Regenerative ~ Reconstructive ~ Rehabilitative

Lower Cross Syndrome

Lower Cross Syndrome
Explained using parallel lines

Introduction

Lower Cross Syndrome (LCS- also known as Pelvis Cross Syndrome) is a condition characterized by chronically contracted (shortened) spinal extensors and hip flexors, as well as chronically extended (elongated) abdominal musculature and hamstring group. It can lead to postural imbalances and structural dysfunctions such as anterior pelvic tilt (“sway back”), hyperlordosis, disk pathologies- especially at L4-S1, and knee hyperextension.

Obviously, lower back pain is a natural consequence of LCS, as well as a decreased range of motion in the sacroiliac joint, acetabulofemoral joints, and tibiofemoral joints. Soft tissue pain may also be present in these joints as well, and compensatory patterns may lead to other structural dysfunctions.

Typically, LCS is seen in office workers, professional drivers, and even some bicyclists. Anyone who spend an exceptional amount of time seated is at higher risk for developing LCS, and LCS can aggravate or inflame disk pathologies already present in the client.
The Mechanics of Lower Cross Syndrome
LCS_crossThe first line of the cross is characterized by, at the superior posterior aspect, contractively hypertonic Erector Spinae group and Quadrates Lumborum. Contractive hypertonicity is also found at the inferior anterior aspect at the Quadriceps group. The iliopsoas group is often isometrically contracted, aiding to stabilize the sacroiliac joint.
The 2nd line of the cross is characterized by, at the superior anterior aspect, eccentric contraction of the abdominals. At the inferior posterior aspect of the line, the Hamstrings are typically found to be eccentrically contracted.
It’s important at this point to make note of terminology. In some circles of manual therapy, the term “turned off” is often used where I use the term “eccentric contraction”. This term can be misleading in that muscles can’t truly be turned off and still be functional. In this case, if the body truly did turn off the functionality of the muscles I have listed as eccentrically contracted, the body would very literally fold itself in half like a taco. In fact, these muscles are still functional, though there functionality is compromised.

They are acting to stabilize the torso in its position but may not be strong enough to fully compensate for the contracted antagonists.
This brings to light another term commonly used. Many times these muscles are called “weak”, but this term is not entirely accurate. Though the muscles are weakened and compromised, it doesn’t necessarily mean the muscles are weak. Weak is a relative term- that is, the muscle is weak in comparison to the antagonist. Once the antagonist releases, it is entirely possible to find the protagonist is perfectly strong, although thoroughly spent from the constant eccentric contraction its’ had to maintain.
As with much of western medicine, many issues which come across the table of a manual therapist have a label. Once that label is given- and in line with human nature- the issue gets infinitely over complicated. As an example, research the dangers of Dihydrogen Monoxide.
This is an attempt to simplify Lower Cross Syndrome for manual therapists.
The first step is to simplify the imagery. The main visual queue for LCS is the anterior tilt to the pelvis (“Sway Back”). This obviously points to, at the superior aspect of the tilted pelvis, tight erector spinae. This is where we start.
As manual therapists, we must remember that practically every voluntary muscle or voluntary muscle group has an antagonist muscle or group. That antagonist articulates the specific joint or joints in the opposite action (flexion/extension, abduction/adduction, etc).
Now, it’s also important to have a basic understanding of Reciprocal Inhibition, also called Sherrington’s law of Reciprocal Innervation. Sherrington’s law of reciprocal innervation states that: When a muscle contracts, its direct antagonist relaxes to an equal extent allowing smooth movement. In the case of LCS- the spinal extensors are tight (erector spinae, et al) the spinal flexors (the abdominals) release to an equal extent. In order to keep some semblance of posture and balance, the abdominals must then contract, albeit eccentrically, to stabilize the spine. If it wasn’t for the eccentric contraction of the abdominals, the client would not be able to stand. Instead the client would fully extend the spine until the maximum contraction of the extensors was reached, the skeletal and ligamental structures stop the movements, or the maximum stretch of the flexors had been reached.
As the superior aspect of the pelvis rotates anteriorly, the inferior aspect of the pelvis LCS_parallelrotates posteriorly (creating the sway back). This causes the hip flexors (specifically the Quadriceps and Iliopsoas groups) to tighten. In accordance with Sherrington’s Law, the hip extensors (the Hamstring group) lengthen. The hip extensors will then eccentrically contract to stabilize acetabulofemoral joint. Without the eccentric contraction, the hip would flex fully, until its natural end range had been reached.
In short, it may be a more simple path of understanding for the manual therapist to envision LCS in a more straight forward fashion, that of the protagonist / antagonist relationship between the muscles. This philosophy, of course, effectively removes the label of “syndrome” and reduces it down to its most basic components: objective observation.
By replacing the “cross” imagery with “parallel lines” simplifies- for the therapist- assessment and modality application. Further, it aids the therapist in the way they explain their objective findings to the client. Clients may not have a clear concept of kinetic chain or abstract cause and effect within the soft tissues, but it is very easy to understand the protagonist / antagonist muscle relationships, especially when described as a part of normal joint function.

