Fisioterapista che valuta la postura della colonna vertebrale di un paziente in studio

Low Back Pain: Causes, Diagnosis and Treatment Guide

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This content is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider.
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In brief:

  • The iliopsoas muscle is a fundamental and often underestimated cause of chronic low back pain, connecting trunk and legs.
  • A sedentary lifestyle shortens the iliopsoas, causing hyperlordosis and disc compression, significantly contributing to back pain.
  • A shortened or contracted iliopsoas can alter posture, increase lumbar curve and overload vertebral discs.
  • Iliopsoas spasms can result from sudden efforts, trauma or chronic emotional stress, directly affecting your well-being.

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Table of Contents

Low back pain (lumbar back pain) is one of the most widespread medical conditions in the world: it affects about 80% of the population at least once in their lifetime and represents the leading cause of disability globally. Among the numerous causes of low back pain, the iliopsoas muscle plays a fundamental and often underestimated role.

Clinical experience demonstrates how the iliopsoas is involved in most cases of chronic and recurrent low back pain. This deep muscle, the most powerful hip flexor, directly connects the lumbar spine to the femur and represents a true biomechanical “bridge” between trunk and lower limbs. Its dysfunction — shortening, contracture or weakness — is one of the most frequent and treatable causes of back pain.

Anatomy of the Iliopsoas

The iliopsoas is a deep abdominal muscle group connecting the spine and pelvis to the thighbone, crucial for hip flexion and spinal stability. The iliopsoas is actually composed of two muscles that merge into a single tendon:

  • Psoas major muscle: originates from the vertebral bodies and intervertebral discs from T12 to L5 and from the transverse processes of the lumbar vertebrae
  • Iliacus muscle: originates from the internal iliac fossa of the pelvis

The two muscles unite and the common tendon inserts on the lesser trochanter of the femur.

Functions of the Iliopsoas

  • Hip flexion: bringing the thigh toward the trunk (e.g. climbing stairs, walking)
  • Lumbar spine stabilization: maintains physiological lordosis during upright stance and gait
  • Postural control: fundamental role in balance of the pelvis and posture

How the Iliopsoas Causes Low Back Pain

Iliopsoas Shortening

Iliopsoas shortening is the most frequent condition and is closely linked to sedentary lifestyle. Sitting for many hours a day keeps the iliopsoas in a shortened position, leading over time to true muscular retraction.

A shortened iliopsoas causes:

  • Increased lumbar lordosis (hyperlordosis): the muscle pulls the lumbar vertebrae forward
  • Pelvic anteversion: the pelvis rotates forward, accentuating the lumbar curve
  • Intervertebral disc compression: increased lordosis overloads the posterior part of the discs and facet joints
  • Reflex contracture of paravertebral muscles: to compensate for the anterior pull of the iliopsoas

This biomechanical pattern underlies many chronic low back pain and lumbosciatica cases in sedentary workers.

Iliopsoas Spasm

Spasm (acute contracture) of the iliopsoas can occur following:

  • Sudden effort in hip flexion
  • Direct trauma to the lumbar region
  • Protective response to a disc herniation or vertebral pathology
  • Chronic emotional stress (the iliopsoas is known as the “stress muscle”)

The Iliopsoas in the Kinetic Chain

The iliopsoas occupies a strategic position in the body’s kinetic chain. Its dysfunction affects all directions:

  • Upward: altered lumbar lordosis, thoracic and cervical compensations
  • Downward: altered hip mechanics, knee overload
  • Laterally: pelvic imbalance with possible contralateral trochanteric bursitis

Symptoms of Iliopsoas Low Back Pain

  • Deep lumbar pain: often bilateral, belt-like, worsening when standing for long periods
  • Morning stiffness: difficulty getting out of bed and straightening in the first hours of the morning
  • Pain when rising from chair: the shortened iliopsoas is stretched abruptly
  • Groin pain: the iliopsoas tendon crosses the groin region and can cause anterior hip pain
  • Inability to lie prone: the prone position stretches the iliopsoas and can be painful
  • Pain when walking uphill or climbing stairs: the iliopsoas works intensively in hip flexion

