Flat Back Syndrome – Diagnosis and Exercises

If you’re over the age of 35 and have spent years either sitting behind a desk, diving, labouring, or otherwise being very physically active, you might have a condition commonly called Flat Back Syndrome.

If you’re over the age of 35 and have spent years either sitting behind a desk, driving, laboring or otherwise being very physically active, you might have a condition commonly called Flatback Syndrome.

What is Flatback Syndrome?

Flatback Syndrome is really not a syndrome as such. I prefer to call it flatback posture or the correct medical term, alordosis.

Lumbar Lordosis is the normal inward curvature in the lower spine. “Alordosis” means “absence of lordosis” – the normal curvature isn’t present, and instead, the lower back is “flat.” The pelvis is usually tipped backward (posterior tilt), associated with or causing the normal spinal curve to flatten. This is Flatback Syndrome

alordosis

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Signs and Symptoms of Flatback Syndrome

  • flat lower back curve
  • forward head  
  • round shoulders
  • low back pain often described as ‘aching.’
  • groin pain
  • leg pain
  • spinal stiffness, especially on waking 

This list is only a guide. You may have many of the signs and symptoms listed, only a few or none of them. The list is to assist you in recognizing whether you have Flatback Syndrome.

What Causes Flatback Posture?

Incorrect Sitting

If you have spent years sitting incorrectly – sitting on your bottom muscles instead of sitting with your back aligned over your hips – you may have developed chronic muscular imbalances – short, tight abdominals, short, tight hamstrings, and weak hip flexors – pulling the pelvis into a tucked-under position (called posterior pelvis).

Slouch Back

Slouch Sitting – copyright Posturo Global Ltd

Disc Degeneration

Incorrect sitting and standing posture, poor nutrition, injuries, athleticism, and manual labor can lead to worn spinal discs and pain in a patient. The lower spinal discs should be wedged-shaped, which gives the lumbar region a healthy inward curve, known as lumbar lordosis.

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Interesting: When people say, ‘I’ve got lordosis in my lumbar spine,’ what they usually mean is that they have hyperlordosis or sway back. The hyper suggests an increase to the normal lumbar curve. We should ideally all have lordosis in our lumbar spine.

If the lumbar curve is exaggerated, it is a hyperlordosis; if it is flat, it’s an alordosis or without a lordosis. Saying you have ‘lumbar lordosis’ is actually saying you are normal. That always makes me laugh – in a kind-hearted doc sort of way.

When our spinal discs degenerate, they lose their natural wedge shape, causing a reduction in natural lordosis. This may result in flatback posture. It may also be common to see spinal curvature.

Herniated Disc

A herniated disc is just a severely degenerated disc, where the gelatinous, toothpaste-like material normally found contained inside the disc has leaked through the outer cartilage rings. This also causes loss of the natural wedge shape, which leads to a change in the normal lordotic curve.

Chronic Muscular Imbalance

Many of the muscles responsible for posture and body movement are found in “pairs.” One muscle (or group of muscles) moves a body part in one direction, while the paired muscle moves the same body part in the opposite direction. The two sides of such a pair are said to be “opposers” since the effort of one side opposes – works in the opposite direction to – the other side.

Both sides of a muscle pair’s efforts may also be exerted simultaneously (when sitting or standing relatively still) to provide the tension and support needed to hold a body part steady in a desired balanced position.

Further Resources: Balance Exercise for Beginners

When one of the muscles of a pair becomes stronger than its opposer, we say that the stronger one has become dominant. Dominant muscles tend to become short, tight, and over-aroused – or facilitated – neurologically. The weaker opposing muscle becomes long and under-aroused or passive.

Although these muscular imbalances are fairly predictable, individual differences do, of course, exist. Muscle imbalances commonly found in people with flatback posture include:

Dominant Short Muscles

  • Abdominals
  • Hip flexors

Passive Long Muscles

  • Hamstrings
  • Gluteals

Because posture and muscular imbalances affect the way we move, problems in one area lead to problems in other areas. Flatback posture often contributes to the development of round shoulders and forward head posture.

Other problems may result from the muscular imbalances found in flatback posture, including:

  • Sciatic leg pain (from inflamed, bulging discs)
  • Chronic lower back pain
  • Acute lower back muscle spasms (often one-sided)
  • Scoliosis
  • Degenerative disc disease
  • Deformity

 

It is not essential to know the exact cause of your flatback syndrome. Still, it suggests some daily posture exercise habit is needed to return mobility and optimal alignment to the spine. Spinal surgery correction or other surgical treatment is not ideal. However, surgery and physical therapy can help you, especially if you have a pinched nerve, neck pain, or other severe pain.

