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Atlas · Lower Back

Quadratus Lumborum

Quadratus lumborum, or QL, is a deep muscle between the pelvis and lowest rib that contributes to trunk and pelvic control. It may be tender during a back-pain episode, but no single stretch, side-bend test or tender point proves that it is the pain source. Flank pain with urinary symptoms or fever needs a different assessment.

Quadratus Lumborum
Body region
Lower Back
Trigger points
4
documented in this muscle
Common symptoms
4
patterns cataloged
Contributors
4
Factors to assess

Muscle overview

Symptoms and first steps

Practical first steps

  • Keep comfortable daily activity and use shorter bouts if a task flares symptoms.
  • Try small easy trunk movements, then build carrying and lifting from a tolerable starting load.
  • Avoid deep ball pressure into the flank, forceful side-bending stretches and self-prescribed heel lifts for apparent pelvic tilt.

When to seek assessment

  • Seek emergency care for new bladder retention or loss of control, saddle numbness, or rapidly progressive leg weakness. New foot drop or persistent numbness needs prompt assessment.
  • Seek urgent assessment for flank pain with fever, vomiting, blood in the urine or painful urination.
  • New severe pain after trauma, inability to function, unexplained systemic symptoms or progressive unrelenting pain needs medical assessment.

Use bending, carrying, getting up and rolling in bed as measurable functions. “QL tightness,” pelvic asymmetry and a weak side plank are not stand-alone diagnoses or reasons to prescribe a heel lift.

Examination, palpation and treatment evidence

Illustrated overview

Quadratus Lumborum

Blue highlights the muscle. Crosses mark representative trigger-point sites; shaded areas show possible referred pain. These examples do not correspond one-to-one with the numbered points below. Patterns vary and cannot diagnose the cause of pain.

Illustrated overview

Quadratus Lumborum · Anatomy and referred pain 1

Representative source regions. The illustrated markers and pain pattern are not individual assignments to the numbered trigger points.

Open full-size image

Trigger points

1. TrP1

Location. Lower back, sides of spine

Trigger point map
Quadratus Lumborum — Quadratus Lumborum · Trigger-point examples 1Open full-size image

Regional muscle reference; this is not an individual map of the selected numbered trigger point.

Referred pain map
Quadratus Lumborum — Referred pain mapOpen full-size image

Regional muscle reference; this is not an individual map of the selected numbered trigger point.

Pain referral. Lower back, hip, buttock

Pain Pattern

  • Lower back
  • Iliac crest
  • Hip
  • Buttock
  • Groin
  • Outer thigh

What This Pain Feels Like

May change with position or loading; this regional complaint has muscular, spinal and non-musculoskeletal causes. These are useful repeatable tasks for judging whether care improves daily movement.

What Patients Report

  • Deep lower back ache
  • Pain when standing from sitting
  • Hip pain
  • Difficulty turning in bed
  • Pain with cough or sneeze

What Makes It Worse

  • Standing from sitting
  • Bending to side
  • Coughing/sneezing
  • Prolonged sitting
  • Lifting
  • Twisting
Browse related exercises (7)

Symptoms patients report

One-sided waist or low-back ache May change with position or loading; this regional complaint has muscular, spinal and non-musculoskeletal causes.

Pain with turning in bed or standing up These are useful repeatable tasks for judging whether care improves daily movement.

Discomfort with side bending or carrying These tasks load several trunk muscles and joints, so symptom reproduction is not specific to QL.

Flank discomfort New severe flank pain, urinary symptoms, fever or feeling unwell should not be attributed to a back muscle without assessment.

Contributors to assess

An unfamiliar lifting or carrying demand More load, repetition or duration than usual may provoke a back-pain episode without proving tissue damage.

Long periods in one position Vary positions according to comfort; there is no universally correct sitting angle that prevents QL pain.

Reduced movement confidence or capacity Gradual practice can rebuild tolerance after pain or inactivity without labeling the spine unstable.

Poor sleep and ongoing stress These may influence pain and recovery and are worth addressing alongside physical activity.

For clinicians and supervised training

Clinical reference

Use the map to orient the examination; record the actual familiar pain distribution alongside movement, loading and neurological findings.

Anatomy and palpation

Anatomical relationships

QL forms part of the posterior abdominal wall. Its attachments include the iliac crest and iliolumbar ligament, lumbar transverse processes and twelfth rib. It contributes to lateral trunk control, extension and stabilization of the last rib during breathing.[8]

  • The iliac crest forms the lower boundary of the region.
  • The twelfth rib is the upper bony reference; it can be short and is not a target for forceful pressure.
  • QL lies deep and lateral to the lumbar extensor mass, not as a superficial cord beside the spine.

