The Many Faces of Iliacus Dysfunction
A Closer Look at One Aspect of Iliopsoas Syndrome

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Overview

Iliacus Dysfunction comes in many shapes and sizes. If you're experiencing chronic or recurrent pain (or tingling, numbness, aching, or hot/cold sensations) in any of the following regions...

• Lower abdomen
• 
Groin

• Buttocks
• 
Down the leg
• 
Hip Joint
  
• 
Lower back
• 
Sacroiliac Joint

• Across the top of the hip bone (iliac crest)
• Wrapping around to the lower back or buttocks

... and these symptoms have not responded to treatments such as injections, physical therapy, rest, etc. and/or the diagnosis has been inconclusive or vague, then you may be suffering from Iliacus Dysfunction.


Anatomy of the Iliacus and Psoas (aka Iliopsoas)

Tucked inside your hip bone and hidden from easy hands-on access lies one of the most potentially troublesome muscles in the body: the iliacus muscle.

This muscle is the often-ignored neighbor of the more well-known psoas muscle. Together the iliacus and psoas are often referred to collectively as the iliopsoas because they share a common attachment at the upper inner thigh, the lesser trochanter.

Here's what the two muscles look like together... ------> The muscle attaching along the lumbar spine is the psoas. While they are both primary hip flexors with a common attachment, they are distinct muscles and can cause unique problems. Here I will focus on the iliacus. Over many years of treating chronic pain I have found that this muscle is the root of much unexplained misery.

What's the Basic Problem?

One very common problem of the iliacus is that it can shorten over time. This can be due to prolonged sitting and/or driving and the absence of regular stretching. Shortness in this muscle can be a particularly tenacious problem in athletes who don't stretch enough because their iliacus muscles may be quite strong.

A strong, flexible, resilient muscle is a good thing.

But a strong, dense, short, inflexible muscle is not.

Prolonged sitting with the iliacus in a shortened state, or just the lack of stretching over time, can lead to the iliacus getting used to its shortened position. Put another way, the iliacus adapts to the shortened position. It becomes its natural state or typical state.

Once in an adapted state, the iliacus has trouble returning to its normal resting length. And this is where the trouble starts.


Chronic Muscular Contraction

If a muscle cannot return to its normal, healthy resting length, it then resides in a state of chronic contraction and numerous undesirable consequences can result:

1. A chronically contracted iliacus can become ischemic (low blood flow). Imagine the white knuckles of a clenched fist. No blood flow there. An ischemic muscle is often a painful muscle. 2. A chronically contracted iliacus can develop trigger points which refer pain (or numerous other possible sensations – thermal, tingling, numbness, aching) either radiating out from the muscle or felt in other parts of the body. Triggers points in the iliacus can refer sensation to the groin, the hip, down the leg, etc.

3. A chronically contracted iliacus can distort the movement of the hip joint. For example, movement at the front of the hip joint could be reduced or restricted thus overworking other muscles in the hip. 4. A chronically contracted iliacus can cause a variety of compensations or distortions in the body. If, for example, a tight iliacus reduces movement in one hip, then the other hip or the spine or other parts of the body may be called upon to compensate and change their normal pattern of movement.

Potential Regions of Pain Due to Iliacus Dysfunction

What this means for an individual whose iliacus is tight and short and ischemic (low blood flow) is that pain might be experienced in any of a variety of places in the body. During my twenty years of treating iliacus dysfunction, clients have presented with pain in all following areas of the body:

The problem an individual may face when being examined by a physician not trained in soft tissue problems is that examination of any of the above areas of pain may reveal exactly nothing.

Many standardized allopathic tests, including neurologic tests, will come back negative because they are not designed to evaluate soft tissue problems. Such problems can only be properly assessed with skilled palpation and structural evaluation.

Of particular difficulty in the case of the iliacus is the fact of its hidden location. This muscle is not easy to palpate if you don’t have any practice at it. On top of that, an ischemic muscle is often extremely sensitive and painful to the touch.

