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fascia and at which orientation, understanding sources of dysfunction should become more predictable. PALPATION AND ASSESSMENT AND LOAD-TRANSFER: THE THORACOLUMBAR FASCIA Palpation and assessment strategies need to take account of this load- sharing phenomenon. The scale of the palpation puzzle can be seen in the illustration of the huge number of potential links available from just one massive fascial structure, the thoracolumbar fascia. This ties together the erector spinae, latissimus dorsi, quadratus lumborum, psoas, transversus abdominis, and diaphragm muscles, as well as countless other minor muscle structures (Images 1 and 2). UNRAVELING THE PUZZLE As we focus attention on the assessment of relative shortness in named muscles, we need to maintain awareness that multiple fascial connections exist that bind together muscles with different names into a virtual interconnecting tensegrity structure. An important distinction needs to be made in our search for culprit areas of restriction. There is a need to identify both the location of restriction (for example, shortened hamstrings), as well as the source of the restriction that could be in the hamstrings, but also possibly in the thoracolumbar fascia or elsewhere. Testing particular key muscles for relative restriction/loss of full range of motion, as well as for functional efficiency, allows a more focused evaluation as to where restrictions exist. There are strategies that can help to identify areas that may be responsible for dysfunction: 1. General observation: e.g., of normal posture and movement, such as standing and walking as described above (see Active F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 67 Transversus abdominis Latissimus dorsi Quadratus lumborum Anterior layer Middle layer Posterior layer Thoracolumbar fascia Erector spinae Psoas major A transverse view of the fascial wrapping that binds together key muscles including quadratus lumborum, psoas, erector spinae, latissimus dorsi, and transversus abdominis. (Gray's Anatomy) D D F F C C B A B E E A 1 1 2 2 LR LR The deep layer of the thoracolumbar fascia and different fiber directions of attachments to: A. Sacrotuberous ligament connecting to hamstrings B. Fascia of gluteus medius C. Fascia of internal oblique D. Serratus posterior inferior E. Erector spinae muscles LR—Lateral raphe provides attachment for part of external oblique and latissimus dorsi, as well as distributing tension from the surrounding hypaxial and extremity muscles into the layers of the thoracolumbar fascia. All of these fascial layers and structures interconnect with each other via the thoracolumbar fascia, which, as seen in Image 1, invests the erector spinae groups as well. 1. Posterior superior iliac spine 2. Sacrum Note multiple directions of force transmission in the sacral region. Palpated tenderness may help to identify directions of restrictive tension with potential influence on specific muscles. Note that there exist direct fascial connections between the upper extremity, the trunk, and the lower extremity. Multiple indirect, less obvious, fascial connections allow for force transmission of load, with profound clinical implications. FASCIA-REL ATED DYSFUNCTION 1 2