Individuals believe that maintaining a straight/flat back is healthy. However, the back is made up of natural curves that allow flexibility and optimal movement. If there is a lack of these curves, it can lead to spine issues, discomfort, and pain. A common problem to develop from a spine lacking natural curvature is abnormal kyphosis. This is when the natural curve in the thoracic spine – mid-back or lumbar spine – low back disappears, which results in a flat back. Restoring the curvature can be challenging, as flatback syndrome requires chiropractic adjustments to gently shift and realign the spine back into a healthy curve and re-train the spine to maintain the curve.
Causes of Flat Back Syndrome
Flatback syndrome is usually a result of muscle tightness in the lower back muscles, specifically in the psoas muscle. Or it could be degenerative disc disease, where the cartilage supporting the spine begins to weaken. Other causes include arthritis and osteoporosis. Practicing unhealthy posture habits can worsen these conditions, speeding up the loss of the spine’s curvature. Loss of spinal curvature does not occur rapidly, as the body will begin to present with symptoms. The following symptoms could be an indication:
Fatigue when trying to stand upright
Balance problems
Restricted mobility
Muscle spasms
Chronic low back pain
Thigh pain
Groin pain
Disc herniation
Back pain and problems with balance are the earliest warning signs of flatback syndrome.
Symptoms
Flatback symptoms usually get worse as the day progresses, with a sense of fatigue and increasing difficulty to stand upright. Individuals tend to flex or bend their hips and knees to get into an upright position. This can become an exhausting process as the day progresses. Individuals can also have symptoms of sciatica and/or spinal stenosis with leg pain and weakness that gets worse when walking. Neck and upper back pain can begin to present while straining to align themselves. The symptoms become disabling, often requiring pain medications that limit the individual’s ability to perform daily activities.
Realignment Treatment
A chiropractor must determine the severity of the deviation through a thorough assessment and examination. This shows the loss of curvature to help a chiropractor plan a realignment/remodeling adjustment schedule. Restoring a natural kyphosis is done through a combination of adjustments and bracing. Scheduled spinal adjustments will realign and shift the vertebrae back to neutral, while a back brace supports to prevent any deviation. Stretching and exercising relevant muscle groups is also part of a chiropractic treatment plan. An example is core exercises for strengthening the muscles supporting the spine.
Body Composition
Personalized Nutrition
Because the body is so complex and dynamic, there is no perfect fit when it comes to diet, exercise, or a combination. Fad diets typically recommend that individuals adhere to the same eating guidelines, indicating they will reach an expected result like fat loss. These diets work because they focus on a simple reduction in calorie intake, especially processed and fast foods. The problem is that some of these fad diets can restrict critical nutrients that negatively affect an individual’s health. More information about an individual’s body and how it works is an excellent resource in improving body composition and overall health. Personalized nutrition is an innovative and favorable approach to preventing and treating obesity and related conditions. This approach identifies:
Genetic markers
Dietary patterns
Environment
Metabolism
Educated recommendations can be made based on these factors.
References
Drabsch, Theresa, and Christina Holzapfel. “A Scientific Perspective of Personalised Gene-Based Dietary Recommendations for Weight Management.” Nutrients vol. 11,3 617. 14 Mar. 2019, doi:10.3390/nu11030617
Farcy, J P, and F J Schwab. “Management of flatback and related kyphotic decompensation syndromes.” Spine vol. 22,20 (1997): 2452-7. doi:10.1097/00007632-199710150-00025
Lee, Chang-Hyun, et al. “‘Lumbar Degenerative Kyphosis’ Is Not Byword for Degenerative Sagittal Imbalance: Time to Replace a Misconception.” Journal of Korean Neurosurgical Society vol. 60,2 (2017): 125-129. doi:10.3340/jkns.2016.0607.001
Lu, Daniel C, and Dean Chou. “Flatback syndrome.” Neurosurgery clinics of North America vol. 18,2 (2007): 289-94. doi:10.1016/j.nec.2007.01.007
Wiggins, Gregory C et al. “Management of iatrogenic flat-back syndrome.” Neurosurgical focus vol. 15,3 E8. 15 Sep. 2003, doi:10.3171/foc.2003.15.3.8
The latissimus dorsi or lats are the large flat muscles on each side covering the width of the middle and lower back. They connect the bone of the upper arm to the spine and the hip. When pain presents in these muscles, it is typically caused by:
Repetitive overuse in a job or doing a task/chore that requires constant
Bending
Pulling
Pushing
Reaching
Twisting
Kneeling
A result of poor technique in sports or similar physical activities.
