Psoas' I Was Saying...
Inspired by a recently anatomy image of the relationship between the psoas muscle and the lumbar plexus nerves, this episode shares my thoughts and approach to "tight" psoas muscles and poor hip flexor performance.
I discuss the role the psoas plays with the viscera, nervous system, and movement and offer my thoughts on assessment and simple treatments that don't really involve endless stretching, smashing, or strengthening of the psoas muscle.
Join me on this anatomical exploration!
Resources mention in this episode:
Born to Run by Christopher McDougall- https://amzn.to/46ErsZQ
Episode 15 "Hard No to the Hard Tools in the Gut- https://www.movementrev.com/podcast/season-1-episode-15-hard-no-to-the-hard-tools-in-the-gut
Physiopedia-https://www.physio-pedia.com/Psoas_Major
Instagram thread post on the psoas and lumbar plexus- https://www.threads.net/@movementrev/post/CyCp2-BLGwe
Femoral Nerve glide- https://www.instagram.com/p/CQPXhbfF6Y8/
Lateral Femoral Cutaneous Nerve Glide- https://youtu.be/Spi6jin36oU
Obturator Nerve Glide- https://youtu.be/LcHqK_cy12g
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Hey there and welcome. I'm Anna Hartman and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello, hello, welcome back to another episode of the unreal results podcast. I,
I was not a hundred percent sure what I want to talk about today on today's podcast. I had two options. They're, they're a little bit related to each other. Um, first was inspired by an image I saw. of the lumbar plexus the other day, and then the other was inspired by a, um, client that I recently worked with, um, who had back pain.
So how these relate to each other, um, with the lumbar plexus, the picture that I saw, which was, I was like, Oh, I, I kind of knew this, but this image made me really appreciate it that the lumbar plexus. Anatomically is within the psoas muscle, which was a little bit of like a light bulb moment for me because the psoas, I'd say, A lot of people know where the psoas is.
A lot of people like to do like self massage, like smash the psoas. Um, a lot of people blame it with low back pain, which you might not be wrong. Um, a lot of people like focus on it for strengthening and just, it gets blamed and contributed to like a lot of things in the, in the world of sports medicine.
And, um,
and. I think it's also really misunderstood, to be honest, which makes sense because it is so deep in our abdomen. Um, it's like hard to see, like our quads, we can see them, our calf, we can see them. When you can see a muscle, you have a little bit better and more intimate understanding of. What it is, what it does, how it functions, because your eye, you see it with your eyes and so it's easier to believe.
Um, so, you know, if you've never seen the psoas with your eyes, it's a little bit hard to, like, comprehend. Um, which, you know, on a complete side note, like, why? Being able to be in an anatomy lab is so important if you're going to especially if you're going to go go into any career in sports health care So anyways So that image really inspired me to like oh I need to share with the world about this a little bit more and then my patient he had back pain and you know you could have easily just Blamed it on the psoas, released the psoas, and probably gotten some relief to be honest, and we'll talk about that.
But, ultimately, what was really driving his back pain was a visceral restriction to the small intestines, and the small intestines, the root of the small intestine, which is Called the mesenteric root. Um, it, it, it goes on like an oblique angle and it crosses the psoas, really both of those psoas, but a lot of the right psoas and, um, in fact, the distal end of the mesenteric root, um, ends up being in the pelvic bowl, which.
I think, too, a lot of people when you're doing manual therapy on the psoas, the tight thing you feel, the thing you're pushing on is often more of the mesenteric root, especially when you're on the right side, um, versus the hip flexor itself, um, the, the psoas itself or the iliacus and um, which same thing like on the left side, sometimes when you're pushing on there, you're likely more pushing on their sigmoid colon than the muscle, unless you are really good at, I don't think it's.
Let me rephrase this, I don't think it's not possible, it is possible, um, to be palpating and working directly on the muscles in the posterior abdominal wall, but it takes a very skilled, sensitive touch to be able to differentiate what structures you're pushing on, viscera so that you can sort of maneuver yourself in the spaces between.
So, um, this is why they're interrelated. That's, that's probably like the only bit I'm going to talk about when, uh, about the small intestines and the mesentery and low back pain, just for the sake of the episode not being super long and to focus really on the anatomy of the psoas and a little bit more of the function of the psoas.
But from a visceral standpoint too, whenever we're. Whenever our viscera are not happy in terms of, and what I mean by not happy, meaning the function of the viscera is being affected by inflammation or illness, disease, um, the nervous system, right? Like what messages it's getting, um, digested. for digestion or not, um, the organs, you know, related to our reproductive systems, like how well the hormones are affecting them, right?
