SaveYourself.ca • Sensible advice for aches, pains & injuries
published 8/13/09, updated 9/05/11
Myofascial release (MFR) therapy is a popular style of massage therapy or manual therapy, intended to treat a wide range of conditions, especially low back pain and other common chronic pain problems. There is considerable public and professional confusion about the terms “myofascial” and “fascial” in combination with the words “therapy” and “release.” It’s important for massage therapy consumers to understand that “myofascial release” means pretty much whatever a therapist wants it to mean, as long as it has something to do with muscle (myo), fascia (connective tissue), and any technique that allegedly “releases” these things.
When I was a massage therapist, patients often asked me, “What do you think of myofascial release?” But “myofascial release” is such a vague and abused term that it could refer to virtually anything I was doing at the moment they happened to ask. In this review, I'll stick to some of the central, defining ideas of MFR — the ideas and claims that make MFR what it is.
An inevitable complaint about this article is that it tars “all” fascial therapists with the same brush. It doesn’t. I have used some fascial massage techniques myself, and I know some excellent therapists who still do. However, there are distinct and troubling patterns in the world of MFR. Pointing out some of those patterns is a legitimate and necessary criticism.
Although the words “myofascial release” are generic and not trademarked — they are just Latin — they are nearly synonymous with some trademarked, proprietary treatment methods sold for big profits with no regulation. The for-profit packaging of a therapeutic idea is known as a “modality empire”1 — a method of manual therapy, championed and promoted by a therapist-turned-entrepreneur. Most modality empires make big promises of healing powers and make their money by selling expensive therapy and workshops, plus of course books and DVDs. Professionals are sold on the opportunity to purchase credibility for themselves in the form of increasing “levels” of certification, but the quality of these certifications is dubious and — this is very important — completely unregulated.
The elite modality emperors also typically get paid lavishly to speak at alternative medicine conferences and events.
Over the last few decades, there have been at least three modality emperors who have earned major cash from the idea of “fascia” as a target for therapy. I will be referring to them collectively as “the emperors” for the remainder of the article. My purpose, of course, is to point out that they have no clothes.
There are also countless therapists cashing in to a lesser degree on no-name-brand variants of MFR. Many massage therapists seem to be thrilled with MFR and similar ideas, regarding them as the bleeding edge of bodywork, often using more generic terms fascial release or fascial therapy or fascial stretching. When I was in school in 1999, I did an internship with a particularly popular therapist with a bad case of “Healer Syndrome” — the belief that you are God’s gift to patients — who taught and practiced an incredibly painful style of “fascial release,” which is still the most extreme example of a painful therapy I have ever encountered. To this day, the term “fascial release” seems to be particularly common in Vancouver.
As far as I can tell, the treatment philosophy of “fascial release” is precisely the same as MFR — it’s simply being done without any of the certifications offered by one of the emperors.
“Myo” is the Latin prefix for muscle, and “fascia” refers to the sheets of connective tissue that wrap everything in our anatomy. Gristle in a steak is cow fascia.
Fascia is an integral component of the muscular system (as it is of all systems). It certainly is neat stuff.23 The emperors like to call it a physiological system itself, but that’s hyperbole. It may have some system-like qualities, but it’s definitely not a physiological system — it’s a simply a component of all systems, like the re-bar and concrete in a building.
So, referring to “myofascial” anything is basically the same as referring to “the muscular system” and the connective tissues that permeate it.
And what about this “release” stuff? Well, “release” sounds good. Who wouldn’t want to be released? It implies that something is stuck and must be unstuck.
What’s the difference? Therapists with any kind of expensive certification in fascia work are unlikely to describe their technique as mere “therapeutic massage.” Trademarked modalities are always allegedly advanced treatment systems — much superior to the hum-drum, ho-hum clinical tools of the average massage therapist.4 While ordinary massage therapy has been around for a long time, MFR is invariably touted as being some kind of super-cool therapeutic innovation, like sharks with frickin’ lasers. It’s not hard to find this kind of hyperbolic marketing language on their websites for yourself.
And yet all the MFR modalities seem to lay claim to many different techniques, most of which overlap with other popular manual therapy modalities — an awful lot of stuff that the emperors definitely do not have exclusive rights to, but it looks nice in a bullet list.
If there is anything clearly unique about MFR, it is techniques devoted to stretching fascia, one way or another. That is the big idea of MFR, and that is primarily the idea that I’m reviewing.
And there’s yet another point of confusion with the term “myofascial.”
