Quadratus Lumborum Pain Management

Chapter 1: Anatomy of the quadratus lumborum



A human’s upper body consists of large muscles that support the back and the loins. These muscles are responsible for body posture and mobility. Without them, a person could not sit or stand for extended hours. Or he could not straighten his back after bending or twisting his body to either side. He could not even breathe well without any of these muscle groups. 


There are several muscles in the upper torso, one of them is an abdominal muscle known as the quadratus lumborum.



The Quadratus lumborum  


Quadratus lumborum (QL) comes from the Latin words “quadus” and “lumbus”, which mean “square” and “loin”, respectively. This is also known as the “back muscle” as it lies in the lumbar area. Despite its name, the quadratus lumborum is actually rectangular-shaped, and not square. It is a thick, flat, and quadrilateral muscle sheet resting in the innermost part of the posterior abdominal and underneath the lower back. Thus, the quadratus lumborum is known as the deepest abdominal muscle in the lumbar region. 


Every person has a pair of quadratus lumborum resting on either side of his spine. The muscle extends between the lowest rib and the pelvis on each side. It originates from the transverse processes of the 1st to the 4th vertebrae of the lumbar region, the iliolumbar ligament, and the back surface of the iliac crest, depending on the muscle fibers composing it. Finally, it inserts to the mid-lower edge of the last rib and sometimes to the transverse processes of the lumbar spine. 


The lumbo-dorsal aponeurosis surrounds the quadratus lumborum, with the psoas major muscle in front and the sacrospinalis at the back. The anterior ventral rami of the upper three to four lumbar nerves and of the 12th thoracic nerve supplies the nerves of the quadratus lumborum. 


The back muscle fills most of the abdominal cavity. As such, we can find some organs like the kidneys, the colon, and the diaphragm surrounding the quadratus lumborum. 



The QL muscle fibers


The quadratus lumborum is one of the many muscle groups that constitute the muscular system of the upper body. It consists primarily of three sets of quadratic fibers, namely the iliocostal, iliolumbar, and lumbocostal fibers. It is essential to know about these three muscle fibers because these are determinants of the possible areas that can affect how the quadratus lumborum functions or malfunctions.


  1. Iliocostal fibers are also called lateral fibers because they attach to the outer side of the ilium and runs vertically to attach to the mid-lower, anterior side of the lowest rib.


  1. Meanwhile, iliolumbar fibers also attach to the iliac crest together with the iliocostal fibers. But instead of running vertically to the rib, iliolumbar fibers cross diagonally to join to the transverse processes of the 1st to the 4th lumbar vertebrae. Since they go across the midline, they are also called as the medial fibers.


  1. Finally, the lumbocostal fibers attach to the transverse processes of the 1st to the 4th lumbar vertebrae just like the iliolumbar fibers. Then they go diagonally up to attach to the 12th


If any of these fibers fail because of over-contraction or over-extension of the back muscles, it will activate trigger points that could cause pain in the lumbar region. More discussion about the trigger points will follow in the succeeding chapters. 



Looking for the QL muscle


The quadratus lumborum is the deepest abdominal muscle. This makes it so difficult to find the back muscle as it is in the innermost part of the abdominal wall. That is why a mere self-massage cannot easily access the muscle without the help of certain tools. Even imaging studies like x-rays or CT scans cannot accurately show the QL. However, with proper knowledge of its anatomy, any person can find the QL muscle with ease. 


To do this, instruct the client to lie prone. Then, using your fingers, identify the three bony landmarks of the QL: 


  1. First is the 12th rib in the bottom-most part of the ribcage.
  2. The second landmark is the posterior iliac crest situated above the buttocks.
  3. And lastly, the third landmark is the transverse processes of the lumbar vertebrae located laterally from the spine.


It is in the fleshy part in between these three landmarks that the quadratus lumborum rests. Again, since the QL muscle lies deep inside the abdominal wall, palpating it may seem difficult. However, if the client is in the prone position, you can feel the QL muscles contract when the client pulls his pelvis toward his ribcage (which is the act of hip-hiking).





Chapter 2: The normal functions of QL in the human body



As a back muscle, the quadratus lumborum performs several functions to support the lumbar region of the body. It is responsible every time the body bends sideways or forward. It also helps the upper trunk to stay erect to keep the spine straight and stable. It contributes to the person’s gait, especially when the hips rock side to side as the pelvis tilts. It may not seem so but QL muscles help as well in the person’s breathing. 


The following discusses the different functions of the quadratus lumborum in the human body:



Lateral flexion and/or extension of the vertebral column  


The quadratus lumborum primarily acts as a lateral flexor of the lumbar spine. This occurs when the QL, along with the internal and external oblique muscles, contracts on one side (ipsilateral contraction) which causes the trunk to bend sideways toward that direction. This lateral flexion is also called as “hip-hitching” or “hip-hiking”. 


Furthermore, when this muscle contracts bilaterally, the vertebral column slightly extends. As a result, it keeps the trunk upright and it also enables the body to bend forward to a small degree. This role, however, is merely incidental. The prime mover of lumbar extension is still the erector spinae. 


Noticeably, the QL muscles can contract either ipsilaterally or bilaterally. There is ipsilateral contraction when only one of the QL muscles contract, such as during lateral flexion. To illustrate, when a person bends sideward to his right, the right QL contracts to pull the torso toward that direction. The other QL extends as a result of the pull of its partner muscle. 


In contrast, when there is bilateral contraction, both of the QL muscles contracts at the same time. This happens when the QL acts as an extensor to bend the trunk forward. 



Stabilization of the lower back


The spine cannot stay straight without the support of several muscles dynamically working with each other to keep it steady. One of these muscles is the quadratus lumborum. Without it, the spine becomes unstable. Thus, the QL muscle is essential to support the postural alignment of the spine and, ultimately, the lower back. 


As a postural muscle, the quadratus lumborum supports the lower back by stabilizing the spine and the pelvis for sedentary activities like sitting or sleeping. It is highly active when a person sits, especially so if he is bending sideways to reach over an object on the floor. It ensures that the body returns to an upright position every after a person bends or twists to one side. 


