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May 18, 2022

Maignes syndrome is essentially when the joints/tissues at the junction between the thoracic spine and lumbar spine are gunky / have inflammatory chemicals building up around them after they got overloaded past their capacity for one reason or another. When there is dysfunction at these transitional joints, it can cause referred pain to the low back, hip, abdominal, and/or groin area. This is due to the nerve pathways from those joints - the brain sends "help me" signals not to the source itself, but along the nerve pathway, hence "referred pain"

These referred pain areas are why this syndrome is often missed / misdiagnosed. Too many times no one looks/assesses outside of the area of main complaint.

Full evaluation from a clinician familiar with Maignes/Thorocolumbar Syndrome is the quickest way to get on track. It's actually very simple - If the junctional joints reproduce symptoms during joint play evaluation, that's "positive"

The even better news is, with some manual mobilizations in the area and targeted strengthening and mobility, this is a fairly straight forward rehab!

Image showing the levels of the spine. Copyright: American Academy of Orthopedic Surgeons website

The 3 most common referral patterns from the thoracolumbar junction

Here’s a case example from someone I treated:

This won't be everything and I've gotta be careful with HIPAA, but this will be plenty to get a good idea of one way it may present and then how I tackled day 1 treatment.

Patient arrived with main complaint of left (L) sided low back pain (LBP) that came on after a heavy deadlift day. Upon detailed questioning about pain location/patterns, I find out patient does have some on/off groin pain as well (immediately mentally add Maignes as a hypothesis due to this). No pain down past gluteal fold on the L. No pain on R side or up into mid back on either side. Further history gathered including several years of inactivity after being a collegiate athlete and then recent completion of the gym's on-ramp program to get back into lifting and working out safely. During this time of getting back into the gym, patient has also been dialing in nutrition and sleep to the recommended levels, but does have a high stress job and main stress reliever is the gym, which pain is currently preventing.
States feeling some of the L LBP off/on while getting back into training, but never more than 24hrs. This time, felt some the day before the 5RM deadlift day, but it really flared up during deadlifts and remained agitated for 48hrs & the day after, it "hurt to move to do anything like bend over to pick something up or turn to look behind me."

(Sound familiar to anyone so far??)

Ok…this next bit with all the underlined stuff is my assessment findings…you may find it helpful to read through, but it’s admittedly more for the other practitioners who read this and would be interested in eval presentation and actual measurements. If you just wanna know the treatment, jump down to below that!)

Average pain with daily activities since recent onset: 7/10
Aggravating factors: getting up from bed, lifting from ground (currently 50% DL can increase it to 7/10. On "bad days", donning pants will cause same level), first 400m running ("eases up a bit after that") - all cause immediate increase to 7+/10 pain
Easing factors: gentle movement. Time it takes to come back to baseline "usually 15 min, but this time it's 48 hrs and still only down to a 4/10"

(Main hypotheses at this point in no particular order: Maignes, intraarticular hip issue, flexion derangement)

Main objective findings were as follows:
Range of motion (ROM) of the low back: all normal, including flexion (so not likely a derangement). Pain only with L SB and quadrant.
Hip ROM: normal, including quadrants (mentally throw out intraarticular hip hypothesis)
Strength testing: normal except L hip flexor and hip abduction (3+/5. 2/10 symptom reproduction)
Sorensen test looking at low back endurance: 34"
Thoracic rotation via lumbar lockout: normal R, 15 deg L
Palpation of hip structures: nothing significant
Joint play: insignificant through lumbar spine until I get up to T8/9 - as soon as I put solid pressure on L side there, immediate reproduction of L LBP and mild groin pain.

*** Maignes confirmed as primary issue

I wanna take a second to note that the “impaired” findings above, such as the strength limitations and the low back endurance being less than a minute don’t necessarily tell me if there’s any true weakness on board just yet. These findings can be very much caused by pain inhibition versus true weakness. (As you’ll see in a second, it was definitely pain inhibition here)

Ok, treatment time!

Did a couple quick manipulations at that junctional site to get stuff moving again (without getting too clinical, when you get a manip, that gapping of the joint suddenly creates lower pressure in the area which causes fluid to rush in, and then it’ll flow back out right after….think of it like a quick flush of any inflammatory chemicals that are chillin and gunking up the area). We followed that up immediately with some exercises:

4 rounds for quality:
X10 ea side weighted psoas march
X5 bent over rows with 5" negative
X2 thoracic CARS (instructed pt to avoid sharp pain and how to "move around" that range)

Patient had an immediate decrease in pain from 7/10 to 4/10 after the first session and then down to 2/10 after session 2 (and they were able to get back to deadlifting without pain!!)…saw them for a total of 6 sessions with a lot of focus on making them & that area more resilient to decrease the likelihood of this coming back.

