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Quadratus Lumborum Knotted Up

I recently hurt my low back, maybe about a month ago, doing a bent over row at 135. I had been airporting and figured hip flexion for hours did it. My core just shut off and a few compensations later, i couldn’t bend over without some pretty substantial pain.

I’ve been SMR’ing and dynamically stretching, ending workouts with static stretches.

I have a unilateral quadratus lumborum knot that has been breaking up and reforming. I’m assuming this has something to do with a tight hip flexor (iliopsoas) on the same side. I’ve been pushing my core strength and glute activation the last couple weeks.

What I’m curious about is how my hamstrings/quad dominance play into this. I’ve been strengthening my abductors but just recently added in hamstring (isolated) strengthening. They were sore to the touch for a couple days, so I’m thinking they are really weak. Thinking they’re tight too. ROM is up to about a 90 degree hip flexion.

Could hamstring weakness and tightness majorly play into my QL/low back pain? Should I avoid lower back exercises to reduce the effects of lower-crossed syndrome? so many questions…

That is definitely a lot of questions going in multiple directions.

When you say “knot” can you feel a bulge or do you just feel the sensation of a cramp? What type of pain is it and exactly what movements cause the pain? Also is this “knot” close to the anterior or posterior side of your body? I am asking because it’s common to mistake QL pain for an external oblique or even part of the erector spinae group. You very well could have hurt the QL but it’s important to narrow it down if you want to attempt to rehab it and find the culprit. Another possibility could be the Latissumus Dorsi.

I have 3 thoughts and I’m thinking it’s most likely a combination of the 3:

  1. Tight errector spinae (which limits your ability to keep upright posture)
  2. Weak Core (I don’t doubt you have defined abdominals but unfortunately it doesn’t mean they are functionally strong for the amount of posture stability needed to perform bent over rows with heavy resistance).
  3. Weak retractors (particularly rhomboids and middle trapezius).

It’s fairly common to see a push vs pull imbalance in the upper torso in a dedicated lifter. It’s also common to see a flexion vs extension imbalance (in the back and hips) in a dedicated lifter. They tend to have a stronger anterior chain (anterior delts, pecs, quads, iliopsoas, etc) with the exception of the abdominals. Their posterior chain (hamstrings, glutes, erector spinae) are often not able to generate as much force and power and they are also not conditioned enough to maintain good posture and form.

When you are doing bent over rows, your erector spinae (3 long muscles running from the back of your skull all the way down to your pelvis) work to keep your back in extension as well as your spine in good alignment. The exercise you were doing has weight pulling in the opposite direction while your trunk is flexed over your body. This is an incredible amount of force for your erectors to take on.
NOW imagine on top of that you have weak scapular muscles which does not allow for the proper force development to be lifting 135 lbs towards your chest (which involves the middle trap and rhomboids pulling your shoulder blades closer together). If your shoulder blades aren’t retracting to their full capability, that means your lower back muscles do not have a good foundation for force development. They are too busy compensating for the weakness above.

So NOW we come to the QL. Keep in mind, this is a lot of speculating and I am by no means attempting to say this exact chain of events is what caused your QL to ball up in a little fist of fury. But if you are going to attempt to strengthen some possible weaknesses in this situation, the muscles above are what I would focus on. The QL is similar to the erector spinae in that it aids in extending the spine. It is a MAJOR postural muscle. It also is what keeps your pelvis aligned when you walk/run, and provides bilateral flexion of the spine.

One easy way to injure the muscle is if you are positioned in trunk flexion and trying to maintain that posture while bearing a load and turning/twisting. My reasoning for thinking the shoulder retractors may be part of your problem is because once they tire out during your rowing movement (usually one side tires quicker than the other) it’s going to place an imbalance on your spine. What is the first back extensor muscle that will most likely be stressed by this imbalance? The QL. So you might not have felt like you were ACTUALLY twisting while you were doing rows or turning to one side, but the weakness up above was enough to place a different type of force through your QL.

Again, I don’t want to cover every scenario. It could be endless. If you went to a chiro and they told you they thought they new the exact problem (or a PT) they would be full of sh*t. You can’t know exactly what happened, but you can be proactive which you seem to be. Your questions are all important.

So…if I had advice…
I would do a lot of core work (particularly stiffening around the spine and endurance based exercises with breathing). I would stay away from exercises that place your trunk into flexion (ESP CRUNCHES). I would also work on slowly incorporating more retraction exercises for your shoulders to strengthen that area.

