Botox for Quadratus Lumborum (QL) Pain and Stubborn One Sided Back Spasm
Quick answer. Botox (botulinum toxin type A) injected into the quadratus lumborum may relieve persistent one sided lower back or flank spasm when physiotherapy, dry needling and trigger point injections have provided only temporary relief. Direct evidence for treating this specific muscle is limited, so the case for treatment comes mainly from the muscle’s behaviour and the wider evidence on low back and myofascial pain.
Medically reviewed by Dr Gerard Ee of The Clifford Clinic, Singapore. Last updated July 2026.
The quadratus lumborum, or QL, is a deep flank muscle connecting the lowest rib and lumbar spine to the pelvis. When it remains in spasm, it can cause a deep ache on one side of the lower back, often aggravated by standing, walking, coughing or turning in bed. The pain may be mistaken for a problem in the hip, sacroiliac joint or elsewhere because the muscle lies deep and refers pain widely. Persistent cases can resist manual therapy and standard injections. Botulinum toxin may then be considered as a way to reduce the spasm directly, although the evidence has important limits.
What QL syndrome is
QL syndrome is myofascial pain arising from the quadratus lumborum. The muscle stabilises the spine and contributes to side bending and hip hitching while working continuously during standing and walking. Overuse, uneven loading, prolonged sitting, differences in leg length or a previous back injury can leave it in persistent spasm with tender trigger points. Pain is usually deep and one-sided, may spread to the hip, buttock or sacroiliac region, and often worsens during weight bearing. Some people also find it difficult to stand upright or turn over in bed.
Why QL pain is so difficult to treat
The QL is difficult to reach reliably because it lies beneath the erector spinae. Its trigger points can refer pain away from the muscle, leading treatment towards the wrong site. It also remains active during most upright movement, so the provoking load rarely disappears completely. Massage, dry needling and trigger point injections may therefore give only brief relief in resistant cases.
Why QL tightness causes pain
Sustained contraction restricts blood flow within the QL and encourages taut bands and trigger points to form. Because the muscle links the rib, spine and pelvis, one sided spasm can also alter the load across the lumbar joints and sacroiliac region. Referred pain may resemble a hip, sacroiliac or even kidney problem, which can delay the correct diagnosis.
How Botox works for QL pain
Botulinum toxin blocks the release of acetylcholine, the chemical signal that makes a muscle contract. After injection into the QL, resting tone falls gradually over one to two weeks. Taut bands may soften, blood flow may improve, and the abnormal pull on the pelvis and lumbar spine may ease. The toxin may also reduce local pain signalling. Its effect typically lasts about two to six months, long enough to interrupt the spasm and work on the loading pattern through rehabilitation. Because the QL is deep, ultrasound guidance is used to place the injection accurately and avoid nearby structures.
What the evidence shows
No high-quality trial has examined botulinum toxin in the quadratus lumborum alone. Studies of chronic low back pain usually treat groups of paraspinal muscles, so their results cannot establish a specific benefit for the QL. The broader evidence on myofascial pain provides a plausible basis for treatment: botulinum toxin reduces the contraction that sustains trigger points and may provide longer relief than shorter-acting injections. This makes it a possible option for carefully selected, resistant QL pain, not a routine treatment supported by strong direct evidence.
There is little direct trial evidence for the quadratus lumborum, so we are honest about that. Where the pain is clearly muscular and has resisted other measures, a carefully targeted injection is a reasonable step, and we escalate to imaging and orthopaedic review if anything suggests a structural cause.
Dr Gerard Ee, Medical Director, The Clifford Clinic
The QL is deep, so we target it under ultrasound guidance and combine the injection with rehabilitation that corrects the loading pattern, which is what keeps the spasm from returning.
Dr Dinesh Sirisena, Consultant in Sports and Exercise Medicine, The Clifford Clinic
Who may benefit, and who should avoid treatment
QL Botox Treatment: Who May Benefit
| May Benefit | Should Avoid or Delay |
|---|---|
| Chronic one-sided lower back or flank pain from confirmed QL spasm | Pregnancy or breastfeeding |
| Active QL trigger points that keep recurring after standard injections | Neuromuscular disease such as myasthenia gravis |
| Failed physiotherapy, dry needling and trigger point injections | Infection at the injection site |
| Willing to correct the loading pattern with rehabilitation | Allergy to botulinum toxin products |
The procedure and preventing recurrence
Once examination has identified the QL as the likely source of pain, the skin is cleaned, and the clinician uses ultrasound to guide the needle into one or more points in the muscle. The procedure takes about 15 minutes and is performed as a day case. Soreness or bruising may last for a day or two. Muscle relaxation develops over one to two weeks and usually lasts for two to six months. That period should be used for rehabilitation: correcting one-sided carrying or poor loading, strengthening the hips and gluteal muscles, and improving core control so that the QL no longer has to compensate. Some patients need no further injection once the underlying pattern has changed.
