Ep 132 – The Quadratus Lumborum, A Case of Youngest Child Syndrome: “The Rebel MT” with Allison Denney

0:00:00.2 Speaker 1: Anatomy Trains is happy to announce our return to the dissection lab in person, January 10th to the 14th, 2022, at the Laboratory of Anatomical Enlightenment in Boulder, Colorado. We are thrilled to be back in the lab with Anatomy Trains author, Tom Myers, and Master Dissector Todd Garcia. Join students from around the world, and from all types of manual, movement, and fitness professions to explore the real human form, not the images you get from books. This is an exclusive invitation. Email info@anatomytrains.com if you'd like to join us in the lab.

0:00:37.0 Speaker 2: This episode is brought to you by The Massage Mentor Institute. Diane Matkowski, also known as The Massage Mentor, and Allison Denney, also known as Rebel Massage, have teamed up to bring you The Massage Mentor Institute. MMI is a collection of teachings and education opportunities from industry leaders around the world, because your continuing education experience should be whatever you want it to be. They are building community one body part at a time, and they want you to be a part of it. Head over to themassagementorinstitute.com today to see more, learn more, and do more.

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0:01:23.7 Allison Denney: Hi. My name is Allison Denney, and this is the Rebel MT podcast, where you'll hear me forcibly colliding the worlds of anatomical jargon and humour. I believe that when you know your anatomy, the what, and you know your physiology, the how, the techniques will follow, but the loads of Latin and the gobs of Greek can make a cranium convulse. It is a little overwhelming to dip your toe into the sea of anatomical knowledge, only to find that it is a bottomless ocean. You are smart, but this is intimidating. You will get there eventually. In the meantime, let's look at things differently so that you will actually want to take a swim or at least hop on a boat and take a peek at what's under the surface.

0:02:10.7 AD: Being a muscle can often be like being the youngest child in a large family at a dinner table. Everyone is talking, everyone has a story about their day, and they discuss things that seem big and important. They even talk over each other, but they are all somehow keeping up with the conversation. There is a pace that feels unattainable, and no one is paying attention to you. No one is pausing to get your opinion or to hear your perspective, no one is even looking at you. But you wanna fit in, you wanna feel like you are a part of things, so you start talking. Maybe you tell a story, maybe it makes no sense, maybe you just make car noises or animal noises or fart noises, but one thing is certain, the more noise you make, the more you get ignored. And so, of course, the more you get ignored, the louder you get. It is total common sense.

0:03:02.4 AD: It is, actually, it would seem from an outsider's perspective that an ignored child would take the hint and just be quiet, kind of like when you honk your horn at someone who cut you off while driving, and there is some part of you that actually expects that they will hear your honk, find remorse, and never cut anyone off again. But it turns out this is not the case. We know this because how many times have you honked at someone and the moment you both came to a stoplight, they waved you down so they could apologise? Never. That youngest child is responding with the same tenacity, he will just get louder the more he is ignored. Attempting to suppress or ignore an issue is almost a surefire way to create the opposite response.

0:03:46.8 AD: In the world of psychology, this is known as the ironic process theory. You know the thought experiment, if I ask you not to think about a pink elephant, it becomes the exact thing to occupy your thoughts. Even now, I've got a version of a pink elephant in my head that is super cute, a baby pink elephant with an elaborately adorned blanket on its back and a matching headpiece, walking on a stone path, splashed with flower petals through a small gathering of people. Good luck not envisioning all of that. I'm not sure I would label it ironic though. I would call it something along the lines of irritatingly forcing you to question your own sanity. All the logic in our brains somehow lead us to believe that when we tell someone to be quiet, that they will actually be quiet, or if we use force to make something fit when it's not fitting, it will miraculously slide into place, or if we feel something difficult or uncomfortable and suppress it down, that it will go away.

0:04:46.1 AD: If you are a human on this Earth, then you know that none of these things happen. When we suppress an emotion, that emotion often gets amplified. Whatever that emotion may be, anger, irritation, even laughter, trying not to laugh in a quiet moment can produce the need to burst out in hysterics. The same is true for pain, and I'm not just talking about emotional pain. Physical pain can grab you by the ears and force you to stare it in the eye. We may not want to, we may ignore it and convince ourselves that it's not that big of a deal or that it will go away, but suppressing it just makes it poke at you a little harder. It will eventually grab your head and force you to focus in. It will, like that child at the dinner table, just keep getting louder.

0:05:35.4 AD: When a muscle withstands this level of neglect, it is no different. Take the quadratus lumborum, for example. Commonly referred to as the QL, it is the quintessential youngest child in a very large family of muscles. Buried and often smothered by the paraspinals in the back and the abdominals and the psoas in the front, this muscle gets suffocated by the cacophony that surrounds it. Here is what I mean. The QL is a core muscle, probably the corest of the core. Located at the base of the spine and the top of the hip, it is almost as close to centre as you can get when it comes to human anatomy. And because it is latched onto the ribcage and the pelvis, it has quite the set of demands being placed on it. Let me map it out for you.

0:06:22.3 AD: The QL is a thick square muscle that originates at the posterior iliac crest and inserts onto the last rib and the transverse processes of L1 through L4, that is to say it attaches to the top of the back of the hip, the big thorny things that jut out either side of each vertebrae of your low spine and the bottom of your ribcage. It also has a small laundry list of actions it's responsible for. Bear with me here. If one of the QLs is contracting, like just the right one or just the left one, anatomists call this unilaterally, it will do a couple of different things depending on its end game. You see, normally with a muscle, there are two attachment sites, an origin and an insertion. The origin typically stays put, like a mom sitting on a bench at the park, while the insertion gets to move around, like her kid running up the ladder, sliding down the slide, and chasing his big sister.

