June 18, 2015 Nigel Morgan

The Upper Crossed Syndrome

Dr Vladimir Janda, a Czech Physician and Physiotherapist was the first to identify the common muscle imbalance denoted the upper crossed syndrome1, also commonly referred to as a slouched posture. This syndrome is characterized by rounded shoulders with an anteriorly tipped shoulder blade (scapular) and forward poking chin (figure 1).

upper crossed

Figure 1.

For a brief explanation, this structural imbalance results from tight or facilitated muscles that pull the shoulder girdle up and forward, resulting in the chin poking forward with hyperextension of the upper cervical spine as we attempt to keep the gaze facing forwards. As a consequence (or cause?) of this posture, the muscles that assist in holding the scapula back in a neutral posture and keeping the neck in correct alignment with the rest of the spine become long and weak, thus forming the two lines of the cross. Clinically, this is also correlated with tight internal rotators of the shoulder (glenohumoral) joint itself, namely the latissimus dorsi, subscapularis, and locked long but painful external rotators infraspinatus and teres minor.

Since the scapula floats in a sea of muscle upon the rib cage, the lengths and relative synergy of these muscles will determine its posture and control at rest and with movement. The rounded shoulders and forwardly tipped scapula position in upper crossed syndrome has been repeatedly shown in the literature to increase the risk of shoulder injuries2. The protracted neck posture also increases the compressive loads on the upper cervical spine and shortens the sub-occipital muscles at the base of the skull both of which can be causative of neck stiffness, headaches and dizziness.

The upper crossed syndrome is a classic example of patients we see who work long hours sitting at a desk, with shoulder and neck pain eventuating from continued use most commonly of the mouse hand in this sub-optimal shoulder posture. For the athletic population, with a high volume of overhead pressing, pulling and dipping movements together with the difficulty in maintaining adequate shoulder posture under external load and as fatigue sets in3, a loss of correct shoulder control will favor the use of muscles associated with the upper crossed syndrome. Myofascial tightening then occurs, and a sub-optimal relationship between scapular muscles eventuates increasing the potential for shoulder pain.

Now, as desk work is hard to avoid, and because we love to press, pull and dip as much as the next person, we need some strategies in place to identify and minimize the shortening of dominant structures and increase the activation of inhibited structures.

For a quick self-test to determine the flexibility of the shoulder complex and thoracic spine:

  1. Stand with your feet 10cm away from a wall, hip width apart, and in a ¼ squat position
  2. Have your hips, shoulders and head resting on the wall
  3. Pull your chin in to flatten your neck on the wall
  4. Pull your rib cage down to almost flatten your lower back against the wall
  5. Bring your arms out to the side 90 degrees to your body, elbows bent to 90 degrees and with the back of your forearm, wrist and hand against the wall.
  6. If you cannot get into this arm position without your lower back lifting off the wall you are restricted through your shoulder and thoracic spine complex

Methods to minimize the structural imbalance around the shoulder joint and decrease the resultant stress on vulnerable tissues include soft tissue release techniques, joint mobilizations, neural mobilizations, and of course self-management strategies. For the desk worker, a short routine every 30-60min moving the shoulder girdle in different planes of motion will assist in maintaining soft tissue mobility. In the gym, incorporating a graded amount of pre-activation work for your specific weaknesses (usually the lower trapezius and external rotators) prior to lifting, fascial stretching of the lats, pecs and upper traps, and self-release techniques using balls, kettlebells and barbells (only to a necessary degree) will help prevent the above imbalances.

Nigel Morgan
Physiotherapist, Accredited Exercise Physiologist

  1. M. (2014). Conditioning the upper trapezius. The Journal of Bodyworrk and Movement Therapies. 18(2), 292–297
  2. P., Reynolds. J. (2009). The Association of Scapular Kinematics and Glenohumeral Joint Pathologies. J Orthop Sports Phys Ther, 39(2), 90–104
  3. N. (2003). Effects of muscle fatigue on 3-dimensional scapular kinematics. Archives of Physical Medicine and Rehabilitation. 84(7), 1000-1005