Last year I wrote an article talking about a common root cause of back pain. Since that time, I’ve worked with clients of all ages and demographics, and have consistently seen similar postural faults. From high schoolers, to active and sedentary adults, and now junior hockey players, the postural fault leading to low back pain, hip flexor pain, and a host of other downstream problems known as lower cross syndrome is more common than I ever expected.
To recap, lower cross syndrome is when our hip flexors and low back muscles become increasing strong and tight, and our hip extensors and abdominals become increasingly weak as a result of being in a hip-flexed position for most of our life. The result is that our pelvis gets pulled forward in the front, and up in the back by our tight hip flexors and low back, and our hip extensors and abs do not have the strength to pull it back to neutral. So, our pelvis tilts forward and our low back arches excessively.
The concept is relatively simple, and so is the solution. But, getting athletes into the neutral position that we’re looking for can be very difficult. The first step is getting people to understand the concept. This is especially a challenge with some kids. But, even adults have many misconceptions that their lower back hurts because their low back muscles are too weak. Athletes tell me how doing back extensions to strengthen their low back hasn’t helped. If you understand lower cross syndrome, this is no surprise. Their back is already strong. It’s overactive, not weak. What we need to solve the problem is proper hip extension (glute and hamstring recruitment) and abdominal recruitment, which brings the lower back to a neutral spine position. This works because the abs bring the pelvis up in the front, and the hip extensors bring the pelvis down in the rear. The result is an overall posterior shift in the pelvis, and our muscles properly doing their job.
The next step, and I think the hardest step, is getting athlete’s bodies to understand it. The concept might make perfect sense, but getting their muscles to do exactly what we want to do can be difficult. Here are the cues I use to get the pelvis into a neutral position. All of these cues are designed to achieve the same outcome. What’s been interesting to me as a coach is how some cues that work great for some people, don’t work for others. So take what’s useful and discard the rest. But just know that the cue you discarded is exactly the cue that someone else needed.
- Tighten your core like you’re about to be punched
- When you’re bracing to get punched, you instinctively turn your abs on. For some, the threat of me punching them while they’re doing a plank is all it takes to get their spine neutral.
- Squeeze your butt
- This is conjunction with a braced core is the essence of what we need to do. If your butt, the main hip extensor, is contracted then our low back and hip flexors can relax.
- Extend your hips
- Visualize hip extension as opposed to lumbar extension. Think about your hips coming forward. This can result in stronger glute and hamstring activation than if you had just said, “squeeze your butt.” Emphasize the extension beginning from the bottom of your butt first, so that the low back does not extend along with the glues.
- Stand tall
- Especially at the top of squats and deadlifts, asking the athlete to stand tall results in glute activation at the top of each rep.
- Flatten back against wall/floor – “Do not let me get my hand underneath you.”
- When doing this against a wall or on the floor, it gives the athlete a goal to reach. If their back is completely flat, then we know that the pelvis is neutral.
- Visualize angle of pelvis in sagittal plane coming up to neutral.
- For visual learners, it helps to use a clipboard or folder to show what the angle of the pelvis is while relaxed, and that we want to tilt it posteriorly.
- Scoot your butt underneath you. What muscles would you have to turn on to get your butt underneath your torso?
- That’s right. Glutes and abs.
- Visualize and feel your butt tuck underneath you.
- Draw belly button in.
- Suck your belly button in as far as you can. This cue has worked great with younger athletes, even if they don’t yet understand the concept.
- Cylinder concept: The ribs come down, and the pelvis comes to make perfect cylinder position in your torso.
- It’s common with extended backs that the rib cage also flares up. So think about the ribs coming down, and pelvis flattening out to create a cylinder that’s parallel to the ground.
- I have to give credit to Michelle Boland for this cue.
- The Two-Hand Rule: This is essentially the same as the cylinder concept.
- Place one hand at the angle of your ribcage, and the other at the angle of your pelvis. Then anteriorly tilt the ribcage, and posteriorly tilt the pelvis so that your hands become parallel. If the hands are parallel, then you’re in a neutral position.
- This one is taken from Kelly Starrett’s book.
- Deep Exhale:
- In most exercises, we will also tell the athlete to have as slow an exhale as possible. This is because the diaphragm is an antagonist muscle to the deep abdominals. The diaphragm is most relaxed at the deepest point in the exhale. At this point, we can get a stronger deep abdominal contraction. Focus on letting as much air out as possible while squeezing your abs.
