0:04 This is Brent of the Brookbush 0:05 Institute and in this video we're going over 0:07 static manual release of the psoas and 0:09 iliacus. I know a lot of you have been 0:11 waiting for this video. But if you are 0:12 watching this video, I'm assuming you're 0:14 watching it for educational purposes and 0:16 that you are a licensed manual therapist 0:18 following the laws of scope of practice 0:20 in your state. Physical therapists, 0:22 athletic trainers, chiropractors, massage 0:25 therapists, osteopaths - you're probably all 0:28 in the clear and I'm probably forgetting 0:29 a couple professions. Personal trainers, 0:32 this probably doesn't fall within your 0:34 scope, especially this technique which 0:36 does pose certain risks. However, you 0:41 could possibly use this in a learning 0:43 environment with supervision of a manual 0:46 therapist to help you with your 0:47 functional anatomy knowledge. I'm going to 0:49 have my friend Sonja come out. She's 0:51 going to go ahead and help me 0:52 demonstrate this technique. She's going 0:54 to lay on her back here. With the 0:56 potential discomfort with this technique 0:59 and the fact that it does pose some 1:00 risks being close to some sensitive 1:02 structures, once again, I want to be 80 to 1:06 90% sure that her psoas and 1:09 iliacus are involved in the dysfunction 1:12 that I've seen or the movement 1:13 impairment that I've seen, her complaints 1:16 that she's come in with. So, I've 1:19 done either an overhead squat assessment, 1:21 maybe goniometry, maybe the Thomas 1:25 test. This could be related to 1:27 things like an excessive lordosis and 1:30 asymmetrical weight shift, lumbar spine 1:33 pain, a positive Thomas test or hip 1:35 extension goniometry all would be 1:37 good indicators that maybe I should take 1:40 a look at her psoas and iliacus. With 1:43 all of our manual release techniques we 1:45 follow a very similar protocol which 1:47 comes down to palpate and compress but 1:50 we do want to get a little bit more 1:51 detailed than that. We want to know how to 1:53 palpate this muscle, we get some bonus 1:56 points for knowing where the trigger 1:57 points are. On this video I'm going to 1:58 have a harder time showing you this 2:00 particular trigger point or its location 2:03 compared to some of our other videos 2:04 because your psoas and iliacus are deep 2:07 to all of your abdominal muscles and 2:10 your psoas deep to a lot of viscera. 2:12 We have to know what's around these 2:15 muscles that we could be potentially 2:18 insulting or could potentially disrupt 2:22 with pressure. In the case of the psoas 2:25 and the iliacus, we do have to consider 2:28 that we have our abdominal aorta and 2:32 common iliac artery, so if it pulses get 2:34 off it. We have our femoral nerve, so if 2:37 you start getting any tingling down the 2:39 thigh, probably a good idea to move. And 2:42 we have to realize that we're on viscera 2:43 so we want to be pretty good at 2:46 this palpatory technique. It's going to 2:47 take a little practice but we don't want 2:50 to be moving around a lot in there. We 2:53 don't want to be lost, not really 2:57 having a good sense of our anatomy 2:58 because we still have things like the 3:01 small intestines and the ureters and 3:04 the kidneys and some other stuff around 3:07 the area that maybe we don't want to be 3:09 boxing around with pressure. And then 3:13 of course, last we have to think about 3:15 position which that's going to come down 3:17 to patient comfort which I think a lot 3:19 of therapists are really good at but 3:21 then our comfort. Where should I 3:24 be to ensure that I can use my bodyweight 3:27 to apply pressure and not use my 3:31 hands and my grip strength and put 3:34 all these delicate IP joints at risk, 3:37 especially over a career. For this 3:40 particular technique, I'm going to 3:41 show you a couple tricks. I'm going to go 3:43 ahead and have Sonja move her hands up. 3:46 Can you bring your shirt up to belly 3:49 level? Chances are I could probably 3:52 palpate through a thin shirt like 3:55 Sonja's got on but if things are a 3:58 little thicker it's just going to make 3:59 it that much harder to get in. Can I move 4:02 this? I'm going to move 4:04 Sonja's waistband just a little bit down 4:06 here because I want to find the top of 4:10 her ASIS. The two landmarks 4:13 we're going to use to really help us 4:15 with this palpation are going to be her 4:17 ASIS, her semilunar lines, which are those 4:21 lines that that give the rectus 4:24 abdominus its 4:25 shape, they're kind of in between the 4:27 external obiques and the rectus abdominus. 