Epidemiology Upper Crossed Syndrome

Epidemiology Upper Crossed Syndrome

Upper Crossed Syndrome Tightness of the upper trapezius, pectoralis major, and levator scapulae and weakness of the rhomboids, serratus anterior, middle and lower trapezius, and the deep neck flexors, especially the scalene muscles.1
Incidence Population studies suggest that 6-48% of adults have pain in one of

these areas.3

Age Studies have shown a reduction in proprioception for neck movements of persons over the age of 45 years, regardless of NP. Therefore, age-related changes may contribute to a more forward head posture even in the absence of pain.4
Pain location Upper body
History of injury This atypical posture produces stress on the cervicocranial joint, the C4-5 and T4 segments and shoulder by its limited range of motion of the glenohumeral joint (in atypical posture).5 Too much stress on segment T4 may provide regular chest pain or pseudo-angina.5 The altered position of the axis of the glenoid fossa causes rotation and abduction of the scapula. Which means that the levator scapula and upper trapezius muscle must deliver more to the humeral head to stabilize.2 This is accompanied by an increased constant activity of the supraspinatus and causes a earlier degeneration of this muscle.5
Pathology This syndrome can cause a multitude of dysfunctions within the body

including headaches, early degeneration of the cervical spine, and loss of the cervical curve. In addition, UCS can cause an abnormal kyphotic thoracic spine and altered biomechanics of the glenohumeral joint. Altered biomechanics of the cervical spine may lead to a loss of cervical curve and, if not addressed, degeneration of the cervical spine. The alterations in function of the musculature, in people with UCS, often cause these individuals to develop chronic headaches. Age-related degenerative changes have an impact on the structure of tissues and the subsequent mechanics of the cervical spine.

Kinematics Muscle tightness has been implicated in subacromial impingement. In particular, during elevation, anterior shoulder girdle muscle tension may affect the tension on the leading edge of the coracoacromial ligament, predisposing it to tightness ultimately leading to structural impingement.6 Tightness of the pectoralis major creates an anterior force on the glenohumeral joint with a consequent decrease in stability.8 A tight pectoralis minor limits scapular upward rotation, external rotation, and posterior tilt, thereby reducing SAS.9 This alteration in scapular kinematics occurs in three separate planes of movement and differs from scapular kinematics of those with normal muscle length.7,10
  1. Moore, MK. Upper Crossed Syndrome And Its Relationship To Cervicogenic Headache. JMPT July/Aug. 2004;27,6:416.
  2. Christensen K. Manual muscle testing and postural imbalance. Dynamic Chiropractic 2000;15:2.
  3. Sim, J, Lac ey RJ, Lewis, M. The impact of workplace risk factors on the occurrence of neck and upper limb pain: a general population study. BMC Public Health 2006;6:234
  4. Silva A, Punt D, Et. al. Head Posture and Neck Pain of Chronic Nontraumatic Origin: A comparison Between Patients and Pain-Free Persons. Arch Phys Med Rehabil 2009;90:673.
  5. Janda compendium. Vol II. Minneapolis: O.P.T.P., p. 7-13.
  6. Bigliani L.U., et al. , The relationship of acromial architecture to rotator cuff disease. Clin Sports Med. 1991;10(4):823–838.
  7. Mottram S.L., Dynamic stability of the scapula. Man Ther. 1997;2(3):123–131.
  8. Labriola J.E., et al. , Stability and instability of the glenohumeral joint: the role of shoulder muscles. J Shoulder Elbow Surg. 2005;14(1 Suppl S):32S–38S.
  9. Borstad J.D., Ludewig P.M., The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. J Orthop Sports Phys Ther. 2005;35(4):227–238.
  10. Borstad J.D., Resting position variables at the shoulder: evidence to support a posture-impairment association. Phys Ther. 2006;86(4):549–557.


