Rob Zukowski is a New York State LMT, certified by the National Certification Board for Therapeutic Massage & Bodywork, a Certified Medical Massage Therapist and holds a degree in Occupational Studies, with a focus on massage therapy, from the prestigious Swedish Institute College of Health Sciences. He has advanced training in sports massage, various relaxation therapies, and training in multi-therapeutic approaches to massage for oncology.

In addition to private practice, his experience includes being a massage therapist, lead therapist and member relationships manager in assorted fitness centers, spas, clinics and holistic healing settings and working in corporate wellness environments. Rob also works as a client services manager at a healing center, authors his own column on the subject of complementary and alternative medicine in a national HIV/AIDS magazine, works in student outreach and lectures on therapeutic massage for various pathologies.

Wednesday, February 17, 2016

Low Back Pain: Quadratus Lumborum

Low back is a common complaint among people who seek out massage therapy. With the complex anatomy of the back, coupled with daily wear and tear, any number of muscles could be responsible for what ails you.

Often times, when a client complains of low back pain, the erector spinae group of muscles is targeted. This is a complex group of muscles that, very generally speaking, run from the sacrum and lumbar spine area to the neck and the base of the skull. The iliopsoas muscle, which is actually made up of two separate muscles located in the anterior of the hip area, may also be the culprit. Indeed, these are an excellent muscles to target and consider when a clients chief complaint is lower back pain. But, one particular muscle, sometimes overlooked, called Quadratus lumborum, or “QL” for short, is often a source of lower back pain. To provide an idea of where a muscle "lives" inside you, I like to discuss the origin(s) and insertion(s) of muscles. That being said, anatomists will often disagree about the pin point accurate origins, insertions and actions  of certain muscles. QL is one of those sometime debated muscles. QL originates on the pelvis. More specifically, on the posterior lip of the iliac crest of the illiim. It is also said that QL, in part, originates on the illiolubar ligament. It runs on an upward, sightly medial trajectory from its origin(s) and inserts onto both the transverse processes ( bony protrusions on either side of a vertebra) of the lower lumbar vertebrae, approximately  L4 through L5, depending on what book you read or who you ask, and on the lower border of the 12th rib.

QL is a hard working, busy muscle. It performs a number of common actions. When the muscle contracts ipsilaterally,  meaning either only the muscle on the right side or left side is contracting at once, QL performs lateral flexion of the lumbar spine, or bending the trunkk of your body to one side. Additionally, when only one side contacts at a time, QL “hikes” the hip. With bilateral contraction, meaning both the right and left muscle contact at once, QL extends the lumbar spine, or helps us to stand up straight. Not only does it help to bring us to an erect position, but it keeps us there, making it a postural stabilizer. A lot of pressure is put on QL as not only does it help to keep us upright, but it is located in an area of the body that takes the brunt of our upper body weight. It is also said, by some anatomists, that when contracted, QL, holds the last rib in place, or fixes the last rib by its contraction. It therefore acts as a muscle of inspiration (inhalation) by helping to stabilize the lower attachments of the diaphragm. It is also a common area for trigger points (deep, hyperirritable bands of tissue)

Pain from QL is generally deep, dull, and achy, but it may be sharp during movement. If you are suffering from low back pain related to QL there are certain symptoms you may note such as pain when you are in an unsupported, upright position, pain on only one side of the lower back, a feeling of restriction in your spine,  pain when rolling to either side while lying down,  pain that seems to travel towards the pelvic, gluteal and groin region, or pain felt along the crest of the ilium (pelvis). Tenderness may be felt in the greater trochanter (mid, lateral hip). Coughing and sneezing can be painful.

What causes pain in QL? Many of the usual suspects, such as sleeping on a mattress that is too soft, lifting heavy objects, a frequent seated position, twisting as you lift or a slip or fall. Horseback riding, golfing and kayaking are also hard on QL. In addition, a discrepancy between the length of your legs – one leg shorter than other - can be a cause. This, of course, can be natural, born occurrence or due to injury. It is also often seen after a leg has been in a cast or splint. Dysfunction in QL may arise from labored breathing, weakness in gluteus medius, or imbalances in other postural muscles.  Tightness in this muscle contributes to excessive lumbar lordosis and anterior pelvic tilt and may cause trigger point referral pain in the gluteus minimus and cause it to refer its pain down the leg and mimic sciatica. It is said that QL dysfunction may be the cause of non-congenital scoliosis. 

From a fitness standpoint some exercises that target QL are side planks, side bridges (a more dynamic version of the side plank), and asymmetric kettle bell carries. In fact, asymmetric kettle bell/weight carries target challenge the QL muscles on opposite side because they are working to keep your spine straight. But in general, any exercise, such as lifting, that stresses the low back or twists the spine will have an impact on QL. 
Common techniques for relieving pain in QL include muscle stripping, which is a deep pressure applied along the muscle fibers from origin of the muscle to insertion, ischemic compression, or deep pressure, to release trigger points within the muscle and passive stretching of the muscle. Personally, I like to employ the use of heat prior to bodywork and stretching to make the tissue more malleable.

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