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| Ref: https://www.miamivalleygolf.org/ |
Low back pain is usually classified as ‘specific’ or ‘non-specific’. Quadratus lumborum (QL) is one of the common sources of pain that can be overlooked easily. Specific low back pain is defined as that caused by a specific pathophysiological mechanism, such as disc prolapse or herniated nucleus pulposus, infection, inflammatory arthopathy, tumour, osteoporosis or fracture.
Non - specific low back pain is defined as low back pain not attributable to a recognizable, known specific pathology. Quadratus lumborum pain syndrome is a myofascial pain syndrome. QL has a strong relationship with low back pain because of anatomy. The QL is located between the posterior pelvic and lumbar spine and 12th rib, which is an intimate lower back muscle. The pain is due to spasm and stiffness of the muscle. Many times, weak back muscles are compensated by quadratus lumborum leading to painful spasms.
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| Ref: https://radiopaedia.org/ |
In my physiotherapy experience, I have seen QL spasm and stiffness in patients with non - specific low back pain. They illustrated limited torso lateral flexion and tenderness of QL, additionally it may or may not cause spasm of the lower back muscle. This muscles always involve scoliosis condition. In the case of disc herniation, the QL muscle spasm never showed up. Patients with scoliosis have always seen the QL impairment that has been related to gluteus medius weakness.
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| Neutral spine (left), Scoliosis spine (right) (Ref: https://www.pinterest.com/) |
6 ways to stretch QL
Exercise #1: Basic stand torso lateral bending: Bend torso to opposite side of target muscle. Be careful: focus at torso, not head and neck.
Exercise #2: Wall torso lateral bending: Target muscle is next to the wall. Then, put the forearm and pelvic on the wall which is the target side. Remark: the case of lumbar disc herniation should stretch under supervision of physiotherapist. Additional, If you feel worse pain and/or leg's nerve irritation, should stop and consult physiotherapist.
Exercise #3: Side lying push up: Lying on the target muscle. Then, push up or on elbow for upper torso elevation with keep pelvic on the floor.
Exercise #4: Side lying on foam roll: Lying on foam roll or towel that put the non-target on foam roll.
Exercise #5: Cross sitting with lateral torso bending: Bend torso to opposite side of target muscle with hand support for more relax. Be careful: focus at torso, not head and neck.
Exercise #6: Half cross sitting with lateral torso bending: One leg is in front and other is rear leg. Bend torso to opposite side of target muscle that mean bend away from the front leg. Be careful: focus at torso, not head and neck.
Quadratus lumborum (QL) is a posterior abdominal wall muscle and bottom - up layout muscle.The QL originates from the posteromedial iliac crest and inserts into the medial border of the 12th rib and the transverse processes of the 1st to 4th lumbar vertebrae. The lateral free border of quadratus lumborum is angled from craniomedial to caudolateral.
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| Ref: https://www.physio-pedia.com/ |
About their osseous attachments, the principal types of fascicles were iliocostal, iliolumbar, iliothoracic, and lumbocostal. These fascicles arose from the iliac crest passed to the 12th rib (iliocostal), from the transverse processes of lumbar vertebrae (iliolumbar), from the lateral surface of the 12th thoracic vertebra (iliothoracic), or from the lumbar transverse processes and passed to the 12th rib (lumbocostal) respectively. On the iliac crest the muscle occupied an area extending from 5 to 7 cm laterally from a point opposite the tip of the L4 transverse process. Occasionally, fascicles arose from the iliolumbar ligament instead of the iliac crest. On the 12th rib, fascicles attached to an area on the lower anterior surface that extended to between 4.5 and 7 cm from the head of the rib.
It involves the muscle nearby including the quadratus lumborum and psoas major muscles traverse posterior to the lateral and medial arcuate ligaments of the diaphragm, respectively. The QL muscle lies in front of the erector spinae muscle group, consisting of the multifidus, longissimus, and iliocostalis. Moreover, one fascia is a fibrous composite of aponeurotic and fascial tissue that surrounds the QL which is the thoracolumbar fascia.
