Upper-Crossed Syndrome: Difference between revisions

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'''Levator scapulae m.'''  is examined in a similar manner, except that the head is also rotated to the contralateral side<ref name=":6" />.
'''Levator scapulae m.'''  is examined in a similar manner, except that the head is also rotated to the contralateral side<ref name=":6" />.


'''Pectoralis major m.''' is tested with the patient supine. The trunk must be stabilized before the arm is placed into abduction because a possible twist of the trunk might mimic the normal range of movement. The arm should reach the horizontal level. To estimate the clavicular portion, the arm is allowed to hang down loosely and the examiner applies a posterior glide to the shoulder. Normally, only a slight soft barrier is felt<ref name=":6" /><ref name=":6" />.
'''Pectoralis major m.''' is tested with the patient supine. The trunk must be stabilized before the arm is placed into abduction because a possible twist of the trunk might mimic the normal range of movement. The arm should reach the horizontal level. To estimate the clavicular portion, the arm is allowed to hang down loosely and the examiner applies a posterior glide to the shoulder. Normally, only a slight soft barrier is felt<ref name=":6" />. V.Janda had suggested testing pectoralis major muscule. The different portions of the pectoralis major are tested separately. The clinician is able to target the specific portions by changing the amount of shoulder abduction.
 
• Lower sternal fibers. The clinician abducts the patient's arm to 150° with slight external rotation. The normal length of these pectoral fibers allows the patient's arm to rest in a horizontal position; slight overpressure produces end-feel resistance. The clinician should also palpate the sternal fibers medial to the axilla for tenderness. Shortness or hypertonicity of the muscle is indicated by an inability of the arm to reach horizontal or a palpable tenderness in the muscle.
 
• Midsternal fibers. The clinician abducts the patient's arm to 90° and palpates the muscle fibers at the second rib interspace. The normal length of these fibers allows the patient's arm to rest below the horizontal. There is gradual end-feel resistance when the clinician applies slight overpressure. Palpation does not produce tenderness.
 
• Clavicular fibers. The clinician places the patient's arm in an extended position close to the body and allows the arm to come to a rest. The normal length of these fibers allows the patient's arm to rest below the horizontal. The clinician applies a gentle anteroposterior and caudal pressure through the glenohumeral joint as well as palpates the fibers just inferior to the clavicle. Resistance to this pressure should be gradual and fibers should not be tender to palpation.


'''Pectoralis Minor m.''' is tested swith the patient supine.The clinician views the mark on the patient from a superior view. The normal distance between the acromion and the table is 1 in. The horizontal levels of the anterior aspects of the acromions can be compared with each other. The two acromions should be on the same level; a higher acromion indicates possible pectoralis minor tightness<ref name=":1" />.
'''Pectoralis Minor m.''' is tested swith the patient supine.The clinician views the mark on the patient from a superior view. The normal distance between the acromion and the table is 1 in. The horizontal levels of the anterior aspects of the acromions can be compared with each other. The two acromions should be on the same level; a higher acromion indicates possible pectoralis minor tightness<ref name=":1" />.

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Original Editor - Inga Balciuniene Top Contributors - Inga Balciuniene, Kim Jackson, Lucinda hampton and Joao Costa

Introduction[edit | edit source]


Upper-crossed syndrome (UCS) is also referred to as proximal or shoulder girdle crossed syndrome. In UCS, tightness of the upper trapezius and levator scapula on the dorsal side crosses with tightness of the pectoralis major and minor. Weakness of the deep cervical flexors ventrally crosses with weakness of the middle and lower trapezius. This pattern of imbalance creates joint dysfunction, particularly at the atlanto-occipital joint, C4-C5 segment, cervicothoracic joint, glenohumeral joint, and T4-T5 segment. Janda noted that these focal areas of stress within the spine correspond to transitional zones in which neighboring vertebrae change in morphology. Specific postural changes are seen in UCS, including forward head posture, increased cervical lordosis and thoracic kyphosis, elevated and protracted shoulders, and rotation or abduction and winging of the scapulae. These postural changes decrease glenohumeral stability as the glenoid fossa becomes more vertical due to serratus anterior weakness leading to abduction, rotation, and winging of the scapulae. This loss of stability requires the levator scapula and upper trapezius to increase activation to maintain glenohumeral centration[1].Exposure of the human body to gravity forces, e.g., when standing or walking, is necessary to ensure proper activity of the skeletal muscles responsible for maintaining good body posture. When these muscles are not stimulated to resist gravity for an extended period, e.g., during prolonged sitting or lying, their stabilizing function is disturbed by the hypoactivity reaction resulting in muscular weakness and atrophy. The deficit of the locomotor system stability triggers a compensatory mechanism—the stabilizing function is overtaken by the mobilizing muscles. However, as a side effect, such compensation leads to mobilizers’ increased activity (hyperactivity) and, subsequently, their decreased flexibility, which may finally lead to a pathological chain of reactions within the musculoskeletal system[2][3][4][5][6][7].

