Janda’s Pelvic Cross Syndrome
Janda’s Pelvic Cross Syndrome, also known as the “Lower Cross Syndrome”, has been widely used in rehabilitation and corrective exercise strategies. The purpose of this post is to share some of the wisdom taught by Professor Janda, and to describe how I incorporate the Pelvic Cross methods in my work.
The pelvic cross syndrome is characterised by the imbalance of tight and short hip flexors and inhibited and weakened gluteal and abdominal muscles. The syndrome promotes a forward tilt of the pelvis with an increased lumbar lordosis, and a slightly flexed position of the hips. The hamstrings are often found to be tight in this syndrome, which may be a compensatory mechanism to lessen the anterior pelvic tilt, or the over-activity and perceived tightness could be a functional compensation for the inhibited gluteal muscles. Over-activity and tightness of the Erector Spinae muscle in the presence of inhibited and weakened Gluteal muscles will alter the pattern of hip extension, which is a fundamental part of the gait-pattern.
The postures resulting from the imbalances in this syndrome change the distribution of forces in both the lumbar segments and the hip joints. If the hips lose their ability to extend to the range required in the gait cycle, there will be compensatory patterns of further increased anterior pelvic tilt and hyper extension of the lumbar spine (L5-S1 and L4-5 hyper mobile). The result of the excessive loading of the lumbar spine and hip joints may lead to stiffness, irritation and inflammation of the joints and surrounding soft tissues. The lumbar spine gets over-loaded at the posterior aspect of the disc spaces and the intervertebral joints, which normally do not carry load but only control movement.
The instability of the lower lumbar spine is often compensated by a stiff kyphosis of the Thoraco-Lumbar junction, and an increase of the cervical lordosis develops in efforts to balance the body against gravity and to keep the head and eyes in an upright position. The compensatory changes of posture may lead to symptoms of pain and stiffness in these areas.
An imbalance can also exist in the lateral Lumbo-pelvic musculature, where inhibition of the Gluteus Medius is compensated for with a hyper-activity and tightness of the ipsi-lateral (same side) Quadratus Lumborum (QL) and Tensor Fascia Latae (TFL)
The Assessment of the Pelvic Cross Syndrome can be divided into three stages:
- 1. Evaluation of standing
- 2. Examination for muscle tightness
- 3. Examination of movement patterns
The Assessments should not be performed on patients in acute pain, since the pain might distort the posture and muscle function to such a degree that tests yield invalid information. In such patients the emphasis should be placed on acute care and the assessment should only be conducted when the acute episode has subsided and the patient has regained the habitual posture and movement patterns.
1- Evaluation of standing
Many abnormalities of posture can occur in the lower back patient and the therapist has to differentiate between possible causes, as many factors including structural variations, age, altered joint mechanics, muscle imbalances and residual effects of pathology can all causes postural deviations. Certain signs can be observed that reveal whether or not muscle impairment is causing or contributing to the altered posture. Change in size and/or shape of muscles known to react either by over-activity and tightness or inhibition and weakness.
Muscles prone to develop tightness: Triceps Surae (calf – Gastroc and Soleus), Hamstrings, short thigh adductors, hip flexors (Ilio-psoas, Rectus Femoris and TFL), Piriformis, QL, Spinal Erectors, Pectoralis, Upper Trapezius, Levator Scapulae, Sterno-Cleido Mastoideus, and the short deep neck extensors.
Muscles prone to inhibition: Tibialis Anterior, Vastus Medialis, Rectus Abdominis, Lower Stabilizer of scapula (Serratus Anterior, Rhomboids and lower & Middle Trapezius) and the deep neck flexors (DNF)
To evaluate the patient:
Observe the position of the pelvis- Imagine the belt line – Is the belt line horizontal or is there an anterior pelvic tilt?
Gluteal Muscles- Ideally the Gluteal muscles should be symmetrical and well rounded. If they are inhibited and weak the muscles tend to hang loosely (“Bags of water”- Janda). Asymmetry of the gluteal muscles where only one side is affected may indicate hip pathology, a leg length discrepancy or most commonly an S/I joint dysfunction ( see separate blog about S/I joint and Gluteal inhibition)
The hamstrings are usually well developed, but it is important to look at their bulk relative to that of the Gluteal muscles, for when the latter are inhibited the hamstrings become dominant. This is very evident when there is unilateral (one-sided) inhibition of the gluteus Maximus.
Tightness of the short hip adductors can be seen as a distinct bulk of muscles at the upper third of the inside of the thigh.
Careful attention should be paid to the back muscles. The bulk of the Erector Spinae should be compared from side to side as well as from the lumbar and Thoraco-lumbar regions. There should be no difference in bulk between the sides and regions. Prevalence of the Thoraco-lumbar portion indicates that there is poor muscle stabilization in the lower lumbar region.
The Abdominal muscles should flat and not sagging and protruding.
From the initial observation of standing the therapist should have gained an overall impression of the patient’s muscle status, and important syndromes such as the Pelvic Cross been identified. The standing assessment should lead the therapist to specific tests of both muscle length and movement patterns.
2- Examination of muscle length
Place the patient end of the table and get them to flex the opposite hip and knee up to the chest, thus eliminating the lumbar lordosis. The patient then rolls backwards maintaining a flattened lumbar spine until laying supine. This position is very important, if there is not adequate stabilization of the pelvis and lumbar spine there will be false results in the length tests. The tested leg hangs freely over the edge of the table.
