SECTION ONE

CHAPTER

Clinical anatomy and function of psoas

6
major and deep sacral gluteus maximus

S Gibbons

Introduction
Research since the 1990s has brought a new understanding of muscle
function, and the role of muscles in providing stability is now well
recognized. The concept of stability in itself is somewhat controversial
and there are different schools of thought (Comerford & Mottram 2001a,
McGill 2002, Richardson et al 2004, Sahrmann 2002). Some conflict has
arisen because muscles can have a primary role in providing stability
or can have multiple roles in movement and stability. This is further
complicated by what demands are required under normal low load daily
activities versus higher loads required for manual handling, and contact
sports (low load versus high load stability) (Gibbons & Comerford 2001).
Our understanding has been enhanced by a better awareness in anatomy,
physiology, biomechanics, imaging techniques, and how to interpret the
results of research studies.
Psoas major (PM) is a unique muscle. It originates on the lumbar
spine with segmental attachments, attaches to the sacroiliac joint as it
crosses it, and inserts into the hip. This anatomical position places PM
in an ideal position to function as an important stability muscle for the
lumbar spine (Gracovetsky et al 1981, Nachemson 1968). Despite this, it
is not fully understood and there is still considerable debate regarding its
functional role (Aspinal 1993, Bachrach et al 1991, McGill 2002, Richardson
et al 2004). A mechanism to simultaneously flex the hip and stabilize the
lumbopelvic region is needed. It does not seem logical that a muscle such
as PM would have a detrimental effect to the lumbopelvic region.
Conversely, there is little debate regarding the importance of gluteus
maximus (GM). It is considered an important stability muscle of the
lumbopelvic region (Lee 2004), as well as of the hip (Sahrmann 2002). This

Ch06-F10178.indd 95 12/21/06 1:29:55 PM

 96 Movement, Stability and Lumbopelvic Pain
is supported by motor control studies (Bullock-
Saxton et al 1994, Hungerford et al 2003) and
biomechanical analysis (Pool-Goudzwaard et al
1998). One issue of confusion involves overactivity
and shortness of GM (Lee 2004, Sahrmann 2002).
This can have an effect on such things as postural
alignment, recruitment strategies, and compensatory
movement patterns. A mechanism to understand
how a very important stability muscle can become
potentially harmful has not been described.
The purpose of this chapter is to present evidence
of a stability role for PM and introduce a new role
for GM in sacroiliac joint (SIJ) stability. A better
understanding of the implications of the function
of PM and GM on the stability of the lumbopelvic
region might improve clinical management of
related dysfunction. This could also highlight new
areas of research in the field.
Muscle function
Muscle function is more complex than considering
‘origin to insertion,’ or assessing activity profiles
with electromyography (EMG). Information regard-
ing muscle function can be obtained from four
key sources (Gibbons 2005b). These are listed in
Table 6.1.
Table 6.1 Sources of information for understanding
muscle function in order to functionally classify muscles
(reproduced with permission from Kinetic Control)
Function Dysfunction
• Anatomical location • Consistent &
& structure characteristic
• Biomechanical changes in the
potential presence of pain
• Neurophysiology or pathology
Table 6.2 Characteristics of local stability muscles in normal function and after the presence of pain (dysfunction)
(Review: Comerford & Mottram, 2001)
Function
• BMuscle stiffness to control segmental translation
• No or minimal length change in functional movements
• Anticipatory recruitment prior to functional loading
provides protective stiffness (as required)
• Activity may be continuous and independent of the
direction of movement
Ch06-F10178.indd 96
Muscle classification
A new classification system of muscle function has
been presented (Comerford & Mottram 2001b).
This divides muscles into local stabilizers, global
stabilizers, and global mobilizers. Of particular
interest to this chapter are the local stability muscles.
Their characteristics are presented in Table 6.2.
Anatomy
Psoas major
PM has anterior and posterior fibrous attachments
to the spine (Fig. 6.1). The anterior attachment is
to the anteromedial aspect of all the lumbar discs
and adjoining bodies with the exception of the
L5–S1 disc. The posterior attachment is on the
anteromedial aspect of all the lumbar transverse
processes (Bogduk et al 1992, Gibbons 2004). The
fasciculii of PM are about the same length within
specimens and have a unipennate fiber orientation.
