Thoracolumbar Fascia as Storyteller

Each treatment modality serves as a lens through which to view a certain aspect of our being. Myofascial release allows us access to a depth and breadth of tissue. The myofascia encompasses a lot of our physical matter and energetic potential. It’s implicit here that, of course, each technique also has its limits. Most issues that bring any of us into treatment involve multiple systems and so as people working with the body it is nice to dive deep into multiple modalities – then integrate the understandings that emerge. As Gil Hedley, somanaut and connective anatomist par excellence, so elegantly stated at a talk in Portland, OR, we must always hold our models lightly.

I really believe that’s true – and we must work from some model or models – and be willing to adjust or abandon them as our curiosity and openness offers us opportunities for new insight.

 

One model I work from is based in osteopathy; the body contains the wisdom for its own healing. If this is true then it is our role working with people’s bodies to learn how to hear that wisdom. Another way to say this is that the body has a story to tell – it speaks, at least in part, through the tissues.

This leads me to another model of sorts – listening hands. I want to be able to listen to the tissue with my hands. I use the metaphor of dialogue to orient myself into this listening approach. I want to be present and soft in my hands, receptive. It’s a unique form of touch, that with practice, allows the tissue to come forward.

These two concepts are central to my love of myofascial release work – they allow for the body to express itself in a unique way on the table and if I can listen and follow these expressions then we (patient’s conscious mind, patient’s body consciousness and me) can engage with this story.

crosshands myofascial release .jpg


 

Thoracolumbar Fascia: The Big Picture

Let’s look at these two sets of drawings from Endless Web: Fascial Anatomy and Physical Reality by Louis Schultz and Rosemary Feitis. They are, like any good art, compelling without explication. Look at them yourself before reading any further – you will probably have ideas I haven’t considered.

Schultz, R. L. & Fetis, R.  E   ndless Web: Fascial Anatomy & Physical Reality  . North Atlantic Books, 1996.

Schultz, R. L. & Fetis, R. Endless Web: Fascial Anatomy & Physical Reality. North Atlantic Books, 1996.

Schultz, R. L. & Fetis, R.  E   ndless Web: Fascial Anatomy & Physical Reality  . North Atlantic Books, 1996.

Schultz, R. L. & Fetis, R. Endless Web: Fascial Anatomy & Physical Reality. North Atlantic Books, 1996.

The infant series shows the central fascial pathway along our spine, its’ density at the occiput and the sacrum and fascial connections into the glutes and iliotibial band. It also points some to how we evolve from crawling to standing. This tissue has been with us from the beginning! Possibly containing some trace of physical memory of what we experienced in our bodies way back then.

The second set of drawings shows different layers of the fascia of the back body. The second and third images show specifically the centrality of the thoracolumbar fascia and, without words, shows how connected that tissue is to other major myofascial pathways in the body.

The major connection remains the same as in the infant – at the deepest level. However, we see distinct relationship with the latissimus dorsi and in the third image from the adult series also the trapezius. Research has shown that the thoracolumbar fascia actually derives from the latissimus dorsi (more on this later).

To me these pictures are already pointing to a story of body, a map if you will. When we use a myofascial approach or lens, we are engaging with this story of body in at least a couple of ways. One powerful way, is that the myofascial system is a potent map of how energy moves through matter in our body. Of course, energy moves all throughout the body and not just within the myofascia – but the myofascial system is central to our physical experience (and appears to also have significant relationship with aspects of the nervous system).

Rachelle Wunderink's :  "anatomy: muscles"  pen and gouache on paper, 2016

Rachelle Wunderink's: "anatomy: muscles" pen and gouache on paper, 2016

 

True Confessions

Full confession here. I learned about fascia and fascial properties before I really understood anatomy. In the early 2000’s I spent three weeks in Arizona studying myofascial release with John Barnes. He taught us a simple hold that remains the root of my work: one hand was placed on the sacrum and the other at the midline at the thoracolumbar junction. Essentially, at either point on the diamond shape of the thoracolumbar fascia in the 2nd and 3rd images above. I loved the technique. I somehow felt oriented in the session – I didn’t know enough then to understand how or why, but, I was curious and badly wanted my work to be effective.  So began my deep inquiry into understanding fascia and the body-consciousness and story. My curiosity has only deepened the more I’ve pursued my questions. As my inquiry deepened so too did my perceptive skills. (This idea, that the more we study and contemplate an aspect of the body the more our perceptive skills increase is core to how we teach our courses).

