By Whitfield Reaves
After years of experience, I have come to believe there is nothing more complex to differentiate, diagnose, and treat than low back pain. Western orthopedic evaluation does a great job when there is a disc herniation with a protrusion or fragment lodged on a spinal nerve root. Anything else, in my opinion, is either art or guesswork. I see many patients who have been to numerous physicians, each diagnosing a different cause of pain. Unfortunately, TCM diagnosis is no better. I gave up on treatment based upon the meridian (jing-luo) perspective years ago when Bladder meridian points such as Bl 23, Bl 25, Bl 40 and Bl 60 gave my patients inadequate results. And from an internal organ viewpoint, I have never found treating the Kidney, which controls the lower back, to be clinically reliable.
Back pain is a complicated and comprehensive condition, and it is not the purpose of this article to articulate on the subject. However, I would like to discuss how acupuncture treatment to the quadratus lumborum (QL) muscle is important to consider in any treatment plan for lumbar, sacral, and gluteal pain. While this muscle might not be the entire cause of pain - other points, treatments, and techniques may be necessary - the simple techniques that follow benefit many patients and may serve as an important protocol for acupuncture treatment.
The following is a brief summary of the pain due to quadratus lumborum dysfunction:
Common patient complaints
- Acute back pain and spasm
- Patient may report the spine feels "locked up"
- Pain is often one-sided
- Pain may radiate towards the gluteal region
- Some patients may have chronic QL dysfunction.
- Pain upon palpation at the superior attachment of the quadratus lumborum in the region of the extraordinary point Pi gen, about 3.5 cun lateral to the first lumbar vertebrae.
- Elevated pelvis on the side of pain
- Lumbar region may be slightly flexed laterally to the side of pain (antalgic position)
- Acute injury often accompanied by lifting and twisting movements
- Always differentiate referral pain from lumbar nerve root, as well as consider how the disc or facet joint may contribute.
First, let's review the anatomy, as this is important when it comes time to insert needles. The origin of the quadratus lumborum is along the posterior iliac crest, in the region of the extraordinary point Yao yan. It inserts superiorly on the 12th rib near the extraordinary point Pi gen, as well as at the transverse processes of L1, L2, L3 and L4. It is important to note that the QL is deep to the para-spinal muscles, where the inner and outer Bladder meridians are located.
Important yet elusive, Dr. Janet Travell calls the quadratus lumborum the "joker of low back pain".[i] No major acupuncture points access this important lumbar muscle. From a meridian (jing-luo) perspective, most of the QL is too far lateral to be considered purely Bladder meridian dysfunction. Yet, it is not on the Shao yang surface of the lateral body, and thus Gall Bladder meridian pathology is not definitive.
Acupuncture Treatment and Techniques
The following are several points and techniques to consider in the treatment of the QL muscle. This protocol is organized into four steps, an approach that I use in sports medicine acupuncture. It makes point selection and needle technique simple, logical, and systematic. And it is both easy-to-understand and inclusive for acupuncturists from differing traditions and backgrounds.
Using points and techniques that may have an immediate effect on the patient, such as a decrease in pain or an increase in range of motion.
Yao tong xue
This set of paired points is used for acute lumbar strain/sprain. While Chinese texts frequently mention Yao tong xue, I do not find this point combination works on a high percentage of patients with acute lumbar pain. However, it is certainly worth a try!
Ling gu + Da bai
From the Master Tong system of empirical points, Ling gu and Da bai are recommended for sciatica; the point combination may also benefit back pain due to QL dysfunction.
While empirical points may bring relief, I almost always include points and techniques from Steps Two, Three, and Four.
Using meridian and microsystem points that are NOT located at the site of injury. These are usually distal points, and are chosen based upon the signs and symptoms of the patient.
The Shu-Stream Point Combination
BL 65 affected side + SI 3 opposite side Tai yang pain
GB 41 (or GB 42) affected side + SJ 3 opposite side Shao yang pain
* GB 42 is often more sensitive than GB 41, and should be considered as an alternative shu-stream point for this meridian.
These two protocols utilize BOTH right/left and upper/lower point combining. Tai yang and Shao yang shu-stream points are an important part of the treatment of lumbar, sacral, and gluteal pain.
Traditional Point Categories
GB 34 + Bl 60 He-sea point + Jing-river point
For back and hip pain: This combination includes both Shao yang and Tai yang points, and is generally more effective on the QL patient than the more commonly used formula Bl 40 + Bl 60. I frequently use electrical stimulation between these two points with surprisingly good results.
Using palpation, consider other distal points specific to the needs of the patient. The possibilities are too numerous to list!
Using points that benefit the qi, blood, and the zang-fu organs.
Acute spasm of the quadratus lumborum is usually not associated with internal organ imbalances. In chronic and recurring cases, it would be remiss not to consider the Kidney, which controls the low back. However, the practitioner should also be alert to Liver and Gall Bladder dysfunction, which is probably more common than the Kidney.
