This Hip Flexor Can Contribute to Lower Back Pain: the Psoas

There is one hip flexor muscle that often contributes to lower back pain: the psoas.

The psoas muscle is hard to find and easy to annoy. It is not just a hip flexor, it is also a spinal muscle and the only muscle to bridge the upper and lower body. You can learn more about the location of the psoas and how it relates to the other muscles of the torso by checking out these posts on core anatomy and hip anatomy.

How the Psoas Hip Flexor Causes Lower Back Pain

Because of its attachment points all along the inside of the lumbar spine, when the psoas muscle isn’t properly supported, strengthened, and lengthened it can pull on the vertebrae of the lower back. If this goes on long enough it creates conditions that are conducive to spasms. When you hear someone say that their “back has gone out” (where did it go?) or if you have had that unpleasant sensation of excruciating lower back pain that causes you to lie on the floor and cry for two days, there is a good chance that your psoas was in rebellion.

Studies have also shown a correlation between weak, underused psoas muscles and degeneration of other spinal muscles.

Chronicly tight hip flexors, in particular the psoas, can contribute to long-term spinal pain and can even pull the vertebrae out of place. The psoas can even affect chronic issues liks spondylolisthesis and spinal stenosis.

Two major factors that can contribute to tight hip flexors and cause the psoas to pull on the lower back are sitting for long periods of time and poor posture. Both of these activities can make the psoas squashed, weak, and tight. You can learn more about posture and hip tightness here, and see a posture tutorial here.

How to Take Care of Your Psoas to Prevent Lower Back Pain

The good news is that there are things that you can do to take care of your hip flexors and psoas to prevent lower back pain and injury. While stretching can play a part in this regimen, sitting in a lunge alone will not usually be enough. Lunges can be a great tool, but you have had the experience of sitting in lunges for hours only to find your hip flexors tighten right up afterwards, you will know that stretching alone is not enough to change the way that your hips work.

Most often there needs to be a combination of elements including improving the cooperation of the core muscles to improve the support of the spine, strengthening for the hip extensors (hamstrings and glutes), and a nice, loving targeted routine to strengthen and mobilize the psoas muscle so that it feels free and empowered. I have a routine that I have used for years and has greatly helped my lower back pain, in tandem with all of the other tools mentioned here, in this post on how to have a strong, flexible psoas.

Even though the psoas hip flexor is a difficult muscle to work with because if its internal position and how many different ways it can move, it is worth the investment since it has a profound effect on lower back pain and your long term spinal health.

Happy  Bendings!

Video for you visual learners…

Can Beginner Running Compliment Flexibility Training?

Everyone knows that running and flexibility exist in opposition to each other. Right?

Ask any flexibility coach about cardio cross-training and the vast majority will tell you to stay away from running. Ask any runner about flexibility training and most will groan and treat it as a boring and unpleasant but necessary evil to keep them from turning into one big, gristled tendon.

Convention will tell you that running makes you inflexible and flexibility training and being highly flexible or hypermobile makes you unsuitable for running.

But what if, by focusing on impeccable running technique, proper pre-conditioning, warm-ups, balance, and an almost exclusive application of active over passive flexibility exercises, these two disciplines could complement each other instead of oppose each other?

This is my experiment of one, as I test the capabilities of my own body in the lab of life.

Running with Proper Technique

Fortunately, with running technique I don’t have to invent the tools because someone else has already done it and written the book.

In the process of preparing for and recovering from foot surgery for osteoarthritis in my right foot I started running. I had been working with a client who was a trail runner and he had recommended that I read “Born to Run” by Christopher McDougall. The running technique he describes in the book flipped my preconceptions about running being hard on the joints, positing that with the right technique and preparation running can strengthen and heal our bodies (and be insanely fun at the same time and I’m always down for fun).

