Physiotherapy on thoracolumbar fascia release in shoulder and low back pain

 

Parivrtta Baddha Parsvakonasana which can stretch related TL fascia muscles
(Ref: https://doctorlib.info/anatomy/yoga-anatomy/7.htm)

Thoracolumbar fascia (TLF) is a strong aponeurosis of a large, roughly diamond - shaped area of connective tissue constituted by the thoracic and lumbar parts of the deep fascia enclosing the intrinsic back muscles. Moreover, the superficial part separates the paraspinal muscles from the muscles of the posterior abdominal wall and serves as an attachment site for various muscles of the back.  

Many muscles connected to TLF include multifidus, erector spinae, latissimus dorsi, transverse abdominis, gluteus maximus, biceps femoris of hamstring, and trapezius that can be related with shoulder problems and lower back problems.

TL fascia and connected muscles
(Ref: https://www.greatbigcanvas.com/)

Some studies stated TLF release was effective in reducing shoulder pain. The results of this study can be applied in clinical practice for TLF release performed to reduce shoulder pain. According to some studies addressed TLF release can help to improve low back pain as well. The TLF release technique was recommended in the terms of manual fascia release and foam rolling. 

In my opinion, the manual fascia release must be run by practitioners that cannot do home base exercise. Foam rolling and stretching has the potential to do the self TLF release that I would like to present in this article.

Manual TL fascia release 
(Ref: https://www.researchgate.net/publication/
282410517_The_clinical_efficacy_of_thoracolumbar_fascia_release_for_shoulder_pain)

Conclusion of thoracolumbar fascia release (Please stop and see physiotherapist in case of strong worse pain, radiation of numbness or pain to leg, dizziness. Moreover, patients with disc herniation must consult physiotherapist before start this instruction.)

Exercise #1: Foam rolling: roll around pelvic bone including sacrum and iliac crest, and lumbar area.

Exercise #2: Tennis ball massage: roll around pelvic bone including sacrum and iliac crest, and lumbar area.

Exercise #3: Multifidus and Erector spinae stretch: bend torso to opposite side of target muscle.

Exercise #4: Latissimus dorsi stretch: do this exercise on the floor for more stability.

Exercise #5: Gluteus maximus stretch: move the knee to opposite shoulder.

Exercise #6: Hamstring stretch: keep knee and lower back straight.

Exercise #7: Trapezius stretch: this is modified stretching pose that need bend over with following of bend head forward. Patients with disc herniation or dizziness problems must do it carefully and consult physiotherapist before start stretching.

Exercise #8: Torso rotation stretch: move both knee to opposite target muscle. During stretching need keep both knees together with keep ribs and thoracic spine on the floor.

Additionally, to improve TLF imbalance and pain does not need only stretching but also strengthening all muscles which attach to TLF. 

Anatomically, TLF covers lower thoracic spine, lumbar spine, and sacrum level. This configuration creates a previously undescribed fat-filled lumbar interfascial triangle situated along the lateral border of the paraspinal muscles from the 12th rib to the iliac crest. This triangle results in the unification of different fascial sheaths along the lateral border of the TLF, creating a ridged-union of dense connective tissue that has been termed "the lateral raphe". 

The lateral raphe (LIFT)
(Ref: Schuenke MD, et al. A description of the lumbar interfascial triangle and its relation with the lateral raphe: anatomical constituents of load transfer through the lateral margin of the thoracolumbar fascia. J Anat. 2012 Dec;221(6):568-76.)

This complex structure becomes especially notable at the caudal end of the lumbar spine where multiple layers of aponeurotic tissue unite and blend to form a thickened brace between the two posterior superior iliac spines (PSIS) and extending caudalward to reach the ischial tuberosities. Various myofascial structures with differing elastic moduli contribute to the formation of this thoracolumbar composite (TLC).

Dimples are the surface anatomy landmark of posterior superior iliac spine
(Ref: https://www.stalbanstherapyclinic.co.uk/sacroiliac-joint-pain) 

 Numerous descriptions of this structure have presented either a two-layered model or a three-layered model. Both models will be summarized, and a consensus approach will be attempted to present a summary diagram illustrating the two- vs. three-layered model of the TLF.

