00:00:0400:00:05
This is Brent of the Brookbush
00:00:0500:00:07
Institute and in this video we're going over
00:00:0700:00:09
static manual release of the psoas and
00:00:0900:00:11
iliacus. I know a lot of you have been
00:00:1100:00:12
waiting for this video. But if you are
00:00:1200:00:14
watching this video, I'm assuming you're
00:00:1400:00:16
watching it for educational purposes and
00:00:1600:00:18
that you are a licensed manual therapist
00:00:1800:00:20
following the laws of scope of practice
00:00:2000:00:22
in your state. Physical therapists,
00:00:2200:00:25
athletic trainers, chiropractors, massage
00:00:2500:00:28
therapists, osteopaths - you're probably all
00:00:2800:00:29
in the clear and I'm probably forgetting
00:00:2900:00:32
a couple professions. Personal trainers,
00:00:3200:00:34
this probably doesn't fall within your
00:00:3400:00:36
scope, especially this technique which
00:00:3600:00:41
does pose certain risks. However, you
00:00:4100:00:43
could possibly use this in a learning
00:00:4300:00:46
environment with supervision of a manual
00:00:4600:00:47
therapist to help you with your
00:00:4700:00:49
functional anatomy knowledge. I'm going to
00:00:4900:00:51
have my friend Sonja come out. She's
00:00:5100:00:52
going to go ahead and help me
00:00:5200:00:54
demonstrate this technique. She's going
00:00:5400:00:56
to lay on her back here. With the
00:00:5600:00:59
potential discomfort with this technique
00:00:5900:01:00
and the fact that it does pose some
00:01:0000:01:02
risks being close to some sensitive
00:01:0200:01:06
structures, once again, I want to be 80 to
00:01:0600:01:09
90% sure that her psoas and
00:01:0900:01:12
iliacus are involved in the dysfunction
00:01:1200:01:13
that I've seen or the movement
00:01:1300:01:16
impairment that I've seen, her complaints
00:01:1600:01:19
that she's come in with. So, I've
00:01:1900:01:21
done either an overhead squat assessment,
00:01:2100:01:25
maybe goniometry, maybe the Thomas
00:01:2500:01:27
test. This could be related to
00:01:2700:01:30
things like an excessive lordosis and
00:01:3000:01:33
asymmetrical weight shift, lumbar spine
00:01:3300:01:35
pain, a positive Thomas test or hip
00:01:3500:01:37
extension goniometry all would be
00:01:3700:01:40
good indicators that maybe I should take
00:01:4000:01:43
a look at her psoas and iliacus. With
00:01:4300:01:45
all of our manual release techniques we
00:01:4500:01:47
follow a very similar protocol which
00:01:4700:01:50
comes down to palpate and compress but
00:01:5000:01:51
we do want to get a little bit more
00:01:5100:01:53
detailed than that. We want to know how to
00:01:5300:01:56
palpate this muscle, we get some bonus
00:01:5600:01:57
points for knowing where the trigger
00:01:5700:01:58
points are. On this video I'm going to
00:01:5800:02:00
have a harder time showing you this
00:02:0000:02:03
particular trigger point or its location
00:02:0300:02:04
compared to some of our other videos
00:02:0400:02:07
because your psoas and iliacus are deep
00:02:0700:02:10
to all of your abdominal muscles and
00:02:1000:02:12
your psoas deep to a lot of viscera.
00:02:1200:02:15
We have to know what's around these
00:02:1500:02:18
muscles that we could be potentially
00:02:1800:02:22
insulting or could potentially disrupt
00:02:2200:02:25
with pressure. In the case of the psoas
00:02:2500:02:28
and the iliacus, we do have to consider
00:02:2800:02:32
that we have our abdominal aorta and
00:02:3200:02:34
common iliac artery, so if it pulses get
00:02:3400:02:37
off it. We have our femoral nerve, so if
00:02:3700:02:39
you start getting any tingling down the
00:02:3900:02:42
thigh, probably a good idea to move. And
00:02:4200:02:43
we have to realize that we're on viscera
00:02:4300:02:46
so we want to be pretty good at
00:02:4600:02:47
this palpatory technique. It's going to
00:02:4700:02:50
take a little practice but we don't want
00:02:5000:02:53
to be moving around a lot in there. We
00:02:5300:02:57
don't want to be lost, not really
00:02:5700:02:58
having a good sense of our anatomy
00:02:5800:03:01
because we still have things like the
00:03:0100:03:04
small intestines and the ureters and
00:03:0400:03:07
the kidneys and some other stuff around
00:03:0700:03:09
the area that maybe we don't want to be
00:03:0900:03:13
boxing around with pressure. And then
00:03:1300:03:15
of course, last we have to think about
00:03:1500:03:17
position which that's going to come down
00:03:1700:03:19
to patient comfort which I think a lot
00:03:1900:03:21
of therapists are really good at but
00:03:2100:03:24
then our comfort. Where should I
00:03:2400:03:27
be to ensure that I can use my bodyweight
00:03:2700:03:31
to apply pressure and not use my
00:03:3100:03:34
hands and my grip strength and put
00:03:3400:03:37
all these delicate IP joints at risk,
00:03:3700:03:40
especially over a career. For this
00:03:4000:03:41
particular technique, I'm going to
00:03:4100:03:43
show you a couple tricks. I'm going to go
00:03:4300:03:46
ahead and have Sonja move her hands up.
