My dad used to chide me all the time, asking me to stop slouching on the table and sit up tall. “You will end up with neck pain like me. I did not listen to my dad and see where it got me!” That would work like a charm for a whole of two minutes.

I think of him often as I see patients slouched forwards with rounded shoulders and a forward head posture: a package deal, buy-1-get-3-free deal, a hunched back screaming kyphosis, shoulders drooping forwards, and the head poking out like a turtle out of its shell.

Historically, rounded shoulders have been identified as a component of postural syndrome, and not a stand-alone affliction or condition. Several terms became popular to describe the triad of rounded shoulders, kyphosis, and forward head posture towards the end of the last century. The most popular of these is the upper crossed syndrome, which continues to be used by rehabilitation professionals.

Upper crossed syndrome is described as the combination of tightness in the chest and neck muscles, coupled with weakness of the deep neck flexor muscles and weak scapular muscles. This combination is thought to throw the upper body out of alignment so that the center of gravity shifts anteriorly, causing a forward head posture and increased thoracic kyphosis, among other postural changes.

What causes rounded shoulders?

Rounded shoulders are caused by the anterior tilting of the scapulae, along with possible increase in scapular internal rotation. This is usually coupled with tight pectoral muscles and can gradually lead to increased tightness in the soft tissue structures anterior to the shoulder joint. It is common to see individuals with rounded shoulders with their arms turned inwards as the shoulder joints assume an internally rotated and adducted position.

Researchers from Jamia Millia Islamia in New Delhi, India, described the change in posture resulting from regional interdependence, which means that since the center of gravity passes through several anatomical landmarks, change in one part of the body can result in a domino effect as the body adapts. Thus, it is very common to see a person with upper crossed syndrome also present with an anterior pelvic tilt and a lordosis

Similarly, the lower crossed syndrome and its prevalence among young adults is described in this paper published by the International Journal of Advanced Research in 2017. Two hundred healthy young men and women were included in this study. The authors found that lower crossed syndrome, consisting of tightness in the hip flexor muscles and the spinal extensor muscles coupled with weakness of the abdominal and hip extensor muscles, is more prevalent among young women than men in the same age group.

Rounded shoulders have been attributed to cause shoulder pain due to change in alignment of the scapula during overhead activities. Subacromial impingement syndrome and neck pain can result from this maladaptive posture. Repeated shoulder movement in individuals employed in jobs requiring overhead activities such as electricians and construction workers can lead to ongoing irritation of the structures in the subacromial space. The resulting sequelae can vary from partial rotator cuff tears to acromioclavicular joint disease.

Neck pain is another common condition associated with the postural triad of rounded shoulders, forward head posture, and thoracic kyphosis. The Medical Journal of the Islamic Republic of Iran published a 2014 article indicating that patients who had neck pain were more likely to present with this postural impairment.

Do rounded shoulders cause back pain and shoulder pain?

Going up the chain, it is not unusual to see patients with cervicogenic headaches and jaw pain present with rounded shoulders. Treatment of these conditions invariably includes exercises directed at the upper body posture. The temporomandibular joint (TMJ) pain that can often be treated without so much as touching the TMJ, as the cause is by and large postural changes in the cervicoscapular region.

Similarly, tightness in the suboccipital muscles can cause entrapment of the greater and lesser occipital nerves, resulting in symptoms radiating from the upper neck to the base of the skull, the ipsilateral ear, and to the temporal/eye, causing retro-orbital headaches, among other symptoms.

A kyphotic spine limits the ability of the shoulders to elevate completely, as spinal extension contributes to endrange overhead shoulder movement. The effects of kyphosis go beyond structural issues such as neck and shoulder pain. Koelé et al. concluded that in older adults, increased kyphosis can be a factor in increased fall risk and fractures.

The long-term prognosis of these conditions in the elderly is concerning. The consequences include decreased physical function, decreased pulmonary function, increased pain, lower quality of life, and increased mortality. This downward spiral can be easily prevented by exercise therapy targeted at improved strength and endurance of postural muscles.

Other studies have also noted the correlation between kyphosis, osteoporosis, and chronic upper and mid back pain in older women.  Similarly, this study found increased thoracic kyphosis has been associated with upper back pain in postmenopausal women.

