SPECIAL COMMUNICATION
Iliopsoas the Hidden Muscle: Anatomy,
Diagnosis, and Treatment
Liran Lifshitz, BPt, MSc, PT; Shlomo Bar Sela, BPt MPE; Noga Gal, BPt, MSc;
RobRoy Martin, PhD, PT; and Michal Fleitman Klar, BPt
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Abstract
The iliopsoas is a deep muscle group which anatomically connects the
spine to the lower limbs. It is composed of the iliacus, psoas major, and
psoas minor muscles. The iliopsoas functions as the primary hip flexor.
Because the iliopsoas is important for daily activities, including sports,
impairments and pathology associated with this muscle group can cause
significant limitations. Evaluating pathology associated with the iliopsoas
muscle group can be challenging because the patient's complaints are
often vague and difficult to discern from other hip problems. This article will
review relevant anatomy, discuss common pathologies, present clinical
based examination methods, and outline conservative treatment interven-
tions focusing on manual therapy and active exercises.
Introduction
The term iliopsoas syndrome is a nonspecific term used to
describe iliopsoas tendinopathy, iliopectinal bursitis, and/or
internal snapping (1). The iliopsoas is important clinically,
since impairments associated with this muscle group can be in-
volved in orthopedic conditions of the spine, hip, and knee.
Extraarticular anterior hip and groin pain are commonly asso-
ciated with iliopsoas pathology but also may result from other
structures that surround the hip.
Little has been written on iliopsoas pathology and the inter-
ventions directed at associated impairments and function lim-
itations. The aim of this article is to expand the knowledge
regarding this muscle group based on clinical experience and
the existing literature.
Iliopsoas Anatomy
The psoas major is a long muscle, originating from the
transverse processes, vertebral bodies, and intervertebral disks
of T5 to L5. The iliacus is a shorter muscle, originating from
the superior two thirds of the iliac fossa, ventral lip of the iliac
crest, and sacral ala. There are medial and lateral bundles as-
Physio & More Clinic, Tel Aviv, Israel
Address for correspondence: Liran Lifshitz, BPt MSc PT, Physio & More
Clinic, 27 Ya'akov Shabtai St., Tel Aviv, Israel; E-mail: ptliran@gmail.com.
1537-890X/1906/235–243
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sociated with the iliacus (2,3). The psoas
major and iliacus converge to form the
iliopsoas muscle at the L5 to S2 levels
and inserts on the lesser trochanter of
the femur as the iliopsoas tendon (2,3).
The iliopsoas tendon has some variants
with single, double, or triple tendon
bundles. The psoas major tendon is lo-
cated medial to the more lateral iliacus
tendon (4). The deep portion of the
iliopsoas muscle is located anterior and
lateral to the labrum of the hip joint.
This close relationship between the
iliopsoas and labrum may have clinical
relevance and can be associated with intraarticular hip impair-
ment and pathology. The iliopectineal or iliopsoas bursa is the
largest bursa in the human body located between the iliopsoas
muscle, bony surface of the pelvis, and proximal femur (2,3).
The psoas minor is separate from the psoas major and
iliacus muscles. It is located in the posterior wall of the abdo-
men, lateral to the lumbar spine (5), and present in only 59%
to 65% of individuals (3,5,6). When present, it originates on
the T12 and L1 vertebrae to attach on the iliopubic eminence
and, therefore, functions as a weak trunk flexor with no action
on the lower extremity.
The femoral triangle is located in the anterior hip and bor-
dered by the inguinal ligament anteriorly, sartorius laterally,
and the adductor longus medially. The floor of the triangle
contains the iliopsoas and pectineus muscles, as well as blood
vessels and nerves. Therefore, the triangle is a place to identify
muscular trigger points in the iliopsoas (Fig. 1).
Function
The iliopsoas is the primary hip flexor and may assist in
tilting the pelvis anteriorly. It also functions as an external
rotator of the hip (7) and is considered to be a core muscle be-
cause of its attachments to the spine (8). Because the iliopsoas
muscle connects the spine and lower extremity, it plays an im-
portant role in many activities of daily living, including sports.
For instance, the psoas major assists in sitting and maintaining
in an erect position of the spine (3,9). The iliopsoas contrib-
utes significantly to running, especially initiating the swing
phase, as it performs early and rapid hip flexion (3,10,11).
Current Sports Medicine Reports 235
 High activation of the iliopsoas also has been observed in a
kicking motion (12). It has been shown that the iliopsoas mus-
cle is active throughout the entire kicking movement, includ-
ing during deceleration of the thigh (13).

Iliopsoas Clinical Relevance

The iliopsoas is often overlooked in the diagnostic process
in those with lumbar spine and lower extremity injuries. How-
ever, due to its anatomy and function, impairments of the
iliopsoas should be considered in those with low back and
lower extremity pathology.

Acute groin injuries

The iliopsoas is frequently involved in acute groin injuries
as 17% to 25% of all acute groin injuries are iliopsoas related
(14). This type of injury often occurs in sports, especially those
that involve kicking and/or changing directions (14).