My feet and ankles have always been a weak point. As a dancer I struggled with a perfect relevé, always wobbling like a faun. I’ve sprained both ankles more times than I can remember, over-stretched my feet and toes in pursuit of perfect lines, danced for years in high heels, and suffered bouts of tendonitis in my ankles. Now, with osteoarthritis limiting the flexion in my right big toe, it seemed so easy to follow the doctor’s advice and resign myself to a life of supportive shoes, cushy insoles, and a strict avoidance of impact training.

But everything I know about bodies in general, and my body in particular, told me that this medically recommended course of action would cause me nothing but misery. Because I’m hypermobile, constant strengthening and stability work is essential to keep me out of pain. If I’m not working out, everything falls apart very quickly. If I stop challenging my feet and ankles I’ll soon be walking around on a couple of melted marshmallows. What will that do to my knees, hips, back, and psyche? Nothing good.

So McDougall’s book spoke to me. He had also defied countless medical opinions to become an ultramarathoner and running devotee. His book chronicles his training with coach Eric Orton who rebuilt his running technique based on the timeless, tried and true form used by all the world’s best runners like the Tarahumara people of Mexico’s Copper Canyons. The way we ran before our obsession with over-engineered sneakers robbed our feet of their agency and power—what is now called minimalist running because you don’t need much more than your own body to do it.

Learning Beginner Running When Flexible

I started running about one year prior to my scheduled surgery date. I bought myself some minimalist running shoes (the Xero HFS) and hopped on the treadmill a few days a week. I quickly found that the only kind of running that didn’t make my knees and ankles scream at me was sprinting. A steady jog hurt, but sprinting felt great. I couldn’t do it for very long, so my running sessions were all done as interval training, alternating between uphill walks, 1-2 minute sprints, and recovery walks. These training sessions, as well as the extensive foot and ankle strengthening I did every morning, sent me into surgery with the strongest feet I had had since ballet training and certainly aided in my fast recovery.

A few weeks ago, three months post surgery, I started running again as part of my rehab. My cardio was utter crap after three months of inactivity, but as usual I found that a slow jog was painful so I was gasping through 30-60 second sprints with 4 minute recovery walks in between.

It was then that I had the good fortune to find myself on a Zoom call with Chris McDougall and Eric Orton themselves! It was exciting to have the opportunity to chat about fitness in general and beginner running in particular, and share my story.

I described how running had been part of my pre- and re-hab from the osteotomy surgery but that I was really only comfortable with sprinting, and Eric asked me about my cadence.

Cadence? What is cadence?

Eric explained that extensive observation of effective running technique has shown that everyone, regardless of leg length or the speed they are running, has optimal form when their feet hit the ground at 180 beats per minute.

If you aren’t a musician or dancer, I’ll tell you that 180 bpm is a pretty fast clip. Think of The Ramones’ Judy is a Punk or, Eric and Chris’ favorite, the B52s’ Rock Lobster. Eric explained that even if you are chugging along at a stately pace of 4.5 mph you want to keep that quick cadence. At 180 bpm your feet are boinging back up off the ground like the spring-loaded shock absorbers they are designed to be, and there is no time to sink into your joints. Most of your time is spent in the air where gravity can’t hurt you.

At the earliest available opportunity I was back on the treadmill, ready to try out this new approach. I loaded up the B52s in my headphones, momentarily transported back to my efforts to create a mosh pit at the 7th grade dance, and started trotting.

The effects were just as Chris and Eric describe in their new running technique book Born to Run 2, immediately effective and delightful. From 1 minute run/4 minutes walk I was instantly able to do an effortless 2 minutes run/3 minutes walk. A few days later 2.5/2.5. With no joint pain at all. I had been relying on sprinting to protect my joints because, at 7.5mph I had no choice but to spring back up off my feet.

Most people without squishy joints can get away with jogging at a lower bpm without pain, at least for a while, until something starts to feel worn or overworked and then that 70% injury rate for runners kicks in. For better or for worse I don’t have the ability to run slow and heavy at all. Hypermobile folks don’t have any of that desirable stiffness in our connective tissue that many runners rely on to protect their joints and help their muscles work more efficiently. Thumping along I was relying solely on muscles to hold me together, and with the slower cadence my feet were spending long enough on the ground with every stride that the muscles couldn’t hold on and I was sinking down into every joint. Pain appeared almost immediately.