Diagnostic Test: The Thomas Test

The Thomas test is the most used clinical test to evaluate iliopsoas shortening:

  • The patient lies supine on the edge of the table
  • Flexes one hip to chest with both hands
  • If the opposite thigh lifts from the table, the iliopsoas on that side is shortened
  • The lifting angle indicates the degree of shortening

Physiotherapy Treatment

Manual Therapy

  • Iliopsoas myofascial release: specific deep pressure techniques on the iliopsoas through the abdomen. Requires experience and delicacy
  • Lumbar vertebral mobilizations: to restore mobility of hypomobile segments
  • Muscle energy techniques (MET): isometric contractions of the iliopsoas followed by passive stretching
  • Release of synergistic muscles: quadratus lumborum, piriformis, rectus femoris, adductors

Instrumental Therapies

  • High-power laser
  • Deep tecar therapy
  • Ultrasound
  • TENS for pain control

Exercises for Iliopsoas Low Back Pain

Phase 1 — Release and Stretching Exercises (Weeks 1-4)

Exercise: Kneeling Iliopsoas Stretch
Kneeling Iliopsoas Stretch

Exercise 1: Kneeling Iliopsoas Stretch

Difficulty: Easy | Equipment: Mat, cushion | Duration: 5 minutes

Person in lunge position with right posterior knee resting on a cushion on the ground, left foot forward with knee at 90 degrees. Torso is upright, glutes contracted and pelvis in posterior tilt (pubis upward). Arrow indicating direction of pelvic advancement without lumbar arching - low back pain

Starting position:
Lunge position with posterior knee resting on ground on a cushion. The front foot is well planted on the ground with knee bent at about 90 degrees. The torso is upright and hands can rest on the front knee.

Step-by-step execution:

  1. Step 1: Contract glutes and bring pelvis into posterior tilt (rotate pubis upward), flattening the lumbar area
  2. Step 2: Maintaining the posterior tilt, slowly advance body weight forward until feeling a stretch in the front of the hip and thigh of the side with knee on ground
  3. Step 3: Hold position for 30 seconds breathing deeply, then return to initial position and repeat on other side

Sets and repetitions: 3-5 repetitions of 30 seconds per side — Perform 2-3 times daily, especially after sitting periods

Common errors to avoid:

  • Arching back during lunge (most frequent error, completely nullifies stretching effect)
  • Losing pelvic posterior tilt when advancing too much
  • Leaning torso forward instead of keeping it upright

How to know you’re doing it correctly:
You feel a stretch in the front of the hip and thigh of the side with knee on ground. The lumbar area remains flat and stable. No back pain is felt. This is the most important exercise for treating iliopsoas low back pain.

Exercise 2: Iliopsoas Stretch on Bed Edge

Difficulty: Easy | Equipment: Bed or table | Duration: 4 minutes

Person lying supine on edge of bed, left leg flexed to chest and held with hands. Right leg hangs outside bed edge downward, stretched by gravity. Side view showing bed edge at hip level and hanging leg relaxed

Starting position:
Lie supine on edge of bed with both legs resting on mattress. Bring one leg toward chest and grasp with both hands. Let other leg slide off bed edge.

Step-by-step execution:

  1. Step 1: Flex one leg to chest and hold firmly with both hands
  2. Step 2: Let other leg slide off bed edge, allowing gravity to stretch the iliopsoas on that side
  3. Step 3: Completely relax the hanging leg, letting weight pull it downward. Hold for 30-60 seconds, then change sides

Sets and repetitions: 2-3 repetitions of 30-60 seconds per side — 15-second pause between repetitions

Common errors to avoid:

  • Not bringing opposite leg sufficiently to chest (opposite hip flexion stabilizes pelvis)
  • Contracting hanging leg instead of completely relaxing it
  • Positioning too far from bed edge, limiting leg range

How to know you’re doing it correctly:
You feel a gradual and progressive stretch in the front of the hip of the hanging leg. The sensation is one of passive release, without effort. If the iliopsoas is shortened, the thigh of the hanging leg doesn’t reach the horizontal plane of the bed.

