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Understanding iliopsoas: clinical implications for the massage therapist.

One of the most enigmatic muscles in the human body is the ilipsoas (also known as the psoas). Travell and Simons name it the 'hidden prankster,' (1) and I suspect that a significant number of massage therapists are puzzled about how to manage this prankster in the clinical setting. In researching and reading the vast amount of literature written about this significant muscle, it appears that just like one of Pablo Picasso's cubist paintings, it possesses many angles and ambiguities that make it both fascinating and profoundly difficult to address and treat in practice.

Some of the conditions involving the iliopsoas muscle include lower back pain, sacroiliac pain, sciatica, disc trauma, scoliosis, hip and knee pain, menstrual pain and digestive problems. We may also include biomechanical problems such as pelvic tilt, leg length discrepancies, kyphosis and lumbar lordosis.

This article precedes the Complete Guide to Working with the Iliopsoas workshops to be held around Australia and New Zealand in 2009. I hope that it raises some interesting issues about the accepted management processes and protocols a massage therapist may currently employ to ease pain in a dysfunctional psoas.

Location

The psoas major, psoas minor and the iliacus muscles combine to become the iliopsoas. Psoas minor is present in roughly 40% of the population (2). If present, psoas minor assists in the superior rotation of the pelvis--an action oppsite to psoas major. Psoas minor is, as Koch describes it, '... a vanishing muscle, disappearing as we evolve from a semi-flexed to an up-right being' (3). Psoas major and minor both insert on the lesser trochanter of the femur (4). They are considered part of the posterior abdominal wall due to their position and their role in cushioning the abdominal viscera. Koch sees the iliopsoas as the 'keystone of a balanced, well-organised body' (3).

There are two psoas major muscles attaching to each side of the transverse processes of all lumbar vertebrae (L1-L5) and the body of T12. All lumbar vertebrae are innervated by branches of the L1-L3 lumbar spine nerve roots. Iliacus originates in the superior two thirds of the iliac fossa and the anterior ligaments of the lumbosacral and sacroiliac joints. It inserts at the lesser trochanter of the femur. There has always been an anecdotal relationship between iliopsoas dysfunction and inguinal pain and this will be discussed later.

Function

Iliopsoas is considered by most therapists and physiologists to be the main hip joint flexor--it flexes and laterally rotates the thigh as is exemplified when kicking a football. The iliopsoas muscle works in tandem with iliacus, rectus femoris, pectineus, tensor fascia latae and sartorius (5). Acting from its insertion at the lesser trochanter of the femur, it flexes the trunk, such as when rising from a supine position.

As well as flexing the hip, the iliopsoas can assist with extension of the lumbar spine, thereby increasing lumbar lordosis when an individual stands in normal lordosis. It also plays a significant role in maintaining an upright posture (1).

Ida Rolf wrote that, 'The psoas does not bulge forward; it lengthens and falls back within the abdomen [as it flexes]' (6). There is some controversy concerning exactly what the iliopsoas achieves when it flexes. Despite Rolf's genius as a 'structure and function expert', most bodyworkers, including myself, would probably disagree with her. We have all experienced feeling the psoas leaping anteriorly as we ask our client to undertake hip flexion. Perhaps the question to ask is whether the iliopsoas is contracting and lengthening at the same time by using individual fibres within the one muscle.

Do not expect consensus or accord when the function of the iliopsoas muscle arises in discussion amongst therapists. It may be more useful to ask how important the iliopsoas is when hip flexion is required, and does it have other, more significant, functions to perform?

Professor Nic Bogduk, an Australian researcher from Newcastle University, has been a major influence and world authority in this area over the past ten years and asserts that, 'Biomechanical analysis reveals that the psoas has only a feeble action on the lumbar spine with respect to flexion or extension' (7). He believes that the psoas has its major function as a stability muscle for the lumbar spine through axial compression (7). Mottram and Comerford (8) agree with Bogduk and develop his theory further by arguing that this axial compression fixes the spine in neutral alignment while longitudinally pulling the head of the femur into the acetabulum.

