Compton - Psoas

8/11/2019 Compton - Psoas

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Grand Rounds 2014Heath Compton


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Patient Details

Male

Early 60s

Retired

Healthy: cycles and swims


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Presenting Complaints

Onset of Lower Back and Hip Pain 9 months

Recent (12 weeks) increased Lower Back Pain

Recent (6 weeks) increased Left Hip Pain

Unable to sleep through the night due to Hip Pain

Unable to Lift left leg into/ out of car and bed without using hands to help


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History of Trauma

Fractures of the distal Tibia & Fibula (1990) Plate and series of screws fixate distal Fibula

2 screws fixate the distal Tibia

Marked secondary OA

Ankle, Subtalar, Talonavicular &Naviculocuneiform joints


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History of Presenting Complaint

M : Pain Left Hip - X-ray diagnosis: OA Left Hip

A : Noted the patient was depressed and angry about his condition/predicament

R : Pain down left leg in femur

C : Dull constant aching

O : 9 months previous

S : 3/10 on good day, 8/10 on bad day

D : 9 months

R : Good weather

A : Straightening leg whilst lying down or lying on hip

F : Constant

T : Osteopathic, Acupuncture, Massage but not for this condition


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Differential Diagnoses

OA of the Left Hip

As diagnosed by a GP from X-Ray

Current clinical practice guidelines recommendexercise to treat OA(Thomas, & Kravitz, 2014).

SIJ Sprain due to Chronic Poor Gait Pattern

Subjects with sacroiliac joint dysfunction had significantly more external hip rotation on the side ofthe posterior innominate bone(Cibulka, Sinacore, Cromer, & Delitto, 1998; as cited in Knutson, 2004).

Trauma is suspected as the cause of sprain of the SIJ ligaments(Fortin, 1993; as cited in Knutson, 2004).


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Differential Diagnoses

Iliopsoas Syndrome

Conditions involving the iliopsoas muscle include: LBP, sacroiliac pain, disc trauma, hip pain, pelvic

tilt, leg length discrepancies, kyphosis and lumbar lordosis(Morling, 2009).

DJD of the Lower Lumbar

Lumbar degenerative disease present with modification of the sagittal balance, loss of lumbar

lordosis, and increase of pelvis tilt(Barrey, 2004; as cited in Barrey, Roussouly, Le Huec, DAcunzi, & Perrin, 2013).


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Physical Examination Findings

Anterior tipping Right Scapula

Right Foot Supinated and Plantar Flexed 20

Muscle wasting of Entire Right Leg

Active Flexion of Left Hip

External Rotation Left Leg

Posteriorised Left Innominate

Loss of Lumbar Lordosis

Flexed T11T1! segments


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Clinical Reasoning

Treatment Soft Tissue: LE, ES Lx/Tx

Inhibition: Gluteal, Piriformis, Psoas

MET: Hamstrings, TFL, Int/Ext rotation LE, Gluteal, Innominate Rotation L, Lx Rotations

Mobilization: L Hip under Traction

Management Ongoing OMT

Exercise Physiotherapist

Podiatrist


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Working Diagnosis

Left SIJ Sprain due to abnormal gait pattern from severely reduced Right Ankle

Motion and poorly compensating postural musculature, exacerbated by OA of the LeftHip


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PSOASLet us be clear about this: the legs do not originate movement in the walk of a balanced body; the legs support an

Movement is initiated in the trunk and transmitted to the legs through the medium of the (ilio)psoas. Ida


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The Psoas not Iliopsoas

The Psoas differs from the Iliacus(Sajko, & Stuber, 2009).

Different Architecture

Different Innervation

Different Function

Psoas is comprised of both Major and Minor

Psoas minor is often absent

Psoas minor is present in roughly 40% of the population(Biel, 1997)


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Psoas Major Anatomy

Fibrous attachment to lumbar transverse processes

Attachment to anteromedial aspect of all lumbar disc except for L5/S1 disc

Shares common insertion with iliacus muscle

Inserts on the lesser trochanter of the femur

Not a sausage but an elegantly formed muscle

Separate fibres cascade in an almost open spring arrangement from origin to insertion(Morling, 2009)


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Psoas Connections

Diaphragm

The psoas is closely connected to respiration process

Major and minor connect to the central tendon

Pelvic Floor

Psoas major in particular forms a link between the diaphragm and the pelvic floor

Possible role in stabilising the lumbar spine during certain phases of the respiratorycycle.(Richardson, Jull, Hides & Hodges, 1999; as cited in Morling, 2009)


