The psoas is a true celebrity. In terms of the attention it gets, the psoas has superstar status in fields as diverse as yoga, massage, physical therapy, Pilates, chiropractic, strengthening and conditioning, martial arts, structural integration, and Rolfing. Like other famous stars, the life story of the psoas is probably a mixture of fact and fiction, where mystery, hyperbole, and controversy blend with the psoas’ truly special qualities, eccentricities, and abilities.
Hidden away deep in the abdomen where its workings are less observable than other more superficial muscles, the psoas is the subject of numerous (and often contradictory) theories and assertions.
Right or wrong, some of the many claims about the psoas include:
• Along with the tongue, it is the most sensitive muscle in the body.1
• It is the strongest hip flexor, or not a hip flexor at all.2
• It is a lateral rotator of the hip, a medial rotator of the hip, or not a rotator of the hip.3
• It is able to deepen the lumbar curve by contracting, able to flatten the lumbar curve by contracting, or it is not related to lumbar curve.4
• It is involved in most back pain, or it is not particularly relevant to back pain.5
• It is “just another spinal muscle,” or it is the “muscle of the soul.”6
• It is important to work directly, should never be worked directly, or is physically impossible to work directly.7
Controversy
From this list, we can see there is quite a bit of debate about the psoas’ biomechanical function. But another thing is also clear: direct myofascial work with the psoas is itself controversial. It is easy to find heated online and social media debates about the effectiveness, methods, or advisability of psoas work; some of these exchanges have even spurred threats of legal action.8
Rather than trying to argue which parts of the psoas’ divisive, larger-than-life reputation might be either true or false, I’ll make some simple and practical suggestions for working with the psoas. My suggestions are based on my own clinical, teaching, and supervising experience, and though admittedly biased by my own training, style, and proclivities, my views are tempered by my in-depth readings and study of many others’ reports, opinions, and approaches.
Psoas Anatomy
The term psoas is usually shorthand for the psoas major, a pair of layered muscles deep in the abdomen. The psoas’ posterior layer attaches to the transverse processes of the five lumbar vertebrae, and its anterior layer to the side (lateral aspect) of the vertebral bodies and intervertebral disks of T12–L5. The psoas major joins with the iliacus muscle in a common tendon at the lesser trochanter of the femur to form the iliopsoas complex, which is surrounded by the thin, tough iliac fascia (Image 1).
The left and right psoae, together with the left and right spinal erector groups, are arrayed around the spinal column like four guy-wires around a mast. In sitting or standing, the two psoae work bilaterally to stabilize the vertical spine. In sidebending and twisting, they work unilaterally to exert powerful torques on the spine. Because of their role in twisting the trunk, surgically severing the short psoas was at one time thought to improve severe scoliosis, until this extreme measure was thankfully deemed ineffective.9
The psoas is extremely sensitive. This is likely related to its proprioceptive function in upright postures. If we think of the psoas as a proprioceptive sensor, sending information about spinal position and movement to the central nervous system, rather than solely as a motoric muscle, it’ll help us approach it with the sensitivity and subtlety it needs.
The psoas’ sensitivity is also due to the numerous nerves that pass around, within, and through its muscle mass (Image 2). Lying alongside the spinal nerve exits, the psoas’ front and back layers sandwich the nerves of the lumbar plexus. These nerve trunks, which give rise to the obturator, genitofemoral, sciatic, and other nerves, pass right though the psoas’ belly. This unique anatomy gives the psoas a potential role in certain types of nerve entrapment pain, such as groin pain, sciatic pain, or femoral nerve pain.10 In my practice, I have observed a clear improvement in many clients’ axial sciatic pain after careful work with and around the psoas (see “Assessing Sciatic Pain,” Massage & Bodywork, July/August 2011, page 110).
Is Psoas Work Safe?
Many critics of direct manual therapy with the psoas are concerned about the risk of internal damage. They do have a point—the psoas is indeed surrounded by structures more delicate than the muscles and dense connective tissue that most bodyworkers are accustomed to working, stretching, and releasing. Without a doubt, insensitive, painful, or strong work around these structures of the abdomen is ill advised and could even be dangerous.
Fortunately, injuries from psoas work seem to be rare. Although my reasonably extensive Internet searches found just one account of client injury associated with psoas techniques in myofascial, massage, structural integration, manual therapy, or physical therapy (and that single report being an uninvolved party’s social media account of a practitioner apparently stepping on a client’s psoas), the potential for client injury from insensitive abdominal work is real.11
But strong pressure is rarely (if ever) needed in our approach to the psoas—its delicate, proprioceptive nature means it responds quickly and easily to gentle touch. This gentle touch, especially when used with the necessary sensitivity and communication with the client, is (in my opinion and experience) unlikely to damage or disrupt the surrounding structures.
