For the past 3 weeks, we have been working with a middle-aged male who presented with residual patellar tendinosis (a chronic knee condition in which the knee tendon has not been able to heal fully, leading to knee pain) that has been ongoing for the past six months. His exercise program has been built up gradually, working on supporting musculature for the knee (core, hamstrings, pelvis, gluteus medius, and gluteus maximus). While all the exercises have been helpful (as you will see the importance of them later in this blog) what really moved the needle in his recovery was the simple exercise of a banded long arc quad knee extension, where he is holding out for 10 seconds at a time with oscillating movements going into a straight-leg hip flexion in the sitting position, targeting the rectus femoris muscle.
It was a simple exercise. Not a plyometric single-leg split squat, no balancing a foam roll against a wall while rotating with a medicine ball, no compound movement like a Romanian Deadlift with a weight- all fine exercises, but for way down the line. Just a simple exercise targeting a simple muscle, to resolve a seemingly “complex” issue that wouldn’t allow the patient to progress to more complex activities in his life.
We often get patients coming in with expectations from YouTube that they’ll be jumping off the walls, contorting their bodies that look interesting and cool on camera, but in actuality, targeting individual weakened muscles through simple and effective exercises is required first, not optional. No area of the body with its associated contributing muscles is more representative than the thoracolumbar fascia of the lower back and pelvic area.
Thoracolumbar Fascia: Helps Protect Your Lower Back
You see this pattern all the time in mobile spine care: someone has been exercising, doing all these compound multidirectional movements (exercises that work more than one muscle group across multiple joints, ie., a squat or deadlift), and their back still hurts with bending, lifting, twisting, or carrying. The problem is often not lack of effort; it’s that they’ve skipped the specific muscles and movement control strategies that help the thoracolumbar fascia do its job, which you can see the muscle contributions to it are quite extensive.
Now, don’t get overwhelmed by the picture above. Just appreciate that many muscles of your hips and core contribute to the proper functioning of your thoracolumbar fascia. So what is it? The thoracolumbar fascia is a tough sheet of tissue in your lower back that wraps around your thorax like a corset and helps your body share and transmit force when you move. It assists your back, stomach, hips, and legs to work together so you can stand, reach, walk, lift, and turn without hurting yourself. It also helps your body know where it is in space and has pain nerves in it to signal if something hurts. If the muscles (see below) that help support it get weak, your back may not move or hold up as well, and that can lead to pain as the forces don’t transmit through the body as they should but get absorbed by pain-sensitive structures (disc, nerves, facet joint capsules).
The Muscles that Contribute and Their Importance
Latissimus dorsi
Serratus posterior inferior
Trapezius
Gluteus maximus
Transversus abdominis
Internal oblique
External oblique
Quadratus lumborum
Psoas major
Erector Spinae (iliocostalis, longissimus, spinalis)
Multifidus
Each of these muscles contributes a different kind of support. Some help with trunk stiffness, some with hip power, some with rotation control, and some with fine spinal segment control —but they all matter because they help tension the fascia in a coordinated way, and if any of them are weak, then the stabilization of posture and transfer of forces with activities is compromised, with your spine bearing the brunt of the breakdown.
Why This Matters for Lower Back Pain
Low back pain often appears when the body can’t distribute load efficiently. If the deep abdominals are underactive, the glutes are not helping enough, or the spinal stabilizers are not doing their part, then the pain components (disc, nerves, facet joint capsules) of the lower back may absorb too much stress because the fascia is not efficiently doing its job.
Researchers have found that in people with long-lasting low back pain, the thoracolumbar fascia does not slide and stretch as well as it should; about 20% less in lower back pain individuals compared to non-pain individuals. Other studies suggest this thoracolumbar fascia may also help send pain signals. In simple terms: when the thoracolumbar fascia gets stiff or does not move well, it may cause pain and make your back feel tight.
Why Isolated Exercises Come First
This is why we do not usually start people with the flashy exercises seen on YouTube, especially if patients desire to get back to doing high-level activity as quickly as possible. Multi-direction, athletic-looking exercises are useful and needed, but only after the foundational muscles are working well. If we are trying to target a specific weak muscle that contributes to the thoracolumbar fascia, let’s say the gluteus maximus, then the fastest way to strengthen that muscle will be a simple front step-up exercise, as it shows the highest gluteal activation (according to EMG studies) with the lowest spine-jarring impact. If we rush too early with complicated multiplane exercises, the goal of strengthening the gluteus maximus is limited by the patient’s inability to purely focus on the weakened muscle and have to perform multidirectional or multicomponent movements (having to concentrate on balance or using other muscle groups that shouldn’t be the focus). Compensation through the lumbar spine instead of controlling motion through the hips and trunk takes place, putting undue stress on pain-receptive structures (disc, nerves, facet joint capsules).
In case you are curious what the progression and process is, see below:
Rebuild muscle activation of the associated muscles that contribute to thoracodorsal lumbar tightening.
Improve motor control and be able to brace the trunk efficiently (being able to move your limbs while stabilizing all your postural muscles).
Reduce unwanted lumbar movement until pain is fully abolished.
Prepare the thoracolumbar fascia for higher-level movement (getting to more athletic movements).
Takeaway Message
If your back keeps flaring up, the answer is rarely more random multiplane exercises (but not always, and this is where we make our money). The better strategy is to restore the muscles that support the thoracolumbar fascia, then progress into more complex movement once the foundation is solid. That is how we move from pain management to true resilience. In a nutshell, we don’t care about looking cool. We care about getting you out and back to your active life as quickly as possible and making sure you understand the principles to be able to sustain that. Reach out if you have questions and know that we are here to help, Mobile Spine Family!
Sources:
Langevin, H.M., Fox, J.R., Koptiuch, C., Badger, G.J., Greenan-Naumann, A.C., Bouffard, N.A., Konofagou, E.E., Lee, W.-N., Triano, J.J., Henry, S.M., 2011. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskelet Disord 12, 203.
Sinhorim, L., Amorim, M.D.S., Ortiz, M.E., Bittencourt, E.B., Bianco, G., Da Silva, F.C., Horewicz, V.V., Schleip, R., Reed, W.R., Mazzardo-Martins, L., Martins, D.F., 2021. Potential Nociceptive Role of the Thoracolumbar Fascia: A Scope Review Involving In Vivo and Ex Vivo Studies. JCM 10, 4342.
Willard, F.H., Vleeming, A., Schuenke, M.D., Danneels, L., Schleip, R., 2012. The thoracolumbar fascia: anatomy, function and clinical considerations. Journal of Anatomy 221, 507–536.