This ranges from 75° in the superior aspect of the
fasciculii to 45° in the inferior aspect of the fasciculii.
The fiber length ranges from 3 to 8 cm and 3 to 5 cm
in the anterior and posterior fasciculii, respectively
(Gibbons 2004). The fasciculii run inferolaterally to
reach a central tendon, where they descend over
the pelvic brim and share a common insertion with
iliacus to the lesser trochanter (Bogduk et al 1992,
Gibbons 2004, Santaguida & McGill 1995).
PM also has significant fascial relations. The
medial arcuate ligament is a continuation of the
superior PM fascia that continues superiorly to
the diaphragm. The right and left crus comprise the
spinal attachment of the diaphragm. They attach
to the anterolateral component of the upper three
vertebrae and bodies. The crus and their fascia
overlap PM and appear continuous with the muscle
until they come more anterior and blend with the
Dysfunction
• Uncontrolled segmental translation
• Segmental change within cross-sectional
area
• Altered pattern of low-threshold
recruitment
• Motor recruitment timing deficit
12/21/06 1:29:58 PM

Clinical anatomy and function of psoas major and deep sacral gluteus maximus
Fig. 6.1 The spinal attachments of psoas major. The
attachment on the disc and adjoining body and transverse
process have been termed ‘anterior’ and ‘posterior’,
respectively. (Reproduced with permission from PSPR Ltd.)
anterior longitudinal ligament. As PM descends,
its inferomedial fascia becomes thick at its lower
portion and is continuous with the pelvic floor
fascia. This also forms a strong link with transversus
abdominus (TrA) and the internal oblique (OI). PM
attaches firmly to the pelvic brim as it passes over it
(Gibbons 2004). This attachment may constitute an
‘innominate ligament’ (Fig. 6.2) (Gibbons 2005a).
The nerve supply to PM is not reported
consistently because most anatomical texts list two
or three different variations. These are listed under
PM (at the hip and lumbar spine), the lumbar plexus,
and the femoral nerve (Moore 1992, Romanes
1987, Williams et al 1989). In a dissection study of
24 cadavers, all specimens had a separate nerve
supply for the anterior and posterior fasciculii. The
anterior fasciculii were supplied by branches of
the femoral nerve from L2, L3, and L4, whereas the
posterior fasciculii were supplied by branches of
the ventral rami. In 13 specimens the nerve supply
was segmental from T12, L1, L2, L3, and L4 (Gibbons
2005a). In light of this, PM should be considered
as two distinct parts: anterior and posterior. Also,
Ch06-F10178.indd 97
97
Pelvic Attachment
PM
Iliac Fossa
Fig. 6.2 Psoas major and iliacus descend over the
iliopectineal eminence and have a strong attachment to
the pelvic brim (identified by the arrow). This attachment
may constitute an innominate ligament. (Reproduced with
permission from PSPR Ltd.)
the term ‘iliopsoas’ should be reconsidered. This
pattern of separate functional roles within PM
may be similar to the superficial and deep lumbar
multifidus, which have been shown to have different
EMG to spinal perturbations (Moseley et al 2002).
Deep sacral gluteus maximus
GM has been previously subdivided into superficial
and deep (Kapandji 1987) and cranial and caudal
(Jaegers et al 1992, Moore & Dalley 1999). Recently,
it was found that GM has three subdivisions:
superficial sacral fibers, deep sacral fibers, and deep
ilium fibers. The superficial sacral fibers run to the
iliotibial band in 7–10 fascicular arrangements;
some of these fibers also attach to the gluteal
tuberosity. The deep ilium fibers run predominately
to the gluteal tuberosity. Superiorly, the deep sacral
fibers cross the SIJ and attach to the posterior pelvic
brim just lateral to the posterior superior iliac spine.
These are present in approximately two thirds
of specimens. Inferiorly, they are short and are
orientated inferolaterally. These deep sacral fibers
cross from the lateral sacrum to the posterior ischial
spine, the ischial tuberosity, and the sacrotuberous
ligament. The deep fibers are present in all muscles.
No separate nerve supply could be located for
individual groups of fibers (Gibbons & Mottram
2004).
