ACADEMIA Letters

Postural and Musculoskeletal Relations of Inferior Cross

Syndrome
Willians Cassiano Longen, Physical therapist. Post-Doctorate. Master’s Program in
Public Health-PPGSCol, University of the Extreme South of Santa Catarina-UNESC
Taís Sparremberger Justo, Fellow of the Center for Studies and Research in Workers’
Health-NEPST of the University of the Extreme South of Santa Catarina-UNESC

ABSTRACT
Introduction: Pelvic Cross Syndrome is characterized by muscle imbalance, such as inhi-
bition of muscles that are part of the pelvic joint muscle group, identification of incorrect
activation, excessive strength and shortening or weakness of some of these muscles, which
may lead to mechanical and postural dysfunctions, due to these imbalances cross-section.
Objectives: To identify the connections and the existence of a relationship between postural
patterns and musculoskeletal imbalances with the manifestation of inferior cross-syndrome.
Methods: The research involved the review of studies such as articles from journals and jour-
nals, dissertations and theses, in Portuguese and English, with a database available on the
Internet. Results: It was identified that pelvic cross syndrome is characterized mainly by
muscle imbalance caused by the gluteus and abdominal muscles that are inhibited and the
eerormuscles of the spine, psoas and iliac contracted. Conclusion: it was possible to identify
a certain connection of musculoskeletal imbalances and certain postures such as hyperlordosis
and pelvic anteroversion in individuals with inferior cross syndrome. Another finding of the
study, although it was not the central objective, is that there is a predisposition to these people
to present a pain in the lumbar segment.

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.

1
Keywords: Pelvic cross syndrome, inferior cross syndrome, hip muscles, lumbar lordosis,
pelvic anteroversion

INTRODUCTION
Currently much has been discussed about what would be the ideal and correct posture. How-
ever, according to authors, the correct posture is one where there is a balance in the distri-
bution of forces over musculoskeletal structures. The lower the stress generated in the joints,
the lower the activation of adjacent muscles, instigating a posture with minimal muscle effort,
characterized as “ideal”.[1,2] Equilibrium is a concept that describes a situation in which the
present forces are equal or in which none exceeds the sum of the others.[3] It is in this con-
dition that the actions of the agonist muscles and antagonists of the spine are minimized and,
therefore, more efficient.[4] As mentioned by Magee, poor posture is caused by the lack of
balanced interaction between the various parts of the body, pelvic anteroversion induces an
increase in overload in the nearest joints, which may result in pain in the lumbar region.[5]
The main region responsible for sustaining the loads imposed on the human body is the
lumbar spine, and may be associated with the fact that there are so many cases of chronic pain
in this segment.[1] The trunk supports the upper limbs and the lower limbs, consequently, for
the muscle groups of the respective ones as well. This way, any misalignment can affect the
different segments. Some muscles can perform torques on the hips to generate accelerations
and decelerations, and the inhibition or weakness of these muscles can end up negatively
resulting in mobility and stability of the body as a whole, also contributing to the appearance
of syndromes.[4]
Most movement syndromes that disturb the hips are related to muscles that have dysfunc-
tions and are inserted into the femur. However, the very detailed analysis of hip movements
and muscles has the function of counseling, in order to distinguish whether the movement
syndrome originates in the hip, spine or both.[2] Musculoskeletal evaluation is fundamental
to analyze the patient’s posture, discussing human movement patterns and conducting a spe-
cific treatment in the face of needs.[6] Muscle imbalances are changes in the recruitment of
one or more muscles within a given movement, which can generate dysfunctions and con-
tribute to the emergence of pathologies that are often disabling from the functional point of
view.[7] Pelvic Cross Syndrome is associated with pelvic anteroversion and is characterized
by muscle imbalance, such as inhibition of muscles that are part of the pelvic joint muscle
group, identification of incorrect activation, excessive strength, shortening or muscle weak-
ness of some of these components of the group, which may lead to mechanical dysfunctions
and postures cross-shaped, in which certain muscles start the action of others.[8] In agree-

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.