Nearby structures. Kidneys and retroperitoneal structures lie anteriorly; the subcostal region, nerves and pleural reflection near the last rib make deep pressure or blind invasive treatment inappropriate for self-care.

Palpation

Patient position. Side-lying with the waist and legs supported, or prone with a comfortable abdominal support, after screening non-musculoskeletal flank symptoms.

Find the landmarks

  • Identify the iliac crest and lower rib gently; locate the lateral edge of the lumbar extensor mass.
  • Keep the distinction between a regional deep tenderness finding and a confidently isolated QL band.

Examination sequence

  1. A trained clinician uses broad graded contact in the posterolateral waist, allowing normal breathing and asking about familiar symptoms.
  2. Compare light contraction during a small pelvic hike or side bend with relaxation; this helps regional orientation but cannot isolate deep fibers.

Document the findings

  • Record the location and familiarity of tenderness, whether it is local or referred and whether a functional task reproduces it.
  • Muscle tenderness can accompany nonspecific back pain without identifying a unique treatable lesion.

Limits and precautions

  • Do not push under the last rib or deeply into the abdomen or flank.
  • Stop for sharp abdominal/flank pain, nausea, radiating symptoms or breathing difficulty.
  • Palpation is not a kidney screen and does not confirm pelvic misalignment or vertebral instability.
[8][3]

Examination and tests

3

Lumbar movement and symptom-response assessment[7][4]

Identify useful movement limitations and whether symptoms behave as a regional mechanical back complaint.

Position
Standing near support, then another comfortable position if needed.
Technique
Compare slow flexion, extension and side bending within tolerance. Record movement range, familiar pain and whether symptoms remain local or spread. Repeat only a tolerable movement to observe consistency.
Positive finding
A reproducible restriction or familiar symptom change relevant to the presenting complaint.
Interpretation
Helps select and monitor movement practice; distal symptom spread changes the assessment priority.
Limitations
Side-bending pain is not a QL-specific test. It loads joints, discs, nerves and multiple muscles; no diagnostic cutoff for QL trigger points is established.

Modified side-support endurance task[4][8]

Establish a repeatable lateral trunk loading baseline.

Position
Side-lying on a padded surface with knees bent and elbow beneath shoulder, only if shoulder and hip tolerate it.
Technique
Raise the pelvis for a brief comfortable hold while breathing. Compare quality, symptoms and hold tolerance on each side; stop before form fails or pain rises. Use a standing wall-supported version if floor loading is too demanding.
Positive finding
The usual pain, early loss of position or a meaningful side-to-side difference in tolerated effort.
Interpretation
Identifies a functional training target; document whether the limit was back pain, shoulder discomfort, balance or general fatigue.
Limitations
This is a functional task, not a validated QL diagnostic test. Many trunk and hip muscles contribute; asymmetry does not establish pathology.

Lower-limb neurological and neural-tension screen[7][5]

Check for nerve involvement when back pain spreads to the leg.

Position
Seated or supine for strength, sensation and reflexes; supine for gentle straight-leg raise if indicated.
Technique
The clinician compares dermatomal sensation, myotomal force and reflexes, then assesses familiar leg symptoms during gentle neural loading in the context of lumbar movements.
Positive finding
Objective neurological change or familiar radiating pain consistent with the history.
Interpretation
Supports further lumbar/peripheral nerve assessment rather than a QL-only plan.
Limitations
No single neural test proves the anatomical site; a normal examination does not establish a muscular diagnosis.

Distinguishing other causes

Renal infection or ureteric stone[9][10]

Findings that matter. Flank pain with fever, urinary burning, blood in the urine, vomiting or severe waves of pain toward the groin.

Next step. Arrange urgent medical assessment; do not attempt to massage away flank pain.

Lumbar referred pain or radiculopathy[5][7]

Findings that matter. Back and leg pain changed by lumbar movement, especially with sensory loss, reflex change or weakness.

Next step. Perform a lumbar and neurological examination and escalate progressive deficits; imaging is based on likely impact on management.

Hip or gluteal tendon disease[6]

Findings that matter. Groin pain with passive hip restriction or focal trochanteric pain with side-lying and abductor loading.

Next step. Examine the hip joint and tendons rather than assuming distant QL referral.