Low back pain

The interrelationship between the hip and spine is sup-
ported in the literature, as a loss of hip motion was found to
contribute to lumbar spine pain and disability (15–21). Specif-
ically, hip disorders that cause a limitation in terminal hip
extension can aggravate and/or cause lumbopelvic pain
secondary to increased pelvic rotation, hyperlordosis, and
facet overload (22–24). In addition, the psoas major activa-
tion is associated with compressive and shear forces on the
spine (25) while acting as a lumbar spine stabilizer (9). More-
over, the study by Avrahami and Potvin (26) found stretching
the iliopsoas muscle, decreased pain and disability with pa-
tients with low back pain. This is consistent with the authors'
clinical experience, as identifying and treating a loss of hip ex-
tension from iliopsoas inflexibility has resulted in successful
outcomes in patients with low back pain.

Pelvic pain
The iliopsoas acts as a pelvic and hip stabilizer, especially
during single leg stance activities (3,27). This is particularly
true of the iliacus muscle with its origin being on the pelvis.
In addition, the iliopsoas also functions to tilt the pelvis ante-
riorly. Therefore, the iliopsoas may be important in those un-
dergoing pelvic rehabilitation.

Overuse injuries
Iliopsoas injury is the second most common groin injury in
soccer (28). With iliopsoas overuse injuries, ultrasound or
magnetic resonance imaging scans commonly identify tendi-
nopathies, tendinosis, or thickening of the tendon. Although
commonly overlooked, muscle spasms and trigger points also
are related to overuse injuries in the iliopsoas muscle.

Figure 1: Iliopsoas anatomy. © F. Netter, MD.
Postoperative pain
During the first few days after hip surgery, patients often
complain of significant pain as they maintain their hip in a
flexed position for comfort and to protect their incision. In this
flexed position, the iliopsoas muscle is highly active and, there-
fore, prone to muscle spasm. From the authors' experience,
anterior hip pain after surgery is commonly related to
the iliopsoas.

236 Volume 19  Number 6  June 2020 Special Communication

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Hip snapping
There are different reasons for hip snapping. Iliopsoas or in-
ternal hip snapping is described as a painful audible and/or
palpable snapping of the iliopsoas over the iliopectineal emi-
nence. This snapping can occur as the hip is brought from a
position of flexion, abduction, and external rotation (FABER)
to extension (3). It should be noted that this snapping is not al-
ways symptomatic (3). Iliopsoas snapping also may be associ-
ated with deeper structures, such as the head of the femur and/
or iliopectineal line.
Other
As noted above, the hip labrum and iliopsoas are in close
proximity. Because the psoas tendon crosses the anterior part
of the hip joint, it might have a role in symptomatic acetabular
labral impingement (29). This anatomical relationship may be
of particular importance in those with labral pathology and a
tight iliopsoas tendon (29).
Moreover, because the iliopsoas muscle group is in close
anatomical proximity to the abdominal area, there is a con-
nection between the iliopsoas and the diaphragm, respiratory
system, and other internal systems. However, there is a gap of
knowledge regarding these connections.
Examination
Examination of the iliopsoas muscle group can be divided
into three parts: medical history, clinical examination, and im-
aging. While imaging may provide useful information, it is
outside the scope of this article.
The medical history (subjective examination)
The medical history of those with pathology and impair-
ments associated with the iliopsoas muscle group can be chal-
lenging because there may not be unique symptoms that are
different from other common hip problems. Therefore, medi-
cal history alone is often not enough for detecting an iliopsoas-
related problem. Because the common complaint of those with
iliopsoas pathology is anterior hip and/or groin pain, it is com-
monly confused with intraarticular hip pathology, such as
femoroacetabular impingement syndrome (FAIS). Those with
iliopsoas-related pain often have more superficial diffuse ante-
rior hip pain, as opposed to the deep, well localized groin pain
associated with intraarticular hip pathology. Pain while
kicking (especially during the back-swing), walking with large
steps, uphill running, and climbing stairs are common com-
plaints in those with iliopsoas pathology. In some cases, low
back pain also may be reported.
The clinical examination (objective examination)
A structured clinical examination provides important infor-
mation related to differential diagnosis. For those with potential
iliopsoas pathology, five tests are recommended and include an
assessment of muscle function, flexibility, and palpation.
The first three tests are commonly used to assess for poten-
tial iliopsoas muscle involvement:
1. An isometric-resistance muscle test: this test is used to
evaluate muscle strength and pain reproduction. Clin-
ically, when hip flexor muscle strength is decreased
with reproduction of pain, the iliopsoas muscle is typ-
ically involved. From the authors' experience, we
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have found that the ideal position to test the iliopsoas
muscle is supine with the hip and knee flexed to 90
degrees.
2. Modified Thomas Test: This commonly performed
test is used to evaluate the flexibility of the hip flexors.