Like if the function of the organ is limited, or even if there's been some sort of trauma or injury to the area that's going to affect the ligaments in the, in the fascia that are holding the visceral organs to the skeleton. Within the abdomen and then therefore the organs cannot move well Which eventually will end up meaning they won't function well because just like our body needs movement in order to like maintain good health Our organs need movement to maintain good health What happens is the muscles around them Go into a protective mode and literally like splint the area and Since the psoas is part of the abdominal cavity It's the deep posterior wall of the abdomen Oftentimes, it will tighten up reflexively to protect these organs.
Now, what we often forget about from a visceral organ standpoint is that the nerves, the peripheral nerves are also extensions of the visceral organs and the, um, Vascular structures, right? The large vascular structures like the aorta and the vena cava and the mesenteric artery and vein and the portal vein, like all of these large vascular structures, but then even the smaller vascular structures in our limbs.
Those are extensions of viscera too. And so we have to consider also the viscera within the psoas, which is going back to the, um, Inspiration for this podcast episode was that picture I saw of, um, the lumbar plexus that I found just with the Google search.
And I'll, I'll share it if you're watching this video on, or watching this podcast on YouTube, I'll throw up a picture.
And then of course, you know, you can always go to my Instagram. Um, I definitely shared it there too, but understanding that the nerves of the lumbar plexus. through the psoas means that the psoas is always going to be sort of the, um, protector or the bodyguard of the lumbar plexus. And when the lumbar plexus is not able to slide and glide or is getting not clear messages through it, it's going to result in the, so as being tight.
And this goes back to as well, like how we treat it, right. Instead of, you know, when we look at the so as, so let's go back to thinking about the so as in terms of just a muscle standpoint, like what it does. We, I said it was a posterior abdominal wall muscle. which means it's on your back. Um, it lies on top of or to the side of your lumbar spine.
It originates from the body of the lumbar spine, the ligaments of the lumbar spine, the transverse processes of the lumbar spine. It has multiple levels of Um, attachments there as well. It interdigitates with the, um, tendons, uh, and parts of the, of the diaphragm. And this is something that if you look at, um, evolutionary biology and in how our, like how.
The relationship between the psoas and the diaphragm are related in animals. In some animals, it was very related to the diaphragm in terms of the leg movement helped to move the diaphragm to facilitate respiration. And so this is a very intimate connection between the two. I believe I read about that in the Book born to run.
Um, I'm pretty sure that's a book if it is. I'll double check and then I'll link whatever book it is in the show notes, but it's either, I'm pretty sure it was a born to run book anyways. Um, so the, so as then travels down the posterior abdominal cavity through the bowl of the pelvis joins up with the iliacus muscle and then attaches to the lesser trochanter of The femur is very high up and very medial and even a little bit posterior on the femur.
So understanding where this is, is really important for function. And um, I would say my athletes, when I am evaluating their hip flexion performance, this is probably one of the biggest things. that they don't do well, and fundamentally, sometimes it's as simple as because they do not understand where their hip joint is, and where the iliopsoas is attaching to the leg.
And once you can understand where the hip joint is, and where that lesser trochanter is, and the job of the iliopsoas as a hip flexor, what it's really doing is just moving the femur and setting it. in the acetabulum and helping it to sink posteriorly. Um, once they understand this, then we can do the exercises and be so much more specific about, I don't, not necessarily maybe targeting the psoas, but ensuring that hip flexion involves really good action of the psoas and the iliacus.
So, um, I was reading. You know, whenever I do a podcast, I always kind of like to read a little bit about the anatomy and whatever I'm talking about, just a review, just to make sure I'm not missing anything or not missaying things. Um, but one of my favorite websites on the internet to read about anatomy is Physiopedia.
I don't know who runs Physiopedia, but they do a great job. Um, because they have more than just anatomy. Like, I even, like... I read about some like aside joint special tests on on their website. I just really love that website. Um, So Physiopedia, I really love Kenhub as an online like anatomy atlas But for the most part whenever I'm searching anatomy, I just search search into Google images But then it usually the the pictures I like are coming from those Sites or journal articles and things like that.
So anyways in When I was reading in Physiopedia about the psoas and they were talking about this relationship to the lumbar plexus as well, and they were actually saying that the psoas has an anterior compartment and a posterior compartment that's actually almost like two different muscles. That are separated by the, um, lumbar plexus, which is a little bit different than the image I saw on, um, Google search that, um, showed, showed this relationship between the lumbar plexus and the.
