Core strengthening is a popular treatment modality among physical therapists, as well as being popular in the mainstream of exercise. There have been a number of articles written critical of core strengthening (see The Myth of Core Stability). Based on my experience, one serious flaw has to do with tightness that most physical therapists pay little attention.
Tightness of the anterior (front) spinal and pelvic musculature can play a great role in back, sciatic, and pelvis pain. Shortness or tightness of the iliopsoas musculature can cause the lumbar spine to become drawn forward and downward. The psoas originates at the transverse process of L1-L5, with fascial slips into each of the lumbar discs. Tightness of one or both sides of the psoas and surrounding fascia can lead to commonly felt back pain and dysfunction. I find this a repeating theme among patients with back pain and one that I spend a great deal of time in education and treatment. Repeated exercise can lead to shortening of a muscle, if not properly stretched.
Some common symptoms that can result from shortness in this region are pain with prolonged standing, or standing while leaning forward (doing dishes), pain on rising to stand after sitting, especially when you are leaning forward (computer use or bleacher sitting), and lying flat on your back with the legs flat.
If the psoas and surrounding fascia is restricted, further strengthening these areas easily leads to further exacerbation of the back pain. This is what often results from core strengthening. The traditional medical model, including the traditional physical therapy model, pays little attention to these interplays. While your therapist may have put you on a general stretching program for your pain, the prescribed exercises seldom target the hip flexors. Strengthening the trunk and back to better support is a repeating theme among the patients I see who have not been helped (or have been hurt) by this approach to pain.
Myofascial release stresses identifying the restricted or shortened musculature and soft tissue that may be causing excessive strains on the body. In my Foundations in Myofascial Release Seminars™, I stress a unique deep model of evaluation as a part of Myofascial Release training. Without this proper type of evaluation, this tightness is often overlooked. Demand more of your therapist. Don’t settle for what each and every back pain patient receives. No two cases are alike, so why allow yourself to be treated by everyone else?
Walt Fritz, PT
www.MyofascialResource.com
Walt, this is a great article,,, thanks!
Walt, you make an excellent point. I couldn’t agree more. When I herniated two discs (@ L4/L5 and L5/S1, a very common weak point) in 2007, my physical therapist educated me that all of my yoga without complementary muscle strengthening had resulted in amazing flexibility (which I already have genetically), but very weak “core” muscles, as well as weak quadriceps and hamstrings. And the physiatrist my general practitioner referred me to also recommended strengthening of these muscles, especially as my MRI had shown early-onset osteoarthritis. My PT did not stretch my iliopsoas (something I had greatly benefited from w/massage therapy, ever since I had learned about it in Massage School). However, I was informed enough to also see a chiropractor in conjunction with my PT. She needed to stretch my iliopsoas every week for the entire 7 months I was in PT. It helped tremendously. The iliopsoas is so overlooked by so many practitioners – and because stretching it may seem “invasive” or uncomfortable to some clients/patients, I think practitioners shy away from stretching the iliopsoas. But in our culture, where as you point out so much time is spent either standing upright or sitting down for long periods of time, our iliopsoas definitely needs MORE attention.
Kim,
I could not agree more. The psoas is key to many of the ills we suffer. I do have to remind myself that the psoas as an exact entity is too narrow focused. Despite what I in gross anatomy (a well defines muscle leading from the transverse process of L1-L5 and connecting to the lesser trochanter of the femur), it took me a long time to peel away the fascia. Had I been in tune with Myofascial Release at that time, I would have taken more time to see just what is connected to what. I think I would have had a much greater appreciation as to just how “soft tissue” tightness can effect function. Of course this was not possible, as all of that fascia was just something we had to cut away to get at the good stuff.
I give the majority of my patients a simple home psoas stretch. Not terribly painful when I select which of the stretches suits them best, based on their tightness and pain level. (This and other stretches are available on the Archives page of my website for you to download). I have found, though, that unless I start the process of releasing the psoas, etc in session, the home self stretching is less effective.
Walt,
I also find that you have to release quadratus lumborum along with psoas to make a difference.
Without a doubt there are other areas to deal with, including the QL’s. I also pay attention to the quadriceps. I find that the hamstrings actually play little role in back pain. Treat the anterior structures and lumbar region and hamstring issues will fade away.
Hi Walt, would you comment on Pilates? I know it is so much about core strengthening, have a number of clients that do this on a regular basis, they say it helps them, feel better, less pain, and yet they are amazingly tight!!!!!
look forward to your response
Antonia
Antonia,
I have had many clients who benefit from Pilates. I believe it comes down to not putting everyone in the same box. Whether it is cookbook-style core strengthening from physical therapy or Pilates, without an understanding of an individual’s specific needs and impairments, it can be a recipe for disaster.
Maintaining a fixed posture of hip flexion, when preexisting psoas region dysfunction exists, can really be a problem. If I have a client who is doing either core work or Pilates, I will demonstrate what the danger poses/exercises are, educated them on why, and encourage them to back off or eliminate those exercises for the present time until we lengthen the region, or at a minimum to stress elongation of the anterior spine and hip following any type of this work. More often than not they have already begun to suspect that certain postures increase their pain, so they are usually willing to alter their routine.
