The Lateral Raphe: An Important Structure of the Low Back

The Lateral Raphe, Quadratus Lumborum and the 2023 FSOMA conference

I will be presenting about the lateral raphe and the quadratus lumborum at the 2023 Florida State Oriental Medical Association )FSOMA) annual conference on Aug. 27. Details are available here. This post and the video below will give a preview of a portion of this presentation. I hope to see you there!

The Lateral Raphe and Low Back Health

Many manual therapists use high velocity low amplitude (HVLA) adjustments (such as a chiropractic or osteopathic adjustment) to move the body frame and reposition joints. I follow more of the structural integration model where I use the fascia as a lever to move and mobilize the body's skeletal framework. The lateral raphe of the low back is one of these important levers that can influence so much of the low back that it is important to understand the anatomy and use this understanding to better mobilize and move the body.

Netter Image
showing TLF

The lateral raphe is part of the larger thoracolumbar fascia (TLF). The TLF is the diamond shape aponeurosis (wide, flat tendon) seen in musculature illustration of the back. These illustrations don't do it justice since this isn't simply a single layer structure, but is, instead, a multilayer fascial structure with attachments to so many prominent structures of the low back.

From Human Structure and Shape
by John Hull Grundy

The fascia from the abdominal muscles, primarily the internal obliques and transverse abdominis continue to wrap around to the back to join with the TLF. Specifically, these fascial layers converge into a seem at the lateral edge of the iliocostalis lumborum and the quadratus lumborum. This seem then separates again into two layers with one layer traveling superficial to the erector spinae to connect with the spinous processes of the lumbar vertebrae, while the second layer travels deep to the erector spinae and between the erectors and the quadratus lumborum (so, superficial to the QL) to connect with the transverse processes of the lumbar vertebrae. This seem is the lateral raphe. It has connections to the abdominals all the way to the rectus abdominis; it has connections to the erector spinae and QL, and it has connections to bony landmarks of the lumbar spine and even the deep lumbar multifidi muscles. 

This fascial seem helps integrate and balance pushes and pulls produced by all of these structures while providing a stable support for the muscles to pull on. You want the lateral raphe to be supple and strong so that it can be a structure that supports the spine while allowing the various muscles that attach to it to communicate mechanically with each other. This mechanic communication is how the myofascial knows where they are in space compared to their functional partners. 

Here is a video featuring palpation and giving a brief demo of techniques to affect the lateral raphe and influence low back health. 

The Lateral Raphe and its Sinew Channel Relationships

The lateral raphe is a meeting point in the fascial system. This plays out also when looking at its channel relationships, particularly looking at the sinew channels/ The following jingjin meet at the lateral raphe:

• Urinary Bladder jingjin - via pull from the erector spinae
• Stomach jingjin - following the lateral branch that travels up the vastus lateralis and into the gluteus medius and minimus fascia to the TLF and LR
• Liver jingjin - via the pull from the quadratus lumborum
• Kidney jingjin - via the pull from the lumbar multifidi

We will explore this more at the FSOMA conference and look at both local treatment and distal points to influence this important structure/

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Assessment and Treatment of the Channel Sinews: Pes Planus

Fig. 1: A technique referenced below which can be used for pes planus 

Last Fall, Matt Callison and I put together a presentation for the Pacific Symposium in San Diego, CA. We presented on pes planus, a condition where the foot rolls into excessive pronation during weight bearing due to a collapse of the medial arch.

In the presentation, we discussed assessment and treatment of pes planus and discussed some common injuries associated with it. The role the channel sinews (jingjin) play in proper support of the medial arch and how imbalances can contribute to pes planus was emphasized. This month, Matt Callison will be expanding on this presentation for the keynote presentation at the Sports Acupuncture Alliance. I won't be able to make this event, but thought I would write a bit of an intro for those attending. You can consider this a study guide.

For those not able to attend, you can get a small flavor of the class and start to play with some of the information. If you are interested in expanding on this, it is taught in the Sports Medicine Acupuncture Certification starting in San Diego, June 19-24.

Fig. 2 Pronation includes dorsiflexion, eversion, and abduction;
supination includes plantarflexion, inversion, and adduction.

During gait, the foot is in supination at heel strike. After heel strike and as the weight travels into the foot, it transitions into pronation as it absorbs the body's weight (Fig. 2).

Normal pronation causes an increase in tension (a good thing, in this case) as the elastic myofascial structures in the foot are lengthened. The result of this is an elastic recoil which helps propel the weight off the foot and back into supination.

Fig. 3

In pes planus, the foot over-pronates and cannot recover into supination for adequate push-off from the big toe (Fig. 3).

Due to the altered mechanics in the foot and into the leg, pes planus sets a person up for a host of potential injuries such as plantar faciosis, Morton's neuroma, tibialis posterior tendinopathy, tarsal tunnel syndrome, Achilles tendinopathy, shin splints, medial knee injuries and injuries into the low back and hip. Clinicians working with these conditions will achieve far better results if they help correct pes planus, thus reducing the mechanical strain that led to the injury.

For the acupuncturist, it is important to understand the channel relationships associated with pes planus. This can be facilitated by looking at the muscles and other fascial structures which support the medial arch and understanding which channel sinew they are part of. The two main channel sinews which support the medial arch are the Spleen and the Kidney. The relevant anatomy is below:

Fig. 4: Yellow line is tibialis
posterior (medial side) &
anterior (lateral side) - SP&ST;
blue line is peroneus longus
and brevis - UB;
black line is soleus and
abductor hallucis - KID.

• Spleen jingjin - tibialis posterior, flexor hallucis brevis
• Kidney jingjin - soleus, plantar fascia (main portion), abductor hallucis

The Stomach jingjin is also involved. A relevant structure is the tibialis anterior which also helps support the medial arch.

In pes planus these structure fail to lift the medial arch, they are inhibited and become over-lengthened as the foot overpronates. The qi of these structures is dropped and needs to be lifted.

In pes planus as the Spleen and Kidney jingjin fails to lift and support the medial arch, other structures become excessively shortened. These structures are part of the Urinary Bladder jingjin and include:

• Urinary Bladder  jingjin - gastrocnemius, peroneus longus and peroneus brevis, adductor digiti minimi, plantar fascia (lateral band)

In pes planus the Urinary Bladder jingjin is locked-short and is pulling excessively up. The qi of these structures excessively lifts and needs to be dropped and lengthened.

A technique that we teach in SMAC and Matt will be teaching at the Sports Acupuncture Alliance involves needling motor points of the involved structure and lifting, dropping, or lengthening the channel sinew. This is an advanced technique and can best be taught in a class setting. There is a sample in the image at the top of this blog post which involves lengthening the lateral band of the plantar fascia, a myofascial structure which becomes short and tight in pes planus.

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