 


Grays Anatomy, Thoracolumbar Aponeurosis

Grays Anatomy, Thoracolumbar Aponeurosis

 

 

 

Here is a standard image of the thoracolumbar fascia (TLF), often called the thoracolumbar aponeurosis (broad flat connective tissue). Which it is, but it’s so much more. So, it can be misleading to just call it an aponeurosis.

 

 

Before we go further let’s orient more specifically. The TLF attaches on the dorsal surface of the sacrum, the posterior iliac crests, and the spinous processes of the lumbar and lower thoracic vertebrae. It is likely that it has some connection with the posterior surface of the lower ribs. At this superficial level we can also see its strong connections with the latissimus dorsi, serratus posterior inferior and trapezius. Those are real and important but there’s more here than meets the eye and requires some other pictures.


There’s a crucial reality to understand about the TLF that fundamentally differentiates it from this idea of an aponeurosis. The thoracolumbar fascia has volume. Meaning it has depth and, well volume, encompassing some important muscles and also differentiating and becoming other fascial structures in the abdomen.
 

First, in its depth it becomes the tendon that connects the erectors to their bony attachment sites: sacrum, ilium and spinous processes. Some fibers of the erectors blend with the origin of gluteus maximus fibers.
 

In addition to serving as the tendon for the erector spinae, the TLF is also their fascial compartment, meaning it surrounds the erectors for their entire length. So, it is a volume in depth that extends itself longitudinally along the back body from the sacrum to the occiput (see earlier images).
 

When we are discussing this orientation of the TLF, I think it’s really important to bring up one other set of relationships. The TLF is in the middle of arguably the main myofascial pathway in the body – the Superficial Back line and from a Chinese medicine perspective, the Bladder sinew channel. Both of these understand a fascial relationship from the head to the bottoms of the feet.

Gray's Anatomy, Erector Spinae

Gray's Anatomy, Erector Spinae


The Three Layers of the Thoracolumbar Fascia

The image below is a cross section of the TLF at the level of the sacrospinalis. (In Grays this means the erectors before they differentiate into three muscles. The cross section is at the level of the lower lumbars.)

I love this image! It was somewhat of a game changer for me. It explained to me things I had only had a felt sense of but no other understanding. I had come to feel that from treating the thoracolumbar fascia I could read or hear into other structures. Especially, the quadratus lumborum and the psoas.

 

Grays Anatomy, Cross Section at Lower Lumbars

Grays Anatomy, Cross Section at Lower Lumbars

 

What we see here are the three layers of the TLF; posterior, middle and deep. (Note: the image doesn’t name the middle layer, but I think functionally it is appropriate to consider it this way.) The posterior layer is surrounding the sacrospinalis muscle, the middle layer and anterior layer are wrapping the quadratus lumborum and then the anterior layer forms the posterior border of the psoas. There’s more to see here too.

 

The Posterior Layer of the Thoracolumbar Fascia

The posterior layer is attached to the spinous processes of the lumbar vertebrae and then arcs out laterally and anteriorly to attach to the transverse process. This is the layer that was described above as encompassing the sacrospinalis muscle and then moving superiorly as a fascial tube of sorts encompassing the length of the erectors. As this posterior layer moves superiorly, it differentiates into both the tendinous connections of the spinalis, longissimus and iliocostalis and the fascial sheath surrounding each muscle.

One structure differentiates itself from apparent singularity into a multiplicity of form, function and connection.

 Let’s keep going. Within the posterior and middle layer of the TLF are also the transversospinalis muscles (multifidi and rotatores). These are small muscles that link the vertebrae to one another. The rotatores travel from spinous process to transverse process. The multifidi fill the space alongside the posterior aspect of the spinous process. Typically, they are thought to span three vertebral joints.

