Koda Integrative Therapy Group

Therapeutic Massage and Health Partners for Recovery and Performance

The impact of the Lower Cross Syndrome on Back Pain

Lower Crossed Syndrome: From the Core Out - Six Steps to Improve Lower Cross Syndrome

Poor posture, muscle imbalance resulting in pain symptoms in back and knee affect a large number of people in our society today. Other disorders of the musculoskeletal system disrupt lifestyle and activities to the extent that people spend millions of dollars on pharmaceuticals and other treatments and gadgets to address symptoms caused by our misalignment and imbalance in our bodies. The reliance on "the quick fix" is unfortunate, because proper exercise is a far better treatment for postural and musculoskeletal issues. Coaches, trainers, and manual health practitioners who know functional rehabilitation and corrective exercise know how to apply proper practices.

Logical steps to correct the imbalance and faulty movement patterns that create the development of muscle imbalance like Upper Cross Syndrome (UCS) and Lower Cross Syndrome (LCS) makes it possible to turn the vicious cycle underneath these conditions into a productive one. Typical activities for dealing with LCS and UCS can be taught to clients as guides which give average (experience) in clients a general idea of how to treat the symptoms and alleviate these painful conditions.

These guides are general information, and are should not be considered exhaustive. People who suffer from muscle imbalances and the LCS and UCS syndromes should seek out the help of therapists who have experience with treating these disorders. I'm not saying this because I work as a therapist, but my experience shows me that a lot of people find it very difficult to correct their postural imbalance, and then train their muscles effectively.

Besides the Upper Crossed Syndrome (UCS), the next most common muscle imbalance pattern is related through the Spiral Anatomy Train - creates the Lower Crossed Syndrome (LCS) is the opposition as it supports the upper chest and trunk. This condition is prevalent, particularly among females and people who sit for extremely long periods - think anyone in the IT field.

As sitting for prolonged periods leads to shortening of the hip flexors, increased tension on the lower back, and glute muscle atrophy. This is especially true when there is an underdevelopment of abdominal core strength, hip flexor tension and lack of support from the lower diaphragm - yes, the pelvic floor. No surprise that LCS is so conventional in our desk-bound society today, that when the problem develops over time, there is no warning. Suddenly a daily activity, like tying your shoes, causes pain or there is just 'lower back' pain, hip pain, or reduced ranges of motion that are concerning.

As with UCS, it's essential to be aware of and able to correct muscle imbalance patterns before they create more significant compensation in movements. These 'modifications' in progress set the stage for poor exercise techniques, injuries, lower back pain, impaired physical performance, and some more painful disorders such as osteoarthritis and degenerative joint disease. Poor posture, in general, isn't aesthetically appealing, but exercises and mobility drills can be aimed at treating UCS and LCS - and may also improve your physical appearance when a better posture.

Lower Crossed Syndrome

Lower-Crossed Syndrome (LCS) is also pervasive tightness of pelvic floor and rotated pelvis creating the symptom pain. With LCS the tightness of the thoracolumbar extensors is over-stretched from the dorsal (back) side that crosses over to the front with the tightness in the iliopsoas and rectus femoris. Weakness from the deep abdominal muscles reduces the balance in the ‘front' line' of muscles as they limit the movement pattern with weakness in the gluteus maximus and medius muscles. The problems created by this pattern of imbalance show in symptoms of joint dysfunction, particularly for the spine at the L4-L5 and L5-S1 segments of the lower back, as well as SI joint, and hip joint. (1) These are all common complaints of lower back pain.

What does this mean exactly for people with this postural problem?

It means that there is a weakness and lengthened stress in the abdominals and gluteals; at the same time, there is tightening and shortening of the hip flexors and lower back muscles. LCS create reciprocal inhibition or the process where opposing muscles on one side of a joint are relaxing to allow contraction on the other side of that joint.


- Prolonged sitting, particularly with bad posture

- Physical inactivity

- Regular workouts, movement, and activities that involve an uneven stimulation of the muscles that are engaged in LCS

- Poor exercise mechanics (e.g., lumbar hyperextension in the deadlift, press, and squat).

- Imbalanced strength training (e.g., a lot lower back and hip flexor training rather than glute and abdominal strengthening)

- Genetic predispositions

The development of LCS creates a vicious cycle because the gluteals and abdominals are weakened, they force overuse in the hamstrings and lower back. When their function is compromised, other muscles are recruited to assist in performing the activities that they are required to keep the body upright against gravity. The majority of these functions are walking or running, and includes squatting or sitting result in a high level of overuse or repetitive stress. Because these happen through a great deal of the hours in the day, this leads to chronic pain symptoms. When muscles are tired and tight, they stretch muscles like the hamstrings and lower back muscles, when in discomfort' ‘ force more compensation,’ and further weakness into the abdominals and gluteals.

Common signs and symptoms

- Anterior Pelvic Tilt (APT) can be a good trait, but at a certain degree of APT leads to poor posture. Exercise techniques to compensate for this fundamental challenge, and retrain the muscles impacted (hamstrings and lower back) will build the strength in the glutes and abdominals while taking the "stretch" for hamstrings and lower back.