Sacroiliac-region pain[7][6]

Findings that matter. Pain near the posterior pelvic joint provoked by specific transfers or weight bearing can overlap with lumbar and hip conditions.

Next step. Use a regional examination and, when appropriate, a clinician-performed cluster of pain provocation tests. Visual pelvic tilt or isolated tenderness does not diagnose joint displacement.

Treatment selection and progression

Clinician-delivered care

Dry needling as a short-term adjunct for chronic low-back pain[4]

Consider when. Assessed chronic low-back pain when short-term pain relief may support exercise and activity.

A trained clinician selects a lumbar muscular target after regional and neurological assessment. Use DN alongside active care; surface tenderness does not determine deep needle placement.

Dose and review
An individualized, time-limited trial; the guideline does not establish an isolated-muscle dose or mandatory course.
Progression
Compare walking, transfers or carrying over days to weeks and discontinue if tenderness changes without useful activity gains.
Stop or reassess
Stop and reassess new leg weakness, numbness, infection signs or sustained worsening.
Evidence and limits
The 2021 low-back guideline permits considering DN with other treatments for short-term pain and disability relief. This is regional evidence; it does not show isolated quadratus lumborum treatment restores muscle activation or provides durable benefit.

Clinician-delivered care

Radial shockwave for an assessed QL myofascial presentation[1][2]

Consider when. Persistent low-back pain with a clinically concordant QL presentation after flank, hip and neurological causes have been considered.

A clinician localizes the posterior abdominal-wall target and reviews nearby rib, renal and neurovascular structures before selecting exposure. Pair symptom relief with tolerable activity.

Dose and review
The small RCT reports five sessions but contains conflicting timing descriptions; no session schedule or device settings are adopted here.
Progression
Recheck pain with transfers, walking and carrying in 2–4 weeks; judge function before further sessions.
Stop or reassess
Reassess urinary/systemic symptoms or new neurological deficits instead of repeating local treatment.
Evidence and limits
A 54-person comparison favored corticosteroid/lidocaine injection for early pain/disability measures at 2 weeks, and ESWT for disability/quality of life at 4 weeks. No sham and short follow-up limit confidence. A separate 30-person retrospective study favored ESWT for pain, with no disability difference.

Self-care and activity

Maintain activity with manageable task doses[5][4]

Consider when. Assessed nonspecific back pain without red flags.

Choose a useful activity such as walking, cooking or a short work task. Break it into comfortable bouts and vary position. Spread a large carry across smaller loads close to the body.

Dose and review
Example: several brief walks or task bouts across the day, starting below the duration that produces a sustained flare; no QL-specific schedule is validated.
Progression
Add a little time or load after several tolerable exposures, keeping the next-day response in view.
Stop or reassess
Reassess for new leg weakness, spreading neurological symptoms or systemic/flank symptoms.
Evidence and limits
Regional back guidelines support active self-management. They do not establish that a particular posture or carrying technique prevents QL trigger points.

Exercise and rehabilitation

Explore comfortable trunk motion[4]

Consider when. Movement-related stiffness when small motions are comfortable.

In sitting or standing with support, slowly bend a short distance to either side and return. Alternatively use a small hands-and-knees rock-back if knees and wrists tolerate it. Choose the motion that improves ease rather than forcing a stretch.

Dose and review
Example: 5 slow repetitions once or twice daily; this is an extrapolated regional rehabilitation option, not a validated QL treatment dose.
Progression
Build range gradually, then connect the movement to a task such as reaching or getting up.
Stop or reassess
Stop the direction that causes sharp pain, spreading leg symptoms or a lasting flare.
Evidence and limits
Movement practice may support activity and confidence. No evidence here shows that isolated QL lengthening corrects a pelvic fault.

Exercise and rehabilitation

Build lateral trunk endurance[4]

Consider when. A person ready to add loading who finds carrying or prolonged standing difficult.

Begin with a standing side support: forearm on a wall, step the feet slightly away and hold the body in a comfortable line while breathing. A clinician can progress to a knee-supported side bridge if the hip and shoulder tolerate it.

Dose and review
Example: 3 holds of 5–10 seconds per side on alternate days. It is not a trial-validated QL-specific protocol.
Progression
Increase comfortable hold time before lever length or external load, and then practice a light carry relevant to daily life.
Stop or reassess
Reduce effort if symptoms remain worse the next morning; stop for radiating pain or shoulder/hip pain that changes the movement.
Evidence and limits
Regional trunk-strength and endurance exercise is supported for some back-pain presentations. Side supports recruit many muscles and do not isolate QL.

