Psoas Major
Origin: TVPs of T12-L4 + lateral aspects of the discs between them |
Insertion: Lesser Trochanter of the femur |
Nerve: Lumbar plexus - anterior branches of L1-L3 nerves |
Action: Flexion of hip, flexion of upper lx, extension of lower lx |
Psoas Major - Trigger Points
- Patients with unilateral iliopsoas TrP tend to feel LBP that runs up and down the spine. Pain from bilateral TrPs tends to be felt across the back as in QL and rectus abdominis TrPs
- Iliopsoas TrPs do not cause pain on deep inspiration or coughing whereas QL TrPs do
- TrPs in Psoas may be associated with spinal manipulable lesions around the thoracolumbar junction
Iliopsoas Minor
- Sometimes absent |
Origin: lies anterior to psoas major, sides of the bodies of 12th tx and first lx and from the disc inbetween them |
Insertion: Pecineal line and iliopectineal eminence and laterally to the iliac fascia |
NS: Lumbar plexus Ventral rami L1 |
Action: Flexion of the trunk |
Trps same as Psoas Major |
Psoas minor syndrome where an overly taught psoas minor mimics appendicitis.
- Taught band on RLQ of the abdomen
Iliacus
- Origin: superior 2/3 of concavitiy of the iliac fossa, inner lip of the iliac crest, ventral SI and iliolumbar ligaments and upper surface of the lateral part of the sacrum |
- Insertion: Lesser trochanter of the femur |
- NS: Femoral nerve L2-L3 |
- Action: Flexion and external rotation of the thigh |
TrPs same as psoas |
Levator Ani
Consists of:
- Ischiococcygeus
- Iliococcygeus
- Pubococcygeus
Ischiococcygeus
- At posterosuperior portion |
- Attached to pelvic surface and tip of the iliac spine |
- Base attached to lateral margins of coccyx and 5th sacral segment |
- Usually tendinous than muscular |
- Sometimes fused with sacrospinous ligament |
Iliococcygeus
- Attached to inner surface of ischial spine |
- Posterior fibres attached to the tip of the sacrum and coccyx |
Pubococcygeus
- Attached to the back of the body of the pubis |
- Medial fibres run lateral to the urethra and its sphincter (puboperinealis/pubourethralis)) |
- Forms part of the urethral sphincter - fibres decussate across the midline directly behind urethra |
- In males, fibres lie lateral and inferior to the prostrate (levator prostatae) In females the fibres form a sling around the posterior wall of the vagina ( pubovaginalis) |
NS: 2nd and 3rd sacral spinal segments from pundendal nerve |
Action: Lateral compressor of the canals - reinfoirces external anal sphincter, reduces anteroposterior dimension of the ano-urogenital hiatus |
Gluteus Maximus
Origin: posterior gluteal line of the ilium, aponeurosis of ES, dorsal suface of lower part of the sacrum and side of the coccyx, sacrotuberous ligament and gluteal aponeurosis |
Insertion: Superficial fibres = iliotibial tract of the fascia lata Deep fibres = gluteal tuberosity |
NS: Inferior gluteal nerve L5-S2 |
Actions: Extends flexed thigh, walking, climbing stairs, lateral rotation of the thigh Upper fibres abduct the thigh inactive during standing, swaying forwards at the ankle joints, bending forwards at the hip joints |
Glut Max TrPs
- Can develop with manipulable lesions in SI joint
- Increased Tx kyphosis and AHC can increase hip flexion
- Sitting on a wallet or uneven chair
- Glut med, hamstrings,minimus can develop satellite TrPs with glut max
- Hamstrings,lower paraspinal muscles distorts pelvic structure when tight - anatagonist iliopsoas and rect fem developing Trps - treating these eases pressure off glut max
Glut Medius
- Origin: Outer surface of the ilium between iliac crest and posterior gluteal line above and anterior gluteal lone below |
- Insertion: Lateral surface of GT |
- NS:* Superior gluteal nerve L4-S1 |