 

 

 

 

Anatomy

Joints:
Gray90Zygapophysial joint (also known as a Facet joint) is a gliding joint comprised of a bilateral superior and inferior articulation processes on the vertebrae. These joints articulate flexion/extension and rotation of the spine.
Sacroiliac joint is a condyloid joint which articulates between the sacrum and the Ilium (or superior aspects of the coxal bones).
Acetabulofemoral joint is a ball and socket joint which is comprised of the head of the femur fitting inside the acetabulum, a shallow bowl located at the inferior aspect of the coxal bone.

Ligaments:
Joint capsules- The joint capsule of the hip- as well as all other joint capsules in the body- is comprised of a thin layer of fascia comprised mostly of collagen fibers which is an extension of the periosteum of the bone. The joint capsule acts not only to help stabilize the joint, but to contain synovial fluid, or the joint’s natural lubricant. It’s the deepest layer of connective in the body.

Sacrotuberous ligament Spans from the Ischial tuberosity (“sits” bone) to the edge of the Posterior Inferior Iliac Spine (PIIS) and posterior edge of the Sacrum. Serves, in part, as the origin for the lower fibers of the Gluteus Maximus.
Illiolumbar ligament  Spans from the transverse process of L5 to the posterior iliac crest. In LCS this ligament is often stretched.
Posterior Sacroiliac ligament Spans deep from between the sacrum and ilium posteriorly. The superior fibers (short posterior sacroiliac ligament) are almost horizontal, and pass from the first and second transverse tubercles on the back of the sacrum to the tuberosity of the ilium.
The inferior fibers (long posterior sacroiliac ligament) lay obliquely. It spans from the third transverse tubercle of the posterior sacrum, and the posterior superior spine of the ilium.
In LCS this ligament is often stretched.
Supraspinous ligament (caudal aspects) Spans the spinous processes from the C7 to the sacrum. Above the C7, the supraspinous ligament is continuous with the ligamentum nuchae. Caudally, it will shorten at the sacrum through the lower lumbar region.

Gray320
Gray301

 

 

 

 

 

 

 

 

 

Note: the Anterior Sacroiliac ligaments, Interspinous ligaments and Interosseous Sacroiliac ligaments are also affected but are so deep as to be almost impossible for a manual therapist to work.

Muscular Structures
Stretched or elongated musculature:

Rectus AbdominisGrays_Anatomy_image392
Origin: Pubic Crest, Pubic Symphysis
Insertion: Cartilage of fifth, sixth, and seventh ribs, and xiphoid process
Action: Flexes the vertebral column

External Oblique
Origin: Anterior aspects of the lower 8 ribs
Insertion: Anterior aspect of the iliac crest, abdominal aponeurosis
Action: Bilaterally: Flexes the vertebral column
ipsilaterally flexes the torso, contralaterally rotates the spinal column

Gray395Internal Oblique
Specifically the anterior fibers

Origin: Lateral inguinal ligament, iliac crest, thoracolumbar fascia
Insertion: Cartilage of the bottom three ribs, and abdominal aponeurosis
Action: Bilaterally: Flexes the vertebral column
Unilaterally: ipsilaterally flexes the vertebral column, ipsilaterally rotates the vertebral column

 

 

 

 

Illiopsoas group:
Psoas Major

Origin: Anterior transverse processes and vertebral bodies T12-L5Psoas-major
Insertion: Lesser trochanter
Action: Hip flexion (unilaterally and bilateral), Spinal flexion(bilateral), posteriorly rotates the acetabulofemoral joint (bilateral)
Iliacus

Origin: Iliac fossa, anterior inferior iliac spine
Insertion: lesser trochanter
Action: Acetabulofemoral joint flexion (unilaterally and bilateral), Spinal flexion(bilateral), posteriorly rotates the acetabulofemoral joint (bilateral), adducts the acetabulofemoral joint (unilaterally and bilaterally)

 

Hamstrings Group:

250px-Biceps_femoris_muscle_long_headBiceps Femoris

Origin: Long head- Ischial tuberosity, Short head- lateral lip of the Linea aspera
Insertion: Head of the Fibula
Action: Flex the knee, extends the acetabulofemoral joint, tilts the pelvis posteriorly

