Muscle:Rotatores

The Rotatores are the deepest layer of the deep paraspinal (transversospinal) group and the shortest muscles of the spine. They span only one segment (rotatores breves) or two segments (rotatores longi) and lie directly against the vertebral laminae. Their trigger points (TrPs) produce midline pain centred on the spinous process adjacent to the TrP — the most segmentally specific pain pattern of all the paraspinal muscles. They are the deepest spinal stabilisers, acting primarily as dynamic ligaments and position sensors for fine adjustments between individual vertebrae rather than as prime movers.

The severe aching "bone" pain from TrPs in any of the deep paraspinal group is persistent, worrisome, and disabling. Rotatores TrPs are specifically distinguished from multifidus and semispinalis involvement by the articular scope of the dysfunction they induce: rotatores → single-level; multifidi → two to three levels; semispinalis → four to six levels.

Anatomy

The rotatores form the deepest layer at both the thoracic and lumbar levels and occur above the sacral level — only the multifidi extend across sacral segments.

• Rotatores breves — short; attach to adjacent vertebrae (span one segment)
• Rotatores longi — long; span one segment throughout the spine

Attachment pattern: medially and above near the base of a vertebral spinous process; laterally and below to a transverse process. As the paraspinal muscles become progressively deeper, their fibres become progressively shorter and more horizontal, increasing their rotational component relative to extension.

Function: The deepest transversospinal muscles act as dynamic ligaments and position sensors for fine adjustments between individual vertebrae — fine adjustments rather than gross spinal movements. Acting bilaterally with the rest of the deep group, they contribute to extension of the vertebral column. Acting unilaterally, they rotate the vertebrae to the contralateral side.

Innervation: Medial branches of the dorsal primary divisions (rami) of the spinal nerves. In the lower thoracic and lumbar regions, the nerve, the rotator muscle, and the tip of the spinous process with the same number are all at the same level — the basis for the single-segment innervation and articular specificity.

Referred Pain Patterns

TrPs in the rotatores produce midline pain centred on the spinous process of the vertebra adjacent to the TrP. In the lumbar region, pain may be referred a few segments caudally.

Referred tenderness: Tapping on the adjacent spinous process reproduces or aggravates the pain. This spinous process tenderness:

• Is easily located by tapping each spinous process in succession
• Disappears after inactivation of the responsible TrPs
• May arise from TrPs on either or both sides of the spine — only deep palpation can determine which side
• Is used as an osteopathic sign of articular-dysfunction involvement of that vertebra

Symptoms

When the complaint of "lumbago" is due to TrPs in the deep lumbar paraspinal muscles, the pain is a unilateral, extremely disagreeable, steady ache deep in the spine. It becomes bilateral as muscles on both sides become involved. The patient finds little relief by changing position and is often convinced the pain originates in the bony spine, not in the muscles — a characteristic subjective feature of deep paraspinal TrP involvement.

Articular Dysfunction Association

TrPs in the rotatores can induce a concurrent single-level articular dysfunction. The number of segments involved by articular dysfunction correlates with the depth of muscle involved:

Muscle	Articular levels involved
Rotatores	Single level
Multifidi	Two to three adjacent levels
Semispinalis thoracis	Four to six segmental levels; apex segment exquisitely tender

This segmental specificity makes rotatores TrPs the most precise indicator for identifying the exact vertebral level of articular dysfunction. The apex segment is often the most tender to palpation.

Activation and Perpetuating Factors

The same activation and perpetuating factors apply as for the superficial paraspinal group — see Superficial Paraspinal: Activation and Perpetuating Factors. The deep group is more likely than the superficial group to show isolated muscle involvement, whereas the superficial muscles tend to accumulate associated TrPs in functionally related muscles including the contralateral side.

Specific associations:

• Deep lumbar paraspinal TrPs are likely to occur in patients with either excessive or absent lumbar lordosis
• Deep thoracic paraspinal TrPs (including rotatores) tend to occur in patients with marked thoracic kyphosis

Nerve root compression: Muscles supplied by a compressed nerve root or any cause of mild entrapment neuropathy are likely to develop TrPs. Myofascial TrPs per se do not cause neurological deficits unless the taut band entraps a peripheral nerve. The number of specific muscle-nerve entrapment syndromes is limited, and the degree of nerve damage is rarely more than neuropraxia. When radiculopathy activates TrPs, they may persist long after nerve root compression has been relieved — this is a mechanism of the post-laminectomy pain (failed-back) syndrome.

Clinical Examination

Active TrPs in the deep paraspinal muscles cause guarded movements and restrict side-bending, rotation, and hyperextension of the trunk.

Hallmark finding: During forward flexion, a flat area or slight hollow develops in the normally smooth curve of the spinous processes, spanning one to three vertebrae at the level of the involved TrP.

