Upper Crossed Syndrome

Author :  Matthew Voigts DO Atlas Zone Practitioner

This term was first described by Vladimir Janda a Czech Doctor. It is also referred to as proximal or shoulder girdle crossed syndrome. In essence it is a muscle imbalance characterised by short tight facilitated pectorals on the anterior aspect crossing with short tight facilitated upper trapezius, levator scapulae and suboccipitals on the posterior aspect. A reciprocal inhibition and weakening of the deep neck flexors on the anterior aspect crosses with inhibition and weakening of the rhomboids, serratus anterior, middle and lower trapezius on the posterior aspect. This muscle imbalance becomes self-fulfilling and encourages forward head posture and protraction of the shoulders. According to Janda it also 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 neighbouring vertebrae change in morphology.

More simply put common signs of this condition are forward head carriage, rounded shoulders and an increase in the curve of the upper back. You only have to look around the office or at people walking in the street and observe that most of our population are suffering from this condition.
Unfortunately this muscle imbalance causes the body to work inefficiently which leads to a higher use of energy and more strain on the body
Manual therapists spend much of their time treating symptoms generated from this condition.


Rounding or Protraction of the Shoulders:-
Short pectorals cause rounding of the shoulders and as a result when raising the arms impingement of tendons and muscles at the level of the shoulder joint can occur and will result in inflammation and pain. When the shoulders are rounded the clavicles drop onto the first rib which may cause brachial plexus compression. Symptoms associated with this type of entrapment neuropathy are upper extremity pain, numbness, swelling and paraesthesia.

Increased Lordosis (Curve) of the neck:-
Descending and shearing forces come into play at the level of the lower neck due to forward head carriage. These forces may initiate inflammation and disc herniations. The net result over time is early onset disc degeneration ie spondylosis. Also as a result of this situation entrapment neuropathies in the neck are therefore more likely which will also give upper extremity symptoms of pain, numbness and paraesthesia.

Headache Disorders
Short tight suboccipital musculature can irritate nerves and blood vessels in the upper neck which may cause chronic tension type headaches.

Reduced Lung Capacity
As a result of an increased curve in the upper back (hyperkyphosis) the ribs movement during breathing is inhibited. This may predispose people to breathing problems.
As a result of forward head posture the mandible retracts which alters the mechanics of the TMJ or jaw joints which predisposes them to dysfunction.

So what causes this syndrome which appears to be so globally epidemic?
Is it purely generated by bad postural habits ie, sitting slouched at desks, driving, reading or watching TV as most manual therapists will lead us to believe?
Or is there an underlying catalyst, something else going on setting the scene for this postural abnormality?
Is Upper Crossed Syndrome purely a biomechanical compensation for forward head carriage?
If so what causes forward head carriage?

Dysfunction of the atlanto-occipital joints may be the main predisposing factor for this postural condition.

Dysfunction at these joints has been verified by a 5 year 3D CAT SCAN and MRI Study at the Mulheim Institute of Diagnostic and Interventional Radiology in Germany. This study also showed that vibro-pressure stimulation to the suboccipital muscles is effective for correcting this condition.
It has been observed that following vibro-pressure treatment postural changes occur immediately and furthermore changes continue to occur for at least a few years.

The displacement of the Centre of Gravity of the skull and spinal column due to atlanto-occipital joint dysfunction as seen in UCS increases the occurrence of herniated discs. This is due to the poor vector distribution of forces that is produced because of this displacement causing a permanent download on discs which may exceed their coefficient of elasticity.

Atlanto-occipital dysfunction causes occipital condylar compression which displaces the centre of gravity of the skull. In a subconscious effort of the body to bring the skull back to the midline an overload in the suboccipital muscle insertions is produced. It is this situation that is at the root and the catalyst for the generation of the upper cross syndrome condition. Atlanto-occipital dysfunction is the main aetiological factor for forward head posture and UCS is a postural compensation for this condition. Once established, as Dr Janda postulated, the syndrome is self-fulfilling as short tight muscles become tighter and long weak ones weaker.

Using vibro-pressure to correct the abnormal physiological state of the suboccipital musculature which results in occipital condylar decompression
When atlanto-occipital dysfunction is corrected a domino effect is produced in a descending and progressive way. Lumbar disc herniations tend to reabsorb weeks or months after the application of the vibro-pressure stimulation and logically occurs through correction of the fascias descending motion from occiput to sacrum. This corrective movement begins to reverse the displacement of the centre of gravity of the skull and spine. The spinal column tends to return to its natural axis which allows discs to recover their natural elasticity coefficient.