Risks and side effects
Botulinum toxin is generally well tolerated at the doses used for QL pain. Temporary soreness, bruising and mild weakness in the treated muscle are the most common effects. If the toxin spreads slightly, a nearby muscle may also weaken until the treatment wears off. Ultrasound guidance helps reduce the risks associated with injecting a deep flank muscle. All botulinum toxin products carry a boxed warning about the rare possibility of wider spread. Treatment is avoided during pregnancy and breastfeeding, in certain neuromuscular disorders and where the injection site is infected.
Clinical approach to the quadratus lumborum
Reviews of botulinum toxin for non specific chronic low back pain report worthwhile, reasonably durable improvements in pain and function for some patients. Results are at least comparable with steroid and local anaesthetic injections in some studies, but the treatment is relevant to muscular and paraspinal tightness rather than back pain generally. Benefits have also been reported in lumbar fasciitis and sacroiliac joint dysfunction, conditions that may coexist with QL tightness.
The quadratus lumborum is my injection target in much of this pain. Tightness here is often a significant contributor to one sided or localised lower back pain, and relaxing it can help, provided it is done as part of a wider plan with activity modification and rehabilitation.
Dr Dinesh Sirisena, Consultant in Sports and Exercise Medicine, The Clifford Clinic
Speak to our doctors
Botulinum toxin for muscle and joint pain is a considered, individualised treatment. To determine whether it is appropriate, arrange an assessment with the team at The Clifford Clinic or read more about the work of Dr Gerard Ee. The clinicians will review the history, perform an examination and explain the available options before any treatment is planned.
Frequently Asked Questions
What is QL syndrome?
QL syndrome is myofascial pain arising from the quadratus lumborum, a deep flank muscle. Spasm and trigger points can cause a deep, one sided pain in the lower back or flank that worsens with standing, walking or turning in bed. The pain may also spread to the hip or buttock.
Is there strong evidence for botulinum toxin in the QL?
No. There is no high quality trial examining the QL in isolation. Support comes indirectly from wider research on chronic low back and myofascial pain, together with the known behaviour of the muscle. Treatment is therefore reserved for carefully selected, resistant cases rather than offered routinely.
Why is QL pain difficult to treat?
The QL is deep, difficult to reach and capable of referring pain to other areas so that the source may be missed. It also works continuously during upright activity. These factors help explain why massage, needling and other standard treatments may give only temporary relief.
Can botulinum toxin stop recurrent QL spasms?
It may help in suitable cases. Botulinum toxin reduces muscle overactivity for about two to six months, providing a longer opportunity than a standard trigger point injection to break the recurring spasm. Physiotherapy during this period should address the loading pattern that contributed to the problem.
How is the injection done safely?
The clinician uses ultrasound to see the QL and needle in real time. This allows accurate placement and helps avoid nearby structures.
Related Conditions
Explore other articles in our series on botulinum toxin for musculoskeletal pain.
- Botox for Muscle Pain (main guide), the overview of botulinum toxin for musculoskeletal pain
- Botox for Lower Back Pain, chronic low back pain and lumbar muscle spasm
- Botox for Tight Hip Flexors, anterior hip pain in runners and cyclists
- Botox for Iliopsoas Syndrome, psoas spasm and snapping hip
- Botox for Gastrocnemius Tightness, calf tightness and cramps
- Botox for Plantar Fasciitis, chronic heel pain that resists other measures
- Botox for Trapezius and Shoulder Myofascial Pain, trapezius tightness and shoulder trigger points
Compare Treatments and Procedures
Compare the available treatments and what each procedure involves.
