Continuing Education Activity

Psoas syndrome is a disorder of the iliopsoas muscle leading to back pain, groin pain, snapping hip, buttock up, or difficulty standing. Psoas dysfunctions are common in athletes but can also impact the general population due to their frequent activation as a hip flexor during walking and everyday activities. This activity reviews the muscle energy treatment of the iliopsoas muscle and highlights the role of the interprofessional team in evaluating and treating this condition.

Objectives:

• Review the classic presentation and physical exam findings of psoas syndrome.
• Describe the anatomy of the iliopsoas muscle related to psoas syndrome and mechanisms underlying muscle energy and counterstrain treatments.
• Describe the muscle energy treatments of the iliopsoas muscle from both the supine and prone positions.
• Review the contraindications to muscle energy and counterstrain treatment of the iliopsoas muscle.

Introduction

Psoas syndrome results from dysfunction of the iliopsoas muscle and causes a constellation of symptoms, including low back pain, groin pain, pelvic pain, or buttock pain. The primary action of the iliopsoas muscle is hip flexion. Therefore, back pain may occur with standing, walking, or changing position from sitting to standing.[1] The associated buttock pain is often on the contralateral side and can radiate down to the knee. When the iliopsoas tendon passes over a bony prominence, it can cause rubbing at these points that produce a “pop” or “snap,” leading to a condition called Coxa Saltans or snapping hip.[2] However, psoas syndrome can occur independently of snapping hip. 

Psoas syndrome is commonly seen in athletes, especially jumpers, dancers, and runners, and is among the most common causes of groin pain in this group.[3] However, psoas syndrome can occur in non-athletes due to overuse, given its function as a hip flexor and external rotator of the leg. Treatment typically consists of conservative measures such as activity modification, physical therapy, manual therapy, NSAIDs, and corticosteroid injections. If conservative measures do not relieve symptoms, surgical iliopsoas release can be a consideration.[4]

This procedure review focuses on the use of osteopathic manipulative treatment (OMT) to treat iliopsoas dysfunction. The two specific osteopathic manipulative treatment modalities for the iliopsoas that will be discussed are muscle energy treatment (MET) and counterstrain (CS).

MET is a direct technique where the muscle or joint is taken into a restrictive barrier and asked to provide an isometric muscle contraction against the provider.[5] Following the isometric contraction, the muscle is relaxed, and the provider takes the dysfunction further into the restrictive barrier. The most common MET protocol, and the one described here, uses three to five repetitions of isometric contraction followed by relaxation.

CS is an indirect technique where a tenderpoint is localized and moved into a position of ease for 90 seconds while monitoring for the reduction of pain and change in the texture of the tenderpoint. The muscle or joint returns to a neutral position, and the tenderpoint is released, resulting in a decrease in hypersensitivity and proprioceptive activity.[6]

Anatomy and Physiology

The anatomy of the iliopsoas is critical in understanding its role in psoas syndrome and the proper technique of MET and CS treatment of iliopsoas dysfunction. The iliopsoas divides into two parts: 1) the psoas (major and minor) muscle and 2) the iliacus muscle. The psoas major originates at the T12 through L5 vertebrae and inserts on the lesser trochanter of the femur. The psoas minor originates at the T12 to L1 vertebrae and inserts at the iliopubic eminence. The iliacus muscle originates within the iliac fossa/sacral ala and inserts at the lesser trochanter of the femur.[7] 

The psoas major and minor muscles receive innervation of the L1-3 branches of the lumbar plexus, while the iliacus receives innervation from the femoral nerve.[7] The psoas and the iliacus muscle fibers pass deep to the inguinal ligament and merge to insert on the less trochanter of the femur. The iliopsoas is primarily responsible for hip flexion but also aids in external rotation of the leg and may also act as a stabilizer of the spine during hip flexion. A study done by Hu et al. found that the contralateral psoas muscle was activated with hip flexion and is likely involved in spine stabilization.[8]

OMT is used to treat iliopsoas somatic dysfunctions to decrease pain, improve range of motion, and restore neuromusculoskeletal function.

There are several proposed mechanisms for MET, but the two commonly accepted principles are 1) post-isometric relaxation and 2) reciprocal inhibition. Both principles take advantage of the proprioceptive mechanisms within muscle fibers and joints, including the alpha motor neuron and Golgi tendon organ. Post-isometric relaxation is based on the theory that the muscle enters a refractory period following isometric contraction. During this refractory period, there is reduced muscle tone, which allows the muscle to be taken further into the restrictive barrier. Reciprocal inhibition hypothesizes that there is a period of antagonist muscle relaxation following the contraction of the agonist muscle, which allows the muscle to be taken further into the restrictive barrier.[5] 

CS tenderpoints form due to injury or dysfunction of the muscle resulting in altered proprioception and hyperactivity of the affected muscle. During CS, the muscle becomes passively shortened to reset the Golgi tendon and return the muscle to its proper length and alignment.[6]

Indications

Before initiating OMT, a somatic dysfunction should be present. Somatic dysfunction is a change in joint or muscle function or architecture. Somatic dysfunction describes tissue texture changes, asymmetry, restriction of motion, and tenderness. Examples of possible somatic dysfunctions of the iliopsoas include hypertonic tissue texture, restriction in hip extension, and tenderness of the iliopsoas. Patients who would benefit from MET or CS treatments may also present with symptoms of psoas syndrome, as described above.

The choice of MET or CS as a treatment modality depends on the patient’s status and physician preference. CS is a passive treatment that involves monitoring the psoas, shortening the muscle into a position of ease, and holding this position for an extended period. CS is appropriate for a patient in extreme discomfort or someone unable to produce a coordinated muscle contraction. MET is an active treatment that requires the patient to provide a voluntary isometric muscle contraction against the physician, followed by muscle relaxation during which the physician will take the dysfunction further into the restrictive barrier. During both techniques, the patient must be able to provide feedback to the physician. 