Exercise 3: Pelvic Tilt

Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Person supine with bent knees and feet on ground. First image: visible space between lumbar area and floor. Second image: lumbar area completely flattened against floor. Arrow indicating posterior pelvic rotation movement

Starting position:
Lie supine with knees bent and feet on ground at hip width. Arms are extended along sides. Notice natural space between lumbar area and floor.

Step-by-step execution:

  1. Step 1: Gently contract abdominals and glutes simultaneously
  2. Step 2: Flatten lumbar area against floor, rotating pelvis backward (pubis lifts toward ceiling)
  3. Step 3: Hold position for 10 seconds breathing normally, then release slowly

Sets and repetitions: 15-20 repetitions of 10 seconds hold — 5-second pause between repetitions

Common errors to avoid:

  • Lifting pelvis off ground (this is not a bridge)
  • Pushing with feet to force movement
  • Holding breath during hold

How to know you’re doing it correctly:
The space between lumbar area and floor completely disappears. You feel simultaneous contraction of lower abdominals and glutes. This exercise “deactivates” the shortened iliopsoas and activates its antagonists: after several repetitions, you feel reduced lumbar tension.

Exercise 4: Knees to Chest

Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Person supine hugging both knees bringing them toward chest, lumbar area rounded and relaxed. Variation: gentle lateral rocking to massage lumbar area

Starting position:
Lie supine on mat with legs extended and arms along sides.

Step-by-step execution:

  1. Step 1: Slowly bend both knees and bring them toward chest
  2. Step 2: Hug knees with both hands, gently pulling them toward torso
  3. Step 3: Rock gently left and right to massage lumbar area. Hold for 30-60 seconds, then slowly release legs

Sets and repetitions: 5 repetitions of 30-60 seconds — 10-second pause between repetitions

Common errors to avoid:

  • Pulling knees with too much force, causing pain
  • Lifting head off ground creating cervical tension
  • Performing movement with jerky motions

How to know you’re doing it correctly:
You feel pleasant stretching of contracted lumbar extensor muscles and decompression of lumbar area. Lateral rocking provides gentle massage of paravertebral musculature. Lumbar tension gradually decreases.

Exercise 5: Child’s Pose

Difficulty: Easy | Equipment: Mat | Duration: 3 minutes

Person kneeling seated on heels with torso bent forward, arms extended forward on floor, forehead resting on ground. Lumbar area is stretched and completely relaxed

Starting position:
Kneeling on mat, seated on heels. Arms are along sides.

Step-by-step execution:

  1. Step 1: Slowly bend torso forward, extending arms in front on floor
  2. Step 2: Rest forehead on ground (or on cushion if you can’t reach) and completely relax entire lumbar area
  3. Step 3: Breathe deeply with diaphragm for 30-60 seconds, letting body relax further with each exhale

Sets and repetitions: 3-5 repetitions of 30-60 seconds — 15-second pause in upright position between repetitions

Common errors to avoid:

  • Lifting glutes off heels during stretch
  • Holding breath or breathing superficially
  • Forcing position if knee pain is felt (in this case, place cushion between glutes and heels)

How to know you’re doing it correctly:
You feel deep relaxation and comfortable stretching along entire lumbar spine. Breathing becomes slow and deep. Lumbar tension progressively melts away.

Phase 2 — Antagonist Strengthening (Weeks 4-8)

The goal is to strengthen muscles that oppose the shortened iliopsoas: glutes, abdominals and hamstrings.

Exercise 6: Bridge (Glute Bridge)

Difficulty: Easy | Equipment: Mat | Duration: 6 minutes

Person supine with bent knees and feet on ground lifting pelvis, contracting glutes and abdominals. Body forms straight line from knees to shoulders. Arms extended along sides with palms on ground

Starting position:
Lie supine with knees bent and feet on ground at hip width. Arms extended along sides with palms facing down.