12/21/06 1:29:58 PM
 98 Movement, Stability and Lumbopelvic Pain
Biomechanics
Psoas major
The studies that have investigated the biomechanics
of PM are limited by using incorrect or incomplete
anatomy and unsubstantiated assumptions. Of
the studies with merit, a consistent finding is that
the primary force of PM on the lumbar spine is
axial compression and that the compression force
is always greater than shear (Bogduk et al 1992,
Gibbons 2004, Rab et al 1977, Santaguida & McGill
1995). Compression from PM can create segmental
stiffness (Janevic et al 1991) and can resist shear
forces (McGill 2002). Due to the size, most of the
force will come from the anterior fasciculii (Bogduk
et al 1992, Gibbons 2004). The line of action of PM
is too close to the axis of rotation to contribute to
significant spinal movement (Fig. 6.3) (Bogduk et
al 1992, Gibbons 2004, Santaguida & McGill 1995).
There is a small amount of extension at L1, L2,
and L3, whereas there is a small amount of flexion
from L4 and L5 (Bogduk et al 1992, Gibbons 2004).
This closely resembles a neutral lumbar lordosis.
PM crosses the pelvis and therefore must exert
a force on the SIJ. It has been generally thought
that PM produced a force to anteriorly rotate the
innominate (Bachrach et al 1991, Snijders et al 1995);
however, this has recently been called into question.
The PM muscle was modeled as a pulley over the
pelvic brim in the erect posture (Gibbons et al 2001).
A B C minimally involved in producing spinal movement,
Fig. 6.3 The psoas major lines of action from the
individual fascicle attachments to the lumbar spine and a
straight line to the iliopubic eminence. (Reproduced with
permission from PSPR Ltd.)
Ch06-F10178.indd 98
Several scenarios were considered to include the
PM attachment to the innominate described above.
In all scenarios, the resultant force was posterior
rotation of the innominate.
PM is unipennate muscle, not a fusiform
muscle, and the fiber length and ability of the
muscle to shorten is less than believed. This calls
into question its efficiency as a hip flexor. Yoshio
et al (2002) conducted a detailed morphological
and biomechanical study of PM at the hip. They
concluded that the primary role of PM was for
lumbar stability and that PM contributed very
little to hip flexion. The primary role for PM at the
hip was for stability. This was achieved through
maintaining the femoral head in the acetabulum.
Their findings are summarized in Table 6.3.
Neurophysiology
Psoas major
Although EMG has been used in more than 20
studies to assess the function of PM, very little
information has been obtained. This is because PM
cannot be assessed with superficial EMG and the
EMG from iliacus cannot be considered the same
as EMG from PM. Further, normalization concerns
exist, and the methodologies used have been
unable to provide useful information regarding the
complex function of PM.
After assessing the articles that have used EMG,
there is evidence to suggest that PM plays a role in
hip flexion but is not the dominant hip flexor; iliacus
appears to be more active than PM during hip
flexion. Andersson et al (1995) found that, during
hip flexion, PM EMG ranged from 49%, 69%, and
86% as active as iliacus during hip flexion to 30°,
60°, and 90° respectively. It is not known if the EMG
activity of PM is active to stabilize the lumbar spine,
pelvis, or hip; to produce hip flexion; or all of these.
Similar comments could also be made regarding
the activity of iliacus during hip flexion. It should
be noted that other hip flexors, such as rectus
femoris, tensor fascia latae and sartorius, also
contribute to hip flexion (Andersson et al 1997).
All these are more efficient hip flexors than PM
and iliacus (Dostal et al 1986). Both Andersson et
al (1995) and Juker et al (1998) found that PM is
but it might contribute to maintaining or producing
the lumbar lordosis (Andersson et al 1995). It might
lower the spine eccentrically during side flexion
(Andersson et al 1995) and control side flexion during
12/21/06 1:29:59 PM

Clinical anatomy and function of psoas major and deep sacral gluteus maximus
Table 6.3 Summary of the functions of psoas major as a function of hip flexion angle. Hip stability is created
due to psoas major maintaining the femoral head in the acetabulum. Psoas major is an effective hip flexor
between 45°–65°. Lumbar stability is created because psoas major maintains the lumbar curve (Yoshio et al
2002)
Hip flexion angle
0°–15°
15°–45°
45°–60°
60° +
gait (Andersson et al 1997). It should be noted that
the recordings appear to have been taken from the
anterior fasciculii, hence the functions mentioned
above should be considered from anterior PM and
not posterior PM.