As stated atlanto-occipital correction initiates the reversal of forward head posture and upper cross syndrome but needs to be combined with further support in the form of corrective exercise and postural aids for best results. This is particularily so in cases where compensatory patterns and motor engrams have been established for many years.

I have discussed the atlas role in the generation of upper cross syndrome and forward head posture. However one factor should also be considered that plays an incredibly important role in the aetiology of these postural faults.


Mouth breathing is very common and usually develops in infants. Its development is often caused by thumb sucking or the use of dummies (sixty eight percent of parents give dummies to their babies before 6 weeks of age (AAP 2011)).

The normal physiological rest position of the tongue is on the roof of the mouth. This not only ensures a good anchorage or origin of attachment for the deep flexor muscles of the neck but the upward forces from the tongue ensure good formation/development of the maxilla or roof of the mouth. When the tongue is in this position it is also impossible to breathe through the mouth.
Thumb sucking and dummies disturb this function of the tongue and as a result the tongue will no longer rest on the roof of the mouth at rest. This will encourage mouth breathing. Well what has this got to do with forward head posture and upper cross syndrome? Well in an effort to get air through the mouth the head moves forward from the vertical gravitational axis to open the airway. Overtime the forward head posture results in other biomechanical compensations such as upper cross syndrome to accommodate this deviation from the vertical gravitational axis.
I must add that there are other causes of mouth breathing such as allergies, nasal congestive disorders and diseased tonsils and adenoids. However these are often temporary and may not alter the natural tongue resting position for the long term unless they are very chronic. Unresolved allergies to foods like milk and wheat in children may cause future problems.
Unfortunately mouth breathing has tragic consequences which may appear unrelated. When the tongue rests on the floor of the mouth in children the face will grow long and narrow which causes overcrowding of the front teeth. The lower third of the face grows down and backwards which causes recession of the jaw which will cause back teeth overcrowding and result in wisdom tooth impaction. This reduces tongue and airway space. As the head moves forwards in its attempt to create more airway space biomechanically this is the catalyst for the evolution of a number of conditions. Tempero-mandibular dysfunction can occur as these joints are thrown off there axis compromising there optimal function. The angle of the Eustachian tube is altered disturbing its function which may be responsible for many of the ENT problems in children.

Mouth breathing is the main cause of snoring and sleep apnoea. 65% of people that have strokes have associated sleep apnoea. Mouth breathers are much more likely to grind or clench their teeth at night as this mechanism causes the jaw to move forward and open the airway.
Mouth breathers breath rate and volume is double that of nasal breathers. Mouth breathers over-breathe and blow off excessive carbon dioxide. From a bio-chemistry perspective in a nut shell this creates acidity in the body. The effects of an over acidic environment in the body are well documented.
What can be done?
It is important that manual therapists ascertain if the patient is a mouth breather otherwise postural correction using vibro-pressure and treatments aimed at correcting muscular imbalance will be limited. Once recognised it is possible to correct this faulty motor engram. Orofacial myofunctional therapists specialise in correcting this condition – see the International Association of Orofacial Myology – www.IAOM.com
A good starting point with patients as Professor John Mew, Founder of the London School of Facial Orthotropics says is ‘ keep your lips sealed and your tongue on the roof of your mouth’.

Over the last few centuries the western diet has become softer and softer. The implications of this regarding forward head posture and poor posture are largely conjecture. However for sure the muscles of mastication are being underutilised and weakened causing facial dystrophy and orofacial bone growth retardation. This fact has been highlighted by a study published in the European Journal of Orthodontics, Vol 12 Issue 2. Titled the effects of attritive diet on craniofacial morphology the study compared Finnish skulls from the 15th/16th century with present day Finns. The results indicated that a soft diet effects mandibular growth.
In conclusion if someone mouth breathes forward head posture and upper cross syndrome are an inevitable outcome as biomechanically the body will adapt to enable itself to receive air to survive.
To correct forward head posture and upper cross syndrome atlanto-occipital dysfunction correction with vibro-pressure is the first step. Then to ascertain if the patient mouth breathes. If this is the case the next step is to address this problem. Following this the faulty motor engrams which have developed need to be addressed.