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]
According to Karel Lewit (1994), muscle imbalance usually occurs before functional dysfunction[2]. 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[3][4]. 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[3][4].
Furthermore,muscule imbalance 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[5].
| 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].
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[6][7][8][9][10][11].
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Clinical Presentation[edit | edit source]
Individuals who present with upper crossed syndrome will show a forward head posture (FHP), hunching of the thoracic spine (rounded upper back), elevated and protracted shoulders, scapular winging, and decreased mobility of the thoracic spine[12][13]. 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[14].
One of the faulty postures related to upper crossed syndrome is kyphotic. 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[14][6].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[14][6]. Tightness of the pectoralis major creates an anterior force on the glenohumeral joint with a consequent decrease in stability[15].A tight pectoralis minor limits scapular upward rotation, external rotation, and posterior tilt, thereby reducing SAS[16].This alteration in scapular kinematics occurs in three separate planes of movement and differs from scapular kinematics of those with normal muscle length[17]. 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” [18].
Proprioceptive senses are the senses used to control the positions and motions of the trunk and parts of the body in space[19]. 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[20] 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[21]. 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[22][23].
Diagnostic Procedures[edit | edit source]
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Outcome Measures[edit | edit source]
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Management / Interventions[edit | edit source]
Badposture and its direction affect the physical activity and lead to increased stress on supportive structures as well
as the habitual bending or falling in individuals [14] Therefore, the optimum mechanical condition of the body and the energy consumption in daily life and exercise have particular importance
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[5].
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 1.4 Page P, Frank C.C, Lardner R. Assessment andtreatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.
- ↑ Lewit K. The functional approach. Orthop J Sports Med. 1994;16(3):73-4
- ↑ 3.0 3.1 Moore MK. Upper crossed syndrome and its relationship to cervicogenic headache. J Manipulative Physiol Ther. 2004; 27(6):414-20
- ↑ 4.0 4.1 Janda V. Muscle function testing. Elsevier; 2013; 230-58
- ↑ 5.0 5.1 Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes.Int J Sports Phys Ther. 2011 Mar; 6(1): 51–58.
- ↑ 6.0 6.1 6.2 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.
- ↑ Public Education Section Department of Business and Consumer Business Oregon OSHA.Introduction to the Ergonomics of Manual Material Handling. Diunduhdari: Diakses Tanggal Maret; 2012.
- ↑ Page P, Frank C.C, Lardner R. Assessment andtreatment of muscle imbalance: The Janda Approach 2010, Champaign, IL: Human Kinetics.
- ↑ 14.0 14.1 14.2 14.3 Kendall F, McCreary E, Provance PG, Rodgers M, Romani WA. Muscle testing and function with posture and pain. Baltimore: Lippincott Williams & Wilkins; 2005
- ↑ 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
- ↑ Page P. Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes.Int J Sports Phys Ther. 2011 Mar; 6(1): 51–58.
- ↑ Janda V: Muscles and motor control in cervicogenic disorders. New York: Churchill Livingstone, 1994
- ↑ 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.
- ↑ Hogervorst T, Brand RA J Mechanoreceptors in joint function. Bone Joint Surg Am. 1998 Sep; 80(9):1365-78.
- ↑ 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.
- ↑ Haldeman S: Principles and practices of chiropractic. 3rd ed. USA: Appleton & Lange, 2004