This is distinct from the phasic muscles, such as the gluteus and the deltoids. These muscles have ‘fast twitch’ muscle fibers that produce powerful contractions to help a person move. The problem with these is that the faster they work, the quicker they get tired. And because they are short-lived, they weaken up instead of tightening after a workout.  


Postural muscles, in contrast, consists of muscle fibers that are ‘slow twitch’ in nature. This means that, unlike the quick-acting phasic muscles, postural muscles can work slowly over time. Because of this, they do not easily wear off and they can sustain long periods of contractions to keep the lumbar spine stabilized. That is why postural muscles, like the quadratus lumborum, can keep the upper body upright even for the entire day. 


But it is because of this ability that postural muscles tighten up. Since they do not get tired even after a long day’s work, the tendency is that postural muscles do not weaken over time. What happens is the reverse. They continually work until the contractions make them tight and short. This results in muscle spasm which eventually leads to QL pain. More of this will follow later. 


All of this happens because the quadratus lumborum wants to fulfill its duty to stabilize the spine. 




Pelvic lifting


There are some people who walk with their hips swaying from side to side. This happens when a person lifts his pelvis up to the ribcage and down with the help of the quadratus lumborum. 


Not only does it occur while walking. When a person sits with his legs crossed, the QL muscle helps bring up the leg by contracting to tilt the hip. This is why sitting with legs crossed is not advisable. If you think that position makes you feel comfortable, same is not true in one of your QL muscles. Instead, it becomes overworked as it tries to keep itself contracted even if the person is at rest. 


Another position where pelvic lifting is relevant is when a person sits in Indian-style or pretzel-style. In this case, both QL muscles work to help a person sit that way. Meditation poses usually use this sitting position. It is less harmful to the pelvis compared to sitting with legs crossed, but it does not assure complete safety to the quadratus lumborum. If habitually used, this position can also predispose a person to chronic QL pain. 



Assistance in normal inhalation and/or forced exhalation


At first glance, the quadratus lumborum does not seem to have any relation to the respiratory system. Of course, with limited knowledge, a person can only associate the QL muscle with keep the lumbar spine stable. The thoracic region is usually out of the context. 


Nonetheless, the quadratus lumborum actually plays a large role in respiratory function. 


In chapter 1, we identified the bones to which the QL muscle fibers attach. Most of them end in the 12th rib. Thus, when the thoracic cavity expands during inhalation, the QL is there to support the rib cage. This is how the quadratus lumborum contributes to the breathing process. 


At the same time, it provides a base to help the diaphragm relax during forced exhalation, such as coughing, speaking, or singing. Because of this, most medicine books consider the quadratus lumborum as an essential accessory organ for respiration. Its function is primarily to support the rib cage when it expands or relaxes during inhalation or exhalation. 










Chapter 3: Major symptoms of QL tightening



When the quadratus lumborum functions normally, it contracts without causing any pain or discomfort to a person. The pain only sets in when there is instability somewhere around the lumbar spine and the hips. To the QL muscle, this is alarming. Since its job is to stabilize the lower back, any imbalance would require the QL muscle to work extra hard in re-stabilizing the lumbar region.  


There is no problem if the quadratus lumborum takes the burden once. However, if this instability repeats every time, the QL muscle has no choice but to work double or triple than its usual load. In effect, it becomes overworked. Although it can endure extended hours of work, it will not exempt the QL muscle from getting tense. Thus, a person suffers muscle tension over time. 


Improper lifting, bending or twisting of the torso further tenses the QL. When this happens, the muscle tightens and the pain in the lower back intensifies. If it continues to contract abnormally, it will shorten the quadratic fibers resulting to restrictions in the person’s body movements. 


The following are among the symptoms a person may experience due to the abnormal tightening of his quadratus lumborum:





Pain may vary among clients. Most of them suffered from a deep, dull ache throbbing in either side of their lower back. This is attributable to the site of the muscle, which lies in the innermost part of the lumbar region.  


Some others noticed a sharp-shooting pain stabbing them in the back and across their hip bone. This arises from the trigger point areas that lie on the borders of the lumbar vertebrae. Since they are close to the spine, any soreness of the QL muscle can easily irritate the bundles of nerves scattered there. This is why the pain originating from these areas felt electrocuting and sharp. 


Some men even reported pain and tenderness in their groin, testicle, or scrotum. These are mostly referred pain caused by the trigger point areas of the quadratus lumborum. More about the trigger point areas will follow in Chapter 5. 


Since some of the quadratic fibers attach to the last ribs, injury to these fibers irritate the nerves scattered around the thoracic cavity. As a result, a person may consider a cough or a sneeze ten times more painful during QL dysfunction. 


Often, the pain worsens with prolonged sitting or by staying in the same place for hours. This is worst when a person exhibits poor posture. This is because the muscles continue to contract (sometimes irregularly due to distorted posture) just to keep the body steady and the spine straight. 


The client may even have difficulty rolling over to his side or rising from the bed. In severe cases, the pain aggravates and radiates down the sides of the thighs to the lateral knee. 


Depending on the cause, the pain onset may either be gradual or sudden.


There is gradual pain onset, without prior physical trauma (such as a fall or an accident), when the client experiences tightening of his back muscles over time. This is generally caused by sitting daily with poor posture especially when a person habitually crosses his legs. This engages only one side of the quadratus lumborum, which means the muscle has to double its work every time a person sits with his legs crossed.


Meanwhile, sudden pain onset transpires usually 20 minutes after doing lumbar stressors, like gardening, lifting, or bending. The pain intensifies when a person bends and twists his torso on one side at the same time. This puts extra tension on the back muscles as it performs two duties simultaneously – the bending and the twisting. 



Limited range of movements or immobility


The ‘slow twitch’ muscle fibers of the QL allow it to contract gradually for a long time. This normally helps to keep the person in an upright position. They do not tire easily unlike the ‘fast twitch’ muscle fibers of phasic muscles (e.g. the gluteal muscles), which weakens after minutes or hours of work. Because of this, the QL has the tendency to contract for extended periods without rest. 


What makes this contraction problematic is when it goes on continually without giving time for the quadratic fibers to relax. As a result, blood could not flow efficiently to the muscle, which will deprive the QL of the oxygen it needs. Without oxygen, the quadratus lumborum cannot function in its full capacity. Worse, it could immobilize the upper body.


