  Just underneath these muscle attachments are the suboccipital muscles.  Although not true structural components of the superficial back line, the rectus capitis posterior and obliquus capitis muscles are considered integral functional parts of the superficial back line.

The erector spinae attach at the base of the occipital bone at the superior nuchal line.  Here the superficial back line continues via the galea aponeurotica.  The galea aponeurotica (scalp fascia) is a tough layer of dense fibrous tissue which covers the upper part of the cranium (skull); in the back, it is attached to the occipitalis muscle, to the external occipital protuberance and highest nuchal lines of the occipital bone; in the front, it forms a short and narrow prolongation between its union with the frontalis muscle, which goes on to attach to the brow-line on the frontal bone.

This completes the myofascial anatomy of the Superficial Back Line.  Below is a visual summary.

Superficial Back Line

Yoga Applications

From an applied functional perspective, the superficial back line actively holds the body in an erect position when standing.  In strengthening backbend postures like salabhasana (locust pose), the superficial back line is activated anti-gravity and strengthened.  To see a graphic animated display of this yoga pose click on this link:    http://www.bandhayoga.com/flyarounds.html  (then click on salabhasana tab) Can you identify the key muscles of the superficial back line?

In forward bending postures, like uttanasana (standing forward bend), the superficial back line is stretched.  To see a graphic animated display of Uttanasana, click on this link and then click the uttanasana tab. http://www.bandhayoga.com/flyarounds.html (click on the uttanasana tab)

Massage Applications

In massage, I often spend considerable time using myofascial release techniques to release the erector spinae, including the lumbosacral fascia. This is an exellent place to begin lengthening work on the superficial back line (SBL). Particularly the lumbar erector spinae and lumbosacral fascia are often restricted and cause compression on the lumbar vertebrae. The cervical erector spinae are also an important access point for the SBL. Often there is tension in these muscles that can be released by inferior to superior stripping finger glides and OA release techniques. The hamstrings, gastrocnemius muscles and plantar fascia often respond to functional releases, which stretch the tissue in a more active way.  Many of my patients suffer from plantar fasciitis, inflammation of the plantar fascia.  To learn more about this condition, you can check out another course on this website, Research-Based Massage for Plantar Fasciitis

    Myers, Thomas.  Anatomy Trains. Harcourt Publishers. 2001.

 

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