The main difference between the Thomas test and the
modified Thomas test is that in the Thomas test, the
patient is lying flat on the examination table, while
in the modified test, the patient is lying on the edge of
the table (Fig. 2). Although commonly used, studies
reporting on the validity and reliability of the test are
limited (30). To properly interpret test results, it is im-
portant to remove the lumbar lordosis. The tested limb
should be lowered off the table edge with the hip angle
being evaluated relative to the horizontal axis (30) as
the clinician assess for reproduction of pain and tight-
ness. The authors have found that when the iliopsoas
is involved, pain can be reproduced during this test.
3. Palpation: With palpation it is important to map out
painful areas and connect them to the relevant ana-
tomical structures. There are three main palpation
points to assess in those with potential iliopsoas pa-
thology: the first palpation point is just medially to
the anterior superior iliac spine (ASIS) where the
iliacus muscle can be assed. The second point is just
medial (1 cm to 2 cm) to that, at which point the ther-
apist can palpate the psoas major muscle. The third
point of palpation is just below the inguinal ligament
where the iliopsoas muscle can be assessed in the floor
of the femoral triangle (Fig. 3). As the superficial Sar-
torius muscle crosses the ASIS (in the direction of the
pes anserinus), the common tendon of the iliopsoas
muscle will be located just medially from this point.
When palpating further medially from the common
tendon of the iliopsoas, one may feel a pulse, suggest-
ing that the blood vessels inside the femoral triangle
are being palpated. At these three palpation points,
the therapists can confirm that they are in the correct
location by asking the patient to raise their leg. The
muscle contraction should be easy to palpate if the
therapist is properly on the iliopsoas muscle.
Two additional tests may be used to assess the iliopsoas
muscle group: the flexion-adduction-internal rotation (FADIR)
and skin rolling tests. Although these two tests are not com-
monly performed in those with potential iliopsoas involvement,
the authors have found them to be useful.
The FADIR test is commonly used to assess those with FAIS
and is found to have high sensitivity (0.94–0.99) but low spec-
ificity (0.05–0.09) (31). The FADIR test is performed with the
patient supine and the therapist passively flexing, adducting,
and then internally rotating the hip. In this position, the la-
brum can be pinched between the femoral head-neck junction
and the acetabular rim. There are additional structures in the
hip region that can be pinched with this test, including the
iliopsoas tendon. Therefore, iliopsoas tension involvement
needs to be considered when pain is reported during the
FADIR test. If the patient complains of pain with the applica-
tion of overpressure of normal motion, extraarticular soft
Current Sports Medicine Reports 237
Figure 2: Modified Thomas test.
tissue, including the common tendon of the iliopsoas, may be
the source of impingement. However, if there is a significant
loss of motion associated with pain and a firm or hard end-
feel, the test results may indicate a mechanical problem in
the hip joint, such as FAIS.
The second clinical evaluation test that the main author
uses is the skin rolling test. As identified in the “trigger point
map” (32), one of the referred points of the iliopsoas muscle
is the low back. The skin rolling test is performed with the pa-
tient lying prone as the therapist grabs the skin and soft tissue
around the patient's low back and roles the skin in the direc-
tion of the stiff soft tissue. The following can be observed with
a positive skin rolling test: 1) reduced skin movement; 2) local-
ized tenderness and erythema of the skin; and 3) stiffness of
the soft tissue on the affected side. It is important to consider
that the movement and elasticity of the patient's skin is largely
genetic. Therefore, skin movement and elasticity must be com-
pared on both sides of the lumbar spine. This skin rolling
maneuver also may be used as a manual treatment technique,
as described later.
Treatment
Physical therapy is the mainstay of treatment for those
with iliopsoas syndrome, since most patients respond to
Figure 3: The femoral triangle.
238 Volume 19  Number 6  June 2020
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conservative management (1). In this article, we will discuss
conservative treatment solely, which includes manual therapy
and active exercise.
Manual therapy
While several options exist for manual therapy techniques,
the authors have found spine mobilization, strain counter
strain, soft tissue mobilization directed at a trigger point,
passive range of motion, contract-relax, and skin rolling to
be effective.
Spine mobilization
Because the iliopsoas has an origin on the lumbar spine,
manual treatment directed at the spine may help in those with
muscle tightness and limited joint mobility. The first author
recommends using a Maitland© posterior-anterior joint mo-
bilization technique on the affected side. This may be done
at the beginning of the treatment in an effort to loosen the af-
fected iliopsoas muscle.
Strain counter strain
The strain counter strain technique, also known as posi-
tional release therapy, is performed by first having the thera-
pist identify a tender trigger point in the affected muscle. A
position that creates no tension on this point is used for treat-
ment. The authors commonly position the patient supine with
both knees flexed, legs crossed, and rested on the therapist's
leg (Fig. 4). In this position, the therapist may combine other
techniques, such as approximation, rotation of the hip, and
deep breathing to assist in relaxation and pain reduction. After
the pain decreases, the patient lies in this position for at least
90 s. The patient can use this position as a self-treating exer-
cise by resting his or her legs on a chair or physioball at home.