In the long run, the quadratic fibers become hypertonic, making it difficult for the client to control the muscle even by conscious effort. The QL stiffens and it will eventually restrict the client’s range of motions. 


If this happens, even the simple act of bending over to pick grocery bags or rolling to one side of the bed can become frustrating. A driver can no longer turn to his side while reversing his car. A golf player who takes pride in swinging his club may end up screaming in pain if he insists on doing so. 


Thus, any damage to the quadratus lumborum can cause a negative impact on the person’s activities of daily living. 



Respiratory problems  


As an accessory organ for respiration, the quadratus lumborum supports the thoracic cavity and enables a person to breathe normally. However, when the QL muscle becomes spastic, it could no longer hold the thoracic cage effectively. As a result, the lungs will be unable to expand to its full capacity. Ultimately, this impairs the inspiration process. 


Likewise, the QL supports the diaphragm during forced exhalation. If it turns out defective, simple acts such as speaking and singing start to be challenging.


Also, when a person coughs or sneezes, all the muscles attached to the rib cage forcefully contracts to increase the pressure in the lungs and help them expel the sputum or dirt. One of these muscles is the quadratus lumborum. This is the reason coughing and sneezing worsen QL pain. And since most people find this extremely painful, they would often try to inhibit coughing and sneezing. Problem is, these two reflexes are the body’s way to respond to foreign bodies and irritants. So, when a person voluntarily stops himself from coughing or sneezing, he assumes the risk of developing respiratory tract infections in the future. 



Balance and postural problems


In Chapter 2, we classified the quadratus lumborum as a postural muscle. This means the QL is responsible for maintaining a person’s posture and balance when he sits, stands, walks, or sleeps. 


However, QL’s ability to stabilize the lower back becomes impaired due to muscular overload. Instead of resting, the quadratus lumborum continues to contract and the muscles tighten which leads to compression of the lumbar vertebrae. This sometimes leads to lordosis (or swayback), which is the excessive inward curving of the lumbar spine.  


Other people suffer from leg length discrepancy. This happens when one of the legs appear longer than the other. To some, this problem is congenital. But usually, if it involves the QL, the discrepancy is functional. This means the person is not born with it but rather he develops it as he grows. 


A functional discrepancy is distinct from a structural one. In the latter, there is a real difference in the sizes of both the tibia and the femur. On the other hand, in functional discrepancy, the bone length of each leg remains the same. 


The problem in functional leg length discrepancy lies in the abnormal contraction or shortening of the muscle that pulls the leg up, creating the illusion that this leg is shorter than the other. This happens when the QL tightens and tugs the leg up to compensate for the weakness of the other muscle groups. In effect, a muscular imbalance takes place, which interferes with the person’s gait. 



Chapter 4: Quick motor test to find out QL imbalance



There is QL imbalance when there is over-tightening of one side of the muscle. This contraction becomes involuntary if left untreated over time. If this happens, the client may gradually or completely lose control over his back muscles, thus disabling him from performing his daily tasks. 


Before it gets worse, it is best to have the impaired QL muscle treated. However, to isolate the quadratus lumborum from the other muscles that could cause low back pain, the physician or therapist (or even the client alone) can do a quick motor test to check whether there is indeed a muscular imbalance. 


The following are some tests to determine possible QL dysfunction:



Test in the supine position


The following are the steps to determine QL imbalance while the client is lying supine:


  1. Assist the client to lie supine on the examination table.
  2. Instruct him to stabilize himself by using his hands to clasp the sides of the table.
  3. Keep his legs aligned, with the pelvis and knees extended.
  4. Position his legs toward the side being tested (the affected side) by flexing his lumbar spine and pelvis laterally.
  5. Stand at the client’s side opposite to the one being tested.
  6. Hold his unaffected lateral pelvis with one hand.
  7. With the other hand, reach under his legs and hold the contralateral leg distally. 
  8. Pull both legs toward your side. The legs will act as levers to bring the lumbar spine and pelvis to an ipsilateral, lateral flexion.
  9. If the client reports pain or discomfort during lateral flexion, it is positive for QL imbalance.




Test in the side-lying position


The following are the steps in doing the stretch test while the client is lying on his sides:


  1. Assist the client to lie on his unaffected side at the edge of the examination table. 
  2. Place a pillow under his waist. This enables a minimal lateral flexion of the lumbar spine.
  3. Instruct the client to slowly drop his affected leg off the examination table. At the same time, tell the client to stretch his affected arm above his head.
  4. Gently apply some pressure on the distal thigh.
  5. If the client complains of any pain or discomfort, the test is positive, which indicates a muscular imbalance.



Test in the prone position


The following are the steps in testing the strength of the QL muscles while the client is lying prone:


  1. Assist the client to lie prone on the examination table.
  2. Instruct him to stabilize himself by locking his arms underneath the table.
  3. Tell him to lift his affected pelvis toward his rib cage (this refers to “hip-hike”).
  4. Stand at the foot part of the client, on the side being tested.
  5. Grab the distal part of the leg and gently pull toward self.
  6. If the client resisted the pull, the QL is working properly. But if he complains of any pain or discomfort, it is a positive sign of QL imbalance.



Self-test in the sitting position


This test involves three sets. This can be done with or without a partner. Prior to that, the client must sit in a comfortable, straight-back chair.


  1. Pelvic lift.


Instruct the client to lift his pelvis up and down, with the right side first and then the left, for three times each. If the client reports pain or discomfort, there is a positive muscular imbalance.


  1. Deep lateral flexion.


First, instruct the client to keep his pelvis still. Then, let his upper body bend to his right and then to his left. Repeat this for three counts. 


Make sure that the client effectively flexes his torso laterally, as if his ears are leaning against an imaginary wall. 


If he complains of any pain or discomfort, there is an imbalance in the quadratus lumborum. 



  1. Pelvic rotation.


Instruct the client to do pelvic rotations while sitting. Let him push his pelvis forward to the right for three counts and then to the left for another three counts. If there is pain or discomfort, a muscular imbalance exists. 