Step-by-step execution:

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  1. Step 1: Contract glutes and abdominals, pressing feet into ground
  2. Step 2: Lift pelvis off ground until aligning knees-pelvis-shoulders, focusing on glute contraction (not lumbar muscles)
  3. Step 3: Hold position for 5 seconds at top, then lower slowly one vertebra at a time

Sets and repetitions: 3 sets x 12-15 repetitions with 5-second hold — 30-second pause between sets

Common errors to avoid:

  • Hyperextending lumbar area in top phase (don’t lift pelvis beyond knee-shoulder line)
  • Using lumbar muscles instead of glutes to lift pelvis
  • Placing weight on neck and shoulders

How to know you’re doing it correctly:
You feel intense work in glutes, which are the primary movement drivers. Lumbar area is relaxed. Glute bridge strengthens direct antagonists of iliopsoas, reestablishing pelvic muscle balance.

Exercise 7: Dead Bug

Difficulty: Intermediate | Equipment: Mat | Duration: 7 minutes

Person supine with arms extended toward ceiling and knees bent at 90 degrees. Second image: right arm extended overhead and left leg extended forward, back flat on ground

Starting position:
Lie supine with arms extended toward ceiling and knees bent at 90 degrees with hips flexed at 90 degrees. Lumbar area must be adherent to floor.

Step-by-step execution:

  1. Step 1: Activate abdominals flattening lumbar area against floor
  2. Step 2: Exhaling, slowly extend right arm overhead and left leg forward, bringing them toward floor without touching
  3. Step 3: Inhaling, return to starting position and repeat with opposite side, always keeping back flat on ground

Sets and repetitions: 3 sets x 10 repetitions per side — 45-second pause between sets

Common errors to avoid:

  • Arching lumbar area when extending arm and leg (reduce range if necessary)
  • Performing movement too quickly losing control
  • Forgetting to coordinate breathing with movement

How to know you’re doing it correctly:
Lumbar area stays glued to floor throughout movement. You feel deep abdominal work without back tension. This exercise teaches lumbar stabilization while limbs move — exactly what’s needed in daily life.

Exercise 8: Front Plank

Difficulty: Intermediate | Equipment: Mat | Duration: 5 minutes

Person in plank position on forearms and toes, body perfectly aligned from head to heels. Dashed line showing correct alignment. Side view

Starting position:
Prone position, supported on forearms (elbows under shoulders) and toes. Body should form straight line from head to heels.

Step-by-step execution:

  1. Step 1: Position forearms on ground with elbows under shoulders
  2. Step 2: Lift body supported on toes, activating abdominals and glutes. Bring pelvis into slight posterior tilt to protect lumbar area
  3. Step 3: Hold position for 20-40 seconds (increase progressively), breathing normally

Sets and repetitions: 3 sets with 20-40 second hold — 30-second pause between sets

Common errors to avoid:

  • Letting pelvis drop downward, creating hyperlordosis (dangerous for lumbar area)
  • Lifting pelvis excessively in “tent” shape
  • Holding breath

How to know you’re doing it correctly:
Body forms straight line from head to heels without lumbar sag. You feel uniform work of abdominals, glutes and shoulders. Front plank is fundamental for core stabilization and lumbar spine protection.

Exercise 9: Clamshell with Elastic

Difficulty: Easy | Equipment: Mat, resistance band | Duration: 6 minutes

Person lying on left side with bent knees, elastic positioned just above knees. Upper knee (right) opens upward like a clamshell opening, keeping feet together. Front view showing knee opening and lateral glute contraction

Starting position:
Lying on side with knees bent at about 45 degrees and hips flexed at about 60 degrees. Resistance band positioned just above knees. Feet are overlapped and together. Head rests on lower arm.

Step-by-step execution:

  1. Step 1: Stabilize pelvis by lightly contracting abdominals (pelvis should not rotate during movement)
  2. Step 2: Keeping feet together, open upper knee upward like a clamshell opening, externally rotating hip
  3. Step 3: Hold open position for 2 seconds, then slowly return to starting position

Sets and repetitions: 3 sets x 15 repetitions per side — 30-second pause between sets

Common errors to avoid:

  • Rotating pelvis backward during knee opening (pelvis must stay still and vertical)
  • Lifting upper foot with knee (feet stay together)
  • Using elastic with excessive resistance, compensating with trunk

How to know you’re doing it correctly:
You feel specific work in lateral glute area (gluteus medius). Pelvis stays perfectly stable. This exercise strengthens gluteus medius, fundamental muscle for pelvic stabilization and often weak in patients with iliopsoas low back pain.