Trigger point treatment
Trigger points are defined as focal, hyperirritable spots lo-
cated in a taut band of skeletal muscle. The spots are painful
and can produce referred pain (33). There are some common
Special Communication
Figure 4: Strain counter strain position.
methods to treat trigger points, such as massage therapy,
sustained pressure, and transverse or rotation movement on
the trigger point. During the irritable phase of an injury or in
the first couple of weeks postsurgery, it is recommended to
perform the technique with the muscle in a relaxed position.
This position is typically with the patient lying supine, with
his or her legs resting against the therapist's thigh (Fig. 5). In ad-
dition, the therapist can ask the patient to contract the gluteus
maximus muscle to further relax the iliopsoas muscle through
contract relax and activation of the antagonist muscle.
Friction therapy by hip movement
This technique has two versions. The first one is for patients
with highly irritable pain. The patient lies supine with the hip
positioned in 45 degrees of flexion and the feet placed on the
treatment table. A mobilization belt is wrapped around the
Figure 5: Trigger points therapy position.
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therapist's pelvis to laterally distract the patient's hip. The
therapist places pressure on the trigger point while distracting
the patient's hip laterally. In this technique, passive friction
massage to the muscle is accomplished by the hip movement.
For patients with less irritable pain, the authors recommend
a more advanced technique. For this, the patient position
changes to 90 degrees hip flexion with the feet being unsup-
ported. In this position, the iliopsoas muscle will be activated.
The therapist uses the belt, positioned as described above, to
create a circumduction movement of the hip. Again, the fric-
tion massage is accomplished by the hip movement.
Soft tissue technique in a modified Thomas test
The first stage of this treatment method is suitable for pa-
tients with irritable pain. The patient is positioned as described
in the modified Thomas test position with the affected limb off
Current Sports Medicine Reports 239
the edge of the table. A mobilization belt is secured to the
patient's thigh and therapist so that the limb is supported
and full hip extension is prevented. The therapist puts pressure
on the trigger point with his/her thumb or thenar eminence
while performing a contract-relax technique incorporating ac-
tive hip flexion. The advantage of this technique is that the limb
is supported in slight hip flexion with the iliopsoas muscle ex-
posed. In this technique, there should be no stretching on the
iliopsoas muscle.
To progress this technique for those patients with non-
irritable pain, the patient's thigh is not supported with the
mobilization belt. An advantage of using this contract-relax
technique in the modified Thomas test position without sup-
port is that the iliopsoas muscle can be activated and stretched
into extension through a full range of hip motion.
Skin rolling
The skin rolling treatment technique can be applied when
skin rolling test results are positive. In this treatment, the ther-
apist mobilizes the stiff tissue and rolls in the direction of the
stiffness, typically present in the thorax and lumbar spine
(Fig. 6). The purpose of this treatment is to make the tissue
flexible and mobile. When choosing this technique, the thera-
pist should be cautious in patients who have high pain irrita-
bility because this treatment technique may provoke pain.
Active Exercise
Exercises to strengthen the iliopsoas muscle are not as com-
monly performed when compared with exercises directed at
the gluteus medius, gluteus maximus, hamstrings, and/or
quadriceps muscles. Perhaps, it is because there are some con-
cerns that strengthening the iliopsoas could cause or aggravate
hip pathology. Therefore, the authors are creative and cau-
tious when prescribing exercises for the iliopsoas muscle. To
diversify the exercise program, positions, leverage arms, and
speed of movements are varied. Additionally, a combination
of isometric, concentric, and eccentric exercises is used.
During the first stage of rehabilitation after injury, typically
the first 2 wk, isometric exercises with isolated muscle con-
traction are recommend. Short leverage arm exercises also
are recommended at this stage to avoid muscle overload and
aggravation of symptoms. As symptoms subside, treatment
can be progressed to more dynamic exercises with longer lever
Figure 6: Skin rolling.
240 Volume 19  Number 6  June 2020
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arms. These exercises combine coordination, core strength,
and muscle balance. The exercises presented in this article
are described in a progression of increased difficulty. The pa-
tient should be advanced during the rehabilitation period
gradually; starting with the isometric exercise progressing
along the continuum of exercises from concentric to eccentric
over time as symptoms allow.
The average dosage of the exercise is presented in the Table.
The therapist should make sure the patient performs each spe-
cific exercise with proper form at all times according to the
dosage prescribed. When the patients are not in an irritable
stage of pain, the exercise can be done with slight pain accord-
ing to the pain monitoring model (34,35). This model suggests
that during an exercise, pain is allowed to reach level 5 on the
visual analog scale, where 0 is no pain and 10 is the worst pain
imaginable. The patient should be aware that the pain should
not increase during the exercise, and the pain should subside
by the following day. In addition, the pain should not increase
from week to week.
The therapist should be aware of contraindications and pre-
cautions when strengthening the iliopsoas muscle. This is espe-
cially true during the first few weeks following hip surgery or
when working with a patient experiencing highly irritable pain.
In the first author's experience, the patient should not begin
iliopsoas isometric exercises for at least 4 wk (average time) af-
ter hip arthroscopy.