The patient’s objective is to ultimately restore good alignment by establishing healthy posture habits and daily routines. Good posture is a habit and one that you can learn to love. It also helps to avoid spine surgery or other intrusive treatments for the spine.

After Thought – Best Ergonomic Tip

Fully upright posture (90°) is hard on the discs in your low back, so avoid buying the “perfect ergonomic chair” that keeps you bolt-upright. Research has shown that reclining at a 135° angle is the least damaging to our lumbar discs when seated.

Before you jump and adjust your seat angle, recognize that such a position is impractical for working at a computer. You’d be so far back, you’d be straining to reach the keyboard, and you’d almost certainly increase your forward head position.

It seems that 110-120° is about perfect for reducing any forward head posture that could occur if you incline the seat back any further. Personally, I favor 120°, with lumbar back support.

In any event, do remember to keep your head back, nicely inline above your shoulders. Please don’t force it back; allow a gentle lengthening to lift your head back into alignment.

Review the chin tuck exercise for forward head posture if you are unsure.

Inclining your seat 5° downward at the front and using armrests can further reduce lumbar disc pressure.

Happy sitting!

Why Women Have an Increased Rate of Low Back Pain | Posture Doctor

What was most interesting was that for men low back pain was associated with older age, low education (I’m guessing this suggests the likelihood of more physically demanding jobs), high blood pressure and smoking; but for women if was occupational and ergonomic factors.

Recently I came across this study about the factors that affect low back pain in men and women. This was a fairly large study of 600 participants. They looked at the prevalence of low back pain over a one week period. The men’s prevalence of low back pain was 40% and for women, a shocking 60%!

Low back pain occurs in about 60–80% of people at some point in their lives. Menstrual cycle fluctuations can influence pain sensitivity and may help to explain the sex difference. Further explanation may include, biologic response to pregnancy and childbearing, and perimenopausal abdominal weight gain.

Postmenopausal women also show accelerated spinal disc degeneration due to relative estrogen deficiency. While overall females have higher prevalence of low back pain (LBP) across all age groups, LBP prevalence further increases after menopause. Cue the violins for us over 50s.

What was most interesting was that for men low back pain was associated with older age, low education (I’m guessing this suggests the likelihood of more physically demanding jobs), high blood pressure and smoking; but for women if was occupational and ergonomic factors. Even more interesting is that those occupational hazards were standing posture leaning forward and sitting posture leaning forward.

Stooping
Perching

These postures can be described as stooping and perching. They cause forward flexion of the spinal column; and flexion increases compressive forces, that can cause inflammation of spinal joints (facet joints) and disc degeneration and pain.

Even more interesting was this study on the effect of regular posture exercise in improving skeletal pain. The studied concluded that, shoulder pain, mid back pain, and low back pain were relieved with a posture correction exercise program performed for 20 minutes, 3 times a week for 8 weeks.

The reason why a regular posture habit reduces skeletal pain, is that correct posture minimizes the strain on the human body by maintaining balance of the muscles and skeletal alignment. Correct posture implies not inclining the body forward (stooping) backward, left, or right.

Further Resources: Posturecise – How to Create a Healthy Posture Habit

Posture School


If you’re interested in our posture community it’s probably because you look at your health differently. You’re different from most people and you want take control of your own health. You’re different from most people, because you are willing and motivated to take action. However, even though you are more action oriented (I know this because you are still reading), you may still suffer the same challenges as your common variety slouch potato.

My job is to support you before your posture becomes a chronic problem.

The symptoms


Here’s a summary of why you find it challenging to correct your posture:

Doing it wrong

We often jump in great guns with new posture exercises, not knowing if we’re even doing the exercises correctly.

Maintenance

Awareness seems to be a big problem. It’s not so hard to do the posture exercise, but 5 minutes later, we are slouching again.

Pain sucks

Sometimes trying to correct our posture is painful, which isn’t exactly encouraging.

Habit formation

It’s fine doing an exercise here and there, but putting exercises together into a daily practice seems challenging, to say the least.

Further Reading: The Neurology of Habits

Going it alone

There’s a lot of pressure on us to do it all and we find ourselves alone when we need others the most.

It’s OK not to be OK

We need to be OK with opening up and sharing our doubts and struggles. Poor posture affects self esteem and confidence, and this is a universal problem.

The cure


Invest in your well-being

We should hold ourselves accountable for investing in our well-being and development. We should set time and money aside to spend on wellness or self-care.

Remember the mind-body connection

We need to watch what we eat and consider activities such as Posturecise, meditation (even just 1 minute a day), and walking outdoors to help boost our mood, sharpen our focus and enhance our emotional resilience.

Enjoy micro wins

You know that course you are enrolled on at Posture School but haven’t yet started? Set aside 20 minutes and begin watching your first lecture. email me and let me know you did it. Micro win … YES!

