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