Physiotherapy with 6 tips to stretch iliopsoas muscle

Ref: https://www.rowperfect.co.uk/

     

        Hip flexion or anterior hip bending was caused by hip flexor muscles contraction. A group of hip flexor muscles consist of iliopsoas, sartorius, tensor fascia lata, and rectus femoris which work as prime - mover, and, pectineus, adductor longus, adductor brevis, and the most anterior fibers of the adductor magnus and the gluteus (medius and minimus) which work as accessory muscle. 

My experience in the physiotherapy clinic, I have seen tightness in some or all of the hip flexor muscles in patients with IT band syndrome, groin pain, and low back pain. One muscle which differs from others is “iliopsoas” because its origins connect to the spine. 

“To stretch the tightness of iliopsoas is used in my physiotherapy session to improve the symptoms often.” 

6 options to stretch iliopsoas muscle

Exercise #1: Standard half kneeling stretch where the target muscle is on the rear leg. The pose need keep back straight with shift pelvic in front that no need to arch the back.

Exercise #2: Supine leg off the side bed

Exercise #3: Basic Thomas stretch that the target muscle is straight leg

Exercise #4: Advance Thomas stretch that the target muscle is off bed

Exercise #5: Upward - Facing dog pose. The pose need elevation of pelvic.

Exercise #6: Chair stand posterior pelvic tilt

    The iliopsoas is the most powerful of the hip flexors. The function of iliopsoas such as sit up, elevate leg, leg swing during walking, control sitting balance, and control lordotic curve of lumbar spine. 

Ref: https://womencycles.com/blog/

  

    Iliopsoas is a compound muscle which consists of the psoas major and iliacus. The psoas major is placed lateral to the vertebral column. It corresponding intervertebral discs of the last thoracic and all the lumbar vertebrae that originates at  the 12th thoracic vertebrae until to the vertebral body of the lateral surface of the 5th lumbar vertebrae and extends to the transverse process of the lumbar vertebrae 1st to 5th, and, the superior two-thirds of the bony iliac fossa and the iliolumbar and ventral sacroiliac ligaments. It goes down and palpable just deep to the inguinal ligament, where it lies bordered by the sartorius muscle laterally and the femoral artery medially, and, finally attaches to the femur lesser trochanter and the linea aspera medial. 

Ref: https://www.optimaphysio.com/

The iliacus has several points of origin; it starts with the iliac crest, anterior inferior iliac spine, iliolumbar ligament, and anterior sacroiliac ligament. And eventually attaches to femur lesser trochanter and linea aspera medial that seem to be the same tendon of psoas major. 

Ref: https://www.osteopathyny.com/

While sitting or standing, the iliopsoas is constantly active and plays an important role in stabilizing the pelvis and lumbar region along with the erector spinae and quadratus lumborum. Hence shortening or straining of the iliopsoas can cause excessive pelvic anterior tilt or increased spine extension during hip joint motion, thereby acting as a risk factor for low back pain. A shortening of the iliopsoas muscle can result in anterior pelvic tilt and trunk extension. Finally, it is leading to low back pain.

Ref: https://www.pinterest.com/

            Shortening of the iliopsoas muscle was found to be the primary cause of lumbar hyperlordosis and excessive anterior pelvic tilt. This abnormal alignment may inhibit the function of the Transversus Abdominis (TrA). Back muscle guarding from lumbar hyperlordosis resulted from the shortening of the iliopsoas muscle. This is impaired circulation by muscle guarding, leading to increased pain (pain-spasm-pain model). 

Back pain and improved excessive lumbar lordosis angle can be reduced by lengthening the iliopsoas muscle and increasing TrA activation capacity.

The principle of muscle stretching is simple: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations in one muscle as demonstrated VIDEO. 

Reference: 

https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000843_web.pdf 

https://www.jptrs.org/journal/view.html?doi=10.14474/ptrs.2021.10.2.225 

https://www.thaiscience.info/journals/Article/JMAT/10971199.pdf

To release IT band syndrome by 5 ways foam roll massage

     

Ref: https://www.runwell.net.au/blog/

        Foam roll massage and tennis ball massage is a popular technique of muscle - fascia tension release for prevent and treatment benefits. It is applied to many parts of the body and musculoskeletal impairments including the IT band syndrome. 