“Myofascial trigger points” (TrPs) is the the “correct” term for the phenomenon popularly called muscle knots, the words that were sensibly prescribed for general use by Travell and Simons.5 The treatment of TrPs should not be confused with “myofascial release” although the concepts do have some overlap — a therapist describing myofascial release might well be referring to therapy for myofascial trigger points.
MFR proponents claim that MFR techniques are essential for effective treatment of myofascial trigger points. In short, I disagree: after a decade of delving deeply into the subject of trigger points, I am unaware of evidence that any single form of therapy is clearly more effective at getting rid of trigger points. I discuss this in much more detail in my trigger points tutorial.
Practitioners and propopents of fascia-focussed therapy are rarely specific about why fascia matters, and tend to focus on general excitement about the complexity and ubiquity of fascia, as though the complexity and wide extent of a tissue type is reason enough to make it the target of a therapy. They claim that it has functions barely known to science, but then they claim to be able to exploit those barely known properties for the benefit of their patients.6
Some fascia research is quite interesting, and what most (not all) researchers are saying about fascia is reasonable and does not reach beyond what the data indicates. Unfortunately, too many therapists fascinated by fascia are reaching well beyond the implications of the research.
Beware the implication of therapeutic significance from scraps of basic biology. It is easy to sound cool talking about biology. It is hard to make it useful.
In fact, on one occasion, a rather pedantic experimental psychologist was telling him about a long, complicated experiment he had done, incorporating all the proper controls and using considerable technical virtuosity. When he saw Crick’s exasperated expression he said, “but Dr. Crick, we have got it right — we know it’s right,” Crick’s response was, “The point is not whether it’s right. The point is: does it even matter whether its right or wrong?”
Certainly a lot of fascia science is “right.” But I question whether or not it matters.
For instance, a popular idea is that piezoelectric effect is at work in fascia. It is hardly clear that this is actually the case. However, even if we took it as fact, in what way is it at work? Do we know the physiological intricacies of that phenomenon? Do we know why it evolved? What it does, how it does it? Can we affect it? And, if we don’t know these things, how can we possibly use it to devise a reliable therapy? Obviously we cannot.8
“The point is not whether it’s right. The point is: does it even matter whether its right or wrong?”Consider the known example of piezeoelectricity in bone: it’s pretty well-documented that piezoelectric effect is used as a way of guiding bone remodelling in response to stresses, which is super cool. It’s a terribly clever system! And it also has absolutely nothing to do with anything a manual therapist could ever do to a bone.9 And that is going to be the case for the great majority of physiological systems, known and unknown — even if you understand them, it doesn’t mean you can exploit them. Proponents protest that we should not dismiss MFR because “not enough is yet known,” but it’s just the opposite: because not enough is known, we should not use it to rationalize a therapeutic modality.
This is the basic problem with most of the hand-waving about the supposedly neato properties of fascia: some of it might be real and biologically interesting, but none of it can actually inform clinical reasoning. There simply are no confirmed properties of fascia that have useful implications for manual therapy.
Another fine example of vague scientific enthusiasm is Gil Hedley’s popular “fuzz” speech. In this widely circulated video, Hedley plays fast and loose with a dissection observation: there are cobwebby layers of fine, loose connective tissue between thicker sheets of fascia. The anatomy is interesting — anatomy is always interesting — but Gil Hedley’s rambling, sloppy interpretations of what he sees are not. He makes a great many assumptions about the significance of that tissue. His leaps of logic are large. “That stiff feeling you have is the solidifying of the fuzz,” Hedley confidently explains.
At best, that is an extremely unsafe assumption, and one that conspicuously ignores many other highly relevant factors (like, oh, neurology). He does not know what happens to that tissue in a living body. For all he knows, that fuzzy texture only manifests post mortem! At worst, and more likely, his theory is hopelessly wrong. Almost any amount of reasonably normal movement is quite sufficient to sustain mobility, strongly suggesting that “fuzz solidification” either isn’t happening or doesn’t matter. There are quite a few much better explanations for the sensation of stiffness — many of which have nothing to do fascia or its fuzz.
Hedley wants the credibility of what appears to be a scientific perspective on fascia, but he confesses his own disrespect for science: “Science to me is another religion among many, whose dogmas I am attempting to shed.” That kind of talk could be the the lyrics for a pseudoscience anthem, and it’s a dead giveaway that Hedley really has no idea what science is or how it works, even as he’s abusing its methodology. And yet his incoherent fuzz theory has been accepted by countless fascia enthusiasts as a serious, scientific explanation for stiffness, and a rationale for fascial “release” and stretching.