Yoshio et al (9) also conclude that the primary role of the psoas major is lumbar stability and that it contributes very little to hip flexion. They further argue that the primary function of the psoas is at the hip for stability. Moreover, the psoas may be considered to be clinically deficient if it fails to segmentally hold the vertebrae in place at the level of pain in clients who have segmented lumbar dysfunction (hypermobile segments).

In refuting both Bogduk and Yoshio et al, Myers presents another considered and persuasive argument. He states that the psoas is a major flexor of the hip and may well operate on the lumbar spine as one muscle but with opposing functions and forces within it--not unlike the deltoid that engages one or all of its three compartments during movement (10). He argues that while the iliopsoas certainly acts as an extensor of the lumbar spine and a flexor of the hip, it may not be true that all the fibres that make up the muscle are involved in any one action. Several, sometimes conflicting functions, may be present within the iliopsoas muscle.

Myers's insight informs some of the techniques that are described later in this article. It is easy to agree with his multi-functional possibility when one examines the iliopsoas in a prosected specimen. On examination, it is easy to recognise that iliopsoas is not a 'sausage,' but an elegantly formed muscle displaying many separate fibres that cascade in an almost 'open spring' arrangement from origin to insertion. Myers suggests that if we work on the inner fibres of psoas, we affect fibres connecting to L4 and L5, and if we treat the outer fibres of psoas, we affect T12 and L1 (11).

Walking

Let us be clear about this: the legs do not originate movement in the walk of a balanced body; the legs support and follow. Movement is initiated in the trunk and transmitted to the legs through the medium of the (ilio)psoas.

--Ida Rolf (12)

Like Rolf and others, Gracovetsky (13) considers the spine to be the 'primary engine' of walking. He contends that an efficient gait is driven by the action of the spine rather than the legs. The psoas major and minor, as one unit, are the only muscles, besides the piriformis, that connect the vertebral column to the legs. 'A free, pendulum movement of iliopsoas muscle, uninhibited by dysfunction or pain, will give the leg its free swing. The iliopsoas links the vertebral column to the legs, inside to outside, axial to appendicular, and respiration to walking ... and provides the most important initiation of walking' (11).

The iliopsoas muscle acts continuously in peaks during the walking cycle. Of the three muscles (iliacus, psoas major and psoas minor) that make up the iliopsoas, the iliacus provides the major force for anterior propulsion (1).

Respiration

The iliopsoas muscle is closely connected to the respiratory process at the diaphragm--the main muscle of respiration. It also has an intimate connection with the medial and lateral arcuate ligaments which lie around the top of the psoas minor and psoas major respectively. Both psoas minor and psoas major also connect to the central tendon of the diaphragm.

Psoas major in particular, has intimate anatomical attachments to the diaphragm and the pelvic floor. This unique anatomical position allows iliopsoas to act as a link between the diaphragm and the pelvic floor and that could mean that iliopsoas plays an important role in stabilising the lumbar spine during certain phases of the respiratory cycle (14).

Innervation And Visceral System

Iliopsoas is positioned posterior to the bladder, the reproductive organs and some intestinal viscera. The kidneys lay each side of psoas major and psoas minor. It is imperative that massage practitioners do not palpate deeply into this region due to the sensitivity of these organs lying under the iliopsoas. There is an interrelationship between these body parts, the iliopsoas muscle and the supplying nerves, in particular, the ilio-inguinal nerve which arises from the L1 lumbar vertebrae.

The ilio-iguinal nerve emerges laterally from the psoas major muscle and then passes anterior to the posterior abdominal wall, running around the trunk and inferiorly through the inguinal canal. It terminates on the inner anterior aspect of the inguinal region, supplying sensation to this area and the transverse abdominals. It has always been argued that psoas tightness will lead to movement dysfunction around the hip and pelvis and that this can lead to pain around the lower abdomen and inguinal region.

