Quadratus lumborum and back pain

Quadratus lumborum (QL) trigger points can play a prominent role in chronic low back pain.

The quadratus lumborum muscle

The quadratus lumborum muscle has a small and somewhat hidden muscle group that plays such a prominent role in normal body mechanics that without its functioning the upright posture of the human being is impossible to maintain.

  • The iliocostal fibres (shown below in blue) attach on the iliac crest and run vertically upward to attach to the 12th rib.
  • The iliolumbar fibres (shown below in green) attach on the iliac crest and run diagonally upward and medially to attach to the tranverse processes of the lumbar vertebrae (L1 to L4)
  • The lumbocostal fibers (shown below in red) attach on the lumbar vertebrae and run diagonally upward and laterally to attach to the 12th rib.

The most important biomechanical consideration with the QL muscle relates to the guy-wire fibre arrangement discussed above. The primary antagonist to each QL muscle is the opposing QL muscle on the other side of the body. Thus, if one muscle develops trigger point activity, the muscle on the other side will become overloaded and develop trigger points as well.

The quadratus lumborum trigger points

As shown in the diagrams above, there are four potential trigger points in the QL muscle:

  • The upper QL trigger point is found just lateral to where the lumbar paraspinal muscles and the 12th rib meet. Note: this trigger point lies underneath the paraspinal muscle mass in this region.
  • The lower QL trigger point lies deep in the region where the paraspinal muscles meet the hip crest (iliac crest).
  • The middle or deep QL trigger points lie closer to the spine than the superior or lower trigger points, next to the 3rd and 4th  lumbar vertebrae.
  • Typically, all four trigger points in this muscle present simultaneously.

Quadratus lumborum pain

The referred pain from the QL trigger points is usually described as an intense, deep ache, but it may also have a sharp, knife-like quality at times, particularly during movement. The distribution of the referred pain is as follows:

  • The upper trigger point (shown to right in blue) refers pain to the flank region of the low back, along the crest of the hip, and around the front to the upper groin region. It may also refer pain to the sacroiliac (SI) joint.
  • The lower trigger point (shown to right in red)  refers pain and tenderness to the hip joint region, making laying on that side too painful during sleep.
  • The middle trigger points (shown above in green) refer pain and tenderness strongly to the SI joint and lower buttock regions. Occasionally, these trigger points may refer a sharp, electrical pain to the front of the thigh.

Quadratus lumborum symptoms and findings

The signs and symptoms associated with active QL trigger points are as follows:

  • Severe, deep, aching low back pain during movement or rest, and in a sharp, knife-like pain when moving the hips/pelvis is common.
  • One attempts to support and stabilize the upper body with the hands. This bracing with the hands occurs during walking and sitting, and is the hallmark sign of active QL trigger points.
  • Coughing and sneezing can creating episodes of agonising pain as the muscle contracts to stabilise the rib cage.
  • Forced to crawl on hands and knees to the bathroom when getting out of bed in the morning.
  • Unable to roll to either side when laying in a face-up position.
  • The pain from untreated QL trigger points may progress to involve the groin, genitalia, and sciatic symptoms.
  • The low back pain from QL trigger points may also transform into severe hip pain over time that resembles trochanteric bursitis.
  • A common postural distortion with QL trigger points is an elevated hip crest on the painful side.

What causes quadratus lumborum trigger points? 

The following factors may activate or reactivate trigger points in the QL muscle:

  • Any activity that involves bending and/or twisting at the waist, such as reaching for an object on the floor, can overload the QL muscle.
  • Lifting heavy or awkward objects, such as a TV, especially if it involves twisting at the waist.
  • Bending over to put on pants, especially if the foot becomes entangled in the pants and they lose their balance
  • Car accidents.
  • A structurally short leg that causes a lateral tilt in pelvis, or walking or running on a sloping surface (side of the road), may predispose the QL muscles to overload and trigger point activity.
  • A soft bed that sags like a hammock may activate or reactivate QL trigger points by placing the muscle in a shortened or stretched position for an extended period.

Associated trigger points

The effective treatment of the QL trigger points will also require addressing associated trigger points in other muscle groups as well as correcting lumbopelvic or spinal dysfunction. In acute cases of low back pain, the therapist should include the gluteus medius trigger points in their treatment routine. In chronic cases, the gluteus medius trigger points, gluteus minimus trigger points, gluteus maximus trigger points, and piriformis trigger points will need to be addressed by the therapist.

The quadratus lumborum-gluteus medius/minimus connection

The referred pain from the upper QL trigger point is projected to the gluteus medius and gluteus minimus muscles, and therefore can activate trigger points in these muscle groups (termed satellite trigger points).

