Acupuncture for Quadratus Lumborum Trigger Points
What is the QL?
The quadratus lumborum muscle (QL muscle) is a low back muscle that connects the lumbar spine and 12th rib to the hip. Due to it’s location, the QL is often involved in cases of low back pain. It serves to stabilize the lumbar spine, hike the hip up, laterally flex the spine, and help with forced exhalation like coughing or sneezing.
QL muscle pain can cause pain similar to radicular pain from the low back. Trigger points in the gluteus minimus often form along with QL trigger points and extend the referral pain down the side of the leg.
QL pain can feel very intense and mimic disc issues in the low back, trochanteric bursitis in the hip, and sacroiliac joint pain (SI joint).
Read more to learn about the quadratus lumborum, and how QL muscle tightness can lead to trigger points and low back pain.
Origin and insertion of QL muscle
The quadratus lumborum muscle originates along the posterior iliac crest. It inserts along the last rib (12th rib) and the transverse processes of the 1st through 4th lumbar vertebrae.
Based on the origin and insertion of the QL muscle, we can see that it pulls the back of the hip and low back closer together. QL tightness can make it difficult to bend or twist from the low back.
The QL muscle has three distinct fiber directions:
Iliocostal fibers: vertically from the 12th rib down to the crest of the ilium and the iliolumbar ligament.
Iliolumbar fibers: diagonally from the transverse processes of L1-L4 to the same iliac attachment below. These fibers are less in number and extend medial to the iliocostal fibers.
Lumbocostal fibers: Diagonally from the 12th rib to the spaces between L2-L4 or L5 for some people. The QL muscle has the least of these fibers and they crisscross with the iliolumbar fibers.
Actions of the Quadratus Lumborum muscle
Unilaterally - The QL laterally tilts or elevates the pelvis (lifts the hip up)
Unilaterally - The QL laterally flexes the vertebral column to the same side (side bend)
Bilaterally - The QL fixes the last rib (12th rib) during forced inhale or exhale
Bilaterally - The QL helps to extend the vertebral column
When we think of moving the QL we can think of lifting our hip up toward our shoulder or hiking our hip up. Tightness in the QL can lead to a tight low back.
Source: Biel, A., & Dorn, R. (2010). Trail guide to the body: A hands-on guide to locating muscles, bones and more. Boulder, CO: Books of Dicovery.
Quadratus Lumborum Trigger Points
Quadratus lumborum trigger points are very common in cases of low back pain. Travell and Simons refer to the QL muscle as the “joker of low back pain” and the “hip hiker.'“
Quadratus lumborum pain is often caused by four trigger point locations. Two of the QL trigger points are more lateral and superficial, while the other two are deeper and more central, closer to the spine.
Due to its referral patterns, QL muscle tightness can look like other types of pain including sacroiliac joint dysfunction, lumbar or sacral ligament pain, or hip bursitis. Low back tightness can lead to trigger points in the QL which restricts movements like bending and twisting.
These trigger points can be the source of intense pain and can be mistaken for low back issues which don’t resolve after surgical intervention.
Associated trigger points include the internal and external obliques, psoas major, erector spinae, and rectus abdominis muscles.
QL trigger points can also be involved in cases of sciatica with the gluteus minimus muscle. Together, these muscles can cause low back pain and create pain that mimics true sciatica due to a disc issue. Deactivating these trigger points together can eliminate both sciatica pain and low back pain.
Signs and Symptoms of QL trigger points
Acute low back pain
Pain when sitting or standing
Persistent deep ache and pain when at rest
Hip pain sensitive to the touch
Difficulty rolling over in bed
Difficulty climbing stairs
Pain when coughing or sneezing
Unable to turn or lean to the opposite side and may walk bent over
A strange one, but not so funny when it’s happening: may need to crawl to the bathroom when getting out of bed
What causes quadratus lumborum trigger points?
A lower length discrepancy - either structural or functional
Lifting things awkwardly - especially while bent with a twist
Carrying children or heavy things on one side of the body
The nervous system’s “fight or flight” response which causes tightness in the low back in order to mobilize a response to a threat
Shoveling (because it involves bending and twisting)
Poor posture that involves twisting or bending to one side for long periods of time
Sudden trauma like a car accident or a fall
It is common for QL trigger points to form when performing activities that involve simultaneous bending over and reaching to one side to either lift or pull something - like shoveling, yard work, playing with children, playing sports like hockey, or moving heavy things.
The quadratus lumborum can get overloaded if it has to compensate for weak hip abductor muscles like the gluteus medius or gluteus minimus muscles. This can put excess strain on the QL while walking and then lead to the formation of QL trigger points.
Issues with foot mechanics that can cause gait issues can also lead to muscular overload in the low back. The QL tends to be affected by gait issues which can also lead to the formation of trigger points here.
Quadratus Lumborum Trigger Point Locations
QL trigger point #1 (superficial) - refers pain to the iliac crest, lower quadrant, and upper aspect of the groin above the inguinal ligament
QL trigger point #2 (superficial) - refers pain to the greater trochanter and outer part of the thigh
QL trigger point #3 (deep) - refers pain to the sacroiliac joint (SI joint)
QL trigger point # 4 (deep) - refers pain to the lower buttock
How can acupuncture release QL trigger points?
Trigger point acupuncture and dry needling can provide a quadratus lumborum release by identifying the taut bands of muscle that create the pain referral pattern and eliciting a twitch response to relax the muscle to restore function, improve range of motion, and reduce pain.
Identifying trigger points and providing QL muscle release with acupuncture and dry needling is one of the most effective ways to relieve pain in this muscle.
Other modalities like electroacupuncture, cupping, gua sha, and tui na can also help with low back tightness and QL trigger points. Acupuncture and cupping for low back pain are commonly used together in intense cases of QL pain.
Other muscles involved in low back pain:
Gluteus medius - weakness or trigger points in this muscle can cause the QL to be overloaded
Multifidi - these trigger points can refer pain to the buttock area and SI joint
Iliopsoas - may refer pain up and down the lumbosacral spine rather than across the back.
Longissimus thoracis - may refer pain down the back to the SI joint area and buttock
Rectus abdominis - may refer low back pain across the low back at the level of the sacroiliac joints.
Iliocostalis thoracis - these trigger points can refer pain to the buttock area and SI joint, as well as up toward the back of the shoulder
Iliocostalis lumborum - may refer pain to the mid-buttock area and low back.
Travell, J. G., Simons, D. G. (1993). Myofascial pain and dysfunction: The trigger point manual (Vol. 2). London: Lippincott Williams & Wilkins.
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