Balancing The Core

There is some discussion in the literature about the counterbalance between iliopsoas and the rectus abdominal muscles. Koch (3) writes about the 'chest out/belly in posture' caused by a shift in gravity superiorly towards the chest when iliopsoas is not counterbalanced with the abdominals. The quest for the 'body beautiful' has led, according to Koch, to an overemphasis on the development of the abdominal muscles in order to develop a 'six-pack'. This corresponds to a loss of balance between the abdominal muscles and the psoas. She contends that this process is a contributor to the loss of 'core integrity.' Furthermore, Koch notes that an overloaded pushup and sit-up exercise program that strengthens the abdominals, also weakens the psoas muscle, unbalances the relationship between these two major muscle groups and tenses the back muscles.

I found no real evidence to support Koch's view and some, like Myers for example, argue that, 'You could have washboard abdominals and still support the lumbar spine adequately (10). He contends that there are four 'gullies' around the spine--the erector spinae muscles posteriorly and the iliopsoas muscle anteriorly fill these gullies, and support and balance the lumbar spine (15). The inference here is that the abdominal muscles have little influence, if any, with balancing the so-called core.

The common description of the iliopsoas muscle as core is, in my opinion, a limiting one. Bruce Stark, from the Sydney Orthobionomy Training Institute is another Australian, and a world leader in orthobionomy. He describes the psoas as the 'body conductor'. He insists that, without first developing a trusting 'relationship' with this psoas conductor, far less clinical success will be achieved with the other body structures that are influenced by it (16).

In my view, kindness shown to the 'maestro' will result in a far longer and sweeter symphony. The iliopsoas is more than a core or a prankster; it possesses the sensitivity of the most talented massage therapist and should be treated with the upmost respect. It will be 'clinically compliant' when bullied by painful overstretching, and unkind prodding, but then, as Bruce Stark says, 'go back to where it was' before it walked its legs into your clinic!

A contracted iliopsoas muscle may stay contracted due to postural habits brought on by a sedentary lifestyle or an unbalanced standing or sitting posture. The way we stand, walk and sit can distort the iliopsoas muscle. 'A deteriorated iliopsoas ... chronically flexes the body at the level of the inguinal region, so that it prevents a truly erect posture,' wrote Ida Rolf (17).

Sitting through the day will cause the psoas major muscle to shorten so that we stay biomechanically balanced for a seated posture. Krost writes that, 'Over time, we develop a 'normal' way of holding the iliopsoas that is dysfunctional. Unresolved trauma can also keep the psoas short and reactive' (18).

Causes of unresolved trauma may include a history of physical or psychological abuse, family or marriage break-up, or other forms of emotional loss that your client may have experienced. Palpation of the iliopsoas may bring back the fear associated with these events as a reactive response (reflex) (3). Krost, Stark and others including Koch and Myers would most likely agree that the instinctive fear reflex can hold the psoas 'frozen.' They would argue that the cause of a shortened psoas can be biomechanical, psychosomatic, or both, and to balance this core we must be prepared for a reactive response in the treatment process.

Reactive Responder To Perceived Danger

It is well-recognised by scientists that when the body experiences shock, trauma or great danger, it can go into a 'freeze' (19). Not unlike the mouse trapped in the cat's claws, the human too, may be in a state of immobility when in shock. This is one of the three primary responses available to reptiles and mammals when faced with an overwhelming threat. The other two, 'fight' and 'flight' are better known to us.

With shock, the mouse goes into the immobility state as a last ditch survival strategy: there may be a possibility that the cat will be distracted and, in that instant, the mouse may awake from its frozen state and make a hasty escape. The mouse is able to discharge the vast amounts of reactive, compressed energy during its escape.

Levine (19) believes that there is a substantial similarity between animal and human experience in relation to this reactive response, except that humans find it far more difficult to shake off the residual effects of the immobility response than their animal counterparts.

Koch says that the survival response is activated when the iliopsoas muscle is palpated (20). Some of us in clinical practice may have experienced overt emotional and/or strong physical reactions from clients when we use direct palpation techniques to the psoas major. It could be argued that direct palpatory techniques may trigger reactive compressed energy originating from unresolved trauma that is present in the iliopsoas.