While the physical characteristics mentioned above are indicative of structural differences (tightness, weakness, contracture), they may also be a reflection of underlying psychological changes such as depression.

A study published in the Brazilian Journal of Psychiatry in 2010 notes the postural changes identified in 34 individuals with major depressive disorders versus 37 healthy controls. The individuals with depressive disorders presented with scapular abduction, pelvic tilt, forward head posture, and thoracic kyphosis during episodes of depression, but their posture was similar to that of controls during periods of remission.

The effects of psychological health on an individual’s wellness and health cannot be over-emphasized. Postural changes can be a clue to these psychological issues, and early detection and treatment can make significant changes to an individual’s quality of life.

Rounded shoulders exercise

Treatments for rounded shoulders consist of exercise therapy, bracing, manual therapy, and more invasive procedures such as surgery in more involved cases. Scapular bracing devices are helpful to reduce forward shoulder angles and correct rounded shoulders and have been found to improve muscle activity associated with corrective posture.

However, as noted in this randomized controlled clinical trial of 38 healthy overhead athletes reported in the Journal of Athletic Training in 2013, postural braces should not be a stand-alone treatment and clinicians should incorporate therapeutic exercises before and after bracing.

Decision to include treatments other than exercise therapy is also dependent on factors such as the degree of kyphosis, the progression of deformity, the flexibility of the spine, symptoms present, and age. The international consensus is that the goal is to improve or maintain the quality of life.

Exercise therapy remains an effective treatment for postural disorders. The idea behind corrective exercises for rounded shoulders is to provide the body with movement in the direction opposite to the one it has assumed for long periods of time, whether it be due to the nature of one’s work, or just habitual.

The exercises follow the following framework: stretching of the tight muscles, and strengthening of the muscles supposed to be weak. While the evidence to support upper crossed syndrome is weak, there is a gathering body of evidence to suggest that exercise can help prevent pain.

It is uncertain if it is the exercise itself that helps or the change from static posturing. It is also possible that individuals who exercise regularly end up being more aware of their posture and move better and move more frequently, and that maybe the secret ingredient!

The stretching exercises shown in the prospective, randomized controlled study in 2017 target the anterior chest structures such as the pectorals, and the neck muscles, including the suboccipital muscles which connect the neck to the head. The exercises included are the doorway stretch, snow angels, and corner stretch.

The stretch has to be easy and gentle, and if done correctly, the individual will be able to experience more give as they ease into the stretch. The stretch should be held for about 30 seconds and done at least two to three times. The neck exercises include the chin tuck series. This is done to stretch the soft tissue connecting the head to the neck, and reduce the forward head posture. The individual lays flat on the bed/floor and without raising the head, attempts to bring the chin down towards the chest. The sternocleidomastoid is another muscle that is prone to being taut and stretching of this muscle should be included in the neck mobility exercises.

Strengthening exercises include strengthening of the deep neck muscles, the scapular muscles, and the upper back muscles. The study mentioned above included a sample size of 130 adolescents from two schools presenting with forward-head rounded shoulders posture.

These students were randomized into control and experimental groups. The students in the experimental group were given strengthening and stretching exercises. The chin tuck exercise is performed laying on the back. The chin tuck position described above can be progressed by lifting the head slightly off the table in a motion that draws the chin down towards the chest.

This motion strengthens the deep neck flexors in front of the neck. This is an endurance exercise, which means that the motion is very little, but it is the time to which it is held that is important. The goal is to hold from 30 to 45 seconds at least, progressing incrementally and maintaining good form.

The scapular strengthening exercises consist of rows, shoulder extension with scapular squeeze, T’s, W’s, Y’s, and the push up plus series. The exercises involve squeezing the shoulder blades while pulling them down, and avoiding shoulder hiking.

The push-up plus series includes exercises where the upper back is more rounded as the shoulder blades move away from each other. All these exercises strengthen the scapular stabilizer muscles, improving the body’s capacity to remain in a corrected position for an extended period.

Scapular rows

woman doing scapular rows for rounded shoulders

Scapular rows. Photo: Tanvi Maharaja

Lay on your stomach face down with your elbow straight and hanging over the side of the table or bed, and slowly raise your arm upward while bending your elbow. Keep your elbow close to your body. You can use small weights to begin and progress with weights.

