Deeper isn’t necessarily better. But with skill and sensitivity, working deeper can sometimes help in ways that nothing else can. In our last column (“Working With the Lumbars: The Thoracolumbar Fascia,” Massage & Bodywork, September/October 2014, page 114), we discussed how strain and microtearing in the sensitive thoracolumbar fascia (TLF) has recently been implicated in many kinds of previously unexplained back pain.1 Some of the richly innervated TLF’s layers are just below the skin; in our Advanced Myofascial Techniques seminars, we often encourage participants to work with less pressure, and at more superficial layers than many are accustomed to. The powerful results they get with back pain come as a revelation to both practitioners and their clients.
However, the TLF has very deep layers, and it makes sense to also include these in our work with back pain. In addition to greater sensitivity and skill, deeper work also requires greater tissue preparation and client rapport. The Iliac Crest and Thoracolumbar Fascia Techniques described in the last column are ideal preparation for the deeper, more specific techniques I’ll discuss this time. Use them, or any other approach that helps differentiate tissue layers, relax resting tone, and accustom your client to your touch before attempting the deeper techniques described here.

The Thoracolumbar Fascia
As a refresher, the TLF envelops many of the muscular structures of the low back, including the erector spinae and quadratus lumborum (Images 1 and 4). It also serves as the tissue bridge that connects the abdominal muscles (transversus abdominis, etc.) to the spine. Its central position in the body means the TLF connects each arm to its opposite side leg, giving the TLF a crucial force transmission role in contralateral activities such as walking, running, reaching, and throwing.
Working with the TLF is most clearly indicated when clients complain of low- or mid-back stiffness or pain. Back pain has been correlated both to TLF thickness and to lack of sliding between its many layers, and hands-on myofascial work has been shown to improve both of these parameters.2,3
Deeper TLF work is also useful when the motion of diaphragmatic breathing is posteriorly limited, or when arm/leg cross-patterns (such as a tennis serve, using elliptical trainers, running, or walking) elicit back pain or strain. And, because the TLF links upper and lower body as well as left and right, it is indirectly implicated in many other complaints, among them hip or sacroiliac pain, hamstring pain, abdominal wall issues (such as pain or restriction after cesarean section, hernia repair, etc.), and more.

Iliolumbar Ligament Technique
Back pain linked to the iliolumbar ligaments (ILLs) will often be felt by the client as a deep, dull, generalized ache, or sometimes as a deep, sharp, sudden pain with spinal sidebending, rotation, or flexion. ILL pain can also refer to the hips, groin, rectum, or genitals.4
As their name suggests, the iliolumbar ligaments connect the iliac crests to transverse processes of the lumbar vertebrae. Rather than being discrete bands of tissue, as they are usually depicted in anatomy illustrations, these ligaments are simply areas of greater thickness and fiber density within the sheet-like TLF. This area’s tissue density varies between different individuals, and this means we need to approach each person uniquely. You’ll find these ligaments are easily accessible on some people, while others may require several sessions of preparatory work—differentiating and increasing the elasticity of each of the outer layers—before you can comfortably access the iliolumbar ligaments.
Some sources even describe the iliolumbar ligaments as too deep to be palpated in living bodies, since they are just inside (slightly anterior to) the iliac crest.5 Although it is probably true that palpating the iliolumbar ligaments is impossible from a posterior direction (for example, working from behind with a prone client), our thorough preparation of the surrounding tissues  and the use of a side-lying position will allow us to gently approach the ligament from an anterolateral direction. This allows us to access the ILL by going around and in front of the thick mass of the erectors.
After preparing and relaxing the outer layers of the low back and hip, including the erectors and the iliac crest region, use your two thumbs together to slowly, gently sink into the area just anterior to the iliac crest, and just anterior to the mass of the erector muscles. This area will be sensitive or even ticklish on many people, so a slow, patient approach is imperative. Take your time, and while you do, care for your thumbs by maintaining a small amount of flexion at each thumb joint. Stop and readjust your position, body use, pace, or direction (or do additional preparation) if the work is uncomfortable for either you or your client.
Once you’ve arrived at the lower corner of the space described by the iliac crest’s juncture with the lumbars, pause and allow your client to relax even more. Small, active movements of your client’s hip, or deep, slow breathing can facilitate the reduction in tonus, increased fascial elasticity, and proprioceptive refinement that are our goals. Patiently, gently, with minimal movement on your part, work both left and right iliolumbar ligaments.

