What is the approach to physical therapy for a patient with an Iliopsoas (muscle in the lower back) hematoma?

Physical Therapy Approach for Iliopsoas Hematoma

Physical therapy for iliopsoas hematoma should begin only after adequate hematoma resolution is confirmed by imaging, typically within 3 months of the initial episode, with a gradual progression from gentle stretching to functional strengthening exercises.

Initial Assessment and Precautions

• Evaluate for common presenting symptoms:

  • Hip, thigh, and groin pain
  • Hip flexion contracture
  • Abdominal tenderness
  • Paraesthesia in femoral nerve distribution
  • Quadriceps weakness

• Confirm hematoma resolution via imaging (ultrasound or MRI) before initiating active therapy

• Assess femoral nerve function (sensation along anterior thigh, quadriceps strength)

• Document baseline pain levels using standardized scales

Physical Therapy Protocol

Phase 1: Acute Phase (During Hematoma Presence)

• Pain management and rest are primary goals
• Medical treatment takes precedence over physical therapy 1
• Avoid activities that increase intra-abdominal pressure
• Gentle passive range of motion only if tolerated and approved by physician

Phase 2: Early Rehabilitation (After Hematoma Resolution Begins)

• Begin approximately 6 days after initiation of medical treatment 1
• Focus on:
  • Gentle passive stretching of hip flexors
  • Isometric quadriceps exercises if femoral nerve function is intact
  • Ankle pumps and gentle knee range of motion exercises
  • Pain-free hip mobility exercises

Phase 3: Progressive Rehabilitation (After Confirmed Hematoma Resolution)

• Gradually increase intensity of exercises:
  • Active hip range of motion in all planes
  • Progressive resistance training for quadriceps
  • Core strengthening with focus on transversus abdominis
  • Balance and proprioception training
  • Gait training if mobility was affected

Phase 4: Advanced Rehabilitation

• Functional exercises mimicking daily activities
• Sport-specific training if applicable
• Continued strengthening of hip flexors and surrounding musculature
• Prevention strategies for recurrence

Special Considerations

• For patients with femoral neuropathy from hematoma compression:

  • Include nerve gliding exercises
  • Focus on quadriceps activation and strengthening
  • Monitor for improvement in sensation and motor function

• For patients with hemophilia or on anticoagulation:

  • Coordinate with hematology team before advancing exercise intensity
  • Avoid high-impact activities
  • Monitor for signs of recurrent bleeding

Duration and Monitoring

• Complete physical therapy program typically lasts approximately 20 days 1
• Monitor for complications such as heterotopic ossification (myositis ossificans) which may develop as a long-term complication 1
• Ultrasound findings related to iliopsoas hematoma typically disappear within 3 months from initial episode 1

Treatment Outcomes

Most patients with iliopsoas hematoma who undergo appropriate physical therapy can expect:

• Complete resolution of pain
• Return to normal quadriceps strength (grade 5/5)
• Resolution of numbness in femoral nerve distribution
• Return to previous functional status

Early and effective physical therapy is essential in preventing long-term complications such as muscle weakness, contractures, and functional limitations following iliopsoas hematoma 1.