More than often I will find that patients with hip flexor tightness are not tight through this region, but using these muscles too much for stability during movement. Zach Long discusses how to assess if tightness is a true issue in his blog on hip flexor function. To assess someone's hip flexor demands a full hip assessment of structure, function and biomechanics. The main point I am trying to make here is that there is much more going on around the anterior hip that may contribute to sensations of "tightness" or "pain" that could be driven from structures other that iliopsoas.

Anterior hip assessment

Functional: Control of movement and activation patterns during a stalk test looking at gluteal activation on the weight bearing leg and the movement of hip flexion on the non weight bearing leg. Assessment of their main aggravating movement.

Palpation: Palpation of all the different muscles around the hip using movements such as hip rotation, hip adduction, hip abduction to confirm which muscles you are feeling. Palpation of the psoas muscles and iliacus around the abdominal region. Palpation of the bony landmarks - pubic symphysis, ASIS and along the line of inguinal triangle

Muscle function: Squeeze test for adductor muscle function. Control of movement, pain provocation and stability during an ASLR test . Control of hip extension and pelvic rotation during a bridge or single leg bridge test .

Range of motion testing: Prone hip passive extension. Thomas test position (iliopsoas) - Zach Long's blog (the Barbell Physio) covers the Thomas test technique in more depth as well as some exercise and manual therapy options. Ober's test (ITB and lateral thigh structures).

Neurodynamics assessment: Prone knee bend (neurodynamic assessment of femoral nerve). Some studies have explored the correlation between reduced iliopsoas length (using the Thomas Test) and altered femoral nerve mobility (Prone knee bend test) and they found that: similarly to the interaction between neural mobility and muscular mobility in the upper limb or posterior thigh, that the Prone knee bend test and Thomas test are closely related (Anloague et al, 2015). SLR test (neurodynamic assessment of sciatic nerve) and the reason I say this is because if we cannot lengthen through the posterior chain, it will affect our ability to fold through the anterior chain and vice versa.

Joint assessment: Flexion, abduction and external rotation (FABERS). Flexion, adduction and internal rotation (Quadrant). Compression and distraction. External and internal rotation in supine (90 degrees) and prone (more neutral hip position).



Clinical tips

So I began this blog by saying that iliopsoas often gets too much attention and blame. What I was trying to illustrate is the complexity of the anterior hip and that not all injuries are related to iliopsoas dysfunction. But there definitely are people who suffer from iliopsoas tightness and anterior hip pain, and if after you have completed your assessment, you feel these structures are at fault, here are some clinical tips.

When palpating this region I always start just above their ASIS or the crest of the anterior hip. The initial aim is to palpate the general area to check for tenderness through the abdomen and hip before going in deeper to palpate along the line of the iliopsoas.

My hand position of preference is with one hand over the other and fingers gliding down the fibre of the muscles. Depth is dependant on the patient's weight but it doesn't need to be forceful. Treatment of the iliopsoas is uncomfortable to a degree but this discomfort is often out-weighed by the response of releasing the iliopsoas muscle and surrounding region. Generally the iliopsoas muscles doesn't need a long treatment to gain relief, taking around 2-3 mins each side.

After treatment I recommend that the patient has the night to recover but depending on the severity of the injury or complaint, the patient should be able to get back into training or game day as soon as they feel comfortable (Kate).

treatment tips for iliopsoas

The most common position to begin treatment is in supine with legs straight. Try to palpate the abdomen with the pads of your fingers, not your fingers nails and using the patient's natural breathing rhythm to move deeper into the tissues is a great way to move through resistance.

Other positions you can try are with knees bent up and asking the patient to slide their leg into a straight position (hip flexion/extension) or to drop their knee to the side (hip external and internal rotation), while you maintain a constant pressure on psoas major. For a more progressed position, the patient can lie in the Thomas Test position with their foot supported on a stool or block, to have the hip on stretch during treatment. This position also gives great access to treatment of rectus femoris and other anterior thigh structures below the ASIS.

Once the muscle has been palpated the therapist will do techniques such as trigger point therapy, cross friction massage and stripping, or ask the patient to actively move through a direct (flexion/extension) or indirect (rotation) range (Kate).

Anterior hip Stretches