Benefits of Psoas Work
In our Advanced Myofascial Techniques trainings, we include gentle, direct work with the psoas in our repertory, as we have seen clear benefits that are not easily accomplished by other means. However, we do so with extreme respect, caution, and reverence for the unique sensitivity and potency of the psoas.
Many other practitioners and their clients find benefits from careful psoas work, for a wide variety of reasons.1
Each manual therapy system that includes the psoas in its repertory has its own rationales for doing so. For example, Ida Rolf placed special importance on the psoas’s role in her work. “A balanced body lengthens,” she said. “There is no shortening. If the ‘psoas’ muscle is where it belongs, the body lengthens in all movement.”13
In our Advanced Myofascial Techniques trainings, we work with the psoas as one of many possible avenues for furthering our two primary therapeutic goals, which are:
1) more options for movement, and
2) proprioceptive refinement.14
In particular, we have observed that careful, direct work with the psoas produces beneficial effects such as:
• Immediate and lasting improvements in certain clients’ back or sacroiliac pain (both acute and chronic);
• The already-mentioned improvements in nerve entrapment pain in the sciatic, femoral, obturator, genitofemoral distribution areas; and
• Client reports of increased awareness and proprioceptive (felt) sense of length, ease, mobility, balance, or continuity through the midsection of the body in standing, walking, and running.
The Psoas Technique, then, is particularly indicated in cases of back pain and nerve pain such as axial sciatica, as well as lumbar, pelvic, or hip joint mobility restrictions. And because of its unique role as a connector of the upper and lower body, as well as its high sensitivity and proprioceptive function, we often use the Psoas Technique in the closing, integrative stages of a session or series. At this stage, the goals have shifted from mobilizing or lengthening specific structures to awakening proprioceptive awareness of large (broad) relationships in the body, as well as calming, balancing, and completing a session of hands-on work.
Psoas Technique (Supine)
With your client supine, ask her to bring her knees up (Image 3). This slackens the myofascial layers of the abdominal wall, helping the work be more comfortable and less invasive. We typically don’t put a bolster under the knees, as we will ask for active movements a bolster would obstruct.
As you prepare to touch your client, make sure your own approach and mindset are soft, sensitive, and unhurried. In “Working with the Mesentery” (Massage & Bodywork, March/April 2015, page 106), we described the kind of touch needed for working in the abdomen as similar to touching a soap bubble without bursting it. You’ll use the same touch for working with the psoas.
Begin at about the midpoint between the umbilicus and your client’s side. Use a delicate, sensing touch, never pushing or pressing. Gently, with your client’s breath, allow this soft touch to sink into your client’s abdomen. Imagine gently sinking into a tub of water balloons (Image 4), patiently making your way to the bottom as the slippery, delicate balloons (the viscera) slide out of the way. Slowly sink posteromedially—toward the back, and slightly toward the center of the body.
The safest approach is to stay at or below the level of the umbilicus. Above this level, the kidneys and their vasculature lie close to the psoas, and although our touch remains so soft and sensitive that any damage or bruising is unlikely, it’s a good practice to stay below (caudal to) the umbilicus, at least until you are experienced with the kind of patient, listening touch needed in the abdomen.
Stay in close verbal communication with your client, checking in about comfort level, pace, etc. Encourage easy diaphragmatic breathing. Your client’s exhalation will draw your hands deeper into the abdominal space. At some point, usually after at least 5–10 of these slow, relaxed breaths, you’ll stop sinking, and find yourself resting against the slightly firmer posterior abdominal wall. Ask your client to make a very small movement of her leg, lifting the knee toward the ceiling. This will allow you both to feel the slight contraction of the psoas. Adjust your position if needed, and repeat, until the contraction of the psoas is clear to you both. Although this area is very sensitive, at no time should the work be painful or unpleasant.
As long as the work is comfortable for your client, you can invite different slow but active movements in order to help your client feel the psoas/leg connection in various ways. Try slowly dropping the knees from side-to-side (Image 5) or sliding the leg out along the table. Direct your client to slow down even more, and ease off on your touch if you find movements that are difficult or particularly sensitive. Once you’ve both clearly felt the psoas’ participation in these various motions, withdraw your touch just as slowly and deliberately as you began. Repeat on the other side.
