Upper Crossed Syndrome describes a collection of symptoms in the upper body that accumulate over time. It is a condition where muscular imbalances create joint dysfunctions in multiple areas and the longer it remains untreated the more it progresses.
The joints that are greatly affected are: the atlanto-occipital joints, 5th Cervical vertebrae, cervical thoracic junction (7th cervical vertebrae and 1st thoracic vertebrae), 4th-5th thoracic vertebrae, and glenohumeral joints. These areas are mainly described as transitional areas because of the different anatomy that is present on each side of the joint.
It is not unusual for upper crossed syndrome to be identified by the naked eye. Changes in the overall posture include forward head posture, thoracic kyphosis, elevated shoulders and winging of the shoulder blades. These postural changes greatly affect the biomechanics of the upper body and shoulder girdles. The altered biomechanics over time may lead to overuse injuries and arthritis.
How does Upper Crossed Syndrome happens?
Skeletal muscles are connected to the brain through spinal nerves and the spinal cord. Through these, the two are constantly exchanging information like muscle tension, and any change in tension. Proper tension between agonist and antagonist muscles is important to maintain good posture and biomechanics against gravity. If certain postural muscles are not used against gravity for prolonged periods of time, like sitting or laying for hours at a time, they are less activated by the brain. Over time, this causes muscle weakness and elongation and atrophy. This muscle imbalance triggers other muscles, usually the larger ones we use for motion, to pick up the slack. The large muscles increased activity leads to increased tension and finally decreased flexibility.
In summary, some muscles become long and other muscle compensate by becoming short and stiff. These changes have been shown to cause pain and inflammation.
What happens in Upper Crossed Syndrome?
In upper Crossed Syndrome, the deep neck flexors and posterior shoulder girdle muscles are hypoactive, weakened and elongated, whereas the back upper neck muscles and the lower front neck muscles are overactive, tense, and inflexible. This is how postural changes like forward head posture and rounding of the shoulders, happen. These changes lead to improper movement patterns, joint restrictions/dysfunctions and possibly degeneration.
What will you see in Upper Crossed Syndrome?
Because UCS is not something that develops overnight, patients that experience pain due to UCS, are usually in a progressed stage. Some of the most common presentation of patients with UCS are:
Forwards Head posture:
Looking from the side, the ear, shoulder, hips, knees and ankles should all be aligned with each other. When forward head posture is present, the ear breaks this alignment. Because of the weight the human head has, each inch the ears sit forward to the rest of the body, the force required to keep it upright is multiplied. This adds more stress on the lower cervical/upper thoracic spine. As a result, there is a loss in cervical lordosis and an increase in the thoracic kyphosis.
Winging of the scapulae:
The scapula, or shoulder blade, is a huge component of the shoulder girdle. It provides stability and support to the shoulder during movement. When it comes to Upper Crossed Syndrome, there are 2 muscle groups in this area that need to be mentioned. The serratus anterior and the two rhomboids, minor and major. Their job is to keep the shoulder blade close to the body so that the shoulder motion is fluid and controlled. When these muscles are hypoactive and elongated, the shoulder blade is not stable against the chest, therefore shoulder movements can be choppy, hesitant, and not through the full range of motion.
Rounding of the shoulders in Upper Crossed Syndrome, is simply the compiled effect of the two previously mentioned presentations. When the thoracic spine is in a flexed position due to forward head posture, and the shoulders blades are not supported against the chest wall, gravity and hyper active pectoralis muscles pull the glenohumeral joints forward and down. This is a biomechanically suboptimal position which causes a lot of compensations and overuse injuries like rotator cuff injuries.
Deep Neck flexors: Just like their name implies, their activation flexes the cervical spine. In the case of Upper Crossed Syndrome, they are underactive which will lead the head into an extended position.
Serratus anterior: It is positioned between the front side of the shoulder blade and the chest wall. This position gives the muscle its responsibility of stabilizing the shoulder blade to the chest wall and assisting in maintaining stability during movements of the shoulder. When this muscles is underactive, the shoulder blade is easily lifted off the chest wall, hence the term scapulae winging.
Rhomboids major and minor: Originating from the spine 7th cervical vertebrae – 5th thoracic vertebrae) and inserting on the medial boarder of the scapula, the rhomboid’s main responsibility is to keep the shoulder blade retracted, close to the spine, and together with serratus anterior, stabilize the shoulder blade on the chest wall during shoulder movement.
Lower and middle trapezius: Although these seam as the continuation of the upper trapezius, due to their different origin and insertion points, they have almost opposing actions. In Upper Crossed Syndrome, the lower and middle trapezius become underactive, weak and elongated. They no longer assist in scapulae retraction, depression or stabilizing the scapula as they should.