Isometric resistance exercise
For the isometric exercise, the patient lies supine with the af-
fected hip in FABER while the heel rests on the flexed knee of
the unaffected side. Resistance is applied to the thigh of the af-
fected limb by either self-assisted or with an external force
(Fig. 7). For the self-assisted exercises, resistance can be gener-
ated by the patient's hand. In this method, the resistance is self-
controlled, typically less painful, and therefore, suitable for an
a patient with irritable pain. The ipsilateral hand gives resis-
tance to the affected limb in a direction that is parallel to the
muscle fibers. The therapist can add manual resistance to the
ankle dorsiflexors, to get a resistance similar to proprioceptive
neuromuscular facilitation training. The exercises can be
advanced so that the affected hip and knee are flexed to a
90-degree angle, without support from the unaffected limb.
As illustrated in Figure 7, one can generate resistance by using
a ball on the involved limb (e.g., a soccer ball or a basketball
to associate the exercise with the patient's sport).
Eccentric resistance exercise
Eccentric resistance can be performed with the patient su-
pine and a resistance band around the feet. The exercise begins
with both knees pulled toward the patient's chest. The unaf-
fected limb is straightened while the patient uses both hands
to support the affected limb. The patient can then slowly re-
lease his or her hands, thereby adding resistance to the affected
hip. At first, the patient should try maintaining this position
for 2 s using an isometric contraction. This exercise can be
progressed so that the patient slowly extends the affected hip
as he or she is resisting the band using an eccentric contraction
of the iliopsoas. The therapist and patient should pay atten-
tion that the lumbar lordosis does not increase during this
exercise. The technique is presented in supplemental video
1 (http://links.lww.com/CSMR/A55).
Special Communication
Table.
The average dosage of exercise.
Exercise Dosage Recovery (s) Notes
a
Isometric resistance exercise 5  15–45 s 20–75 Recovery time should increase as the contraction time increases.
The contraction time increases according to the patient's ability
and symptoms
Eccentric resistance exercise 15  3 30 If the patient's ability and symptoms do not allow 15  3
repetitions repetitions, the patient should begin the exercise 15  1/2
repetitions
Hip flexion in quadruped/high 15  3 30
plank position repetitions
Reverse origin insertion-sitting 15  3 30
repetitions
Iliopsoas strength in half 15  3 30
kneeling position repetitions
Hip flexor training with a 15  3 30
resistance band (standing) repetitions
Standing on a BOSU ball with 15  3 30
straight leg repetitions
Dynamic and coordination 20–45 s 20–45 Activity time equals recovery time. The therapist should consider
exercises the type of sports the patient participates in
Plyometric exercise 10  3 120 High intensity training
repetitions
a
As presented in the study on Rio, 2015 (15).

Hip flexion in quadruped
This exercise combines the contraction of the iliopsoas mus-
cle with an addition of core activation. The patient is in a
quadruped position with a resistance band wrapped around
the patient's thighs. The exercise is performed by having the
patient flex the hip against the resistance of the band. This
technique is presented in supplemental video 2 (http://links.
lww.com/CSMR/A56).
Hip flexion in high plank position
This exercise is an advanced version of the previous exercise
with the patient in a high plank position and a resistance band
around the patient's feet. The patient will flex the hip to acti-
vate the iliopsoas muscle. As mentioned earlier, the iliopsoas
is considered a core muscle (18) and will be highly active dur-
ing this exercise. This exercise also includes activation of the
upper limbs, lower limbs, and trunk muscles. The technique
is presented in supplemental video 3 (http://links.lww.com/
CSMR/A57).
Reverse origin insertion sitting with a belt or with upper
pulley
Because the iliopsoas originates from a large area in the
lumbar spine and inserts in the lesser trochanter of the femur,

Figure 7: Isometric resistance exercise.

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when the patient extends his/her spine, activation of the
iliopsoas may be less stressful as compared with the flexion
of the hip. In this exercise, the patient sits with the affected
hip positioned in FABER. The ankle rests on the knee of the
unaffected limb. The patient needs to keep their torso straight
and lean back slowly in a diagonal line while the foot of the af-
fected limb pushes down toward the limb that is on the
ground. This eccentric contraction is followed by a concentric
contraction as the patient comes forward toward the affected
limb to the starting upright position. In this exercise, the inser-
tion of the muscle is fixed at the origin while the spine is mov-
ing with iliopsoas muscle activation. An advanced version of
this exercise can be done with the affected hip fixed to an ex-
ternal object instead of resting on the unaffected leg. This po-
sition allows the iliopsoas to be active through a larger range
of motion. The technique is presented in supplemental video
4 (http://links.lww.com/CSMR/A58).
Iliopsoas strength in half kneeling position
For this exercise, the patient kneels on a chair on the unaf-
fected limb, with the knee of the affected limb flexed and a re-
sistance band placed around both thighs. With the trunk
upright and stabilized, the patient moves the affected limb
from flexion to an extension, activating the iliopsoas through
the desired range of motion. The patient should hold onto the
back of a chair for support to emphasize the iliopsoas muscle
activation. The exercises can be further progressed by per-
forming the exercises while standing on an unstable surface,
such as a balance pad. This technique is presented in supple-
mental video 5 (http://links.lww.com/CSMR/A59).