Physical examination

Janda divided muscles into two groups: postural and phasic muscles.7 He believed that postural / tonic muscles, are the muscles designed to ensure the maintenance of good posture and tend to be short and hypertonic in pathology, tend to cause contractures, but are less likely to atrophy. The phasic muscles, which are almost every other muscles, tend to weaken and inhibit in pathology. The examiner must be careful in assessing the type of muscle, including the ROM that it can achieve, just like the power and the production of pain that the muscle can create when tensioned. Table 1 shows the postural / tonic muscles that tend to tightness and the phasic muscles and that tend to weakness. Table 2 shows the characteristics of the postural and phasic muscles. If a muscle imbalance is detected, the shortened / tight muscle must first be stretched and made normo tonus before there can be started to strengthen the muscle.8,9
Janda et al implemented this concept further as the “upper crossed syndrome” and “pelvic crossed syndrome, whereby muscles (mainly postural) on one side of the joint tense and hypertonic and on the other side are the weak and lengthened muscles.9,10 This concept of tense and hypertonic muscles in one side of the joint and on the other side weakened and lengthened muscles is a concept that researchers must comply at all joints. This concept should mainly be remembered in chronic joint disorders where both muscle types require a different method of treatment.
Table1. Functional Division of Muscle Groups*1
Muscles Prone to be Tightness (Postural) Muscles Prone to Weakness (Phasic muscles)
Gastrocnemius and soleus Peronei
Tibialis posterior Tibialis anterior
Short hip adductors Vastus medialis and lateralis
Hamstrings Gluteus maximus, medius and minimus
Rectus femoris Rectus abdominis
Iliopsoas External oblique
Tensor Fasia Latae Serratus anterior
Erector spinae (lumbar, thoracolumbar and cervical parts) Rhomboideus
Quadratus lumborum Trapezius ascendens
Pectoralis major Short cervical flexors
Trapezius descendens Extensoren of the upper extremity
Levator scapulae
Flexors of the upper extremity
*Janda considered all other muscles neutral
Tabel2. Characteristics of Postural and Phasic Muscle Groups1
Muscle Prone to Tightness Muscles Prone to Weakness (Phasic Muscles)
Predominantly postural function Primarily phasic function
Associated with flexor reflexes Associated with extensor reflexes
Primarily two-joint muscles Primarily one-joint muscles
Readily activated with movement (shorter chronaxie) Not readily activated with movement (longer chronaxie)
Tendency to tightness, hypertonia, shortening, or contractures Tendency to hypotonia, inhibition, or weakness
Resistance to atrophy Atrophy occurs easily
At a protracted position of the head or ‘poking chin’, the occipital muscles adaptively shorten. This posture also makes sure that a misa ment ment (poor posture) occurs for any increased stress on the facet joints and posterior discus and other posterior elements. The position can also cause weakness of the deep neck flexors.2 Janda describes this as “Upper crossed syndrome”.3

It is important to note that the upper-cross syndrome is often accompanied with cervical instability. Female patients also have generally a greater AROM than men, except in the case of flexion, however, these differences are not large. The ROM available decreases with age, except for rotation in C1-C2 which can get bigger.4,5

Next to the upper crossed syndrome there also is a pelvic crossed syndrome described by Janda and Jull. This syndrome is sometimes accompanied with the upper crossed syndrome. The two syndromes together called the layer syndrome.6

  1. Jull G and Janda V: Muscles and motor control in low back pain. In Twomey LT and Taylor JR, editors: Physical therapy for the low back: clinics in physical therapy, p.258, New York, 1987, Churchill Livingstone
  2. Watson D, Trott P: Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance, Cephalalgia 13:272-284, 1993.
  3. Janda V: Muscles and motor control in cervicogenic disorders: Assessment and management. In Grant R (ed): Physical therapy of the cervical and thoracic spine, New York, 1994, Churchill Livingstone.
  4. Youdas JW, Garrett TR, Suman VJ, et al: Normal range of motion of the cervical spine: An initial goniometric study, Phys Ther 72:770-780, 1992.
  5. Dvorak J, Antinnes JA, Panjabi M, et al: Age and gender related normal motion of the cervical spine, Spine 17:S393-S398, 1992.
  6. Jull G, Janda V: Muscles and motor control in low back pain. In Twomey LT, Taylor JR, editors: Physical therapy for the low back, New York, 1987, Churchill Livingstone.
  7. Janda V: On the concept of postural muscles and posture in man, Aust J Physiother 29:83-85, 1983.
  8. Schlink MB: Muscle imbalance patterns associated with low back syndromes. In Watkins RG, editor: The spine in sports, St. Louis, 1996, Mosby.
  9. Jull GA, Janda V: Muscles and motor control in low back pain: assessment and management. In Twomey LT, Taylor JR, editors: Physical therapy of the low back, New York, 1987, Churchill Livingstone.
  10. Janda V: Muscles and motor control in cervicogenic disorders: assessment and management. In Grant R, editor: Physical therapy of the cervical and thoracic spine, New York: Churchill-Livingstone, 1994.


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