I have it out on loan right now, but in an issue of the Journal of Bodywork and Movement Therapy there was a critical review of core strengthening research and came to the conclusion that abdominal weakness was not a contributing factor in lower back pain. Facial tightness in the lumbar, deep hip rotators and psoas areas are more often causative factors in my experience. I’ll cite the issue when I get it back.
Thanks, Anthony. I’d love to see that research citation.
Walt ~ i agree… Bodywork makes a very big difference… do you associate psoas major’s slow twitch (postural muscle) fibers — segments of deep psoas major — with the chronic shortness that is often not resolved through movement exercises only? Are we not trying to retrain those cells/fascicles and without releasing them the segments remain incapable of a mild contraction and don’t provide stability? Once released, the nervous system realizes there is a choice and it can recruit the segments of deep psoas major gently — like a “whisper”, providing stability for the lumbopelvic complex.
Jaya,
Very good points. For most psoas (and other areas) issues, I don’t feel that movement exercise can truly resolve the restriction if injury, trauma, or postural patterning has set the tightness firmly in place. I think of the restriction as scar tissue, holding on with physiological changes in tissue make up.
Your image of the whisper is an apt one. Stability with choice is what we are seeking.
Walt,
I totally agree with you re:psoa restrictions. I have done my share of lumbar stabilization training and see this much in the PT world. Years ago Janda documented heavily the restrictions in the psoas and how it not only alters spinal and pelvic alignment but it also inhibits the firing of the abdominals. So all this lumbar stabilization training is a complete waste if you don’t address te core issue (psoas restrictions)
Martha
Martha,
While general exercise certainly has its place, do you think core strengthening is still a waste of time even AFTER you address the core issue (psoas)? I would love a link to that article you mentioned.
Walt
Walt,
Its amazing that I got your email with this blog link today. Tomorrow my kids, ages 14 & 17 go back to martial arts. Although I really like their Sensei, I’ve asked my son if he would be embarrassed if I had a chat with his Sensei.
He had them doing core (specifically, hip-flexor) exercises last week that had them limping for 3 days. It was intense, repetitive work, that I believe is unnecessary. While my kids are young and healthy, I generally don’t believe in this kind of exercise because I am very frequently treating shorted hip-flexor/QL/Quad conditions in my practice. I think if the psoas needs anything, it is generally stretch, not strengthening. I don’t want to offend him, but I also don’t want to see my kids end up with low back issues, either. Any advice you can give me for our ‘talk’?
Thank you
I sympathize with your predicament. My practice is full of folks with tight psoas and quads and I would never recommend extra strength training to these areas without great emphasis paid to the tightness.
When a new patient comes to me with back pain, I spend a good deal of time education them on how shortness can lead to imbalance and pain. Many come with a belief that an imbalance in strength is the cause of their pain or dysfunction. I try to reorient them to the effects of tightness, then show them where in their body they are tight.
Might an approach such as this with with your sons’ Sensei? Come from a place of knowledge, without challenging his/her role. Voice your concerns that length can lead to strength, and that excessive strengthening without providing adequate stretch can be damaging to the muscle and connective tissues. While you could certainly provide homework for your kids to assure they do not lose flexibility, using a feather to sway their Sensei may be the best outcome.
Best of luck and let me know how your conversation goes.
Hi Walt,
I definitely think core strengthening has its place after the psoas has been addressed. I will try to find that article for you.
Martha
The issue I find most often is with the psoas minor. Bending, twisting and lifting often strain the T11, T12 area. The resulting imbalance of the stabilization of the pelvis from the ramus of the pubic bone causes pelvic distortion. I use Structural Relief Therapy that I learned from Tay Countryman to reset neuromuscular balance then interactive movement to restore function.
Hans,
Good point.
On a side note, after Googling a bit on the psoas I came across this study:
Anatomical differences in the psoas muscles in young black
and white men
Two interesting points are mentioned in this study:
1. “The psoas minor muscle (PMI) was absent in 91% of the black subjects, but only in 13% of the white subjects.”
2. “At each segmental level, the calculated anatomical cross-sectional area (ACSA) was more than 3 times greater in the black group compared with the white”
Might these findings may cause us to rethink how we deal with back pain, etc, across races?
Walt,
With all due respect, I have to take issue with your stance, as it is based on several faulty premises, many of which start with Eyal Lederman’s article. His article is interesting and provocative, but like Stuart McGill from Canada, it is also based on faulty premises and reasoning, and, as becomes obvious only later in the article, he has an axe to grind and his own treatment protocol to promote.
A very nice rebuttal of Lederman’s paper was written by Glenn Withers, founder of the Australian Physiotherpay & Pilates Institute (http://www.ausphysio.com/Files/files-filename-24.pdf) in response to an article based on Lederman’s paper that appeared recently in the UK Times. Mr. Withers rebuttal is cogent and timely and I highly recommend you read it, along with the plethora of research that has come out of New Zealand in the last 15 years, and replicated all over the globe, which details the mechanism by which REAL core stability training affects low back pain.
I won’t take up the space right now to detail the problems with McGill’s research, but they are many.
