Psoas and Illiacus Static Manual Release

Differentiation

1. The psoas and iliacus are deep muscles, lying behind the abdominal muscles and viscera. This is a more advanced palpation technique, and may not be recommended for individuals new to manual therapy.
2. With your patient in supine, ask them to adjust their clothing to reveal their abdominal region. (With a little practice this technique may be performed through thin clothing; however, for patient comfort, it may be better to move clothing and reduce the amount of friction between skin, clothing, and practitioners fingers.)
3. Ask your patient to assume a "hook-lying" position, with a slight posterior pelvic tilt to reduce the tension in the abdominal wall muscles.
4. Identify the anterior superior iliac spine (ASIS) and semilunar lines (lateral borders of the rectus abdominis).
   • Psoas
5. Place one hand over the other so that your extended fingers are braced with the extended fingers of the other hand.
6. Place your fingertips on the semilunar lines below the level of the umbilicus.
7. Depress your fingers into the abdomen toward the lumbar spine.
   • Remember the psoas originates on the lumbar spine and inserts into the lesser trochanter; the belly of the muscle is likely deep or medial to the semilunar lines. I often see this technique demonstrated as if the psoas was very lateral, abutting the external obliques . They do not! Although I appreciate the notion of "working around" the abdominal viscera, doing the technique inaccurately likely poses a larger risk than responsibly pressing into the viscera and applying the technique with as little additional "searching" or "pressure" as possible.
8. To aid in reducing the discomfort of depressing into the abdominal contents and stretching skin, continue to adjust the skin on the fingertips to reduce tension, and try to press deeper with your patient's exhalations. Following the belly down during breathing makes this technique more comfortable.
9. Look for a vertically oriented, tube-like structure that is a bit denser than other soft tissues in the area.
10. Key Point: Once you believe you have found the psoas , test your hypothesis by asking your patient to flex their hip (have them bring their knee into your arm or armpit). If the structure you are on gets denser and moves with hip flexion, it is very likely your psoas (internal organs don't contract with movement). Do not assume that any dense structure is a muscle, various structures may feel dense as you compress into the abdomen.
    • Iliacus
11. Place one hand over the other so that you are bracing extended fingers with extended fingers.
12. Place your fingertips just medial and superior to the ASIS.
13. Depress your fingers into the abdominal contents as if trying to wrap your fingers around the ASIS.
14. The iliacus covers most of the internal face of the pelvis. Your palpation should be done with the intent of applying pressure back toward you (somewhat posterior to anterior) to the internal face of the pelvis. Unfortunately due to limits in skin extensibility and placement of abdominal organs, only a small portion of the iliacus will be palpable (the area within a few inches of the ASIS).
15. To aid in reducing the discomfort of depressing into the abdominal contents and stretching skin, continue to adjust the skin on the fingertips to reduce tension, and try to press deeper only with your patient's exhalations. Following the belly down during breathing makes this technique more comfortable.
16. Key Point: Once you believe you have found the iliacus test your hypothesis by asking your patient to flex their hip (have them bring their knee into your arm or armpit). If the structure you are on gets denser and moves with hip flexion, it is very likely your iliacus (internal organs don't contract with movement). Do not assume that any dense structure is a muscle, various structures may feel dense as you compress into the abdomen.

Potentially Sensitive Tissues

• This is an advanced palpation, primarily because of the potential to compress sensitive tissues. The abdominal aorta, common iliac artery, femoral nerve, and viscera may be compressed while doing this technique. Although momentary, responsible amounts of compression likely pose a little risk; aggressively rubbing across tissues or maintaining a compressive force for several seconds or minutes may pose risk. Rule of thumb: if it pulses, numbs, tingles, or results in sharp pain, GET OFF IT!
• Note, to date I have yet to find a single published case of injury from the manual release of the psoas . Although two case studies have reported complications from needling (92, 93), based on the nature of the injuries, it is unlikely they could be replicated manually. Of course, risk is always a concern with any technique; however, it may be reasonable to deduce that the responsible application of this technique by a licensed manual professional has not resulted in any reported cases over several decades of use.

Trigger Points

• Common trigger points for these muscles (that are reachable with manual therapy):
  • In the middle of the belly of the psoas ; just below the level of the naval.
  • An iliacus trigger point can be found about two inches posterior the ASIS, and an inch inferior to the iliac crest.

Release Technique

1. With your patient in supine, ask them to adjust their clothing to reveal their abdominal region. (With a little practice this technique may be performed through thin clothing; however, for patient comfort, it may be better to move clothing and reduce the amount of friction between skin and practitioner's fingers.)
2. Ask your patient to assume a "hook-lying" position, with a slight posterior pelvic tilt to reduce the amount of tension in the muscles of the anterior abdominal wall.

• Psoas
  1. Identify the semilunar lines (lateral borders of the rectus abdominis).
  2. Place one hand over the other so that your extended fingers are braced with the extended fingers of the other hand.
  3. Place your fingertips on the semilunar lines, below the level of the umbilicus.
  4. Depress your fingers into the abdomen toward the lumbar spine.
  5. To reduce the discomfort of pressing into the abdomen and stretching skin, continue to adjust the skin on the fingertips to reduce tension, and press deeper only with your patient's exhalations. Following the belly down during breathing makes this technique more comfortable.
  6. Look for a vertically oriented, tube-like structure that is a bit denser than other soft tissues in the area.
  7. Key Point: Once you believe you have found the psoas , test your hypothesis by asking your patient to flex their hip (have them bring their knee into your arm or armpit). If the structure you are on gets denser and moves with hip flexion, it is very likely your psoas (internal organs don't contract with movement). Do not assume that any dense structure is a muscle, various structures may feel dense as you compress into the abdomen.
  8. Look for denser or more sensitive regions along the length of the psoas . Note, it is likely not possible to feel fascicles or nodules due to the amount of tissue being palpated through.
  9. Consistent pressure is held until the dense region softens under your fingers, or tissue density/sensitivity is significantly reduced (generally 30 - 120 seconds).
• Iliacus
  1. Identify the ASIS
  2. Place your fingertips just medial and superior to the ASIS.
  3. Depress your fingers into the abdominal contents as if trying to wrap your fingers around the ASIS.
  4. The iliacus covers most of the internal face of the pelvis. Your palpation should be done with the intent of applying pressure back toward you (somewhat posterior to anterior), to the internal face of the pelvis. Unfortunately due to limits in skin extensibility and placement of abdominal organs, only a small portion of the iliacus will be palpable (the area within a few inches of the ASIS).
  5. To aid in reducing the discomfort of depressing into the abdominal contents and stretching skin, continue to adjust the skin on the fingertips to reduce tension, and try to press deeper only with your patient's exhalations. Following the belly down during breathing makes this technique more comfortable.
  6. Key Point: Once you believe you have found the iliacus test your hypothesis by asking your patient to flex their hip (have them bring their knee into your arm or armpit). If the structure you are on gets denser and moves with hip flexion, it is very likely your iliacus (internal organs don't contract with movement). Do not assume that any dense structure is a muscle, various structures may feel dense as you compress into the abdomen.
  7. Look for denser or more sensitive regions on the portion of the internal face of the ilium that you can reach. Note, it is likely not possible to feel fascicles or nodules due to the amount of tissue being palpated through.
  8. Consistent pressure is held until the dense region softens under your fingers, or tissue density/sensitivity is significantly reduced (generally 30 - 120 seconds).