- Botox vs Steroid Injection, how the two injections differ and when each is chosen
- Botox vs PRP, muscle relaxation compared with tissue healing
- Botox vs Dry Needling, two trigger point options compared
- Ultrasound Guided Injections, why guidance matters for deep muscles
- Recovery and Physiotherapy after Botox, what to expect and how to get the most from treatment
More from The Clifford Clinic
Read about related treatments and services available at The Clifford Clinic.
- Platelet Rich Plasma Injections for Musculoskeletal Injury Recovery
- Botox for the Trapezius Muscle
- Botox Treatment for Cervical Torticollis
- Bioscaffold Therapy for Musculoskeletal Regeneration
- Hyaluronic Acid Injection for Knees
About the Authors
Dr Dinesh Sirisena is a Consultant in Sports and Exercise Medicine at The Clifford Clinic. He completed his sports and exercise medicine training in the United Kingdom and has cared for elite football, rugby, athletics and hockey teams, including at the London 2012 Olympic and Paralympic Games. He specialises in ultrasound guided injections and other non surgical treatments for muscle, tendon and joint pain, has led a musculoskeletal service as its medical director, and is an assistant professor at the NUS Yong Loo Lin and NTU Lee Kong Chian schools of medicine.
Dr Gerard Ee is the Medical Director of The Clifford Clinic. He trained at St George’s University of London and is a Member of the Royal College of Surgeons of Edinburgh, and built his orthopaedic experience at National University Hospital and Singapore General Hospital with a focus on the knee, joint and spine. He has published widely in peer reviewed orthopaedic and spine journals. You can also read more about his work at drgerardee.com.
Dr Dinesh Sirisena is a Consultant in Sports and Exercise Medicine at The Clifford Clinic. He trained in sports and exercise medicine in the United Kingdom and has worked with elite football, rugby, athletics and hockey teams, including at the London 2012 Olympic and Paralympic Games. He specialises in ultrasound guided injections and other non surgical treatments for muscle, tendon and joint pain. He has also led a musculoskeletal service as medical director and is an assistant professor at the NUS Yong Loo Lin and NTU Lee Kong Chian schools of medicine.
Selected orthopaedic and spine publications by Dr Gerard Ee
- Ee G, Srivastava A, Peng CWB, Tan SB, Tow BPB. Management of the neglected and healed bilateral cervical facet dislocation. European Spine Journal. 2014.
- Ee WWG, Lau WLJ, Yeo W, Yap VB, Yue WM. Does minimally invasive surgery have a lower risk of surgical site infections compared with open spinal surgery. Clinical Orthopaedics and Related Research. 2014.
- Ee G, Jiang L, Guo CM, Yeo W, Tan SB, Tow B, Chen J, Yue WM. Comparison of clinical outcomes and radiographic measurements in four treatment modalities for osteoporotic compression fractures. Journal of Spinal Disorders and Techniques. 2015.
- Ee G, Pang SY, Kumar N, Malhotra R. A silent acute abdomen in a patient with spinal cord injury. BMJ Case Reports. 2013.
References
- The efficacy and safety of botulinum neurotoxin type A in treating chronic low back pain, a systematic review and meta analysis. European Journal of Pain. 2025.
- Efficacy of botulinum toxin type A for treating chronic low back pain, a systematic review and meta analysis. European Journal of Clinical Pharmacology. 2026.
- Myofascial pain syndrome, an update on clinical characteristics, etiopathogenesis, diagnosis and treatment. Muscle and Nerve. 2025.
- Neurobiological mechanisms of botulinum neurotoxin induced analgesia for neuropathic pain. Pharmacology and Therapeutics. 2024.
- Approved uses and prescribing information for botulinum toxin type A. United States Food and Drug Administration. 2024.
- Meta analysis of botulinum toxin for fasciitis pain in the lumbar and neck and shoulder regions. Medicine. 2023.
- Review of botulinum toxin for sacroiliac joint dysfunction. European Spine Journal. 2024.
- Stiff person spectrum cohort with paraspinal and hip flexor injection. Therapeutic Advances in Neurological Disorders. 2025.
- Double blind randomized trial of botulinum toxin for mechanical chronic low back pain. World Journal of Methodology. 2024.
Medical disclaimer. This article is for general education and does not replace a consultation with a qualified doctor. Botulinum toxin for musculoskeletal pain is an individualised treatment that is off label for most of these conditions. Suitability, dosing and outcomes vary between people. Please seek an in person assessment at The Clifford Clinic before making any treatment decision.