Quadratus Lumborum

Clinical Notes

• One of the most common muscular sources of conditions/low-back-pain — QL pain is typically unilateral, deep, and poorly localized. Clients often describe it as a "deep ache" in the flank region that worsens with prolonged sitting or standing, transitions from sit-to-stand, and rolling over in bed.
• The QL is a major contributor to pelvic obliquity — unilateral QL shortening hikes the pelvis on that side, creating a functional leg length discrepancy. This can produce compensatory patterns throughout the kinetic chain: contralateral pelvic drop, lumbar scoliosis, and altered gait mechanics.
• Involved in conditions/facet-joint-syndrome — QL hypertonicity increases lateral compressive forces on the lumbar facets on the ipsilateral side.
• Respiratory connection — QL stabilizes the 12th rib for the diaphragm. In clients with compromised respiration (COPD, asthma, chronic anxiety with diaphragmatic dysfunction), QL may be chronically overloaded from respiratory accessory work.

• QL is hypertonic in a large percentage of low back pain presentations, yet students rarely assess or treat it directly because it is deep and not taught with the same emphasis as the erector spinae. Palpation typically produces an immediate recognition response from the client — "That's it, that's the spot."
• Unilateral QL hypertonicity is more common than bilateral. Check for pelvic height asymmetry (iliac crest height in standing) as a screening indicator — the high side is the hypertonic QL side.

• Responds well to sustained compression and stripping along the fiber direction (12th rib to iliac crest). Side-lying is the optimal position because the top arm can be reached overhead to open the QL space.
• Post-treatment, pelvic height often equalizes visibly — the previously elevated iliac crest drops to a level position. The client typically reports immediate relief of the deep unilateral ache.
• QL spasm can be dramatic — in acute cases, the client may be laterally shifted (leaning away from the painful side) and unable to stand upright. Acute QL spasm requires gentle, gradual treatment over multiple sessions.

• The kidneys lie anterior to QL — the costovertebral angle is directly over the kidney. Deep percussion at the costovertebral angle should not reproduce QL-type pain; if it does, consider renal pathology (infection, calculi) and refer for medical evaluation.
• The subcostal nerve (T12) and iliohypogastric nerve (L1) pass through or near the QL. Deep sustained pressure can irritate these nerves, producing radiating pain or numbness along the anterior lower abdomen or groin.
• The 12th rib is a free-floating rib and can be fractured with excessive focal pressure. Use broad contact (thumb pad, not thumb tip) when working the 12th rib attachment.

• If piriformis release does not hold between sessions, check the contralateral QL. Unilateral QL shortening creates pelvic obliquity — the pelvis drops on the contralateral side, forcing the piriformis on that side to overwork as it attempts to stabilize the SI joint against the pelvic drop. Treating the piriformis without correcting the QL-driven pelvic obliquity ensures the piriformis will tighten again. Always think one step up the chain.