After 30 minutes of high cadence running intervals, never going faster than 5mph, I had no joint pain. The muscles in my feet and calves were singing, but it was a song of new challenge and strength-building, not the lament of damaged connective tissue. To my surprise I woke up the next morning ready to do it again and felt even better the second day. My challenge was to not get so excited that I over-trained, and remember that I’m still in rehab and I need to take it slow.

After two weeks I felt brave enough to try running around the Silverlake Reservoir, away from the safety of the treadmill. Running on uneven surfaces makes me exceedingly nervous. Every pebble and sidewalk crack is a chance for my foot to land funny and my ankle to stage a repeat performance of it’s spectacular 90 degree lateral collapse, which has landed me on my back countless times since I was a kid. But I took it slow, trotted to the sound of the Ramones in my head, and trusted the strength I was building.

The idea of a real, up and down, rocky, trail run still feels impossible in my body. But I know what it’s like to achieve things I once felt were impossible. I didn’t think that I could ever sit on my own head either, but I learned to do that, a little at a time.

Tightness vs. Stiffness for Running and Flexibility Training

In my flexibility coaching I often talk about cultivating stiffness without tightness. Stiffness comes from stability in the joints that results from both healthy connective tissue and neurological control of the full range of motion. Flexibility without stiffness, often found in hypermobile, over-stretched people, is dangerous and debilitating. Tightness is an absence of flexibility. It means that a muscle is in a locked state, unable to either fully contract, fully relax, or both. Tightness has a variety of root causes, but most often it comes from stressed-out muscles that don’t trust each other and lock up to prevent you from moving into a position that your nervous system has deemed unsafe. Tight muscles are no longer working together as a team.

What I have learned from Chris and Eric is that running with proper preparation and form can be a vehicle to cultivate stiffness, even in people like me for whom stiffness is not an innate trait. If running is making you tight it’s because something is going on to foment mistrust and poor cooperation in the muscles and joints. Your form is off or you aren’t prepared.

With this new understanding, I am deeply curious and even optimistic that I could be both a runner and flexible, and that these two skills could actually compliment each other. Goals like running a marathon and being able to do a comfortable standing split and waterfall backbend seem less like pipe dreams and more like a compelling puzzle challenge. I just have to figure out the right pieces and put them in place.

This is my experiment for the next year or two. To take these two historical enemies and cultivate a romance between them, using the theater of my rather worn-in 48-year-old body as a setting. Let’s see what happens!

Hip Anatomy: Get to Know Your Hip Flexors to Diagnose Tight Hips

What is a “hip flexor”?

The term “hip flexor” is often used as if it describes one muscle, when in fact there are multiple muscles that do the job of hip flexion (bringing the knee towards the chest). Tightness in the front of the hips is a massively common complaint, and it’s much easier to address if you know which of your hip flexors are tight.

Like GI Joe said, knowing is half the battle…

This blog and video are a quick introduction to the 6 primary hip flexors, where they are, how they work, and how they affect your hip mobility. I’m not going to hide my un-secret agenda to promote better awareness of the iliopsoas (the deep hip flexors)!

The most important thing is to gain greater understanding of how your hips work so that you can work with them in a way that is optimal for your body.

So here are the main players in the hip flexor game:

The IlioPsoas (Psoas and Iliacus)

The Iliopsoas

Let’s start with the big dogs… the Illiopsoas is a combo of the psoas and the iliacus. These are both hip flexors that attach to your upper inner thigh right in the groin area. They are your biggest, most effective hip flexors but they have some challenges.