Semitendinosus

Origin: Ischial tuberosity
Insertion: Proximal medial shaft of the Tibia at the Pes anserinus
Action: Flex the knee, extends the acetabulofemoral joint, tilts the pelvis posteriorly

Semimembranosus

Origin: Ischial tuberosity
Insertion: Posterior aspect of the medial condyle of the Tibia
Action: Flex the knee, extends the acetabulofemoral joint, tilts the pelvis posteriorly

 

 

 

Shortened or contracted musculature:

Erector Spinae group
Spinalis Gray389_-_Erector_spinae

Origin: Spinous process of the superior lumbar and inferior thoracic vertebrae, Ligamentum nuchae, spinous process of C7
Insertion: Spinous process of the superior thoracic and cervical (except C1)
Action: Bilaterally- extends the vertebral column. Unilaterally- Ipsilaterally flexes the spinal column

Longissimus

Origin: Common thoracic tendon, transverse process of T1-T5
Insertion: medial aspects of the inferior 9 ribs, transverse process of the thoracic and cervical vertebrae, mastoid process
Action: Bilaterally- extends the vertebral column. Unilaterally- Ipsilaterally flexes the spinal column, lateral flexion and rotation of the cervical spine

Iliocostalis

Origin: Common lumbar tendon, posterior surface of the ribs
Insertion: Transverse process of L1-L3, posterior surface of the ribs, transverse process of the inferior cervical
Action: Bilaterally- extends the vertebral column. Unilaterally- Ipsilaterally flexes the spinal column, lateral flexion and rotation of the cervical spine

 

Quadriceps

QuadricepsRectus femoris

Origin: Anterior inferior iliac spine (AIIS)
Insertion: tibial tuberosity, via the patellofemoral tendon
Action: Extends the tibiofemoral joint, flexes the acetabulofemoral joint

Vastus intermedius

Origin: Anterolateral femoral shaft
Insertion: tibial tuberosity, via the patellofemoral tendon
Action: Extends the tibiofemoral joint, flexes the acetabulofemoral joint

Vastus lateralis

Origin: Lateral lip of the linea aspera, gluteal tuberosity
Insertion: tibial tuberosity, via the patellofemoral tendon
Action: Extends the tibiofemoral joint, flexes the acetabulofemoral joint

Vastus medius

Origin: Medial lip of the linea aspera
Insertion: tibial tuberosity, via the patellofemoral tendon
Action: Extends the tibiofemoral joint, flexes the acetabulofemoral joint:

Deep Layer Muscles

Multifidi and Rotatores- Specifically the Lumbar region250px-Multifidi

Origin: Sacrum and transverse process of the lumbar through cervical vertebrae
Insertion: Spinous process of the lumbar vertebrae through the second cervical vertebra (Multifidi span 2-4 vertebrae, while Rotatores span 1- 2 vertebrae)
Action: Bilaterally- extends the spinal column Unilaterally- contralaterally rotates the spinal column

Protocol Overview
Massage Therapy protocols:
The primary consideration- after doing a complete intake, making note possible causative factors, osseous, spinal, and muscular pathologies, RoM and postural baselines, and so forth- is the release of the contracted musculature. This can be accomplished by using a number of common modalities and concepts many massage therapists are familiar with.
Passive stretching- The therapist will articulate the clients joints- with no active participation from the client- moving the protagonist muscles into a stretch.

Active Stretching- the client moves themselves into a stretch by contracting the antagonist muscle or group. When the client has reached the end range of their stretch, the therapist moves the protagonist muscle group deeper into the stretch.

Gains are often reported because of a neurological principle called “Reciprocal Inhibition”. When a protagonist muscle or group is contracted, the brain sends a message to the antagonist muscle or group to lengthen. Therefore, the therapist uses this principle to the advantage of the client by having the client contract the antagonist muscle for the initial stretch and helping at the end range.

Proprioceptive Neuromuscular Facilitation- Commonly called PNF stretching, this works by taking the protagonist muscle or group and placing it into a stretch. The client then contracts the protagonist muscle or groups against the therapists’ opposition. When the client releases, the therapist is able to achieve gains in flexibility and range of motion in the protagonist muscle or group.

More “advanced” techniques; usually requiring additional training can be extremely useful as well.

Fascia lengthening- Fascia is the most prevalent connective tissue in the body. There are two types of fascia in the body that need to be manipulated in order to affect positive change: Superficial fascia and Deep fascia. There is a third- Visceral fascia- but it is very unlikely it’s affected for this purpose and therefore left for another, future discussion.