Upper crossed syndrome

Mechanism of Injury / Pathological Process[edit | edit source]

According to Karel Lewit (1994), muscle imbalance usually occurs before functional dysfunction[8]. V Janda (2013), also describes this muscle imbalance as a condition in which some muscles become inhibit and weak and others become short and stiff. Such imbalance can bring changes in tissues, which may cause inappropriate movement patterns in the individual. Such conditions can eventually cause side effects such as pain and inflammation. Janda attributes these predicted patterns to a large extent, due to the immobile conditions and repetitive tasks[9][10]. Muscle balance can be defined as a relative equality of muscle length or strength between an agonist and an antagonist; this balance is necessary for normal movement and function[1].

In this syndrome, mainly the posterior superior muscles in the neck and the anterior neck, which are tonic, are short and the anterior deep muscles of the neck and posterior shoulder girdle, which are mainly phasic, are inhibited and weakened. This condition is caused by the changes in the elevation, protraction and abduction of the shoulder by increasing the angle of forward head and hyperextension of the upper part of the cervical spine, which are often associated with forward head, round shoulder, protracted scapulae, and thoracic kyphosis[9][10].

Muscles may become unbalanced as a result of adaptation or dysfunction. Such muscle imbalances can be either functional or pathological:

  1. Functional muscle imbalances occur in response to adaptation for complex movement patterns, including imbalances in strength or flexibility of antagonistic muscle groups[1]. The structural approach focuses on actual damage to musculoskeletal structures such as rotator cuff tendonitis or a ligament injury. The functional approach examines factors that contribute to structural lesions. This approach is most useful for physical therapy management of chronic ‘dysfunctions’ such as persistent joint pain and tendonitis[11].
  2. When muscle imbalance impairs function, it is considered to be pathological. Pathological muscle imbalance typically is associated with dysfunction and pain, although its cause may or may not result from an initial traumatic event. Pathological imbalance may also be insidious; many people have these muscle imbalances without pain. Ultimately, however, pathological muscle imbalance leads to joint dysfunction and altered movement patterns, which in turn lead to pain. Note that this muscle imbalance continuum may progress in either direction; muscle imbalance may lead to altered movement patterns and vice versa. Some injuries cause muscle imbalance, while others may result from muscle imbalance.Sometimes pathological imbalances are a functional compensation for an injury[1].For example, unbalanced biomechanical joint stresses that result from muscle imbalance may lead to joint damage, setting up a vicious cycle of pain and inflammation. The structural inflammation then affects the neuromuscular system of the joint, creating further dysfunction. Eventually, the body adapts the motor program for movement to compensate for the dysfunction. The functional cause of the problem is muscle imbalance, while the symptom is pain and inflammation resulting from a structural lesion. Therefore, it is possible to have both a structural and a functional lesion, but for accurate diagnosis and treatment, the clinician must decide which lesion is the actual cause of dysfunction[1].
Functional imbalance Pathological imbalance
Atraumatic With or without trauma
Adaptive change Adaptive change
Activity specific Associated with dysfunction
No pain With or without pain


Proprioceptive senses are the senses used to control the positions and motions of the trunk and parts of the body in space[12]. Proprioceptive senses related to the spatial recognition of the head require not only information from the vestibular organs and visual information, but also proprioceptive sense information from the cervical spine[13] Proprioceptive senses perform two important roles in the neck: they provide information on posture and motion of the cervical spine to the central nervous system, and they provide cervical reflexes for stability and protection of the cervical spine[14]. Pathology, injuries, muscle fatigue, and aging have been reported as causes of damage to cervical spine positional senses, and recent studies have reported that position sense declines in patients with damage to the cervical spine or who complain of pain[15][16].

.

Clinical Presentation[edit | edit source]

Individuals who present with upper crossed syndrome will show a forward head posture (FHP), hunching of the thoracic spine-as well as changed function in the shoulder girdle, elevated and protracted shoulders, scapular winging, and decreased mobility of the thoracic spine[17][18]. Ofen upper crossed syndrome is is associated with postural disorders and other dysfunction of upper body. Kendall et al. proposed a definition of good human posture: “good posture is that state of muscular and skeletal balance which protects the supporting structures of the body against the injury or progressive deformity, irrespective of the attitude (erect, lying, squatting or stooping) in which these structures are working or resting. Under such conditions, the muscles will function most efficiently, and the optimum positions are afforded for the thoracic and abdominal organs[19].