The iliopsoas muscle is an essential part of the instinctive fear reflex and, as such, it is very sensitive. It should also be noted that this muscle is responsible for taking the body into a foetal position to protect the vulnerable organs of the body from a deadly blow or fall (21). It is not unreasonable, therefore, to assume that iliopsoas is the muscle that holds this reactive response energy to protect the body from harm.

The possibility of eliciting the fear reflex response with invasive massage techniques is something that we need to be aware of as a clinical possibility. To take this one logical step further; invasive massage techniques such as direct finger frictions, could have the unfortunate effect of further traumatising the iliopsoas muscle.

Dysfunction And Pain Symptoms

Typically, a dysfunctional iliopsoas muscle can be caused by injury, poor posture, prolonged sitting or stress. It can alter the biomechanics of the pelvis and refer pain down the anterior part of the thigh and vertically along the lower to mid vertebral column. Along with pain in the posterior hip, sacrum and piriformis, the iliopsoas muscle can torque the spine to the right or left, pull it forward, and twist the pelvis into various distortions.

Krost (18) states that, 'Frequently the iliopsoas will shorten and pull the spine and/or pelvis to our dominant side. This can cause scoliosis, kyphosis, lordosis and spasms in back muscles attempting to resist the pulling of the iliopsoas.' This tug of war causes a lack of integrity in the relevant intervertebral discs of the lumbar spine causing nagging lower back pain.

Agnew writes that, 'The psoas presents several problems associated with lower back pain. Because of its attachment along the thoracic and lumbar spine, flexion of the hip causes a pull on the discs at this attachment. This is also known as the psoas paradox, where the lumbar spine is hyper-extended as the hip is flexed. Also, the iliopsoas muscle will tilt the pelvis anteriorly when limited, and this places another vector force along the lumbar spine.

This is one of the reasons why most herniated discs occur at L3, L4 and L5' (22). It is my contention that not only can there be disc degeneration from the action of the shortened psoas, but there can also be destabilisation at the hip and back where the psoas makes its distal and proximal connections.

Nearly fifty years ago, Michele (23) wrote a 550 page book on the iliopsoas muscle in which he stated that, 'Any or all defects of the spine and the hip joint structures should be evaluated in terms of disturbance of function of the iliopsoas muscle.' His insight was not overstated. He was also, as far as I know, the first to recognise the functional relationship of the iliopsoas muscle to both the spine and the hip.

My inference is that the major function of the psoas is very much a stabilising one. It plays its part in flexion but stabilisation is its forte. The research by Bogduk, Mottram and Comeford, and particularly Yoshio, all cited and referenced in this article, allude to this assertion.

In Search For The Appropriate Treatment

Koch (21) warns all therapists against palpating the psoas muscle. She concludes that any physical intervention could lead to negative psychological or physiological effects in all cases. She states that 'It is counterproductive to massage the psoas directly' (3).

I do not subscribe to this view and while there must be careful assessment of each client prior to treating the iliopsoas, I have always used non-invasive techniques that honour the 'maestro' so as not to traumatise my clients. These techniques include hot water heat packs and warm stones to replace direct finger frictions, and positional release techniques.

The final section of this article presents a small selection of the protocols I incorporate in assessing and releasing the iliopsoas muscle. It should be noted that these procedures may not be a silver bullet, and your client may need to attend your clinic for a series of treatments as well as follow up his/her program with an appropriate stretching regime.

Locating The Psoas Major

You will find the psoas major muscle half way between the anterior superior iliac spine and the navel. Treat the navel as a strict border that you do not cross with deep frictions as the kidneys lay close to this area.

Check the associated graphic for the position of the psoas major muscle and the iliacus muscle. If your assessment procedure causes pain or panic in your client you must stop immediately. As we have discussed, you may be initiating a reactive response or just creating too much discomfort.

[ILLUSTRATION OMITTED]

Assessment 1

With your client lying supine on the massage table, ask them to raise and hold both legs 30 cm off the table. You may need to assist when working with elderly or infirm clients by supporting their legs while you perform this assessment. Raising the legs may produce discomfort, but usually only a weakness, especially on the injured side.

