The Dreaded Lower Cross Syndrome
Low back pain accounts for an astounding number of medical office visits per year. An entire medical practice could be sustained by visits for this concern. Low back pain can be a very debilitating problem for people and can be a heck of a headache for physicians. Typically, the pain will be present in the lower back or sacral region (sacral is basically the butt area). There can be several causes of pain in the area, all of which I am not going to delve into for this post, but there is a wide differential to keep in mind for this region. There are some ‘red flags’ to pay attention to as well. However, based on what I’ve seen in practice and read about in literature, the majority of pain in this area will be the result of inactivity and subsequent muscle imbalances in the body. This will be due to the typical sedentary American lifestyle of sitting at a desk, on the couch, or in the car for most of the day. Interestingly, studies have shown that if a physician offered no interventions for many back-pain problems then the pain likely would resolve on its own in 13-18 months. Yeah… If not a darn thing was done, the pain would probably go away by itself in over a year! BUT I can’t think of anyone that would tolerate being in pain for that long in today’s world and society. With all our hustle and bustle and busy every-day lives, (present pandemic situation excluded – hopefully everyone is exercising more since the last post to prevent dealing with back pain while stuck at home!) to quote a popular YouTube clip, “Ain’t nobody got time for that!”
Before I get into the typical cause of low back pain that is referenced in the title let’s talk about those red flag symptoms that could mean something else. First and foremost, always discuss symptoms with your primary care physician. This blog is meant for educational and entertainment purposes and in no way replaces guidance or advice from your physician. Now that that’s out of the way, if you have pain during the night when in bed and that wakes you from sleep, you should be seen and evaluated in clinic. Numbness down the leg or weakness, either on one side or both, also warrants prompt evaluation. Numbness in the nether regions? Be seen!! Loss of control of bowel or bladder functions? That is considered an emergent problem and should be worked up right away.
Okay PSA over with. Just know not all back pain is treated equally. Now to the common one. I referenced the typical sedentary American lifestyle previously. We have fashioned much of our time at work and at home sitting for prolonged periods of time. Likely shoulders are slouched forward, head and neck are angled forward and down (especially if reading or watching something on a phone), and hips and legs are bent to about 90 degrees - or some variation depending on the chair style and height. Ergonomics typically do not get much love but help a significant amount. Regular movement and exercise is another big factor in preventing back pain. Unfortunately, this typically doesn’t get much focus until a problem occurs. People will sit for most of the day, then go home and sit some more. Rinse and repeat, day upon day. On the weekend, they may attempt to do some yard or house work, or they are inspired and do a workout or go to the gym. Mid-lift or mid chore they feel a pang of pain in the low back- they ‘threw their back out’. Sometimes, the motion is as benign as standing up and bending over, like when putting something on the bottom rack of the dishwasher. The pain can be intense at times but typically stays right at the low back and hip region, usually on one side or the other.
Described above can be the typical presentation of Lower Cross Syndrome. There is no specific diagnosis code for this syndrome in our current system. It will likely be labeled as a ‘muscle strain’ which is still accurate, technically. But that is a more specific diagnosis to the problem and the syndrome is what is causing those symptoms. This syndrome causes an anterior (forward) tilt to the pelvis as a result of different muscle groups being tight and others weak, or imbalanced. This syndrome doesn’t discriminate between sedentary folks and those who are actively training in sports. It can affect anyone. The culprit that is causing the pain is the muscle group in the low back that works in hip flexion and posture. One particular muscle in this group that causes many a backache when it is in spasm or is dysfunctional is the Psoas (silent P). This muscle works on hip flexion and specifically attaches in the low back and front of the thigh – it can really hurt when it flares up!
Typically in Lower Cross Syndrome the hip flexor (that Psoas muscle) will be tight along with tight quadriceps muscles. This is coupled with weak lower abdominal muscles and weak hamstring muscles. No one likes doing hamstring curls… This imbalance causes an increased arch in the low back and tight muscles that are now very used to sitting (office work and sedentary lifestyle). I tried to draw a picture, but my art skills are abysmal. However, a simple internet search can show the picture I wanted to include. Imagine the waist as the horizontal portion of a cross. The vertical portion is the body’s midline. In a person without Lower Cross Syndrome this should look like a plus sign (+). However, with tight hip flexors and quads, the pelvis tilts forward causing the axis to dip forward. This pulls the back side up and the front side down (making it more of an ‘x’). Take into account the muscle imbalances discussed already and you can get a mental picture of what is going on here - the dreaded but common Lower Cross. The longer we stay seated and with our hips flexed and back slouched, it just adds up. Then when we suddenly try to stretch those muscles we find out that when a muscle is stretched, it will contract against the stretch. So when the muscles are stretched past the point where they have been sitting for prolonged periods of time, it can strain, tear, or spasm.
The website Physio-pedia has good information on this and images that you can check out: https://www.physio-pedia.com/Lower_Crossed_Syndrome.
From MacKenzie Institute
Athletes can see this pattern as well, but instead of being due to inactivity, it is from overtraining and strengthening the problem areas and not focusing on the others. The hip flexor and quad can be very strong and the hamstring very flexible - this is typically harped on during training. And honestly, who in their right mind really likes to do crunches? This was the most skipped part of the workout when I participated in college sports.
Without diving too much deeper into an anatomy lesson, let’s just talk about what can be done to avoid this problem. The main thing to focus on is mobility. Take time to stand up and move and try not to sit in one spot for longer than 60 minutes. A timer or some sort of reminder can be helpful. Some fitness trackers will notify users if there hasn’t been enough movement in an hour. Exercising is important and will help many other facets of health. One of the major components of physical fitness is flexibility. Add in some stretching for the hip flexor and the quads (the good old knee-to-butt stretch and a lunge stretch) to your daily routine. These two muscle groups will typical be VERY tight in people, while the lower abdominal muscles and the hamstring are weaker by comparison. Exercises and stretches primarily focusing on the hip flexor and the quadriceps flexibility will do the most good, however ALL will need work eventually. Simply increasing movement and working on quad and hip flexor flexibility is a high yield place to start in the process of reversing this painful and nagging but otherwise benign issue. If extra motivated and looking for a little ‘razzle-dazzle’, then add in some lower abdominal exercises to target those lower rectus abdominus muscles and some hamstring strengthening exercises to help reverse the tilt of the pelvis and lengthen the Psoas.
Now these are just simple and general things to try and help with this syndrome and the pain that accompanies it. This is not meant to be diagnostic for anyone specifically or to replace advice from your personal doctor. If simple changes don’t help, it could be something else that needs further attention. Seeing your doctor, a sports medicine doctor, or a Physical Therapist would be a great idea. Always reach out with questions. In times like these with a pandemic going on, telehealth can be utilized and is a great tool to avoid exposure.
Stay safe out there and keep on moving toward your goals in health and wellness.