This 'pressure' to maintain a compensation in the pelvic bones creates an increased risk of knee pain, reduced ranges of motion in hips and knees, and lower back pain or injuries, as well as other musculoskeletal disorders that run rampant in the modern world.

- Increased lower back curve (sway back)

- "Bulging" (not necessarily fat) abdomen

- Knee hyperextension

- Lower back pain

- Poor exercise technique; especially with displays of poor movement patterns in exercises such as the squat and deadlift. This pattern is characterized by an overextension of the lumbar spine, and knees - while lack of glute involvement drives the overcompensation into the quad and low-back dominance muscle groups.

These signs and symptoms of discomfort reveal that stiff hip flexors, weak gluteal muscles, and lack of abdominal muscle strength, and compensatory movements are reliable indicators of LCS.

How to improve your posture

Some health practitioners and coaches say that treatment of muscle imbalance patterns requires a series of Complimentary Alternative Medical appointments to "change" the imbalance - chiropractic intervention, myofascial release, trigger-point therapy, and a wide variety of exercises and mobility drills to strengthen and lock-in the changes. More straightforward mindfulness should be based mainly on postural awareness, exercises, and strengthening of the weakened muscles through stretching and activities with the opposing muscles is also useful.

This may be all that is needed, which is the point of most manual therapy - bring things to their attention and stimulate change. Research studies show that exercise interventions can modify lumbar posture and relieve musculoskeletal pain associated with poor posture if done regularly. The body will remember the newer stimulus - not old habits. But the "slow healing," is more time consuming than most people's patience allows.

Being a good coach requires an understanding that all exercises, mobility drills, etc. should be included only if they serve a purpose or help the client meet a goal. This more critical when training clients with muscle imbalance patterns, because 'improper' exercise technique and selection will aggravate the problem.

After trying various approaches to deal with LCS, there's only so much you can learn from readings and theory on the subject, I've discovered that there are specific patterns of exercise that work - and other's that don't. Although there isn't one standard approach for every client, there are certain general principles that your clients use to succeed in changing the imbalance. These protocols serve as essential guidelines and can build a foundation through a step-by-step workout.

Hip flexor stretches are considered essential for the 'releasing' muscles during the treatment of LCS. But, in general, it's more important to strengthen the muscles that produce Posterior Pelvic Tilt (PPT) and reinforce proper movement patterns at the same time. The order generally is specific to the individual.

Since there is a range of spinal alignments that are considered "normal," and quite a lot can be done to strengthen muscles through training, some people will naturally have a greater anterior tilt to the pelvis regardless of what they do (female hip alignment is different). Also, it's important to remind people that creating change with LCS symptoms requires persistence and effort. Only doing some light pull through at the gym occasionally is not going to get you very far with the solution. If you don't have the will or experience to attack this problem through your self-care and are severely affected by LCS, then I recommend that you work with an experienced coach, trainer or therapist that can treat this condition with the proper workout strategy

1) Mechanics of the lying pelvic tilt

LCS suffers often have no idea that their low back sways, abdomen bulges, and that back pain are manifestations of a series of the muscle imbalance that creates these patterns to a great extent - or that they can be treated. Moreover, these individuals have typically forgotten how to tilt their pelvis posteriorly do to the LCS posture. For these people, step 1 should help them learn how to get the pelvis into a neutral position and understand what the posterior tilt feels like. The lying pelvic tilt is an excellent exercise for achieving this, as "push the lower back into the ground" is a natural cue, and will help people to understand where that neutral position is.

Instructions: Lie on the floor and have the client push the lower back into the ground, then anteriorly tilt the pelvis by creating the curve in the lower back; repeating the exercise several times.

2) Mechanics of the standing pelvic tilt and glute squeeze

When you manage the proper lying pelvic tilt and understand how to control the alignment of your pelvis, proceeding with the standing pelvic tilt is the next step.

Instructions: Stand with your feet at shoulder width apart and squeeze the glutes, which will trigger you to tilt the pelvis posteriorly. Hold this contraction for 30 seconds, and then relax. Repeat the exercise several times.

3) Learn the feel of the hip-hinge position

The pull through is an excellent exercise to learn how to feel the hip hinge during movement patterns. The movement in the pull through closely resembles that of the deadlift, or kettlebell swing, or other hip dominant exercises. However, there's one key difference. In the pull through with the band or cable is attached behind you, this "forces" you into a posterior tilt and shift of the weight.

Instructions: Concentrate on keeping the chest high, but focus on NOT overarching the lower back. Push the hips back, rather than bending the knees and entering into a quad-dominant squat, and finish the movement by squeezing the glutes for several seconds.

4) Strengthening the muscles that produce posterior pelvic tilt (PPT):

Focus on the obliques, abdominals, gluteal attachments with different movements, and the opposition to the lower back and hamstring

Cable pull throughs and a modified version of the plank are among the most effective exercises for treating LCS. PPT hip thrusts, American deadlifts, and other activities can be used to strengthen the PPT movement patterns and develop weak muscle groups like glutes and abdominals with regular practice.