In your statement you cite the frequency with which we see tight musculature and fascia on the anterior spine and hip, particularly the psoas and quads. The psoas, quads and QL’s are prime movers, and therefore destabilizers of the spine. They have a secondary or possibly even a tertiary stabilizing function, but strengthening them is NOT part of a well-crafted core stability program. Doing crunches is NOT core stability and is not part of the Pilates system. The misconceptions about what constitutes core stability work are legion.
Furthermore, core stability in and of itself, is useless without being able to apply it in a functional way. Pilates is especially effective at varying the core stabilization challenge in a dynamic way, providing very good carry-over to ADL’s and many if not most sports. In fact, when I evaluate core stability in my patients, it almost always during dynamically challenging activities. I have encountered far too many people with strong rectus abdominis muscles, overly developed psoas, quads and back extensors, that couldn’t stabilize their pelvis to save their lives (which is why they ended up in my clinic in the first place.)
With almost 30 years experience teaching Pilates, and having been a Master Trainer in two national Pilates certification programs, I can also assure you that real Pilates does indeed promote true core stability without adverse effect on the psoas, quads or QL’s, and has helped countless people learn to manage their low back pain.
Part of the problem with Pilates these days, is that any gym rat (or PT for that matter) who thinks he knows enough to be a personal trainer, can take a weekend seminar in Pilates and call themselves ‘certified.’ The entire Pilates system is incredibly complex with hundreds of separate exercises amongst all the apparatus and matwork, and that certainly can’t be learned in only a weekend or two of seminars. A well trained instructor knows how to adapt the system to a specific client’s needs and goals, with the ultimate goal being to provide a balanced whole body workout, that includes stretching as well as strengthening.
Most people’s experience with Pilates these days is with poorly trained individuals teaching ersatz Pilates in group classes. That certainly is a recipe for injury, as is evidenced by the increasing number of personal injury torts since Pilates has gone ‘mainstream’ in the fitness industry.
This is a guess, but it sounds to me like you haven’t taken the time to fully understand the biomechanics and physiology of the core muscular system, and are basing some pretty erroneous conclusions on that misunderstanding. I know I wasn’t taught this in PT school, and so far I have encountered few recent PT grads that fully comprehend the concepts taught in a rigorous Pilates teacher training program. You would be doing your patients and those that look to you for advice a great service by looking into this in more depth before making public pronouncements.
Chris,
I appreciate and respect your reply. The basis for my observations is in fact what you mentioned “Part of the problem with Pilates these days, is that any gym rat (or PT for that matter) who thinks he knows enough to be a personal trainer, can take a weekend seminar in Pilates and call themselves ‘certified.“.
The patients who I am seeing in my practice are being treated by physical therapists who apparently do not possess the degree of training that you have. But this is what is being passed off as Pilates to my community at-large. I was wrong to broad brush Pilates as a whole in the manner that I did and, for that, I apologize.
Effective education of the public on what you expressed seems part of the problem, as the proficiency that you spoke is not what I am seeing as outcomes.
As for conflicting research and papers, we both know that opposite opinions can be found for most interventions. I respect your objections to the literature I cited and I will certainly better acquaint myself with the paper you supplied.
Aloha Walt ~ to follow up on Chris’ comment, I think we all agree that normalizing soft tissue is too often overlooked in a rehab program. We are fortunate to have bodywork methods for releasing long held patterns in muscles and connective tissue. Similarly, exercise systems like Pilates, Feldenkrais and others are great for restoring proper movement patterns, yet they usually work better with bodywork. Are physical therapists not taught to first normalize the soft tissue dysfunction?
Though the PT curriculum may have changed over the years since I graduated, the attention to soft tissue was more in the realm of tone normalization. Certainly not the type of soft tissue work that I do today. There were a few student DPT’s the seminar I taught last weekend who told me that they get a fair deal of manual therapy in school, which is a plus.
I’ll repeat what I had said previously: If the modality is performed by a well trained individual, the outcomes are usually very good. Unfortunately it is the poorly trained “instructors” out there that are seeing the bulk of people, and the results are often not pretty.
Thanks Walt ~ I am not sure what tone normalization means. This is helpful for me to better understand physical therapy.
Tone normalization refers to utilizing NDT (neurodevelopmental technique), PNF (proprioceptive neuromuscular facilitation), etc, to reduce high tone or increase low tone in the neurologically impaired.
Walt, I just archived your core strengthening article and I to have an issue with how the low back is dealt with by PT’s. I have many patient that come to see me with no results or they have more problems. I have always believed that strengthening the core is not the way to go. I have found also that the hip flexors are not dealt with many times. I give a thorough evaluation before treatment with new patients and find many of them have hip flexor issues as well as psoas problems. Many times we as therapists just touch the low back where the pain is felt. We need to not neglect the psoas and hips. Thanks for a great article.
Hi John,
Strength certainly plays a role in function, but to choose weakness as the primary limiter with regard to pain is short sighted. Proper attention paid to anterior and posterior pelvic and lumbar fascial and related soft tissue elements usually clears up the pain without the need for strengthening. Then, and only then, should properly applied exercise be begun.
Walt