Because the QL is a postural muscle, you are always using it. I would stray from any exercises involving side bending for awhile. Isometric holds (like planks) are perfect as long as it does not get noticeably tighter. Working on slow,deep breaths during the plank holds will create a much bigger stiffening affect around your spine than if you were to just hold your breath or breath lightly. If the planks make your QL then just be patient and wait a few days/weeks. It will respond to rest. The one other thing I have found that works wonders on a tweaked back/postural muscle is an E-stim machine. They are anywhere from $30-$1000 dollars if you search online. I picked up a great one on Amazon for 60$ when I pulled an intercostal and couldn’t get the muscle to un-knot and calm down. It helped immensely.

Hopefully some of this is helpful.

[quote]paulclear wrote:

I have a unilateral quadratus lumborum knot that has been breaking up and reforming. I’m assuming this has something to do with a tight hip flexor (iliopsoas) on the same side. I’ve been pushing my core strength and glute activation the last couple weeks.

What I’m curious about is how my hamstrings/quad dominance play into this. [/quote]

Hi Paul. Well, in the body everything affects everything else, for sure. I too have battled with low back pain for many years. One day, my massage therapist alerted me to some knotting in my QL.

LONG-LONG story short, a pelvic alignment issue was behind this. The QL strain was one of many warning signals for me concerning my degrading alignment (too much sitting!). Piriformis strain was another. Weak hip-flexor group. Weak abductors. Tight hamstrings. Glutes turned off. Lumbar curve non-existant. All of this indicated excessive posterior pelvic tilt on my left only. After lots & lots of my time investment I finally figured-out, thru trial and error, how to successfully address this complex problem. Please address your own postural faults NOW, so you can reverse course and avoid progressively worsened form and a greater chance for injury.

Regarding psoas-QL connection (You ARE correct)…
Please read this article http://blog.corewalking.com/next-door-neighbors-psoas-major-and-quadratus-lumborum/

Regarding possible quad dominance…
Have you already read Robertson/Cressey articles? (Read this one again)

Focus on fixing your pelvis, FIRST. You must apply carefully selected exercises with enough intensity, based upon where & how you stand–to get the results you want. Everything else is secondary.

neliah09 = u r a moron.

posture perfect i am sick of you peddling anterior pelvic tilt as the be all and end all of back pain causes.

Wow Neliah09 i really don’t know where to start, you are a wealth of knowledge maybe you could write a book or something…

Seriously please don’t, much of what you wrote was so wrong, please go back to your textbooks or something…

Is your pain anterior or posterior? I assume the OP knows the QL is a superficial muscle of his back, not sure how you could commonly mistake a quadratus lumborum pain for an anterior pain?

No a dedicated lifter works to ensure that they don’t have an imbalance, I’m not sure if you have been around here much but the majority of guys talk about ATG squats and deadlifting like a superhero. I don’t know many who can deadlift and squat fully with a weak posterior chain.

This incredible amount of work you are talking about, lifting 135lbs while bent over slightly is not a lot of weight. If you think it is then you clearly are either 1) a girl and i appoligise or 2) you haven’t been lifting much yourself. If it’s 2 then i wonder if you are qualified to make statements with regards to lifting abilites/techniques etc… I don’t mind a academic talking but only if they talk sense…

Now your accumption that a chiro or PT would be unable to diagnose this condition is fully inaccurate, don’t project your lack of diagnostic abilities onto another professional. They may know exactly what the problem is. You seem to have given a lot of advise to the OP with very little information put forward on his behalf.

I don’t know how you do your planks? But you should be working your abdominals not your back muscles…

And please an e-stim machine?? maybe if you are a PT that graduated 40yrs ago. Seriously OP don’t let someone put a machine on your back like that, it really won’t help. Oh and Nelia if you spent more time actually working on clients backs instead of placing fancy machines on them you might actually diagnose conditions correctly, get some results and not have treatments drag on for weeks with little progress…

Hi OP, my above wouldn’t have helped you much. It will be hard for you to strengthen your glutes and abdominals while your illiopsoas is still really tight. You will have to loosen it first.

Hi Mr Stern,

I must admit I was a bit disappointed in your response. A forum is a great place for people from different backgrounds, levels of professional as well as personal experience, and all types of demographics to collaborate and debate a bit on topics such as the one the OP posted about. However your response was rather negative, shallow, and had no true constructive criticism let alone an idea to offer.

