OK, I’ve relented and decided to write about a topic that was one of the first big online debates I had that soon turned into a heated argument around the down right stupid and completely ridiculous manual therapy technique called ‘Psoas Release’!
Now some of you may remember this argument started when I questioned the plausibility and feasibility of this technique, which got a few therapists really wound up, even causing a couple of deluded sports therapists from a UK based massage teaching organisation to threaten me with legal action for questioning this practice.
So what is my ‘beef’ with Psoas release?
Well first is the word ‘release‘ which is used a lot in manual therapy! Releasing implies we are freeing things up of restrictions, seperating it from being confined. All of which is complete nonsense and totally misleading. This technique should actually be called ‘bloody painful sustained deep stomach prodding‘.
I see this a lot within the world of manual therapy, techniques having names or descriptions that are implying an action or effect that just doesn’t happen or ever will happen!
Now having had my own psoas ‘released‘ on a course a few years ago, and I am ashamed to say, having inflicted it on a few of my poor patients when I was a young, naive and impressionable physio. I am well aware of what it involves and feels like.
However for those of you who are fortunate enough never to have had ‘psoas release’ inflicted upon them, let me briefly explain what it involves and feels like.
Imagine you are lying relaxed on a treatment couch, first you feel a therapist pressing on your stomach just inside your pelvic bone, it feels weird, kinda tickly which isn’t so bad I hear you say.
However, the therapist then starts to push their fingers deeper and deeper down through your guts until they are up to their knuckles in your intestines and it feel like they are trying to perform an appendicectomy with no scalpel or anaesthesia.
I can assure you this is as uncomfortable as it sounds, it is a truly unpleasant, nauseating, and painful experience, in fact it feels like your internal organs are about to implode.
Psoas release
So what’s the point of this so called ‘therapy’?
Well before we look at the dubious clinical reasoning of why do psoas release, lets first look at the implausibility of how the psoas is supposedly ‘reached’.
The psoas muscle is a deep muscle. A very, very deep muscle within your abdomen and pelvis. It is attached to the side of your lumbar spine and the intervertebral discs. It travels down through the pelvis and inserts onto a bony projection on the femur called the lesser trochanter. It blends with another muscle called the iliacus within the pelvis and so is sometimes referred to as the iliopsoas.
The Iliopsoas (in blue)
However it is covered by a lot of other structures, a hell of a lot of other strucutures, both front and back. At the front it’s mostly the small intestines and the colon, and a little higher up the kidneys and the vascular structures of the external iliac artery and vein which then become the femoral artery and vein as they pass across the inguinal area lower down.
The psoas also has the genitofemoral nerve lying in front of it, and is finally surrounded a by strong dense fascial blanket. To top this all off, all these structures are then covered by three layers of abdominal muscles and then some fatty adipose tissue (some more than others) and skin.
If you where to try and approach the Psoas from the back it is also covered by multiple layers of thick, dense and very strong lumbar spinal muscles, as well as more adipose and skin tissue. So to reach the psoas from either the front or back you have to ‘go through’ a lot of other stuff first!
Now some say they can move this stuff aside as they press down! Which is just bull shit, where exactly do they move this stuff aside to, it’s not as if we have empty zones or reserve spaces in our bodies for pushing things into, do we?
Ok soft tissues and intestines do mush, slide and glide around a bit, but news flash people your colon and kidneys are very firmly imbedded and attached to the retro peritoneal wall and they do not just slide out of the way. Neither do muscles, tendons or fascial blankets they just get compressed, painfully compressed.
The Iliopsoas (in blue) with abdominal contents on top, abdominal wall removed from one side
So is it possible to touch the Psoas through all this stuff?
Of course its bloody not!
The Psoas sits so deep and is surrounded by so many layers of other tissue, the only way it is possible to touch or reach it is via surgery, and even then it takes a surgeon about 30 minutes of careful dissecting and moving abdominal stuff out the way first.
Now most therapists I talk to about psoas release argue, so what if other stuff is in the way! They argue that it is the pressure we exert through the other structure that causes the release effects.
Well ok, let’s say for the sake of argument that applying pressure through another tissues does do something therapeutic such as ‘release’ a tight muscle, what about the other muscles you have pressed through too are they also released? Why is it only one structure effected.
Also what about those other more delicate abdominal structures, such as internal organs and neurovascular structures, don’t they get affected? When I question this many therapists just laugh and shrug saying, so what, they squish and move, it’s not a problem.
This mentality just reflects many manual therapist complete lack of understanding of anatomy. Talk to any surgeon who actually sees and handles internal organs such as intestines and bowels daily for a living, and they will have a very different opinion of how much they can squish and smoosh!
Don’t believe me, have a watch of this video of US surgeon discussing what it involves for her to reach the Psoas muscle but more importantly how she talks about how she handles and respects the intestines and what she thinks of therapists poking around down there.
In my opinion, many therapists understanding of anatomy is full of myths and misconceptions due to them having very little, if no, cadaver or dissection experience. Most rely on text books for anatomy teaching and they don’t get to see it in real life. Most therapists are also taught by other therapists who also have only seen the anatomy in the text books. This leads to the development and snowballing of some ridiculous ideas and implausible manual therapy techniques such as psoas release.
Anatomy dissection
What’s the clinical reasoning for Psoas Release.
The main argument for using this technique I hear is to reduce tightness, spasm, or ‘over activity’ of the psoas, which is often thought to be a cause of pain that can be felt in the back, abdomen, groin or all of these areas.
The other common reason I hear psoas release being used is to ‘excite’, ‘wake up’ or ‘stimulate’ an ‘under active’ psoas back into action when it’s weak or not working optimally in those undertaking sports or exercise.
Before we go any further, could someone please tell me how the hell can one technique be both inhibiting an over active muscle one moment, and then suddenly switch to increasing an under active muscle the next?
And how the hell do you know or test for an over or under active psoas?
Well I guess you could check its cross-sectional area on MRI scans. There is some research that shows a tenuous link between its size with those suffering low back pain (source), or perhaps you could use fine wire EMG directly into the psoas to record its activity. But these are costly, impractical and potentially unreliable with no robust evidence.
How about good old manual muscle testing to see if the psoas is weak? However the role of the psoas is still debated. Some say it is a hip flexor and external rotator and adductor. Others say it has minimal role in hip action due tinted orientation of its muscle fibres and is more involved in lumbar spine stability and control.
So does pressing on a weak psoas make it stronger?
Of course it bloody doesn’t. Resistance training makes muscles stronger. Poking or rubbing a muscle doesn’t make anything stronger, it doesn’t cause hypertrophy, it doesn’t create endurance.
However, I have had first hand experience of some of those ‘poking makes you stronger’ nonsense courses. On one course a tutor tried to convince me and others in the audience that after he ‘released my psoas’ my strength had miraculously improved!
Well, it might have, as I really wanted to use my poked hip flexors to kick the pretentious prat in the face really hard after he had just inflicted a great deal of pain on me in front of everyone on the course, making me cry out as he ground my guts to mush whilst asking me “is this pain is going to kill you?” to which I quickly replied “no, but it might kill you if it carries on any longer!”
So does psoas release loosen or lengthen the muscle?
I hear many therapists using it for this reason and lots of anecdotes of its susccess. But why does the psoas become tight or over active, and how can we tell?
Many say the psoas gets tight due to extended periods of sitting in hip flexed positions. I question this. Most of us do sit too long, no questioning about that! But even the most sedentary sitter will still spend long periods of time out of hip flexion positions, such as when moving around or in bed (not many curl into fetal positions over the age of 2). Also think about other joints that do the same as the hip, like the elbow a lot of us keep our arm flexed as well at desks, computers etc but our elbows dont suddenly not go straight.
The Thomas Test is often used (see below) to identify tight hip flexors. Now don’t get me wrong I use this test and position often but what information it gives me I take with caution. There is evidence to show that a poor Thomas test with lack of hip extension, doesn’t equal poor hip extension in other positions (source) and there is also evidence to show that even if you do improve hip extension by ‘releasing’ the psoas or stretching in the Thomas position it doesn’t translate into increased movement in other positions and tasks (source).
A tight hip flexor as seen in a Thomas Test, this is actually done on a Tom, the Running-Physio.com Tom Goom
What about the evidence?
When it comes to evaluating and critiquing the research and evidence for the psoas release technique that’s easy, there is nothing robust to look at. In fact there isn’t anything even remotely flimsy to look at just a few very poor case studies.
