The quadratus lumborum muscle, commonly referred to as QL, nestles deeply within the lumbar region. Extending from the pelvis to the last rib, QL contracts while sitting, walking, and standing. As such, it often proves highly susceptible to the formation of pain. This article explores the structural and functional components of the quadratus lumborum, while also examining the common causes of pain. Finally, we offer some suggestions for stretching and working through this region in an attempt to correct imbalances and relieve discomfort. 

The “Quirky Trickster” Region

Many fitness professionals may not have had much opportunity to address quadratus lumborum issues, as most clients typically come to us with “generic low back pain.” Often called the “quirky trickster,” it can elicit a variety of symptoms depending on the individual, and this area of the body goes largely unaddressed for several reasons. This muscle attaches to the iliac crest, the transverse processes of lumbar vertebrae 1 to 4, and the 12th rib. Its complex organization makes a precise diagnosis difficult, particularly when trying to pin down its actions through the contraction of its fibers. 

An integral part of the thoracolumbar fascia, the QL consists of a myofascial system that covers the posterior trunk and involves parts of the lower and upper limbs. Quadrangular and flat in shape, it works with the multifidus and erector spinae to antagonize the abdominal muscles. 

Complexity of Muscle Fibers

The quadratus lumborum consists of three muscle fiber layers. The thin anterior layer comprises iliocostal (iliac crest to ribs) and iliothoracic (iliac crest to the T12 vertebral body’s lateral margin) muscle fibers, which terminate with a tendon or muscle. 

The middle layer includes the lumbocostal muscle fibers, which originate from the transverse processes of the lumbar vertebrae and insert on the 12th rib. These muscle fibers vary significantly in size, direction, and thickness.

The posterior layer consists of lateral iliocostal fibers and medial iliolumbar fibers, connecting the iliac crest to the lumbar vertebrae’s transverse processes. 

Function of the QL

Anatomy textbooks commonly describe the quadratus lumborum as a lumbar spine extensor and stabilizer; however, a study on cadavers has led scientists to raise doubts about its specific actions.

During extension, the quadratus lumborum exerts only a force of 10 N, compared to the erector spinae’s 100 N. Extending the lumbar area in the sagittal plane with such a small force seems unlikely. In addition, the lateral location of the QL seems to only exert a force of 10 N during a lateral trunk tilt.

Given these cadaver observations, a consensus points to the likelihood of the quadratus lumborum serving more as a junction for forces exerted by neighboring muscles, influencing the vectors of various tensions due to its strategic position/fiber arrangement. 

Origins of QL Pain

Athletes and recreational exercisers often rightly hold a stiff QL responsible for a persistent aching lower back. As with other tight muscles, a mix of surrounding weaknesses in the back extensor muscles creates a perfect storm. Pain can also arise from overuse; prolonged standing in the same position reduces blood flow to the area, leaving it open to pain. 

“Like other muscles of the lumbar spine, it can become hypertonic or stiff in response to overloading, fatigue, or strain,” explains Kevin Carr, certified functional strength coach, licensed massage therapist, and co-founder of Movement as Medicine. “When this happens, the QL may limit spinal mobility, contribute to asymmetrical movement patterns, and place additional stress on surrounding tissues.”

When clients inquire about vague ongoing back pain, trainers might suggest they consider the following aspects of their current lifestyle:

• Poor posture/prolonged sitting: Situations such as these can actually alter pelvic alignment, thereby inciting excessive muscle strain.
• Weak surrounding muscles: In the absence of a strong core/glutes, the QL muscle must take over and compensate in an effort to stabilize the pelvis and trunk.
• Repetitive motions: Frequent side bending/twisting/lifting movements may elicit QL discomfort.
• Improper exercise form: This holds especially for those clients who run or lift weights regularly. 
• Structural imbalances: Anatomical factors such as a discrepancy in leg length can cause a lateral tilt in the pelvis, overworking the QL to the point of pain.