Here’s a video compilation of those manips and what those exercises look like, though there are videos linked in the workout above so you can get a better look at them. (Sorry, y’all…tried several times to embed the video, but it wasn’t cooperating)

I’m sure there are questions after reading this, so let me know! Drop them in the comments or email me at [email protected]


Much love fam,



"Your knees are shot and if you keep up all the activity you're doing, you won't walk at 30"- what I was told by medical professionals at age 18 after my 3rd knee surgery. Fast forward to today, and I'm 32 and not only do I Crossfit 4-5 days a week, but my off days are usually spent trail running and/or hiking. And the only time I have knee pain is when I take 4 or more days off from activity. You see, the stronger the muscles around a joint are, the more they can unload the joint - i.e. the ligaments, meniscus, and cartilage in the knee don’t have to absorb quite as much force as they would otherwise. And less pressure = less risk of damage or pain. 


For years, I avoided squatting below parallel, catching heavy weight in a squat such as full cleans and snatches, and had a crazy wide squat stance. I also avoiding running and would get nervous hiking downhill. Why? Because I let the nocebo (negative thoughts) given to me medical professionals dictate my movement. You see, I've had three knee surgeries, with the 1st one being in 5th grade and the last being a cartilage graft during college. Most of my knee injuries have been due to Osteochondritis Dissecans (Rare condition. Lack of blood flow to bone causing cracks to form in the cartilage and underlying bone. Cause unknown). Though one surgery was an ACL reconstruction where they took out part of my patellar tendon and put it where the ACL should be.


With each of these instances (a few others didn't require surgery), I was told yet again that I should stop doing any high impact activity, never run on hard ground, that I should never do heavy squats, and definitely don't go below parallel even without weight. This is devastating news to a very active and athletic fifth grader. And let's be real, still devastating to an active college student. Thankfully, I'm stubborn. I agreed to quit all hard court sports like basketball (though to be fair, as soon as everyone else hit their growth spurt, I probably wouldn't have lasted) and gymnastics. But I refused to give up soccer. And with that came weight training once I got to high school.


I still lift and do Crossfit 4 days a week and trail run or hike in the off days. I honestly LOVE heavy squats and deadlifts, and I am constantly challenge myself! And you know what I realized once I left soccer but was still in the gym doing weightlifting? My knees only bothered me when I did one of 2 things: wayyyyy overdid it or skipped the gym and hiking several days in a row.

Two main takeaways from this bit:


1. Don't let a doctor's opinion dictate your own opinion or your life.

Every profession has it's bad and good apples. And a certain degree does not make one infallible.


2. Heavy squats fix everything (read: your body wants to be loaded. Strength training has countless benefits and should definitely be a part of your life)


So I bet you’re like “Sweet, so strength is important. Got it. But what are some ways to build up strength?” Here ya go:


First, I should explain that it’s not always as simple as “get stronger.” Mobility and technique also need to be considered when figuring out the cause of knee pain. And it’s almost never directly the knee. Typically, if a mobility issue is at play, it is either from the hips or ankles, though it could be from further up as well. This will be it’s own blog (or maybe Eboko!) soon

As far as technique goes, it really kind of depends on when you’re having pain. For example, if it’s just with running, maybe you’re not keeping enough bend in your knee throughout the gait cycle, causing increased stress on the knee. If it’s just at the transition point at the bottom of a squat, maybe you’re only going to parallel, which is actually the knee angle with the highest amount of pressure on the knees. Or maybe you’re letting your knees come inward even just slightly with squats or sumo deadlifts and causing undue stress. If you are having pain with a certain lift/movement and want it assessed, or just want to dial in technique, I do offer movement assessments. Ok, gonna get nerdy and dive a bit deeper to include some research on technique for the next few paragraphs...(if you don’t care about research and just want the takeaways…skip to the next bolded line)

Research by Bloomquist et al showed that deep squats improved strength throughout the range of motion while shallow squats did improve strength a little more at shallow depth, but minimal strength increase at deeper positions. In other words, if you constantly squat above parallel, you;ll get stronger in that position, but not really improve strength  for things like getting up and down from the floor, squatting down to pick up heavy items off the ground, catching nd standing a clean or snatch at full depth. Squat jump strength also improved only with full depth squats, not quarter squats according to research by Hartmann et al.

Hartmann et al also found that the compressive forces in the knee are highest at 90 degrees and have little quad tendon support, yet when you squat deeper, there is actually a protective wrapping effect around the knees! My mom can attest to that. One of my biggest recent “wins” is finally getting my mother to listen to me (seriously, it’s like pay back for not listening as a child) about squats. She does not have ACLs in either knee and then retore an MCL about 10 years ago while waterskiing. She has at least listened to me for awhile that the best thing she can do for her knees is keep up strength to create the extra support needed in lieu of those ligaments. About a  month ago, I finally got her to start doing a few exercises I wrote including some goblet squats with increased weight. However, she’s been scared to squat below parallel. So she called me up and told me her knees were achy. I explained the above research and told her to just give going below parallel a shot for a few days and call me back. Guess what?! Her knee pain was GONE!

