Definition[edit | edit source]The ‘Unterkreuz syndrome’ is also known as pelvic crossed syndrome, lower crossed syndrome or distal crossed syndrome. The lower crossed syndrome (LCS) is the result of muscle strength imbalances in the lower segment. These imbalances can occur when muscles are constantly shortened or lengthened in relation to each other. The lower crossed syndrome is characterized by specific patterns of muscle weakness and tightness that cross between the dorsal and the ventral sides of the body. In LCS there is overactivity and hence tightness of hip flexors and lumbar extensors. Along with this there is underactivity and weakness of the deep abdominal muscles on the ventral side and of the gluteus maximus and medius on the dorsal side.[1] The hamstrings are frequently found to be tight in this syndrome as well. This imbalance results in an anterior tilt of the pelvis, increased flexion of the hips, and a compensatory hyperlordosis in the lumbar spine. Show
Figure 1: lower crossed syndrome [2] Clinically Relevant Anatomy[edit | edit source]The lower crossed syndrome involves weakness of the trunk muscles: rectus abdominis, obliques internus abdominis, obliques externus abdominis and transversus abdominis, along with the weakness of the gluteal muscles: gluteus maximus, gluteus medius and gluteus minimus. These muscles are inhibited and substituted by activation of the superficial muscles. There is co-existing over activity and tightness of the thoracolumbar extensors: erector spinae, multifidus, quadratus lumborum and latissimus dorsi; and that of the hip flexors: iliopsoas and tensor fasciae latae. The hamstrings compensate for anterior pelvic tilt or an inhibited gluteus maximus. Characteristics/Clinical Presentation[edit | edit source]This muscle imbalance creates joint
dysfunction (ligamentous strain and increased pressure particularly at the L4-L5 and L5-S1 segments, the SI joint and the hip joint), joint pain (lower back, hip and knee) and specific postural changes such as: anterior pelvic tilt, increased lumbar lordosis, lateral lumbar shift, external rotation of hip and knee hyperextension. It also can lead to changes in posture in other parts of the body, such as:
increased thoracic kyphosis and increased cervical lordosis.[3][4] Type A: The first subgroup is the posterior pelvic crossed syndrome. In this subgroup there is a domination of the axial extensor.[3] Because the hip flexors are shortened, the pelvis is tilted anteriorly and the hip and knee are in slight flexion. Associated with this is an anterior translation of the thorax because of an increased thoraco-lumbar extensor activity.This gives an expression for the compensatory hyperlordosis of the lumbar spine and hyperkyphosis in the transition from thoracic to lumbar spine. This leads to a decrease in the quality of breathing and of the postural control. Above that the entire thorax will move up, due to the minimal inferior stabilization created by the abdominals. The infra-sternal angle will go up to more than 90° and the postero-inferior thorax will be hyper-stabilized through which it will cause a limited postero-lateral costo-vertebral movement.[3] The more anterior and elevated position of the thorax will disturb the stabilization synergies of the Lower Pelvic Unit. The patient will lift the thorax during inspiration which causes an upper chest breathing pattern. This means that the active exhalation will be difficult, because the abdominal activation fails to bring the thorax down and back into the more expiratory caudal (or neutral) position. The abdominal activation is also not sufficient to create the essential intra abdominal pressure. We will notice that the expiratory phase is shortened. This problem arises when the coordination and co-activation between the transverses and the diaphragm is missing. The patient is forced to use the Central Posterior Clinch behavior, which results in an overactivity of the psoas.[3] Type B : It is also called ‘The Anterior Pelvic Crossed syndrome. In this type the abdominal muscles are too weak and too short. This is associated with a predominant tendency of the axial flexor activity.[3] The compensation is reflected by a minimal hypolordosis of the lumbar spine, a hyperkyphosis of the thoracic spine and protraction of the head. The pelvis is postured more anteriorly and the knees are in hyperextension.[4] Figure 2: type A [2]
Figure 3: type B [2] Examination[edit | edit source]Examination for Lower crossed syndrome should follow the same patterns as for examining a patient for Low Back Pain. Some specific examination points for LCS include the following:
- Position of the pelvis. There is usually an increase of anterior tilt of the pelvis. This can be associated with increased lumbar lordosis.
Hip extension - is examined to analyze the hyperextension phase of the hip in gait. Use straight leg lifting. Figure 4: Hip Abduction [5] Figure 5: Trunk Curl up [5]
Physical Therapy Management[edit | edit source]The treatment of tightness is not in strengthening as it would further increase tightness and possibly result in more pronounced weakness. A tight muscle should be stretched efficiently. Stretching of tight muscles results in improved strength of inhibited antagonistic muscles, probably mediated via the Sherrington’s law of reciprocal innervation (level of evidence: 2C). [4] [6] This may involve purely soft tissue approaches. Stretch the specific muscle for a duration of 15 seconds. A five week active stretching program significantly increases active and passive ROM in the lower extremity. [7] (level of evidence: 1B) Iliopsoas stretch in thomas position Iliopsoas stretch (and rectus femoris) [8] The patient is placed in Thomas position. The not-stretched side is maximally flexed to stabilize the pelvis and flatten the lumbar spine. The other leg is normally in flexed position because of the tightness of the iliopsoas. Push this leg into the neutral position (onto the table). Hold this position 15 seconds. If you want to integrate the rectus femoris into this stretch, bend the knee more than 90° while performing the iliopsoas stretch (level of evidence: 2C). Self stretching of hip flexors Erector spinae stretch [9] The patient lies supine in the fetal position, their knees to their chest with their arms wrapped around their knees. Exhale and stretch. Hold this position for 15 seconds. The solution for these common patterns is to identify both the shortened and the weakened structures and to set about normalizing their dysfunctional status. This might involve:
References[edit | edit source]
Which postural distortion is characterized by anterior pelvic tilt and excessive lordosis of lumbar?The term swayback can be used to describe two different postural distortion patterns of the lumbosacral region. It can be used to describe the lower crossed pattern of excessive anterior tilt of the pelvis and hyperlordosis of the lumbar spine (because the lumbar spine “sways back”).
Which posture distortion is characterized by anterior pelvic tilt?An anterior pelvic tilt is part of a postural distortion pattern affecting the low back and pelvic muscles called the lower crossed syndrome. The lower crossed syndrome got its name from the pattern of tension in the muscles when the body is viewed from the side (Fig. 8.19).
What is anterior pelvic tilt caused by?Anterior pelvic tilt is caused by the shortening of the hip flexors, and the lengthening of the hip extensors. This leads to an increased curvature of the lower spine, and of the upper back. The hip flexors are the muscles that attach the thigh bone to the pelvis and lower back.
Does anterior pelvic tilt cause lordosis?An anterior pelvic tilt will naturally extend the spine, resulting in lumbar lordosis, or a larger curvature of the lumbar spine. Over time, lumbar lordosis can lead to lower back pain, stiffness, and complications with range of motion.
|