If there are no reasonably clear properties of fascia, what about stranger properties at the fringes of science? Who knows. But scientific mystery cuts both ways. If fascia does have exotic properties, then why do MFR therapists claim to have fine-tuned control over that behaviour? And not just control, but the ability to produce reliable therapeutic effects with it?
The problem with trying to exploit subtle and poorly understood physiological complexity is that it’s pretty hard to be sure that you know what you are doing — because it’s mysterious, after all. If there’s anything we can all absolutely agree on it, it’s that biology is mind-bogglingly complex. So why do MFR therapists believe that they not only “get it” better than biologists, but that they “get it” so well that they can use the knowledge to get specific, helpful physiological effects?
It’s a bit daring to claim that you can do something really well that no one else can do at all, based on your masterful understanding of something no else understands.
Despite all the talk of exotic properties of fascia, fascia’s clinical importance is often reduced to simplistic rationales: it’s everywhere (well, yeah), and it gets tight (not clear, see below). A strong theme in MFR is the emphasis on the interconnectedness of anatomy via fascia, always making the point that pulling on any one part of fascia affects the whole body, like pulling on the corner of a sweater affects all the threads.
(That sweater analogy appears virtually everywhere online that fascia is mentioned. It gets really tiresome, actually.)
The central idea is that this stuff can get tight and restrictive, and then needs to be released, and that therapists can achieve this by various methods of yanking on it. The yanking may be extremely intense, too — some implementations of fascial therapy can be among the most painful of all hands-on techniques. Methods vary.10
That’s what MFR boils down to — an extremely simplistic explanation, a long way from the pretentious talk of exotic biological properties! It amounts to “fascia good” …
Not all fascia talk is fancy, and I have encountered much too much overly simplistic communication about fascia. Many therapists are perfectly capable of discussing the topic intelligently, of course, but my point is that low quality communication about fascia is distressingly common (and my exposure is quite extensive, due to the large volume of email I receive). For instance, in a recent massage appointment, a therapist said this to me, with lots of “ums”:
Well, your problem is fascia. The fascia is the thing you have to do something with. If you fix the fascia, everything gets more … well, the fascia will make everything better.
Come again? In my experience, this is the low intellectual level of many casual pronouncements about fascia — worse than just oversimplified. Or consider this gem of simplistic rationalization, described by Barrett Dorko, PT (he didn’t say it himself, he reported it):
Restricted fascia is full of pockets. When the tissue starts to release, these pockets are opened up. When these pockets open, the sensations that were trapped in them are released.
Nonsense. Again, I’ll emphasize that this kind of overconfident, poor quality clinical reasoning isn’t universal — just excessively common within the culture of fascia enthusiasts.
If MFR can’t “loosen” fascia, it’s game over: MFR without fascial stretching would be like chiropractic without joint popping. This central claim of MFR must hold up, or the rest of the vague ideas and excitement packaged with it are a largely moot point.
Unfortunately for MFR, fascia is extremely tough stuff, like sheets of flexible iron. It has lots of natural elasticity, and there are strict limits on that elasticity. Pull it hard enough and it will tear, but that’s extremely difficult and painful — it’s an injury! Pull it less hard and it simply sproings back to the way it was.
Slow, steady microtearing (“wicking”) might achieve what’s known as “remodelling” — ripping it ever so slightly and then allowing it to heal — but this would require extraordinary intensity and persistence, and the effects would be difficult to predict. For instance, the tissue might well “heal” with no significant change in extensibility, or even less.
Manipulation of fascia undoubtedly temporarily softens it via thixotropic effect — but that’s just a minor and very temporary change in texture, not a lasting change in extensibility that could have any meaningful therapeutic effect.
Perhaps “loosening” could be achieved by tearing adhesions between layers of fascia? This is vaguely plausible. Fascia does stick together, Velcro-like, and when this process advances far enough it can cause significant limitations. Strong pressure can tear them loose. The fascia itself isn’t being stretched, but there is something you could call a “release” there. But adhesions aren’t an important clinical phenomenon in very many people! Like bed sores, they tend to matter to people with pretty significant injuries, spasticity and paralysis. The average person with back pain isn’t likely to have adhesions of any importance.
I think there is very little (maybe even nothing) that a therapist can do to change or “loosen” fascia. At best, it’s just not clear how it can be achieved in any practical or lasting way.
