One of the panelists at a large international conference that I recently zoom-spoke at (about ‘demystifying anatomy for everyday use’) asked me what I think about fascia. It was an excellent question, especially as she’d done her research and had found out that this is a subject that I’m passionate about.
Having researched and written a doctoral thesis and then a few academic publications about fascia, I could have answered her question in several different ways … and at potentially yawn-inducing length! But that wasn’t what her question was about. She wanted me to say something short and to-the-point that might be interesting to the audience she was representing. My allocated time was running out, so whatever I said also needed to be short and clearly expressed. I paused as I reflected on how best to reply, then couldn’t help but smile with the word that popped into my head! It seemed so right for that setting, even though I’d never thought to use it before then.
My respect for this particular audience – most of whom were senior and highly accomplished Indian anatomists and medical faculty members (i.e., far more senior, and highly accomplished anatomists than I) – meant that I began by acknowledging that fascia is a ‘contentious’ (i.e., controversial) subject. I couldn’t assume that we thought about it in the same way. In fact, I suspected this was highly unlikely.
The head-nods that followed suggested that they appreciated this answer … and were possibly open to my briefly expanding on this. Which I did – by saying that people’s understanding of fascia varies in accordance with the ways it is perceived (reminding them about the parable of the six blind men examining an elephant), and is used (i.e., is therapeutically interpreted and applied) in a variety of academic and clinical contexts.
Fascia is a widely used anatomical term yet, ever since its early 17th century entry into English medical language, it has been accompanied by lots of vagueness, ambiguity, and confusion about which part(s) of the body this term specifically refers to. Over time, the word fascia has variously been used to relate to, for example: some, or all, of the body’s membranous parts; many distinct (i.e., dissectible) sheets and sheaths of dense fibrous tissue; several distinct (superficial, deep, and visceral) connective tissue layers; a distinct type (or types) of connective tissue; and a three-dimensional, global continuum of soft connective (fascial) tissue (Adstrum & Nicholson, 2019).
Little wonder that Susan Standring, Editor-in Chief of Gray’s Anatomy (the ‘gold standard’ clinical anatomy textbook) described fascia as a “generic term” that is anatomically “applied to sheaths, sheets or other dissectible masses of connective tissue that are large enough to be visible to the unaided eye” as well as the tissue from which they are composed (2016, p. 41).
Around about the first decade of the 21st century, fascia began to be explicitly studied by many different types of scientists and health care practitioners – including, but not mostly (as in the past), anatomists and surgeons. Their wide-ranging interests in, means of obtaining, and therapeutic application of the knowledge obtained from their multiple-discipline-spanning research findings soon revealed that, between them all, they too had some quite different ideas about what the word fascia meant to them. Was it a dissectible piece of tissue? The tissue that made up the dissectible pieces of fascia? Or a whole body-pervading web of a soft tissue substance that assumed a variety of function-related textures and forms?
A historical lack of clear definition meant fascia was concurrently being interpreted to mean any or all three of these things – a type of body tissue (or structural element), a type of dissectible body part (cf. body organ), and a type of organ system. This ambiguity was coupled with disparities in the way fascia was being portrayed in medical dictionaries, anatomy textbooks, scientific research reports, in different countries, and in different clinical professions. Everyone had their own ideas about what fascia was, and (just like the six blind scholars who described an elephant) sort of assumed that everyone else thought about it in the same way. The problem was that they didn’t.
Once they realised what was happening, alarm bells rang within the emerging multidisciplinary fascia research community. Their members were rightly concerned that erratic use of this word to refer to any of several types of body part was interfering with people’s (not least their own) understanding of, and communication about, fascia (Adstrum et al., 2017). The international anatomy profession also seemed to be experiencing some difficulty with reaching a consensus nomenclatural agreement about which parts of the body may (or may not) be legitimately regarded as fascia. The longstanding uncertainty about the definition of fascia – and the confusion and controversy that had long gone with it – had clearly become a problem that could no longer be ‘swept under the carpet’ and quietly ignored.
For health care professionals, anatomists, and other types of scientists, it is vital that every anatomical term (including fascia) explicitly relates to one and the same type of body part. If it doesn’t, any ambiguity needs to be fixed, and fixed fast. Fortunately the fascia research community was able to do this by devising, and publicly proposing the use of, two new anatomical terms – ‘a fascia’ (Stecco & Schleip, 2016), and ‘the fascial system’ (Adstrum et al., 2017; and Stecco et al., 2018) – which might, with any luck, help people say what they meant, and know what others were saying, when they talked about fascia.
As a result of fascia research community’s discussions, the following terms are now increasingly being used to help people distinguish between the following four different (yet overlapping) aspects of fascia:
Anatomical knowledge of fascia – including the language used to express it – is created, interpreted, and utilised by people. This means that there will be many ways of describing it, which won’t always be entirely commensurable or in agreement … and will most likely continue to change over time.
This in turn raises questions about how we might best (constructively) deal with the here-and-now existence of several different (albeit overlapping) sets of fascia-relating knowledge.
- Do we choose to ignore this demonstrable variability in the interpreted meaning of the term fascia, and blithely carry on with our usual (whatever flavour of ‘usual’ that may be) understanding about what fascia is? This may be necessary for some people – especially if their conforming with a particular viewpoint is linked to protecting their professional reputation and future career prospects.
- Do we accept that there is now a range of ways people think about fascia? If so, do we regard them as co-existing alongside, competing with, or complementary to each other? Not everyone is academically equipped or has the time to do this.
- Do we make a point of gathering information and learning some more about them all? This may be professionally sufficient for some people … yet not everyone is academically equipped or has the time to do this.
- Are we willing to combine the information pertaining to several sets of people’s ideas about develop more complex, and possibly richer, integrative anatomical understandings of fascia. Again, not everyone is academically equipped or has the time to do this, although it already appears to have begun, to a variable extent, within the nascent interdisciplinary fascia research environment.
Whatever your present way of thinking about fascia might be, it is important to realise that there is no one ‘right’ way of answering these questions. In reality, there are many ways of validly perceiving and relating to fascia … so it is important that we are all very clear in saying which one of them we are using when we are communicating about fascia with others – be they our ‘higher ups’, peers, colleagues, publications’ readers, students and patients. None of us can afford to presume that whoever we are communicating with thinks about fascia in the same way as we do (whoever we are).
If we want to talk about fascia with others, it helps if we are considerate and well-mannered about doing this. In practice, this might mean:
- Acknowledging that you are aware that fascia means different things to different groups of people
- Explaining how you are interpreting this term, and also,
- Respectfully finding out what this term means to them.
Doing this with a generous and open mind has potential to help us all learn some new and potentially useful things about bodies, fascia, and health care from each other.
Adstrum, S., Hedley, G., Schleip, R., Stecco, C., & Yucesoy, C. A. (2017). Defining the fascial system. Journal of Bodywork and Movement Therapies 21(1): 173-177.
Adstrum, S., & Nicholson, H. (2019). A history of fascia. Clinical Anatomy 23(7):862-870.
Standring, S. (Ed.). (2016b). Gray’s anatomy: The anatomical basis of clinical practice (41st ed.). Edinburgh, UK: Churchill Livingstone.
Stecco, C., Adstrum, S., Hedley, G., Schleip, R., & Yucesoy, C. A. (2018). Update on fascial nomenclature. Journal of Bodywork and Movement Therapies 22(2): 354.
Stecco, C., & Schleip, R. (2016). A fascia and the fascial system. Journal of Bodywork and Movement Therapies 20(1): 139-140.