4:29 That's a good good place to start our 4:31 palpation. And of course we want to know 4:34 where the umbilicus is. The psoas, a 4:37 lot of people make the mistake of going 4:39 "Oh let me go after the ASIS, that's where 4:43 the psoas is." That's actually not true, 4:45 your psoas goes from lumbar spine to 4:48 lesser trochanter 4:49 which means when you place your fingers 4:51 down on the semilunar lines they're 4:53 actually going to be pointing towards 4:55 the lumbar spine. If I start with my 5:00 fingers here and I'm actually going 5:03 to have her start in a hip flexed 5:04 position so I take her a little bit into 5:06 a posterior pelvic tilt, take some of the 5:09 tension off of her abdominal wall here. 5:11 Then I have her take a deep breath 5:15 for me and I start my pressure inward as 5:20 she breathes out. This will be a lot more 5:22 comfortable for her. 5:25 After she takes that big breath, she'll 5:28 go back to taking normal breaths and 5:31 maybe even a little shallower breath than 5:33 normal, still within comfort because I 5:36 don't want her to take deep breaths and 5:38 keep pushing me out of her abdomen. 5:43 To check whether I'm on her psoas 5:46 of course I'm looking for something 5:48 that's that's fairly vertically aligned. 5:51 I'm looking for something that feels 5:53 fairly tube shaped under my fingers. 5:56 I know that the psoas is moderately 6:01 thick, I guess maybe about this the 6:03 thickness of somebody's wrists. 6:06 So I'm searching for something that's 6:08 shaped like that but so I don't go 6:09 searching all over her abdominal cavity, 6:11 what I'll usually do is I'll get in this 6:14 position where I have this hand applying 6:15 pressure and then I can use these 6:18 fingertips to actually apply the 6:21 pressure. I started with these guys 6:23 applying pressure now I'm going to relax 6:25 this hand and let this hand do most of 6:27 the work. And then if I put my 6:29 arm down over Sonja's knee, I can 6:32 ask her, "Hey, can you push your 6:35 knee into my arm, pull up into hip 6:37 flexion?" and her psoas will pop right 6:40 into my fingers. If I don't feel it, then 6:41 I can move either medial or lateral, have 6:45 her go again 6:46 a little harder, there we go. 6:51 Found it. Now once I find it, I 6:55 can go and look for the the densest 6:59 portion of that muscle and then again 7:03 just like all of our other techniques, 7:05 I'm going to get nice and comfortable 7:07 here. Try to use my bodyweight and wait 7:10 for a release. Generally that takes about 7:13 30 seconds to 2 minutes. Hopefully 7:16 they're pretty good at relaxing, you 7:18 don't have to stay in there for two 7:19 minutes to get a good release. 7:22 How you doing? As soon as I feel a 7:26 reduction in tissue density, that release 7:30 that we're looking for, I'm done with 7:32 this technique. And then I could go on to 7:35 reassessment. Being that this particular 7:38 technique can cause some discomfort, I 7:41 would definitely do some level of 7:45 reassessment right after this 7:47 intervention. You should be doing 7:49 reassessment after many of your 7:51 interventions to test if they were the 7:52 appropriate technique for that 7:54 individual but specifically with this 7:56 technique if it didn't do anything to 7:58 improve her movement, I'm not going to do 8:01 it again. I don't want to do things that 8:02 are uncomfortable and ineffective. I'm 8:04 okay with a certain level of 8:06 uncomfortable and effective but 8:08 uncomfortable and ineffective, never 8:11 okay. The iliacus is a little tricky, 8:14 actually kind of trickier than the psoas. 