Trigger Points

A trigger point refers to a highly sensitive area of ​​muscle or connective tissue that incites pain when stimulated or pressed. Pressing on a trigger point “knot” can also cause directed or radiating pain. Quadratus lumborum trigger points typically cause pain in the lower back, pelvis, and hips, which can feel like a sharp stab; coughing and/or sneezing often brings on this stabbing sensation.

Several potential trigger points lie within the QL muscle:

• The upper QL trigger point is just lateral to where the lumbar paraspinal muscles and the twelfth rib meet. 
• The lower QL trigger pointlies deep in the region where the paraspinal muscles meet the hip crest (iliac crest).
• The middle or deep QL trigger points lie closer to the spine than the superior or lower trigger points, next to the third and fourth lumbar vertebrae.

What Causes Quadratus Lumborum Trigger Points? 

The following factors may activate or reactivate trigger points in the QL muscle:

• Any activity that involves bending and twisting at the waist, even something as simple as reaching for an object on the floor
• Lifting heavy or awkward objects, especially if it involves twisting at the waist
• Automobile accidents
• Walking or running on a sloping surface regularly may predispose the QL muscles to overload and trigger point activity
• A soft, sagging mattress may activate or reactivate QL trigger points by placing the muscle in a shortened/stretched position for an extended period
• Poor posture
• Sedentary lifestyle
• Obesity
• Muscle spasms
• Pregnancy

Referred pain from the middle or deep QL trigger points may also activate satellite trigger points in the gluteus maximus and piriformis muscles. One other trigger point associated with QL pain involves that which lies within the iliopsoas muscle group. Because both of these muscle groups share the function of stabilizing the lumbar spine, trigger point -induced weakness in one of the muscle groups tends to overload the other, causing secondary trigger points to develop within it.

Homeopathic Healing

Most individuals find that they can treat quadratus lumborum pain at home with fairly conservative steps. Physical therapists and physicians suggest the following tips:

• Live an active lifestyle:  Aerobic exercise of any kind promotes blood flow. Use pain level as a guide when selecting an activity. For example, upright walking or running might prove more comfortable than bending over on a stationary bike. In addition, exercises that stretch/strengthen the QL and surrounding back muscles will help with pain relief. Even some yoga moves that hone in on the back area can help as much as traditional stretching and strengthening exercises.
• Adjust body position: Remaining in the same postural position for too long leads to tension and stiffness. If a client works at an office or desk job, suggest he gets up every 30 minutes or so to walk around or stretch.
• Over-the-counter pain medications: Products such as ibuprofen (Advil, Motrin), naproxen (Aleve), and acetaminophen (Tylenol) work wonders for many individuals living with quadratus lumborum pain. Check with a physician or pharmacist to ascertain whether these products might interact with any current prescription medications.  
• Foam rolling/massage therapy: Both of these formats can help to relieve trigger points that may contribute to pain. They facilitate the draw of healing nutrients to the affected area, helping the body to safely rebuild the muscles in the area.
• Acupuncture: A 2020 review of 33 studies with more than 8,000 participants found that acupuncture proved highly effective at treating back pain.
• Physical therapy: A licensed physical therapist can help figure out the factors contributing to the QL pain and how to manage it optimally through with targeted exercises. 

Suggested Stretches and Movements to Mitigate QL Pain

Since QL syndrome can stem from a variety of sources, any of a number of stretches/exercises might prove helpful in minimizing pain and restructuring muscular imbalances. Here we offer some of the moves most often recommended by personal trainers and physical therapists.

Side Bend Stretch

1. Stand with feet staggered, hip-width distance apart, right foot in front of left.
2. With the right hand alongside the body and the left extended overhead, slowly bend the torso to the right. Pause upon feeling the stretch, holding for a few seconds, then return to the starting position.
3. Repeat on the opposite side.

Side Bend Isometrics

Option 1: Side Plank: Support the upper body with the forearm, straighten legs, stack feet, and maintain body in a straight line. If needed, simplify the move with a short side plank on knees, or elevate the upper body on a bench or a box.

Option 2: Suitcase Carry: Hold a weight in one hand, bring the torso as tall and vertical as possible, and walk across the room. To return, switch hands.