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Psoas Actions

The primary role of the Psoas

Lumbar Stability or Hip Flexion? Most therapists consider it to be the main hip flexor

Iliopsoas flexes and laterally rotates the thigh(Morling, 2009)

Biomechanical Analysis(Bogduk, Pearcy, & Hadfield, 1992; as cited in Morling, 2009))

Feeble action on Lumbar Flexion or Extension

Axial Compression stabilises the Lumbar Spine

Pulling Femur into the Acetabulum


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Psoas States

Contracted Psoas

Due to Postural Habits A deteriorated iliopsoaschronically flexes the body at the level of the inguinal region, so that it prevents atruly erect posture (Rolf, 1989).

When shortened can pull on the spine and/or pelvis to our dominant side

Spasms of Back Muscles resisting the iliopsoas can cause scoliosis, kyphosis and lordosis


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The Psoas Effect

Chronic Psoas Spasm (Chila, 2011. p 1014)

Create persistent strain across Lumbosacral Junction Impede resolution of Lumbosacral Somatic Dysfunction in spite of OMT and Exercise directed at L-SRegion

L1 or L2 vertebrae is Flexed and Rotated to the side of the Hypertonic Psoas Muscle


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The Psoas Effect

The Psoas Paradox(Agnew, n.d; as cited in Morling, 2009)

The Lumbar Spine hyper extends as the Hip is flexed

Disc Degeneration

Attachment site of the psoas pulls the discs on activation

Causes dysfunctional vector forces on the Lumber Spine when psoas is shortened

Destabilization

Hip and Back at distal and proximal Psoas connections


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Not Just a Muscle

The Instinctive Fear Reflex(Koch, 2005)

Can cause a frozen psoas Psoas is responsible for the foetal position

The Reactive Response(Koch, 2005)

Overt emotional and/or strong physical reactions

Fear associated with unresolved trauma


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Psoas Assessment

Psoas Syndrome(Chila, 2011. p 572)

Patient walks flexed forward and listing to one side Restricted hip extension

Psoas Dysfunction(Chila, 2011. p 594)

Leg Extension restricted

Foot tend to be Everted

Referred tenderpoint

1cm medial and just inferior to inferior ASIS


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Psoas Assessment

Assessment 1:

Client supineActive raise and hold both legs 30cm off the table

Client sit up to 45 against resistance

+ve with moderate pain in the inguinal region


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Psoas Assessment

Assessment 2:

Client supine Hands together with palms touching above their head

+ve when one palm lower than the other

+ve when body flexed to one side

Can pull the spine into lateral flexion


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Psoas Assessment

Assessment 3:

Thomas Test The thigh being held to the chest should be at approx. 45

+ve if extended thigh, viewed laterally, is horizontal or above


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Psoas Treatment(Chila, 2011, p 572)

Psoas Syndrome

Key to treat flexed upper lumbar component Treating the psoas

Muscle energy, Still technique, Counterstrain, direct stretching

Home exercises to stretch psoas

Note

Underlying disc protrusion causing spasm

Underlying visceral issue causing psoas hypertonicity


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References

Barrey, C., Roussouly, P., Le Huec, J., DAcunzi, G., & Perrin, G. (2013). Compensatory mechanisms contributing to keep the

sagittal balance of the spine.European Spine Journal, 22(6), 834-841. doi:10.1007/s00586-013-3030-z

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

American Osteopathic Association. (2010).Foundations of osteopathic medicine. A. G. Chila (3rded.). Lippincott Williams &

Wilkins.

Koch, L. (2005). Iliopsoas -- the flee/fight muscle for survival. Positive Health, (108), 54-57.

Knutson, G. A. (2004). The Sacroiliac Sprain: Neuromuscular Reactions, Diagnosis, and Treatment with Pelvic Blocking.Journal

Of Chiropractic,41(8), 32.

MORLING, G. (2009). UNDERSTANDING ILIOPSOAS: CLINICAL IMPLICATIONS FOR THE MASSAGE THERAPIST. Journal

Of The Australian Traditional-Medicine Society, 15(1), 7-12.

Sajko, S., & Stuber, K. (2009). Psoas major: a case report and review of its anatomy, biomechanics, and clinical implications.

Journal Of The Canadian Chiropractic Association, 53(4), 311-318.

Thomas, J., & Kravitz, L. (2014). Exercise Benefits People With Osteoarthritis.IDEA Fitness Journal,11(4), 16-19.

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Compton - Psoas