Upper-Crossed Syndrome
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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].
Mechanism of Injury / Pathological Process[edit | edit source]
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. Muscle balance may also refer to the strength of contralateral (right versus left) muscle groups.Muscles may become unbalanced as a result of adaptation or dysfunction. Such muscle imbalances can be either functional or pathological.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[2].
| Functional imbalance | Pathological imbalance |
|---|---|
| Atraumatic | With or without trauma |
| Adaptive change | Adaptive change |
| Activity specific | Associated with dysfunction |
| No pain | With or without pain |
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].
Clinical Presentation[edit | edit source]
The upper crossed syndrome involves weakness of the of the of the deep cervical flexors ventrally crosses with weakness of the middle and lower trapezius. tightness of the upper trapezius and levator scapula on the dorsal side crosses with tightness of the pectoralis major and minor[3]. 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[4].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[5][6][7][8][9][10].
Janda described the problem of forward head posture (FHP) as upper crossed syndrome and argued that the syndrome occurred when a slouched sitting posture was sustained for a prolonged period. This poor posture weakens deep neck flexors and scapular retractors such as the lower trapezius fibers and rhomboids and shortens the upper trapezius, levator scapulae, pectoralis major, and pectoralis minor[11].
The shoulder complex relies on muscles to provide dynamic stability during its large range of mobility. Proper balance of the muscles surrounding the shoulder complex is also necessary for flexibility and strength; a deficit in flexibility or strength in an agonistic muscle must be compensated for by the antagonist muscle, leading to dysfunction. These muscular imbalances lead to changes in arthrokinematics and movement impairments, which may ultimately cause structural damage. Dr. Janda suggested that subacromial impingement results from a characteristic pattern of muscle imbalance including weakness of the lower and middle trapezius, serratus anterior, infraspinatus, and deltoid, coupled with tightness of the upper trapezius, pectorals and levator scapula.1 This pattern is often referred to as part of Janda's “Upper Crossed Syndrome” [12].
Tightness of the pectoralis major creates an anterior force on the glenohumeral joint with a consequent decrease in stability[13].A tight pectoralis minor limits scapular upward rotation, external rotation, and posterior tilt, thereby reducing SAS[14].This alteration in scapular kinematics occurs in three separate planes of movement and differs from scapular kinematics of those with normal muscle length[15].
The kyphotic posture represents a faulty posture that differs from the good one by the following: increased thoracic kyphosis, head protraction, flattened or reversed lower cervical lordosis, increased upper cervical lordosis, and protraction of shoulders and scapulae[4][5].In the kyphotic posture, the head line is shifted anteriorly to the thoracic spine, lumbar vertebral bodies, and hip and knee joint axis. The base line usually runs at the back of the head line.
Diagnostic Procedures[edit | edit source]
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Outcome Measures[edit | edit source]
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Management / Interventions[edit | edit source]
While structural impingement sometimes requires surgery to alleviate pain, functional instability requires the implementation of precise therapeutic exercises with the goal of restoration of normal neuromuscular function. It is important for clinicians to understand the pathomechanics of functional impingement in order to guide appropriate examination, assessment, and intervention, as well as to consider prevention[2].
Differential Diagnosis[edit | edit source]
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Resources[edit | edit source]
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References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 Page P, Frank C.C, Lardner R. Assessment andtreatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.
- ↑ 2.0 2.1 Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes.Int J Sports Phys Ther. 2011 Mar; 6(1): 51–58.
- ↑ Page P, Frank C.C, Lardner R. Assessment andtreatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.
- ↑ 4.0 4.1 Kendall F, McCreary E, Provance PG, Rodgers M, Romani WA. Muscle testing and function with posture and pain. Baltimore: Lippincott Williams & Wilkins; 2005
- ↑ 5.0 5.1 Sahrmann S. Diagnosis and treatment of movement impairment syndromes. St. Louis: Mosby; 2002
- ↑ 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.
- ↑ Richardson C. The muscle designation debate: the experts respond. J Bodyw Mov Ther. 2000;4(4):235–236.
- ↑ 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.
- ↑ 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.
- ↑ . 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.
- ↑ Harman K, Hubley-Kozey CL, Butler H: Effectiveness of an exercise program to improve forward head posture in normal adults: a randomized, controlled 10-week trial. J Manual Manip Ther, 2005, 13: 163–176.
- ↑ Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes.Int J Sports Phys Ther. 2011 Mar; 6(1): 51–58.
- ↑ 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
- ↑ 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
- ↑ Borstad J.D., Resting position variables at the shoulder: evidence to support a posture-impairment association. Phys Ther. 2006;86(4):549–557
