Quadratus Lumborum Syndrome

Original Editor - Kardelen Aktas

Top Contributors - Nupur Smit Shah, Kardelen Aktas and Kim Jackson  

Introduction

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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.

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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.