Most therapists or physicians have encountered the otherwise healthy patient with an episode of severe and unexplained low back pain. Often accompanied by an alarmed relative, the patient usually feels that a “kidney” ailment or worse is to blame. It usually turns out that the cause may be much more benign. An active trigger point in the quadratus lumborum muscle (QL) is often the source of pain. The increased activity in these focal points within the muscle may result from sustained poor posture such as bending and twisting while lifting, running on a sloped surface, or sleeping on a sagging and unfamiliar mattress.
As per Travell and Simons, myofascial trigger points are present in the majority of musculoskeletal pain disability cases. Their exact cause is unknown, but they are highly irritable circumscribed focal points of pain within the muscle or fascia that come to light with seemingly routine physical activity. In the case of QL, the underlying activity is often related to posture, given that this muscle is prominent in our normal upright posture. This muscle has three distinct parts which act as guywires for the lumbar spine maintaining spinal postural alignment for both trunk and extremity movements. Trigger points in this muscle are deep to the lumbar paraspinals and may go undetected with a superficial palpation of the back. Approaching the muscle in side-lying will more readily reveal the active QL trigger point(s).
Along with the extreme pain, the patient may report pain with coughing and sneezing with a need to support the trunk with the hands when walking or sitting. Practitioners are often concerned with the possibility of a protruded lumbar disc since pain may radiate to the groin, and even mimic a sciatic nerve distribution. Signs and symptoms may also resemble trochanteric bursitis. With the absence of any positive nerve irritability signs, treatment can proceed by directly addressing the trigger point from a side-lying position ensuring that the patient’s posture and activities do not result in further irritation of the trigger point. Postural correction, local therapies such as electro-therapy and manual therapy will be useful. However exploring the patient’s typical activities will offer clues as to how best prevent recurrence. Additionally, treatment for the contralateral side as well as for “satellite” trigger points in the gluteus medius is highly recommended. When the trigger point becomes less active treatment should be rounded off with conditioning to core and hip muscles.
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