An advanced variation of the 90-90 QL opener involves rotating the chest downward toward the floor while holding the stretch, which produces a much deeper activation of the QL muscle, held for 30 seconds and repeated 3-5 times with progressive deepening.

All exercises in this protocol can be done at home and may provide quick pain relief within 30 seconds.

The most advanced self-massage variation involves combining hip pressing, chest lift, knee-to-chest movement, and toe-reaching movements while rolling on the ball, holding each position for 1-2 seconds, repeating 10-15 times, which 'floss' the muscle.

The quadratus lumborum is a muscle that originates at the top of the pelvis, connects to the side of the lumbar spine in the lower back, and attaches at the bottom rib.

For self-massage of the quadratus lumborum, a tennis ball, lacrosse ball, or racquet ball can be used effectively.

Proper execution of the 90-90 QL opener produces a deep stretch in the lower back on the painful side extending into the hip, and should be held comfortably for about 30 seconds, repeated up to five times, with progression by building deeper into the stretch with each repetition.

The quadratus lumborum is located approximately above the hip off to the side of the spine, right below the rib cage, and should not be massaged directly over the spine as this can cause irritation.

When the quadratus lumborum becomes inflamed, tight, and achy, it produces one-sided deep lower back pain that can run through the pelvis and into the hips.

The three-part treatment protocol for QL pain consists of knocking out muscle tightness with self-massage, actively lengthening the muscle through stretching, and then strengthening it through targeted exercises.

Self-massage of the QL muscle should be performed by lying on the affected side with the ball pressed into the muscle, lifting hips up and down, rolling forward, and exploring the area with circular motions for about 10 seconds per repetition, repeated multiple times with increasing pressure.

The 'ballerina' stretch is a standing exercise performed throughout the day to keep the QL muscle loose, executed by crossing the painful-side leg over the non-painful side, placing the non-painful-side hand on that hip, positioning the painful-side arm overhead bent at 90 degrees, then driving the hip toward the painful side while leaning through the waist toward the non-painful side.

The hip hiker exercise is best performed at the edge of a staircase, executed by placing one foot on the stair edge with the other leg hanging off the side, keeping both legs straight at the knees, and driving the hip upward toward the ceiling as much as possible.

An advanced variation of the self-massage technique involves rolling to press down with the hip while lifting the chest upward, focusing on moving the bottom ribs away from the hip to create deeper activation of the quadratus lumborum.

The 90-90 QL opener is a stretching exercise performed with one leg straight in front with the knee bent at 90 degrees and the other leg off to the side, also bent at 90 degrees, targeting the side with pain as the back leg.

In the 90-90 QL opener, the back hip should be pressed down toward the floor during the exercise, and the arm on the painful side should be straightened and reached over toward the non-painful side to stretch the bottom ribs away from the hip.

Both sides of the body should be stretched with the 90-90 QL opener for balance and symmetry, even if pain is only present on one side.

Proper execution of the ballerina stretch focuses on opening the area from the bottom of the rib cage into the lower back into the hip, should be held for about 30 seconds, repeated up to five times, with each repetition building deeper into the stretch, and should be performed on both sides for balance.

If the goal is to eliminate quadratus lumborum pain permanently, the focus must concentrate most heavily on strengthening and stability exercises rather than massage or stretching alone.

The hip hiker should be performed by holding the upward hip drive for about 5 seconds, relaxing, and repeating 10-15 times at a slow pace, with optional additional sets, and can be easily integrated into daily stairs usage.

An advanced variation of the hip hiker involves not only raising the hip upward but then slowly lowering the hanging leg downward toward the floor without letting it touch, which activates muscles on the opposite side and provides a two-for-one exercise benefit.