2
ment with the statements, one study reported that such imbalance in the pelvic region results
in PCS, in which it leans previously, triggering an accentuation of lumbar lordosis, in which
some muscles are shortened/rigid, while others are weak and inhibited.[9] With the intention
of bringing greater knowledge about the subject, the study sought to identify the connections
and the existence of a relationship between postural patterns and musculoskeletal imbalances
with the manifestation of inferior cross syndrome.

METHODOLOGY
The present study involves a review research, carried out in databases available on the In-
ternet. The databases accessed were: BIREME (Virtual Health Library); SciELO (Scientific
Electronic Library Online), LILACS (Latin American and Caribbean Literature on Health
Sciences); PubMed and GOOGLE (free and free site). The search for the databases occurred
through the following descriptors: pelvic cross syndrome, inferior cross syndrome, hip mus-
cles, lumbar lordosis, pelvic anteroversion, which are registered in the System of Descriptors
in Health Sciences - DeCS.
The research involved articles from journals and journals, dissertations and theses, in Por-
tuguese and English, based on scientific data and with years of publication between 2000 and
2020. The studies found were reviewed and the inclusion criteria were articles published in
Portuguese and/or English in the time interval of the period mentioned, which would under-
stand and contribute to the objective of the research. Those who did not meet these criteria
were considered exclusion (as shown in flowchart 1).

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.

3
 Flowchart 1. Stages of the study methodology.

RESULTS AND DISCUSSION

The Inferior Cross syndrome (SCI) or Pelvic Cross syndrome is described by the authors by
an imbalance of the extensor, thoracolumbar, hip flexor, iliopsoas and femoral reto muscles,
with inhibition of abdominal muscles and gluteus muscles.[6] Such a syndrome is character-
ized by specific patterns of muscle weakness and stiffness that intersect between the dorsal
and ventral sides of the body. In the inferior cross syndrome, there is an increase in activity
and, therefore, stiffness of the hip flexors and lumbar extensors. Along with this, there is a
decrease in the activity and weakness of the deep abdominal muscles and of the maximum
and middle glutes.[10] Often, hamstrings are also contracted in the inferior cross syndrome.
This imbalance results in an anterior inclination of the pelvis, increased flexion of the hips

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.

4
and a compensatory hyperlordosis in the lumbar spine.[9]

Figure 1. Representation of muscle imbalance in the inferior crossed syndrome.

As we can observe (Figure 1), SCI is characterized by the imbalance that affects the hip
muscles, which can change the position of the pelvis and cause a disorganization in posture. In
the case of anteroversion, it is caused due to shortening of the erecting muscles of the spine and
iliopsoas, along with the presence of inhibited abdominal and gluteal muscles. Therefore, the
individual may present an increased curvature of the lumbar lordosis, which may lead to the
appearance of pain in the lumbar segment. This statement corroborates with Boyle’s study
(2015), in which he says that the lack of strength of the core muscle groups and the glutes
are the main causes of low back pain. Depending on the degree of the problem, it may also
occur that the knees suffer a slight flexion and the shoulders rotate in front.[8] Magge (2005)
says that the hip that stays long in the flexed position can present in flexion contractures, so

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.