In this same position, ask your client to perform a 45 degree sit-up against your resisting arm/hand. This may produce some moderate pain in the inguinal area. Both tests should indicate the affected side.

Assessment 2

With your client in the supine position, stand at the top of the massage table and take both of your client's hands above their head. Place your client's hands together with palms touching and take their touching hands above their head.

The distortion, contraction and the hypertonic nature of a shortened psoas major muscle will not only cause the body to flex to one side, but it can pull the lumbar spine into a lateral flexion. You should notice that one palm is lower than the other--this is the shortened psoas side in nearly all cases.

Assessment 3

This is both an assessment and treatment procedure. The hypertonic psoas major plays a fundamental role in most anterior innominate rotations. This test/treatment procedure is commonly known as the Thomas Test and I have found it to be a little too intense, causing pain in some clients.

To explain the recognised Thomas Test, the client leans on the edge of the treatment table without sitting on the table. The client brings the knee that is not being tested, to the chest. Once the knee is drawn to the chest, the therapist assists the client in rolling back onto the table. The thigh being held to the chest should be at about 45 degrees to the table. If the client's extended thigh, viewed laterally, is horizontal or above, hypertonicity in the psoas major muscle is indicated.

This assessment is also used by some as a technique to stretch the psoas. An alternative procedure (and the one I prefer) is basically the same except the practitioner draws both knees to the chest and stretches both legs laterally. The practitioner is more able to control the psoas stretch in this position. This technique is similar to the 'held stretch' used in orthobionomy, as is the first of the treatment procedures below.

Treatment Procedure (Supine)

Iliopsoas release with stretch/heat

Fowlie points out that, 'Heat and stretch together decrease spasm and increase range of motion and the stretching ability of muscles more than heat alone or stretch alone' (24).

(a) To begin this sequence, place a heated hot water pack, heated stone, or both over the abdominal area. Stand on the affected (shortened) side. With your client supine, abduct and externally rotate the affected leg while holding the ipsilateral wrist.

(b) Gently compress into the client's hip from the pelvis while holding the foot/leg. At the same time, pull the client's arm/shoulder gently towards the client's feet. The client's body will automatically move into a curved position on the affected side. This exaggerates the position of a severely shortened psoas. This procedure should be repeated slowly and precisely several times before returning the client's body to a straight supine position.

(c) Remove heat packs and/or stones. Bring the client's knees towards their chest. Standing on the affected side, draw both legs up (flexed). Hold both legs together and gently press into the client's hip from the knees, towards the affected side. Hold for 10-20 seconds.

Combination rib cage release and heat application

(a) Move to the affected side and gently draw the iliac crest and the ribcage into a medial direction with vibration massage. Follow with vibration and light direct friction on the psoas major muscle and a medial roll of the heated stone (or long edge of the hand) using lateral to medial movements over the psoas major muscle.

(b) Return the heat pack to the abdominal area and work on the sacrum with your client in a supine position. Using light and explorative palpation in this position feels extremely nurturing and in my experience, will help to dramatically decrease lower back pain caused by a dysfunctional psoas major.

Above are a few of the supine assessment and release techniques I use to relax the iliopsoas muscle. I avoid the common technique of plunging my fingers directly on to the iliopsoas as I believe this can be counterproductive in many cases.

When an assessment indicates a lack of stability in the lower back and/or pain, I use a number of further techniques including Goodheart's coccygeal lift. For this lift, the client lies supine and the practitioner's hand monitors sensitivity in the cervical region as the coccyx is eased towards the head.

These techniques are followed by directed stretching and strengthening exercises that the client can also do at home following the massage treatment. These exercises range from what Koch describes as a 'constructive rest position' (25) where the client spends 20 minutes a day simply lying supine with legs flexed at the knees, to more challenging stretching that requires the client to perform forward lunges and the yoga-style 'warrior pose.'

Conclusion

Making sense of all this conflicting research is not easy, and like most massage therapists in clinical practice, I listen to my client carefully. I test the function of the iliopsoas muscle, and become informed by the types of investigation and literature presented by those cited in this article and others. I then make decisions about management strategies to ease the pain and discomfort caused by a tight iliopsoas muscle or one that is in spasm--a very common condition.

