The term upper cross syndrome was first used by Vladimir Janda. He found a consistent pattern of alternating tightness and weakness in the upper quarter and named this pathological pattern as upper cross syndrome.

Upper cross syndrome (UCS) is an extremely common condition which is generally produced by poor postural habits.  Individuals who have desk jobs or use computers for prolonged duration tend to suffer from UCS, however because this is essentially a muscle imbalance sometimes even individuals from active populations also suffer from UCS.

The various therapeutic approaches that are directed to restoration of  tensegrity and regaining unconscious as well as automatic  control of the myofascia to reduce pain, improve function and posture are collectively termed myofascial modulation. In this article we will outline the clinical entity of UCS and then find probable solutions in myofascial modulation.

The pathology:

According to Janda (1983), the striated muscles that stabilize posture are arranged vertically in the body in alternating tiers of “tightness-prone” and “weakness-prone” muscle types. The tightness-prone muscles have the ability to inhibit the tonus of the adjacent tiers of weakness-prone muscles. The tighter they become, the greater the inhibitory effect. 1   The tightness prone (mobiisers) and weakness prone (stabilisers) muscles in UCS are as follows:

Tight musclesWeak muscles
Pectoralis majorRhomboid major
Pectoralis minorRhomboid minor
Upper trapeziusLower/mid trapezius
Levaor scapulaeSerratus anterior
Sternomastoid 

While UCS starts with poor posture, later on it produces to shortening and adherence of myofascia as well as alterations in the skeletal structure locally and globally.

Locally, this pattern of imbalance creates joint dysfunction, particularly at the atlanto-occipital joint (hyperextension), C4-C5 segment, cervicothoracic joint (Dowager’s hump at tlmes), glenohumeral joint, and T4-T5 segment. Janda noted that these focal areas of stress within the spine correspond to transitional zones in which neighboring vertebrae change in morphology.2 The forward head posture also shifts the COG of head anteriorly, which increases the load of head on the spine. For every inch of forward head posture there is an additional 10 lbs load on the spine3.  So if someone’s head is protracted 3 inches the effective weight of the head becomes 42 pounds (21 kgs) from the normal 10 pounds. It’s like a 3 yrs old child (16kgs) sitting on the patient’s head all the time!

In shoulders, because of the tight pectorals the shoulders are protracted, internally rotated, reducing the subacromial space. The altered glenoid orientation also needs increased activity of certain muscles including supraspinatus to stabilize the shoulder.4 Thus many of these patients end up with some variety of shoulder pathology, impingement, tendinitis and periarthritis in the later stages.

In the thorax involvement of serratus anterior affects the ribcage and prevents its normal excursion. Involvement of the rib cage, serratus anterior muscle and the spine hinders in the stabilization of the scapulothoracic joint.

Changes occur even in the trunk and lower limbs. The thorax slumps to excessive kyphosis in upright, the posture is maintained more by non-contractile structures than the muscles. Predictably the long extensors of the trunk get disuse weakness and eventually the altered COG along with increased tension in the myofascial linkage may produce another set of dysfunction, called lower cross syndrome.

The problem list:

Although the postural abnormality is most obvious clinical feature, patients are most bothered by the pain.  Primarily the pain is in the upper trapezius after prolonged sitting. Slowly the time to elicit this pain decreases and new pains develop in the focal areas of stress described by Janda (C0-C1, C4-C5, C7-T1, T4-T5, GHJ). The shortened muscles, overworked and with an inefficient length tension relationship often produce referred pain, trigger points (Sternomastoid, upper trapezius, supraspinatus, rhomboids, muasticatory muslces9) and otherwise, creating headache and pain down the arms. Moreover, nerve compressed in the inter vertebral foramen or the thoracic outlet 5, 6 may also produce pain symptoms.

Reduced range of motion, due to tightness/adhesion in the myofascia represent another set of problem.  The commonly involved shortened muscles (mobilisers) have already been mentioned. Additionally the myofascial linkages (Anatomy Trains) that traverse the involved area, namely, superficial back line, superficial front line and spiral line shows changes that affect the whole body7.