Clinician-delivered care

Regional massage for chronic low-back pain[11]

Consider when. Assessed nonspecific chronic low-back pain with a defined walking, bending or sit-to-stand limitation; evidence is regional rather than an isolated muscle diagnosis.

In comfortable prone or side lying, the clinician may use slow gliding or kneading over accessible posterior lumbar tissue, then repeat the chosen activity. This contact choice is a clinical adaptation of regional massage. Deep abdominal or flank pressure is unnecessary; superficial tenderness does not confirm an isolated quadratus lumborum source.

Dose and review
The trial used ten weekly visits: 75–90 minutes initially, then 50–60 minutes. Use this as a studied reference; agree a limited course with early review of disability and daily activity.
Progression
Record the chosen activity and a disability measure, and continue only when relief carries into daily function. Use the easier movement window to practise tolerable activity.
Stop or reassess
Stop persistent symptom aggravation or repeated care without useful functional improvement. New leg weakness, spreading numbness or other neurological change needs reassessment.
Evidence and limits
In 401 analyzed participants, relaxation and structural massage improved Roland disability scores by 2.9 and 2.5 points over usual care at ten weeks. Function differences were smaller at 26 weeks, while symptom differences were not significant at 26 or 52 weeks. Structural massage was not meaningfully better; the study did not isolate a lumbar muscle.

Reassessment and follow-up

  • Select two tasks such as rising from the same chair, rolling in bed, carrying a light bag or walking; track pain and ease under similar conditions.
  • Record pain distribution and any neurological or urinary changes, not just a pain score.
  • Repeat a tolerable trunk movement or endurance task with the same support and position; interpret changes as regional function.
  • If an agreed active-care trial produces no functional progress, reconsider the diagnosis, activity dose, sleep and recovery barriers; do not simply increase pressure.

Evidence and sources

  1. Eftekharsadat et al. Comparison of efficacy of corticosteroid injection versus extracorporeal shock wave therapy on inferior trigger points in the quadratus lumborum muscle

    2020 · Randomized clinical trial

    54 patients with chronic low-back pain and inferior QL points; radial ESWT versus corticosteroid/lidocaine injection, with advice/stretching. Short follow-up and inconsistent timing descriptions prevent adopting its schedule as a protocol.

  2. Hong et al. Extracorporeal Shock Wave Therapy Versus Trigger Point Injection in the Treatment of Myofascial Pain Syndrome in the Quadratus Lumborum

    2017 · Retrospective comparative study

    Retrospective comparison of 30 patients; greater pain improvement with ESWT, no clear disability difference. Nonrandom allocation limits causal inference.

  3. International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study

    2018 · Expert Delphi consensus

    Expert criteria and familiar symptom recognition; no diagnostic gold standard or fixed referral map.

  4. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

    2021 · Clinical practice guideline

    Regional low-back rehabilitation recommendations; does not validate isolated QL dysfunction or a QL-specific exercise dose.

  5. Low back pain and sciatica in over 16s: assessment and management

    2020 · Clinical practice guideline

    Assessment, continued activity, selective imaging and manual therapy within an exercise package.

  6. Hip Pain in Adults: Evaluation and Differential Diagnosis

    2021 · Professional clinical review

    Regional hip, lumbar and posterior buttock differential; examination findings must be interpreted together.

  7. Approach to Musculoskeletal Examination

    2021 · Clinical examination textbook

    Regional examination techniques; general movement and strength findings are not trigger-point diagnostic tests.

  8. Anatomy, Abdomen and Pelvis, Quadratus Lumborum

    2024 · Clinical anatomy reference

    Posterior abdominal-wall anatomy and adjacent structures; not evidence of a diagnostic QL palpation test.

  9. Kidney infection

    2025 · NHS patient guidance

    Urinary and systemic symptoms requiring medical assessment.

  10. Kidney stones: Symptoms

    2022 · NHS patient guidance

    Flank/groin pain, vomiting and urinary warning signs.

  11. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial

    2011 · Randomized trial

    401 analyzed participants with nonspecific chronic low-back pain; ten weekly relaxation or structural massage visits versus usual care. At ten weeks, Roland disability scores favored massage by 2.9 and 2.5 points respectively. Function differences were smaller at 26 weeks; symptom differences were not significant at 26 or 52 weeks. No isolated QL, erector spinae or multifidus effect.

Associated Trigger Points