Two large hip flexor muscles are given unusual emphasis by many massage therapists and chiropractors. The popularity of psoas work — usually meaning both the psoas major muscle and iliacus muscle — is partly due to hype and mystique, and partly because it can be helpful at times (like massaging nearly any muscle can be).
Both patients and therapists need to consider whether it’s really necessary, however — psoas work is an uncomfortable, time-consuming, and expensive treatment to experiment with.
Some have called it “the muscle of the soul.” So deep! So mysterious! So core! Pso-as!
Iliopsoas massage is often pretentiously called psoas “work” — as in, “let’s do some psoas work today.” It implies something more profound and productive than mere massage.1 But the mystique of iliopsoas massage is mostly due to simple geography: it’s just a tricky muscle to get to. The mechanics can defeat therapists, and the sensations can be rough for the patient.
It can be hard to even find iliopsoas if you don’t know exactly what you’re looking for, and many massage therapists with minimal training don’t know the anatomy even in the abstract, let alone how to tell the difference between the abdominal structures under their fingertips. True story: a well-trained therapist once confidently told me, “I’ve reached your psoas, and it’s really tight,” when she was actually pressing on my spine. Things went downhill from there.2
It can also be a physically difficult muscle to get to, even when you know just where to press — nearly all of it is hidden behind a wall of abs and guts. It’s easier to get to than you might think, considering its location, but much depends on the patient’s build. In slender people with a prominent lumbar curve, it can be almost effortless. Thicker people with less lordosis are a completely different story, and the psoas is out of reach in some heavy patients.
I can’t think of a muscle, other than the levator ani, that brings out the crazies like the the psoas.
The other big challenge is sensory: psoas massage is usually unpleasant. Like most flexors,3 the iliopsoas is quite sensitive to pressure — not to mention the tissues overlying it — and the quality of pain is almost always unpleasant. It takes time and caution to do it well and without causing significant discomfort.
What is easy is for everyone involved to fool themselves into thinking that the treatment is important simply because it’s so uncomfortable. Anything that hurts that much must be important and effective, right? A sensitive iliopsoas might need therapy, but you can’t assume that just because it feels bad. Even a happy, healthy psoas may feel quite sensitive. It can be uncomfortable regardless of whether it makes one bit of difference clinically.
Published in 1997, the year I started massage therapy college, The Psoas Book by Liz Koch4 is an influential, but short and amateurish hagiography5 of the psoas muscle. Every sentence oozes credulous enthusiasm and hyperbole about the profound clinical and emotional importance of the iliopsoas muscle. Example:
[The psoas] affects every facet of your life, from your physical well-being to who you feel yourself to be and how you relate to the world. A bridge linking the trunk to the legs, the psoas is critical for balanced alignment, proper joint rotation, and full muscular range of motion. …Whether you suffer from a sore back or anxiety, from knee strain or exhaustion, there's a good chance that a constricted psoas muscle might be contributing to your woes.Liz Koch, The psoas book, 1997
The mystique of the psoas has come entirely from this gushing, ridiculous book. It’s Liz Koch’s fault.
That goofy legacy is perpetuated today by many articles that pile on with fresh hyperbole, like this one on “TheMindUnleashed.com”: The ‘Muscle of the Soul’ may be Triggering Your Fear and Anxiety. This is a mind-bogglingly dumb article, but it’s extremely popular among massage therapists on Facebook, where they promoted it on an mind-boggling scale — 135,000 likes and counting. That is a lot of foolish people. They are all probably huge fans of Ancient Aliens, too.6 Despite progress, the profession of massage therapy still mostly still deserves its flaky reputation.
Psoas massage is over-rated because it just isn’t needed for most people, most of the time. (Many people would argued that it is never needed, and they might be right.) Thanks to professional folklore and a tradition of psoas evangelism, most massage therapists and many chiropractors believe that the psoas is the missing piece in a biomechanical puzzle, particularly for back pain patients. This is a classic example of “structuralism”: the excessive focus on specific biomechanical origins of pain, especially ones that suggest marketable solutions.7 The message to patients is: “I can treat your back pain, because I understand how important the psoas is, unlike therapists with less insight into the intricate workings of the human body.”