Deep sacral gluteus maximus
During an initial pilot study, it was hypothesized
that the deep sacral gluteus maximus (DSG) would
be active in positions of counternutation when the
sacrotuberous ligament was not tensioned. Fine-
wire EMG was placed in the cranial and caudal
aspects of gluteus maximus (Jaegers et al 1992)
and the DSG just posterior to the sacrotuberous
ligament. This was confirmed with real-time
ultrasound imaging. Slouched sitting was used
because this has been shown to produce a position
of counternutation of the sacrum (Snijders et al
2004). When a vertical force was placed through the
shoulders of subjects, the activity of DSG suggested
it may have a separate role in vertical loading from
the cranial and caudal GM fibers.
During gait, it has been suggested that the
sacrum torsions (or rotates) to face the innominate
that is posteriorly rotated. In the existing biomechan-
ical theory of the gait cycle, when the femur is
extended and internally rotated, the innominate
is relatively anteriorly rotated on that side.
Conversely, when the femur is flexed and externally
rotated, the innominate is relatively posteriorly
rotated on that side (Lee 2004). During a trunk
twist to the left in normal standing, the right femur
Ch06-F10178.indd 99
99
Function of psoas major
• Hip stability
• Lumbar stability
• Hip stability
• Lumbar stability
• Hip flexion
• Hip stability
• Lumbar stability
• No action on femoral head
• Lumbar stability
will be relatively extended and internally rotated,
whereas the right innominate is in relative anterior
rotation. Here the sacrum will torsion, or rotate
to the left. During trunk twisting (to create pelvic
torsion), increased activity was observed in the
DSG that was different from the cranial or caudal
GM fibers. These observations suggest that the DSG
might be involved in controlling aspects of vertical
loading and pelvic torsion. It should be cautioned
that these are preliminary observations and further
investigation is needed before conclusions can
be drawn (unpublished pilot study, Gibbons et al
2004).
Consistent changes in
the presence of pain and
pathology
Local stability muscles show consistent and charac-
teristic changes following a significant episode of
pain (Comerford & Mottram 2001b); these are listed
in Table 6.2. The characteristics that are revelant for
PM include segmental atrophy and altered patterns
of low threshold recruitment.
Segmental atrophy
Psoas major
Dangaria & Naesh (1998) assessed the cross-sectional
area (CSA) of PM in unilateral sciatica caused by
disc herniation. There was significant reduction in
the CSA of PM at the level and ipsilateral to the site
12/21/06 1:29:59 PM
 100 Movement, Stability and Lumbopelvic Pain
of disc herniation. Barker et al (2004) assessed the
CSA of PM and lumbar multifidus in subjects with
unilateral LBP. There was a significant reduction
of the CSA on the side of symptoms. The decrease
in CSA was largest at the level of symptoms, with
smaller changes one level above and below for both
muscles. A similar pattern of atrophy is seen in
lumbar multifidus in acute LBP (Hides et al 1994).
It has been proposed that the posterior aspect
of PM plays a more specific role in spinal stability
(Gibbons 2004, Gibbons et al 2001, 2002a). A
protocol was developed to observe and measure
the width of the posterior fascicles of the PM muscle
utilizing a helical scan and a coronal oblique view
with computed tomography (CT) imaging (Gibbons
& Whalen 2003). A pilot study found reliability
to be high, and the validity of this technique was
demonstrated in cadavers (Gibbons et al 2002b).
The preliminary results of a current investigation
show a trend towards more specific atrophy in the
posterior fasciculii in PM in subjects with first-time
acute unilateral LBP.
Altered pattern of low-threshold
recruitment
Psoas major
Indirect methods of measurement of muscle
function have been used in research when direct
methods have been invasive or difficult due to
the deep location of certain muscles (Jull 2000,
O’Sullivan et al 1997). A specific low-threshold
exercise was developed for PM (Gibbons et al
2002a). Briefly, this is a hip-shortening exercise
where there is vertical shortening of the femoral
head into the acetabulum. Superficial EMG was
recorded during the exercise from multi-joint hip
muscles that could potentially contribute to the
movement. Subjects either had a history of LBP and
were pain free at the time or did not have a history
of LBP. PM was observed via ultrasound imaging
at the pelvic brim and the neutral spine position
was monitored with a pressure biofeedback. The
subjects with a history of LBP exhibited significantly
higher amounts of EMG activity during the exercise
and tended to loose the neutral spine position. It
was hypothesized that one of the reasons this may
have occurred was due to poor function in PM in the
LBP subjects (Gibbons et al 2005).