The other major lie that we’ve all heard is that your knees can’t past your toes. Absolute BS. In fact, I can personally say that the first time I really felt my quads fire during a squat was when I finally let my knees go past my toes. It’s also the first time I didn’t end of having soreness in my low back after a bunch of squats. Here’s why: Fry et al did some research looking at joint forces at the hips and knees when knee movement is restricted to avoid going past the toes or allowed to do so. They found that if it is restricted, there’s a 1000% increase in hip forces. One thousand y’all! It also caused your torso to come more forward since the hips had to stay back. This then places more pressure on your back. Between those factors, it’s no wonder my back was getting sore with back squats! Some of whether or not your knees need to come forward and the degree to which they do is definitely dependent on your specific anatomy.


Okay, now for the fun stuff. Strength. Note that this is specific for the person dealing with knee pain with squatting…

As I mentioned earlier, if you have strength surrounding the joint, it will unload it and you won’t deal with pain that comes from pressure on the internal structures (for example, osteoarthritis bone changes won’t cause pain) But…how do you build strength if you’re dealing with knee pain already?? The following exercises will be a great start!! 

Even better if you mix in things to spike your heart rate like a 30” arm only bike sprint…gets your heart rate going, thereby increasing fluid circulation to the legs/knees which will drastically help “flush out” any inflammatory chemicals. Therefore, decreased swelling and pain!

There are plenty of great drills not listed here, but this is a great start:


-Knee Gapping. 

Ok this one is for you if you just feel a lot of pressure in your knee when you squat and feel like it limits you. You know that feeling when your knee is even a little swollen and it won’t quite bend all the way back into full flexion? Yea, this helps with that. A ton. You can use a small ball, like a lacrosse ball, or a tightly rolled up towel like I am here. This helps glide the tibia (the lower leg bone) forward as you go into end range motion, which is what’s needed, and increase the joint space so it doesn’t get as much of that pressure feeling. Help yourself into end range flexion by grabbing your lower leg and pull it in, as shown. Make sure to get some calf motion in by moving your ankle around as the gastroc does cross up over the knee and assist in this motion. (side note: please ignore the squeeky ball in the background from the pups)
Video Poster Image

- Spanish squats. 

Easily my favorite exercise to not only get a quick solid quad burn, but to unload the knee and allow better movement. I’ve used this countless times with acute knee pain, chronic arthritis, post surgical, and a whole host of other people (and myself) to be able to squat sooner and build/maintain strength. The band is placed directly behind the knees. You want to make sure there is solid tension in the band throughout the movement - as you can see in this video, the band can hold my weight. Unlike a normal squat, you keep your shins perpendicular to the ground. The kettlebell is mostly to counterbalance and help me keep my chest upright. Shoutout to Zach Long, PT, DPT (aka @thebarbellphysio) for introducing me to these several years ago while we were at a course together. 
Video Poster Image

- Copenhagen Planks.

So it may not be readily obvious how these help your squat, but the truth is the inner thigh muscles play a HUGE role in full depth squats, and if their capacity isn’t adequate, it can cause knee pain, particularly on the inside of the knee. Now, this exercise is MUCH harder than it looks, so I highly recommend starting it where you have the top knee supported on the bench (or couch or whatever you’re using). If that’s still too much, you can leave the bottom leg on the ground and allow it to help support as much as needed, but as little as possible (don’t cheat yourself!)
Video Poster Image

- Bulgarian Split Squats.

Not just for lifters. This is a fantastic exercises for hikers and trail runners as it not only works on the muscles you use in your sport, but it also challenges single leg and trunk/core stability which are very important. Get into a lunge position with the back leg up on a box/bench/couch/whatever and then drop your trunk straight down while both knees bend. I’m using a kettlebell in a goblet hold here, but you can also do a barbell in the front/back/Zercher position
Video Poster Image

- Hip Thrusters 

Yes, I know, this is a butt exercise. But without strong glutes, your knees will be trying to compensate for lack of stability. No bueno. Besides, lets be real, is there a downside to having a nice ass? No. 
In this video, my fiancé is demonstrating with both legs, but going single leg is a great option as well! Please note, he’s also going absurdly light with the weight here. You want to go HEAVY on this exercise. You’ll probably surprise yourself with how heavy you can go…I have multiple patients over 65 that do this one well over 100, if not 200 pounds for reps. Just make sure you can actually hit full extension at the top (meaning your hips finish in line with your knees and shoulders)

No barbell? That’s fine! Use a super heavy dumbbell or kettlebell…just know you’ll be limited by getting the weight on/off your lap and will need to up the reps to have any benefit. 

Video Poster Image

Ok, hopefully these exercises are helpful!


One last quick note that I’d be remiss if I didn’t mention: When discussing knee pain, you have to consider lifestyle factors. All too often, knee pain is due to any increase in the body’s inflammatory response. And I’m not just taking about the injury response. If our diet, our sleep, and/or our stress is trash, it affects our entire system. So while I don’t wanna vilify the occasional cup of ice cream (that would make me a hypocrite), I do want to point out that if you’re crushing a whole pizza, McDonalds, and M&Ms every day, then it’s not entirely surprising that you feel lie you have “bad knees”…but if you take away the inflammatory-inducing foods, get 8 hrs of sleep, and move your body regularly, I bet you would find that you actually have good knees! They were just mad at you and letting you know they were mad…


Alrighty, drop any comments/questions below! 

And please share this blog with anyone you think would find it helpful! 


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