Quadratus Lumborum Syndrome
Introduction
Quadratus Lumborum is the deepest muscle of the lumbar region. Extends from pelvis to last rib. It contracts while sitting, walking and standing and is therefore very susceptible to pain formation. Pain is usually caused by overuse, but can sometimes be caused by weakness and tension. Constantly standing in the same position will reduce blood flow and thus pave the way for pain. At the same time, the weakness of the back extensor muscles can also form the basis of the pain as it will put a load on the Quadratus Lumborum.
Symptoms
The majority of the patients with quadratus lumborum involvement, present with low back pain.
Low back pain is divided into three syndromes:
Cervical back pain syndrome:
Pain below the nuchal line and above the first transverse process of thoracic vertebrae and laterally around the lateral surface of the neck.
Thoracic back pain syndrome:
Pain is experienced in the upper and middle of the trunk between T1 to T12.
Lumbosacral back pain syndrome :
This is the synonym for lower back pain. Pain is situated below the 12th rib and above the gluteal folds. In some cases, there can be radiating symptoms in the lower extremity. Quadratus lumborum syndrome falls into this category of low back pain.
Myofascial pain syndrome (MPS) of the spinal stabilizer muscles is one of the most frequent causes of chronic low back pain. However, MPS is often overlooked. Among the spinal stabilizer muscles, the quadratus lumborum (QL) is frequently a trigger point and location of referred low back pain Overuse and strain of the QL is one of the major causes of chronic pain in the lower back.
MPS is characterized by symptoms that include localized muscular tenderness, myofascial trigger points, a palpable intramuscular taut band, and muscular twitching response. MPS is a common cause of pain and dysfunction in the musculoskeletal system and accounts for 20% to 95% of cases with musculoskeletal pain presenting at outpatient clinics and pain management centers. The primary goal of managing MPS is to break the vicious cycle of pain through the elimination of trigger points. There are various treatments for the elimination of myofascial trigger points, including trigger point injection (TPI), ischemic compression, stretching, massage, and treatment modalities, including ultrasound and transcutaneous electrical nerve stimulation. A variety of treatments exist, but the most effective treatment for MPS is still under debate. It is characterized by pain and tension in the lumbar region.
The type and severity of pain can vary. Low back pain is often described as a deep ache, but it can also be felt as sharp and acute depending on the cause. Although the discomfort usually occurs at rest, it can get worse with movement. Lying, walking, standing, and rolling may aggravate the pain. Sharp pain may also be felt when sneezing or coughing. Quadratus lumborum pain can even interfere with daily activities such as walking and sitting.
Quadratus lumborum pain can become chronic. Long-term pain often impairs a person's quality of life and well-being, and also affects them physically. People with chronic low back pain are more likely to experience anxiety and depression than those without chronic pain.
Also, if one part of the body is causing pain, other parts try to support the painful area. For example, if the quadratus lumborum is tight and painful, we may find that the person begins to twist or change their gait by changing their body posture. This changing posture can place an additional load on other parts of the body, such as the hips, further increasing the pain.
Palpation of Quadratus Lumborum
Place of palpation: Inner lip of iliac bone on the paraspinal part.
- Hypersensitivity in this area indicates that muscle is under tension. Iliopsoas and Quadratus lumborum both fuse together on the inner lip of the iliac crest so the increase in tension will be on both the muscles.
Trigger Points
A trigger point is a sensitive area of muscle or connective tissue that hurts when stimulated or pressed. Trigger points are also often described as small knots. Pressing a trigger point can also cause directed or radiating pain. Radiating pain is the discomfort felt more in a different part of the body when the sensitive point is pressed. Quadratus lumborum trigger points can cause pain in the lower back, pelvis, and hips.
Quadratus lumborum trigger points can cause deep pain in the lower back or a stabbing sensation in the hips or pelvis. It can also cause sharp pain when the QL shortens when coughing or sneezing.
Causes
- Poor posture
- Occupational stresses such as prolonged sitting or standing at the workplace or continuous lifting activities.
- Sedentary lifestyle
- Obesity
- Muscle spasm( quadratus lumborum)
- Pregnancy
Outcome Measures
- Pressure Pain threshold: This is measured by a pressure algometer. The algometer is vertically applied to the tender point of the muscle and the patient has to say 'STOP' once the pain is felt. The unit in which it is measured is kg/cm2.
- Visual Analogue Scale: Commonly used outcome measure for pain.
Physiotherapy Management
Since the Quadratus lumborum Syndrome is under the heading of lumbosacral back pain Syndrome, many surrounding structures need to be addressed during the treatment.
Strategies:
- Relieving the tension of iliopsoas and the muscles and fascia in contact with it. And Muscles that remain structurally connected to the sacrotuberous ligament.
