Grand Rounds 2014

Heath Compton
Patient Details
Male
Early 60s
Retired
Healthy: cycles and swims
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
History of Trauma
Fractures of the distal Tibia & Fibula (1990)
Plate and series of screws fxate distal Fibula
2 screws fxate the distal Tibia
Marked secondary OA

Ankle, Subtalar, Talonavicular &

Naviculocuneiform joints
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
Diferential Diagnoses
OA of the Left Hip
As diagnosed by a GP from X-Ray
Current clinical practice guidelines recommend
exercise to treat OA (Thomas, & Kravitz, 2014).
SIJ Sprain due to Chronic Poor Gait Pattern
Subjects with sacroiliac joint dysfunction had signifcantly more external hip rotation on the side of
the 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).
Diferential 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 modifcation 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).
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

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
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 Left
Hip
PSOAS
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
The Psoas not Iliopsoas
The Psoas difers from the Iliacus (Sajko, & Stuber, 2009).
Diferent Architecture
Diferent Innervation
Diferent 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)

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 fbres cascade in an almost open spring arrangement from origin to insertion (Morling, 2009)
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 foor
Possible role in stabilising the lumbar spine during certain phases of the respiratory
cycle. (Richardson, Jull, Hides & Hodges, 1999; as cited in Morling, 2009)
Psoas Actions
The primary role of the Psoas
Lumbar Stability or Hip Flexion?
Most therapists consider it to be the main hip fexor
Iliopsoas fexes and laterally rotates the thigh (Morling, 2009)
Biomechanical Analysis (Bogduk, Pearcy, & Hadfeld, 1992; as cited in Morling, 2009))
Feeble action on Lumbar Flexion or Extension
Axial Compression stabilises the Lumbar Spine

Pulling Femur into the Acetabulum

Psoas States
Contracted Psoas
Due to Postural Habits
A deteriorated iliopsoaschronically fexes the body at the level of the inguinal region, so that it prevents a
truly 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
The Psoas Efect
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-S
Region
L1 or L2 vertebrae is Flexed and Rotated to the side of the Hypertonic Psoas Muscle
The Psoas Efect
The Psoas Paradox (Agnew, n.d; as cited in Morling, 2009)
The Lumbar Spine hyper extends as the Hip is fexed
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
Not Just a Muscle
The Instinctive Fear Refex (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
Psoas Assessment
Psoas Syndrome (Chila, 2011. p 572)
Patient walks fexed 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
Psoas Assessment
Assessment 1:
Client supine
Active raise and hold both legs 30cm of the table
Client sit up to 45 against resistance
+ve with moderate pain in the inguinal region

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 fexed to one side
Can pull the spine into lateral fexion
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
Psoas Treatment (Chila,2011,p 572)
Psoas Syndrome
Key to treat fexed 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
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 (3
rd
ed.). Lippincott Williams &
Wilkins.
Koch, L. (2005). Iliopsoas -- the fee/fght 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 Benefts People With Osteoarthritis. IDEA Fitness Journal, 11(4), 16-19.