On average, 8-15% of clients have a shortened psoas major muscle condition related to their back pain (26). This condition also mimics hip pain and leg pain either individually or in combination. Such a sensitive and complex muscle that communicates with the visceral system has a plethora of connections. Furthermore, it is considered to be intimately associated with human emotion and therefore deserves the massage therapist's utmost respect.

I maintain that there are a many correct ways to address the dysfunctional iliopsoas muscle, but none of them involve producing pain or eliciting the fear response in the client.

References

(1) Travell J, Simons D. Myofascial pain and dysfunction: the trigger point manual. Williams & Wilkins, 1991.

(2) Biel A. Trail guide to the body. Books of Discovery, 1997.

(3) Koch L. The psoas book. Felton, CA: Guinea Pig Publication, 2007.

(4) Riggs A. Deep tissue massage: a visual guide to techniques. North Atlantic Books, 2007.

(5) Schuenke M, Schulte E, Schumacher U. Thieme atlas of anatomy. New York: Thieme, 2006.

(6) Rolf IP. Rolfing. San Francisco: Rolf Institute, 1977.

(7) Bogduk N, Pearcy M, Hadfield G. Anatomy and biomechanics of the psoas major. Clinical Biomechanics, 1992.

(8) Comeford MJ, Mottram SL. Movement and stability dysfunction: contemporary developments. Manual Therapy 2001;6(1):15-26.

(9) Yoshio M, Murakami G, Sato T. The function of the psoas major muscle: passive kinetics and morphological studies using donated cadavers. Journal of Orthopaedic Science 2002;7(2):199-207.

(10) Myers T. The opinionated psoas, part 2 (serial on the internet). [Cited on 12.12.08]. Available from http://www.massage therapy.com.

(11) Myers T. The opinionated psoas, part 1 (serial on the internet). [Cited on 12.12.08]. Available from www.massagetherapy.com.

(12) Rolf I. Rolfing, the integration of human structures. New York: Barnes and Noble, 1977.

(13) Gracovetsky S. Interview with Professor S. Gracovetsky. The spine engine: a unified theory of the spine? [Cited on 13.12.08]. Available from: www.somatics.de/Gracovetsky/Interview.pdf.

(14) Richardson C, Jull G, Hides J, Hodges P. Therapeutic exercise for spinal stabilisation: scientific basics and practical techniques. Churchill Livingston, 1999.

(15) Myers T. Anatomy trains. Churchill Livingstone, 2001.

(16) Conversation with Bruce Stark from the Sydney Orthobionomy Training Institute in December, 2008.

(17) Rolf I. Rolfing: re-establishing the natural alignment and structural integration of the human body for vitality and well-being. Healing Arts Press, 1989.

(18) Krost PB. Psoas release techniques e-manual. Self Published, 2008.

(19) Levine P. Waking the tiger. North Atlantic Books, 1997.

(20) Koch L. Iliopsoas: the flight and fight muscle for survival. Positive Health 2005;108.

(21) Koch L. Psoas health: trauma recovery protocol. Massage & Bodywork On-line Magazine. [Cited on 3.12.08]. Available from www.massageandbodywork.com.

(22) Agnew T. Treating low back pain: are you treating the symptom? [Cited on 15.12.08]. Available from www.downeastschoolofmassage. net.

(23) Michele AA. Illiopsoas. Ill: Springfield Publishers, 1962.

(24) Fowlie L. Heat and cold as therapy: physiological effects of heat. Toronto: Curties-Overtzet Publications, 2006.

(25) Koch LA. Fluid core: redefining core strength. Positive Health on Line. [Cited on 10.1.09]. Available from www.positivehealth.com.

(26) Rich K. The iliopsoas muscle: the great pretender. Dynamic Chiropractic 1997;15(5).

Greg Morling has been a massage therapist for 25 years and runs workshops around Australia and New Zealand for massage therapists and other practitioners on how to work on the iliopsoas muscle. He can be contacted on (02) 9713 9256 or info@mostlymassage.com.au.
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