So as, but it makes sense that it would be like that. But also I have a feeling. It's sort of like the pure form is in that sense is, I think a lot of us know that there is variations. of the relationship between the piriformis and the sciatic nerve. I've even talked about it on the podcast. Um, in some people, the sciatic nerve, like, pierces right through the middle of the, um, piriformis.
In others, it goes underneath the piriformis. And in some, it goes on top of the piriformis. Or some variation of all three of those. And so, um, I'm sure, probably, if we looked at the cadavers, um, We would see probably Variations of this relationship between the lumbar plexus and the psoas, but, um, whatever it may be, whether the, the, the nerves pierce through the psoas as a whole muscle or between two compartments, um, of the muscle.
It's still very intimately connected, the psoas and the lumbar plexus. So, um, the psoas besides being a hip flexor, it also stabilizes the spine. Um, it has a very strong relationship with our, um, core container, uh, being part of the posterior abdominal wall and interdigitating with the, um, diaphragm and, and being on the lumbar spine like that.
And also it can create. Lateral flexion of the spine, which is, you know, makes sense when you look at the origin of it because of how it inserts on the transverse processes. Um, and then, of course, when the legs are fixed, it can, you know, flex the spine as well. So, um, all that said, because I want us to sort of, what do I want out of this podcast is one just getting a better understanding of the anatomy of the psoas to understanding how we can affect the psoas from both a movement standpoint as a hip flexor, a movement standpoint as a core container muscle, a movement standpoint as a protector of the lumbar plexus.
So. I actually want to walk you through, um, first probably, well actually let's, let's, let's, let's do this how I would do it in real life, um, with this lens of view of the viscera are the most important thing to the body. If I evaluate someone and I think their psoas is tight, which first of all, how am I coming to that conclusion?
Good question. Cause it's, I don't think it's the most straightforward thing because there's so many inflexors and there's so many literally moving parts. to examine, but how I like to test the hip flexors in general from their mobility into hip extension standpoint is in side lying so I can monitor the spine and I can monitor the pelvis and Then I bring the leg the thigh up into hip flexion and then I start to move into hip extension and I like to see when the spine or when the pelvis starts to move if I feel the spine moving before the pelvis that can be more indication of the psoas versus the other hip flexor muscles.
But then where I call their hip extension is where either spine movement or Um, pelvis movement starts happening, right? That's like the relative stiffness point. And then you can also sort of, again, when you get good at trusting what you feel in your hand, you can just kind of feel where is that tension coming from?
Does it feel like it's more in the muscles that are attaching to the pelvis? Is it more medial or is it more lateral? And, um, so that's a good way to test it.
Um, however you want to arrive at the, so as being tight is totally your goal. It can be a postural assessment. Um, it can. Yeah, whatever. So, but going back to if it's tight or if it's weak, so how do I test the strength? I mean a straight up manual muscle test of 90 90 hip flexion is usually great to do, you know, the more You're in that hip flexion piece, you know, theoretically the more you're getting iliopsoas though if we look at the function with the actual function of the psoas as the hip flexor is in the first 15 degrees of hip flexion is when it Centrates the femur in the hip socket.
So I also like to look at long axis hip flexion and You can usually see so long axis, long axis hip flexion, meaning, um, supine. So lying on the back and you have asked somebody to lift their leg just, you know, a few inches off the table, which is usually like between 10 and 30 degrees of hip flexion. And if you have them do this and you see a huge pelvic rotation to the side that they're lifting.
This is usually indicative of them trying, of them, not trying, of them using more of their pelvic, um, hip flexors that attach to the pelvis muscles than the psoas itself. And why this makes sense is because, so, if we have the pelvis here, right, and we look at the hip flexors that attach to the pelvis, that's going to be the, um, rectus femoris.
The sartorius, the TFL, when we see those act on the leg in hip flexion, those attach to the ASIS. And so when... What happens is when the weight of the leg lifts up and we're already sort of pulling on the ASIS, it creates a rotation just because of where the pull is coming from on the pelvis. Whereas if the leg was being lifted more by the medial structures like the iliopsoas and the adductors, you would be moving closer to the midline of the body.
And so the pelvis would say stabilize. So that's a good way to check, um, for hip flexor strength and performance, but, at the end of the day, whenever you're checking hip flexor performance or hip flexor strength with a manual muscle test or movement test like this, you're really assessing all of them together.