Set mini goals

Ridiculously simple wins every time. Pick a favourite posture video, re-watch it, and do the exercise daily – at exactly the same time – for 7 days straight.

Connect, connect, connect

We need to surround ourselves with a trusted support network.

The low back pain study specifically dealt with low back pain, but I found it a useful reminder, that pain is often influenced by our posture.

Did any of the symptoms mentioned above resonate with you? If so, which of the cures will you be taking on? Make sure to pick one and make it a tiny habit, as small positive changes can have huge effects over time.

Are you ready to make posture correction a daily habit?


If you believe in healthy posture in the same way you believe in getting 7-8 hours sleep each night and eating right, AND you really don’t want to live at the gym, then join our tribe. The road to good posture isn’t a quick-fix strategy; it’s a life-long journey and investment in yourself and your health; and may determine how well you age.

Still not sure yet? Feeling like something is holding you back and you don’t know whether to invest in yourself by becoming a member? Then why not watch this video to get some inspiration:

Morning Stiffness | Do You Have Wear & Tear?

Sometimes called degenerative joint disease or “wear and tear”. Wear and tear is a euphemism for osteoarthritis (OA); the most common chronic condition of the joints. It occurs when the cartilage or cushion between joints breaks down; often leading to pain, stiffness and swelling.

In front of me you can see four models of the same two lumbar vertebrae, presented as textbook normal and phase 1, 2 and 3 of spinal degeneration. This is also known as osteoarthritis (osteo meaning bone), degenerative disc disease, or commonly wear and tear.

Normal vs. Phase 2

I don’t like euphemisms. I think you can handle the truth and that like me, you probably don’t like being talked down to. So let’s call it what it is … osteoarthrtis or degenerative discs or spinal arthritis. 

A normal lumbar segment has two vertebra and a healthy cartilage disc in between. If you look at the disc from the top, you can see that the gelatinous or gel-like toothpaste substance, is well contained within the cartilage rings of the disc.

There should also be good symmetrical bony alignment. You may choose to have a chiropractor detect whether or not you have any spinal misalignments. Early on, these subluxations are easily detected and corrected.

A normal spinal segment will also have healthy nerve roots. Lots of space for them to communicate with the body (your organs, bloodvessels and glands). Because our nervous system runs our body, we don’t want any interference from misaligned vertebra (poor posture) or degenerative discs.

Incorrect Posture May Cause Degeneration

Asymmetry in the body (incorrect posture) can lead to early degenerative changes. Posture is so much more than what we see on the outside of our body.

Phase 1

In Phase 1 of spinal degeneration, we may start to see wear in the discs. Evidenced only on MRI imaging, this is a kind of dehydration that occurs in the cartilage tissues..

The rings of cartilage that make up our spinal discs, start to break down. The gelatinous center begins to dry out, a little bit like the toothpaste that is stuck around the outside of the cap. There are likely no effects as yet (or mild effects) to your nerve system.

Phase 1

These people may not present with health problems at this early stage, or they may have some mild symptoms.

Phase 2

After a decade with incorrect posture from poor habits, childhood injuries, athleticism and manual labouring, it is more common to see people with Phase 2 degenerative changes.

Typically, discs are now very dehydrated. The gelatinous nucleus (the toothpaste-like substance) has often leaked right through the dried out cracks in the cartilage rings, that buldge into the space where the spinal cord lives. This is known as a slipped or herniated disc.

There is often nerve irritation in Phase 2. These people often present with leg pain (sciatica); as the nerves that exit the lower lumbar segments, travel through the buttocks and down the leg.

Phase 2 – Herniated or Buldging Discs

Further Resources: Sciatic Leg Pain Relief

They may also present with other health issues (bowel and bladder troubles), as these nerve roots supply our organs, blood vessels and glands in the pelvic region.

In Phase 2, the vertebral bones get closer together, and the ligaments and muscles become slack. There is now excess movement in the bony segments. They have become unstable, and the body responds by laying down more calcium to stabilise the segment. These calcium deposits or bone spurs aren’t generally painful, but lead to stiffness.

Morning stiffness is a strong indicator of spinal degeneration. After waking, it may take a few hours before a person with Phase 2 degeneration feels mobile. 

Phase 3

After a several decades with incorrect postural alignment, past accidents, poor lifestyle, we begin to see advanced arthritic (degenerative) changes. In Phase 3, the discs have completely dried up and can lead to total bony fusion between the vertebral segments of the spine.

Not only is this person extremely stiff, but their spinal segments no longer move independently. This person surprisingly, is often without pain but they are extremely stiff and immobile.

Phase 1, 2 and 3 can only be diagnosed by x-ray and/or MRI. X-Ray imaging show us bony changes and MRI show tissue changes. MRI is the imaging of choice for degenerative disc diagnosis, and x-ray imaging is gold standard for alignment and postural diagnosis.