If you go on Pubmed and search ‘psoas release‘ you get 202 articles, but they are all related to surgical techniques that involve actual cutting or tenotomising the muscle, such as for contractures suffered in those with cerebral palsy or for true psoas muscle impingement’s after hip replacements. If you search Pubmed for ‘psoas +/- manual therapy‘ this time you only get 16 papers and only those few limited single case studies!
Search on Google Scholar and the same thing a few papers on psoas cross sectional area size in those with low back pain, and the same few case studies. The rest is just references to chapters in books and manuals on teaching the technique!
Basically there is NO research on its application, its effects nor it’s results, doesn’t that seem strange for such a widely used and promoted technique?
In summary psoas release techniques are not based in ANY sound anatomy, not founded on ANY sound clinical reasoning and are usually not practised by ANY sound therapist.
As always, I welcome the debate and discussion my blogs can create, and I think this one may cause a bit, so please comment below, but keep it civil and please leave the ad hominem attacks or legal threats out as they simply don’t work, just like psoas release!
Thanks for reading
Adam
Interesting read, I’m assuming the American surgeon respects ” intestines” not intensities Adam
Thanks Gary, good spot and corrected
As with the majority of conservative techniques there is very little evidence to support any of them. However as therapist ourselves many of us still use numerous ‘unproven’ techniques. Yet, do many still not seem to produce results? Is it placebo? Is it confidence in the practitioner and the costly treatment? is it that the pain associated convinces us that it works? Or do they actually work, just RCT’s etc etc are near impossible on such techniques!
My point; if the problem/complaint is fixed or performance enhanced does it matter?
Hi Laurence
My argument here is where do you draw the line, if something just works according to who? We need research and evidence to guide practice or we are open to abuse and dangerous practices and psoas release does come with some risks in my opinion
Regards
Adam
Along those lines, if there is a technique that has similar effect, but causes less pain then we should choose than one. Why “release” the psoas when perhaps mobilizing the sacrum with prescribed glute max/med strengthening can provide relief and positive treatment outcomes for example?
I would further suggest that spinning these kind of narratives to patients degrades their ability to understand and deal with their injuries. In some cases it can be nearly crippling – PT’s are very quick to criticise doctors when they use inappropriate language, we seem to have a huge, whopping, immense blind spot for how we do the same.
What message does the patient (victim) take home – and live with.
ANdy
Yes it matters. A placebo is a temporary ‘fix’ at best. The only thing that improves long term is the wallet of the therapist.
Thanks to the Sports Physio for having the courage to keep us honest. I really appreciate the research and articles he shares. Thank you.
Why is placebo temporary? Pain and protective guarding are a lot about expectations, conscious and subconscious. If you take pain away long enough to change expectations is can that not lead to permanent change?
I have been following this Psoas Release debate with real interest. It has confirmed many of my concerns regarding the fact that after relatively little training and education, ‘therapists’ are unleashed on the world and allowed to jam their fingers into some poor client’s gut. If there is so little support for the BMM, then why is it still allowed to be taught in 2014?! I was taught and have used Psoas Release in the past, but you argue the case against it so convincingly that I don’t see how people can honestly continue to use it. This, in addition to the many other ‘controversial’ issues you focus on, has opened my eyes to the importance of evidence based practice and good old common sense in manual therapy.
Hi Liz
Many thanks for your kind comments, one down, 3.5 million to go, please spread the word
Cheers
Adam
It’s people like you…… etc etc. Thought I’d start the slagging off.
I learned an expression in Bulgaria from my awesome translator whilst in the same debate with someone who had never seen a psoas. “Never try and teach a pig to sing. It wastes your time and it just annoys the pig.”
If I might throw in my two ‘pennorth, it may or may not mitigate some of the comments by forthcoming singing pigs that might be upset by your post. You are totally correct regarding your anatomy and the colon kidney elements. However as an addition I might add that if you’re trying to do psoas ‘releases’ on a woman, you will be mucking around near some serious girly bits.
It is for all intents and purposes, a deep paraspinal structure and along the same lines as QL (which is another bug bear) in terms of accessibility and depth. Above all it’s not even the functional muscle that we want it to be, but much more of a stabiliser than anything else. The idea of release here is puzzling. How has it become so ‘trapped’ that it needs to be ‘released’? It’s the terminology that I struggle with as much as anything else and we need to reconfigure our language if we are going to make any sense at all.
From a continuity perspective the psoas major fascia is virtually always continuous with the diaphragmatic fascia as well as that of QL around the 12th rib all converging in a nice thickened mass around T12. As well as the kidneys to contend with, you also have the ureters, that have a mind of their own in terms of where they will wander. The iliac artery is another consideration when messing around down here.
Psoas releases are purely designed from a theoretical stand point, with the idea drawn from an anatomy book with a pretty picture of a psoas that looks (and to some degree feels) like it’s accessible. It’s not. In reality it doesn’t look anything like the pictures above and has an enormous amount of guts sitting on top of it. Even the anatomy picture above has had lots taken away to even see the trimmed up kidney.
Does a psoas release work? I have no doubt that it does in many instances but as you have already pointed out, with a lot of these things it’s probably a secondary action. There are plenty of things that you could do that didn’t involve what is, in my view a pointless and if performed even slightly wrongly, a potentially dangerous practice. OK done now, be nice!
Haha, thanks Julian, singing pigs eh and I thought I was random at times, let’s see what the debate brings forth!
How does the applied force generated to the iliopsoas through a sustained `release`compare with the forces generated within the abdomen in movements such as abdominal crunches with weight, sneezing or in contact sports such as rugby and american football. when contact is taken anteriorly to the abdomen in these sports Prevalence of intenstinal, kidney and abdominal injuries is low. In football Shay Given sustained such injury versus a collision with marlon harewood. A quick youtube clip will give you an idea of the huge force that was applied to his abdomen. In addition, kidney injuries through trauma are predominantky linked to posterior lateral force such as seen in boxing or RTAs. My point being that I do not disagree the idea of isolating and releasing iliopsoas through this technique is certainly misleading, however the idea this relative low level slow sustained force in this position can replicate a force to sustain an internal organ injury is most misleading of all.
Hi Liam
Thanks for your comments and I agree the force needed to damage internal organs from external impacts is usually large, and the chances of internal damage during psoas release are rare, but they are still present, and for what effect?
Also it’s not the force but the sustained pressure that is applied for 30-60 secs at a time as I was taught or have watched performed is what concerns me and what I question, this extended period of pressure could cause ischemic damage such as ischemia colitis http://en.wikipedia.org/wiki/Ischemic_colitis etc and the surgeons I speak to and on the video I posted cannot comprehend why therapists apply sustained pressure to the abdomen, when they treat them so carefully and delicately in surgery
Regards
Adam
Hmm it’s an interesting point. I was taught psoas treatment both proximally (through the abdomen) and distally on the thigh, as well as iliacus treatment by pressing on the inner surface of the ilium above the ASIS. I did ask the question of what happens to the organs under the pressure and I was told that they just move out of the way. Maybe they do, maybe they don’t, I’d say the only way to tell is under ultrasound, and then to determine whether there is infact the potential for damage to occur.
As for not being able to put pressure onto the psoas I beg to differ, I’ve had it done many time as a patient and just as any other ‘trigger point’, the acute pain does alleviate after 30 seconds or so. As a therapist, I treat through the abdomen almost on a daily basis and I can feel the muscle (I confirm by asking the patient to flex their hip, and I don’t think the large intestine has that ability), and I can feel the pressure turn from nearly rock hard to soft as a sponge as the patient reports a reduction in pain.
As for whether it does anything? My answer is almost always. Pre-testing and re-testing hip extension flexibility.
Hi Rob
Thanks for the comments, again as with my reply to Aran, the question is why do we need to do this technique to imporve hip extension when we test it as we know it doesnt transfer into other more functional postions, also the release you feel will more than likely be abdominal muscle layers, NOT the psoas under need the colon and intestines, and USS wont help us gain anymore info im afraid, its just impossible to press down that hard, through that many structures to reach the psoas, as said by any anatomist or surgeon when you talk to them.
Thanks
Adam
With crunches the distribution of force is very different than with deep psoas work. Pressure will tend to push outward, downward and upward in all directions. While there is some of this in all directions pressure change in deep psoas work, there is significant concentration of downward force.
With regards abdominal contact in sport, I have seen some pretty hard knocks over the years. Most resulted in the athlete (Australian Rules Football) jumping back up and continuing on. A few resulted in ambulance trips to the hospital, surgery to repair their insides and a stay in intensive care.