Superficial fascia is located subcutaneously, and blends with the deepest layer of the skin, holding it in place. This fascia can be highly elastic, but also high reactive to circumstances. It will tighten with trauma or inactivity, resulting in restrictions ranging from trigger point to taught bands to fully restrictive sheets over broad areas.

Releasing the superficial facial layer is a matter of light, directional pressure with a broad (relatively speaking) contact and holding for 60 –90 seconds. Though movement is seen prior to that time, it is important to hold the stretches for that long in order to engage the cologne fibers fully in the fascia.

Deep fascia is found surrounding muscle fibers, incasing muscles, blends to make tendons, and attaches to the osseous structure by way of the periosteum. Deep fascia is released through different methods- that of traction. Traction is a form of passive stretching in which the stretches are held by the therapist or by an apparatus for elongated periods of time- slowly moving the affected joints deeper into the stretch as gains are made. These are small, sometimes minute changes held over times spans of 90- 120 seconds. Care must be taken when traction is released.

Pin and stretch- By using thumbs, fingers, palms, forearms, elbows, etc to apply static pressure to the muscle fibers, the therapist can restrict the movement of the muscle while moving it into a stretch for the client. This serves to increase the stretch though the range of the stretch stays the same.

Active stretching with directional tension- Though reciprocal inhibition can be very effective on its own, further gains can be made by the therapist on a specific muscle or muscle group using directional tension in addition to the active stretching. This is done by using the thumb, finger, or palm and applying tension along the fibers in the direction of the stretch.

Golgi Tendon Reflex activation- In order to understand why this is important we must briefly discuss the Golgi Tendon organ and the Golgi Tendon Reflex.

The Golgi Tendon organ is a proprioceptive sensory receptor located at the musculotendinous junction at both the origins and insertions of skeletal muscles. They play an integral role in detecting tension caused by end range elongation of muscle fibers and activating the “Golgi Tendon Reflex” action. The Golgi tendon reflex is a protective measure whereby the Golgi tendons send a message (the short version) to the muscle fibers to further relax during the stretch.

A therapist can activate the Golgi tendon reflex locating the musculotendinous junction at both the origin and insertion of a muscle, and applying static pressure to these areas while the client actively moves the protagonist muscle in a stretch.

This is especially effective for clients who have muscles which are habitually tight. It does take an in depth knowledge of the anatomy of the muscle being manipulated in order to hit the correct areas.

Most modern advanced modalities are based- to varying degrees, with great variation of execution- off of these principles and techniques.

Warming the area first, using a variety of techniques, is essential for the deeper and more active work. Swedish techniques aid in the warming of the more superficial fascia and musculature, allowing for a greater range of movement and some pain relief. It also allows the therapist to assess the tissues more thoroughly.
With the client prone, spinal erectors should be worked through their entire length, but with special attention paid to the more caudal fibers. At this time identifying and working adhesions, TrPs, facial restrictions, and so forth is advisable. Tissues should be worked until a noticeable change in muscle feel is noted. It’s important note here that- especially in the beginning- the changes in the feel of the tissues may be minimal. Do not over work the area chasing the change.
With the client supine, we can work the Quadriceps group. Passive and active stretching of the lumbar region can be done at this time as well.
From the supine position, Swedish work can be done on the abdomen and Hamstring group as well. Deeper layer fascia release techniques can used in this position, and the side lying position.
From the side lying position, the deeper abdominal and lumbar structures can be worked, albeit unilaterally.
At the end of the session it’s important to re-assess RoM and posture and chart the progress. If multiple sessions have passed and the client has reached a therapeutic plateau, but is still not in the normal range of motion and posturally appear to be anteriorly rotated, focus may need to be shifted to the ligamental structures. Do not attempt to work the ligaments if you have not been tutored or trained in such techniques. It can be painful, and trying to achieve change in the structures can be overdone, undermining their structural purpose.

Homework
A wide variety of exercises are available for the client. This includes back and quad stretches, strengthening exercises for abs and hamstrings, yoga, and the like. Until the balance has been restored between the muscle groups, it is not advisable to do lumbar or quad (leg extensions or squats) strengthening.
Further, workplace habits may need to be modified. Arranging time to get up and walk around for a minute or two every hour, or reconfiguring ones workspace where they can alternate between sitting and standing are indicated. Light stretching throughout the day and light exercise at breaks- such as walking- are beneficial.
Postural awareness, as well, is necessary. Placing the client in the correct posture and having them return to it several times in order for them to feel what is correct is advisable. This then can be taken home and into the workplace, where the client can work to correct postural imbalances in between sessions.

 

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