Shoulder ReHab pt 3: Only Skin (or Fascia) Deep? Yes, It's a money move

Last week, in part 2 of the right shoulder rehab story, we looked at how a nerve running past the liver and into the diaphram might be adding to shoulder noise. That was - for me - a very new idea in looking at right shoulder rehab. This week, we're back stepping from the edge of the new to some of the lessons learned in my left shoulder revelation might apply on the right and accelerate right side recuperation. In particular, we're focusing on the Skin and Fascia - and their movement.

Superficial dissection showing fiberous
fascial layer of shouler, head, neck.

One of the key things i learned in that dramatic (to me) treatment session on the left shoulder was an object lesson in the site of pain is not the source of pain. Frickin Doh!. Muscularly, this meant that while i was having a big biceps tendon issue, the thing firing up the biceps was around the extensors and brachioradialis. We'll look more at muscle investigation and muscle work, next time.

But a related lesson to this muscle work was skin and fascia work: that sometimes if we don't assess and work with the skin and fascia - while doing all the other good movement stuff - we miss an opportunity to accelerate a path to performance increase (pain decrease).


Only Skin Deep - or a little deeper. 
So, today, looking at lessons from the left shoulder and my actions from that on the right shoulder, lets consider the stuff above the muscle that connects the muscle, guts, bones, etc. In other words, let's look at the both the skin and under skin, the fascia.

Sometimes working these layers can be an incredible way in to performance improvement, as i learned with my left shoulder and have seen again with my right.

Aside: i KNOW this stuff - about skin and fascia work as part and parcel of muscle/joint/visual/vestibular work - what i'm describing below is the kind of work i do regularly with clients. Somehow, sometimes, when we're looking at ourselves we forget our own deliberate practice. Pain, i think, makes us stupid.  So i offer the following thoughts for all of us coping with our own pain who mayn't be thinking straight about it. 

A little about Skin. Skin is called the biggest single organ of the body. Like the heart is an organ, the skin is an organ. It's also the biggest component of an entire system in the body, the integumentary system (one of 11 systems we run). On the organ side (like the heart that pumps blood or lungs to refresh our air supply) the skin is far more than a single function organ. It is deeply involved with managing homeostasis: it contributes to regulating system temperature, and also protecting us from abrupt temp changes; it is a barrier to infection; it is a waterproof casing; it is a protective wrapper to more delicate tissue beneath it. The skin is where the action is for getting vitamin D out of the sun.

skin deep: it's actually pretty deep.

On top of these roles, the "cutaneous distribution" of nerves means that we feel things through the skin that affect our position in space, and how we respond to our space. We feel heat, cold, pressure, and so on at the skin layer. Many nerves that have motor functions also have sensory functions - and a cutaneous distribution - so sometimes just working at the skin level of a muscle's nerves or related nerves can have a powerful effect. How deep is the skin? How hard can you press without your cuticles going white? That's all skin stuff.

How the skin feels is important. Signals go in; signals go out. There are directions to skin movement that tell us a lot about its healthy or not movement, too.

Myers's anatomy trains is
a popular intro to
fascial layers,
connections and
movements

A little about Fascia.  Beneath the skin layers are fascial layers. The role of the fascia is a new country for discovery.  Many folks are coming to the fascia via the book Myer's Anatomy Trains. Myer's work seems highly influenced by much earlier German work by Hoepke in 1936, Das Muskelspiel des Menschen - showing that the under wrapping of the body the layers that connect muscles and groups of muscles to each other along with other tissue, organs, bones, is a neurologically active wrapping. That means it's responsive. Nerves innervate tissue for a purpose; nerves run into the fascia. What's happening?

Some very interesting contemporary work at Ulm University in Germany at the Fascia Research Project is focusing on the active contractility of the fascia. Muscles contract. These researchers, in particular Robert Schleip, are looking at how fascia has active properties to act *actively* in a muscle-like way (their pdf describing this model of fascia).

Fascia Between Muscle Fibers

Indeed, part of anatomy trains is that the fascia is plastic: it can get wound (as in fascia-as-sheet(s), hence fascial winding) in a direction that has effects along the line of its connection through the body, pulling the rest of the body along to comply with this dissonant shape. Thus, the fascia must be likewise be unwound (often manually is the suggestion) to get back to an appropriate form to enable appropriate mechanical function.

That view kinda presents the fascia as more like playdough: the fascia takes the shape of the stresses upon it and holds that shape.

The Fascia Research Group suggest that fascia is more (re)active in its responsiveness to movement. Likewise they suggest that there is a nociceptive function to fascia - that when it is damaged, it may connect to musculoskeletal pain (pdf review).

If fascia is actively engaged in our bodies' structural integrity and it's responding actively to movement issues, and if there is this direct component around nociception, then perhaps working actively with the fascial layer in movement for improving performance is a good idea.

Skin and Fasica - so what? Well, it's part of a path. How many folks when they go see a physio or chiro have that specialist check the movement of the skin or fascia layer around the nerves of a given muscle firing up a pain cry? Or, even if there's no pain, but say one's shoulder press is seemingly stuck, think to check skin/fascial barriers to multi-directional movement?

Turns out that often a little bit of checking of skin/fascia restrictions can yield a whole lot of improvement in range of motion, performance, decrease in pain. It's worth knowing if your coach or carer or therapist works with skin/fascia in a pain free way.

