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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Futu (ST 32) and the Extrapoint Xinfutu for Low Back Pain

Fig 1: ST Jingjin Thigh and Torso
Anterior View (L image) and Posterior View (R image)
image modified from image created with zygote body,
information © Brian Lau

At the end of last year, I was a guest on the excellent Qiological podcast hosted by Michael Max. We discussed the channel sinews and how they relate to structure and function. The podcast is below, or you can check it out here.



On the notes page of this podcast is a nice clinical tip regarding a branch of the Stomach channel sinews which links to the low back. Many practitioners have noticed this branch when looking at illustrations of the channel sinews in books such as Peter Deadman's A Manual of Acupuncture. Furthermore, many practitioners have noticed indications of Stomach channel points which have indications for low back pain. Specifically, ST 31 - ST 34 have indications for lumbar pain.

ST 31 happens to be the motor point for the rectus femoris, the only quadriceps muscle that attaches to the innominate bone (it attaches to the AIIS). Shortness in this muscle will pull excessively on the innominate bone and contribute to an anterior tilt of the pelvis and excessive lordosis of the spine. This is an obvious biomechanical explanation for why this specific point would help with lumbar pain, as reducing tension in the rectus femoris would affect pelvic and lumbar mechanics. This would be especially helpful for patients with pain in the lumbar facet joints (facet syndrome), as these joints would be jammed together when the patient has an anterior pelvic tilt.

The points ST 34 - ST 32, however, require a different explanation for their impact on the low back. These points would not be on the rectus femoris; they would have a greater influence on the vastus lateralis muscle. This muscle does not attach to the innominate bone, so tension in this muscle would not directly affect pelvic and lumbar mechanics. Understanding how this muscle affects the lumbar region requires a different explanation. The explanation will require an review of the Stomach channel sinews. Fortunately, it will provide some relevant diagnostic information that you can use in clinic.

The Stomach channel sinews mostly follow the Stomach primary channel. However, there is a branch that connects to the lumbar spine.  Here is a quote from Chapter 13 of the Lingshu, translated by the Vietnamese scholar Nguyen Van Nghi: "The Zu Yangming (St) Jing Jin begins at the extremity of the third toe, inserts in the ankle joint, climbs obliquely along the fibula and inserts in the lateral surface of the knee, goes vertically to the hip joint where Huantiao (GB 30) is located, runs along the false ribs, and ends at the spinal column." The remainder of the ST channel sinews is then described to complete the entry for the Stomach. This follows the primary channel.

What anatomy could this be describing? A few highlights are helpful. First, this branch is more lateral than the remainder of the Stomach channel sinews on the thigh (the portion which follows the primary channel), and it goes to the hip joint (where GB 30 is located). If you look at the vastus lateralis muscle, you will notice that it goes very lateral; it actually attaches to the posterior portion of the femur at the linea aspera. This attachment comes very close to the femoral attachment of the gluteus maximus on the gluteal tuberosity. The fascia of each of these muscles merges and creates a fascial continuity. If you press on GB 30, you are pressing on the gluteus maximus, so this connects the Stomach channel sinews to GB 30 as described above.

The gluteus maximus then has a fascial continuity with the thoracolumbar fascia (TLF), a thick aponeurotic structure in the lumbar region which attaches to the lumbar spine. The TFL is a bit complex and multilayered. The gluteus maximus blends with the superficial layer of the TLF. There are 3 layers of the TLF. A layer wraps over the erector spinae muscles (this is the layer that the gluteus maximus blends in with), another layer wraps deep to the erector spinae, and a third layer wraps deep to the quadratus lumborum.

Fig 2: Image of the TLF and the lateral raphe, from
an excellent article written by Warren Hammer, DC

In Sports Medicine Acupuncture®, we palpate the TLF a number of ways. One way is to palpate the lateral raphe, which is a region where the multiple fascial layers meet before separating into the 3 layers described above (Figs. 1 and 2). You can think of it as a fascial seam or meeting point. This fascial seam is a meeting place of forces coming from several directions. It can be palpated most easily at the level of L3 with the fingers following the lateral border of the iliocostalis and following the edge of the muscle with the fingers pointed slightly medial towards the navel. Just past this muscle, you will run into the fascial wall of the lateral raphe. Medial to this, the fascial layers will differentiate into the 3 layers describes.

For patients with significant tension at both the lateral raphe and at the vastus lateralis, palpate the lateral raphe and ask the patient to report the pain with palpation on a scale of 1-10. You can then needle one of the Stomach channel points such as ST 32 (futu) to see if it reduces tension in the TLF and reduces pain. However, you might consider using the motor point of the vastus lateralis instead; this is located at the extrapoint xinfutu which is found 1-2 cun lateral to ST 32. This point will have a stronger effect on the vastus lateralis muscle.

Locate xinfutu, the MP of the vastus lateralis, needle this to the depth of 0.5-1 cun, obtain deqi, and return to palpate the lateral raphe. Frequently, the patient will report a reduction of pain by 50% or greater.

This is easiest to do with the patient supine, and palpation of the lateral raphe will require you to reach under the patient. But it will give you immediate feedback that you have reduced tension on the TLF from at least one vector, that of the Stomach channel sinews following up the vastus lateralis and gluteus maximus to the TLF. Other forces can also tension the TLF, such as the abdominals, the latissimus dorsi and the muscles of the lumbar spine. These need to be looked at separately and can be left to another discussion. The takeaway for now is to consider reducing tension in the vastus lateralis for patients with low back pain if their lateral quadriceps are very rigid. This will add to your clinical effectiveness when treating low back pain.

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