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Pronation Part I – What is pronation I

Up till now, our posts have addressed stiff upper backs, tight muscles, and certain postures that can contribute to chronic neck and/or low back pain. However, what we haven’t addressed is WHY the thoracic spine gets stiff and WHY those muscles get tight. More specifically, what causes them to end up that way and what causes your body to end up in the same position time and time again.

The answer? YOUR FEET! More specifically, pronation: the inward rotation of the foot when weight bearing. This forces the weight onto the inside of the foot, as opposed to being evenly spread when the foot is in a subtalar neutral (stable) position, as seen in below:

Pronating also often comes with a flattening of the arches, which shouldn’t be confused with flat feet (to be covered later on). As the foot pronates, the knee rotates internally, (represented in the video links below).

Pronation 1_3_pronation anterior view

Pronation 1_4_pronation posterior view


When this happens on both sides of the body, the hips will drop into anterior pelvic tilt. Once that happens, the body’s weight will begin to shift forward. In order to keep ourselves from falling forward, the lower back will extend backwards to maintain the center of gravity. In order to keep the center of gravity in line with the hips, the thoracic spine becomes curved while the shoulders round out. More often than not, the head will also be shifted slightly forward (“turtleneck” position).

Here you can see how the body’s posture is affected by pronated feet vs feet set in subtalar neutral. The posture caused by pronation worsens over time as joints become stiffer and muscles become tighter. This chronic posture is why many people find it hard to simply sit or stand up “straight” and maintain that posture, as well as why many lower extremity injuries persist. It has nothing to do with how strong or weak the muscles are, but rather, with how their body compensates as a result of its structure – i.e., the bone structure of the foot having a bottom-up effect on areas higher up on the body.

Supine Thoracic Spine Mobilization

This mobilization for the thoracic spine involves the palm placed behind the stiff thoracic segments of the patient’s spine, while the other hand is used to support the patient’s head and take strain off the cervical spine. For this mobilization, we’re using the heel of the palm as a fulcrum and taking advantage of gravity to help facilitate movement and get those stiff segments to move.

Having the patient bring her arms up into flexion will help further facilitate extension of the thoracic segments, as the vertebrae naturally extends when the arms are brought over head. While the static mobilization shown in the first image is enough to aid in extension, this dynamic movement allows for a more effective mobilization.

Supine T-spine mob_arm flexion/extension

For patients who have exceptionally stiff thoracic spines and are more sensitive to something placed against the vertebrae to act as a fulcrum, this mobilization can be modified by having the patient on a sitting position. Dr. Letgolts can be seen pushing into the stiff segments (posteriorly -> anteriorly), while having the patient simultaneously lift up the chest and the chin. This action mimics the shoulder flexion that’s accompanied by thoracic extension.

Seated Thoracic Spine Mobilization

One of the most common complaints our patients have is chronic low back pain. We treat this in our clinic by addressing the body’s compensation patterns. The path of least resistance is a concept applicable to many fields and physical therapy is no different. Since the entire body is connected, it shouldn’t be a surprise that one area of the body can affect another. In other words, if a movement involves junctions A, B, and C, and one of those is stiff (e.g., B), then the other areas (e.g., A and C) will compensate by working even more to produce the same movement.

A common contributing factor to low back pain (LBP) is the mobility of the spine as a whole. When the thoracic spine gets stiff and doesn’t move as well, movement will occur in the areas above and below. In other words, the lumbar spine will be forced to move more than it normally does due to thoracic stiffness. Over prolonged periods of time, that excessive movement and stress on the lumbar spine causes LBP.

In order to alleviate some of the strain on the low back, the thoracic spine can be mobilized such that the lumbar spine won’t have to compensate for that immobility. Dr. Letgolts can be seen here mobilizing a patient’s upper back. Extension of the thoracic spine can be facilitated by placing the knee against the stiff segments and pulling on the patient’s raised elbows. Once those segments move better, the lumbar spine no longer needs to compensate. Given that the thoracic mobility is maintained, the low back pain should be alleviated.

back pain Westwood

Thoracic Spine (T1-T4) Mobilization

The wedge is often used by professionals to mobilize—i.e., crack—patients’ backs. However, wedges can also be used for self-mobilization. This is a variation of the foam roller mobilization that was posted on Wednesday. For patients who have especially stiff upper thoracic spines, the wedge offers a more aggressive alternative to self-mobilize with when compared to the foam roller. Since T1 – T4 are very hard to mobilize on a foam roller, using a wedge also allows for a more specific placement of a fulcrum, to target those segments that get stiff.