Take note that the above motor tests are mere superficial assessments. As such, the results are not conclusive, but are merely suggestive, of quadratus lumborum dysfunction. 


Although it is more likely to involve the QL, it may also affect the other nearby muscles. To make sure, the health practitioner must conduct further tests, work-up, and imaging studies to double-check the results. Nonetheless, the practitioner can still use the above motor tests as a quick, baseline tool to assess client’s condition. 





Chapter 5: Trigger points for pain arising from QL


Pain involving the quadratus lumborum differs depending on the affected trigger point area. A trigger point, or sometimes called the “muscle knot” refers to a sensitive part of the body which, when pressed, produces referred pain. 


The pain may not necessarily manifest on the QL site. It can even travel down the thighs to the legs, depending on how severe the QL impairment is. The primary culprit for this is muscular overload due to exertion, overuse, repetitive stress, or improper posture. 


Trigger points can help trace the muscle or the connective tissue from which the pain originates. Massage therapists often use this method to relieve symptoms of muscular spasms.


In the quadratus lumborum muscle, three trigger points exist, which are representative of the three quadratic fibers. These muscle knots are:


  1. The upper QL trigger point;
  2. The lower QL trigger point; and
  3. The middle QL trigger point.


Each trigger point covers certain sites in the body. The connections are primarily due to the muscle fibers in the back muscle. You can refer to Chapter 1 for a quick review about QL muscle fibers. 



Upper QL trigger point


The upper QL trigger point arises from the iliocostal fibers which attach vertically from the hip crest to the 12th rib. 


This creates the pain which may radiate across the flank area of the lower back, the iliac crest, the upper front of the groin, the sacroiliac joint, and the testicles or scrotum. 



Lower QL trigger point


The lower QL trigger point arises from iliolumbar fibers. These fibers also attach on the hip crest like the iliocostal fibers of the upper trigger point. But, while the iliocostal fibers run vertically, the iliolumbar fibers of the lower trigger point extends diagonally to the center to attach to the transverse processes of the 1st to the 4th lumbar vertebrae. 


This trigger point refers to any pain arising at the hip-joint. This pain becomes more troublesome when a person lies on his affected side. 



Middle QL trigger point


Middle QL trigger points are also called deeper points. They arise from the lumbocostal fibers, which originated on the lumbar spine and attached diagonally and laterally to the lowest rib. 


This commonly triggers a throbbing pain at the sacroiliac joint and lower buttocks. Furthermore, since the points lie along the borders of the spine, the referred pain becomes sharp and excruciating in character that often travels down the thighs. 



Other associated trigger points


When the lower back aches, we cannot always blame the QL muscle for it. In fact, there are several muscles that contribute to these trigger points. 


QL trigger points can also activate other trigger points, primarily those of the piriformis, gluteus minimus, gluteus maximus, and gluteus medius. 






Chapter 6: Major causes of developing tightness in QL



Just like any back pain, the quadratus lumborum tightens because of many contributory factors. A person may be constantly exposed to repetitive activities that could stress the QL muscle because of work. 


There are other causative factors that lead to the development of QL tightness. Among these include repetitive stress, over-exertion, poor posture, physical trauma, and other biological causes. 



Repetitive stress  


Repetitive stress is the most common cause of muscular pain. Any activity, whether active or passive, that continually uses the back muscles without rest, can slowly damage the quadratus lumborum. This can happen during an active task, like weightlifting or gardening, or in a more passive one, like sitting or sleeping. 


When a person works for a few hours, muscle tension may not be noticeable at first. This is attributable to the QL’s characteristic as a postural muscle. As such, it can withstand long periods of contraction without easily getting tired. This makes it distinct from the other fast-twitch muscle groups, which wear off easily after a few minutes of work. 


Because of this characteristic, the QL develops muscle tension only after days, weeks, or months of doing a stressful, successive routine. It is only after such time that the QL starts to feel tired. Consequently, it is only by then that a person starts to feel pain in his lower back. 


If this goes on and the QL muscle is left in a contracted state on a daily basis, it might find itself unable to adjust back to its normal relaxed state. Thus, it continues to tighten up and induce pain in the trigger point areas. 





Even if the task is not habitual and the client performed it only once in his life, but he used too much effort in doing so, this over-exertion can also lead to harmful effects on his back muscles. 


A classic example is when a person engages in resistance training for the first time. His back muscle is still not conditioned to carry heavy loads. If he instantly lifts a barbell twice his weight, his back muscles would have to compensate for the weakness of the muscles in his arms. This will strain the quadratus lumborum as it tries to protect and stabilize the spine from any possible fracture. 


Problem is the QL muscle is not yet familiar with this type of stress, so it becomes tense in the process. When stressed, the QL muscles start to activate trigger point areas. As a response, it induces the brain to feel pain and refers it to other areas of the body. This is why clients complain of a sudden sharp-shooting pain not only on the lumbar area but also on the lower back. This usually happens after he performs a task he is not used to doing.



Poor posture


While physical exertion is the most evident cause of QL pain, it is not the only reason for the problem. There are patients who complain of lumbar pain even though they are not doing anything at all. They just sit all day and sleep all night and yet they still complain of pain and tenderness in their lower back. 


The reason behind this is poor posture. 


Even if the person seems to be comfortably sitting in one corner, but his body leans to one side, there is hip-hiking. This means that the quadratus lumborum is at work even if the person is at rest. 


Indeed, such sedentary lifestyle can cause tightening of the quadratus lumborum. This is typical among those who work full-time on computers or even among those who do not work at all but spend most of their time indoors playing games or watching movies. 


During these activities, the back muscles do not work as much as when a person walks or lifts heavy loads. Yet, this inactivity puts the back muscles in an overstretched or over-shortened state for a prolonged time, especially when the person rests with poor posture. 


An example is when a person sits daily for extended hours with legs crossed. This posture produces an unequal force on each side of the back muscles. For example, the left QL may try to bear the weight and stabilize the pelvic side of the uncrossed left leg, while the right QL contracts to tilt the pelvis on the side of the crossed right leg. This uneven distribution of weight and force between the back muscles results in a muscular imbalance causing QL dysfunction. 