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| QL is next to psoas, and both of them connect to diaphragm (Ref: https://pocketdentistry.com/) |
The thoracolumbar fascia is part of a myofascial girdle that surrounds the lower torso and is important for posture, load transfer, and stabilization of the lumbar spine. It comprises multilayered fascia and aponeuroses, with two proposed models including the two-layered model and the three - layered model. Although the three-layered model is the most commonly used, regardless of which model is accepted. Because the fascial planes in the abdominal compartment follow the quadratus lumborum and psoas muscles through the medial and lateral arcuate ligaments and the aortic hiatus of the diaphragm, forming the endothoracic fascia.
In the three-layered model describes the posterior thoracolumbar fascia layer surrounds the erector spinae muscles, the middle layer passes between the erector spinae muscles and quadratus lumborum, and the anterior layer lies anterior to both quadratus lumborum and psoas muscles.
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| The three-layered model of thoracolumpar fascia Ref: https://www.lecturio.com/ |
The characteristic of each layer was explained as below,
(1) The posterior layer: consisting of iliocostal fascicles laterally and iliolumbar fascicles medially. The iliocostal fascicles arose from the lateral third of the iliac attachment site but passed to all thirds of the costal attachment site, inserting behind or lateral the fascicles of the middle layer. The more lateral fascicles of the posterior layer typically became tendinous and appeared to insert into the middle layer of thoracolumbar fascia, but their tendons could be traced, through the fascia, into the 12th rib. The iliolumbar fibers arose from all thirds of the iliac site and passed to the tips of the upper lumbar transverse processes, most consistently to L3 and L1, and less often to L2 and L4. The posterior layer was wedge shaped in a longitudinal profile: thick inferiorly and tapering superiorly. This feature arose because, from below upwards, individual fascicles twisted, such that more lateral fibers covered their more medial companions, as the fascicle flattened out towards its costal attachment. As a result, fascicles with a thick, but narrow, origin from the iliac crest assumed a wide, but thin, linear insertion on the 12th rib.
(2) The intermediate layer: consisting of a set of lumbocostal fascicles. This layer was distinguished by the radiate arrangement of its fascicles. Most consistently, fascicles radiate from the tip of the L3 transverse process to various points on the costal attachment site of the muscle, behind the fascicles of the anterior layer. These fascicles were supplemented by similar fascicles arising most often from the L4 transverse process, and less often from the L2 and L5 transverse processes.
(3) The anterior layer: formed the anterior surface of the muscle, and presented a smooth quadrangular surface of regularly arranged fibers. It was a thin layer, consisting of iliocostal and iliothoracic fascicles, which assumed muscular or tendinous attachments at either end. The iliocostal fascicles arose from various points along the anterior margin of the attachment site on the iliac crest; only occasionally did fascicles arise from the iliolumbar ligament. They were distributed to various points along the entire attachment site on the 12th rib. The iliothoracic fibers arise from various points along the iliac site and converge to the lateral surface of the body of the twelfth thoracic vertebra. In some specimens they were joined by fascicles from the L4 and L5 transverse processes. In one specimen, a fascicle from the iliolumbar ligament reached the L1 transverse process.
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| Thoracolumbar fascia (green) (Ref: https://bodyworksprime.com/) |
The functions of the quadratus lumborum muscle are questionable. The QL clearly causes lateral flexion, raises the pelvic crest and is an important stabilizer of the lumbar spine. But uncertainty applies to extension that ‘probably helps to extend’ or ‘may extend’ the lumbar spine.
A sustained contraction of QL is required during sitting, walking, lying, and other functional activities in order to stabilize the trunk and maintain body mechanics. Poor posture and body positioning alters the body mechanics which results in development of myofascial pain syndrome in this muscle. Therefore, treatment of QL disorders need not only stretching or massage, but also strengthening and postural control.
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| Function of QL (Ref: https://www.themedicalmassagelady.co.uk/) |
The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following a demonstrated VIDEO.
Reference:
https://journals.sagepub.com/doi/pdf/10.1243/09544119JEIM266
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