The two-layered model presents a posterior layer that attaches to the tips of the spinous processes of the lumbar vertebrae as well as the supraspinous ligament, and wraps around the paraspinal muscles reaching a raphe on their lateral border. The posterior layer is typically described as being composed of two sheets, a deep lamina that invests the paraspinal muscles and a superficial lamina that joins the deep lamina in the lower lumbar region. In the cervical region, the deep lamina of the posterior layer continues to cover the paraspinal muscles (all the muscles innervated by the posterior primary ramus) including the splenius capitis, as it blends with surrounding cervical fascias; eventually this paraspinal fascial sheath fuses to the cranial base. 

The two - layered model of TL fascia
(Ref: https://www.physio-pedia.com/Thoracolumbar_Fascia)

The three-layered model has strong similarities with the previously described model containing two layers. It is the most commonly used model in most research studies that is the reason why I wrote in the QL stretching article previously. The posterior layer consists of two laminae: superficial (the aponeurosis of the Latissimus Dorsi); and deep lamina. In between these laminae above the L4 level, the aponeurosis of the Serratus Posterior Inferior is present. The Middle Layer of TLF is the fascial band that passes between the paraspinal muscles and the QL. The anterior layer is defined as passing anterior to the QL and ending by turning posterior to pass between the QL and the psoas. The anterior layer has been described as being an extension of the transversalis fascia. As previously stated, typically authors using the two-layered model refer to the fascia anterior to the QL simply as transversalis fascia and exclude it from the model.

The three - layered model of TL fascia
(Ref: https://ittcs.wordpress.com/tag/thoracolumbar-fascia/)

The TLF envelops the back muscles from the sacral region, through the thoracic region, and is composed of anterior (ALF), middle (MLF), and posterior (PLF) layers. Of these, the PLF consists of superficial and deep laminae. The superficial lamina of the PLF is continuous with the latissimus dorsi (LD), and partially continuous with the gluteus maximus, external abdominal oblique (EO) and trapezius and contribution from the serratus posterior inferior (SPI). The deep lamina of the PLF has contributions from the SPI, lumbosacral attachments to interspinous ligaments, the long dorsal sacroiliac ligament, and the iliac crest and cranial attachments extending into the cervical paraspinal region. Along the lateral border of the PRS, a complex interaction occurs between the attachments of the abdominal muscles. The blending of the aponeurotic sheaths of the transversus abdominis (TA) and internal oblique (IO) muscles along with the lateral margin of the TLF gives rise to a ridged-union of dense connective tissue. This area of fascial fusion exists just lateral to the paraspinal muscles through much of the lumbar region, and was coined the lateral raphe (LR). The LR extends from the iliac crest caudally to the 12th rib cranially. Thus, the raphe is formed at the location where abdominal myofascial structures join the fascial structures surrounding the paraspinal muscles. Since Bogduk and MacIntosh’s original use of the phrase ‘lateral raphe’, several articles. 

TL fascia layer and muscles
(Ref: https://id.pinterest.com/pin/703898616752662141/)

TLF plays a multi role including enveloping posterior and lateral torso muscles, stability of spine and posture, movement of limbs and spine, transmission force between upper and lower limbs.

The lumbosacral spine plays a central role in sustaining the postural stability of the body; however, the lumbar spine alone is not capable of sustaining the normal loads that it carries daily. To stabilize the lumbar vertebrae on the sacral base requires the assistance of a complex myofascial and aponeurotic girdle surrounding the torso. On the posterior body wall, the central point of this girdling structure is the thoracolumbar fascia (TLF), a blending of aponeurotic and fascial planes that forms the retinaculum around the paraspinal muscles of the lower back and sacral region 

Stabilizer function of TL fascia
(Ref: https://www.researchgate.net/publication/
51654116_Reduced_thoracolumbar_fascia_shear_strain_in_human_chronic_low_back_pain/
download)

Movement and stability of the lumbosacral region is contingent on the balance of forces distributed through the myofascial planes associated with the thoracolumbar fascia (TLF). This structure is located at the common intersection of several extremity muscles (e.g. latissimus dorsi and gluteus maximus), as well as hypaxial (e.g. ventral trunk muscles) and epaxial (paraspinal) muscles. The mechanical properties of the fascial constituents establish the parameters guiding the dynamic interaction of muscle groups that stabilize the lumbosacral spine.

