The Thoracolumbar Junction: The place you need to know, but maybe don’t…

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One of the most important regions of the body when it comes to treating myofascial pain and some visceral issues is the thoracolumbar junction (TLJ). It is where the thoracic spine meets the lumbar spine - and a whole lot more. 

If you’ve ever been frustrated by doing great work at the site of a client’s/patient’s chief complaint only to have the pain recur quickly after treatment then the TLJ is for you. I was first keyed into this area from studying Ida Rolf’s phenomenal book, Rolfing, written in 1977! I am not a Rolfer but Ida Rolf’s insights around fascia, seeing the body as an integrated whole and the interrelationship between emotional patterns and the physical form contributed to an integrated field of somatic work being practiced by multiple disciplines  that is thriving today - so big thanks to Ida Rolf! 

Ida Rolf’s book is where I first encountered one of my professional guideposts, where it is, it isn’t. Meaning, what is causing someone’s pain or discomfort is likely somewhere other than where they are experiencing that symptom. That just made sense way back then and 20 years of clinical work has shown it to be so helpful.

So, how do we find where it is, if it isn’t where it hurts? This is where the TLJ becomes relevant. Ida Rolf made the point, that in part due to the way the ribs inhibit movement of the thoracic vertebrae, that we rely on the TLJ much of the dynamic movement of our torso; our ability to rotate and laterally flex all depend on this area. If it is restricted in its movement, then it can impact the lumbosacral junction, the thoracic outlet, cervicothoracic junction and either the upper or lower extremities. 

Based on Ida Rolf’s signaling and my own curiosities and clinical feedback, I have made both the TLJ and the thoracolumbar fascia major points of focus of my work and study. 

The TLJ  is not an area that I hear discussed much, so imagine my surprise and curiosity when I opened the fall issue of Acupuncture and Integrative Medicine  and saw  an article by Brian Lau about Thoracolumbar Junction Syndrome. It is an area of supreme importance from a clinical perspective. And, the article offers some nice descriptions of the neural correlations with the channels along the spine along with emphasizing this important area for clinicians. 

At the TLJ we have multiple myofascial, visceral,  neural and skeletal convergences. From a clinical perspective and in tune with one of my points of inquiry when studying or treating - how does the body experience itself - these different tissue types are completely interrelated and the body likely does not see any tissue type as more important from any other - what is essential is how they all interact with and inform one another to create our felt and lived experience. 

Myofascial Mapping from the Thoracolumbar Junction

The TLJ is a myofascial nexus that links the low back, thoracic regions with the pelvis, abdomen and upper and lower extremities. If we combine this with its closely linked structure, the thoracolumbar fascia (TLF) we are decidedly in an important region. Another way to think about this is that we have myofascial links both vertically and horizontally (wrapping around the body). 

Erectors and Thoracolumbar Fascia 

The erectors and TLF are a major part of the vertical component here. If we follow the erector spinae group both superior and inferior we can gain insight into how tension in this area may be moving up or down from here. 

The thoracolumbar fascia has been written about a lot here (We even have a dedicated  class just on it!). One key aspect of the TLF is that it serves as the tendon for the erector groups inferior attachment and the TLJ is the uppermost border of the thoracolumbar fascia - so from this vantage point they become blended. Sometimes the meaning of anatomy isn’t absolute or objective but rather a matter of perspective - what relationships are we most interested in seeing?

Treating tensions found here can be essential for helping free up this part of the body for better movement and in the process also release tension that may be transmitting either superior or inferior. 

Upper Extremity

We often depend on rotating at the TLJ to position our glenohumeral joint in space to reach things either in front or behind us, if this is inhibited it can lead to irritation in the g/h joint or thoracic outlet. 

Myofascially, the lower fibers of both the trapezius and lat dorsi are blending into the thoracolumbar fascia at the TLJ and this adds even more dynamic tension when there is inhibited  motion at the TLJ. .

Lower Extremity

There is an interesting dynamic that occurs if the TLJ is restricted in movement, it will often result in decreased movement at the lumbosacral junction and can contribute to all sorts of pain patterns in the lower back, sacrum, pelvis and lower extremity. Add to this that the thoracolumbar fascia has major connections with the gluteus medius and maximus along with  main players of low back and pelvis issues - the psoas and ql. A major clinical insight for me has been prioritizing treating any tension I find here for low back or SI joint issues, it can be so helpful. 