Upper trapezius: The upper trapezius muscle originates from the base of the skull and the cervical spine, and attaches to the shoulder blade on either side. In Upper Crossed Syndrome, it is responsible for shoulder elevation.
Levator scapulae: A muscle that originates in the upper cervical region and inserts in the medial tip of the shoulder blade. In Upper Crossed Syndrome, it is responsible for shoulder elevation.
Sternocleidomastoid: Originating from middle portion of the clavicle and sternum, Sternokleidomastoid, inserts on the skull, right below the ears. It is responsible for bringing the head in a forward position.
Scalenes: Although, Scalenes are small in size, their contribution to UCS cannot go unmentioned. It is a group of 3 muscles on each side that originate from the 1st and 2nd ribs and attach to the skull right below the ears. Even though they are not the primary movers, they contribute to anterior head posture by allowing that position to feel normal.
Pectoralis major and minor: The large muscles of the chest, that originate from the sternum and insert on the shoulder girdle. Their actions cause rounding of the shoulders and restrict the shoulder range of motion.
Evaluation begins with observation. In UCS, the patients is evaluated in standing position, from all sides of the body. This is where the forward head posture, elevated and or rounded shoulders, winging of scapulae, and any other postural alterations will be identified.
The active range of motion of the cervical spine is observed in flexion, extension, lateral flexion and rotation. The usual pattern of deficits in UCS is decreased or painful extension and lateral flexion of the cervical spine. Rotation could be affected on one side more than the other if a rotational component is present.
A joint by joint evaluation of the whole spine is required to find joint restrictions that developed due to UCS.
Complications of Upper Crossed Syndrome
Just like explained above, Upper Crossed Syndrome is caused by muscular imbalances that induce joint restrictions and the total effect is poor biomechanics of the neck, upper back and shoulder girdle. Over time, the compensations that take place may cause over use injuries like rotator cuff inflammation or tears.
The biomechanics of the body are not the only thing affect by Upper Crossed Syndrome. Breathing is greatly effected as well.
How does UCS Change Your Breathing Pattern
As humans, in order to get air into our lungs and exchange carbon dioxide with oxygen, we need to create negative pressure in the chest cavity. This draws in air from the outside, therefore allowing for the desired exchange of gases. There are two ways that this happens.
The first way is by utilizing a large muscle that was designed for exactly this reason. It is called the diaphragm and it sits right between the thoracic and abdominal cavities. In its resting state, it looks like a dome that sits above the abdominal area. When it contracts, it flattens, therefore creating the negative pressure needed for inhalation. This is the way babies use to breath because it is the most efficient way. It does not require a lot of energy and it is closely connected with the parasympathetic nervous system, or otherwise called rest and digest system.
The second way of breathing, most often adopted by adults uses ancillary muscles. The small muscles between the ribs, the scalenes and SCM are used to lift up the rib cage to create negative pressure in the chest wall. This mechanism is supposed to be used as a reserve for difficult situations. It is highly connected with the sympathetic nervous system, or the fight of flight response. It requires more energy and better coordination.
In Upper Crossed Syndrome, because of the constant muscle activation of the scalenes and SCM, the nervous system is more prone in utilizing the second mechanism of breathing. Although the least efficient breathing mechanism, it tends to be the one most adults use on a daily bases. From our clinical experience, a lot of adults with Upper Crossed Syndrome that have been utilizing this mechanism of breathing from many years, actually forgot how to use the first one.
Over time the constant activation of the sympathetic nervous system may lead into anxiety and nervousness.
Find out how to properly perform belly breathing HERE
How to correct Upper Crossed Syndrome
When looking at the whole picture and the basis of what needs to be done are simple. The short and tight muscles need to be stretched, the long and weak muscles need to strengthen and any joint restrictions need to be corrected.
Although this sounds simple, the implementation of it is a little more complex. That is because the musculoskeletal system is not a static system. Its always in motion, and continuously directed by the nervous system. If the nervous system is not involved in the correction of the imbalances, the changes will only be temporary.
- Step 1: A thorough evaluation by a knowledgeable health care provider is necessary. This will help properly identify your specific weaknesses, and movement patterns that need to be corrected. Moreover, a chiropractor will be able to assist you with removing joint restrictions in the spine and shoulder girdle that are promoting the imbalances described earlier.
- Step 2: A series of stretching and strengthening exercises need to take place to properly inhibit and activate the overactive and underactive muscles respectively. It’s important to start from a basic level of control and increase resistance and intensity as you progress. Some therapists breakup the treatment into two phases. The Improvement phase where you are just first starting to activate the inactive muscles and de-active the others, and the maintenance phase where you are basically relearning proper movement patterns using the appropriate biomechanics.
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