We often find Iliopsoas trigger points in women with a history of chronic pelvic pain. A trigger point: a hyper-irritable area of the muscular tissue. According to Simons et. al. (1999), a trigger point is associated with a hypersensitive nodule of tissue . When this muscle area is compressed, it is locally tender and can give rise to referred pain. In addition, compression of the trigger point may produce referred tenderness as well as an autonomic phenomena. Trigger points are generally the result of the muscle being overloaded following an acute, prolonged, or repetitive incident. Travell and Simons discuss these trigger points in their book Myofascial Pain and Dysfunction The Trigger Point manual Vol 2.
The woman with Iliopsoas trigger points may experience lower quadrant pain, low back pain with symptoms radiating slightly into the superior gluteal region, or they may report symptoms of the anterior thigh. Functional symptoms may include the report of increased pain of these regions with prolonged sitting and/or standing. She may report increased discomfort when attempting to perform sit-ups or when jogging. Functionally, these trigger points can be activated with any type of weight bearing activities. She will report a reduction of her symptoms when lying down.
The Psoas Major portion of the muscle originates from the lumbar vertebrae while its insertion is at the Lesser Trochanter. The Iliacus portion of the muscle originates from the upper two thirds of the Iliac Fossa and then joins the Psoas and inserts at the Lesser Trochanter. The primary action of the Iliopsoas is to flex the thigh at the hip. It also plays a role in the stabilization of the spine during standing. The Psoas is especially active during sitting. Active trigger point restricts the muscle from fully lengthening and weakness develops in the muscle. Abdominal weakness is also often present in conjunction with Iliopsoas trigger points. Retraining of abdominal muscles becomes crucial in achieving the proper musculoskeletal balance and eliminating recurrent Iliopsoas trigger points.
Examination for this trigger point is critical in the treatment of CPP. Palpation for this trigger point occurs at three places:
- Palpation occurs along the lateral border of the Rectus Abdominus and below the Rectus deeply and medially to assess for tenderness of the Psoas against the lumbar spine placement.
- Palpate along the inner border of the Ileum behind the ASIS to locate the trigger points of the Iliacus.
- Palpate deeply at the Lesser Trochanter along the lateral border of the femoral triangle to assess for the distal trigger point of the Iliopsoas.
Postural observations include an anteriorally tilted Pelvis, a hyper Lordosis as well as a positive Thomas Test. We often find these trigger points in women with a history of low back or abdominal surgery, a history of postural deviations including women with LB, or with Sacroiliac dysfunctions. Decreased abdominal strength/lumbar stabilization is also present in these women.
Physical Therapists can initiate treatment of this muscle through the use of myofascial release techniques, trigger point work, the use of spray 'n stretch, moist heat, and instruction in a home exercise program . The home program consists of regular stretching as well as the use of heat and cold . Visceral work may also play a role in the deactivation of this muscle. It is extremely important to educate the woman in activities she can avoid to prevent Iliopsoas activation. Functional recommendations include limiting prolonged sitting, sitting in a slightly reclined position, standing symmetrically, limiting the amount of weight bearing activities, and avoiding performing sit-ups.
If trigger points persist, further assessment may include evaluation for Rectus Abdominus, internal/external obliques, and quadratus lumborum trigger points. Unequal leg length may also contribute to the perpetuation of this trigger point. A complete assessment of muscle imbalance is also necessary.
As previously discussed in The Iliopsoas Trigger Point, the iliopsoas muscle has a major part to play in the woman with CPP. This article will focus further on the treatment aspect and, specifically, the correct ways to stretch this muscle.
The iliopsoas is primarily a hip flexor; however, it also has a role in each of the following muscle actions:
· Extension of the lumbar spine when the individual is standing with a normal lordosis.
· Forward flexion when the person attempts to bend forward.
· Hip lateral rotation (the iliopsoas has a small amount of involvement with this).
The following method effectively stretches the iliopsoas:
· Place the hip in extension,
· Place thigh in slight medial rotation or a neutral position,
· Place hip in adduction or in a neutral position.
While being stretched, the patient lies on the uninvolved side with her lower back very close to the edge of the treatment table, supported by the clinician.
Before treatment of the iliopsoas, it is essential to treat any mechanical dysfunction of the lumbar spine, as well as address any musculoskeletal imbalances that are present. Muscles to assess include: the hamstrings (bilaterally), postural extensor muscles, the gluteals and the quadratus lumborum.
The application of intermittent cold, well described by Travell and Simons, provides an effective method of treatment in conjunction with stretching. A therapist completes the technique of intermittent cold by stroking the iliopsoas muscle with ice. Filling a papercup with water, inserting a stick and then freezing it provides an easy way to deliver this treatment. The flouri-methane spray method is no longer recommended. Following the application of ice and stretching, apply a moist heat pad to the abdomen, then move the muscle through the full range of motion (shortened and lengthened positions).
An additional method of treatment is the utilization of postisometric relaxation. This is the process of isometrically contracting the muscle against applied resistance, and then allowing the muscle to relax. Hold the contraction for 3-10 seconds and at less than 25% of maximal effort, then release the contraction and apply a direct stretch to the muscle fibers. Travell and Simons have described this in Vol. 2, Myofascial Pain and Dysfunction: The Trigger Point Manual.
It is very important for the woman receiving treatment to continue with her individualized home exercise program. This will promote the reduction of the trigger points. Home stretching may include lying with the hips flat on the table and then pushing up with the arms while the hips remain flat on the table. There are many alternative ways of stretching this muscle, including supine and kneeling positions. Postural recommendations to the patient should include limited prolonged sitting. When the individual is sitting, it is recommended she sits with an open angle at the hips, so that the seat is raised slightly for the thigh to slope down toward the front of the seat. To relieve pain, a woman with an iliopsoas trigger point could also position herself on her hands and knees. When sleeping, it is recommended to avoid sleeping on one's side so as to avoid activating the iliopsoas.
After lengthening the iliopsoas, it is essential to establish a program of strengthening. Particular emphasis needs to be placed on strengthening the rectus abdominus in conjunction with the iliopsoas.
Treatment of the iliopsoas trigger point may require the implementation of a variety of techniques. It is imperative that lengthening programs, and eventually strengthening programs, are implemented to achieve a long-term resolution of the condition. The woman must also be faithful in following through with a home exercise program.
Myofascial Pain and Dysfunction: The Trigger Point Manual, The Lower Extremities. Janet G. Travell, M.D.