Iliopsoas-related low-back pain
Iliopsoas-related back pain is the most common single
pattern seen in my practice. Most cases resolve in one visit, but
occasionally more visits are required. Back pain without an abrupt
onset requires the patient to stretch on a regular basis to maintain
|| Source: Travell
JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger
Point Manual, Vol. 2, Williams & Wilkins, Baltimore, 1992,
p. 90. Reproduced with the permission of Lippincott
Williams & Wilkins.
Symptoms: Pain in a pattern lateral to and parallel
to the lumbar spine and/or in the S/I joint. Pain may be unilateral
or bilateral. Pain may occur with sitting, standing, lifting, getting
out of a seated position, and/or walking up stairs. Patient cannot
lie down comfortably without support under the knees.
Signs: Hip extension is restricted and may be less
than zero. Extreme lumbar lordosis. Patient may limp. Patient may
be unable to stand straight. Degenerative or herniated lumbar discs
may be present.
- patient wakes up in the morning with pain, especially if the
patient sleeps on her side in a fetal position
- patient falls backwards
- patient sits in a car during an auto accident, sees the accident
coming and tightens his muscles in anticipation of collision
- patient sits with her hips acutely flexed
- patient rides a low-handled bicycle
- patient lifts something heavy
- patient suffers other trauma while his psoas muscle is contracted
Tandem Point approach: Psoas and iliacus trigger points
with Sp 9, Sp 8, Li 6, Sp 6, Ki 4, Ki 5, Sp 5, Li 4, Sp 4, P4, P5,
P6, Bl 60 and Sp 21. The patient presses a psoas trigger point near
the navel and Sp 21 or any referred pain point on the low back.
Release trigger points in any of the following antagonists: piriformis,
gluteus maximus, gluteus medius, gluteus minimus, with Bl 61, then
release the psoas again. Stress the iliopsoas by having the patient
walk up stairs. Repeat the approach. Sometimes trigger points in
the rectus femoris limit hip extension, and those points need to
be released as well. When the rectus femoris is in contracture,
it must be released along with its antagonist, the biceps femoris.
Occasionally psoas minor will play a role in this pattern and is
released with Ki 5. In advanced patterns, where the patient has
been suffering significant pain for a long period of time, it may
be necessary to alternate work on the anterior and posterior sides
of the body several times during one session. Also, it is important
to release muscles on both the left and right sides of the body,
even if pain appears only on one side.
Cases: The following cases display some of the assorted
causes and courses of iliopsoas-related back pain, and some of the
combined syndromes often seen.
Female, 45, nurse. Her account of her injury, August 13, 1999:
"I fell backwards over a suitcase and landed flat on my back, with
the impact evenly distributed. It took my breath away and I instantly
felt pain in my flank and low back. I don't remember any radiating
leg pain. I immediately iced my back for several hours and took
Advil fairly regularly (600mg every 4-6 hours). Hours later when
I tried to go out for dinner, I could barely manage to walk. The
pain was intense in my low back and around my hips. I tried to sleep,
but fitfully. The next morning it took all my effort to get out
of bed and walk -- stooped over -- to the bathroom." Tandem Point
therapy was applied about 10 a.m. August 14 and was limited to work
on the iliopsoas and related tandem points. No points were taken
on the posterior side of the body. Her account: "I could immediately
walk, straighten up and most of my pain was gone, except a little
stiffness for a few days. Stretching helped, too. Since then [as
of March 1, 2000] I have tried to 'find those points' when my back
is sore or stiff from moving boxes or furniture, but I can't remember
the exact stretches."
Female, 45, nurse. History: Patient suffered a low back injury
in 1993 (pain in the left sacroiliac joint) while lifting a patient
in the hospital. M.D. referred her to physical therapy. She did
not find PT helpful and only went two times. She received Tandem
Point therapy for her low back on February 1, 1999: iliospsoas plus
Ki 4, also gluteus medius plus Bl 61. Immediately following therapy
she had no pain in her left S/I joint. She stretched her psoas and
gluteus medius irregularly for a few weeks. On February 21, 1999,
she reported no pain in her left S/I joint. She started working
out in May, 1999, and developed pain in her right S/I joint, which
was addressed in her next two sessions. [This case indicates the
importance of treating both the left and right sides of the body
whenever time permits, even if the pain appears only on one side.]
Follow-up treatment: November 11, 1999, Tandem Point therapy addressed
psoas muscles briefly, as well as other pain problems. Follow-up
by phone: March 8, 2000: the patient had just gone cross-country
skiing; she had no pain in either S/I joint; her low back is "fine."
She now does assorted yoga stretches daily.
Female, 24, medical research professional. History: Patient had
injured her low back in 1992 rowing crew. She was diagnosed with
a lumbosacral sprain. She received muscle relaxants and three months
of physical therapy, which did not have an effect on her back pain.
She reinjured her back in the spring of 1993, when her dog ran into
her and knocked her on her back. Her back pain eventually went away.
She awakened July 20, 1999 with acute low back pain. The patient
called in sick to work because of her severe back pain. Sitting
and rising from a sitting position were especially painful. Her
pain extended along her lumbar spine to the top of her S/I joint.