Phase 3 — Stabilization and Function (Weeks 8+)

Exercise 10: Controlled Squat

Difficulty: Intermediate | Equipment: None | Duration: 6 minutes

Person standing with feet shoulder-width apart performing controlled squat. Side view showing upright back, knees not exceeding toes, and pelvis descending until thighs parallel to floor

Starting position:
Standing with feet shoulder-width apart, toes slightly rotated outward. Arms extended forward for balance or crossed on chest.

Step-by-step execution:

  1. Step 1: Activate abdominals to stabilize spine and maintain upright back
  2. Step 2: Bend knees and hips as if sitting in chair, bringing thighs parallel to floor (or as far as possible without pain)
  3. Step 3: Push with heels to return to upright position, contracting glutes in rising phase

Sets and repetitions: 3 sets x 12-15 repetitions — 45-second pause between sets

Common errors to avoid:

  • Rounding back during descent
  • Lifting heels off ground
  • Bringing knees excessively beyond toes

How to know you’re doing it correctly:
You feel work in glutes and quadriceps. Back stays upright throughout movement. Knees follow direction of toes. Squat strengthens entire posterior chain, effectively counteracting iliopsoas shortening.

Exercise 11: Lunge with Iliopsoas Stretch

Difficulty: Intermediate | Equipment: None | Duration: 6 minutes

Person performing forward lunge with right foot forward and left foot back. Pelvis in active posterior tilt. Side view showing upright back and pelvic posterior tilt, with arrow indicating iliopsoas stretch of posterior leg

Starting position:
Standing with feet together, arms along sides or hands on hips.

Step-by-step execution:

  1. Step 1: Take long step forward with one foot, bending front knee to about 90 degrees
  2. Step 2: Actively bring pelvis into posterior tilt (contract glutes, rotate pubis upward) to stretch iliopsoas of rear leg
  3. Step 3: Hold for 2 seconds, then push with front foot to return to starting position. Alternate legs

Sets and repetitions: 3 sets x 10 repetitions per side — 30-second pause between sets

Common errors to avoid:

  • Losing pelvic posterior tilt during lunge (arching back)
  • Bringing front knee beyond toe
  • Losing balance by leaning torso forward

How to know you’re doing it correctly:
You simultaneously feel strengthening work (glutes and quadriceps) and iliopsoas stretch of rear leg. Lumbar area stays flat and protected. This exercise effectively combines strengthening and stretching in single functional movement.

Exercise 12: Romanian Deadlift

Difficulty: Intermediate | Equipment: Light dumbbells (2-4 kg) | Duration: 5 minutes

Person standing with light dumbbells bending forward from hip, keeping back straight and knees slightly bent. Dumbbells descend along thighs. Side view showing hip hinge and neutral back position

Starting position:
Standing with feet hip-width apart, knees slightly bent. Dumbbells held in front of thighs with arms extended.

Step-by-step execution:

  1. Step 1: Activate abdominals to stabilize spine in neutral position
  2. Step 2: Bending from hip (not back), lower dumbbells along thighs to mid-shin, pushing glutes backward. Back stays straight throughout movement
  3. Step 3: Contract glutes and hamstrings to return to upright position

Sets and repetitions: 3 sets x 10 repetitions — 45-second pause between sets

Common errors to avoid:

  • Rounding back during descent (back must stay neutral)
  • Completely locking knees (should stay slightly bent)
  • Using excessive weight in first weeks

How to know you’re doing it correctly:
You feel stretch in back of thighs (hamstrings) during descent and intense glute work during ascent. Back stays neutral throughout movement. Romanian deadlift strengthens entire posterior chain, fundamental for counteracting shortened iliopsoas effect.

Exercise 13: Walking and Swimming

Difficulty: Easy | Equipment: Walking shoes / swimsuit | Duration: 30-45 minutes

Person walking briskly in park with upright posture, arms swinging naturally. Second image: person swimming freestyle in pool

Starting position:
For walking: upright posture, relaxed shoulders, forward gaze. For swimming: position in water according to chosen style.