Examination technique:

1. Patient recumbent in the semiprone position, or seated and leaning slightly forward to flex the spine
2. Tap or press on the tips of successive spinous processes to elicit tenderness — locate the flat area
3. When a spinous process in the flat area is hypersensitive, palpate deep musculature on each side: firm pressure in the groove between the spinous process and the longissimus muscle
4. For the rotatores specifically: direct deep finger pressure along the side of the spinous process to exert pressure against the underlying laminae — locate a spot of maximum tenderness
5. If two or three spinous processes are tender, expect adjacent TrPs on at least one side at each level

Depth interpretation:

• Single-level midline tenderness → rotatores
• Two to three adjacent levels → multifidus
• Four to six levels with exquisitely tender apex → semispinalis thoracis

Differential Diagnosis

Condition	Key distinguishing features
Interspinous ligament strain	Midline spinous process tenderness from rotatores TrPs may mimic interspinous ligament strain; distinguished by deep palpation locating the TrP lateral to the spinous process; TrP inactivation resolves the spinous tenderness
Articular dysfunction (single segment)	Rotatores TrPs can induce concurrent single-level articular dysfunction; articular and myofascial components may coexist and treating one often helps the other; the spinous process tenderness is the osteopathic sign of that vertebra's involvement
Lumbar facet (zygapophysial) joint pain	Referred pain from lumbar facet joints overlaps with deep paraspinal pain patterns; manual release techniques for articular dysfunctions are equally effective for releasing tense deep spinal muscles
Spinal fracture / metastasis	Persistent midline spine tenderness requires imaging to exclude structural bony pathology when clinical context warrants; myofascial TrP tenderness disappears after TrP inactivation; structural bony pathology does not
Spinal stenosis	Deep paraspinal aching pain aggravated by extension; neurogenic claudication on standing and walking; distinguished by neurological examination and MRI; myofascial TrPs and stenosis may coexist
Radiculopathy	When radiculopathy activates TrPs, they may persist after nerve root compression is relieved, producing symptoms similar in distribution to the original radicular pain — the failed-back syndrome mechanism; distinguished from active radiculopathy by absence of objective neurological deficit

Treatment

Trigger Point Release

To stretch the rotatores, the seated patient's spine is simultaneously flexed and rotated, turning the chest toward the side of the involved muscle:

1. Apply initial sweeps of vapocoolant spray in a diagonal pattern over the deep muscles
2. Take up the slack that develops and repeat several times to achieve full normal range of motion
3. To incorporate postisometric relaxation (PIR): the patient looks first toward the contralateral side while the examiner resists any attempt to turn the torso; then the patient relaxes and turns toward the involved side
4. Augment release through reciprocal inhibition: the patient gently voluntarily assists rotation toward the involved side

Note: A tight contralateral iliocostalis thoracis may need to be released first before full release of the deeper muscles can be achieved.

Many manual release techniques directed toward spinal articular dysfunctions are as effective for releasing tense deep spinal muscles as they are for releasing restricted joint movement. Given the single-segment articular specificity of the rotatores, manual therapy directed at the identified dysfunctional segment is particularly relevant.

Trigger Point Injection

See Concept:Trigger_Point_Injection.

• Needle at least 5 cm (2 in) long
• Directed somewhat caudally and medially, nearly parallel to the long axis of the spine
• Aimed toward the base of the spinous process — not between the spinous processes
• The caudal slant is required because of the shingle-like overlap of the laminae
• This angle eliminates the risk of entering the pleural cavity (between ribs) or the epidural space (between vertebrae)
• Penetration deeper than the laminae is unnecessary and undesirable

Corrective Actions

See Concept:Paraspinal_Corrective_Actions for the full programme: structural asymmetry correction, seating, lifting mechanics, sleep posture, and exercises.

Satellite Trigger Points

• Multifidi — overlying layer; commonly co-active; induces two to three segment articular dysfunction
• Semispinalis thoracis — outermost of the deep group; induces four to six segment articular dysfunction
• Longissimus thoracis — overlying superficial layer at the same segmental level
• Iliocostalis thoracis — superficial lateral layer

Related Pages

• Muscle:Thoracolumbar_Paraspinal/Deep — Full deep paraspinal group page: semispinalis thoracis, multifidi, rotatores
• Muscle:Thoracolumbar_Paraspinal/Superficial — Superficial erector spinae group
• Concept:Paraspinal_Corrective_Actions — Full corrective actions programme
• Concept:Trigger_Point_Injection — Deep paraspinal injection technique

References

• Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1: The Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. Chapter 48.
• Macintosh JE, Bogduk N. The biomechanics of the lumbar multifidus. Clinical Biomechanics 1:205–213, 1986.