Hip flexor training with a resistance band (standing)
This exercise is inspired and similar to that used by
Thorborg et al. (27). The results of their study showed a
17% increase in muscle strength after 6 wk of training. The
exercise is performed in a standing position. Resistance is
placed just above the patient's ankle. In this position, the pa-
tient performs a hip flexion movement against resistance. This
exercise can be done emphasizing concentric, isometric, and/
or eccentric types of muscle contractions. A sport-specific pro-
gression for soccer players can include combining the standing
exercise with a kicking motion. The contractions can be al-
tered by incorporating a high kicking motion and slow release,
with a concentric contraction of 1 s and a longer eccentric con-
traction of 3 s. The technique is presented in supplemental
video 6 (http://links.lww.com/CSMR/A60).
Standing on a BOSU with a straight leg
This is a functionally advanced exercise that includes
iliopsoas strengthening, core activation, proprioception, bal-
ance, and motor control. The patient stands on a both sides
up (BOSU) ball using one leg while performing functional or
sport-specific tasks using the other leg. These sport-specific
tasks should incorporate an iliopsoas muscle action, such as
hip flexion and rotation of the limb over a hurdle, as presented
in supplemental video 7 (http://links.lww.com/CSMR/A61).
The affected and unaffected limbs can alternate as the stance
leg on the BOSU ball depending on the goal of the exercise.
242 Volume 19  Number 6  June 2020
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Dynamic, plyometric, and coordination exercises
In the late phase of rehabilitation, especially when athletes
are able to return to their sport-specific training and practice,
it is important to combine more dynamic, coordination re-
lated, and plyometric exercises for the iliopsoas. The therapist
should be aware of the different dosage for plyometric-,
dynamic-, and coordination-related exercises. Plyometric
training is defined as high-velocity eccentric to concentric
muscle loading (36,37) (e.g., jumping). The activity interval
should be short, and the recovery time should be long. The lit-
erature recommends 3 to 5 or 9 to 12 repetitions per set with 3
or 4 sets per exercise (38,39). Based on the authors' experi-
ence, the dosage recommended is 3 sets of 10 repetitions of
maximal force with each exercise and a long recovery time
of 2 min. This is different than the dynamic and coordination
exercises in which the activity time should approximately
equal the recovery time. However, the therapist should con-
sider the type of sports the patient participates in and base
the time rest interval according to the demands of the specific
sport. It is recommended to add resistance during these exer-
cises as the patient advances. Resistance bands can be placed
above the knees to best isolate resistance to the iliopsoas.
Examples for this kind of exercise can be seen in supplemental
videos 8 (http://links.lww.com/CSMR/A62) and 9 (http://
links.lww.com/CSMR/A63).
Conclusion
The purpose of this article is to raise readers' awareness
about impairments and pathology associated with the
iliopsoas muscle group. Despite being essential for basic activ-
ities of daily living, as well as sports, it is often overlooked by
clinicians. This may be because the iliopsoas muscle group is
poorly understood, difficult to examine, and problematic to
treat. There also is controversy related to the value of strength-
ening exercises directed at the iliopsoas muscle. A common
misconception is that strengthening the iliopsoas muscle can
harm the muscle and overload the hip joint. In addition, it is
viewed by many that this muscle group is often shortened
and treatment should focus only on stretching. However,
strengthening this muscle group may be as important as
strengthening any other muscle group. Based on clinical expe-
rience, a progression of strengthening exercises have been pro-
vided. More research is needed regarding the examination and
rehabilitation of the iliopsoas muscle and its associated pa-
thology. An area of particular interest should focus on exer-
cises for the iliopsoas muscle group, including evidence to
support the need for strengthening exercises, how best to
perform exercises, and how to use exercises to manage
associated pain.
The authors declare no conflict of interest and do not have
any financial disclosures.
References
1. Tyler TF, Fukunaga T, Gellert J. Rehabilitation of soft tissue injuries of the hip
and pelvis. Int. J. Sports Phys. Ther. [Internet]. 2014; 9:785–97. Available from:
https://www.ncbi.nlm.nih.gov/pubmed/25383247.
2. Tatu L, Parratte B, Vuillier F, et al. Descriptive anatomy of the femoral portion of
the iliopsoas muscle. Anatomical basis of anterior snapping of the hip. Surg.
Radiol. Anat. [Internet]. 2001; 23:371–4. Available from: https://www.ncbi.
nlm.nih.gov/pubmed/11963618.
Special Communication
 3. Christian N, Anderson MD. Iliopsoas. Clinics Sports Med. [Internet]. 2016; 35:
419–33. Available from: https://www.clinicalkey.es/playcontent/1-s2.0-
S0278591916300096. doi: 10.1016/j.csm.2016.02.009.
4. Philippon MJ, Devitt BM, Campbell KJ, et al. Anatomic variance of the iliopsoas
tendon. Am. J. Sports Med. [Internet]. 2014; 42:807–11. Available from: https://
journals.sagepub.com/doi/full/10.1177/0363546513518414.
