Iliopsoas Muscle and the Management of Iliopsoas Syndrome

Introduction

The iliopsoas is a deep muscle group that connects lower limbs to the spine. The iliopsoas has a significant role in daily activity and sports, and it is considered the significant hidden root cause of pain in the lower back, hip, and thigh. Hence, any traumatic injury to the muscle results in restricted spine, hip, and knee movement.

What Is Iliopsoas, and What Are the Functions of Iliopsoas?

The iliopsoas complex muscle comprises two muscles

• Iliacus

• Psoas major

Iliacus: The triangle-shaped inner hip muscle that flexes and rotates the thigh bone, eventually helping to bend, run, walk, sit, and maintain correct posture. It is one of the primary muscles of hip flexion (bringing the knee to the chest) that enables forward tilt of pelvic and side bending.

Psoas Major: Psoas major is a long, thick, fusiform muscle that runs from the lumbar spine through the groin, connecting the upper and lower body. The psoas major act along with the iliacus to promote hip flexion. Despite its attachment to the lumbar spine, the psoas plays a predominant role in maintaining an upright posture. Hence the contraction of this muscle affects the lumbar vertebra resulting in pelvic torsion (twisting due to force excursion) when there is a rupture of these two muscles resulting in iliopsoas syndrome.

What Is Iliopsoas Syndrome?

The ischemic condition of the iliacus and psoas major gives rise to iliopsoas syndrome. Hip and groin pain are commonly associated with iliopsoas syndrome but may also result from the trauma of other structures surrounding the hip. Unfortunately, due to its complexity, the iliopsoas pathology is hard to distinguish from others. The iliopsoas syndrome is characterized by

• Acute Groin Pain: The groin pain is frequently related to iliopsoas. Primarily seen in sports, people who involve kicking and changing direction - football and soccer.

• Lower Back Pain: The loss of hip motion contributes to lumbar spine pain and disability and increases pelvis rotation and lordosis (a high lumbar curve affects the posture of the hip). The studies show that stretching of iliopsoas reduces lower back pain.

• Pelvis Pain: The iliopsoas stabilizes the hip and pelvis during single-leg balance. Hence play a significant role in pelvis rehabilitation.

• Hip Snapping: The painful, audible and palpable (touch sensation) snapping occurs when the hip is moved from flexion to an extension.

• Others: Pain can also occur in the following organs:

• Lower abdomen.

• Buttocks.

• Thigh and lower leg.

• Sacroiliac joint (joint connecting spine and pelvis).

• Across the top of the hip bone (iliac crest).

• Wrapping or clicking sound in the lower back or pelvis.

What Are the Causes of Iliopsoas Syndrome?

Iliopsoas syndrome is mainly caused by the contraction of the iliac and psoas major muscles due to prolonged sitting. The muscle usually adapts to the contraction state and is problematic in returning to its normal position. Other causes are

• Sports - Commonly seen in athletes due to continuous hip flexion.

• Malnutrition results in poor strength.

• Abnormal leg length.

• Pelvis torsion.

• Lordosis (high lumbar curve affects the posture of the hip).

• Cycling.

• Ballet dance.

• Track work with improper training.

• Repeated up and down movement of feet (jogging).

What Is the Other Consequence of Iliopsoas Syndrome?

The chronic construction of the muscles results in various undesirable consequences like

• Ischemia - Loss of blood flow to the affected muscle.

• Referred Pain - The pain radiates from one part of the body to other. Familiar pain sensations are tingling, numbness and aching.

• Restricted hip joint movement.

• The abnormal body posture; hyperflexion of hip or forward head posture.

• Nerve injury or entrapment.

How to Diagnose Iliopsoas?

The iliopsoas muscle group evaluation is based on medical history, clinical examination, and imaging.

Medical History: Gathering past medical information is complex because it may not be distinguished from other hip conditions by specific symptoms. Therefore, it is sometimes difficult to identify an issue with the iliopsoas based on medical history. The anterior hip and groin pain is the most typical symptom of iliopsoas syndrome and is frequently mistaken for an intraarticular hip condition.

Clinical Examination: The followingfive tests assess muscle function, flexibility, and palpation:

• Isometric-Resistance Muscle Test: Used to evaluate muscle pain and strength. Generally, hip strength decreases with pain.

• Modified Thomas Test: The test is performed when the patient lies on the edge of the table and is frequently used to measure hip flexibility.

• Palpation: The muscle contraction of the iliopsoas is easy to palpate while using the appropriate technique. Simultaneously, the pulse is noted on the palpated site when the muscle has increased blood supply. The therapist only carries palpation.

• Flexion Adduction Internal Rotation: Less commonly used because of higher sensitivity.

• Skin Rolling Test: Evaluate trigger or referred points, erythema, movement, and stiffness of the skin of the lower back's iliopsoas muscle.

Imaging Tests: X-rays, ultrasound, MRI (magnetic resonance imaging), and CT (computed tomography). X-rays are used to evaluate fractures; CT scans are the standardized protocol with three dimension imaging technique. MRI is used along with CT to evaluate more details of soft tissue.

How to Manage Iliopsoas Syndrome?

Initially, iliopsoas was managed by the R.I.C.E technique.

• Rest: Significant amount of rest is required to reduce inflammation.

• Ice Therapy: Ice packs get rid of erythema and promote healing.

• Compression: Along with ice pack compression results in a good prognosis.

• Elevation: Increase the blood supply on the affected site.

Physical Therapy: Physical therapy is the primary strategic protocol in managing the iliopsoas syndrome. The conservative management of physical therapy involves spine mobilization, strain counter strain, soft tissue mobilization directed at a trigger point, passive range of motion, contract relaxation, and skin rolling.

• Spine Mobilization: Spine mobilization is carried out after a joint mobilization program on the affected side, which helps to tighten the muscles and to limit joint movement.

• Counter Strain: The patient is often positioned supine with both knees bent and legs crossed to avoid stress on the affected region, promote muscular relaxation, and reduce pain. The therapist performed the strain technique with trigger point evaluation on the lower back for a significant result. The patient was advised to remain in this posture for a minimum of 90 seconds to relieve pain. Hence, it is called positional release treatment.

• Trigger Point Treatment: Techniques for treating trigger points include massage, prolonged pressure, and transverse or rotational movement. The technique was performed after two weeks of surgery in a relaxed position.

• Friction Therapy: The pressure the therapist applies in the triggering point while side-tracking the hip. The patient's posture is modified to a 90-degree hip flexion with unsupported feet. As a result, the iliopsoas muscle will contract. And the mobilization belt is used to alter the patient's hip.

• In a Modified Thomas Test, Soft Tissue Technique: The technique differs from one person to another based on pain frequency and irritability. When a patient experiences irritable pain mobilization belt is placed in the patient's thigh and secured to avoid hip extension because the iliopsoas muscle should not be stretched with this approach. In contrast, the non-irritable patient is not supported with a mobilization belt. This technique allows the iliopsoas muscle to be activated and extended with hip motion.

• Skin Rolling: After a positive skin rolling test, the technique promotes flexibility and joint mobility.

Conclusion

The iliopsoas is essential for basic day-to-day activities, as well as sports. Although the iliopsoas muscle group is poorly understood, difficult to examine, and problematic to treat, muscle strengthening programs play an active role. Unfortunately, Iliopsoas muscle strengthening is frequently believed to harm the muscle and cause strain on the hip joint. But many studies show that it is ultimately a misconception.