Deep sacral gluteus maximus
A specific low-threshold exercise was developed
for the DSG. This involved a medial swelling
Ch06-F10178.indd 100
contraction of GM without a lateral swelling
contraction. A pilot study was conducted similar
to the above study (with regard to subject criteria).
Superficial EMG was recorded during the exercise
from the medial GM region over the sacrotuberous
ligament, the lateral GM region between the
ischial tuberosity and the greater trochanter, biceps
femoris, rectus femoris and tensor fascia latae. GM
was observed via ultrasound imaging over the
sacrotuberous ligament and subjects had to achieve
a 1-cm swelling contraction. The subjects with a
history of LBP exhibited higher amounts of EMG
activity during the exercise, particularly in rectus
femoris and the hamstrings (unpublished pilot
study, Gibbons et al 2003).
Purpose of this research
Movement dysfunction and specific motor control
stability exercise has been growing in its research
base since the 1990s. Existing paradigms of muscle
function and advances in technology have facilitated
new ideas for research. A pattern has emerged in
which some muscles, or specific fibers of muscles,
have a separate role in providing stability. Two
such muscles are PM and GM. We should aim to
investigate these further and explore other muscles
for their roles in stability. It is hoped that our
group can collaborate with other researchers to
share ideas and gain a better understanding of the
mechanisms of specific muscle function in spinal
stability. From this, we might be able to provide
enough evidence to facilitate a change, improve
clinical interventions and the management of
related musculoskeletal disorders.
Summary
There appears to be evidence of a stability role for
PM. The anatomy of PM suggests that it: (1) does
not significantly change length; (2) can provide
compression to the sacroiliac joint; and (3) has two
separate components, which might have individual
roles. The biomechanics of PM show that it: (1)
does not contribute significantly to spinal motion
except to produce a lumbar lordosis; and (2)
produces axial compression in the lumbar spine.
At the hip, it produces vertical shortening into the
acetabulum and does not contribute significantly
to hip flexion. At the SIJ, it has the potential to
produce posterior rotation of the innominate. The
neurophysiology suggests a separate role for iliacus
and PM. It appears that PM is not the dominant hip
12/21/06 1:29:59 PM

Clinical anatomy and function of psoas major and deep sacral gluteus maximus
flexor. With dysfunction, it has a segmental change
in cross-sectional area and it exhibits an altered
pattern of low-threshold recruitment during a
specific exercise.
The DSG is a recent finding, therefore little is
known about its function. The anatomy of the DSG
suggests it does not contribute to physiological
movement. The neurophysiology suggests a
specific role that is separate from the cranial and
caudal fibers. In dysfunction, it might have an
altered pattern of low-threshold recruitment during
a specific exercise. However, as noted, these were
pilot studies and any interpretation from these
results should be made with caution.
A new description of PM is that the anterior
and posterior fasciculii have separate functions
and that the posterior fasciculii might have a
separate function in controlling lumbar segmental
translation. No direct evidence comes from neuro-
physiology, although there are some unique
findings. First, the separate nerve supplies for the
anterior and posterior fasciculii suggest a different
function. Second, the posterior fasciculii have
segmental attachments and are located in an ideal
position to control intersegmental motion. Third,
they are much smaller and cannot generate much
force or contribute significantly to range of motion.
Further, the vast fascial connections of PM to the
diaphragm, TrA, and the pelvic floor place it in
an ideal position for cocontraction mechanisms to
enhance stability.
It is proposed that GM consists of three separate
functional subdivisions. It is likely that the super-
ficial sacral fibers of GM are the ones involved in
dysfunction of overactivity (Lee 2004) and prone
to shortness, which can lead to compensatory
movements (Sahrmann 2002). This is because these
fibers continue into the iliotibial band and thus
constitute a multi-joint muscle and might be prone
to overactivity (Comerford & Mottram 2001b).
Further research is warranted to investigate
the role of PM and DSG in lumbopelvic stability.