Ref: https://onlinelibrary.wiley.com/doi/10.1111/j.1469-7580.2012.01511.x

There is bilateral force transmission from gluteus maximus to the latissimus dorsi and lower trapezius muscles. These muscles are connected by the fascial network of the back. The gluteus maximus and latissimus dorsi share the origin from the aponeurotic posterior layer of the thoracolumbar fascia (PTLF). In conditions like idiopathic back pain, radiating pain, etc., instead of focusing on single structures like a muscle or a fascia, more holistic approaches seem appropriate. In pathological conditions, the connection through PTLF may contribute to altered biomechanics of the back of the trunk. 

Force transmission tarjectory to opposite side obliquely (Ref: https://openhealthclinic.com/)

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Reference: 

https://www.uni-ulm.de/fileadmin/website_uni_ulm/med.herti/Forschungsprojekte/Publikationen/2012_Thoracolumbal_Fascia_Anatomy_J_Anat.pdf 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512280/ 

https://kmbase.medric.or.kr/Fulltext/10120/2015-4-1/55-59.pdf

https://www.mskscienceandpractice.com/article/S1356-689X(16)30756-1/pdf

http://www.mltj.online/role-of-posterior-layer-of-thoracolumbar-fascia-in-epimuscular-myofascial-force-transmission-from-gluteus-maximus-to-latissimus-dorsi-and-lower-trapezius/ 

https://www.researchgate.net/publication/284278045_Do_exercises_with_the_foam_roll_short_impact_on_the_thoracolumbar_fascia_A_randomized_controlled_trial

https://www.kenhub.com/en/library/anatomy/thoracolumbar-fascia 

Physiotherapy with 3 options to stretch latissimus dorsi for shoulder pain or back pain.

  

Ref: https://jackhanrahanfitness.com/

Anatomically, Latissimus dorsi is a large flat muscle attached between the half lower spine and shoulder. It plays a vital role in pathomechanics of mechanical low back pain. Including shoulder pain, upper back pain, and maybe neck pain because it can make scapular motion changes or scapular dyskinesis. 

Ref: https://www.quora.com/

In my physiotherapy experience, weakness and stiffness of latissimus dorsi develops poor posture. For example, I have named The Gorilla posture which I have seen in muscular men because of the stiffness of this muscle, moreover, I have called it as The swimmers posture which I have seen in swimmers athletes. It frequently causes shoulder pain in this posture. According to some reports, they mentioned to canoeists and rugby players that I never treated them. 

Ref: https://www.dreamstime.com/

Occasionally, I took care of a neck pain patient with breast augmentation. They had neck pain, upper back pain, or shoulder pain that could trick me to treat other muscles i.e. rotator cuff. The involved soft tissue of breast augmentation may result from incision scar and myofascial fascia stiffness and latissimus dorsi stiffness. 

Therefore, latissimus dorsi stretching is necessary for shoulder pain and back pain. 

3 poses option to stretch latissimus dorsi

Exercise #1: Stand latissimus dorsi stretch: to bend the torso to the opposite side of the target muscle that needs to place the hand on the wall for balancing and place the same foot behind the non - target side. Shift body weight to the hip which has the same target muscle side.

Exercise #2: Child pose lateral bending: start with child pose and bend the torso to the opposite side of target muscle.

Exercise #3: Gym ball latissimus dorsi stretch: this is floor exercise with the gym ball. Put non - target muscle on the ball, then place both feet anywhere which is the most stable. Elevate arm with close to the ear. 

  

The latissimus dorsi is primarily considered a muscle with actions at the shoulder, despite its widespread attachments at the spine. There is some dispute regarding the potential contribution of this muscle to lumbar spine function. 

Latissimus dorsi is a unique muscle in terms of its anatomical design. It is a relatively thin, fan-shaped muscle, and is one of the largest in the body in surface area. It covers a significant portion of the back to shoulder that there is some dispute regarding the potential contribution of this muscle to lumbar spine and shoulder function. 