In my physiotherapy clinic experience with IT band syndrome patients, I have used this technique many times that roll on the IT band directly as the standard management. The outcomes demonstrated both effectiveness and ineffectiveness. Finally, I found a way to massage with the foam that I always recommend to patients who are with IT band syndrome. 

Ref: https://physioworks.com.au/pain-injury/knee-pain/itb-friction-syndrome/

I have seen muscle spasm not only at mid IT band but also above knee cap, rear hip joint, calf muscles. 

5 ways to do roll massage in IT band syndrome

Exercise #1: IT band: lying on the side to roll.

Exercise #2: Gluteus maximus: it is necessary to bend hip joint with half - prone in front.

Exercise #3: Tensor Fascia Lata: prone on the ball to roll.

Exercise #4: Biceps femoris: lying on the side with half - supine.

Exercise #5: Vastus lateralis: lying on the side with half - prone.

I would like to introduce all muscles anatomy  which I have recommended to do foam roll; include,

    (1) The IT band

    IT band is a strong thick wide tendinous band located on the lateral thigh. IT band origin is insertion attachment of gluteus maximus (Gmax) and Tensor Fascia Latae (TFL) that extend their part into the IT band directly. The mass of the IT band descended along the lateral thigh to the knee joint that covers the vastus lateralis muscle. The IT band has 2 primary attachments, including the lateral epicondyle and the Gerdy tubercle. 

Ref: https://www.mygcphysio.com.au/

The first iliotibial band attachment is into the distal femur at the upper edge of the lateral epicondyle. The histologic makeup is consistent with tendon and has a layer of adipose tissue underneath the iliotibial band attachment area. The adipose tissue contains pacinian corpuscles, is highly vascular, and may be “the site of the inflammation” that causes pain during compression.

The second attachment of the iliotibial band is the insertion into the Gerdy tubercle of the tibia and serves as a ligament in structure and function. The Gerdy tubercle attachment is tensed during tibia internal rotation as the knee flexes during the weight-acceptance phase of gait. Internal tibial rotation explains the occasional connection between toeing in and iliotibial band “strain”

Moreover, there are many distal attachments that span out to the lateral border of the patella (by way of epicondylopatellar ligament and patellar retinaculum), patellar tendon, lateral patellar retinaculum before its insertion on Gerdy’s tubercle of the tibia, the biceps femoris, and vastus lateralis. 

About this muscle, I have seen trigger points at mid IT band and 2 - 5 cm. above knee joint the most. 

(2) Gluteus maximus (Gmax)

We can see Gmax at the rear hip which is the biggest muscle that is why origin attachment of Gmax covered large area; include, posterior ilium, posterior layer of thoracolumbar fascia, posterior superior iliac spine (PSIS), posterior gluteal line, posteroinferior sacrum, coccyx, sacrotuberous ligament, and over on gluteal fascia. It is used for support and bumpers while sitting in our daily lives. Gmax has two distinct portions that consist of inserts into the IT band and the inferior portion inserts into the femur. The Gmax pulls posteriorly on the IT band and femur to extend the hip.    

According to its insertion, there is thickening and stiff soft tissue behind the greater trochanter. 

     (3)Tensor Fascia Lata (TFL)

Origin of TFL started on anterolateral of an iliac crest that is approximately 15 - 76 millimeters wide. TFL has many origin attachments; include, the lateral aspect of the anterior superior iliac spine (ASIS). The iliac tubercle, a notch located below the superior spine of the ilium, the anterolateral iliac fossa that is slightly below the crest, and the deep surface of the fascia lata of the thigh. 

Insertion of TFL has been recorded in many locations. There are disputes , for example, on greater trochanter or around there, to the middle layer of the IT band. So, It is not clear whether such tendinous tissue belongs to the fascia lata, or is the muscle’s own tendon. However, the TFL pulls anterosuperiorly on the ITB to flex the hip generally.