00:03:4600:03:49
Can you bring your shirt up to belly
00:03:4900:03:52
level? Chances are I could probably
00:03:5200:03:55
palpate through a thin shirt like
00:03:5500:03:58
Sonja's got on but if things are a
00:03:5800:03:59
little thicker it's just going to make
00:03:5900:04:02
it that much harder to get in. Can I move
00:04:0200:04:04
this? I'm going to move
00:04:0400:04:06
Sonja's waistband just a little bit down
00:04:0600:04:10
here because I want to find the top of
00:04:1000:04:13
her ASIS. The two landmarks
00:04:1300:04:15
we're going to use to really help us
00:04:1500:04:17
with this palpation are going to be her
00:04:1700:04:21
ASIS, her semilunar lines, which are those
00:04:2100:04:24
lines that that give the rectus
00:04:2400:04:25
abdominus its
00:04:2500:04:27
shape, they're kind of in between the
00:04:2700:04:29
external obiques and the rectus abdominus.
00:04:2900:04:31
That's a good good place to start our
00:04:3100:04:34
palpation. And of course we want to know
00:04:3400:04:37
where the umbilicus is. The psoas, a
00:04:3700:04:39
lot of people make the mistake of going
00:04:3900:04:43
"Oh let me go after the ASIS, that's where
00:04:4300:04:45
the psoas is." That's actually not true,
00:04:4500:04:48
your psoas goes from lumbar spine to
00:04:4800:04:49
lesser trochanter
00:04:4900:04:51
which means when you place your fingers
00:04:5100:04:53
down on the semilunar lines they're
00:04:5300:04:55
actually going to be pointing towards
00:04:5500:05:00
the lumbar spine. If I start with my
00:05:0000:05:03
fingers here and I'm actually going
00:05:0300:05:04
to have her start in a hip flexed
00:05:0400:05:06
position so I take her a little bit into
00:05:0600:05:09
a posterior pelvic tilt, take some of the
00:05:0900:05:11
tension off of her abdominal wall here.
00:05:1100:05:15
Then I have her take a deep breath
00:05:1500:05:20
for me and I start my pressure inward as
00:05:2000:05:22
she breathes out. This will be a lot more
00:05:2200:05:25
comfortable for her.
00:05:2500:05:28
After she takes that big breath, she'll
00:05:2800:05:31
go back to taking normal breaths and
00:05:3100:05:33
maybe even a little shallower breath than
00:05:3300:05:36
normal, still within comfort because I
00:05:3600:05:38
don't want her to take deep breaths and
00:05:3800:05:43
keep pushing me out of her abdomen.
00:05:4300:05:46
To check whether I'm on her psoas
00:05:4600:05:48
of course I'm looking for something
00:05:4800:05:51
that's that's fairly vertically aligned.
00:05:5100:05:53
I'm looking for something that feels
00:05:5300:05:56
fairly tube shaped under my fingers.
00:05:5600:06:01
I know that the psoas is moderately
00:06:0100:06:03
thick, I guess maybe about this the
00:06:0300:06:06
thickness of somebody's wrists.
00:06:0600:06:08
So I'm searching for something that's
00:06:0800:06:09
shaped like that but so I don't go
00:06:0900:06:11
searching all over her abdominal cavity,
00:06:1100:06:14
what I'll usually do is I'll get in this
00:06:1400:06:15
position where I have this hand applying
00:06:1500:06:18
pressure and then I can use these
00:06:1800:06:21
fingertips to actually apply the
00:06:2100:06:23
pressure. I started with these guys
00:06:2300:06:25
applying pressure now I'm going to relax
00:06:2500:06:27
this hand and let this hand do most of
00:06:2700:06:29
the work. And then if I put my
00:06:2900:06:32
arm down over Sonja's knee, I can
00:06:3200:06:35
ask her, "Hey, can you push your
00:06:3500:06:37
knee into my arm, pull up into hip
00:06:3700:06:40
flexion?" and her psoas will pop right
00:06:4000:06:41
into my fingers. If I don't feel it, then
00:06:4100:06:45
I can move either medial or lateral, have
00:06:4500:06:46
her go again
00:06:4600:06:51
a little harder, there we go.
