Combining Manual Therapy and Exercise for Upper Crossed Syndrome

Upper Crossed Syndrome (UCS) is a common postural imbalance characterized by tightness and weakness in certain muscles of the upper body. This syndrome typically results from prolonged poor posture, such as sitting at a desk for long periods with a forward head position and rounded shoulders.

 Causes of Upper Crossed Syndrome

Upper Crossed Syndrome (UCS) is primarily caused by postural imbalances and lifestyle habits that lead to muscle imbalances over time. Here are some common causes:

• prolonged poor posture
• sedentary lifestyle
• repetitive movements that involve forward bending or reaching e.g., typing, driving
• improper exercise technique
• muscle imbalances
• injury that affect the shoulders, neck or upper back can lead to compensatory movement patterns
• congenital factors such as scoliosis or congenital spinal deformities
• chronic stress

Respiratory Muscles Involved In Upper Crossed Syndrome

Along with cervical and thoracic spine muscles, respiratory muscles are also involved.

 

Clinical presentation of Upper Crossed Syndrome 

• Neck Pain
• Headaches
• Rotator Cuff Syndrome
• Shoulder Blade Pain
• TMJ Pain
• Cervicobrachial Syndrome
• Chest Wall Pain
• Thoracic Outlet Syndrome

 

Diagnosing Upper Crossed Syndrome (UCS)

Patient History

• Inquire about the patient’s daily activities, work environment and any habits that might contribute to poor posture.
• Ask about specific symptoms like neck pain, shoulder discomfort, headaches and any limitations in movement.
• Discuss the patient’s physical activity routine, including any exercises or sports they engage in and whether they’ve noticed any changes in their ability to perform certain movements.
• Consider any history of injuries, particularly to the neck, shoulders or upper back, that may contribute to muscle imbalances.

 

Postural Assessment

Observe the patient’s posture from the front, side and back. Use a plumb line to assess alignment. The ideal posture should have the ear, shoulder, hip, knee, and ankle aligned vertically when viewed from the side. Deviations from this line indicate postural imbalances typical of UCS.

Key postural signs of UCS include:

• forward head posture
• rounded shoulders
• increased thoracic kyphosis
• scapular winging

 

Palpation

Palpate the cervical and thoracic spine to check for any tenderness of hyperactive muscles or areas of increased tension leading to formation of trigger points.

• tenderness of hyperactive muscles

1. SCM
2. Upper trapezius

• trigger points

Physical Examination

Movement Patterns

Checking muscle coordination is an important component during physical examination. Poor movement patterns effects both joint and muscle biomechanics.

Physiotherapist can check following movements:

• hip extension
• hip abduction
• trunk curl up
• head flexion
• shoulder abduction
• push up
• head and neck flexion
• shoulder abduction

Muscle Length Tests

Pectoralis Major/Minor: Assess the flexibility of the chest muscles. Tightness can be indicated by limited shoulder retraction or a forward shoulder position.

Upper Trapezius and Levator Scapulae: Evaluate the length of these muscles by gently stretching them and noting any resistance or discomfort.

Other muscles that can be checked include:

• SCM (shortened)
• Suboccipitals (shortened)

Muscle Strength Tests

• Test the strength of the deep cervical flexors by having the patient perform a chin tuck and resist upward force.
• Assess the strength of the lower trapezius by testing scapular depression and retraction. 
• Serratus anterior strength can be evaluated through the scapular protraction test or push-up plus exercise.

 

Functional Movement Assessment

• Cervical Range of Motion (ROM): 

Assess the patient’s ability to flex, extend, rotate, and laterally bend the neck. Restricted ROM may indicate muscle tightness associated with UCS.

• Scapular Movement: 

Observe the movement of the scapula during arm elevation and overhead activities. Look for signs of scapular dyskinesis, such as winging or abnormal movement patterns.

• Wall Angel Test: 

Have the patient stand against a wall with their back, head, and arms pressed against the wall. Instruct them to slide their arms up the wall while maintaining contact. Difficulty in maintaining contact or discomfort indicates tight chest muscles and weak scapular stabilizers.

• Push-Up Plus Test: 

Evaluate the function of the serratus anterior by having the patient perform a push-up with an emphasis on scapular protraction at the top of the movement. Weakness or winging of the scapula indicates dysfunction.

 

Special Tests

• Cervical Flexion-Rotation Test: 

This test assesses the rotation of the upper cervical spine, which can be restricted due to muscle tightness in UCS.

• Scapular Assistance Test (SAT): 

Assesses the contribution of the scapula to shoulder pain by manually assisting the scapular motion during arm elevation.

