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 Abdominis

Rectus Femoris Oblique
TFL Gluteus maximus
Adductor Group Gluteus medius
Errector Spinae Hamstrings
Gastrocnemius,Soleus

Resulting in… Common Injuries

Anterior rotation of pelvis Low back pain

Increased lumbar lordosis Knee pain
Hips in flexion Hamstring strains
Knees may be hyperextended

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.