Chiropractic treatment, along with exercises, can help prevent and relieve this pain.
Symptoms of lat pain
The objective is to diagnose whether the pain is located in the latissimus dorsi or other muscles in the shoulders or back. If the latissimus dorsi is injured, an individual might feel pain in several areas, these include:
Lower, middle, and upper back
Back of the shoulders
The base of the shoulder blade
Lower arms
Inside of the arms, extending down to the fingers
In certain cases, the pain will present without warning and can be felt in the surrounding muscles. This type of pain often gets worse when the individual:
Extends their hands forward and out in front
Raises their hands above their head
Tosses or throws an object
Damage or injury to the latissimus dorsi
Tissue damage or injury can cause other symptoms to present. These include:
If the source of the back pain cannot be identified, or if it is accompanied by:
Fever
Breathing problems
Abdominal pain
Consult a doctor as these could be symptoms of a more serious condition.
Uses and Causes
The lat muscles are used in everyday activities. These include:
Picking up objects like grocery bags
Opening heavy doors
Chest expansion for breathing
Pushing against the armrests of a chair to stand up
Using handrails to climb stairs
For sports or working out, the lats are used in:
Weightlifting exercises using the upper body
Bench-presses
Rowing
Swimming
Throwing
Common causes of pain include:
Overusing the muscles
Using poor techniques
Exercising without warming up
Risk of injury
Individuals that are at risk of developing this injury include those that:
Are continually reaching overhead
Regularly chop wood
Perform regular shoveling
Move furniture or other heavy objects
Regularly practice poor posture
Tearing the latissimus dorsi is possible, especially for athletes. Some athletes with increased risk include:
Golfers
Baseball pitchers
Gymnasts
Swimmers
Tennis players
Exercises that can help bring relief
Certain exercises can alleviate the aches, pain, and strengthen the lat muscles to prevent and/or worsen the injury. It is recommended to consult a doctor, sports chiropractor, or personal trainer before beginning a therapeutic exercise regimen. This is to ensure that the exercises are right for the individual and their condition and that they use the correct form. Here are two exercises that can help reduce the pain. The doctor, chiropractor, or trainer will recommend the frequency the individual should perform the exercises.
Back bow
This pose is known as the superman pose. To perform:
Lay facedown on the floor
Extend the legs so they are straight
Stretch arms away from the body, so they are in front of the head
Bend the knees like for a sit-up with the heels close to the buttocks
Keeping the hands and feet in place
Lift the pelvis upward
Slowly lower back to the floor
Prevention
Individuals can prevent lat pain with lifestyle adjustments. These include:
Using proper technique and posture during work, sports, and exercise
Staying aware to not overuse the muscles
Staying hydrated
Warming up and cooling down thoroughly before and after a workout, sports, physical activities
Regular stretching
Applying ice and heat before and after work, sports, and physical activities
Chiropractic care
Physical therapy massage
Body Composition
Nutrition and Recovery Advantage
Two important steps to achieve optimal health include:
Nutrition
Having a proper protein intake is important for muscle adaptability or the way muscles adapt to stress during exercise and/or strength training. This is also important to stimulate muscle protein synthesisafter exercising and/or strength training. To ensure the body is getting the strength and hypertrophy improvement from exercise and strength training, it is recommended to eat around 25g of high-quality protein after workout sessions.
Recovery
For those doing aerobic and strength training, maximize recovery time between workout sessions. This is because strength and aerobic fitness health gains are low when the two only have a separation of 6 hours or less. Twenty-four hours between sessions is recommended especially if the priority is endurance performance.
References
Anderson, S. E., Hertel, R., Johnston, J. O., Stauffer, E., Leinweber, E., & Steinbach, L. S. (2005, November). Latissimus dorsi tendinosis and tear: imaging features of a pseudotumor of the upper limb in five patients. American Journal of Roentgenology, 185(5), 1145–1151 www.ajronline.org/doi/abs/10.2214/AJR.04.1247
Donohue, Benjamin F et al. “Sports Injuries to the Latissimus Dorsi and Teres Major.” The American journal of sports medicine vol. 45,10 (2017): 2428-2435. doi:10.1177/0363546516676062http://journals.sagepub.com/doi/abs/10.1177/0363546516676062?journalCode=ajsb
Henseler, J. F., Nagels, J., Nelissen, R. G. H. H., & de Groot, J. H. (2014, April). Does the latissimus dorsi tendon transfer for massive rotator cuff tears remain active postoperatively and restore active external rotation? Journal of Shoulder and Elbow Surgery, 23(4), 553–560 www.jshoulderelbow.org/article/S1058-2746(13)00399-6/fulltext%20
George, Michael S, and Michael Khazzam. “Latissimus Dorsi Tendon Rupture.” The Journal of the American Academy of Orthopaedic Surgeons vol. 27,4 (2019): 113-118. doi:10.5435/JAAOS-D-17-00581
Lehman, Gregory J et al. “Variations in muscle activation levels during traditional latissimus dorsi weight training exercises: An experimental study.” Dynamic medicine: DM vol. 3,1 4. 30 Jun. 2004, doi:10.1186/1476-5918-3-4
The goal is to have an economical stance and gait that does not require excessive energy.