If you have been diagnosed with wear and tear without an x-ray, you have been done a disservice, in my opinion. A good practitioner can probably accurately guess your diagnosis from signs, symptoms and examination, but they will never be able to accurately assess whether you are in Phase 1, 2 or 3. This is why I would never practice without on-site x-ray facilities.

My first Chiropractic Clinic Align

A person with Phase 3 may present with multiple health issues because the nerve roots are usually seriously comprised in this phase of degeneration. 

Obviously the right time to start paying attention to your posture is at the stage of postural misalignments – before the discs and nerve roots become compromised. While it is never too late to start creating a healthy posture habit for life, the longer we put off getted started, the more likely we are to enter Phase 1, making improvements more challenging and time consuming. 

If I can correct and improve my posture, given my bunion (argh), anatomical short leg, lumbar scoliosis and disc degeneration, anyone can. But please start today!

Why You Should Stop Doing Sit-Ups |Posture Doctor

Many personal trainers are still teaching the wrong position for core exercises – a position that will wear out your discs, cause premature aging and ruin your posture and balance long-term.

Your ‘core’ is comprised of a number of muscles working together to achieve and maintain a stable spine. A strong core and perhaps more importantly, a core with good endurance allow us to move with ease and mechanical advantage; in order to avoid injury!

Your core muscles include: rectus abdominis, internal and external oblique, transversus abdominis, but also – you may be surprised to learn – the quadratus lumborum, and the gluteal muscles.

Your goal when working on your core is to create spinal stability. Stability may be achieved by increasing core strength, but Dr Stuart Mcgill (Professor of Biomechanics at the University of Waterloo) reminds us that improving core endurance may be more important than strength. Endurance provides the ability to maintain a stable spine throughout a variety of activities.


Many therapy approaches have the objectives of strengthening muscle and increasing spine range of motion. This is problematic (Parks et al, 2003) since those who have more motion in their backs have a greater risk of having future back troubles. Strength may, or may not, help a particular individual as strength without control and endurance to repeatedly execute perfect form increases risk. Dr Stuart McGill


McGill goes on to explain that people with ‘troubled backs’ tend to have faulty movement patterns like “gluteal amnesia” and more motion in their backs and less motion in their hips.

With the goal of stability in mind, it would be prudent to strengthen gluteal muscles, increase range of motion in our hips and choose abdominal exercises that do not put unnecessary stress and strain through the low back and discs.

No sit-ups or crunches

It is for this reason, that I will NEVER recommend crunches or sit-ups. Both of these exercises involve repetitive flexion of the lower back (lumbar spine). Repetitive flexion can lead to degeneration of the spinal joints and discs over time.

Effective spinal stabilization should begin with a solid understanding of what stability is. “Stability has little to do with the ability to balance on a gym ball. Sitting on an exercise ball performing movement exercises is generally a poor choice of back exercise until quite late in a therapeutic progression,” says Mcgill. “True spine stability is achieved with a “balanced” stiffening from the entire core musculature.”

Reducing risk of injury

One of the most effective exercises for improving spinal stability is the abdominal brace. Many personal trainers are still teaching the wrong position for core exercises – a position that will wear out your discs, cause premature aging and ruin your posture and balance long-term.

How to Engage Your Core

The abdominal brace is a super little exercise, that teaches you how to engage your core whether you are standing in a line, talking on the phone or simply walking down the street!

How to Avoid Bad Pregnancy Posture

The most common posture type I see during pregnancy is Swayback Posture – when the normal lumbar lordosis (curve) becomes exaggerated and the pelvis tips too far forward.

Recently, while reading a MedHelp Forum, I came across a question about pregnancy posture: “Does anyone else feel like their posture has gotten bad now that they’re pregnant?”

I kept my answer pretty basic and this is what I said:

“This is certainly a common finding. During pregnancy the hormone relaxin ‘softens’ and relaxes ligaments and the walls of the uterus (a very good thing). Relaxin causes less ‘holding’ in the pelvic joints and this can result in kind of hyper-mobility in joints around the lower back and pelvis, resulting in an altered pelvic position.

The most common posture type I see during pregnancy is Swayback Posture – when the normal lumbar lordosis (curve) becomes exaggerated and the pelvis tips too far forward. Often, as a result of the posture being tipped forward, our center of gravity travels forward and the head will also begin to move forward (forward head posture).”

Learning how to do a simple rib tuck is helpful. It is of course preferable to work on body posture prior to becoming pregnant, but I realize that in practice this may not always happen.



It’s never too late to improve posture, just a little more challenging when pregnant. What postural changes have you noticed since becoming pregnant?