Slouching also contributes to a distorted posture. It keeps the QL muscles in an abnormally shortened state all the time. Remember that the QL’s duty is to keep the upper body straight and stable. If a person curves his body forward, it would stimulate the QL muscle to extend the body and keep it in an erect posture. But if the person continues to slouch, it opposes the QL muscle from doing its job. This will lead the QL muscle to either exert extra effort to straighten the body or simply leave it that way because of weariness. In any way, the QL muscle is not working properly. In the end, it can impair the quadratus lumborum. 


Another incorrect position is sleeping on a soft mattress or a hammock. Apparently, a person cannot lie flat on his back if the mattress is too soft. This is more apparent when he sleeps in a hammock, as it is irregularly-shaped. 


Even lying in a prone or a fetal position contributes to QL impairment. What is common among these sleeping poses is that the lower back is not kept upright. When that happens, the QL muscle bears the burden of stabilizing the lower back again. And since most of the sleeping positions develop out of habit, the QL muscle constantly attempts to keep the body erect. 


Other factors include standing for long hours and excessive bending. When a person stands, the QL muscles act as extensors to support the lumbar spine. When a person bends sideways, the QL acts as a lateral flexor that pulls the body to the direction desired. If done excessively, even the simple of act of standing or bending sideways can impair the QL muscle. 




Physical trauma


When a person is not careful enough, he may sustain injuries due to fall, vehicular accident, or any form of direct damage to the upper body. This physical trauma activates the trigger points in the back muscle, leading to referred pain. 


Also, injuries may disfigure the body. A person becomes prone to hip-hiking when he suffers a leg sprain or a hip fracture. In this case, the QL muscle compensates for the loss or inability of the other injured muscles. This again burdens the quadratus lumborum. 



Other biological causes


Physical issues are not the only cause of QL impairment. Even psychological and physiological factors can tense the quadratus lumborum. 


One psychological cause is emotional stress. It does not directly damage the muscle, but it can produce negative effects indirectly. 


Emotional stress can trigger the sympathetic nervous system to produce hormones that stimulate all the nerves and muscles to constrict. This forces the back muscles to contract in response to the stressful stimuli. In case of chronic stress, the contraction continues for a long time. This will ultimately strain the QL to tighten up and cause pain – which is why stress, in general, can still affect the muscles. 


Nutritional imbalance, especially in calcium, iron, and potassium, also predisposes a person to activate trigger points throughout the body. Furthermore, poor metabolism makes the back muscle hypersensitive to muscular overload. 



Chapter 7: Treatment for QL pain



Pain in the quadratus lumborum is manageable. Adherence to therapy can help reduce, or even remove, the symptoms of QL dysfunction. However, therapeutic management of QL pain is not a one-sided treatment on the part of the health practitioner alone. 


The approach has to involve client’s participation. The health team encourages the client to take part in protecting his lower back against any further harm. 


This chapter will outline the three stages essential for treating QL dysfunction. The goal of this treatment plan is not only to relieve the current symptoms but also those that could arise even after the program.


There are three stages of the QL pain treatment plan:


Stage 1 addresses the causative factors. To recall, in chapter 6, we pointed out the major causes of QL tightness, namely repetitive stress, over-exertion, poor posture, physical trauma, and other biological causes. In the next discussion, we will give some measures to overcome these causes.


Stage 2 provides remedies to loosen QL tightness. We mentioned before that the quadratus lumborum tightens as it continually contracts due to muscle tension. Eventually, this activates trigger points or muscle knots that cause referred pain to other parts of the body. In this stage, we will discuss ways to loosen these knots as a relief to QL tightness. 


Finally, Stage 3 tackles about a variety of stretching exercises to release the quadratus lumborum. These exercises will help stop the muscles from constantly contracting and thus relieve the body from QL tightening. 





Stage 1: Addressing the causative factors



As mentioned earlier, the approach in this phase requires client involvement. The treatment plan is entirely useless if the client would refuse to take part in protecting his lower back. 


Even if the therapist loosens the knots in his QL muscles, when the client proceeds to lift heavy weights during the period of treatment, he gives the back muscle no opportunity to relax. As a result, the QL muscle continues to work and the health plan becomes of no use – which is an utter waste of both the client and the practitioner’s time and effort. 


Thus, it is important for the client to take part in the treatment process for purposes of holistic intervention. The following are some tips to overcome the causes of QL dysfunction. These are helpful not only during the course of the health plan but also afterward. 



Reduce repetitive stress


The health plan cannot impede the client’s daily activities. The goal, however, is to regulate these activities to prevent further injury to the client’s lumbar region.


If the client regularly exercises in the gym using weights, he has to avoid this for the time being and shift to less strenuous, yet still effective, exercises like Tai Chi or yoga. Walking is also a good exercise. 


Gardening is a common activity among the adults and elderly. However, this requires bending and twisting that could worsen QL tightness. Again, the client must keep away from doing these tasks in the course of the therapy. 


Also, habitual sitting can result into repetitive stress, although passively, on the back muscles. Regulate this by taking breaks every 20 minutes. 



Avoid over-exertion


Exerting too much effort can take a toll on the body, especially so to the back muscles. It is best to adjust the activities according to the strength and ability of the back muscles to contract and expand. 



  1. When Lifting


  1. Use brace or support


Lumbar braces and support devices aid in maintaining the body’s erect posture. This also limits the body from excessive bending or twisting to prevent strain on the lower back. These devices come in various designs and sizes. For the best fit, the client can look for a brace support specialist that could take his proper size. Obviously, it is useless to wear the brace if it is too tight or too loose to support the back. 


  1. Place the thing close to the body


Before lifting, keep the object as close to the body as possible to prevent over-reaching and stretching of the back muscles. Take time to go near the object and never attempt to exert extra effort in picking it up. Otherwise, over-exertion will stress the back muscles and activate the trigger points in the affected area. 


  1. Keep the back straight and tighten the abs


Do not attempt to lift the object with an arched back. When a person lifts with his back curved, it overloads the back muscles to do two conflicting duties all at once – that is first, to extend the QL for bending, and second, to contract the QL for lifting. 


  1. Bend the knees, not the waist


Relate this to the topic earlier on keeping the back straight when lifting. In picking up an object, do not bend the waist to avoid unnecessary strain on the lower back. Instead, bend the knees to reach the object. This is less painful to the back muscles unlike in bending the waist. 


