Back to School Doesn’t Have to be a Pain

Geoff Lecovin

It’s back to school time. Backpacks, sitting and poor studying posture can mean your “kinetic chain” is going to get yanked and kinked, potentially resulting in pain.

Fortunately, there are strategies students may use to reduce the risk and discomfort by:

  • Maintaining optimum length and tension in posturally strained muscles;
  • Improving alignment and reducing stress at joints; and
  • Facilitating optimum recruitment patterns to deal with mechanical stressors that can tease the nervous system into compensation patterns.

Backpacks and backpain

In a study of 1540 children aged 11-14, 37% reported back pain. Backpacks were used by 97% of children. Of the children who reported back pain, 34% limited their activity due to the pain, 14% used medication for pain relief, and 82% believed their backpack either caused or worsened their pain.

The incidence of back pain in early adolescence has been shown to approach that seen in adults. This study identifies two factors associated with back pain in early adolescents that could be changed: availability of school lockers and lighter backpacks. These findings may be useful in advising families and influencing school policies (Skaggs, 2006).

Gluteal Amnesia

The term “Gluteal Amnesia” was coined by Stuart McGill, PhD, a spinal biomechanics expert. Prolonged periods of sitting place the hip flexors in a relatively shortened position.

Over time, this results in decreased neural drive and altered reciprocal inhibition to the gluteus maximus (the functional antagonist to the hip flexors), along with synergistic dominance of the erector spinae and hamstrings. Essentially, the gluteus maximus forgets its role in hip extension and the synergists take over. The end result is faulty movement patterns and low back pain.   (McGill, 2007, 2009)

Criss-Cross-Applesauce, Hands on Knees Please   

In the 1970s Dr. Vladimir Janda studied and described muscle compensation patterns, which he confirmed with electromyography. Janda identified two functional classifications of muscles, termed tonic and phasic. The tonic system consists of the flexors. These muscles are involved in repetitive or rhythmic activity. The phasic system consists of the extensors. These muscles work eccentrically against the force of gravity.

Janda observed that the tonic system muscles are prone to tightness or shortness, and the phasic system muscles are prone to weakness or inhibition. Through these observations he discovered that people developed predictable patterns of dysfunction that he called upper crossed syndrome and lower crossed syndrome.

Upper crossed syndrome (UCS) is characterized by facilitation of the upper trapezius, levator scapulea, sternocleidomastoid, and pectoralis muscles, along with inhibition of the deep cervical flexors, lower trapezius, and serratus anterior. There is a tendency to have a forward head carriage and rounded shoulders. Individuals with UCS often develop neck or upper back pain, shoulder pain, headaches and upper extremity dysfunction.

Lower crossed syndrome (LCS) is characterized by facilitation of the thoraco-lumbar extensors, rectus femoris, and iliopsoas, along with inhibition of the abdominals (i.e. transversus abdominus) and the gluteal muscles. There is a tendency toward an increased anterior pelvic tilt. Individuals with LCS often develop low-back or hip pain, knee pain and lower extremity dysfunction.                           (Page, 2003)


LowerX Lower Crossed Syndrome



UpperX Upper Crossed Syndrome



Take a Deep Breath

Individuals who exhibit UCS often have dysfunctional breathing patterns characterized by the aforementioned overactivity/tightness of the upper trapezius, scalenes, sternocliedomastoid, levator scapulae, and pectoralis minor (secondary respiratory muscles).

This leads to chest breathing, which can further exacerbate the postural dysfunction. Restricted breathing can also result from the position of the rib cage in this posture. This may force the secondary respiratory muscles to work more during rested breathing to help lift the rib cage to allow the lungs to expand.

Chest (shallow) breathing versus diaphragmatic breathing results in hyperventilation and eventually decreased oxygen perfusion. This can lead to neck pain, shoulder pain, headaches, dizziness and even anxiety, stress, and panic attacks. None of these are conducive to learning.

See Also: The Voice of Posture

Assessing for dysfunctional breathing can be done by observing dysfunctional movements commonly seen in the overhead squat assessment, as well as the static observations previously mentioned.