While your questions were mostly aimed in sarcasm, I will try to answer a few of them:

  1. “I assume the OP knows the QL is a superficial muscle of his back, not sure how you could commonly mistake a quadratus lumborum pain for an anterior pain?”

That is a legitimate question and the fact you are so rash to think otherwise tells me that you do not think outside of the box when it comes to interpreting the pathway to an injury. It also tells me you don’t look at people on an individual basis.
I by no means think the OP does not know where his QL is. My main concern was if there is more than one issue to address regarding his pain, which is why I asked the question. Sometimes, the QL is not the muscle that is acutely injured. I cannot count the amount of times I’ve had an athlete come into the clinic who is complaining of significant pain in their side/lower back and often they describe a “knotting”. Many times, via imaging, we have been able to diagnose that while the QL is hypertonic and causing lower back/side pain, the actual ACUTE injury was to an oblique. Depending on the angle of the injury, the athlete does not always feel this. The discomfort they are focused on is the chronic pain/tightness coming from postural muscles (such as the QL) which are now working over time to protect the area. It’s important to catch issues like this early because it will change the rehab process and what muscles you want to stretch and which you want to strengthen.

2.“No a dedicated lifter works to ensure that they don’t have an imbalance, I’m not sure if you have been around here much but the majority of guys talk about ATG squats and deadlifting like a superhero. I don’t know many who can deadlift and squat fully with a weak posterior chain.”

YES, yes they CAN have an imbalance. Out of all of your comments, I think this is the one that let’s me know it’s futile to have an educational conversation with you. Some of the top authors who contribute articles for this website and are also very serious lifters can certainly attest for the fact that EVERYONE has imbalances. I believe the problem is your definition of an “imbalance” is much more negative than the term is meant to be. I am by no means calling any lifter on this forum weak or not dedicated. I would like to think the majority of the TNation population is quite the opposite. I will give you an example…

2 years ago I worked with a top collegiate football player (has since been drafted and went pro). This guy was a great strength and power athlete --power cleaned 365, squatted a hair under 700, benched 495, and was still capable of running a 4.6x 40 yd dash despite his size. He came to us with complaints of chronic lower back and side pain/tightness and also for constantly having hamstring and groin issues. He had already been seeing several PTs who were treating him for an anterior pelvic tilt (which he DID have). However it was not severe and we were not convinced it was his problem. While there was not immediate evidence from his lifts that there was a quad/hamstring imbalance, that was the first suspicion we had. We tested him in an isokinetic machine (2 different ones) and each time find that he had a bilateral imbalance between the quads and hamstrings of 65%:35% respectively. That’s a VERY significant imbalance for an athlete of that level. Did it mean he was weak or not dedicated? NO, OF COURSE NOT. It just meant that at his level of performance, that imbalance was causing him multiple issues. While still working on the ATP, we began specific and individualized strengthening for his lower body. He saw progress within 2 weeks that continued to drastically improve throughout a period of 4 months. If either him or his coaches had tried to argue the point that it was impossible for him to have an imbalance strictly because he was a “dedicated” athlete then he’d most likely still be plagued with the same problems.

  1. “This incredible amount of work you are talking about, lifting 135lbs while bent over slightly is not a lot of weight. If you think it is then you clearly are either 1) a girl and i appoligise or 2) you haven’t been lifting much yourself. If it’s 2 then i wonder if you are qualified to make statements with regards to lifting abilites/techniques etc.”

I don’t see where in my post I said 135 lbs was an extremely heavy load. You are misinterpreting the message I was trying to convey. Not to state the obvious, but muscles are unique from each other in terms of their job due to multiple factors: fiber type, angle of pennation, origin & insertion, length of fibers, etc. When you change the angle at which a load is exerting on a muscle it can drastically change the force applied at the origin or insertion. In the OP’s post, he was describing how he believed bent over rowing was the movement he was doing that originally caused the problem. If you have worked with any type of client regarding back injuries or done ANY research, you would know that over 75% of lower back injuries do not occur due to an acute incident (such as a crash, blow, giant pull, etc). They occur because the person has had an imbalance for a certain period of time, causing microdamage to muscle/connective tissue for an extended period, often going unnoticed, and then there comes a breaking point where the muscle is not able to compensate like before and gives (OFTEN happening under a moderately light load).

