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.