Summary
To review, our goals in this gentle technique are more (a) options for movement, which we accomplish by the easy, active movements; and (b) refined proprioception, which occurs naturally when the sensations of psoas work are gradual and mild enough to be not only tolerated, but actively explored by the client. This enhanced proprioceptive awareness of the psoas is in itself therapeutic, and the gentle intensity of experience, the connection to movement in novel ways, means there is often something deeply satisfying about receiving skillful psoas work.
Notes
1. Liz Koch, “Tom Myers & Liz Koch: A Psoas Conversation Part 1,” accessed June 2015, www.coreawareness.com/podcasts/apsoasconversation.
2. W. Platzer, Atlas of Anatomy (New York: Thieme, 2006), 422–23; Liz Koch, “The Psoas is NOT a Hip Flexor,” Pilates Digest, accessed June 2015, www.pilatesdigest.com/the-psoas-is-not-a-hip-flexor.
3. A. D. Skyrme et al., “Psoas Major and its Controversial Rotational Action,” Clinical Anatomy 12, no. 4 (1999): 264–5; Robert Schleip, “Lecture Notes on Psoas & Adductors,” Rolf Institute: Rolf Lines, November 1998; Nikolai Bogduk, Clinical Anatomy of the Lumbar Spine and Sacrum (Edinburgh: Churchill Livingstone, 1997): 102.
4. Joseph Hamill and Kathleen M. Knutzen, Biomechanical Basis of Human Movement, 3nd ed. (Baltimore: Lippincott Williams & Wilkins, 2008); Ida P. Rolf, Rolfing (Vermont: Healing Arts Press, 1989); K. Copaver, C. Hertogh, and O. Hue, “The Effects of Psoas Major and Lumbar Lordosis on Hip Flexion and Sprint Performance,” Research Quarterly for Exercise and Sport 83, no. 2 (June 2012): 160–7.
5. D. P. Denmark, “The Psoas is Involved in Most Back Pain,” accessed June 2015, www.bowen.asn.au/bowen-therapy/articles/psoas-muscle-and-back-pain.; Paul Ingraham, “Psoas, So What?,” Pain Science, accessed June 2015, www.painscience.com/articles/iliopsoas.php.
6. Paul Ingraham, “Psoas, So What?”; Liz Koch, “The Primordial Psoas and the Chakra System,” Positive Health 168 (March 2010).
7. Ida P. Rolf, Rolfing; Liz Koch, “Tom Myers & Liz Koch: A Psoas Conversation Part 1”; Adam Meakins, “Psoas … Please Release Me, Let Me Go!,” The Sports Physio, March 26, 2014, accessed June 2015, https://thesportsphysio.wordpress.com/2014/03/26/please-release-me-let-me-go.
8. Adam Meakins, “Psoas … Please Release Me, Let Me Go!”
9. A. Hugo et al., “Scoliosis,” Clinical Symposia 30, no. 1 (1978).
10. L. Rassner, “Lumbar Plexus Nerve Entrapment Syndromes as a Cause of Groin Pain in Athletes,” Current Sports Medicine Reports 10, no. 2 (March/April 2011): 115–20.
11. Antony Lo, The Physio Detective, “Serious Warning—If You Do Any Releases to Your Psoas or Abs, You Must Read This,” accessed June 2015, www.physiodetective.com/2015/01/21/serious-warning-if-you-do-any-releases-to-your-psoas-or-abs-you-must-read-this.
12. Various contributors, Zeel, “Deep Tissue Massage: Any Benefit From Deep Tissue Massage on the Iliopsoas Muscle?,” accessed June 2015, www.zeel.com/t/deep-tissue-massage/expert-answers/any-benefit-from-deep-tissue-massage-on-the-iliopsoas-muscle.
13. Ida P. Rolf, Rolfing.
14. Til Luchau, Advanced Myofascial Techniques, Vol. 1 (Scotland: Handspring Publishing, 2015).
Til Luchau is a member of the Advanced-Trainings.com faculty. He is a Certified Advanced Rolfer and originator of the Advanced Myofascial Techniques approach. Contact him via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page. His book Advanced Myofascial Techniques, Volume 1 has just been released, with Volume 2 slated for publication by the end of 2015.
An expanded version of this column, including a discussion of body-mind aspects of psoas work and a side-lying version of the psoas technique, will appear in Til Luchau’s upcoming book, Advanced Myofascial Techniques Vol. 2, to be published early 2016 and available at Advanced-Trainings.com.