In all but one case of serious injury, the player lost consciousness. This meant no protective spasming of the abdominal muscles. Protective spasming allows a significant proportion of the force to be transferred to the ribs and bones of pelvis, sparing the abdominal contents.
When doing deep psoas work we usually ask our client to relax so that we can get in deep. This leads to force being transferred downward through the abdomen, rather than being transferred through the bony elements on either side.
Thanks, really interesting article as ever. I struggle with some terminology in our profession and “release” is at the top of the list. I worked with someone who released so many things in clinic he should have worked for the Born Free Foundation
I also think a lot of it is down to training, but that is probably another post.
Great blog as always Ad. My background is SMT and must confess to being guilty as charged in the past. Not used it since becoming a PT though (CR got the better
of me!!)
Thanks Rich, leave those psoas’s alone now…
Psoas’s or Psoasi ???
Now there’s a dilemma
Thanks Adam, great post!
Im a recent graduate but I’ve always questioned the benefit of such “releases” and the reasoning as to why? Many of the reasons have been based around the effect of the psoas on pelvic posture, anterior pelvic tilt and the rest. I have yet to find any research article to confirm this, the majority conclude that the psoas has an important role in spinal compression and has no significant anterior pull on the spine.
I will continue to defy the teachings of the majority.
Thanks again,
Jordan
Thanks for your comments Jordan
Enjoyed the post. When my bathroom has finished I may do a few on the issues I have!!
I’ll say, I have dabbled in the ‘release’ technique – with scepticism as its so deep. I have had some success but its short-lived and likely a Nphys phenomena – usually the patient feels ‘freer’. I dont really understand why it has to hurt like hell either (or any technique for that matter). Rarely do a thomas test as im not sure how useful it is (how functional is it?) and I dont treat many hurdlers and gymnasts these days. Far better to use active movement in functional positions.
Effort – write one on US (therapeutic?)
Ade
Haha ageing rock star, who you trying to kid Ade…
Get your writing head on mate, if you want to guest blog, would be great to have you on the site dude… Not sure about US thou…
Keep rocking
Adam
I suspect the special allure of ‘psoas release’ is that it seems to be working deep inside the body, as opposed to the superficial application of most manual therapy.
You’re probably right there Steven, and the no pain, no gain rubbish as well!
Mostly I agree with the intent of your article – obviously many manual therapists need to reconsider their ‘beliefs’, and start looking at what is actually known and not known about what happens under their hands and during the interaction with a patient. Until educators in the manual therapy profession embrace this I’m afraid I don’t see things changing overall.
I would argue your point that manual therapists don’t understand anatomy well enough, and that more anatomy such as dissection would help. Many manual therapists I have met have a high standard of anatomical knowledge. E.g. cranial osteopaths usually have a very detailed understanding of the anatomy under their hands in what is an extremely complex part of the body. This however does not cause them to be self-critical evidence informed practitioners who can evaluate accurately the true physiological impact of their manual contact on the scalp!!! In general osteopaths for instance get a high standard of anatomy in their education but this does not equate to a logical application of manual techniques. In fact the knowledge can be used as unreasonable justification for all sorts of weird and wonderful approaches.
In terms of the psoas release itself, while it is a very questionable technique, psoas is probably a readily palpable structure. Although its origins are deep, its lateral and lower borders are palpable, and the overlying viscera in the iliac fossa are intraperitoneal and free from the posterior abdominal wall and internal surface of the false pelvis (e.g. the caecum which is usually peritoneal) thus allowing them to move considerably and quite safely with careful contact. Dissection of the region illustrates how close psoas is to the anterior abdominal wall once it enters the false pelvis before passing under the tight space between the inguinal ligament and the iliopectineal line. I would say from the lower part of L4 to the floor of the femoral triangle it is easily palpable (with the caveat that you must be cautious of the external iliac vessels). Anything above (i.e. L3-L1) is obviously going to be difficult, even if the hip is flexed and the muscle contracted. I think it is important not to ignore this region, and good palpation can help differentiate anterior hip/groin pain of different aetiologies, and furthermore the body of psoas should at least be investigated for trigger points which refer extensively (e.g., http://onlinelibrary.wiley.com.ezproxy.is.ed.ac.uk/enhanced/doi/10.1111/pme.12224/).
Hi Ter
Thanks for your comments, you sound like you have some dissection experience yourself? I agree that therapists know anatomy but knowledge and understanding are two separate things, just because you know where a muscle, ligament etc runs to/form doesn’t mean you know how it sits within the other structures.
You mention cranial osteopathy which again as I’m aware is also a therapy which has very little evidence or sound reasoning in its use, the idea of moving cerebral spinal fluid under the cranial bones seems highly unlikely?
Regards
Adam
Really enjoyed the article and the ensuing discussion. Quick question about the anatomy and potential therapeutic benefits/causes:
Is it equally difficult to apply pressure to the ilacus? The pictures imply that it could potentially be easier to access, though still somewhat obstructed potentially by the colon.
Just as muscle excitation/contraction irradiates to surrounding muscles could the reverse also occur with potential relaxation if the ilacus were subjected moderate sustained pressure?
Thanks!
Brian
Hi Brain
Theoretically yes I guess the lateral portion of the Iliacus is slightly easier to access to press on than the psoas, but it still will be only a small portion of the entire muscle so what influence you can have on it has to be questioned in my opinion
Thanks for your comments
Cheers
Adam
Hi Adam,
Firstly thank you for a great article, I applaud anyone looking manual therapy with a critical eye and a healthy amount of skepticism. I recognise this is a blog post and not journal editorial so a certain amount of opinion and controversy are always good things.
Overall I support a lot of what you are saying here but I do have a few issues with some of your statements implied or otherwise.
The first is the question of safety, I am happy to admit at best you can only feel psoas through a significant (5-10 cm?) amount of tissue. But feel it you can as when palpating and asking for a hip flexion you can feel it (IMO). Now if psoas “releases” where potentially rupturing, lacerating or otherwise causing a lesion to any of the surrounding tissue when performing a release we should have a pandemic of rupture colons occurring (especially in sporting teams and running tracks) around the globe every week!
That being said, I personally conclude the the “effectiveness” of a psoas or psoai release is in the sensation triggered in the “release”. I do believe the strong pressure is both potentially dangerous and uncomfortable, but probably also counter productive. Personally I see the effectiveness in this technique deriving from a “normalisation” of function. By this i mean, palate the approximate region of psoas, (mild to moderate discomfort) and ask for active movement of the hip through slow comfortable movement of hip flexion/extension. My clinical hypothesis is that as the movement becomes more comfortable there is neuromuscular re-organisation of the region and performance of hip movement that can lead to changes in Thomas and his test.
So in summary, I put forward there is value in the psoas release but we need to consider other neurological mechanisms and the likelihood of any myofascial or trigger point release would only occur via an afferent/efferent pathway.
Aran
Hi Aran
Thank you for your comments and thoughts, its this healthy debate that I think is needed for all manaul therapy techs. I agree the risk of bowel ‘injury’ or problems is small with this tech as you say otherwise there would be more cases in A&E departments. However the issue is that there are structures that are attached to the retro peritinal wall in front of the psoas such as the colon that just dont move, and its full of stool all the time, pressing on through that isnt in my mind going to achieve anything significant to the psoas.
However if the pressure has some other effect eg release of abdominal reflex or some other neuro muscular modulation as you state, which I agree it possible does, then fair enough, but can this be achieved via anything else, most of the mechanoreceptors that will effect this neuro modualtary response will be in the abdominal skin and wall, not in or behind the guts, so do we have to press even moderatly hard into the abdomen to achieve this, i dont know, i just question, would be an interesting study thou?
Also normalisation of the thomas test will only ever mean normalisation of the thomas test, the research shows it doesnt transfer into other more functional postions such as lunging or running, so why do we need to normalise this position, usually IMVHO just for the therapists benefit to feel as if something has been done, it doesnt help our patient or athlete with their function or performance again IMVHO… what do you think?
Once again thansk for the comments, I do value the debate
Cheers
Adam
Hi Adam,
I have to admit, I am doing my best to play devil’s advocate here and honestly struggling a bit. I pretty much dropped the strong psoas release from my grab bag a while ago for no other reason than the pressure on my fingers (never mind the groaning patient). That being said I never really thought the tech was the holy grail it was claimed to be BUT there was definitely a functional and sensory change after the technique was performed that could be identified in the Thomas Test and changes to subjective pain levels.
I am proposing that there is still validity in the tech but we need to;
A. Focus on the iliacus or even the skin/oblique musculature recognising the limited mechanical pressure to the psoas
B. Reduce the pressure (lest we end up in the …..)
C. Maintain only mild discomfort that changes quickly with active movement
D. Consider the outcomes from a more comprehensive functional movement assessment that would mimic an identified pre-existing issue, perhaps kicking, jumping or bounding?
I am still arguing there is a baby in the bath water.
Aran
Haha, but maybe the baby in the bath water isn’t a baby!
I like your thinking, especially the more functional testing, the difficulty I see with functional testing regularly is the subjectivity of it, what I may see as an improvement in pre v post treatment, you may not and visa versa, which leads to biases and mis leading beliefs of effects and correlations where there maybe not any!
Again the rationale for pressure to the front lateral abdominal wall has to be questioned, why do it & what will it achieve?
Why? Is it to touch the obliques & maybe a small portion of Iliacus. For what reason? Improve their action? reduce their ‘tightness’? Both? How do we know if it’s one or the other etc etc, as you can see I have more questions than answers, and the only definite I have is that I have no definite’s
So is that baby just a rubber ducky… That needs throwing out!
Cheers
Adam
Ter,
I’m glad you posted that because I agree totally that in certain areas the psoas is easily palpable. The article tries to imply that it’s a waste of time trying.
I’d also be interested to see the facts around the number of injuries to various other structures that have occurred during ‘psoas release’.
Indeed are there any reports at all of this occurring
Hi Patrick
I’m not implying that psoas release is a waste of time, I’m categorically stating that its a painful and ridiculous method and so in this form psoas release IS a waste of time!
If as you say there is a small partial area of the psoas that is possibly accessible the question is then what effect are u going to have on such a large muscle when you can only ‘touch’ a small part of it, also the effects of ‘therapeutic pressure’ to the abdominal wall are unknown and maybe there is a neurological effect via mechanoreceptors here as with all manual therapy techniques but as no one has done ANY research on it we cannot say if risk or effect are dangerous or advantageous and so I stand by my statement that NO therapist should use this technique
Regards
Adam (author) ex psoas releaser
This leaves me so disheartened. I am a manual therapy student and the psoas release is one if not the main focuses of the course in relation to lower back pain.Now I’m divided on it’s credibility also. I’ve had a colorful relationship with this muscle! A tutor decides to demo a release on me, it was very painful and as I sat up on the bed I was weak, had heart palpatations and cried uncontrollably for 2 hours . Didn’t feel right for days Mortified to say the least. Since then I’ve had this release performed on me by other practioners and the experience was completly different.. no major pain on palpation and it does however ease my lower back pain???? I’ve practiced this technique on several clients and have had overall almost instantaneous relief of lumbar pain. Confused.com
Hi Aideen
Thanks for your comments, confusion is good, it drives us to question and explore looking for answers, embrace uncertainty it’s a good thing and a good place to be
There is no simple answer here, I’m sure different pressures cause different effect, deep pressure = pain, damage! Light pressure = who knows? Placebo? Abdominal reflex? Neuro sensory modulation? All of the above?
Keep confused!
Regards
Adam
First, while there may not be a broad base of research supporting manual therapy on the psoas specifically, there is a wealth of evidence for manual therapy in general, especially in regards to working with fascia and myofascial trigger points. Therefore, there is evidence to support that massage and other manual therapy does work, and it would be short-sighted to dismiss deep muscles like the psoas.
I was taught a different method of testing and working the psoas than it seems all of you were. The test that I was taught tests the deep abdominal fascia (which includes the fascia attached to the iliopsoas). With the client supine, move the client’s arms into position or have the client flex their arms to full flexion (the hands will obviously be past the end of the table). With your hands firmly (but not painfully) gripping the client’s forearms gently pull until you feel resistance. With an uninhibited psoas and abdominal fascia, you will feel a soft elastic response, and the client will feel a comfortable stretch. If there are adhesions in that deep fascia, there will not be an elastic response, and it will feel like the stretch just stops. The client may have trouble breathing in this position if that is the case. If the psoas is involved, you will feel the golgi tendon reflex instead of the elastic response (it takes practice to know the difference-practice you can gain by working on other parts of the body).
If it’s the fascia that’s inhibited, moderate work on the abdomen will usually be enough to warm it up and increase the elasticity. If the psoas is involved, I then have the client flip over so they are prone. With the client prone, I then press into the table to slide my hands under the client, hooking my fingers gently around the anterior surface of the ilium. I don’t force my way into the abdomen. I don’t even compress anything. I allow gravity to move the “guts” and superficial tissues away from the ilium and deep abdominal muscles to provide me greater access. This method also uses gravity to stretch the fascia at the same time. Once the client’s body has allowed my fingers to reach the iliopsoas (psoas+illiacus), I gently apply transverse friction to the tissues to which I have access. While this method doesn’t give access to all of these muscles’ fibers (nothing would), it does open it more than any other technique that I have heard, attempted, or studied.
This technique is far more effective than the traditional method (at least in my experience and the experience of other therapists that have adopted this method) as it is much gentler on the client. Since it so much gentler, this also keeps the client’s body from guarding and feels much less invasive. The extra bonus is that it takes far less effort from the therapist.
In conclusion, while the arguments in the host article are valid against the traditional methods, don’t disregard all deep work.
Dear Abigail
Thank you for your comments, I’m afraid that you seem to be making many of the common assumptions and mistakes in your reasoning that many many manual soft tissue therapists make!
Simply that the notion you are softening, releasing, increasing elasticity of fascia, muscle, tendon or any other human tissue with your techniques and rubbing is just not happening nor is it possible! The forces you generate with your hands will not change human tissue it’s been shown and proven in the literature, even if u did the tissue will return to its previous resting state within seconds, there are no lasting mechanical effects to any manual therapy techniques
Now that’s not to say soft tissue rubs and pulls don’t do anything, of course they do, I use them and many feel benefit but this is ALL achieved via neural modulation via the nervous system the effects of reduced stiffness, pain etc etc is all sensations and interpretation from the nervous system not actual changes in the tissue
So again question why the need to press rub stretch pull aggressively on tissues, superficial or deep ones when it will never ever affect them, why not get the same effects simpler easier and less painful for our patients
Many thanks
Adam
Hello Abigail,
I think it is greatly important to consider ways in which we may work with clients in a way that is more comfortable for them and us. I question whether it is relevant to go “to the psoas” at all, ever. After reading your post, two studies come to mind.
1. Three-dimensional mathematical model for deformation of human fasciae in manual therapy (http://www.ncbi.nlm.nih.gov/pubmed/18723456 free full text)
It does not seem likely that we are mechanically deforming anything fascial, but rather communicating with our client’s NS, providing multi-dimensional inputs and context conducive to catalyzing an altered perception and motor output. We can use positioning, movement, education, manual input of the much less deep variety, to provide the opportunity for change.
2. Why do ineffective treatments seem helpful? A brief review (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770065/)
We are not sure how it is manual therapy works or, as the article above describes, if it ‘works’ at all. There are lots of interventions which seem to work, but it is important to determine by which mechanism those changes take place and consider the subjective, variable nature of perception. As a manual therapist myself, I utilize this mode of communication every day and observe changes in others I contact. I think sometimes it is important to take a step back and view the science from a standpoint which doesn’t already assume “manual therapy works because I’ve seen it work.”
Neither of these articles are definitive in the least, but do offer another angle to evaluate what we do (to whichever degree you are comfortable, of course).
A few thoughts,
Bryan
Thanks Bryan for sharing these excellent articles I must admit to not having fully read Chaudry’s 3D mathematical paper only the discussion due to the maths blowing my mind, way above my intellect
Regards
Adam
Hi Adam,
I had another go at trying argue for abdominal pressure, it was tricky, but here’s where I ended up.
It is my clinical hypothesis that the effectiveness of this technique is sensory, enhanced by active movement and post-isometric relaxation techniques. My experience is that you can achieve the same effect as the typical psoas release by either palpating the distal common tendon of the iliopsoas, the iliacus just medial to the ASIS or the tendinous attachments of TFL/Rec Fem whilst performing active movement or PIR. There are some times when palpating at the abdominal wall seems to enhance the clinical effectiveness of reducing tone and “stiffness”.