Note the following:
- Ilio-Psoas- the femur rests at horizontal and the thigh may be depressed a further 10-15 degrees without excessive soft-tissue resistance
- Rectus Femoris- with the femur horizontal the lower leg should hang vertically (knee 80-90 degrees flexion) and the knee should be able to be passively flexed to approximately 105 degrees of flexion without excessive resistance.
- Hip Adductors- with the thigh horizontal, the hip should be able to be abducted 15-20 degrees without either movement of the pelvis or soft-tissue resistance. Tightness of the short adductors is indicative of a possible hip-joint lesion. A Flexed knee position tests the length of the short while a straight leg will test the length of the long adductor muscles.
- TFL-adduct the horizontal thigh until the pelvis moves. There should be 15-20 degrees of adduction.
- Ilio-Tibial-Band (ITB)- A groove visible on the lateral aspect of the thigh indicates a tightness of the ITB. This is confirmed by restricted passive extension/adduction of the thigh with the knee flexed at 90 degrees.
Further information from the same position:
- When the thigh does not rest horizontally when held in the midline (adduction/abduction), extend the knee and observe what additional range of hip extension is available when the Rectus Femoris has been taken off-stretch position.
- Abduct the thigh and observe what additional hip extension is possible when the TFL is off its stretch position. In this position any residual lack of extension from the horizontal position is likely to be from the Iliopsoas muscle.
Note: it is not possible to eliminate the influence of any shortening of the joint-capsule in this position.
When testing the hamstrings have the patient in a supine position with the other leg flexed, as a tight Iliopsoas will cause an anterior tilt the pelvis. It makes more sense to regard the hamstrings as feeling tight due to the anterior pelvic position than being shortened. I personally prescribe more strengthening exercises than stretches for the hamstrings in this syndrome.
3- Movement patterns to evaluate: Janda recommended 6 patterns, out of which two play a major role in the pelvic cross syndrome. The relevance of inhibited or weak muscles is not in their lack of maximum strength capacity, but mainly in the onset of activation during movement.
- Hip Extension Test: Hip extension is the most important and affected part of the gait cycle. The patent lays supine with the feet off the end of the table, and is instructed to slowly lift the leg off the table. The practitioner observes the different muscles regarding timing and quality of activation. Hamstrings can initiate the movement, but Gluteus Maximus closely follows. The Order of activation should be 1-Hamstrings, 2-Gluteus, 3-contra-lateral lumbar extensors, 4-ipsi-lateral lumbar extensors, 5-contra-lateral Thoraco-lumbar extensors, 6- ipsi-lateral Thoraco-lumbar extensors. The activation does not have to follow the entire chain, but it is important that it follows the correct sequence. Activation of the lumbar extensors prior to Gluteus, activation of the ipsi-lateral lumbar extensors before the contra-lateral part, or a too early activation of the Thoraco-lumbar region indicates muscle inhibitions and stabilization issues. In severe cases the Thoraco-lumbar extensors as well as neck muscles are recruited to initiate the movement. Faulty patterns most often create an anterior pelvic tilt and a hyper-lordosis of the lower lumbar spine.
- Hip Abduction Test- Testing for inhibition of the Gluteus Medius and Minimus. Approximately 85% of the gait cycle is spent in a one leg stance. Inhibition of the Gluteal muscles creates poor lateral stabilization which results in a walk with increased pelvic sway with the use of ligaments and TFL for lateral stabilization. Place the patient on the side with the bottom leg flexed. The patient is instructed to slowly lift the top leg off the table. There should be approximately 20 degrees of straight hip abduction without any flexion, hip elevation or trunk rotation. Flexion of the hip indicates TFL tightness. A hip elevation (hike) indicates that QL has been recruited as a prime mover instead of its normal stabilization function.
The treatment protocol for a Pelvic Cross Syndrome:
- Normalize joint function – Dysfunction of the S/I joint will inhibit Gluteal function.
- Lengthen tight muscles (Rectus Femoris, iliopsoas, TFL, back extensors).
- Activate/facilitate inhibited and weakened muscles- using small contractions (30%). Patient is instructed to maintain a controlled position while light load is added. Additional facilitation can be added by stroking or tapping the targeted muscle.
- Gradually integrate the facilitated muscle back into basic movement patterns
- Progress the movement patterns- Pay close attention to ideal muscle recruitment and do not exceed what can be performed using correct muscle activation.
- Progress patterns using parameters of speed and load.
Point 6 is often introduced too early since a common belief is that the muscles are weak and just need strengthening. Proper activation has to be achieved before strength training can occur and no training should exceed what can be achieved with ideal movement patterns.
Mobilization of a tight Thoraco-lumbar region when a Pelvic cross syndrome is present often takes compensatory stabilization away and the patient may get worse. Mobilizing the compensatory stabilization segments is not recommended until the muscles are balanced.
Hip Flexor Stretch
Rectus Femoris Stretch
Glute-excercise: with the hands supported, stand on one leg with the oposite leg elevated behind the body. Sit back and stretch the elevated leg backwards. Make sure that the knee on the supporting leg does not move inwards (valgus collapse) or in front of the foot. Slowly move back and forth over the supporting hip.