00:06:5100:06:55
Found it. Now once I find it, I
00:06:5500:06:59
can go and look for the the densest
00:06:5900:07:03
portion of that muscle and then again
00:07:0300:07:05
just like all of our other techniques,
00:07:0500:07:07
I'm going to get nice and comfortable
00:07:0700:07:10
here. Try to use my bodyweight and wait
00:07:1000:07:13
for a release. Generally that takes about
00:07:1300:07:16
30 seconds to 2 minutes. Hopefully
00:07:1600:07:18
they're pretty good at relaxing, you
00:07:1800:07:19
don't have to stay in there for two
00:07:1900:07:22
minutes to get a good release.
00:07:2200:07:26
How you doing? As soon as I feel a
00:07:2600:07:30
reduction in tissue density, that release
00:07:3000:07:32
that we're looking for, I'm done with
00:07:3200:07:35
this technique. And then I could go on to
00:07:3500:07:38
reassessment. Being that this particular
00:07:3800:07:41
technique can cause some discomfort, I
00:07:4100:07:45
would definitely do some level of
00:07:4500:07:47
reassessment right after this
00:07:4700:07:49
intervention. You should be doing
00:07:4900:07:51
reassessment after many of your
00:07:5100:07:52
interventions to test if they were the
00:07:5200:07:54
appropriate technique for that
00:07:5400:07:56
individual but specifically with this
00:07:5600:07:58
technique if it didn't do anything to
00:07:5800:08:01
improve her movement, I'm not going to do
00:08:0100:08:02
it again. I don't want to do things that
00:08:0200:08:04
are uncomfortable and ineffective. I'm
00:08:0400:08:06
okay with a certain level of
00:08:0600:08:08
uncomfortable and effective but
00:08:0800:08:11
uncomfortable and ineffective, never
00:08:1100:08:14
okay. The iliacus is a little tricky,
00:08:1400:08:16
actually kind of trickier than the psoas.
00:08:1600:08:18
I'm going to use the same technique but
00:08:1800:08:23
my iliacus runs along the face of my
00:08:2300:08:25
ilium. If you palpate
00:08:2500:08:30
their iliac crest, you can get a good
00:08:3000:08:32
idea of where your fingers should be
00:08:3200:08:35
headed. I'm going to find her ASIS,
00:08:3500:08:38
have her do the same deep breath
00:08:3800:08:42
and breathe out and the reason why I say
00:08:4200:08:45
that the iliacus is a little rougher is
00:08:4500:08:47
because despite it being really easy to
00:08:4700:08:51
find initially, you really can only get
00:08:5100:08:54
to the most anterior fibers. You start
00:08:5400:08:56
pulling up so much tissue and you start
00:08:5600:08:58
getting so much tissue stretch and so
00:08:5800:09:00
much stretch from all those
00:09:0000:09:02
abdominal muscles: your external obliques,
00:09:0200:09:04
your internal obliques, your transverse
00:09:0400:09:07
abdominus that you really don't get to
00:09:0700:09:10
access that much. You can gather up
00:09:1000:09:13
some tissue from the midline to try to
00:09:1300:09:17
get a little deeper but I think you
00:09:1700:09:20
will find that my best guess is you're
00:09:2000:09:23
probably getting about halfway maybe to
00:09:2300:09:26
the the middle of the iliac crest that
00:09:2600:09:27
you're probably not going to be able to
00:09:2700:09:29
hit any of those fibers on the posterior
00:09:2900:09:32
iliac crest. Nonetheless, if you find
00:09:3200:09:36
dense tissue, you're going to go ahead
00:09:3600:09:40
and hold and wait for a release.
00:09:4300:09:47
And again once I finish with this
00:09:4700:09:48
release technique, let's say she had a
00:09:4800:09:51
really positive modified Thomas test,
00:09:5100:09:53
it's real easy for me to go back and go
00:09:5300:09:57
"okay go ahead and hold, did that get
00:09:5700:10:00
better?" If it didn't then maybe this is
00:10:0000:10:02
one of those techniques that I don't
00:10:0200:10:05
actually need to help correct the
00:10:0500:10:06
movement impairment she's going to be
00:10:0600:10:09
complaining about. We'll move on to
00:10:0900:10:11
our close-up recap. For a close-up
00:10:1100:10:13
recap of psoas and iliacus release, a
00:10:1300:10:15
couple landmarks we need to keep in mind.