By clinical effectiveness I mean a reduction of tone and subjective pain sensation, therefore a length change with sensory changes as well. If the sensory changes lead to a loss of pain inhibition then we can (and I have) seen improvements in functional testing. I can’t really argue for strength as how can we measure? (As you addressed above)
My *baby* is that the palpating of the abdominal region can assist with a sensory identification of dysfunctional tone in psoas and synergists (but we can probably gain the same effect via the distal tendon or region around the proximal rec fem tendon). This may only be temporary but if can trick the brain to let go of tone and we reinforce this with functional testing, movement, PIR or whatever approach can assist with functional movements, we can still have a clinical reason for *releasing* the psoas.
Aran
p.s. I cannot argue for the mechanical release of psoas and gave up on this clinically many moons ago, but I still believe there is a baby in here somewhere.
Hi – there are so many errors of logic here I hardly know where to start, but there’s some good stuff too, so I’ll wade in. Firstly, I hope you will indeed go to dissection classes with the jovial and dedicated Julian Baker to add some actual ‘autopsy’ (seeing for yourself) to your ‘book larnin’, as we say in the States. And then I could recommend – but it would be self-serving – that you undertake this worthy project at one of our dissections with untreated cadavers in Arizona, as this is another experience altogether.
Secondly, I am very sorry that your experiences of psoas release – not a term I prefer – have been performed so insensitively. I maintain – and honest men may differ – that there is value in touching toward / affecting / creating increased kinesthesia – or however you want to put it – the ‘psoas complex’ (psoas major and minor, iliacus, pectineus, and QL – see Anatomy Trains for more info). In can be (American word) ‘intense’, but painful stretching, any attack on the femoral nerve or it;s sheath, and any gassy, hot, or searing pain would contraindicate the technique.
That said, I have found these techniques, sensitively applied after full testing and gaining of trust, to create lasting changes in psoas-induced rotoscolioses, lumbar lordosis and kyphosis, and for general lumbar stability. Not alone, of course, but in conjunction with a coordinated program of ‘release’ and strengthening.
I would separate – and here I reveal my own prejudice – the manual therapy applications I often see in sports applications (as in your pic) and unfortunately also in too many physiotherapists or chiropractors from the sensitive, listening, tissue-respecting approach taught in our program, osteopathic schools, and others.
Although the psoas is retroperitoneal, it is quite easy to work with the mesocolon, ileocecal valve, and the mesentery with respect and no damage. This is all clinical observation – you are totally correct that none of this has been research verified. But if all we worked only with that which has been verified by research, most surgeons and physiotherapists, not to mention the rest of us, would be immediately out of business
We all wish to be judged by our highest aspirations, and tend to judge others by their lowest expressions – it’s a human trait. But one, I think, to be avoided. I respect your skeptical search for the truth, but in this blog you have spoken from less than full information.
Wow, hello Mr Tom ‘Anatomy Trains’ Myers…. its an honour to have your comments on my little blog, very much unexpected and a pleasant surprise!
Firstly, I fail to see what errors of logic I have made, perhaps you could explain more! Next i’m unsure why you think my blog is insinuating that I dont think there is any merit in ANY hands on treatment, I havent said that nor do I think that, however, there are many manaul therapy techniques that do require critique and this is definitly one of them, if not the one that does.
The notion that we can access and influence the psoas muscle by pressing through the abdomen is just complete and utter nonsense, no matter how one tries to justify it or explain its actions, and why would a physiotherapist want to work with the mesocolon, ileocecal valve and mesentery is beyond me!!!
I’m sure YOU have found success in this technique, as YOU teach it and YOU are a key driver in its use in our field, but I would ask you to perhaps consider the notion of YOUR confirmation bias and illusory correlations here?
Also your comment about lack of evidence in our industry meaning that we wouldnt do much is a weak and flimsy one. Everything I do, as a responsible, conscientious, honest, evidence ‘based’ physiotherapist is ‘based’ in some evidence! Yes there are some areas where evidence is scant or inconclusive, and research is lacking on many, many things, but there usually is some, helping to guide us to make an informed decision based on multiple factors. I recognise that some techniques need time to build an evidence base, but I was taught the Psoas Release Technique (im intrigued to know what you call it) nealy 10 years ago, so I would have thought that would have been ample time for SOME research to have been conducted in its use efficacy or usefulness, no???
Finally your eloquent qoutes regarding human traits is very nice but your closing statement claiming I have spoken from less than full information is incorrect, as there is NO more information, just opinion and conjecture!
Regards
Adam
From an observers viewpoint,perhaps when Tom said the article/comments lacked some logic was what I kept hearing repeated is that you can only access a small part of the complex I.e. Iliacus in the lower abdomen, then how can we affect the whole psoas? To me it’s a bit like saying if you have 2 bits of string attached to different points a foot apart and you can only access the last inch then you can’t affect the length of string, if you took a pair of scissors to that last inch and cut it you will most definately effect the entire length of string.
Also slightly off the psoas topic but on the evidence based practice in manual therapy, I agree if we stuck to the letter of the law (or evidence) none of us could honestly lay a finger on a patient or give an exercise with reliability. Until we can find a large study group of people exactly the same, and physical therapists who can deliver the exact same technique/exercise/treatment to each one the debate will continue!
Hi Nigel
Thanks for your comments, I agree with your comment with regard to only, possibly, maybe getting some small amount of pressure onto the Psoas in a tiny portion of it as it passes under the inguinal ligament, so what effect are we going to have, I’d suggest little to none directly to the psoas and as such I don’t believe it has any effect to it, instead the mechanisms of relief are via ‘another’ process which isn’t understood fully but it certainly isn’t the Psoas being ‘released’
Your other comment on the use of evidence based practice (EBP) however I strongly disagree with, I hear this a lot from many therapists.
There are many, many techniques that have evidence supporting them in the manual therapy world and I suggest that this comment shows a therapists lack of awareness of the evidence base not a lack of evidence!
Sure some techniques have more or stronger evidence than others, but when a technique has been around 20 years like Psoas release and hasn’t got a scrap of research supporting it then simply it’s not to be used, also if a technique has evidence showing lack of efficacy then it should be stopped which they don’t tend to be.
Simply we MUST follow EBP otherwise it gives opportunity for charlatans and quacks to profiter and practice ineffective and possibly dangerous treatments, I’m aware and agree some new techniques need time to build an evidence base but we simply must be guided by EBP, there is NO excuse and saying you couldn’t touch a patient if u followed EBP is a weak and flimsy argument
Hope that wasn’t too ranty
Regards
Adam
Hi Tom,
The concern I have regarding ‘psoas release’ is, as mentioned above, it perpetuates misconception regarding what is happening in human bodies as it relates to the lived pain experience and reasonable mechanism(s) of manual therapy for clients as well as practitioners. People have responded that they can reliably palpate this deep muscle, my question is: What does it matter? The muscle is not the bodily entity responsible for post intervention change, i.e we do not need to travel ‘to the muscle to catalyze favorable change’. We treat physiology not anatomy. I can understand monitoring the area for palpable change while working with a client but change does not occur by means of directly affecting musculature (unless someone has a reasonable explanation regarding mechanical deformation or something of the like but that is a whole other bag of worms).
Even if we as practitioners understand the physiological mechanics of manual therapy, telling a client we must travel into the abdomen to ‘release’ their psoas portrays an overly pathoatomical expansion for their symptoms (reinforced by the “I do unto you upon a structure technique”). Our explanations are equally important as ‘what’ we do.
A few thoughts.
Bryan
Thanks for your comments Bryan, you put across in a paragraph what I was trying to do in a whole blog!
Regards
Adam
@Tom Myers
1. dissecting dead bodies cannot tell us much about living organisms
2. Show us some evidence that deep manual pressure along the psoas is more beneficial in any way than active stretching
Thank you.
Evan Raftopoulos,PT
I am interested in your response Tom. You have accused Adam as making several errors in logic. I am curious what type of fallacies you suspect he committed? This is quite a strong accusation from one who has made many “assumptions” in his own writings (including his comments above).
I agree that the psoas major cannot be released but the ilacus can be reached with dry needling to great effect. I have treated many a footballer effectively with this technique as part of a wider rehab program.
Hi Andy
Thanks for your comments, I have two questions, how does a needle in the ilacus ‘treat’ it, and how do you know that the iliacus needs treatment in the first place?
Great blog Adam! Spot on as usual and I couldn’t agree with you more. When is the manual therapy blog coming, I really want to read that!
Ha cheers Dan, the manual therapy piece is pending, every time I do some work on it another topic pops into my head. This manual therapy article is going to be my ‘Eleanor’ as Nicolas Cage would say so I want it to be spot on… Watch this space
Awesome, i will look out for it! I’m taking a session at nuffield soon, called myths, misconceptions and madness. Going to try and spend an hour debunking some myths and getting people to wake up and smell the coffee! I’ll send you a copy once it’s done if you fancy a read of the slides.