Another assessment option is instructing an individual to breathe normally and assessing whether they breathe naturally through their belly or by lifting their chest. If they are chest breathers this may indicate overactivity of the secondary respiratory muscles. This assessment can also evaluate neuromuscular control of the intrinsic core stabilizers.  (Clark, 2012)

Strategies for Back to School Pain

  1. Roll that pack! There are backpack options that enable the pack to be pushed or pulled on wheels.
  2. Take micro-breaks. Encourage teachers and students to get up and stretch for 30-60 seconds every 30-60 minutes.
  3. Incorporate Corrective Exercise (CEx) into PE classes.
  4. Set up ergonomic workstations at home for homework (e.g. stand-sit options).
  5. Follow a home exercise program to address upper and lower crossed syndromes. Ideally this should incorporate the NASM CEx model:
  • Inhibit overactive muscles
  • Lengthen short muscles
  • Activate underactive or weak muscles
  • Integrate dynamic multi-planar functional movements


Sample home exercise strategies for Upper Crossed-Syndrome

  1. Inhibit overactive muscles with self-myofascial release to the pectoralis muscles, latissimus dorsi and upper trapezius.
  2. Lengthen tight muscles with static stretching to the pectoralis muscles, latissimus dorsi and upper trapezius.
  3. Activate weak or inhibited muscles to facilitate intramuscular coordination using chin tucks, wall angels and prone cobra.
  4. Integrate functional movements to facilitate intermuscular coordination with a squat to row or single leg Romanian dead lift with a PNF pattern.

Sample home exercise strategies for Lower Crossed-Syndrome

  1. Inhibit tight muscles with self-myofascial release to the hip flexors (TFL, rectus femoris and psoas).
  2. Lengthen tight muscles with static stretching to the hip flexors.
  3. Activate weak or inhibited muscles to facilitate intramuscular coordination using a gluteal bridge and quadruped opposite-arm, opposite-leg.
  4. Integrate functional movements to facilitate intermuscular coordination with squats, tube walking, and planks.

Acute variables

  • Inhibit: Foam roll or compress overactive muscles on 1-3 tender areas for 30-60 seconds, 3-5x/week.
  • Lengthen: Static stretch tight muscles, 1-3 sets for 30-60 seconds, 3-5x/week.
  • Activate: 1-3 sets, 10-15 repetitions, 4/2/1/ tempo, 3-5x/week.
  • Integrate: 1-3 sets, 10-15 repetitions, slow and controlled, 3-5x/week.



Clark, M.C., Lucett, S.C., & Sutton, B.G. (2012). NASM Essentials of Personal Fitness Training, Fourth Edition. Baltimore, MD: Lippincott, Williams & Wilkins.

McGill, S.M. (2009). Ultimate Back Fitness and Performance, Fourth Edition. Waterloo, Canada: Backfitpro Inc. (www.backfitpro.com)

McGill, S.M. (2007). Low Back Disorders: Evidence Based Prevention and Rehabilitation, Second Edition. Champaign, IL: Human Kinetics Publishers.

Page, P., Frank, C. (2003). The Janda approach to chronic musculoskeletal pain emphasizes muscle function. Pain Points. On ADVANCE for Physical Therapy & Rehab Medicine. 12,(1) 27. http://physical-therapy.advanceweb.com/Article/The-Janda-approach-to-chronic-musculoskeletal-pain-emphasizes-muscle-function.aspx

Skaggs D.L., Early S.D., D'Ambra P., Tolo V.T., Kay R.M. (2006). Back pain and backpacks in school children. J Pediatr Orthop. May-Jun;26(3):358-63.

The Author

Geoff Lecovin

Dr. Lecovin is a chiropractor, naturopathic physician and acupuncturist. He graduated from the Los Angeles College of Chiropractic in 1990 with a Bachelor of Science in Biology and Doctor of Chiropractic, earned a Masters in Nutrition from the University of Bridgeport in 1992, and then went on to complete the Doctor of Naturopathic Medicine and Masters in Acupuncture programs at Bastyr University in 1994. Dr. Lecovin completed another Masters in Exercise Science from California University of Pennsylvania in 2015. He holds additional certifications in exercise and nutrition from the National Strength and Conditioning Association (CSCS), International Society of Sports Nutrition (CISSN), Institute of Performance Nutrition (ISSN Diploma and Performance Nutrition Diploma), International Olympic Committee (Sports Nutrition Diploma), Precision Nutrition (Nutrition Coach) and National Academy of Sports Medicine (CPT CES PES Nutrition Coach), where he is also a Master instructor.