, so once you determine that it is limited, now we're taking the lens of view of it's tight or weak, more than likely because it's in protection mode. And why is it in protection mode? So you've got the large digestive and pelvic visceral organs that it could be protecting or or the lumbar plexus itself.
And this is where a good evaluation comes in, right? To be able to determine those things. This is why I'm like so big on the LTAP is because it helps us to figure out if there is an, um, abdominal or pelvic organ causing this. Um, Versus is it central nervous system right from the, from the more, um, spinal dura components of the central nervous system or is it peripheral nervous system?
And now we're looking at lumbar plexus. And so depending on what one of those things it is, you're going to treat that specifically. So with my client the other day, it was. small intestines. So I treated small intestines first. And then his hip mobility had totally changed the, um, for the sake of this conversation, we're going to talk about like, okay, so it wasn't abdominal or pelvic organs.
This leaves and it wasn't central nervous system. So this leaves the peripheral nervous system in the lot And so let's take a look at the lumbar plexus. So the lumbar plexus the best way I actually like to assess the Mobility or the slide and glide abilities of the lumbar plexus is the prone knee bend Or at least legs test.
It is a nerve tension test. And so in prone I take their, um, lower leg and move into passive knee flexion. And what I'm paying attention to is what's the tension like and how soon does their pelvis and body sort of rotate away from that side or go into extension in the back. And this is, you know, some people will see this and be like, Oh, they're quadriflexors tight.
But I see this and it's like, no, this is a neural thing. And so, um. Once I have that identified, then we can go and do some specific things for the lumbar plexus. So the lumbar plexus nerves are going to be the operator nerve, it's going to be the femoral nerve, it's going to be the lateral femoral cutaneous nerve, the iliohypogastric nerve, and the genitofemoral nerve.
They basically come out. Go through the psoas and then sort of come down into the bowl of the pelvis. The, um, iliohypogastric and the genitofemoral nerve kind of actually just wrap around the bowl of the pelvis. And then the obturator nerve, femoral nerve, and the lateral femoral cutaneous nerve kind of come more straight down in front of the SI joint as they cross into the hip.
And, um, We can have an effect on these by one, just doing manual therapy at L1, L2, L3, or doing standing or kneeling. Lumbar plexus nerve glides. So another way too is you can kind of work on the skin or the soft tissue in the area of the lumbar triangle on the back. So sometimes I do dynamic cupping on the backside here.
Um, and sometimes you can even pick up some of the cutaneous nerves from this area at the transition between sort of the paraspinals and the obliques on the side body. Um But then I love the half kneeling operator nerve glide, the half kneeling or standing lateral femoral cutaneous nerve glide, or half kneeling and standing femoral nerve glides.
All of these are great and this involves Um, and you know, create a little bit of trunk flexion, upper body, hip extension, and then either maintaining a neutral position of the thigh, or with a little bit of a deduction or a deduction, depending on which nerve you're sensitizing, and you can even, Um, and then you'll take your pelvis and you're moving your pelvis back and forth to sort of, you know, quote unquote, floss the nerve.
Um, you can also, if you don't want to use the pelvis, you can hold the pelvis in a tucked position and then use the head. You can use trunk rotation. You can go in and out of hip extension and flexion. You know, you can use any driver for that nerve floss, but the key is one, that you're not holding it in a stretch and two, that the intensity stays low.
Um, and I think too, it works better when you can embody where the nerves are. So when I am teaching my athletes how to do this, I'm teaching them the nerve flies. So that's, that's where I would start either treat the underlying visceral component, treat the underlying peripheral nerve or central nervous system component.
And then we work on hip flexion performance and the most important. thing I found for my athletes to have a movement experience is, is like I talked about at the beginning, is knowing where the hip joint is, knowing where the psoas attaches on the lesser trochanter and how it feels to move from there.
And the best way to do that is have somebody find their hip joint and I do that in standing. I'll even stand up and see if I can show you. In standing, I have them find their greater trochanter on the side of their leg, you know, like wiggle around until you feel that knobby part with a flat hand, replace it with your thumb, and then wrap your hands around the front of your leg, where the longest finger ends, slide up into the crease of your hip, right there is your hip joint, the lesser trochanter is going to be sort of like just medial and posterior to that, and that is where we're hip hinging.
That is where the psoas attaches. So once you can identify that, you can either do hip hinging exercises or you can do supine hip performance, hip flexion performance. And I tell people like, imagine you have, you're like a marionette puppet. Now, you know where that is. So as it attaches and it comes in the midline right above your belly button and the poles coming from there and when the poles coming from there to move your leg, what you'll see is this really clean movement that's moving just the thigh instead of thinking about the lower leg.