Good luck with the writing!!
Damn yes I would like a copy mate, I’ll send you mine in return of a talk I’m doing next month called ‘Palpation, a skill, an art or an illusion…’
great article. Loving all the comments also. I’m a massage therapist that has questioned the effectiveness of the psoas release. I hate seeing clients in pain from a technique I am doing, so I tend to avoid it. My question is what is your approach for treating clients with tight hip flexors?
Hi, thanks for your comments, this topic seems to be splitting opinion. To answer your question I don’t ‘treat’ that many tight hip flexors, I do see many many ‘tight’ hip flexors but in my opinion they are not a cause or a source of pain/dysfucntion, and whats tight for the text books or so called norm isnt always actually tight at all. If on a rare occasion I do think the hip flexors are over active and ‘dysfunctional’ then I usually ‘treat’ them by getting the patient/client to start a functional movement and mobilising program combined with a posterior chain strengthening program.
I dont really ‘treat’ anything, I just direct the patient to fix themselves occasionally
Regards
Adam
Surely if the risks were dangerous there would be some reports to this extent. You don’t need studies to prove this. The results of numerous patients being injured during treatment would surely be well documented. But of course its makes the blog a bit more dramatic….Amusingly I think you accused someone else of confirmation bias!
Not all risks are high or dangerous as you put it, and why would adverse effects from a Psoas release be recorded anywhere? Are all injuries and pains documented and presented as research papers, I don’t think so, also most of the ‘injuries’ from this technique wont be that serious that the ‘victim’ attends an A&E dept or seeks medical advice, most will just be sore and painful for a few days after. If it helps you realise that this technique can be painful and cause other issues then please read through the comments section more as I have already had one comment left stating they were in pain for days afterwards, and I have had many other comments sent to me via twitter saying the same, one even told me he suffered hematuria for a day after. Finally how am I guilty of confirmation bias, you obviously dont understand the term, I maybe guilty of over exaggeration or flamboyant use of vocabulary but definitely not confirmation bias!
“Confirmation bias (also called confirmatory bias or myside bias) is a tendency for people to favor information that confirms their preconceptions or hypotheses” — me thinks its not a bad description but I’d argue its almost preferential to exaggeration. Why the need to exaggerate?
And as for people being in pain somebody else stated they were in pain once and numerous other times were not. So is it the technique or a shit therapist? If I give somebody inappropriate exercises or poor instruction they may end up in pain after performing them….is this because exercise is dangerous or the fact I’m crap at exercise prescription. Funny thing is I rarely use this technique and actually more for assessment but maybe I’m just old and narky and when I read articles that are filled with exaggeration and flamboyant vocabulary it just grates on me!! And makes me question a little more??
Please stay old and narky its a good trait to have! Your description is accurate for confirmation bias but I fail to see how I am guilty of it when I question a techniques method & use and find no evidence or personal experience to continue to use it, instead all I get is others opinion & conjecture, which would then make me guilty of blindly accepting things on faith and guruism and so not critically thinking or evaluating for myself, a far worse crime in my opinion!
I agree the technique of psoas release differs widely and as I have stated on many times its the sustained DEEP abdominal pressure that I question, light touch to the abdomen is completely different and in no way can or should be called psoas release more abdominal massage and I think works through different mechanisms as again I have already said
Lastly I don’t think article is really guilty of exaggeration or flamboyant vocabulary, I’m not that good a writer, just good it seems at ruffling feathers, asking difficult questions and questioning silly ridiculous nonsense such as psoas release!
Great post! I used to “release the psoas” back in my early massage training but there was always something that grated about the theory and practice. When people learn to move and feel their whole body differently, psoas obviously has to change too. For me, “releasing psoas” isolates a part of anatomy out of the context of the whole and elevates it as a magic button to be pressed. It’s also too easy for client and practitioner alike to fall into the notion that change will only happen where the practitioner touches. Psoas comes up all the time in clinic, but so does the rest of the body and I don’t have to physically touch everything to help my clients.
I realize that I am extremely late to this conversation. I was searching for some information on the psoas and stumbled upon this post…. Having acknowledged that this was discussed long ago, I am hoping that you may just feel like continuing this topic for me. I am a massage therapist and, for clients that need the work, I do manual therapy on the psoas. I think this post raises some good points that need to be heard but I also very much believe in the benefit of working the psoas.
Having a healthy understanding that there is much I do not know, I ask: As a massage therapist, what (within my scope of practice) would you suggest is the most effective way to help localize the psoas and get some movement/flexibility in the area to help reduce low back pain? I apologize for the novel. I just wanted to respond, explain and pose my question…. If anyone is still paying attention after all this time passed, I would very much appreciate any thoughts on what I may be able to do to help my client or any suggestions I could make for him to be doing on his own to help alleviate some of his low back pain…. Thank you
I have already done my troubleshooting and history with my client to determine that the psoas is the most likely root to the pain. Now I am left with determining where to go from there. I have my own problems with the ‘psoas release technique’ that I was taught. I have never had the results I learned I would in school. Having said that, I have had positive results in manipulating the muscle to help gain some movement in the hips and in turn relieve much of the pressure causing pain.
You need to have a look at your assessment techniques in regards the source of pain relating to the lower back and I suggest you re read the post above
What do you mean?
Hi Adam,
I thought the words of Engelbert should be expanded upon as he has a bit to say on the topic. His message could be applied to a few other topics as well.
“Please release me, can’t you see
You’d be a fool to cling to me
To live our lives would bring us pain
So release me and let me love again”
Cheers,
Aran
Haha, very good Aran… But didn’t Engelbert also sing
You’d be like heaven to touch
I wanna hold you so much
At long last love has arrived
And I thank God I’m alive
You’re just too good to be true…
He truly does have a lot to say on manual therapy, who knew!!!
Cheers
Adam
Actually, that was Frankie Valle and the Four Seasons.
Hi Adam
Very thought provoking. I use the technique and always thought I could palpate it lower down and have had good results. It is not a technique I use on a daily basis though. The results could be neurophysiological though. I also use light touch fascial work that I was taught in 1998 which again may work due to effects on the nervous system. I have attended one of Julians dissection workshops which was excellent but at that time we just dissected the cadaver in prone so did not explore frontal anatomy. Maybe I need to revisit this. Very well put together argument though and will be interested to see Tom Myers reply.
In my opinion the late Louis Gifford had it right by looking at the body from an evolutionary perspective. After thousands and thousands of years of evolution, has natural selection failed us so badly that we are prone to developing tight psoas’s? I don’t think so. It is just another anatomically driven theory that some numpty came up with, and for some reason the bandwagon has been jumped on (just like it did with core stability) and it has permeated its way into our practice. How about everyone just leaves the psoas alone, starting from now.
Great post Adam. @Pete Grey I don’t think 1000’s of years of evolution prepared our bodies to be sat at desk and laptops for hours on end either. If you don’t routinely move your hips into EOR extension you could argue that this may habitually reduce hip flexor ROM and “tighten” the hip flexors.
I think the argument of a therapeutic ‘release’ is a semantic one (what/how are we releasing?) as these kind of manual techniques only ‘permeate’ into our practice when there has been repeatable, experiential success/proof in treating people’s pain and/or loss of function.
For what its worth; I’ve had good, immediate resolution of symptoms of many hip and some LBP complaints using Soft Tissue Release techniques on distal attachment of ilopsoas/adductors around the lesser trochanter. As Tom Myers said I would never use a force or pressure that causes sustained pain in the abdominals (or any other region for that matter). Improvements can be maintained with an exercise programme as described by Adam above.
p.s.
Surely if anyone expresses any opinion or argument about manual therapy you are guilty of confirmation bias…?
Hi Mark
Thanks for your comments, you make some interesting points. The notion of modern man sitting for extended periods causing hip flexor tightness is an argument I’ve heard lots before and I don’t think it holds water, man has always sat, even when chasing wooly mammoths around I still bet we sat for ‘extended’ periods afterwards!
And does extended sitting habitually cause tightness, I don’t think so I see inflexibility and flexibility in all types of people from all different backgrounds and occupations lifestyles etc etc, sitting it seems to be a nice convenient scapegoat to blame!