  1. Inhale before lifting, exhale during lifting


Before lifting an object, take a deep breath and let the oxygen flow into the body and to the back muscles. This gives the QL muscle enough energy to contract well when it works on the lifting. Then, start picking up the object and exhale while doing so. Exhalation helps relax the body to prevent the QL from consistent contractions. 


  1. Avoid body twist


Twisting the body can lead to irregular shortening and stretching of either of the QL muscles. If a person twists his trunk to one side, it engages the QL muscle to contract on that side while the opposite QL extends toward that direction. If done together with lifting, the QL muscles have to double its duty to twist and to bear the weight of the thing all at once. 


  1. When carrying


  1. Hold the thing at waist level close to the body


Same reason with lifting, a person should carry an object close to his body to prevent his arms from extending, which necessarily causes his back muscle to contract. Also, keep the object at waist level for the same reason. 


  1. In carrying one thing, place it in the middle of the body


For example, in carrying a large box, take it with both arms to the middle of the body. This helps support the spine to a neutral state and prevent the back muscles from extending with extra effort. 


  1. In carrying more than one thing, distribute weight equally on each side of the body


In carrying two or more grocery bags, for instance, distribute their weight equally on each side of the body. Do this by carrying the grocery bags, one in each arm, making sure that the weight of the bag in one hand is equal to that of the other hand. The purpose is to prevent the body from tilting on one side, thereby inducing the QL muscle to extend to that direction. 



Maintain good posture


Even if the client is at home or at work, he must make sure that his back muscles are not overly stretched or shortened. He can still do all his activities of daily living, provided he maintains a good posture in doing so. 


1.    When sitting  


  1. Use a firm and straight chair


Most people spend more time sitting either for work or for leisure. To prevent strain on the lower back, it is advisable to look for a firm and straight-backed chair to sit on. Also, some workstations have ergonomic chairs made specifically to support the back area. This ensures the proper alignment of the spine and prevents the QL muscle from working too much to stabilize the lumbar vertebrae.


  1. Keep buttocks close to the back of the chair


When sitting, place the buttocks as close to the back of the chair as possible. This prevents the person from slouching for a prolonged period that could abnormally shorten his quadratus lumborum. 


  1. Keep feet flat on the ground


Also, keep the feet flat on the ground as much as possible. If a person sits with legs crossed, such posture fails to distribute the weight and force evenly to the two QL muscles on his lower back. This position forces one QL to contract and tilt the hip to one side, while the other QL bears the weight on the buttocks. That is why it is better to rest both feet on the floor when sitting to prevent the QL muscle from overworking. 


  1. Avoid long hours of sitting


Avoid sitting for extended hours as it induces the QL muscles to contract always without rest. If the client is working, tell him to take short breaks in between. Stand up, stretch, or walk for a while to relax the back muscles and to prevent them from continually shortening. 


2.    When standing


  1. Chin up, pull shoulders back, relax the knees


As much as possible, the body should stay in a neutral upright position while standing. Keep the chin up and pull the shoulders back to prevent slouching. Do not over-extend the knees. Instead, keep them relaxed to avoid straining the legs and the back. Remember that QL trigger point areas extend down the thighs. It is better to keep them relaxed to avoid activation of these trigger points. 


  1. Avoid back-arching


Arching the back distorts body posture. This may lead to slouching, which shortens the QL muscle over time. Thus, avoid an arched back and keep up an erect posture while standing. 


  1. Take breaks and elevate one foot


While a person stands, the back muscles work mostly to keep a steady spine. If this continues, the QL muscles cannot relax and will continue to contract until it tightens. As a remedy, take short breaks in between to give the back muscles a breather. Elevate the foot on a furniture to flex the knees. This rests the leg, abdominal, and back muscles from exerting pressure. 


  1. Shift weight of the body from one foot to another


For some people, the nature of their work requires them to stand for long periods or even for the entire day. Some employers even discourage employees to sit during working hours. This is often true among salespersons or military men. As a result, the extensor back muscles overwork themselves and become strained in the process. 


To remedy this, tell the client to alternately shift his body weight to one foot and then to the other from time to time. This helps equally distribute the force to the back muscles without straining them both all at once. 


3.    When driving or riding  


  1. Fix the seat to the desired position


Whether driving or riding, always move the seat to the desired position. This means it is not too close or too far from the wheel, dashboard, or front. Otherwise, there is a tendency for the person to lean forward and over-extend his back. 


  1. Place left foot flat on the floor, if not stepping on the pedals


Vehicles with automatic transmission usually have no pedal for the left foot. To prevent muscle strain, place this free foot flat on the floor. 


  1. Sit upright


While driving or riding a car, make sure to sit up straight and avoid arching the back. Refer to the guidelines above exclusively for sitting. 


4.    When sleeping  


Sleeping is a subtle way of harming the lower back. It is at bedtime that a person cannot consciously control his body movements. Without knowing, he ends up flexing and extending his QL muscles every time he curls himself in one corner or rolls to one side. However, by applying the guidelines below, a person can cut the stress on his lumbar region. 


  1. Use a firm mattress


Soft mattresses or hammocks depress certain areas of the body while sleeping, which may lead to irregular extension or flexion of the back. It is better to sleep on a firm mattress to keep the back straight during bedtime. To avoid buying a new one, simply insert a plywood underneath the mattress to make it firm. 


  1. Sleep in the proper position


There are two desirable positions to ease the lumbar pain, namely the supine and the side-lying position. These give a neutral position on the spine and helps reduce the back muscles’ efforts to keep the vertebrae straight.


In the supine position, the person must sleep flat on his back with a pillow placed under his knees. 


On the other hand, in a side-lying position, he must sleep on his side, preferably the left, with a pillow placed between his legs. 


  1. Do not sleep prone


Sleeping prone aggravates QL dysfunction as this curves the back in and stimulates the back muscles to contract. Thus, avoid sleeping prone. Instead, sleep on the side or on supine. 


  1. Do not stretch arms overhead while sleeping


Stretching the arms overhead causes the extensor back muscles to expand. That is why it is better to keep arms on the side while sleeping. 



