Wednesday, January 1, 2014

An Introduction to Upper Cross Syndrome

With my last post I discussed the value of creating stability in the shoulder through reactive stability drills and exercises. However, like every joint the shoulder requires some degree of both stability and mobility. Today I want to address some of the common postural distortion patterns for the upper body and corrective strategies. 

There are an unlimited number of potential injuries and imbalances that can occur in the upper body but today's post will focus on problems arising from the postural distortion known as upper cross syndrome (UCS). It was a concept defined in 1979 by Dr. Vladimir Janda [1]

Upper Cross Syndrome
Aside from having no skin the image above should look very familiar to anyone who frequents the gym. This is the standard presentation of upper cross syndrome (UCS). It is identifiable by the forward head and internally rotated shoulders, as well as a hunchback position and winging scapula in more advanced cases. Difficulty achieving an overhead position is also common. UCS has two main areas of weakness and two main areas of tightness. Before we begin a piece by piece breakdown let's discuss why this is a relevant impairment. 

Weakness across the deep cervical flexors and lower trapezius combined with tightness in the pectorals, upper traps and levator group leads to joint dysfunction in the spine from the mid thoracic area all the way up to the atlanto-occipital (top of your spine) joint, as well as in the glenohumeral joint. These specific patterns lead to forward head posture, and exaggerated curvature of the spine (increased lordosis of the cervical region and increased kyphosis of the thoracic region), as well as internally rotated, elevated and protracted shoulders (aka douchebag shoulder syndrome). 

The cervical spine position and upper trapezius tightness has been associated with migraine headaches and the internally rotated shoulder position makes overhead movements challenging, decreasing performance and significantly increasing likelihood of shoulder impingement, as well as a host of other much nastier shoulder injuries. Hopefully through this brief breakdown you understand the relevance of upper body posture. So let's examine the details of the movement disorder and discuss how to fix these issues, starting with the muscles that are too tight and then looking at the areas of weakness.

Tight: Pectorals. The pectoral group, both pectoralis major and minor, are tight for a multitude of reasons. Primary among them is the way that most people sit throughout the day. An excessive amount of training for the chest in relation to the back also contributes. 
Fix: Stop doing so much volume on your pressing movements and stop sitting like a caveman. Additionally some soft tissue work on the pec minor can be very beneficial. This video has some awesome tips, but it's an aggressive drill so if you aren't accustomed to a lot of soft tissue work start with just a lacrosse ball against a wall. Mobility work in the warmups can be beneficial as well

Advanced soft tissue work

Tight: Upper trapezius/levator scapulae. Similar problems to the pecs. Poor posture throughout the day places constant tension on the upper trapezius and levator group. Direct training for the upper trapezius is also a detriment to posture in many cases, as the ratio of strength between upper and lower trapezius is skewed heavily in favor of the upper traps. If you didn't know before you will know now. I hate shrugs. Do some real exercises (deadlifts, oly lifts, rows and chinups) and your traps will grow without developing the distortions discussed here.[2]
Fix: There are some stretches for the traps as well as some soft tissue work but in my experience when the lower trap is strengthened the upper traps will calm down. Also, no more shrugs, seriously. You're killing yourselves with this crap.

Weak: Lower trapezius and rhomboids. Can you tell me what the ratio is in your current program of protraction to retraction exercises. Or internal rotation vs external rotation. Probably too much of the former, not enough of the latter. Weak lower traps allow the upper traps to take over movements and weak rhomboids allow the pectorals to exert a greater pull on the humerus.
Fix: This one is easy. Add in some extra rowing variations and lower trap drills like Y pulls on cables or TRX. The line of pull on the lower trap is about 130 degrees so that is the angle we aim for when directly targeting the lower trap. It will lead to a pull that resembles the letter Y. Here as some great examples.

                                       Beginner exercise for the lower trap

                                   Lower trap strength training progression

Weak: Deep cervical flexors. These muscles help pull the head back into a position of cervical retrusion, or the "double chin position". This position feels unfamiliar to most people but only because we are all living with our heads too far out in front of our bodies. Do this quick test. Stand up with your normal neck position and hold your hands out in front of you. Have someone try to knock you over by pushing your hands. Try it again while actively pulling your head back into the double chin  or packed neck position. I've done this with dozens of athletes and they are always stronger in the double chin position. Always.

Good neck position
Bad neck position. Bad everything position
Fix: In addition to lifting with proper neck position check out this video for additional exercises for the deep cervical flexor muscles. These can be incorporated into a warmup, cooldown or as filler between strength sets. Additionally it serves as a great time to work on proper belly breathing patterns [3]


That covers all of the components of Janda's upper cross syndrome. Hopefully this has given you the ability to identify and treat the most common upper body postural deviation in both athletes and weekend warriors. Next post will look at lower cross syndrome. 

[1] Dr. Janda's work revolutionized the field of physical therapy and influenced some of the best therapist in the world today. If you are interested in this field I would highly recommend reading his work.
[2] The upper traps do play a role in aiding upward rotation of the scapula, allowing for safe overhead activity for many. In this instance train the movement in question. Add an overhead shrug with bodyweight or low load as an activation drill.
[3] proper breathing will be a post all on it's own

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