Palpation of the iliacus that is too deep or sudden or rough can elicit a defensive reaction causing inflammation and bracing in the muscle. Great care and gentleness is required in order to effectively treat it.


If I think this is the problem, can't I just stretch it out?

Yes, definitely. Sometimes stretching alone can relieve iliacus dysfunction. And stretching should always be part of an ongoing preventive strategy.

But often a tight, ischemic iliacus will not release without some gentle and detailed hands-on treatment.

Reason: Because a muscle that has become chronically locked and ischemic will often respond to the act of being stretched by clenching protectively. This can be true of any tight muscle in the body but seems particularly true of the iliacus.


Treatment for Iliacus Dysfunction

Iliacus Dysfunction can be remedied. Muscles that are extremely tender and ischemic often respond quickly to careful, gentle, and detailed hands-on treatment.

But treatment can't be rushed. While Iliacus Dysfunction will respond quickly to skillful and patient hands-on treatment it's really easy to try to do too much too quickly.

I will often spend the better part of entire hour applying slow and gentle and gradual manipulations. It's essential to stay in the patient's comfort zone and to not fall into the trap of thinking that pressing harder will be faster. It doesn't work that way.

Sometimes the patient will be complicit with this type of hurrying approach. "Just do it, I can take it" is one common refrain from a patient anxious to be free of chronic pain. This is understandable, but it is a trap. It's the surest way to slow down the treatment. It's far faster, more efficient, and more lasting to peel away layers of ischemia gradually.


Treatment Protocol for Practitioners

The basic technique for treating iliacus dysfunction is not complicated but it requires patience and skill. Below I've included a basic treatment protocol for therapists who already possess knowledge and skill in the palpation of the iliacus muscle.

This is not a substitution for hands-on training and should not be attempted by someone who has no soft tissue training. Health practitioners who possess little or no soft tissue training are often heavy-handed. The practitioners who often best understand the subtlety of this technique are massage therapists. If their anatomy training has been adequate, massage therapists know how to properly listen with their hands.

The following is an introduction to treatment and is not an attempt to describe a comprehensive protocol for iliacus dysfunction.

Iliacus Treatment

I. Static Pressure

A) Client supine with the knee bent, foot on the table on the treating side
B) Practitioner stands on opposite side of the table and reaches across abdomen resting hands on iliac crest
C) If you’re having to bend forward, ask client to scoot toward you
D) Very slowly and gently sink thumbs obliquely into iliac fossa near crest of ilium. The iliacus can be very tender!

1. Gently compress with thumbs just enough to contact muscle


2. Thumbs should hook under crest of ilium, pressing pads almost toward the ceiling
3. Fingers grasp and stabilize at hip, gathering tissue to make entry point more slack

IMPORTANT - Pressure directly down into the table will intrude on organs, so be sure to hook under with thumbs rather than press down.

E) Ask client to very slowly initiate raising left knee 1/8 of an inch then rest (when iliacus flexes into thumbs it can be painful if the muscle is ischemic)

1. This a very tiny movement


2. Client is in control


3. Movement just enough so the slightest increase in sensation is felt upon lifting


4. Tell client not to push off with the ball of the foot or pivot on the heel, but rather pull up through the top of the knee otherwise the muscle will not be properly engaged


5. The movement ends almost as soon as it starts, just long enough for you and the client to sense the muscle, then relax

F) Repeat 4-6 times or until tenderness is decreased
G) Explore other points along the muscle, making certain you arrive at a static spot before asking the client to initiate movement with leg

II. Gentle Compression and Release

A) Gently compress iliacus along length of ilium, first at superficial level then increasingly more deeply
B) Work in rows, first along the top with gentle thumb compression, then slightly deeper and so on
C) Check for trigger points with 3 communications:

1. Is it tender?


2. Does it refer (or is it only a local sensation)?


3. Tell me when the referred sensation begins to fade.

IMPORTANT - Do not hold trigger points longer than about 12 seconds. If sensation increases rather than decreases either at the local point of contact or in the referred region it means you’re using too much pressure (Arndt-Schultz Law). Leave the point and return to it later with lighter pressure.



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