No one actually has the faintest clue or evidence that the psoas is truly the key to back pain or anything else. It’s just another spinal muscle, no more or less important than any other. There is no reason to emphasize it. If anything, there are great reasons not to. In particular, there doesn’t seem to be much of a relationship between tight psoas muscles and back pain, if any.89
Massage for low back pain is modestly effective10 without bothering with the expensive and unpleasant process of trying to tackle the prickly psoas. Professionals should remember that most patients consider any therapy to be a major and regrettable expense. Many patients can barely afford three appointments, and therapy should always be pragmatic and as efficient as possible, with a strict focus on doing only what is the most strongly indicated: bang for buck is critical.11 It doesn’t matter that many of those patients might benefit from a little psoas work — what matters is that most of them don’t need it enough to bother.
As a therapist, my attitude towards psoas was always “only suggest psoas work to my patient if we’re out of other options, and they’re still desperate, and we have some clear and specific reason to believe that it might make a difference.” Many other therapists take quite a different attitude: “Psoas is the secret to life itself: massage it first and strongly for $80/hour, or all is lost.” Psoas is a bit of a religion for some therapists. That attitude is rarely a good idea.
In my opinion, it’s merely an interesting muscle, occasionally important … but usually just over-rated.
In early 2015, this article made the rounds on social media: “SERIOUS WARNING – If you do any releases to your Psoas or Abs, you MUST READ THIS.” I don’t care for it, and I’m not recommending it … but I sure do agree with its main point. It is indeed a “disturbing trend” that coaches and trainers are “helping people release by stepping on them,” including stepping on abdomens to target the iliopsoas muscle. I wasn’t aware that this was happening. If it actually is, it’s insane — the apotheosis of psoas hype. Sadly, I don’t have much trouble believing it.
The article is mainly a cautionary tale of an appendix rupture, which may well have been caused by amateurish, aggressive “release” of the psoas:
Karin told me she saw someone last week twice and during that time there were lots of “adjustments” and her “Psoas” was released fairly aggressively (Karin’s description)… [she] felt unwell after the session and got worse, such that she threw up twice within half an hour. She tried to put up with it (she is a tough girl) but couldn’t get any sleep that night and every time she moved, she had severe pain. She still had the vomiting and now diarrhea. When she contacted me, I told her to go straight to emergency as I thought she had a ruptured appendix.
Basically, she did.
When they operated on her, she they took it out and found it had a small rupture in it.
Now, it could be that it was ready to go and a sneeze could have set it off but she had this pain since straight after the treatment and it only got worse. That is part of the risk of working in the abdomen – whether it is Psoas or Iliacus or whatever deep structure you are going for. There is a lot going on in there.
The article is poorly written and full of sloppy clinical reasoning, and all the vague talk about releasing muscles — as if that’s actually a meaningful clinical concept — grated on my nerves so badly it was hard to get through the piece.
But these are quibbles. The main point is sound. Standing on guts to release the psoas muscle is a Very Bad Idea.
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
From the abstract: “Tight hamstring- or psoas muscles could not be shown to correlate to current back pain or to the incidence of back pain during the follow-up period.”BACK TO TEXT
From the abstract: “Among all the factors tested, endurance of the back extensor muscles had the highest association with LBP. Other factors such as the length of the back extensor muscles, and the strength of the hip flexor, hip adductor, and abdominal muscles also had a significant association with LBP. It appears that muscle endurance and weakness are associated with LBP and that structural factors such as the size of the lumbar lordosis, pelvic tilt, leg length discrepancy, and the length of abdominal, hamstring, and iliopsoas muscles are not associated with the occurrence of LBP.”BACK TO TEXT
This review of 13 studies of massage therapy found that “massage is beneficial for patients with subacute and chronic non-specific low-back pain in terms of improving symptoms and function,” and that it “may save money” and the benefits “are long lasting (at least one year after end of sessions).” Although the studies were of poor average quality, most found clear evidence of benefit, and the better quality studies found even clearer evidence of benefit — precisely the kinds of results expected from a therapy that is difficult to standardize, but nevertheless effective. The data so far are still not conclusive, but they do strongly suggest that massage works for low back pain.BACK TO TEXT