Contraindications

Contraindications to MET include:

• Fracture in the affected area
• Unstable pelvis or hip joint
• Recent surgery, or low energy[9]
• Inability to provide isometric contraction of the affected area
• Inability to follow directions

Contraindications to CS include:

• Inability to voluntarily relax
• Inability to provide feedback to the physician
• Fracture in the affected area
• Torn ligament or tendon in the affected area [9]

Equipment

The only required equipment for this procedure is a firm OMT or massage table.

Personnel

A clinician trained in OMT is required. 

Preparation

The clinician should discuss the risks, benefits, and alternative treatment options to OMT with the patient before performing OMT and obtain consent from the patient to proceed with OMT. 

After obtaining informed consent, the physician should establish the pain scale, assess the range of motion and strength of the affected muscle, and perform any appropriate neurologic testing. Also, an osteopathic structural exam of the lumbar spine, pelvis, and hip should be performed. Special considerations for the iliopsoas include the Thomas test to assess the flexibility of the iliopsoas muscle. 

Technique or Treatment

Muscle Energy Technique with the Patient in the Prone Position

Physician position: Standing on the contralateral side of the dysfunction

Patient position: Lying prone

Technique:

• Place the cephalad hand on the posterior aspect of the patient's affected hip.
• Grasp the anterior portion of the thigh on the affected side, just proximal to the knee using the caudad hand.
• Extend the patient's hip until feeling the restrictive barrier.
• Continue to engage the restrictive barrier and instruct the patient to pull the anterior hip down towards the table for 3 to 5 seconds (isometric contraction).
• Instruct the patient to relax and move the hip further into extension until the restrictive barrier is again felt. 
• Repeat the last two steps 3 to 5 times. 
• After the last repetition, passively return the patient's leg to a neutral position.
• Reassess the somatic dysfunction. 

Muscle Energy Technique with the Patient in the Supine Position

Physician position: Standing on the ipsilateral side of the dysfunction

Patient position: Lying supine with lower leg hanging off the end of the table

Technique:

• The patient flexes the contralateral hip and knee to hug the lower extremity to the chest. 
• Using one hand to keep the contralateral leg flexed, the other hand will provide a downward force immediately proximal to the knee until reaching the restrictive barrier.
• Continue to engage the restrictive barrier and instruct the patient to bring the knee up toward the ceiling to achieve hip flexion for 3 to 5 seconds (isometric contraction).
• Instruct the patient to relax and move the hip further into extension by providing a downward force just proximal to the knee. 
• Repeat the last two steps 3 to 5 times.
• After the last repetition, passively return the patient's leg to a neutral position. 
• Reassess the somatic dysfunction.

Counterstrain:

Physician position: Standing on the ipsilateral side of the dysfunction

Patient position: Lying supine

• Identify the tender point within the iliopsoas muscle, which is often located just medial to the ASIS. 
• Assess the pain level at the tender point. Keep a finger on the tender point for monitoring purposes. 
• Passively bring both of the patient's hips into flexion and allow the lower legs to rest on the clinician's thigh, which is propped onto the treatment table. 
• Cross the patient's ankles and allow the hips to rotate externally. 
• Reassess the pain at the tenderpoint. Adjust the patient's position either with more hip flexion or external rotation to decrease the pain level by two-thirds. 
• Hold the position for 90 seconds or until you feel the tender point softening beneath your finger. 
• Passively return the patient to a neutral position. 
• Reassess the tenderpoint. 

Complications

When performed correctly, MET and CS are very safe procedures. However, patients may have mild soreness following treatment. The muscle soreness is often expected and self-limited. Patients are advised to ensure relative rest and adequate hydration following OMT to limit or decrease post-procedural discomfort. 

Clinical Significance

OMT is beneficial for the treatment of dysfunction of the iliopsoas muscle, including manifestations of psoas syndrome. The exact prevalence of psoas syndrome is unknown, but it is more common in those with pre-existing low back or hip conditions. A study done by Adib et al. reported the incidence of iliopsoas tendonitis in total hip arthroscopy patients to be 24%.[10] 

OMT is a treatment option with fewer complications than other proposed non-surgical measures like corticosteroid injections or pharmaceutical intervention. The iliopsoas muscle connects the lumbar spine, pelvis, and leg; therefore, untreated and undertreated psoas dysfunction leads to compensatory changes along the kinetic chain and ultimately will result in pathology in other parts of the body, including the thorax, piriformis, sacrum, pelvis, and knee. 

Enhancing Healthcare Team Outcomes

Interprofessional communication is important for promoting safe and effective osteopathic manipulative treatment. The interprofessional healthcare team includes clinicians (particularly osteopaths), nursing staff, and possibly physical therapists.

All healthcare team members need to understand the proper use of OMT and the risks and benefits of OMT for various medical conditions. Each healthcare team member can assist with patient education to promote the safe and appropriate use of OMT as well as explain differences between manual modalities available to the patient. Muscle energy treatment and counterstrain treatments are amongst the safest and most effective osteopathic treatment modalities.[5][6] [Level 2]

Nursing, Allied Health, and Interprofessional Team Interventions

Awareness of osteopathic manipulative treatment by nursing, allied health, and the interprofessional team is essential for continued use of osteopathic manipulative treatment. It is an effective treatment option that can be taught to fellow clinicians and knowledge shared through the healthcare professions to improve patient care.

Nursing, Allied Health, and Interprofessional Team Monitoring

Monitoring and feedback with osteopathic manipulative treatment are critical for the success of both the patient and physician. Awareness of procedures utilized and the progression of patients after a visit can ensure the most effective and personalized healthcare is delivered.