Gait Analysis

Muscle imbalance can significantly affect gait mechanics. Physiotherapist should observe:

• pelvic tilting
• winging of scapulae  with arm movement
• altered arm swing movement 

 

Ergonomic Assessment

If relevant, discuss regarding the patient’s workspace or common daily environments. Look for factors that might contribute to poor posture, such as improper chair height, monitor positioning or desk setup.

Differential Diagnoses for Upper Crossed Syndrome

• Cervical Radiculopathy
• Thoracic Outlet Syndrome
• Rotator Cuff Tendinopathy
• Shoulder Impingement Syndrome
• Myofascial Pain Syndrome
• Cervicogenic Headaches
• Adhesive Capsulitis (Frozen Shoulder)
• Scapular Dyskinesis (isolated)
• Degenerative Disc Disease (Cervical Spine)
• Postural Orthostatic Tachycardia Syndrome (POTS) related to poor posture

 

Physiotherapy Management of Upper Crossed Syndrome (UCS)

Physiotherapy management of Upper Crossed Syndrome involves a comprehensive approach that addresses the muscle imbalances, postural deviations and associated symptoms. The goal is to reduce pain, restore proper posture and improve overall function. Here’s a detailed explanation of the physiotherapy management:

Patient Education

• Provide advice on ergonomic adjustments at work or home to prevent the recurrence of UCS. Suggest optimal desk setup, monitor height, chair support and foot positioning to promote good posture.
• Teach the patient to take regular breaks from sitting or repetitive tasks, incorporating stretches and movements that counteract prolonged static postures.
• Discuss stress management techniques, as stress can contribute to muscle tension and poor posture. Encourage practices like deep breathing, mindfulness, or relaxation exercises.
• Provide guidance on maintaining proper posture and muscle balance long-term. Emphasize the importance of continuing exercises and ergonomic adjustments even after symptoms have resolved.

Pain Management Techniques

• Heat Therapy
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Therapeutic Ultrasound 

Postural Correction

• Educate the patient on the importance of maintaining a neutral spine and proper head alignment during daily activities.
• Encourage the patient to frequently check their posture, especially when sitting for long periods.
• Provide tips on ergonomic adjustments at the workplace or home, such as correct chair height, monitor placement at eye level and proper desk setup to reduce forward head posture and rounded shoulders.

Postural Exercises:

• Chin Tucks
• Wall Slides

 

Stretching Exercises

Stretching exercises are performed to improve the flexibility of muscles, static stretching is preferred. Following muscles are targeted.

• upper trapezius
• subscapularis
• sternocleidomastoid
• suboccipital muscles
• pectoralis major and minor
• scalenes

Examples of exercises

Pectoralis Major and Minor:

• Doorway Stretch: Instruct the patient to place their arms on either side of a doorway at shoulder height and step forward to stretch the chest muscles.
• Foam Roller Stretch: Have the patient lie lengthwise on a foam roller, with arms extended outward to allow the chest muscles to stretch.

Upper Trapezius and Levator Scapulae:

• Upper Trapezius Stretch: The patient can sit or stand, gently bringing one ear toward the shoulder and using the hand to increase the stretch.
• Levator Scapulae Stretch: Instruct the patient to rotate the head slightly and tilt the chin toward the chest while using the hand to gently pull the head downward, stretching the levator scapulae.

 

Strengthening Exercises

• Lower Trapezius:

Prone Y-Raises: Have the patient lie face down and lift their arms overhead in a Y shape, focusing on squeezing the shoulder blades together.

• Serratus Anterior:

Push-Up Plus: Instruct the patient to perform a push-up, but at the top of the movement, they should protract their shoulder blades (push them forward) to engage the serratus anterior.

• Rhomboids and Middle Trapezius:

Scapular Retractions: The patient can perform this by squeezing the shoulder blades together while keeping the arms at their sides or holding a resistance band.

 

Manual Therapy

Myofascial Release

Apply techniques, such as trigger point release or myofascial release, to reduce tension in the tight muscles, particularly the upper trapezius, levator scapulae and pectoral muscles.

Active Release Technique (ART):

The process involves identifying the exact location of the adhesions, applying pressure to that area, and then moving the tissue through its range of motion.

Joint Mobilizations

Mobilize the thoracic spine and cervical spine to improve mobility, reduce stiffness and restore proper movement patterns.

• mobilize cervicothoraric junction and sternoclavicular joint
• mobilize CO-Cl and cervicothoracic junction
• mobilize upper thoracic spine

 

Functional Training:

Integrate exercises that mimic daily activities, helping the patient apply proper posture and movement patterns in real-life situations. This could include overhead reaching exercises, lifting techniques, and ergonomic corrections for workstation tasks.