Thoracic Spine (T1-T4) Mobilization – Wedge

What to do:

  1. Find the stiff segments in the thoracic spine
  2. Lie back on the wedge with the edge against the stiff areas
  3. Gently lean backwards over the wedge while supporting the head
  4. Bring both arms up over the head
  5. Move the arms up and down 10-12 times.


The up-and-down movement of the arms combined with the wedge acting as a fulcrum helps further mobilize the thoracic vertebrae as the t-spine naturally extends with flexion of the arms.

For those who don’t have access to a wedge, the same mobilization can be achieved with a foam roller placed lengthwise along the spine, with the end of the foam roller acting as a fulcrum against the upper T-spine. With this variation, it’s important to use both hands to support the head as you’re coming down onto the foam roller and coming up off of it, as seen in the video. A pillow can also be placed under the head to elevate it if too much pressure is felt with the head resting on the ground. See the video below:

Thoracic Spine (T1-T4) Mobilization – Foam Roller Variation

back pain Brentwood

Thoracic Spine Foam Roller Mobilization (General)

Thoracic Spine Foam Roller Mobilization (General)

Suffering from low back pain or neck pain? Mobilizing your thoracic spine on a foam roller may help! This is one of the most common exercises we teach our patients to help them improve and maintain their thoracic extension.


What to do:

  1. Lay down with knees bent and the foam roller placed horizontally underneath the upper back (t-spine)
  2. Start with the roller placed at the lower t-spine
  3. Place your hands behind your neck to support your head
  4. Point your elbows forward (away from your face)
  5. Gently bend backwards over the foam roller and hold briefly
  6. Come back off the foam roller (like a sit up motion) and gently bend backwards again
  7. Repeat for 10-12 reps
  8. Move the foam roller higher up on the t-spine and repeat in at least 3 different places on the t-spine (lower/mid/upper)


Key points:

  • Having the elbows pointed forward keeps the shoulder blades apart (protracted), allowing the foam roller more access to the vertebrae
  • Roller should be placed no lower than the bottom of the rib cage and no higher than C7-T1
  • You can move the foam roller higher up on the t-spine by rolling it up with your elbows or by scooting your bottom further down
  • As you move higher up, the foam roller may start to slide. You can avoid this by lifting up the hips to get a better placement on the foam roller.
  • Feel around for those stiffer segments and spend more time on those areas!
  • Keep the stomach tucked in and the abs tight to help prevent extension from the lumbar segments to get the most out of this mobilization!
lower back pack Los Angeles

Psoas Stretch

A common contributor to low back pain is tight hip flexors. The psoas originates from L1 – L4 and inserts on the lesser trochanter of the femur (thigh bone). Therefore, when they get tight, they tend to pull the lumbar spine closer to the femur, which drops the pelvis into anterior tilt. Chronic anterior pelvic tilt forces the back to hinge excessively at the lumbar segments, which contributes to the low back pain. In order to get out of it, those hip flexors must be stretched out!

Hip Flexor Stretch How-To Video

What to do:
(1) Start off in a kneeling position, with one leg in front of the other. If kneeling hurts, something underneath to take off some pressure
(2) Tuck the pelvis into a neutral position. If you have trouble with this, place one hand in front of and behind your hips. Think of a hip thrust motion and remember to squeeze the glutes!
(3) Gently shift the torso forward, keeping it upright and perpendicular to the ground. You should feel a stretch in the front of your upper thigh from just moving slightly forward
(4) Hold for 30 secs
(5) Shift your weight backwards to come off of the stretch, then repeat for another 30-second hold
(6) For additional stretch, reach overhead and side bend to the opposite side OR lift up the lower leg (this will also stretch out the rectus femoris, one of the quad muscles)

Standing variation for those who have trouble kneeling altogether:
• Place the knee on a flat surface (chair, stool, coffee table, etc.) with the foot hanging off the edge
• The opposite foot is placed slightly in front of the torso, similar to a lunging position
• The surface on which the knee rests should be just below knee height in order to accommodate for the leading foot, so the hips remain level when shifting the weight forward

Things to remember:
• Avoid having the hips tilt forward and overarching the low back. This means you’ve lost the neutral position and are not getting an effective stretch
• Keeping the hips parallel (i.e., not rotating one side forward) will result in a better stretch
• If you have trouble maintaining a neutral pelvis, do this in front of a mirror and focus on your pelvic positioning