00:10:1500:10:17
I've actually pulled the waistband of
00:10:1700:10:20
Sonja's shorts here right down to the
00:10:2000:10:22
top of the ASIS so I know where that is.
00:10:2200:10:24
And then Sonja, go ahead and give
00:10:2400:10:27
me a little contraction of your abs.
00:10:2700:10:29
You see this little dark shadow right
00:10:2900:10:31
here, this is her semilunar lines. It's a
00:10:3100:10:33
good place for us to start sinking our
00:10:3300:10:36
fingers in towards the lumbar spine.
00:10:3600:10:38
Remember, our psoas goes from lumbar spine
00:10:3800:10:42
to lesser trochanter of the femur. To
00:10:4200:10:45
get to the psoas, what I usually have my
00:10:4500:10:47
clients do is try to relax the best they
00:10:4700:10:50
can and then I'll have them take a nice
00:10:5000:10:54
deep breath for me. And then as they
00:10:5400:10:57
breathe out, I'll just let my fingers
00:10:5700:11:00
sink in towards their lumbar spine.
00:11:0000:11:04
Notice I'm going in that direction.
00:11:0400:11:08
I'm going to feel something kind of
00:11:0800:11:10
tubular shaped, it's going to
00:11:1000:11:13
be kind of a thick tube, the psoas is. The
00:11:1300:11:15
way I'm going to check that as I
00:11:1500:11:16
mentioned in the previous videos, I'm
00:11:1600:11:18
going to go ahead and have Sonja pull
00:11:1800:11:22
her or lift her knee into my armpit or
00:11:2200:11:25
elbow and I should feel that psoas
00:11:2500:11:27
contract pretty good.
00:11:2700:11:30
Alright, good right there. Once
00:11:3000:11:35
I found that, I can then go a little
00:11:3500:11:38
proximal to distal here to find
00:11:3800:11:42
the most tender point. Once I've found it
00:11:4200:11:43
I'm going to make sure she's totally
00:11:4300:11:46
relaxed, she's just trying to breathe
00:11:4600:11:48
normally maybe a little shallower than
00:11:4800:11:50
normal because big deep breaths aren't
00:11:5000:11:52
going to feel real great but we're just
00:11:5200:11:55
going to wait for that release to happen.
00:11:5500:12:00
Do remember, the psoas is very close to a
00:12:0000:12:02
lot of sensitive tissues. If you
00:12:0200:12:05
feel a pulse, get off it. There's no
00:12:0500:12:07
need to compress something with a pulse,
00:12:0700:12:10
that's an artery. If Sonja started
00:12:1000:12:12
complaining about tingling through her
00:12:1200:12:16
leg, her thigh, the bottom of her foot,
00:12:1600:12:20
we need to move, we need to
00:12:2000:12:22
get off that nerve. This is very
00:12:2200:12:26
close to the femoral nerve. We also need
00:12:2600:12:28
to consider that we're pretty close to
00:12:2800:12:30
some internal organs so if we have any
00:12:3000:12:34
other weird sensations. For example, all
00:12:3400:12:36
of a sudden needing to use the restroom,
00:12:3600:12:39
again we need to probably reset and
00:12:3900:12:43
move. Once we feel a release happen
00:12:4300:12:46
though, we should be good and then we'd
00:12:4600:12:49
retest. I was just using
00:12:4900:12:53
one hand here. Compared to Sonja, I'm
00:12:5300:12:56
a pretty large guy, you could go finger
00:12:5600:12:58
tip over finger, just be careful not to
00:12:5800:13:02
double the breadth of your contact
00:13:0200:13:03
surface because then you're just
00:13:0300:13:05
stretching out all of that abdominal
00:13:0500:13:08
musculature, all of the skin over her psoas
00:13:0800:13:10
that much more and it's going to be
00:13:1000:13:12
that much more uncomfortable. I would
00:13:1200:13:15
start with one hand and then place your
00:13:1500:13:16
fingers over the others to add a little
00:13:1600:13:19
bit of pressure. For the iliacus, the
00:13:1900:13:22
iliacus is really easy to find, not very
00:13:2200:13:25
easy to release, unfortunately. The
00:13:2500:13:28
iliacus is going to be against the face
00:13:2800:13:30
of our ilium, so all we need to do
00:13:3000:13:33
is come right over the ASIS and then
00:13:3300:13:36
curve around. I'm going to have Sonja
00:13:3600:13:39
take a nice deep breath for me. As she
00:13:3900:13:41
breathes out, I'm going to go ahead and
00:13:4100:13:44
sink in. The big problem with the iliacus
00:13:4400:13:47
is because of the tension in her skin
00:13:4700:13:49
and her transverse abdominis and the
00:13:4900:13:52
abdominal fascia and her external and
00:13:5200:13:54
internal obliques and all that stuff
00:13:5400:13:56
that we're having to palpate through, I
00:13:5600:13:58
just can't get to very much of her
00:13:5800:14:01
iliacus. It's not like I'm going to get
00:14:0100:14:03
down to the posterior wall. I'm probably
00:14:0300:14:05
just going to mostly affect
00:14:0500:14:11
the fibers closest to her ASIS. How's that
00:14:1100:14:16
feel? Feels good. As we mentioned in
00:14:1600:14:18
previous videos Sonja is kind of a
00:14:1800:14:22
masochist, she kind of likes pain.