Also, I’m not so much concerned with the fact you think it matters if I’m male or female (yes, I am a female), but more so with the matter that you somehow are assuming I am not qualified to give general advice or suggestions as to how to go about dealing with a musculoskeletal concern. I have a masters in Exercise Science, am finishing a degree in Physical therapy, have competed both at the DI-DIII level in the NCAA, and have worked with athletes both on a personal training level and in physical therapy clinics. I also have numerous graduate courses in advanced level biomechanics. Do I think any of this makes me an expert? NO!! Not at all. But I can’t see where in your post you are attempting to be anything other than negative and argue based solely on…well, nothing from what I can gather. Like I said before, that’s disappointing.

This post is already too long. I am not going to bother attempting to acknowledge your next few comments (which carried even less weight than your previous ones). If you’d like to have a constructive discussion with well thought out feedback, I am all for it. I enjoy learning from ideas that others have ( it’s usually where I learn the most). It’s unfortunate you don’t seem to be capable of that.

I will end with one last thought, regarding your unexplained hatred for the e-stim machine. Stim machines are not meant to cure a musculoskeletal or nerve related issue. In regards to the OP, the idea of possibly using an stim machine is on an acute care level. It’s not to solve the issue. It’s to help calm down any surrounding musculature that is hypertonic in nature (he mentioned feeling a knot and had tightness pain). Stim is WONDERFUL for doing this. It can be very difficult to get rid of a knot in a postural muscle that you obviously use every hour of the day unless you are laying flat on your back. They tend to stay chronically tight/knotted and respond poorly to stretching. I’m not only speaking from countless experiences both in an inpatient and outpatient setting, but also from personal experience.

Hi Neliah,
I’m glad you put so much effort and detail into your response. You cleared up any misconceptions documented from your original post. Your original post was vague and you made a lot of assumptions based of very few comments from the OP.

I don’t doubt that it is highly likely that the quadratus lumborum is not the initial area of injury and may just be a secondary complication, for all I know he could even just have a lumbar sprain?
You are saying that frequently athletes where you study come in with a QL type concern and it turns out to be an external oblique. Do you routinely MRI all your patients?

The OP just complained of pain on bending over, and while rowing may be a mechanism for injuring the external obliques he said nothing about pain with rotations and he suggested the pain was his quadratus lumborum. Your post was rather condescending towards him suggesting that the pain may even be coming from his front when he suggested that it was from his back. Obviously posts over the internet are very subjected in nature and accurate diagnosis’s are difficult.

I said all decent lifters work TOWARDS not having an imbalance. Your definition of imbalance was a cooker cutter method from the most basic of text books. Most lifters are aware of such imbalances and therefore tend to be much more complicated. Yes I’m sure you can think of many examples of where correcting imbalances would have appeared to fix the problem and congratulations to you.

There are also examples of people with imbalances such as runners who have no symptoms, correct their imbalances on the advice of the likes of exercise physiologists or PT students and perform considerably worse. In fact many of the best athletes in the world have had such imbalances or technique faults and still destroying everyone else in competition.

Yes changing the angle of a movement will increase the amount of stress on a muscle. That’s right it’s physics. Research states… we can all find percentages in research and pull out the statistics that suit our purpose and then dress them up in a way that makes us look correct.

So you have some degrees and I’m glad you are still learning… Welcome to the internet where anyone can be whoever they want and claim whatever they want.

That’ s right it’s impossible to diagnose a problem immediately??? It’s easy to hide behind expensive diagnostic equipment but just remember as you become reliant on them that even they don’t tell the full story.

I haven’t read all the posts…

I think I might have a similar issue. Best I can figure my QL on both sides is one bunch of tight knots.

I learned about a recruitment / firing test…

Basically you lie on your stomach and try and fire your glutes while allowing your hamstring and lower back muscles to stay relaxed.

I found my lower back muscles would fire before my ass.
I found my hamstrings would fire before my ass.

What that means…

Is that when I’m doing my back squats… My deadlifts… My hip extensions… All those movements where my ass should be the prime mover… My QL (or whatever other lower back muscles) are trying to be prime mover (firing first) which results in them cramping up all tight (owch) and my being prone to lower back overuse injury.

Maybe this helps you. But then again, maybe not…

(I’m currently trying to rehab by way of working on neuromuscular control to have my glutes fire first and my abs get and stay engaged).

that is a very cute cat, Mr. Stern :slight_smile:

Resurrecting this thread…

This is what I think I have - quadratus lumborum or external oblique tightness/knotting.

It’s not a pain, but a bulging sensation on my left lower-to-mid back, side and even front (lower abs).

Spinal flexion and extension does not hurt it - bending forwards and to the side (away from the side with the tightness) seems to give relief.

Would be grateful for some advice on diagnosis and what to do to make it go away.