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The Untold story of Mighty Psoas Part 1

There seems to be lot of “dysfunctional psoas causing back pain” articles. We like to offer another viewpoint.

How psoas  effects  on posture?   

The answer is a general facilitation along the anterior kinetic chain. The body doesn’t like to be in a position to  stabilize. If it is weak in an action such as flexion, the body will move more into flexion, which gives the illusion of being in a safe position. Lots of questions, and each person has their unique answer. Looking deeper into causation instead of chasing symptoms is a good practice.



                               Don’t just treat what you see, Peel off layer step by step.

The psoas is involved in posture, stability, and breath. The psoas is a multisegment muscle, as it crosses multiple joints from the thoracic lumbar junction through each lumbar vertebrae. The psoas connects the axis of the spine to the appendicular function of the hip. The attachment on the thigh, the lessor trochanter, gives the psoas mechanical advantage in external rotation of the hip. The psoas is a lumbar stabilizer, a hip flexor, and is also a synergist in the breathing .

The psoas is central to movement stability.  However, muscles that cross multiple joints don’t have as much mechanical leverage. Moreover , they are good at  dynamic stability of hip joint.  In the case of hip flexion, the function of the psoas is stabilization of the lumbar while its synergist, the iliacus, generate power .

The psoas is a multi-planer stabilizer that works in a three-dimensional model. The psoas more like to associate with  the quadrates lumborum,(QL). The QL has a fascial compartment just posterior of the psoas(as you can see in fighure). The compartments need to have the capacity to glide across one another , therefore it discreet function can happen in the sagittal, coronal and transverse planes.

In sagittal plane movement the psoas and QL work in ipsilateral pairs on the same side. This is also true for the coronal plane. Though in the coronal plane, while one side is shortening, the opposite side is lengthening. This is called lateral flexion. The function of the psoas in the transverse plane is related to the walking gait. The transverse plane pairing is contralateral.

One side of the psoas is working with the opposite side QL to stabilize the lumbar as the pelvis is moving around the axis of the spine.

The psoas is a primary compartment of the greater lumbodorsal fascia. This fascial sheath connects the torso to the pelvis so that the action of the appendicular skeleton and axial skeleton wind-up and release elastic energy throughout the cycle of the walking gait.

Psoas has its relationship to the breathing pattern. Further, the psoas shares connective tissue with the thoracic diaphragm. This is significant because when the psoas doesn’t play well with the breathing apparatus.


Biomechanics : An overview

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Rehabilitation Guideline after meniscus repair surgery

Meniscus injuries within the knee are a common occurrence.  In spite of this high event, numerous irregularities keep on existing in the restoration of a patient after meniscus repair surgery, especially including the rate of weight bearing and range of movement.

Rehabilitation Follow Meniscus Repair

Restoration after surgical debridement of the meniscus is entirely clear. We restore the patient’s range  of movement, quality and function,  their manifestations and let pain and swelling guide the recovery procedure (an exceptionally broad guide yet one frequently utilized by numerous rehabilitation specialists).

In any case, when the meniscus is really repaired and not only debrided, there are different variables to consider. At the point when a meniscus is repaired, the tear is approximated utilizing stitches to enable the tear to heal.

Rehabilitation following a meniscus repair has to be more conservative, however, despite research saying otherwise, there are still many rehabilitation protocols floating around the orthopaedic and sports medicine world that recommend limiting weight-bearing and range of motion after a meniscal repair.  We continue to ignore the literature because of fear that the ‘stress’ on the meniscus with walking and range of motion may be too high.

So if we’re going to talk some  protocols, take a look at these studies from way back when from Shelbourne et al  and Barber et al   that showed excellent results in patients undergoing a combined ACL-meniscus repair procedure and utilizing no limitations in weightbearing or range of motion, similar to a protocol for an isolated ACL reconstruction.

Recent studies from VanderHave et al  and Lind et al on isolated meniscus repairs have shown similar results using an “aggressive” program of immediate weightbearing compared to a more conservative approach.

Again, these studies show meniscal repair outcomes are no different while using restricted weight bearing and range of motion versus an “aggressive” protocol of immediate weight-bearing and unlimited range of motion.

 Weightbearing After Meniscus Repair : 

Things being what they are, if immobilized in extension, for what reason do we restrict weightbearing?

During weightbearing, compressive forces are loaded across the menisci. These tensile forces create ‘hoop stresses’, which expand the menisci in extension. These hoop stresses are believed to help the healing procedure in many tears by approximating the tissue.