Step-by-step execution:

  1. Step 1: For walking: walk at sustained pace maintaining upright posture, letting arms swing naturally. Ideal cadence is about 100-120 steps per minute
  2. Step 2: For swimming: prefer freestyle and backstroke, which favor anterior chain stretching and posterior chain strengthening
  3. Step 3: Maintain activity for 30-45 minutes, gradually increasing duration over weeks

Sets and repetitions: 30-45 minutes aerobic activity — 3-5 times per week

Common errors to avoid:

  • Walking with curved shoulders and gaze on phone
  • Starting with sessions too long or too intense
  • For swimming: avoid breaststroke if it causes lumbar pain

How to know you’re doing it correctly:
After aerobic activity you feel reduced lumbar stiffness and general well-being. Walking and swimming improve circulation, reduce muscle contracture and promote endorphin release with natural analgesic effect.

Recovery Times

Type of low back pain Improvement Resolution
Acute iliopsoas 1-2 weeks 4-6 weeks
Chronic postural 4-6 weeks 2-3 months
With associated herniation/protrusion 6-12 weeks 3-6 months
Chronic recurrent 4-8 weeks 3-4 months (with maintenance)

In clinical practice, improvement begins from the first week when the patient consistently performs iliopsoas stretching.

Prevention

  • Get up from chair every 30-45 minutes: take brief active break
  • Daily iliopsoas stretching: 2-3 times daily if

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    Disclaimer medico: Le informazioni contenute in questo articolo hanno finalità esclusivamente educativa e informativa. Non sostituiscono il parere del medico o del fisioterapista. Per diagnosi e trattamento rivolgersi al proprio medico o fisioterapista di fiducia.

    For a broader overview of related conditions, see our our comprehensive back and spine guide.

    Sources and Scientific References

    1. Lara-Palomo IC et al. (2022). Electrical dry needling versus conventional physiotherapy in the treatment of active and latent myofascial trigger points in patients with nonspecific chronic low back pain. Trials. 23:238. DOI | PubMed
    2. Peretro G et al. (2024). Comparison of aquatic physiotherapy and therapeutic exercise in patients with chronic low back pain. J Bodyw Mov Ther. 38:399-405. DOI | PubMed
    3. García-Moreno JM et al. (2022). Effectiveness of physiotherapy interventions for back care and the prevention of non-specific low back pain in children and adolescents: a systematic review and meta-analysis. BMC Musculoskelet Disord. 23:314. DOI | PubMed
    4. Peacock M et al. (2023). Neural mobilization in low back and radicular pain: a systematic review. J Man Manip Ther. 31:4-12. DOI | PubMed
    5. Mescouto K et al. (2022). A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disabil Rehabil. 44:3270-3284. DOI | PubMed

    Frequently Asked Questions

    How important is the iliopsoas muscle in causing low back pain?

    The iliopsoas muscle is a fundamental and often underestimated cause of chronic low back pain, acting as a biomechanical “bridge” between the trunk and lower limbs. Its dysfunction, such as shortening or contracture, is a frequent and treatable cause of back pain, involved in most chronic and recurrent cases.

    How does a sedentary lifestyle affect my iliopsoas and contribute to back pain?

    Sitting for many hours a day keeps the iliopsoas in a shortened position, leading to muscular retraction over time. This shortening causes increased lumbar lordosis, pelvic anteversion, and intervertebral disc compression, significantly contributing to chronic low back pain.

    What are the common signs or symptoms of iliopsoas-related low back pain?

    A shortened or contracted iliopsoas can lead to an increased lumbar curve (hyperlordosis) and pelvic anteversion. This biomechanical change overloads vertebral discs and facet joints, often resulting in chronic low back pain and sometimes reflex contracture of surrounding muscles.

    Can emotional stress cause problems with my iliopsoas muscle?

    Yes, chronic emotional stress can directly contribute to iliopsoas spasms, which can manifest as low back pain. These spasms can also occur due to sudden efforts in hip flexion or direct trauma to the lumbar region.

    What kind of treatment does a physical therapist provide for iliopsoas-related low back pain?

    Physiotherapy treatment for iliopsoas-related low back pain typically involves manual therapy, instrumental therapies, and a structured exercise program. This program progresses through phases of release and stretching, antagonist strengthening, and stabilization to restore function and reduce pain.