I have found tightness, stiffness, and trigger points on this muscle often that related IT band tension progressively.  

Ref: https://www.pinterest.com/pin/

   

(4) Biceps femoris

Biceps femoris is a member of the hamstring muscle which is located on the lateral side of the posterior thigh. They consist of long head and short head that short head originated medial to the linea aspera of the distal femur and descended distally and laterally. 

The first component of the short head was a proximal muscular attachment to the anterior and medial side of the tendon of the long head. Other significant insertions included an attachment of the capsular arm to the posterolateral joint capsule,  the attachment of the capsuloosseous layer to the iliotibial tract (biceps-capsuloosseous iliotibial tract confluens),  a lateral aponeurosis, two tendinous attachments-the direct arm,  the anterior arm, and capsular attachment in the interval between the tendon of the lateral head of the gastrocnemius. Perhaps, insertion anatomy caused patients with IT band syndrome to feel tense calf muscle. 

My own opinion, it is not clear between biceps femoris tightness or posterior fiber of IT band stiffness. 

Ref: https://anatomy.app/encyclopedia/biceps-femoris

     

(5) Vastus lateralis (VL)

VL is a member of quadriceps composed structurally of four distinct muscles; include, the rectus femoris, vastus lateralis, vastus medialis and vastus intermedius. The vastus lateralis is considered the largest part of the quadriceps femoris to form thick, wide and fusiform appearance is intimately attached to the vastus intermedius in its middle third. 

          The origin of the vastus lateralis is on the greater trochanter, lateral lip of linea aspera femoris and the lateral intermuscular septum and its insertion at the base patellar ligament using the patella and tibial tuberosity.

Vastus lateralis muscle has presented two parts; include, long and oblique parts. The oblique portion arises from the linea aspera of the femur and lateral intermuscular septum, a more fibrous expansion of the iliotibial tract by inserting the tendon itself, which is directed inferior and lateral to the vastus lateralis muscle over this by joining the superolateral border of the patella tendon to form a single, often attached to the joint capsule. The distal fibers of the vastus lateralis oblique were presented in interdigitated lateral retinaculum, which is formed from the expansions of tendinous insertions of the vastus lateralis muscle, inserted in the tibia and patella which, in turn, reinforces the anterolateral region of knee, and iliotibial tract. Morphologically, the vastus lateralis oblique is divided into: a distal surface and a spiral proximal portion with deep longitudinal fibers in the femoral shaft below the belly of the vastus lateralis muscle along, mingling with the vastus intermedius. 

Ref: https://learnmuscles.com/glossary/vastus-lateralis/

The vastus lateralis longus has its origin in the femoral trochanter and lateral lip of linea aspera of the femur, as found in the anatomical literature. showing extensive superficial aponeurosis in more than two thirds of the proximal surface and a deep aponeurosis in the distal  1/3 separating it from the vastus lateralis obliquus.  Its insertion is on the superolateral border of the patella by the patellar ligament by means of union with the tendon of vastus lateralis oblique, forming a single tendon. 

Therefore, the extensive lateral oblique is clouded by the IT band giving rise to the lateral retinaculum and completely covering the vastus lateralis oblique.

Bridging kneeout to strength glut
(Ref: https://www.skimble.com/)

Finally, I would like to recommend you to make rolling massage combine strengthening glut muscles that is very important and stretching that follow on https://yimphysionearme.blogspot.com/2022/05/physiotherapy-with-6-optionals-tfl-itb.html 

Reference: 

https://www.researchgate.net/publication/51211560_Iliotibial_Band_Syndrome_Soft_Tissue_and_Biomechanical_Factors_in_Evaluation_and_Treatment/link/59dce6f8458515e59df9eeca/download 

https://link.springer.com/content/pdf/10.1007/s40279-021-01634-3.pdf 

https://www.scielo.br/j/rbme/a/htP9y5rrfQdkGFLDkZPQF6r/?lang=en&format=pdf

http://www.jms.periodikos.com.br/article/587cb49f7f8c9d0d058b47a1/pdf/jms-28-4-587cb49f7f8c9d0d058b47a1.pdf 

https://www.researchgate.net/publication/14561312_The_Biceps_Femoris_Muscle_Complex_at_the_Knee/link/5421e5de0cf2a39f4af766e9/download 

https://www.researchgate.net/publication/51823221_A_review_of_the_anatomy_of_the_hip_abductor_muscles_gluteus_medius_gluteus_minimus_and_tensor_fascia_lata 

Physiotherapy with 6 optionals TFL & ITB stretching in iliotibial band syndrome

 

Ref: https://www.knee-pain-explained.com/lateral-knee-pain.html

    Some of my patients who are with knee pain include lateral pain, fore - knee cap pain, and medial pain. Lateral thigh evaluation is one of my routine standard physical assessments. I have found some patients with iliotibial band syndrome or iliotibial friction band syndrome (ITBS).

My patients with ITBS are distance runners, cyclists, and triathlon, the most. Recently, I found it in an ice hockey player. They have trigger points, high - tension, and tightness on the IT band that stretch IT band uses for prevention and treatment of ITBS. 

6 Optionals of IT band stretching 

Exercise #1: Stand stretch TFL & IT band

Exercise #2: Chop stretch TFL & IT band

Exercise #3: Half cross sitting stretch TFL & IT band

Exercise #4: Half kneeing stretch TFL & IT band

Exercise #5: Side lying stretch TFL & IT band (easy)

Exercise #6: Side lying stretch TFL & IT band (advance)

Anatomically, the IT band is a thick tendinous big band that locates on the lateral thigh. It is a continuation of the tendinous portion of the tensor fascia lata (TFL) muscle with some contributions from the lateral gluteal muscles. The IT band has many distal attachments that span out to the lateral border of the patella (by way of epicondylopatellar ligament and patellar retinaculum), patellar tendon, lateral patellar retinaculum before its insertion on Gerdy’s tubercle of the tibia, the biceps femoris, and vastus lateralis. 

IT band anatomy picture that has origin near hip joint
and many insertions end around knee joint; ITB: IT band
(Ref: https://www.researchgate.net/figure/The-iliotibial-band-and-site-of-injury-at-lateral-epicondyle-of-the-femur_fig1_51211560)

The site of injury is near the insertion at the lateral epicondyle. Majority of the injury mechanism is repetitive friction and compression of the IT band against the lateral epicondyle. IT band sliding over the lateral femoral epicondyle, moving anterior to the epicondyle as the knee extends and posterior as the knee flexes, and remaining tense in both positions. Repetitive irritation can lead to chronic inflammation, especially beneath the posterior fibers of the ITB, which are thought to be tighter against the lateral femoral epicondyle than the anterior fibers. The critical friction angle of the knee occurs at or at slightly less than 30 degrees of knee flexion which is called  ‘‘impingement zone’’ that associates during walking, running, and cycling. 

Triathlon consists of swimming - biking - running 
Ref: https://www.drjimtaylor.com/

The intrinsic factors consist of leg - length discrepancies that the longer one is more risky, and biomechanics that are very strongly related to muscle performance include strength, endurance, flexibility, and segmental coordination. Strength of  the gluteus medius and gluteus maximus muscles is important to control hip adduction and knee varus and valgus because strength deficits in the hip abductors are believed to play a role in the development of ITBS. 

Extrinsic factors are related to training methods as well as running shoes or cycle fit. Several training factors have been related to ITBS, including excessive running in the same direction on a track, downhill running, a lack of running experience, abrupt increase in running distance or frequency, and running long distances. 

Downhill running
(Ref: https://www.runpacers.org/pasadena/downhill-race-training/)

According to a subjective examination in my physiotherapy clinic, I have heard patients' stories, for example, change speed running immediately, increase distance immediately, not enough recovery, etc. For objective examination some patients never know the cause of pain, for example, weakness of hip abductor muscles, improper running shoes, etc. 

One case came to see me with fore - knee pain who just bought popular and expensive running shoes. She is mid foot strike pattern and her shoes have a narrow outsole at mid and heel section. I informed her of two options; include, change the strike pattern to forefoot strike pattern, or change to new shoes which are wide mid and heel section outsole.    

Clinical present with complaints of a sharp or burning pain roughly 2 cm superior to the lateral joint line. The pain may radiate proximally or distally. There usually is tenderness on palpation of the ITB 2 to 3 cm above to the lateral joint line. There may be local edema or crepitation. The pain always makes it difficult to go up - down stairs, bend knee, and sports performance drop.  

Ober's test use for IT band tightness assessment
(Ref: http://corebalancetherapy.com/wp-content/uploads/2013/09/Iliotibial-Band-Syndrome-review-PMR-2011.pdf)

Michael and Adam (2006) classified ITBS recovery into 4 phases including acure, subacute, recovery - strengthening phase, and Return - to - running phase. Stretching exercises are suggested to start after acute inflammation subsides that mean they should start in the subacute phase. 

The way to stretch is simple: stretch to the point where “tightness without pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 repetitions in one muscle as demonstrated in the video. Stretching exercise is one of the important management parts of ITBS. However, gluteus medius and gluteus maximus strength is very crucial management part for prevention and treatment, as well. 

Reference: 

https://www.researchgate.net/publication/51211560_Iliotibial_Band_Syndrome_Soft_Tissue_and_Biomechanical_Factors_in_Evaluation_and_Treatment/link/59dce6f8458515e59df9eeca/download 

https://www.researchgate.net/publication/7004336_Practical_Management_of_Iliotibial_Band_Friction_Syndrome_in_Runners/link/5665d83208ae192bbf927368/download 

Physiotherapy with 13 various stretch for tennis elbow and lateral elbow pain

Ref: https://www.usta.com/

         Tennis elbow sounds familiar and seductive to think of tennis related injury, especially professional players because of the accommodation of repetitive and forceful movements of the arms. Not only sports, but also occupations that include butchers, manual laborers, and employees in the fish processing industry are at high - risk of work related injury. In a physiotherapy clinic, I have seen tennis elbow in golfer, squash, swimmers, weight lifter, carpenter, gardener, mob & sweep, etc.  

Ref: https://hughston.com/wellness/tennis-elbow/

13 various stretch for tennis elbow and lateral elbow pain

Exercise #1: Tennis elbow stretch with hand open which consists of arm hyper - pronation plus wrist flexion plus wrist bend to little finger

Exercise #2: Tennis elbow stretch with hand open which consists of arm hyper - pronation plus wrist flexion plus wrist bend to little finger

Exercise #3: Standard backhand stretch with supination and hand open

Exercise #4:  Standard backhand stretch with supination and hand closed

Exercise #5: Reverse prayer stretch

Exercise #6: Standard backhand stretch with pronation and hand open

Exercise #7: Standard backhand stretch with pronation and hand closed 

Exercise #8: Table backhand stretch with supination and hand open

Exercise #9: Table backhand stretch with pronation and hand open

Exercise #10: Floor backhand stretch with pronation and hand open

Exercise #11: Floor backhand stretch with supination and hand open

Exercise #12: Brachioradialis stretch

Exercise #13:  De Quervain’s stretch

      History of tennis elbow was first described by Runge in 1863. This condition mechanism occurs in tennis players secondary to an improper backswing. Then, Official nomenclature of this entity was declared in 1883 as “Lawn Tennis Elbow”.

The presenting symptoms of tennis elbow typically involve the insidious onset of pain in the lateral aspect of the elbow, which may radiate distally into the forearm. Pain is often exacerbated with resisted wrist extension or repetitive wrist movements, especially with the elbow full extension. Patients also may complain of weakness in grip strength occurring with attempts to grasp or carry objects with the affected upper limb. Edema or erythema at the lateral epicondyle is uncommon, and patients typically have transient symptom relief with activity modification or relative rest of the symptomatic limb. Tenderness is also typically localized to the tendinous origin of the extensor carpi radialis brevis. The pain can be aggravated by gripping, heavy lifting, or simple tasks of daily living. 