This might help dispel some common myths and
misconceptions regarding PM and provide new
avenues for research in the field.
References
Andersson E, Oddsson L, Grundstrom H et al 1995
The role of the psoas and iliacus muscles for stability
and movement of the lumbar spine, pelvis and hip.
Scandinavian Journal of Medicine, Science and Sports
5:10–16
Andersson EA, Nilsson J, Thorstensson A 1997 Intra-
Ch06-F10178.indd 101
101
muscular EMG from the hip flexor muscles during
human locomotion. Acta Physiologica Scandinavica
161:361–370
Aspinall W 1993 Clinical implications of iliopsoas
dysfunction. The Journal of Manual and Manipulative
Therapy; 1(2):41–46
Bachrack RM, Nicelorra J, Winuk C 1991 The relationship
of low back pain to psoas insufficiency. Journal of
Orthopedic Medicine 13(2):34–40
Barker KL, Shamley DR, Jackson D 2004 Changes in the
cross sectional area of multifidus and psoas in patients
with unilateral back pain. Spine 29(22):E515–E519
Bogduk N, Pearcy M, Hadfield G 1992 Anatomy and
biomechanics of psoas major. Clinical Biomechanics
7:109–119
Bullock-Saxton JE, Janda V, Bullock M 1994 The influence of
ankle injury on muscle activation during hip extension.
International Journal of Sports Medicine 15:330–334
Comerford MJ, Mottram SL 2001a Functional stability
retraining: Principles and strategies for managing
mechanical dysfunction. Manual Therapy 6(1):3–14
Comerford MJ, Mottram SL 2001b Movement and stability
dysfunction – contemporary developments. Manual
Therapy 6(1):15–26
Dangaria T, Naesh O 1998 Changes in cross-sectional area
of psoas major muscle in unilateral sciatica caused by
disc herniation. Spine 23(8):928–931
Dostal WF, Soderberg GL, Andrews JG 1986 Actions of hip
muscles. Physical Therapy 66(3):351–361
Gibbons SGT 2004 A hypothetical link between psycho-
social factors, pain and sensory motor function using
a biomechanical model of psoas major. MSc Thesis in
Health Ergonomics, University of Surrey, UK
Gibbons SGT 2005a Anatomy and functional relations of
psoas major. Submitted
Gibbons SGT 2005b Muscle function – a critical evaluation.
Proceedings of the Second International Conference
on Movement Dysfunction. ‘Pain and Performance:
Evidence & Effect.’ 23–25 September, Edinburgh, UK
Gibbons SGT, Comerford MJ 2001 Strength versus stab-
ility. Part I: Concepts and terms. Orthopaedic Division
Review. March/April, 21–27
Gibbons SGT, Mottram SL 2004 Functional anatomy of
gluteus maximus: deep sacral gluteus maximus – a
new muscle? Proceedings of: The 5th Interdisciplinary
World Congress on Low Back Pain. November 7–11,
Melbourne, Australia
Gibbons SGT, Whalen B 2003 Computed tomography
imaging of posterior psoas major. Proceedings of the
52nd Annual Conference of the Newfoundland and
Labrador Association of Medical Radiation Technolo-
gists. St John’s, Newfoundland
Gibbons SGT, Pelley B, Molgaard J 2001 Biomechanics and
stability mechanisms of psoas major. Proceedings of the
Fourth Interdisciplinary World Congress on Low Back
Pain. 9–11 November, Montreal, Canada
Gibbons SGT, Comerford MJ, Emerson P 2002a Rehabili-
tation of the stability function of psoas major. Ortho-
paedic Division Review Jan/Feb: 7–16
12/21/06 1:29:59 PM
 102 Movement, Stability and Lumbopelvic Pain
Gibbons SGT, Comerford MJ, Whalen B 2002b Inter
and intra tester reliability of posterior psoas major.
