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.
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.
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