Hip Flexor Tightness: Why Digging on Your Psoas With a Lacrosse Ball or Hook Tool Isn’t the Answer

Hip flexor tightness is a common symptom I treat in my physical therapy practice. Many patients tell me they stretch their hip flexors frequently, which helps temporarily, but the tightness always seems to come back. In recent years, I’ve also had many patients ask about doing self-release work using a lacrosse ball or a tool called a “Hip Hook,” which is designed specifically to “release” the hip flexor muscles.

There are several reasons why I don’t recommend using these types of tools on your hip flexors - or anywhere else in your abdomen or pelvis. In this blog post, I’m going to explain why I don’t recommend these tools and how I approach treating hip flexor tightness instead.

First, Let’s Talk About Anatomy

There are several muscles involved in flexing your hip, including the iliacus, psoas, rectus femoris, pectineus, sartorius, and tensor fascia lata. Each of these muscles also performs other actions, and they are more or less involved in hip flexion depending on the movement being performed. In this blog post, I’m going to focus on the iliacus and psoas muscles, as they are the primary movers for hip flexion and are typically the muscles being targeted with tools and manual therapy.

The psoas and iliacus are two separate muscles; however, they come together to insert on the femur and are therefore often referred to as the iliopsoas. The psoas muscle originates from T12–L5 (the lower thoracic and lumbar vertebrae) and inserts on the femur (thigh bone) at the lesser trochanter. The iliacus originates on the iliac crest, forming a fan-shaped muscle along the inside of the ilium, and inserts at the lesser trochanter along with the psoas muscle.

There are also many fascial and ligamentous attachments connecting these muscles to structures in the low back, abdomen, and pelvis. For the sake of this blog post, I’m going to rein in the anatomy “nerding out,” but if you’d like to dive deeper, here are a few resources to check out:

·       Deeper anatomy dive on the psoas muscle:
https://www.ncbi.nlm.nih.gov/books/NBK535418/

·       Deeper anatomy dive on the iliopsoas muscle:
https://www.ncbi.nlm.nih.gov/books/NBK531508/

These attachment points highlight a few important considerations regarding how these muscles function. The psoas plays an important role in posture due to its attachments to the spine and can also affect breathing because of its relationship with the diaphragm.

Often, when we see images online of the psoas, iliacus, or iliopsoas, we see only the muscles themselves. However, if you open an anatomy textbook, you’ll see many incredibly delicate and important structures that lie close to—or directly in front of—the psoas. These include the kidneys and ureters, the ascending and descending colon, the lumbar nerve plexus, and much more.

Now Let’s Talk About Why Your Hip Flexors Feel Tight

Hip flexor muscles can hold tension for many different reasons. Posture and prolonged sitting are often blamed for hip flexor tightness, and they can certainly be contributors. However, based on the anatomy discussed above, it’s also important to consider breathing patterns, pressure management within the thorax, abdomen, and pelvic floor, and overall muscular imbalances.

It’s important to note that a “tight” muscle is not the same as a “strong” muscle. Hip flexors may feel tight because they are actually weak and creating tension or gripping in an attempt to find stability. They may also be guarded and compensating due to pain or a lack of mobility elsewhere in the body.

The psoas can also become tense due to shallow breathing or guarding related to emotional stress or trauma. During traumatic events, the body can enter a protective pattern and sometimes continues to hold onto that pattern even after the event has passed. In these cases, restoring breathing mechanics and incorporating other supportive therapies can be beneficial for long-term relief.

How to Actually Resolve Hip Flexor Tightness (and Why I Don’t Recommend Hard Tools)

Like most things, hip flexor tightness often has more than one underlying cause. This is why a comprehensive assessment is so important. Looking at your history, posture, strength, mobility, spine, pelvis, and possible restrictions in deeper structures helps determine the most effective treatment approach.

When I evaluate a patient, I use a combination of orthopedic and pelvic floor therapy assessments, including strength, flexibility, movement patterns, and special tests. We also discuss past medical history, when symptoms started, what makes symptoms better or worse, and any other treatments you have tried.

I also perform an osteopathic listening assessment, which can help determine whether the issue is primarily muscular, joint-related, or stemming from a deeper structure such as an abdominal or pelvic organ. One of my favorite examples of this is a patient I treated who had been receiving hip flexor release work for years. While it provided temporary relief of her left hip flexor tightness, the symptoms always returned. During my assessment, I was drawn to her left kidney. After treating it once, her hip flexor tightness fully resolved.

The problem with hard tools like the Hip Hook or a lacrosse ball is that they apply very direct, deep pressure to the delicate structures that lie on top of the iliopsoas. There is no way to reach the muscle without compressing these structures.

Instead, I recommend softer tools such as Yoga Tune Up Balls or, my personal favorite, the Coregeous ball. These allow for gentler pressure that can mobilize the structures overlying the muscle as well as have an effect on the muscle itself.

In addition to manual techniques, nerve glides may be helpful if neural tension is contributing to symptoms. Femoral or obturator nerve glides may be appropriate in some cases. Depending on the assessment findings, treatment may also include breath work, nervous system regulation, core stabilization, posture education, and hip strengthening.

A pelvic floor assessment may also be beneficial if you experience symptoms such as urinary leakage, pain with pelvic exams or intimacy, constipation, or other pelvic health concerns.

My best recommendation is to seek an individualized assessment so you can understand what treatment approach will work best for you. In the meantime—skip the hard tools.

If you’re interested in setting up a virtual appointment or an appointment at one of my offices in the Memphis area, you can schedule here.

Blog post written by Alexis Hutchison, PT, DPT, OCS