Conditions & Treatments - Lower Crossed Syndrome

 

Lower Crossed Syndrome (LCS), also known as pelvic crossed syndrome, is described as a muscle imbalance pattern that affects the lower kinetic chain which includes the lumbopelvic hip complex, knee, and ankle (1, 2). This syndrome can be found in individuals who sit for prolonged periods, continuously perform tasks for extending periods of time utilizing poor posture, or have been immobilized (1). It can also be found in individuals who perform repetitive actions such as running or jumping (1).

Vladimir Janda, MD, an expert in the research of muscle imbalances, characterized Lower Crossed Syndrome by over activity of the thoraco-lumbar extensors, rectus femoris, and iliopsoas, as well as reciprocal weakness of the abdominals and the gluteal muscles (1, 2, 3). The image above illustrates Lower Crossed Syndrome where tightness of the thoracolumbar extensors on the dorsal side crosses with tightness of the iliopsoas and rectus femoris (4). Weakness of the deep abdominal muscles ventrally crosses with weakness of the gluteus maximus and medius (4). Table 1 lists the actions of muscles involved in Lower Crossed Syndrome.

Table 1 - Actions of Muscles Involved in Lower Crossed Syndrome (5)

Rectus AbdominisAction: Flexion and lateral flexion of the trunk. In standing position, supports organs anteriorly, gives anterior support to lumbar spine. With aid of gluteus maximus and hamstrings keeps pelvis from going into anterior pelvic tilt, decreasing lumbar lordosis.

Transversus AbdominisAction: Constricts abdominal contents; assists in forced expiration.

Erector Spinae
Iliocostalis Lumborum - Action: Acting bilaterally, extension of the spine, acting unilaterally, laterally flexes the spine.
Iliocostalis ThoracisAction: Acting bilaterally, extension of the spine. Acting unilaterally, laterally flexes the spine.
Longissimus ThoracisAction: Acting unilaterally, laterally flexes the vertebral column. Acting bilaterally, extension of the vertebral column; draws ribs down.
Spinalis Thoracis Action: Acting unilaterally, lateral flexion of the spine. Acting bilaterally, extension of the spine.

IliopsoasPsoas Major - Action: Flexion of the thigh at the hip. Minimal action in lateral rotation of the thigh.
IliacusAction: Flexes thigh at the hip. Minimal action in lateral rotation of the thigh.


Rectus FemorisAction: Extension of leg at the knee. Flexion of thigh at the hip. Reversed Origin-Insertion Action: Flexes the pelvis on the femur and gives anterior stabilization to the pelvis.

Tensor Fasciae Latae Action: Thigh flexion at the hip, abduction and medial rotation. Stabilizes the knee laterally. Tenses the ITB tract.

Adductor Group (pectineus, adductor brevis, adductor magnus, adductor longus)Action: Adduction of thigh at hip. Assistance in thigh flexion and medial rotation at the hip.

GastrocnemiusAction: Plantar flexion and inversion of the foot. Reversed Origin-Insertion Action: Flexes leg at the knee. Dorsiflexion of foot increases knee flexion capability.

SoleusAction: Plantar flexion and inversion of the foot at the ankle. Reversed Origin-Insertion Action: When standing, the calcaneus becomes the fixed origin of the muscle. The soleus muscle stabilizes the tibia on the calcaneus limiting forward sway.

Gluteus MaximusAction: Extends thigh at the hip, assists in laterally rotating the thigh. The upper 2/3 of the musculature are abductors and the lower 1/3 is inactive as an abductor or an adductor in the standing position.

Glutues Medius Action: Abducts femur at the hip and rotates it medially. Possible lateral rotation. With gluteus minimus is major lateral pelvic stabilizer. Aids in early activity of hip flexion.

Hamstrings –
Biceps Femoris (lateral hamstring)Action: Flexion and lateral rotation of the leg at the knee, extends, adducts and laterally rotates the thigh at the hip. Reversed Origin-Insertion Action: The long head gives posterior stability to the pelvis and extends the pelvis on the hip.
Semitendinosus (medial hamstring)Action: Flexes and medially rotates the leg at the knee. Extends, adducts and medially rotates the thigh at the hip. Reversed Origin-Insertion Action: When thigh is fixed, assists posterior stability of the pelvis and extends the pelvis on the hip.
Semimembranosus (medial hamstring)Action: Flexes and medially rotates the leg at the knee. Extends, adducts and medially rotates the thigh at the hip. Reversed Origin-Insertion Action: When the thigh is fixed, gives posterior stability to the pelvis and extends the pelvis on the hip.


This imbalance of the muscles at the lower kinetic chain will result in postural changes and movement dysfunction for individuals who present with LCS. These individuals with LCS will likely display excessive arching of the back, a protruding stomach, and a flat butt due to weakness in the glutes (6). They may complain of symptoms such as low back pain, knee pain, piriformis syndrome and hamstring pain given the compomised posture which results in added stresses to the various surrounding structures & tissues (1, 7).

PT Findings in Patients with Lower Crossed Syndrome
Besides the imbalances and postural deviations found in patients with LCS such as an anterior pelvic tilt, lateral lumbar shift, lateral leg rotation and knee hyperextension, physical therapists may also find joint dysfunction, particularly at the L4-L5 and L5-S1 segments, SI joint, and hip joint (1, 4).


Lower Crossed Syndrome Treatment Options for a PT
• Postural Training / Functional Training
• Sensorimotor training
• ROM exercises
• Stretching (see videos 36, 25, 31, & 28 for lumbar spine/back and hip/groin/knee)
• Strengthening/Stabilization (see videos 37, Z9, & Z11  for lumbar spine/back and hip/groin/knee)
• Manual Therapy / Joint Mobilization / STM / Myofascial Release
• Modalities

 

When treating patients with LCS the shortened muscles must be restored before embarking on training of the weakened muscles. This is based on Sherrington's Law of reciprocal inhibition which states that when one muscle is shortened or tightened its opposite muscle relaxes (2, 3).

 

Comment - Message Board

 

Last revised: May 10, 2011
by Chai Rasavong, MPT, MBA

 

 

References
1) Lower-Crossed Syndrome - Lifewest.edu Accessed 5/10/11
2) Hertling D & Kessler R. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Fourth Edition. Lippincot Williams & Wilkins. 2006;150.
3) Page P & Frank C. The Janda Approach to Chronic Musculoskeletal Pain. www.jblearning.com/samples/0763732524/The%20Janda%20Approach.doc Accessed 5/10/11
4) Muscle Imbalance Syndromes - Lower Crossed Syndrome www.muscleimbalancesyndromes.com/janda-syndromes/lower-crossed-syndrome/ Accessed 5/10/11
5) Flash Anatomy - The Muscles: Origins, Insertions, Action, Innervation, Synergist. Bryan Edwards Publications. 2000
6) Lower Crossed Syndrome - "S" Posture www.pgatour.com/2007/mygame/10/04/s.posture/index.html?eref=sitesearch Accessed 5/10/11
7) Posture:Alternatives to the Prevailing Paradigm
www.fascialrelease.com/tag/lower-cross-syndrome Accessed 5/10/11


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