The key postural distortions associated with Janda's upper crossed syndrome (UCS) are forward head and rounded shoulders. If I see this distortion on a static posture analysis, I follow up with ROM and movement assessments.
How It's Supposed to Work
A typical treatment plan for uncomplicated UCS includes in-office hands-on therapy and at-home-training of fascial release to the SCMs, suboccipitals, upper trapezius, levator scapulae, pectoralis group and latissimus dorsi.
Corrective exercise includes supine chin tucks (Lynch, et al., 2010);1 static and/or dynamic stretching techniques for the pectorals: standing "goal post" stretch in the doorway with the arms at various heights, the latissimus dorsi stretch (child's pose), and side-lying posterior cuff static stretch ("sleeper stretch"). Strengthening exercises incorporate standing scapular retraction (Brugger's maneuver), rear deltoid flies, and squat to a high pull and rows starting with bands. Some patients may progress to prone "I's, Y's, W's and T's" with the chest on a stability ball.
When the Patient Doesn't Respond
But what happens when this protocol does not provide significant relief? Is it prolonged sitting in poor posture, a poor "rest / sleep to repair" ratio, incorrect workouts or sports training cycles? My goals remain to improve static and dynamic postures, improve motion, decrease pain, and additional implementation of corrective exercise interventions to address the UCS.
Evaluate Breathing Mechanics
An often-overlooked potential cause of upper crossed syndrome is inefficient breathing mechanics. Patel and Patel (2005)2 consider diaphragmatic breathing to be the most efficient manner in which an individual should breathe. This manner of breathing should be utilized during rest and exertion. Diaphragmatic breathing simply is where the chest or abdomen rises and falls during inspiration and exhalation. The diaphragm is the core of your core and needs to be used properly. Remedial treatment might be teaching patients to breathe to create expansion of the rib cage.
Static posture evaluation could reveal anterior lower rib "flares," which are adaptations of extension patterns of the rib cage because of polyarticular chains that directly link to extension patterns of the pelvis. The unresponsive UCS may be related to a polyarticular muscle chain known as the anterior inferior chain (AIC) (taught by Ron Hruska), which is a link composed of the following muscles: diaphragm, iliacus, psoas, tensor fascia lata, vastus lateralis and biceps femoris.
There is also an integrated role of the abdominals in the transverse and frontal plane for respiration, tri-planar performance and gait. The abdominal obliques and transverse abdominals have a large surface area to control inlet and outlet position of the pelvis, along with rib internal rotation for the Zone of Apposition [the area of the diaphragm that directly apposes the rib cage] for the diaphragm to maximize respiratory function.
The obliques cover the lower eight ribs (that's more than half of the rib cage!). The rectus abdominis (RA) has small attachments to the rib cage and it's a sagittal plane muscle (flexion vs. extension). It's mostly going to flex to oppose overactive extensors.
The RA can depress the sternum, but not necessarily rotate ribs like the obliques. As for the pelvis, the RA can superiorly pull up on the pubic bone (without closing the iliums). It may influence the pelvis, but not the diaphragms position for respiratory function. Clearing trigger points in the RA and the paraspinals is good practice; I often see overactive RAs with overactive paraspinals. If you have an unresponsive UCS, you must go back and look at the pelvis and rib alignments.
Without good rib mobility and a zone of apposition, apical expansion and posterior mediastinum airflow will be compromised – further compromising trunk rotation and the spine's ability to flex and rotate. Without good rib mobility, the body is going to compensate with more extension muscles approximating.
It's possible that the loss of rib mobility in normal breathing causes accessory / compensatory respiratory patterns that cause the abdominals to shut down and therefore overuse the back and neck muscles. Restoring rib mobility is important, so in the unresponsive UCS, pay close attention to the muscles that cover the most surface area on the rib cage.
Other Important Rechecks
In addition to rechecking respiration, recheck the pelvis and the cervicals. With the phrenic nerve roots at C3-C5, it seems vital to treat compensatory patterns directly involving the cervical or brachial plexus (or both). It's common to observe sympathetic tone being caused by that sensory afferent information.
C5 influences the subclavius, serratus anterior and other muscles related to the cervicothoracic and scapulothoracic region. C4 innervation relates to the trapezius, levator and SCM. The treatment rational is restoring the relationship between the diaphragm and pelvic floor.
Editor's Note: In part 2 of this article, Dr. Tucker presents corrective exercise strategies for the difficult UCS patient.
References
- Lynch S, et al. The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. Brit J Sports Med, 2010;44:376-381.
- Patel K, Patel S. "Re-Educating the Posture." SportEX Dynamics, 2005;5:17-21.
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