Lower cross syndrome is one of several types of postures that many manual therapists and personal trainers may have learned early in their career. Personally, I had spent many years as a trainer and learned to try to “fix” or “correct” clients with lower cross syndrome. However, the premises behind such “syndromes” and posture correction—via corrective exercise—are not supported by scientific evidence.

Many print and online depictions of lower cross syndrome tend to show a sideway view of someone with an “X” drawn in the middle of the abdominal and pelvic region to show which muscles in the lower back and hips are “tight” and which ones are “weak.” The aim is identify these areas to bring the pelvis and spine as close to “neutral” position as possible.

On the surface, these ideas seem reasonable and intuitive, but scientific evidence shows that lower cross syndrome and other types of posture (e.g. anterior pelvic tilt, posterior pelvic tilt, forward head posture, upper cross syndrome) may not be as important as many therapists and trainers believe.

History of lower cross syndrome

Although some medical professionals have known about the concept of “crossed syndromes” to help explain why some people have musculoskeletal pain, the terms “lower cross syndrome” and “upper cross syndrome” got popular in the 1970s from the research by a Czech neurologist named Vladimir Janda.

The ideas of the posterior pelvic tilt and similar types of postures (e.g. anterior pelvic tilt, lateral pelvic tilt) came from the works of Dr. Vladimir Janda (1928-2002), who was a Czech neurologist who taught in various manual therapy schools in the late 20th century. He introduced the concept of functional anatomy, which is like a hybrid of anatomy and kinesiology. This is based on the idea of “functional pathology of the motor system” that was proposed by Dr. Karel Lewit (1916-2014), who was a close colleague of Janda.

In a 1978 paper published in The Neurobiologic Mechanisms of Manipulative Therapy, Janda described the patterns of muscles that are overactive or underactive, which are usually associated with the spine, his, and shoulders. When one group of muscles are “tight” or “shortened,” their opposite groups are “weak” or “lengthened.”

He wrote, “There are sufficient observations that some muscles usually respond to a given situation (e.g. to pain) by tightness, while others react by inhibition, atrophy and weakness.” He gave a few examples, such as tightness in the upper trapezius, levator scapulae, and chest muscles versus weakness in the lower stabilizers of the shoulder blades and deep neck flexor muscles.

These relationships eventually became known as “Janda’s Postural Syndromes,” which include upper cross syndrome and lower cross syndrome.

Janda argued that clinicians tend to look only at the site of pain and not at other parts of the body that may be the source of pain. He wrote that a “local lesion” may be a secondary symptom to another lesion that may be remote from the site of pain.

“…some types of cervical headaches due to altered function of the muscle-joint complex of the pelvis and hip. It is evident, of course, that such a relationship may seem doubtful to those who are accustomed to think in terms of localisation as is usual in structural changes. On the other hand, many good clinicians who have noticed a relationship between signs which might be described as ‘far distant symptoms’ did not understand the chain of reflex reactions resulting in the clinical picture,” Janda wrote.

Janda’s observations led him to postulate that when one group of muscles gets tight and/or shortened, the opposing muscles get weak and inhibited, lacking sufficient motor control and coordination to produce movement. Sometimes muscles tighten up in response to certain conditions, such as pain.

He wrote: “It is known that tightness of hamstrings or truck erectors frequently develops in these and similar postural defects, whereas abdominal and gluteal muscles show signs of weakness.”

Based on this idea, if you were to have anterior pelvic tilt, your hip flexor muscles (e.g. iliopsoas) would be considered “tight” or “shortened,” and your glutes and lower back would be “weak,” which pulls your pelvis forward. This posture may increase your likelihood of low back pain and limited hip extension due to “weak” glutes and “tight” hip flexors. So, one intervention could be an exercise program that involves stretching your hip flexors and strengthening your glutes and lower back.

Thus, this provides a foundation to what some trainers and manual therapists call a “joint-by-joint” approach to treatment and exercise programming to address upper and lower cross syndromes and other types of posture “issues.”

Despite the popularity and acceptance of Janda’s and Lewit’s ideas, which eventually were (and are still) taught in many manual therapy schools, pain research at least since the 1950s finds that there is more to pain and treatment than muscles, joints, and other biomechanical factors.

Lower cross syndrome types

There are two types of lower cross syndromes: posterior pelvic tilt and anterior pelvic tilt. Both of these can affect the upper body, including the neck and head. This is why upper and lower cross syndromes tend to be addressed together since they affect each other, according to Janda.

Posterior pelvic tilt

woman with posterior pelvic tilt

Traditional idea behind the posterior pelvic tilt. Image: Nick Ng

The posterior pelvic tilt is where the pelvis is rotated back in the sagittal plane, causing a reduction in the curvature of the lumbar spine and buttocks. Sometimes the pelvic tilt exaggerates the upper spine curvature, making the person appear more slouched, kind of like Shaggy from the cartoon “Scooby Doo.”

Details on posterior pelvic tilt.