 

Scapular retraction with shoulder extension using resistance band

Stand holding an elastic band in each hand with your arms in front of you and your elbows straight, hands turned out so that your thumbs are away from you, squeeze your shoulder blades together, as you pull the band back. Do not allow your shoulders to raise up.

As it gets easier, increase to holds by 3-10 seconds.

Scapular T’s

Scapular T's

Scapular T’s. Photo: Tanvi Maharaja

Laying on your stomach face down, draw your shoulder blades together as your arms move away from you with the thumb facing towards the ceiling as the hands move up in line with your shoulders. Your arms make a “T” with your body.

Scapular Y’s

Scapular Y's

Scapular Y’s. Photo: Tanvi Maharaja

Stand facing a flat wall with your arms overhead resting on the wall making a “Y” with your body. Lift hands and arms off of the wall, pulling shoulder blades down and back. Slowly lower arms back to the wall and repeat.

Scapular W’s

Lie with a pillow under your hips and raise your arms up off the ground with your shoulders and elbows at a 90 degree angle, so that your arms make a “W” with your body. Concentrate on squeezing your shoulder blades together and maintain this position for the desired time.

Push-up plus

modified push-ups

Modified push-ups. Photo: Tanvi Maharaja.

Standing on a kitchen counter with your hands supporting your body and your feet a little behind your hips so that you are inclined forwards a little. Start by keeping elbows straight and let your shoulder sink in. Elbows are still straight, push through the shoulder blades as if you are pushing something away from you. This exercise is about pushing your hands into the counter and moving your body away from the counter, unlike a regular push up where you go towards the surface.

Do you need corrective exercises for rounded shoulders?

While corrective exercises may help encourage muscle flexibility and strengthening, they may not suffice if the individual does not accompany that with an increase in postural awareness. This means that indulging in frequent self-assessment of one’s posture and knowing how to prevent repetitive or prolonged posture may be as much, if not more important, than the exercises themselves. This should be borne in mind whenever prescribing or performing these exercises.

There is a growing body of literature emphasizing the importance of movement variability and activity pacing to counter the effects of static posture, as discussed in this article published in Human Movement Science in 2011. More studies are coming out to state that an optimal posture is not defined by a fixed or static position of the body, but rather by the continual change in body positions, allowing for a variety of movement, while avoiding fixed, repetitive movements or positions.

This underscores the importance of movement and activity rather than fixation on an idea of perfect posture. There is growing evidence to suggest that there is no strong cause and effect relationship between posture and pain. Pain is a complex phenomenon which is now widely accepted to respond best to a biopsychosocial response, with emphasis shifting from the highly biological models and explanations to a more psychosocial approach.

Should I still learn how to “fix” rounded shoulders?

While rounded shoulders have been adequately demonized, it is illogical to believe that a posture consisting of adducted and posteriorly tilted shoulder blades, like the military posture, would be the answer to all impairments related to rounded shoulders.

The bottom line remains that while it may be useful to be aware of the likely postural deviations and the means to correct them in a population that is prone to repetitive tasks or movements, just a piece of the puzzle, only a means to an end—the end being education and awareness about the dynamic nature of the human body and ways to cultivate healthy habits and behaviors.

So while understanding why, how, and when rounded shoulders may become a problem, knowing that the issue can be easily resolved by dynamic movement, variability in posture, and through the use of corrective exercises is helpful in preventing secondary issues.

We all slouch every now and then, the body is designed so that we can when we need to. As long as you don’t remain slouched all the time, it is okay. So don’t stress much about that text neck, but make sure that is not all you are doing throughout the day!

See more on narrative medicine for clinical practice.

Tanvi Maharaja
Tanvi Maharaja, DPT, OCS

My name is Tanvi Maharaja. I work as a Physical Therapist in an outpatient hospital setting in the Greater Boston Region. I have a Doctor of Physical Therapy degree, and I am a Board-Certified Specialist in Orthopedic Physical Therapy. I am also an eclectic practitioner of manual therapy, being a Certified Manual Therapist through NAIOMT, with a special interest in the spine. I love to write, cook, swim, and go on long walks to nowhere with my family.