Besides, the compressive loads connected while weightbearing in full expansion following a vertical, longitudinal repair or container handle repair have been appeared to lessen the meniscus and settle the tear, as noted by Rodeo et al.  and all the more as of late by McCulloch et al.

There are studies said “A repaired longitudinal medial meniscal tear undergo compression, not gapping, during simulated gait ”

What about early range of motion? 




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Gluteal Amnesia and selecting the most effective interventions

Most people spend a huge proportion of their time in a position of hip flexion (sitting down). An inactive lifestyle is a Janda approachsure-fire way to create glute dysfunction. Extended periods of time in this posture over the long term will lead to negative adaptations in the hip flexor muscles.

Shortened hip flexors don’t allow for full hip extension, which is where your glutes are able to contract with the most force. Additionally, being an antagonistic pair, short and tight hip flexors will actually inhibit your glutes. The actual physical compression associated with sitting on your gluteus maximus will also impair blood flow and neuromuscular function.

Gluteal amnesia is a condition where your body can’t or forgets how to properly activate the gluteal muscles, whether it’s due to postural flaws or lack of use. As a result, you may lose the ability to move your hips through a full range of motion which adds stress to your knee, lower back, and even your shoulder joints! Common injuries associated with gluteal amnesia are patellofemoral pain syndrome, Iliotibial Band Syndrome, Disc Herniation, and Piriformis Syndrome. Fortunately, you can reverse this condition with the right corrective exercises.

A postural flaw that can lead to gluteal amnesia is known as anterior pelvic tilt. This occurs when the pelvis tilts forward and the stomach protrudes. The forward tilt of the pelvis stretches your gluteals into a relaxed state which decreases your ability to properly activate them. Other causes of gluteal amnesia are as follows:

• Too many quadriceps dominant exercises.
• Poor sitting or static posture.
• Improper abdominal training.
• Soft tissue contractures (i.e., tight hip flexors and low back extensors).
• Articular (joint) fixations.
• Not landing properly from jumps (i.e., landing from a rebound in basketball).
• Knee or back pain sufferer.

The gluteus maximus and lower back stability
Activating and strengthening the glutes needs to form an important part of your core routine.

Co-contraction of the gluteus maximus with the psoas major contributes to lumbo-sacral stabilisation The gluteus maximus provides stability to the sacroiliac joint (SI joint) by bracing and compression. Excess movement at the SI joint would compromise the L5-S1 intervertebral joints and disc and could lead to SI joint dysfunction and low back pain.

kinetic chain, gluteus maximmus, eric dalton

Coutrsey : Ericdalton

The gluteus maximus also provides lower back stability through its connection with the erector spinae and thoraco-lumbar fascia. Some of its fibres are continuous with the fibres of the erector spinae. A contraction of the gluteus maximus will generate tension in the erector spinae muscle on the same side, providing stiffness to the spinal column.

Gluteus maximus contraction also exerts a pull on the lower end of the thoraco-lumbar fascia, which is a thick layer of ligamentous connective tissue. Tightening of this fascia stabilises the vertebras. People with low back pain often have weak and deconditioned glutes.

Here are some simple but superbly effective exercises to tone up glutes muscles.


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Lower Back Pain When You Bend Forward? Here’s how you should manage.

Lower Back Pain When You Bend Forward? Here’s how you should manage.

Lumbar pain during flexion movement  is one of the commonest symptoms that we all face in our routine practice. There are a number of clinical reasoning processes, which need to be considered.

Much of the literature focuses on the changes in intra-discal pressure associated with spinal flexion. Which indicate that spinal flexion pain is associated with increased disc strain.  In order to strengthen the hypothesis of disc related flexion pain the clinician needs to establish other components of discogenic characteristics to support the hypothesis.

Here are some few things to remember when patient come with lower back pain.

  1. Observe everything, from entering into our examination room, starting with the client rising from a chair.
  2. History – link injury mechanisms, pain mechanisms with specific activities and past exercise regimens. Is there any “red flags” appear or not .
  3. Perform provocative tests – what loads, postures and motions exacerbate, what are relieving factors and what are aggravating factors? This needs to be address.
  4. Perform functional screens and tests – Are there perturbed postural, motion and motor patterns?
  5. If the clinical picture is complex and beyond your comfort zone, develop a referral relationship with a competent corrective exercise specialist.

It is not a matter of client performing an exercise – it is a matter of the client performing the exercise with perfection.