It's moving just the thigh and the socket and then that's when you get to see that beautiful centrating of the femur in the hip socket and the sinking down into posterior glide when they come up into hip flexion. That's when you feel that deep connection as the hip flexor activates in what you'll feel in your own body doing this with athletes will feel is this like, um, opening across their low back and this connection into their proximal stability and core control.
And so then once they feel that movement experience, then you can take it to like. Standing, hanging, any sort of hip flexion activity, wall drills, anything you're going to do with hip flexion. Now they have the movement experience of what it feels like for the femur to sink in, be centrated into the socket and moving the thigh as a lover.
I always tell people it's almost like a teeter totter, right? When your knee comes up, your femur should be sinking down and back. Um, that's when they get really good control around the hip joint and really good function of the psoas. And, you know, vice versa, when you have good function of the psoas, you more than likely are going to get good Like nerve mobility nerve glide through for the lumbar plexus, right?
Because it's almost like pelvis on femur versus femur on pelvis motion. Same thing with the nerves We can glide the nerve through the muscle or we can move the muscle around the nerve, right? and so when the muscle fibers are And the muscle cells, the muscle fibers, however you want to consider it, are working optimally, um, and activating and doing their job as this centrator and hip flexor and core control muscle, then they're, those filaments, those fascia is gliding around the nerve plexus as well.
So, um. It's sort of a vice versa, like interconnected relationship quite, quite well. So, you know, yeah, I don't want you to think that hip flexor hip flexion performance isn't something or strength isn't something that we can work on, but I just would say that it works a lot better when we can first get it out of the protective mode and then second, um, understand where it is, what it does, and then add the movement on once you feel that movement experience.
Um, One of the other ways that I actually love stretching the psoas be so, you know, if you do want to work on more of that eccentric lengthening and, you know, you do, you know, you've done the nerve glides and you feel like it is just more muscular. I, um, love to actually stretch it in relationship to the diaphragm.
And so one of my favorite ways is lying on your back. With your legs wide, hook line position, hips abducted, feet dorsiflexed to protect the knee joint. But then you're going to drop one side, the side you're stretching, you're going to drop that knee in towards midline. So you're going to hip internal rotation.
And then you're doing good, um, posterolateral breathing, really focusing on the diaphragm dropping down and widening. And you get to feel this nice, uh, Lengthening of the psoas as the diaphragm pulls. on that tendon, that relationship between the, um, hip flexor and the diaphragm. So that's actually one of my favorite ways to actually stretch it.
Because when you're stretching half kneeling, most of the time in the half kneeling stretches, you're actually, it's more of a nerve glide than a stretch. And so if you're holding it, or if you're making an intense, you're actually irritating the nerve more than you're helping it. So, um, this, this supine position stretch, I feel like It really does get deeper into the posterior abdominal wall.
And like I said, then sometimes doing some self massage back there on the posterior abdominal wall. I do, um, teach people how to use a soft Franklin ball to do a hip flexor release, um, in the gut. Um. Yeah, I do like that though. It is a more of a general technique, but it's also so important for the Utensil to be soft.
I did a whole podcast episode on that right end of the gate early on in the in the Beginnings of this podcast and so can't emphasize that enough if you're gonna have people releasing and for those of you listening and I'm doing air quotes releasing their hip flexor with a massage tool lying on their stomach, which I do.
To help people, you know, show people how to do. It needs to be a soft tool. No hard tools in the gut. Your visceral organs can be injured. There's nerves there. There's vascular structures there. You don't want to fuck around injuring that shit. And so, um, A softball. And then again, it all, it's not just blindly going in.
It's, I spend a lot of time teaching people how to know where the ball is, where they are in space, so they're more likely targeting the right thing. And, um, yeah. Anyway, so I'll link, I'm going to link a lot in the show notes. The book I mentioned. I'll link Physiopedia for you as it's a favorite. I'll link The Instagram posts with the picture that inspired this.
I'll link the hip flexor release and I'll link some of the nerve flights for you, too So you can try those out and see how it feels Um, what I'm not covering in this because it'll be in another podcast episode and it would be way too much It's just all the visceral stuff that we talked about because that's its own sort of conversation, but know that that is a piece of it and figuring out if it's visceral or neural is an important thing because that helps guide what you're going to do treatment on.
So anyways, uh, as usual, this podcast went longer than I thought it would. Hopefully it was helpful information and, uh, has you looking at the psoas in a different light. So have a great day. We'll see you next time.
