7/14/18 OBJECTIVE WHAT IS LOWER CROSSED SYNDROME?

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1 LOWER CROSSED SYNDROME: A DIFFERENTIAL DIAGNOSIS FOR LOW BACK PAIN Kimberly Hansen ATC, LAT, CES Industrial Sports Medicine Professional with InSite Health Committee on Practice Advancement District 7 Representative Gilbert, AZ kimh@insitehealthteam.com OBJECTIVE 1. Define Lower Crossed Syndrome (LCS) 2. Cause and Symptoms 3. Who is affected 4. Assessments indicating LCS 5. Treatment using only OSHA first-aid protocols 6. Prevention 7. Case Studies and Return on Investment WHAT IS LOWER CROSSED SYNDROME? Medically known as Unterkreuz syndrome Also known as: lower crossed syndrome pelvic crossed syndrome distal crossed syndrome. Lower crossed syndrome (LCS) is the result of muscle strength imbalances in the lower segment. 1

2 MUSCULOSKELETAL STRUCTURES 1. Lower crossed syndrome is caused by muscular imbalances that affect the underlying structures 2. Tight muscles Lower Crossed Syndrome Hip Flexors Thoracolumbar Extensors 3. Weak Muscles Abdominals Gluteus Maximus and Medius 4. Also Seen Hamstring tightness is sometimes a contributing factor Tight Calves (especially from wearing heels) push pelvis forward UNDERLYING STRUCTURES AFFECTED 1. This pattern of imbalance creates joint dysfunction, particularly at the L4-L5 and L5S1 segments, SI joint, and hip joint. 2. Specific postural changes seen in LCS include: Anterior pelvic tilt Increased lumbar lordosis Lateral lumbar shift ER of the Hip Knee hyperextension INDIVIDUALS AFFECTED IN THE INDUSTRIAL SETTING Kneeling 2

3 INDIVIDUALS AFFECTED IN THE INDUSTRIAL SETTING Crouching INDIVIDUALS AFFECTED IN THE INDUSTRIAL SETTING Climbing INDIVIDUALS AFFECTED IN THE INDUSTRIAL SETTING Sitting 3

4 INDIVIDUALS AFFECTED IN THE OFFICE SETTING 1. Individuals that spend a majority of their time sitting increase the likelihood of hip flexor becoming tight 2. Ergonomics and incorporating daily stretches play a key factor in prevention of lower crossed syndrome INDIVIDUALS AFFECTED IN TRADITIONAL SPORTS Baseball and So3ball Catchers and Short Stop Rugby players Golfers Football Lineman Basketball Players Wrestlers Volleyball- Outside HiKer and SeKer BASEBALL AND SOFTBALL CATCHERS AND SHORT STOP 4

5 VOLLEYBALL FOOTBALL LINEMAN / RUGBY PLAYERS BASKETBALL PLAYERS 5

6 WE CAN T FORGET TO TAKE CARE OF OURSELVES! ATHLETIC TRAINERS AND PUBLIC SAFETY INSITE PICTURE HERE EVALUATION PHYSICAL OBSERVATION 1. Standing Tight hip flexors lead to an anterior pelvic tilt. Observe Beltline. Would the belt buckle be lower than the waist band? Tight spinal erectors lead to lordosis of lumbar spine Hyperkyphosis of thoracolumbar spine is more easily observed in forward flexion - Next the shape, size and tone of the tightened/inhibited muscles. 6

7 PHYSICAL OBSERVATION Sitting versus Standing SiSng Standing SQUAT OBSERVATION 1. Hips Externally Rotate Tight piriformis 2. Knees move outward Tight TFL and IT band Weak Adductors 3. Hyper lordosis (unable to maintain a neutral spine) Tight hip flexors Weak gluts and core 4. Weight in Balls of feet with chest drop Tight calves and pectorals 5. Limited hip extension in end position Tight hip flexors Weak Gluts Note: If symptoms such as low back pain or sciatica are present, use professional discretion to determine if squat may exacerbate symptoms. ACTIVE RANGE OF MOTION OBSERVED 1. Hip Extension Observe during gait Is Stride length shortened due to limited hip extension? Do hips tilt forward? 2. Hip abduction Side lying Pt. Abducts hip Watch for hip flexion and Hip External Rotation when abducting 3. Supine to Sit Laying in Supine position Does Pt. feet lift before chest? Indicates over active hip flexors and a weak core 7

8 SPECIAL TESTS AND PASSIVE ROM FABER- Flexion, ABduction, and External Rotation Thomas Test- Indicates tight hip flexors Look for symptoms indicating SI joint dysfunction, Iliopsoas tightness, and Hip Impingement SPECIAL TESTS AND PASSIVE ROM Straight Leg Test (with and without dorsiflexion) Indicates tight hamstrings and symptoms of Sciatica SPECIAL TESTS AND PASSIVE ROM Trendelenburg - Weak Glut Medius 8

9 WHEN TO SUSPECT LOWER CROSSED SYNDROME 1. Associated Symptoms 1. Joint Pain 1. Lower Back Pain 2. Hip Pain 3. Knee Pain 2. Postural Changes 1. Lumbar lordosis 2. Anterior pelvic tilt 3. Knee hyperextension SECONDARY INJURIES 1. Muscular imbalance increases tension on joint ligaments leading to joint dysfunction. Joints affected include 1. L4-L5, L5-S1, SI joints and hip joints. 2. Bulging Disc 1. Caused by excessive lumbar extension 3. Disc herniation 1. Axial loading plus LCS increases risk of herniation 4. Pinched nerve (Sciatica) 1. Pressure from tight piriformis 2. SI Joint dysfuntion 3. Bulging or herniated disc HOW IS LOWER CROSSED SYNDROME MANAGED? 1. Can be managed through OSHA first-aid alone. 2. Patients biomechanics and ergonomics need to be evaluated and corrected. 1. Posture correction 3. If no secondary issues are suspected, no referral to physician is needed. 4. Correct muscular imbalance 1. Lengthen tight muscles 1. Hip flexors 2. Quadriceps 3. Quadratus Lumborum 4. TFL and IT band 2. Strengthen Weak Muscles 1. Core muscles 2. Gluts 9