With regards to my confirmation bias, you maybe right, but I do use manual therapy daily, I just don’t believe the mechanical anatomical nonsense that surrounds it, so my confirmation bias isn’t against manual therapy rather against the unevidenced and outlandish claims surrounding it. More of my thoughts can be heard here http://www.strengthphysio.com/archives/770
Thanks again for your comments
Regards
Adam
re: “If you don’t routinely move your hips into EOR extension you could argue that this may habitually reduce hip flexor ROM and “tighten” the hip flexors.”…It would seem that this is a very ‘western’ viewpoint. By the same logic, one could argue that eastern cultures (who will often rest in a squatting posture/position) would be more inclined to experience such tightness, no? I have never seen any evidence to support such a conclusion.
Very nice posting, btw, Adam.
Adam,
Great post. “Hip flexor tightness, activation, inactivation, dysfunction, flexibility, inflexibility more than likely comes from an “infinite” ability of the human body to COMPENSATE motions in all our movements ( especially Gait ). The million dollar question is which motion compensations are feeding into the hip flexor dysfunction ? I.E. Lack of Dorsi flex In back leg in gait or lack of IR in opposite side hip ???? But, if one understands the principles of AFS ( Applied Functional Science) the one can discover CAUSES of the dysfunction. Because most importantly, in probably NOT the hip flexor’s Fault, it’s the symptom. There for most manual therapy is just treating the symptom rather than the causes of the dysfunctional Part ( hip flexor )
Kerry
I can’t believe there isn’t any research to back such a widely used and taught technique! I will still ask my massage therapies to release my psoas when my back is feeling stiff! Good read, thanks!
Thank you for this article, is was very interesting and I pretty good read.
Mine is a layman’s point of view. I’ve never had my Psoas ‘released’ by a physio, but instead I use a lacrosse ball and lie with my stomach down on it and I push my stomach against in while inspiring and then I let it sink into my gut as I exhale and relax.
When I first learned about the technique, I thought “nonsense, no way your can reach the Psoas!”, but when I used it, my low back pain disappeared. It was impressive. And not that painful. 2-3 minutes on side are enough. You know when it’s enough because you stop feeling pain when applying pressure. Once a week. Tried it more than once, and it didn’t make any difference.
Not always I get results as impressive as that first time. But for the little time it takes, this manouver pays huge dividends. And who knows what am I “releasing”, probably not the psoas. But it damn works.
Hey Adam,
I’m glad you left the blood vessels on the anatomy diagram … OUCH!
Interestingly extravascular surgical release of the fascial tissue surrounding the common iliac artery and external iliac artery, is one of the SURGICAL methods of dealing with arterial flow problems in young athletes. http://www.ncbi.nlm.nih.gov/pubmed/22186674
They could have saved a lot of money and got PT’s to do it … I NAYSAY to that!
Cheers
Alan
Hi Adam,
Good article, thanks for sharing. I very much agree with you on your main points. Reading through the comments has been so fun seeing people share their (very strong!) opinions, which are coming from their personal beliefs/experience. I think at least engaging in conversations like these shows that everyone involved is at least willing to look at their beliefs and at least entertain a new way of thinking.
I think questioning what we each do as therapists (I’m a postural alignment therapist, not manual therapist or physical therapist) is one of the most important things we can do. Why do we use a certain technique? What does it really do? How do I know it does that? Is this correcting the dysfunction/cause of the problem or just treating the symptom/compensation? Just because they feel better now, does that mean they will be better tomorrow or next year? Will the pain or tightness or whatever come back? Why? Is there a better way to achieve the desired result? These questions are the only way we get better at what we do and how the profession of manual therapy or physical therapy or whatever gets better. When clients/patients come in to see me one of the first things we do together is talk about what therapies they have tried, what those therapists told them the problem was, what treatments they did, how did those treatments affect the problem, did it work, etc. When having these conversations it blows me away how many clients/patients were never told what the cause of the pain/problem was, how the treatments would affect that cause, and show the common sense connections between those things.
I love to hear how others think, because we can learn so much from each other, so I am wondering how many of the therapists commenting on here know that a psoas needs to be released? Do you do functional tests? Manual muscle testing? Evaluate gait? Postural assessment? Palpation?
Do you think about whether the “tight” psoas is the dysfunction or just a compensation? How do you test this?
Then do you retest after treatment? What changes?
Depending on what the retest results tell you, where do you go next? Does it matter?
I like to hear how people connect the dots and make common sense out of it all. That at least is always my goal. Thanks for any continued conversation!
Really well written points. I haven’t used a deep tissue “release” technique like that in a long long time. Found MET to be much more effective and less invasive. Going to revisit this ‘comments’ section when I have some more time to take in all the different approaches. Great stuff on here- thanks!
Hello Adam,
Thanks for your post. I found it fascinating.
I came across your blog by searching ‘psoas release’ as I am wondering whether psoas release surgery might give me some relief from chronic pain (I had a THR of that hip almost two years ago and the groin/hip pain started about 9 months later). The surgical release seems to be a very imprecise solution (at least when it is conducted because of positioning of the prosthesis and the tendon rubbing over it). I’ve also read some article suggesting the tendon can tighten up again.
What, if anything, is your experience with surgical release of the tendon and long-term recovery? I understand if you’re too busy to write a response, but perhaps you could provide a link or two to some helpful studies?
Thanks,
Kate
Hi
Thanks for your comment, im afraid I have not had any personal experience of this issue you describe, although in my searching for evidence for the other type of psoas release I did come across lots of journals and papers on this type of surgery for this type of problem, so I am sure there is info and people who can help, just not me Im afraid
Sorry
I find it interesting that you choose to compare the theory of psoas tightness to the elbow, and not the shoulders. The reason that the current thinking on adaptive shortening of the psoas with new world postures is more directly relatable to the pectorals major & minor, is it not? As they have a tendency to shortening that is plainly visible.
Do you not believe that the “rounded shoulders” posture commonly seen in those that sit at a desk (either work, hobby, student, etc) falls under the same category? If not, I’m curious as to what your thinking is on tight pecs and what causes it, as well as how this could not relate to the iliopsoas.
Especially when you take into account the lower and upper cross syndromes, and hyperlordosis. It’s hard to ignore the biggest of the hip flexors when it comes to obvious bad posture (especially if you perform Ely’s and RecFem isn’t the one that is tight).
I believe you shouldn’t dismiss a likely condition just because you think the technique being used is ridiculous. I have to admit you’ve swayed me to not use this type of psoas release to directly access the psoas, as to not cause harm to the overlying structures. However, if someone comes to me with a posterior pelvic tilt and hyperlordosis, as well as a Thomas test that is positive for an anteriorly pulled spine, I am going to treat psoas.
I usually put them in sidelying and pin the iliacus (after warming the area) and then passively move their leg into extension to stretch out the fascia and underlying muscle. The same can be done in prone by pinning below the organs on the lower part of psoas (and granted the abs aswell) and slowly straightening the legs. This one is harder to do, of course.
Either way, I find myofascial as a good approach to treating the psoas (and surrounding area), and then once it has been loosened, the client can be instructed on neutral pelvis, and TA & glute strengthening as well as iliopsoas stretching.
However I did enjoy your post, it made me question a lot of things and determine my stance on the subject. So thankyou.
– Caitlin
(p.s. I made an account on here just to comment. I am really curious about your stance on rounded shoulders that I mentioned in the start)
(p.s.s. I think one of the things Tom was saying is that you denied that therapists have an effect on tissue and fascia, and only the NS. Or at least it appeared that way via your comments. But, it’s been proven that massage has circulatory effects so clearly it’s not all neurological. And a properly trained therapist can lengthen fascia. I have performed and had myofascial release done to me and the effects are still lasting. If the problems reoccur within a year, a lot of the time it is due to not being educated on corrective posture habits, or lack of participation in performing remex, meaning the root issue hasn’t been corrected. At least that’s what I’ve learned.)
Adam. you conclude by saying that psoas release – “doesn’t work”….heres how you got to that argument…
a. there are too many bodily structures/organs in the way to reach the psoas (this may be correct – I accept that)
b. most clinicians/pt’s don’t use it (likely true)
c. therefore it doesn’t work…ergo provides not benefit and those practicing it are incorrect in doing so
You can failed to consider that perhaps it is not the “psoas” that it receiving the benefit. Suggesting that the “technique” provides patients no benefit also suggests that you have somewhat of a superior understanding of the inner workings of the human body. This is where science tries to get ahead of itself by forming conclusions before it has properly investigating its own hypothesis…Your using some scientific reasoning to disprove the existence of a phenomena, however you also haven’t investigated it fully. What you need to understand is that observation is key, and that one observation cannot simply to used to disprove other observations. You reasoning in (a) and (b) above is inadequate to draw the conclusions you have.
