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What is it?
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
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.
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.