How to fix that pesky quad pull
AND the 15 second test to see if your hip flexors are working properly.
I was just reading a blog post by Boston fitness guru Mike Boyle. He has been reading about the work of physical therapist Shirley Sahrmann. This caught my eye: “The wisdom that Sahrmann shares in her book “Diagnosis and Treatment of Movement Impairment Syndromes” explains many of the injury riddles of the strength and conditioning field, particularly the “hip flexor” or “quad” pull.”
He goes on to say that he, like many others, never differentiated between the five different hip flexors that the body can use to lift the leg off the ground. Three of them (quad, sartorius, and TFL) attach to the front edge of the hip or iliac crest. The other two hang onto the spine (aka psoas) and inside of the hip bone (aka iliacus).
The psoas and the iliacus are pictured below. Since they have the same function, they are often grouped as one muscle called the iliopsoas. To get to these muscles, we would have to scoop out all of your intestines. We won’t do that today. 🙂
Further, “In the case of a weak or under-active psoas or iliacus the femur may move above the level of the hip but it is not from the action of the psoas and iliacus but rather from the momentum created by the other three hip flexors. With this knowledge in hand, I believe that our knowledge of back pain, “hip flexor strains”, and ‘quad pulls” is drastically expanded.”
Simple English: IF your psoas and iliacus aren’t working, you’ll compensate with other muscles in the back and quad, leading to “quad pull syndrome” or “back pain” among other things.
Great. I am actually fairly familiar with this, but what can you do about it?
A simple test
Well, you should figure out if your REAL-in-the-hip (psoas and iliacus) hip flexors are working. Try a simple test!
Boyle says, “Sahrmann’s test is simple. In single leg stance, pull one knee to the chest and release. Inability to keep the knee above ninety degrees for 10-15 seconds indicates a weak psoas or a weak iliacus.
Other signs of weakness:
- a cramp at the iliac crest in the region of the TFL (front of outside of leg)
- an immediate backward lean to compensate
- a large pelvic shift to the right or left
- a quick drop from the top with a “catch” at the ninety degree point “
However, Mr. Boyle likes his version of the test even better:
“If …the subject is a skilled compensator, we have developed a better test that also has become our favorite psoas/iliacus exercise. The test was actually developed by strength and conditioning coach Karen Wood. Have the client or athlete stand with one foot on a plyo box ( 24″ works well for most) that places the knee above the hip. With the hands overhead or behind the head, attempt to lift the foot off the box and hold for 5 sec. Inability to lift and hold is indicative of a weak psoas and or iliacus.”
Here is the funny thing. I was not super awake when I read this blog for the first time, and I didn’t follow the very simple instructions very well at all when I decided to experiment with my client Elizabeth. She had back surgery about 18 months ago and her left hip is difficult at best to get working.
We started warming up with a simple squat which gave her…. BACK PAIN! Remember… see above… the “back pain” reference? A compensation jumped out at me and it was time to demonstrate to her that her hip flexors needed to be on board!
So, drawing from a foggy memory, I had her do the following:
Rest her foot on a platform, shift her weight to the glute on the straight leg, and simply try and pick her foot up off of the platform. Her hands are at her sides.
Here she is with the weight on the right glute, trying like mad to pick up the left foot. She has her lips pursed in her very concerted effort.
Any luck picking that left leg up, Elizabeth?
Nope. It didn’t budge.
She looked at me in astonishment.
“How then have I ever managed to walk up stairs?”
My answer: “Your quads!”
(Which, if you then ever pull your quad, but keep inadvertently using it to pick your leg up off the ground all day every day, you start to develop a “syndrome”– “quad pull syndrome”. That quad just never seems to heal, and re-injures so easily…)
Now we shifted sides, and I had her try the same thing with the right knee in the air. She manages a small smile this time as she clears a good couple inches with her right foot.
So now we know one iliopsoas is not working (left side) and one is working faintly (right side). What could we do to develop these muscles?
That’s how they develop in the first place- when you were a baby!
Here is Elizabeth crawling forward and backward, using the “Perfect Pushup” handles.
Here is Elizabeth crawling sideways.
Go, Elizabeth, Go!
Now, as a final test, I really did follow some of the test protocol and got her knee higher than the hip by resting it on the medicine ball.
“Now lift it!” I told her. She could barely move it, but this time it was patently obvious she was using her iliopsoas. She could feel it distinctly.
Therefore, by first identifying her lack of true-blue-muscles-in-the-hip-flexors, and then isolating and strengthening them, her squat was no longer painful. She was no longer compensating with her back for what her hip wouldn’t or couldn’t do.