Psoas Treatment Sequence

The iliopsoas complex is the most prominent of the lumbar and hip flexors, and is almost always involved in  low back pain conditions.

Iliopsoas Muscle Complex: Hip Flexors

The iliopsoas complex is the most prominent of the lumbar and hip flexors, and is almost always involved in  low back pain conditions. Dr. Janet Travell suggests that unidentified iliopsoas trigger points are in part, frequently responsible for a failed low back post-surgical syndrome.

When the psoas is shortened, fibrotic, and weakened it will cause the lumbar spine to become hyperlordotic and limit hip extension. A person with a short psoas will usually exhibit hyperlordotic posture that worsens upon rising to a standing position after being seated for any length of time.
When the iliopsoas is shorter or tighter on one side it causes a rotational imbalance in the lumbar spine and pelvis. This imbalance may then cause further stresses on all other soft tissues and joints of the low back complex. Iliopsoas issues can eventually lead to a facet syndrome.

Psoas Origin (T12 to L5)

  • Attaches by thick fasciculi to the sides of the 12th thoracic and all lumbar vertebral bodies and their corresponding intervertebral discs.
  • Attaches by more slender fasciculi to the lumbar transverse processes.
  • Crosses many articulations including those of the lumbar spine and the lumbosacral, sacroiliac, and hip joints.

Iliacus Origin

  • Upper two-thirds of the inner surface of the iliac fossa and anchors to the internal lip of the iliac crest.
  • Crosses only the hip joint.

Common Insertion

  • Iliacus and psoas form a common tendon attachment to the lesser trochanter of the femur.
  • This tendon exits the pelvis through a restricted outlet along with the femoral nerve and creates a potential for nerve entrapment due to a shortened (thickened) iliopsoas muscle.

Function

  • Primary action is flexion of the hip.
  • When standing or sitting the psoas plays a significant role in maintaining upright posture.

Referred Pain

  • Pain from the psoas extends along the spine ipsilaterally from the thoracic region to the sacroiliac area, and sometimes the upper buttock.
  • Pain is referred similarly from the iliacus and often also to the anterior thigh and groin

Symptoms

  • Complaint primarily of low back pain that runs vertically up and down the spine when patient has unilateral trigger points (TP’s).
  • Bilateral TP’s may result in pain perceived as running horizontally across the low back, as also felt with bilateral quadratus lumborum TP’s.
  • A frequent additional complaint is pain in the front of the thigh.
  • Trigger points are aggravated by weight bearing activities and relieved by recumbency.

Activation of Trigger Points

  • Prolonged sitting with the hips acutely flexed which shortens the muscle  (desk work, driving, sitting on unsupportive furniture).
  • Common in truck drivers, cyclist, sprinters, hockey players.
  • Sleeping in the fetal position with knees drawn up to the chest may activate latent TP’s.
  • Common in pregnancy due to increased anterior tilt of the pelvis.
  • Tightness of the rectus femoris that prevents full hip extension can perpetuate TP’s.

Associated Conditions

The iliopsoas and quadratus lumborum muscles are usually involved together through their stabilizing action on the lumbar spine. Bilateral involvement of the psoas leads to bilateral involvement of the quadratus lumborum but one side is usually more severely affected than the other. Other synergistic muscles often involved with iliopsoas TP’s include the rectus abdominis, rectus femoris, tensor fascia lata, pectineus and lumbar paraspinal muscles. Antagonists to the iliopsoas include the gluteus maximus and hamstring muscles. Hamstring tightness and a weak gluteus maximus are often of key importance to most low back pain syndromes.

A shortened iliopsoas is also frequently associated with an anterior tilt of the pelvis, hyperlordosis and weak lower abdominals. The result is a distorted posture that overloads the back and neck muscles, perpetuating TP’s in them. The victimized muscles may include the hamstrings, gluteals, thoracolumbar paraspinals and posterior cervical muscles.

Iliopsoas Trigger Point Examination

  • Sink slowly and gently into the tissues investigating for lesions.
  • Use firm but not sharp pressure with a broad contact surface (Soft knuckles, flattened thumbs or finger pads, soft elbow or forearm).
  • Remember, hip flexor trigger points are often very painful.
  • When accessing either the psoas or iliacus, palpate slowly and communicate with your client. If at any point they do not feel comfortable or safe, slowly remove your hands. You must develop a trusting relationship with your client to be able to engage the tissues deep enough to affect a positive change.
  • Starting treatment position: Supine – hip slightly flexed and laterally rotated with a pillow under the treatment knee, or knee bent with foot flat on table.
  • Client must have relaxed abdominals (arms down) for you to access the psoas. Laughing and/or tensing the abdominals will prevent you from getting where you need to go.
  • Most common TP is approximately the level of the umbilicus but is often tender along its entire length of the psoas.
  • Palpate along the abdominal wall just lateral to the lateral border of the rectus abdominis. Slowly compress into the abdomen with a downward and medial pressure, moving deeper when your client exhales. Increasing pressure medially toward the lumbar spine transmits the correct force.
  • To confirm you are engaging the psoas, instruct your client to perform isometric hip flexion against your resistance. The psoas should “pop up” under your contact point.
  • The psoas lies just lateral to the abdominal aorta. If you feel a strong pulse directly beneath your fingers when accessing the muscle, realign them more laterally.
  • Use both downward and medial pressure. Using only direct downward pressure, may elicit tenderness of other abdominal contents.
  • Go slowly, increasing your pressure gradually as your client relaxes into your pressure. It’s amazing how a little pressure elicits so much pain, when the psoas harbors active trigger points.