Iliopsoas treatment

Replies to This Discussion

Permalink Reply by Christopher V Jones on December 13, 2009 at 9:46pm

Whitney, was this published somewhere? I do not recall reading it.

Permalink Reply by Michelle Doyle, D.C., CNMT on December 13, 2009 at 11:10pm

I don't recall reading any reports about this either, but I'm sure there are risks involved with any procedure. I think Iliopsoas work is safe if done correctly and by obtaining a thorough medical history to rule out abdominal aortic aneurysm and other contraindications. Although AAA may be asymptomatic, abdominal and low back pain are common symptoms. If these symptoms present in combination with a family and/or patient history of high cholesterol and heart disease...it may be wise to avoid abdominal approaches for treatment of the iliopsoas, especially compression treatments in that region. I would be interested to hear what other approaches are being used for treatment of the iliopsoas.

Michelle

Permalink Reply by Joseph E. Muscolino on December 13, 2009 at 11:21pm

Hey Whitney,

I know that you are not a big fan of direct massage on the iliopsoas. I do not have any definitive answers to this, but would probably echo Michelle in that every procedure has a certain level of risk. My concern in taking massage of the iliopsoas off the table as a treatment option is that regarding physical approaches, it only seems to leave stretching as a therapy of choice. That seems pretty limiting treatment option-wise... It is not that I think that stretching is not effective, it is just that the combination of massage (and heat if possible) followed by stretching is so effective, and in my experience, stretching, as much as I love it, by itself is not "that" effective unless the tissue is somehow warmed up first.

Permalink Reply by Allison Ishman on December 14, 2009 at 12:46am

This sounds like a genuine risk. I have long wondered why Iliopsoas treatments that are taught in core massage programs so heavily emphasize treatment at the upper attachment sites, but not at the femoral attachment. Most massage professionals in my fascial CE classes struggle to accurately palpate the femoral Iliopsoas (IPS) attachment without help and practice. Many tell me they've never taken the time to specifically palpate it before. Since the femoral attachment is so much easier and less invasive to work with, it makes sense to approach the femoral attachment fibers before going to deep abdominal work.

Working with the IPS attachment on the femur is usually sufficient to release this muscle group when when treated in combination with compensating structures such as Iliotibial Band (ITB), Tensor Fascia Latae, Quadratus Lumbourm, etc. However, I concede that I'm using fascial links, and am therefore using two points to release the lower IPS attachment. I typically link IPS with Flexor Retinaculum by the Calcaneus, or with the ITB. (Interestingly enough, IPS shares fascial links to either ITB. The right IPS links fascially with right ITB or left ITB interchangeably.)

I haven't had to fight my way through an abdomen in so long I can't remember when it last was. The suggestion that it may rupture an aneurysm is further incentive to avoid it. I would be interested in referencing the report, if you will share it. I'm still in writing mode.

Permalink Reply by Whitney Lowe on December 14, 2009 at 2:01am

This was not a published account. I'll see if I can track down the source and get further documentation on it.

Another issue of concern that I don't hear many people speaking about with this treatment is the fact that you are putting direct pressure on the small intestines and pressing them against the underlying iliopsoas. I know people teach that you wiggle your fingers back and forth a little until you move between them, but let's be serious. Looking at the amount of small intestine in this area, I think its pretty clear that slighly wiggling your fingers back and forth is not going to magically move you in between all these tissues. In conditions such as Ehlers-Danlos syndrome there is excessive weakness of the connective tissues. Applying this kind of pressure in the abdomen could be extremely dangerous in a case like that.

Granted I would hope that we'd pick up most of these potential contraindications in an interview/evaluation but I have serious doubts about whether this happens as frequently in practice as it should. I am quite concerned about the educational level of many students entering the profession these days (which seems to have gone down significantly in the last 10 or so years). Consequently, I have great reservations about the large majority of massage therapists attempting to perform this treatment and that is one of the reasons I advocate such caution.

Permalink Reply by Stephen Jeffrey on December 14, 2009 at 7:40am

I agree with you Whitney, and Allison.

I had treatment to my iliopsoas 7 yrs ago via abdominal wall as part of the 10 series of rolfing....certainly seemed to stir up alot of emmotional "stuff". I dont work this muscle in this way.

Has anyone ever thought about what happens to the internal organs/space when this muscle is over developed "body builder" style ??

Permalink Reply by Joseph E. Muscolino on December 14, 2009 at 8:22am

regarding the concern with bodybuilding and overdeveloping this muscle for the internal visceral organs, I do not see it as likely that there is a danger. I was just teaching cadaver labs over the last few weekends and seeing the structures up close. The intestines have a lot of motility and an extra bit of muscle mass should not matter much in my opinion. Its overdevelopment, especially if it is tight would seem more a potential danger for the roots of the lumbar plexus that run through it.
I do agree about the unlikeliness of wiggling the intestines out of the way. I heard a similar statement made about working it with the client on the side to make the intestines fall out of the way. I doubt it.

I am not so sure about releasing the muscle by just working one point along the muscle. I am not saying that I know that it does not work, I am just not convinced. I often hear about a muscle being released IF this one point or another is worked. Perhaps. I would love to see the rationale and/or any evidence backing it up. :)

IF there is a central TrP in the belly of the muscle, then I am not sure how effectively it can be released without direct work. This work does not have to be "invasive" or horribly uncomfortable for the client. Deep work can be done more gradually...

All told, I do recognize your concerns Whitney, just not enough to avoid working the muscle in some clients whose condition really indicate it.