- Reducing the atrophy of gluteus medius, gluteus maximus, sacrotuberous ligament, and erector spinae.
- Reeducation of correct motor firing patterns of the trunk and hip by exercises.
Physiotherapy treatment
Quadratus lumborum syndrome is usually seen in patients with low back pain(as mentioned above) and also in the patellofemoral pain syndrome. In the condition of chronic low back pain, the quadratus lumborum is under tension and presents with trigger points.Manual trigger point therapy is effective and provides relief from trigger points. Dry needling is another form of treatment that provides instant relief in trigger point pain and inurn reduces the tension and sensitivity of the hyperactive muscle. Few commonly used modalities for this condition are TENS and ultrasound. It helps in reducing the pain and irritability.Stretching of the quadratus lumborum is also effective in patients with nonspecific low back pain. The patient can continue self-massage and cryotherapy at home.
Quadratus Lumborum
Introduction
The Quadratus Lumborum (QL) is the deepest back muscle and originates from the iliac crest and inserts on the transverse process of lumbar one through five and the lower part of the twelfth rib. The QL muscle is flattened and has a quadrangular shape.
The QL muscle is an integral part of the thoracolumbar fascia, a myofascial system that covers the posterior area of the human body, involving part of the lower and upper limbs.
Innervation of the QL is via the twelfth thoracic nerve and the spinal rami of the lumbar spinal nerves.
Along with the multifidus and erector spinae muscles, the QL helps to create an antagonist force to the muscles of the anterolateral abdomen wall.
Image: Quadratus lumborum (highlighted in green) - anterior view
Anatomy
The muscular organization is complex (comprises three layers with muscle fibers that have different vectors) and it is difficult to identify precisely the actions that occur through the contraction of fibers.
Generally, the QL muscle is located medially to the aponeurosis of the transverse abdominal muscle.
The quadratus lumborum (QL) muscle is:
- An integral part of the thoracolumbar fascia and also
- One of the muscles of the posterior abdominal wall.
- One of the Core Muscles
- One of the paraspinal muscles
Origin
Iliolumbar ligament and internal lip of Posterior iliac Crest.
Insertion
Medial half of lower border of 12th rib and tips of transverse processes of lumbar vertebrae.
Nerve Supply
- Subcostal nerve (T12)
- Iliohypogastric and Ilioinguinal nerve (both from L1)
- Branches from the ventral rami (L2 and L3)
Function
The anatomy texts describe the quadratus lumborum muscle as an extensor of the lumbar spine, a stabilizer of the lumbar area, capable of pelvic tilting laterally and capable of acting as an inspiratory accessory muscle.
However findings show
- During extension, the QL exerts a force of 10 N, compared to 100 N and 150 N of the erector spinae muscles and the multifidus. It seems unlikely that it can extend the lumbar area on a sagittal plane with such a small force (10 N).
- The QL during a lateral tilt of the trunk it participates with less than 10% of the force required for a coronal inclination.
It seems likely that QL could act as a crossroad of the forces exerted by the neighboring muscles, influencing the vectors of the different tensions produced, thanks to its :strategic position; disorganised scheme of its fibers; and its function in the myofascial system.
Actions
Classic described actions given below:
- Quadratus Lumborum fixes the 12th rib to stabilize diaphragm attachments during inspiration
- Lateral flexes the vertebral column
- Extends lumbar vertebrae
- It forms with the contralateral Tensor fascia lata and Gluteus medius a lateral myofascial sling which aims to maintain frontal plane stability of the pelvis.
Physiotherapy Implications
The muscle group is considered a postural muscle group and part of the Core muscles. The core is the group of trunk and hip muscles that surround the spine, abdominal viscera and hip. Core muscles are essential for proper load balance within the spine, pelvis, and kinetic chain. They spare the spine from excessive load and are essential for lad transfer between the upper and lower body.
Quadratus lumborum is a continuation of transverse abdominal muscle. The transverse abdominal muscle is part of the anterior fascial system of the body. The transversalis fascia penetrates the abdominal musculature. It's one of the muscles that tends to be tight and overactive In this situation adversly affects the resting tension of the QL, altering the distribution of the lumbar region load.
Trigger points can involve the QL. This condition could also mimic a painful syndrome of the lumbar area. Trigger Point Referral Pattern
For more see Quadratus Lumborum Syndrome
Lumbar spine pathologies eg bulging discs, and facet joint hypertrophy from chronic inflammation may effect nerve conduction and response to the QL and Iliopsoas resulting in poor muscle stabilisation and mechanical stress from chronic contracture.
QL can cause low back pain with the emergence of a heterotopic ossification or myositis ossificans. The latter may result from direct trauma and inadequate healing.