Posture.jpg

Weak muscles:

  1. lower and middle trapezius
  2. serratus anterior
  3. infraspinatus
  4. deep neck flexors

Tight muscles:

  1. upper trapezius
  2. pectorals,tightness of the pectoralis major creates an anterior force on the glenohumeral joint with a consequent decrease in stability[20].A tight pectoralis minor limits scapular upward rotation, external rotation, and posterior tilt, thereby reducing SAS[21].
  3. levator scapula [22].
Upper crossed syndrome summary according to NASM[23][edit | edit source]
Short muscles Lengthened muscles Altered joints mechanics Possible injuries
Upper trapezius Deep cervical flexors Increased: Headaches
Levator scapulae Serratus anterior Cervical extention Biceps tendonitis
Sternocleidomastoid Rhomboids Scapular protraction/elevation Rotator cuff impingement
Scalenes Mid-trapezius Thoracic outlet syndrome
Latissimus dorsi Lower trapezius Decreased:
Teres minor Teres minor Shoulder extention
Subscapularis Infraspinatus Shoulder external rotation
Pectoralis major/minor
Kyphotic.jpg

Diagnostic Procedures[edit | edit source]

  1. In clinical practice, it is advisable to begin muscle evaluation by analyzing erect standing posture and gait. The c1inician is given an overall view of the patient's muscle function through posture and gait analysis and is challenged to look comprehensively at the patient's entire motor system and not to limit attention to the local level of the lesion[24].
  2. Muscle Analysis of Standing Posture:Posterior View/Anterior View/Lateral View[1].
  3. Evaluation of Balance[1].
  4. Evaluation of muscle imbalance in a patient with an acute pain syndrome, however, is unreliable and must be undertaken with precaution. A precise evaluation of tight muscles and movement patterns can be performed only if the patient is pain-free or almost pain-free. Its usefulness is greatest in the chronic phase or in patients with recurrent pain after the acute episode has subsided[24].

Upper-Quarter Muscles[edit | edit source]

The muscles of the upper quarter include those of the cervical spine, shoulder, andarm. The muscles prone to tightness are those involved in a protective flexor response. Tightness of the upper trapezius, pectoral muscles, and suboccipitals in particular is a hallmark sign of Janda's UCS[1].

Upper trapezius m.is tested with the patient supine, with the head passively flexed and side-bent to the contralateral side. Once the slack is taken up, the shoulder girdle is pushed distally. Normally, a sort barrier is felt at the end of the push; however,when the movement is restricted, the barrier has an abrupt firm to hard end-reel[24].

Levator scapulae m. is examined in a similar manner, except that the head is also rotated to the contralateral side[24].

Pectoralis major m. is tested with the patient supine. The trunk must be stabilized before the arm is placed into abduction because a possible twist of the trunk might mimic the normal range of movement. The arm should reach the horizontal level. To estimate the clavicular portion, the arm is allowed to hang down loosely and the examiner applies a posterior glide to the shoulder. Normally, only a slight soft barrier is felt[24]. V.Janda had suggested testing pectoralis major muscule. The different portions of the pectoralis major are tested separately. The clinician is able to target the specific portions by changing the amount of shoulder abduction.

• Lower sternal fibers. The clinician abducts the patient's arm to 150° with slight external rotation. The normal length of these pectoral fibers allows the patient's arm to rest in a horizontal position; slight overpressure produces end-feel resistance. The clinician should also palpate the sternal fibers medial to the axilla for tenderness. Shortness or hypertonicity of the muscle is indicated by an inability of the arm to reach horizontal or a palpable tenderness in the muscle.

• Midsternal fibers. The clinician abducts the patient's arm to 90° and palpates the muscle fibers at the second rib interspace. The normal length of these fibers allows the patient's arm to rest below the horizontal. There is gradual end-feel resistance when the clinician applies slight overpressure. Palpation does not produce tenderness.

• Clavicular fibers. The clinician places the patient's arm in an extended position close to the body and allows the arm to come to a rest. The normal length of these fibers allows the patient's arm to rest below the horizontal. The clinician applies a gentle anteroposterior and caudal pressure through the glenohumeral joint as well as palpates the fibers just inferior to the clavicle. Resistance to this pressure should be gradual and fibers should not be tender to palpation.

Pectoralis Minor m. is tested swith the patient supine.The clinician views the mark on the patient from a superior view. The normal distance between the acromion and the table is 1 in. The horizontal levels of the anterior aspects of the acromions can be compared with each other. The two acromions should be on the same level; a higher acromion indicates possible pectoralis minor tightness[1].