Fascia is tough stuff, like sheets of flexible iron.Like so many other manual therapies, MFR cannot actually demonstrate that it can do the central thing that it claims it can do. Craniosacral therapists can’t demonstrate that they can move skull bones;11 chiropractors can’t find “subluxations” to correct;12 massage therapists can’t agree on the diagnosis of trigger points.13
A particularly popular notion in MFR is that the meridians of Chinese medicine correspond directly to fascial anatomy and function. If you polled MFR therapists, I think you would find that nearly all of them believe that MFR is doing the same thing that acupuncture is doing. MFR therapists believe that MFR works for the same reasons. Most MFR therapists probably believe that acupuncture works.
Unfortunately for MFR, acupuncture has been consistently failing fair scientific tests for years now,14 and is simply not what it seems to be. Acupuncture as we know it today is not so ancient after all: its current form is a modern invention of the pediatrician Cheng Dan’an (承淡安, 1899-1957) in the early 1930s (see The Acupuncture and Fasciae Fallacy and Ramey). Before that, for most of history, it existed primarily as a method of bloodletting — exactly like the prescientific medieval European practice. And then there’s the myth of acupuncture’s popularity (see How popular is acupuncture?). Even its alleged popularity and widespread use in China is quite trumped up — it is, for instance, not actually used for anaesthesia (see Acupuncture Anesthesia). These are rather embarrassing facts for acupuncture.
In short, acupuncture is mostly just a silly mess of Chinese superstition and American hype and wishful thinking. And so the association between MFR’s “fascial meridians” and TCM’s “qi meridians” is of dubious value indeed. Even if meridians and all the other mystical rubric of acupuncture were real, though, acupuncturists are unable to demonstrate their power clearly. And if the acupuncturists can’t manipulate these meridians effectively enough to achieve clearly measurable effects, why would pulling on fascia be able to do it?
Every dubious therapy is at least a double-whammy: mostly ineffective on the one hand, but on the other hand also expensively distracting from other things that might actually work. MFR goes one whammy worse than that and probably actually does harm to many patients. Not only is MFR is chosen at the expense of more rational manual therapies, but it is diametrically opposed to some of the best, to the peril of patients.
Every human is wrapped in an ultra-sensitive layer of tissue — the skin — designed to provide beautifully detailed information about the environment around us. That layer is a protective layer, above all else. Like a perimeter fence studded with cameras and sensors and alarms, its job is to supply your brain with information about potential threats, a lot of information, information the brain processes with avid attention. This is one of the most important concepts in modern rehabilitation science. Nearly everything about chronic pain and healing can be better understood if you view a human being as a threat-assessment device — and all the senses are the sources of data for that device, especially the skin. Even the tiniest organisms have sensors on their “skin” (membranes), even if they have no other senses at all.
The MFR therapist not only tends to ignore the opportunities suggested by this neurology, but blasts right through that defensive layer, in many cases painfully, because they are fixated on manipulating the muscle and fascial tissues beyond the perimeter. They pay little or no attention to the neurology of pain and act like a dangerous invader. Having paid through the nose, patients often interpret the flood of unpleasant sensory information as a sign of strong medicine rather than a threat. But many others, for many reasons, interpret it at least partially as a threat — their adrenalin pumps, they squirm and sweat.
MFR therapists are usually dismissive of painful reactions as a cost of doing MFR business, collateral damage. I cannot emphasize strongly enough that I have experienced this attitude myself many times, personally witnessed the careless disregard for the comfort of a patient — me! — in the name of fascial manipulation. There is no question that my nervous system was abused, regardless of what was done for my fascia. And I have encountered many patients who suffered the same and felt genuinely harmed by it.
MFR may well be dangerous. Many patients with chronic pain — the very same patients most likely to try an expensive therapy like MFR — are suffering from pain system dysfunction or warning-system hyperactivity. Their nervous system is set like a car alarm that goes off too easily. The last thing a they need is more nociception (pain sensation). What they patient does need is sensory reassurance. Their warning system needs to be dialed down, soothed — not tested!
For example …
This is one of the most striking stories of incompetent and harmful manual therapy that I have ever received from a reader. It is notable not only for the seriousness of the outcome, but also for the glaring excess of the treatment: so unnecessary!
Funny drawing for a most unfunny story. (Drawing by Claude Serre.)
Funny drawing for a most unfunny story. (Drawing by Claude Serre.)