Proceedings of the Thirteenth Annual Orthopaedic
Symposium. Canadian Physiotherapy Association
Orthopaedic Division. 21–22 September, Saskatoon,
Canada
Gibbons SGT, Holmes MWR, Grandy C et al 2005 Altered
hip and trunk muscle recruitment in subjects with
chronic low back pain during a specific exercise for the
psoas major muscle. Submitted
Gracovetsky S, Farfan HF, Lamy C 1981 The mechanism of
the lumbar spine. Spine 6(3):249–262
Hides JA, Stokes MJ, Saide M et al 1994 Evidence of lumbar
multifidus muscle wasting ipsilateral to symptoms
in patients with acute/subacute low back pain. Spine
19(2):165–172
Hungerford B, Gilleard W, Hodges PW 2003 Evidence of
altered lumbopelvic muscle recruitment in the presence
of sacroiliac joint pain. Spine 28(14):1593–1600
Jaegers S, Dantuma R, de Jongh HJ 1992 Three-dimensional
reconstruction of the hip muscles on the basis of
magnetic resonance images. Surgical and Radiologic
Anatomy 14(3):241–249
Janevic J, Ashton-Miller JA, Schultz AB 1991 Large
compressive pre-loads decrease lumbar motion segment
flexibility. Journal of Orthopedic Research 19:228–236
Juker D, McGill S, Kropf P et al 1998 Quantitative intra-
muscular myoelectric activity of lumbar portions of
psoas and the abdominal wall during a wide variety
of tasks. Medicine & Science in Sports and Exercise
30(2):301–310
Jull G 2000 Deep cervical flexor muscle dysfunction in
whiplash. Journal of Musculoskeletal Pain 8(1/2):
143–154
Kapandji IA 1987 The physiology of the joints. Volume two:
lower limb, 5th edn. Churchill Livingstone, Edinburgh
Lee D 2004 The pelvic girdle, 3rd edn. Churchill
Livingstone, Edinburgh
McGill S 2002 Low back disorders. Evidence-based
prevention and rehabilitation. Human Kinetics,
Champaign, IL
Moore KL 1992 Clinically oriented anatomy, 3rd edn.
Williams & Wilkins, Baltimore, MD
Moore KL, Dalley AF 1999 Clinically oriented anatomy,
4th edn. Williams & Wilkins, Philadelphia, PA
Ch06-F10178.indd 102
Nachemson A 1968 The possible importance of the psoas
muscle for stabilisation of the lumbar spine. Acta
Orthopaedica Scandinavica 39:47–57
O’Sullivan PB, Twomey L, Allison G et al 1997 Altered
patterns of abdominal muscle activation in patients
with chronic low back pain. Australian Journal of
Physiotherapy 43(2):91–98
Pool-Goudzwaard AL, Vleeming A, Stoeckart R et al 1998
Insufficient lumbopelvic stability: a clinical, anatomical
and biomechanical approach to ‘a-specific’ low back
pain. Manual Therapy 3(1):12–20
Rab GT, Chao EYS, Stauffer RN 1977 Muscle force analysis
of the lumbar spine. Orthopedic Clinics of North
America 8(1):193–199
Richardson C, Jull G, Hodges PW et al 1999 Therapeutic
exercise for spinal segmental stabilization in low back
pain: scientific basis and clinical approach. Churchill
Livingstone, Edinburgh
Richardson C, Hodges PW Hides 2004 Therapeutic exercise
for lumbopelvic stabilization, 2nd edn. Churchill
Livingstone, Edinburgh
Romanes GJ 1987 Cunningham’s manual of practical
anatomy, 15th edn. Vol II: Thorax and abdomen. Oxford
University Press, Oxford, UK
Sahrmann S A 2002 Diagnosis and treatment of movement
impairment syndrome. CV Mosby, St Louis, MO
Santaguida PL, McGill SM 1995 The psoas major: a three
dimentional geometric study. Journal of Biomechanics
28:339–345
Snijders CJ, Vleeming A, Stoeckart R et al 1995 Bio-
mechanical modeling of sacroiliac joint stability in
different postures. Spine: State of the Art Reviews
9(2):419–432
Snijders CJ, Hermans PFG, Niesing R et al 2004 The
influence of slouching and lumbar support on ilio-
lumbar ligaments, intervertebral discs and sacroiliac
joints. Clinical Biomechanics 19(4):323–329
Williams PL, Warwick R, Dyson M et al 1989 Gray’s
anatomy, 37th edn. Churchill Livingstone, Edinburgh
Yoshio M, Murakami G, Sato T et al 2002 The function of the
psoas major muscle: passive kinetics and morphological
studies using donated cadavers. Journal of Orthopaedic
Science 7:199–207
12/21/06 1:30:00 PM