Deep posterior neck m. muscles can be tested only by thorough palpation. Evaluation of the sternocleidomastoid is not reliable because it crosses too many segments[24].

[25]

Outcome Measures[edit | edit source]

add links to outcome measures here (see Outcome Measures Database)

Management / Interventions[edit | edit source]


Differential Diagnosis[edit | edit source]

add text here relating to the differential diagnosis of this condition

Resources[edit | edit source]

add appropriate resources here

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Page P, Frank C.C, Lardner R. Assessment and treatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.
  2. ↑ Sahrmann S. Diagnosis and treatment of movement impairment syndromes. St. Louis: Mosby; 2002
  3. ↑ Richardson CA, Hodges PW, Hides J. Therapeutic exercise for lumbopelvic stabilization: a motor control approach for the treatment and prevention of low back pain. 2. Edinburgh: Churchill Livingstone; 2004. 
  4. ↑ Richardson C. The muscle designation debate: the experts respond. J Bodyw Mov Ther. 2000;4(4):235–236.
  5. ↑ Magnetic resonance imaging assessment of trunk muscles during prolonged bed rest. Hides JA, Belavý DL, Stanton W, Wilson SJ, Rittweger J, Felsenberg D, Richardson CA Spine (Phila Pa 1976). 2007 Jul 1; 32(15):1687-92.
  6. ↑ Hides JA, Lambrecht G, Richardson CA, Stanton WR, Armbrecht G, Pruett C, Damann V, Felsenberg D, Belavý DL.The effects of rehabilitation on the muscles of the trunk following prolonged bed rest.Eur Spine J. 2011 May; 20(5):808-18.
  7. ↑ . Belavý DL, Richardson CA, Wilson SJ, Rittweger J, Felsenberg D.Superficial lumbopelvic muscle overactivity and decreased cocontraction after 8 weeks of bed rest.Spine (Phila Pa 1976). 2007 Jan 1; 32(1):E23-9.
  8. ↑ Lewit K. The functional approach. Orthop J Sports Med. 1994;16(3):73-4
  9. ↑ 9.0 9.1 Moore MK. Upper crossed syndrome and its relationship to cervicogenic headache. J Manipulative Physiol Ther. 2004; 27(6):414-20
  10. ↑ 10.0 10.1 Janda V. Muscle function testing. Elsevier; 2013; 230-58
  11. ↑ Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes.Int J Sports Phys Ther. 2011 Mar; 6(1): 51–58.
  12. ↑ Janda V: Muscles and motor control in cervicogenic disorders. New York: Churchill Livingstone, 1994
  13. ↑ Repositioning error in low back pain. Comparing trunk repositioning error in subjects with chronic low back pain and control subjects. Newcomer K, Laskowski ER, Yu B, Larson DR, An KN Spine (Phila Pa 1976). 2000 Jan 15; 25(2):245-50.
  14. ↑ Hogervorst T, Brand RA J Mechanoreceptors in joint function. Bone Joint Surg Am. 1998 Sep; 80(9):1365-78.
  15. ↑ Pinsault N, Vuillerme N, Pavan P.Cervicocephalic relocation test to the neutral head position: assessment in bilateral labyrinthine-defective and chronic, nontraumatic neck pain patients. Arch Phys Med Rehabil. 2008 Dec; 89(12):2375-8.
  16. ↑ Haldeman S: Principles and practices of chiropractic. 3rd ed. USA: Appleton & Lange, 2004
  17. ↑ Public Education Section Department of Business and Consumer Business Oregon OSHA.Introduction to the Ergonomics of Manual Material Handling. Diunduhdari: Diakses Tanggal Maret; 2012.
  18. ↑ Page P, Frank C.C, Lardner R. Assessment andtreatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.
  19. ↑ Kendall F, McCreary E, Provance PG, Rodgers M, Romani WA. Muscle testing and function with posture and pain. Baltimore: Lippincott Williams & Wilkins; 2005
  20. ↑ 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
  21. ↑ 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
  22. ↑ Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes.Int J Sports Phys Ther. 2011 Mar; 6(1): 51–58.
  23. ↑ NASM https://www.nasm.org/docs/PDF/nasm-cpt-website-exam_study_final.pdf
  24. ↑ 24.0 24.1 24.2 24.3 24.4 24.5 Liebenson C. Rehabilitation of the Spine: A Practitioner's Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007
  25. ↑ Physiotutors. Muscle Tightness Explained: Why do my muscles feel tight?Available from: https://www.youtube.com/watch?v=-N5OxSz-5L0 [last accessed 23/4/2020]
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