jessephysio

Love this picture!

A few months ago I wrote an article on how muscle tightness might be a result of a skeletal imbalance as apposed to simply a shortened muscle. I discussed how an anterior pelvic posture might actually lengthen the hamstrings due to their origin and insertion being forced further away from one another leading to a series of events that causes the hamstrings to group to seem tight. In this case, the hamstrings aren’t tight, thy’re in tone via the sympathetic nervous system telling the muscle group to stay tense as not to allow tearing to occur. Read my previous post HERE to get caught up.

Awesome Diagram

Professor Janda was a revolutionary in the field of muscle imbalances. Through both study and observation he derived what we now call the upper and lower crossed syndromes. In today’s society where we sit almost all the time, the lower crossed syndrome is almost epidemic! Think about it for a second…when you get up in the morning you sit to have your coffee, have breakfast or read the paper. You sit in your car to get to work, and most of us sit almost all day at work! Then we go home and sit down to eat dinner and relax in front of the T.V! That is a lot of sitting. If you don’t think sitting is detrimental to our health, click HERE to find out more.
From a biomechanical perspective, sitting puts the hip flexors in a shortened position for hours on end. This causes the gluteal muscles to “turn off”in what Professor Stu McGill calls Gluteal Amnesia (reciprocal inhibition). When the glutes turn off and the hip flexors become tight, we see the pelvis pulled anteriorly and then (to make matters worse) the lower back paraspinals get placed in a shortened position and the rectus abdominus gets places in a lengthened position. These changes only help to solidify the pelvis is an anterior position. Clinically, you can measure this by simply looking at the angle between the PSIS and ASIS. In her book Muscle Testing and Function, Florence Kendall states that the PSIS should be no more than 5-10 degrees higher than the ASIS.

See the belly on her? You might have a belly and it has NOTHING to do with your weight...

If it is higher, you might consider the patient has having an anterior tilt. Other things to look at are as follows:

Size of lumbar spine lordosis: An increased lordosis indicates the hip flexors and lumbar spine erectors are pulling the pelvis forward which creates an extension moment at the lumbar spine. As stated in the picture above, an increased lordosis might make it look like you have a spare tire around your waist…even if you’re skinny!

Positive Thomas Test: If the psoas, iliacus (NOT iliopsoas!) or rec fem are tight it will be evident in this test. Personally I like it because it’s fairly objective and a positive test is easy to identify. I don’t have the studies off hand, but I can only assume inter-rater reliability would be quite good. It’s hard to miss a leg popping off the table during the test!

 Hip bridge test: Have the patient do a bridge and palpate the glutes and hamstrings. Which are they using more? In the bridging position, the hamstrings are in a shortened position and because of this they should be using mainly their butt muscles to extend the hips off the table. If they are using too much hamstring, or they complain of muscle cramps in the hamstring, they have gluteal amnesia (a weak butt).

 So what do I do clinically for clients that have this issue (and MANY do!)?  There are a few different techniques I use depending on subjective complaints but on the whole, this is what I do (and it’s not rocket science).

1) Lengthen the hip flexors (rectus femoris, psoas, iliacus, and even tensor fascia latta if need be. I like to do this as a PNF (contract-relax) stretch in the Thomas test position because I can get all the above muscles at pretty much the same time. I also like this position because it prevents the lumbar spine from being pulled into extension as seen so much in people who try to stretch their hip flexors.

2) I do soft tissue work to the lumbar spine erectors to try and decerase their tone. I will often follow this by manually rotating the pelvis posteriorly to increase the stretch of the paraspinals and to simply help place the pelvis back where it should be. I like doing my posterior pelvic mobilizations in a side lying position.

3) Glute strengthening/activation. You can literally have a whole post dedicated to glute exercises but for simplicity sake I usually start off by having my clients’ squeeze their glutes while they feel the muscle contract while I palpate the hamstrings. I want to teach them how to fire up their butt while not using their hamstrings…often easier said than done! Mike Reinhold has a great modification to the bridge that I give my patients to strengthen their butt. Here is the video:

4) Core strengthening. Again, not getting too detailed here because there are 100’s of ways to do this. For my average sedentary clientele I give McGill curl ups, plank modifications (off a wall, on knees etc) or even crook posterior pelvic tilts to fire the rectus abdominus and push the pelvis posteriorly. For my athletic patients I like to give front/side planks with harder modifications, dead bug, stir the pot using a physioball, or shoulder touches in a pushup position

5) I do a lot of soft tissue release to the hip flexors, hamstrings, lower back thoracolumbar fascia and paraspinals. It makes the client feel better and hey, is that ever a bad thing?

 6) EDUCATION!! I always tell my clients they need to get up every 30-40 minutes to take a walk around the office. No one position for any extended period of time is good for the body…the lotion is in the motion! I have given my clients instructions to use a stop watch or there is even an app one can download on their home screen that will make a buzzing sound every 30 minutes reminding them to get up.

As always, different patients need different things and this is a general overview of what I do. By no means is it exclusive. A cookie cutter approach will yield cookie cutter results.

Thanks for reading,

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist