Why All the Quadratus Lumborum Back Pains and How I Treat It

We have had snow and cold weather past week. Over past 2 days, I have seen 4 quadratus lumborum based back pains responding to treatment based to it. None would have been better with usual physio for non-descript back pains. Have to think, cold weather causes this problem to surface.

Quadratus lumborum – because the superficial part of it refers laterally, they will often point more laterally – rather than paraspinous as you see in facet syndrome or more sacral dimples as you see in SI joint syndromes.

If you pinch flank (assuming you can because bottom rib might end up on hip crest) – if you dig in, you can pinch the tight

Quadratus lumborum band is only about a fingers breath in thickness and the more anterior of the back muscles:
ql_strip

What will surprise you and patient, is that it will be much more tender on the front side palpated. I pinch it with both hands and shake it back and forth at least 120 times to see if it can be shook out. 1/4 cases ( a woman with a small muscle) could be shook out.

 

For the rest, the superficial lateral muscle can be injected laterally. Travell & Simon taught you could put a finger on either side and inject down towards back transverse processes. If they are too big to do that accurately, you can insert needle bit anterior to it and aim it posteriorly to avoid injecting abdomen. Either way you should feel muscle tighten when you enter it and see reaction of patient to its entry. I use either a 2 inch 25 gauge or a 22 gauge spinal needle.  I used to inject 0.25% lidocaine because stronger is too acidic but found better results injecting small quantities of 5% lidocaine –  0.5 mls nearer to ribs and 0.5 nearer to iliac crest.  That high a concentration knocks out the motor nerves for a while and gets a better motor release. -Tried it with strong  and weak lidocaine and there is a definite preference for stronger.

Next would be to do the deep quadratus lumborum – just up from L4-5 and L2-3 transverse processes.  – 0.5 mls of 5% each spot so total is not over 2 mls (1.5 mls for small and elderly)

I will press posteriorly above iliac crest and aim above l4-5 transverse process – you can tell when you hit muscle by it grabbing and the patient response. The one above l2-3 is considered quite important in Chinese literature called it “third lumbar transverse process syndrome” and used a cutting tool, needling or botulinum. I discussed it here:
http://painmuse.org/?p=2924
(half way down)

I would pinch the flank and aim from the back above the transverse processes. You can definitely feel when you hit the right place.

After, I then shake the muscle 120 x plus to work it out some.

There was an Chek doctor, Janda, who describes a vigorous stretch for muscles  – Patient will use muscle against your hand and after 15 second fully release. At same time you thrust muscle into a stretch.

I have adapted it for use with quadratus lumborm.:

  • while patient has bad side up, s/he takes buttock slightly off edge or bed ( if you have a stool about same height  – put it there).
  • Have patient put arm over head
  • I put my hand above iliac crest and instruct him/her to hike up hip crest – (some have trouble catching onto this as you do not have to raise leg) – have him/her push for 15 sec.
  • I shout to say release to get them to do a good release and the thrust hip crest down – – you should see leg dip down at same time. (A point of caution – do not push leg down although you will be tempted – doing so will activate triggers in iliotibial band and create trouble for you)
  • I put leg temporarily back on table and sturm side muscle with knuckles 40 times or so – you can feel it loosening.
  • Then drop leg down again and do two more times – they will not believe how good a release you can get – (in combo with injections and shaking pre-treatment)
  • Afterward, the remaining 3/4 felt muscle better.

I teach a stretch that involves you not trying to stretch:

  • lean against a wall, with arm over head and bend sideways.
  • go to sleep – or try – gravity will gradually pull you down without you trying – try breathing or whatever relaxes you. Much better stretch the purposeful ones.

Comment – cold weather obviously tightened things up for people. The abdominal cavity lies next to it so abdominal problems can impact.  I took a course on wise practicing – they felt usual flexion/extension exercises were the thing – none of these cases would have benefited from that. I’m afraid they live in the 20th century where 85% of back pain was undetermined – come -on you can do better then that now…

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