Anterior pelvic tilt

young woman with lower cross syndrome

Traditional idea behind the anterior pelvic tilt.       Image: Nick Ng

The anterior pelvic tilt is where the pelvis is rotated forward in the sagittal plane, causing an increase of the lumbar spine curvature. This position tilts the gluteal muscles upward, exaggerating its round appearance for some people. Sometimes the pelvic tilt decreases the upper spine curvature, making the person appear to have a flatter upper back.

Details on anterior pelvic tilt

Lower cross syndrome and pain

Followers of the ideas behind Janda, Lewit, and other influencers often associate lower cross syndrome with various types of back pain, hip pain, knee pain, and even foot pain. However, people’s pain experience is more complex than just muscle imbalances and joint “dysfunction.”

Early theories of pain in the 19th and early 20th centuries treat pain mostly as a biological phenomenon. Any mention of psychosocial factors that may also influence pain would likely be dismissed by many clinicians at the time. As psychology and other social sciences advanced, clinicians and scientists began to see a connection among biological, psychological, and sociological factors.

While the gate control theory of pain, which was proposed by Dr. Ronald Melzack and Dr. Patrick Wall in 1965, revolutionized how pain was understood and treated, it was still highly biological. However, in the late 1980s, Melzack proposed the neuromatrix theory of pain, which included cognitive, emotional, and environmental factors that also give us the pain experience.

Posture and biomechanics do influence how we perceive pain, but they are not as a large influence as many clinicians and trainers think. Research on the relationship between posture and pain finds that it is quite poor and inconsistent.

A 1988 study found no relationship between “tight” hip flexors and back pain among 600 young, Swedish soldiers. Researcher and physical therapist Anna-Lisa Hellsing wrote that having tight muscles is not necessarily “good or bad,” rather it is a byproduct of heavy physical activity, like military training.

​“Experience of pain in the tight muscles themselves during the test differed very much between the subjects, but was not systematically recorded,” she wrote.

In 2002, an Iranian study of 600 people failed to find a relationship between those with or without low back pain based on  the degree of the anterior pelvic tilt, leg length discrepancy, and the length of the iliopsoas and abdominal muscles.

In 2003, researchers from Lyon, France, found that the degree of lordosis among 160 pain-free subjects varies, ranging from less than 35 degrees to more than 45 degrees as the sacral slope. Thus, posture is not a reliable prediction to determine who has pain or not if a clinician were to measure scores of pelvises and attempt to diagnose.

Ultimately, in a comprehensive systematic review in 2014, led by Dr. Robert Laird formerly of Monash University in Frankston, Australia, found no difference between subjects with or without low back pain in terms of lumbar lordosis angle (eight studies), hip extension (four studies), and pelvic tilt in the standing position (three studies).

They also found people with low back pain have a reduced sense of proprioception (body awareness in space), tend to move slower, and have greater movement variability than those with no low back pain.

Related: Janda’ Lower Crossed Syndrome Has Not Been Validated

Lower cross syndrome exercises: do they work?

Current research suggests that no exercise type is better than another for some types of musculoskeletal pain. A 2016 Cochrane Review reviewed 29 randomized controlled trials with a total of more than 2,400 subjects that compared the effectiveness of core exercises with other types of exercises for chronic low back pain.

They found that while core exercises offer some pain relief, based on very low to moderate quality level of evidence, higher-quality evidence found that there are “similar outcomes to manual therapies” and low to moderate levels of evidence found core exercises have “similar outcomes to other forms of exercises.”

A German 2020 systematic review of eight randomized-controlled trials and two non-randomized controlled trials also found similar results. The authors said that low-quality trials seem to “overestimate” the effects of core exercises on low back pain.

It is more likely that exercise in almost any form can alleviate pain by changing how the central nervous system and the brain process pain and modulating behavior and immune response.

Since there are no ideal exercises or exercise system to treat pain, perhaps the “right” exercise for you would be something that you can do regularly with little or no pain and you enjoy it, whether you have lower cross syndrome or not.

Given that the current weight of the scientific evidence does not support the premises behind the “crossed syndromes,” perhaps it is best for health and fitness professionals to follow and continue to question the evidence of old and new theories and research.

Lewit was quoted that “we should keep an open mind for new ideas that sometimes shows that what we taught and believed before was wrong. As new discoveries are made, new truths [are] discovered… institutions must advance also to keep pace with the times.

He warned that clinicians should not “be a slave of methods, but to let the methods serve the goals.”

 

Further Reading

Why Massage Therapists Should Learn How Pain Works

Pain Science 101 for Massage Therapists 

The Invention of Posture

When Biomechanics Matter

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A native of San Diego for nearly 40 years, Nick Ng is the founder and editor of Massage & Fitness Magazine, an online publication for curious massage therapists and the public who want to explore the science behind touch, pain, and exercise, and how to apply that in their hands-on practice or daily lives.

An alumni from San Diego State University with a B.A. in Graphic Communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. Prior to entering the massage profession, he also had worked as a personal trainer for 14 years.