Latissimus dorsi muscle (Bright red)
(Ref: https://www.physio-pedia.com/)

  Its attachments from the spinous processes of the lower six thoracic vertebrae, lumbar vertebrae, and sacrum, as well as to the ilium via the thoracolumbar fascia. Muscle fibers then converge superiolaterally toward the axilla via inferior 3 or 4 ribs and inferior angle of scapula , where the fibers converge to a single twisted tendon that is inserted in the intertubercular groove of the humerus which is onto the anterior aspect of the proximal humerus. 

Insertion of latissimus dorsi
(Ref: https://www.medicinebau.com/)

Muscle function of latissimus dorsi includes shoulder adducts, shoulder extends and shoulder internal rotates that are hand behind back. It provides a powerful rotator of the trunk and assist back extension. It is the antagonist of deltoid and trapezius muscle. The structural characteristics of this muscle are those of a global mobiliser. The muscle will therefore shorten, this will cause limited glenohumeral joint flexion and external rotation.

Hand behind back
(Ref: https://www.medistudents.com/)

The latissimus dorsi plays an important role in basic back activities such as trunk extension and rotation. There is a prevalence rate of 73% for latissimus dorsi tightness in active mechanical low back pain patients. A decrease in length or increase in stiffness of latissimus dorsi can lead to alterations in movement patterns and postures which cause exacerbation of low back pain that is a pathomechanics low back pain. A decrease in length or an increase in stiffness of this muscle can lead to alterations in movement patterns and/or postures which can cause an increase in low back pain. Latissimus dorsi in association with thoracolumbar fascia helps in force distribution that the posterior layer of thoracolumbar fascia which is formed through latissimus dorsi can effectively contribute to low back pain. 

Latissimus dorsi length test: normal length (left), stiffness (right)
(Ref: https://www.mitchmedical.us/)

The length of latissimus dorsi can be assessed by means of a reliable test to maintain treatment efficacy and objectivity. An latissimus dorsi length test explained by McConnell (1994) described a patient in crook lying. The patient has to decrease the lumbar lordosis actively by controlling the anterior pelvic tilt (by actively keeping the back flat) to do flexion with the glenohumeral joint in a neutral position with no glenohumeral rotation being allowed. The range of motion of glenohumeral joint flexion is measured using a goniometer at the point when the patient’s lumbar spine starts tilting anteriorly and lifts off the plinth, or when the glenohumeral starts to internally rotate. 

Discussion from above, to reverse muscle function for stretching this muscle should illustrate torso rotation and shoulder abduction. VIDEOs did not demonstrate torso rotation and shoulder abduction, however, torso lateral bending and shoulder adduction in flexion. Other motions are the same as above including shoulder flexion, shoulder external rotation, and lower back flexion.   

Ref: https://www.enjoy-swimming.com/

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Reference: 

https://www.scielo.cl/pdf/ijmorphol/v24n4/art30.pdf 

https://onlinelibrary.wiley.com/doi/full/10.1111/joa.12074 

https://www.sciencedirect.com/science/article/pii/S2095254613000215 

https://www.ijsar.in/Admin/pdf/to-study-the-prevalence-of-latissimus-dorsi-tightness-in-patients-with-mechanical-low-back-ache.pdf 

https://www.ijsr.net/archive/v9i8/SR20730124217.pdf 

https://www.researchgate.net/publication/323702778_Inter-_and_intra-rater_reliability_of_a_technique_assessing_the_length_of_the_Latissimus_Dorsi_muscle 

Physiotherapy with 9 stretching exercise to improve rounded shoulders

            

Rounded shoulders
(Ref: Singla D., et al. Association Between Forward Head, Rounded Shoulders, and Increased Thoracic Kyphosis: A Review of the Literature. J Chiropr Med 2017;16:220-229)

            Rounded shoulder posture is one of the most common poor posture characteristics in physiotherapy clinics. In my experience, I see both cases of rounded shoulders accompanied with a forward head and only rounded shoulder alone. Chief complaint never talked about rounded shoulders; but, it is about muscle pain of neck, shoulder, upper back, and scapular. 

