Lordosis

Did You Know?

• Measurement and diagnosis of lumbar hyperlordosis can be difficult; obliteration of vertebral end-plate landmarks by interbody fusion may make traditional measurement more difficult.
• The L4–L5 and L5–S1 levels are most commonly involved in fusion procedures and contribute to normal lumbar lordosis.

Types

The natural curve of the lower back, known as lordosis, is a secondary curvature that develops because the front and back of the intervertebral discs are not the same thickness. This curve can become more pronounced during puberty, though it might not be noticeable until a person reaches their early or mid-twenties. In medical imaging, a lordotic view is an X-ray where the patient leans backward. When the lower back arches more than usual due to stress or extra weight, it is called lumbar hyperlordosis, which can cause muscle pain or spasms. This condition, often called swayback, is frequently seen in dancers. It is typically caused by muscle imbalances, such as weak hamstrings and tight hip flexors, and a key sign is a forward tilt of the pelvis, which then rests on top of the thighs. Several health issues can lead to hyperlordosis, including achondroplasia, spondylolisthesis, osteoporosis, obesity, hyperkyphosis, discitis, and benign juvenile lordosis. Rare conditions like Ehlers-Danlos syndrome, where joints are overly flexible and unstable, can also be a factor. Other names for excessive lordotic curvature are hollow back and saddle back, though swayback usually describes a different postural problem that looks similar at first. Common contributors include tight lower back muscles, excess visceral fat, pregnancy, and rickets.

Signs and symptoms

Lumbar hyperlordosis, or anterior pelvic tilt, can cause a person to lose between half an inch and two and a half inches in height, with the loss occurring in the torso. When the condition is corrected, a person’s Body Mass Index drops and their stomach looks slimmer. This height loss is real and measurable, unlike the perceived shortening from slouching. The spine’s vertebrae are bent in a way that reduces vertical height, though no vertebra is actually lost. Causes include genetics, spinal trauma, pregnancy, excess abdominal fat, or a sedentary lifestyle—sitting too much being the most common. While it may make the back appear stronger, lumbar hyperlordosis often leads to moderate or severe lower back pain. The most serious complication is a herniated disc, where strain damages or ruptures the discs between vertebrae. In dancers, trouble with positions like attitude and arabesque can point to a weak iliopsoas muscle; tightness in this muscle makes lifting the leg high difficult. Weak abdominal muscles and a tight rectus femoris in the quadriceps indicate that improper muscles are being used, contributing to the condition. The clearest signs are lower back pain during dance or everyday activities, along with a swayed-back appearance.

Causes

Possible causes of lumbar hyperlordosis include natural spinal factors, such as having more lumbar vertebrae allowing too much flexibility, or fewer lumbar vertebrae leading to insufficient flexibility and injury. Leg length discrepancy can cause hip imbalance and strain on back posture, potentially leading to permanent damage. Genu recurvatum (swaying back knees) forces a dancer to adjust to unstable postures. Common hip problems include tight hip flexors causing poor lifting posture, hip flexion contracture, and thoracic hyperkyphosis, which causes compensation for limited hip turn out. Weak psoas forces the dancer to lift from the back instead of the hip when lifting the leg into arabesque or attitude, causing stress and risk of injury. Uneven muscles are a major contributor: when abdominal muscles are weaker than the lumbar spine and hamstring muscles, the muscular imbalance pulls down the pelvis in the front, creating a swayback. Younger dancers are more at risk during growth spurts because the lumbar fascia and hamstrings tighten. Improper lifts, where male dancers lift with incorrect posture, pushing arms up while letting the core and spine curve, can also cause hyperlordosis.

Treatment

Corrective exercises can alleviate lumbar hyperlordosis, but it may take several months to fix, provided the person sits less, stands with a neutral pelvis, and sleeps on their back. Since the condition is usually caused by habitual poor posture rather than an inherent physical defect, it can be reversed by stretching the lower back, hip-flexors, and quads, and strengthening the abdominal muscles, hamstrings, and glutes. Strengthening the gluteal complex is a commonly accepted practice, as increased gluteal muscle tone helps reduce excessive anterior pelvic tilt and lumbar hyperlordosis. Local intra-articular hip pain can inhibit gluteal contraction potential, meaning hip pain may be a main contributing factor to gluteal inhibition. Dancers should avoid straining during rehearsals and performances. For lifts, isometric contraction is important for stability and posture. Treatment may also involve strengthening the hip extensors on the back of the thighs and stretching the hip flexors on the front. Only the muscles on the front and back of the thighs can rotate the pelvis forward or backward while standing. Back hyper-extensions on a Roman chair or inflatable ball, stiff-legged deadlifts, and supine hip lifts strengthen the posterior chain without involving the hip flexors. Controversy exists regarding the degree to which manipulative therapy can help; if therapeutic measures reduce symptoms but not the measurable degree of lordotic curvature, this could be viewed as a successful outcome based on subjective data.