Injury & Rehab: Lower Crossed Syndrome

If your client’s buttocks and stomach constantly protrude, they probably have a postural distortion syndrome that is affecting the lower kinetic chain.

Lower crossed syndrome (LCS) is a postural distortion syndrome affecting the lower kinetic chain (lumbopelvic hip complex, knee and ankle). It is characterised by people demonstrating a lordotic postural stance in which the buttocks and stomach protrude. Common causes include wearing high-heeled shoes over a prolonged period of time, pregnancy, or the classic ‘beer gut’ posture.

Tight hip flexors and lower back muscles characterise this syndrome, while neurological inhibition (weakness) with constant stretching of the lower abdominals and gluteal muscles promotes this easily identifiable posture. Weak, lengthened and inhibited lower abdominal muscles subject the joints of the lower back to greatly increased loads and increased risk of facet joint injury.

The imbalance of muscles that occurs in lower crossed syndrome results in anterior tilt of the pelvis, increased hip flexion and a compensatory hyperlordosis in the lumbar spine. This imbalance tends to over-stress both hip joints and leads to complaints such as lower back pain and sacroiliac joint dysfunction. The functionality of the gluteal muscles (particularly gluteus maximus) has been linked to sacroiliac/pelvic joint dysfunction.

The effects of the lower crossed syndrome are exacerbated by performing exercises involving double leg lifting and lowering. The increased load on the hip flexors, particularly in individuals with weak core stabilising muscles, increases the risk of compressing and loading of lumbar spine facet joints (photo 1).

Prevention and treatment

When it comes to treating lower crossed syndrome, the focus is on normalising the short and weak muscles, with the objective of restoring balance. This may involve stretching the specific tight muscles for a duration of 30 seconds. A five-week active stretching program can significantly increase active and passive range of movement in the lower extremity, e.g. iliopsoas, rectus femoris, TFL and lumbar erector spinae group.

It is also important to strengthen those muscles that have been weakened, so as to enhance optimal muscle function and improve postural alignment of the lower back, e.g. adductor, core and abdominal exercises, gluteus maximus and medius exercises, hamstring exercises and gastrocnemius and soleus exercises.

Exercises for addressing lower crossed syndrome

Instruct your client to try and hold all stretches for 30 seconds.

Hip flexor stretch (photo 2)

Adopt a lunge position, with hand on wall for balance. Keep body in upright position and reach to the back foot, gently lifting it off the ground to feel a stretch at the front of the thigh. If knee is sore on the floor, rest it on a rolled up towel or yoga mat.
Repeat x 3 both sides

Lower back cat (photo 3)

On hands and knees, arch the back upwards, tucking bottom under and chin to chest. Extend spine and drop back downwards. Bring bottom back over feet.
Repeat x 20

Supine ball squeeze (photo 4)

Lie supine in neutral spine position. Activate core abdominal muscles. Breathe out to squeeze medicine ball/chiball, holding contraction for 5 seconds. Make sure it is an even contraction for both adductor muscles, and that there is no gluteal activation or pelvic tilting.
Repeat x 12

Arm/leg extension (photo 5)

Extend one leg and the opposing arm simultaneously away from the body. i.e. right arm and left leg. Hold the extension for 5 seconds and then change to the other side. Keep weight shifting and movement to a minimum, and maintain neutral spine.
Goal: 3 sets of 10 each side

Bridges (photo 6)

Lying prone with palms downwards, take a breath in to prepare, and during exhalation push through the mid foot to lift the hips and trunk off the floor, activating the gluteus maximus and hamstring complex. Hold for the count of one. Exhale to return to the floor. Inhale to rest for one count, then exhale to repeat the movement. Ensure neutral spine is maintained and that there is no over extending from the lumbar spine.
Repeat x 10


Merrin Martin, BAppSc (Physio), is the founder of Active Anatomy Physiotherapy & Health Professional Workshops in Sydney. An experienced physiotherapist, exercise scientist, health educator and qualified Pilates instructor, Merrin is considered an expert in exercise rehabilitation. activeanatomy.com