On any given day there are seven million Americans off work as a result of low back pain. After the common cold, back pain is the number one reason for visits to medical doctors. When considering the cost of medical care along with disability costs, it becomes the most expensive “disease” in America. Yet, despite its prevalence, there is no clear agreement on causation or treatment among medical and health care professionals. Interesting theories on low back pain abound. It’s the spinal ligaments, the postural fascia, the bulging disks, the trigger points, the core instability, secondary gain, tight muscles, weak muscles, the sacroiliac joint or even the repression of infantile narcissistic rage!
There is probably an element of truth in all of these theories, but a more important question also remains unanswered: Why is the vast majority of all back pain episodic? In other words, why is it recurrent? Why does it keep coming back? Why does back pain seem to come and go regardless of our theories, our treatments, and our many, many approaches to obtaining a cure?
One of the more intriguing physical medicine theories is that the fundamental imbalance between postural and phasic muscles in and around the pelvis, perpetuates imbalance, strain and altered movement patterns, which accounts for the re-injuring of these key structures. Thirty-three muscles attach to the pelvis and when primary relationships between agonists and antagonists become altered, there is postural distortion and painful movement patterns.
Virtually all practitioners within physical medicine agree that the quadratus lumborum is a vitally important muscle for pelvic stability, structural alignment and functional ef. ciency. Indeed the quadratus lumborum “may be the most overlooked source of low back pain,” according to Doctors David Simons and Janet Travell.
The Quadratus Lumborum and its referred pattern of pain
Attaching superiorly to the 12th rib and the transverse processes of L1 to
L4, and inferiorly to the posteromedial iliac crest and iliolumbar ligament,
the quadratus lumborum has as some of its major functions:
• Lateral Flexion of the spine
• Elevation or hiking of the ipsilateral hip when the spine is fixed
• Bilateral extension of the spine
• Stabilization of the 12th rib during inhalation and forced exhalation
Quadratus lumborum is usually bilaterally hypertonic in clients with an anteriorly tilted pelvis or the lower crossed syndrome. In lateral pelvic tilt or functional scoliotic patterns it is most likely hypertonic on the side of the elevated hip. Quadratus lumborum muscle pain is usually deep, cryptic, and aching, but may be lancinating during movement. In severe cases it may prevent clients from standing or walking, and its “devastatingly urgent” pain may necessitate moving on the hands and knees until relief is obtained. Many clients claiming “my back goes out” actually have bilateral quadratus lumborum spasm which has a paralyzing effect on weight bearing movement.
Trigger points from quadratus lumborum are especially interesting for the manual therapist. The greater trochanter, the ischial tuberosity and the sacroiliac joints are three of the main referral pain regions from the quadratus lumborum (see attached drawing). Over the years I have encountered many clients who either thought they had, or were diagnosed as having, sacroiliac joint dysfunction, trochanteric bursitis or hamstring tendonitis only to have the condition completely clear up with two or three sessions of neutralizing quadratus lumborum trigger points and restoring normal resting length to the muscle. I often wonder if many so called disk, joint or ligament problems are really quadratus lumborum trigger points in disguise. Doctors Travell and Simons certainly suggest that this is often the clinical reality.
Combination movements often overload the quadratus lumborum. For instance, the combination of bending and twisting while getting out of a car or lifting a child or a dog off the floor can be an overlooked causal factor for pain and spasm, especially if there is a pre-existing muscular imbalance around the pelvic, abdominal, or lumbar regions.
Other activities that produce quadratus lumborum hypertonicity and pain include:
• Moving furniture in a clumsy or off-balance fashion
• Washing an uncooperative dog in a bathtub
• Lifting heavy packages out of a car
• Coming up suddenly from a hammock or bucket style chair
• Asymmetrical gait during running or walking or twisting movements while doing household chores
Any position of sustained torso flexion combined with sudden or off-balance extension or twisting can be hazardous for clients at risk for myofascial strain and imbalance. Even simple activities such as reaching for the soap in the shower, picking up the morning newspaper, or doing the dishes can trigger overload of the quadratus lumborum, especially if there is an existing imbalance of key postural muscles.
In treating quadratus lumborum hypertonicity and trigger points, appropriate pressure, precision and penetration is vital. Attachments, fibrosis, stuck fibers and tender spots must be identi.ed and released. Fascial investments surrounding quadratus lumborum must be softened before deep work is performed.
The accompanying photograph (below) presents an interesting and highly effective method for releasing an angry and hypertonic quadratus. Developing skill and precision when releasing this low back troublemaker will greatly enhance your clinical results.
Best wishes for successful therapeutic outcomes!
Bob King will be at DSM teaching his annual workshop This year the topic is Myofascial Approaches for Head, Neck, and Upper Back Pain. Dates are July 14, 15, 16, 2006. See details in his ad in this newsletter.
|Release of Quadratus Lumborum
Myofascial Stand perpendicular to your side-lying client. Thoroughly warm and release the oblique musculature with kneading, friction and light compressions. Utilize the olecranon process at a 45 degree angle of entry between the iliac crest and the 12th rib. Coordinate your depth with your client’s respiration, gradually engaging the lateral border of quadratus lumborum. Slowly angle your elbow superiorly toward the 12th rib, lingering on areas of tension and hardening. Explore the lower attachment by gently shifting your pressure toward the iliac crest. Allow your client’s breath to lift and lower your point of contact. Be certain not to press straight down, potentially bruising soft tissue against the lumbar transverse processes. Spend 5 to 7 minutes thoroughly melting troublesome areas. Performed with accuracy and slow, conscious engagement, this method of myofascial release can generate tremendous physical relief from chronic low back pain.