The rotatores have a high density of proprioceptors and are important in maintaining the integrity of vertebral joint movement. Due to their depth and small and specific size, the rotatores are difficult to access directly in treatment. Working with clear intention and myofascial principles the rotatores can be engaged and treated.

 

The Middle Layer of the Thoracolumbar Fascia

The middle layer begins at this transverse process attachment and moves laterally and then anteriorly and surrounds the quadratus lumborum muscle! The quadratus lumborum (QL) is arguably one of the most important muscles in the entire body. It forms a dynamic functional myofascial unit with the psoas and the diaphragm. It is crucial in understanding and treating low back pain cases and can serve to fix the thoracic cavity leading to problems in the upper extremity and neck.

 

The Anterior Layer of the Thoracolumbar Fascia

The anterior portion of the middle compartment that surrounds the QL also forms the posterior and most medial border of the psoas.

It can be confusing, we are more comfortable when a thing is only one thing and not serving as two or more things. But this is the truth of fascial structures, they move and morph and are constantly becoming other structures.

 This most central aspect of the TLF is attached to anterior surface of the transverse process and the lateral surface of the vertebral body.

This is just one constellation of relationships that we can explore via the thoracolumbar fascia. From this perspective, we are now oriented longitudinally – from sacrum superior to lower thoracic spine and then via the fascial relationship of the erectors à to the cervical spine and occiput. Inferiorly from the sacrum and the sacral fascia and ligaments (especially the sacrotuberous ligament) we can follow myofascial continuity to the hamstrings all the way down to the plantar fascia! Woot!!!!

 

Psoas – Quadratus Lumborum – Diaphragm Complex

 
The image below is from Gray’s Anatomy and shows an inferior view of the diaphragm.  We can also see the upper two or three lumbar vertebrae. On the right we can see the psoas merging with the diaphragm and a little further over there is the quadratus lumborum. If you shift your gaze just a little further to the right you can see a gray tissue forming a triangle of sorts – it reaches out to the inner rib surface and merges with the tissue of the diaphragm and the QL. This is a tendon that links QL and diaphragm – both to one another and to the rib surface!

 

Grays Anatomy: Psoas - Quadratus Lumborum - Diaphragm Complex

Grays Anatomy: Psoas - Quadratus Lumborum - Diaphragm Complex

Now, this image isn’t detailed enough to show all of the fascial relationships that we just discussed – but they are still present – just not shown. Anatomical drawing can never show all of the relationships within a given frame – choices are always being made.

Gil Hedley has video dissections that illustrate these relationships within actual bodies. One of the important points that is coming from the world of fresh cadaver dissection is that while we are all similar in form, there are also lots of differences between forms. How we use our body and our genetics influence the shapes that our bodies take.

 

Thoracolumbar Fascia as Cylinder Too!

Tired yet?

Go back to the cross section image where we discussed the three layers of the TLFAt the most lateral aspect, where the middle layer turns back towards the midline to become the anterior layer, you can see a continuation of the TLF (shaded in blue) beginning to wrap around towards the front of the body. At this specific point it is becoming the fascia that wraps the transverse abdominus! If we move a little bit posterior to the portion that extends off of the transverse process – it is also continuing laterally and forms the fascial surrounding for the obliques!

The image below shows these relationships in more detail.

I will also add here that, after studying several of Gil Hedley’s fascial dissection videos, it seems clear to me that there is a strong fascial relationship between the transverse abdominus and the diaphragm. So, based on this and the fact the psoas-QL-diaphragm form one interconnected functional unit, we can understand the thoracolumbar fascia as being in some sort of relationship with the diaphragm.

So, one structure, in volume and length it extends superior-inferior and also from posterior to anterior, from transverse process wrapping around via a connection with the transverse abdominus to the rectus abdominus and linea alba. It is indeed broad and general and also (to borrow a phrase) contains multitudes.