00:14:2200:14:23
Since these techniques are so
00:14:2300:14:26
uncomfortable, they are a little
00:14:2600:14:27
different than some of the other
00:14:2700:14:28
techniques as we're having to push
00:14:2800:14:31
through viscera and we're having to push
00:14:3100:14:34
through that sensitive abdominal area
00:14:3400:14:35
and there's tends to be a little bit
00:14:3500:14:37
more skin stretch with these techniques.
00:14:3700:14:39
Make sure you're doing your reassessment,
00:14:3900:14:40
I mean you should be always doing
00:14:4000:14:42
reassessment between interventions but
00:14:4200:14:46
especially in this case. If you did not
00:14:4600:14:48
get a result from releasing the psoas or
00:14:4800:14:50
releasing the iliacus manually, for
00:14:5000:14:53
example, an increase in hip extension, a
00:14:5300:14:56
decrease in excessive lumbar lordosis
00:14:5600:14:58
during an overhead squat assessment,
00:14:5800:15:01
don't do the technique again. It's that
00:15:0100:15:04
simple. If it's effective, I'll take a
00:15:0400:15:07
little uncomfortable for effective
00:15:0700:15:10
outcomes. What I won't take is
00:15:1000:15:12
ineffective and uncomfortable.
00:15:1200:15:14
There you have it. Static manual release
00:15:1400:15:16
of the psoas and iliacus. I think the
00:15:1600:15:18
most important thing to remember with
00:15:1800:15:20
this particular technique is you are in
00:15:2000:15:23
close proximity to some very sensitive
00:15:2300:15:26
tissues when you do this technique. That
00:15:2600:15:28
means several things. Number one, you must
00:15:2800:15:32
assess before you do manual techniques.
00:15:3200:15:36
You need to be certain that the
00:15:3600:15:40
technique itself is worth whatever risk
00:15:4000:15:43
it imposes. You also need to be aware of
00:15:4300:15:46
those structures, things like the femoral
00:15:4600:15:49
nerve, the abdominal aorta and common
00:15:4900:15:51
iliac artery, the viscera, even the
00:15:5100:15:53
small intestines that are in there. They
00:15:5300:15:59
all have the potential of being insulted,
00:15:5900:16:01
we'll say, by pressure and moving around.
00:16:0100:16:04
If you feel something pulse,
00:16:0400:16:07
get off it. If you start causing tingling
00:16:0700:16:09
down somebody's thigh, that's not a good
00:16:0900:16:12
thing. Move. Make sure you're testing your
00:16:1200:16:15
position with that little hip flexion
00:16:1500:16:17
trick I showed you so that you know you
00:16:1700:16:20
are on the psoas itself and you don't
00:16:2000:16:22
spend a lot of time rummaging around
00:16:2200:16:25
potentially releasing something like the
00:16:2500:16:28
small intestine. And of course,
00:16:2800:16:31
last, make sure you practice this on some
00:16:3100:16:35
colleagues before you move in to doing
00:16:3500:16:37
this with a patient. and if at all possible,
00:16:3800:16:41
grab somebody who has experience with
00:16:4100:16:44
this particular technique so that you
00:16:4400:16:46
can do it on them and a manual
00:16:4600:16:49
therapists can give you feedback. It's
00:16:4900:16:52
the best education you can get for all
00:16:5200:16:54
of the manual techniques which we show. I
00:16:5400:16:57
hope you get great outcomes with
00:16:5700:16:59
this technique, I hope it does fill a big
00:16:5900:17:02
gap of psoas an iliacus release that
00:17:0200:17:05
maybe you couldn't do before but knew and
00:17:0500:17:07
some patients needed to be done. I look
00:17:0700:17:09
forward to seeing your comments. I'll