0:07:19.7 AD: But the QL, a little Freaky Friday happens and it gets to switch roles. So, sometimes the origin at the hip stays put, which means that the spine and the ribs get to move. When the QL pulls down on those bones, we call this lateral flexion. Or when you turn your head so far sideways to try to figure out what your teenager is talking about, that you end up crunching your shoulder down to your hip, but sometimes after the old Hollywood magic has allowed mom and kid to swap roles, the insertion stays put and the origin, or the hip in this instance, gets to wiggle. When this happens, we call this a lateral tilt of the pelvis or a hip hike, not because your hip has decided it's a good day for a walk up a pretty mountain path, but because the hipbone gets hiked up towards the ribcage, kind of like when your Uncle Bert passes gas while sitting on the family couch.

0:08:14.0 AD: Then there's the bilateral contraction of muscles when both QLs are firing at the same time. If this happens, they extend the vertebral column or help you stand straight again after picking up the potato chip you just dropped on the floor. They also do this other little trick that happens to be one of my favourite actions that a muscle can do. They fix the last rib during forced inhalation. This means that they grab on to the last rib and hang on for dear life if you are suddenly startled by that plot twist at the end of the movie and find yourself gasping for air. Why would they have to do this? Because the ribcage needs to expand, like an accordion, when you take a deep breath in, so that the lungs can expand out in all the directions. But also, could you imagine if your lower ribs followed your upper ribs with that startled inhale? The entire upper half of your body would skyrocket off your hips, and your ribs would end up around your head. A little turtles on the imagery there for you.

0:09:15.3 AD: So, if you think about these bony landmarks and points of reference, and you think about the complex set of purposes of the QL, you'll see that it's not just a simple low back muscle. It's a complicated mass of fibres pushing and pulling at three major parts of the skeleton and questioning its own destiny, because on top of everything else, it's considered both a postural muscle and a phasic muscle, which means it has slow twitch and fast twitch fibres, which means it is responsible for both explosive movements and stabilisation. The quadratus lumborum is a beautiful mess of anatomical chaos, and it is no wonder it wants to scream sometimes.

0:09:55.0 AD: With that comforting thought, let's dig a little deeper. Now you know where it is and what it does. Remember, too, that it is sandwiched in the middle of all of its siblings, and its older siblings are not self-aware enough to put their own drum aside to let the QL be heard. Before we even get a glimpse of the QL, we have to first make our way through the rest of the kids. From the back, we are greeted by the thoracolumbar aponeurosis and then the erector spinae group. From the side, we make our way through the external and internal obliques and the transverse abdominis. And from the front, we've got the rectus abdominis, the internal organs, and the psoas major. The QL is at the very centre of all of that. The expectation that it is going to sit quietly while everyone else gets a voice is a little too much. Like a kid who has to wake up early, get to school, pay attention, solve math problems, understand the English language, play nice, eat healthy, cooperate in a sport, and then come home and do homework, it just kind of makes sense that sitting quietly at the dinner table is the last straw. It has gotten pushed aside, ignored, and suppressed for the last time. It will do what needs to be done to get attention, including fart noises.

0:11:13.8 AD: This is often the crux of low back pain. This is the pain that makes people question their own sanity. It seems to come out of nowhere and drop them to their knees. This is the kind of pain that can turn a person to QL abuse. We start digging and hammering and jamming tools into it in hopes that something will stop the racket. We will do anything to shut it up, but the abuse will often just make it scream even louder. Perhaps a different approach is the key. The QL just wants to be noticed, it wants to be acknowledged as an equal member, it wants to be heard, but has never been taught how to communicate correctly. If you find yourself dealing with an irritatingly obnoxious quadratus lumborum, try coming at it from a different perspective. Offer it the space to speak its mind before diving in to correct whatever it is you assume is wrong, calmly pass by the paraspinals and the obliques and say "hi" to the psoas while you were there. Sit with the QL, find a peaceful moment, teach it how to say whatever it needs to say nicely, and then give it a hug. We all know what it's like to want to be acknowledged, we all feel like what we have to say is equally as important as the next guy, and none of us want to feel bad about not knowing how to say it. Treat it with respect and it will start to follow your lead, because we all have a little QL in us.

0:12:43.4 AD: And here we are, the end of the episode. Thank you to the extraordinary crew over at ABMP for helping me get my words into your ears. And if you wanna get any of your words into my ears, or more accurately into my brain via my eyeballs from a computer screen, drop me a line at rebelmt@abmp.com. That's R-E-B-E-L-M-T@abmp.com. I always wanna hear your questions, comments, suggestions or salutations. Also, if you're interested in checking out anything else I'm doing, head over to rebelmassage.com, where you will find all sorts of fun things to click on, like homemade organic products for your practice, cool links to continuing education classes, thoughts I have typed up and posted here and there, and other Rebel Massage dabblings. I'm impressed you've made it all the way to the end, but because you have, allow me to offer a glimpse into our next episode.

0:13:37.1 AD: Tune in next time as we explore the autonomic nervous system, the world of hyper-wellness, and attempt to answer the question of whether or not you can get too many massages.

0:13:49.0 S2: Members are loving ABMP Five-Minute Muscles and ABMP Pocket Pathology, two quick-reference web apps included with ABMP membership. ABMP Five-Minute Muscles delivers muscle-specific palpation and technique videos, plus origins, insertions and actions for the 83 muscles most commonly addressed by body workers. ABMP Pocket Pathology, created in conjunction with Ruth Werner, puts key information for nearly 200 common pathologies at your fingertips, and provides the knowledge you need to help you make informed treatment decisions. Start learning today. ABMP members, log in at abmp.com and look for the links in the featured benefits section of your Member homepage. Not a member? Learn about these exciting member benefits at abmp.com/more.