Standing Forward Fold

1. Stand tall with feet hip-width apart. 
2. Slowly hinge forward at the hips, reaching toward the toes while keeping knees as straight as possible/comfortable. 
3. Allow head, back and arms to relax toward the floor.
4. Slowly curl spine back up to standing.

Egg Roll (literally a gentle massage for the spine)

1. Lie supine, hugging both knees tightly to the chest. With chin gently tucked in toward chest, round the spine into a small “egg” shape. 
2. Slowly rock forward and back.

Child’s Pose with Side Reach

1. Begin on all fours with the hands under the shoulders, knees wide and feet narrow, toes touching. 
2. Press back such that the hips rest on the heels. 
3. Ensure that abdominals remain between knees, arms stretched out long in front of body, with forehead resting on the floor.
4. Walk hands to one side of the mat, with body still elongated, feeling a stretch on the opposite side. 
5. Hold for several long breaths before switching to the opposite side.

Deadlift

1. Stand with feet hip-width apart and a kettlebell or heavy dumbbell vertically between feet.
2. Push hips back, maintaining a neutral spine, bending knees slightly to grip the kettlebell handle or head of the dumbbell with both hands.
3. Exhale and drive through heels to stand tall, straightening legs. 
4. Reverse the movement to lower the weight to the floor with control.

Other bodyweight exercise options include bird dogs, prone Supermans, hip thrusts and bridges.

To ensure the safety and efficacy of these stretches, make sure clients understand the importance of proper preparation. Begin with a light warm-up to increase blood flow and loosen the muscles, which will diminish the risk of strain or injury. Brisk walking, dynamic stretches, or gentle yoga movements can help the body prepare for the stretches to follow.

Strive to attain proper form and alignment when engaging in these movements. A neutral spine, controlled motion, and attention to posture ensure that the QL gets effectively targeted without overloading other muscles/joints. Stretch only to a point of mild tension; cease immediately upon experiencing sharp/persistent pain.

Long-term benefits require consistency. Integrate QL stretches into clients’ routines several times a week, or even daily if needed for significant tension. Combined with steady, controlled breathing to relax the muscles, these moves will enhance flexibility, reduce discomfort, and support better back health over time.

Final Thoughts

The good news about QL pain: regardless of the exact musculoskeletal tissue involved, the aforementioned suggestions and strategies can prove easy to execute and very effective. Although low back pain often feels scary and mysterious, in most cases we can take the same approach as one would for a minor ankle sprain in most cases – take it easy for a couple of days as needed and slowly resume a normal routine. 

Trainers might caution clients to temporarily modify, minimize, or avoid aggravating activities, whether related to sports, specific exercises in the gym or certain daily activities like sitting for a prolonged period of time. 

If one-sided low back pain starts to recur with increasing frequency/intensity, try to identify and address the primary contributing factors; work with a professional to assess how to make reasonable lifestyle adjustments.

Lastly, incorporate exercises that will gradually train the muscles of the low back. Movements that create a stretch under tension may seem daunting at first, so suggest clients begin with supervised bodyweight and/or isometric exercises/ static holds. As tolerance and confidence increase, trainers can move clients through larger ranges of motion, adding weight and/or other more advanced exercises to create a consistent challenge.

References:

https://www.onepeloton.com/blog/quadratus-lumborum-stretches-exercises

https://www.physio-pedia.com/index.php?title=Quadratus_Lumborum_Syndrome&veaction=edit&section=4

https://www.physio-pedia.com/Quadratus_Lumborum

https://www.ncbi.nlm.nih.gov/books/NBK535407

https://www.progressive-pt.com/blog/blog-post-title-three-l9hds

https://www.hingehealth.com/resources/articles/quadratus-lumborum-pain/#:~:text=1.,stiffness%20and%20soothe%20back%20discomfort.

https://blog.elitemedicalsupply.com/quadratus-lumborum-syndrome-an-overlooked-cause-of-back-and-hip-pain#:~:text=Quadratus%20Lumborum%20Syndrome%20happens%20when,for%20long%20hours%20without%20breaks

https://pubmed.ncbi.nlm.nih.gov/40629164

https://pubmed.ncbi.nlm.nih.gov/36483943