The iliacus attaches to the upper inside of the back of the pelvic bone. The psoas attaches all along the inside of the lumbar spine. These attachment points are higher up on the body than any of the other hip flexors, giving these muscles better leverage to lift your leg, especially if you want it to go higher than your hip (hello dancers, aerialists, gymnasts, yogis and contortionists). Both of these muscles are deep in the body, making it hard to find them with your hands or brain.

Fun fact: the psoas is the only muscle that bridges the upper and lower body.

The psoas is affects and is affected by posture. If you sit a lot, or if you have an exaggerated bend in your lower back (check out the Bendy Back Tight Hips post) then your psoas can be chronically compressed into a scrunchy, tight, weak state where it is no longer effective either as a postural muscle or as a hip flexor. The illiacus right along with it!

Check out my upcoming series on core muscles and the psoas for some exercises and info to start to transform that predicament, if that sounds familiar to you.

In the meantime, let’s meet some more hip flexor friends.

The Pectineus

This little guy attaches to the base of the pelvis and has a short journey down to the inside of the thigh bone. It is definitely an adductor (squeezes the legs together) as well as a hip flexor and you can see just by looking at it that it isn’t as big or as well-positioned as the iliopsoas for hip flexion. That wont stop it from trying to help out though, and if it gets over worked you can find yourself with some tight, grouchy inner thighs!

The Pectineus

The Tensor Fasciae Latae (TFL)

This outer hip muscle is so important it got its own TFL blog post. This muscle attaches to the front outside of the pelvis and runs down the outer front hip, attaching to the famous IT band. Often tightness in the IT band can be traced back to a tight, overworked TFL. And it is easy to overwork the TFL because it can do so many different things: hip internal rotation, hip abduction (lifting the leg out to the side), and hip flexion. Like many competent beings, it can get stuck picking up the slack for under-performing friends.

A tight, weak, sad TFL can show up as outer hip pain, lower back pain, sciatica, and even knee and ankle pain.

The Tensor Fasciae Latae

The Sartorius

The sartorius is one of the two hip flexors that crosses both the hip and the knee. This elegant, swooping muscle runs from the front outside of the pelvis down across the thigh to attach on the inside of the lower leg. That means it can help to straighten the knee, externally rotate the hip, and flex the hip. It is most effective at hip flexion when the leg is turned out, as in a ballet passé. In fact, this muscle is usually super strong on ballet dancers! It just isn’t as effective if you are trying to lift your leg straight out in front of you.

The Sartorius

The Rectus Femoris

The Rectus Femoris

So many dancers, circus performers, and other athletes I have worked with over the years are very familiar with the rectus femoris. This is the biggest of your quadriceps muscles, crossing both the knee and the hip, right up the front of the leg. You can feel the big tendon in the front of the hip, just inside the hip bone, where this muscle attaches to the pelvis. Many people experience that tendon as being tight, tender, and possibly even inflamed due to overworking in the rectus femoris.

This muscle is the primary go-to for people who have difficulty accessing the illiopsoas, which can make the rectus femoris super cranky and tight. It can also create hypertrophy in that muscle so it gets really big and bulky (at the studio we fondly refer to that as femoris enormous or quadrisaurus rex). This is frequently an indication that the iliopsoas needs some love and encouragement.

Because the rectus femoris is both a knee extensor and a hip flexor, and because it attaches much lower on the body, it will never be as good at hip flexion as the iliopsoas. But it tries its best, bless its heart.

My hope in writing this article is that you now have a better sense of what is going on in your hips in order to tailor your workouts and your stretches to the muscles that need them most. If you suffer from chronically tight, painful hips and stretching isn’t helping, it’s likely due to an imbalance between these muscles where someone on the team isn’t pulling their weight, and other team members are having to play overtime and are getting resentful.

For the second half of the battle, check out the hip and core workouts on YouTube or the full length workouts on Video Club for some exercises and stretches that I have found useful to deal with hip challenges in both my own body and with my clients. I particularly recommend the next blog post on lunge variations to target specific hip flexors.

Happy Bendings!