TLJ and Quadratus Lumborum, Psoas, Diaphragm and Viscera

This is where the TLJ becomes very interesting. Once, we have invoked the presence of the ql and psoas we are in the fascinating territory of the diaphragm and I think this becomes a crux of the TLJ’s importance to all types of work and allows it to be such a meaningful place to treat, regardless of complaint. 

The ql, psoas and diaphragm make up a dynamic and functional unit with three parts. The diaphragm has its posterior attachments on the vertebrae around the TLJ. The transversalis myofascia cross hatches into the diaphragm as well as attaching onto the ribs (for folks with some familiarity with channel theory this is a clear reference to the dai mai). 

This horizontal connection, from my 20 years of clinical experience, is essential. If you watch some of Gil Hedley's recent dissections you can appreciate the absolute interconnection between the transversalis fascia and the peritoneum (the fascial bag surrounding the viscera), not to mention the nerve connections. 

However, I do think sometimes we can overemphasize nerve links and under-appreciate the intelligence and communicative aspects of the tissue realm. Of course, they are interrelated and treating the soft tissue milieu will have a correlative effect on the nerves - for that reason I feel confident treating what I find within the tissues (whether with acupuncture or hands-on work) and trusting the body’s intelligence to do the work). It is common in myofascial courses where we are working on the TLF and TLJ for folks to comment on the profound felt sense in their guts. 

I cannot discuss this area without also commenting on what has been a major area of study and inquiry during the pandemic (which correlates with further studies into how traumas - especially developmental traumas - impact the tissues and felt sense). The diaphragm is often constricted in people without them being consciously aware of it - how often does a client or patient come in and say my diaphragm is tight or hurts? It happens, of course, especially if we have body aware people we treat but many of us are unaware of the tension patterns we carry, or if we are aware, unaware of how they might be impacting other body regions or systems. The diaphragm is often tight or restricted and folks just don’t know - but we can find and treat that tension by including curiosity about the TLJ in our work. 

One of my favorite Gil Hedley quotes is something he said in summation of a long (4 or 5 hour lecture!)  I had the honor to attend, “it’s all connected, just not how you might think…” I love that, I love thinking about that and holding that as an open question when I am working and teaching. These are relationships I know from the interrelationship of study, long time clinical practice and many many hours in the classroom exploring and refining these ideas with colleagues. And, all models are incomplete and so maintaining an open heart-mind and yet still having models to use in our work is a really nice place to be. For me, thinking in this way about this region has been so helpful and helped me help people, which is what it is all about. 

Let’s look at a case example to see how this can play out in treatment. 

Case Study

I treated a mid-30’s adult who had scoliosis and significant kyphosis. The person’s chief complaint was L shldr pn. They were a serious mtn biker and proactive in self-care and research for ways to address their condition. Pn was located in the g/h joint with some radiation down the arm and concurrent L side cervical pain. There was limited ROM in all planes due to the scapula being positioned anterior and somewhat immobile.

Treatment began with the person face down and it was immediately apparent that the rt side TLJ was an issue - there was visible compression there and on palpation the tissues were very tight. Hypertonicity was in the erectors but more importantly, in the deeper structures.

I performed myofascial release for the TLJ with the person face down and then with them lying on the L side so I could treat the right. Treatment focused on the quadratus lumborum, transversalis, diaphragm and psoas from this position (all covered in our mfr courses). 

I spent a small amount of time in treatment on the L shldr and neck. When they returned for their follow up visit they were surprised at the amount of relief they experienced when I didn’t particularly focus on the shoulder itself. 

When this person first came for care they were considering flying to Texas for a specialized surgery. After some sessions together they decided that would not be necessary.

It doesn’t always happen like this of course. This is a dramatic example of a dynamic that I still maintain is important - if there is tension at the TLJ it is worth treating, regardless of symptomology. 

The TLJ in Your Practice

I have found this area is well treated clinically with either myofascial release work or acupuncture. Depending on the patient one may work better than the other, and if you have skills and licensure for both that can work too. However, hands-on work alone is phenomenal and should never be underappreciated professionally.

If you want to learn more about treating the TLJ and this way of being with the body our Myofascial Release series is great. Also, check out our new clinical cafe for case discussions and of course our anatomy talks are a wonderful way to get useful connective anatomy inspirations! 

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