- Action: Abduct the thigh, anterior fibres rotate it medially, posterior fibres create lateral rot Maintains upright trunk posture when walking (foot on opposite side is raised from the ground - makes pelvis sag downwards on unsupported side) |
Glut Med Trps
- Presents similar to SIJ dysfunction
- Sitting for too long/leaning forward/lying on affected side can activate Trps
- Unequal leg length, walking on uneven ground can perpetuate TrPs
- Secondary Trps can develop in piriformis, posterior part of glut min and max when posterior fibres of glut max develop TrPs
- When anterior glut max fibres are involved, 2ndary Trps can delevop in the TFL and satellite TrPs from QL
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Glut Minimus
- Origin: Outer surface of ilium |
- Insertion: Anterolateral ridge on GT |
- NS: Superior Gluteal Nerve L4-S1 |
- Actions: Abduction of the thigh and anterior fibres rotate it medially, maintains upright posture of trunk when foot of the opposite side is raised from the ground |
Glut Minimus and Medius - Palpation
Glut Min TrPs
- Referred to as pseudosciatica - severe and persistant pain down leg
- TrPs in anterior fibres = mimics L5 Radiculopathy
- TrPs in posterior fibres = mimics S1 Radiculopathy
- Can cause SIJ Dysfunction
- Associated with TrPs in piriformis, gluteus medius, vatus lateralis, fibularis longus, quadratus lumborum and gluteus maximus
Piriformis
Origin: Anterior surface of sacrum, Gluteal surface of ilium, Sacrotuberous ligament |
Insertion: Medial side of upper border of GT |
NS: Branches from L5-S2 |
Action: Rotates extended thigh laterally, abducts flexed thigh |
Piriformis TrPs
Associated trigger points include the gluteus medius, gemelli, obturator internus, levator ani and coccygeus
- Causes Pain and paresthesia in LB, Grion, perineum, buttock,hip, posterior thigh, leg and foot, defaecation
- Aggravated by prolonged sitting, hip flexion, adduction, internal rotation
Short Lateral Rotators
Consists of: |
- Obturator Internus |
- Oburator Externus |
- Gemellus inferior and Gemellus superior |
- Quadratus Femoris |
TrPs usually presents as tenderness deep to glut max and inferior to piriformis (medial to upper third of GT - Gemelli or obturator internus) |
Tendersness deep to medial border of the GT = Quadratus femoris/obturator externus |
- Obutartor externus can present with groin pain, check pectineus and adductor brevis |
Oburator Internus
- Origin: Ischiopubic Ramus and obturator membrane
- Insertion: Medial aspect of GT
- NS: Nerve to obturator internus (L5-S2)
- Action: Abducts and lateral rotates extended hip, abducts the flexed thigh at the hip and stabilises hip during walking
Obturator externus
-Origin: Obturator foramen and Obturator membrane
- Insertion: Trochantic fossa of femur
- NS: Posterior branch of obturator nerve (3rd and 4th lx nerves)
- Actions: Adduct thigh, laterally rotates thigh
Gemellus inferior and gemellus superior
- Top: Inferior Gemellus
- Bottom: Superior Gemellus
Superior Gemellus
- Origin: Dorsal surface of ischial spine |
- Insertion: Medial surface of GT |
- NS: Nerve to Oburator internus L4-S1 |
- Action: rotates extended thigh laterally and abduct flexed thigh |
Inferior Gemellus
Origin: Upper part of lateral surface of the ischial tuberosity |
Insertion: Medial surface of GT |
NS: Nerve to Quadratus Femoris L4-S1 |
Action: Rotate extended thigh laterally and abduct the flexed thigh |
Quadratus Femoris
Origin: Upper part of external aspect of ischial tuberosity
Insertion: Middle of trochanteric crest of the femur
NS: Quadratus Femoris nerve L5 and S1
Action: Lateral rotation of the thigh
Quadratus Femoris - Palpation
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