It may be the most popular muscle in the world.
For some reason, it gets a lot of credit for things and stirs up more debate than any other muscle (at least from what I’ve seen).
Yes, we’re talking about the muscle of the soul! The wonderful Psoas.
It’s been given credit for many a thing, including but not limited to:
- anterior pelvic tilt
- breathing disruption
- manifesting physical symptoms of fear
- knee pain
- digestive problems
- low back pain
- and even somehow is part of our reptilian brain?
Whoa, this muscle is doing a lot!
When we look at some of these statements, they are often prefaced with “believed to,” and while people are entitled to believe whatever they want, some of these things are also taken as fact within our profession.
When I was in college, this was often touted as the main reason people have low back pain.
The muscle’s biomechanics showed us how a tight psoas was creating an increased lumbar lordosis when it was in a “shortened” position in everyone from office workers to cyclists.
But what does the updated research say? Well…let’s get into that!
First, it’s probably important to do a quick review (and yes, I had to look this up).
It starts on the transverse process of T12-L4 as well as the intervertebral discs and inserts on the lesser trochanter of the femur.
This research article(1) takes that a bit deeper and shows there are attachments on the anterior part of all lumbar TVP’s and the anteromedial aspect of the lumbar discs and bodies except on the L5/S1 disc. Where it attaches to the TVP’s is considered the posterior attachments, whereas the disc and bodies’ connections are considered the anterior attachments. There was an argument that those anterior attachments would pull the lumbar spine into and increased lordosis, but that was with an assumption the attachments were more on the anterior surface of the vertebral body, not the TVP.
When I was in school (and granted that was quite a while ago), we were taught that Psoas was primarily a hip flexor that worked along with Iliacus to accomplish the movement. However, some more recent studies(1) have shown it plays some other roles, including:
- advancing the lower limb while walking
- controlling deviation of the trunk while sitting
- some action with rotation, abduction, and adduction of the hip
- lumbar spine stabilization
- hip stabilizer
Interestingly, the study (1) looked at how the Psoas influenced hip pain in a hockey player, but not much discussion around low back pain.
So, is the Psoas a culprit for patients presenting with low back pain?
Size And Role
A couple of studies looked at Psoas under MRI to compare cross-sectional size between those with low back pain and those without, and the results are pretty to interesting.
They found those patients dealing with low back pain had a larger Psoas Major than those without pain. (2)
One possible reason for this is that Psoas is a lumbar spine stabilizer; the muscle’s hypertrophy was due to increased activity in those with some degenerative disorders in the lumbar spine, so it’s working as a support or protection for the area. (2)
When they looked at fat infiltration and whether it plays a role, there was a correlation with some atrophy of the lumbar paraspinal muscles, which would cause Psoas to increase its activity as a stabilizer for the lumbar spine. However, there was minimal infiltration of fatty tissue within Psoas.
One other study looked at how Psoas was affected in older generations and did show there was a difference in size between men and women, which is likely due to hormone deficiencies after menopause. (3)
When there were degenerative changes with the lumbar discs or segmental instability in the spine, they noticed that Psoas actually got smaller. However, this is likely because more pain is associated with these degenerative changes, so the size change is because of disuse. This could also directly correlate to fear avoidance, where a person stops certain activities because they’re worried about reinjuring the area or making it worse, especially after getting what sounds like a scary diagnosis.
To me this is a little bit of a chicken or the egg. Could Psoas be causing pain, or is it’s size adapting because of pain resulting from something else? I’d argue it’s the latter.
So now we understand that Psoas is more of a support to the lumbar spine rather than something that is pulling it into lordosis or causing pain; the question remains…do we treat it?
Well, there’s a lot of controversy around this, and I’d say it depends.
Although I know if I do a treatment in this area in the way I was shown in school, I can definitely feel the psoas “pop up” under my fingers. However, we also know there is A LOT of stuff in the way to be able to palpate something that deep. Because in reality, we can’t palpate something that deep even though we can feel it “pop up”.
I have a person who comes in once a month for treatment and really enjoys getting their Psoas worked on. They feel it benefits them greatly for the activities they participate in. So, yeah, I’ll treat it for them. However, if this was a new person coming in and saying their back pain is a result of the Psoas, well then I’d be digging a bit deeper into their reasoning and having more of a conversation to educate them on how Psoas is probably helping more than it is causing an issue. It’s one of those things where our clinical experience and decision making have to come in to play. Some say we should never treat the area but we also have to take patient preference into account and what they believe will help them. If you’ve been treating the area and having reasonable success and your patients like it, then keep on keeping on. But change the narrative around it. Take the time to educate a little and see if it’s really necessary. Especially if you’ve been giving this kind of treatment and the person is uncomfortable during the treatment (let’s be honest, it’s a pretty sensitive area), then offer to change things up and try something different. Just make it a joint decision between the two of you and strengthen that therapeutic relationship.
If you haven’t subscribed yet, check out our new podcast HERE, we’ll be discussing Psoas this week and discussing some of the research around it.
- Sajko S, Stuber K. Psoas Major: a case report and review of its anatomy, biomechanics, and clinical implications. The Journal of the Canadian Chiropractic Association. 2009 Dec;53(4):311.