Permalink Reply by Thomas Myers on December 14, 2009 at 8:55am

• That the iliopsoas should be approached from the lateral side, sliding down the 'ski-slope' of the iliacus toward the psoas from the ASIS above the inguinal, not from the edge of the rectus abdominis as I have heard some teachers recommend.
• Having your supine client lift his foot should immediately identify the confines of the psoas to your hand, allowing you to differentiate from the femoral nerve or iliac artery, ureters, et al.
• That any hot, searing, or gassy pain should be an order to stop and reapproach (mesocolon and other intestinal ligaments are here on the outside)
• That any pushback (pulse) from the tissues should be a stop order as well.

The problems with a little back pressure on the external iliac artery should be negligible in most of our clients, though I just dissected a guy with an abdominal aneurysm the size of my fist, so I am glad I wasn't trying to do any abdominal work on him.

Permalink Reply by Joseph E. Muscolino on December 14, 2009 at 5:32pm

Hey Tom,

Is your reasoning to approach from so far lateral simply to access the iliacus too? Or is it also based on how you feel the psoas major belly itself should be accessed, and if so, why?

Thomas Myers said:

• That the iliopsoas should be approached from the lateral side, sliding down the 'ski-slope' of the iliacus toward the psoas from the ASIS above the inguinal, not from the edge of the rectus abdominis as I have heard some teachers recommend.
• Having your supine client lift his foot should immediately identify the confines of the psoas to your hand, allowing you to differentiate from the femoral nerve or iliac artery, ureters, et al.
• That any hot, searing, or gassy pain should be an order to stop and reapproach (mesocolon and other intestinal ligaments are here on the outside)
• That any pushback (pulse) from the tissues should be a stop order as well.

The problems with a little back pressure on the external iliac artery should be negligible in most of our clients, though I just dissected a guy with an abdominal aneurysm the size of my fist, so I am glad I wasn't trying to do any abdominal work on him.

Permalink Reply by Thomas Myers on December 15, 2009 at 4:52am

There's so much in all these posts, I don't know where to reply, so here goes and hope it lands in the right place. The small intestine really does 'move out of the way' if your hands are soft and they insinuate their way to the psoas (lumping together the iliacus and the psoas into an 'IPS" is an error. They may share an origin (or so I see it) with the pectineus at the femur, but iliacus is an app-app muscle, while psoas is an axial-app muscle, and therefore of a different order). If you do some dissection or watch some surgery, you will see how moveable and slippery the small intestine is; it is very difficult to pin it between you and the back wall. There is the possibility of pinning the mesenteric root, but if you are that close to the back wall and the midline, I have to ask, "What are you doing there?"

The large intestine is less moveable, though it has to be somewhat loose to allow for filling and emptying, as well as peristaltic movement. On the left, the descending colon / sigmoid transition is something to watch for and avoid in the valley between the iliacus and the psoas (the home of the sometimes restricting iliac fascia, which houses at its root both the femoral nerve and the femoral / iliac artery). On the right, the cecum is very large and loose and moveable. I don't experience problems with either of these approaches to the iliacus or psoas, where you can access, lateral to medial: ASIS, iliacus, iliac fascia, lateral psoas, psoas minor, medial psoas (I distinguish lateral and medial psoas in terms of function, too long to explain here), and finally ureters and other viscera I generally avoid unless visceral restrictions are indicated - but I don't recommend this without training in Barall's Visceral manipulation)

Likewise, it is quite possible to access (and to teach access) to the distal end of the psoas / iliacus / pectineus complex at the lesser trochenter without compressing the femoral artery. There is a simple pulse test for an abdominal aneurysm, but soft hands are the essential element in my book - soft hands and precise placement.

Personally, I cringe when someone tells me they are working the upper attachment sites of the psoas major or minor, as this is where the kidney 'sock' attaches, and I am loathe to ptose a kidney. My students can only approach the upper psoas when they can tell me accurately about the arterial supply to the kidney and how they are going to avoid it. Having basic massage students go for these attachments makes me wince, and they ain't doin' it on me! (My measure for how safe something is - if I will not let my students do it on me, then it ain't safe enough.)

I am sure there are risks involved with a hidden AAA or IBS or other conditions, but I have gotten such consistently good results from treating the psoas over the years that I would hate to give it up. I likewise do not 'fight' with an abdomen to get there, but I will dance with an abdomen (even a Pilates-overtrained one) to get the release for a compressed lumbar spine, or undo a thoraco-lumbar rotation, or hydrate the lumbar plexi (good for 'obstipation' as the Europeans call it), or most commonly to correct either a flat lumbar spine (over-short upper psoas fibers) or a lordotic one (lower psoas fibers).

Permalink Reply by Joseph E. Muscolino on December 15, 2009 at 9:59am

The beauty of these discussions for me is that it focuses my attention to critically think and look for something that I would not have otherwise looked for or even had on my radar. Tom, seeing the mass of the small intestines and being aware of their fascial connections made me write and makes me think that they would not really move out of the way, and I was just in the cadaver lab for 15 hours in the last two weeks. But, I will go back in and explore his more fully. Perhaps one can wiggle down between them. Thanks for your input.
I will add one note, and that is with all the talk and concern of pressing on an artery, short of an aneurysm, I would think that if sustained compression were to be put on a vein, IVC or perhaps the renal vein, that would cause more potential damage in causing a bit of a back up of drainage from the region...

Permalink Reply by Robert Downes on December 17, 2009 at 4:10pm

Another manual therapy to try is Functional Manual Reaction http://3doptimalperformance.blogspot.com/2009/12/introduction-to-fu.... You can effectively mobilze the iliopsoas by targeting each plane in a stable environment (True Stretch). You can also add wedges to influence the kinetic chain to put more emphasis on the hip flexors. You can also add "activation" techniques to the glutes to decrease the neural drive to the hip flexors.

• ‹ Previous
• 1
• 2
• Next ›
• Page