Using local and adjacent points at the site of injury: The quadratus lumborum muscle.
The extraordinary point Pi gen
The extraordinary point Pi gen is at or near one of the important trigger points of the quadratus lumborum, and is frequently an ah shi point.[ii] The texts locate Pi gen 3.5 cun lateral to the spinous process of the first lumbar vertebrae.[iii] But don't be concerned if it is located level with L2 or further lateral than 3.5 cun, as there are some variations with this empirical point. Palpation is the key to both its location and successful needling.
With the patient prone (face-down) or side lying (lateral recumbent), start palpating about 4 cun lateral to the spine, approximately level with L1, and immediately inferior to the 12th rib. You should be just off the lateral border of the para-spinal muscles and the outer Bladder meridian. Palpate medially towards the vertebral column until the painful point is found. To repeat, it is deep to the para-spinal muscles. And make sure you press toward the spine, rather than performing the more common perpendicular palpation along these para-spinal muscles and the course of the Bladder meridian. The patient will often exclaim "that's the spot!"
Either position - the prone or lateral recumbent - is acceptable to needling. However, it is important to insert needle with the same angle, direction, and vector that produced the pain during palpation. Patient size will determine the length of the needle to be used, which is usually 2 to 3 inches. After insertion, direct the needle obliquely toward the spine, deep to the para-spinal muscles, until the taut and dense tissue of the QL is reached. Review the anatomy! It is important to avoid deeper insertion into the kidney, the peritoneum, or the pleural cavity.
The motor point of the QL
After finding the point Pi gen, the practitioner should continue to palpate down the lateral edge of the quadratus lumborum muscle. Often, a second point can be found about 1 cun inferior to Pi gen. This is in the region of the motor point of the QL. It is located level with L2, from .5 to 1 cun lateral to Bl 52.[iv]
The combination of the trigger point (Pi gen) and the motor point of the QL is usually successful in relieving pain and spasm of the muscle. Consider electrical stimulation between these two paired points, although some patients do not tolerate such strong stimulation.
The extraordinary point Yao yan
There is often an ah shi point at the inferior attachment of the QL, just superior to the iliac crest. This is the region of the extraordinary point Yao yan, described in the texts as 3.5 cun lateral to the lower border of the spinous process of L4.[v] Keep in mind that the point is just superior to the iliac crest, which is not how it is pictured in Deadman's text.
Needle insertion at Yao yan is much less complex than Pi gen and the motor point. Start with perpendicular insertion, needling up to 1.5 inches, and angle in the direction that pain was produced by palpation. And because the QL inserts along a considerable portion of the iliac crest, point location may vary from the text description. Yao yan can be paired with Pi gen or the motor point, and electrical stimulation considered.
It is not uncommon to complete the needle treatment to the QL with cupping. And if the case is relieved with heat, indirect moxa or thread moxa may be applied.
The gluteus medius and minimus
It should be pointed out that the gluteus medius and minimus muscles are frequently involved with quadratus lumborum dysfunction. Consider one or two sets of paired points in sensitive ah shi points of these muscles. Perpendicular needles are inserted to a depth of 2 to 3 inches, depending upon patient size. Generally, the region of GB 29, the extraordinary point Jian kua ("posterior GB 29"), and the iliac fossa may be considered.
Acupuncturists are always looking to refine their treatment protocol for treating back and hip pain. While the quadratus lumborum might not always be the primary cause, it often contributes to the case, and may be overlooked by the acupuncturist due to its more complex anatomical orientation.
Portions of this article are excerpts from The Acupuncture Handbook of Sports Injuries and Pain (Hidden Needle Press, 2009), by Reaves and Bong.
Whitfield Reaves, OMD, L.Ac. is a nationally certified acupuncturist, and has been in the forefront of sports medicine acupuncture since 1981. His clinical experiences includes medical care for athletes at the 1984 Olympic Games in Los Angeles, as well as numerous triathlons, skiing, running, and cycling events during the last 25 years. In 2009, Whitfield published The Acupuncture Handbook of Sports Injuries and Pain, which is the compilation of more than 25 years of clinical experience treating competitive athletes.
Whitfield Reaves can be reached at www.WhitfieldReaves.com.
Chad Bong, MS, L.Ac. is a nationally certified acupuncturist and holds a Master's degree in Exercise Science. He is a contributing writer to The Acupuncture Handbook. Chad is a lifelong athlete, and he combines acupuncture with western sports medicine and fitness training.
Illustrations by Deborah Kelley.
Acupuncture points (pinyin)
Bl 40 Weizhong
Bl 52 Zhishi
Bl 60 Kunlun
Bl 65 Shugu
SI 3 Houxi
GB 29 Juliao
GB 34 Yanglingquan
GB 41 Zulinqi
GB 42 Diwuhui
SJ 3 Zhongzhu
Please visit Whitfield Reaves' website: www.WhitfieldReaves.com