8:16 I'm going to use the same technique but 8:18 my iliacus runs along the face of my 8:23 ilium. If you palpate 8:25 their iliac crest, you can get a good 8:30 idea of where your fingers should be 8:32 headed. I'm going to find her ASIS, 8:35 have her do the same deep breath 8:38 and breathe out and the reason why I say 8:42 that the iliacus is a little rougher is 8:45 because despite it being really easy to 8:47 find initially, you really can only get 8:51 to the most anterior fibers. You start 8:54 pulling up so much tissue and you start 8:56 getting so much tissue stretch and so 8:58 much stretch from all those 9:00 abdominal muscles: your external obliques, 9:02 your internal obliques, your transverse 9:04 abdominus that you really don't get to 9:07 access that much. You can gather up 9:10 some tissue from the midline to try to 9:13 get a little deeper but I think you 9:17 will find that my best guess is you're 9:20 probably getting about halfway maybe to 9:23 the the middle of the iliac crest that 9:26 you're probably not going to be able to 9:27 hit any of those fibers on the posterior 9:29 iliac crest. Nonetheless, if you find 9:32 dense tissue, you're going to go ahead 9:36 and hold and wait for a release. 9:43 And again once I finish with this 9:47 release technique, let's say she had a 9:48 really positive modified Thomas test, 9:51 it's real easy for me to go back and go 9:53 "okay go ahead and hold, did that get 9:57 better?" If it didn't then maybe this is 10:00 one of those techniques that I don't 10:02 actually need to help correct the 10:05 movement impairment she's going to be 10:06 complaining about. We'll move on to 10:09 our close-up recap. For a close-up 10:11 recap of psoas and iliacus release, a 10:13 couple landmarks we need to keep in mind. 10:15 I've actually pulled the waistband of 10:17 Sonja's shorts here right down to the 10:20 top of the ASIS so I know where that is. 10:22 And then Sonja, go ahead and give 10:24 me a little contraction of your abs. 10:27 You see this little dark shadow right 10:29 here, this is her semilunar lines. It's a 10:31 good place for us to start sinking our 10:33 fingers in towards the lumbar spine. 10:36 Remember, our psoas goes from lumbar spine 10:38 to lesser trochanter of the femur. To 10:42 get to the psoas, what I usually have my 10:45 clients do is try to relax the best they 10:47 can and then I'll have them take a nice 10:50 deep breath for me. And then as they 10:54 breathe out, I'll just let my fingers 10:57 sink in towards their lumbar spine. 11:00 Notice I'm going in that direction. 11:04 I'm going to feel something kind of 11:08 tubular shaped, it's going to 11:10 be kind of a thick tube, the psoas is. The 11:13 way I'm going to check that as I 11:15 mentioned in the previous videos, I'm 11:16 going to go ahead and have Sonja pull 11:18 her or lift her knee into my armpit or 11:22 elbow and I should feel that psoas 11:25 contract pretty good. 11:27 Alright, good right there. Once 11:30 I found that, I can then go a little 11:35 proximal to distal here to find 11:38 the most tender point. Once I've found it 11:42 I'm going to make sure she's totally 11:43 relaxed, she's just trying to breathe 11:46 normally maybe a little shallower than 11:48 normal because big deep breaths aren't 11:50 going to feel real great but we're just 11:52 going to wait for that release to happen. 11:55 Do remember, the psoas is very close to a 12:00 lot of sensitive tissues. If you 12:02 feel a pulse, get off it. There's no 12:05 need to compress something with a pulse, 12:07 that's an artery. If Sonja started 12:10 complaining about tingling through her 12:12 leg, her thigh, the bottom of her foot, 12:16 we need to move, we need to 12:20 get off that nerve. This is very 12:22 close to the femoral nerve. We also need 12:26 to consider that we're pretty close to 12:28 some internal organs so if we have any 12:30 other weird sensations. For example, all 12:34 of a sudden needing to use the restroom, 12:36 again we need to probably reset and 12:39 move. Once we feel a release happen 12:43 though, we should be good and then we'd 12:46 retest. I was just using 12:49 one hand here. Compared to Sonja, I'm 12:53 a pretty large guy, you could go finger 12:56 tip over finger, just be careful not to 12:58 double