The curves need to be well-balanced.
The gravity line should fall through:
The head and cervical spine
Behind the sacrum
Through the center of the hips
Like this minimum energy is exerted for standing and walking.
When these curves are not balanced, like what happens with excessive kyphosis in the thoracic spine or loss of normal lordosis in the lumbar spine, the patient may begin to experience symptoms.
Loss of lumbar lordosis or actual kyphosis in the lumbar spine that presents symptoms is named flatback syndrome.
Symptoms
The main symptoms of flatback are:
Difficulty standing up straight
Low back pain
Thigh pain
Groin pain
Symptoms will worsen as the day progresses with fatigue and increasing difficulty to stand up straight with correct posture.
Individuals will flex or bend their hips and knees to get into an upright position.
This is what causes the exhaustion as the day goes on.
Some patients also have symptoms of:
Sciatica
Spinal stenosis
Leg pain
Weakness made worse from walking
Some individuals have neck and upper back pain as they strain to get themselves upright.
Trying to live like this can lead to a disabling condition that requires pain medications, and limits the individual’s ability to perform daily activities.
This was the earliest type of spine implantation to correct scoliosis.
This instrumentation had a tendency to flatten the normal curve or lordosis in the lumbar spine.
This system was used from the 1960s to the 1980s.
With today’s implant systems and techniques, this problem doesn’t really occur anymore.
But not to knock the system, those treated with�Harrington�rods did very well for decades.
The spine compensates for the flattening of the lordosis with the normal discs underneath the fused area.
However, when the discs below the fusion would wear out (degenerate), the patients would lose the ability to stand upright and pain would develop.
Other causes include:
Ankylosing Spondylitis
A chronic inflammatory arthritic disease that causes stiffness and loss of lordosis.
Degenerative Disc Disease
The normal aging process of the wear and tear/degeneration of the discs, that are the shock absorbers of the spine.
In the lumbar area, these discs contribute to normal curvature.
As the discs degenerate, the spine stiffens and the curvature disappears.
The patient has progressive difficulty in achieving an upright posture.
Post-Laminectomy Syndrome
After a laminectomy procedure used to decompress the spine nerves, loss of lordosis and instability can develop.
This type of procedure is associated with failed back surgery syndrome.
Compression Fractures
Single or multiple vertebrae collapsing can result in loss of lordosis and flatback.
The vertebrae are the building blocks of the spine.
Diagnosis
The diagnosis begins with a patient’s history.
A doctor will look for the common symptoms like the presentation of difficulty standing upright along with back pain.
If there is a history of prior surgery or a disease making them susceptible to the syndrome.
Full standing x-rays will be ordered.
The lateral side view is specifically the side that will be helpful (see x-ray).
The patient stands, knees straight, the posture can be seen to be stooped forward.
This is depicted by the gravity line/plumb line falling in front of the sacrum.
Finally, MRI’s, CT scans, can be utilized to provide information about the health of the:
Discs
Vertebrae
Degree of openness of the spinal canal to see if there is compression of the spinal nerves or not
Non-surgical Treatment
Patients should try non-surgical treatment first like:
Chiropractic
Physical therapy
Non-steroidal anti-inflammatory medication
Conditioning and endurance exercise programs can provide relief. But, if the structural problem is too great for conservative therapy then surgery is an option.
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NCBI Resources
Sometimes low back pain comes out of nowhere, but that sudden twinge in the lower back does have a cause. With some cases, there�s a�trigger, like picking up a heavy object/furniture from an awkward position.� But sometimes it can be a mystery and a challenge to diagnose.
It is important to know the cause of lower back pain to figure out the proper treatment plan. Otherwise, one could receive treatment for the wrong diagnosis and possibly exacerbate the existing injury.
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