10 WHAT IS OSHA* FIRST- AID? *Only pertains to work-related injuries 1. First aid refers to medical attention that is usually administered immediately after the injury occurs and at the location where it occurred. 2. It often consists of a one-time, short-term treatment and requires little technology or training to administer. 3. First aid can include: cleaning minor cuts, scrapes, or scratches; treating a minor burn; applying bandages and dressings; the use of non-prescription medicine; draining blisters; removing debris from the eyes; massage; drinking fluids to relieve heat stress. OSHA FIRST-AID Treatment of Musculoskeletal Disorders 1. Massage 1. Myofacial mobilization 2. Trigger point release 3. PROM 2. Ice 3. Heat 4. Education 1. Biomechanics and Ergonomics Assessments 1. Assess Biomechanics and Ergonomics associated with risk factors contributing to LCS 2. Posture 3. Lifting techniques 4. Preventative stretching and strengthening programs TREATMENT OVERVIEW 1. Remove adhesions. 2. Deactivate trigger points 3. Regain normal lumbar flexion mobility 4. Core stabilization exercises to strengthen the abdominal muscles. 5. Re-education of posture and body usage. 1. It is necessary to relearn the specific activiation of every element within the Lower Pelvic Unit. This will establish the important fundamental patterns of intra-pevlic control and will also integrate these patterns into basic functional patterns of movement control iniated from the pelvis. 10

11 REMOVE MUSCULAR / MYOFASCIAL Use Myofascial tools or hands ADHESIONS 1. Perform myofascial release to the gluteus muscles, iliopsoas, tensor fasciae latae (IT band) and calves. 2. Without stripping the adhesions, muscles are restricted from performing full range of motion potential. DEACTIVATING TRIGGER POINTS 1. Overused muscles, muscles in spasm, or muscles that have recovered from a recent trauma develop a knot. 2. The knot stops blood flow at the trigger point preventing tissues of oxygen and nutrients 3. Waste and toxins build up in the area resulting in tension and pain. 4. Knots and trigger points can be found by massaging the length of the muscle from distal to proximal. When you hit a point of restriction, or discomfort, apply steady pressure until muscle relaxes and then continue massaging the length o the muscle to help disperse toxins to be cleared from the muscle. 5. Trigger points to release: 1. Iliopsoas 2. Piriformis 3. Quadratus lumborum 4. TFL BODY MECHANICS 4 Principles to Body Mechanics 1. Power Stance - Foundation of body mechanics Most efficient work position that produces greatest force and stability 2. Work Zone - 3 power zones that position your body to utilize the greatest strength 3. Optimal Joint Positions - working in neutral and efficient body positions 4. Varying Positions & Tools - rotating task, taking breaks, or using proper tools to improve body mechanics 11

12 STANCE Using the Power Stance 1. Position that allows body to: ü Produce greatest amount of force ü Places joints in their Optimal Position ü Provides for a solid base of support ü Position of greatest balance while standing 2. Most efficient work position ü Recruits core muscles ü Improved readiness to react 3. Places the support column Spine in position of greatest stability insitehealthteam.com. BEST POSITIONS: BACK Back BAD 1. Base position: Staggered stance 2. 3 natural curves of spine 3. Use 3 point contact when possible Unsafe Zone 1. Base position: narrow stance, using one foot, off balance 2. Loss of curves 3. Back flexed > 20 degrees 4. Twisting or Lateral flexion 5. Extension 6. Not using 3 point contact GOOD insitehealthteam.com. ERGONOMICS 12

13 PREVENTION Physical Conditioning LACK OF PREVENTION Stages of Injury Stage 1: Muscle Tightness & Fatigue Stage 2: Discomfort Stage 3: Pain Stage 4: Disability PREVENTION When to Stretch? 1. As a warm-up prior to activity 2. Daily for general muscle health 3. As breaks every 20 minutes 13

14 PREVENTION Areas of Focus 1. Rapid Warm-ups, Stretches, and 20/20 Breaks should target the following areas: Hip Flexors Quadriceps Quadratus Lumborum Hip Abductors Calves Spinal Erectors and Rotators Gluts As a warm-up prior to activity 1. Used to increase muscle tissue: 1. Blood flow 2. Joint movements 3. Tissue elasticity 2. Works all muscles around a joint 3. Improves movement patterns Daily for general muscle health Stretch only to the point of tension or tightness NEVER to the point of pain. If you feel pain back off! Perform each stretch in a smooth gentle motion Do not bounce Hold each stretch for seconds Remember to use proper FORM Remember that practice improves your flexibility 14

15 Stress & Fatigue Reduction second break every 20 minutes 2. Job Rotation 3. Conditioning Break 4. Micro Rest Breaks Break or position change once every 20 mins. CASE STUDIES 1. ANDY WHY IS THIS IMPORTANT? 1. Patient happiness and quality of life 2. Decrease risk of injury 1. Acute disc herniation 2. Chronic Disc degeneration, Sciatica 3. Return on Investment 1. Decrease 1. Use of prescription and OTC Pain Killers 2. Employee turnover 3. Cost of workman s comp claims 4. Lost work days- Time on the Bench 2. Increase 1. Employee morale 2. Productivity 3. Efficiency 15

16 REFERENCES QUESTIONS? 16