Rounded shoulder posture refers to a posture characterized by acromion protraction in front of the line of gravity, shoulder protraction, and downward rotation as well as anterior tilt.

    External cause factors, for example, computer and smartphone lifestyle, job characteristic, workstation, or temperature, ect. As internal cause factors reveal soft tissue impairment; include, weakness of scapular stabilizer muscles, upper back, rotator cuff, and shortening of chest muscle, upper arm muscle, some shoulder ligaments. 

In this physiotherapy article presents shortening of front upper part soft tissue shortening; and, how to stretch them.    

3 Major muscles involved rounded shoulders

            1. Pectoralis major

                The pectoralis major is a large, flat muscle of the pectoral girdle of the upper limb. It is a fan shaped that appears with 3 heads or portions: the clavicular, the sternocostal, and the abdominal head. This distinct tendon enters in contact towards the insertion on the humerus. Rounded shoulders is related to the shortening pectoralis major which pulls the humeral head anterior. It needs stretching and manual release from a physiotherapist to correct the posture.

Pectoralis major muscle
(Ref: https://link.springer.com/article/10.1007/s00064-021-00760-5)

            2. Pectoralis minor

                Pectoralis minor located between lateral 3rd, 4th, 5th rib to the coracoid process of scapular. When this muscle shortens, the scapular wiil be changed posture to be scapular anterior tilt, scapular internal rotation, and scapular downward rotation. It needs stretching and manual release from a physiotherapist as well.

Pectoralis minor muscle 
(Ref: https://www.orthobullets.com/anatomy/10007/pectoralis-minor)

            3. Biceps brachii

                Biceps brachii affects the shoulder joint becasue there are 2 different attachments of muscle; include, long and short heads. The long head of the biceps brachii is attached from the supraglenoid tubercle of the scapular and passes through the bicipital groove, and the short head of this muscle is attached from the coracoid process of the scapular.

      

Biceps brachii
(Ref: https://fitmachtgesund.de/en/musculus-biceps-brachii/)

The rounded shoulder posture as a result of lower trapezius muscle, serratus anterior muscle, and rhomboid muscle is prolonged lengthening that develops weakness and pain. In my experience, stretching and massaging them cannot improve pain. I always massage and stretch all 3 muscles which we talked about above. To exercise scapular stabilizer muscle is one of crucial treatments; but, it is not my point in this article. 

I prefer static stretching the most because it is more effective than dynamic stretching and easier than PNF stretching. The way to stretch is simple: stretch to the point where “tightness without pain” or “noticeable tension without pain” will hold at that point for 30 seconds of 3 - 4 repetitions in one muscle. 

Remark: If you feel neck and head discomfort from these stretching, you should decrease stretching range of motion. While these 3 muscles are very tight, the scapular and neck muscles try to beat them to achieve a range of motion that increases stress on scapular and neck muscles. Therefore, start at a small tension point and go further gradually.  

9 poses of stretching to improve rounded shoulders 

Exercise #1: Horizontal doorway pectoral stretch

Exercise #2: High doorway pectoral stretch

Exercise #3: Double shoulder external rotation stretch

Exercise #4: Active anterior deltoid stretch

Exercise #5: Chair anterior deltoid stretch

Exercise #6: Single horizontal pectoral stretch 

Exercise #7: Single shoulder external rotation stretch

Exercise #8: Half wall (chair) hang stretch

Exercise #9: Biceps brachii stretch

Reference:

https://he01.tci-thaijo.org/index.php/NurseNu/article/view/178634/143838 

https://www.researchgate.net/publication/318858178_Relationships_Between_Rounded_Shoulder_Posture_and_Biceps_Brachii_Muscle_Length_Elbow_Joint_Angle_Pectoralis_Muscle_Length_Humeral_Head_Anterior_Translation_and_Glenohumeral_Range_of_Motion/link/59a6a1ccaca272895c1671f2/download 

https://www.researchgate.net/publication/320543998_Changes_in_rounded_shoulder_posture_and_forward_head_posture_according_to_exercise_methods 

https://www.researchgate.net/publication/335136115_A_Detailed_Review_on_the_Clinical_Anatomy_of_the_Pectoralis_Major_Muscle/link/602e4fdb92851c4ed57c6f02/download