By Megan Beda, PT, DPT
Physical Therapist, Pittsburgh,  PA

One of the main roles a physical therapist serves is helping to strengthen our patients’ lower extremity musculature. Lower extremity strength is essential in order to safely transfer, stand upright, participate in walking and maintain balance. All leg muscles are important to be able to function in day-to-day activities, but the posterior chain is of great importance and tends to be overlooked.

There is a tendency across all populations to focus on the muscles on the front side of the body (anterior chain). This is because they are the most easily visible to an individual when looking in a mirror. How often have you been in a gym and seen people with huge chest, anterior deltoid and bicep muscles, but little muscle bulk in the back, hamstrings and calves? This is because the chest and biceps have become glamorized as the definition of being strong and well-defined. 

While these “glamor” muscles are important — we need all muscles to be strong, after all — look at the posture of someone with an overly built-up anterior chain. Typically you will see a forward head, rounded shoulders and very tight chest muscles. This is the exact posture that we as physical therapists are trying to correct and prevent in our patients, especially our older adult patients.

What is the Role of the Posterior Chain?

First, let’s discuss exactly what the posterior chain is. The posterior chain consists of a group of muscles on the backside, or posterior, side of the body. This includes the erector spinae, rear deltoid, latissimus dorsi, gluteus maximus, hamstrings and calves. All of these muscles work in tandem to “control backward force and help stabilize the spine and hips, keeping the body upright.” 

The role of the posterior chain is important across all age groups including the geriatric population. There are four reasons why training the posterior chain is crucial to the well-being of our patients:

1. Better Posture

Our society has become one that relies on sitting and encourages a forward flexed position, leading to weaker and over stretched posterior muscles. As we age, we tend to sit even more, whether due to fear of falling, weakness, or fatigue. If the backside of our body is strong, our posture will be better and more balanced. 

2. Reduce the Risk of Injury

When we have an imbalance, some muscles become tight while others become overstretched and weak. For example if we sit for long periods of time, the glute muscles become weak losing their ability to “stabilize and extend the hip” while its opposing muscle group, the hip flexor/quadriceps becomes tight creating an imbalance between the anterior and posterior chain. 

During walking activities, the hip flexor/quadriceps will start to compensate leading to a poor quality of gait pattern with an inefficient stride. Hamstring weakness is also common with excessive sitting and this will affect our ability to change gait speeds. 

3. Improve Gait Speed

Glute, hamstring, and calf muscle firing all contribute to gait speed as they help the acceleration process from mid stance to terminal stance to swing phase. The better our gait speed and quality of gait pattern, the less of a fall risk we are. 

4. Improve Digestion and Breathing

With a forward flexed posture, our internal organs become compressed and don’t work efficiently leading to issues such as bloating and gas, limited lung expansion and decreased blood flow secondary to tight muscles. When we have a balanced posture our breathing gets deeper leading to increased lung capacity, increased digestion and increased blood flow which promotes improved overall wellbeing for our patients. 

How Can We Strengthen the Posterior Chain?

The good news is that we can always improve and strengthen our posterior chain. The first thing that we should focus on as physical therapists is identifying the tight muscle groups and addressing those deficits through stretching before working on strengthening the opposing muscle groups. This will provide more range of motion for the weaker muscles allowing a longer lever to pull weight. 

There are a number of exercises that are beneficial in strengthening the backside of the body, but these are my five favorites from my time as a personal trainer, physical therapist, and someone who enjoys weightlifting. 

1. Bridging: This is a great way to initiate glute and hamstring activation with our patients and it is a relatively easy exercise that can be modified and progressed in a number of ways.
2. Row: Want to engage the upper and mid back? This exercise has to be a part of your program with your patients. The good news is it can be done in sitting or standing, making it beneficial for all types of patients.
3. Squats: Yes, this will be working the anterior chain as well, but squats engage the glutes, hamstrings and quads and are essential in our ability to be able to transition from sit to stand to sit
4. Lunges: Again this will engage some of the anterior chain, but lunges are a great way to work on hamstring and glute strength with decreased stress on the lower back. And, as a bonus, it works on balance too!
5. Deadlift: This may be a little more difficult for our more low level patients, but the deadlift is one of the best exercises for glute and hamstring strengthening/activation.

When we think of our older adult patients, we need to remember that the rules of strength training apply to them as well.  Ignoring muscle groups, especially the posterior chain, will only continue to reinforce poor posture, difficulty with walking, and poor balance. Our role as physical therapists is to provide our patients with a well rounded exercise program that will help them function in their day to day activities.