No Pain, No Pain.  Why do i say pain free? After all, some folks LOVE a  massage that just reefs into the deep tissue (i.e. muscle) and just makes one grit one's teeth until the muscle or whatever just lets go. Like pounding one's head against a wall, it feels so good when it stops. Well, yes, that's one way to freak out the nervous system. But pain - and that's what that kind of presure can be - causes startle. Startle's a threat response; it's a shut down/protective response. And who or what performs better under threat, while freaking out?

It seems there are alternative ways to work with skin and fascia that achieve the same ends -  even actively to get good motor learning - that do not induce more startle, more threat.

If you're curious about why such pain free tissue work is "just as good as" the stuff that makes one weep, i'd recommend Eyal Lederman's Sciene and Practice of Manual Therapy. It has a lovely discussion of how tissue moves, and how working with that - actively and necessarily without pain - creates positive performance benefits.

A part of such an active (vs manual) approach to engage with the skin or fascia - once a direction of effective action has been detected - a next step may simply be to bring active awareness to that part of the body.

Enter Kinesio Tape.
 There is a well known process in physical therapy that talks about this kind of skin based stimulation - just rubbing gently on an area to bring awareness to that area. Sometimes that's all one needs to help sort out a movement issue. It's a powerful tool for helping address muscular amnesia, for instance - where a muscle just doesn't fire when it should - the body has developed what's become known as sensory motor amnesia, as Thoman Hanna puts it.

Sometimes one needs simply to bring a little awareness to an area to get it to turn on again. With my left shoulder, working with skin and fascial movement assessments showed that there was relief and improved range of motion with just a little bit of a shift in an area of fascial action. How was this tested? Gosh - gently holding the fascial layer in that direction while moving: is range of motion improved? Pain go down? Great, let's bring some awareness to that area.

With my right shoulder, knowing from various Z-Health courses like 9S: Strength and Suppleness and from T-Phase a bit about skin stim, muscle activation and various neural connections, and remembering my own left side rehab, i started exploring myself if there were directions in moving or stimulating either fascia or just skin in my shoulder or arm or neck area (going with all the nerve pathways that can affect the shoulder) that allowed greater range of motion/less pain. Yes. There were. Quite a few.

Kinesio Tape - the
origintal: accept
no substitutes

And so also using some knowledge of the application of kinesio tape - an amazing stuff that supposedly works with the skin/fascia to support movement (what they call lifting) in a given direction - i applied a wee bit of it to an area with appropriate directional testing, and then immeidately retested my arm. Improvement. I'll take it.

I've made the soggy error of laying down a bit of tape after testing direction only to have missed the spot. This stuff does not like being relaid. So ya grit your teeth and chuck that expensive bit of therapy assist and try again. Measure twice as they say. It's this retesting immeidately that is SO important.

Over the next couple days i had a wee pattern of tape - about three pieces - deployed with this test/retest approach to see what was working to support improved movement/performance. The tape stayed on for three to five days, and seemed to help deliver what was on the tin.

Active Skin Stim? The kinesio tape - it seems - whether it's designed to work this way or not - seems to have the effect of bringing a low level but constant awareness to an area where skin level direction of movement has an effect. It seems to offer a way to get reps in - to help the skin and perhaps underlying fascia move in a more optimal direction - or perhaps being taped towards a given direction that tests well is just opening up better neural awareness so that Good Things Happen.


Take Aways: Respect the Fascia

• For some, some level of guided skin or fascial support is sufficient to let them "fix" their issue. I've seen this numerous times with mine and others clients, and it always amazes me. 
• This layer or suites of layers covering our bodies and interconnecting other systems (muscular, skeletal, visceral) is not to be underestimated or forgotten in treatment.
• Learning how to work with these layers - a big focus of zhealth t-phase as one example for where such education happens - can lead to potent results.
• Sometimes, as an awareness assist, a bit of kinesio tape it seems can help the body learn this new movement pattern at the skin/fascial level. Kinesio tape is an active movement support. Sometimes, that tape isn't necessary, but it's a nice tool when it is.

For me, working with just the fascial/skin layers was not the total killer ap for my left shoulder or my right, but it was a HUGE contributor in opening up performance by especially opening up the range of pain free movement in my shoulder. Checking out how your coach/trainer/therapist works with skin/fascia as part of their (active) rehab work is a Good Idea. If they don't include such consideration, maybe you want to find someone who does - pain free.

It's remarkable to me that sometimes such a gentle stimulation can have such a potent and immediate effect.

My caveat in this space is as always: test and reassess immediately. Knowing how to apply this stuff is as nothing to knowing how to test *immediately* whether the application has had a positive effect.


Next time, promise: exploring end range of motion work with bands for super potent rehab and performance restoration like you would not believe.

Other Posts in this series:

• Rehab Journal Part 1: overview of a journey
• Rehab Journal Part 2: the phrenic nerve and thinking other site/source thoughts

Related posts:

• The Shoulder: Scapula engineering
• Shoulder Engineering: the g/h joint
• tendon - opathies and eccentric contractions for repair
• Fish oil and being anti-inflammatory.
• One less rep: the differnece between injury and success?
• What's a movement assessment?
• Active vs Passive Therapy - what's it mean and why care?

Related Resources
- here are some awesome cadaver dissection images of the muscles of the shoulder