Lower Crossed Syndrome

Lower-Crossed Syndrome What is it? Lower-crossed syndrome is a postural distortion syndrome affecting the lower kinetic chain (lumbopelvic hip complex, knee, and ankle). The lower kinetic chain is one of two basic parts of the musculoskeletal system that are controlled and innervated through the CNS. The muscles can often serve as “windows” to the function of the CNS. The CNS regulates 2 muscle groups: The tonic muscle group and the phasic muscle group. These muscle groups oppose each other in function. The tonic muscle group functions as a facilitator, the phasic muscle groups inhibition. Pain, pathology or adaptive changes in the system result in compensations or adaptations that lead to systemic and predictable patterns of muscle imbalance. This results in chronic pain and disability. In lower-Crossed syndrome the pattern of muscle imbalances often leads to changes in movement patterns with hip extension, hip abduction and trunk flexion. “Altered movement pattern” is a movement pattern in which a change occurs in the coordination of the muscle firing sequences for a specific group of muscles, facilitating a specific joint movement. The primary muscle responsible for specific joint movement may become weak and inhibited, causing a synergistic muscle/muscles to become hyperactive. As a result, a different sequence of muscular contractions occurs. This is a sign of muscle imbalance in the body because of muscular dysfunction. Because the structural integrity of the lower kinetic chain is compromised in lower cross syndrome, abnormal distorting forces result on all structures within the kinetic chain. When any component of the kinetic chain is not working properly (tight or long muscles, reciprocally-inhibited muscles, adhesions, joint dysfunction), neuromuscular control is altered. This alteration may be observed with the patient sitting, standing, or walking. In lower-crossed syndrome the patient usually presents with anterior pelvic tilt, increased lumbar lordosis (swayback), and weak abdominals muscles. These patients usually experience chronic low back pain, piriformis syndrome and anterior knee pain. The predictable pattern of muscle imbalances most often include the following:

Tight/Faciliated

Weak/Inhibited

Iliopsoas Rectus Femoris TFL Adductor Group Errector Spinae Gastrocnemius,Soleus

Rectus Abdominis Oblique Gluteus maximus Gluteus medius Hamstrings

Resulting in…

Common Injuries

Anterior rotation of pelvis Increased lumbar lordosis Hips in flexion Knees may be hyperextended

Low back pain Knee pain Hamstring strains

Other consequences of this syndrome are seen in anterior tilt of the pelvis and flexion of the hip that exaggerates the lumbar curve. L5-S1 may have soft-tissue and joint stress with pain and discomfort. This progresses to instability of the sacroiliac joints and piriformis, and knee involvement. Lower-cross syndrome may develop from a number of scenarios such as chronic, repetitive actions such as running. Inaction may also have a negative impact on the body’s mechanics, such as immobilization, disuse, or chronic postural stress such as sitting for long periods of time or poor workstation posture. Sports injuries or injuries that never healed properly can lead to pathology. Pain, pathology, or adaptive changes can lead to patterns of muscle imbalance that can lead to a situation of lower-cross syndrome. Assessing for Lower-Crossed Syndrome: 1. Postural assessment- The first step in assessing a patient for LCS is to do a spastic postural distortion analysis. This gives fast and reliable information indicating whether or not further testing is to be performed.

2. Global Assessment- Overhead Squat Test (OST) is the most basic, full body functional analysis test that can be done. We recommend using the OST for assessing because it tests the total kinetic chain neuromuscular efficiency, integrated-functional strength, dynamic flexibility, and unlike most other clinical tests, involves a degree of muscular fatigue. Must be aware of patient form while performing this test. Patient: The patient places his feet shoulder-width apart, with arms straight over their head and elbows extended. The patient then slowly squats down to a position that is comfortable. These squats should be done under control for 6-15 repetitions. Doctors: Do not tell the patient specifically what you are looking for, as they will tend to try to “correct” the movement. It is very important for the patient to perform multiple repetitions in order to display the postural deviations that result from fatigue. Walk around the patient during the test, making sure to observe the anterior, lateral, and posterior views checking the feet, knees, lumbar curve, arm movement, chin elevation, and stomach protrusion. Standard deviations for LCS that commonly occur are: feet flattened and toe flaring out, knees buckling inward, and low back arching. These deviations may occur bilaterally or unilaterally and may present in a combination of one or all of theses deviations.

3. Normal Firing Pattern of the Pelvis- With the patient lying prone the doctor with his/her superior hand places the thumb and index finger on the erector spinae muscles bilaterally and with his/her inferior hand places the thumb on the gluteus maximus and little finger on the hamstring. Having the patient extend his/her leg the normal firing pattern should be the contralateral erector spinae, followed by the ipsilateral gluteus maximus, and then the ipsilateral erector spinae and hamstrings. If the ipsilateral erector spinae fires before the gluteus maximus, this indicates an inhibited gluteus maximus.