I have re-written the story a little to anonymize and condense it, but it is otherwise presented here as it was received:
I visited a massage therapist a month ago for treatment for soreness/achiness in the balls of both feet and in the toes. Claiming that tight calf muscles and hamstrings were causing my heel to lift too far (thus placing pressure on the balls of my feet), she proceeded with a half hour myofascial release therapy on my calves, using her full weight and her elbows.
It was extremely painful, but I gritted my teeth, thinking it necessary “to break up the knotty muscles.” She moved from point to point up and down my calves, twice. A week later I had another such treatment, and she also also persuaded me to buy a rubber roll so that I could do the “therapy” at home. She told me I should try to reproduce the same pain level, on calves and hamstrings. I did this every day for one hour for five days. I did the same with a wooden roller under my feet, using my own weight.
During that time, I started getting stabbing and burning pains in my feet, the backs of my legs, and then later my hands and armpits. The stabbing pains varied from a pinprick feeling to electric-shock/lance-like, and they varied in their frequency rate. The burning was either tingly or felt like bad sunburn. The pain seemed to be aggravated by walking, and was always worse by afternoon/evening. I had trouble sleeping, because I could not have heavy bedclothes on my feet, and nor could I put one leg on top of the other, without pain.
I returned to my GP, had blood tests, x-rays, a CT scan. Because my symptoms seemed neuropathic in nature, I was referred to a neurologist. After eliminating a number of other diagnoses, the neurologist thinks the problem is biomechanical or related to muscles, and that the MFR may have caused an oversensitivity to pain.
I then searched the Internet for information about myofascial release being damaging or making pain worse. It was very difficult to find, because of all the “positive” hype around MFR. Fortunately, I found your website …
This patient’s prognosis is impossible to call: it could last another week, or this patient could suffer excessively for the rest of her life. The conceptual cancers at the heart of this incident are structuralism and prideful devotion to a supposedly “advanced” treatment method.
For the duration of my decade as a massage therapist, I had a reputation as a gentle therapist, and many of my patients were “refugees” from excessively intense treatment, many of whom vented angrily to me about the abuse they had received from other therapists. Vancouver is a “fascial release” mecca, with many therapists who seem to believe that there is no gain without pain, and many or all painful problems are caused by fascial “restrictions” that must be painfully “released.” As a therapist who defined himself in opposition to this trend, I was treated to many, many outraged patient anecdotes about the brutality of other therapists.
Having experienced that intense style of fascial release myself many times, I knew all too well what these patients were talking about. Almost none had found the courage to discuss their concerns with the confident (overbearing?) therapists who had mistreated them. Almost all had even earnestly tried to like it, at first. Sometimes, rather sadly, they were even still trying to rationalize it as positive, i.e. “I’m sure it was probably what I needed, but I just couldn’t take it anymore!”
Of course some people enjoy intense therapy — if your nervous system is okay with it, that’s fine. Most of those therapists have many devoted patients who, for various reasons biological and psychological, are more willing and able to tolerate extreme therapy. However, they are also leaving behind them a trail of angry, injured patients … patients who never raised a word of objection.
That’s why stories like this are important. There are bound be therapists reading this who have actually done this to patients, who do it every day. Many will react defensively. Many will delude themselves into believing that they would never do anything like this. But some, perhaps a few who are already questioning their own methods, will probably be moved further in that direction. I hope.
Better still if patients feel emboldened to reject such treatment more quickly.
Any honest person would forgive MFR its theoretical uncertainties as long as it actually worked. If it works, great! We’ll figure out why eventually, right?
That is the spirit of evidence-based medicine.
However, I am not aware of any tests of the effectiveness of MFR therapists working on patients with significant pain problems of any kind. Scientific testing has not yet shown that MFR works. The sole study done to date in which MFR was compared directly to another therapy — an “isometric contract-relax technique” — actually found it to be inferior!15
That’s right: MFR was a less effective treatment than clenching and relaxing muscles.
This is a classic example of a test of therapy failing to impress — which it should be able to do quite easily if it’s even half as great as advertised. If it works, where’s the easily obtained proof? If it works even half as well as claimed, it should be easy to produce a few studies demonstrating its awesome potency. I look forward to reading the results of that research.
MFR proponents will point to their satisfied clients, but this is not evidence — manual therapy clients are generally eager to think well of their therapists. The history of medicine and quackery is overflowing with people who “believed” in treatments that were poisoning and even killing them — such as the popular mercury, radiation, and colloidal silver “cures,” and many more — never mind all the treatments that were simply useless. It is simply ridiculous and unethical to confidently claim curative powers for a treatment method that has never actually been studied.
