Download Assessment and Massage of the Psoas Major

CHAPTER 5
Massaging the Anterior Abdomen and Pelvis 147
ROUTINE 5-3: PSOAS MAJOR PROXIMAL (ABDOMINAL) BELLY
View the video “Psoas Major Abdominal Belly
Palpation” online on thePoint.lww.com
The psoas major muscle is rarely assessed or worked. This is
unfortunate because this muscle is functionally important as
a postural stabilizer of the lumbar spine and often becomes
tight due to the principle of adaptive shortening because it
is a hip flexor muscle and so much time is spent seated with
the hip joints flexed. The psoas major attaches proximally on
the anterolateral spine from the levels of T12-L5, and distally
onto the lesser trochanter of the femur (Fig. 5-13).
Figure 5-14
5.4
THERAPIST TIP
Placing a Roll under the Bottom Fitted Sheet
Psoas
major
A roll is placed under the client’s knees to flex the hip
joints so the pelvis relaxes into posterior tilt, relaxing and
slackening the anterior abdominal wall. If you do not have
a large roll or a number of smaller rolls, then you can help
the client be relaxed in a position of flexion at the hip joints
by placing a roll under the bottom fitted sheet immediately distal to the client’s feet. The friction against the table
combined with the tension of the fitted sheet are usually
sufficient to hold the roll in place, thereby holding the client’s feet in position so that the hip joints remain flexed.
Figure 5-13 The right psoas major.
Starting Position:
■ The client is supine with one large roll or a number of
smaller rolls under the knees. This relaxes the hip flexor
musculature so that the pelvis can drop into posterior tilt,
relaxing and slackening the anterior abdominal wall.
■ You are standing at the right side of the table (Fig. 5-14).
■ The finger pads of your left hand are the treatment contact, and the finger pads of your right hand are the support that braces the left hand treatment contact. Note: This
could be reversed; the right hand could be the treatment
hand and the left hand the support (Fig. 5-15A).
Muscolino_Ch05.indd 147
Step 1: Locate Target Musculature:
■ Begin by locating the RA as explained in the “Overview of
Technique” section (see Figs. 5-1 through 5-5), then find
the lateral border of the RA.
■ After locating the lateral border of the RA, drop immediately off it (laterally) (see Fig. 5-15A).
■ To access and palpate directly on the psoas major, ask
the client to take in a breath; as the client gently exhales,
slowly sink in toward the spine by pressing into the anterior abdomen in a posterior and slightly medial direction
(Fig. 5-15B). Do not try to reach all the way to the psoas
major; it is better to take your time to arrive at the muscle.
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PART TWO
148 Treatment Techniques
motion; a large range of motion will engage the anterior
abdominal wall to stabilize the pelvis from anteriorly tilting. If the anterior abdominal wall engages, it will become
difficult to palpate through it to reach the psoas major.
Figure 5-15A
Psoas major
Figure 5-15C
Figure 5-15B
■
■
■
Ask the client to take in another breath, and as the client exhales again, reach in farther toward the psoas major
on the anterolateral bodies and transverse processes of
the spine. If necessary, repeat this process a third time to
reach in all the way to the muscle. The psoas major can
usually be reached on the second or third exhale. Because
the psoas major is located deep against the posterior abdominal wall, is rarely worked, and the intestines are located between the therapist’s fingers and the psoas major,
clients are often sensitive and feel vulnerable here, so pressure should be applied very slowly and gradually.
Because the psoas major lies directly against the spine, it is
usually easy to know when it has been reached because you
will feel the firmness of the anterior bodies of the spine deep
to them. If you do not feel the firmness of the spine deep to
the muscle, you are probably not on the psoas major.
To confirm that you are on the psoas major, have the
client try to gently flex the thigh at the hip joint against
the resistance of gravity (Fig. 5-15C). This will cause the
psoas major to contract, and you will feel it engage. Note:
Be sure to ask for only a very small thigh flexion range of
Muscolino_Ch05.indd 148
Step 2: Perform the Technique:
■ Once you are sure of your placement on the abdominal
belly of the psoas major, you can work it by performing
short longitudinal strokes running vertically along the
musculature with mild to moderate pressure (Fig. 5-16).
Strumming transversely across the musculature can also
be performed. Circular strokes are also very effective.
■ The psoas major attaches along the entire lumbar spine,
so once one level has been worked, continue to work the
musculature in a similar fashion superiorly as far as possible
and then inferiorly as far as possible. As you work inferiorly,
keep in mind that the psoas major gradually becomes more
superficial, lying closer to the anterior a­ bdominal wall.
■ Once the muscle has been worked with mild to moderate
pressure, if it is within the client’s tolerance, deeper pressure can be used.
Figure 5-16
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CHAPTER 5
Massaging the Anterior Abdomen and Pelvis 149
The abdominal aorta is located along the midline of the body, over the anterior
aspect of the bodies of the lumbar vertebrae, medial to the abdominal belly of
the psoas major (see Fig. 1-45A). When sinking into the client’s abdomen to
assess and treat the psoas major, it is important to aim for the anterolateral aspect of
the spine. If the pulse of the aorta is felt, you are too far medial and need to readjust the
direction that you are sinking in to be slightly more lateral. Always feel for the pulse of
the aorta before exerting deep pressure into the psoas major.
Because pressure must be exerted through the abdominal contents to reach the psoas
major, it is important to make sure that the client will be comfortable. If the client has
any type of intestinal condition, has just eaten, or needs to void the bladder, working
into the psoas major can be uncomfortable.
5.5
PRACTICAL APPLICATION
Alternate Positions for the Psoas Major
Working the psoas major with the client supine is probably the most common position in which this muscle is
worked, perhaps because the client is so often in this position. However, side-lying and seated positions are good
alternatives. The advantage of side-lying position is that if
the client is overweight and has a large abdomen, it falls
away from your palpating fingers, making it easier to access
the psoas major. Preferable to pure side-lying position is
¾ side-lying position in which the client is approximately
half-way between side-lying and supine. The advantage of
this position is that the therapist can better use body weight
to drop down into the psoas major (Fig. A). When working
the psoas major with the client side-lying or ¾ side-lying,
it is important to have his hip and knee joints flexed so that
A
Muscolino_Ch05.indd 149
the anterior abdominal wall is relaxed and slackened. To
confirm that you are on the psoas major, ask the client to
perform a small flexion range of motion of the thigh at the
hip joint.
Seated position can also be very effective for working the
psoas major because it allows the client to slightly flex the
trunk to relax and slacken the anterior abdominal wall. Another advantage is that the abdomen also tends to fall out
of way in seated position. To confirm that you are on the
psoas major, ask the client to perform a very small hip flexion range of motion by lifting the foot slightly off the floor
(Fig. B). Regardless of the position (supine, side-lying, or
seated), be sure to direct your pressure posteriorly and medially toward the anterolateral spine.
B
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