I would suggest that your conclusion would be better left at …”it is very unlikely that the psoas technique is directly manipulating the psoas muscle in most patients”. This is all your evidence can conclude.
Hi Markus
Thank you for your comments, you are quite right I can not truly say that this psoas release technique ‘doesn’t work’ in helping people with musculoskeletal issues
However, what I am suggesting and what I thought I had made clear in this blog, I guess not clear enough, is that it this technique doesn’t work under the premise of reaching the psoas muscle and releasing it, as the name of the technique implies, and it doesn’t work in helping those I have used it on in the past, or those who have told me they have had it done to them.
Your assumption that I haven’t considered other possible mechanisms for effect, is not correct. I am well aware of the neuromodulation effects of ALL manual therapy and these effects may or may not have a positive effect.
But the intention of this blog was not to discuss these effects, rather explain the stupidity and absurdity of those therapists doing psoas release, pressing through abdomens in a belief they are reaching the psoas, its bloody stupid and ridiculous, almost borderline abuse and so I argue should be stopped being practiced immediately
If neuromodulatory effects are wished to be achieved then there are simply much safer, much friendlier, much more pleasant means to achieve these.
Regards
Adam
could this release cause a tarry (bloody) stool 24 hours later in a patient with crohns?
Yes…
OMG! A massage therapist just did this to me, no warning. I’m now sick. Thank you!
What’s up everyone, it’s my first visit at this web page, and paragraph is actually fruitful in support of me, keep up
posting these types of articles or reviews.
Hi Adam,
I recently started reading a few blogs and found myself agreeing with your thoughts on a range of topics. I read this one and it was in stark contrast to my clinical experience and after a few days musing over the conflicts, I would appreciate your thoughts on the points which are troubling me.
Anatomically –
I am a Physio and I predominately work in a young and sporting population with age ranges from 14-25. When I first saw this technique while I was training I considered it an anatomical impossibility in a lot of the population but it is a technique I would consider is possible in the population I work in with levels of discomfort taken into consideration when applying the technique. You certainly can feel a pulse from the Abdominal Artery on the left and I believe both are located at a similar depth in the abdomen.
Palpation and symptom reproduction –
**Firstly, I am very aware of palpation limitations and if this was my only point of contention, I wouldn’t bother writing a reply.**
My belief on why I consider palpation is possible stems from palpation which elicits the clients direct symptoms, often Lx or groin pain if it is a technique I would then choose to implement. My head is happy with that theoretical link. In the lower portion of the muscle I believe that you can certainly palpate the difference between an active and relaxed muscle when the client is asked the lift their knee from a crook lying position. I struggle to think of another structure in that vicinity which is causing their mechanically patterned pain.
Treatment progression-
In instances where I get a favourable response during and between treatments for Lx or groin pain, a treatment progression I have used is Dry Needling the Iliospoas at the lesser trochanter (in the circumstance that palpating this portion of the muscle does also elicit their symptoms). I have had this treatment progression favourably improve symptoms on re-assessment. The same symptoms which were initially improved by treating the Psoas with my hands. I have deduced that this makes sense because I am treating he same structure, just in a different way.
Symptoms Resolution-
I agree with a number of replies to this blog, that treating Iliopsoas is addressing a symptoms, with out treating the problem. I do how ever have one patient in mind who was a snow boarder, 3 weeks post a hyper extension injury to his back. Once vertebral fractures were ruled out, my assessment ticked the theoretical boxes for Psoas contributing to his pain. After two isolated Psoas treatments with hands, no needles, his Lx AROM and combined movements were pain free and were what he considered normal. He returned to boarding for the season with no aggravation. I know that is just one case study, similar to the ones you can find online and I know you can find the same type of stories about K-tape and all sorts of other crap out there, but what ever I did in isolation to his stomach considerably improved his level of function. My mind runs with other situation where Psoas treatment in isolation has considerably improved someone’s between treatment re-assessment. To date, I believe it was a useful technique in their management.
From my experience, they are the sticking points in my mind about this one. Currently, I find it a difficult one to just throw out of my tool box of interventions.
Lastly and more generally, your point about there being no research for such a widely used technique perplexed me. Now, I am not a researcher and have no experience in the area but I expect that there would be a number of things that therapists all over the country do with in the scope of our “evidenced based profession”, which have not been rigorously researched to categorically deem them effective treatments. Treating Pec Minor for shoulder pain, Flexor Digitorum Longus for medial ankle pain or MTSS, fibularis brevis for poster-lateral ankle pain following inversion sprain, Tib Ant for anterior ankle pain in competitive walkers etc. etc. Certainly quick Google Scholar searches of these topics yield nothing but these are interventions that I admit to having used and each one of these examples I have seen positive post treatment effects with in, and between treatments. As a profession we are proud to have our practice based in science and evidence and I value that greatly, but the application of research to our practice is very difficult. As an example, just because I know a study on eccentric exercises for an Achilles Tendinopathy was completed in a demographic of 18-30 year old men and I have a 35 year old female in my treatment room, it doesn’t mean I am not going to use my clinical reasoning and implement that program if I deem it appropriate. Likewise, the patient who comes to me with Lx or groin pain which I believe has a symptom relationship to the Psoas muscle, has not had a RCT conducted on them, so I assess, treat and then re-assess to know if I am correct. That’s my research and evidence.
Thanks for taking the time to read and hopefully discuss my points. I am very aware that in 5,10,15 years time I will be a totally different Physio to the one that I am now and perhaps treating the Psoas is something I will one day laugh about…
Hi Brent
Many thanks for your detailed comments. I don’t want to spend too long going over everything as I have talked about this technique for way too long.
First just because you can feel a pulse of the abdominal artery doesn’t mean your are close to it, I can feel my heart beating through my chest but I cant palpate it.
Next you simply can not reach the psoas with palpation, the depth of most of it and the other structures in the way just make is impossible
Even if you could, using palpation techniques to decide if something is tight, tense, soft,relaxed etc are all prone to confirmation bias of the palpater, ie you feel what you want to believe you feel. When blinded to patients symptoms and history, palpation is no better than guess work.
You’re right the evidence base is lacking for a lot of things therapists do to patients, should we stop everything, no! If there is no risk of harm and plausible rationale reasons for doing a treatment or technique, then we can continue. However digging around someones abdomen as I mentioned is not without risks and and stretches levels of plausibility beyond any sane persons levels of common sense, so yes we should stop psoas releasing
Kind Regards
Adam
At age 37 I was diagnosed with 3rd stage breast cancer. I opted for a tram flap reconstruction instead of a implant. You don’t hear much about this procedure anymore as it is extremely painful and recovery time is extra long. I was cut open hip bone to hip bone and they used my vertical oblique muscles to reconstruct the breast which was removed. I am a LMT, CMMP and MTI. Trust me their is no way possible to reach the psoas to release it. I hear other therapist and theachers saying your hip is higher on one side and your psoas is so tight that is the cause for the symptoms.
After watching my own surgery on video and working on women who use to get old fashion tummy tucks. Even using MFR, palpitations, & stretching. You are no where close to reaching the actual psoas without surgery being involved. Yes, patients will even tell me “my psoas is out” (many are Bikram yoga students). I’m in no way putting down Bikram Yoga even though I do disagree with them using the same routine ever session and it is unhealthy for the body to not diserfy when doing any kind of exercise. I suggest using postural and muscle testing the MFR, ART and sidelining and the release of hip flexors will loosen up and you possibly might get a gentle release which allows the body to self align which then causes the lower back, hip flexors and other ares to let go and you cause the patient little to no pain. Their out of pain and strengthening exercises given to ones who will do them and those areas will stop pulling everything out of alignment.
But you are not getting anywhere close to their psoas. This is my out look on it and sole opinion. No complaints about how much better the patient feels when they leave after 21 years of practice.
If you ever want to talk about Lymphedema their is another area that in the US has been treating people wrong for so long.
Great discussion. Changeling my mind is always good for me and helps keep me young and on my toes while I teach others.
Thank You!
Healthy (90% ok 80%) of the time. It is the holiday season. ??????
So, what CAN I do to get my psoas to release? I’ve been struggling with hip/leg pain for almost two years now and I have to take something for it daily. I’ve been for massage, acupuncture and to an osteopath with no relief. Any help?
why do you think it has anything to do with your psoas and why do you think it needs to release, it maybe that you have had no change / relief because its not the issue?