Friday, August 26, 2011 — Rewrote and expanded my explanation of the problem with reaching too far into basic and fringe science for a rationale for MFR.
Friday, May 27, 2011 — Revision and new references for the acupuncture section. A new case study. And numerous other minor edits.
Friday, October 29, 2010 — Some more revisions for readability. Upgraded intro and conclusion. Add the section, “At the expense of what?”
March 22, 2010 — Corrected some typographic errors and updated a couple references.
February 2, 2010 — Edited for length and readability. The article is much less wordy now.
I would never normally be interested in this paper. In fact, I would never have chosen to read it myself, because I don’t think it’s good enough science. I am spending some time on it only as a gesture of good faith to a critic, who supplied the paper as an example of basic fascia science that matters. It may not have been a good choice for that purpose.
This is a test tube study showing that naked cells handled stress better (fewer signs of harm) if they were treated with, believe it or not, “simulated” myofascial release (MFR). A meaningful, accurate simulation of manual therapy on naked cells is an amusing notion, and it’s clear that what happened to those cells differs dramatically from what would happen in a real living body.
Even if true and reproducible, this data would mainly support the rationale for MFR specifically for post-exercise soreness — something of a dead end for the clinical relevance of MFR, because exercise-induced soreness has little to do with the main claims of MFR, which primarily concern correcting postural asymmetries, eliminating alleged restrictions, and treating chronic pain.
Post-exercise soreness is comparatively trivial, and patients don’t seek therapy for it (it’s usually over before they can get to an appointment). There’s a lot of research showing that exercise-induced soreness is basically invincible anyway. For this property of fascia to be clinically relevant, it would have to imply that MFR might be able to treat chronic pain from other causes … not the transient annoyance of soreness after a game of soccer.
This isn’t a rejection of all possible clinical relevance of the data. My point is that there are so many problems that its relevance is watered down to quite a thin sauce — way too thin.
I do concede that the paper shows some evidence that fibroblasts have interesting and perhaps positive responses to mechanical forces. That is inherently interesting, and probably worth investigating further, but it’s a mighty reach to postulate any clinical relevance to what most therapists do, most of the time, with patient’s fascia.
“Reach” is what the authors do, in spades. They claim to have no conflicts of interest, and they probably don’t, technically. Nevertheless, I suspect their egos are deeply invested in the notion that “fascia is important,” because they seem to be seeking evidence to support their pre-conceptions — typical of research funded by The National Center for Complementary and Alternative Medicine, and a hallmark of junk science.
It’s quite likely that if less biased researchers did this experiment, they would not be able to reproduce these results.
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Comments: I do enjoy reliability studies, and this is one of my favourites. Three chiropractors were given twenty patients with chronic low back pain to assess, using a complete range of common chiropractic diagnostic techniques, the works. Incredibly, assessing only a handful of lumbar joints, the chiropractors agreed which joints needed adjustment only about a quarter of the time (just barely better than guessing). That’s an oversimplification, but true in spirit: they couldn’t agree much, and researchers concluded that all of these chiropractic diagnostic procedures “should not be seen … to provide reliable information concerning where to direct a manipulative procedure.” BACK TO TEXT BACK TO TEXTBACK TO TEXTOBJECTIVES: To assess the current state of scientific knowledge about myofascial release, a noninvasive manual treatment technique, and to identify the reliability of diagnostic tests for myofascial dysfunction and efficacy of the treatment.METHODS: A literature search was undertaken, as well as exploring more widely for information concerning the subject, allowing an assessment of the rationale for the treatment and of the studies carried out.RESULTS: Twenty-three items were identified in the literature search. No studies were found with which to determine reliability of the diagnostic method, but four randomised controlled studies of the treatment were identified. Two of the efficacy studies comprised several different modalities of treatment, so that no conclusions could be drawn. In one further study, the numbers were too small to allow safe conclusions; in the other, the myofascial release treatment was inferior to an isometric contract-relax technique. Overall, no good evidence of efficacy has been shown.CONCLUSIONS: We are unable to reach any conclusion on the diagnostic criteria and methods or on any efficacy of myofascial release. We recommend strongly that reliability studies be performed on diagnostic tests for myofascial dysfunction (tightness/looseness), so that efficacy studies can be performed on a more solid diagnostic foundation.