the breadth of your contact 13:02 surface because then you're just 13:03 stretching out all of that abdominal 13:05 musculature, all of the skin over her psoas 13:08 that much more and it's going to be 13:10 that much more uncomfortable. I would 13:12 start with one hand and then place your 13:15 fingers over the others to add a little 13:16 bit of pressure. For the iliacus, the 13:19 iliacus is really easy to find, not very 13:22 easy to release, unfortunately. The 13:25 iliacus is going to be against the face 13:28 of our ilium, so all we need to do 13:30 is come right over the ASIS and then 13:33 curve around. I'm going to have Sonja 13:36 take a nice deep breath for me. As she 13:39 breathes out, I'm going to go ahead and 13:41 sink in. The big problem with the iliacus 13:44 is because of the tension in her skin 13:47 and her transverse abdominis and the 13:49 abdominal fascia and her external and 13:52 internal obliques and all that stuff 13:54 that we're having to palpate through, I 13:56 just can't get to very much of her 13:58 iliacus. It's not like I'm going to get 14:01 down to the posterior wall. I'm probably 14:03 just going to mostly affect 14:05 the fibers closest to her ASIS. How's that 14:11 feel? Feels good. As we mentioned in 14:16 previous videos Sonja is kind of a 14:18 masochist, she kind of likes pain. 14:22 Since these techniques are so 14:23 uncomfortable, they are a little 14:26 different than some of the other 14:27 techniques as we're having to push 14:28 through viscera and we're having to push 14:31 through that sensitive abdominal area 14:34 and there's tends to be a little bit 14:35 more skin stretch with these techniques. 14:37 Make sure you're doing your reassessment, 14:39 I mean you should be always doing 14:40 reassessment between interventions but 14:42 especially in this case. If you did not 14:46 get a result from releasing the psoas or 14:48 releasing the iliacus manually, for 14:50 example, an increase in hip extension, a 14:53 decrease in excessive lumbar lordosis 14:56 during an overhead squat assessment, 14:58 don't do the technique again. It's that 15:01 simple. If it's effective, I'll take a 15:04 little uncomfortable for effective 15:07 outcomes. What I won't take is 15:10 ineffective and uncomfortable. 15:12 There you have it. Static manual release 15:14 of the psoas and iliacus. I think the 15:16 most important thing to remember with 15:18 this particular technique is you are in 15:20 close proximity to some very sensitive 15:23 tissues when you do this technique. That 15:26 means several things. Number one, you must 15:28 assess before you do manual techniques. 15:32 You need to be certain that the 15:36 technique itself is worth whatever risk 15:40 it imposes. You also need to be aware of 15:43 those structures, things like the femoral 15:46 nerve, the abdominal aorta and common 15:49 iliac artery, the viscera, even the 15:51 small intestines that are in there. They 15:53 all have the potential of being insulted, 15:59 we'll say, by pressure and moving around. 16:01 If you feel something pulse, 16:04 get off it. If you start causing tingling 16:07 down somebody's thigh, that's not a good 16:09 thing. Move. Make sure you're testing your 16:12 position with that little hip flexion 16:15 trick I showed you so that you know you 16:17 are on the psoas itself and you don't 16:20 spend a lot of time rummaging around 16:22 potentially releasing something like the 16:25 small intestine. And of course, 16:28 last, make sure you practice this on some 16:31 colleagues before you move in to doing 16:35 this with a patient. and if at all possible, 16:38 grab somebody who has experience with 16:41 this particular technique so that you 16:44 can do it on them and a manual 16:46 therapists can give you feedback. It's 16:49 the best education you can get for all 16:52 of the manual techniques which we show. I 16:54 hope you get great outcomes with 16:57 this technique, I hope it does fill a big 16:59 gap of psoas an iliacus release that 17:02 maybe you couldn't do before but knew and 17:05 some patients needed to be done. I look 17:07 forward to seeing your comments. I'll 17:09 talk with you soon.