Varieties of lunges and planks can be great add ons.

Instructions for the modified plank: Perform a regular plank, but also focus on squeezing the glutes all you can during alternate repetitions. Try to work from the core out.

Instructions for the cable pull through: Concentrate on keeping the chest high, and the back should not overarch the lower muscles. Push the hips back, rather than bending the knees and entering into a quad-dominant squat, and finish the movement by squeezing the glutes for 2-3 seconds.

5) Proper performance of squats, deadlifts, presses

In addition to other multi-joint exercises proper execution of these positions helps retrain muscles.

When lifters tend to round their backs during dominant hip exercises, the "arch!" is often a cue to get people into better movement patterns - because this is incorrect posture for these exercises. However, when working with someone who possesses APT, this cue does more harm than good, typically, because the lift position ends up with an exaggerated lumbar curve and overstretched muscles.

While many new lifters, including those with no apparent postural problems, tend to overextend their backs when locking out the deadlift at the top of the motion, people with LCS often display excessive back arch during the entire movement. This lift position is considerably more damaging than the spinal flexion commonly seen.

People with LCS typically overextend their lumbar spine during presses, pulldowns, and a wide range of other exercises. This creates back strain and pain when the muscles tighten and lose flexibility. In combination with dominant quad lifts, reduced glute involvement, and forward knee drift (e.g., in the squat), the poor alignment of the spine allows strengthening of muscle groups that are already strong enough and increases the risk of injury.

While some lifters prefer a rounded because their experience has taught them that upper back position can be modified in the deadlift, the general recommendation for MOST lifts is to keep the spine neutral. The best way to achieve this position varies from person to person. For someone with a standard (neutral or slight APT) or posteriorly tilted pelvis, use your posture and think about arching the back. Even better would be to pulling the chest tall - or upwards. Anyone with excessive APT has to get the chest up to change the pelvis orientation around the center of gravity fundamentally. Focus on arching the back may be a mistake because this can quickly lead to overextension of the lumbar spine.

The position of the neck/head, tucking the chin and maintaining a neutral neck position is always a safety tip. However, many of the strongest deadlifters and squatters in the world look straight ahead during the lift. There is an argument that the body is most durable when lifting with a neutral neck position, but if there is an advantage to this position, then it is quite small.

Besides the focus on spinal alignment, other top tips for a perfect deadlift and squat position are to spread the floor apart and push against the outside of your heels. Try to pull the floor apart beneath you. Dive through the heels down, and position the bar should travel up-and-down in a vertical line over the mid-foot.

Don't just focus on during lower body exercises, because the alignment of the pelvis and spine is essential. Don't forget to squeeze the glutes and posteriorly tilting the pelvis during activities such as the press, push-up, chin-up, pushdown, and bicep curl is an excellent bio-mechanic recommendation. Posterior tilt of the pelvis during these types of exercises stabilizes the spine and even gives you some static glute training to increase your strength. Also, when performing dominant hip exercises such as the deadlift, hip thrust, and box squat, always finish the contraction part of the lift by squeezing the glutes.

6. Pay attention to your everyday posture,

By incorporating some mobility drills, stretches, and strength exercises into your daily life, you will reinforce these good habits.

- test your posture by putting you heals, pelvis and lower back against the wall. Then see if you can place the back and upper back/shoulders against the wall as well. Finally, move the head back and see if you can stand there comfortably for 6 - 8 breaths.

Besides performing the activities above, it can help to include some mobility drills, stretches for the lower back and hip flexors, and strength exercises into your daily life. The isometric glute squeeze showed in step 2, for example, asily can be performed at home every day. This will provide you with postural awareness and stronger glutes every time you practice. When using several repetitions and holding the contraction for 20-40 sec. Every time.

Finally, postural training is an integral part of treating LCS.

Pay special attention to sitting posture is vital to retraining the muscles. Incorporate this plan for better body mechanics into a training program. To include these steps into a workout routine:

1) Resistance training

Incorporate step 1, 2, and three into your warm-up routine before strength training sessions.

Spend 10-20 minutes on step 4 during a workout by a focus on exercises that target the muscles that produce PPT. When you're training the lower body one day, perform these movements as part of your workout. If you're not, include the pull through, plank, and other exercises movements that strengthen the PPT movement pattern at the end of the training session. Remember to squeeze the glutes, as well, during activities such as the press, push-up, etc. (step 5).

2) Endurance workouts and group training

Spend 15-30 minutes after you complete your endurance workout and group training session where you go through step 1, 2, 3, and 4. Spend the most time on level 4.

Workouts with the sole purpose to treat LCS should include

10-20 minutes on step 1, 2, and 3, and then move on to the cable pull through, box squat, and other exercises that target the weakened musculature.

3) Stretching opposing muscles

Spend 10-15 minutes after completion of the workouts ‘releasing’ tense muscles like Hamstrings through a series of stretches for both the upper and lower attachments. The other thing to focus on is releasing the muscle adhesions through self-myofascial release.

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