Why does poor psoas get all the blame?

Many times you heared from your patient that I have very tight hip. What we would prefer to call it is anterior hip tightness/pain/dysfunction as we feel that hip needs to be address as an entire functional unit, not a single muscle. 

How to manage with anterior hip pain !!

There are two approach for the same.

1. Identify and address the underlying dysfunction that caused the hip problem i.e. poor lateral stability, poor gluteal function, poor centring of the femoral head etc. 
2. Anterior hip muscles should be targeted

Clinical anatomy

There are many structures to consider in our assessment of the anterior hip.

• Anterior:  Sartorius, rectus femoris, iliacus, psoas major, psoas minor, iliocapsularis and pectineus.
• Lateral:  Gluteus medius, Glutues minimus and TFL

There is also the femoral nerve, artery and vein to pectineus, psoas major, psoas minor and iliacus. 

When we look close to the hip anatomy, there are many structures and we only claim to only one muscles without assessing others and limit our clinical reasoning. 

If you are checking the stability of hip joint The muscles considered to act as deep stabilisers of the hip are quadratus femoris, gluteus minimums, the gamelli, obturator internus and externus, iliocapsularis and deep fibres of iliopsoas. Hence, if you are going to assess stability of the hip, considering the function of each of these muscles is important to remember. 

If iliopsoas is a hip stabiliser (still there id debate going on for the same), lumbar stabiliser and hip flexor, then it’s behaviour and function is going to be impacted by all the other muscles acting as hip stabilisers or hip flexors.  

We found from our clinical outcomes that tight psoas is not always tight through this region, but these muscles too much for stability during movement. 

Anterior hip assessment

• Functional assessment:
  • Control of hip movement and activation patterns during a stalk test, looking at gluteal activation on the weight bearing leg and the movement of hip flexion on the non weight bearing leg. 
  • What are the aggravating factors of movement dysfunction. 
• Palpation:
  • Palpation of all the different muscles around the hip joint by using movements such as hip rotation, hip adduction, hip abduction to confirm which muscles you are feeling and targeting for rehabilitation. 
  •  ASIS and along the line of inguinal triangle
• Muscle function:
  • Control of movement, pain provocation and stability during an ASLR test.
  • Control of hip extension and pelvic rotation during a bridge or single leg bridge test. 
• Range of motion testing:
  • Prone hip passive extension.
  • Thomas test position (iliopsoas)
  • Ober’s test (ITB and lateral thigh structures).
  • SLR test
• Joint assessment
  • External and internal rotation in supine (90 degrees) and prone (more neutral hip position).

Clinical tips

[restrict]We always listen from our colleague that patient`s iliopsoas are very tight and we directly blame on it. However, not all injuries are related to iliopsoas dysfunction. But there are definitely people who suffer from iliopsoas tightness and anterior hip pain, here are some clinical tips that we conclude from our clinical practice. 

When palpating this region we always start just above ASIS or the crest of the anterior hip. The initial aim is to palpate the general area to check for tenderness through the abdomen and hip before going in deeper to palpate along the line of the iliopsoas.

Our preference of postion is with [restrict]one hand over the other and fingers gliding down the fibre of the muscles. Depth is dependant on the patient’s weight but it must not to be forceful. Treatment of the iliopsoas is uncomfortable to a degree but this discomfort is often out-weighed by the response of releasing the iliopsoas muscle and surrounding region. Generally the iliopsoas muscles doesn’t need a long treatment to gain relief, taking around 2-3 mins each side.

Treatment tips

You can try  with knees bent up and asking the patient to slide their leg into a ship flexion/extension or to do hip external and internal rotation) during these movement you maintain a constant pressure with your fingers on psoas major. Once the muscle has been palpated the therapist will use relevant techniques to treat the cause.

Anterior hip Stretches

 

My hope is that this blog has broadened your imagination about the many ways you can reduce the problem of anterior hip tightness and pain. There is a lot more to assess than the Thomas Test or treat than the kneeling hip flexor stretch. The aim for the second blog is focussing on enhancing abdominal muscle technique without loading the hips or lower back. 

 

References:

Anloague, P. A., Somers-Chorny, W., Childs, K. E., Frankovich, M., Graham, C., & Birchfield, K. (2015). The Relationship between Femoral Nerve Tension and Hip Flexor Muscle Length. Journal of Novel Physiotherapies, 2015.

Babst, D., Steppacher, S. D., Ganz, R., Siebenrock, K. A., & Tannast, M. (2011). The iliocapsularis muscle: an important stabilizer in the dysplastic hip.Clinical Orthopaedics and Related Research®, 469(6), 1728-1734.

Retchford, T. H., Crossley, K. M., Grimaldi, A., Kemp, J. L., & Cowan, S. M. (2013). Can local muscles augment stability in the hip? A narrative literature review. J Musculoskelet Neuronal Interact, 13(1), 1-12.

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