Psoas Obsession

Disclaimer.  This blog is not disputing your clinical outcomes!

I need to emphasize that your specific clinical outcomes are not being disputed here.  What I want to focus on is the reasoning.  When treating the psoas, positive clinical outcomes are likely for very different reasons than “releasing” the psoas.

Why spend time blogging about the psoas?  

My initial purpose for blogging was to get my thoughts, ideas and opinions heard so I could hope to influence the standard of education and practice behaviours of massage therapists.  I want my profession to be better.  I know we can be better. I want us to become evidence informed.  I want us to throw away outdated and unhelpful ideas.  We have an excellent opportunity to be leaders in the assessment, treatment and management for people experiencing musculoskeletal (MSK) pain.  We need to start questioning the ideas and beliefs the profession holds closely.  My objectives in this blog, amongst many others, are for clinicians to realize that many of the things we are taught in MT college, which are then often perpetuated in cont ed courses, are unsupported by current evidence, oftentimes unnecessarily complex, potentially unhelpful and at times they can be harmful.  Having thoughts and beliefs challenged will make you uncomfortable.  That is okay and that is normal.  I’ve been there, I have gone through the cognitive dissonance.  It is uncomfortable, but being open-minded to change is the best way to grow personally and professionally.  Although people will not always agree with what is being discussed, it is important for the profession to question and challenge prior assumptions as this is necessary for us to  evolve.

The one muscle that seems to consistently create great debate and excitement amongst the MSK professions is the psoas.  There are numerous articles written in blogs (which I am not going to link here as I don’t think they deserve anymore attention) describing how wonderful and important this single muscle is and how it can be responsible for so many problems.  Everything from low back pain, pelvic floor dysfunction or its ability to influence the diaphragm and effect breathing.

It seems that not much has changed in the 15+ years since I finished massage therapy school.  Clinicians love the psoas and assign a lot of unnecessary importance to it?! I remember spending an inordinate amount of time learning about it.  We were told we could palpate its attachments, learned the specific actions it had at the hip and lumbar spine.  We spent many hours learning how to be specific with our treatments and it was emphasised that the psoas should be treated in cases of low back pain.  Like pretty much everything else I learned in massage school, my class was told to believe what we were told as this was supposedly effective MSK care, and more importantly, we needed to know this stuff in order to pass our board exams.  Even though much of what I learned often didn’t seem to make much sense, I studied relentlessly to learn everything as I was under the impression that the curriculum was evidence informed and this information was important to know in order to be a valued MSK healthcare provider

Recently there has been a surge of chatter on social media with some interesting debates about the psoas.  I have been part of discussions where the importance is placed on its precise attachments, its lever system, and its mechanism of action is debated.  Is the psoas a spinal flexor, hip flexor or spinal stabilizer?  How does it exert its impact on the lesser trochanter and therefore influence hip movement and mobility.  When I see this conversations all I can think to myself is, who cares!  This overcomplicating of anatomy, physiology, biomechanics and its role in someones unique subjective experience of pain is not helpful.  Ask a patient who is suffering from low back or hip pain if they care WTF their psoas muscle does?  Guaranteed they won’t care unless a healthcare provider or wellness website has planted some nocebic story in their mind making them think this incredibly detailed understanding of the psoas and its role in the biomechanics of MSK care is important.  Patients want to get better.  They don’t need unsupported stories.  It is about changing the narrative, the expectations, the beliefs and understandings that needs to be embraced.  Treat the anterior hip and abdomen, perform some of the techniques that work for you and your patient (gently in the abdomen please) but I can’t stress enough, don’t spend time thinking that the psoas is the lone culprit.

I have not seen any quality evidence to suggest the psoas is important for low back or hip pain.  Clinical reasoning which equates psoas activity to low back pain is based on structural narratives which are not supported by research.  The role of biomechanics as the singular cause in most pain presentations does not have quality research to support it.  Although nothing is linear and biomechanics can play a role in someone’s pain experience, the notion that the psoas is an important contributor to low back pain does not have any evidence either in the pain literature or the biomechanical literature to support that narrative.

Also, I have not seen any research to suggest that we can accurately palpate it.  There is a thick layer of skin, adipose tissue, muscles and viscera.  Depending on the gender and size of the person, this is at least 15-30 cms before you get to the anterior spine.  Being able to accurately palpate anything through that is near impossible.  Youtube an abdominal dissection to see what I mean, or you can visit this link here.  I am super squeamish. Watching that stuff makes me feel unwell!  More importantly, contemplate whether it is necessary to massage the psoas to achieve clinically meaningful results?  Can people’s low back symptoms improve without a deep psoas treatment?  Of course they can.  If you find results with treating that area, I think the least wrong way to achieve results is by providing a pleasant sensation to the abdomen and structures of the anterior hip.   However, I will stress that therapists can still get positive results without “deep” pressure through the abdomen.

My understanding for mechanisms of effect

What is happening to a patient when you do a psoas treatment and their symptoms improve?  A significant sensory experience is delivered to the abdomen (touch), a therapist confidently explains (contextual effects) how the psoas attaches to the front of the spine and can contribute to low back pain, and there is often a degree of contract/relax to the anterior hip and abdomen (therapeutic movement).  There is a significant ritual of care with expectations, contextual factors, movement and touch which can have a very powerful analgesic effect.  This explanation is much more plausible and is consistent with current understandings of how MSK interventions work.

What is psoas’s function?

Studies show the psoas is important for spinal stability.  It works in conjunction with other spinal muscles to keep us upright as we move.  Let’s keep it simple and leave it at that. Low back and hip pain is very common.  All pain is multifactorial.  The psoas might have a role to play in the person’s presentation, although I would think it is very rare.  Even if it does, it is only one piece of a much larger puzzle of the person’s pain experience.  Complicated biomechanical reasoning is behind us.  If the profession of massage therapy wants to move forward we need to stop the arguing and embrace a modern, less wrong understanding of how things work.  This means to move away from pathoanatomical structuralism and embrace the complexity of the individual experience. We don’t have all the answers, but we can pretty confidently suggest that the psoas obsession needs to disappear.

Last thoughts

I wanted to finish by emphasizing again, that treating someone’s anterior hip/pelvis and/or abdomen can be helpful.  Although I am arguing against these overly biomechanical claims, and linear thinking of the psoas, this does not negate the fact that some people will feel relief when they receive treatment to the hip and abdomen.  The reasons for the outcomes are what needs updating.

Please have a listen to my podcast that I do with Jamie Johnston.  The Massage Therapists Development Initiative.  New episodes released every 2 weeks.

https://podcasts.apple.com/ca/podcast/the-massage-therapist-development-initiative/id1553205390

Interested in becoming part of the evidence informed revolution for massage and manual therapists?  Join my private members online virtual training community, The Manual and Movement Therapists Community (MMTC).

https://mailchi.mp/ericpurves.com/the-manual-and-movement-therapists-community

References

• Arbanas J, Pavlovic I, Marijancic V, Vlahovic H, Starcevic-Klasan G, Peharec S, Bajek S, Miletic D, Malnar D. MRI features of the psoas major muscle in patients with low back pain. European spine journal. 2013 Sep;22(9):1965-71.
• O’ Sullivan et al.  Unraveling the complexity of low back pain. Journal of Orthopaedic Sports Physical Therapy 2016; 46(11):932–937.
• Sions JM, Elliott JM, Pohlig RT, Hicks GE. Trunk muscle characteristics of the multifidi, erector spinae, Psoas, and quadratus lumborum in older adults with and without chronic low back pain. journal of orthopaedic & sports physical therapy. 2017 Mar;47(3):173-9.