The relationship between the trigger points in these muscle groups is so strong, that palpation on the QL trigger points can produce the referred pain associated with the gluteus medius and minimus trigger points.

The quadratus lumborum-gluteus maximus/piriformis connection

Referred pain from the middle or deep QL trigger points may also activate satellite trigger points in the gluteus maximus and piriformis muscles.

The quadratus lumborum-iliopsoas connection

One other trigger point that can be associated with QL trigger point activity is the trigger point in the iliopsoas muscle group. Because both of these muscle groups share a similar function, stabilising the lumbar spine, trigger point induced weakness in one of the muscle groups tends to overload the other muscle group and cause secondary trigger points to develop within it.

The benefits of inflavonoid intensive care

Inflavonoid Intensive Care is a unique formula to relieve acute inflammation, developed after long studies and research by a team of health care experts which includes scientists, researchers, and naturopaths.

Inflammation is characterised by pain, heat and swelling.

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  • Improved health and vitality

Positive outcomes of Inflavonoid Intensive Care:

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The ingredients in Inflavonoid Intensive Care work at various points within the inflammatory cascade to decrease inflammation and pain via the following:

  • Boswellia prevents 5-lipoxygenase (5-LOX).
  • White willow bark prevents prostaglandin synthesis by inhibiting cyclo-oxygenase (COX-2) mediated prostaglandin release shown in vitro.
  • Ginger suppresses prostaglandin synthesis through inhibition of COX and LOX.
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  • Volatile oils, naturally found in BCM-95™ Turmeric, contribute to its effect.

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Teenage pain often dismissed as growing pains

teenage child back hip neck chronic pain

A common belief is that pain in children will just go away or be forgotten when life takes over.

In the absence of an identifiable injury such as a sprain or fracture, childhood and adolescent pain is often disregarded – by doctors and parents alike.

The most common type of pain is spinal (back or neck), and many more adolescents complain of pain than is commonly recognised. Between one-third and half of all adolescents aged 13 and over report back pain about every month or even more often1. In fact, the prevalence of these conditions rises so sharply in early adolescence the rates approach adult levels by 18 years.

It’s becoming increasingly clear so-called non-specific “musculoskeletal conditions”, the leading causes of disability worldwide, are significant health issues in children.

Non-specific conditions mean that pain cannot be attributed to a defined and diagnosable anatomical cause. In adults, these conditions are recognised as complex disease states that have biological, psychological and socioenvironmental underpinning.

For a significant proportion of adolescents, non-specific pain has extensive impacts on health and quality of life. For example, in a study in Western Australia, about 20% of 17-year-olds reported either missing school, seeking health care, taking medication, interference with normal activities, or interference with physical/sporting activities due to back pain2. There is also evidence that persistent pain symptoms in adolescence predict chronic pain problems in adulthood3.

The blame for pain in kids is often directed at school bags, computer and small-screen device usage, posture, and/or other biomechanical targets. It is also sometimes believed (permanent) damage is being done to the spine, with lifelong consequences.

However, there is little evidence this is true.

Studies show socioeconomic, lifestyle, cognitive and psychological factors are just as strongly, or even more strongly, related to pain (particularly chronic pain) as physical factors4. These societal beliefs about “physical” causes of pain may be not only incorrect, but detrimental if they cause worry about the spine being fragile and discourage children from physical activity.

To date the complex interaction between painful events, the growing body, health influences, social or environmental influences from family, health care providers and schooling is not fully understood. In particular, very little is known about what brings on initial episodes of painful conditions and whether this underpins the link with future chronic pain.

Given wide recognition that early life events are critical in shaping health as people grow older, understanding the context of common painful conditions in early life is critical to inform future health.

It is important to provide effective treatment to those at risk of developing persistent pain. It is also important not to create medical problems out of transient aches and pains, i.e. not every child needs to be sent off for diagnostic imaging and intensive treatments. But a shift away from the narrow and outdated focus on school bags, posture and damaged spines as the only source of problems is a must.

Efforts to update the narrative around pain are as important for children as for adults.

References:

  1. Kamper, S.J., et al., Musculoskeletal pain in children and adolescents. Braz J Phys Ther. http://dx.doi.org/10.1590/bjpt-rbf.2014.0149
  2. Beales, D.J., et al., Low back pain in 17 year olds has substantial impact and represents an important public health disorder: a cross-sectional study. BMC Public Health, 2012. 5 (12): p. 100.
  3. Hestbaek, L., et al., The course of low back pain from adolescence to adulthood: eight-year follow-up of 9600 twins. Spine, 2006. 31(4): p. 468-72.
  4. Chambers, C.T., et al., The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain, 2011. 152(12): p. 2729-38.


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