“OMM Workshop” David B. Fuller, D.O. David B. Fuller, D.O., F.A.A.O. Associate Professor Department of Osteopathic Manipulative Medicine, PCOM Board certified in: Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Family Medicine Integrative Holistic Medicine 1 A Look at the Role of the Psoas in Low Back Pain Review anatomy and function of the psoas and related structures Causes of psoas dysfunction Patient presentation Treatment with OMT Iliopsoas Chief flexor of the thigh Most powerful hip flexor with the longest range One of the body’s most powerful muscles Relatively hidden, with most of its mass located in the posterior wall of abdomen and pelvis The only muscle attached to the vertebral column, pelvis, and femur Unique position to stabilize as well as move POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 1 “OMM Workshop” David B. Fuller, D.O. Psoas Major Muscle Origin: Transverse processes of T12L5 (deep portion) Lateral aspects of discs between them (superficial portion) Can also attach to the lateral borders of the anterior longitudinal ligament Insertion: Lesser trochanter of the femur Psoas Major Muscle Major action Flexes thigh Dynamic stabilizer of trunk on thigh Can side bend lumbar spine Nerve supply (somatic) Lumbar plexus from anterior branches of L1-L3, especially L2 Sympathetic innervation T12?-L2 Iliacus Origin Iliac crest, iliac fossa, sacral ala, anterior SI ligaments Insertion Tendon of psoas major (most of the fibers) Lessor trochanter, and femur distal to it Innervation Femoral nerve (L2, L3) Action Acts with psoas major to flex thigh at hip and in stabilizing the joint Does not participate in movement of the lumbar spine POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 2 “OMM Workshop” David B. Fuller, D.O. Psoas Fascia Endoabdominal fascia l Lines the posterior abdominal wall and is continuous with the transversalis fascia that lines the transversus abdominus muscle Psoas fascia Endoabdominal fascia covers anterior aspect of psoas, known as psoas fascia A thickened area over superior aspect forms the medial arcuate ligament, attaching to lumbar vertebrae and pelvic brim Lumbar Plexus Composed of nerve roots T12-L4 Nerve roots enter directly into the psoas muscle, emerging from the borders and surface of the psoas Psoas muscle spasm can compress these nerves, producing pain referred to the anterior thigh Psoas Major Muscle Action: Major actions = flexes thigh and stabilizes trunk on thigh Decreases lumbar lordosis Unilateral action = lumbar sidebending Active with standing, walking, and running POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 3 “OMM Workshop” David B. Fuller, D.O. Psoas Major Muscle Passes through the diaphragm via the median arcuate ligament Which attaches to L1 and or L2 vertebral body and arcs around to transverse processes Along with the sympathetic chain Psoas Minor A small weak muscle Present in 60% people Anterior to psoas major Ataches to sides of T12 and L1 vertebrae and disc Inserts at iliopubic eminence and pectineal line of pubic ramus Action: A weak flexor of pelvis and lumbar spine Other Hip Flexors Sartorious Tensor fascia lata Pectineus Quadraceps Rectus femoris POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 4 “OMM Workshop” David B. Fuller, D.O. Age Associated Changes in Psoas Psoas size declines steadily from 20 to 60 years of age Significant decline occurs between 60 and 70 years Studies of people standing do not show any statistically different measurements in hip extension with progression of age Walking studies do show a difference Older subjects demonstrate decreased hip extension Anterior pelvic tilt Consider addressing with OMT and exercises and/or gait training Psoas-Kidney Connection Kidneys and psoas share fascial connections Psoas fascia connected with the… Renal (Gerota’s) fascia Lumbar plexus associates with psoas Nerves pass psoas in some fashion (ant, post, lat, med, or directly through) Renal sympathetic innervation T10/11-L1 Renal sensory innervation T10-L3 Psoas somatic innervation L1-L3 Psoas sympathetic innervation T12?-L2 Other Abdominal Causes of Psoas Irritation Psoas abscess Especially with lumbar tuberculosis, extends along sheath to thigh Kidneys, ureters, cecum, appendix, sigmoid colon, pancreas, lumbar lymph nodes, nerves of posterior abdominal wall Positive iliopsoas test with lateral recumbant resisted hip extension Sacroiliac disease can irritate the iliacus portion of the iliopsoas, causing a protective reflex POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 5 “OMM Workshop” David B. Fuller, D.O. Lower Crossed Syndrome Tight facilitated iliopsoas Tight facilitated upper lumbar erector spinae Inhibited weak abdominal mm Inhibited weak gluteus maximus Anterior pelvic tilt Tight piriformis and hamstrings Pelvic Side Shift Stabilize upper trunk with one hand and laterally translate waist with the other