 

Back to our Listening Hands…

 Let’s think back to our listening hands and some basic myofascial-osteopathic principles. If we remember the basic myofascial release hold that got all this started – hand on sacrum and other hand a little above thoracolumbar junction at the midline – a little bit of slow sinking to engage our listening and our myofascial treatment – all of sudden we are contacting and engaging a rich realm of relationship.

We have discussed the TLF in length along the entire back body and in depth to the psoas-QL-diaphragm (and even peritoneum) and cylindrically around the obliques and transverse abdominus to the midline. So, as we listen with our hands we are able to feel complex tension patterns. Our listening quickly becomes treatment allowing the body to explore the possibility of releasing some of this stored energy.

Understanding this structure in this way and approaching it with myofascial listening and treatment allows us to interpret and treat according to how the body is experiencing itself – meaning according to the tension the body is holding and not the location of the dominant symptom.

 

These Images Look Like What Listening Hands Hear

 I just discovered these images and the linked article (which goes into much more depth) last year doing some prep for a class. They blew my mind! I looked at them for weeks before I could even bring myself to read the text. I was seeing for the first time what my hands had been feeling for all these years. It was validating in one of those strange ways – where you didn’t really think you needed validation but then it when it arrived unbidden there was something so affirming.

The pictures so beautifully illustrate the different lines of tension that can be perceived from this tissue structure. Of course, there are infinite lines and manifestations, but these are the most common and are great places to start working from as we develop more specific listening skills.

 

Loosening My Hold on a Model

It ends where it begins. Gil said hold your models loosely. As you can tell, I really like the TLF. Well, when I finally brought myself to read the article I was heart-broken. I had created an image in my mind where the TLF was some originary structure within the body, the source from which the rest of the myofascial previously discussed emerged and returned to – I really did imagine it that way.

Well, the article proceeded to say that the TLF derived from the tissue of the latissimus dorsi! Ack!

When I first read this, it didn’t make much sense. I’d developed such a strong TLF bias that I struggled to picture how such a central structure could have evolved from the lat. And then I started thinking more in terms of evolution and picturing a primate form that was not yet upright (or infant humans crawling around) and even other four-legged mammals. I imagined the running motion of a four-legged mammal and realized quickly how powerful and dominant the lat would be in that motion. It would be contributing an incredible amount of energy from the power of the foreleg through the back to the pelvis and hind leg. Because these mammals were not upright, they would not need the support that we need – so the fascia of the spine wouldn’t be as essential structurally. But the energy moving through the form as it ran and walked and, in the case of our primate ancestors, climbed and swung, the lat would be crucial and would need a strong link to the pelvis. Thus, the adaptive qualities of the fascia generated the complexity of the TLF as we know it.

Since learning this I’ve been exploring, in treatment, treating the link between TLF and the latissimus dorsi. There are often strong releases along the tendinous connection formed at the border of the two structures.

Another side-note from the connective anatomy-based fresh cadaver dissections is that it is common for there to be muscle to muscle tendon connections. This is showing us the reality of informed connection between muscles without relying on bony links or nerves.

These schematics also illustrate the strong myofascial connection between the TLF and both gluteus maximus and minimus. This is important to remember – especially when we are thinking of using this structure as both assessment and treatment. We can listen into a tension pattern within the glutes that can lead us further into the lower extremity or hip rotators that might not seem initially obvious.

Rachelle Wunderink's :  "untitled: self-portrait no.1"  mixed media collage, 2017

Rachelle Wunderink's: "untitled: self-portrait no.1" mixed media collage, 2017

 

Curiosity as Modality . . .

 It’s funny, I’m having a hard time finding a way to conclude this big explication of something that began for me over 15 years ago as a curiosity. I think that’s because I’m not done yet. I know there’s more to learn and probably things said here to release when new learnings emerge.

But, I do feel confident in one thing. Our work with people, their bodies, is so complex and so much is not yet known. Our curiosity may just be our best skill and possibly modalities are vehicles for our curiosity to express itself and not techniques to master.


These concepts and structures are truly the foundation for how I have come to work with the body. And, this is the basis for why and how we have restructured our Myofascial Release Course Series around a foundational course on working with the TLF.