Ref: https://orthoinfo.aaos.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis/

According to anatomy, the lateral elbow is the proximal of wrist extensor or backhand muscles. The origin of the wrist extensor group is lateral condyle of the humerus region. The extensor carpi radialis longus originates from the supracondylar ridge below the origin of the brachioradialis. This attachment is between the brachialis medially and the extensor carpi radialis brevis inferolaterally. The extensor carpi radialis longus crosses the elbow and carpal joints to insert onto the dorsal base of the second metacarpal and is covered by the brachioradialis over most of the forearm. Its function is that of wrist extension, radial deviation, and possibly elbow flexion. Originating from the lateral inferior aspect of the lateral epicondyle, the extensor carpi radialis brevis origin is the most lateral of the extensor group. The extensor carpi radialis brevis is covered by the extensor carpi radialis longus and its fibers are almost indistinguishable from those of the extensor carpi radialis longus and extensor digitorum communis in most cases. The extensor carpi radialis brevis muscle also has additional attachments to the radial collateral ligament and the intermuscular septa between it and the common extensor muscles. The extensor carpi radialis brevis tendon inserts to the dorsal surface of the base of the third metacarpal bone. Pure wrist extension with some assistance in radial deviation are the main functions of the extensor carpi radialis brevis.

Ref: https://orthoinfo.aaos.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis/

There is one muscle that has been installed in the lateral elbow area which is brachioradialis. It originates from the lateral supracondylar ridge, the lateral aspect of the diaphysis of the humerus, and the lateral intermuscular septum and inserts into the lateral aspect of the styloid process of the radius. So, it seemed to be a neighbor of backhand muscles. The primary function of the brachioradialis is as a concentric elbow flexor and secondarily assists in forearm pronation.

Brachioradialis muscle location
(Ref: https://gvaat.com/blog/how-to-draw-forearm-anatomy-a-step-by-step-guide/)

Khandaker and et al., suggested stretching  for tennis elbow like De Quervain’s tenovaginitis stretching. De Quervain’s tenovaginitis is a disease that is more common among people who perform manual work, owing to the unique mobility of the human thumb. Patients with this condition mostly complain of soreness and tenderness on the radial side of the distal radius that is exacerbated by ulnar deviation of the thumb; by a strong grasp combined with flexion and radial deviation of the wrist or by a firm pinching together of the index finger and thumb. Physical examination reveals tenderness and swelling directly over the first dorsal compartment. Within this compartment lie the tendons of extensor pollicis brevis (EPB) and abductor pollicis longus (APL). 

(Ref: https://orthofixar.com/hand-surgery/de-quervain-tenosynovitis/)

All of the above are thumb side linkages that possible transmit force to each other. The force may make the musculotendinous junction of the wrist extensor muscles group degenerate and injured afterward. As above, wrist extension force can pull the muscle - tendon unit directly. Moreover, very strong force of wrist flexion and grip can pull there indirectly because wrist extensor muscles have to contract while gripping to stabilize the wrist joint.   

Stretching exercise, one of physiotherapists' protocols, is used to decrease the risk factor of musculoskeletal injuries. Muscles would be soft and length enough to tolerate the force which pulls them. The way to stretch is simple: stretch to the point where “tightness without pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 repetitions in one muscle as demonstrated in the video.  

So, as my physiotherapist experience, I  would like to recommend stretching both sides of the lateral arm often to prevent lateral elbow injury that you can study wrist flexor stretching on https://yimphysionearme.blogspot.com/2022/05/physiotherapy-with-11-ways-to-stretch.html 

Reference:

https://www.researchgate.net/publication/286800895_The_effect_of_stretching_exercise_in_the_management_of_lateral_epicondylitis/link/6006b00445851553a053fc8b/download 

https://www.researchgate.net/publication/23664987_The_Function_of_Brachioradialis/link/5c4b97d8299bf12be3e405f7/download 

https://www.researchgate.net/publication/235337854_The_wrist_hyperflexion_and_abduction_of_the_thumb_WHAT_test_a_more_specific_and_sensitive_test_to_diagnose_de_Quervain_tenosynovitis_than_the_Eichhoff's_Test/link/5540779e0cf2320416ed06a9/download 

https://www.jospt.org/doi/pdf/10.2519/jospt.1994.19.6.357