Observation Point:

  • Look for a dysfunctional movement pattern
  • Not able to hip hinge properly.
  • Allow the lower lumbar spine to flex forward.
  • Look for the patient get up from their seat
  • Do they difficulty to maintain neutral spine or bend forward into flexion as they arise?
  • Do they have pain while getting up from chair?
  • In the treatment room, watch them take off their shoes.
  • Ask patient to pick object from floor and observe behavior pattern of movement.
  • Look for fear or uncertainty at the prospect of bending forward.

Physical examination :

This is the main part one should find out what exact pathology it is.

  • Positive straight leg raise. Often you’ll see more subtle findings than in classic sciatica. They may experience more tightness in the back of the leg on one side or the other. They may experience buttock pain. I prefer the sitting straight leg raise. If needed, add foot dorsiflexion, have the patient bend forward, and/or add a Valsalva maneuver.
  • One of Comerford’s tests for flexion control is called the waiter’s bow. Briefly teach the patient to bend forward while maintaining the spine in neutral. Stand to the side and watch them do this. Do they do it well or do they lose neutral? For tactile feedback, place your index finger horizontally on the sacrum, and the other hand’s index finger just above, across the L5 spinous process. Now have the patient bend forward using the waiter’s bow. Do your fingers separate? Recheck between L5 and L4. If your fingers are separating, the patient’s lumbar spine in moving into flexion. It means that even when they are trying to, they cannot control flexion. See pictures below.

  • Palpate the interspace for tenderness. Place the patient prone with a pillow under their abdomen, so the lumbar spine is in slight flexion. Apply deep digital pressure to the interspinous spaces and the inferior spinous process, pushing simultaneously posterior to anterior and inferior to superior. I start with L5-S1 and work upward to at least L3-4. Is the interspace tender? Ask them to rate the tenderness on a 1-3 scale: 1-mild, 2-moderate or 3-severe. (I used to think this was the ideal test, but it is not always positive, even in those I know have flexion intolerance. Maybe it represents increased inflammation in those with flexion intolerance.)
  • Repeated end-range loading of extension This can be done prone or standing. Does this relieve or centralize their pain?
  • If they are not in acute pain, you can do repeated end-range loading of flexion, either from standing or in a long sit posture. Ask them to slump forward. Does this aggravate their pain; does this elicit increased buttock or leg pain, or sensory changes?
  • Palpate the lower lumbar paraspinal muscles. In disc-related pain, a discrete area will often feel atrophied, often unilaterally. There is often a divot, a hole, a small area of atrophy, at the level of the disc injury. As chiropractors, we are much more used to getting information on the restricted side, rather than the side that is moving too much.

 Unlock the mystery of pain

  • Treatment of flexion-intolerant pain is primarily self-care. Yes, your soft-tissue work and mobilizations can help, but self-care is primary and essential. There is no magic you can do that will override what the patient is doing 24/7. You have to teach them to move differently to solve flexion-intolerant pain. According toStuart McGill, “The first step in any exercise progression is to remove the cause of the pain, namely the perturbed motion and motor patterns.”9
  • There are two components of self-care. First, have them quit doing stupid stuff that is reinjuring them over and over. Totally stop the sit-ups and crunches. They cannot do yoga-style prolonged flexion. Pilates is not much effective as it often uses too much uncontrolled flexion. Don’t assume the patient knows this; they likely don’t. If they are sitting too much and for too long, help them figure out how to change that habit via frequent breaks and/or by utilizing a standing workstation.
  • Second, train them to move differently.
  • Yes, they need to strengthen their inhibited core muscles, but they need start with these simple movements, done precisely.


  1. Yin-gang Zhang, Tuan-mao Guo, Xiong Guo, Shi-xun Wu. Clinical diagnosis for discogenic low back pain.Int J Biol Sci, 2009;5(7):647-658.
  2. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode of low back pain.Spine, 1996;21(23):2763-2769.
  3. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain.Spine, 1993;19(2):165-172.
  4. O’Sullivan P, Twomey L, Allison G, et al. Altered patterns of abdominal muscle activation in patients with chronic low back pain.Aust J Physio, 1997;43:91-98.
  5. MacDonald D, Moseley GL, Hodges PW. People with recurrent low back pain respond differently to trunk loading despite remission from symptoms.Spine, 2010 Apr 1;35(7):818-24.
  6. Gibbons SGT, Comerford MJ. Strength versus stability. Part 1: Concept and terms.Orthopaedic Division Review. March / April: 2001:21-27.
  7. Liebenson C. “Flexion Intolerant Back” (10-minute video). Toronto, Ontario, 2011; filmed and edited by Phillip Snell.
  8. McGill S. “Designing Back Exercise: From Rehabilitation to Enhancing Performance.” (Guide to training the flexion-intolerant back.)


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