Upper cross syndrome, also referred to as upper crossed syndrome or UCS, names a pattern of movement and postural variance attributed to the interaction between “tight” and “weak” muscles in the upper body resulting in poor posture, discomfort, and pain.
A client I see regularly for massage therapy fits many of the telltale signs associated with upper cross syndrome. They work primarily in front of a computer, sitting at a desk for long hours. Their posture is hunched, and their shoulders are rounded forward, causing their chest to look almost concave. When they come in to see me, the usual complaint is rhomboid pain, pain in the upper back and shoulders, and sometimes a headache that starts in the neck and goes into the jaw.
We tend to attribute significance to posture, whether due to aesthetic preferences or as an indicator of structural problems in the body. As it progresses, research into the experience of pain reveals a more complex relationship than causal correlation between structure and sensation.
History of upper cross syndrome
The term “upper cross syndrome” was coined in 1978 by Dr. Vladimir Janda, a twentieth century Czech neurologist, professor, and researcher. Janda was a pioneer in the fields of manual therapy and rehabilitation, championing the blend of anatomy and movement in clinical work, known as functional anatomy. His work posited that issues of joints, the musculoskeletal system, and the nervous system would affect the way other parts of the body functioned both locally and systemically.
He presented the idea of several “crossed syndromes” including lower crossed syndrome and layer syndrome. These “postural syndromes” he described as musculoskeletal imbalances centralized around the shoulder girdle and the pelvic girdle.
The hallmark of these postural deviations is overactivity in some areas and under activity in the opposing muscles. As the conflict between forces continues, the condition can worsen towards injury.
Just as upper crossed syndrome affects the upper body, lower crossed syndrome follows a similar crosswords path of oppositional weak and tight muscles in the lower body. Layer syndrome affects both the upper and lower portions of the body as a combination of the upper and lower cross syndromes.
Upper cross syndrome symptoms
The imbalance displayed by upper cross syndrome expresses itself in the neck and shoulder area. The upper trapezius, levator scapulae, sternocleidomastoid, and pectoral muscles are seen to be overactive and strained, or “tight”. The deep cervical flexors, lower trapezius, rhomboids, and serratus anterior are seen to be underactive or “weak”. These exhibit as a forward head posture, rounded shoulders, winged scapulae, and a convex curvature of the thoracic spine (kyphosis). These lines of tension create an “X” pattern and put stress on the joints of the neck and shoulder.
Upper cross syndrome can manifest with back pain, neck pain, shoulder pain, jaw pain, or headaches. The pain in the back could even feel like a rhomboid strain. It can cause sensations of tightness across the chest, shoulders, and neck, even compromising movement in the upper body. For many people, the hunched shoulders and forward head posture have the added negative effect of being considered aesthetically undesirable.
Does Janda’s upper cross syndrome hold up to modern scientific scrutiny?
While many in therapeutic fields are still informed by the perspective linking pain and abnormal movement, the last several decades of pain research have encouraged a shift away from this cause and effect relationship. Janda partially attributed the issue of upper crossed syndrome to maintaining a slouched position while sitting. In particular, the link between posture, pain, and dysfunction seem to be quite weak.
Australian researchers from the School of Physiotherapy at the Curtin University of Technology conducted a cross-sectional study in 2009 to investigate the relationship between sitting posture and physical, psychological, and social factors in adolescents. They found that the relationship between back pain and posture was particularly complex and heavily influenced by other biopsychosocial factors like negative thoughts and self image, gender, body mass index, and activity.
The same study did find some evidence that more upright postures could still have positive impacts on quality of life, like emotional state, motivation, productivity, and in some cases back pain. Ultimately, however, it was concluded that the correlation between sitting posture and back pain was weak, and that the general prescription of upright posture was not something that could be said to be a fit for every candidate.
In another study from Curtin University of Technology in Australia, published in 2016, researchers focused on neck posture while sitting. They gathered data by measuring the angle of subjects’ neck posture through photographs, and information about subjects’ pain level and lifestyle factors through questionnaires. They found similar results that surrounding factors like exercise, mental state, and body mass index were indicated over sitting posture influencing neck pain and headaches.
While Dr. Janda’s work continues to influence manual and rehabilitative therapy, the case for posture directly correlating with dysfunction is weak. The influence of biological, psychological, and social factors on the pain experience shows it to be much more complex than singularly connected to biomechanical causes.
Upper cross syndrome treatments
There are a variety of approaches and professions that will treat upper cross syndrome and its symptoms. Some of the treatments promote a “fix” for the condition. The evidence for a quick fix is not there, but combinations of techniques have the most promise of symptomatic relief.
Physical therapy can combine stretching, range of motion and strengthening exercises, manual therapy, and patient education to improve upper cross syndrome. biological, psychological, and social factors on the pain in South Korea published a study in 2018 that compared the effects on head posture from combinations of the McKenzie exercise, a series of repeated movements and sustained positions that focus on patient experience, kinesio taping, in which an elastic adhesive tape is applied to the skin in a way that creates a directional line of tension, and myofascial release, a soft tissue manipulation therapy focused on the fascial layer of the body.
In this study, subjects were split in three groups. One measuring the effects of the McKenzie exercise combined with myofascial release, another pairing the McKenzie exercise with kinesio taping, and a third group that underwent a combination of the three. While the small sample size and short study duration limit the impact of the findings, overall positive results from each intervention and a cumulative positive result of all three interventions encourage further research into the efficacy of these approaches and the mechanics behind them.