The patient was seen on July 20, 1999, at 1 p.m. Tandem Point therapy
was applied to the iliopsoas only, with Sp 3, Sp 4, Sp 6 and Ki
5. At the end of 45 minutes of therapy, the patient reported no
pain. The patient went on a camping trip that weekend and had no
pain. The patient was seen for neck pain on September 27, 1999,
and she reported her back was "totally perfect." Follow up by telephone
on March 5, 2000: the patient stretched her psoas for about five
days after her injury but has not continued to stretch. She has
had no back pain since July 20, 1999.
Male, 36, dancer in professional dance theater. The patient suffered
an injury in early October, 1999, caused by "stretching from standing
still" during a photo shoot. The next day he had some pain, and
it grew worse during the week. The patient had pain sitting, walking
up stairs, lying down, and sleeping. He felt pain in his groin and
in his low back. The patient telephoned his doctor and was referred
directly to physical therapy without a doctor's visit. His two physical
therapy visits "helped a little." The physical therapist provided
him "good exercises, but nothing that fixed the problem." The patient
was gravely concerned that he would be unable to accept an upcoming
dance role that was being developed with him in mind. He presented
for Tandem Point therapy on November 21, 1999. Therapy involved:
pectineus plus Ki 20, Ki 27, and Ki 5, and later St 30; iliopsoas
plus H 7 and Sp 8; gluteus medius, gluteus maximus, and tensor fascia
latae. Following this session, he reported that about 85% of his
pain was gone, and three days later he was able to dance. Follow
up treatment January 11, 2000 involved Tandem Point therapy for
the pectineus, psoas, quadratus lumborum, and tensor fascia latae.
After this session, 100% of his pain was gone. His dance performances
were in February, 2000, and he noted that during the first week
of performances the theater was very cold. He had some pain, which
he relieved with self-acupressure to psoas major. During follow
up treatment February 22, 2000 his psoas was treated again, with
Sp 22, Bl 60, and Li 4.
Male, 42, attorney. History: Low-back pain onset mid-1980's (15
years duration). Symptoms: Periodic severe spasms required him to
spend a couple of days in bed. These spasms would happen once or
twice a year and were getting worse through the years. The spasms
would come on unexpectedly, but usually involved some sort of bending
motion. At the most extreme he was unable to move. He had to work
at a "standing desk," because he could not sit down for extended
periods. Tests by M.D.: X-rays and MRIs. Diagnosis from M.D.: degenerative
disc L4-L5; L5-S1 disc worn down to almost nothing. Treatment before
Tandem Point therapy: physical therapy that only included exercises,
which helped somewhat. The exercises emphasized strengthening rather
than stretching. Because the patient kept having episodes of severe
pain, his M.D. prescribed a TENs unit, which the patient used for
"a little while." At one point a physiatrist tried acupuncture.
The patient also tried massage, chiropractic, exercises and stretching
30 minutes/day, including sit-ups. The patient presented for Tandem
Point therapy May 23, 1999. Tandem Point therapy was applied to
soleus trigger point 3 plus Ki 4, gluteus medius plus Bl 61, psoas
plus Li 4. At the end of this session, the patient had no back pain.
Follow up treatment June 20, 1999: The patient and his family were
moving to the Midwest. The patient had been lifting a lot of boxes,
and he had just started to have some pain. Tandem Point therapy
was applied to the soleus, semitendinosus, semimembranosus, gluteus
medius, gluteus minimus, psoas plus Li 6, and quadratus lumborum.
Patient has no back pain at the end of this session. Follow up by
telephone on February 13, 2000: His back was "doing OK." He had
one episode since he moved to Midwest, playing tennis. He leaned
down to hit a low ball, then had to spend a lot of time lying down,
and he had to cancel teaching class. He has been feeling pretty
well the last several months. He is doing a variety of exercises,
stretching his abdominal muscles more, including doing Travell and
Simons's stretches for the psoas, and stretches for the hamstrings.
He still does sit-ups. Mostly he works standing up, but he can now
work sitting down. Tandem Point therapy "helped tremendously, .
. . brought immediate pain relief, which was great . . . .The most
important thing was helping me to understand what was going on with
it, so I was better able to take care of it."
Female, 52. History: Injury occurred three years previously after
a long, hard, mountain bike ride. Her chiropractor thought she had
suffered a "bulged disc." She had a lot of discomfort for several
months, during which she could not sit for any period of time without
discomfort. She did not perform any exercise or stretching for almost
a year. Later she found that stretching actually was the only thing
that seemed to help. She first presented August 24, 1999 for Tandem
Point therapy for neck pain and headaches. At her second session,
September 9, 1999, she received Tandem Point therapy for psoas minor,
psoas major, and the piriformis, including holding a point in psoas
major with a point in the piriformis. Follow up March 7, 2000: She
reported that Tandem Point therapy "made a huge difference" in her
low back pain. While the discomfort still comes and goes, she can
now use pressure points and stretching to make the discomfort go
away. She estimates that she has 50% of the pain she used to have
before one session of Tandem Point therapy for the low back.
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