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Thoracolumbar Junction – Back Pain that Doesn’t Resolve with Traditional Treatment

The thoracolumbar junction – or TLJ for short – is a unique area in the human body that can produce back, hip, gynecologic, urologic, testicular, and lower GI pain. While the dysfunction often occurs at the thoracolumbar junction, the pain rarely appears at the source. Because of this, it’s one of the most commonly underdiagnosed – or missed – causes of pain.

If you’ve been struggling with any of those types of pain and are not experiencing relief, your symptoms could be coming from the TLJ. We’re going to dive into –

  • What the thoracolumbar junction is
  • Why the TLJ causes pain in unexpected locations
  • Two types of TLJ dysfunction
  • Exercises to help relieve pain

What is the Thoracolumbar Junction?

The thoracolumbar junction is where the thoracic spine (mid back) switches to the lumbar spine (low back). As the mid back transitions to the low back, the direction of the joints between the spinal segments (vertebrae) changes.

In the thoracic spine, the joints are aligned to facilitate motion in a rotational direction. However, in the lumbar spine, the joints are aligned to encourage forward and backward movement. Whenever the direction of the vertebral joints changes, it is easier for too much or not enough motion to occur, which causes pain.

This area is also an attachment site for many muscles and thick connective tissue. Here’s a few –

  • Diaphragm (main breathing muscle)
  • Iliopsoas (hip flexor)
  • Erector spinae (big back muscles)
  • Quadratus lumborum (often tight in moms who hold a kiddo consistently on the same hip)
  • Latissimus dorsi (pull-up muscle)
  • Thoracolumbar fascia (tight connective tissue)

This is a LOT of attachments. Unfortunately, sites that have lots of attachments also tend to be areas of the body where it’s common to get discomfort. If one thing isn’t working properly, lots of muscles and structures become affected.

If you take a dive into the research, very little is known about TLJ discomfort. It’s often studied as another name – Maigne’s Syndrome. The available research is mostly case studies, which isn’t the highest quality evidence. (As a side note, Maigne’s Syndrome and TLJ dysfunction can be used interchangeably. Here, we’re just using TLJ because it’s less of a mouthful).

Because of the limited research, the information in this article comes from a compilation of case studies, conversations with colleagues, and our clinical experience.

What Thoracolumbar Junction Pain Looks Like

As we discussed at the beginning, TLJ discomfort can occur in a variety of areas. This is because the nerves at the thoracolumbar junction innervate all of those areas. The discomfort typically shows up in one of the areas depicted in the image below.

When we refer to TLJ pain, we referring to any and all of the areas commonly affected by TLJ dysufnction (back, hip, gynecologic, urologic, testicular, and lower GI pain).

thoracolumbar junction pain locations

The Two Types of Thoracolumbar Junction Pain

At the TLJ, there’s two reasons why pain can be present: there’s too much motion (and thus pain comes from things moving excessively) or not enough motion (and thus pain comes from things moving that shouldn’t be moving).

We’ll discuss the not-enough-motion type of TLJ discomfort first. 

TLJ Dysfunction from Lacking Mobility

Individuals who have TLJ pain because they don’t have enough mobility at their thoracolumbar junction typically have the following characteristics –

  • Pain starts after performing a repetitive rotational activity (pickleball, hockey, golf, etc.)
  • Often sedentary throughout the day or desk-bound
  • More often male than female
  • Occasionally have hip and ankle mobility limitations as well

The goal with TLJ pain due to a lack of mobility is to get the thoracolumbar junction moving! The better it moves, the less pain these folks have.

While there is typically early pain reduction, it can take up to 8-12 weeks for full symptom resolution. And, for some individuals, especially those who don’t move much throughout the day, they often need to keep up with some sort of mid back mobility routine throughout their lives.

Here’s a couple exercises we’ve seen be successful for individuals struggling with pain associated with lacking mobility at the TLJ.

TLJ Dysfunction from Lacking Stability

The other type of TLJ dysfunction comes from using the thoracolumbar junction for stability. While the TLJ does inherently provide some stability, the issue comes from relying on the joints (and not other supporting structures like muscles) to provide most of the stability. Excessively using the TLJ for stability happens due to one of these three reasons –

  1. A lack of strength or endurance in postural muscles
  2. A lack of awareness as to how movement is being performed
  3. A lack of shoulder mobility to lift weights directly overhead (back arches to compensate)

Here’s the thing – most folks who are over-using their TLJ for stability have no idea they are doing it. They’ve usually always done it without issue. But, one day, it becomes an issue.

And, it’s hard to identify. It’s not straightforward. Depending on the volume, weight, and other factors (sleep, stress, nutrition, hydration), the pain isn’t always consistent. Because of this, we often see these folks after they’ve moved this way for quite some time (usually years) and it becomes hard to correct.

There’s also typically more than one thing that causes this type of discomfort. Here are some common culprits – 

  • Tight hip flexors
  • Weak lower abdominals
  • Difficulty isolating back and hip movement
  • Coordination (especially under fatigue)
  • Weak hip flexors
  • General increased mobility
  • Decreased shoulder strength or mobility

Because there are so many things at play, for those who experience this type of discomfort, we recommend coming in for an assessment to get individualized care. Some injuries are straightforward and it’s possible to DIY. This is not one of those injuries. 

We are including a couple exercises below to help with the coordination piece of TLJ stability-related discomfort. These exercises focus on improving technical aspects of common fitness movements, which is a key part in recovering from TLJ discomfort due to a lack of stability.

Wrapping up Thoracolumbar Junction Pain

TLJ dysfunction can be tricky to diagnose because the symptoms – while coming from the TLJ – most frequently don’t occur at the TLJ. Instead, they pop up in the back, hip, gynecologic, urologic, testicular, and lower GI areas. While TLJ dysfunction can be tricky to diagnose, it often gets good results with treatment.

Eliminating TLJ dysfunction involves a combination of exercises and hands-on therapy. If you’ve been struggling with a weird hip or back pain that won’t go away with the traditional exercises, it might be time to consider the TLJ.

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