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Psoas muscle pain

Relieve psoas muscle pain

Chris Mallac has some unusual advice on how clients can self-manage tricky psoas muscle problems

Sports and musculoskeletal therapists are well versed in educating athletes on self-management of muscle tone/tightness problems and self-release techniques for trigger points. Indeed, 'trigger balls', muscle mates and tennis/golf balls are common contents in the kit bags of athletes, for self-treatment in hotels while on tour, or after training sessions. However, certain muscles in the body, such as the psoas, are particularly tricky when it comes to self-management techniques and relieving pain.

The psoas is a deep hip muscle that has often been clinically implicated in low back pain syndromes and problems of the groin and pelvis. Here, we look at a novel way to self-manage psoas trigger points using a broomstick. I have called this the ‘Buzzy broomstick’ out of respect for the former international rugby player Mark ‘Buzzy’ Connors, who first showed me this innovative technique.

Psoas muscle anatomy and function

The psoas is a deep hip muscle that originates on the vertebral bodies and transverse processes of the lumbar vertebrae (L1-5) and discs of T12/L1 to L4/5. It is functionally divided into psoas major and minor, although it will be considered as a single muscle here. It courses vertically downwards to cross the front of the pelvis and insert on to the lesser trochanter (inside edge) of the femur. It is innervated by branches of the L1-3 lumbar spinal nerve roots.

The main functions of this muscle are: i. to flex the hip ii. to compress the spine (in the vertical direction) iii. to flex the trunk with bilateral contraction (with the thigh fixed) iv. to flex one side of the trunk with unilateral contraction (with the thigh fixed).

Of particular anatomical interest is the close relationship the psoas has with the ilioinguinal nerve and the iliopectineal bursa.

Ilioinguinal nerve: The ilioinguinal nerve arises from the L1 lumbar nerve. It emerges laterally at the psoas muscle and then passes in front of the posterior abdominal wall, running around the trunk and down through the inguinal canal. It terminates on the inner front of the groin. The nerve innervates the lower transversus abdominis muscle and supplies sensation to the inner groin area.

The clinical and often anecdotal relationship between psoas dysfunction and groin problems has always been of interest to sports medicine practitioners. It has often been argued that psoas tightness will lead to movement dysfunction around the hip and pelvis, and this can lead to breakdown of the myofascial elements around the lower abdomen and groin region.

However, the ilioinguinal nerve may also cause problems as a result of its close anatomical relationship to the psoas muscle. It is hypothetical that the muscle-nerve relationship might be a precursor to groin syndromes if the interface between the two becomes pathological, in a similar way to how, for instance, tarsal tunnel syndrome and posterior tibial nerve compression lead to medial arch pain and dysfunction.

Thus, a neuropathy in the ilioinguinal nerve may lead to conduction problems to the motor component of this nerve – the transversus abdominis. Inhibition and dysfunction in the firing in this muscle may then lead to delayed and ineffective stability at the lumbar spine and the symphysis pubis. This in turn may produce excessive shear force around the symphysis during movement, resulting in breakdown of the joint.

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Furthermore, the transversus abdominis forms part of the medial and posterior wall of the inguinal canal. Weakness in this area may lead to breakdown of the myofascial elements such as the inguinal canal, adductor tendons and conjoined tendon.

Iliopectineal bursa This bursa (sac of fluid) lies between the lower psoas muscle and the iliopectineal eminence of the pelvis. It acts as a cushion to reduce friction between muscle and bone during muscle contraction. It has been suggested that an excessively tight psoas muscle and repeated hyperextension of the hip (as with kicking) may predispose this bursa to excessive friction and compression, causing an acutely painful bursitis.

Pathology and dysfunction in the psoas

There is not much published literature examining the contribution of psoas/iliopsoas to musculoskeletal problems around the lumbar spine and groin. A few studies have demonstrated a reduction in the crosssectional area of the muscle at the level of spinal dysfunction. Cooper (1992)(1) found atrophy in the psoas in patients with recent and chronic low back pain, with more pronounced wasting in the chronic back pain sufferers. Dangaria and Naesh (1998)(2) looked at psoas major in the context of unilateral sciatica associated with disc herniation, and found a reduction in the cross-sectional area of the muscle at the level and the site of disc herniation.

Points has received a great deal of interest in the sports medicine literature over the years. For a detailed discussion of trigger points, see Ulrik Larsen in SIB 10 and 11.

Citing six case studies, Ingber (1989)(3) demonstrated that he was able to improve hip and spinal extension and reduce low back pain in patients after iliopsoas trigger point injections (dry needling).

According to Travell and Simons(4), iliopsoas trigger points may refer pain laterally to the lumbar spine and into the sacroiliac joint. This may occur with sitting, standing, lifting and getting out of a sitting position. This commonly imitates discogenic back pain. The therapist may assess that hip extension is restricted, the client stands with extreme lumbar lordosis and/or may be unable to stand upright. At www.tandempoint.com/ p20.htm you can refer to the classic Travell and Simons diagram that highlights psoas trigger points and their referral pattern.

Self-management with the Buzzy broomstick Assessment

Prior to any athlete impaling themselves on a broomstick, it is best that they consult a sports physiotherapist to assess the psoas muscle and its involvement in any lower back problems or pelvic/groin problems they may be suffering. Accurate palpation of the psoas for trigger points is necessary so that the client has an appreciation and ‘feel’ for depth of penetration through the abdominal wall to access this deeply situated muscle.

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The stick

If it’s not possible to raid the nearest quidditch match, the athlete will need to pick up a 6ft broomstick from a local hardware store. One end of the stick should be rounded to avoid causing a great deal of pain and discomfort.

The position (Figure 2)

Place one end of the broomstick into a corner at approx hip height. Standing in front of the broomstick but slightly off centre, place the rounded end of the stick 1in to 2in (2.5cm to 5cm) lateral to the rectus abdominis (sixpack) muscle. This is the best position to find the psoas muscle. The exact height of penetration will depend on where the trigger points are located in the muscle. As a guide, starting at umbilical height and working up and down from there, you should find some nice and nasty trigger points. The key to this self-management technique is to keep the abdominals completely relaxed to allow easy and pain-free penetration into the deeply situated psoas muscle.

A variation on the standing position shown in figure 2a-c is to perform the same procedure in sitting. The benefit of sitting is that the abdominal muscles are completely relaxed and off-stretch, making it easier to penetrate the abdominal wall. The downside is that the psoas is also off-stretch, and often the best trigger points are found with the hip in neutral or slight extension (as it would be in standing).

The length of hold on the trigger point and frequency of treatment will very much depend on the individual. A psoas subjected to repeated stress in the form of hip flexion movements (eg cycling) may require prolonged and deep treatment to relieve any longstanding muscle tone issues. If the client does nothing but play cards and collect stamps all day, and has suffered an acute onset of back pain related to psoas spasm, then they will only need short duration and infrequent treatment.

References

1. Cooper et al (1992) British Journal of Rheumatology 31:389-94

2. Dangaria TR and Naesh O (1998) Spine 23(8):928-931

3. Ingber RS (1989) Archives of Physical Medicine and Rehabilitation 70:382-386

4. Travell JG, Simons DG (1992) Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol 2, Williams & Wilkins, Baltimore, p90

Psoas muscle pain