- Arbanas J, Pavlovic I, Marijancic V, Vlahovic H, Starcevic-Klasan G, Peharec S, Bajek S, Miletic D, Malnar D. MRI features of the psoas major muscle in patients with low back pain. European spine journal. 2013 Sep;22(9):1965-71.
- Sions JM, Elliott JM, Pohlig RT, Hicks GE. Trunk muscle characteristics of the multifidi, erector spinae, Psoas, and quadratus lumborum in older adults with and without chronic low back pain. journal of orthopaedic & sports physical therapy. 2017 Mar;47(3):173-9.
Tony Gentilcore makes some great points about beliefs surrounding “bad” workouts and self-efficacy with one’s routines. We can likely translate these points very well when it comes to programming home exercise programs for clients as well.
Do Bad Workouts Exist? – Tony Gentilcore
We wrote a similar blog to this one a few weeks ago, but the content bears repeating. The words we say and the way we say it can have a major impact on the outcomes we have with our patients. Let’s start to change not only the narrative around what we do, but also what we say.
Words Matter – Eric Purves
We talk lots about patient safety, but our safety is just as important (if not more). So when I saw this shared by one of our friends I knew it was worth the share (well…also cause I’m a firefighter).
Oily Linens – Massage Therapy – Fire Safety – Megan Crozier
Pretty cool review of the receptors in our bodies and what they do.
Types Of Receptors – Dr. Matt & Dr. Mike
There is many a frustrating debate online, no matter what the topic is. This is a pretty cool little flow chart on how we could handle some of these discussions. While Taylor meant this for himself, it might be something I use as well.
On Discussions And Debate – Taylor James Laviolette
A reader who works with a chronic pain, military population recently asked if I had any tips to prevent burnout. Here are some of mine and also some I gathered from Social Media.
1) Take Different Con Ed Courses
- Most of us gravitate toward con-ed courses we are familiar with, have a certain reputation, etc
- A good way to prevent burnout is to expose yourself to a good seminar on a topic that is novel and challenging
- To most I would recommend Explain Pain or Therapeutic Neuroscience Education
- Getting new ways to interact with patients, especially a chronic pain caseload that does not respond rapidly helps
- Changing your mindset as to how you view these patients prevents the “I feel powerless to help”
2) Hangout and interact with like minded professionals
- join a group like PT: Practice, Education, and Networking on facebook started by my buddy Rick Daigle of Medical Minds in Motion
- participate in a forum like Manual Therapists, ask questions and chime in on other people’s posts
- try to start a local Clinician’s group where you can practice techniques, assessments and discuss cases semi regularly
- avoid arguing on the internet or with colleagues who are stuck in a model that disagrees with your practice (to a point)
3) Consider taking part time cases in a different setting
- if you’re in outpatient, try home care
- even 2 different cases in a different setting once a week really helps prevent burnout
- prior to all my different endeavors, I worked full time in a private clinic (as a manager), did Clinical Peer Review, and taught at 3 different PT schools, needless to say, I did not get bored!
4) Don’t take your work home with you
- obsessing over a case you think you could have done better often prevents you from relaxing at home
- if you need help, ask online in a facebook group, twitter, or a forum, but otherwise enjoy your time away from work
- just like I tell my chronic pain patients, make sure you take time to listen to your favorite music, have a glass of wine, or watch your favorite movie
5) Strive to change and adapt regularly
- part of stagnation or burnout is a lack of change, we all need variability
- if you have not changed the way you assess, treat, or the framework at which you make your clinical decisions at least every 2-3 years, it is time for you to rethink things!
- finding a mentor, whether it’s online or in person really helps with this as you watch them in their patient interactions
We’ve got some big news this week! We’ve launched a podcast! Together with Eric Purves we’ll endeavour to put out a new podcast every two weeks. Give this one a listen as we look into some research that shows how client, community, and clinician can influence a persons pain. Subscribe on one of your favourite podcast platforms!
Client, Community, and Clinician – Jamie Johnston & Eric Purves
There’s lots of talk about education in this week’s articles. This one specifically shows us the importance of the conversations researchers or doctors have with patients when discussing nocebo effects.
We are all taught to not chase pain and to avoid making assumptions purely based on palpation and tenderness. However, we have some emerging evidence that physical tenderness might be a more valid predictor for making return-to-activity decisions that we once though, once we learn how to quantify it.
Have you ever recommended that clients cease running in order to conserve the cartilage in their knees? Or are you on the other side, suggesting that it’s beneficial? Research is still working on a definite answer, but hopefully the current evidence can help you with an informed decision.
Why Don’t Runners’ Knees Fail More Often? – Alex Hutchinson
We understand there can be psychosocial factors associated with pain, however we have to be careful how we discuss this with our patients. While the title of this post lends itself to the idea that a doctor told someone their pain is all in their head, there’s much more to the pain education that is necessary and what was given.
My Doctor Told Me My Pain Was All in My Head. It Ended Up Saving Me. – Isobel Whitcomb
Mike Reinold provides us a good review of the literature regarding compression therapy and its effects on acute soreness and recovery following exercise.
Compression Therapy for Recovery – Mike Reinold