Weakness in the stabilizers is another hallmark of UCS. This calls for additional muscle work from non stabilizer muscles4, which then cannot perform their normal function.  This may affect the normal functional patterns (dyskinesia) and ability of the patients to perform activities. For example EMG analysis of normal shoulder activity shows activation of rectus femoris, gluteus maximus and erector spinae before activation of shoulder muscles 8 and all of these muscles are affected in upper and lower cross syndromes. So, it can be inducted that normal shoulder activity will be hindered in these patients.

Management:

Effective management of UCS needs restoration of tensegrity by myofascial modulation which includes postural correction, ergonomics, corrective exercise and manual therapy. Perhaps most important (and most difficult) part is to make the patient responsible and committed for change. Most patients expect a quick fix solutions and a lot of symptomatic relief can be given in a PT session. But as this is a lifestyle disease, unless the patient honors his end of the bargain there is no gain in the long term. Postural exercises focusing on shoulder posture and head posture9 are essential. To help the patient maintain good posture taping the scapulae in retraction, a McKenzie roll or a raised seat (as advised by Mulligan) can be helpful. To prevent poor posture while sitting McKenzie also advocates slouch-overcorrect10 exercise. It may take about 3 weeks to get unconscious postural control.

For the tight and weak structures the generally accepted protocol involves releasing the trigger points, if any, and then stretching the tight structures before attempting to activate the weak muscles. Trigger points can be released by direct pressure, stretch or needling. While stretching the tight muscles it is necessary to remember a large muscle (like pectoralis major) may have several sets of fibers, which need to be stretched separately. Some muscles can be stretched better with METs, while others may need direct release via MFR. The joints in the cervical and thoracic region may need to be addressed. McKenzie retraction and/or Mulligan’s Reverse NAGs are useful.

The usefulness of strengthening is a matter of debate. While McKenzie is against strengthening it finds favor among many other therapists. Even if gross strengthening is unnecessary gentle activation of the weak and stretched muscle will facilitate proprioception and help in learning the corrected posture. If the forward head  posture results from poor lumbar stability then a core stabilization program may be helpful . Similarly, in case of scapular dyskinesia a scapular stabilization protocol may be added.

Finally, the nutritional considerations should not be overlooked. Adequate hydration, electrolytic replenishment (Na, K, Ca etc) and vitamin supplementation can help the patient to recover early.

To Conclude:

The Upper Cross Syndrome is a complex clinical entity. While this article provides a basic outline, many other aspects of the condition remain to be explored. However, in the long term what matters most is the patient’s  adherence to posture and ergonomic measures.

References and further reading

  1. Mitchell FL, Mitchell PKG, The muscle energy manual, Volume 1,1995 p144
  2. http://www.muscleimbalancesyndromes.com/janda-syndromes/upper-crossed-syndrome/#sthash.Sy1DlNz2.dpuf
  3. Kapandji, Physiology of Joints, Vol.3
  4. Chaitow L. muscle energy techniques. Edn 3 2006, Churchill Livingstone, p 60
  5. G Fitgerald. Thoracic outlet syndrome of pectoralis minor etiology mimicking cardiac symptoms on activity: a case report. J Can Chiropr Assoc. 2012 Dec; 56(4): 311–315.
  6. Hooper T et al. Thoracic outlet syndrome: a controversial clinical condition. J Man Manip Ther. 2010 Jun; 18(2): 74–83.
  7. Myers T. Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, Edn 2, Churchill Livingstone
  8. A Kinetic Chain Approach for Shoulder Rehabilitation. John McMullen, MS, ATC; Timothy L. Uhl, PhD, ATC, PT. Journal of Athletic Training 2000;35(3):329–337
  9. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual VOLUME 1. Upper Half of Body Second Edition
  10. R McKenzie. The Lumbar spine: Mechanical diagnosis and therapy