12th Rib Technique
Ida Rolf, the originator of Rolfing structural integration, placed special importance on freeing the 12th rib.6 As the posterior bony attachment of the diaphragm, and a stopover structure for many myofascial layers of the low back (including the TLF, Image 4, page 109), the smallest pair of ribs plays an outsized role in posture, breathing, and back health.
Our aims in working with the 12th rib region are increased mobility, fascial elasticity, and proprioception. All of these are beneficial in and of themselves, and often result in less back pain. Although the 12th rib is a floating rib and so potentially quite mobile, when there is back pain, the rib is often sunk deep into dense, inelastic myofascial structures of the lower mid-back. When these structures are differentiated and proprioceptively awakened, people often experience increased fullness of breath, as well as freer, less painful movement of the back.
As the upper border of the lumbar space (the soft-tissue region between the rib cage and pelvis), the 12th rib can be thought of as the complement or reflection of the iliac crest, which forms the lower margin of this same space. Starting far apart at their medial junctures with the spinal column, the 12th rib and iliac crest are much closer together at their lateral extremes. The distance between the end of the 12th rib and the iliac crest varies from person to person, affected by both the overall shape of the skeleton (such as torso length), and the elasticity of the TLF and the muscles it surrounds. When these soft tissues are denser and shorter, the distance between the rib end and the crest diminishes, and in some cases (such as with very short, compact waists or severe scoliosis) the rib can actually overlap the iliac crest and be found inside the pelvic bowl.
Left/right differences in this space’s size can indicate spinal scoliosis or rib cage asymmetries, even when too mild to be otherwise noticeable. From a classical Rolfing and structural integration perspective, more distance and greater left/right evenness are generally considered desirable.7 We take a slightly different view in our Advanced Myofascial Techniques approach, where we emphasize evenness of mobility, elasticity, and body sense (proprioception), rather than focusing primarily on symmetrical distances, positions, or shapes. In my own clinical experience, symptoms such as back pain seem to correlate more clearly with mobility asymmetries than they do with positional asymmetries, and research findings support this.8 From this perspective, mild scoliosis or rib cage asymmetries are not necessarily problematic, unless there is pain or diminished function. Furthermore, these symptoms often respond more readily to work aimed at achieving our goals of improved tissue elasticity, mobility, and proprioception, than to changes in position alone.
As we did in the Iliac Crest Technique (“Working with the Lumbars: The Thoracolumbar Fascia,” Massage & Bodywork, September/October 2014, page 115), we’ll focus on the soft-tissue attachments to these bony structures. This will leverage the Golgi tendon organs’ ability to modulate the resting tone of the entire muscular group.9 First, to reach the level of these osseous attachments, it is important to work down through the outer layers of the back’s myofascia, including the superficial fascia, the serratus posterior inferior, the outer layers of the thoracolumbar fascia, and the muscular tissue of the erectors, as we did in the Thoracolumbar Fascia Technique in the previous column.
Once you’ve prepared these outer structures, carefully locate the sensitive end of the 12th rib. While meticulously avoiding pressure directly against this rib’s end (or into the free end of the 11th rib just lateral and superior to it), use your thumbs to gently apply pressure to the 12th rib’s inferior margin. It is on this lower edge of the rib’s shaft that most of the back’s tissue layers attach. If the rib is difficult to distinguish, or seems deeply embedded within the back’s tissue layers, additional preparation may be needed.
Once on the rib’s lower margin, ask for full, gentle breath in order to facilitate fascial softening, and to increase proprioceptive awareness of this often-forgotten region. Keep your pressure directed superiorly into the lower margin of the rib, staying right on the bone, in order to avoid pressing into organs or the lumbar transverse processes. You’ll sometimes feel thicker, hardened tissue along this bony margin; these are the attachments of the TLF. Wait in each place for a tissue response, and then proceed medially and superiorly, pausing in each place to facilitate increased elasticity and awareness.
The lateral arcuate ligament is a thickening in the most anterior layer of the TLF, similar to the iliolumbar ligament at its lower attachment— in this case, just anterior to the 12th rib. Although it is probably too small and too far anterior to be directly palpated, your work to free the 12th rib’s mobility will indirectly affect this ligament as well.

Summary
These two techniques work the dense, ligamentous parts of the thoracolumbar fascia at the upper and lower extremes of the lumbar space. As with the TLF in our last column, using these two techniques on acute or unstable back conditions, including acute disk problems, is contraindicated in most cases—at least until you have gained a considerable amount of experience in their application, and are very familiar with how your individual client responds to direct work.
But applied correctly, they are quite safe, and with most mild to moderate low-back pain, you’ll see obvious and gratifying results. Although preparation, sensitivity, patience, rapport, and skill are all important when working at these deep levels, the often dramatic improvements in low-back mobility and comfort of the low back will make it all very worth the effort.  

Notes
1. Andry Vleeming, Vert Mooney, and Rob Stoeckart, Movement, Stability & Lumbopelvic Pain (Edinburgh: Elsevier, 2007): 64–73.
2. Helene M. Langevin et al., “Ultrasound Evidence of Altered Lumbar Connective Tissue Structure in Human Subjects with Chronic Low Back Pain,” BMC Musculoskeletal Disorders 10 (2009): 151.
3. Antonio Stecco et al., “Ultrasonography in Myofascial Neck Pain: Randomized Clinical Trial for Diagnosis and Follow-Up,” Surgical and Radiologic Anatomy 36, no. 3 (2013): 243–53.
4. Janet G. Travell and David G. Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual—The Lower Extremities (Lippincott Williams & Wilkins, 1998).
5.  J. Y. Maigne and R. Maigne, “Trigger Point of the Posterior Iliac Crest: Painful Iliolumbar Ligament Insertion or Cutaneous Dorsal Ramus Pain? An Anatomic Study,” Archives of Physical Medicine and Rehabilitation 72, no. 10 (1991): 734–7.
6. Ida P. Rolf, IPR Audio Files, Tape A2, 8:50, accessed September 2014, www.rolfguild.org/av/rolfa2.html.
7. Ida P. Rolf, IPR Audio Files, Tape A2, 13:00, accessed September 2014, www.rolfguild.org/av/rolfa2.html.
8. Diane Lee, The Pelvic Girdle, 3rd ed. (Churchill Livingstone, 2004).
9. Robert Schleip, “Fascial Plasticity—A New Neurobiological Explanation, Part I,” Journal of Bodywork and Movement Therapies 7, no. 1 (2003): 14.

Til Luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the United States and abroad. He is a Certified Advanced Rolfer and originator of the Advanced Myofascial Techniques approach. Contact him via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page.