4. Thomas Test- The patient sits and the end of the table bringing one of their thighs to their chest and holding while lying back onto the table. With the knee approximated to the chest, the examiner observes the opposite limb. The thigh and knee should be resting flat on the table. Elevation of the thigh or knee with a space between the limb and table indicates a positive test. Normally, the lower limb should have enough hip flexor stretch to allow extension of the thigh so that it lies flat on the table. With hip flexor tightness or in flexion deformity of the hip, the extension is deficient. Here, we are specifically testing the iliopsoas muscle.

5. Forward Bending Test- The patient is seated on the table with their legs extended and knees locked. The feet should be at right angles with no internal or external rotation. The examiner instructs the patient to reach as far as they can towards their toes and hold. The low back should have a natural curve, which should continue into the upper back. The examiner should notice the angle between the table and the sacrum. It should be 70-90 degrees. An angle less than 70 indicates tight hamstrings and an angle greater than 90 indicates elongated hamstrings. The muscles we are testing here are the upper back, lower back, hamstrings, and calf muscles.

6. Gluteus Maximus Strength Test- The patient is in the prone position with one knee flexed at 90 degrees. The examiner stabilizes the sacrum, the patient lifts thigh up off the table while the examiner pushes the raised thigh towards the table. This test should be performed bilaterally comparing muscle strength.

7. Psoas Major Strength Test- The patient is supine with one leg elevated and abducted with their foot rotated externally 45 degrees. The examiner stabilizes

the opposite ASIS while pushing straight down on the patient’s elevated leg as they resists. This test should be performed bilaterally comparing muscle strength.

8. Erector Spinae- Schober's test assesses the amount of lumbar flexion. In this test a mark is made at the level of the posterior iliac spine on the vertebral column, i.e. approximately at the level of L5. The examiner then places one finger 5cm below this mark and another finger at about 10cm above this mark. The patient is then instructed to touch his toes. If the increase in distance between the two fingers on the patient’s spine is less than 5cm then this is indicative of a limitation of lumbar flexion or over-active erector spinae. 9. Transverse Abdominal Muscle- The patient in the prone position (by pulling in the stomach you increase intra-abdominal pressure stabilizing the lumbar spine and possible the SI joint)

10. Rectus Femoris- With the patient is supine they flex one hip to a 90 degrees and their knee is also brought to 90 degrees. The examiner instructs the patient to resist while they push against the flexed knee. This test should be performed bilaterally comparing muscle strength.

Stretch 1. Hamstrings- The patient lies supine with their leg extended, knee locked, and their low back flat on the tale so the pelvis is level. The examiner places the patients leg with the knee that’s locked onto their shoulder, supporting the knee while flexing the hip to stretch the hamstring. The examiner instructs the patient to contract their quadriceps while they hold for a count of ten. This can be done

for 3 to 5 cycles. With each cycle the examiner should be able to increase the stretch on the hamstring. Always do bilaterally.

2. Hip Flexors- The patient sits and the end of the table bringing one of their thighs to their chest and holding while lying back onto the table. The examiner places one hand on the held knee and the other hand on the thigh to be stretched. The patient can also do lunges to stretch the hip flexors. Another exercise uses the physioball to stretch the hip flexors. This, however, requires more stability and should only be done once the patient has regained strength and core balance.

3. Erector Spinae- The patient lies supine in the fetal position, their knees to their chest with their arms wrapped around their knees. The examiner places their inferior hand under the sacrum pulling down in a scooping motion with the super hand pushing up on the patient’s knees.

4. Gluteus Maximus- The patient is supine with one leg flexed at the hip and the knee. The examiner’s inferior hand is under the leg and their superior hand is on top of the leg. This gives the examiner more control of the stretch. The examiner stretches the patient for 10 seconds followed by the 10 seconds of the patient pushing against the examiner.

Strengthen 1. Hamstrings- There are three choices to choose from using the thera-band depending upon the patient’s stability. Either seated with their leg extended, standing with one leg straight, or lying prone with their legs extended. Attach the tubing around the ankle having the patient contract their hamstring. The patient should contract for 2 seconds, hold for 2 seconds, and release for 2 seconds. (also exercise ball)

2. Transverse Abdominals- First, have the patient lie on their back with their knees bent. Instruct them to pull their umbilicus in towards their spine and then up without moving their pelvis. Once they can do this repeat the process with the patient sitting up. Finally, have the patient lie prone with a tennis ball under their umbilicus. Have them draw their umbilicus up and in towards the spine attempting to lift their stomach off the tennis ball. Always remind them to do the motion without moving their pelvis. We want to isolate the TVA. 3. Gluteus Maximus- Have the patient stand facing the wall with the tubing around their ankle. Instruct them to have their knee locked in extension or bent at 90 degrees to isolate the gluteus maximus while extending the hip away from the wall. This motion can also be done in the prone position depending on the patient’s stability. Have the patient contract for 2 seconds, hold for 2 seconds, and release for 2 seconds.

4.

Hip Flexors- Have the patient on the hands and knees with tubing around one ankle. Instruct the patient to pull their knee towards their chest. The patient should contract for 2 seconds, hold for 2 seconds, and release for 2 seconds.

5. Erector Spinae- Have the patient lying prone with their hands behind their head extending their back. The patient should contract for 2 seconds, hold for 2 seconds, and release for 2 seconds.