5
the flexors can generate a large activation and, on the contrary, the extensors weaken.[12] A
normal lumbopelvic posture leads to alignment of the spine, however an altered lumbopelvic
posture leads to misalignment of the spine. This change may occur due to a set of factors, such
as the stiffness of the connective tissue around the lumbar spine, compensation of some poor
alignment in another region, sedentary lifestyle or inadequate physical exercises, and antalgic
postures.[5]
Muscle imbalance generates joint dysfunction (ligament tension and increased pressure,
particularly in the L4-L5 and L5-S1 segments, in the sacroiliac joint and hip joint), pain in
the joints and specific postural changes. In addition, it can create changes in posture in other
parts of the body, such as increased thoracic cifosis and increased cervical lordosis.[13] Some
authors emphasize the function of the proper joints, since, in the loss of their burden, it may
end up generating dysfunctions in adjacent joints.[14]
One study shows that hip flexion in orthostatic position may have as its cause the weakness
of the abdominal muscles and in contrast the hip flexors are shortened and rigid. In view of
this situation, there may be a marked anterior inclination of the pelvis and increased curvature
in the lumbar segment, eventually generating a decrease in the hip extension angle during
gait.[2]
Consolidating the statements, Neumann (2011) maintains that, one of the factors that can
contribute to PCS in anteroversion, is related to the pattern of decreased muscle activation
of the abdominal rectum, the action of hip flexion being performed with a degree of force
of moderate to high, the rectum of the abdomen and the external obliques should perform a
degree of force sufficient to go from against the action of pelvic anteroversion produced by the
hip flexors, causing pelvic retroversion action so that the forces imposed on the pelvis remain
neutral.[15]
One study showed that in people with low back pain, muscle dysfunction such as the mid-
dle gluteus increases spinal load and reduces spine stability.[16] Corroding with this state-
ment, another study showed that when extensor multiples of the spine are shortened and hip
extensors such as inhibited glutes may occur a change in the position of the pelvis and lumbar
spine, generating pelvic anteroversion and hyperlordosis.[17] According to the authors Bar-
bosa, Filipe and Marques (2011) the increase in the angle of lumbar lordosis is caused by in-
creased strength and retraction of hip flexors and lumbar paravertebral scans, by the reduction
of the strength of the hip and abdominal extensors and by the retraction of the hamstrings.[18]
Specific patterns of muscle involvement, such as those known as SCI, in the loin-pelvic
region have been coincided with chronic pain in the lumbar region. In pelvic cross-syndrome,
muscles are called phasic, characterized by weakness of the abdominals and glutes, or postu-
ral, due to stiffness in the hip flexors and extensors of the spine. Phasic and postural muscle

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.

6
deficiencies can lead to exaggerated lumbar lordosis, since it may end up causing chronic low
back pain.[19] The literature points out that hyperlordosis is created by weak abdominals and
pelvic obliqueness and when it is greater than 20º, it will have an increase in lordosis and
thus a displacement of the center of gravity and realignment of all curves for compensation.
Antonio, Jassi and Miyajima (2014) show in their study that there is no lumbar hyperlordo-
sis without pelvic anteroversion, and there is no pelvic anteroversion without hyperlordotic
posture.[20]

CONCLUSION
The inferior Cross Syndrome is characterized by an adaptive postural process, with very char-
acteristic and common muscle imbalances, as the studies shown. Certainly several are the
causes that lead to muscle tension, and that can cause weakening, shortening, inhibition or
excessive strength of a muscle group. The analysis of the relationship between pelvic cross
syndrome and muscle imbalances and postural habits was seen in this review. Musculoskele-
tal imbalances may lead to certain postural habits, which are correlated with PCS. However,
it was possible to identify a certain connection of musculoskeletal imbalances and certain
postures such as hyperlordosis and pelvic anteroversion in individuals with inferior cross syn-
drome. This is because the extensor muscles of the spine, such as the spine eers and hip flexors
such as the iliac and psoas perform a greater contraction in relation to the muscles that oppose,
such as the abdominals and glutes, which would be inhibited. Another finding of the study,
although it was not the central objective, is that there is a predisposition to these people to
present a pain in the lumbar segment. It is extremely important that further studies be con-
ducted to know the subject, in order to bring clarity and better resolution about treatments to
be done with individuals who have a certain dysfunction.

Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.

7
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Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.

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Academia Letters, December 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Willians Cassiano Longen, [email protected]

Citation: Cassiano Longen, W., Sparremberger Justo, T. (2021). Postural and Musculoskeletal Relations of
Inferior Cross Syndrome. Academia Letters, Article 4281. https://doi.org/10.20935/AL4281.