5. Guerra DR, Reis FP, Bastos AA, et al. Anatomical study on the psoas minor
muscle in human fetuses. Int. J. Morphol. [Internet]. 2012; 30:136–9.
Available from: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=
S0717-95022012000100024&lng=en&tlng=en. Doi: 10.4067/S0717-
950220120001000024.
6. Neumann DA, Garceau LR. A proposed novel function of the psoas minor re-
vealed through cadaver dissection. Clin. Anatomy [Internet] 2015; 28:243–52.
Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/ca.22467. Doi:
10.1002/ca.22467.
7. Fitzgerald P. The action of the iliopsoas muscle. Ir. J. Med. Sci. 1969; 2:31–3.
8. Ambegaonkar JP, Mettinger LM, Caswell SV, et al. Relationships between core
endurance, hip strength, and balance in collegiate female athletes. Int. J. Sports
Phys. Ther. [Internet]. 2014; 9:604–16. Available from: https://www.ncbi.nlm.
nih.gov/pubmed/25328823.
9. Andersson E, Oddsson L, Grundström H, Thorstensson A. The role of the psoas
and iliacus muscles for stability and movement of the lumbar spine, pelvis and
hip. Scand. J. Med. Sci. Sports. 1995; 5:10–6.
10. Dorn TW, Schache AG, Pandy MG. Muscular strategy shift in human running:
dependence of running speed on hip and ankle muscle performance. J. Exp. Biol.
[Internet]. 2012; 215(Pt 11):1944–56. Available from: https://www.ncbi.nlm.
nih.gov/pubmed/22573774. Doi: 10.1242/jeb.064527, 215, 1944, 1956.
11. Mann RA, Moran GT, Dougherty SE. Comparative electromyography of the lower
extremity in jogging, running, and sprinting. Am. J. Sports Med. 1986; 14:501–10.
12. Kellis E, Katis A. Biomechanical characteristics and determinants of instep soccer
kick. J. Sports Sci. Med. [Internet]. 2007; 6:154–65. Available from: https://
www.ncbi.nlm.nih.gov/pubmed/24149324.
13. Dörge HC, Andersen TB, Sørensen H, et al. EMG activity of the iliopsoas muscle
and leg kinetics during the soccer place kick. Scand. J. Med. Sci. Sports. 1999; 9:
195–200.
14. Serner A, Tol JL, Jomaah N, et al. Diagnosis of acute groin injuries. Am. J. Sports
Med. [Internet]. 2015; 43:1857–64. Available from: https://journals.sagepub.
com/doi/full/10.1177/0363546515585123. Doi: 10.1177/0363546515585123.
15. Redmond JM, Gupta A, Hammarstedt JE, et al. The hip-spine syndrome: how
does back pain impact the indications and outcomes of hip arthroscopy? Ar-
throscopy [Internet]. 2014; 30:872–81. Available from: https://www.
clinicalkey.es/playcontent/1-s2.0-S0749806314001704.
16. Gebhart JJ, Weinberg DS, Conry KT, et al. Hip-spine syndrome: is there an as-
sociation between markers for cam deformity and osteoarthritis of the lumbar
spine? Arthroscopy [Internet]. 2016; 32:2243–8. Available from: https://www.
clinicalkey.es/playcontent/1-s2.0-S0749806316301992. doi: 10.1016/j.arthro.
2016.04.025.
17. Weinberg D, Xie K, Liu R, et al. Increased pelvic incidence is associated
with a more coronal facet orientation in the lower lumbar spine: a cadaveric
study of 599 lumbar spines. Spine [Internet]. 2016; 41:E1145. Available
from: https://www.ncbi.nlm.nih.gov/pubmed/27031765. doi: 10.1097/BRS.
0000000000001577, 41, E1138, E1145.
18. Weng W, Wu H, Wu M, et al. The effect of total hip arthroplasty on sagittal
spinal-pelvic-leg alignment and low back pain in patients with severe hip osteo-
arthritis. Eur. Spine J. [Internet]. 2016; 25:3608–14. Available from: https://
www.ncbi.nlm.nih.gov/pubmed/26883265. Doi: 10.1007/s00586-016-4444-1,
25, 3608, 3614.
19. Prather H, Cheng A, Steger-May K, et al. Hip and lumbar spine physical exam-
ination findings in people presenting with low back pain, with or without lower
extremity pain. J. Orthop. Sports Phys. Ther. [Internet]. 2017; 47:163–72.
Available from: https://www.ncbi.nlm.nih.gov/pubmed/28158964. doi: 10.
2519/jospt.2017.6567, 47, 163, 172.
20. Hicks GE, Sions JM, Velasco TO. Hip symptoms, physical performance, and
health status in older adults with chronic low back pain: a preliminary investiga-
tion. Arch. Phys. Med. Rehabil. [Internet]. 2018; 99:1273–8. Available from:
https://www.sciencedirect.com/science/article/pii/S0003999317312881. doi: 10.
1016/j.apmr.2017.10.006.
www.acsm-csmr.org
Copyright © 2020 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
21. Miyagi M, Fukushima K, Inoue G, et al. Hip-spine syndrome: cross-sectional-
study of spinal alignment in patients with coxalgia. HIP Int. [Internet]. 2019; 29:
21–5. Available from: https://journals.sagepub.com/doi/full/10.1177/
1120700018803236. doi: 10.1177/1120700018803236.
22. Watelain E, Dujardin F, Babier F, et al. Pelvic and lower limb compensatory ac-
tions of subjects in an early stage of hip osteoarthritis. Arch. Phys. Med. Rehabil.
2001; 82:1705–11.
23. Gómez-Hoyos J, Martin R, Martin H. Current concepts review: evaluation and
management of posterior hip pain. J. Am. Acad. Orthop. Surg. [Internet]. 2018;
26:597–609. Available from: https://www.ncbi.nlm.nih.gov/pubmed/
30080760. doi: 10.5435/JAAOS-D-15-00629, 26, 597, 609.
24. Moreside J, Wong I, Rutherford D. Altered erector spinae activity and trunk mo-
tion occurs with moderate and severe unilateral hip OA. J. Orthop. Res. [Inter-
net]. 2018; 36:1826–32. Available from: https://onlinelibrary.wiley.com/doi/
abs/10.1002/jor.23841. doi: 10.1002/jor.23841.
25. Bogduk N, Pearcy M, Hadfield G. Anatomy and biomechanics of psoas major.
Clin. Biomech. 1992; 7:109–19.
26. Avrahami D, Potvin JR. The clinical and biomechanical effects of fascial-
muscular lengthening therapy on tight hip flexor patients with and without
low back pain. J. Can. Chiropr. Assoc. [Internet]. 2014; 58:444–55. Available
from: https://www.ncbi.nlm.nih.gov/pubmed/25550670.
27. Thorborg K, Bandholm T, Zebis M, et al. Large strengthening effect of a hip-
flexor training programme: a randomized controlled trial. Knee Surg. Sports
Traumatol. Arthrosc. [Internet]. 2016; 24:2346–52. Available from: https://
www.ncbi.nlm.nih.gov/pubmed/25796586. doi: 10.1007/s00167-015-3583-y,
24, 2346, 2352.
28. Werner J, Hägglund M, Walden M, Ekstrand J. UEFA injury study: a prospec-
tive study of hip and groin injuries in professional football over seven consecu-
tive seasons. Br. J. Sports Med. [Internet]. 2009; 43:1036–40. DOI: 10.1136/
bjsm.2009.066944.
29. Heyworth BE, Shindle MK, Voos JE, et al. Radiologic and intraoperative
findings in revision hip arthroscopy. Arthroscopy [Internet]. 2007; 23:
1295–302. Available from: https://www.clinicalkey.es/playcontent/1-s2.0-
S0749806307009619.
30. Dennis RJ, Finch CF, Elliott BC, Farhart PJ. The reliability of musculoskele-
tal screening tests used in cricket. Phys. Ther. Sport [Internet]. 2007; 9:
25–33. Available from: https://www.clinicalkey.es/playcontent/1-s2.0-
S1466853X07000983.
31. Reiman MP, Goode AP, Cook CE, et al. Diagnostic accuracy of clinical tests for
the diagnosis of hip femoroacetabular impingement/labral tear: a systematic re-
view with meta-analysis. Br. J. Sports Med [Internet]. 2015; 49:811. Available
from: http://dx.doi.org/10.1136/bjsports-2014-094302.
32. Simones D, Travel J, Simons L. Myofascial Pain and Dysfunction the Trigger
Point Manual. 2nd ed. Butler J, editor. Philadelphia (PA): Lippincott Williams
& Wilkins; 1993. p. 90.
33. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am. Fam.
Phys. [Internet]. 2002; 65:653–60. Available from: https://www.ncbi.nlm.nih.
gov/pubmed/11871683.
34. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity,
using a pain-monitoring model, during rehabilitation in patients with Achilles
tendinopathy. Am. J. Sports Med. [Internet]. 2007; 35:897–906. Available from:
https://journals.sagepub.com/doi/full/10.1177/0363546506298279.
35. Thomeé R. A comprehensive treatment approach for patellofemoral pain syn-
drome in young women. Phys. Ther. 1997; 77:1690–703.
36. Voight M. Stretch strengthening: an introduction to plyometrics. Orthop. Phys.
Ther. Clin North Am. 1992; 1:243–52.
37. Kisner C, Allen L.Therapeutic Exercise Foundations and Techniques. 5th ed.
Pine JA editor. Philadelphia (PA): F.A Davis Company; 2007. p. 208–10.
38. Lesinski M, Prieske O, Granacher U. Effects and dose-response relationships of
resistance training on physical performance in youth athletes: a systematic re-
view and meta-analysis. Br. J. Sports Med [Internet]. 2016; 50:781–95. Avail-
able from: http://dx.doi.org/10.1136/bjsports-2015-095497.
39. Rio E, Kidgell D, Pudram C, et al. Isometric exercise induces analgesia and re-
duces inhibition in patellar tendinopathy. Br. J. Sport Med [Internet]. 2015;
DOI: 10.1136/bjsports-2014-094386.
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