A unilaterally tight psoas will cause a pelvic side shift to opposite side This can in turn affect sacroiliac mechanics and cause a positive standing forward flexion test on that opposite side Effects of Psoas Tension/Spasm Bilateral spasm can increase pressure across the disc spaces Also causes patient to lean forward (flexed hip posture) Unilateral spasm causes classic psoas posture Listing to one side (pelvic side shift away) Type two dysfunction Forward bent Type two dysfunction at thoracolumbar or upper lumbar segments, often flexed POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 6 “OMM Workshop” David B. Fuller, D.O. Psoas and Knee Psoas spasm can affect knee Knee flexion associated with Tight hip flexors Hamstring tension Somatic dysfunction of knee can cause postural imbalance, usually unilateral Postural imbalance from pelvis or vertebral column can produce knee compensation L5-S1 Effects of Psoas Restriction L5-S1 are free of psoas attachment This area compensates for the loss of lumbar extension that occurs with psoas dysfunction by going into increased extension This is a potential source for lower back pain Treatment needs to focus on the psoas spasm, and not manipulation of the painful lumbosacral junction Psoas Major and Short Leg Syndrome Mechanics Typical short leg syndrome will have pelvic side shift to long leg side Effort to keep sacral base level Lumbar area tends to shift back to center line, causing a group curve convex on the side opposite the pelvic side shift (to short leg side) Psoas can be involved, but does not have to be POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 7 “OMM Workshop” David B. Fuller, D.O. Psoas Major and Short Leg Syndrome Mechanics Psoas spasm on the long leg side can decrease or negate the compensatory lumbar curve and pelvic side shift Psoas spasm on the short leg side can increase the pelvic side shift to the long leg side Short Leg Mechanics Anatomic landmarks (iliac crest, PSIS, greater trochanter) lower on short leg side Pelvic side shift to long leg side Lumbar convexity to short leg side (away from PSS) Sacrum engages oblique axis on the long leg side in a forward torsion pattern Typically find an anterior sacral base on the short leg side Psoas Spasm - Primary Primary spasm of psoas major Most often bilateral with one side predominating Pelvis will side shift away from the tighter psoas Can be produced by somatic dysfunction of the upper half of the lumbar spine Especially type two mechanics of L1 on L2, and L2 on L3 Typically in flexion with rotation and sidebending toward the side of the spastic psoas Treatment of the upper lumbar dysfunction will alleviate the spasm POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 8 “OMM Workshop” David B. Fuller, D.O. Psoas Spasm - Secondary Associated with lumbosacral instability Disc protrusion, spondylolisthesis Inflammation Discitis, renal pathology, retrocecal appendicitis Physiologic splinting occurs as a response to the primary trigger, resulting in psoas spasm Treatment is to stabilize any unstable lumbosacral junction or treat the underlying trigger Presentation Remember – the psoas is a long restrictor, so hypertonicity compresses the hip joint, SI joint, and lumbar spine Pain in lumbar spine Pain in lumbosacral junction Groin or proximal anterior thigh pain Flexed hip or hips (unilateral vs. b/l) Acute spasm – may not be able to lie prone Pelvic side shift Tenderpoint medial (superiomedial) to ASIS Psoas Tenderpoint Diagnosis Located 2/3 of the distance from the ASIS to the umbilicus or midline Treatment Physician stands same side, patient supine Marked flexion of b/l knees and hips with sidebending ankles towards side of dysfunction Might need to bring knees a little towards physician At least 70% reduction, treat 90 seconds, reposition and reassess POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 9 “OMM Workshop” David B. Fuller, D.O. Iliacus Tenderpoint Diagnosis Found 1/3 of the distance from the ASIS to the midline Treatment Physician stands same side, patient supine Lay patient’s crossed ankles over doctor’s knee/thigh Opposite ankle on top Externally rotate patient’s hips Fine tune and treat with counterstrain principles Treatment Sequence Consider treating counterstrain psoas tenderpoint/anterior lumbar TP Innominates while supine, or later Treat thoracolumbar, L1, L2 dysfunction Then can treat psoas directly if not in acute spasm Muscle energy Sacrum References Foundations of Osteopathic Medicine, 3rd ed, 427-428, 447, 550, 551, 557, 563, 598, 599 Sergueef, Nicette and Nelson, Kenneth. Osteopathy for the Over 50s. Handspring Publishing: Edinburgh. 2014. 245-246 Nelson, Kenneth, ed. Somatic Dysfunction in Osteopathic Medicine. Lippincott, Williams & Wilkins: Baltimore, MD. 2007. 111-112, 414-422 POMA 106th Annual Clinical Assembly April 30 – May 3, 2014 10
© Copyright 2024 ExpyDoc