Now that the athlete understands the concept, and we’ve found a handful of cues to help them get into the position we’re looking for, now it’s time to apply it through exercises. Ultimately, this is where the skill can translate most effectively into sports and life. Holding a safe position while standing or lying down is great, but to cross over into the athlete’s activities, we must progressively apply more movement, more load, and more difficult situations.
- Low ab activation with MB overhead. Focus on flattening back, activating abs by deepening exhale.
- The simplest way to initially grasp the concept has been to start lying down on the floor. The reason for this is that now we can use the cue of flattening the back against the floor, which gives athlete an external indicator of whether or not they’re doing it correctly. In this sense, we’ve made the “pelvic tilt” a pass/fail test. In group setting, I can immediately see who doesn’t understand it yet, and who already has a strong grasp. I like to add the light med ball overhead just to relax the neck and shoulders.
- Low ab activation against wall.
- Now we’re doing essentially the same thing, but against a wall. This variation can be progressed and regressed easily. If you bring your feet further from the wall, it’s easier, and vice-versa. An athlete who is proficient in the movement, may still struggle immensely to stand with his feet just an inch or two from the wall with a flat back.
- Low ab activation against wall with overhead reach.
- A progression from the previous exercise. Reaching the arms overhead causes you to want to extend your back, which you will have to resist.
- A great exercise, but only if coached well. Now we’re asking the athlete to maintain a neutral pelvis position while holding himself up. Gravity makes you want to extend, and you have to resist this.
- I think that “butt down” is a bad cue with a good intention in the plank. I’m more concerned with the angle of their pelvis, than if their butt is sticking up a little bit. If the athlete doesn’t have the core strength yet to hold a perfect plank, then making sure that their whole body is parallel to the ground can result of using their low back instead of their abs. Instead, we instruct tight abs and tight glutes with slow exhales.
- Stability Ball Rollout – only after plank is successful.
- View the SBR as a dynamic plank. As you roll out, you must resist extension. If I could only choose to do one ab exercise, it would be the SBR/ab wheel movement. It forces us to apply the principles of a posterior tilt combined with movement. As a result, it crosses over into resisting extension on the field/court/ice well.
- Mini-Band Walks
- The emphasis is still on flattening the back by using glutes and abs. From a side view, the low back should almost look rounded.
- I also really like this movement because where the athlete feels it is a great indicator if they’re doing it right. If you can feel outer glutes then your low back is not being used as the primary hip abductor, and the side glutes are activating properly.
- Cook Hip Lift
- Hugging the opposite knee in causes the low back to round, and therefore not be able to activate well. Now, the extension has to come entirely from the glutes and hamstrings. If done correctly, this exercise is very humbling for most athletes with overactive low backs and tight hip flexors. They’ll realize how little extension they can actually get without the help of the low back.
- The hip lift is a great mean of assessing active hip extension range of motion. If you can see progress with this exercise among, it says a lot about your improved ability to extend your hips.
- Glute Bridge
- Same thing but on two legs. Sometimes the one leg hip lift variation is too difficult just because of active range of motion restrictions. So, we let them start with both feet on the ground and instruct them to begin the extension at the bottom of the butt, and end at the top of the butt. Holding at the top with a deep exhale helps the athlete to turn on their glutes.
- Quadruped hip extension on elbows.
- This is another variation to get strict hip extension. Lean back like you’re doing a Child’s Pose. This, as with the hip lifts, puts the low back in a position where it can’t activate. From here, reach one leg back. Keep the toes pointed straight down as you reach the heel to the sky and hold it. You should feel your butt.
My methods have changed a lot in the last year, but the principles have stayed the same. Get out of the hip-flexed, back-extended position and teach your body how to be back in neutral. Over time, athletes who are able to develop this skill, and translate it into their sport, will not suffer from chronic low back tightness or hip flexor tightness. Their chance of overuse injuries will drastically decrease, and as a result, they’ll be able to spend more time practicing their sport because they won’t have to be concerned with overdoing it and tweaking a hip flexor or their back. As fitness professionals this is our job. It is our job to better prepare our athletes to withstand the high physiological demands of their activities. The posterior pelvic tilt is an essential skill to help athletes cope with these demands, as well as improve performance.