Protect self from physical trauma


Accidents may happen and they always come by surprise. The health plan cannot avoid that. Yet, for purposes of therapy, the client must remain cautious to prevent unnecessary trauma to his body. 


One example is to substitute motorcycle-driving with taking a public transport or any vehicle with four wheels. That way, chances of a motor crash decline because four-wheeled vehicles are more stable than two-wheeled ones. That does not mean cars are not prone to accidents. It only means that cars are less prone to accidents than motorcycles. Thus, the aim of the client’s treatment is to cut, and not remove, any possible injury that may arise from motor accidents. 


Another example is in case of athletes or sportsmen. They must take a rest from whatever sport they are playing and focus on strengthening their back muscles. Otherwise, they may end up damaging their body to the point of early retirement. 



Deal with the biological factors


When emotional stress triggers muscle tension, the best way to deal with this is to relax the body. This is easier than done, but not impossible. To avoid stress, the client has to improve his coping skills by resorting to an effective support system, like parents or friends. He can also submit to meditation techniques, like Yoga or Tai Chi. These two exercises promote deep breathing that can help relax tensed muscles. 


Nutritional imbalance deprives the muscles the nutrients they need to work well. Eating a healthy and balanced diet answers this problem. 





Stage 2: Loosening the QL


When the back muscle contracts, especially for a long period, it activates the trigger points or muscle knots in certain areas of the body (see discussion in Chapter 5). These trigger points are painful until properly massaged to loosen up the muscle knots. 


There are various ways to help loosen these knots. Some of these techniques include the use of Theracane and a softball. 



Theracane for massaging the muscle


Theracane is a self-massaging tool widely used to get rid of muscular tension. As its name implies, a theracane is cane-shaped with several knobs (or balls) strategically placed to hit major muscle groups during the massage. 


It helps relieve muscle stiffness in any part of the body by targeting trigger points. Theracanes are popular because, unlike massage chairs, they allow a wide range of motion such that a person can use it with his hands to apply pressure to the muscles of his lower back without over-reaching.


Because it is for self-massage, anyone can use it within the comfort of his home. He would no longer need a therapist or any person to help him in using the tool, as long as he can find the proper trigger points. 



Softball roll over technique for loosening the muscle. 


The softball roll over technique helps break off tight muscles by rolling over a softball on the trigger point areas. This is distinct from the more popular foam roller massage therapy. 


Firstly, foam rollers are bigger and less firm than softballs. Secondly, while foam rollers are effective against superficial muscles, softballs can reach deeper ones. Thirdly, foam rollers are trendy and expensive, while softballs are less appealing which makes them a lot cheaper. 


For purposes of treating QL pain, softballs are better alternatives to foam rollers. 


To recall, in Chapter 1, we identified the QL muscle as the deepest abdominal muscle in the lumbar region. This location makes it almost impossible for the foam rollers to get access to. Unlike softballs, foam rollers are less precise in handling deep muscle knots because of these rollers’ large size. That is why it is preferable to use the softball rolling technique.


In performing the technique, the therapist brings the ball over the client’s aching spot. Then, applying some force, he rolls the ball over the affected site and the client will start to feel pain in the area. But unlike before, this painful sensation is more satisfying and relieving. This means that the muscle knots are slowly coming off. If the client winces or grits his teeth during the massage, the force applied is not therapeutic. So, to give relief, the therapist must adjust the pressure accordingly.  


In the alternative, the client can do the softball roll over technique alone. First, he traps the ball between his body and a flat surface, like a wall or a floor. Then, he glides his body up and down against that flat surface with the ball rolling over the aching spot. Again, the client must feel a satisfying, painful sensation. Otherwise, the therapy is not relaxing. 


For best results, apply heat pads over the affected muscle to warm this up before the massage therapy. Warming the muscle improves blood flow and promotes healing of the damaged tissues. 











Stage 3: Stretches to release QL  



After addressing the factors causing pain in the quadratus lumborum in Stage 1 and after loosening the muscles knots using self-massage therapies in Stage 2, the client will finally undergo the crucial phase of his rehabilitative regimen. He is now ready to take Stage 3 – the stretching exercises. 


Stretching is an important step to release the tightness of the QL muscles. It enhances flexibility and strength of these muscles to prevent them from shrinking. For purposes of the client’s health plan, stretching will involve the concept of isometrics. 


An isometric exercise is a form of resistance training where a person maintains a static position. The exercise does not involve any changes in muscle length or joint angle during contractions, unlike isotonic exercises. This is ideal for persons having QL dysfunction because it strengthens the muscles without requiring a strong impact that could damage the already injured muscles. 


These exercises have multiple variations but they can be categorized into two, namely the partner-stretches and the self-stretches. 





  1. Supine with leg pull QL partner-stretch


This isometric exercise involves hip-hiking to strengthen the back muscle’s capacity to lift the pelvis. 


  1. Preparation


  1. Place the client supine on a firm bed or table.
  2. Stand at his foot part.
  3. Cross the client’s legs while holding the affected leg over the other.
  4. Gently pull the affected leg as tolerated and then hold this as the starting position. This will lengthen the QL muscle in preparation for the isometric exercise.



  1. Application


  1. Instruct the client to pull his affected hip bone toward his armpit. This movement is called “hip-hike”. Make sure that he is not flexing his hip by lifting his leg up to the ceiling.
  2. Tell the client to stay in this position for 6 counts while breathing normally. This refers to “isometric contraction”.
  3. Let him inhale deeply and relax while slowly assuming the starting position.
  4. Then, instruct him to exhale while you pull the affected leg further for a deeper stretch. For an added stretch, let the client extend the arm on the affected side over his head.
  5. Repeat the steps for two to three cycles.



  1. Side-lying QL partner-stretch


This is an isometric exercise which stretches the vertical fibers that compose most of the QL muscle. It aims to contract the affected QL muscle by doing side-bends and hip-hikes at the same time. 


Some clients find this exercise hard. This is especially true among those with severe cases of QL dysfunction. Even then, therapists still recommend this method because of its dual purpose. If the client cannot do it, he may opt to change the routine to the first earlier discussed (the supine method). 


  1. Preparation


  1. Assist the client to lie on his unaffected side with his back at the edge of the bed.
  2. Hyperextend his affected leg and let it hang over the edge of the bed.
  3. Bend his unaffected leg toward his chest.
  4. Extend his arm of the affected side over his head. This will help further lengthen the back muscle.
  5. Then, while standing behind the client, cross your arms and place each of your hand atop the client’s exposed hip crest and rib cage.


  1. Application


  1. Instruct the client to contract his affected QL muscle by moving his exposed hip and ribs toward each other. This results in a synchronized hip-hike and side-bend movement.
  2. Repeat the preceding step while your arms pushing down to resist the client’s movements. This is called the “isometric push”.
  3. Thereafter, instruct the client to inhale and relax while slowly dropping his hyperextended leg down to reach the floor as much as he could. Do this while increasing the stretch of his extended arm.
  4. Repeat the steps for two to three cycles.





Even without a partner or therapist, the client can perform stretches on his own. He can actually do any form of exercises with the end view of strengthening his quadratus lumborum. But for purposes of this book, we will mention two of the most common self-stretches.


  1. Sitting with side-bend QL self-stretch


  1. Preparation


  1. Sit upright on a straight-back chair or a comfortable bench.
  2. Straighten the spine and do not slouch.
  3. Tie a long towel or strap on the unaffected foot.
  4. Raise the arm of the affected side over the head.
  5. Gently bend sideways to stretch the affected QL muscle. Do this while reaching for the towel and as close to the foot as possible. Keep this as the starting position. This will lengthen the QL muscle in preparation for the next exercises.


  1. Application
    1. Try to sit up straight while using the towel to prevent the motion.
    2. Isometrically contract the affected QL muscle for 6 counts.
    3. After this, inhale deeply and relax.
    4. Then, exhale while bending further to the unaffected side to deepen the stretch of the affected QL muscle.
    5. Repeat this for two to three cycles.



  1. Standing with side-bend QL self-stretch


  1. Preparation


  1. Stand up straight with both feet slightly apart.
  2. Extend both arms above the head with palms facing each other.
  3. Let the wrist of the unaffected side hold the opposite wrist.
  4. Pull the wrist of the affected side and bend sideways toward the unaffected side as tolerated. This will stretch the affected QL muscle. Make sure not to shorten the lower back.


  1. Application


  1. Isometrically contract the affected QL muscle for 6 counts.
  2. After this, inhale deeply and relax.
  3. Then, exhale while bending further to the side for an additional stretch of the affected QL muscle.
  4. Repeat this for two to three cycles.












Chapter 8: Stretches to avoid that can lead to aggravation of QL pain  



While stretching exercises help release tight muscles, not all exercises can relieve pain in the quadratus lumborum. There are certain stretches that aggravate QL instability simply because the client failed to execute them correctly. 





In case of QL pain, the most common stretch to avoid is over-extension. Truly, there are instances in Stage 3 of the health plan where the client has to extend his arms or bend his body further to get a deeper stretch of his affected QL muscle. This is not contradictory.  


A person will not suffer from QL pain by merely extending his back. As a matter of fact, QL muscles also act as extensors, aside from the common belief that it only focuses on lateral flexion. Thus, stretching the QL is not harmful at all, as long as the stretch is tolerable and is properly executed. 


This is true especially among people blessed with muscle flexibility that allows them to stretch their body beyond normal range with ease. Yoga positions require a lot of stretching but seldom could you find a yogi complaining of backaches. 


The problem only arises when, during a stretch, the client winces or cries in pain. This indicates that the stretch is no longer therapeutic but injurious to him. 


Moreover, excessive stretching can potentially pull the muscle fibers apart and prevent them from contracting like they normally do. When a person stretches past his capacity, it stimulates the receptors of the nervous system to create protective contractions supposedly to prevent further stretches. In the end, it causes the muscle to contract instead of attempting to stretch it. 


Thus, stretching is harmful to the quadratus lumborium only when the stretch goes way beyond the person’s limits. 



Stretching by foam rolling


We already introduced the concept of foam rolling in Stage 2 of the treatment plan. There, we emphasized that the softball roll over technique is a better alternative to foam rolling. However, there are two views on the matter. 


First, according to popular belief, foam rolling can help reduce QL pain. The problem with this is that foam rollers could not target specific muscles because of its large diameter. At most, rollers can loosen the other superficial muscle groups stacked over the QL, such as the erectors, psoas, or iliacus. But it is difficult for such tool to reach the deepest quadratus lumborium. It only works generally, rather than specifically, to treat back pain. 


Of course, there are some people who found relief in foam rolling. But again, this primarily arises from the wrongful impression that the rollers hit the QL when in fact it was the surrounding sore muscles. 


The second view is less popular. Here, it opposes the use of foam rollers to loosen tight QL. According to this view, foam rollers are harmful in QL pain management because, instead of working specifically on the QL, rollers compress the neighboring muscles and may even injure the unimpaired ones. In effect, instead of reducing pain to the QL, it can add damage to the other healthy muscles, thereby aggravating low back pain. This is why softballs are preferable than foam rollers in treating QL dysfunction. 





The quadratus lumborum (QL) is the deepest abdominal muscle lying in the lumbar region. It consists of three muscle fibers that help the QL function as a lateral flexor or extensor of the lower back, stabilizer of the spine, lifter of the pelvis, and supporter of the rib cage.  


When repetitive stress, over-exertion, poor posture, physical trauma, and other biological factors cause impairment in the quadratus lumborum, it activates the trigger point areas which cause pain in the lumbar region. 


Other than lumbar pain, a patient can also experience restricted movements, respiratory problems, muscular imbalance, and postural distortions. But since the QL is surrounded by multiple muscles that can also cause lumbar pain, it is better to perform a quick motor test to ascertain QL imbalance. 


The treatment of QL dysfunction involves a three-stage health plan. The first stage aims to prevent the causative factors of QL pain. The second stage focuses on loosening the muscle knots through Theracane self-massage or the softball roll over technique. Finally, the third stage helps release QL tightness by stretching exercises. 


Overall, any person can manage QL pain with discipline and proper adherence to the treatment regimen. 


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