A few common threads that may be responsible for the successes of these treatments are patient empowerment and the engagement of proprioception, the sensory awareness of the position and movement of the body, by engaging mechanoreceptors in the skin.
Further approaches that may take advantage of these factors are Muscle Energy Technique (MET) and massage therapy. MET is a stretching technique that actively engages the patient in the therapy. This technique when used in combination with conventional physical therapy has shown some promising positive results in managing upper cross syndrome. However, for chronic low back pain, the evidence is lacking and mixed.
Massage therapy can use soft tissue manipulation, assisted stretching, and even heat therapy to facilitate relief for upper cross syndrome. Activating the relaxation response can help decrease stress levels, increase patient resilience, and stimulate the parasympathetic nervous system to calm the body, which could in turn relieve discomfort from upper cross syndrome.
General strengthening and stretching exercises are the most common treatments for upper cross syndrome. This can be achieved through movement practices like strength training, self-stretching, yoga, and pilates.
Some treatment approaches focus on both the body and the surrounding environment. Ergonomic adjustments can be made when workplace conditions contribute to upper back, neck, and shoulder pain. Neck and shoulder pain related to work affects many different industries and increases as technological advances put more workers in fixed positions engaging in repetitive movements.
Researchers from the Departments of Rehabilitation Sciences and Medical & Health Sciences at Hong Kong Polytechnic University and Tung Wah College in China published a study on workplace ergonomic interventions on work related neck and shoulder pain in 2019.
This study integrated stretching and movement exercises, patient education, and workspace modifications. The study found that a blend of educating participants on proper workspace layout and ergonomic risks, applying the ergonomic improvements, and adding in physical exercises was helpful in relieving work related neck and shoulder pain, and would be applicable to other musculoskeletal complaints. It was limited, however, in designing protocols that would fit work environments outside of an office and applied outside of a controlled research setting.
Overall, engaging the participant in their treatment, encouraging movement, and stimulating sensory awareness seem to have positive effects for treating upper cross syndrome. The evidence is not strong for any specific methods of treatment, however, and is often limited by sample size, study duration, and repeatability.
Upper cross syndrome exercises: do they work?
Corrective exercise is a common intervention for upper cross syndrome, focusing on fixing deviations from a neutral posture. However, there is not a large body of data to support the efficacy of exercises that specifically target upper cross syndrome. The idea of correcting posture does not always take into account natural variations in body structure.
One reason that positive results can be achieved with upper cross syndrome from an exercise perspective is that exercise can have an analgesic effect by releasing endorphins. If pain reduction is a goal of the therapy, it is important to note that with chronic pain, exercise can also stimulate a negative response, and that any approach should be modified and tailored to the individual and their responses.
Positive effects of strengthening and stretching exercises are demonstrated by a few sources. Dr. Con Hrysomallis of the Centre for Ageing, Rehabilitation, Exercise, and Sport in Australia published a 2010 review of exercises targeting abducted scapulae suggesting that while there is evidence to support stretching in order to move the position of the scapula, the shortage of available data encourages conservative use of that intervention.
In 2016, a group of physical therapists at Pusan Medical Center in South Korea focused a study on strengthening and stretching the trapezius and levator scapulae. Their results showed a positive impact on structural symptoms of upper crossed syndrome, but could not speak to pain reduction as that was not a factor asked of the participants.
Dr. Hrysomallis and Dr. Craig Goodman of Victoria University in Australia noted that any improvements from these exercises and resistance training methods may be offset by a return to normal activity. It is difficult to rely on results gained in a fully controlled setting when there are so many variables involved in the daily mechanics of life.
Exercise as a whole is a generally positive way to impact pain and discomfort in the body, without much evidence for “fixing” postural deviations. Taking breaks from sedentary, immobile positions to engage in regular and varied movement can improve discomfort.
Every individual is a unique case. Listen to your body. If it feels painful or uncomfortable, it may not be the right approach for you. Further concerns can be addressed by scheduling a consultation with a medical professional.
As a massage therapist in the U.S., I do not provide a diagnosis. However, it is easy to start noticing patterns and wanting to assign a name to them internally. I prefer to engage with my clients by talking about the sensations they are experiencing, and use that as the model for formulating a treatment, rather than being the one to determine what needs to be “fixed” in them. There are so many variations of what is “normal” in every person. It is rare to find someone that matches a textbook normal out in the world.
I have had great success with the client I mentioned by approaching the symptoms that cause them discomfort without pathologizing. Slow, gentle interventions that give them the time to reconnect with their nervous system, and letting their feedback inform the process. Sometimes trying to move the shoulder back feels good, and sometimes it triggers pain and resistance in their neck and jaw that needs to be eased back. A soft hand, a warm pillow, and a check in can get it back on track.
I have not noticed a big postural change in getting their shoulders down and back, but we have made great progress in lessening the back pain and the headaches, which leads me to agree with the current supposition that the two factors need not be interconnected.
Feature photo: Nick Ng
Halley Moore, LMT
Halley E. Moore is a private practice licensed massage therapist, freelance writer, and small business consultant (Calliope Insights) in St. Louis, MO. Her diverse array of educational credits include a B.S. in Business, a massage therapy certification from The Healing Arts Center in St. Louis, various training in trauma-informed care, current enrollment in a web development coding course, and a dream of a private investigator’s license.
Halley first discovered an interest in anatomy by hanging upside-down from a trapeze as an aerial artist. Everyday after practice, new bits of her body hurt, so she figured it might be worth learning their names.